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Objective: To determine the response to a pulmonary rehabilitation (PR) program and minimal important differences (MIDs) for the Short Physical Performance Battery (SPPB) subtests and SPPB summary score in patients with chronic obstructive pulmonary disease (COPD)., Design: Retrospective analysis using distribution- and anchor-based methods., Setting: PR center in the Netherlands including a comprehensive 40-session 8-week inpatient or 14-week outpatient program., Participants: A total of 632 patients with COPD (age, 65±8y; 50% male; forced expiratory volume in the first second=43% [interquartile range, 30%-60%] predicted)., Interventions: Not applicable., Main Outcome Measure: Baseline and post-PR results of the SPPB, consisting of 3 balance standing tests, 4-meter gait speed (4MGS), and 5-repetition sit-to-stand (5STS). The chosen anchors were the 6-Minute Walk Test and COPD Assessment Test. Patients were stratified according to their SPPB summary scores into low-performance, moderate-performance, and high-performance groups., Results: 5STS (∆=-1.14 [-4.20 to -0.93]s) and SPPB summary score (∆=1 [0-2] points) improved after PR in patients with COPD. In patients with a low performance at baseline, balance tandem and 4MGS significantly increased as well. Based on distribution-based calculations, the MID estimates ranged between 2.19 and 6.33 seconds for 5STS and 0.83 to 0.96 points for SPPB summary score., Conclusions: The 5STS and SPPB summary score are both responsive to PR in patients with COPD. The balance tandem test and 4MGS are only responsive to PR in patients with COPD with a low performance at baseline. Based on distribution-based calculations, an MID estimate of 1 point for the SPPB summary score is recommended in patients with COPD. Future research is needed to confirm MID estimates for SPPB in different centers., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease characterized by airflow limitation and is associated with decreased balance and increased fall risk. Since falls are related to increased mortality, interventions targeting balance and fall risk could reduce morbidity and mortality. The objective of this review was to systematically assess the effects of exercise-based interventions on fall risk and balance in patients with COPD., Methods: PubMed, Web of Science, EMBASE, and CINAHL were screened for randomized controlled trails and within-group studies evaluating effects of exercise-based interventions on fall risk or balance in patients with COPD. Data were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement., Results: Fifteen studies were identified, 6 randomized controlled trails and 9 within-group studies. All interventions reported positive effects on balance outcomes. No studies reported fall risk. Taking current recommendations of balance outcome measures in patients with COPD into account, pulmonary rehabilitation combined with balance training had the highest effect size. Nine papers had concerns regarding bias, mostly due to the lack of blinding outcome assessors., Conclusions: Exercise-based interventions have a positive effect on balance in patients with COPD. Pulmonary rehabilitation with balance training seems to have the most beneficial effect on balance. The effects on fall risk, as well as the long-term intervention effects remain unclear. A standardized balance assessment and research on long-term effects and fall risk are recommended.

Introduction : Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team. Areas covered : The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed. Expert opinion : Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are common among patients attending pulmonary rehabilitation (PR) and may compromise its outcomes. Neuromuscular electrical stimulation (NMES) seems one of the few exercise modalities that can actually be continued during AECOPD, due to its low burden on the impaired respiratory and cardiovascular system. However, the quality of evidence is low. The purpose of this study was to assess the impact of mild-to-moderate AECOPD on adherence/outcomes of a high-frequency (HF) or low-frequency (LF) NMES training program, as part of inpatient PR, in severely dyspneic, weakened individuals with COPD. 62 patients who received NMES as the sole supervised muscle training modality during an 8-week PR program (HF-NMES: n = 33; LF-NMES: n = 29) were analyzed retrospectively. 48.4% experienced ≥1 AECOPD during PR and were classified as exacerbators. Exacerbators completed 75 NMES sessions (interquartile range: 73-78) and were able to increase training intensity with 24 mA (15-39), while non-exacerbators completed 76 sessions (73-79) and increased training intensity with 35 mA (22-50), with no between-group differences (p = 0.474 and p = 0.065, respectively). The median change in 6-min walking distance, cycle endurance time, and isokinetic quadriceps strength and endurance did not differ between the exacerbation and non-exacerbation group. To conclude, the occurrence of mild-to-moderate AECOPD during a PR program primarily focused on NMES, does not affect adherence, intensity, and clinical outcomes in patients with severe COPD. Continuing NMES seems a feasible way to potentially counteract exacerbation-related lower-limb muscle dysfunction and improve outcomes of PR, with HF-NMES being the preferential muscle training modality., Competing Interests: Declaration of competing interest FMEF reports grants and personal fees from AstraZeneca, personal fees from Boehringer Ingelheim, personal fees from Chiesi, personal fees from GlaxoSmithKline, grants and personal fees from Novartis, personal fees from TEVA, outside the submitted work; MAS reports grants from Lung Foundation Netherlands, during the conduct of the main study; EFMW reports grants from the Weijerhorst foundation Netherlands, during the conduct of the main study. RM, MJS, AAFS, HWHH, BB and PHK have nothing to disclose., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Chronic obstructive pulmonary disease (COPD) patients often experience lower limb muscle dysfunction and wasting. Exercise-based training has potential to improve muscle function and mass, but literature on this topic is extensive and heterogeneous including numerous interventions and outcome measures. This review uses a detailed systematic approach to investigate the effect of this wide range of exercise-based interventions on muscle function and mass. PUBMED and PEDro databases were searched. In all, 70 studies ( n = 2504 COPD patients) that implemented an exercise-based intervention and reported muscle strength, endurance, or mass in clinically stable COPD patients were critically appraised. Aerobic and/or resistance training, high-intensity interval training, electrical or magnetic muscle stimulation, whole-body vibration, and water-based training were investigated. Muscle strength increased in 78%, muscle endurance in 92%, and muscle mass in 88% of the cases where that specific outcome was measured. Despite large heterogeneity in exercise-based interventions and outcome measures used, most exercise-based trials showed improvements in muscle strength, endurance, and mass in COPD patients. Which intervention(s) is (are) best for which subgroup of patients remains currently unknown. Furthermore, this literature review identifies gaps in the current knowledge and generates recommendations for future research to enhance our knowledge on exercise-based interventions in COPD patients.

Background: Strength training and neuromuscular electrical stimulation (NMES) are effective training modalities for improving muscle function, exercise performance and health status in individuals with COPD. The aim of the present study was to analyze the metabolic load of these training modalities at baseline, half-way, and at the end of an eight-week interdisciplinary pulmonary rehabilitation program in a subgroup of individuals with COPD of the DICES trial., Methods: Of 24 individuals with COPD (FEV1: 34 ± 2% predicted, men: 58%, age: 66 (61-68) years), peak oxygen uptake (VO2), peak minute ventilation (VE), heart rate, oxygen saturation and symptom scores were assessed during HF-NMES (75 Hz), LF-NMES (15 Hz) and strength training at three moments during their pulmonary rehabilitation program., Results: Intervention-related peak VO2 did not change over time during HF-NMES, LF-NMES or strength training. Intervention-related peak VE did not change over time during strength training or LF-NMES and increased slightly, but significantly over time during HF-NMES. Peak VO2 and VE were significantly higher during strength training compared to HF-NMES or LF-NMES. Oxygen saturation significantly decreased after the first measurements during HF-NMES and strength training group to baseline, while no significant changes in oxygen saturation were observed during the other measurements. Heart rate significantly increased compared to baseline in all groups at all moments and was significantly higher after strength training compared to HF-NMES or LF-NMES. Median end scores (points) for dyspnea, fatigue and muscle pain ranged from 1 to 3, from 0.5 to 2 and from 0 to 6 after HF-NMES, from 2 to 3, from 2 to 5 and from 0 to 9 after LF-NMES and from 2 to 5, from 1.5 to 4 and from 0 to 28 after strength training respectively., Conclusions: To conclude, the metabolic load and symptom scores remain acceptable low over time with increasing training loads during HF-NMES, LF-NMES or strength training., Trial Registration: NTR2322.

Rationale: Strength training and neuromuscular electrical stimulation (NMES) improve lower-limb muscle function in dyspnoeic individuals with chronic obstructive pulmonary disease (COPD). However, high-frequency NMES (HF-NMES) and strength training have never been compared head-to-head; and effects of low-frequency NMES (LF-NMES) have never been studied in COPD. Therefore, the optimal training modality to improve lower-limb muscle function, exercise performance and other patient-related outcomes in individuals with severe COPD remains unknown., Objectives: To study prospectively the efficacy of HF-NMES (75 Hz), LF-NMES (15 Hz) or strength training in severely dyspnoeic individuals with COPD with quadriceps muscle weakness at baseline., Methods: 120 individuals with COPD (FEV1: 33±1% predicted, men: 52%, age: 64.8±0.8 years) were randomised to HF-NMES, LF-NMES or strength training as part of a comprehensive inpatient pulmonary rehabilitation programme. No treadmill walking or stationary cycling was provided., Measurements and Main Results: Groups were comparable at baseline. Quadriceps muscle strength increased after HF-NMES (+10.8 Newton-metre (Nm)) or strength training (+6.1 Nm; both p<0.01), but not after LF-NMES (+1.4 Nm; p=0.43). Quadriceps muscle endurance, exercise performance, lower-limb fat-free mass, exercise-induced symptoms of dyspnoea and fatigue improved significantly compared with baseline after HF-NMES, LF-NMES or strength training. The increase in quadriceps muscle strength and muscle endurance was greater after HF-NMES than after LF-NMES., Conclusions: HF-NMES is equally effective as strength training in severely dyspnoeic individuals with COPD and muscle weakness in strengthening the quadriceps muscles and thus may be a good alternative in this particular group of patients. HF-NMES, LF-NMES and strength training were effective in improving exercise performance in severely dyspnoeic individuals with COPD and quadriceps weakness., Trial Registration: NTR2322., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To develop normative values for right and left handgrip strength after stratification for confounders like gender, age, and height., Design: Cross-sectional, descriptive., Setting: General population., Participants: A total of 502,713 people living in the United Kingdom., Intervention: None., Measurements: Handgrip strength was measured using a Jamar hydraulic hand dynamometer, which is considered to be an accurate instrument to measure handgrip strength. In addition, self-reported chronic conditions and ethnic background were registered, and lung function was assessed using spirometry., Results: After exclusion of all individuals with missing data, a nonwhite ethnic background, the presence of 1 or more self-reported conditions, and/or an obstructive lung function (defined as FEV1/FVC <0.7), new normative values for right and left handgrip strength were derived from 224,830 and 224,852 individuals (54.2% women; age: 55.0 [8.0] years; height: 169.0 [9.2] cm; body mass index: 26.9 [4.4] kg/m(2)) with a nonobstructed spirometry (FEV1: 3.0 [0.8] L). Men were stronger than women. Moreover, significant associations were found between handgrip strength and height, and between handgrip strength and age. Finally, percentiles 5, 10, 25, 50, 75, 90, and 95 were calculated for right and left handgrip strength, after stratification for gender, age, and height., Conclusion: The UK Biobank dataset provided the opportunity to determine new normative values for handgrip strength in men and women aged 39 to 73 years. These normative values take into consideration age, height, and measurement side. Therefore, these new normative handgrip strength values are of broad clinical interest., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Transcutaneous neuromuscular electrical stimulation (NMES) can be applied as a complementary intervention to regular exercise training programs. A distinction can be made between high-frequency (HF) NMES and low-frequency (LF) NMES. In order to increase understanding of the mechanisms of functional improvements following NMES, the purpose of this study was to systematically review changes in enzyme activity, muscle fiber type composition and muscle fiber size in human lower-limb skeletal muscles following only NMES., Methods: Trials were collected up to march 2012 and were identified by searching the Medline/PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and The Physical Therapy Evidence Database (PEDro) databases and reference lists. 18 trials were reviewed in detail: 8 trials studied changes in enzyme activities, 7 trials studied changes in muscle fiber type composition and 14 trials studied changes in muscle fiber size following NMES., Results: The methodological quality generally was poor, and the heterogeneity in study design, study population, NMES features and outcome parameters prohibited the use of meta-analysis. Most of the LF-NMES studies reported significant increases in oxidative enzyme activity, while the results concerning changes in muscle fiber composition and muscle size were conflicting. HF-NMES significantly increased muscle size in 50% of the studies., Conclusion: NMES seems to be a training modality resulting in changes in oxidative enzyme activity, skeletal muscle fiber type and skeletal muscle fiber size. However, considering the small sample sizes, the variance in study populations, the non-randomized controlled study designs, the variance in primary outcomes, and the large heterogeneity in NMES protocols, it is difficult to draw definitive conclusions about the effects of stimulation frequencies on muscular changes.

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous respiratory disease with important extra-pulmonary features and comorbidities. The aim of this study was to assess clinical heterogeneity in a well-defined subgroup of individuals with COPD GOLD D, including possible gender differences., Methods: Pulmonary function, arterial blood gases, exercise performance, quadriceps muscle function, problematic activities of daily life, dyspnea, health status and comorbidities have been assessed in 117 individuals with a MRC dyspnea grade 4/5 and COPD GOLD D entering pulmonary rehabilitation., Results: A broad range of values were found for diffusion capacity, exercise capacity, quadriceps muscle function and health status. Indeed, the high coefficients of variation were found for these outcomes. Problematic activities of daily life as well as objectified comorbidities also varied to a great extent. Moreover, significant gender differences were found for exercise performance, lower-limb muscle function and various comorbidities., Conclusion: The current findings emphasize that COPD is a heterogeneous disease whose clinical presentation varies significantly, even in individuals with very severe COPD with the same degree of dyspnea and all classified as GOLD D., Trial Registration: NTR2322., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: The cardiopulmonary exercise test (CPET) and the 6-minute walk test (6MWT) are used to prescribe the appropriate training load for cycling and walking exercise in patients with chronic obstructive pulmonary disease (COPD). The primary aims were: (i) to compare estimated peak work rate (Wpeak(estimated)) derived from six existing Wpeak regression equations with actual peak work rate (Wpeak(actual)); and (ii) to derive a new Wpeak regression equation using six-minute walk distance (6MWD) and conventional outcome measures in COPD patients., Methods: In 2906 patients with COPD, existing Wpeak regression equations were used to estimate Wpeak using 6MWD and a new equation was derived after a stepwise multiple regression analysis., Results: The 6 existing Wpeak regression equations were inaccurate to predict Wpeak(actual) in 82% of the COPD patients. The new Wpeak regression equation differed less between Wpeak(estimated) and Wpeak(actual) compared to existing models. Still, in 74% of COPD patients Wpeak(estimated) and Wpeak(actual) differed more than (±) 5 watts., Conclusion: In conclusion, estimating peak work load from 6MWD in COPD is inaccurate. We recommend assessment of Wpeak using CPET during pre-rehabilitation assessment in addition to 6MWT.

Transcutaneous neuromuscular electrical stimulation (NMES) involves the application of an electrical current through electrodes placed on the skin over the targeted muscles. During high-frequency NMES (HF-NMES), oxygen uptake, minute ventilation, and the degree of symptom perception (dyspnea and fatigue) have been shown to be acceptable in chronic obstructive pulmonary disease (COPD). Currently, oxygen uptake and ventilation load have never been assessed during low-frequency NMES (LF-NMES) of the lower-limb muscles. The purpose of this study was to compare prospectively oxygen uptake, ventilation, and symptom perception during a single session of LF-NMES versus a single session of HF-NMES of quadriceps muscles in patients with COPD. In 17 COPD patients (mean FEV(1) = 45% predicted, mean body mass index = 26.2 kg/m(2)), peak exercise capacity, functional exercise capacity, and the Medical Research Council dyspnea grade were evaluated. In addition, oxygen uptake, minute ventilation, heart rate, and Borg symptom scores were assessed during one session of LF-NMES (15 Hz) and one session of HF-NMES (75 Hz) and compared with peak values. Mean oxygen uptake (LF-NMES: 327 ml/min vs. HF-NMES: 315 ml/min), minute ventilation (LF-NMES: 14 L vs. HF-NMES: 15 L), and heart rate (LF-NMES: 86 BPM vs. HF-NMES: 83 BPM) were similar during both NMES frequencies. Patients used a relatively low proportion of their peak aerobic capacity during both NMES sessions (LF-NMES: 34% vs. HF-NMES: 33%; P = 0.397). In addition, symptom Borg scores for dyspnea and leg fatigue were also comparable. Oxygen uptake, ventilation, and symptoms of dyspnea and fatigue were comparable and tolerable during LF-NMES and HF-NMES in patients with COPD. Therefore, LF-NMES and HF-NMES may both be suitable rehabilitative modalities to be used in severely dyspneic patients with lower-limb muscle dysfunction.

Resistance training and transcutaneous neuromuscular electrical stimulation (NMES) are new modalities in rehabilitation of severely disabled patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to compare the metabolic response during resistance training and during NMES of the quadriceps femoris muscles in patients with COPD entering pulmonary rehabilitation. Pulmonary function, body composition, peak aerobic capacity, the Medical Research Council dyspnoea grade, the one-repetition maximum strength assessment were evaluated in 13 COPD patients. Additionally, peak oxygen uptake, peak minute ventilation and Borg symptom scores were assessed during a resistance training session and a NMES session. The median peak oxygen uptake and median peak minute ventilation during the resistance training session were significantly higher compared to the NMES session. Additionally, these higher metabolic responses were accompanied by higher symptom Borg scores for dyspnoea and leg fatigue. To conclude, the metabolic response was significantly lower during a NMES session compared to a resistance exercise training session in patients with COPD. Nevertheless, both modalities seem to result in an acceptable metabolic response accompanied by a clinically acceptable sensation of dyspnoea and leg fatigue.