288
Current Respiratory Medicine Reviews, 2008, 4, 288-294
Prescription of Exercise Training in Patients with COPD Ioannis Vogiatzis* Department of Critical Care Medicine and Pulmonary Services, Pulmonary Rehabilitation Centre - Evangelismos Hospital and Department of Physical Education and Sport Science, National & Kapodistrian University of Athens, Greece Abstract: Exercise training should be tailored to address the individual patient’s limiting factors (central cardiorespiratory and/or peripheral muscle) to exercise. Patients who are capable of exercising for prolonged periods of time at high intensities will equally benefit from performing either continuous or interval training regimes. In patients with intense dyspnea symptoms, interval exercise is more appropriate. Resistance exercise should be complementary to endurance exercise so as to improve the strength of both the upper and the lower body muscles. In patients with profound muscle weakness resistance exercise should constitute a training priority. Regardless of mode and type of exercise implemented, a training regime should be designed to progressively overload the organism beyond the regularly encountered levels. The overloading procedure should be continuously adjusted to maximize training adaptations. During training supervision is necessary to avoid complications and to record the rate of progress. This review provides several practical aspects to guide rehabilitation therapists on how best to implement the principles of training when exercising patients with COPD.
Keywords: COPD, exercise training, interval exercise, endurance exercise, exercise tollerance, deconditioning. PHYSIOLOGICAL FACTORS LIMITING EXERCISE TOLERANCE IN COPD Exercise intolerance is common in patients with COPD and it is known to compromise both participation in activities of daily living and health-related quality of life [1]. The major symptoms that curtail the patients’ level of physical activity are associated with both breathing and leg discomfort. Abnormal lung mechanics, impaired pulmonary gas exchange and destruction of the pulmonary vascular bed are well recognized factors limiting exercise tolerance in patients with COPD. One of the leading factors of exercise intolerance in the majority of patients with COPD is the development of dynamic hyperinflation and the concurrent mechanical constraints on ventilation that contribute importantly to perceived respiratory discomfort [2,3]. Secondary to dynamic hyperinflation and concomitant high mean intrathoracic pressure, cardiac performance and hence, supply of oxygenated blood to the malfunctioning peripheral muscles are further compromised, thereby aggravating muscle discomfort [4]. Moreover, excessive recruitment of expiratory muscles in the face of expiratory flow limitation is known to augment the oxygen cost of breathing which becomes an important fraction of the total body oxygen uptake [5]. This may result in competition between the respiratory and locomotor muscles for the available oxygen supply. Inadequate oxygen supply to meet the metabolic demands of the locomotor muscles may play a more dominant role in limiting exercise capacity in some patients with COPD than impaired lung function or dynamic hyperinflation [6, 7].
*Address correspondence to this author at the National & Kapodistrian University of Athens, Thorax Foundation, 3 Ploutarhou Str. 106 75, Athens, Greece; Tel: +30 210 7235521; Fax: +30 210 7239127; E-mail:
[email protected]
1573-398X/08 $55.00+.00
In addition to the above factors, the morphological and biochemical changes within the locomotor muscles of these patients (including abnormal fiber-type distribution, reduced fiber cross-sectional areas decreased muscle capillarity and oxidative enzyme activities as well as mitochondrial dysfunction) are associated with an early activation of anaerobic glycolysis, lactic acidosis and premature establishment of muscle fatigue during exercise [8-12]. Today there is strong evidence that exercise training, constituting the cornerstone of pulmonary rehabilitation, improves patients’ exercise tolerance, dyspnoea sensations, functional capacity and quality of life in patients with COPD [1, 13, 14]. Accordingly, the major issue that arises is the selection of the appropriate training method that is tailored to the cardiovascular, pulmonary and peripheral muscle limitations of the individual patient and is aimed at maximizing the effect of exercise conditioning. The effectiveness of such a programme depends on the thorough assessment of the patients’ capacity for exercise and on the implementation of the following principles of exercise training [15]. PRINCIPLES OF EXERCISE TRAINING Overloading In order to achieve a training effect it is necessary to expose the organism to an overload, that is, to a stress that is greater than the one regularly encountered during everyday life. Training overload is modulated by the intensity, duration and frequency of physical training. Progressive Overloading The intensity of the load required to produce an effect increases as the exercise performance is improved in the course of training. Therefore, as an adaptation to a given load takes place the training intensity has to be continuously increased in order to achieve further improvement.
© 2008 Bentham Science Publishers Ltd.
Prescription of Exercise Training in Patients with COPD
Specificity of Loading The physiological adaptations are specific to the type of exercise (i.e. endurance or resistance training) to the exercising muscle groups (upper or lower extremity) and to the mode of exercise (continuous or interval exercise). De-Conditioning The physiological adaptations established with training are reversed when exercise training stops. IMPLEMENTATION OF TRAINING PRINCIPLES INTO THE CLINICAL PRACTICE Program Duration and Frequency Although the total duration of the training program varies among studies, it is generally believed that longer programs (lasting 7, 8 or 12 weeks) produce greater physiological effects than shorter programs (lasting 4 or 6 weeks) [16-18]. In addition, 6 months of exercise training has been shown to have more endurable effects compared to 3 months of training. In general, patients undertake three to five training sessions per week for 30 to 40 min each time [1, 19, 20], although training twice-weekly has also been shown to produce training physiological effects [21]. Exercise Intensity It has long been recognized that high intensity endurance training (80% peak exercise capacity) yields greater physiological effects than low intensity training (50% peak capacity) [22]. However, not all patients with COPD are able to sustain such high intensities for the required period of time (i.e.: 30 to 40 min) [20]. Accordingly, at the beginning of an endurance training program exercise intensity has to be set at moderate levels (50 to 60% peak) [23], or alternatively interval training [24-26] may be applied (see below for details). Adjusting Training Intensity Regardless of the mode of exercise (continuous or interval) exercise intensity needs to be continuously increased throughout the training program [19, 20, 24-26]. Accordingly, mean training intensity throughout a training program typically averages ~75% of peak work capacity for continuous exercise and ~120% of peak work capacity for interval exercise [24-26]. In practice, training intensity is appropriate when breathing and leg discomfort are rated between 4 and 6 on the modified Borg Scale (with a range of 0 to 10 points) [27]. Specificity of Loading The majority of programs in COPD involve lower body exercise either on a treadmill or a stationary bicycle ergometer. Both exercise modalities improve the capacity of the lower limbs to exercise, however these improvements are not transferred to the upper limbs. Therefore, upper limb exercise is necessary because many daily activities require substantial strength and stamina. Upper body exercises can be performed on an arm cycle ergometer, using free weights or on weight training machines. De-Conditioning This principle is based on the observations that the effect achieved by training is lost after the exercise training is
Current Respiratory Medicine Reviews, 2008, Vol. 4, No. 4
289
stopped. Therefore, it is necessary to implement maintenance training programs, but the frequency of training and the minimum effective duration remain to be determined. ENDURANCE VERSUS RESISTANCE TRAINING Most training programs in COPD are based on endurance training involving lower body exercise either on a treadmill or a stationary bicycle ergometer. Endurance training is commonly implemented because it simultaneously addresses the major cardiorespiratory and peripheral muscle limitations of the individual patient that commonly lead to intolerable breathing and leg discomfort. Accordingly, it has been shown that the degree of exercise-induced dynamic hyperinflation and the intensity of dyspnea sensations are significantly reduced after a period of 8 to 10 weeks of exercise training [28-30] at moderate exercise workloads (60-70% peak work capacity) whereas the kinetic response of oxygen uptake and heart rate to constant-load exercise were speeded up, thus suggesting improved cardiovascular function [31]. Furthermore, endurance training has been shown to reverse, at least in part, the morphological and biochemical muscle abnormalities (i.e.: abnormal fiber-type distribution, reduced fiber cross-sectional areas, and decreased muscle capillarity and oxidative enzyme activities) within the vastus lateralis muscle of patients with COPD [26, 32] and increase muscle bioenergetics [33]. Resistance training is also valuable in patients with COPD especially in the ones with profound muscle weakness as this type of training enhances muscle mass and strength to a greater degree that endurance training [34-36]. In addition, resistance training is highly applicable to patients with severe airway obstruction and intense dyspnea sensations as it results in less dyspnea than endurance training [37]. Furthermore, conditioning of the upper body muscles is best achieved with weight training. Ideally, the combination of endurance and resistance training constitutes the best strategy to deal with both central and peripheral limitations [38] in patients with COPD. A typical resistance session [37] may include two or three sets of eight to twelve repetitions each at 50 to 75% of the maximum weight that can be lifted only once (i.e.: the so called one repetition maximum - 1 RM). Interestingly, such a resistance training program has been shown to have similar effects as to that of endurance training on peripheral muscle force, exercise capacity and health-related quality of life in COPD patients with peripheral muscle weakness [35]. Practice Guidelines For continuous leg exercise the intensity should be initially set at 50 to 60% of maximal work capacity. The intensity should increase every 3 to 5 sessions as tolerated. Dyspnea and leg discomfort symptoms should range between 4 and 5 on the 1-10 Borg scale. Patients should be able to exercise without interruptions for 20 min and progressively for 30 to 40 min. For resistance training 3 to 5 sets of 10 to 12 repetitions is advisable. The load should correspond to 7080% of 1 RM. Between each set one or two minutes of rest is necessary. After completing 5 sets of upper body muscles, patients should engage the lower body muscles before exercise again the upper body muscles. Five or six major muscle groups should be trained in each session.
290 Current Respiratory Medicine Reviews, 2008, Vol. 4, No. 4
INTERVAL TRAINING
VERSUS
CONTINUOUS
EXERCISE
Although high-intensity constant-load exercise is generally argued to be needed for an improvement in exercise capacity [22], ventilatory limited patients are usually unable to sustain such intensities for sufficiently long periods [25, 39]. An alternative approach that allows high-intensity exercise to be performed for sufficiently long periods of time is interval exercise that comprises a sequence of on- and off- highintensity muscular loading events. In healthy subjects with this type of exercise it is possible to impose maximal loads upon both muscles and oxygen-transporting organs without significant engagement of anaerobic processes and appreciable accumulation of lactic acid, thus allowing a great amount of work to be performed before exhaustion sets in [40]. In patients with advanced COPD, interval exercise consisting of repeated bouts of high or even maximal-intensity work separated by periods of lower intensity work or rest intervals, has been shown to be associated with a small increase in lactate concentration, lower ventilation and degrees of dynamic hyperinflation and low symptoms of dyspnoea and leg discomfort, thus allowing the total amount of work performed to be significantly greater than that of continuous exercise (Table 1) [25, 39]. The duration of the exercise training bouts could be as short as 30 s [24-26] or 60 s [39] or even longer lasting 2 to 3 min [41, 42]. In the latter cases exercise intensity has to be 80 to 90 % of peak work capacity.
Ioannis Vogiatzis
Arterial oxygen saturation can be easily monitored by pulse oximetry. In addition, ECG monitoring is another technique that may be employed for close supervision of patients, especially the ones with known history of cardiac dysrhythmias. Blood pressure monitoring is necessary to perform before and during the exercise session in hypertensive patients. During the actual exercise session recording dyspnea and leg discomfort is necessary to assess and adjust the relative intensity of training. The duration of exercise and the work rate sustained are also useful information to record during each session for each patient so as to effectively monitor the degree of improvement and adjust the training load. Table 1.
Responses to Constant-Load Exercise (CLE) and Interval Exercise (IE) Protocols End of CLE
End of IE
Exercise time, min
10.3 ± 1.6
32.7 ± 3.0
V´O2, L. min-1
0.93 ± 0.07
0.81 ± 0.05
V´CO2, L. min-1
0.95 ± 0.07
0.75 ± 0.04
R
1.00 ± 0.02
0.95 ± 0.02
38.4 ± 2.2
33.1 ± 1.5
85 ± 3
76 ± 4
1.14 ± 0.06
1.01 ± 0.05
33 ± 1
34 ± 1
128± 5
123 ± 5
IC, L
1.53 ± 0.08
1.59 ± 0.08
IC, % pred
51.9 ± 3.0
53.9 ± 2.6
IC L
-0.46± 0.05
-0.39± 0.05
IC, % pred
- 15.6± 2.4
- 13.3± 1.5
V´E, L. min
-1
V´E /MVV % VT, L
Implementation of interval exercise in patients with advanced COPD has been shown to be equally effective to continuous training in terms of improvements in exercise tolerance, in vastus lateralis muscle fibre characteristics (Fig. 1) and quality of life [24,26]. However, interval training was more comfortable to patients since it was associated with lower symptoms of breathing and leg discomfort during the actual training sessions (Fig. 2). This feature makes interval exercise particularly applicable to patients with severe dynamic hyperinflation [25] and peripheral muscle weakness [26].
f, breaths. min
VT /IC %
75.2 ± 1.7
66.4 ± 2.0
Practice Guidelines
IRV, L
0.38± 0.03
0.58± 0.06
We have shown [24-26] that alternating 30 s of work at 100% peak work capacity by 30 s of rest or work at lower intensity (i.e.: 50% peak capacity) is very effective training modality in patients with advanced and severe COPD. Alternatively, 60 s of work alternating by 60 s of rest is also effective in patients with moderately severe COPD. During interval training session duration can be extended to an hour or more. Intensity may increase as often as every 3 sessions and should be targeted to induce dyspnea and leg discomfort symptoms ranging between 3 and 4 on the 1-10 Borg scale.
IRV, % pred TLC
5.9 ± 0.5
8.9 ± 0.8
PaO2, mmHg
66.7 ± 2.6
68.7 ± 2.5
PaCO2, mmHg
45.4 ± 1.2
44.0 ± 1.3
pH
7.34 ± 0.07
7.38 ± 0.06
VD, L
0.53± 0.02
0.48± 0.02
46± 6
48± 8
5.81 ± 0.41
3.89 ± 0.36
SUPERVISION AND MONITORING OF EXERCISE
Dyspnoea, Borg scale
4.8 ± 0.3
4.3 ± 0.3
Close clinical supervision of exercise programs is the most important day-to-day factor in pulmonary rehabilitation. Clinical supervision starts thorough patient education in selfassessment and reporting of changes in symptoms, appearance and well being. Patients who are receiving long-term oxygen therapy should have this continued during exercise training, whilst they may need to increase the flow rates [1]. In nonhypoxaemic patients oxygen supplementation also allows for higher training intensity and/or reduced symptoms [43].
Leg discomfort, Borg scale
4.9 ± 0.4
4.6 ± 0.5
fc, beats. min
-1
-1
VD/ VT, % -1
Lactate, mmol. L
With permission from ref. [25]. Data are means ± SEM. V´O2: oxygen uptake; V´O2 % pred; V´O2 as a percentage of predicted value; V´CO2: carbon dioxide output; R: respiratory exchange ratio; V´E: minute ventilation; V´E /MVV, %: V´E as a percentage of MVV; VT: tidal volume; f: breathing frequency; fc: cardiac frequency; IC: inspiratory capacity; IC % pred normal: inspiratory capacity as a percentage of predicted normal value; IC from rest: change in IC from rest; IC from rest, % pred: change in IC from rest as a percentage of predicted normal value; VT/IC %: percentage ratio of V´T to IC; IRV: inspiratory reserve volume; IRV, % pred TLC: IRV as a percentage of the predicted value for Total Lung Capacity; PaO2: arterial oxygen tension; PaCO2: arterial carbon dioxide tension; VD: physiological dead space; VD/VT %: V D to tidal volume ratio expressed as a percentage; lactate: arterial lactate concentration;. denotes significant differences between IE and CLE.
Prescription of Exercise Training in Patients with COPD
Current Respiratory Medicine Reviews, 2008, Vol. 4, No. 4
291
ENHANCING EXERCISE TRAINING EFFECTIVENESS The effects of exercise training can be enhanced by combining it with adjunctive therapeutic approaches such as long-acting bronchodilators; supplemental oxygen and noninvasive mechanical ventilation [44-46]. It is well known that bronchodilators may reduce exercise-induced dynamic hyperinflation, dyspnoea sensations and enhance exercise tolerance in flow-limited patients [47, 48]. Therefore, use of bronchodilation therapy may shift the cause of exercise limitation from breathing to leg discomfort, thus allowing patients to sustain higher exercise intensities. Indeed, exercise training combined with bronchodilation therapy results in greater improvement in exercise capacity than exercise training alone [49]. In hypoxemic patients, exercise training with supplemental oxygen leads to improved exercise tolerance and lower dyspnoea sensations [43]. In non-hypoxemic patients, oxygen supplementation allows higher training work rates to be sustained even in the absence of arterial oxygen saturation. This is probably mediated by the effect of oxygen on the exercise-induced ventilatory requirement [50]. Non-invasive mechanical ventilation also reduces dyspnoea sensations and improves exercise tolerance in some patients with COPD [51, 52]. These effects are mediated through reduction in respiratory muscle load. Furthermore, use of proportional assist ventilation enables patients to sustain higher training intensities, thus leading to important physiological training effects [53, 54]. Therefore, the above methods should be considered as an adjunctive therapy in those patients who demonstrate a positive response. Fig. (1). With permission from reference 26. Changes in the cross sectional areas (CSA) of the different fibre types of the vastus lateralis muscle following (A): interval exercise (IE) training and (B): constant-load exercise (CLE) training. * p < 0.05; comparisons are between pre-post training. Data are presented as mean ± SEM.
GUIDELINES TO EXERCISE TRAINING There are important guidelines to follow when implementing a training program. First of all at the beginning of the program the exercise load should be maintained at low levels to avoid muscle soreness and joint pain that are likely to occur following several years of sedentary living. This is also necessary to avoid excessive breathing and leg discomfort symptoms during the actual training session that would discourage the patients’ willingness for participation. Prior to the start of each training session a warm up period (usually 10 to 15 min) at a low intensity has to be implemented to progressively engage the cardiorespiratory system and raise the temperature of the body. More importantly, after the end of the session a cool-down period for 10 to 15 min has to be incorporated to prevent blood from pooling in the large veins of the exercises muscles. Venous pooling can instigate a drop in blood pressure and cause less blood to circulate to the heart and the brain, thereby causing dizziness and irregularities in cardiac rhythm that could trigger dangerous episodes.
ELIGIBILITY AND PATIENT EVALUATION PRIOR TO TRAINING Patients with symptomatic chronic lung disease of varying degrees of severity experiencing functional limitation are eligible to participation to an exercise training program [1, 55]. Patients should be in a clinically stable condition with standard medical therapy for several weeks before initiation of the training regime. Patients should not present any other interfering or unstable medical condition which could significantly interfere with the capacity to exercise. Patients need to be in the care of physician who refers them to the program and is informed of their progress on a regular basis. More importantly, patients should be well motivated to be involved and be responsible for their own health-care and certain that could adhere to the training program. The training program itself should be tailored to the patient’s capabilities and requirements. Accordingly, assessment of the patient’s exercise capacity is necessary in order to identify the factors limiting his/her capacity and also to formulate the exercise prescription. Evaluation of patient’s exercise capacity can be achieved by performing a cardiopulmonary exercise test or a field test. Cardiopulmonary exercise testing provides an objective measure of exercise capacity, identifies the mechanisms limiting exercise tolerance, establishes indices of the patient's prognosis, and monitors
292 Current Respiratory Medicine Reviews, 2008, Vol. 4, No. 4
Ioannis Vogiatzis
Fig. (2). With permission from reference 26. Average values for (A): training intensity sustained during the program sessions expressed as a percentage of peak work rate achieved during an incremental cycle ergometer test prior to rehabilitation, (B) cardiac frequency (fc), (C) dyspnoea and (D) leg discomfort for the interval exercise (IE: open circles) and constant-load exercise (CLE: closed circles) training groups. All parameters are expressed as fractions of the peak values achieved at peak work rate during the baseline incremental test. Data are shown as mean ± SEM.
disease progression and the response to exercise training [56]. Cardiopulmonary exercise testing can be performed either on a treadmill or on a bicycle ergometer and can be either incremental or at constant-load/speed. ECG monitoring allows detection of cardiac arrhythmias, whereas the degrees of hypoxemia, dyspnoea and leg discomfort should be simultaneously recorded. The field tests are simpler to perform without the requirement of the additional equipment and reflect well the patient’s functional capacity. These tests are either self paced such as the 6-min walk test [57], or externally paced, such as the shuttle walk test [58]. During those tests measurement of heart rate, arterial oxygen saturation and symptoms of dyspnea and leg discomfort can be assessed.
limbs on the same station. Free weights may also be used to exercise small muscle groups (i.e.: biceps, triceps etc.).
EXERCISE TRAINING SETTING AND STAFFING
REFERENCES
The majority of rehabilitative exercise training programs are hospital-based operating as outpatient centres. The centre is usually equipped with endurance exercise devices such as treadmills, stationary cycle ergometers, arm and rowing ergometers. Such devices should comprise digital displays to demonstrate the work rate or speed and preferably should provide a print out of the total work accomplished during the training session. For resistance training multi-station equipment allow patients to alternatively exercise upper and lower
[1]
The exercise room should be designed to have provision of oxygen to patients. In addition, facilities to resuscitate patients in danger should be available. To monitor cardiac function and arterial oxygen saturation ECG monitors comprising pulse oximetry are necessary. A medical doctor is the director of pulmonary rehabilitation. Ideally, exercise training programs can be designed by exercise physiologists. Physical therapist and rehabilitation specialists may implement and adjust the training workload. Physiotherapists are also important to teach and ensure the implementation of breathing techniques during exercise.
[2] [3]
[4]
Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390-413. O´Donnel DE, Revill SM, Webb KA. Dynamic hyperinflation and exercise intolerance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 164: 770-7. Calverley PMA, Koulouris NG. Flow limitation and dynamic hyperinflation: key concepts in modern respiratory physiology. Eur Respir J 2004; 25: 186-99. Aliverti A, Maklem PT. How and why exercise is impaired in COPD. Respiration 2001; 68: 229-39.
Prescription of Exercise Training in Patients with COPD [5] [6]
[7] [8]
[9] [10]
[11]
[12]
[13] [14]
[15]
[16]
[17] [18]
[19]
[20]
[21]
[22]
[23] [24]
[25]
[26]
Macklem PT. Exercise in COPD: damned if you do and damned if you don’t. Thorax 2005; 60: 887-8. Simon M, Le Blanc P, Jobin J, Desmeules M, Sullivan MJ, Maltais F. Limitation of lower limb oxygen uptake during cycling exercise in COPD patients. J Appl Physiol 2001; 90(3): 1013-9. Montes de Oca M, Rassulo J, Celli BR. Respiratory muscle and cardiopulmonary function during exercise in very severe COPD. Am J Respir Crit Care Med 1996; 154: 1284-9. A statement of the American Thoracic Society and European Respiratory Society. Skeletal muscle dysfunction in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: S1-S40. Rabinovich RA, Bastos R, Ardite E, et al. Mitochondrial dysfunction in COPD patients with low body mass index. Eur Respir J 2006; 29(4): 643-50. Whittom F, Jobin J, Simard PM, et al. Histochemical and morphological characteristics of the vastus lateralis muscle in COPD patients. Med Sci Sports Exerc 1998; 30: 1467-74 Maltais F, Simard AA, Sinard C, Jobin J, Desgagnes P, Le Blanc P. Oxidative capacity of the skeletal muscle and lactic acid kinetics during exercise in normal subjects and in patients with COPD. Am J Respir Crit Care Med 1996; 153: 288-93. Gosker HR, Mameren H, Dijk PJ, van der Vussue GJ, Wouters EF, Schols AM. Skeletal muscle fiber-type shifting and metabolic profile in patients with chronic obstructive pulmonary disease. Eur Respir J 2002; 19: 617-25. Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2005; 172: 19-38. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest 2007; 131 (5 Suppl): 4S-42S. American College of Sports Medicine. Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998; 30: 975-91. Green RH, Singh SJ, Williams J, Morgan MD. A randomised controlled trial of four weeks versus seven weeks of pulmonary rehabilitation in chronic obstructive pulmonary disease. Thorax 2001; 56: 143-5. Lake FR, Henderson K, Briffa T, Openshaw J, Musk AW. Upperlimb and lower-limb exercise training in patients with chronic airflow obstruction. Chest 1990; 97: 1077-82. Bendstrup KE, Ingemann JJ, Holm S, Bengtsson B. Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease. Eur Respir J 1997; 10: 2801-6. Casaburi R, Porszasz J, Burns MR, Carithers ER, Chang RS, Cooper CB. Physiologic benefits of exercise training in rehabilitation of patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155: 1541-51. Maltais F, LeBlanc P, Jobin J. Intensity of training and physiological adaptation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155: 555-61. Vogiatzis I, Williamson AF, Miles J, Taylor I. Physiological response to moderate exercise workloads in a pulmonary rehabilitation program in patients with varying degrees of airflow obstruction. Chest 1999; 116 (5): 1200-7. Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF, Wasserman K. Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis 1991; 143: 9-18. Punzal PA, Ries AL, Kaplan RW, Prewitt LM. Maximum intensity exercise training in patients with chronic obstructive pulmonary disease. Chest 1991; 100: 618-23. Vogiatzis I, Nanas S, Roussos C. Interval training as an alternative modality to continuous exercise in patients with COPD. Eur Respir J 2002; 20: 12-9. Vogiatzis I, Nanas S, Kastanakis E, Georgiadou O, Papazahou O, Roussos C. Dynamic hyperinflation and tolerance to interval exercise in patients with advanced COPD. Eur Respir J 2004; 24: 35863. Vogiatzis I, Terzis G, Nanas S, et al. Skeletal muscle adaptations to interval training in patients with advanced COPD. Chest 2005; 128: 3838-45.
Current Respiratory Medicine Reviews, 2008, Vol. 4, No. 4 [27]
[28]
[29]
[30] [31]
[32]
[33] [34]
[35] [36]
[37] [38]
[39] [40]
[41] [42]
[43] [44]
[45] [46]
[47]
[48] [49]
293
Horowitz MB, Littenberg B, Mahler DA. Dyspnea ratings for prescribing exercise intensity in patients with COPD. Chest 1996; 109: 1169-75. Porszasz J, Emtner M, Goto S, Somfray A, Whipp BJ, Casaburi R. Exercise training decreases ventilatory requirements and exerciseinduced hyperinflation at submaximal intensities in patients with COPD. Chest 2005; 128: 2025-34. Puente-Maestu L, Martinez Abad Y, Pedraza F, Sanchez G, Stringer WW. A controlled trial of the effects of leg training on breathing pattern and dynamic hyperinflation in severe COPD. Lung 2006; 184: 159-67. Georgiadou O, Vogiatzis I, Stratakos G, et al. Effects of pulmonary rehabilitation on operational chest wall volumes during exercise in COPD patients. Eur Resp J 2007; 29(2): 284-91. Puente-Maestu L, Sanz ML, Sanz P, Ruiz de Ona JM, RodriguezHermosa JL, Whipp BJ. Effects of two types of training on pulmonary and cardiac responses to moderate exercise in patients with COPD. Eur Resp J 2000; 15(6): 1026-32. Maltais F, LeBlanc P, Simard C, et al. Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 154: 442-7. Sala E, Roca J, Marrades RM, et al. Effects of endurance training on skeletal muscle bioenergetics in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 1726-34. Bernard S, Whittom F, LeBlanc P, et al. Aerobic and strength training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 896-901. Spruit MA, Gosselink R, Troosters T, De Paepe C, Decramer M. Resistance versus endurance training in patients with COPD and skeletal muscle weakness. Eur Respir J 2002; 19: 1072-8. Ortega F, Toral J, Cejudo P, et al. Comparison of effects of strength and endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2002; 166: 669-74. Simpson K, Killian K, McCartney N, Stubbing DG, Jones NL. Randomised controlled trial of weightlifting exercise in patients with chronic airflow limitation. Thorax 1992; 47: 70-7. Bernard S, Whittom F, LeBlanc P, et al. Aerobic and strength training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 896-900. Sabapathy S, Kingsley RA, Schneider DA. Continuous and intermittent exercise responses in individuals with chronic obstructive pulmonary disease. Thorax 2004; 57: 1026-31. Astrand PO, Rodahl K. Physical Training. In: Astrand PO, Rodahl K, Eds. Textbook of Work Physiology. New York, NY, McGrawHill, 1986; 412-76. Gosselink R, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med 1996; 153: 976-80. Coppolse R, Schols AM, Baarends EM, et al. Interval versus continuous training in patients with severe COPD: a randomized clinical trial. Eur Resp J 1999; 14: 258-63. O'Donnell DE, D'Arsigny C, Webb KA. Effects of hyperoxia on ventilatory limitation in advanced COPD. Am J Resp Crit Care Med 2001; 163: 892-8. Ambrosino N, Strambi S. New strategies to improve exercise tolerance in chronic obstructive pulmonary disease. Eur Respir J 2004; 24: 313-63. Spruit MA, Wouters EFM. New modalities of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Sports Med 2007; 37(6): 501-16. Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Resp Crit Care Med 2005; 172: 19-38. O'Donnell DE, Lam M, Webb KA. Measurement of symptoms, lung hyperinflation, and endurance during exercise in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158: 1557-65. O'Donnell DE, Voduc N, Fitzpatrick M, Webb KA. Effect of salmeterol on the ventilatory response to exercise in COPD. Eur Respir J 2004; 24: 86-94. Casaburi R, Kukafka D, Cooper CB, Witek TJ, Kesten S. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Chest 2005; 127: 809-17.
294 Current Respiratory Medicine Reviews, 2008, Vol. 4, No. 4 [50]
[51] [52]
[53]
Ioannis Vogiatzis
Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic COPD patients. Am J Respir Crit Care Med 2003; 168: 1034-42. O'Donnell DE, Sanii R, Younes M. Improvement in exercise endurance in patients with chronic airflow limitation using continuous positive airway pressure. Am Rev Respir Dis 1988; 138: 1510-4. O'Donnell DE, Sanii R, Giesbrecht G, Younes M. Effect of continuous positive airway pressure on respiratory sensation in patients with chronic obstructive pulmonary disease during submaximal exercise. Am Rev Respir Dis 1988; 138: 1185-91. Hawkins P, Johnson LC, Nikoletou D, et al. Proportional assist ventilation as an aid to exercise training in severe chronic obstructive pulmonary disease. Thorax 2002; 57: 853-9.
Received: June 30, 2007
[54]
[55] [56]
[57] [58]
Bianchi L, Foglio K, Porta R, Baiardi R, Vitacca M, Ambrosino N. Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients. Respir Med 2002; 96: 359-67. Ries A. What pulmonary rehabilitation can do for your patients? J Respir Dis 1995; 16 (8): R16-R24. Palange P, Ward SA, Carlsen K-H, et al. J Recommendations on the use of exercise testing in clinical practice. Eur Respir J 2007; 29:185-209. American Thoracic Society Statement. Guidelines for the sixminute walk test. Am J Resp Crit Care Med 2002; 166: 111-7. Singh SJ, Morgan MD, Scott S, Walters D, Hardman AE. Development of a shuttles waking test of disability in patients with chronic obstructive pulmonary disease. Thorax 1992; 47: 1019-24.
Revised: August 7, 2007
Accepted: August 7, 2007
