Egyptian Journal of Chest Diseases and Tuberculosis (2017) 66, 231–236

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Egyptian Journal of Chest Diseases and Tuberculosis

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Endurance and strength training in pulmonary

rehabilitation for COPD patients

Rasha Daabis a,*, Marwa Hassan b, Mohamed Zidan a

a
Dept. of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
b Dept. of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Received 13 May 2016; accepted 17 July 2016

Available online 8 October 2016

KEYWORDS
Abstract Objectives: This study aimed to evaluate whether strength training is a useful addition to
Early pulmonary rehabilita- aerobic training in an early pulmonary rehabilitation (PR) program implemented for patients with
tion; COPD. Also to assess the outcomes of this program on the patients’ symptoms, spirometry, peripheral
COPD; muscle strength, exercise capacity and health-related quality of life (HRQL).
Strength training; Endurance Patients and methods: The study included 45 patients hospitalized with acute exacerbation of COPD.
training; Combined exercise After receiving standard treatment for acute exacerbations, patients were randomly allo-cated to three
training; Outcomes groups. Besides medical treatment, the first two groups were assigned to an early PR program. Group1
performed endurance training (ET) alone, while group 2 performed combined training (CT) in the form
of endurance plus strength training. The third group received medical treatment only. Baseline and
outcome assessment included Medical Research Council dyspnea scale (mMRC), spirometry, peripheral
muscle strength by measuring one repetition maximum (1RM), 6 min walk test and HRQL using St.
George’s Respiratory Questionnaire.
Results: Both training modalities resulted in significant improvements in the degree of dyspnea, the
HRQL and the functional exercise capacity measured by 6MWT. The CT was associated with additional
improvements in peripheral muscle strength without increasing the duration of the train-ing sessions (P <
0.01).
Conclusion: PR is an effective intervention for the post-exacerbation management of COPD patients.
It leads to significant improvements of dyspnea, HRQL and functional exercise capacity. When added to
a program of ET, strength training confers additional benefits in muscle force, but not in overall exercise
capacity or health status.
2016 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

* Corresponding author at: Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alazarita, Alkhartoom Square, Egypt. E-mail addresses:
[email protected], [email protected] (R. Daabis).
Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.
http://dx.doi.org/10.1016/j.ejcdt.2016.07.003
0422-7638 2016 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
232 R. Daabis et al.

Introduction Another aim of the study was to assess the outcomes of this early
rehabilitation program on the patients’ symptoms, pul-monary
functions, peripheral muscle strength, exercise capac-ity and
Dyspnea, impaired exercise tolerance and reduced quality of life
health-related quality of life.
are common complaints in patients with chronic obstruc-tive
pulmonary disease (COPD) [1]. However, these features are often
impaired out of proportion to lung function impair-ment [2]. Patients and methods
Hence, therapies that improve the patient’s lung func-tion may
have a relatively limited impact on the above-mentioned The present study included 45 patients admitted to chest dis-eases
outcomes [3]. Other factors, such as peripheral muscle weakness, department, Alexandria Main University Hospital with a primary
deconditioning and impaired gas exchange, are now recognized as diagnosis of acute exacerbation of COPD.
important contributors to reduced exer-cise tolerance [4,5]. The diagnosis of COPD was made by a clinical course that is
consistent with chronic bronchitis and/or emphysema, a long
The consequences of exercise intolerance appear important to history of cigarette smoking, and pulmonary function test find-
COPD patients. Reduced exercise capacity and muscle weakness ings revealing irreversible airflow obstruction [12].
render these patients disabled with a high utilization of healthcare An exacerbation was diagnosed by a sustained worsening of
resources [6]. They refrain from their work due to their disease the patient’s respiratory symptoms, that is beyond day to day
and become socially isolated. Poor exercise capac-ity has also variations and leads to a change in medication [12]. The wors-
been shown to contribute to mortality [7]. ening of symptoms should be severe enough to warrant admis-
Optimal bronchodilatation can be seen as a first step in the sion to the hospital.
treatment of patients with chronic obstructive pulmonary dis-ease Exclusion criteria:
(COPD); however, greater treatment effects (e.g., improvements
in exercise performance, symptoms, and health-related quality of (1) Hypoxemic patients at rest or exercise.
life) are often achieved only after the addition of pulmonary (2) Comorbidity that could limit exercise training like car-
rehabilitation [8]. diovascular, musculoskeletal or neuromuscular diseases.
Comprehensive pulmonary rehabilitation programs aim at (3) Patients who attended a pulmonary rehabilitation pro-gram
tackling the systemic consequences of COPD, as well as the in the preceding year.
behavioral and educational deficiencies observed in many patients
[9]. All subjects were enrolled in the study after a written informed
Guidelines on the management of COPD published by the consent according to a protocol approved by the Ethics
National Institute for Clinical Excellence (NICE) and the Bri-tish Committee of the Hospital.
Thoracic Society recommend that pulmonary rehabilita-tion
should be made available to all appropriate patients [10,11]. Protocol
Moreover, the GOLD guidelines recommend offering pulmonary
rehabilitation to COPD patients who have at least moderate
severity of the disease [12]. All admitted patients received standard treatment, including
Exercise training is now considered an essential component of nebulized bronchodilators, oral or intravenous antibiotics, non-
pulmonary rehabilitation in patients with chronic obstruc-tive invasive ventilation (if required), and a one week course of oral
prednisolone (30–40 mg daily). Before being discharged on
pulmonary disease (COPD) [13,14]. Although it does not change
optimal medical treatment, patients were randomly allo-cated to
pulmonary function, exercise training improves exer-cise capacity
three groups.
and reduces dyspnea. However, there is no con-sensus about the
optimal training strategy and the mechanisms of improvement Besides medical treatment, the first two groups were assigned
[15,16]. Whether the goal of training should be strength, to an early pulmonary rehabilitation program (within 10 days of
endurance, or both is still under investigation. hospital discharge), which consisted of patients’ assessment,
exercise training, in addition to patients education in the form of
self management of the disease, nutrition, and lifestyle issues.
Lower-extremity aerobic training consistently improves
However, these two groups differed in their exercise training
exercise tolerance in patients with chronic obstructive pul-monary
program, group one performed endurance training (ET) alone,
disease (COPD), but has little effect on muscle atro-phy and
while group two performed combined training (CT) in the form of
weakness, two problems common in patients with COPD and
endurance plus strength training (ST). Both exercise training
which can contribute to their poor exercise toler-ance and quality
programs lasted for 8 weeks, in the form of three sessions per
of life [5,17]. Strength training can promote muscle growth and
week.
strengthening in normal subjects [18], and may therefore
represent a useful addition to whole-body aerobic training in The third group (control group) received medical treatment
patients with COPD. only and was not enrolled in the rehabilitation program.
Moreover, most guidelines report extensively on the bene-fits
of pulmonary rehabilitation in patients with stable lung disease. Patients’ assessment
Much less is known about the effects of pulmonary rehabilitation
immediately after or even during acute exacerba-tions [19]. It included baseline assessment and outcome assessment at the
end of the program in the form of:
Therefore, this study aimed to evaluate whether strength
training is a useful addition to aerobic training in an early Dyspnea assessment by modified Medical Research Council
rehabilitation program implemented for patients with COPD. dyspnea scale (mMRC dyspnea scale). It is a 5 point scale
Endurance and Strength Training in Pulmonary Rehabilitation 233

based on degrees of variable physical activities that precip- The CT consisted of 30 min of ST which consisted of exer-
itate dyspnea with a score ranging from 0 to 4 [20]. cises performed on weight training machines, for pectoralis major,
Pulmonary function tests: All patients underwent standard deltoid, biceps brachii, triceps and quadriceps muscles. Patients
spirometry before and after 15 min of bronchodilator were submitted to three sets of 12 repetitions with a 2-min rest
inhalation according to American Thoracic Society/Euro-pean between sets and with a workload at 50–80% of that achieved on
Respiratory Society standards [21]. the 1-RM test. The 1-RM test was repeated every 2 weeks to
Peripheral muscle strength: Peripheral muscle strength was reestablish the workload.
assessed by the determination of the one repetition maxi-mum The remaining 30 min were devoted to ET at half the vol-ume
(1-RM). The agreed convention for the 1-RM is the heaviest (i.e., 15 min of walking at a self-determined intensity and an
weight that can be lifted throughout the complete range of additional 15 min at half the number of repetitions of low-
motion related to the exercise performed. The 1-RM was intensity resistance training with free weights). All exercise
assessed for exercises carried on weight training equipment: regimens were conducted in 60 min sessions, which included
knee extension machine with pelvic strap, and chest press. A pacing for breathing [25].
warm up of 3–5 min followed by 10 repeti-tions with a light
load was performed prior to the test to minimize the effect of Statistical analysis
learning. The 1-RM test was initiated near the suspected
maximum to minimize repetition fatigue. All subjects attained
the 1-RM within 3–5 attempts. Sub-jects were allowed to rest Data were collected, tabulated, then analyzed using SPSS Ver.13.
for 2–3 min between attempts [22]. Qualitative data were presented as numbers and per-centage.
Six-minute walking distance (6MWD): A six-minute walk-ing Quantitative data were expressed as means and stan-dard
test (6MWT) was performed according to the standard deviation. Differences between the groups were analyzed using
Student’s unpaired t-test and v2 tests where appropriate. 5% level
procedure and was used as a measure of exercise capacity.
was chosen as a level of significance in all statistical tests used in
Patients were asked to walk on a 20 m course over a 6 min
period. Then the distances covered by the patients during this the study.
time interval in minutes were recorded [23].
Health-related quality of life (HRQL): Health-related qual-ity Results
of life (HRQL) was measured using the validated St. George’s
Respiratory Questionnaire (SGRQ) for COPD patients Thirty patients concluded the training protocols with adequate
(SGRQ-C). The results are reported as percent [24].
adherence (ET = 15; CT = 15), having completed more than 85%
of the scheduled sessions. 15 patients received medical treatment
Exercise training programs only.

General characteristics of the study population

Exercise training programs lasted for 8 weeks, in the form of
three sessions per week. The ET consisted of 30 minutes of
treadmill training at an intensity of 75% of the results of the Baseline characteristics of the 3 groups are presented in Table 1.
6MWT and an additional 30-min of low-intensity resistance No significant differences were found between groups in terms of
training with free weights. The number of repetitions used was age, BMI, airflow obstruction, or arterial blood gases. According
based on physiologic endurance principles, including a high to the GOLD Combined assessment, the patients were grouped as
number of repetitions with a low load [25]. B, C or D. No patient presented evi-

Table 1 General characteristics of the study population randomly assigned to endurance training (ET), combined training (CT) or medical
treatment only.
Characteristics Endurance training (ET) Combined training (CT) Medical treatment
Age 61 ± 8 58 ±7 60 ± 8
BMI (Kg/m2) 24 ± 7 26 ±5 27 ± 6
FEV1% 53.2 ± 9.5 56.4 ± 8.3 54.6 ± 7.1
PaO2 78 ± 6.6 77 ±8.4 76 ± 9.5
PaCO2 44 ± 3.3 43 ±4.1 42 ± 5.7
Gold combined assessment n (%)
B 2 (13) 3 (20) 1 (7)
C 6 (40) 6 (40) 6 (40)
D 7 (47) 6 (40) 8 (53)
mMRC 2.62 ± 0.76 2.58 ± 0.69 2.53 ± 0.89
Quadriceps strength (1RM, kg) 18.9 ± 5.6 17.9 ± 6.7 18.7 ± 7.2
Chest press (1RM, kg) 21.3 ± 4 22.1 ± 6.2 21.6 ± 3.3
6MWT, m 224.1 ± 108.6 215.1 ± 120.9 240.1 ± 96.4
SGRQ% 68.2 ± 18.6 64.45 ± 20.1 66.9 ± 17.6
Data are expressed as Mean ± SD unless otherwise specified.
234 R. Daabis et al.

dence of arterial hypoxemia; defined as PaO2 < 55 mmHg/ SpO2

Table 4 FEV1, mMRC dyspnea scale, peripheral muscle strength,
< 89% at rest or exercise (Table 1).
6MWD and HRQOL before and after medical treatment.
At the end of the training period, none of the groups pre-
sented significant changes in lung function or BMI.
Baseline End of program P value
Effects of exercise training on the mMRC dyspnea scale and FEV1% 54.6 ± 7.1 56.3 ± 9.5 NS
HRQL mMRC 2.53 ± 0.89 2.38 ± 0.86 NS
Quadriceps 18.7 ± 7.2 19.2 ± 1.2 NS
strength
Baseline mMRC dyspnea scale and HRQL did not differ sig- (1RM, kg)
nificantly among groups. There was significant improvement in Chest press 21.6 ± 3.3 21.8 ± 3.9 NS
the mMRC dyspnea scale and the HRQL (P < 0.001 for both) in (1RM, kg)
the 2 groups who underwent exercise training. How-ever there 6MWT, m 240.1 ± 96.4 249 ± 93.8 NS
was no significant improvement in both parameters in the third SGRQ% 66.9 ± 17.6 63 ± 14.6 NS
group who received the medical treatment only (Tables 2–4).
Data were expressed as Mean ± SD and compared using student t-test.

*
: Statistically significant at P 6 0.05.
Effects of exercise training on exercise capacity

Effects of exercise training on peripheral muscle strength

Baseline 6-min walked distance (6MWD) did not differ signif-
icantly among groups. There was a significant improvement in the
exercise capacity as measured by the 6MWT (P < 0.001 for both) Baseline peripheral muscle strength did not differ significantly
in the 2 groups who underwent exercise training. However there among groups. Patients in the CT group presented a significant
was no significant improvement in the third group who received post-training improvement in the 1-RM values of the quadri-ceps
the medical treatment only (Tables 2–4). muscle and the chest press muscles (P < 0.01 and P = 0.016
respectively), whereas no significant changes in 1-RM values
were observed in the ET or medical treatment groups (Tables 2–
Table 2 FEV1, mMRC dyspnea scale, peripheral muscle strength, 4).
6MWD and HRQOL before and after endurance training.
Comparison between the studied groups according to% change in
Baseline End of P value mMRC, peripheral muscle strength, 6MWD, SGRQ% by the end
program of the program
FEV1% 53.2 ± 9.5 55.1 ± 12.3 NS
mMRC 2.62 ± 0.76 1.48 ± 0.81 <0.001* The% change in the 1-RM values of the quadriceps muscle and
Quadriceps strength 18.9 ± 5.6 22 ± 3.6 NS the chest press muscles was significantly greater in the CT group
(1RM, kg) than in the ET group (P < 0.001 for both muscle groups). In
Chest press 21.3 ± 4 23.1 ± 3.2 NS contrast, the magnitude of the changes in mMRC dyspnea scale,
(1RM, kg) exercise capacity (6MWD) and quality of life were comparable
6MWT, m 224.1 ± 108.6 347 ± 89.3 <0.001* for the two groups (Table 5).
SGRQ% 68.2 ± 18.6 49.4 ± 17.7 <0.001*
Data were expressed as Mean ± SD and compared using student t-test. Discussion
*: Statistically significant at P 6 0.05.
This study sought to evaluate whether strength training is a useful
addition to aerobic training in patients with COPD. We found that
the combination of aerobic and strength train-ing was safe and
Table 3 FEV1, mMRC dyspnea scale, peripheral muscle strength, well tolerated despite the severity of the underlying lung disease,
6MWD and HRQOL before and after combined training. and was associated with additional improvements in peripheral
muscle strength without increasing the duration of the training
sessions.
Baseline End of P value
program
FEV1% 56.4 ± 8.3 57.9 ± 11.7 NS Table 5 Comparison between the studied groups according to
mMRC 2.58 ± 0.69 1.37 ± 1 P < 0.001* % change in mMRC, peripheral muscle strength, 6MWD, SGRQ
Quadriceps 17.9 ± 6.7 24.1 ± 2.1 P < 0.01* by the end of the program.
strength (1RM, kg)
Chest press 22.1 ± 6.2 28.2 ± 3.7 P = 0.016* ET CT P
(1RM, kg) % change mMRC 44 46 NS
6MWT, m 215.1 ± 120.9 348 ± 97.3 P < 0.001* % change Quadriceps strength (1RM, kg) 15 32 P < 0.001*
SGRQ% 64.45 ± 20.1 46.4 ± 17.7 P < 0.001* % change Chest press (1RM, kg) 8 23 P < 0.001*
Data were expressed as Mean ± SD and compared using student t-test. % change 6MWT, m 35 42 NS
% change SGRQ% 20 23 NS
*: Statistically significant at P 6 0.05. *: Statistically significant at P 6 0.05.
Endurance and Strength Training in Pulmonary Rehabilitation 235

In contrast with previous studies [26,27] that showed resulted in significant improvements in the degree of dyspnea
increased peripheral muscle strength in COPD patients with measured by the mMRC score, the health-related quality of life
endurance training alone we did not find a significant increase in measured by the SGRQ and the functional exercise capac-ity
muscle strength in the ET group. On the other hand, similar to our measured by 6MWT [27]. The benefit of PR in improving
results, other studies [28,29], that compared the effect of strength exercise capacity, breathlessness and QoL is level of evidence A
training alone or combined with endurance training to isolated as demonstrated by the recent ATS official statement on PR [31].
endurance training in patients with COPD did not observe any
change in peripheral muscle strength after endur-ance training Moreover, this study showed that pulmonary rehabilitation
only. These discrepancies may be attributable to the differences in administered shortly after an acute exacerbation of COPD was
the modalities and the intensity of training employed. safe and well tolerated by the patients and was associated with a
favorable outcome on breathlessness, exercise capacity and
The majority of established exercise programs are based on quality of life [32]. A recent meta-analysis summarized the cur-
endurance training of the lower limbs with different exercise rently available evidence and concluded that pulmonary reha-
modalities, such as walking, treadmill, and stationary bicycle. bilitation established after exacerbations enhances health-related
Although exercise rehabilitation programs have systematically quality of life, improves exercise capacity and reduces the risk for
omitted activities of strength training primarily because of fear of re-admissions [33].
an abrupt increase in heart rate and arterial pressure asso-ciated There are several possible explanations for this. First, exac-
with isometric contractions in small muscle groups, recent studies erbations lead to significant reductions in muscle function [34]
[17,25,26] have shown that strength training is beneficial and well and physical activity [35]. This initial deterioration may render
tolerated as well. Moreover, in patients with mild COPD, Clark patients more likely to improve from PR. Pulmonary rehabil-
and colleagues [30] identified reduced isoki-netic muscle function itation is a particularly potent intervention to revert physical
in patients with COPD as compared to healthy subjects and inactivity [36] and it has been shown that patients who improve
showed that intervention with weight training was effective in their physical activity levels have less chance of being readmit-ted
countering this deficit. [37]. Second, since those eligible patients had been hospital-ized
In this study, the strength training program was successful in for a COPD exacerbation, there may be an existing deficiency in
increasing strength in all muscles that underwent training. The self-management or education among this group. This deficiency
results of the present study confirm that such patients retain the may be partially targeted with the rehabilita-tion intervention, and
capacity for improved peripheral muscle function with an patient education may be of particular benefit to modify behavior
adequate training stimulus [26]. in these patients [33].
However, these changes did not translate into further Another advantage of early rehabilitation is that it may
improvement in exercise tolerance as measured in this study. It is provide a window of opportunity for patient education because
possible that a longer duration of training would have produced a patients may be more willing to change their health behavior after
greater improvement in exercise capacity with the combination of an exacerbation. Also, continuity of care is pos-sible if patients
strength and aerobic training than with aerobic training alone. are immediately referred to PR [33].
Perhaps the changes in peripheral mus-cle function in our study In conclusion, pulmonary rehabilitation is an effective
and other studies [26,28] were not of sufficient magnitude to intervention for the post-exacerbation management of COPD
further improve exercise capacity. Another possible explanation patients. It leads to significant improvements of dyspnea, health-
for the dissociation between changes in muscle strength and related quality of life and functional exercise capacity. When
exercise capacity is the relative task specificity of any training added to a program of endurance exercise, resistance training
stimulus: the greatest improve-ment in muscle function is shown confers additional benefits in muscle force, but not in overall
in tests that closely mimic the characteristics of the training exercise capacity or health status.
movement [20]. An important implication of this observation is
that the training movements should resemble activities that are Conflict of interest
relevant to the patient’s daily activities. Further studies are needed
to determine whether greater improvements in peripheral muscle
function can be translated into a gain in exercise capacity by I declare that there is no conflict of interest that could be per-
increasing the duration of the training sessions or by modifying ceived as prejudicing the impartiality of the research reported.
the train-ing movements to resemble activities relevant to the
patients’ daily living. [26]. References

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