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Endurance exercise training (EXT) is singly the most important aspect of rehabilitation for patients with chronic pulmonary disease. When effective, this modality of physical reconditioning leads to improved functional exercise capacity and reduced breathlessness. Early implementation is desirable to obtain more meaningful responses (e.g., when FEV1 falls below 50% of the predicted value in patients with chronic obstructive disease). Preparation for effective EXT requires optimization of respiratory system mechanics (e.g., using bronchodilator therapy), prevention of gas exchange failure (i.e., using supplemental oxygen), nutritional guidance, and psychological support (e.g., to overcome stigmata of disability, fear, and inclination to panic). EXT should be applied using a rigorous, scientifically based aerobic exercise prescription (AXRx) that recognizes basic principles of the human response to exercise prescription while considering individual pathophysiological limitations and identifying safety thresholds for exercise participation. The mode of aerobic exercise should use large muscle groups of the legs (e.g., treadmill or cycle ergometer). The recommended duration is an accumulation of 30 min of exercise per session at the target intensity, achieved by continuous or interval training. EXT should be supervised with a recommended frequency of at least three times per week for 6--8 wk. Target exercise intensity can be monitored by oxygen uptake, work rate, heart rate, or perceived exertion. Target intensity can be determined initially on the basis of 40% of a reference value for maximum oxygen uptake and linked to other variables through predictable interrelationships. All aspects of the AXRx must be reviewed with regard to progression during training. Pulmonary rehabilitation must recognize the importance of achieving clinically meaningful responses (e.g., increased 6-min walking distance of 54 m) as well as the need for maintenance exercise program to sustain the benefits.

Study Objectives: The purpose of this study was to evaluate the effects of a 3-week comprehensive pulmonary rehabilitation program on quality of life as measured by the Short Form-36 (SF-36) in patients with COPD., Design and Setting: We report on the outcomes of 37 consecutive patients referred for pulmonary rehabilitation at a respiratory specialty medical center., Patients: Thirty-seven patients (mean age, 66 years) with COPD and severe airflow limitation (mean +/- SE FEV(1), 29.6 +/- 1.8% of predicted) were studied., Interventions: Rehabilitation consisted of a 3-week pulmonary rehabilitation program incorporating 12 exercise sessions, each of which included bicycle ergometer exercise training, upper-extremity training, strength training, and stretching, along with psychosocial counseling and education., Measurements and Results: The Health Status Index (SF-36) and 6-min walk test were completed before and after rehabilitation. There was an improvement in five of the nine quality-of-life subscales of the SF-36 following pulmonary rehabilitation. Although there was an improvement in functional capacity as measured by the 6-min walk, there was no correlation between improvement in quality of life and improvement in functional capacity. There was no correlation between FEV(1) and improvement in walk distance, but there was a correlation between FEV(1) and improvement in SF-36 physical function and energy/fatigue subscales., Conclusion: Health-related quality of life assessed by the SF-36, a general measure of quality of life, improves following an intensive 3-week pulmonary rehabilitation program. Use of the SF-36 allows comparison of the results of pulmonary rehabilitation to therapeutic interventions in patients with other medical disorders.

Study Objective: To investigate the distribution of reduction in lean body mass (LBM) and whether LBM in legs (LBMlegs) can be a determinant of maximal exercise performance in COPD patients., Methods: Thirty-eight male outpatients with COPD (mean +/- SD FEV1, 47.4 +/- 24.0% of predicted) who underwent complete pulmonary function testing were classified into two groups according to FEV1 expressed as a percentage of predicted value. Group A comprised 21 patients with mild-to-moderate airflow limitation (FEV(1) > or =35% predicted), and group B comprised 17 patients with severe airflow limitation (FEV1 < 35% predicted). LBM, which represents skeletal muscle mass, was measured by dual energy x-ray absorptiometry (DXA) and was assessed separately in arms, legs, and trunk. Maximal oxygen uptake VO2max was measured during maximal exercise on a cycle ergometer., Results: LBM in each region was expressed as a percentage of ideal body weight (IBW). LBM in arms (LBMarms)/IBW, LBMlegs/IBW, and LBM in trunk (LBMtrunk)/IBW were significantly depleted in group B compared with group A (p < 0.01). LBMlegs expressed as a percentage of total LBM (LBMlegs/total LBM) was significantly lower in group B (p < 0.05), although there was no significant difference in LBMarms/total LBM and LBMtrunk/total LBM between the two groups. VO2max correlated significantly with LBMlegs/IBW in group A, but not in group B. By stepwise regression analysis, LBMlegs/IBW appeared to be a significant predictor of VO2max in group A, while not in group B., Conclusion: LBMlegs was a significant predictor of maximal exercise performance in patients with mild-to-moderate airflow limitation, but not in patients with severe airflow limitation who had disproportional reduction in LBMlegs.

Introduction: The purpose of this prospective study is to determine the effects of a pulmonary rehabilitation programme (PRP) conducted at our centre for patients with chronic lung disease., Materials and Methods: Thirty-four patients (27 men and 7 women, mean age 67.7 years) with predominantly moderate-to-severe chronic obstructive pulmonary disease (31 patients), bronchiectasis (2 patients) and interstitial lung disease (1 patient) completed a 6-week outpatient PRP that included education, physical and respiratory care instruction and supervised exercise training. Outcome assessment was performed at baseline, on completion of PRP and 3 months after PRP. Physiologic measures included pulmonary function, incremental exercise and 6-minute walk tests (6MWTs). Disease-specific quality of life was assessed using the Chronic Respiratory Disease Questionnaire (CRDQ)., Results: There was no significant change in resting spirometry or lung volumes after PRP. Maximal oxygen uptake and work-rate improved significantly after PRP by 132.4 mL kg-1 min-1 and 10.7 W, respectively. 6MWT distance improved significantly by a mean of 67.3 m (P < 0.0001). Maximum Borg dyspnoea scores decreased significantly by 1.2 +/- 0.5 (P < 0.038). All domains of the CRDQ completed by a sub-group of patients improved significantly and the total scores increased by a mean of 21.7 points at the end of the PRP. The improvements gained in maximal exercise capacity immediately following PRP were maintained in 17 patients who returned for repeat assessment 3 months after PRP., Conclusion: Patients who completed a comprehensive PRP at our centre showed significant increase in functional capacity, reduction of exertional dyspnoea and improvement in health status.

Background: This article presents a review of the relationship between physical training and airways diseases: the relationship between physical activity and the development of airways diseases, and the effect of physical training in rehabilitation after airways diseases., Material and Methods: The article is a systematic review of exercise-induced asthma (EIA), the effect of physical training upon bronchial hyperresponsiveness and the development of asthma; how chronic lung diseases affect the ability to participate in physical activity; and the use of physical training in rehabilitation after airways diseases., Results and Interpretation: Physical training may provoke EIA in asthmatic patients. Furthermore, heavy regular training over long periods of time may contribute to the development of asthma. Mastering EIA is an important goal in the management of asthma, especially in children and adolescents, in order to foster normal physical and mental development. Physical training improves fitness and the mastering of asthma, but not of bronchial hyperresponsiveness and asthma activity. In other airways disorders like cystic fibrosis or chronic obstructive lung disease, a reduced lung function may limit the ability to participate in physical activity. Training is an important tool in the rehabilitation of patients with pulmonary disorders as it improves physical fitness and quality of life.

Purpose: Pulmonary rehabilitation programs are effective in patients with severe chronic obstructive pulmonary disease (COPD) in the short term, but their long-term effects are not known. We investigated the short- and long-term effects of a 6-month outpatient rehabilitation program in patients with severe COPD., Subjects and Methods: One hundred patients were randomly assigned to receive either an exercise training program that included cycling, walking, and strength training (n = 50) or usual medical care (n = 50). Thirty-four patients in the training group were evaluated after 6 months (end of training), and 26 were evaluated after 18 months of follow-up. In the control group, 28 patients were evaluated at 6 months and 23 after 18 months. We measured pulmonary function, 6-minute walking distance, maximal exercise capacity, peripheral and respiratory muscle strength, and quality of life (on a 20 to 140-point scale), and estimated the cost-effectiveness of the program., Results: At 6 months, the training group showed improvement in 6-minute walking distance [mean difference (training - control) of 52 m; 95% confidence interval (CI), 15 to 89 m], maximal work load (12 W; 95% CI, 6 to 19 W), maximal oxygen uptake (0.26 liters/min; 95% CI, 0.07 to 0.45 liters/min), quadriceps force (18 Nm; 95% CI, 7 to 29 Nm), inspiratory muscle force (11 cm H(2)O; 95% CI, 3 to 20 cm H(2)O), and quality of life (14 points; 95% CI, 6 to 21 points; all P <0.05). At 18 months all these differences persisted (P <0.05), except for inspiratory muscle strength. For 6-minute walking distance and quality of life, the differences between the training group and controls at 18 months exceeded the minimal clinically-important difference., Conclusion: Among patients who completed the 6-month program, outpatient training resulted in significant and clinically relevant changes in 6-minute walking distance, maximal exercise performance, peripheral and respiratory muscle strength, and quality of life. Most of these effects persisted 18 months after starting the program.

Background: It is uncertain whether patients with chronic obstructive pulmonary disease (COPD) given oxygen for symptom relief should be advised to use it before or after exertion., Methods: Eighteen patients with smoking related COPD who desaturated on exercise were given oxygen or air from a cylinder in a single blind manner and in an order determined by Latin square randomisation, before and after ascending stairs. The time of ascent, desaturation, and dyspnoea associated with the ascent was compared across the treatment groups., Results: Oxygen given before or after the ascent reduced maximal dyspnoea from 49.1 mm (95% CI 35.5 to 62.7) to 41.7 mm (95% CI 34.3 to 49.1) of a 100 mm visual analogue scale, reduced desaturation (oxygen before 4.9% (95% CI 3.6 to 6.2), oxygen after 6. 4% (5.3 to 7.5), air before and after 8.2% (6.7 to 9.7%)), but did not affect time of ascent (air before: 5.1 s (95% CI 3.4 to 6.9) reduction from training ascent; oxygen before: 6.1 s (95% CI 2.9 to 9.2) reduction)., Conclusions: Oxygen prescribed for symptomatic relief of dyspnoea benefits selected patients with COPD, but it seems not to matter whether it is taken before or after exertion.

Study Objectives: To investigate whether a 12-week pulmonary rehabilitation program that includes moderately intensive exercise training performed twice weekly can induce a training effect in patients with a wide variation of airflow limitation., Participants: Sixty patients with COPD (38 men) with a mean +/- SD FEV(1) % predicted of 55.1 +/- 19.8 (range, 0.51 to 2.99). All patients performed identical incremental symptom-limited cycle ergometer testing before and after a 12-week study period., Measurements and Results: After 12 weeks, the patients demonstrated a significant (p < 0.05) increase in the peak values for work rate (WR; 77 +/- 30 vs 91 +/- 36 W) and oxygen uptake (1.14 +/- 0.45 vs 1.20 +/- 0.52 L/min). Furthermore, at a given WR during incremental symptom-limited cycle ergometer testing, there were significant (p < 0.05) reductions in minute ventilation (42.4 +/- 16.1 vs 37.0 +/- 13. 6 L/min), carbon dioxide output (1.13 +/- 0.49 vs 1.03 +/- 0.42 L/min), ventilatory equivalent for oxygen (37.6 +/- 8.1 vs 36.0 +/- 6.3), and heart rate (135 +/- 15 vs 128 +/- 16 beats/min). None of the observed physiologic changes correlated with FEV(1) % predicted., Conclusions: A pulmonary rehabilitation program performed twice weekly with moderate exercise workloads can lead to a physiologic training response irrespective of the degree of airflow limitation.

Upper extremity exercise is associated with a significant metabolic and ventilatory cost that is particularly evident in patients with severe chronic airflow obstruction. In these patients abnormal ventilatory muscle recruitment has been hypothesized to relate to impaired diaphragm function resulting from hyperinflation. Similar data have never been reported in patients with isolated diaphragm weakness but without airflow obstruction or hyperinflation, a group that would ideally define the role of diaphragm function during arm elevation (AE). We prospectively studied 15 patients with isolated diaphragm weakness of varying severity (Pdi(sniff), 31.74 +/- 3.75 cm H(2)O) as contrasted with eight normal subjects (Pdi(sniff), 111. 77 +/- 13.35 cm H(2)O) of similar age. Patients with diaphragm weakness demonstrated significant lung volume restriction with normal DL(CO)/VA. There was no difference in resting oxygen consumption (V O(2)), carbon dioxide production (V CO(2)), minute ventilation (V E), and tidal volume (VT) between the two groups; however, a borderline difference in resting breathing frequency (f(b)) (p = 0.056) was evident. Both groups demonstrated a rise in V O(2), V CO(2), and V E during 2 min of AE anteriorly. Normal subjects demonstrated a statistically significant rise in VT but a statistically insignificant rise in f(b) during AE. In contrast, patients with diaphragm weakness demonstrated a statistically significant rise in f(b) during AE but a statistically insignificant rise in VT. In patients the observed rise in VT directly correlated with baseline Pdi(sniff) (r = 0.59, p = 0.02) and Pdi(max) (r = 0.81, p = 0.002). Both groups demonstrated a rise in Pdi during AE. The rise in Pdi during AE directly correlated to Pdi(sniff) in the patients (r = 0.69, p = 0.004). Observed end-expiratory Ppl rose during arm elevation in both the patient group and in the normal control group, but no evidence of a differential response to AE was found. In those patients with greater diaphragm weakness (Pdi(sniff) < 30 cm H(2)O), abnormal respiratory muscle function (lesser rise in Pdi) and a lesser increase in VT during AE were more evident. These data highlight the importance of diaphragm function in determining the metabolic and respiratory muscle response to arm elevation.

Limited information is available regarding the physiological responses to different types of exercise training in patients with severe chronic obstructive pulmonary disease (COPD). The aim of this study was two fold: firstly, to investigate the physiological response to training at 60% of achieved peak load in patients with severe COPD; and secondly to study the effects of interval (I) versus continuous (C) training in these patients. Twenty-one patients with COPD (mean+/-SD forced expiratory volume in one second: 37+/-15% of predicted, normoxaemic at rest) were evaluated at baseline and after 8 weeks' training. Patients were randomly allocated to either I or C training. The training was performed on a cycle ergometer, 5 days a week, 30 min daily. The total work load was the same for both training programmes. C training resulted in a significant increase in oxygen consumption (V'O2) (17%, p<0.05) and a decrease in minute ventilation (V'E)/V'O2 (p<0.01) and V'E/carbon dioxide production (V'CO2) (p<0.05) at peak exercise capacity, while no changes in these measures were observed after interval training. During submaximal exercise a significant decrease was observed in lactic acid production, being most pronounced in the C-trained group (-31%, p<0.01 versus -20%, p<0.05). Only in the I-trained group did a significant increase in peak work load (17%, p<0.05) and a decrease in leg pain (p<0.05) occur. Training did not result in a significant improvement in lung function, but maximal inspiratory mouth pressure increased in both groups by 10% (C: p<0.05) and 23% (I: p<0.01). The present study shows a different physiological response pattern to interval or continuous training in chronic obstruction pulmonary disease, which might be a reflection of specific training effects in either oxidative or glycolytic muscle metabolic pathways. Further work is required to determine the role of the different exercise programmes and the particular category of patients for whom this might be beneficial.

Background: Disability in patients with chronic obstructive pulmonary disease has led to the development of rehabilitation programs to increase exercise tolerance., Objective: To determine, if the effect of training can be improved by giving supplemental oxygen during exercise., Measurements: Ten male patients with COPD (mean FEV1 = 43.2 +/- 17.1% pred) underwent a five day per week cycle ergometer training program for four weeks at least 45 minutes per day at a constant workload of 80% of their highest achieved workrate--measured in an incremental exercise test before training. At this workrate all patients performed exercise above their anaerobic threshold. Five patients were breathing 35% oxygen during exercise, five were breathing roomair (randomised, single blind). To evaluate and compare the results of training before and after the program all patients performed an incremental exercise test (continuously increasing workrate) with roomair., Results: In the group breathing 35% O2 during training the maximally achieved power in the incremental exercise test after training was 15.9% higher. In the group breathing roomair during training the maximally achieved power after training was 36.3% higher than before (p < 0.05). This group also showed significant reductions in lactate levels (p < 0.05) after training at the maximum workload achieved in the pre-training test., Conclusions: Training in the roomair-group resulted in a significant increase in the maximum power and total amount of work. In this group training could induce a physiologic response (increase of aerobic capacity), which was shown by significantly lower lactate levels at a comparable workload.

Background: high walking frames may improve exercise capacity in young patients with chronic obstructive pulmonary disease (COPD). We have assessed the effect of Zimmer, rollator and gutter frames on 6-min walking distance and on arterial oxygenation during exercise in elderly patients with COPD., Methods: 27 out-patients (15 men) aged 70-82 (mean 75) years were recruited. Exclusions comprised: COPD exacerbation or oral steroid use within 6 weeks, confusional state, participation in a pulmonary rehabilitation programme and exercise limitation by other diseases. Subjects completed 6-min walk tests unaided and with the three frames on four separate days in random order 30 min after nebulized salbutamol (5 mg) and ipratropium (0.5 mg) and were accompanied by an investigator blinded to results of all other walk tests undertaken. Oxygen saturation (SaO2) was monitored by finger probe during exercise. Grouped t-tests were used to compare distances and reductions in SaO2., Results: Unaided, the mean (SEM) 6-min walk distance was 210 (16) m and fall in oxygen saturation was 6.0 (1.1)%. Use of a rollator frame did not significantly affect either of these values. Using the Zimmer frame reduced the mean distance to 165 (13) m (t=5.2, P < 0.001 vs unaided walk) with an SaO2 fall similar to that recorded during the unaided walk. Using the gutter frame increased the mean distance to 234 (150) m (t=3. 1, P=0.004 vs unaided walk) and reduced the fall in SaO2 to 3.7 (0.8)% (t=2.3, P=0.03 vs unaided walk)., Conclusions: gutter frames improve exercise capacity and SaO2 during exercise in elderly COPD patients who remain symptomatic on optimal therapy, whereas unwheeled Zimmer frames have a deleterious effect in such patients.

The effect of physical training depends on the intensity at which exercise is performed. Patients with chronic obstructive pulmonary disease (COPD) may not tolerate high exercise intensities during training due to breathlessness. The purpose of the present study was to investigate the cardiorespiratory load of exercise training, during pulmonary rehabilitation, in patients with severe COPD. We also studied the effects of pulmonary rehabilitation on maximum exercise performance. Thirteen patients with stable COPD (FEV1 (S.D.) 1.0 (0.3) L) performed an incremental cycle exercise test at baseline and after a 10 week in-patient pulmonary rehabilitation programme. Exercise training consisted of dynamic and isometric strength training exercises, and training of specific daily life activities. Training sessions were held 5 days per week for 10 weeks. Heart rate (HR) and dyspnoea ratings (Borg scale) were measured during one session in the second or third week of training, and were compared with values obtained during incremental cycle exercise at baseline. The ventilatory load during the training was estimated by using the relationship between HR and minute ventilation (VE) during incremental cycle exercise at baseline. The duration of a training session was 80 (7) min, including periods of rest. The HR during various exercises of the training programme varied between 94 (17) and 103 (14)% of peak HR during incremental cycle exercise. Borg scores during the training varied between 2.0 and 5.7, and were lower than the Borg score at peak exercise (6.5 (2.0)). HR was more than 90% of peak HR during 36 (33) min of the whole training session, which corresponded with a VE of 81 (11)% of peak VE during incremental cycle exercise. Training significantly increased maximum work load (Wmax) from 62 (25) to 73 (21) W (P < 0.05), without any change in peak HR, VE and VO2. In patients with severe COPD, the training intensity in terms of cardio-respiratory load was high in relation to individual maximum values. Pulmonary rehabilitation, including exercise training, improved maximum exercise performance.

A prospective, randomized and controlled study has been performed in 28 patients with severe COPD. A group of 14 has been trained with their lower limbs (LL), while another similar group of 14 patients was also trained with their upper limbs (UL). Results showed improvement in both groups in the endurance test for LL, dyspnea scale, efficiency and muscular working capacity. A considerable improvement was observed in the oxygen uptake at the anerobic threshold (VO2AT) which suggests a training effect, expressed through an improvement in exercise tolerance. Only the group who trained UL showed a remarkable improvement in the dyspnea scale, endurance test and maximal static mouth pressure, showing a better intrinsic working capacity and participation of the UL muscles producing those manoeuvres. At the end of training, quality of life was significantly increased and the hospitalization rate was lower in both groups. According to these findings, it is suggested that patients with severe COPD included in training programmes add UL exercises to the LL usually carried out.

While exercise training for patients with COPD is time consuming and strenuous, we have seen through our experience that patients who comply with this simple and easy exercise program reported subjective improvement in ability to perform their activities of daily living. The key to exercise success is consistency and availability of reinforcement of techniques through the use of both written and in-person instruction.

Objective: We sought to determine whether patients with stable chronic obstructive pulmonary disease (COPD) whose exercise performance is mainly limited by dyspnoea are able to improve their exercise tolerance after rehabilitation with an individualized programme based on aerobic training at the ventilatory threshold (VT) level. PATIENTS AND EXPERIMENTAL DESIGN: Thirteen stable and moderate to severe COPD patients took part in an outpatient rehabilitation programme lasting 4 months. This individualized programme consisted of exercise training (general training on cycle and upper-limb training by rowing at the heart rate corresponding to VT) together with provision of adequate calorie and protein support., Results: Lung function test after rehabilitation revealed significant increases in FVC (82.9 vs 69.2 % pred) and FEV1 (47.2 vs 39.7 % pred), although FEV1/FVC were unchanged (44.8 vs 46.8%). Incremental exercise test performed on cycle revealed significant increases in time, work rate (82.0 vs 63.2 W), peak VO2 (14.6 vs 10.7 ml.kg-1.min-1), peak VO2 (840 vs 701 ml.min-1), peak VT (1309 vs 980 ml), and O2-pulse (8.3 vs 6.7). However, exercise tests were always symptom-limited by dyspnoea., Conclusions: We conclude that this individualized outpatient rehabilitation programme is able to improve exercise tolerance in stab le COPD patients affected by dyspnoea during exercise, through an apparent reconditioning of both skeletal and respiratory muscles and improved gas exchange during exercise, thus reducing the ratio of dead space to tidal volume. In consequence, patients whose exercise capacity is so reduced that they cannot develop significant lactic acidosis may reduce the ventilatory cost for exercise through this individualized therapy.

The consequences of asthma are described in accordance with the definitions of the three levels of the International Classification of Impairments, Disabilities and Handicaps (ICIDH). Because asthma is a chronic disease, health care should emphasize how to cope with it. The goal of physical activities for persons with asthma is the learning of skills which can be used to control the physical situation. Breathing therapy and therapeutic drugs make it possible for the person to control the physical condition. In physical education and sport training, patients are taught to use these means in physically strenuous situations.

Background: In order to evaluate a pulmonary rehabilitation program (PRP) at moderate altitude (1560 m) 62 patients with obstructive lung disease were asked to participate; 37 patients completed a 1-year follow-up at sea level, and 25 patients dropped out. The exercise training program lasted for 10 weeks and consisted of a cycling and running program of 20 min daily, 5 days a week., Methods: Incremental exercise testing, spirometry and histamine provocation tests were performed at sea level before the PRP, on admission to the Dutch Asthma Centre, Davos, after 5 weeks of exercise training, at discharge from the Centre and 6 and 12 months after discharge at sea level., Results: The PRP led to an increase in exercise capacity of the 37 patients who also completed the follow-up as reflected by an increase in Wmax (from 104 +/- 44 watt on admission to 150 +/- 8 at discharge, p < 0.001). HRmax (145 +/- 19/min to 151 +/- 21, p < 0.001), Wmax/HR (0.71 +/- 0.26 watt/beat/min to 0.99 +/- 0.29, p < 0.001), VO2max (1.4 +/- 0.4 l/min to 1.9 +/- 0.6, p < 0.001) and VEmax (49 +/- 18 l/min to 78 +/- 24, p < 0.001) measured at discharge from the Dutch Asthma Centre after the PRP were significantly higher than before the PRP at incremental exercise testing. The group of 25 patients who dropped out showed corresponding improvements in these parameters after the PRP in Davos. The 37 patients who completed the follow-up showed at incremental exercise testing 1 year after the PRP that only two of these parameters were still significantly elevated: VO2max 1.8 +/- 0.6 (p < 0.001) and VEmax 61 +/- 21 (p < 0.001). One year after the PRP arterial PCO2 values at maximum exercise were significantly lower (5.2 +/- 0.8 kPa, p < 0.05) than the baseline values (5.5 +/- 0.9 kPa)., Conclusions: PRP at moderate altitude results in an increase of exercise tolerance in patients with asthma or COPD, but significant long-term effects are few.

Exercise has been shown to be an important component of pulmonary rehabilitation and may be associated with both physiologic and psychological benefits for patients with chronic lung disease. In evaluating patients for pulmonary rehabilitation, exercise testing can be useful in measuring exercise tolerance, assessing causes of exercise limitation, developing a prescription for training, evaluating often unexpected changes in arterial blood gases, and screening for exercise-induced bronchospasm. A variety of testing procedures and measurements are available in pulmonary laboratories. The appropriate test depends on several variables, including patient and program goals, questions identified in the initial patient evaluation, the specific exercise training program, available laboratory expertise, and cost.

In addition to improved functional ability, patients who complete rehabilitation programs typically have positive psychologic changes, including increased motivation and an enhanced quality of life. Potentially, patients with end-stage lung disease awaiting a lung transplant can have similar benefits. However, no studies were identified that examined the impact of an exercise program on quality of life in patients awaiting lung transplantation. This pilot study was an initial step toward evaluating outcomes of a health maintenance program on exercise tolerance and quality of life. Subjects were nine lung transplant candidates who met lung transplant listing criteria and who were randomized to participate in a 6-week health maintenance program consisting of education alone or education plus exercise. Subjects completed cardiopulmonary exercise testing, a 6-minute walk, and the Quality of Well-being scale, Quality of Life Index, and Symptom Frequency/Symptom Distress scale before and after completion of the program. No significant between-group changes were seen. Quality of Well-being scores (p < 0.005) and 6-minute walk distance (p < 0.03) improved over time in both groups. Findings suggest that patients awaiting lung transplantation perceived improved quality of well-being and increased walk distance after participation in a health maintenance program. Education plus exercise conferred no benefits beyond those achieved by education alone. However, the number of subjects studied was small and duration of follow-up was limited.

Until recently, there was little or no emphasis on aerobic upper body exercise training, despite research strongly supports the inclusion of this type of exercise in cardiac rehabilitation programs and adult fitness. The limited degree of transfer of training benefits from trained limbs to another set of untrained limbs appears to discount the practice of recommending aerobic leg exercise alone. In addition, leg training programs fail to accommodate individuals with specific health problems. There is an increased physiological stress during arm training, if compared to leg training. Exercise intensity derived from a bicycle- or treadmill test would therefore cause an inappropriately target heart rate for upper body exercise. Thus, target heart rate has to be reduced by 10 to 20% to be adequate for aerobic arm training. Finally, an example of a progressive arm exercise training program is shown.

Objective: To examine the effects of a rehabilitation programme in patients with asthma or COPD who have major complaints despite the fact that their pulmonary function is not severely disturbed., Setting: Medical Centre Dekkerswald, Groesbeek., Design: Prospective clinical trial., Patients and Methods: The treated group consisted of 44 patients with an obstructive lung disease, FEV1 68.3% of predicted value. This group was compared with 43 patients in a control group. These were volunteers, who were comparable for pulmonary function, reversibility, age, sex, Quetelet index, pulmonary medication and educational level. These groups were examined for 2 years by means of tests and questionnaires. Changes from baseline values were analysed by covariance analysis. Patients followed a rehabilitation programme which consisted of an optimal medical treatment in combination with training of physical endurance, health education and psychological and social support. The duration of the programme was 3 months, 38 hours a week., Results: Pulmonary rehabilitation had a long-term beneficial effect on endurance, several psychological valuables, consumption of medical care, attitude towards way of life, skills, coordination and smoking habits. Bronchial hyperresponsiveness, need of pulmonary drugs and complaints of cough and sputum production did not change after rehabilitation. Airway obstruction and subjective feelings of dyspnoea, allergy and hyperresponsiveness only decreased in the short term (less than I year)., Conclusion: This study shows that pulmonary rehabilitation improves many variables in the short as well as in the long run. When COPD patients do not improve on conventional treatment, pulmonary rehabilitation should be considered.

Exercise training is an essential part of a pulmonary rehabilitation program. Different forms of exercise training can be prescribed in COPD patients, depending on the mechanism of the exercise limitation in the individual patient.

Randomly assigned 119 adults with chronic obstructive pulmonary disease to an 8-week comprehensive rehabilitation program or to an 8-week education control program. Comprehensive pulmonary rehabilitation included education, physical and respiratory therapy instruction, psychosocial support, and supervised exercise training; education control included biweekly classroom instruction and discussions on respiratory therapy, medical aspects of lung disease, clinical pharmacology, and diet, but no exercise training. Both groups received extensive physiological and psychosocial evaluation before and after the intervention. Six months after enrollment, patients randomly assigned to the rehabilitation program showed significant increases in exercise endurance, whereas patients randomly assigned to control program showed nonsignificant increases. Improvement in self-efficacy was correlated with improvements in exercise endurance.

The effects of regular aerobic exercise on state-trait anxiety (Spielberger) and Depression (Zung) were assessed for nine men and six women, 46-71 years of age, with chronic obstructive pulmonary disease (COPD). Treatment subjects (N = 9) were evaluated prior to and following 14 and 28 weeks of exercise. Control subjects (N = 6) were evaluated at the same times but did not participate in the initial 14 weeks of exercise. The exercise regime consisted of stretching before and after 30 minutes of walking at about 50% of maximal oxygen uptake. Analyses showed the exercise intervention to have little impact on state-trait anxiety or depression scores. Anecdotal remarks and perceptions of the subjects suggest that further investigation of the relationship between exercise and psychological status of COPC patients is justified.