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Purpose of Review: This review synthesizes the expanding evidence for pulmonary rehabilitation that has led to its recommended inclusion in the holistic care of people with idiopathic pulmonary fibrosis (IPF), as well as discussing strategies that may maximize and sustain benefits., Recent Findings: Pulmonary rehabilitation is an effective intervention leading to significant improvements in exercise tolerance, symptoms, and quality of life for people with IPF. Improvements in symptoms and quality of life can persist longer term, whereas functional capacity does not; therefore, strategies to preserve functional capacity are an important area of research. Referral early in the disease course is encouraged to promote longer lasting effects. Evidence that high-intensity interval training may optimize benefits of exercise training is emerging. Supplemental oxygen is frequently used to manage exercise-induced desaturation, although its use as an adjunct therapy requires more evidence., Summary: Current evidence strongly supports the inclusion of pulmonary rehabilitation in the standard holistic care of IPF, with early participation encouraged. Further research is needed to establish the optimal exercise strategies, modalities and adjunct therapies that enhance outcomes of pulmonary rehabilitation and promote longer lasting effects., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To establish the effects of pulmonary rehabilitation (PR) in patients with persistent symptoms after COVID-19 infection. In addition, to compare the modalities of PR services (face-to-face and telerehabilitation) and the duration of PR in weeks (4-8 weeks and >8 weeks)., Data Sources: PubMed/MEDLINE, Embase (Elsevier), Central/Cochrane Library, SciELO Citation Index (Web of Science), and CINAHL., Study Selection: Studies determining the effects of PR in patients with post-COVID-19 syndrome were included and grouped according to PR delivery modality., Data Extraction: Data extraction and quality assessment were independently performed by 2 reviewers. The methodological quality was assessed using the Cochrane Risk of Bias Tool 1 (RoB-1)., Data Synthesis: The literature search retrieved 1406 articles, of which 7 studies explored the effects of PR on patients with post-COVID-19 syndrome, with 188 patients randomized to PR. The mean age of participants was 50 years and 49% were women. Meta-analysis showed an increase in exercise capacity with PR compared with control (6-minute walking test: mean difference: 60.56 m, 95% confidence interval: 40.75-80.36), a reduction in fatigue (Fatigue Severity Scale: -0.90, -1.49 to -0.31) but no change in dyspnea (-0.57, -1.32 to 0.17) and muscle strength (3.03, -1.89 to 7.96). There were no differences between telerehabilitation and face-to-face PR regarding effects on peripheral muscle strength (P=.42), dyspnea (P=.83), and fatigue (P=.34). There were no differences between programs 4-8 weeks and >8 weeks regarding exercise capacity (P=.83), peripheral muscle strength (P=.42), and dyspnea (P=.76)., Conclusions: PR improves exercise capacity and reduces fatigue in patients with post-COVID-19 syndrome. Duration of PR (4-8 weeks vs > 8 weeks) or PR modality (telerehabilitation vs face-to-face) did not affect outcomes but data were limited and based on subgroup analysis. Further evidence is required to determine the optimal delivery mode and duration of PR for post-COVID-19 syndrome., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the proportion of people who achieve minimal clinically important differences (MCID) with centre-based or home-based pulmonary rehabilitation and to synthesise data on adverse events. Methods: Cochrane reviews and electronic databases were searched to identify randomised trials comparing centre-based to home-based pulmonary rehabilitation, or either model to usual care, in people with chronic respiratory disease. Primary outcomes were the proportion of participants achieving MCIDs in exercise capacity and disease-specific quality of life. Secondary outcomes were symptoms and adverse events. Cochrane Risk of Bias 1.0 and GRADE were used to assess the risk of bias and certainty of evidence respectively. Results: Forty-nine trials were eligible. Compared to usual care, a higher proportion of pulmonary rehabilitation participants achieved the MCID for exercise capacity (6MWT: 47% vs 20%, p = 0.11), dyspnoea (43% vs 29%, p = 0.0001), fatigue (48% vs 27%, p = 0.0002) and emotional function (37% vs 25%, p = 0.02), with all of these between group differences statistically significant except for exercise capacity. There were no differences between centre-based and home-based pulmonary rehabilitation in the proportion of participants who achieved MCIDs (34%- 58% across studies). Ninety percent of trials reported no adverse events. Certainty of evidence was low-to- moderate with all outcomes except for CRQ-mastery (centre-based vs home-based pulmonary rehabilitation, or pulmonary rehabilitation vs usual care in COPD), ESWT (pulmonary rehabilitation vs usual care in COPD) and 6MWT (pulmonary rehabilitation vs usual care in bronchiectasis) where evidence was very uncertain. Discussion: Clinically meaningful outcomes are achieved by similar proportions of participants in centre-based and home-based pulmonary rehabilitation, with few adverse events. Reporting of trial outcomes according to MCIDs is necessary for informed decision making regarding pulmonary rehabilitation models., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging., Objectives: To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme., Search Methods: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL., Selection Criteria: We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events., Data Collection and Analysis: Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence., Main Results: We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported., Authors' Conclusions: This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objective: A Modified Incremental Step Test (MIST) performed in the home may facilitate entirely home-based pulmonary rehabilitation programs. The aims of this study were to investigate the reliability and responsiveness, and the utility of the MIST for exercise prescription in people with stable chronic lung disease., Methods: The MIST was undertaken at the center and home in random order, before and after pulmonary rehabilitation, with 2 tests at each time point. Reliability was assessed using intraclass correlation coefficient. Responsiveness was evaluated as effect size. The minimal important difference was appraised using distribution and anchor-based methods. In a substudy, physiological responses to MIST were measured by a portable metabolic system, followed by a constant step rate test at 60% of peak oxygen uptake (VO2peak), to evaluate utility for exercise prescription., Results: Forty-six participants were recruited (29% of eligible candidates). There was excellent reliability for number of steps recorded in home- and center-based settings (intraclass correlation coefficient = 0.954, 95% CI = 0.915-0.976). A small-moderate effect size was demonstrated following pulmonary rehabilitation (0.34), and the minimal detectable change was 7 steps. All participants in the substudy achieved 60% of VO2peak and achieved steady state by the fourth minute, with 60% of VO2peak corresponding to a mean 37% (95% CI = 29-44) of the MIST final level., Conclusions: The MIST is reliable and responsive to pulmonary rehabilitation in people with stable chronic respiratory disease. It provides new opportunities to assess exercise capacity, prescribe exercise training, and reassess exercise program outcomes in environments where established field walking tests are not feasible., Impact: Pulmonary rehabilitation is a highly effective treatment that is underutilized worldwide. Home-based pulmonary rehabilitation may improve access for patients and deliver equivalent clinical outcomes but is limited by the availability of a robust exercise test that can be used at home to assess exercise capacity and prescribe training intensity. This study tested the clinimetric properties of the MIST and demonstrated a new way to assess exercise capacity, prescribe exercise training of an appropriate intensity, and reassess exercise capacity in environments where established field walking tests are not feasible., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions-medications, surgery, education, nutrition, exercise-and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature. Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on people diagnosed with pulmonary arterial hypertension. Can exercise-based rehabilitation programs improve exercise capacity and quality of life in people with pulmonary arterial hypertension?, (© 2019 American Physical Therapy Association.)

Background: The aim of this work was to investigate the short- and long-term test-retest reliability of the 6-min walk distance (6MWD), peak heart rate, and nadir oxygen desaturation in idiopathic pulmonary fibrosis (IPF)., Methods: A reliability study of 70 adults with IPF was undertaken within out-patient pulmonary rehabilitation programs at 2 tertiary hospitals. Participants completed 2 baseline 6-min walk tests using a standard protocol, with continuous measures of percutaneous S pO 2 and heart rate via pulse oximetry. The 6-min walk test was completed immediately following an intervention period and 6 months after. Reproducibility was assessed by intraclass correlation coefficient and Bland-Altman analysis., Results: Participants with a mean ± SD diffusing capacity of the lung for carbon monoxide of 48 ± 14% were included. The reliability of the 6MWD was high (intraclass correlation coefficient = 0.96) with a mean learning effect of 21 m (95% CI 12-30 m). The learning effect persisted at 8 weeks (mean 14 m, 95% CI 5-23 m) but not 6 months (mean 15 m, 95% CI -1 to 30 m). Using the best (greatest) 6MWD significantly reduced the proportion of participants who were classified as having a clinically important response to rehabilitation compared with using the first 6MWD (40% vs 54%, P = .002). Nadir S pO 2 was reproducible, with a mean difference of 0.7 ± 2.2%, and limits of agreement of -4 to 5%. Peak heart rate was more variable, with mean difference 5 ± 9 beats/min and limits of agreement of -12 to 20 beats/min., Conclusions: The 6MWD is a reproducible measure of exercise capacity in people with IPF. Whereas the nadir S pO 2 may be accurately determined from one test, evaluating change in 6MWD with interventions may require 2 tests on each occasion. (ClinicalTrials.gov registration NCT0016828.)., (Copyright © 2018 by Daedalus Enterprises.)

Introduction: Evaluating adherence to home-based pulmonary rehabilitation (PR) could be challenging due to lack of direct supervision and the complex nature of the rehabilitation model. To measure adherence to home-based PR in the HomeBase trial, participants were encouraged to work towards a goal of at least 30 min of whole-body exercise on most days of the week and report their participation using a home exercise diary., Objective: This project aimed to evaluate the acceptability and validity of the home exercise diary., Methods: Diary return and completion rates assessed acceptability of the home exercise diary. Home participants underwent physical activity (PA) monitoring using the Sensewear armband during the final week of an 8-week PR. The correlation between self-documented and objective daily exercise minutes was calculated. Objective exercise minutes were defined as bouts of ≥10 min spent in ≥ moderate PA. Differences in self-documented weekly exercise minutes between sufficiently active (≥7000 daily steps) and inactive participants were computed., Results: Diaries were returned by 92% of programme completers. Of those who returned diaries, 72% have completed exercise documentation. Fifteen programme completers underwent PA monitoring [mean age 69 (9) (SD) years, FEV 1 55 (19) %predicted]. A moderate correlation was observed between self-documented and objective mean daily exercise minutes (r = .59, P = .02). Active participants [n = 6, 10 253 (1521) daily steps] documented more exercise (111 min) during week eight compared with inactive participants [n = 9, 2705 (1772) daily steps, P = .002]., Conclusion: The self-documented home exercise diary is an acceptable and valid method to reflect exercise participation during home-based PR., (© 2018 John Wiley & Sons Ltd.)

Background: Bronchiectasis is characterized by a progressive structural lung damage, recurrent infections and chronic inflammation which compromise the exertion tolerance, and may have an impact on skeletal muscle function and physical function., Objective: The purpose of this study was to compare peripheral muscle strength, exercise capacity, and physical activity in daily life between participants with bronchiectasis and controls and to investigate the determinants of the peripheral muscle strength and physical activity in daily life in bronchiectasis., Design: This study used a cross-sectional design., Methods: The participants' quadriceps femoris and biceps brachii muscle strength was measured. They performed the incremental shuttle walk test (ISWT) and cardiopulmonary exercise testing, and the number of steps/day was measured by a pedometer., Results: Participants had reduced quadriceps femoris muscle strength (mean difference to control group = 7 kg, 95% CI = 3.8-10.1 kg), biceps brachii muscle strength (2.1 kg, 95% CI = 0.7-3.4 kg), ISWT (227 m, 95% CI = 174-281 m), peak VO2 (6.4 ml/Kg/min, 95% CI = 4.0-8.7 ml/Kg/min), and number of steps/day (3,332 steps/day, 95% CI = 1,758-4,890 steps/day). A lower quadriceps femoris strength is independently associated to an older age, female sex, lower body mass index (BMI), higher score on the modified Medical Research Council scale, and shorter distance on the ISWT (R2 = 0.449). Biceps brachii strength is independently associated with sex, BMI, and dyspnea (R2 = 0.447). The determinants of number of daily steps were dyspnea and distance walked in ISWT, explaining only 27.7% of its variance., Limitations: Number of steps per day was evaluated by a pedometer., Conclusions: People with bronchiectasis have reduced peripheral muscle strength, and reduced aerobic and functional capacities, and they also are less active in daily life. Modifiable variables such as BMI, dyspnea, and distance walked on the ISWT are associated with peripheral muscle strength and physical activity in daily life., (© 2017 American Physical Therapy Association)

Background and Objective: Supplemental oxygen is commonly prescribed in patients with idiopathic pulmonary fibrosis (IPF), although its benefits have not been proven. The aims of this study were to investigate the effect of oxygen on oxidative stress, cytokine production, skeletal muscle metabolism and physiological response to exercise in IPF., Methods: Eleven participants with IPF received either oxygen, at an FiO 2 of 0.50, or compressed air for 1 h at rest and during a cycle endurance test at 85% of peak work rate. Blood samples collected at rest and during exercise were analysed for markers of oxidative stress, skeletal muscle metabolism and cytokines. The protocol was repeated a week later with the alternate intervention., Results: Compared with air, oxygen did not adversely affect biomarker concentrations at rest and significantly improved endurance time (mean difference = 99 ± 81s, P = 0.002), dyspnoea (-1 ± 1 U, P = 0.02), systolic blood pressure (BP; -11 ± 11 mm Hg, P = 0.006), nadir oxyhaemoglobin saturation (SpO 2 ; 8 ± 6%, P = 0.001), SpO 2 at 2-min (7 ± 6%, P = 0.003) and 5-min isotimes (5 ± 3, P < 0.001) and peak exercise xanthine concentrations (-42 ± 73 µmol/L, P = 0.03). Air significantly increased IL-10 (5 ± 5 pg/mL, P = 0.04) at 2-min isotime. Thiobarbituric acid-reactive substances (TBARs), IL-6, TNF-α, creatine kinase, lactate, heart rate and fatigue did not differ between the two interventions at any time point., Conclusion: In patients with IPF, breathing oxygen at FiO 2 of 0.50 at rest seems safe. During exercise, oxygen improves exercise tolerance, alleviates exercise-induced hypoxaemia and reduces dyspnoea. A potential relationship between oxygen administration and improved skeletal muscle metabolism should be explored in future studies., (© 2017 Asian Pacific Society of Respirology.)

Background: Individuals with pulmonary hypertension (PH) have reduced exercise capacity and quality of life. Despite initial concerns that exercise training may worsen symptoms in this group, several studies have reported improvements in functional capacity and well-being following exercise-based rehabilitation in PH., Objectives: To assess the efficacy and safety of exercise-based rehabilitation for people with PH. Primary outcomes were exercise capacity, adverse events during the intervention period and health-related quality of life (HRQoL). Secondary outcomes included cardiopulmonary haemodynamics, functional class, clinical worsening during follow-up, mortality and changes in B-type natriuretic peptide., Search Methods: We searched the Cochrane Airways Specialised Register of Trials up to August 2016, which is based on regular searches of CINAHL, AMED, Embase, PubMed, MEDLINE, PsycINFO and registries of clinical trials. In addition we searched CENTRAL and the PEDro database up to August 2016 and handsearched relevant journals., Selection Criteria: All randomised controlled trials (RCTs) focusing on exercise-based rehabilitation programmes for PH., Data Collection and Analysis: Two reviewers extracted data independently. For binary outcomes, we calculated odds ratios and their 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE., Main Results: We included six RCTs and were able to extract data from five studies. The majority of participants were Group I pulmonary artery hypertension (PAH). Study duration ranged from three to 15 weeks. Exercise programmes included both inpatient- and outpatient-based rehabilitation that incorporated both upper and lower limb exercise. The mean six-minute walk distance following exercise training was 60.12 metres higher than control (30.17 to 90.07 metres, n = 165, 5 RCTs, low-quality evidence; minimal important difference was 30 metres), the mean peak oxygen uptake was 2.4 ml/kg/minute higher (1.4 to 3.4 ml/kg/min, n = 145, 4 RCTs, low-quality evidence) and the mean peak power in the intervention groups was 16.4 W higher (10.9 to 22.0 higher, n = 145, 4 RCTs, low-quality evidence). The mean change in HRQoL for the SF-36 physical component score was 4.63 points higher (0.80 to 8.47 points, n = 33, 2 RCTs, low-quality evidence) and for the SF-36 mental component score was 4.17 points higher (0.01 to 8.34 points; n = 33; 2 RCTs, low-quality evidence). One study reported a single adverse event, where a participant stopped exercise training due to lightheadedness., Authors' Conclusions: In people with PH, exercise-based rehabilitation results in clinically relevant improvements in exercise capacity. Exercise training was not associated with any serious adverse events. Whilst most studies reported improvements in HRQoL, these may not be clinically important. Overall, we assessed the quality of the evidence to be low. The small number of studies and lack of information on participant selection makes it difficult to generalise these results across the spectrum of people with PH.

Purpose: The 6-Minute Walk Test (6MWT) and Incremental Shuttle Walk Test (ISWT) are used to assess exercise capacity, but the reliability and responsiveness of these tests in individuals with non-cystic fibrosis (CF) bronchiectasis have not been determined. This study aimed to determine the reliability and responsiveness of both tests in adults with non-CF bronchiectasis., Methods: Eighty-five participants completed 2 6MWTs and 2 ISWTs in random order. Testing was repeated at the conclusion of an 8-week intervention period of exercise training. Reliability was assessed using intraclass correlation coefficients (ICC) and Bland-Altman analysis. Responsiveness was measured by effect size (ES) and standardized response mean (SRM)., Results: At baseline, test-retest reliability was high for both tests (ICC ≥ 0.95). The mean (95% CI) increase in the 6MWT from test 1 to test 2 was 20 m (13-26 m): 3% (0-5%) change. The mean (95% CI) increase in the ISWT was 15 m (4-25m): 4% (2-6%) change. A significant learning effect persisted after 8 weeks for the 6MWT (P = .04), but not the ISWT (P = .61). The 6MWT ES was 0.32 and SRM was 0.68; for the ISWT, ES was 0.42 with SRM of 0.71., Conclusion: The 6MWT and ISWT are reliable measures of exercise capacity in non-CF bronchiectasis and responsive to exercise training. The small learning effect in both measures at baseline suggests that 2 of each test are necessary to correctly assess exercise capacity. Completion of 2 6MWTs at followup may minimize the risk of underestimating a treatment effect.

Exercise intolerance, exertional dyspnea, reduced health-related quality of life, and acute exacerbations are features characteristic of chronic obstructive pulmonary disease (COPD). Patients with a primary diagnosis of COPD often report comorbidities and other secondary manifestations, which diversifies the clinical presentation. Pulmonary rehabilitation that includes whole body exercise training is a critical part of management, and core programs involve endurance and resistance training for the upper and lower limbs. Improvement in maximal and submaximal exercise capacity, dyspnea, fatigue, health-related quality of life, and psychological symptoms are outcomes associated with exercise training in pulmonary rehabilitation, irrespective of the clinical state in which it is commenced. There may be benefits for the health care system as well as the individual patient, with fewer exacerbations and subsequent hospitalization reported with exercise training. The varying clinical profile of COPD may direct the need for modification to traditional training strategies for some patients. Interval training, one-legged cycling (partitioning) and non-linear periodized training appear to be equally or more effective than continuous training. Inspiratory muscle training may have a role as an adjunct to whole body training in selected patients. The benefits of balance training are also emerging. Strategies to ensure that health enhancing behaviors are adopted and maintained are essential. These may include training for an extended duration, alternative environments to undertake the initial program, maintenance programs following initial exercise training, program repetition, and incorporation of approaches to address behavioral change. This may be complemented by methods designed to maximize uptake and completion of a pulmonary rehabilitation program.

While recommendations for the duration, frequency, mode and intensity of exercise programmes for people with chronic obstructive pulmonary disease (COPD) are specified in consensus statements, criteria for exercise session attendance are less clear. The review questions were: (i) how commonly are a priori criteria and attendance rates reported for people with COPD participating in exercise programmes and (ii) what is the strength of association between attendance and improvements in functional exercise capacity. Database searches identified primary studies of people with COPD participating in exercise or pulmonary rehabilitation programmes of at least 2 weeks duration. Primary outcomes were a priori criteria for attendance, reports of attendance at supervised exercise sessions and mean improvements in functional exercise assessments. Data extraction processes were confirmed prospectively (>80% agreement). Variants of exercise attendance data were described. Linear associations between attendance and improvements in exercise outcomes were explored (Pearson r, P < 0.05). Of the 234 included studies, 86 (37%) reported attendance and 29 (12%) provided a priori criteria for attendance. In the small sample of studies which reported attendance and functional exercise data before and after the intervention, there was little to no relationship between improvements in functional exercise capacity and training volume (prescribed r = -0.03, P = 0.88; attended r = -0.24, P = 0.18). Reporting of exercise programme attendance rates is low and of variable quality for people with COPD. Consistent and explicit reporting of exercise attendance in people with COPD will enable calculation of dose-response relationships and determine the value of a priori exercise attendance criteria., (© 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.)

Background: Provision of healthcare from a remote site may assist patients to access important services. We aimed to establish the feasibility of monitoring an assessment of exercise capacity using telehealth technology., Methods: Adults with CF completed two 3-min step tests, monitored in-person or remotely via videoconferencing, in randomized order. Measurements were physiological responses to exercise, system usability, ease of clinician interaction, metronome acoustics, and participant comfort., Results: Ten adults (5 male), mean ± SD age 32 ± 7 years, and FEV1 55.4% of predicted (range 38-90% of predicted), completed both tests. Participants reported good system usability, with a mean (95% CI) System Usability Scale score of 85.63 out of 100 (79.8-91.5). Metronome acoustics were rated as significantly poorer remotely (P = .006). There were no differences in measurements of oxyhemoglobin saturation or heart rate between assessment settings., Conclusion: Exercise capacity assessment using the 3-min step test is feasible and accurate via remote videoconferencing in adults with CF., (© 2013 Daedalus Enterprises.)

Background: Interstitial lung disease encompasses a diverse group of chronic lung conditions characterised by distressing dyspnoea, fatigue, reduced exercise tolerance and poor health-related quality of life. Exercise training is one of the few treatments to induce positive changes in exercise tolerance and symptoms, however there is marked variability in response. The aetiology and severity of interstitial lung disease may influence the response to treatment. The aims of this project are to establish the impact of exercise training across the range of disease severity and to identify whether there is an optimal time for patients with interstitial lung disease to receive exercise training., Methods/design: One hundred and sixteen participants with interstitial lung disease recruited from three tertiary institutions will be randomised to either an exercise training group (supervised exercise training twice weekly for eight weeks) or a usual care group (weekly telephone support). The 6-minute walk distance, peripheral muscle strength, health-related quality of life, dyspnoea, anxiety and depression will be measured by a blinded assessor at baseline, immediately following the intervention and at six months following the intervention. The primary outcome will be change in 6-minute walk distance following the intervention, with planned subgroup analyses for participants with idiopathic pulmonary fibrosis, dust-related interstitial lung disease and connective-tissue related interstitial lung disease. The effects of disease severity on outcomes will be evaluated using important markers of disease severity and survival, such as forced vital capacity, carbon monoxide transfer factor and pulmonary hypertension., Discussion: This trial will provide certainty regarding the role of exercise training in interstitial lung disease and will identify at what time point within the disease process this treatment is most effective. The results from this study will inform and optimise the clinical management of people with interstitial lung disease., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12611000416998.

Background: A paucity of studies has examined the effect of exercise training after left ventricular assist device (LVAD) implantation. Previous research has demonstrated that insertion of the LVAD alone improves exercise capacity and quality of life (QOL). This study investigated whether supervised exercise training results in a further improvement., Methods: This prospective, randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis investigated the effect of exercise training on exercise capacity and QOL in 14 patients who underwent LVAD insertion as a bridge to heart transplantation. Exercise training consisted of 8 weeks of gym-based aerobic and strengthening exercises 3 times a week, with a progressive mobilization program, compared with the control group that completed mobilization alone. Exercise capacity was measured before and after the intervention using maximal cardiopulmonary exercise testing and 6-minute walk distance (6MWD). QOL was measured using the Short Form 36-item assessment., Results: No adverse events were reported. There was a trend toward greater improvement in peak oxygen consumption (Vo(2)), 6MWD, and QOL in the exercise group (n = 7) compared with the control group (n = 7); however, no significant between-group difference was detected for improvements in peak Vo(2) [mean difference (exercise--control)] of 2.96 ml/kg/min (95% confidence interval, -1.04 to 6.97), 6MWD at 54 meters (-51 to 159 meters), and QOL scores over time (p > 0.05)., Conclusion: Exercise training is feasible and safe in patients with a LVAD. Trends toward greater improvement in exercise capacity and QOL after exercise training warrant further investigation in a larger trial., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Background: The 3-minute step test is a simple test of exercise capacity for children with cystic fibrosis (CF), but no data have been reported regarding its usefulness in adults or its prognostic value., Objective: To determine the feasibility and acceptability of the 3-minute step test as a test of exercise capacity in adults with CF and whether test performance is associated with 12-month clinical outcomes., Methods: From our out-patient clinic we prospectively recruited consecutive adult patients with CF in stable health. The 3-minute step test was conducted with a standardized protocol that included a 15-cm high step and external pacing at 30 steps/min. We measured heart rate, dyspnea, and S(pO(2)). With multiple linear regression analyses we assessed the relationships between step-test performance and change in FEV(1) and hospital days at 12 months., Results: The participants were 101 adults: 56 male, mean ± SD age 29 ± 9 years, percent-of-predicted FEV(1) 61 ± 23%, body mass index 22 ± 4 kg/m(2). Only 42% of the participants with mild CF achieved 70% of the predicted maximum heart rate during the 3-minute step test, compared to 77% of those with FEV(1) < 60% of predicted. The 22 patients who desaturated to < 90% during the 3-minute step test had a larger number of hospital days over the following 12 months than did those who did not (median 28 d vs 11 d, P < .001). Those who desaturated also had a greater FEV(1) decline (mean difference -117 mL, 95% CI -215 to -19 mL). Desaturation during the 3-minute step test was an independent predictor of both FEV(1) decline and days spent in hospital., Conclusions: Desaturation during the 3-minute step test is associated with long-term pulmonary deterioration and more hospital days in adults with CF. The 3-minute step test may be a useful screening test for patients with moderate to severe CF lung disease, who require increased intervention and monitoring.

There is limited information about the benefits of pulmonary rehabilitation (PR) in patients with bronchiectasis. This study aimed to evaluate the effects of an out-patient PR program in patients with a primary diagnosis of bronchiectasis and to compare them with a matched COPD group who completed the same PR program. A retrospective review was conducted of patients with bronchiectasis or COPD who completed 6 to 8 weeks of PR at two tertiary institutions. The outcome measures were the 6-minute walk distance (6MWD) and Chronic Respiratory Disease Questionnaire (CRQ). Ninety-five patients with bronchiectasis completed the PR (48 male; FEV(1) 63 [24] % predicted; age 67 [10] years). Significant improvements in 6MWD (mean change 53.4 m, 95% CI 45.0 to 61.7) and CRQ total score (mean change 14.0 units, 95% CI 11.3 to 16.7) were observed immediately following PR. In patients with complete follow-up (n = 37), these improvements remained significantly higher than baseline at 12 months (20.5 m, 95% CI 1.4 to 39.5 for 6MWD; 12.1 points, 95% CI 5.7 to 18.4 for CRQ total score). The time trend and changes in the 6MWD and CRQ scores were not significantly different between the bronchiectasis and the COPD groups (all p > 0.05). This study supports the inclusion of patients with bronchiectasis in existing PR programs. Further prospective RCTs are warranted to substantiate these findings.

Objective: To establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD)., Design: Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD., Setting: Outpatient pulmonary rehabilitation program at 2 teaching hospitals., Participants: Seventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9 y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104 m)., Interventions: Not applicable., Main Outcome Measures: Participants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD., Results: The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change (P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20-61 m). There was excellent agreement with distribution-based methods (25.5-26.5m, kappa=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85)., Conclusions: The MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Exercise limitation is a cardinal feature of the interstitial lung diseases and is frequently associated with marked dyspnoea on exertion. People with interstitial lung disease exhibit a rapid, shallow breathing pattern during exercise that worsens as disease progresses. Despite this, ventilatory mechanics are not the major limitation to exercise in most patients, with impaired gas exchange and circulatory limitation playing a more important role. Peripheral and respiratory muscle dysfunction may also contribute to impaired exercise tolerance, either due to systemic manifestations of the underlying disease, treatment side-effects or deconditioning. Measures of exercise capacity or desaturation obtained from maximal and submaximal exercise tests are good predictors of survival in patients with idiopathic pulmonary fibrosis. However, to date few pharmaceutical treatments have affected exercise outcomes despite improvements in other important clinical markers. Supplemental oxygen acutely improves exercise capacity in interstitial lung disease and is recommended for hypoxic patients, although quality of life or survival benefits have not yet been demonstrated. Exercise training improves walking capacity and dyspnoea in short-term trials and is useful to maximize functional capacity. The role of exercise testing in the routine management of patients with interstitial lung disease is not clearly defined. However, given the poor prognosis in patients with idiopathic pulmonary fibrosis and the marked variation in clinical course, assessment of exercise capacity may provide useful information for both clinicians and patients when evaluating the risks and benefits of new treatments. The extent of resting or exercise-induced hypoxia in patients with interstitial lung disease may influence the selection of an appropriate exercise test, and oxygen administration should be standardized on repeat testing.

Study Design: Prospective, observational study., Objectives: To determine the proportion of patients with non-traumatic spinal cord injury (NTSCI) who regain the ability to walk and to describe walking outcomes with reference to three commonly used clinical measures of walking capacity., Setting: Spinal Rehabilitation Unit specializing in NTSCI, Melbourne, Australia., Methods: Demographic, clinical and mobility data collected from a consecutive cohort of patients admitted to the spinal rehabilitation unit between March 2006 and December 2007. Main outcome measures were the Timed Up And Go (TUG), the 10-m walk test (10 mWT) and the 6-min walk test (6MWT). Logistic regression analysis was conducted to explore predictors of walking ability after NTSCI., Results: Of 62 patients, 30 (48%) regained some capacity to walk during inpatient rehabilitation. Initial ASIA grade was the strongest predictor of walking. Twenty-seven patients regained the ability to perform functional tests (TUG, 10 mWT and 6MWT) of walking at approximately 2 months after injury. Their performance at discharge remained low compared with normal scores but were similar to those measured in some studies of subjects with traumatic spinal cord injury (TSCI)., Conclusion: Three simple clinical tests of walking suggest that half of all NTSCI patients are able to walk at discharge from inpatient rehabilitation. Their gait speed, however, remained impaired and not compatible with safe and efficient community walking.

Background: The 6-Minute Walk Test (6MWT) is a widely used measurement of functional exercise capacity in chronic lung disease. While exercise intolerance has been identified in patients with bronchiectasis, the clinical determinants of the 6MWT in this population have not been examined. The aim of this study was to 1) establish the relationship between the 6-Minute Walk Distance (6MWD), disease severity and Health-Related Quality of Life (HRQOL) and 2) identify predictors of exercise tolerance in adults with bronchiectasis., Methods: The 6MWT was performed in 27 patients with bronchiectasis (mean [SD] FEV(1) 73.9% predicted [23.4]). Disease severity was assessed using spirometry and HRCT scoring while HRQOL was evaluated using the St George's Respiratory Questionnaire (SGRQ) and the Short-Form 36 (SF-36). The relationships were evaluated using correlation and multiple regression., Results: The 6MWD correlated positively with FVC (r=0.52, p<0.01), generations of bronchopulmonary divisions (r(s)=0.38, p<0.05) and SF-36 physical summary (r=0.71, p<0.001) while a negative correlation was observed between all domains of the SGRQ (all correlations r>0.5, p<0.001). Multiple regression analysis indicated that the SGRQ activity, symptom scores and generations of bronchial divisions involved were identified as independent predictors of the 6MWD, explaining 76% of the variance., Conclusions: Measures of HRQOL demonstrated a stronger association with the 6MWD compared to physiological measures of disease severity in patients with predominantly mild to moderate bronchiectasis.

Background: Interstitial lung disease (ILD) is characterised by exertional dyspnoea, exercise limitation and reduced quality of life. The role of exercise training in this diverse patient group is unclear. The aims of this study were to establish the safety of exercise training in ILD; its effects on exercise capacity, dyspnoea and quality of life; and whether patients with idiopathic pulmonary fibrosis (IPF) had similar responses to those with other types of ILD., Methods: 57 subjects with ILD (34 IPF) were randomised to receive 8 weeks of supervised exercise training or weekly telephone support. The 6 min walk distance (6MWD), incremental exercise test, modified Medical Research Council (MRC) dyspnoea score and Chronic Respiratory Disease Questionnaire (CRDQ) were performed at baseline, following intervention and at 6 months., Results: 80% of subjects completed the exercise programme and no adverse events were recorded. The 6MWD increased following training (mean difference to control 35 m, 95% CI 6 to 64 m). A significant reduction in MRC score was observed (0.7 points, 95% CI 0.1 to 1.3) along with improvements in dyspnoea (p = 0.04) and fatigue (p<0.01) on the CRDQ. There was no change in peak oxygen uptake; however, exercise training reduced heart rate at maximum isoworkload (p = 0.01). There were no significant differences in response between those with and without IPF. After 6 months there were no differences between the training and control group for any outcome variable., Conclusions: Exercise training improves exercise capacity and symptoms in patients with ILD, but these benefits are not sustained 6 months following intervention.