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Chronic Obstructive Pulmonary Disease (COPD) is usually characterized by a progressive decline of lung function. We reported the 10 years follow-up of an elderly man, a heavy smoker with severe COPD and apical bullous emphysema. During 6 months pulmonary rehabilitation program the patient’s clinical state improved significantly and it associated with a steep increase in forced expiratory volume in one second (FEV1). This case report elaborates on the unexpected gain of FEV1 in the follow-up of a COPD patient. [ABSTRACT FROM AUTHOR]

Inspiratory muscle fatigue (IMF) may contribute to the development of exercise limitation and respiratory failure. Identifying fatigue of the inspiratory muscles requires a rigorous and integrative methodological approach. However, there is no consensus about an optimal protocol to induce and assess the fatigability of the inspiratory muscles. A systematic review was performed to identify, evaluate, and summarize the literature related to the assessment of induced IMF in healthy individuals. The aim was to identify factors that are related consistently to IMF, as well as to suggest possible assessment methods. MEDLINE and EMBASE were searched for relevant articles until February 2012. Only studies with a quantitative description of assessment and outcome were included. The search yielded 460 citations and a total of 77 studies were included. Inspiratory muscle fatigue was produced acutely by inspiratory resistive loading (IRL), whole body exercise (WBE), hyperpnea, or WBE combined with IRL, and under normocapnic, hypoxic or hypercapnic conditions. To detect IMF, most studies (64%) used phrenic nerve stimulation, 44% used a maximal voluntary inspiratory maneuver and the remainder used electromyography. The heterogeneity of the published reports precluded a quantitative analysis. Inspiratory resistive loadings at intensities of 60-80% of maximum, and cycling at 85% of maximum were found to produce IMF most consistently. Hypoxic or hypercapnic conditions, and WBE combined with IRL, exacerbated IMF. The specific outcome measures employed to detect IMF, the magnitude of their change, as well as their functional significance, are ultimately dependent upon the research question being addressed. [ABSTRACT FROM AUTHOR]

Summary: Background: Physical activity (PA) has been reported to be reduced in severe chronic obstructive pulmonary disease (COPD). Studies in moderate COPD are currently scarce. The aim of the present study was to investigate physical activity in daily life in patients with COPD (n =70) and controls (n =30). Methods: A multi-center controlled study was conducted. PA was assessed using a multisensor armband device (SenseWear, BodyMedia, Pittsburgh, PA) and is reported as the average number of steps per day, and the time spent in mild and moderate physical activity. Results: Patients suffered from mild (n =9), moderate (n =28), severe (n =23) and very severe (n =10) COPD. The time spent in activities with mild (80±69min vs 160±89min, p <0.0001) and moderate intensity (24±29min vs 65±70min; p <0.0036) was reduced in patients compared to controls. The number of steps reached 87±34%, 71±32%, 49±34% and 29±20% of control values in GOLD-stages I to IV respectively. The time spent in activities at moderate intensity was 53±47%, 41±45%, 31±47% and 22±34% of the values obtained in controls respectively with increasing GOLD-stage. These differences reached statistical significance as of GOLD stage II (p <0.05). No differences were observed among centers. Conclusions: Physical activity is reduced early in the disease progression (as of GOLD-stage II). Reductions in physical activities at moderate intensity seem to precede the reduction in the amount of physical activities at lower intensity. [Copyright &y& Elsevier]

Summary: Background: Long-term functional outcome of diaphragm paralysis is largely unknown. Methods: A retrospective study was conducted in 23 consecutive patients (21 males, 56±9 years) with uni- or bilateral diaphragm paralysis to examine whether functional respiratory recovery can be predicted from the compound motor action potential (CMAP) of the diaphragm at the time of diagnosis. Pulmonary function and CMAP were evaluated at baseline and at follow-up. CMAP amplitude and latency were recorded by surface electromyography with percutaneous electrical stimulation of the phrenic nerve. Patients were followed for (median) 15 months up to 131 months (range 5–131). Functional respiratory recovery was defined as an increase in forced vital capacity >400ml. Results: Functional recovery occurred in 43% of the patients after 12 months (10 out of 23) and in 52% after 24 months (12 out of 23). Type and etiology of paralysis did not influence recovery. CMAP, anthropometric characteristics and baseline pulmonary function did not predict functional respiratory recovery. Whether respiratory muscle training improved pulmonary function is uncertain. Moreover, it did not result in a greater percentage functional respiratory recovery. Relapse after an initial improvement was observed in 26% of the patients. Conclusions: The present study indicates that functional recovery of diaphragm paralysis is difficult to predict and may occur years after the onset of the paralysis. [Copyright &y& Elsevier]

Abstract: Pulmonary rehabilitation has become part of the evidence-based care in patients with COPD who remain symptomatic and have reduced participation in everyday life, after optimal medical treatment. Pulmonary rehabilitation is—by definition—a multidisciplinary intervention. By consequence the assessment of patients before entering a rehabilitation program includes both physiological and psychosocial assessment. In addition nutritional status and physical activity participation needs to be assessed. Effects of pulmonary rehabilitation are clinically relevant and include effects on the above-mentioned dimensions. In general the effects of pulmonary rehabilitation are larger than the minimal clinically important difference and rehabilitation programs have shown to be highly cost-effective. This review focuses on the exercise training intervention. Different training modalities (endurance, interval and resistance training) are discussed and different ‘supplements’ are highlighted (oxygen, non-invasive mechanical ventilation, testosterone and inspiratory muscle training) along with their suggested indications for use. Lastly other interventions which may also be part of the rehabilitation program are briefly discussed. [Copyright &y& Elsevier]

Abstract: Pitta F, Troosters T, Spruit MA, Decramer M, Gosselink R. Activity monitoring for assessment of physical activities in daily life in patients with chronic obstructive pulmonary disease. Objective: To investigate the degree of agreement between different methods of assessing physical activities in daily life in patients with chronic obstructive pulmonary disease (COPD): video recordings (criterion standard), the DynaPort Activity Monitor (DAM), and patient self-report. Design: Study A: outcomes from video recordings were compared with DAM outcomes and with patient estimation of time spent on each activity after a 1-hour protocol including walking, cycling, standing, sitting, and lying. Study B: DAM outcomes and patient self-report were compared during 1 day in real life. Setting: Outpatient clinic in a university hospital. Participants: Study A: 10 patients with COPD (mean age, 62±6y; forced expiratory volume in the first second [FEV1]=40%±16% of predicted). Study B: 13 patients with COPD (mean age, 61±8y; FEV1=33%±10% of predicted). Interventions: Not applicable. Main Outcome Measures: Time spent on different activities and movement intensity during walking and cycling. Results: Study A: time estimated by the patients in the sitting position was significantly lower than the time showed by the video recordings and the DAM (both P<.001). For the other variables, there were no statistically significant differences (all P>.05). However, Bland and Altman plots and intraclass correlation coefficients showed large disagreement between video recordings and patients’ estimations, in contrast to the high degree of agreement between video recordings and DAM. Changes in walking speed correlated highly to changes in DAM movement intensity (r=.81, P<.01). Study B: patients significantly overestimated walking time (22±47min, P=.04) and underestimated standing time (–45±71min, P=.04). Conclusions: The DAM showed high accuracy in objectively assessing time spent on different activities and changes in walking speed in patients with COPD. Patients’ estimations of time spent on physical activities in daily life disagreed with objective assessment. [Copyright &y& Elsevier]

Abstract: Trappenburg JC, Troosters T, Spruit MA, Vandebrouck N, Decramer M, Gosselink R. Psychosocial conditions do not affect short-term outcome of multidisciplinary rehabilitation in chronic obstructive pulmonary disease. Objectives: To characterize patients referred for pulmonary rehabilitation on a large number of psychologic and sociodemographic variables and to determine the contribution of these variables on the response to rehabilitation. Design: Cross-sectional, explorative. Setting: University hospital and outpatient clinic. Participants: Eighty-one consecutive patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 40%±16% of predicted) were included in outpatient pulmonary rehabilitation. Intervention: Multidisciplinary rehabilitation program. Main Outcome Measures: Pulmonary function, exercise capacity (Wmax, 6-minute walk test [6MWT]), Chronic Respiratory Disease Questionnaire (CRDQ), Modified Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]) were assessed before and after 3 months rehabilitation. In addition, psychosocial adjustment, social support, marital status, mode of transportation, education, employment, and smoking status were assessed at the start of the rehabilitation. Results: Rehabilitation improved exercise performance (Wmax, 6±12W; P<.01; 6MWT, 41±72m; P<.001), quality of life (CRDQ score, 12±13 points; P<.001), functional status (PFSDQ-M activity score, −8±11 points; PFSDQ-M dyspnea score, −6±12 points; PFSDQ-M fatigue score, −4±8 points; all P<.01), HADS anxiety score (−2±3 points, P<.01), and HADS depression score (−3±3 points, P<.001). In single regression analysis, only baseline depression was weakly negatively correlated with the change in maximal workload. No other relations of initial psychologic or sociodemographic variables with outcome were observed. Conclusions: The effects of rehabilitation are not affected by baseline psychosocial factors. Patients with less favorable psychologic or sociodemographic conditions can also benefit from pulmonary rehabilitation. The multidisciplinary approach of the rehabilitation program might have contributed to this improvement. [Copyright &y& Elsevier]

Patients with chronic obstructive pulmonary disease (COPD) suffer frequently from physiologic and psychological impairments, such as dyspnea, peripheral muscle weakness, exercise intolerance, decreased health-related quality of life (HRQOL) and emotional distress. Rehabilitation programmes have shown to result in significant changes in perceived dyspnea and fatigue, utilisation of healthcare resources, exercise performance and HRQOL. Exercise training, which consists of whole-body exercise training and local resistance training, is the cornerstone of these programmes. Regrettably, the positive effects of respiratory rehabilitation deteriorate over time, especially after short programmes. Hence, attention should be given to the aftercare of these patients to prevent them to revert again to a sedentary lifestyle. On empirical basis three possibilities seem to be clinically feasible: (1) continuous outpatient exercise training; (2) exercise training in a home-based or community-based setting; or (3) exercise training sessions in a group of asthma and COPD patients. [Copyright &y& Elsevier]

Summary: Exacerbations of COPD have a profound detrimental effect on the patient and impose a significant burden on healthcare resource utilization. Prevention and treatment of exacerbations are major objectives of the clinical management of COPD. For this approach to be successful, clinicians must combine both pharmacologic approaches and non-pharmacologic strategies aimed at improving the patient''s disease management. Non-pharmacologic approaches include those that can be incorporated into the office setting as well as intervention strategies that are integrated into the lifelong management of COPD. These strategies include developing a partnership with the patient and their social supports, encouraging and facilitating smoking cessation, immunizations, proper use of supplemental oxygen, and most importantly, giving the patient the tools to manage their illness appropriately. Moreover there is clear evidence of an irrevocable decline in pulmonary function after each exacerbation, usually resulting in reduced physical activity and impaired skeletal muscle function. Not surprisingly, pulmonary rehabilitation after such events has been shown to prevent relapse, improve survival and enhance patients'' overall function after acute exacerbations. [Copyright &y& Elsevier]

• Physical fitness only slowly/incompletely recovers after transplantation. • High-intensity training (HIT) restores physical fitness (general population). • Data on HIT among different types of transplantation are lacking. • A 6-month, cycling-based HIT program for different transplant types was developed. • Cardiorespiratory fitness was temporarily improved in all transplant types post-HIT. Organ transplantation is a life-saving intervention that improves quality of life of patients with irreversible organ failure. Although exercise training immediately after transplantation has been suggested to be beneficial, such interventions remain rare in stable transplant recipients, whereas effects of high-intensity training (HIT) are even less frequently investigated. Moreover, sustainability of such interventions has not yet been reported. We investigated the effects of a 6-month, cycling-based HIT program on physical performance in long-term stable solid organ transplant (SOT) recipients, with follow-up evaluation after 6 months. Forty-two adult, stable, and selected SOT recipients participated in a 6-month individualized home- and group-based HIT program. Exercise capacity (VO 2 max), maximal power (Wmax), and body mass index were measured before, at the end, and 6 months after completion of the intervention. The study comprised 12 heart, 7 lung, 8 liver, and 15 kidney recipients (mean age, 41.4 ± 11.1 years; median time posttransplant, 3.4 [1.7-8.0] years). For 6 months, VO 2 max increased in the heart, lung, and kidney groups, Wmax increased in the heart group, and body mass index decreased in the liver group. Six months after the HIT program, the achieved gain in exercise capacity had disappeared in all groups. Despite voluntary participation selection bias, our observations indicate that HIT is safe and may result in a beneficial effect on physical performance in selected, stable SOT recipients. However, there was no sustained beneficial effect once training stopped. Larger scale and longer term studies are still required to investigate longevity of improvement and overall beneficial effects on clinical outcomes. [ABSTRACT FROM AUTHOR]

Highlights: [•] Diaphragm fatigability was examined in 10 low back pain patients and 10 controls. [•] Low back pain patients show a greater susceptibility to diaphragm fatigue. [•] Diaphragm fatigue may be a potential factor in the etiology of low back pain. [Copyright &y& Elsevier]

Background: Reduced physical fitness has been reported to occur after lung transplantation. Pre- and post-transplant factors, including an inactive lifestyle, have been proposed as possible causes. However, daily physical activity has not been objectively assessed so far in lung recipients. The purpose of this study was to objectively measure daily physical activity in lung recipients. Methods: Twenty-two clinically stable patients with single (n = 7) and bilateral lung grafts (n = 15) underwent measurements of physical activity with activity monitors at least 12 months after surgery. Results were compared with findings from 22 healthy, age- and gender-matched control subjects. Results: Substantial and statistically significant differences in daily activity were observed. Steps, standing time and moderate-intensity activity of lung recipients were reduced by 42%, 29% and 66%, respectively, relative to controls. Daily sedentary time was increased by 30%. Daily steps correlated with self-reported physical functioning (r = 0.81), 6-minute walk distance (r = 0.68), quadriceps force (r = 0.66) and maximum workload (r = 0.63). Conclusions: This study has shown for the first time that daily activity is substantially reduced after lung transplantation and related to measures of physical fitness and health-related quality of life. Future studies need to examine whether physical activity can be modified to improve functional recovery after lung transplantation. [Copyright &y& Elsevier]