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Purpose: Although pulmonary rehabilitation (PR) improves function in people with chronic obstructive pulmonary disease (COPD), a community-based exercise program may be necessary to maintain functional capacity. We aimed to determine the effectiveness of a post-rehabilitation, community-based maintenance program on exercise tolerance, functional capacity and quality of life., Methods: Patients with COPD who completed PR were randomized to receive a community-based maintenance program (intervention) or usual care (control). The primary outcome was 6-min walk distance (6MWD), measured immediately post-PR, 6 months and 12 months later. Secondary outcomes included self-reported functional capacity, health-related quality of life, self-efficacy, program cost, and lower extremity muscle strength., Results: Ninety-seven patients (69 ± 9 years) were enrolled. There was a non-significant trend of an intervention effect on 6MWD over time (β = 42, 95% CI: 0.06 to 83.93, p = 0.053). There was no significant impact of group on any of the secondary outcomes. Restricting the analysis to those who attended ≥50% of the exercise sessions showed a significant intervention effect for 6MWD (β = 69.19, 95% CI = 10.16 to 128.22, p = 0.03). The cost of participating in the community maintenance program for the intervention group was $374.77 (SD 142.12) and membership renewal was highest at community centres offering twice weekly, supervised exercise classes., Conclusions: A post rehabilitation, community-based exercise program, will maintain exercise capacity in people with COPD who attend at least 50% of available sessions over one year. An increased focus on factors that determine adherence would help inform improvements in maintenance program design., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: Exercise is an effective treatment for reducing symptom severity and improving quality of life for patients with chronic respiratory diseases. Active video games offer a new and enjoyable way to exercise and have gained popularity in a rehabilitation setting. However, it is unclear whether they achieve comparable physiological and clinical effects as traditional exercise training., Methods: A systematic literature search was performed to identify studies that included an active video game component as a form of exercise training and a comparator group in chronic respiratory disease. Two assessors independently reviewed study quality using the Cochrane risk of bias tool and extracted data for exercise capacity, quality of life, and preference of exercise model., Results: Six studies were included in this review. Because of the heterogeneity of the populations, study designs, length of intervention, and outcome measures, meta-analysis could not be performed. Active video game training resulted in comparable training maximal heart rate and dyspnea levels to those achieved when exercising using a treadmill or cycle (n = 5). There was insufficient evidence (n = 3) to determine whether active video game training improved exercise capacity as measured by 6-min walk test or treadmill endurance walking., Conclusions: Although the quality of evidence was low, in a small number of studies active video games induced peak heart rates and dyspnea levels comparable with traditional exercise training. Larger and longer-term randomized controlled trials are needed to establish the impact of video game training for individuals with chronic respiratory diseases.

Background: As exercise may mitigate cognitive decline in individuals with chronic obstructive pulmonary disease (COPD), its effect has been evaluated in a number of clinical trials. The objective of the present systematic review was to describe the impact of exercise training on cognition in COPD., Methods: Electronic searches of four databases were performed from inception until March 24, 2015 and last updated 23rd October 2017. Included studies reported on at least one cognitive outcome before and after a formal exercise-training program in individuals with COPD. Two reviewers independently rated study quality using the Downs and Black checklist. The protocol was registered on PROSPERO (CRD42015017884)., Results: Seven articles, representing six exercise interventions in 293 individuals with COPD (55% males, mean age 67 ± 2 year) were included. Although each study documented a significant pre-post training improvement in at least one cognitive domain, the heterogeneity in study design, exercise intervention and cognitive outcome measures among studies precluded a meta-analysis. The only randomized controlled trial available reported an improvement on a letter verbal fluency task in the exercise group only., Conclusions: Exercise training may positively impact cognition in COPD patients, but current evidence is limited by the heterogeneity of study design, exercise intervention and cognitive outcome measures. Future studies should emphasize comprehensive reporting of intervention parameters, including program length, type(s) of exercise, and duration of individual sessions, in order to facilitate applied insights to inform replication and/or program development., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Rationale: In patients with chronic obstructive pulmonary disease (COPD), partitioned exercise training using one-legged cycling leads to greater improvements in peak oxygen uptake than conventional two-legged cycling., Objectives: We evaluated the feasibility of incorporating one-legged cycling as the principal aerobic training modality for pulmonary rehabilitation in COPD., Methods: Physiotherapists underwent four teaching sessions about the principles and practical implementation of one-legged cycling training. Patients enrolled in a pulmonary rehabilitation program underwent 6-8 weeks of training in which one-legged cycling three times per week was the principal aerobic exercise activity. Participants cycled for 15 minutes with each leg, in each session. An incremental cardiopulmonary exercise test was completed before and after pulmonary rehabilitation along with standard pulmonary rehabilitation outcome measures. Participants and physiotherapists completed a satisfaction survey at the end of the program., Measurements and Main Results: A total of 22 out of 32 participants (14 male; mean [SD] age, 66 [7] years; FEV1% predicted, 32 [17]%; median [interquartile range] Medical Research Council dyspnea scale, 3.5 [3.0-4.3]) completed pulmonary rehabilitation. Peak oxygen uptake increased 1.1 (0.4-1.7) ml·min(-1)·kg(-1) (8%) from baseline (P<0.01). The mean (95% confidence interval) 6-minute-walk test distance improved by 72 (45-98) m (P=0.001). The change in the Chronic Respiratory Questionnaire total score of 1.6 (1.1-2.1; P<0.001) was achieved by improvement in all four domains above the clinically important difference. All the physiotherapists considered one-legged cycling safe and would continue to prescribe it; 75% of participants would recommend it to other patients., Conclusions: One-legged cycling was successfully implemented into a "real-life" pulmonary rehabilitation program, demonstrating improvements in cardiorespiratory fitness with associated improvement in function for patients with moderate/severe COPD. One-legged cycling should be recommended in professional pulmonary rehabilitation guidelines as an option for exercise training and be available in other pulmonary rehabilitation programs. Clinical trial registered with www.clinicaltrials.gov (NCT01930526).

Background: We have recently demonstrated the efficacy of balance training in addition to Pulmonary Rehabilitation (PR) at improving measures of balance associated with an increased risk of falls in individuals with Chronic Obstructive Pulmonary Disease (COPD). Few knowledge translation (KT) projects have been conducted in rehabilitation settings. The goal of this study was to translate lessons learnt from efficacy studies of balance training into a sustainable clinical service., Methods: Health care professionals (HCPs) responsible for delivering PR were given an hour of instruction on the principles and practical application of balance training and the researchers offered advice regarding; prescription, progression and practical demonstrations during the first week. Balance training was incorporated three times a week into conventional PR programs. Following the program, HCPs participated in a focus group exploring their experiences of delivering balance training alongside PR. Service users completed satisfaction surveys as well as standardized measures of balance control. At six month follow-up, the sustainability of balance training was explored., Results: HCPs considered the training to be effective at improving balance and the support provided by the researchers was viewed as helpful. HCPs identified a number of strategies to facilitate balance training within PR, including; training twice a week, incorporating an interval training program for everyone enrolled in PR, providing visual aids to training and promoting independence by; providing a set program, considering the environment and initiating a home-based exercise program early. Nineteen service users completed the balance training [ten male mean (SD) age 73 (6) y]. Sixteen patients (84%) enjoyed balance training and reported that it helped them with everyday activities and 18 (95%) indicated their wish to continue with it. Scores on balance measures improved following PR that included balance training (all p < 0.05). At six month follow-up balance training is being routinely assessed and delivered as part of standardised PR., Conclusions: Implementing balance training into PR programs, with support and training for HCPs, is feasible, effective and sustainable., Trail Registration: Clinical Trials ID: NCT02080442 (05/03/2014).

Background: Cardiorespiratory fitness, assessed during cardiopulmonary exercise tests by peak oxygen uptake (Vo2pk), is an independent predictor of mortality in obesity. We investigated whether Vo2pk and systemic responses measured during field walking tests were similar to those measured during an incremental treadmill test (ITMT) in obese individuals with treated OSA., Methods: Individuals with treated OSA and a BMI > 30 kg/m2 were recruited. Participants completed an ITMT, two 6-min walk tests (6MWTs), and two incremental shuttle walk tests (ISWTs) on three separate days in a randomized order. Expired gas analysis was performed during all tests., Results: The study was completed by 16 patients (nine men) (mean [SD] age, 58 [12] y; BMI, 36.1 [7.6] kg/m2). There was no difference (P = .27) in Vo2pk assessed by the ITMT and the ISWT (2,266 [478] and 2,017 [561] mL/min, respectively). The Vo2pk measured by the 6MWT (1,778 [360] mL/min) was lower than that measured by the ITMT (P < .01). The limits of agreement for Vo2pk between the ISWT and the ITM were ± 730 mL/min. Cardiorespiratory responses during the ISWT and the ITMT reflected a graded response to a peak, whereas the 6MWT demonstrated a rapid rise to a plateau., Conclusions: The ISWT can be used instead of an ITMT and in preference to the 6MWT to assess cardiorespiratory fitness for a cohort of obese people with treated OSA. However, the imprecision of the agreement in Vo2pk between the ITMT and ISWT means they cannot be used interchangeably in an individual., Trial Registry: ClinicalTrials.gov; No.: NCT01930513; www.clinicaltrials.gov.

Background: The success of pulmonary rehabilitation (PR) is established, but how to sustain benefits over the long term is less clear. The aim of this systematic review was to determine the effect of supervised exercise programs after primary PR on exercise capacity and health-related quality of life (HRQL) in individuals with COPD., Methods: Randomized controlled trials of postrehabilitation supervised exercise programs vs usual care for individuals with COPD were identified after searches of six databases and reference lists of appropriate studies. Two reviewers independently assessed study quality. Standardized mean differences (SMDs) with 95% CIs were calculated using a fixed-effect model for measures of exercise capacity and HRQL., Results: Seven randomized controlled trials, with a total of 619 individuals with moderate to severe COPD, met the inclusion criteria. At 6-month follow-up there was a significant difference in exercise capacity in favor of the postrehabilitation interventions (SMD, -0.20; 95% CI, -0.39 to -0.01), which was not sustained at 12 months (SMD, -0.09; 95% CI, -0.29 to 0.11). There was no difference between postrehabilitation interventions and usual care with respect to HRQL at any time point., Conclusions: Supervised exercise programs after primary PR appear to be more effective than usual care for preserving exercise capacity in the medium term but not in the long term. In this review, there was no effect on HRQL. The small number of studies precludes a definitive conclusion as to the impact of postrehabilitation exercise maintenance on longer-term benefits in individuals with COPD.

Background: Although the short-term benefits of pulmonary rehabilitation (PR) are well established, improvements in exercise tolerance and health status diminish over time. The objectives of this study were to determine the feasibility and within-subject effects of a 1-year community-based maintenance exercise program for patients with COPD following completion of hospital-based PR., Methods: A single-arm longitudinal study was undertaken. After completion of PR, consecutive patients with COPD were recruited to attend a twice weekly exercise program supervised by fitness consultants at a local community centre. The transition from hospital to the community was facilitated by a case manager. Outcome measurements at baseline (pre-PR), post-PR, 6-months and 1-year included the 6-minute walk test (6MWT) for exercise capacity and the Chronic Respiratory Questionnaire (CRQ) for health-related quality of life. Feasibility was assessed primarily through subject adherence., Results: A total of 29 patients (mean age 66.8 ± 7.8 years, mean FEV1 45.1 ± 18.8 percent predicted) were enrolled in the program. Mean compliance to twice weekly exercise was 70%. No adverse events were reported. Statistically significant and clinically important improvements in the 6MWT and CRQ total and dyspnea domain were observed at 6-months and 1-year after PR compared to baseline (all p < 0.01)., Conclusions: A community-based maintenance exercise program is feasible and can successfully preserve exercise capacity and health-related quality of life following institutionally-based PR in patients with moderate to severe COPD. A more formal evaluation of this approach is warranted., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Patients with chronic respiratory diseases often have the simple goal of wanting to walk for longer. We evaluated the properties of a patient goal-oriented, symptom-limited, self-paced walk (SPW)., Methods: Patients with symptomatic chronic respiratory disease, referred for a 6-week course of pulmonary rehabilitation (PR), were screened for eligibility. Baseline assessments included two SPWs with both time and speed measured, two 6-min walk tests (6MWTs), and the Medical Research Council dyspnea scale. On program completion, two SPWs and one 6MWT were performed. The repeatability, responsiveness, and validity of the SPW were assessed., Results: Two SPWs were completed by 50 and 37 patients before and after rehabilitation, respectively. The speed (r = -0.54, P < .001) but not the time (r = -0.23, P = .19) of the SPW correlated with Medical Research Council dyspnea grade. The mean SPW time increased on the second day of testing from 15.1 ± 8.4 min to 17.9 ± 7.7 min (P = .004), and the effect of test day was unaltered by PR (P = .80). The coefficient of repeatability for SPW time was 16.1 min. Both the mean SPW time (10.6 min; 95% CI, 6.6-14.5 min; P < .001) and the mean speed (3.5 m/min; 95% CI, 1.3-5.7 m/min; P < .01) increased after rehabilitation., Conclusions: The SPW time is an easily understandable, patient goal-oriented assessment with construct validity that is highly responsive to the effects of PR. The variability in SPW time makes it better suited to interpreting group rather than individual changes., Trial Registry: ClinicalTrials.gov; No.: NCT00781183; URL: www.clinicaltrials.gov.

Objectives: To describe within-subject effects of pulmonary rehabilitation (PR) on balance in persons with chronic obstructive pulmonary disease (COPD) and to determine whether any observed changes in balance were associated with change in exercise tolerance or health-related quality of life., Design: Single-arm longitudinal study., Setting: Inpatient PR center., Participants: Subjects with COPD (N=29; mean +/- SD age, 69.8+/-10.3y; forced expiratory volume in 1 second, 46.3%+/-22.3% predicted; 59% men [n=17])., Interventions: A standardized 6-week multidisciplinary PR program (exercise training, breathing exercises, education, and psychologic support)., Main Outcome Measures: Balance was assessed using the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and the Activities-Specific Balance Confidence (ABC) scale. Exercise tolerance was determined from the 6-minute walk test (6MWT), and health-related quality of life from the Chronic Respiratory Questionnaire (CRQ)., Results: Subjects showed small improvements in BBS (2.8+/-2.8 points; P<.001) and TUG (-1.5+/-2.4s; P=.003) scores, but not in ABC scores (4.8+/-15.4 points; P>.05). There was a weak relationship between change in BBS and change in CRQ scores (r=.40; P=.045) and no relationship with change in 6MWT., Conclusions: PR contributed to minor improvements in balance and had no effect on balance confidence in subjects with COPD. Further work is warranted to determine the optimal intervention for improving balance in this population.

Background: In patients with chronic obstructive pulmonary disease (COPD), interval exercise has gained recent attention as a possible means of achieving greater physiological training effects compared with continuous exercise. The primary aim of this systematic review was to compare the effects of interval versus continuous training on peak oxygen uptake, peak power, 6 minute walk test (6MWT) distance and health-related quality of life in individuals with COPD., Methods: Randomised controlled trials comparing the effects of interval versus continuous training in patients with COPD were identified after searches of six databases and reference lists of appropriate studies in May 2009. Two reviewers independently assessed study quality. Weighted mean differences (WMD) with 95% CIs were calculated using a random effects model for measures of exercise capacity and health-related quality of life., Results: Eight randomised controlled trials, with a total of 388 patients with COPD, met the inclusion criteria. No significant differences were found for peak power (WMD 1 W, 95% CI -1 to 3) or peak oxygen uptake (WMD -0.04 l/min, 95% CI -0.13 to 0.05) between interval and continuous training. The WMD for the Chronic Respiratory Questionnaire dyspnoea score was -0.2 units (95% CI -0.5 to 0.0). There was no difference in 6MWT distance between groups (WMD 4 m, 95% CI -15 to 23)., Conclusions: Interval and continuous training modalities did not differ in their effect on measures of exercise capacity or health-related quality of life. Interval training may be considered as an alternative to continuous training in patients with varying degrees of COPD severity.

Background: The protocol used for the 6-min walk test (6MWT) influences its results. The only study to examine the effect of modifying track layout performed a retrospective analysis and concluded that institutions using continuous tracks yield greater distances than those using straight tracks. Agreement between the distances measured on different tracks could not be examined. We evaluated the effect of modifying track layout on walk distance and examined the agreement and repeatability of distances measured on different tracks., Methods: In a prospective, randomized, cross-over study, 27 COPD subjects (FEV(1), 38 +/- 14% [mean +/- SD]; 15 men) attended three separate test sessions, completing six 6MWTs. To familiarize all subjects with both tracks, the first two sessions comprised two 6MWTs on either a circular or straight track. During the final session, each subject was tested once on the straight and once on the circular track., Results: The distance walked on the circular track exceeded the straight track by 13 +/- 17 m (p < 0.001). The limit of agreement between tracks was 33 m. Coefficient of repeatability values when the test was completed on different days for the straight and circular tracks were 51 m and 65 m, respectively., Conclusions: When evaluating changes in 6-min walk distance in groups of patients, track layout should be standardized. However, the effect of modifying track layout on an individual's walking distance is small compared to their daily variability in walk distance. Therefore, standardizing track layout for any given individual may be inconsequential when evaluating the change in distances from tests performed on different days.

Background: Most patients with severe COPD are limited by dyspnea and are obliged to exercise at low intensity. Even those undergoing training do not usually have increased peak oxygen uptake (Vo2). One-legged exercise, at half the load of two-legged exercise, places the same metabolic demands on the targeted muscles but reduces the ventilatory load, enabling patients to increase work capacity. The purpose of this study was to determine whether one-legged exercise training would improve aerobic capacity compared with two-legged training in stable patients with COPD., Methods: Eighteen patients with COPD (mean FEV(1), 38 +/- 17% of predicted [+/- SD]) were randomized to two groups after completing an incremental exercise test. Both trained on a stationary cycle for 30 min, 3 d/wk, for 7 weeks. Two-legged trainers (n = 9) cycled continuously for 30 min, whereas one-legged trainers (n = 9) switched legs after 15 min. Intensity was set at the highest tolerated and increased with training., Results: Both groups increased their training intensity (p < 0.001) and total work (p < 0.001). After training, the change in peak Vo2 of the one-legged group (0.189 L/min; confidence interval [CI], 0.089 to 0.290 L/min; p < 0.001) was greater than that of the two-legged group (0.006 L/min; CI, - 0.095 to 0.106 L/min; p = 0.91). This was accompanied by greater peak ventilation (4.4 L/min; CI, 1.8 to 7.1 L/min; p < 0.01) and lower submaximal heart rate (p < 0.05) and ventilation (p < 0.05) in the one-legged trained group., Conclusion: Reducing the total metabolic demand by using one-legged training improved aerobic capacity compared with conventional two-legged training in patients with stable COPD.

Background: In patients with COPD, exercise intensity is often limited by the ventilatory system. We hypothesized that by exercising with a smaller muscle mass, ventilatory-limited patients would perform more high-intensity, muscle-specific work. The study objectives were as follows: (1) to determine the limitations of exercising with a smaller muscle mass, compared with conventional two-legged exercise; and (2) to determine the endurance time, using the same muscle-specific intensity, during one-legged vs two-legged exercise., Methods: Nine patients (mean +/- SD FEV1, 36 +/- 13% of predicted) completed incremental exercise, and nine other patients (mean FEV1, 42 +/- 16% of predicted) completed constant-power exercise. Nine healthy subjects (FEV1, 104 +/- 14% of predicted) completed both tests. All subjects completed tests using two-legged and one-legged pedaling., Results: Peak oxygen uptake (VO2peak) was similar during one-legged and two-legged incremental exercise among patients (difference, 0.03 L/min; 95% confidence interval [CI], -0.10 to 0.16 L/min; p = 0.60), as were ventilation and dyspnea scores. VO2peak was lower during one-legged vs two-legged exercise (-0.57 mL/min; 95% CI, -0.81 to -0.32 mL/min; p < 0.001) among healthy subjects with substantial ventilatory and heart rate reserve. Patients endured one-legged pedaling at a constant power longer than two-legged pedaling (16.97 min; 95% CI, 9.98 to 23.96 min; p < 0.001), resulting in greater work (12.48 kilojoules [kJ]; 95% CI, 2.58 to 22.39 kJ; p = 0.02). Healthy subjects completed similar work (-4.02 kJ; 95% CI, -18.59 to 10.55 kJ; p = 0.54) with one-legged vs two-legged pedaling., Conclusion: These observations demonstrate the effectiveness of using one-legged exercise at the same muscle-specific intensity in extending the duration of exercise among patients with COPD. This has important implications for training approaches designed to enhance exercise function among ventilatory-limited patients.

Pulmonary rehabilitation comprises a variety of interventions grouped into three main categories: exercise training, education, and psychological support. Typically, patients participate in a programme of exercise rehabilitation 2-3 times a week for 6-12 weeks, at the same time being encouraged to incorporate breathing and stretching exercises as part of their daily routine. The physiological rationale for pulmonary rehabilitation in COPD is primarily based on its effect on peripheral muscle dysfunction. A recent meta-analysis demonstrated that pulmonary rehabilitation is effective in reducing dyspnoea and fatigue as well as improving patients' sense of control (mastery) over their condition. Without compliance with a maintenance programme these improvements will diminish with time. The value of various components of rehabilitation, programme length, the required degree of supervision, the intensity of training and the best approach to maintaining programme adherence represent issues that remain to be explored.

The article focuses on a study which examined the effect of upper extremity resistance training on dyspnea while performing activity of daily living (ADL) among patients with chronic obstructive pulmonary disorder (COPD). The study included 36 patients with COPD who were randomized to undergo either arm resistance training or a sham. Study authors found that resistance-based arm training improved arm function, arm exercise capacity and muscle strength. However, such exercise did not improve dyspnea during ADL.