November 2018

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Exercise for the management of COPD

Exercise and COPD has been linked together by international professional. Exercise has been described as one of the main components of pulmonary rehabilitation in COPD management. What is COPD? How do exercise affect patients with COPD? This page, written by Yousef Rifai, will introduce COPD, exercise and the relationship between them which affect patient’s health.

Resistance training has been recently recognised as an important component of the Pulmonary Rehabilitation. What are the mechanisms by which it affects severity of symptoms patients with COPD suffer from? Which exercises could be performed as a part of this training modality? This page, written by Katarzyna Koscielecka will focus on reviewing these aspects in reference to peripheral muscle strength, dyspnoea and exacerbation.

Endurance training has been widely used to complement other treatment modalities, and help individuals suffering from COPD to manage their condition better. Should endurance training be used as an individual treatment option, or continue to be combined with others? This page, written by Conor Goldsmith, will highlight some specific benefits of endurance training for COPD; such as potential improvements in lung function, quality of life and acute exacerbation recovery.

Combination training is now considered an alternative training modality for the treatment of COPD, as opposed to resistance or endurance training alone. But is combination training any better? This page, written by Stacey Harrington, will highlight some of the benefits of combination training and discuss whether it is of greater benefit than other training modalities for the management of COPD.

Exercise & COPD

What is COPD?

COPD is a preventable and treatable disease, caused by exposure to toxic particles or gases, such as those inhaled during smoking or from pollutants in the air, leading to its progressive respiratory symptoms and limiting expiratory airflow (dyspnea) (GOLD, 2017)

It has been recognised as a combination of conditions. These conditions affect parts of the respiratory system such as emphysema, where air sacs (alveoli) in the lungs are damaged, and chronic bronchitis, when the bronchial tubes are inflamed (WHO, 2017 and NHS, 2016). The disease’s global mortality in 2010 was 2.8 million deaths, which was lower than the rate in 1990 of three million, then moving up to an estimation of 3.17 million deaths in 2015 (WHO, 2017 and Burney et al., 2015), Which highlights the importance of prevention.

(BLF, n.d.)

Management using exercise:

As 80% of clinical cases are a result of smoking, smoke cessation may seem the best preventative and managing measure, but it is not the only causation nor the singular solution. In addition, COPD is mainly diagnosed amongst the elderly, and after the underlying conditions have progressed, there is a need for managing the disease. GOLD advises that pulmonary rehabilitation (PR) should be part of patient management. PR is an intervention programme, including many aspects such as behaviour therapy and exercise training. (GOLD, 2017)

Physical activity is musculoskeletal movement which occurs when the body spend energy (ATP). Whereas exercise is a type of physical activity defined by the structure of movement, recurrence and planning, leading to muscle, bone and circulation maintenance (Spruit et al., 2016). According to GOLD guidelines, exercise training is a key contributor to PR, and have multiple types (Endurance training, strength exercise, groups sports, etc.), each type affect patients and improve quality of life (Levin, Netz and Ziv, 2017).COPD patients have reduced exercise capacity due to dyspnea as the increased energy demand required for exercise relies on oxygen. (Aliverti and Macklem, 2008 and Spruit et al., 2013)

WHO warned from physical inactivity implications, others highlighted its association with many health complications (Febbraio, 2017 and WHO 2002). As a result, physical activity and exercise are now being recommended by many professionals. (Febbraio, 2017, NHS, 2018, Khan et al., 2012 and Garber et al., 2011). In addition, researchers suggested that exercise contribute to several health benefits such as cardiorespiratory fitness (increased VO2 and an improved pulmonary ventilation), in line with cardiovascular health, musculoskeletal maintenance and mental health (Febbraio, 2017; Khan et al., 2012; Ortega et al., 2002 and Rimes et al., 2015).

(Aviss Health, 2017)

Exercise benefits:

A study compared the effects of different types of exercise (Strength training, n = 17, endurance training, n = 16 and combined training = 14) on patients with COPD. A twelve weeks, three days a week, intervention was completed in each of the groups. The study didn’t include a control group, however, did complete baseline measurements to compare the findings with it, and for patients to act as their own control. Strength training intervention consisted of multiple weight lifting exercises for muscle groups in the upper and lower body. Only lower extremities exercise protocol was given in endurance training. The study found that VO2 during endurance exercise has significantly improved (mean ± standard deviation) (1.48 ± 0.44 L/min) from baseline (1.32 ± 0.4 L/min). Strength and endurance training improved muscle power output (strength), after the intervention, (baseline strength training Wmax 50 ± 19W, after 55 ± 20 W, baseline endurance training 39 ± 18 W, after 50 ± 18), with significance only observed in endurance training patients. Whereas the combined group presented non-significant improvements in VO2 and Wmax, (baseline VO2 1.26 ± 0.26 L/min, after 1.34 ± 26 L/min, baseline Wmax 41 ± 16 W, after 46 ± 9 W) (Ortega et al., 2002). The study was detailed; the sample size was small, and each group completed different exercise protocol (different muscle groups), which may be the reason why they were unable to discover significance in other groups than endurance exercise. This may also be an indication that lower extremities training seem to be more beneficial to patients with COPD instead of combined training.

A meta-analysis reviewed 160 randomised controlled trials (7487 participants), found that training exercise may significantly improve cardiorespiratory fitness. The analysis did not include much information about VO2, however, when looking at the conducted studies which included these measurements, they collectively reported that VO2 max was improved or did not change after the intervention. Indicating that the exercise intervention had a positive impact on pulmonary ventilation. The studies didn’t reflect large sample sizes, in addition, two of them being gender specific without representing the population. (Lin et al., 2015; De Vito et al., 1999; GORMLEY et al., 2008; Lovell et al., 2010 and Thomas et al., 1981) ;

Many studies looked into PR after COPD hospital admission. Another meta-analysis reviewed thirteen randomised clinical trials (801 participants). The main focus was to look at the mortality rates after hospital admissions. The analysis didn’t find any statistically significant difference in mortality rate. One of the metrics the analysis was looking at was walking distance, which was collected from eight studies, found a statistically significant difference in exercise capacity, measured by six minutes walking distance test. It was found that there was a 76.89 meters improvement after early PR. Resulting in health-related quality of life improvements. However, the analysis suggested that the evidence is moderate quality and not reflecting a strong evidence to support this difference. (Ryrsø et al., 2018)

It is recommended that individuals complete 150 minutes per week of physical activity with an energy expenditure of around 1000 kilocalories per week, allowing to combine moderate and vigorous activity. Not challenging the body by exercising below a threshold or minimum intensity will not result in VO2 increase nor improvements in other physiological parameters. It is argued that the evidence which support the recommendation lack consistency in many studies, which lead the author of the guidance to suggest additional randomised clinical trials and meta-analysis to obtain stronger evidence (Garber et al., 2011).

Conclusion:

Collectively, exercise training affects the body positively in COPD patients. Respiratory and muscular fitness increases. In addition, to gain the best possible outcome for COPD patients, endurance training seems to be the most beneficial type due to the increase of VO2, as COPD patients struggle with breathing. The effects of exercise types are explored in more detail within the website. Visit Resistance training, Endurance training or Combined training pages to find out more.

Written by: Yousef Rifai (17800407)

Abbreviations:

ATP, Adenosine triphosphate; GOLD, The Global Initiative for Chronic Obstructive Lung Disease; L/min, litre per minute; M, meters; n, number of participants; VO2: maximal oxygen consumption, which is a marker for body efficiency in delivering oxygen to the tissues (Levine, 2008); W, watts; WHO, World Health Organisation.

References:

Aliverti, A. and Macklem, P. (2008). The major limitation to exercise performance in COPD is inadequate energy supply to the respiratory and locomotor muscles. Journal of Applied Physiology, [online] 105(2), pp.749-751. Available at: https://www-physiology-org.ezproxy.brighton.ac.uk/doi/full/10.1152/japplphysiol.90336.2008 [Accessed 28 Oct. 2018].
Aviss Health, 2017. COPD and Exercise: Good or Bad?. [Image online] Available at: https://www.avisshealth.com/copd-exercise-good-bad/ [Accessed 10 November 2018]
British Lung foundation (BLF), n.d. Diagram showing the appearance of the airways in bronchitis and emphysema. [image online] Available at: https://www.blf.org.uk/support-for-you/copd/what-is-it [Accessed 10 November 2018]
Burney, P., Patel, J., Newson, R., Minelli, C. and Naghavi, M. (2015). Global and regional trends in COPD mortality, 1990–2010. European Respiratory Journal, [online] 45(5), pp.1239-1247. Available at: http://erj.ersjournals.com/content/45/5/1239 [Accessed 24 Oct. 2018].
De Vito, G., Bernardi, M., Forte, R., Pulejo, C. and Figura, F. (1999). Effects of a low-intensity conditioning programme on VO2max and maximal instantaneous peak power in elderly women. European Journal of Applied Physiology and Occupational Physiology, [online] 80(3), pp.227-232. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10453925 [Accessed 4 Nov. 2018].
Febbraio, M. (2017). Health benefits of exercise — more than meets the eye!. Nature Reviews Endocrinology, [online] 13(2), pp.72-74. Available at: https://www.nature.com/articles/nrendo.2016.218 [Accessed 29 Oct. 2018].
Garber, C., Blissmer, B., Deschenes, M., Franklin, B., Lamonte, M., Lee, I., Nieman, D. and Swain, D. (2011). Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults. Medicine & Science in Sports & Exercise, [online] 43(7), pp.1334-1359. Available at: https://journals.lww.com/acsm-msse/fulltext/2011/07000/Quantity_and_Quality_of_Exercise_for_Developing.26.aspx [Accessed 12 Nov. 2018].
GOLD (2017). GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD – Global Initiative for Chronic Obstructive Lung Disease – GOLD. [online] Global Initiative for Chronic Obstructive Lung Disease – GOLD. Available at: https://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/ [Accessed 24 Oct. 2018].
GORMLEY, S., SWAIN, D., HIGH, R., SPINA, R., DOWLING, E., KOTIPALLI, U. and GANDRAKOTA, R. (2008). Effect of Intensity of Aerobic Training on VO2max. Medicine & Science in Sports & Exercise, [online] 40(7), pp.1336-1343. Available at: https://insights.ovid.com/crossref?an=00005768-200807000-00019 [Accessed 4 Nov. 2018].
Khan, K., Thompson, A., Blair, S., Sallis, J., Powell, K., Bull, F. and Bauman, A. (2012). Sport and exercise as contributors to the health of nations. The Lancet, [online] 380(9836), pp.59-64. Available at: https://www.sciencedirect.com/science/article/pii/S0140673612608654?via%3Dihub [Accessed 30 Oct. 2018].
Levin, O., Netz, Y. and Ziv, G. (2017). The beneficial effects of different types of exercise interventions on motor and cognitive functions in older age: a systematic review. European Review of Aging and Physical Activity, [online] 14(1). Available at: https://eurapa.biomedcentral.com/articles/10.1186/s11556-017-0189-z [Accessed 26 Oct. 2018].
Lin, X., Zhang, X., Guo, J., Roberts, C., McKenzie, S., Wu, W., Liu, S. and Song, Y. (2015). Effects of Exercise Training on Cardiorespiratory Fitness and Biomarkers of Cardiometabolic Health: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials. Journal of the American Heart Association, [online] 4(7). Available at: https://www.ahajournals.org/doi/10.1161/JAHA.115.002014 [Accessed 4 Nov. 2018].
Lovell, D., Cuneo, R., Delphinus, E. and Gass, G. (2010). Leg Strength and the VO2max of Older Men. International Journal of Sports Medicine, [online] 32(04), pp.271-276. Available at: https://www.thieme-connect.de/products/ejournals/html/10.1055/s-0030-1269844?update=true [Accessed 15 Nov. 2018].
National Health Service (NHS). (2018). Benefits of exercise. [online] Available at: https://www.nhs.uk/live-well/exercise/exercise-health-benefits/ [Accessed 29 Oct. 2018].
National Health Service (NHS). (2016). Chronic obstructive pulmonary disease (COPD). [online] Available at: https://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease-copd/ [Accessed 24 Oct. 2018].
Ortega, F., Toral, J., Cejudo, P., Villagomez, R., Sánchez, H., Castillo, J. and Montemayor, T. (2002). Comparison of Effects of Strength and Endurance Training in Patients with Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine, [online] 166(5), pp.669-674. Available at: https://www.atsjournals.org/doi/abs/10.1164/rccm.2107081 [Accessed 31 Oct. 2018].
Rimes, R., de Souza Moura, A., Lamego, M., de Sa Filho, A., Manochio, J., Paes, F., Carta, M., Mura, G., Wegner, M., Budde, H., Ferreira Rocha, N., Rocha, J., R.S. Tavares, J., Arias-Carrion, O., Nardi, A., Yuan, T. and Machado, S. (2015). Effects of Exercise on Physical and Mental Health, and Cognitive and Brain Functions in Schizophrenia: Clinical and Experimental Evidence. CNS & Neurological Disorders – Drug Targets, [online] 14(10), pp.1244-1254. Available at: https://www.semanticscholar.org/paper/Effects-of-Exercise-on-Physical-and-Mental-Health%2C-Rimes-Moura/43f71428f026ed6a277959663a6fce5c5030e918 [Accessed 27 Oct. 2018].
Ryrsø, C., Godtfredsen, N., Kofod, L., Lavesen, M., Mogensen, L., Tobberup, R., Farver-Vestergaard, I., Callesen, H., Tendal, B., Lange, P. and Iepsen, U. (2018). Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulmonary Medicine, [online] 18(1). Available at: https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0718-1 [Accessed 30 Oct. 2018].
Spruit, M., Burtin, C., De Boever, P., Langer, D., Vogiatzis, I., Wouters, E. and Franssen, F. (2016). COPD and exercise: does it make a difference?. Breathe, [online] 12(2), pp.e38-e49. Available at: http://breathe.ersjournals.com/content/12/2/e38 [Accessed 25 Oct. 2018].
Spruit, M., Singh, S., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., Hill, K., Holland, A., Lareau, S., Man, W., Pitta, F., Sewell, L., Raskin, J., Bourbeau, J., Crouch, R., Franssen, F., Casaburi, R., Vercoulen, J., Vogiatzis, I., Gosselink, R., Clini, E., Effing, T., Maltais, F., van der Palen, J., Troosters, T., Janssen, D., Collins, E., Garcia-Aymerich, J., Brooks, D., Fahy, B., Puhan, M., Hoogendoorn, M., Garrod, R., Schols, A., Carlin, B., Benzo, R., Meek, P., Morgan, M., Rutten-van Mölken, M., Ries, A., Make, B., Goldstein, R., Dowson, C., Brozek, J., Donner, C. and Wouters, E. (2013). An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine, [online] 188(8), pp.e13-e64. Available at: https://www.atsjournals.org/doi/full/10.1164/rccm.201309-1634ST# [Accessed 1 Nov. 2018].
Thomas, T., Adeniran, S., Etheridge, G. and Byrd, P. (1981). 1: 45 p.m.: Effects of different running programs on percent body fat and plasma lipids. Medicine & Science in Sports & Exercise, [online] 13(2), p.106. Available at: https://www.ncbi.nlm.nih.gov/pubmed/6733833 [Accessed 4 Nov. 2018].
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World Health Organization (WHO). (2002). WHO | Physical inactivity a leading cause of disease and disability, warns WHO. [online] Available at: https://www.who.int/mediacentre/news/releases/release23/en/ [Accessed 29 Oct. 2018].

Resistance training for the management of COPD

Skeletal muscle dysfunction is one of the extrapulmonary symptoms of COPD leading to increased exercise intolerance and dyspnoea on exertion occurring mainly due to the muscle fibre atrophy and hyperinflation (Liao et.al., 2015; Kim et.al., 2008). Considering the severity of extrapulmonary symptoms there is a substantial need for the nonpharmacological interventions. The impact of resistance training (RT) has been analysed by many researchers and seems to be one of the most effective tools used in the management of COPD. Following the assessment of the severity of the disease and overall health status, it should be introduced as a crucial part of pulmonary rehabilitation. (Zanini et.al., 2015).

RT affects peripheral muscle strength, dyspnoea and exacerbation states amongst COPD patients. These aspects are consecutively reviewed on this page.

Peripheral muscle strength

The specific pulmonary rehabilitation (SPR) and usual pulmonary rehabilitation (UPR) have been compared by Zanini et.al. (2015) in order to access peripheral muscle strength in 60 individuals suffering from COPD. The responsiveness of three muscle strength tests was measured: sit-to-stand-test (STST) for 30 seconds, STST for 1 minute and 1 repetition maximum (1-RM) being the maximal weight that can be properly lifted for one repetition. These were subsequently used to assess the effect on the lower limbs muscles strength. SPR included 15 sessions with 7 resistance exercises each. Significant improvement has been noted in all free tests in the STR group leading to the conclusion that STR has bigger potential to induce peripheral muscle strength among COPD patients than UPR. It has also indicated overall increase in the strength of the muscles assessed. RT induced effects may therefore allow improvement in exercise tolerance among COPD patients (Seymour et.al., 2010).

Source: Zanini et.al. (2015). International Journal of Chronic Obstructive Pulmonary Disease 11 (10)

Supporting evidence was provided by Vonabnk et.al. (2012) who conducted the 12-week study comparing three training groups: strength training (ST), endurance training (ET) and combined training (CT). Assessment of 1-RM was followed by 2 training sessions per week, each including 8 exercises: bench press, chest cross, shoulder press, pull downs, bicep curls, tricep extensions, sit-ups and leg press. Evaluation of the peripheral muscle strength has indicated significant improvement alongside with increase in maximum exercise capacity, surprisingly, at the similar level that was achieved in ET and CT groups. Muscle strength was measured in a very similar manner by Daabis et.al. (2017) before and after 8-week period of ST, ET and CT with 3 RT sessions per week. There was no significant improvement in exercise capacity contradicting the Vonbank’s conclusion, whereas the noticeable change in the muscle strength supported it.

The advantageous effects detected within these studies may occur not only due to peripheral muscle strength improvement, but also as a result of neural adaptations. Additionally, 1-RM which has been used as the strength indicator in all of these studies can result in patients’ muscles fatigue, making it impossible to assess their strength beforehand (Zanini et.al., 2015).

Dyspnoea and exacerbation

Dyspnoea, known as shortness of breath, is another issue which patients suffering from moderate to severe COPD struggle with. Individuals with intolerable dyspnoea that may be unable to perform intense endurance training seem to tolerate RT better, as it leads to less fatigue and is relatively easy to perform. On top of that, RT was found to reduce overall occurrence of this symptom among all the patients (Daabis et.al., 2017).

As stated by Rabe (2006), increased intensity of dyspnoea may be the indicator of the exacerbation. IGF-1, which is critical for the skeletal muscle maintenance and development, was found to be substantially decreased during exacerbations in the COPD patients’ serum (Kythreotis et.al). Similar results were obtained by Gupta et.al. alongside with decrease in dehydroepiandrosterone sulphate (DHEAS) and testosterone levels during both acute exacerbation and stable state. Interestingly, growth hormone, testosterone and IGF-1 were found to be elevated following the performance of resistance exercises leading to the assumption that RT may promote upregulation of these hormones (Kraemer et.al., 2005; Ye et.al., 2012). Therefore, RT should be taken into consideration as a nonpharmacological tool that allow counteracting the mechanisms associated with acute exacerbations by inducing secretion of the hormones strongly related to muscle hypertrophy. It is however unclear and needs further investigation if the RT is the only factor inducing increase in these anabolic hormones.

Source: Gupta et.al., (2014) Biomedical Research, 25 (3)

Training plan

According to Skumlien et.al. (2008) more studies are needed in order to assess if performing RT is leading to the improvement in ease of performing daily activities among COPD patients. Nevertheless, the choice of exercises to be performed by the patients should come from the desired goal of facilitating daily activities such as walking, climbing the stairs, reaching some objects, carrying shopping bags, etc. as recommended by Daabis et.al. (2017). Multi-joint exercises such as deadlifts, static lunges and abdominal crunches were found to affect these activities by efficiently improving muscle strength, whereas single-joint exercises (shoulder raises, bicep curls) were useful to correct muscle imbalances (Zeng, et.al., 2018).

Implementation of RT:

Assessment of the severity of COPD, overall health and physical condition by GP and physiotherapist.
Measurement of 1-RM as mentioned in the section: Peripheral muscle strength.
Establishment of the workload: 50-80% of 1-RM (Skumlien et.al., 2008)
Learning the proper technique and movement patterns.
Implementation of resistance exercises (as shown in Table 1).

Table 1: Sets and repetition range for the multi-joint and single-joint resistance exercises across 1 week for the novice trainees suffering from COPD, as recommended by American College of Sports Medicine (2009).

Exercise	Sets	Repetition range
Deadlift	2	8-10
Static lunges	2	8-10
Shoulder raises	2	12-15
Bicep curls	2	12-15
Abdominal crunches	2	12-20

To be performed 3x/week. Each session: 5 minutes warm up on the treadmill prior to 5 resistance exercises, 2 minutes rest between each set and 3 minutes rest between each exercise (Skumlien et.al., 2008).

Resistance training may lead to progressive decrease in exercise intolerance by targeting peripheral muscles strength and their functionality. This training modality has also proven to decrease an incidence and severity of other extrapulmonary symptoms of COPD. Nonetheless, in order for RT to be effective and feasible, it is crucial to introduce resistance exercises requiring small time investment and possibly minimising muscle fatigue. Combining RT with other physical activities and pharmacological treatment may result in improved quality of lives and decreased mortality of individuals suffering from COPD.

Written by: Katarzyna Koscielecka (17801199)

References

Coad, L., Carter, N. and Ling, J., 2013. Attitudes of young adults from the UK towards organ donation and transplantation, Transplantation Research [e-journal] 2(9) pp. 1. https://doi.org/10.1186?2047-1440-2-9

Liao, W., et.al., 2015. Impact of Resistance Training in Subjects With COPD: A Systematic Review and Meta-Analysis, Respiratory Care [e-journal] 60 (8) pp. 1. https://doi.org/10.4187/respcare.03598

Kim, H. C., et.al., 2008. Skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease [e-journal] 3 (4) pp. 637-658. https://doi.org/10.1164/rccm.201710-2140CI

Zanini, A., et.al., 2015. The one repetition maximum test and the sit-to-stand test in the assessment of a specific pulmonary rehabilitation program on peripheral muscle strength in COPD patients. International Journal of Chronic Obstructive Pulmonary Disease [e-journal] 11 (10) pp. 2423-30. https://doi.org/10.2147/COPD.891176

Seymour, J. M., et.al., 2010. Outpatient pulmonary rehabilitation following acute exacerbations of COPD, Throax [e-journal] 65 (5) pp. 423-8. http://dx.doi.org/10.1136/thx.2009.124164

Vonabank, K., et.al., 2012. Strength training increases maximum working capacity in patients with COPD–randomized clinical trial comparing three training modalities. Respiratory Medicine [e-journal] 106 (4) pp. 557-563. https://doi.org/10.1016/j.rmed.2011.11.005

Daabis, R., et.al., 2017. Endurance and strength training in pulmonary rehabilitation for COPD patients. Egyptian Journal of Chest Diseases and Tuberculosis [e-journal] 66 (2) pp. 231-236. https://doi.org/10.1016/j.ejcdt.2016.07.003

Rabe, K.F., et.al., 2006, Improving dyspnea in chronic obstructive pulmonary disease: Optimal treatment strategies. Proceedings of the American Throacic Society [e-journal] 3 (3) pp. 270-5. https://doi.org/10.1513/pats.200601-002SF

Kythreotis, P., et.al., 2009. Plasma leptin and insulin-like growth factor I levels during acute exacerbations of chronic obstructive pulmonary disease. BMC Pulmonary Medicine [e-journal] 9 (11) https://doi.org/10.1186/1471-2466-9-11

Gupta, M., et.al., 2014. Evaluation of anabolic hormone status in patients with COPD during stable and acute exacerbation state. Biomedical Research 25 (3). Available through: Allied Academies website <http://www.alliedacademies.org/articles/evaluation-of-anabolic-hormone-status-in-patients-with-copd-during-stableand-acute-exacerbation-state.html> [Assessed 14 November]

Kraemer, W., et.al., 2005. Hormonal responses and adaptations to resistance exercise and training. Sports Medicine [e-journal] 35 (4) pp. 339-61. https://doi.org/10.2165/00007256-200535040-00004

Ye, M., et.al., 2012. Evaluation of the significance of circulating insulin-like growth factor-1 and C-reactive protein in patients with chronic obstructive pulmonary disease. Journal of International Medical Research [e-journal] 40 (3) pp. 1025-35. https://doi.org/10.1177/147323001204000321

Zeng, Y., et.al., 2018. Exercise assessments and trainings of pulmonary rehabilitation in COPD: a literature review. International Journal of Chronic Obstructive Pulmonary Disease [e-journal] 13 pp. 2013-2023. https://doi.org/10.2147/COPD.S167098

American College of Sports Medicine, 2009. Progression models in resistance training for healthy adults. Medicine & Science in Sports & Exercise [e-journal] 41 (3) pp. 687–708. https://doi.org/10.1249/MSS.0b013e3181915670

Skumlien, S., et.al., 2008. Endurance or resistance training in primary care after in-patient rehabilitation for COPD? Respiratory Medicine [e-journal]102 (3) pp. 422-9. https://doi.org/10.1016/j.rmed.2007.10.008

Endurance training for the management of COPD

Though pharmaceutical treatments are commonly used for the management of COPD, exercise is considered to be an addition to a prescribed plan. Medications can help in relieving the symptoms of COPD, such as shortness of breath (dyspnoea), but it cannot cure the disease.

Endurance training has been shown to improve the lung function and cardiovascular health of those who are not diseased (Yerg 2^nd et al., 1985; Randers et al., 2013; Matelot et al., 2016). It may, therefore, be possible that endurance exercise can be used as a treatment method to manage the symptoms of COPD with or without the addition of standard medications.

Improvements in lung function

A research paper from Mehri et al. (2007) measured the effect of endurance training on VO2 peak (ml/kg/min). The treatment group (TET) ran 2 times a week for 8 weeks. The control group did not participate in any exercise. The results showed that there was a significant improvement in VO2 peak in the TET group following the 8-week programme. 80% of the participants within this study had severe COPD. However, there were no other measurements of lung functionality. It is also questionable whether these effects are sustained following the end of the intervention.

Ortega et al. (2002) compared the effects of either endurance, strength training or combining the two modalities. The training was performed 2 times a week for a course of 12 weeks. They indirectly confirmed the results of the previous study by showing a significant improvement in VO2 max and maximal ventilation (V_E max) after 12 weeks of endurance training. The results showed that there was a small but significant decrease in VO2 max 12 weeks post-training. Consequently, the training may need to be continued in order to sustain the effects achieved from aerobic training for the indefinite management of COPD.

Source: Ortega et al., (2002). American Journal of Respiratory and Critical Care Medicine, 166 (5), p671.

The previous two papers have highlighted and shown the potential benefits endurance training has on improving VO2 max. It is also apparent, following a study by Puente-Maestu et al. (2000), that other pulmonary function measurements may be improved following an endurance training intervention. The study measured Forced Expiratory Volume (FEV), Total Lung Capacity (TLC) and Maximal Inspiratory Pressure (MIP). Both groups were either supervised or not-supervised and completed a walking intervention 4 times a week for 8 weeks. There was a very small but significant improvement in FEV1 (FEV in one second), TLC and MIP in both groups following the intervention.

Daily tasks such as walking to the shop, going upstairs or getting up from a chair may be made easier due to the improvement in lung function and capacity provided by endurance training. Patients would need to continue the programmes indefinitely which may prove difficult following exacerbations or during periods of decreased motivation.

Health-Related Quality of Life

Quality of life is paramount when suffering from COPD. A chronic condition which deteriorates your lung function over time will have physical and psychological effects. Therefore, it is essential to study the effects of endurance training on quality of life.

Daabis et al. (2017) studied the effects of endurance training on health-related quality of life (HRQL) following endurance, strength or combined training interventions. They used St Georges Respiratory Questionnaire for COPD patients (SGRQ-C) and the modified Medical Research Council dyspnoea scale (mMRC dyspnoea scale) for HRQL. These are commonly used in the assessment of physical and mental quality of life. The endurance intervention demonstrated a significant reduction in mMRC and SRGQ. Though Daabis et al. (2017) showed a significant improvement in HRQL, the endurance group performed treadmill exercise combined with free weights (high repetitions and low weight). This may have influenced the outcome of the results versus performing treadmill training alone. Additionally, though there was an improvement, there were no specifications on which aspects of HRQL was improved.

Ortega et al. (2002) also measured HRQL aspects of endurance training within the same paper. They used the Baseline Dyspnoea Index and Chronic Respiratory Questionnaire (CRQ). Following 12 weeks of endurance training, there was a significant improvement in Baseline Dyspnoea Index score; through the magnitude of the task, magnitude of effort and functional impairment. In addition, the fatigue, emotion and dyspnoea aspects of the CRQ were also shown to be significantly greater following the endurance intervention.

These two papers exhibit evidence that endurance training can improve certain aspects of HRQL. No other aspects of HRQL were measured, therefore it is not certain that all aspects of HRQL can be improved.

Exacerbations and recovery

Exacerbations of COPD decreases lung function (Donaldson et al., 2008; Halpin et al., 2012) and therefore an endurance programme may be impossible to prescribe. This type of intervention may aid in recovery and reduce the number of admissions due to exacerbations.

Kirsten et al. (1998) measured the effect of a short-term exercise intervention in patients with severe COPD following an acute exacerbation. The training group walked as far as possible in 6 minutes and performed five self-controlled walking sessions per day in the hospital corridor. This was performed for 11 days. The control group did not perform any exercise. Both groups received their usual medication through the intervention. Following the programme, there was a significant improvement in lung function measurements compared to the control. This includes Vital Capacity (VC), Residual Volume (RV) and Inspiratory Capacity (IC). Other parameters such as breathing frequency, minute ventilation (VE), heart rate (HR), Partial Pressure of Oxygen (PaO2) and Carbon dioxide (PaCO2) also improved following exercise versus the control.

This paper demonstrates the possible effectiveness of short-term endurance exercise interventions on recovery following an acute exacerbation. However, continual medical treatment without exercise, including physiotherapy and other hospital-based modalities may warrant a good recovery. The inclusion of endurance exercise to aid in recovery would need to be prescribed individually due to the different abilities of patients after an exacerbation.

Source: Kirsten, D et al., (1998). Respiratory Medicine, 92 (10), p1191-1198.

This recent research presents evidence to suggest that both the functional deficit and decreased quality of life experienced when suffering from COPD can be improved. There are few papers measuring exacerbation admission and endurance training. Consequently, we could estimate that those who regularly perform endurance exercise may experience a smaller decrease in lung function or a decrease in hospital admissions due to COPD exacerbations. Individuals with COPD who are physically inactive may be predisposed to a greater amount of hospital admissions or a larger decrease in quality of life compared to those who are active.

Written by: Conor Goldsmith (17802824)

Reference list:

Daabis, R., Hassan, M., Zidan, M. (2017). Endurance and strength training in pulmonary rehabilitation for COPD patients. Egyptian Journal of Chest Diseases and Tuberculosis. 66 (2), p231-236. https://doi.org/10.1016/j.ejcdt.2016.07.003

Donaldson, GC., Seemungal, TA., Bhowmik, A., Wedzicha, JA. . (2002). Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 57 (10), p847-852. http://dx.doi.org/10.1136/thorax.57.10.847

Haplin, DM., Decramer, M., Bartolome, Celli., Kersten, S., Liu, D., Tashkin, D.. (2012). Exacerbation frequency and course of COPD. International Journal of COPD [e-journal]. 7, p653-661. https://doi.org/10.2147/COPD.S34186

Kirsten, D., Taube, C., Lehnigk, R., Jorres, A., Magnussen, H.. (1998). Exercise training improves recovery in patients with COPD after an acute exacerbation. Respiratory Medicine [e-journal] 92 (10), p1191-1198. https://doi.org/10.1016/S0954-6111(98)90420-6

Matelot, D., Schnell, F., Kervio, G., Ridard, C., Thillaye du Boullay, N., Wilson, M., Carre, F. . (2016). Cardiovascular Benefits of Endurance Training in Seniors: 40 is not too Late to Start. International Journal of Sports Medicine . 37 (8), p625-632. doi: 10.1055/s-0035-1565237

Mehri, S., Khoshnevis, S., Zarrehbinan, F., Hafezi, S., Ghasemi, A., Ebadi, A. (2007). Effect of Treadmill Exercise Training on VO2 Peak in Chronic Obstructive Pulmonary Disease. National Research Institute of Tuberculosis and Lung Disease, Iran. 6 (4), p18-24.

Ortega, F., Toral, J., Cejudo, P., Villagomez, R., Sanchez, H., Castillo, J., Montemayor, T. (2002). Comparison of Effects of Strength and Endurance Training in Patients with Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine, [e-journal] 166 (5), p669-674. https://doi.org/10.1164/rccm.2107081

Puente-Maestu, L., Sanz, ML., Sanz, P., Cubillo, JM., Mayol, J., Casaburi, R.. (2000). Comparison of effects of supervised versus self-monitored training programmes in patients with chronic obstructive pulmonary disease. European Respiratory Journal. 15 (3), p517-525.

Randers, M., Andersen, L., Orntoft, C., Bendiksen, M., Johansen L., Horton, J., Hansen, P., Krustrup P. . (2013). Cardiovascular health profile of elite female football players compared to untrained controls before and after short-term football training. Journal of Sports Sciences . 31 (13), p1421-1431. https://doi.org/10.1080/02640414.2013.792950

Yerg 2nd , J., Seals, D., Hagberg, J., Holloszy, J.. (1985). Effect of endurance exercise training on ventilatory function in older individuals. Journal of Applied Physiology. 58 (3), p791-794. https://doi.org/10.1152/jappl.1985.58.3.791

Combination training for the management of COPD

Pulmonary rehabilitation (PR), involving exercise training, is the common treatment prescribed to chronic obstructive pulmonary disorder (COPD) patients. Whilst exercise does not cure COPD, it does treat the symptoms associated with the disease. Exercise training usually consists of aerobic endurance training, however, it is now debated that combination training (CT) of endurance and resistance training is the optimal training modality for patients with COPD for reducing symptoms and improving health-related quality of life (HRQoL).

Impaired exercise tolerance limiting daily activities, dyspnoea (breathlessness) and reduced quality of life (QoL) are common complaints of COPD patients. Endurance training (ET) has been shown to improve exercise tolerance, as seen in the endurance training section, but has little effect on peripheral muscle atrophy and weakness, which is in part responsible for the extensive symptoms and reduced work capacity seen in patients with COPD. Resistance training (RT) promotes muscle growth and strengthening, as seen in the resistance training section, and may represent a useful addition to whole-body ET (O’shea et al. 2009; Paoli et al. 2017).

Effect of combined training on muscle strength

Mador et al. (2004) found that, following CT, there was a significant increase in the strength of quadriceps, hamstrings, pectoralis major, and latissimus dorsi. Only improvements in quadriceps and latissimus dorsi significantly differed when compared to ET alone. A further study by Bernard et al. (1999) saw a significant increase in bilateral muscle mean cross-sectional area (MCSA), and an increase in the strength of quadriceps, pectoralis major, and latissimus dorsi, that all significantly differed from ET only. Improvements in muscle mass and strength confirm that peripheral muscles retain the ability to undergo structural adaptation in patients with COPD, and may go a long way to improving the performance of tasks of daily living. Improvements in muscle strength during CT are due to both muscle hypertrophy and improved neural recruitment patterns.

The majority of papers agree that CT provides a significant improvement in muscle strength compared to ET alone, however, in many cases, this improvement did not translate into additional improvement in exercise performance or HRQoL compared to that achieved by ET alone (Bernard et al., 1998). Furthermore, peripheral muscle strength is often not fully corrected following training, suggesting that either the training period was insufficient, or increasingly more likely, that factors other than chronic inactivity are involved in muscle atrophy and weakness in COPD patients (Clark et al. 2000; Berry et al. 2018).

Muscle strength improvement is still beneficial however as it is associated with improvements in body composition, neurohumoral changes, and bone mineral density (BMD). The improvements in BMD may prove beneficial for patients with COPD in whom osteoporosis is highly prevalent (Heinonen et al. 1996; McEvoy et al. 1998).

Effect of combined training on exercise performance, dyspnoea and quality of life (QoL)

Daabis et al. (2017) found that dyspnoea score, HRQoL and 6-minute walk test (6MWT) significantly improved following exercise training but the magnitude of changes was comparable for CT and ET. HRQoL was measured by the St. George’s Respiratory Questionnaire (SGRQ) and functional exercise capacity was measured by the 6MWT. Ortega et al. (2002) also saw improvements in dyspnoea, and a significant increase in the dimension of emotion was observed in the CT group, but this was not seen in fatigue.

Table 1. Changes in dyspnoea and health-related quality of life before and after different training modalities

Source: Ortega et al. 2002. American Journal of Respiratory and Critical Care Medicine, 166(5), 672

Lacasse et al. (1996) saw pronounced changes in functional exercise capacity. They also saw a significant reduction in heart rate, VE, and blood lactate in both CT and ET, suggesting a physiological effect, but no significant difference between groups was observed.

Mador et al. (2004) also showed significant improvements in dyspnoea and fatigue for CT and ET, but there was no significant difference in the extent of improvement between groups. QoL, as measured by the Chronic Respiratory Questionnaire (CRQ), improved in both ET and CT with no significant difference between groups in the extent of improvements, despite differences between groups in improvements in muscle strength and submaximal exercise endurance. It can be concluded that almost any exercise modality resulted in improvements in QoL, in some areas, in patients with COPD. There may be a ceiling effect however, beyond which the unchanged pulmonary function limits any further improvements, which could explain why CT is not significantly more beneficial than ET for improving QoL (Pulhan et al. 2011; Spruit et al. 2003).

Elements of the CRQ or SGRQ, used to test QoL HRQoL, where improved regardless of the exercise modality, and no modality led to improvements in all areas. It is therefore possible to conclude that some activities of daily living might be improved by RT addition and, if not performed frequently, might not be of sufficient impact to significantly alter the CRQ score. Furthermore, it cannot be fully concluded that CT is not of greater benefit than ET for improving the QoL for COPD patients.

Is combined training a better option for the treatment of COPD?

Ortega et al. (2002) concluded that RT was superior to ET to improve muscle strength and ET was superior to RT to improve submaximal exercise tolerance. CT produced improvements in peripheral muscle strength and endurance comparable to those obtained by each modality alone. Bernard et al. (1999), having reached similar results, further concluded that due to the combined benefits of CT, it should be prescribed as the preferred training modality for patients with COPD.

Daabis et al. (2017) and Spruit et al. (2013) found that CT elicits a reduced cardiorespiratory response compared with ET alone as it demanded a lower level of oxygen consumption and minute ventilation, due to the resistant training elements. CT may therefore be a more attractive and feasible exercise option over ET for patients with COPD who may not be able to complete high-intensity ET, or for patients during times of disease exacerbations.

CT also provides variation in training program. Variation can improve engagement of participants and the continuation of exercise training which is needed to see improvements, regardless of the exercise program followed (Zeng et al. 2018; Emtner et al. 2016).

The use of CT, as part of a pulmonary rehabilitation program, has been shown to limit the impact of the disease on the overall health and wellbeing of its sufferers. Depsite lack of significant evidence to conclude whether CT is of greater benefit than other exercise modalities, it is widely agreed that the additional benefits to muscle strength and endurance, and the variation it provides, makes CT a good exercise modality for the management of patients with COPD.

Written by: Stacey Harrington (17801465)

References:

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Bernard, S., P. Leblanc, F. Whittom, P. LeBlanc, J. Jobin, R. Belleau, C. Berube, G. Carrier, F. Maltais, 1999. Exercise Training in COPD. Am. J. Respir. Crit. Care Med, 159
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Clark, C.J., L.M. Cochrane, E. Mackay, B. Paton, 2000. Skeletal muscle strength and endurance in patients with mild COPD and the effects of weight training. Eur Respir J, 15, 92-97
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Emtner, M., K. Waddell, 2016. Effects of exercise training in patients with chronic obstructive pulmonary disease- a narrative review for FYSS (Swedish Physical Activity Exercise Prescription Book). Br J Sports Med., 50(6), 368-371
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Exercise for the management of Chronic Obstructive Pulmonary Disease (COPD)

Using sports to help lives