Exercise training during rehabilitation of patients with COPD: A current perspective

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Abstract

Patients with chronic obstructive pulmonary disease (COPD) suffer frequently from physiologic and psychological impairments, such as dyspnea, peripheral muscle weakness, exercise intolerance, decreased health-related quality of life (HRQOL) and emotional distress. Rehabilitation programmes have shown to result in significant changes in perceived dyspnea and fatigue, utilisation of healthcare resources, exercise performance and HRQOL. Exercise training, which consists of whole-body exercise training and local resistance training, is the cornerstone of these programmes. Regrettably, the positive effects of respiratory rehabilitation deteriorate over time, especially after short programmes. Hence, attention should be given to the aftercare of these patients to prevent them to revert again to a sedentary lifestyle. On empirical basis three possibilities seem to be clinically feasible: (1) continuous outpatient exercise training; (2) exercise training in a home-based or community-based setting; or (3) exercise training sessions in a group of asthma and COPD patients.

Introduction

Dyspnea, impaired exercise tolerance and reduced health-related quality of life (HRQOL) are everyday complaints of patients with chronic obstructive pulmonary disease (COPD). Various pieces of evidence point to the fact that these complaints are not simply repercussions of detrimental pulmonary function. In fact, lung function impairment shows only a weak relation to impaired exercise tolerance [1]. Other factors, such as peripheral muscle weakness, de-conditioning, and impaired gas exchange in the lung and peripheral muscles are now recognised as important determinants of exercise intolerance [2], [3]. Besides physiological impairments, several studies have found a higher prevalence of emotional distress in COPD patients, such as anxiety and depression [4], [5], [6], [7]. Especially, dyspnea and life threatening exacerbations provoke anxiety in COPD patients. Fear for shortness of breath often results in avoidance of physical activity and, therefore, enhances exercise intolerance and social isolation of COPD patients [4], [8], [9]. The experienced deprivation of exercise and significant decrease in meaningful social activities are, in turn, closely related to depression [4]. Furthermore, a decline in memory and fluid intelligence, which were primarily caused by hypoxemia, hypercapnia and depressive symptoms [10], [11], [12] were documented in COPD patients [13], [14].

Respiratory and peripheral muscle weakness is related to clinically important conditions such as hypercapnia [15], nocturnal oxygen de-saturation [16], dyspnea [3], [17], [18] and mortality, as well as utilisation of healthcare resources [19]. Exercise capacity, measured with the 6 min walking distance (6 MWD), was positively associated with COPD patients’ cognitive functioning [20]. These are important observations since whole-body exercise training and local muscle training are able to improve physical performance, enhance HRQOL, decrease symptoms of dyspnea and fatigue, and possibly prolong survival in these patients [21].

The following current perspective discusses the clinical benefits of respiratory rehabilitation. The contribution of exercise training to these clinical benefits will be outlined in more detail. Special attention will be given to follow-up programmes to maintain the outcomes of rehabilitation on a long-term basis.

Section snippets

Clinical benefits of exercise training in respiratory rehabilitation

Randomised controlled trials on the efficacy of respiratory rehabilitation reported significant improvements in maximal exercise capacity, walking distance and endurance capacity after respiratory rehabilitation [22], [23], [24], [25], [26], [27], [28], [29]. Bicycle ergometry training at workloads of at least 60% of maximal workload, showed improvements in maximal workload (∼30%) and endurance time (∼70%) [22], [25], [30], [31]. Similar improvements were observed in training programmes that

Respiratory rehabilitation programmes

Respiratory rehabilitation programmes are offered to patients, who even after optimal medical treatment, continue to have symptoms of dyspnea and fatigue. Nowadays, respiratory rehabilitation programmes are comprehensive and mostly consist of whole-body exercise training, local resistance training, patient education, breathing exercises, occupational therapy, psychosocial interventions and nutritional support. Ries et al. [27] showed that a rehabilitation programme, consisting of exercise

Long-term benefits and follow-up on respiratory rehabilitation

Reports on long-term benefits are rare. Improvements in functional exercise capacity, HRQOL, anxiety and depression scores after a 6–8-week outpatient respiratory rehabilitation programme decreased to a large extent at the 12-month follow-up [24], [27], [66]. Especially patients with poor initial functional exercise capacity had the greatest declines at follow-up [66]. Improvements in HRQOL and general well-being, but not in exercise capacity were reported 15 months after a 3-month home-care

Conclusions

Respiratory rehabilitation results in a reduction of symptoms of dyspnea, fatigue, and anxiety, a decreased utilisation of healthcare resources, increased exercise performance and health-related quality of life in COPD patients. Exercise training is an essential component of such rehabilitation programmes. Careful exercise prescription and close supervision of patients during exercise training are important to elicit training effects. Endurance training, interval training and resistance

Acknowledgements

Supported by Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Belgium (FWO), Grants #G.0237.01 and #G.0175.99, and FWO ‘Levenslijn’ Grant #7.0007.00. T. Troosters is a post-doctoral fellow of FWO—Vlaanderen.

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