Joseph Ward
Dartmouth–Hitchcock Medical Center
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COPD: Journal of Chronic Obstructive Pulmonary Disease | 2004
Donald A. Mahler; Joseph Ward; Gustavo Fierro-Carrion; Laurie A. Waterman; Timothy F. Lentine; Roberto Mejia-Alfaro; John C. Baird
In this study we developed self‐administered versions of modified baseline and transition dyspnea indexes and compared the scores obtained by this method with the mean value obtained by two trained interviewers. Twenty‐five patients (14 males/11 females) with chronic obstructive disease who had a chief complaint of “breathlessness” were tested. Age was 66 ± 11 years; forced expiratory volume in one second was 48 ± 23% predicted. The baseline total scores were 5.0 ± 1.8 for the interviewers and 5.4 ± 2.0 for the self‐administered method. For the baseline dyspnea scores the correlations were 0.83 (p < 0.0001) between self‐administration and the mean value of two interviewers and 0.75 (p < 0.0001) between the two interviewers. The transition total scores, obtained an average of 102 days (range, 7–377 days) later, were − 0.1 ± 3.0 for the interviewers and − 0.4 ± 3.0 for the self‐administered method. For the transition dyspnea scores the correlations were 0.94 (p < 0.0001) between self‐administration and the mean value of two interviewers and 0.83 (p < 0.0001) between the two interviewers. The self‐administered dyspnea scores had similar correlations with measures of lung function as did the interview dyspnea scores. We conclude that self‐administered versions of the modified baseline and transition dyspnea indexes provide comparable scores as those obtained by trained and experienced interviewers. The advantages of the self‐administered versions include standardized methodology and computerized scoring.
Chest | 2009
Donald A. Mahler; Joseph Ward; Laurie A. Waterman; Corliss McCusker; Richard ZuWallack; John C. Baird
BACKGROUND Although questionnaires are used frequently with patients to self-report the severity of dyspnea as related to activities of daily living, the reliability of these instruments has not been established. The two purposes of this study were to examine the test-retest reliability of three widely used dyspnea instruments and to compare dyspnea scores at different stages of disease. METHODS At paired baseline visits, 101 stable patients with COPD were tested; at paired follow-up visits at 3 months, 89 of these patients were tested. At each visit, patients rated dyspnea with three instruments presented in random order and then performed post-bronchodilator therapy lung function tests. RESULTS Patient-reported dyspnea scores and lung function were similar at baseline (interval, 6 +/- 5 days) and follow-up visits (interval, 4 +/- 2 days). Intraclass correlation coefficients at baseline and at follow-up were 0.82 and 0.82, respectively, for the modified Medical Research Council scale; 0.90 and 0.84, respectively, for the self-administered computerized versions of the baseline dyspnea index and transition dyspnea indexes; and 0.95 and 0.89 for the University of San Diego Shortness of Breath Questionnaire results. Dyspnea ratings were significantly related to the stage of disease severity based on percent predicted FEV(1) (p < 0.001). CONCLUSIONS Test-retest reliability was acceptable for patient-reported dyspnea scores using three clinical instruments at baseline and at the 3-month follow-up. Our results demonstrate for the first time that patient-reported dyspnea ratings are related to the stage of disease severity.
Medicine and Science in Sports and Exercise | 1991
Donald A. Mahler; Bernadette Hunter; Timothy Lentine; Joseph Ward
The purpose of this study was to investigate the hypothesis that locomotor-respiratory coupling (LRC), or entrainment of breathing, develops in the sport of rowing as a result of training. We prospectively evaluated exercise responses over an 8 month training session (October to May) in 12 female subjects who were members of the Dartmouth College novice rowing team. Progressive, incremental exercise testing was performed on the variable-resistance rowing ergometer (Concept II, Morrisville, VT). To relate the pattern of breathing to the mechanics of rowing, the catch and finish of each rowing stroke during the last 30 s of each minute of exercise were marked on the strip chart paper that recorded inspiratory flow measured by using a heated pneumotachograph. Age was 18 +/- 1 yr (mean +/- SE); weight was 67.5 +/- 2.1 kg. Peak oxygen consumption (VO2) increased by 10% from October (40.8 +/- 0.6 ml.kg.min-1) to May (P less than 0.001). Chi-square goodness-of-fit analysis was used to assess whether the proportion of inspirations occurring in each of four quadrants of circle plots representing repetitive rowing strokes exercise intensities of 100 watts (W) and peak VO2 were random or corresponded to a regular pattern of breathing. Although 5 of 12 subjects demonstrated LRC at exercise of 100 W in October, there was no significant change at this submaximal intensity over the training season. Only 2 of 12 subjects showed LRC at peak exercise in October, but there was a significant increase (P = 0.003) in the number of subjects who entrained breathing in Jan (10/12) and May (8/12).(ABSTRACT TRUNCATED AT 250 WORDS)
Medicine and Science in Sports and Exercise | 2003
Donald A. Mahler; Joseph Ward; Roberto Mejia-Alfaro
PURPOSE The purpose of this study was to examine whether patients with chronic obstructive pulmonary disease (COPD) would report similar ratings of dyspnea at the same relative exercise intensity after participation in pulmonary rehabilitation. METHODS Forty-two patients with COPD performed incremental cardiopulmonary exercise testing before and after completion of a 6-wk exercise-training program. Subjects rated dyspnea on the 0-10 category-ratio (CR-10) scale each minute of the exercise test. RESULTS Both responders (21 patients who exhibited an increase in [OV0312]O(2peak) after pulmonary rehabilitation) and nonresponders (21 patients who had no increase in [OV0312]O(2peak)) reported slightly lower ratings of dyspnea ( approximately 0.5 on the CR-10 scale) at the same relative (50% and 75% of [OV0312]O(2peak)) exercise intensities. These changes in dyspnea ratings after pulmonary rehabilitation were not significantly different between responders and nonresponders. CONCLUSION The study suggests that patients with COPD can use the same ratings of dyspnea to monitor training at the same relative exercise intensity whether they achieve a physiological training response or not.
Medicine and Science in Sports and Exercise | 1987
Richard A. Rosiello; Donald A. Mahler; Joseph Ward
The purpose of this investigation was to evaluate the cardiovascular responses to rowing. In the first part of the study, heart rate (HR) and cardiac output (Q) were measured at rest and at three steady-state exercise levels on the variable-resistance rowing ergometer in 10 female and 11 male subjects. Q was determined non-invasively by the equilibration method of CO2 re-breathing, and stroke volume (SV) was calculated. Subjects varied in rowing ability from healthy, inexperienced rowers to competitive athletes. The linear relationships between Q and oxygen consumption for the women (r = 0.57; P less than 0.001; slope = 5.2 +/- 1.1) (mean +/- SD) and the men (r = 0.58; P less than 0.001; slope = 6.1 +/- 1.4) were similar to published values for other types of upright exercises. For both mean and women, SV increased from rest to the first level of exercise, and then reached a plateau at or before the second exercise intensity. Between the second and third levels of exercise, SV decreased significantly in the female subjects (107 +/- 18 vs 94 +/- 16 ml; P less than 0.05), but not in the male subjects (128 +/- 1 1 vs 126 +/- 15 ml; P = not statistically significant). In the second part of the study, HR, Q, and SV were compared on the cycle and rowing ergometers on successive days in eight additional subjects. At similar levels of oxygen consumption and Q, HR was significantly higher, and SV was significantly lower during rowing exercise than with cycle exercise.(ABSTRACT TRUNCATED AT 250 WORDS)
Chest | 2009
James Murray; Laurie A. Waterman; Joseph Ward; John C. Baird; Donald A. Mahler
BACKGROUND Although the cycle ergometer is the traditional mode for exercise testing in patients with respiratory disease, this preference over the treadmill does not consider perceptual responses. Our hypotheses were as follows: (1) the regression slope between breathlessness and oxygen consumption (Vo(2)) is greater on the treadmill than on the cycle ergometer; and (2) the regression slope between leg discomfort and Vo(2) is greater on the cycle ergometer than on the treadmill. METHODS Twenty patients (10 men/10 women) with COPD (mean +/- SD postbronchodilator FEV(1), 50 +/- 15% of predicted) used a continuous method to report changes in breathlessness and in leg discomfort during cycle and treadmill exercise. RESULTS Patients reported an earlier onset of breathlessness and leg discomfort during cycling. Peak ratings of breathlessness were higher on the treadmill, whereas peak ratings of leg discomfort were higher on the cycle ergometer. The regression slopes for breathlessness as a function of Vo(2) and of minute ventilation (Ve) were higher on the treadmill. The regression slopes between leg discomfort and Vo(2) were similar for treadmill and cycle exercise. Peak Vo(2) was significantly higher with treadmill exercise (mean Delta = 8%; p = 0.002). CONCLUSIONS Patients with COPD exhibit different perceptual and physiologic responses during treadmill walking and cycling. Although ratings of breathlessness are initially higher with cycling at equivalent levels of Vo(2), the changes in breathlessness as a function of physiologic stimuli (Vo(2) and Ve) are greater during treadmill exercise. Leg discomfort is the predominant symptom throughout cycling.
Journal of Cardiopulmonary Rehabilitation | 1997
Alejandra Ramírez-Venegas; Joseph Ward; Elaine M. Olmstead; Anna N. A. Tosteson; Donald A. Mahler
PURPOSE This study investigated the possible mechanisms for the expected improvement in dyspnea with pulmonary rehabilitation. METHODS Lung function, clinical ratings of dyspnea, and exercise responses were studied in 44 patients with chronic obstructive pulmonary disease who participated in an outpatient program consisting of 1.5 hours per week of supervised education, breathing training, and upper/lower extremity exercise. RESULTS After rehabilitation, there were significant increases in forced expiratory volume in 1 second (FEV1, 7%; P = .02), maximal inspiratory mouth pressure (PImax, 17%; P < .001), and the transition dyspnea index focal score (3.4; P < .001) and a significant decrease in the slope of dyspnea/power (0.12 versus 0.09; P = .001) during exercise. Patients who demonstrated > or = 0 mL of change in FEV1 or > or = 5 cm H2O of change in PImax exhibited significant decreases in the slopes for dyspnea/power. CONCLUSIONS After pulmonary rehabilitation, there was a significant improvement in dyspnea. Although there was no evidence of a physiologic training response or enhanced mechanical efficiency, the modest increase in FEV1 and the increase in respiratory muscle strength appeared to contribute to the reduction in dyspnea.
Chest | 2011
Donald A. Mahler; Alex H. Gifford; Laurie A. Waterman; Joseph Ward; Sasa Machala; John C. Baird
BACKGROUND Patients with COPD exhibit greater oxyhemoglobin desaturation during walking than with cycling. The purpose of this investigation was to investigate differences in ventilatory responses and gas exchange as proposed mechanisms for this observation. METHODS Arterial blood gas and lactate levels were measured in 12 patients with COPD (aged 68 ± 6 years) during incremental treadmill and cycle exercise. The primary outcome to assess the ventilatory response to exercise was Pao₂. The primary outcome to assess impairment in exercise gas exchange was the difference between partial pressures of alveolar and arterial oxygen (Pao₂ - Pao₂). RESULTS Pao₂ in patients was significantly lower at peak exercise for treadmill walking (51.4 ± 6.8 mm Hg) compared with cycling (60.4 ± 10.7 mm Hg) (P = .002). The initial increase in Pao₂ with cycling occurred prior to the onset of the anaerobic threshold. At peak exercise, Pao₂ was significantly higher with cycling compared with walking (P = .004). The anaerobic threshold occurred at a lower oxygen consumption during cycling than walking (P = .001), and peak lactate levels were higher with cycling (P = .019). With progressive exercise, Pao₂ - Pao₂ increased similarly during treadmill and cycle exercise. CONCLUSIONS The higher Pao₂ during cycling minimized the magnitude of oxyhemoglobin desaturation compared with walking. The enhanced respiratory stimulation during cycling appears due to an initial neurogenic process, possibly originating in receptors of exercising muscles, and a subsequent earlier onset of anaerobic metabolism with higher lactate levels during cycling.
COPD: Journal of Chronic Obstructive Pulmonary Disease | 2011
Alex H. Gifford; Donald A. Mahler; Laurie A. Waterman; Joseph Ward; William J. Kraemer; Brian R. Kupchak; John C. Baird
Background: Endogenous opioids are naturally occurring peptides released by the brain in response to noxious stimuli. Although these naturally occurring peptides modulate pain, it is unknown whether endogenous opioids affect the perception of breathlessness associated with a specific respiratory challenge. The hypothesis is that intravenous administration of naloxone, used to block opioid signaling and inhibit neural pathways, will increase ratings of breathlessness during resistive load breathing (RLB) in patients with chronic obstructive pulmonary disease (COPD). Methods: Fourteen patients with COPD (age, 64 ± 9 years) inspired through resistances during practice sessions to identify an individualized target load that caused ratings of intensity and/or unpleasantness of breathlessness ≥ 50 mm on a 100 mm visual analog scale. At two intervention visits, serum beta-endorphins were measured, naloxone (10 mg/25 ml) or normal saline (25 ml) was administered intravenously, and patients rated the two dimensions of breathlessness each minute during RLB. Results: Patient ratings of intensity (p = 0.0004) and unpleasantness (p = 0.024) of breathlessness were higher with naloxone compared with normal saline. Eleven patients (79%) reported that it was easier to breathe during RLB with normal saline (p = 0.025). RLB led to significant increases in serum beta-endorphin immunoreactivity and decreases in inspiratory capacity. There were no significant differences in physiological responses between interventions. Conclusions: Endogenous opioids modulate the intensity and the unpleasantness of breathlessness in patients with COPD. Differences in breathlessness ratings between interventions were clinically relevant based on the patients’ global assessment.
Research Quarterly for Exercise and Sport | 1987
Donald A. Mahler; Bruce E. Andrea; Joseph Ward
Abstract Only limited information is available evaluating exercise performance on the rowing ergometer with other standard methods of testing. To further investigate physiologic capacity and cardiorespiratory responses during rowing, we compared results from progressive, incremental exercise to exhaustion on the variable-resistance rowing ergometer and on the cycle ergometer in 17 untrained female subjects and 12 collegiate women rowers. Maximal oxygen consumption ([Vdot]RO2max) was significantly greater on the cycle ergometer (M3.4 ± 0.3 1 [mdot] min-1) compared to the rowing ergometer (M3.2 ± 0.2 1 [mdot] min-1) for the rowers (p = .01), but there was no difference for this variable between the two types of exercise in the untrained group. Maximal oxygen-pulse (O2-pulsemax) was significantly greater during exercise on the cycle ergometer in the oarswomen (p = .03). Oxygen consumption ([Vdot]RO2) at the ventilatory threshold (VT) was identical for cycling (1.4 ± 0.2 1 [mdot] min-1) and rowing (1.4 ± 0.2 ...