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High-intensity inspiratory muscle training in COPD Differences in Response to Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis and Chronic Obstructive Pulmonary Disease The Effects of Controlled Breathing during Pulmonary Rehabilitation in Patients with COPD
Background Oxygen desaturation during exercise is common in people with chronic obstructive pulmonary disease ( COPD ) . The aim of the study is to determine , in people with COPD who desaturate during exercise , whether supplemental oxygen during an eight-week exercise training program is more effective than medical air ( sham intervention ) in improving exercise capacity and health-related quality of life both at the completion of training and at six-month follow up . Methods / Design This is a multi-centre r and omised controlled trial with concealed allocation , blinding of participants , exercise trainers and assessors , and intention-to-treat analysis . 110 people with chronic obstructive pulmonary disease who demonstrate oxygen desaturation lower than 90 % during the six-minute walk test will be recruited from pulmonary rehabilitation programs in seven teaching hospitals in Australia . People with chronic obstructive pulmonary disease on long term oxygen therapy will be excluded . After confirmation of eligibility and baseline assessment , participants will be r and omised to receive either supplemental oxygen or medical air during an eight-week supervised treadmill and cycle exercise training program , three times per week for eight weeks , in hospital outpatient setting s. Primary outcome measures will be endurance walking capacity assessed by the endurance shuttle walk test and health-related quality of life assessed by the Chronic Respiratory Disease Question naire . Secondary outcomes will include peak walking capacity measured by the incremental shuttle walk test , dyspnoea via the Dyspnoea-12 question naire and physical activity levels measured over seven days using an activity monitor . All outcomes will be measured at baseline , completion of training and at six-month follow up . Discussion Exercise training is an essential component of pulmonary rehabilitation for people with COPD . This study will determine whether supplemental oxygen during exercise training is more effective than medical air in improving exercise capacity and health-related quality of life in people with COPD who desaturate during exercise . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12612000395831 , 5th Introduction Chronic obstructive pulmonary disease is generally progressive and associated with reduced physical activity . Both pharmacological therapy and exercise training can improve exercise capacity ; however , these are often not sufficient to change the amount of daily physical activity a patient undertakes . Behaviour-change self-management programmes are design ed to address this , including setting motivational goals and providing social support . We present and discuss the necessary method ological considerations when integrating behaviour-change interventions into a multicentre study . Methods and analysis PHYSACTO is a 12-week phase IIIb study assessing the effects on exercise capacity and physical activity of once-daily tiotropium+olo date rol 5/5 µg with exercise training , tiotropium+olo date rol 5/5 µg without exercise training , tiotropium 5 µg or placebo , with all pharmacological interventions administered via the Respimat inhaler . Patients in all intervention arms receive a behaviour-change self-management programme to provide an optimal environment for translating improvements in exercise capacity into increases in daily physical activity . To maximise the likelihood of success , special attention is given in the programme to : ( 1 ) the Site Case Manager , with careful monitoring of programme delivery ; ( 2 ) the patient , incorporating patient-evaluation/programme-evaluation measures to guide the Site Case Manager in the self-management intervention ; and ( 3 ) quality assurance , to help identify and correct any problems or shortcomings in programme delivery and ensure the effectiveness of any corrective steps . This paper documents the comprehensive methods used to optimise and st and ardise the behaviour-change self-management programme used in the study to facilitate dialogue on the inclusion of this type of programme in multicentre studies . Ethics and dissemination The study has been approved by the relevant Institutional Review Boards , Independent Ethics Committee and Competent Authority according to national and international regulations . The results of this study will be disseminated through relevant , peer- review ed journals and international conference presentations . Trial registration number NCT02085161 CONTEXT The initial gain from a Pulmonary Rehabilitation Program ( PRP ) among patients with chronic obstructive pulmonary disease ( COPD ) begins to fade away 6 months after the completion of a rehabilitation program . One possible reason may be due to the poor compliance of the patients to the existing forms of home exercise program ( e.g. , walking , weight training activities , etc . ) . OBJECTIVES This study tested the efficacy of health qigong ( HQG ) , a traditional Chinese exercise , as an adjunct home exercise program in optimizing the gains obtained from PRP until 6 months after discharge . DESIGN This was a r and omized controlled trial ( RCT ) on a mind-body exercise intervention . PARTICIPANTS Eighty ( 80 ) patients with COPD receiving conventional PRP pulmonary rehabilitation program were r and omized to the HQG intervention  group ( n = 40 ) and control group  ( n = 40 ) . OUTCOME MEASURES Assessment s were undertaken by blinded assessors at baseline , discharge from training , and follow-up ( FU ) at 3 and 6 months . Primary outcomes involved functional capacity scales and secondary outcomes involved quality -of-life scales . RESULTS Intention-to-treat analysis identified trends of improvement in all outcome measures in the HQG group , whereas lesser improvement and trends of deteriorations were identified in the control group . Ancillary analysis using a per- protocol method , however , identified significantly better improvements in functional capacity measures among the HQG at the 6-month FU . CONCLUSIONS This RCT provided some evidence to support the positive effect of HQG as an adjunct home exercise for rehabilitation among people with COPD and to support further related research Both interval ( IT ) and continuous ( CT ) exercise training results in an improvement of aerobic capacity in patients with chronic obstructive pulmonary disease ( COPD ) ; however , their effects on cardiac autonomic function remains unclear . The aim of our study was to evaluate the effect of a supervised CT vs IT on autonomic cardiac function in COPD patients BACKGROUND Pulmonary rehabilitation ( PR ) is an evidence -based intervention in patients with chronic obstructive pulmonary disease ( COPD ) which improves the exercise capacity and quality of life ( QoL ) . METHODS We studied 60 patients after an episode of acute exacerbation of COPD ( AE COPD ) . They were r and omised to receive conventional treatment without pulmonary rehabilitation ( CTWPR ) ( n=30 ) or , st and ard treatment plus a 12-week post-exacerbation pulmonary rehabilitation ( PEPR ) programme in addition . Assessment of exercise capacity by six minute walk test ( 6MWT ) and QoL measured by St George 's Respiratory Question naire ( SGRQ ) were carried out initially and at the end of three months . RESULTS The baseline characteristics of both the groups were found to be similar . There was a statistically significant increase in the six minute walk distance ( 6MWD ) ( increase by 37.9 meters , p < 0.001 ) and a significant decline in the total SGRQ score ( by 3.8 units p < 0.001 ) in the PEPR group compared to CTWPR group . CONCLUSION Early pulmonary rehabilitation in patients with an AE COPD has significant benefits on the QoL and exercise capacity BACKGROUND The effects of theophylline or anticholinergic agents on exercise capacity in patients with chronic obstructive pulmonary disease ( COPD ) remain controversial . The aim of the present study was to compare the effect of an oral theophylline with an inhaled anticholinergic agent and to examine the effects of combined therapy on exercise performance using progressive cycle ergometry . METHODS Twenty one men with stable COPD and a mean ( SD ) forced expiratory volume in one second ( FEV1 ) of 1.00 ( 0.40 ) l were studied .  Theophylline ( 600 or 800 mg daily ) , ipratropium bromide ( 160 μg ) , a combination of both drugs , and placebo were given in a r and omised , double blind , four period crossover design study . Spirometric data , pulse rate , and blood pressure were assessed before and at 90 and 120 minutes after inhalation . Symptom limited progressive cycle ergometer exercise tests ( 20 watts/min ) were performed 90 minutes after each inhalation , and dyspnoea was measured during exercise using the Borg scale . RESULTS The mean ( SD ) serum theophylline concentration was 18.3 ( 6.3 ) μg/ml , and seven patients had side effects during treatment with theophylline . Theophylline and ipratropium bromide produced greater increases in FEV1 , maximal oxygen consumption , maximal minute ventilation , and several dyspnoea ratios than placebo . There were no differences between theophylline and ipratropium bromide except in maximal heart rate . A combination of both drugs produced greater improvements in pulmonary function and exercise capacity than either drug alone . CONCLUSIONS Both high dose theophylline and high dose ipratropium bromide  improved exercise capacity in patients with stable COPD . Although data based on short term effects can not be directly applied to long term therapy , theophylline added to an inhaled anticholinergic agent may have beneficial effects on exercise capacity in patients with COPD BACKGROUND The aim of this study was to investigate the clinical characteristics , exercise training response , β-blocker selectivity , and outcomes in patients with heart failure ( HF ) and chronic obstructive pulmonary disease ( COPD ) . METHODS We performed an analysis of HF-ACTION , which r and omized 2,331 patients with HF having an ejection fraction of ≤35 % to usual care with or without aerobic exercise training .  We examined clinical characteristics and outcomes ( mortality/hospitalization , mortality , cardiovascular [ CV ] mortality/CV hospitalization , and CV mortality/HF hospitalization ) by physician-reported COPD status using adjusted Cox models and explored an interaction with exercise training . The interaction between β-blocker cardioselectivity and outcomes was investigated . RESULTS Of patients with COPD status documented ( n = 2311 ) , 11 % ( n = 249 ) had COPD . Patients with COPD were older , had more comorbidities , and had lower use of β-blockers compared with those without COPD . At baseline , patients with COPD had lower peak oxygen consumption and higher V(E)/V(CO)(2 ) slope . During a median follow-up of 2.5 years , COPD was associated with increased mortality/hospitalization , mortality , and CV mortality/HF hospitalization . After multivariable adjustment , the risk of CV mortality/HF hospitalization remained increased ( hazard ratio [ HR ] 1.46 , 95 % CI 1.14 - 1.87 ) , whereas mortality/hospitalization ( HR 1.15 , 95 % CI 0.96 - 1.37 ) and mortality ( HR 1.33 , 95 % CI 0.99 - 1.76 ) were not significantly increased . There was no interaction between COPD and exercise training on outcomes or between COPD and β-blocker selectivity on mortality/hospitalization ( all P > .1 ) . CONCLUSIONS Chronic obstructive pulmonary disease in patients with HF was associated with older age , more comorbidities , reduced exercise capacity , and increased CV mortality/HF hospitalization , but not a differential response to exercise training . β-Blocker selectivity was not associated with differences in outcome for patients with vs without COPD L and -based exercise is often difficult for people with chronic obstructive pulmonary disease ( COPD ) who have coexisting obesity or musculoskeletal or neurological conditions . This r and omised controlled trial aim ed to determine the effectiveness of water-based exercise training in improving exercise capacity and quality of life compared to l and -based exercise training and control ( no exercise ) in people with COPD and physical comorbidities . Participants referred to pulmonary rehabilitation were r and omly allocated to a water-based exercise , l and -based exercise or the control group . The two exercise groups trained for 8 weeks , completing three sessions per week . 45 out of 53 participants ( mean±sd age 72±9 years ; forced expiratory volume in 1 s 59±15 % predicted ) completed the study . Compared to controls , water-based exercise training  significantly increased 6-min walking distance , incremental and endurance shuttle walk distances , and improved Chronic Respiratory Disease Question naire ( CRDQ ) dyspnoea and fatigue . Compared to l and -based exercise training , water-based exercise training significantly increased incremental shuttle walk distance ( mean difference 39 m , 95 % CI 5–72 m ) , endurance shuttle walk distance ( mean difference 228 m , 95 % CI 19–438 m ) and improved CRDQ fatigue  . Water-based exercise training was significantly more effective than l and -based exercise training and control in increasing peak and endurance exercise capacity and improving aspects of quality of life in people with COPD and physical comorbidities In most chronic obstructive pulmonary disease ( COPD ) patients , dyspnoea and functional exercise capacity may improve as a result of inspiratory muscle training ( IMT ) . However , the long-term benefits of IMT have been investigated to a much lesser extent . The present study investigated the short-term and long-term benefits of IMT on inspiratory muscle performance ( strength and endurance ) , exercise capacity and the perception of dyspnoea .  Thirty-eight patients with significant COPD had 3 months of basic IMT and were then r and omised into a group that received maintenance IMT for the next year , and a group that got training with very low load . Following the basic training there was a statistically significant increase in inspiratory muscle performance , 6-min walk test ( 6MWT ) , and a decrease in the dyspnoea . During the second stage of the study , the training group continued to maintain the improvement in all parameters , while there was already deterioration in the inspiratory muscle performance , exercise capacity and dyspnoea in the low intensity group during the 6–12 month period . The present study concludes that , in patients with significant chronic obstructive pulmonary disease , inspiratory muscle training results in improvement in performance , exercise capacity and in the sensation of dyspnoea . The benefits of 12‐weeks of inspiratory muscle training decline gradually over 1 yr of follow-up if maintenance training is not performed Background Pulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease ( COPD ) to improve exercise capacity , symptoms and quality of life , however only a minority of individuals with COPD are able to participate . Travel and transport are frequently cited as barriers to uptake of centre-based programs . Other models of pulmonary rehabilitation , including home-based programs , have been proposed in order to improve access to this important treatment . Previous studies of home-based pulmonary rehabilitation in COPD have demonstrated improvement in exercise capacity and quality of life , but not all elements of the program were conducted in the home environment . It is uncertain whether a pulmonary rehabilitation program delivered in its entirety at home is cost effective and equally capable of producing benefits in exercise capacity , symptoms and quality of life as a hospital-based program . The aim of this study is to compare the costs and benefits of home-based and hospital-based pulmonary rehabilitation for people with COPD . Methods / Design This r and omised , controlled , equivalence trial conducted at two centres will recruit 166 individuals with spirometrically confirmed COPD . Participants will be r and omly allocated to hospital-based or home-based pulmonary rehabilitation . Hospital programs will follow the traditional outpatient model consisting of twice weekly supervised exercise training and education for eight weeks . Home-based programs will involve one home visit followed by seven weekly telephone calls , using a motivational interviewing approach to enhance exercise participation and facilitate self management . The primary outcome is change in 6-minute walk distance immediately following intervention . Measurements of exercise capacity , physical activity , symptoms and quality of life will be taken at baseline , immediately following the intervention and at 12 months , by a blinded assessor . Completion rates will be compared between programs . Direct healthcare costs and indirect ( patient-related ) costs will be measured to compare the cost-effectiveness of each program . Discussion This trial will identify whether home-based pulmonary rehabilitation can deliver equivalent benefits to centre-based pulmonary rehabilitation in a cost effective manner . The results of this study will contribute new knowledge regarding alternative models of pulmonary rehabilitation and will inform pulmonary rehabilitation guidelines for COPD .Trial registration Clinical Trials.gov : NCT01423227 Introduction Although pulmonary rehabilitation ( PR ) is associated with significant clinical benefits in chronic obstructive pulmonary disease ( COPD ) and has been recommended by guidelines , PR with conventional exercise training has not been widely applied in the clinic because of its inherent limitations . Alternative exercise such as Tai Chi has been investigated and the results are promising . However , the strengths and weaknesses of the exercise modality of Tai Chi , conventional PR and a combination of Tai Chi and conventional PR and the possible mechanisms underlying Tai Chi exercise remain unclear . This study aims to address the above research gaps in a well- design ed clinical trial . Methods and analysis This study is a single-blind , r and omised controlled trial . Participants with stable COPD will be recruited and r and omly assigned to one of four groups receiving Tai Chi exercise , conventional PR using a total body recumbent stepper ( TBRS ) , combined Tai Chi and TBRS , or usual care ( control ) in a 1:1:1:1 ratio . Participants will perform 30 min of supervised exercise three times a week for 8 weeks ; they will receive sequential follow-ups until 12 months after recruitment . The primary outcome will be health-related quality of life as measured by the St George 's Respiratory Question naire . Secondary outcomes will include 6 min walking distance , pulmonary function , the modified Medical Research Council Dyspnoea Scale , the COPD Assessment Test , the Hospital Anxiety and Depression Scale , the Berg Balance Scale , exacerbation frequency during the study period , and systemic inflammatory and immune markers . Ethics and dissemination Ethics approval has been granted by the Clinical Trial and Biomedical Ethics Committee of West China Hospital of Sichuan University ( No TCM-2015 - 82 ) . Written informed consent will be obtained from each participant before any procedures are performed . The study findings will be published in peer- review ed journals and presented at national and international conferences . Trial registration number ChiCTR-IOR-15006874 ; Pre- results PURPOSE The effects of a long-term treatment of autogenic drainage ( AD ) and the active cycle of breathing techniques ( ACBT ) were evaluated in patients with chronic obstructive pulmonary disease ( COPD ) . METHODS Thirty clinical ly stable male COPD patients were r and omly assigned to AD or the ACBT treatment for a 20-day treatment period . Patients were assessed through pulmonary function tests , arterial blood gases , a 6-minute walking test , and a modified Borg Scale before , and immediately after the walking test . RESULTS Autogenic drainage improved forced vital capacity , forced expiratory volume in 1 second , peak expiratory flow rate , forced expiratory volume from 25 to 75 % , chronic hypercapnia , arterial oxygenation , exercise performance , and dyspnea perception during exercise . The ACBT increased forced vital capacity , peak expiratory flow rate , arterial oxygenation and exercise performance . Peak expiratory flow rate increased in AD more than in ACBT . In AD treatment , the increase in oxygen saturation was significantly higher than in ACBT treatment . Chronic hypercapnia improved significantly in AD treatment than in ACBT . No differences were found in other lung function parameters . CONCLUSIONS Autogenic drainage is as effective as the ACBT in cleaning secretions and improving lung functions . These techniques can be used in stable COPD patients according to the patients ' and the physiotherapists ' preferences Oxidative capacity and uncoupling protein-3 ( UCP3 ) content are reduced in limb muscles of patients with chronic obstructive pulmonary disease ( COPD ) . It has been hypothesized that the physiological role of UCP3 is to protect mitochondria against lipotoxicity in cases where fatty acid influx exceeds the capacity to oxidize them . Exercise training improves oxidative capacity and reduces UCP3 protein content in healthy subjects , but the response of UCP3 to training in COPD is unknown . We studied the effect of exercise training on UCP3 content in limb muscles of COPD patients . For this , seven healthy age-matched subjects and thirteen patients with COPD were studied . All patients were admitted to an 8-wk exercise training intervention .  Exercise capacity was assessed by means of an incremental cycle ergometry test . Biopsies were taken from the vastus lateralis in which UCP3 and lipid peroxidation levels were determined by Western blotting . Citrate synthase and 3-hydroxyacyl-CoA dehydrogenase ( HAD ; an enzyme involved in fatty acid oxidation ) were measured as indexes of muscle oxidative capacity . UCP3 in COPD was approximately 50 % lower compared with healthy age-matched controls . In COPD , training induced upregulation of UCP3 [ from 67.7 ( SD 41.8 ) to 113.8 ( SD 104.2 ) arbitrary units ( AU ) , P = 0.062 ] , especially in the patients who showed no increase in HAD activity [ from 80.9 ( SD 52.6 ) to 167.9 ( SD 109.1 ) AU , P = 0.028 ] , whereas lipid peroxidation levels remained unaltered . We conclude that exercise-training can restore muscle UCP3 protein level in COPD , and the nature of this response complies with the hypothesis that UCP3 may protect against lipotoxicity BACKGROUND AND OBJECTIVE Non-anaemic iron deficiency ( NAID ) might alter the oxygen pathway in health and disease . The current study aims at assessing the impact of NAID on aerobic capacity in patients with chronic obstructive pulmonary disease ( COPD ) . METHODS A prospect i ve sample of 70 non-anaemic COPD patients c and i date to participate in an 8-week pulmonary rehabilitation ( PR ) programme  was studied . Incremental cycling exercise to peak oxygen uptake ( V'O2peak ) and constant work-rate exercise at 80 % V'O2peak to exhaustion were assessed pre- and post-PR . Training-induced increase of endurance time ( ET ) ≥33 % , which represented the minimal clinical ly important difference , classified patients as responders to exercise training . RESULTS The prevalence of NAID was 48 % ( n = 34 ) showing no relationship with the Global Initiative for Chronic Obstructive Lung Disease stages ( P = 0.209 ) . Patients with NAID showed lower pre-training ET ( P = 0.033 ) and V'O2peak ( P = 0.007 ) than normal iron status ( NIS ) patients after adjustment for potential covariates . Significant training-induced physiological changes were seen in the NIS group ( ΔV'O2peak 68(132 ) mL/min ; P = 0.009 ) , but not in the NAID group ( ΔV'O2peak 26 ( 126 ) mL/min ; P = 0.269 ) . The NAID group showed lower percentage of responders to training ( 56 % ) than the NIS group ( 78 % ) ( P = 0.041 ) . CONCLUSIONS COPD patients with NAID showed lower pre-training aerobic capacity and reduced training-induced response than NIS patients after adjusting for potential confounding variables BACKGROUND Non-invasive ventilation and exercise training might prove beneficial in the management of COPD patients . OBJETIVE to compare the combined use of exercise training and non-invasive ventilation with the two interventions separately in chronic respiratory failure due to chronic obstructive pulmonary disease . As primary objective exercise capacity and secondary objectives gas exchange , peripheral muscle strength , BODE index , quality of life and systemic inflammatory response . METHODS Forty-five patients with severe chronic obstructive pulmonary disease were r and omized into three groups for an intervention of 12 weeks : exercise training alone , ventilation alone and combined treatment . We assessed exercise capacity , pulmonary function , BODE index , perception of dyspnoea , quality of life and several biomarkers . RESULTS All exercise capacity parameters improved after training and the combined treatment . In addition , peripheral muscle strength and six-minute walk distance increased after ventilation . We found differences between the combined group and the ventilation group in submaximal effort and in oxygen consumption . Changes in respiratory function were observed in blood gases that improved after ventilation and the combined treatment , with differences between these groups . BODE index , perception of dyspnoea and quality of life improved in all three groups without differences between groups . Levels of interleukin 8 and tumour necrosis factor α decreased after ventilation , and interleukin 8 , C-reactive protein and surfactant protein D decreased after training , while all four of these markers fell after the combined treatment . No differences between groups were found . CONCLUSIONS The combination of ventilation and exercise training had greater benefits than the separate treatments : improvements were observed in both blood gases and the levels of more biomarkers decreased . In addition , submaximal exercise capacity increased in all groups . The improvements seen in BODE index , perception of dyspnoea and quality of life were similar in all groups Almost half the patients referred to pulmonary rehabilitation with chronic obstructive pulmonary disease ( COPD ) desaturate during exercise . Although oxygen supplementation may ameliorate oxygen desaturation , the effects on outcomes of exercise training have not been rigorously evaluated . This study aim ed to determine whether supplemental oxygen during exercise training was more effective than medical air in improving exercise capacity and health-related quality of life ( HRQoL ) in people with COPD . People with COPD who demonstrated oxygen desaturation < 90 % during the 6-min walk test were recruited to this multicentre trial with r and omisation ( independent , concealed allocation ) to either an Oxygen group or Air group , blinding ( participants , exercise trainers and European Respiratory Journal assessors ) and intention-to-treat analysis . Both groups received the respective gas from concentrators via nasal prongs at 5 L·min−1 during exercise training consisting of treadmill and cycle exercise , three times per week for 8 weeks . Primary outcomes were the endurance shuttle walk test ( ESWT ) time and Chronic Respiratory Disease Question naire (CRQ)-Total score . 111 participants ( 60 males ) , mean±sd age 69±7 years , with moderate to severe COPD were recruited and 97 completed ( Oxygen  group n=52 ; Air group n=45 ) . At the end of the 8-week training programme there were no between-group differences in change in ESWT ( mean difference 15 s ( 95 % CI −106–136 s ) or change in CRQ-Total ( 0.0 points ( 95 % CI −0.3–0.3 points ) ) . Within-group changes at end-training were significant for ESWT and CRQ-Total ( all p<0.01 ) . Exercise capacity and HRQoL improved in both groups , with no greater benefit from training with supplemental oxygen than medical air . Exercise training improved exercise capacity and quality of life in normoxaemic COPD patients who demonstrated oxygen desaturation during exercise , with no greater improvement with supplemental oxygen during exercise training compared to air Background Breathing programs have been reported to have positive effects in alleviating symptoms and optimizing pulmonary function in patients with chronic obstructive pulmonary disease ( COPD ) . However , patients with stable disease may drop out of such programs if they are not modified to the individual ’s exercise tolerance level , or if they are not easy to perform in the home . Little is known about the effectiveness of web-based home breathing programs for dyspnea . The purpose of this study was to evaluate the effectiveness of an online breathing program which included an animated diagram and video-guided instruction on pulmonary function , exercise capacity , and health-related quality of life in patients with COPD . Methods Sixty patients with stable COPD were r and omized 1:1 to an experimental group ( n = 30 ) or a control group ( n = 30 ) . Subjects in the experimental group trained for four months using an online program which included an animated diagram and video-guided instruction while the control group received conventional patient education on discharge from hospital .  Forced expiratory volume , forced expiratory volume in one second (FEV1)/forced vital capacity ( % ) , peak expiratory volume , six-minute walking distance test , and responses to the St George ’s Respiratory Question naire were assessed before and after the intervention . Results Patients in the two groups were well matched for demographic and clinical characteristics at baseline . All outcome measures showed significant improvement in the experimental group but not in the control group . Conclusion The online training program result ed in improved pulmonary function , exercise capacity , and health status . Therefore , it is strongly recommended that patients with stable COPD be trained with such programs PURPOSE Many patients with chronic obstructive pulmonary disease ( COPD ) report dyspnea and fatigue when performing upper limb activities . Unsupported upper limb training has been shown to improve upper limb endurance , but its effects on symptoms and quality of life have not been examined . The aim of this study was to compare the effects of upper limb and lower limb training with lower limb training alone on exercise capacity , symptoms , and quality of life with COPD . METHODS For this study , 38 patients with moderate to severe COPD were r and omly allocated to unsupported upper limb endurance training or to a control group that completed a sham training task . All the patients underwent lower limb endurance training . The 6-minute walk test , the Incremental Unsupported Upper Limb Exercise Test , and the Chronic Respiratory Disease Question naire ( CRQ ) were completed before training and then 6 weeks afterward . Both patients and assessors were blinded to group allocation . RESULTS All the patients reported symptoms associated with upper limb activities on the initial CRQ . Both groups showed significant improvements in all domains of the CRQ and in the 6-minute walk test after training . Only the upper limb training group showed improvement in upper limb endurance time ( 57 + /- 75 vs 2 + /- 58 seconds ; P = .02 ) . There were no significant differences between the groups for 6-minute walk test or any domain of the CRQ . CONCLUSIONS Unsupported upper limb training for patients COPD improves upper limb exercise capacity , but has no additional effect on symptoms or quality of life , as compared with leg training alone . This type of upper limb training may not adequately address the complex interaction between respiratory mechanics and upper limb function The article by McKeough and colleagues in this issue of Chronic Respiratory Disease is the first study to compare different modes of upper extremity training in individuals with chronic obstructive pulmonary disease ( COPD ) . Limitations during exercise and daily activity in individuals with COPD are not limited to lower extremity activities such as walking or stair climbing ; most of the patients experience difficulty during activities that involve their arms due to the sensation of dyspnea and /or arm fatigue . Upper extremity training for patients with COPD is an important component of pulmonary rehabilitation ( PR ) , result ing in improvements in arm exercise capacity , arm function and muscle strength . However , there is limited evidence on what type of training should be performed . The study by McKeough and colleagues adds to the growing body of evidence in the area of upper extremity training in COPD and provides support for the inclusion of arm endurance and strength training as a part of PR . The study is a r and omized controlled trial ( RCT ) that aim ed to compare the effects of arm endurance training ; arm strength training , a combination of arm endurance and strength training ; and no arm training ( control group ) on endurance arm exercise capacity , functional arm exercise capacity and health-related quality of life ( HRQL ) in individuals with mild-tovery severe COPD . The authors found a significant improvement in arm endurance time ( arm endurance capacity ) between the endurance group and control group . There were nonsignificant trends in arm endurance time favoring the strength training and combined groups compared with the control group . In terms of symptoms , the authors demonstrated that the combined group had a significantly greater reduction in dyspnea and rate of perceived exertion at the end of the functional arm exercise test compared with the control and with each of the intervention groups . When the combined group was compared with the other two intervention groups , the improvement in HRQL ( measured using the St George ’s Respiratory Question naire ) exceeded the minimum clinical ly important difference of 4 units , although it did not reach statistical significance . Until the beginning of the century , several RCTs had been conducted to examine the effects of upper extremity training in individuals with COPD . However , there were considerable variations in the exercise protocol s rendering it impossible to determine the optimal training regimen for these patients . Moreover , the impact of upper extremity training on other clinical outcomes besides arm exercise capacity was unclear as shown consistently by four systematic review s. More recently , four RCTs examining the effects of arm exercise training in individuals with COPD have been published . Holl and and colleagues compared the effects of unsupported upper limb endurance training with lower extremity training alone . The authors found that unsupported upper limb endurance training improved upper limb exercise capacity but had no additional effects on the symptoms or HRQL compared with lower extremity training alone . Costi and colleagues examined the effects of upper extremity resistance training in patients with COPD compared with st and ard PR . The authors demonstrated improvement in arm functional exercise capacity ( measured using the 6-minute pegboard and ring test ) and in performance during activities of daily living ( ADL ) measured by an ADL field test . In addition , the authors found a decrease in arm fatigue at the end of the ADL test in the intervention group . Objective : To investigate the effects of elastic tubing training compared with conventional resistance training on the improvement of functional exercise capacity , muscle strength , fat-free mass , and systemic inflammation in patients with chronic obstructive pulmonary disease . Design : A prospect i ve , r and omized , eight-week clinical trial . Setting : The study was conducted in a university-based , outpatient , physical therapy clinic . Subjects : A total of 49 patients with moderate chronic obstructive pulmonary disease . Interventions : Participants were r and omly assigned to perform elastic tubing training or conventional resistance training three times per week for eight weeks . Main measures : The primary outcome measure was functional exercise capacity . The secondary outcome measures were peripheral muscle strength , health-related quality of life assessed by the Chronic Respiratory Disease Question naire ( CRDQ ) , fat-free mass , and cytokine profile . Results : After eight weeks , the mean distance covered during six minutes increased by 73 meters ( ±69 ) in the elastic tubing group and by 42 meters ( ±59 ) in the conventional group ( p < 0.05 ) . The muscle strength and quality of life improved in both groups ( P < 0.05 ) , with no significant differences between the groups . There was a trend toward an improved fat-free mass in both groups ( P = 0.05 ) . After the first and last sessions , there was an increase in interleukin 1β ( IL-1β ) and interleukin 10 ( IL-10 ) in both groups , while tumour necrosis factor alpha ( TNF-α ) was stimulated only in the conventional training group . Conclusion : Elastic tubing training had a greater effect on functional exercise capacity than conventional resistance training . Both interventions were equally effective in improving muscle strength and quality of life The aim of this study was to determine if weekly , supervised , outpatient-based exercise plus unsupervised home exercise following an 8-week pulmonary rehabilitation programme would maintain functional exercise capacity and quality of life at 12 months better than st and ard care of unsupervised home exercise training . Chronic obstructive pulmonary disease ( COPD ) subjects completed an 8-week pulmonary rehabilitation programme  , were r and omised to an intervention group ( IG ) of weekly , supervised , exercise plus home exercise or to a control group ( CG ) of unsupervised home exercise and followed for 12 months . Outcome measurements at baseline ( after pulmonary rehabilitation ) , and 3 , 6 and 12 months included the 6-min walk test and St George 's Respiratory Question naire ( SGRQ ) .  59 subjects with moderate COPD ( Global Initiative for Chronic Obstructive Lung Disease stage II ) were recruited and 48 subjects completed the study . 12-month mean difference showed no significant change from baseline in 6-min walk distance ( IG -11 m , 95 % CI -21–10 m ; CG -6 m , 95 % CI -34–11 m ) or total SGRQ score ( IG 3 , 95 % CI -0.8–7 ; CG -3 , 95 % CI -7–3 ) . 12 months following pulmonary rehabilitation both weekly , supervised , outpatient-based exercise plus unsupervised home exercise and st and ard care of unsupervised home exercise successfully maintained 6-min walk distance and quality of life in subjects with moderate COPD BACKGROUND Exercise is an important part of chronic obstructive pulmonary disease ( COPD ) treatment . However , it is not know about the minimum effective time of physical training that could beneficially modify the cardiac autonomic modulation ( CAM ) and exercise capacity in these patients . AIM To contrast the potential effects of a physical training program ( PTP ) , for 6 versus 12 weeks , on CAM by linear and nonlinear heart rate variability ( HRV ) indices and exercise capacity in COPD patients . DESIGN Prospect i ve r and omized controlled trial . SETTING Outpatient pulmonary rehabilitation . POPULATION Twenty moderate-to-severe COPD patients were r and omly assigned to either a training group ( N.=10 ) or a control group ( N.=10 ) . METHODS HRV at rest and during submaximal test was determined by linear ( rMSSD and SDNN ) and non-linear indices ( SD1 , SD2 and sample entropy [ SE ] ) . In addition , key responses were obtained during  cardiopulmonary exercise testing ( CPET ) , the walking distance ( WD ) during the six minute walking test and submaximal constant speed testing ( CST ) . PTP consisted of 30 minutes of aerobic exercise training on a treadmill , 3 times per week at 70 % of CPET peak speed rate . Patients were evaluated on baseline , 6 and 12 weeks . RESULTS Significant improvements in HRV indices , WD , as well as , other physiological responses were observed after 6 weeks of the PTP and maintained until 12 weeks ( P<0.05 ) . However , after 12 weeks , the SD1 index demonstrated an additional improvement compared with 6 weeks ( P<0.05 ) . Peak oxygen uptake and dioxide carbon production improved only after 12 weeks ( P<0.05 ) . Interestingly , the 6th week-baseline delta ( 6th week-baseline ) of WD , SDNN and SE were significantly higher than 12th week-6th week delta ( P<0.05 ) . CONCLUSION These results indicate that beneficial changes on cardiac autonomic modulation in conjunction with improvement in submaximal functional capacity occur in the first 6 weeks of PTP in moderate to severe COPD . CLINICAL REHABILITATION IMPACT Short-term rehabilitation ( 6 weeks ) is an effective sufficient time to beneficially modify important outcomes as cardiac modulation and exercise capacity in COPD patients This study was design ed to determine the effect of ground-based walking training on health-related quality of life and exercise capacity in people with chronic obstructive pulmonary disease ( COPD ) . People with COPD were r and omised to either a walking group that received supervised , ground-based walking training two to three times a week for 8–10 weeks , or a control group that received usual medical care and did not participate in exercise training .  130 out of 143 participants ( mean±sd age 69±8 years , forced expiratory volume in 1 s 43±15 % predicted ) completed the study . Compared to the control group , the walking group demonstrated greater improvements in the St George ’s Respiratory Question naire total score ( mean difference -6 points ( 95 % CI -10– -2 ) , p<0.003 ) , Chronic Respiratory Disease Question naire total score ( mean difference 7 points ( 95 % CI 2–11 ) , p<0.01 ) and endurance shuttle walk test time ( mean difference 208 s ( 95 % CI 104–313 ) , p<0.001 ) . This study shows that ground-based walking training  is an effective training modality that improves quality of life and endurance exercise capacity in people with COPD  . Walking training  improves quality of life and endurance exercise capacity compared to usual medical care in COPD The oxygen cost of eccentric exercise is lower than that of concentric exercise at similar work-loads . In this study , the response to eccentric cycle exercise training ( EET ) in addition to general exercise training ( GET ) on exercise performance and quality of life was investigated in 24 patients with severe chronic obstructive pulmonary disease ( COPD ) . All patients had a normal resting PaO2 and an arterial oxygen saturation ( SaO2 ) below 90 % at Wmax , achieved during a maximal incremental concentric cycle exercise test . The patients participated in a comprehensive inpatient pulmonary rehabilitation programme of 10 weeks . They were r and omly assigned either to GET ( GET group : mean FEV1 38 % predicted ) or to GET and additional EET ( GET/EET group : FEV1 45 % predicted ) . During EET , the patients were able to cycle eccentrically for 15 min continuously at a mean of 160 ( 69 % ) of Wmax whereas the Borg dyspnoea score did not exceed 3.0 and SaO2 did not fall below 90 % . Parameters of cardiocirculatory fitness and gas exchange improved in the GET/EET group but no further improvement in exercise capacity occurred compared to GET . It is concluded that eccentric cycle exercise is a safe and attractive training modality for patients with severe COPD and can be performed at a high intensity without the patient becoming out of breath or needing supplemental oxygen Background : Passive training of specific locomotor muscle groups by means of neuromuscular electrical stimulation ( NMES ) might be better tolerated than whole body exercise in patients with severe chronic obstructive pulmonary disease ( COPD ) . It was hypothesised that this novel strategy would be particularly effective in improving functional impairment and the consequent disability which characterises patients with end stage COPD . Methods : Fifteen patients with advanced COPD ( nine men ) were r and omly assigned to either a home based 6 week quadriceps femoris NMES training programme ( group 1 , n=9 , FEV1=38.0 (9.6)% of predicted ) or a 6 week control period before receiving NMES ( group 2 , n=6 , FEV1=39.5 (13.3)% of predicted ) . Knee extensor strength and endurance , whole body exercise capacity , and health related quality of life ( Chronic Respiratory Disease Question naire , CRDQ ) were assessed . Results : All patients were able to complete the NMES training programme successfully , even in the presence of exacerbations ( n=4 ) . Training was associated with significant improvements in muscle function , maximal and endurance exercise tolerance , and the dyspnoea domain of the CRDQ ( p<0.05 ) . Improvements in muscle performance and exercise capacity after NMES correlated well with a reduction in perception of leg effort corrected for exercise intensity ( p<0.01 ) . Conclusions : For severely disabled COPD patients with incapacitating dyspnoea , short term electrical stimulation of selected lower limb muscles involved in ambulation can improve muscle strength and endurance , whole body exercise tolerance , and breathlessness during activities of daily living Background : Pulmonary rehabilitation ( PR ) programs are beneficial to patients with chronic obstructive pulmonary disease ( COPD ) , and lower-extremity training is considered a fundamental component of PR . Nevertheless , the isolated effects of each PR component are not well established . Objective : We aim ed to evaluate the effects of a cycle ergometry exercise protocol as the only intervention in a group of COPD patients , and to compare these results with a control group . Methods : 25 moderate-to-severe COPD patients were evaluated regarding pulmonary function , respiratory muscle strength , exercise capacity , quality of life and body composition . Patients were allocated to one of two groups : ( a ) the trained group ( TG ; n = 13 ; 6 men ) was su bmi tted to a protocol of 24 exercise sessions on a cycle ergometer , with training intensity initially set at a heart rate ( HR ) close to 80 % of maximal HR achieved in a maximal test , and load increase based on dyspnea scores , and ( b ) the control group ( CG ; n = 12 ; 6 men ) with no intervention during the protocol period . Results : TG showed within-group significant improvements in endurance cycling time , 6-min walking distance test , maximal inspiratory pressure and in the domain ‘ dyspnea ’ related to quality of life . Despite the within-group changes , no between-group significant differences were observed . Conclusion : In COPD patients , the results of isolated low-to-moderate intensity cycle ergometer training are not comparable to effects of multimodality and high-intensity training programs BACKGROUND AND OBJECTIVE Skeletal muscle dysfunction contributes to exercise limitation in patients with chronic obstructive pulmonary disease ( COPD ) .  Strength training increases muscle strength and muscle mass , but there is an ongoing debate on the additional effect concerning the exercise capacity . The purpose of this study was to compare the effects of three different exercise modalities in patients with COPD including endurance training ( ET ) , progressive strength training ( ST ) and the combination of strength training and endurance training ( CT ) . DESIGN A prospect i ve r and omized trial . METHODS Thirty-six patients with COPD were r and omly allocated either to ET , ST , or CT .  Muscle strength , cardiopulmonary exercise testing , lung function testing and quality of life were assessed before and after a 12-week training period . RESULTS Exercise capacity ( Wmax ) increased significantly in all three training groups with increase of peak oxygen uptake ( VO2peak ) in all three groups , reaching statistical significance in the ET group and the CT group . Muscle strength ( leg press , bench press , bench pull ) improved in all three training groups , with a higher improvement in the ST ( + 39.3 % , + 20.9 % , + 20.3 % ) and the CT group ( + 43.3 % , + 18.1 % , + 21.6 % ) compared to the ET group ( + 20.4 % , + 6.4 % , + 12.1 % ) . CONCLUSIONS Progressive strength training alone increases not only muscle strength and quality of life , but also exercise capacity in patients with COPD , which may have implication s in prescription of training modality . CLINICAL TRIALS.GOV IDENTIFIER : NCT01091623 Many patients with irreversible chronic obstructive pulmonary disease ( COPD ) cl aim symptomatic improvement with steroid therapy , despite a lack of objective improvement in their spirometric data . To determine if steroids actually increase the exercise capacity of these individuals , 13 clinical ly stable patients ( mean age , 63 + /- 4 years ; 12 male patients ) were given methylprednisolone ( 32 mg once daily ) or placebo in a r and omized double-blind crossover fashion . Spirometric data and minute ventilation , oxygen consumption ( VO2 ) , carbon dioxide production , and heart rate during incremental exercise were measured at each visit . Methylprednisolone did not produce a significant change in any of the measured parameters . Three patients had an increase in maximal VO2 of greater than 2 ml/kg/min during therapy with methylprednisolone , while two experienced a decline in maximal VO2 of similar magnitude . The change in exercise capacity was unrelated to the change in the forced expiratory volume in one second in individual patients ( r = 0.08 ) . We conclude that in the absence of any improvement in the usual tests of airway mechanics , steroid therapy does not improve exercise performance in patients with COPD BACKGROUND In addition to the respiratory limitation in patients with chronic obstructive pulmonary disease ( COPD ) , skeletal muscle abnormalities may occur and contribute to the exercise intolerance . This study assessed the ability of the skeletal muscle of patients with COPD to adapt to individualized exercise training at the gas exchange threshold ( GET ) METHODS : Fourteen patients ( 8 in a training group and 6 controls ) performed the following exercise tests before and after a 3-week training period : an incremental exercise test , maximal voluntary contraction of the quadriceps , and three endurance tests consisting of dynamic contractions of the quadriceps until exhaustion . These endurance tests , characterized by three different power outputs , were used to determine muscle limit times and critical power . RESULTS The results showed that training increased exercise tolerance ( + 11 % for symptom limited peak oxygen consumption ( VO2 sl ] , P < 0.05 ) , maximum voluntary contraction ( + 8 % , P < 0.05 ) , limit times ( from + 45 % to + 161 % , P < 0.05 ) and critical power ( + 39 % , P < 0.05 ) . CONCLUSIONS These findings indicate greater muscle strength and endurance after training in COPD patients and suggest better muscular recruitment and improved oxidative capacity in the exercising muscles . The sharp differences in the magnitude of VO2 sl and limit times suggest that the kinetics of peripheral and central changes in response to training are different . In conclusion , peripheral muscle performance can be increased rapidly in response to an individualized training program at the GET in COPD patients Introduction Pulmonary Rehabilitation ( PR ) is an evidence -based intervention that has been recommended in guidelines to be available to those who may benefit . However , not all patients with chronic obstructive pulmonary disease ( COPD ) have access to this service . Healthcare services have shown the need for the provision of PR in other forms to enable patient choice and service capacity . There is an increase in evidence for the use of the internet in the management of long-term conditions to provide education and promote self-management . The aim of this study is to see if an interactive web-based PR programme is a feasible alternative compared with conventional PR . Methods and analysis This is a feasibility study design ed to evaluate the efficacy of providing a web-based PR programme to improve patients exercise capacity , quality of life and promote self-management in patients with moderate to severe COPD compared with conventional PR programmes .  Eligible patients will be r and omly allocated to receive either the web-based programme or conventional rehabilitation programme for 7 weeks using an internet-based r and omisation system . Participants will be recruited from PR assessment s , primary care and community rehabilitation programmes . Those r and omised to the web-based programme work through the website which contains all the information that the patients receive in the PR classes . They receive weekly phone calls by a professional to help progress through the course on line . The outcome measures will be recruitment rates and eligibility as well as that st and ard for a PR assessment including measures of exercise capacity , quality of life question naires and physical activity . Ethics and dissemination The research ethics committee for Northampton has provided ethical approval for the conduct of the study . The results of the study will be disseminated through appropriate conference presentations and peer review ed journals . Trial registration number IS RCT N03142263 Background Chronic obstructive pulmonary disease ( COPD ) is recognized as a systemic illness with significant extra-pulmonary features , such as exercise intolerance and muscle weakness . Pulmonary rehabilitation has been shown to be very effective in counteracting these consequences in patients with more advanced COPD . However , limited data is available on the efficacy of a physical exercise training programme in patients with mild to moderate COPD in primary care . Furthermore , it is unknown if improved exercise capacity translates into enhanced daily physical activities . The aim of this paper is to describe the design of a r and omized controlled trial to assess the efficacy of a physical exercise training programme in patients with mild to moderate COPD . Methods / design In this r and omized controlled trial situated in the primary care setting , 102 patients with mild to moderate airflow obstruction ( FEV1 ≥ 50 % of predicted ) , dyspnoea and a physically inactive lifestyle will be r and omized to an intervention or control group . The intervention group receives a 4-month physical exercise training programme at a local physiotherapy practice , which includes exercise training , resistance training , breathing exercises and advises on how to increase the level of physical activity . The control group receives usual care , i.e. advises on how to increase the level of physical activity and a sham treatment at a local physiotherapy practice of which no physiological training stimulus can be expected . Primary outcome is functional exercise capacity at 4-months measured on the six-minute walk distance . Secondary outcomes include peripheral muscle strength , physical activity in daily life , health related quality of life , Medical Research Council ( MRC ) dyspnoea score and patients ’ perceived effectiveness . Follow-up measurement will take place at 6 months after baseline . Discussion This will be one of the first studies to evaluate the efficacy of a physical exercise training programme in patients with mild to moderate COPD completely recruited and assessed in primary care . The results of this trial may give a unique insight into the potential of the implementation of an easy , close-to-home rehabilitation programme . Trial registration The Netherl and s National Trial Register NTR1471 OBJECTIVE Patients ' beliefs about their disease have been associated with emotional adjustment and outcomes in several severe illnesses . The aim of the present study was to investigate whether illness perceptions before pulmonary rehabilitation influence exercise capacity and quality of life after rehabilitation in patients suffering from chronic obstructive pulmonary disease ( COPD ) . METHODS Ninety-six patients with COPD ( GOLD III/IV ) were approached on admission to rehabilitation and reassessed before discharge . Assessment included medical measures of FEV% predicted , and exercise capacity ( 6 min walk test ) . Additionally , depressive symptoms ( Hospital Anxiety and Depression scale ) , anxiety ( COPD specific anxiety question naire ) and quality of life ( Short Form 36 health survey ( SF-36 ) ) were assessed . Illness beliefs were measured by the Revised Illness Perception Question naire ( IPQ-R ) . RESULTS Exercise capacity and psychological well-being ( SF-36 ) of patients improved after rehabilitation programme , while physical functioning ( SF-36 ) did not change . Additionally , patients showed significantly lower levels of depressive symptoms , COPD specific anxiety and negative perceptions of their illness after pulmonary rehabilitation compared to baseline . In the hierarchical multiple regression analyses , after controlling for socio-demographic data , psychological variables , illness severity and baseline scores of the corresponding variables , it was shown that illness perceptions before rehabilitation predicted exercise capacity and psychological well-being , both assessed at the end of treatment . CONCLUSION COPD patients ' perceptions about their illness before rehabilitation influence exercise capacity and quality of life ( psychological well-being ) after treatment . Therefore it might be relevant to identify and change maladaptive illness perceptions in order to improve medical and psychological outcome in COPD Few studies have shown that the endurance shuttle walking test ( ESWT ) is responsive to treatment in patients with chronic obstructive pulmonary disease ( COPD ) . This exercise test needs to be further investigated because of its relevance for activity of daily living . The aim of the present study was to evaluate , in patients with COPD , the responsiveness of the ESWT in detecting improvement in walking performance after a single dose of salmeterol . In a r and omised , double-blind , placebo-controlled crossover trial , 20 patients with COPD performed two ESWT at 80 % of peak capacity 2.5 h after inhaling either a placebo or 50 µg of salmeterol  . Cardiorespiratory parameters were monitored during each walking test . Inspiratory capacities and Borg ratings for dyspnoea were obtained every other minute throughout the tests . Compared with placebo , salmeterol produced a significant change in lung function and a significant improvement in walking performance ( mean±sd difference in time : 117±20 s ; difference in distance : 160±277 m ) . At isotime ( the latest exercise time that was reached on both ESWT ) , a significant reduction in dyspnoea was observed after bronchodilation . Bronchodilation with salmeterol reduced dyspnoea during walking and improved walking capacity in patients with chronic obstructive pulmonary disease . These findings provide further support for the use of the endurance shuttle walking test as an evaluative tool in chronic obstructive pulmonary disease The effects of adding L-carnitine to a whole-body and respiratory training program were determined in moderate-to-severe chronic obstructive pulmonary disease ( COPD ) patients . Sixteen COPD patients ( 66 + /- 7 years ) were r and omly assigned to L-carnitine ( CG ) or placebo group ( PG ) that received either L-carnitine or saline solution ( 2 g/day , orally ) for 6 weeks ( forced expiratory volume on first second was 38 + /- 16 and 36 + /- 12 % , respectively ) . Both groups participated in three weekly 30-min treadmill and threshold inspiratory muscle training sessions , with 3 sets of 10 loaded inspirations ( 40 % ) at maximal inspiratory pressure . Nutritional status , exercise tolerance on a treadmill and six-minute walking test , blood lactate , heart rate , blood pressure , and respiratory muscle strength were determined as baseline and on day 42 . Maximal capacity in the incremental exercise test was significantly improved in both groups ( P < 0.05 ) . Blood lactate , blood pressure , oxygen saturation , and heart rate at identical exercise levels were lower in CG after training ( P < 0.05 ) . Inspiratory muscle strength and walking test tolerance were significantly improved in both groups , but the gains of CG were significantly higher than those of PG ( 40 + /- 14 vs 14 + /- 5 cmH2O , and 87 + /- 30 vs 34 + /- 29 m , respectively ; P < 0.05 ) . Blood lactate concentration was significantly lower in CG than in PG ( 1.6 + /- 0.7 vs 2.3 + /- 0.7 mM , P < 0.05 ) . The present data suggest that carnitine can improve exercise tolerance and inspiratory muscle strength in COPD patients , as well as reduce lactate production Supplemental oxygen improves exercise tolerance of normoxemic and hypoxemic chronic obstructive pulmonary disease ( COPD ) patients . We determined whether nonhypoxemic COPD patients undergoing exercise training while breathing supplemental oxygen  achieve higher intensity and therefore improve exercise capacity more than patients breathing air . A double-blinded trial was performed involving 29 nonhypoxemic patients ( 67 years , exercise SaO2 > 88 % ) with COPD ( FEV1 = 36 % predicted ) . All exercised on cycle ergometers for 45 minutes , 3 times per week for 7 weeks at high-intensity targets . During exercise , they received oxygen ( 3 L/minute ) ( n = 14 ) or compressed air ( 3 L/minute ) ( n = 15 ) . Both groups had a higher exercise tolerance after training and when breathing oxygen . However , the oxygen-trained group increased the training work rate more rapidly than the air-trained group . The mean + /- SD work rate during the last week was 62 + /- 19 W ( oxygen-trained group ) and 52 + /- 22 W ( air-trained group ) ( p < 0.01 ) . After training , endurance in constant work rate tests increased more in the oxygen-trained group ( 14.5 minutes ) than in the air-trained group ( 10.5 minutes ) ( p < 0.05 ) . At isotime , the breathing rate decreased four breaths per minute in the oxygen-trained group and one breath per minute in the air-trained group ( p = 0.001 ) . We conclude that supplemental oxygen provided during high-intensity training yields higher training intensity and evidence of gains in exercise tolerance in laboratory testing The purpose of this study was to evaluate whether strength training is a useful addition to aerobic training in patients with chronic obstructive pulmonary disease ( COPD ) . Forty-five patients with moderate to severe COPD were r and omized to 12 wk of aerobic training alone ( AERO ) or combined with strength training ( AERO + ST ) . The AERO regimen consisted of three weekly 30-min exercise sessions on a calibrated ergocycle , and the ST regimen included three series of eight to 10 repetitions of four weight lifting exercises .  Measurements of peripheral muscle strength , thigh muscle cross-sectional area ( MCSA ) by computed tomographic scanning , maximal exercise capacity , 6-min walking distance ( 6MWD ) , and quality of life with the chronic respiratory question naire were obtained at baseline and after training . Thirty-six patients completed the program and constituted the study group . The strength of the quadriceps femoris increased significantly in both groups ( p < 0.05 ) , but the improvement was greater in the AERO + ST group ( 20 + /- 12 % versus 8 + /- 10 % [ mean + /- SD ] in the AERO group , p < 0.005 ) . The thigh MCSA and strength of the pectoralis major muscle increased in the AERO + ST group by 8 + /- 13 % and 15 + /- 9 % , respectively ( p < 0.001 ) , but not in the AERO group ( 3 + /- 6 % and 2 + /- 10 % , respectively , p > 0.05 ) . These changes were significantly different in the two study groups ( p < 0.01 ) . The increase in strength of the latissimus dorsi muscle after training was modest and of similar magnitude for both groups . The changes in peak exercise work rate , 6MWD , and quality of life were comparable in the two groups . In conclusion , the addition of strength training to aerobic training in patients with COPD is associated with significantly greater increases in muscle strength and mass , but does not provide additional improvement in exercise capacity or quality of life This study poses two questions : 1 ) is there an abnormality in isokinetic skeletal muscle strength and endurance in mild chronic obstructive pulmonary disease ( COPD ) ? and 2 ) what is the effect of a r and omized , controlled , 12 week hospital outpatient weight training programme in terms of skeletal muscle function and exercise tolerance ? Upper and lower limb isokinetic maximum and sustained muscle function were compared in 43 COPD patients ( age 49+/-11 yrs ) , mean forced expiratory volume in one second ( FEV1 ) 77+/-23 % pred and 52 healthy , sedentary subjects ( age 51 ( 10 ) yrs ) , mean FEV1 109+/-16 % pred . The 43 COPD patients were r and omly allocated into training ( n=26 ) and control ( n=17 ) groups . Isokinetic and isotonic muscle function , whole body endurance , maximal exercise capacity and lung function were measured . The COPD patients had reduced isokinetic muscle function ( with the exception of sustained upper limb strength ) as compared with healthy sedentary subjects . Muscle function improved after weight training in the COPD patients . Whole body endurance during treadmill walking also improved with no change in maximal oxygen consumption . A deficit in skeletal muscle function can be identified in patients with mild chronic obstructive pulmonary disease which can not be explained by factors such as hypoxaemia and malnutrition . Intervention with weight training is effective in countering this deficit which the authors conclude is probably due to muscle deconditioning BACKGROUND Although several studies have assessed the effect of Tai Chi in management of chronic obstructive pulmonary disease ( COPD ) , these studies have a wide sample variation and convey inconclusive results . This study aims to determine if a 3-month Tai Chi program improves lung function , exercise capacity , and health related quality of life ( HRQoL ) in people with COPD . METHODS A r and omised controlled , single blind trial was undertaken . Patients were r and omly allocated to either  Tai Chi group ( n=26 ) or control group ( n=24 ) . Participants in the Tai Chi group received a Tai Chi exercise program three times weekly for 3-months while participants in the control group were advised to maintain their routine activities . Outcome measures included lung function , 6-minute walk distance ( 6WMD ) and COPD Assessment Test ( CAT ) . The measurements took place at baseline and immediately after the 3-month intervention period . RESULTS Of 50 participants , 46 completed the intervention . Compared to control , Tai Chi significantly increased 6WMD ( mean difference 60.5 m , 95 % CI 30.27 - 78.69 ) , and reduced score of CAT ( mean difference 14 points , 95 % CI 11 - 24 ) . An 86 % compliance to the Tai Chi training was noted and no adverse events were observed in Tai Chi group . CONCLUSIONS The Tai Chi program is a safe , effective and feasible method to improve exercise capacity and health-related quality of life in people with COPD QUESTIONS Does an eight-week program of walk training improve endurance walking capacity in people with COPD compared to cycle training ? Does walk training improve peak walking capacity , cycle capacity , and quality of life compared to cycle training ? Is the endurance shuttle walk test ( ESWT ) responsive to change in walking capacity elicited by exercise training ? DESIGN R and omised trial with concealed allocation , assessor blinding , and intention-to-treat analysis . PARTICIPANTS 36 people with stable COPD recruited with four dropouts . INTERVENTION Participants were r and omised into either a walk or cycle training group . Both groups trained indoors for 30 to 45 minutes per session , three times weekly over eight weeks at Concord Hospital . Training intensities were based on baseline peak exercise tests and progressed as able . OUTCOME MEASURES The primary outcome was endurance walking capacity measured by the ESWT . Secondary outcomes included peak walking capacity , peak and endurance cycle capacity , and health-related quality of life . Measures were taken at baseline ( Week 0 ) and following training ( Week 8) . RESULTS The walk training group increased their endurance walking time by 279 seconds ( 95 % CI 70 to 483 ) more than the cycle training group . No significant differences between the groups were found for any other outcome . CONCLUSION Ground walk training increased endurance walking capacity more than cycle training and was similar to cycle training in improving peak walking capacity , peak and endurance cycle capacity and quality of life . This study provides evidence for ground walking as a mode of exercise training in pulmonary rehabilitation programs UNLABELLED The effectiveness of exercise training in people with COPD is well established . However , alternative methods of training such as Tai Chi have not been widely evaluated . This paper describes the study design of a clinical trial which aims to determine if short form Sun-style Tai Chi improves exercise capacity and quality of life in people with COPD . METHOD This r and omised controlled trial will be conducted with concealed allocation and blinded outcome assessment . Participants will be recruited from Concord Repatriation General Hospital , Sydney . After baseline measurement , participants will be r and omised into either a Tai Chi Group or a Control Group . Participants in the Tai Chi Group will undergo supervised training twice weekly for twelve weeks . Participants in the Control Group will undergo usual medical care . Measurements will be taken at baseline ( week 0 ) and after the study period ( week 12 ) . The primary outcome measurement is endurance walking capacity assessed by the endurance shuttle walk test . Secondary outcomes include measures related to peak walking capacity , physical performance , balance , muscle strength and quality of life . Details of the physiological responses during Tai Chi will be collected in a small cohort to determine the training intensity of Sun-style Tai Chi . DISCUSSION If short form Sun-style Tai Chi improves exercise capacity , physical performance and quality of life in people with COPD , this would provide an alternate form of exercise training which does not require exercise equipment thus making effective exercise training more accessible for the large numbers of people with COPD BACKGROUND Different exercise tests are used to evaluate the functional capacity in chronic obstructive pulmonary disease . The cardiopulmonary exercise test is considered the gold st and ard , but the 6 minute walk and the 15 step exercise oximetry test are considerably less expensive . OBJECTIVES To determine whether reliable data could be obtained at lower cost . METHODS The study sample consisted of 50 patients with mild to severe stable COPD . All underwent pulmonary function test and the cardiopulmonary exercise test , 6 minute walk and 15 step exercise oximetry test as part of their regular follow-up visit . Functional capacity was grade d according to each test separately and the functional capacities obtained were correlated . RESULTS The results showed that most of the patients had severe COPD according to pulmonary function tests ( mean forced expiratory volume in the first second 46.3 + /- 19.9 % of predicted value ) . There was a good correlation between the cardiopulmonary exercise test and the 6 minute walk functional capacity classes ( r = 0.44 , P = 0.0013 ) . We did not find such correlation between the 15  step exercise oximetry test and the cardiopulmonary exercise test ( r = 0.07 , P = 0.64 ) . CONCLUSIONS The study shows that the 6 minute walk is a reliable and accurate test in the evaluation of functional capacity in COPD patients The effect of endurance training on muscle electrical activity during general exercise testing was investigated in physically active patients with chronic obstructive pulmonary disease ( COPD ) . Before and after rehabilitation , patients performed identical incremental exercise tests . Pulmonary gas exchange , venous lactate and pyruvate concentrations , and the quadriceps electromyographic signal were sample d every minute throughout exercise testing . Three weeks of rehabilitation increased exercise capacity without modifying pulmonary function . M-wave amplitude , root mean square ( RMS ) of electromyographic activity , and RMS/oxygen uptake were increased significantly during post-rehabilitation testing at the same exercise intensity compared to pre-rehabilitation . Median frequency was significantly lower after training . These modifications reflect greater muscle excitability , greater muscle activation for the same level of exercise , and higher recruitment of slow-twitch fibers . Pulmonary rehabilitation in active COPD patients may normalize the electrical activity of skeletal muscles during incremental dynamic exercise . The electromyographic signal confirms neuromuscular changes after endurance training Background We hypothesized that heterogeneity exists within the Global Initiative for Chronic Obstructive Lung Disease ( GOLD ) 1 spirometric category and that different subgroups could be identified within this GOLD category . Methods Pre-r and omization study participants from two clinical trials were symptomatic/asymptomatic GOLD 1 chronic obstructive pulmonary disease ( COPD ) patients and healthy controls . A hierarchical cluster analysis used pre-r and omization demographics , symptom scores , lung function , peak exercise response and daily physical activity levels to derive population subgroups . Results Considerable heterogeneity existed for clinical variables among patients with GOLD 1 COPD . All parameters , except forced expiratory volume in 1 second (FEV1)/forced vital capacity ( FVC ) , had considerable overlap between GOLD 1 COPD and controls . Three-clusters were identified : cluster I ( 18 [ 15 % ] COPD patients ; 105 [ 85 % ] controls ) ; cluster II ( 45 [ 80 % ] COPD patients ; 11 [ 20 % ] controls ) ; and cluster III ( 22 [ 92 % ] COPD patients ; 2 [ 8 % ] controls ) . Apart from reduced diffusion capacity and lower baseline dyspnea index versus controls , cluster I COPD patients had otherwise preserved lung volumes , exercise capacity and physical activity levels . Cluster II COPD patients had a higher smoking history and greater hyperinflation versus cluster I COPD patients . Cluster III COPD patients had reduced physical activity versus controls and clusters I and II COPD patients , and lower FEV1/FVC versus clusters I and II COPD patients . Conclusions The results emphasize heterogeneity within GOLD 1 COPD , supporting an individualized therapeutic approach to patients . Trial registration www . clinical trials.gov . NCT01360788 and NCT01072396 BACKGROUND Supplemental oxygen therapy has been shown to improve exercise performance in patients with chronic obstructive pulmonary disease ( COPD ) . It is unknown whether the magnitude of this benefit would be affected by participation in a pulmonary rehabilitation program . OBJECTIVE To compare the effects of supplemental oxygen on exercise capacity in nonhypoxemic COPD patients before and after participation in a pulmonary rehabilitation program .  METHODS Sixteen patients with COPD underwent two pairs of constant-load exercise tests before and after participation in a  three-month outpatient pulmonary rehabilitation program .  Each pair of exercise tests consisted of a test performed with room air and a second test performed with 50 % supplemental oxygen , in r and om order . The primary outcome was the difference in exercise duration between tests performed with supplemental oxygen and with room air .  This difference was compared before and after participation in a pulmonary rehabilitation program . RESULTS Supplemental oxygen therapy improved exercise duration by 75 s before participation in a pulmonary rehabilitation program and by 153 s following pulmonary rehabilitation . Rehabilitation alone improved exercise duration by 28 s , but rehabilitation appeared to augment the exercise benefits of  supplemental oxygen therapy  by a mean of 78 s ( 95 % CI 11 s to 145 s ; P = 0.03 ) . CONCLUSION The effects of supplemental oxygen therapy were augmented after pulmonary rehabilitation . The improvement in exercise duration with supplemental oxygen following rehabilitation was greater than either supplemental oxygen or pulmonary rehabilitation alone The effects of endurance training on exercise capacity and health-related quality of life ( HRQL ) in chronic obstructive pulmonary disease ( COPD ) patients have been studied thoroughly , while resistance training has been rarely evaluated . This study investigated the effects of resistance training in comparison with endurance training in patients with moderate to severe COPD and peripheral muscle weakness ( isometric knee extension peak torque < 75 % predicted ) . Forty-eight patients ( age 64±8 yrs , forced expiratory volume in one second 38±17 % pred ) were r and omly assigned to resistance training ( RT , n=24 ) or endurance training ( ET , n=24 ) . The former consisted of dynamic strengthening exercises . The latter consisted of walking , cycling and arm cranking .  Respiratory and peripheral muscle force , exercise capacity , and HRQL were re-evaluated in all patients who completed the 12-week rehabilitation ( RT n=14 , ET n=16 ) . Statistically significant increases in knee extension peak torque ( RT 20±21 % , ET 42±21 % ) , maximal knee flexion force ( RT 31±39 % , ET 28±37 % ) , elbow flexion force ( RT 24±19 % , ET 33±25 % ) , 6-min walking distance ( 6MWD ) ( RT 79±74 m , ET 95±57 m ) , maximum workload ( RT 15±16 Watt , ET 14±13 Watt ) and HRQL ( RT 16±25 points , ET 16±15 points ) were observed . No significant differences in changes in HRQL and 6MWD were seen between the two treatments . Resistance training and endurance training have similar effects on peripheral muscle force , exercise capacity and health-related quality of life in chronic obstructive pulmonary disease patients with peripheral muscle weakness Objectives : Statins by their anti-inflammatory and endothelial stabilizing effect can be beneficial in patients with chronic obstructive pulmonary disease ( COPD ) and pulmonary hypertension ( PH ) . The present study was done to evaluate the effect of rosuvastatin on pulmonary functions and quality of life ( QOL ) in patients with concomitant COPD and PH . Material s and Methods : It was a prospect i ve , r and omized , double-blind , placebo-controlled , study conducted in patients with COPD and PH . A total of sixty patients were assigned to receive either rosuvastatin 10 mg or placebo once a day in addition to their conventional treatment for 12 weeks . Routine blood investigations , pulmonary functions , echocardiogram , exercise capacity , and QOL using a question naire were assessed at the baseline and after 12 weeks . Results : In patients of rosuvastatin group , there was a statistically significant increase in peak expiratory flow rate ( PEFR ) ( P = 0.04 ) but no significant change in other pulmonary functions : Forced vital capacity ( FVC ) , forced expiratory volume at 1 s ( FVC , FEV1 , FEV1/FVC ) , and echocardiogram parameters . There was a significant increase in 6-min walk test ( 6-min walk distance ) ( P = 0.03 ) at the end of 12 weeks . On comparing with placebo , rosuvastatin showed a significant reduction ( P = 0.045 ) in COPD exacerbations while adverse effects did not differ . Conclusion : Statins have a favorable effect on patients with COPD and PH regarding the improvement in PEFR , COPD exacerbations , and exercise capacity . Such effects can be beneficial in these patients and more so in patients with concomitant coronary artery disease or hyperlipidemia where long-term benefits of statins have been established BACKGROUND AND OBJECTIVES The benefits of pulmonary rehabilitation for patients with COPD depend on the intensity of training . Traditional pulmonary rehabilitation programmes ( PRPs ) do not consistently achieve high-intensity training and have variable training effects . This study examined the effects of high-intensity exercise training on cardiac and pulmonary function in COPD patients . METHODS Patients with COPD participated in a 6-week , cardiopulmonary exercise test-based PRP . Spirometry , 6-min walking distance and cardiopulmonary exercise test were used to evaluate cardiopulmonary function , respiratory muscle strength and endurance at rest , during exercise and before and after the programme . Patients were encouraged to complete high-intensity exercise with a targeted training intensity of at least 75 % maximum oxygen uptake ( VO(2 ) ) . RESULTS Thirty-four COPD patients were enrolled into the study ; 16 completed the high-intensity training , 18 did not . At the end of the 12-session PRP , submaximal exercise capacity ( 6-min walking distance , 461.8 + /- 77.2 - 502.7 + /- 66.9 m , P < 0.001 ) improved in both the patients who completed high-intensity training and those who did not . Only the patients who completed high-intensity training had significant improvements in FVC ( 2.47 + /- 0.70 - 2.70 + /- 0.62 L , P = 0.024 ) at rest , maximal exercise capacity ( peak VO(2 ) , 1001.6 + /- 286.4 - 1116.1 + /- 320.4 mL/min , P = 0.020 ) and work efficiency ( 7.3 + /- 1.4 - 8.4 + /- 1.8 mL/min/watt , P = 0.026 ) . There was no statistically significant difference between the two groups in the change in the physiological parameters before and after exercise . CONCLUSIONS Exercise training in a PRP improved submaximal exercise capacity . Only patients who completed high-intensity exercise training showed improvements in maximal exercise capacity , FVC and work efficiency Introduction Chronic obstructive pulmonary disease ( COPD ) is associated with exercise limitation and physical inactivity , which are believed to have significant long-term negative health consequences for patients . While a number of COPD treatments and exercise training programmes increase exercise capacity , there is limited evidence for their effects on physical activity levels , with no clear association between exercise capacity and physical activity in clinical trials . Physical activity depends on a number of behaviour , environmental and physiological factors . We describe the design of the PHYSACTO trial , which is investigating the effects of bronchodilators , either alone or with exercise training , in combination with a st and ardised behaviour-change self-management programme , on exercise capacity and physical activity in patients with COPD . It is hypothesised that bronchodilators in conjunction with a behaviour-change self-management programme will improve physical activity and that this effect will be amplified by the addition of exercise training . Methods and analysis Patients are being recruited from 34 sites in Australia , New Zeal and , the USA , Canada and Europe . Patients receiving a multicomponent intervention design ed to support behaviour change related to physical activity are r and omised to four treatment arms : placebo , tiotropium , tiotropium+olo date rol , and tiotropium+olo date rol+exercise training . The primary outcome is improvement in exercise capacity after 8 weeks , measured by endurance time during a shuttle walk test . The secondary outcome is improvement in physical activity , including objective accelerometer assessment and patient-reported functioning using the Functional Performance Inventory — Short Form and the novel hybrid PROactive instrument . Additionally , the influence of moderating variables ( ie , factors influencing a patient 's choice to be physically active ) on increases in physical activity is also explored . Ethics and dissemination The study has been approved by the relevant Institutional Review Boards , Independent Ethics Committee and Competent Authority according to national and international regulations . The findings of the trial will be disseminated through relevant peer- review ed journals and international conference presentations . Trial registration number NCT02085161 Background : Various exercise training programs are used for patients with chronic obstructive pulmonary disease ( COPD ) of different severity . Objectives : To investigate the impact of individualized high-intensity training on exercise capacity with COPD . Methods : A total of 49 patients agreed to participate . Of these , 31 were assigned to the training group and 18 served as controls .  The training group exercised twice a week for 90 min with consecutively increasing loads . At the time of enrollment ( T0 ) , as well as after 3 ( T1 ) and 6 ( T2 ) months , a 6-min walk test ( 6-MWT ) was performed and data on health-related quality of life , femoral muscle thickness , and various serum markers were obtained . Results : The training group improved in their 6-MWT results ( T0 = 407 ± 152 m vs. T1 = 459 ± 127 m , p = 0.002 , vs. T2 = 483.2 ± 130.1 m , p = 0.004 ) , in their cross-sectional area of the musculus rectus femoris ( T0 = 6.2 ± 1.2 cm2 vs. T1 = 6.9 ± 1.2 cm2 , p = 0.003 , vs. 7.5 ± 1.6 cm2 , p = 0.002 ) , and in their St. George 's Respiratory Question naire ( SGRQ ) score ( T0 = 43.3 ± 18.0 vs. T1 = 36.0 ± 18.4 , p = 0.001 , vs. T2 = 34.7 ± 18 . 0 , p = 0.004 ) . Serum levels of myostatin , irisin , resistin , and α-Klotho did not change significantly within the training period . Of note , the exercise group showed an inverse relationship between serum levels of resistin and those of α-Klotho after 6 months ( r = -0.608 , p = 0.021 ) . Conclusions : COPD patients undergoing an individualized , structured , high-intensity training program improved their exercise capacity , gained muscle mass , and improved their quality of life Introduction Pulmonary rehabilitation ( PR ) is a multidisciplinary program of care for patients with chronic obstructive pulmonary disease ( COPD ) with the goal of improving the functional capacity and quality of life , as well as maintaining the clinical stability of COPD sufferers . However , not all patients are available for such a program despite discomfort with their condition . The aim of this study was to evaluate the effects of a home-based PR ( HBPR ) program on functional ability , quality of life , and respiratory muscle strength and endurance . Patients and methods Patients with COPD according to the Global Initiative of Chronic Obstructive Lung Disease were r and omized ( double-blind ) into two groups . One group performed a protocol at home with aerobic and muscle strength exercises and was called the intervention group ; the other group received only instructions to perform breathing and stretching exercises , characterizing it as the control group ( CG ) . We assessed the following variables at baseline and 2 months : exercise tolerance ( incremental shuttle walk test and upper limb test ) , respiratory muscle ( strength and endurance test ) , and health-related quality of life ( Airways Question naire 20 ) . Results There were no significant changes after the intervention in either of the two groups in exercise tolerance and quality of life . However , the intervention group had improved respiratory endurance compared with the CG , while the CG presented a decrease in the load sustained by the respiratory muscles after the HBPR . Conclusion A program of HBPR with biweekly supervision ( although not enough to provide significant improvements in physical capacity or quality of life ) played an important role in maintaining the stability of the clinical features of patients with COPD ; the patients had no worsening of symptoms during the intervention period according to the daily log This study evaluates the effects of training with noninvasive ventilatory support in patients with chronic obstructive pulmonary disease in a r and omised , controlled , observer-blinded trial . Twenty-nine patients with chronic obstructive pulmonary disease and with a ventilatory limited exercise capacity ( forced expiratory volume in one second < 60 % predicted , breathing reserve at maximal exercise < 20 % of maximally voluntary ventilation , resting arterial oxygen tension ≥8 kPa ( 60 mmHg ) , end-exercise arterial oxygen saturation measured by pulse oximetry ≥85 % ) completed an 8-week supervised outpatient cycle exercise programme .  Fourteen patients were r and omised to training with inspiratory pressure support of 10 cmH2O and 15 patients to training with control ( sham ) inspiratory pressure support of 5 cmH2O . Outcome measures were the incremental shuttle walking test and a constant-load cycle endurance test at 75 % of peak work rate including the measurement of physiological responses , and health status measured using the St. George 's Respiratory Question naire . Statistically significant between-group differences were found in favour of the inspiratory pressure support of 10 cmH2O group for improvement in shuttle walking distance ( 16±17 versus 3±13 % ) , cycle endurance ( 164±124 versus 88±128 % ) , and the reduction in minute ventilation during exercise ( -11±10 versus -2±9 % ) . It was concluded that exercise training with inspiratory pressure support of 10 cmH2O result ed in statistically significantly larger improvements in exercise performance  than training with inspiratory pressure support of 5 cmH2O in patients with chronic obstructive pulmonary disease suffering from a ventilatory limited exercise capacity . Inspiratory pressure support of 10 cmH2O may be considered as adjunct during high-intensity exercise training Limited information is available regarding the physiological responses to different types of exercise training in patients with severe chronic obstructive pulmonary disease ( COPD ) . The aim of this study was two fold : firstly , to investigate the physiological response to training at 60 % of achieved peak load in patients with severe COPD ; and secondly to study the effects of interval ( I ) versus continuous ( C ) training in these patients . Twenty-one patients with COPD ( mean+/-SD forced expiratory volume in one second : 37+/-15 % of predicted , normoxaemic at rest ) were evaluated at baseline and after 8 weeks ' training . Patients were r and omly allocated to either I or C training . The training was performed on a cycle ergometer , 5 days a week , 30 min daily . The total work load was the same for both training programmes . C training result ed in a significant increase in oxygen consumption ( V'O2 ) ( 17 % , p<0.05 ) and a decrease in minute ventilation (V'E)/V'O2 ( p<0.01 ) and V'E/carbon dioxide production ( V'CO2 ) ( p<0.05 ) at peak exercise capacity , while no changes in these measures were observed after interval training . During submaximal exercise a significant decrease was observed in lactic acid production , being most pronounced in the C-trained group ( -31 % , p<0.01 versus -20 % , p<0.05 ) . Only in the I-trained group did a significant increase in peak work load ( 17 % , p<0.05 ) and a decrease in leg pain ( p<0.05 ) occur . Training did not result in a significant improvement in lung function , but maximal inspiratory mouth pressure increased in both groups by 10 % ( C : p<0.05 ) and 23 % ( I : p<0.01 ) . The present study shows a different physiological response pattern to interval or continuous training in chronic obstruction pulmonary disease , which might be a reflection of specific training effects in either oxidative or glycolytic muscle metabolic pathways . Further work is required to determine the role of the different exercise programmes and the particular category of patients for whom this might be beneficial Abstract Rationale : Pulmonary hypertension with exercise is common in chronic obstructive pulmonary disease ( COPD ) and may contribute to exercise limitation in this disease . We aim ed to determine the effects of treatment with sildenafil on exercise capacity in patients with COPD and emphysema . Methods : We performed a r and omized , double-blind , placebo-controlled 2-period crossover trial of sildenafil thrice daily in ten adults with COPD and emphysema on CT scan without pulmonary hypertension . We r and omized study participants to 4 weeks of sildenafil ( or placebo ) followed by a 1-week washout and then 4 weeks of placebo ( or sildenafil ) . The 2 primary outcomes were the 6-minute walk distance and oxygen consumption at peak exercise . Results : Sildenafil had no effect on 6-minute walk distance ( placebo-corrected difference = -7.8 m , 95 % confidence interval , -23.2 to 7.5 m , p = 0.35 ) or oxygen consumption at peak exercise ( placebo-corrected difference = -0.1 ml/kg/min , 95 % confidence interval -2.1 to 1.8 ml/kg/min , p = 0.89 ) . Sildenafil increased the alveolar-arterial oxygen gradient ( p = 0.02 ) , worsened symptoms ( p = 0.04 ) , and decreased quality -of-life ( p = 0.03 ) . Adverse events were more frequent while receiving sildenafil ( p = 0.005 ) . Conclusions : Routine sildenafil administration did not have a beneficial effect on exercise capacity in patients with COPD and emphysema without pulmonary hypertension . Sildenafil significantly worsened gas exchange at rest and quality of life . ( clinical trials.gov NCT00104637 ) The purpose of this study was to examine the effects of two postrehabilitation programmes on functional exercise tolerance and health-related quality of life in patients with chronic obstructive pulmonary disease ( COPD ) . Subjects with COPD ( n=109 ) were r and omised to receive either enhanced follow-up ( EF ) or conventional follow-up ( CF ) . Subjects in the EF group attended a monthly support group and received a telephone call from a staff member at the midpoint ( 2 weeks ) between their visits . Both groups had scheduled appointments with a physical therapist and physician at 3‐monthly intervals after discharge . Longitudinal data were recorded in 85 subjects ( 37 EF and 48 CF ) . Over the course of the study , there was no difference in distance walked in 6 min between the two groups but a significant difference for time and a group-time interaction . There was no difference in total chronic respiratory disease question naire score between groups at baseline or at any time interval despite a significant difference with time . There was a clear deterioration in functional exercise capacity and health-related quality of life after completion of respiratory rehabilitation but no difference between the groups A study was undertaken to determine the usefulness of ubidecarenone in pulmonary rehabilitation in exercise training programs in the management of chronic obstructive pulmonary disease ( COPD ) . The subjects were 20 patients with COPD who had been participating in an exercise training program for at least four weeks . The patients were r and omly assigned either to receive 50 mg of oral ubidecarenone daily or to enter a control group during the program .  Oxygen consumption , expired volume , and heart rate were measured during exercise tests before and after training . Maximum oxygen consumption increased 13 % in the ubidecarenone-treated patients and 7 % in the controls , and maximum expired volume increased 10 % in each group . The increases were significant in the ubidecarenone group but not in the controls . Heart rate increased 2 % in both groups . It is concluded that ubidecarenone deserves further evaluation in exercise training programs for patients with COPD This study aim ed to investigate the relationship between skeletal muscle , fibre type composition , functional respiratory impairment and exercise tolerance in patients with moderate to severe chronic obstructive pulmonary disease ( COPD ) . A group of 22 COPD patients and 10 healthy control subjects were studied . In COPD patients , vital capacity ( VC ) and forced expiratory volume in one second ( FEV1 ) were reduced to 79 % and 51 % , respectively . Diffusion indices ( transfer factor of the lung for carbon monoxide ( TL , CO ) and carbon monoxide transfer coefficient ( KCO ) ) were also reduced . Arterial oxygen tension ( Pa , O2 ) was normal or slightly altered . A maximal exercise test was performed and anaerobic threshold was calculated . Muscle sample s from vastus lateralis were obtained by needle biopsy . Myosin heavy chain ( MHC ) and light chain ( MLC ) isoforms were separated by gel electrophoresis and quantified by densitometry . MHC isoforms were considered as molecular markers of fibre types . The proportion of the fast MHC-2B isoform was increased in COPD patients . TL , CO , KCO , VC and FEV1 were positively correlated with slow MHC isoform content . TL , CO and KCO were also negatively correlated with the content of the fast MHC-2B isoform . No correlation was found between exercise parameters and MHC isoform composition . The co-ordinated expression between MHC and MLC isoforms was altered in COPD patients . We conclude that reduced oxygen availability , probably in combination with muscle disuse , may determine muscle alterations in chronic obstructive pulmonary disease patients . The altered correlations between myosin heavy chain and light chain isoforms suggest that co-ordinated protein expression is lost in chronic obstructive pulmonary disease muscles Introduction Chronic obstructive pulmonary disease ( COPD ) has systemic repercussions that can lead to peripheral muscle dysfunction . Muscle atrophy reduces aerobic capacity , greatly limiting activities of daily living and quality of life . Pulmonary rehabilitation is the gold st and ard treatment for these patients , however , patients may not be able to reach sufficient training intensities for benefits to occur . Technologies such as functional electrical stimulation ( FES ) are currently being adapted and tested to enhance exercise training . We hypothesise that FES coupled with cycling ( FES-cycling ) will improve maximal uptake of oxygen ( VO2 ) and aerobic capacity more than endurance training with placebo stimulation . Methods A r and omised , single-blind , placebo-controlled crossover trial will be carried out to evaluate the effects of FES-cycling on VO2 during endurance exercise on a cycle ergometer in patients with COPD . 25 patients with COPD will carry out two 30 min sessions at a constant load ; one session with active and one with placebo FES . The primary outcome is oxygen uptake recorded with a metabolic measurement system . Secondary outcomes include ventilation equivalent for oxygen , ventilation equivalent for carbon dioxide , cardiac output , lactate values , perceived dyspnoea and perceived muscle fatigue . Results and conclusions Approval has been granted by our Institutional Review Board ( Comité de Protection des Personnes Nord-Ouest 3 ) . The results of the trial will be presented at national and international meetings and published in peer- review ed journals . Trial registration number NCT02594722 Background Coal mine dust exposure causes chronic airflow limitation in coal miners result ing in dyspnea , fatigue , and eventually chronic obstructive pulmonary disease ( COPD ) . Yoga can alleviate dyspnea in COPD by improving ventilatory mechanics , reducing central neural drive , and partially restoring neuromechanical coupling of the respiratory system . Objectives To evaluate the effectiveness of Integrated Approach of Yoga Therapy ( IAYT ) in the management of dyspnea and fatigue in coal miners with COPD . Material s and methods R and omized , waitlist controlled , single-blind clinical trial . Eighty-one coal miners ( 36–60 years ) with stable Stages II and III COPD were recruited . The yoga group received an IAYT module for COPD that included asanas , loosening exercises , breathing practice s , pranayama , cyclic meditation , yogic counseling and lectures 90 min/day , 6 days/week for 12 weeks . Measurements of dyspnea and fatigue on the Borg scale , exercise capacity by the 6 min walk test , peripheral capillary oxygen saturation ( SpO2 % ) , and pulse rate ( PR ) using pulse oximetry were made before and after the intervention . Results Statistically significant within group reductions in dyspnea ( P < 0.001 ) , fatigue ( P < 0.001 ) scores , PR ( P < 0.001 ) , and significant improvements in SpO2 % ( P < 0.001 ) and 6 min walk distance ( P < 0.001 ) were observed in the yoga group ; all except the last were significant compared to controls ( P < 0.001 ) . Conclusions Findings indicate that IAYT benefits coal miners with COPD , reducing dyspnea ; fatigue and PR , and improving functional performance and peripheral capillary SpO2 % . Yoga can now be included as an adjunct to conventional therapy for pulmonary rehabilitation programs for COPD patients Clinical experience suggests that exercise is beneficial for recovery after an acute exacerbation in patients with severe chronic obstructive pulmonary disease ( COPD ) . The aim of this study was to quantify the clinical benefit of exercise in these patients . Twenty-nine in patients were r and omly assigned to a training group ( n = 15 , FEV1 34 % pred ) or a control group ( n = 14 , FEV1 38 % pred ) . On ten consecutive days , patients in the training group performed a 6-min treadmill walking test and , in addition , five walking sessions per day at > or = 75 % of the respective treadmill walking distance . Patients in the control group performed only treadmill walking tests on days 1 , 5 , and 10 . To directly compare the possible benefit of exercise training all patients had an exercise test on day 11 at the same work load as on day 1 . In the training group , 6-min walking distance increased from 237 to 420 m , in the control group from 230 to 255 m over the 10 day period which was significantly different ( P < 0.0001 ) . Minute ventilation and oxygen uptake increased significantly ( P < 0.05 ) in the training but not in the control group . When comparing exercise tests on days 1 and 11 , minute ventilation , oxygen uptake , PaCO2 , lactic acid concentration , and Borg scale were significantly reduced to achieve the same work load ( P < 0.01 ) only in the training group . Intrathoracic gas volume and residual volume decreased , and FEV1 and vital capacity increased in the training ( P < 0.05 ) but not in the control group . Our data demonstrate that exercise training significantly improves the exercise capacity in patients with severe COPD after an acute exacerbation of their disease PH ( pulmonary hypertension ) often complicates the disease course of patients with COPD ( chronic obstructive pulmonary disease ) and is an indication of a worse prognosis . In the present study , we assessed whether pravastatin administration was effective in improving PH and exercise capacity in COPD patients with PH , and whether the pulmonary protection was mediated by inhibiting ET-1 ( endothelin-1 ) production . In a double-blind parallel design , 53 COPD patients with PH were r and omly assigned to receive either placebo or pravastatin ( 40 mg/day ) over a period of 6 months at a medical centre . Baseline characteristics were similar in both groups . The exercise time remained stable throughout the study in the placebo group . After 6 months , the exercise time significantly increased 52 % from 660+/-352 to 1006+/-316 s ( P<0.0001 ) in pravastatin-treated patients . With pravastatin , echocardiographically derived systolic PAP ( pulmonary artery pressure ) decreased significantly from 47+/-8 to 40+/-6 mmHg . There was significant improvement in the Borg dyspnoea score after administering pravastatin . Despite unchanged plasma ET-1 levels throughout the study , urinary excretion of the peptide was decreased and significantly correlated with an improvement in exercise time in pravastatin-treated patients ( r=-0.47 , P=0.01 ) . In conclusion , pravastatin significantly improved exercise tolerance , and decreased PH and dyspnoea during exercise in COPD patients with PH , probably by inhibiting ET-1 synthesis Background Chronic obstructive pulmonary disease ( COPD ) is a complex condition with pulmonary and extra-pulmonary manifestations . This study describes the heterogeneity of COPD in a large and well characterised and controlled COPD cohort ( ECLIPSE ) . Methods We studied 2164 clinical ly stable COPD patients , 337 smokers with normal lung function and 245 never smokers . In these individuals , we measured clinical parameters , nutritional status , spirometry , exercise tolerance , and amount of emphysema by computed tomography . Results COPD patients were slightly older than controls and had more pack years of smoking than smokers with normal lung function . Co-morbidities were more prevalent in COPD patients than in controls , and occurred to the same extent irrespective of the GOLD stage . The severity of airflow limitation in COPD patients was poorly related to the degree of breathlessness , health status , presence of co-morbidity , exercise capacity and number of exacerbations reported in the year before the study . The distribution of these variables within each GOLD stage was wide . Even in subjects with severe airflow obstruction , a substantial proportion did not report symptoms , exacerbations or exercise limitation . The amount of emphysema increased with GOLD severity . The prevalence of bronchiectasis was low ( 4 % ) but also increased with GOLD stage . Some gender differences were also identified . Conclusions The clinical manifestations of COPD are highly variable and the degree of airflow limitation does not capture the heterogeneity of the disease Pulmonary hypertension during exercise is common in severe chronic obstructive pulmonary disease ( COPD ) . It was hypothesised that the use of the endothelin-receptor antagonist bosentan can improve cardiopulmonary haemodynamics during exercise , thus increasing exercise tolerance in patients with severe COPD . In the present double-blind , placebo-controlled study , 30 patients with severe or very severe COPD were r and omly assigned in a 2:1 ratio to receive either bosentan or placebo for 12 weeks . The primary end-point was change in the 6-min walking distance . Secondary end-points included changes in health-related quality of life , lung function , cardiac haemodynamics , maximal oxygen uptake and pulmonary perfusion patterns . Compared with placebo , patients treated with bosentan during 12 weeks showed no significant improvement in exercise capacity as measured by the 6-min walking distance ( mean±sd 331±123 versus 329±94 m ) . There was no change in lung function , pulmonary arterial pressure , maximal oxygen uptake or regional pulmonary perfusion pattern . In contrast , arterial oxygen pressure dropped , the alveolar – arterial gradient increased and quality of life deteriorated significantly in patients assigned bosentan . The oral administration of the endothelin receptor antagonist bosentan not only failed to improve exercise capacity but also deteriorated hypoxaemia and functional status in severe chronic obstructive pulmonary disease patients without severe pulmonary hypertension at rest OBJECTIVES To compare conventional exercise-based assessment of pulmonary rehabilitation ( PR ) with improvement in training exercises employed during a PR program , and to describe the cardiopulmonary response of different training exercises during PR of patients with chronic obstructive pulmonary disease ( COPD ) . DESIGN Observational study . SETTING Inpatient PR . PARTICIPANTS Patients with moderate to very severe COPD ( N=18 ) . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Cardiopulmonary responses to interval cycling , arm exercise , and a test of functional activities of daily living ( ADLs )  were evaluated during the PR training program using a mobile telemetric breath-by-breath system . The effects of PR were evaluated by comparing pre-PR and post-PR training activities , incremental and constant work-rate cycling , and a 6-minute walk test . RESULTS Interval cycling and the ADLs test were moderate-intensity to heavy-intensity exercises ( 70%-80 % of maximal oxygen consumption ) , while the arm exercise was a low-intensity activity ( 40 % of maximal oxygen consumption ) . After 12 weeks of PR , cycle load , arm weights , and walking distances during training activities had increased alongside increased muscle mass . At iso-intensities , no cardiopulmonary changes in the training exercises were observed . Exercise duration of constant work-rate cycling and 6-minute walk distance increased by 160 % and 14 % , respectively , after PR , with concurrent right-shifts of anaerobic threshold and a decrease in heart rate . CONCLUSIONS Supervised increases in weight , load , and walking distance during training activities were useful clinical outcomes for patients , demonstrating the beneficial effects of progressive training on physical performance . However , for physiologic evaluation of PR , conventional tests , such as maximal incremental cycling , endurance cycling , and a 6-minute walk test , had greater validity . Physiologic evaluation of the training exercises showed that the training program complied with the training recommendations for PR 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 r and omised 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 Question naire ; 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 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 Background : Conventional pulmonary rehabilitation programs improve exercise tolerance but have no effect on pulmonary function in patients with chronic obstructive pulmonary disease ( COPD ) . The role of controlled breathing using respiratory biofeedback during rehabilitation of patients with COPD remains unclear . Objectives : To compare the effects of a conventional 4-week pulmonary rehabilitation program with those of rehabilitation plus controlled breathing interventions . Methods : A r and omized controlled trial was performed . Pulmonary function ( FEV1 ) , exercise capacity ( 6-min walking distance , 6MWD ) , health-related quality of life ( chronic respiratory question naire , CRQ ) and cardiac autonomic function ( rMSSD ) were evaluated . Results : Forty COPD patients ( mean ± SD age 66.1 ± 6.4 , FEV1 45.9 ± 17.4 % predicted ) were r and omized to rehabilitation ( n = 20 ) or rehabilitation plus controlled breathing ( n = 20 ) . There were no statistically significant differences between the two groups regarding the change in FEV1 ( mean difference –0.8 % predicted , 95 % CI –4.4 to 2.9 % predicted , p = 0.33 ) , 6MWD ( mean difference 12.2 m , 95 % CI –37.4 to 12.2 m , p = 0.16 ) , CRQ ( mean difference in total score 0.2 , 95 % CI –0.1 to 0.4 , p = 0.11 ) and rMSSD ( mean difference 2.2 ms , 95 % CI –20.8 to 25.1 ms , p = 0.51 ) . Conclusions : In patients with COPD undergoing a pulmonary rehabilitation program  , controlled breathing using respiratory biofeedback has no effect on exercise capacity , pulmonary function , quality of life or cardiac autonomic function
Meta- analysis revealed few clinical ly relevant and statistically significant benefits of " add-on " therapies on exercise performance compared with exercise training .
The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease ( COPD ) .