Sue Jenkins

Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis

A systematic review and meta-analysis was conducted to examine the effect of exercise training on daily physical activity (PA) in people with chronic obstructive pulmonary disease (COPD). MEDLINE, PubMed, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials were searched from their inception to week 27 of 2010, using the keywords ‘COPD,’ ‘exercise,’ ‘therapy’ and ‘physical activity.’ All studies except case reports were eligible for inclusion provided they investigated the effects of ≥4 weeks of supervised exercise training on PA in patients with COPD. Study quality for the randomised trials (RTs) and single-group interventional studies was rated using the PEDro scale and Downs and Black Tool, respectively. No randomised controlled trials met our study criteria. The two RTs had a mean PEDro score of 5. The 5 single-group studies had a mean Downs and Black score of 19 ± 3. When combined, a small effect on PA outcomes was demonstrated (overall mean effect = 0.12; p = 0.01). Taken together, the RTs and single-group studies demonstrate that exercise training may confer a significant but small increase in PA.

Six-minute walk distance in healthy Singaporean adults cannot be predicted using reference equations derived from Caucasian populations.

Objectives:  The 6‐min walk test (6MWT) is commonly used to assess the functional exercise capacity of individuals with cardiopulmonary disease. Recent studies have established regression equations to predict the 6‐min walk distance (6MWD) in healthy Caucasian populations; however, regression equations have yet to be established for the Singaporean population. The aim of this study was to determine 6MWD in healthy Singaporeans and identify contributors to 6MWD in this population. We also compared measured 6MWD with predicted 6MWD from two regression equations derived in Caucasian subjects.

High-intensity inspiratory muscle training in COPD

The aim of the present study was to investigate the effects of an interval-based high-intensity inspiratory muscle training (H-IMT) programme on inspiratory muscle function, exercise capacity, dyspnoea and health-related quality of life (QoL) in subjects with chronic obstructive pulmonary disease. A double-blind randomised controlled trial was performed. Sixteen subjects (11 males, mean forced expiratory volume in one second (FEV1) 37.4±12.5%) underwent H-IMT performed at the highest tolerable inspiratory threshold load (increasing to 101% of baseline maximum inspiratory pressure). Seventeen subjects (11 males, mean FEV1 36.5±11.5%) underwent sham inspiratory muscle training (S-IMT) at 10% of maximum inspiratory pressure. Training took place three times a week for 8 weeks and was fully supervised. Pre- and post-training measurements of lung function, maximum inspiratory pressure, maximum threshold pressure, exercise capacity, dyspnoea and QoL (Chronic Respiratory Disease Questionnaire; CRDQ) were obtained. H-IMT increased maximum inspiratory pressure by 29%, maximum threshold pressure by 56%, 6-min walk distance by 27 m, and improved dyspnoea and fatigue (CRDQ) by 1.4 and 0.9 points per item, respectively. These changes were significantly greater than any seen following S-IMT. In conclusion, high-intensity inspiratory muscle training improves inspiratory muscle function in subjects with moderate-to-severe chronic obstructive pulmonary disease, yielding meaningful reductions in dyspnoea and fatigue.

Differences in Response to Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis and Chronic Obstructive Pulmonary Disease

Background: The benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) are well recognized. However, whether individuals with idiopathic pulmonary fibrosis (IPF) benefit is less clear. Objectives: To evaluate the effects of pulmonary rehabilitation in subjects with IPF and compare their responses with a group of COPD subjects who underwent an identical program. Methods: For- ty-five subjects with IPF and 45 age- and Medical Research Council grade-matched COPD subjects were recruited. Subjects completed an 8-week outpatient pulmonary rehabilitation program. Dyspnea, peripheral muscle force, exercise capacity (6-min walk distance, 6MWD), activities of daily living, and health status (36-item short-form survey, SF-36) were assessed at baseline, immediately following and at 6 months following completion of the program. Results: Adherence to the program was similar in both groups. Significant improvements in dyspnea, muscle force, exercise capacity and ADL were observed in both groups (all p < 0.05); however, the magnitude of improvement in all outcomes was less in the IPF group [mean (95% CI) improvement in 6MWD, IPF 16.2 (7.1–25.4); COPD 53.1 (44.9–61.2)]. All domains of SF-36, with the exception of social function, improved (all p < 0.05) in the COPD group; however, there were no changes in SF-36 scores in the IPF group. The benefits were well maintained in the COPD group at 6 months, but, with the exception of the ADL score, the benefits were no longer present in the IPF group. Conclusions: Pulmonary rehabilitation in IPF produces only modest short-term gains in dyspnea, exercise capacity and ADL, but does not improve health status.

Regression equations to predict 6-minute walk distance in middle-aged and elderly adults

Six-minute walk distance (6MWD) is commonly used as a measure of functional exercise capacity in clinical practice and research. Regression equations to predict 6MWD in healthy individuals are available, but the equations predict distances that vary considerably for an individual. The aims of this study were to 1) measure 6MWDs in healthy Caucasian Australians aged 45-85 years; 2) determine whether evidence exists for Australian-specific prediction equations for Caucasian individuals by comparing measured 6MWDs with predicted 6MWDs derived by using published regression equations; and 3) develop regression equations for males and females. One hundred nine subjects (48 males) completed the 6-minute walk test (6MWT). Measurements of height, leg length, weight, habitual physical activity, and peak heart rate (HR) achieved during the 6MWT were obtained. 6MWD (better of two tests) was 682 ± 73 m (mean ± SD) and 643 ± 70 m in the males and females, respectively (p<0.01). Published regression equations underestimated 6MWDs in female subjects. Gender-specific regression equations using age and anthropometric data explained 40% and 43% of the variance in 6MWD in males and females, respectively. Validation of the regression equations in a prospective subject cohort is required.

Improvements in Symptoms and Quality of Life following Exercise Training in Older Adults with Moderate/Severe Persistent Asthma

Background: Some individuals with moderate/severe persistent asthma develop irreversible airway obstruction. These individuals present with dyspnoea, exercise intolerance and impaired quality of life (QOL), all of which could potentially be alleviated with exercise training. Objective: To investigate whether exercise training improves functional exercise capacity and QOL in middle-aged and older adults with fixed airway obstruction asthma (FAOA). Methods: 35 subjects aged 67.8 ± 10.6 years, with FEV1 59 ± 16% of predicted, were randomised to a 6-week ‘intervention’ period of supervised exercise training (n = 20) or usual care (n = 15). This period was preceded by a 3-week run-in period during which asthma control was assessed weekly. Functional exercise capacity (6-min walk distance, 6MWD) and QOL (Asthma QOL Questionnaire, AQLQ) were measured before, immediately following and 3 months after the intervention period. Results: 34 subjects (exercise group, n = 19, and control group, n = 15) completed the intervention period. Relative to the control group, the exercise group had greater improvements immediately following and 3 months after the intervention in the AQLQ symptom domain (0.61, p = 0.001, and 0.57 points per item, p = 0.005) and AQLQ activity limitation domain (0.43, p = 0.04, and 0.55 points per item, p = 0.04). 6MWD increased (36 ± 37 m, p < 0.01) in the exercise group immediately following training and remained elevated (34 ± 45 m, p < 0.01) at the 3-month follow-up. The magnitude of change in 6MWD between groups was not significant, despite no change in the control group. Conclusions: Supervised exercise training improves symptoms and QOL in adults with FAOA.

Acute lobar atelectasis: A comparison of five physiotherapy regimens

Thirty-five patients with acute lobar atelectasis were allocated to one of five treatment groups (seven patients per group). Intubated patients received manual hyperinflation and suction with or without the addition of postural drainage or modified postural drainage and chest wall vibrations. For the non-intubated patients, deep breathing, coughing and huffing replaced the techniques of manual hyperinflation and suction. Frequency of treatment ranged from hourly for 6 h for four groups, to one treatment only for the fifth group. The results suggest that modified postural drainage is an effective additional component to manual hyperinflation and suction performed hourly for 6 h. The addition of chest wall vibrations to this treatment regimen did not further enhance the response to treatment, nor did the use of traditional postural drainage positions. There was evidence that hourly treatment for 6 h using modified postural drainage, manual hyperinflation and suction was more effective than one treatment only.

Maintaining exercise capacity and quality of life following pulmonary rehabilitation

Objective:  The optimum method for sustaining the benefits gained from pulmonary rehabilitation (PR) has not been determined. In this report the authors describe the 4‐year referral and uptake patterns to a hospital‐based outpatient PR programme, and the sustained benefits of PR in patients with COPD attending a community‐based maintenance exercise programme.

The active cycle of breathing techniques--to tip or not to tip?

The active cycle of breathing techniques (ACBT) in gravity-assisted drainage positions is an effective airway clearance regimen for individuals who produce excess bronchial secretions. This study compared the ACBT in positions with and without a head-down tilt. Nineteen subjects (11 men), mean age 37.1 years (range 18-76 years), with bronchiectasis who produced more than 20 g of sputum per day and had a mean forced expiratory volume in 1 s (FEV1) of 56.9% predicted (range 23-90% pred.) were studied. There was no significant difference in the wet weight of sputum expectorated when using the ACBT in gravity-assisted drainage positions with or without a head-down tilt. Mean (SD) score for perception of breathlessness, measured on a visual analogue scale, increased significantly following treatment with a head-down tilt [2.3 (1.6) to 3.3 (2.0) cm, P = 0.02]. There was no significant difference in oxygenation or lung function (FEV1). Eighteen subjects preferred the ACBT without a head-down tilt. The ACBT in the horizontal position is a simple airway clearance regimen suitable for individuals who produce greater than 20 g of sputum per day. Subjects were less breathless and preferred the ACBT in the horizontal position, thus providing a treatment alternative that may improve adherence in individuals who are required to carry out daily airway clearance treatments.

State of the art : How to set up a pulmonary rehabilitation program

Pulmonary rehabilitation plays an essential role in the management of symptomatic patients with COPD. The benefits of rehabilitation include a decrease in dyspnoea and fatigue, and improvements in exercise tolerance and health‐related quality of life. Importantly, rehabilitation reduces hospitalization for acute exacerbations and is cost‐effective. Although most of the evidence for pulmonary rehabilitation has been obtained in patients with COPD, symptomatic individuals with other respiratory diseases have been shown to benefit. In this review we outline a stepwise approach to establish, deliver and evaluate a pulmonary rehabilitation program (PRP) that would be feasible in most settings. Throughout the review we have specified the minimum requirements for a PRP to facilitate the establishment of programs using limited resources. Recommendations for staffing and other resources required for a PRP are presented in the first section. Exercise training is a focus of the section on program delivery as this is the component of rehabilitation that has the strongest level of evidence for benefit. Program considerations for patients with respiratory conditions other than COPD are described. Different approaches for delivering the education component of a PRP are outlined and recommendations are made regarding topics for group and individual sessions. The problems commonly encountered in pulmonary rehabilitation, together with recommendations to avoid these problems and strategies to assist in their resolution, are discussed. The review concludes with recommendations for evaluating a PRP.