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Informal caregivers play an important role in chronic disease management but their experience is often neglected. The objective of this study was to explore the content validity of the Zarit Burden Interview (ZBI) in caregivers of individuals with COPD in Canada and Portugal. Cognitive debriefing interviews were conducted with informal caregivers of individuals with moderate to very severe COPD. Participants completed the ZBI and verbalised their thinking process to assess the adequacy of the questionnaire's content and instructions. Content validity was assessed using deductive content analysis of interviews and descriptive statistics of questionnaire responses. Nine caregivers from Canada (age = 67 ± 8 years) and 13 from Portugal (age = 69 ± 7 years) participated. For Canadian caregivers, 3/22 items were not understood, and 8/22 items were not relevant to at least 1/3 of them. For Portuguese caregivers, 1/22 items were not understood, and 20/22 items were not relevant to at least 1/3 of them. The distribution of response choices was approximately symmetrical for 17/22 items in the Canadian sample. The response option "no/never" was selected by at least 75% of Portuguese participants for 18/22 items. The instrument was well understood by caregivers of people with COPD, but its relevance is uncertain. Informal caregivers provide essential care for people living with disability and chronic disease, but their experience is often neglected. The Zarit Burden Interview assesses caregiver burden but has not been validated in caregivers of people with chronic obstructive pulmonary disease. In its current form, the Zarit Burden Interview does not adequately represent the experience of COPD caregivers. We recommend selecting tools that assess caregiver burden that have been validated in the caregiver population of interest. [ABSTRACT FROM AUTHOR]

Background: Pulmonary rehabilitation (PR) has major benefits for patients with chronic obstructive pulmonary disease (COPD). An enhanced PR program was developed with a self-management education intervention. The objective of our study was to evaluate the implementation of the enhanced PR program into a single centre. Methods: Pre-post implementation study consisted of two evaluation periods: immediately after implementation and 18 months later. Guided by the RE-AIM framework, outcomes included: Reach, Effectiveness, Adoption, Implementation and Maintenance. Results: Reach: 70-75% of referred patients agreed to a PR program (n = 26). Effectiveness: Clinically important improvements occurred in some patients in functional exercise capacity (64% of the patients achieved clinical important difference in 6-min walk test in the first evaluation period and 44% in the second evaluation period), knowledge, functional status, and self-efficacy in both evaluation periods. Adoption: All healthcare professionals (HCPs) involved in PR (n = 8) participated. Implementation: Fidelity for the group education sessions ranged from 76 to 95% (first evaluation) and from 82 to 88% (second evaluation). Maintenance: The program was sustained over 18 months with minor changes. Patients and HCPs were highly satisfied with the program. Conclusions: The enhanced PR program was accepted by patients and HCPs and was implemented and maintained at a single expert center with good implementation fidelity. [ABSTRACT FROM AUTHOR]

This article examined the conceptual and statistical distinction between perceived competence and self-efficacy. Although they are frequently used interchangeably, it is possible that distinguishing them might assist researchers in better understanding their roles in developing enduring adaptive behavior patterns. Perceived competence is conceived in the theoretical framework of self-determination theory and self-efficacy is conceived in the theoretical framework of social-cognitive theory. Purpose: The purpose of this study was to empirically distinguish perceived competence from self-efficacy for exercise. Method: Two studies evaluated the independence of perceived competence and self-efficacy in the context of exercise. Using 2 extant instruments with validity and reliability evidence in exercise contexts, the distinctiveness of the 2 constructs was assessed in 2 separate samples (n = 357 middle-aged sedentary adults; n = 247 undergraduate students). Results: Confirmatory factor analysis supported the conceptual and empirical distinction of the 2 constructs. Conclusions: This study supports the conceptual and statistical distinction of perceived competence from perceived self-efficacy. Applications of these results provide a rationale for more precise future theorizing regarding their respective roles in supporting initiation and maintenance of health behaviors.

Depression and anxiety are related to physical activity among people with chronic obstructive pulmonary disease (COPD), although the strength and direction of the reported relationships are inconsistent. This study systematically synthesized the relationships between physical activity and i) depression and ii) anxiety in people with COPD. Physical activity measurement type (objective, self-report) was examined as a moderator of these relationships. A systematic search of physical activity and COPD was conducted from inception to February 2022 across 8 databases. Studies were included if they provided correlation coefficients for the relationship between measures of physical activity and depression or anxiety in people with COPD and were published in English. Two reviewers independently screened, reviewed and extracted data, with discrepancies resolved by a third reviewer. Across 13 studies, a small relationship was found between physical activity and depression, weighted r = −0.15, 95%CI [-0.21, −0.10], which was not moderated by physical activity measurement type. Across 8 studies, a negligible relationship was found between physical activity and anxiety, weighted r = −0.03, 95%CI [-0.11, 0.04], although this was moderated by physical activity measurement type, such that self-reported physical activity had a small negative relationship with anxiety (weighted r = −0.09, 95% CI [-0.15, −0.03]) and objectively measured physical activity had a small positive relationship (weighted r = 0.07, 95% CI [-0.13, 0.26]). In COPD, the bivariate association between physical activity and anxiety and depression are small. [ABSTRACT FROM AUTHOR]

Rationale Ventilator Assisted Individuals (VAIs) frequently remain in intensive care units (ICUs) for a prolonged period once clinically stable due to a lack of transition options. These VAIs occupy ICU beds and resources that patients with more acute needs could better utilize. Moreover, VAIs experience improved outcomes and quality of life in long-term and community-based environments. Objective To better understand the perspectives of healthcare providers (HCPs) working in an Ontario ICU regarding barriers and facilitators to referral and transition of VAIs from the ICU to a long-term setting. Methods We conducted semi-structured interviews with ten healthcare providers involved in VAI transitions. Main Results Perceived barriers included long wait times for long-term care settings, insufficient bed availability at discharge locations, medical complexity of patients, long waitlists, and a lack of transparency of waitlists. Facilitators included strong partnerships and trusting relationships between referring and discharge locations, a centralized referral system, and utilization of community partnerships across care sectors. Conclusions Insufficient resourcing of long-term care is a key barrier to transitioning VAIs from ICU to long-term settings; strong partnerships across care sectors are a facilitator. System-level approaches, such as a single-streamlined referral system, are needed to address key barriers to timely transition. [ABSTRACT FROM AUTHOR]

Techniques to increase physical activity among pulmonary rehabilitation patients outside of the rehabilitation context are warranted. Implementation intentions are a strategy used to initiate goal-directed behaviour, and have been found to be useful in other populations. This study compared the long-term effects of exercise and social implementation intentions interventions on objectively measured physical activity in 40 pulmonary rehabilitation patients randomly assigned to condition. Repeated measures ANOVAs found that those in the exercise implementation intentions group took more steps (p =.007) at the end of pulmonary rehabilitation than those in the social implementation intentions group. Improvements attained by the exercise group during the intervention were not maintained 6-months following rehabilitation. Implementation intentions targeting physical activity appear to have positive short term effects on physical activity, although the long term effects are less consistent. This may be due in part to methods used to assess physical activity behaviour. Keywords Pulmonary rehabilitation * Physical activity * Implementation intention * Intervention * Experimental * Longitudinal, Introduction Respiratory diseases are the fourth leading cause of death in Canada, behind cardiovascular disease, cancer, and stroke (Life and breath: Respiratory Disease in Canada, 2007). With an aging population, [...]

Reducing sedentary behavior (SB) in individuals with chronic obstructive pulmonary disease (COPD) is being increasingly recognized as a novel health target. Understanding healthcare professionals (HCPs) behavior that influences a reduction in SB in this population could facilitate achieving this target. To explore the determinants of behavior related to HCPs targeting a reduction in SB in people with COPD. We used a qualitative semi-structured interview approach informed by the Theoretical Domains Framework (TDF). Sixteen HCPs were interviewed. Interview transcripts were mapped against the relevant TDF domain(s) and then higher order themes were generated. Directed content analysis resulted in mapping 949 quotes to the TDF domains with environmental context and resources being the most coded domain. Three higher order themes were identified: 1) HCPs need more knowledge on reducing SB; 2) Strategies suggested to include in pulmonary rehabilitation (PR) to reduce SB; and 3) Barriers to adding SB to PR. Domains of environmental context and resources, knowledge, social/professional role and identity, reinforcement, social influences, skills and beliefs about capabilities were relevant to the study population to reduce SB in people with COPD. Knowledge of SB varied across participants. This study provided information on potential behavioral targets for future interventions that involve HCPs and aim to reduce SB among people with COPD. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to elicit patients' views of research priorities related to pulmonary rehabilitation (PR). Method:We used a modified nominal group technique in which participants with chronic lung conditions who had completed PR attended one of five meetings during which they generated ideas, discussed them with the group, and prioritized their top three topics. Afterward, they completed member checking and satisfaction questionnaires. Results:Fourteen participants (mean age 71 years) prioritized 25 topics, which included music as a motivator, education about the reason for various assessments and exercises, and ongoing patient assessment and follow-up. Most participants "totally agreed" that the summarized topics matched what they thought was important in PR research (75%) and that the meeting was a positive experience (100%). Participants indicated that the findings of this study accurately reflected their priorities. Conclusions:Individuals who have completed PR may have questions about programme components including assessment, treatment, and strategies for promoting motivation. To inform future research projects and identify knowledge translation needs, we will distribute a questionnaire to a larger sample of former PR patients to further prioritize the 25 topics identified in the meetings. Objectif : connaître les points de vue des patients sur les priorités de la recherche en réadaptation pulmonaire (RP). Méthodologie : les chercheurs ont utilisé une technique de groupe nominale modifiée selon laquelle les participants atteints d'une pneumopathie chronique qui ont effectué une RP ont assisté à l'une des cinq rencontres pour générer des idées, en parler en groupe et prioriser leurs trois thèmes principaux. Ils ont ensuite rempli les questionnaires de vérification et de satisfaction des membres. Résultats : quatorze participants (d'un âge moyen de 71 ans) ont priorisé 25 thèmes, qui incluaient la musique comme élément motivateur, l'éducation sur la raison des diverses évaluations et des divers exercices ainsi que l'évaluation et le suivi continus des patients. La plupart des participants étaient « totalement d'accord » avec le fait que les thèmes résumés correspondaient à ce qu'ils considéraient comme important en recherche sur la RP (75 %) et que la rencontre était une expérience positive (100 %). Les participants ont indiqué que les résultats de cette étude étaient un reflet exact de leurs priorités. Conclusions : les personnes qui ont effectué la RP peuvent avoir des questions sur les éléments du programme, y compris l'évaluation, le traitement et les stratégies pour promouvoir la motivation. Afin d'éclairer les projets de recherche et de déterminer les besoins en application des connaissances, les chercheurs distribueront un questionnaire à un plus grand échantillon d'anciens patients en RP afin de mieux prioriser les 25 thèmes établis pendant les rencontres. [ABSTRACT FROM AUTHOR]

Rationale: Pulmonary rehabilitation (PR) is the most effective strategy to improve health outcomes in people with chronic obstructive pulmonary disease (COPD), although it has had limited success in promoting sustained physical activity. PR with a strong focus on disease self-management may better facilitate long-term behavior change. Objectives: To compare a newly developed enhanced PR (EPR) program with a traditional PR program on outcome achievement. Methods: In this randomized parallel-group controlled trial, PR classes were block-randomized to EPR or traditional PR and were delivered over 16 sessions each. The EPR program incorporated new and updated "Living Well with COPD" education modules, which had a stronger focus on chronic disease self-management. Fidelity of the intervention for content and delivery was assessed. Physical activity, self-efficacy, exercise tolerance, and health-related quality of life (HRQoL) were collected before, after, and 6 months after PR. Healthcare visits were collected 2 years before PR and 1 year after. Mortality was recorded 1 year after PR. Results: Of the 207 patients with COPD enrolled, 108 received EPR and 99 received traditional PR. Physical activity (steps) and self-efficacy improved from before to after PR in both programs, with no differences between groups. These effects were not sustained at 6 months. Exercise tolerance and HRQoL improved from before to after PR with no between-group differences and were maintained at 6 months. Visits to primary care providers and respiratory specialists decreased in the EPR program relative to the traditional PR program. EPR was delivered as intended, and there was no meaningful cross-contamination between the two programs. Conclusions: Enhancing PR to have a greater emphasis on chronic disease self-management did not result in a superior improvement of physical activity and health outcomes compared with traditional PR except for reduced resource usage from primary and specialist physician visits in the EPR program.Clinical trial registered with ClinicalTrials.gov (NCT02917915). [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to (i) investigate directional influences of self-efficacy, outcome satisfaction, and attendance during an exercise programme and (ii) examine the predictive capabilities of self-efficacy and outcome satisfaction on participant dropout.Methods: Adults aged 35-65 years were recruited to a 12-month exercise programme. Self-efficacy was collected at baseline, three, six, nine, and 12 months, and outcome satisfaction at the same time-points except baseline. Cross-lagged panel analyses and logistic regression analyses were conducted to examine the primary and secondary objectives, respectively.Results: Coping and scheduling self-efficacy had stronger reciprocal relationships with outcome satisfaction than task self-efficacy, although the strength of these relationships varied across time. Initially, task self-efficacy predicted programme attendance. Midway through the programme, outcome satisfaction predicted attendance, and by the end of the programme, coping self-efficacy was the strongest predictor of attendance. Self-efficacy and outcome satisfaction did not predict programme dropout.Conclusions: The results support the reciprocal relationship between outcome satisfaction and scheduling and coping self-efficacy and highlight the importance of sequentially targeting different beliefs and skills to facilitate successful initiation and maintenance of exercise behaviour. Statement of contribution What is already known on this subject? Self-efficacy and outcome satisfaction are related to exercise behaviour. The relationship between self-efficacy and outcome satisfaction are typically considered unidirectional. The longitudinal relationships among self-efficacy, outcome satisfaction, and physical activity participation are unclear. What does this study add? Outcome satisfaction had reciprocal relationships with both coping and scheduling self-efficacy for exercise. The importance of self-efficacy and outcome satisfaction to exercise attendance changes over time. Task self-efficacy was the strongest predictor of initial programme attendance. Midway through the programme, outcome satisfaction and task self-efficacy were the strongest predictors of attendance, and by the end of the programme, coping self-efficacy was the strongest predictor. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the strength of the relationships between self-efficacy and (i) functional exercise capacity and (ii) physical activity in chronic obstructive pulmonary disease (COPD), and whether self-efficacy assessment type (i.e., COPD symptoms, exercise-task, exercise-barrier, general, falls) and physical activity assessment type (i.e., self-report vs. objective) are moderators. A systematic search of COPD and self-efficacy concepts was conducted using eight databases from inception to 23 January 2019. Studies were included if they provided correlation coefficients of the relationship between self-efficacy and functional exercise capacity or physical activity, were conducted in adults diagnosed with COPD, and were published in English-language journals. A total of 14 correlation coefficients were included in the self-efficacy and functional exercise capacity meta-analysis, and 16 in the self-efficacy and physical activity meta-analysis. Data were screened, reviewed, and extracted independently by two reviewers, with discrepancies resolved by a third reviewer. Stronger self-efficacy was associated with better functional exercise capacity (weighted r = 0.38, 95%CI [0.25, 0.50]), and greater physical activity (weighted r = 0.25, 95%CI [0.17, 0.34]). Exercise-task self-efficacy had the strongest relationship to functional exercise capacity (weighted r = 0.64, 95% CI [0.51, 0.73]). For physical activity, the type of self-efficacy most strongly related was inconclusive. In COPD, self-efficacy has a relationship to functional exercise capacity and physical activity, the strength of which is influenced by the choice of self-efficacy measure. An understanding of these relationships will assist clinicians in selecting the self-efficacy measure most closely related to the outcome of interest. [ABSTRACT FROM AUTHOR]

In people with chronic obstructive pulmonary disease (COPD), there is increasing recognition that the prolonged accumulation of sedentary time (ST) is associated with adverse cardio-metabolic health outcomes. Nevertheless, changing this lifestyle, which has evolved over several decades, is likely to be challenging. This study reports the determinants, perceived by individuals with COPD, as being important for reducing ST. An in-depth understanding of this information is essential when planning an intervention to reduce ST. Fourteen individuals with COPD completed semi-structured one-on-one interviews, which were audio recorded and transcribed verbatim. Both the interview schedule and mapping of data items extracted from the interview transcripts were informed by the Theoretical Domains Framework (TDF). A total of 867 quotes were mapped to the 14 TDF domains. Seven of the fourteen domains were identified as being important determinants for reducing ST: knowledge, beliefs about consequences, beliefs about capabilities, environmental context and resources, social influences, social/professional role and identity, and behavioural regulation. There was a lack of knowledge regarding the meaning of sedentary behaviour. Participants' desire to be educated by knowledgeable health professionals in a formal programme was a dominant theme across multiple domains. The most frequently reported barriers to reducing ST related to the domains of social/professional role and identity and environmental context and resources, while the most frequently reported enablers were related to the domains pertaining to beliefs about consequences and social influences. Potential strategies to reduce ST among people with COPD include education and other determinants identified in this research. [ABSTRACT FROM AUTHOR]

The literature suggests self-efficacy is a determinant of physical activity and management of Chronic Obstructive Pulmonary Disease (COPD). The purpose of this study was to (1) test the effects of two vicarious experience interventions, coping versus mastery modeling, on self-efficacy in COPD patients performing a cardiopulmonary exercise test (CPET), and (2) determine the type of self-efficacy most strongly related to physical activity in COPD patients. After a baseline assessment of self-efficacy (task, coping for exercise, coping for breathing, scheduling, and walking) and potential moderators, 120 COPD patients watched a mastery model or coping model CPET video, or received usual care verbal instructions. Then, self-efficacy was assessed, followed by a CPET, and another assessment of self-efficacy. Fitbits tracked participants' step count the week following contact. Repeated measures MANOVAs assessed the intervention effects and multiple regressions assessed the contribution of self-efficacy subtypes to step count. All self-efficacy subtypes improved in the mastery and coping conditions, although greater improvement of self-efficacy for coping with exercise barriers was observed in the coping condition. Self-efficacy did not improve in the control condition and no moderators were identified. Self-efficacy for coping with exercise barriers was the self-efficacy subtype most strongly related to step count. This research suggests modeling is a useful intervention technique to enhance self-efficacy in COPD patients, although coping models may be more beneficial than mastery models for enhancing capability beliefs during complex tasks. Future interventions in COPD patients should target self-efficacy for coping with exercise barriers. [ABSTRACT FROM AUTHOR]

Objective: Pulmonary rehabilitation (PR) improves functional exercise capacity and health status in people with chronic obstructive pulmonary disease (COPD), although these outcomes are often not maintained following PR. Self-efficacy is a precursor to outcomes achievement, yet few studies have examined the importance of self-efficacy to outcome improvement during PR, or how it develops over time. Further, the contribution of exercise-specific self-efficacy to outcomes in PR is unknown. The aims of this study were to determine (a) whether baseline exercise self-efficacy predicts PR attendance and change in functional exercise capacity and health status over PR, and (b) if exercise self-efficacy changes with PR. Method: Fifty-eight out of 64 patients with COPD completed PR and assessments of exercise self-efficacy (task, coping, scheduling), the 6-minute walk test (6MWT), and St. George's Respiratory Questionnaire (SGRQ) at the beginning and end of PR. Analyses were conducted to predict attendance, and change in 6MWT and SGRQ, while controlling for baseline demographic and clinical indicators. Change in 6MWT, SGRQ, and self-efficacy with PR was also examined. Results: Clinically significant increases in the 6MWT and SGRQ were achieved with PR. Stronger task self-efficacy predicted better attendance, while stronger coping self-efficacy predicted greater 6MWT improvement. No variables predicted SGRQ change. Scheduling self-efficacy significantly improved with PR, whereas task and coping self-efficacy did not. Conclusion: Baseline exercise self-efficacy appears to be a determinant of rehabilitation attendance and functional exercise improvement with PR. Clinicians should evaluate and target exercise self-efficacy to maximize adherence and health outcome improvement with PR. [ABSTRACT FROM AUTHOR]

This article examined the conceptual and statistical distinction between perceived competence and self-efficacy. Although they are frequently used interchangeably, it is possible that distinguishing them might assist researchers in better understanding their roles in developing enduring adaptive behavior patterns. Perceived competence is conceived in the theoretical framework of self-determination theory and self-efficacy is conceived in the theoretical framework of social-cognitive theory.Purpose:The purpose of this study was to empirically distinguish perceived competence from self-efficacy for exercise.Method:Two studies evaluated the independence of perceived competence and self-efficacy in the context of exercise. Using 2 extant instruments with validity and reliability evidence in exercise contexts, the distinctiveness of the 2 constructs was assessed in 2 separate samples (n = 357 middle-aged sedentary adults;n = 247 undergraduate students).Results:Confirmatory factor analysis supported the conceptual and empirical distinction of the 2 constructs.Conclusions:This study supports the conceptual and statistical distinction of perceived competence from perceived self-efficacy. Applications of these results provide a rationale for more precise future theorizing regarding their respective roles in supporting initiation and maintenance of health behaviors. [ABSTRACT FROM PUBLISHER]

Coaching has been recognised as a demanding occupation, associated with a range of stressors. The extent to which coaches perceive stress is likely to be influenced by various personal and situational factors. The purpose of this study was to identify coaches' levels of perceived stress and examine the personal and situational factors that may influence coaches' perceptions of stress. In total, 502 coaches working with university, college, Canada Games, and/or nationally identified athletes completed this study. Coaches completed an online survey, which included questions regarding demographics, work/job-related considerations, and aspects relating to their contract. Coaches also completed the Perceived Stress Scale (Cohen, Kamarck, & Mermelstein, 1983). Overall coaches indicated slightly below average levels of perceived stress (M = 15.13 out of 40) compared with norm-values (Cohen & Janicki-Deverts, 2012). Demographic factors, job-related characteristics, and certain aspects of their contract were associated with coaches' perceptions of stress. In particular, unclear expectations, long-working hours (>40), lack of agreed evaluation criteria, higher salaries, and a lack of social support were related to higher perceptions of stress. As such, the findings of the current study indicate that a reduction in perceived stress is likely to be achieved through a multifaceted approach that addresses multiple factors associated with coaching. [ABSTRACT FROM AUTHOR]

Although participation in pulmonary rehabilitation (PR) improves the health outcomes in patients with Chronic Obstructive Pulmonary Disease (COPD), there are insufficient resources to provide PR to all patients with COPD. Thus, predicting which patients are at risk for drop-out and non-response to rehabilitation is necessary in order to optimize limited resources. This study examined which patient characteristics are predictive of PR drop-out and non-response. 814 patients with COPD took part in standard out-patient PR for 8 weeks. Demographic and standard clinical data were collected before the rehabilitation program had started. Data was analyzed retrospectively to determine if baseline patient characteristics could predict drop-out and non-response to rehabilitation. Drop-out was defined as participation in less than 50% of the rehabilitation sessions. Non-response was defined as improvement less than 4% on the St. George's Respiratory Questionnaire (SGRQ). A discriminant function analysis identified age, smoking history, and health status as predictors of patient drop-out, p < .0001, with younger, current smokers and patients with lower health status being at risk for drop-out. No variables measured significantly predicted who those at risk would be for non-response to rehabilitation, p > .05. Pulmonary function data did not predict drop-out or non-response to PR. These findings indicate that perceived impairment (i.e., health status) is more likely to influence completion of rehabilitation than actual pulmonary impairment and that demographic and standard clinical data do not adequately predict patient drop-out and non-response to rehabilitation. [ABSTRACT FROM AUTHOR]

Purpose: Some patients with chronic obstructive pulmonary disease (COPD) fail to achieve health benefits with pulmonary rehabilitation (PR). Exercise intensity and load represent stimulus for adaptation but it is unclear whether inappropriate exercise intensity and/or load are affected by severity of COPD, which may affect health benefits. The purpose was to determine whether COPD severity and/or the severity of pulmonary limitation to exercise (PLE) impacted exercising intensity or load and whether resultant intensity/load affected health outcomes derived from PR., Methods: Patients with COPD (n = 58, age = 67 ± 7 y, forced expiratory volume in the first second of expiration [FEV1] % predicted = 52 ± 21%) were recruited upon referral to PR. Primary health outcomes evaluated were 6-min walk distance and St George's Respiratory Questionnaire. Patients were stratified for disease severity using Global Initiative for Obstructive Lung Disease (GOLD) staging and PLE severity by change in inspiratory capacity during exercise. Exercise intensity and load were calculated from daily exercise records., Results: Participants achieved comparable training duration and load regardless of GOLD severity. Patients with more severe PLE achieved greater training duration (more severe: 546 ± 143 min., less severe: 451 ± 109 min., P = .036), and relative training load (more severe: 2200.8 ± 595.3 kcal, less severe: 1648.3 ± 597.8 kcal, P = .007). Greater overall training load was associated with greater improvements in 6-min walk distance (r = 0.24, P = .035). No significant relationships were observed between PLE, GOLD severity, training parameters, and St George's Respiratory Questionnaire response., Conclusions: Improvements in exercise tolerance can be explained by achieving greater training loads, demonstrating the importance of appropriate training load to maximize health outcomes in PR.