The aim of this article was to provide practical recommendations to healthcare professionals interested in offering a pulmonary rehabilitation programme for patients with chronic obstructive ...pulmonary disease (COPD). The latest research findings were brought together and translated into clinical practice. These recommendations focus on the description of useful assessment tests and of the most common exercise modalities for patients with COPD. We provide specific details on the rationale of why and especially how to implement exercise training in patients with COPD, including the prescription of training mode, intensity and duration, as well as suggestions of guidelines for training progression.
Field walking tests are commonly employed to evaluate exercise capacity, assess prognosis and evaluate treatment response in chronic respiratory diseases. In recent years, there has been a wealth of ...new literature pertinent to the conduct of the 6-min walk test (6MWT), and a growing evidence base describing the incremental and endurance shuttle walk tests (ISWT and ESWT, respectively). The aim of this document is to describe the standard operating procedures for the 6MWT, ISWT and ESWT, which can be consistently employed by clinicians and researchers. The Technical Standard was developed by a multidisciplinary and international group of clinicians and researchers with expertise in the application of field walking tests. The procedures are underpinned by a concurrent systematic review of literature relevant to measurement properties and test conduct in adults with chronic respiratory disease. Current data confirm that the 6MWT, ISWT and ESWT are valid, reliable and responsive to change with some interventions. However, results are sensitive to small changes in methodology. It is important that two tests are conducted for the 6MWT and ISWT. This Technical Standard for field walking tests reflects current evidence regarding procedures that should be used to achieve robust results.
Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized ...worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients.
The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide.
Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS.
This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR.
The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.
This systematic review examined the measurement properties of the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT) in adults with chronic ...respiratory disease. Studies that report the evaluation or use of the 6MWT, ISWT or ESWT were included. We searched electronic databases for studies published between January 2000 and September 2013. The 6-min walking distance (6MWD) is a reliable measure (intra-class correlation coefficients ranged from 0.82 to 0.99 in seven studies). There is a learning effect, with greater distance walked on the second test (pooled mean improvement of 26 m in 13 studies). Reliability was similar for ISWT and ESWT, with a learning effect also evident for ISWT (pooled mean improvement of 20 m in six studies). The 6MWD correlates more strongly with peak work capacity (r=0.59-0.93) and physical activity (r=0.40-0.85) than with respiratory function (r=0.10-0.59). Methodological factors affecting 6MWD include track length, encouragement, supplemental oxygen and walking aids. Supplemental oxygen also affects ISWT and ESWT performance. Responsiveness was moderate to high for all tests, with greater responsiveness to interventions that included exercise training. The findings of this review demonstrate that the 6MWT, ISWT and ESWT are robust tests of functional exercise capacity in adults with chronic respiratory disease.
The short form of the International Physical Activity Questionnaire (IPAQ) is widely used to assess PA and has already been used in adults with asthma; however, its validity has not been yet studied ...in this population. Therefore, the aim of this study was to verify the convergent and discriminative validity of the IPAQ short form in adults with asthma.
Fifty-three adults with asthma (36 females; 48±15 years; 29±6 kg/m²) wore the triaxial activity monitor Actigraph for eight days to objectively measure steps/day, time in light physical activity (PA), moderate-to-vigorous PA (MVPA), and sedentary behaviour. Participants filled out the IPAQ matching with the same week they wore the Actigraph, with measures of: time of MVPA and total PA/week; categorization of low, moderate or high PA level; time in seated position.
IPAQ self-reported total time of PA/week was weakly correlated with steps/day. The IPAQ categorization correlated moderately with time in light, MVPA and steps/day. Self-reported time in seated position on weekdays was moderately correlated with objective percentage/day of time in sedentary behaviour in the same period. IPAQ categorization in PA levels was able to differentiate between low to moderate and low to high PA levels.
These results cannot confidently infer the convergent validity of the IPAQ to quantify number of steps/day and time spent in PA of adults with asthma. However, this instrument may be useful to categorize patients into three levels of PA.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory ...Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.
The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.
A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.
An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.
The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.
This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force ...of experts representing the ERS Scientific Group 01.02 "Rehabilitation and Chronic Care" determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5-8 years).
Exacerbations of chronic obstructive pulmonary disease (COPD) acutely reduce skeletal muscle strength and result in long-term loss of functional capacity.
To investigate whether resistance training ...is feasible and safe and can prevent deteriorating muscle function during exacerbations of COPD.
Forty patients (FEV(1) 49 +/- 17% predicted) hospitalized with a severe COPD exacerbation were randomized to receive usual care or an additional resistance training program during the hospital admission. Patients were followed up for 1 month after discharge. Primary outcomes were quadriceps force and systemic inflammation. A muscle biopsy was taken in a subgroup of patients to assess anabolic and catabolic pathways.
Resistance training did not yield higher systemic inflammation as indicated by C-reactive protein levels and could be completed uneventfully. Enhanced quadriceps force was seen at discharge (+9.7 +/- 16% in the training group; -1 +/- 13% in control subjects; P = 0.05) and at 1 month follow-up in the patients who trained. The 6-minute walking distance improved after discharge only in the group who received resistance training (median 34; interquartile range, 14-61 m; P = 0.002). In a subgroup of patients a muscle biopsy showed a more anabolic status of skeletal muscle in patients who followed training. Myostatin was lower (P = 0.03) and the myogenin/MyoD ratio tended to be higher (P = 0.08) in the training group compared with control subjects.
Resistance training is safe, successfully counteracts skeletal muscle dysfunction during acute exacerbations of COPD, and may up-regulate the anabolic milieu in the skeletal muscle. Clinical trial registered with www.clinicaltrials.gov (NCT00877084).
INTRODUCTIONWe aimed to compare acute mechanical and metabolic responses of the diaphragm and rib cage inspiratory muscles during two different types of respiratory loading in patients with chronic ...obstructive pulmonary disease.
METHODSIn 16 patients (age, 65 ± 13 yr; 56% male; forced expiratory volume in the first second, 60 ± 6%pred; maximum inspiratory pressure, 82 ± 5%pred), assessments of respiratory muscle EMG, esophageal pressure (Pes) and gastric pressures, breathing pattern, and noninvasive assessments of systemic (V˙O2, cardiac output, oxygen delivery and extraction) and respiratory muscle hemodynamic and oxygenation responses (blood flow index, oxygen delivery index, deoxyhemoglobin concentration, and tissues oxygen saturation StiO2), were performed during hyperpnea and loaded breathing.
RESULTSDuring hyperpnea, breathing frequency, minute ventilation, esophageal and diaphragm pressure–time product per minute, cardiac output, and V˙O2 were higher than during loaded breathing (P < 0.05). Average inspiratory Pes and transdiaphragmatic pressure per breath, scalene (SCA), sternocleidomastoid, and intercostal muscle activation were higher during loading breathing compared with hyperpnea (P < 0.05). Higher transdiaphragmatic pressure during loaded breathing compared with hyperpnea was mostly due to higher inspiratory Pes (P < 0.05). Diaphragm activation, inspiratory and expiratory gastric pressures, and rectus abdominis muscle activation did not differ between the two conditions (P > 0.05). SCA–blood flow index and oxygen delivery index were lower, and SCA–deoxyhemoglobin concentration was higher during loaded breathing compared with hyperpnea. Furthermore, SCA and intercostal muscle StiO2 were lower during loaded breathing compared with hyperpnea (P < 0.05).
CONCLUSIONGreater inspiratory muscle effort during loaded breathing evoked larger rib cage and neck muscle activation compared with hyperpnea. In addition, lower SCA and intercostal muscle StiO2 during loaded breathing compared with hyperpnea indicates a mismatch between inspiratory muscle oxygen delivery and utilization induced by the former condition.
Quantification of physical activities in daily life in patients with chronic obstructive pulmonary disease has increasing clinical interest. However, detailed comparison with healthy subjects is not ...available. Furthermore, it is unknown whether time spent actively during daily life is related to lung function, muscle force, or maximal and functional exercise capacity. We assessed physical activities and movement intensity with the DynaPort activity monitor in 50 patients (age 64 +/- 7 years; FEV1 43 +/- 18% predicted) and 25 healthy elderly individuals (age 66 +/- 5 years). Patients showed lower walking time (44 +/- 26 vs. 81 +/- 26 minutes/day), standing time (191 +/- 99 vs. 295 +/- 109 minutes/day), and movement intensity during walking (1.8 +/- 0.3 vs. 2.4 +/- 0.5 m/second2; p < 0.0001 for all), as well as higher sitting time (374 +/- 139 vs. 306 +/- 108 minutes/day; p = 0.04) and lying time (87 +/- 97 vs. 29 +/- 33 minutes/day; p = 0.004). Walking time was highly correlated with the 6-minute walking test (r = 0.76, p < 0.0001) and more modestly to maximal exercise capacity, lung function, and muscle force (0.28 < r < 0.64, p < 0.05). Patients with chronic obstructive pulmonary disease are markedly inactive in daily life. Functional exercise capacity is the strongest correlate of physical activities in daily life.
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