Which field walking test should be used to assess functional exercise capacity in lung cancer? an observational study Detecting oxygen desaturation in patients with COPD: incremental versus endurance shuttle walking. The endurance shuttle walk test: An alternative to the six-minute walk test for the assessment of ambulatory oxygen Relationship between field walking tests and incremental cycle ergometry in COPD. Six-minute walking versus shuttle walking: responsiveness to bronchodilation in chronic obstructive pulmonary disease Prescription of Walking Exercise Intensity from the Incremental Shuttle Walk Test in People with Chronic Obstructive Pulmonary Disease Shuttle Walking Test and 6-Minute Walking Test Induce a Similar Cardiorespiratory Performance in Patients Recovering from an Acute Exacerbation of Chronic Obstructive Pulmonary Disease Physiologic responses to incremental and self-paced exercise in COPD: a comparison of three tests. 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Background There is emerging evidence regarding the efficacy of exercise training to improve exercise capacity for individuals with non-small cell lung cancer ( NSCLC ) .  Cardiopulmonary exercise testing ( CPET ) is the gold st and ard measure of exercise capacity ; however this laboratory test has limitations for use in research and clinical practice . Alternative field walking tests are the six-minute walk test ( 6MWT ) , incremental-shuttle walk test ( ISWT ) and endurance-shuttle walk test ( ESWT ) ; however there is limited information about their clinimetric properties in NSCLC . Aims : In NSCLC to determine the 1 ) criterion validity of the 6MWT , ISWT and ESWT against CPET ; 2 ) construct validity of the 6MWT , ISWT and ESWT against measures of function , strength , respiratory function and health-related quality of life ( HRQoL ) ; and 3 ) clinical applicability of the tests . Methods Twenty participants ( 40 % male , mean ± SD age 66.1 ± 6.5 years ) with stage I-IIIb NSCLC completed the 6MWT , ISWT , ESWT and CPET within six months of treatment . Testing order was r and omised . Additional measures included Eastern Cooperative Oncology Group Performance-Status ( ECOG-PS , function ) , respiratory function , h and -grip dynamometry and HRQoL. Correlations and regression analyses were used to assess relationships . Results The ISWT demonstrated criterion validity with a moderate relationship between ISWT distance and CPET peak oxygen consumption ( r = 0.61 , p = 0.007 ) . Relationships between CPET and six minute walk distance ( 6MWD ) ( r = 0.24 , p = 0.329 ) or ESWT time ( r = 0.02 , p = 0.942 ) were poor . Moderate construct validity existed for the 6MWD and respiratory function ( forced vital capacity % predicted r = 0.53 , p = 0.019 ; forced expiratory volume in the first second % predicted r = 0.55 , p = 0.015 ) . There were no relationships between the walking tests and measures of function , strength or HRQoL. The ESWT had a ceiling effect with 18 % reaching maximum time . No floor effects were seen in the tests . The mean ± SD time required to perform the individual 6MWT , ISWT and ESWT was 12.8 ± 2.5 , 14.7 ± 3.7 and 16.3 ± 5.0 min respectively ; in comparison to CPET which was 51.2 ± 12.7 min . Only one assessor was required to perform all field walking tests and no adverse events occurred . Conclusions The ISWT is a promising measure of functional exercise capacity in lung cancer . Findings need to be confirmed in a larger sample prior to translation into practice BACKGROUND There has been no direct comparison between an incremental and endurance walking test to detect the relative oxygen desaturation in patients with chronic obstructive pulmonary disease ( COPD ) . This is of some importance as current guidelines have suggested that ambulatory oxygen should only be prescribed after a st and ard assessment and desaturation documented . No clear advice about the nature of the required exercise task is given . This study therefore compared the relative desaturation between the incremental shuttle walking test ( ISWT ) and the constant speed walking test ( ESWT ) and response to ambulatory oxygen . METHODS Forty-one patients ( 29 male ) , mean ( SD ) , age 71.18 ( 7.48 ) yrs , FEV(1 ) 0.85 ( 0.29 ) l with stable COPD were recruited after completion of a 7-week pulmonary rehabilitation programme . Patients completed a baseline ( without carrying a cylinder ) ISWT and ESWT and then , in r and om order in double blind fashion , completed the walk tests with a cylinder of air or a cylinder of oxygen . Measurements included distance walked , oxygen saturation , heart rate , perceived breathlessness and exertion ( Borg scale ) . RESULTS All patients desaturated ( < 4 % below 90 % ) . There was no significant difference in desaturation between the ISWT and the ESWT . There was a significant improvement in performance with supplementary oxygen compared to cylinder air ( p<0.05 ) for both tests . However , compared to the baseline walk , supplementary oxygen did not enhance the distance walked for either test . There was a significant decrease in walking performance on both the ISWT and the ESWT when carrying an air cylinder compared with the control walk . When comparing the percentage difference between oxygen and air for responders ( i.e. those that achieve a 10 % or more increase ) , the ESWT showed a greater percentage change 42.1 % compared to 26.1 % for the ISWT . CONCLUSIONS This study identifies that incremental and endurance walking provokes significant desaturation and that there is a short-term benefit of oxygen versus air in enhancing exercise performance . There was no significant difference in the level of desaturation between tests . Therefore the ISWT is a suitable exercise test that can be used to evaluate desaturation and is practically more realistic UK guidelines for domiciliary oxygen have suggested the six-minute walk test or shuttle walk tests as suitable functional measures for the clinical assessment of ambulatory oxygen ( AO ) . To date , there is limited evidence that would support the use of shuttle walk tests as assessment tools for AO . The endurance shuttle walk test ( ESWT ) is used increasingly as an assessment tool within pulmonary rehabilitation ( PR ) but its potential as an investigative test for AO has not been explored . Using the same test for both PR and AO assessment is appealing since it would improve efficiency and act to st and ardise outcome measures in this patient population . The aim of this study was to examine the responsiveness and repeatability of the ESWT to AO and to compare the response with that of the six-minute walk test ( 6MWT ) .  Twenty-three patients with chronic obstructive pulmonary disease ( COPD ) performed , in r and om order , the ESWT and the 6MWT on air and whilst breathing AO . Oxygen saturation and Borg ratings of breathlessness and perceived exertion were recorded . On a third day , eleven patients repeated the ESWT with AO in order to measure repeatability . There was a significantly greater change in the ESWT with oxygen than the change recorded from the 6MWT ( 66 [ 91 ] vs 6 [ 28 ] m respectively ; P < .05 ) . When repeated on a separate day , the mean difference ( 95 % CI ) between distances walked on the ESWT with AO was 0.91 ( -47 , 49 ) m. The ESWT was more responsive than the 6MWT for detecting improvements in walking endurance whilst breathing AO BACKGROUND AND OBJECTIVE Cycle ergometer training is an important component of pulmonary rehabilitation for patients with COPD . However , incremental cycle tests from which individualized cycle training intensity can be prescribed may not be readily available to clinicians . The aims of the study were to ( i ) investigate the physiological and psychophysical responses to the 6-min walk test ( 6MWT ) , incremental shuttle walk test ( ISWT ) and cycle ergometer test ( CET ) ; and ( ii ) determine whether the distance walked in either the 6MWT or the ISWT could be used to estimate peak work rate on a cycle ergometer . METHODS A repeated measures study was undertaken in COPD patients in a stable condition . The 6MWT , ISWT and CET were performed in r and om order , and physiological responses , rate of perceived exertion and dyspnoea were measured . RESULTS Twenty-two patients with COPD completed the study . There was no significant difference in peak oxygen uptake between the 6MWT , ISWT and CET . The significant correlation between the 6MWD and incremental shuttle walk distance with peak watts on the CET ( r = 0.63 , P = 0.002 and r = 0.75 , P < 0.001 , respectively ) was strengthened by the inclusion of weight , age and gender ( r = 0.89 P = 0.001 and r = 0.91 , P < 0.001 ) . Bl and -Altman analysis demonstrated a strong agreement between peak work rate measured on the CET and that estimated from either the 6MWT or the ISWT . CONCLUSIONS The significant relationships found between the three exercise tests , and the regression equations predicting peak work rate on the CET from the 6MWT or the ISWT , may allow for the estimation of intensity of cycle exercise training from walk tests in COPD patients Background : The responsiveness of the endurance shuttle walk to functional changes following bronchodilation has recently been reported . The current literature suggests that the 6 min walking test ( 6MWT ) is less responsive to bronchodilation than the endurance shuttle walk . Aim : To compare bronchodilator-induced changes in exercise performance with the 6MWT and the endurance shuttle walk . Methods : In a r and omised , double-blind , placebo-controlled , crossover trial , 14 patients with chronic obstructive pulmonary disease ( forced expiratory volume in 1 s ( FEV1 ) 50 (8)% predicted ) completed two 6MWTs and two endurance shuttle walks , each preceded by nebulised placebo or 500 μg ipratropium bromide .  Cardiorespiratory parameters were monitored during each walking test with a portable telemetric gas analyser . Quadriceps twitch force was measured by magnetic stimulation of the femoral nerve before and after each walking test . Results : The 6 min walking distance did not change significantly after bronchodilation despite a significant increase in FEV1 of 0.18 ( 0.09 ) litres ( p<0.001 ) . A similar change in FEV1 ( 0.18 ( 0.12 ) litres , p<0.001 ) was associated with a significant improvement in the distance walked on the endurance shuttle walk ( Δdistance ipratropium bromide – placebo = 144 ( 219 ) m , p = 0.03 ) . Quadriceps muscle fatigue was infrequent ( < 15 % of patients ) after both walking tests . Conclusion : The endurance shuttle walk is more responsive than the 6MWT for detecting changes in exercise performance following bronchodilation Objective This study determined the intensity of walking exercise prescribed from 70 % of peak speed achieved during the incremental shuttle walk test ( ISWT ) in people with chronic obstructive pulmonary disease and whether a steady-state response was achieved when exercising at this intensity . Design Each participant performed lung function tests , an incremental cycle test , two ISWTs , and a 10-min continuous walking exercise at 70 % peak ISWT speed . Oxygen consumption ( V˙O2 ) was collected using a portable system ( Cosmed K4b2 , Rome , Italy ) . The V˙O2 from the 10-min walking exercise was compared with V˙O2peak from the better ISWT as a measure of walking exercise intensity . Results Thirty-four participants completed the study .  The mean intensity achieved during the 10-min walking exercise was 76 % ( 11 % ) V˙O2peak . Steady-state V˙O2 was achieved by minute 5 in the 10-min walking exercise . Conclusions Prescription of walking exercise at 70 % of the peak ISWT speed provided an intensity appropriate for achieving physiologic training responses Background : The incremental shuttle walking test ( SWT ) has recently been proposed as a more valid and reproducible alternative to the conventional 6-min walking test ( 6MWT ) in the evaluation of exercise tolerance in patients with chronic obstructive pulmonary disease ( COPD ) . Objective : To compare the cardiorespiratory performance obtained during two sessions of SWT with that obtained during two sessions of 6MWT . Methods : We examined 18 patients ( forced expiratory volume in 1 s : 48 ± 14 % ) recovering from an acute exacerbation of COPD that had required hospitalization . In the same afternoon , each patient performed two SWT and two 6MWT , with an interval of at least 30 min between each test ; the sequence of the tests was r and omized . Results : Mean walking distance was greater in the second SWT test than in the first SWT . The changes from baseline in systolic blood pressure , heart rate , respiratory rate , oxygen saturation and dyspnea Borg index at the end of the test were similar between the two 6MWT and the two SWT . There was a highly significant correlation between walking distances measured during SWT and during 6MWT ( ρ : 0.85 , p < 0.0005 ) . Neither SWT nor 6MWT correlated with functional data of COPD . Conclusions : SWT , though being considered to be closer to a submaximal exercise test than 6MWT , does not induce a greater cardiorespiratory performance  than 6MWT in patients recovering from acute exacerbation of COPD OBJECTIVES To investigate cardiorespiratory and dyspnea responses to incremental and self-paced exercise tests in patients with COPD . DESIGN A prospect i ve within-subject design was used . PATIENTS Twenty stable subjects ( 15 men ) , with a mean ( + /- SD ) age of 64.0 + /- 7.5 years and moderate-to-severe COPD ( ie , mean FEV(1 ) , 0.8 + /- 0.3 L and 28.9 + /- 7.9 % predicted ) were studied . METHODS Each subject completed a 6-min walk test ( 6MWT ) , an incremental shuttle walking test ( ISWT ) , and a cycle ergometer test ( CET ) , within a 2-week period . The tests were performed at least 24 h apart . St and ardized encouragement was utilized in each test with the aim of maximizing performance . Heart rate ( HR ) and dyspnea were measured each minute throughout the tests , and pulse oximetric saturation ( Spo(2 ) ) was measured before and immediately after each test . The distances walked in the 6MWT and ISWT were compared to peak oxygen uptake ( Vo(2 ) ) values from the CET . RESULTS HR increased linearly with increasing workload during the CET and ISWT , but increased alinearly with a disproportionate increase early in the 6MWT . In contrast , dyspnea scores increased linearly during the 6MWT , but increased alinearly with a disproportionate increase late during the CET and ISWT . Peak HR and dyspnea were not significantly different between tests . Spo(2 ) was significantly lower at the end of both walking tests compared to that at the end of the CET ( p < 0.001 ) . The distance walked in both the ISWT and 6MWT were related to peak Vo(2 ) values on the CET ( for both tests , r = 0.73 ; p < 0.001 ) . CONCLUSIONS The patterns of response in HR and dyspnea seen during the 6MWT suggest that patients with COPD titrate exertion against dyspnea to achieve a peak tolerable intensity . This strategy is not possible in an externally paced ISWT or CET . However , it is a limited strategy , with performance converging at higher workloads . Similar peak exercise responses were achieved in the 6MWT , ISWT , and CET . Greater oxygen desaturation was observed during the field walking tests , suggesting that both the ISWT and 6MWT are more sensitive than the CET in detecting exercise-induced hypoxemia and in assessing ambulatory oxygen therapy needs 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 OBJECTIVES To compare the effectiveness of a once-weekly supervised pulmonary rehabilitation programme with a st and ard twice-weekly format . DESIGN R and omised trial of equivalency . SETTING Pulmonary rehabilitation service of a primary care trust delivered at two physiotherapy outpatient departments . PARTICIPANTS Thirty patients with chronic obstructive pulmonary disease . OUTCOME MEASURES Primary outcomes were the Incremental Shuttle Walking Test ( ISWT ) , Endurance Shuttle Walking Test ( ESWT ) and St George 's Respiratory Question naire ( SGRQ ) , assessed at baseline and at completion of the supervised programme . Secondary outcomes were home-exercise activity , attendance levels and patient satisfaction with the programme . INTERVENTIONS The once-weekly group ( n=15 ) received one supervised rehabilitation session per week , and the twice-weekly group ( n=15 ) received two sessions per week , both for 8 weeks , together with a home-exercise plan . RESULTS After pulmonary rehabilitation , the groups showed similar improvements in exercise tolerance ( median values : ISWT once-weekly 60metres , twice-weekly 50metres ; ESWT once-weekly 226seconds , twice-weekly 109seconds ) . However , for health-related quality -of-life , the once-weekly group 's score did not change ( SGRQ 0 ) , whereas an improvement was seen for the twice-weekly group ( SGRQ 3.7 ) . The number of home-exercise sessions and attendance levels were similar between the groups . Patient satisfaction with both formats was high and almost identical between the groups . CONCLUSIONS This pilot provides data to inform a larger study and shows that the methodology is feasible . The findings suggest that once-weekly supervision may be capable of producing equivalent improvements in exercise tolerance as a twice-weekly programme , but the health-related quality -of-life outcome appeared to be poorer for once-weekly supervision OBJECTIVES ( 1 ) To examine the concurrent criterion validity of the modified shuttle walk test ( MSWT ) by using the 6- ( 6MWT ) and 12-minute walk test ( 12MWT ) , ( 2 ) to examine the concurrent criterion validity of the estimated maximum oxygen uptake ( Vo2max ) of the MSWT with actual Vo2max , and ( 3 ) to determine test-retest reliability of the MSWT in patients with chronic obstructive pulmonary disease ( COPD ) . DESIGN Validation study . SETTING Outpatient pulmonary rehabilitation program . PARTICIPANTS Thirty clinical ly stable adults with COPD . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Subjects were r and omly assigned to receive either the 6MWT and 12MWT or the MSWT first . The MSWT was repeated 1 week later ( N = 30 ) . Estimated Vo2max was calculated , and actual Vo2max was conducted by using the Jones test . Validity of the MSWT was assessed by comparing endurance scores and Vo2max with results from the 6MWT and 12MWT and Jones test , respectively . RESULTS There was a moderately high correlation between the  MSWT  and the 6MWT and 12MWT at initial testing ( .82 and .74 , respectively ) . Correlation between estimated and actual Vo2max was r equal to .68 . Test-retest reliability for the entire sample was high ( intraclass correlation coefficient , .88 ) . Results remained quite stable across severity , age , and sex subgroups . CONCLUSIONS The MSWT is a st and ardized externally paced submaximal endurance walking test . The results indicate that the MSWT has high concurrent validity and test-retest reliability for patients with COPD Background In patients with COPD , both laboratory exercise tests and field walking tests are used to assess physical performance . In laboratory tests , peak exercise capacity in watts ( W peak ) and /or peak oxygen uptake ( VO2 peak ) are assessed , whereas the performance on walking tests usually is expressed as distance walked . The aim of the study was to investigate the relationship between an incremental shuttle walking test ( ISWT ) and two laboratory cycle tests in order to assess whether W peak could be estimated from an ISWT . Methods Ninety-three patients with moderate or severe COPD performed an ISWT , an incremental cycle test ( ICT ) to measure W peak and a semi-steady-state cycle test with breath-by-breath gas exchange analysis ( CPET ) to measure VO2 peak . Routine equations for conversion between cycle tests were used to estimate W peak from measured VO2 peak ( CPET ) . Conversion equation for estimation of W peak from ISWT was found by univariate regression . Results There was a significant correlation between W peak and distance walked on ISWT × body weight ( r = 0.88 , p < 0.0001 ) . The agreement between W peak measured by ICT and estimated from ISWT was similar to the agreement between measured W peak ( ICT ) and W peak estimated from measured VO2 peak by CPET . Conclusion Peak exercise capacity measured by an incremental cycle test could be estimated from an ISWT with similar accuracy as when estimated from peak oxygen uptake in patients with COPD Abstract Background . Patients with lung cancer are often burdened by dyspnoea , fatigue , decreased physical ability and loss of weight . Earlier studies of physical exercise of patients with COPD have shown promising results . The aim of this study was to investigate , if a well-documented COPD rehabilitation protocol can improve physical fitness and quality of life ( QoL ) in patients with lung cancer . Material and methods . Forty-five patients , with a minimum walking distance of 50 meters , absence of cognitive deficits or severe heart disease and motivated for physical training were invited to an exercise intervention .  The intervention consisted of seven weeks of twice weekly training , focusing on walking training , circuit training , h and ling of dyspnoea and instructions in daily diary-based training at home . Prior to , and after the intervention , Incremental- and Endurance Shuttle Walk Test ( ISWT and ESWT ) were performed , and pulmonary function as well as self-reported QoL ( EORTC-QLQ-C30 and LC13 ) were measured . Results . Fourteen subjects dropped out before commencement of the intervention . Seven were excluded after physiotherapeutic evaluation . Of the remaining 24 , three were excluded because of insufficient attendance ( < 65 % of scheduled exercise sessions ) thus 21 patients completed the intervention . For 17 patients with complete pre- and post intervention data , ISWT increased 9 % ( −77 to 39 % ) ( median and range ) ( p = 0.021 ) , while ESWT increased 109 % ( −70 to 432 % ) ( p = 0.002 ) . Twelve of 17 improved in ISWT , while 15 improved in ESWT . No changes in pulmonary function and improvements in QoL were observed . Conclusion . Patients with pulmonary cancer can achieve significant improvements in physical fitness measured with ISWT and ESWT after completion of the intervention program . No changes in pulmonary function and QoL were observed . In addition , we found that a large number of patients dropped out before intervention and that the patients , who succeeded , often discontinued training at home BACKGROUND Patients with Chronic Heart Failure ( CHF ) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD . Although pulmonary ( exercise based ) rehabilitation ( PR ) is an integral part of the management of COPD , the potential for exercise rehabilitation ( ER ) to assist patients with CHF may not be as readily appreciated . We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR . METHODS 57 patients with CHF were r and omized 2:1 to 7 weeks ER ( CHF-ER ) or 7 weeks of usual care ( CHF-UC )  . As a comparator 55 patients with COPD were simultaneously recruited to the same ER program ( COPD -ER ) . The primary outcome measure was the Incremental Shuttle Walk Test ( ISWT ) and the secondary outcome measures were the Endurance Shuttle Walk Test ( ESWT ) , isometric quadriceps strength and health status . RESULTS 27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC . The CHF-ER group made significant improvements , compared to CHF-UC , in the mean ( 95%CI ) ISWT distance ; 62(35 - 89)m vs -6(-11 to 33)m p < 0.001 . The CHF-ER group also made statistically significant improvements in health status . The improvements in exercise performance and health status were similar between patients with CHF and COPD , treated with ER . CONCLUSION Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD . Combined training programs for COPD and CHF are effective and feasible , such that service provision could be targeted around common disability rather than the primary organ disease The aim of this study was to examine the effect of high intensity physical group training in water and on l and for patients with COPD with regard to physical capacity and health related quality of life ( HRQoL ) . A controlled , semi-r and omised study was conducted where 30 patients were r and omised to training either in water or on l and . Thirteen patients constituted a control group . Forty-three out patients , with moderate to severe COPD ( 27w/16 m ) , from two local hospitals in northern Sweden , were included in the study . High intensity physical group training in water ( water group ) or on l and ( l and group ) was performed for 12weeks , three times per week , 45min per session . The control group received no intervention . Pre- and post-intervention , all patients performed incremental and endurance shuttle walking tests ( ISWT and ESWT ) ,  cycle ergometer tests  and  responded question naires about HRQoL ( St. Georges Respiratory Question naire -- SGRQ and SF-36 ) . The patients trained with a mean heart rate of 80 - 90 % of peak heart rate . Both training groups increased the distance walked , i.e. l and group in ISWT ( 25 m ) and water group in ESWT ( 179 m ) . The water group increased the distance in ESWT significantly more that both the l and and the control groups . Both training groups increased the time cycled ( 40 - 85s ) and work load ( 10 - 20W ) in the cycle ergometer test . The control group deteriorated in HRQoL according to total score in SGRQ while the training groups remained constant . The water group improved their activity score in SGRQ and their physical health score in SF-36 and those improvements were significant as compared to the l and and the control groups . In conclusion , high intensity physical group training in water is of benefit for patients with COPD . It was in some areas found to be even more effective regarding improvements in physical capacity and experienced physical health compared to the same kind of training on l and Background Although the endurance shuttle walk test ( ESWT ) has proven to be responsive to change in exercise capacity after pulmonary rehabilitation ( PR ) for COPD , the minimally important difference ( MID ) has not yet been established . We aim ed to establish the MID of the ESWT in patients with severe COPD and chronic hypercapnic respiratory failure following PR . Methods Data were derived from a r and omized controlled trial , investigating the value of noninvasive positive pressure ventilation added to PR . Fifty-five patients with stable COPD , GOLD stage IV , with chronic respiratory failure were included ( mean ( SD ) FEV1 31.1 ( 12.0 ) % pred , age 62 ( 9 ) y ) . MID estimates of the ESWT in seconds , percentage and meters change were calculated with anchor based and distribution based methods .  Six minute walking distance ( 6MWD ) , peak work rate on bicycle ergometry ( Wpeak ) and Chronic Respiratory Question naire ( CRQ ) were used as anchors and Cohen ’s effect size was used as distribution based method . Results The estimated MID of the ESWT with the different anchors ranged from 186–199 s , 76–82 % and 154–164 m. Using the distribution based method the MID was 144 s , 61 % and 137 m. Conclusions Estimates of the MID for the ESWT after PR showed only small differences using different anchors in patients with COPD and chronic respiratory failure . Therefore we recommend using a range of 186–199 s , 76–82 % or 154–164 m as MID of the ESWT in COPD patients with chronic respiratory failure . Further research in larger population s should eluci date whether this cut-off value is also valid in other COPD population s and with other interventions .Trial registration Clinical Trials . Gov ( ID NCT00135538 ) OBJECTIVE To compare the effects of twice- versus once-weekly supervised pulmonary rehabilitation on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease ( COPD ) . DESIGN Prospect i ve , r and omized , parallel-group study . SETTING Hospital outpatient physiotherapy department . PARTICIPANTS Patients with COPD . INTERVENTION Group 1 ( n=46 ) received 1 supervised exercise session a week and 2 unsupervised sessions ; group 2 ( n= 45 ) received 2 supervised exercise sessions a week and 1 unsupervised session for 6 weeks . Patients were assessed at baseline and at 6 weeks , 2 months , and 6 months . MAIN OUTCOME MEASURES Incremental ( ISWT ) and endurance ( ESWT ) shuttle walk tests and Chronic Respiratory Disease Question naire ( CRDQ ) . RESULTS Sixty-six of 91 patients ( group 1 , n=34 ; group 2 , n=32 ) completed the 6-week program . There was no significant difference in key outcome measures between the 2 groups ( ISWT , 13.50 m ; 95 % confidence interval [ CI ] , -10.06 to 37.15 m ; ESWT , 72.64s ; 95 % CI , -96.01 to 241.29s ; CRDQ total score , 2.54 ; 95 % CI , -3.16 to 8.24 ) . The results of the ESWTs suggest there may be an interaction between baseline exercise capacity and benefit of pulmonary rehabilitation , with more disabled patients achieving greater benefit if they are supervised twice weekly . Irrespective of group , allocation benefits after pulmonary rehabilitation had almost dissipated by 6 months . CONCLUSIONS There was no difference in the effectiveness of twice- versus once-weekly supervised pulmonary rehabilitation . This study highlights the need for development of strategies that will maintain the improvement achieved by the initial pulmonary rehabilitation program BACKGROUND Exercise training programmes for patients with COPD are effective in improving exercise capacity . The few trials that have investigated the effects of exercise programmes on daily physical activity show contradictory results . AIM To investigate the relation between daily physical activity level and exercise capacity in patients with COPD using data of a r and omised controlled trial in which the exercise intervention was aim ed at improvement of both physical activity and exercise capacity ( the COPE-II study ) . METHODS These are secondary analyses of the COPE-II study , a r and omised controlled trial in which a community-based physiotherapeutic exercise programme was evaluated .  Daily physical activity  was measured with a pedometer ( steps/day ) . Exercise capacity  was measured with an incremental maximal cycle ergometer test , the incremental ( ISWT ) and endurance shuttle walk test ( ESWT ) . Pearson correlation coefficients were calculated . RESULTS At baseline , correlations between steps/day and VO(2peak ) , ISWT ( m ) , ESWT ( m ) and ESWT ( s ) were 0.54 , 0.59 , 0.44 , and 0.34 , respectively ( all p < 0.01 ) . In the  intervention group , correlations between change in steps/day over 7 months and change in ISWT ( m ) , ESWT ( m ) and ESWT ( s ) were 0.47 , 0.41 , and 0.38 , respectively ( all p < 0.01 ) . In the  control group , these same correlations were weak to non-existent . CONCLUSIONS A moderate to weak relationship was found between daily physical activity and exercise capacity . These results strengthen our beliefs that exercise interventions need to target not only exercise capacity but also behaviour change with regard to daily physical activity to achieve improvements in both parameters INTRODUCTION In severely disabled patients who are not capable of following formal pulmonary rehabilitation ( PR ) and /or tolerating higher training intensities , neuromuscular electrical stimulation ( NMES ) has been successfully utilized as a localized training method . MATERIAL S AND METHODS In this non-r and omized controlled observational study 50 patients with severe chronic obstructive pulmonary disease ( COPD ) , who were allocated into two groups . Endurance training group ( ET ) ( n= 27 ) and NMES group ( n= 23 ) . To compare the effects of NMES and ET on health-related quality of life ( HRQOL ) , exercise capacity , muscle strength , dyspnea , psychological status , and body composition in patients with severe COPD . Before and after PR program , the study parameters were assessed using the Medical Research Council ( MRC ) scale , incremental and endurance shuttle walking tests ( ISWT , ESWT ) , manual muscle testing ( MMT ) , the St. George 's Respiratory Question naire ( SGRQ ) , bioelectrical impedance analysis , and the Hospital Anxiety and Depression Scale ( HADS ) . RESULTS After the PR program , walking distance and endurance time significantly increased in both groups ( p < 0.001 for each ) , whereas the MRC scores of both groups significantly decreased ( p < 0.001 for each ) . In the ET group , significant decreases were noted in all domains of SGRQ and HADS . In the NMES group , significant improvements were observed in the HADS scores and in all SGRQ domain except symptom domain . No significant differences were observed between the NMES and ET groups regarding the changes from baseline to after PR program in walking distance ( p= 0.140 ) , endurance time ( p= 0.376 ) , the MRC ( p= 0.540 ) , HRQOL ( p > 0.05 ) and HADS ( p > 0.05 ) scores , body-mass index ( BMI ) ( p= 0.49 ) , fat-free mass ( FFM ) ( p= 0.50 ) and fat-free mass index ( FFMI ) ( p= 0.94 ) . CONCLUSION NMES can be used as an effective treatment strategy in PR programs for peripheral muscle training in patients with severe COPD Background : The TORRACTO ® study evaluated the effects of tiotropium/olo date rol versus placebo on endurance time during constant work-rate cycling and constant speed shuttle walking in patients with chronic obstructive pulmonary disease ( COPD ) after 12 weeks of treatment . Methods : The effects of once-daily tiotropium/olo date rol ( 2.5/5 and 5/5 μg ) on endurance time during constant work-rate cycle ergometry ( CWRCE ) after 6 and 12 weeks of treatment were compared with placebo in patients with COPD in a r and omized , double-blind , placebo-controlled , parallel-group clinical trial . Endurance time during the endurance shuttle walk test ( ESWT ) after 6 and 12 weeks of treatment was also evaluated in a subset of patients . Results : A total of 404 patients received treatment , with 165 participating in the ESWT sub study . A statistically significant improvement in endurance time during CWRCE was observed after 12 weeks ( primary endpoint ) with tiotropium/olo date rol 5/5 µg [ 14 % ( p = 0.02 ) ] but not with tiotropium/olo date rol 2.5/5 µg [ 9 % ( p = 0.14 ) ] versus placebo . In the ESWT sub study , a trend to improvement in endurance time during ESWT after 12 weeks ( key secondary endpoint ) was observed with tiotropium/olo date rol 5/5 µg [ 21 % ( p = 0.055 ) ] and tiotropium/olo date rol 2.5/5 µg [ 21 % ( p = 0.056 ) ] versus placebo . Conclusion : Tiotropium/olo date rol 5/5 µg improved endurance time during cycle ergometry versus placebo , with a strong tendency to also improve walking endurance time . [ Clinical Trials.gov identifier : NCT01525615 . In a prospect i ve , r and omized study we examined the effect of ( i ) ambulatory oxygen and ( ii ) a portable , inspiratory pressure support ( IPS ) device on the endurance shuttle walk test ( ESWT ) in patients with severe chronic obstructive pulmonary disease ( COPD ) . Ten out patients [ median ( range ) FEV1 0.60 l(0.35 , 1.45 ) ] performed the ESWT under five test conditions : baseline walk ( no assistance ) , IPS at 14 cmH2O from a portable ventilator ( the HIPPY , Friday Medical , U.K. ) , sham IPS ( < 8 cmH2O ) , ambulatory oxygen at 2 l min(-1 ) , and sham oxygen ( carrying the portable oxygen cylinder and breathing air ) . There were significant improvements in the ESWT with  ambulatory oxygen  , but a negative effect with the HIPPY device [ mean ( SD ) time : baseline 172 ( 48 ) sec ; oxygen 242 ( 62 ) sec ; HIPPY 84 ( 35 ) sec ] . The ESWT appeared sensitive to the effect of cylinder weight although differences in endurance capacity were not significant [ sham oxygen 151 ( 45 ) sec ] . The ESWT was sensitive to the acute application of oxygen , demonstrating a beneficial effect on endurance performance in patients with severe COPD . The ESWT could form the basis of a st and ardized assessment for ambulatory oxygen Our objective was to assess the impact of an outpatient physiotherapy-led rehabilitation programme on exercise capacity and anxiety and depression scores in a cohort of adult intensive care survivors . In a prospect i ve study in a teaching hospital , 38 general intensive care survivors following hospital discharge underwent an established physiotherapy-led outpatient rehabilitation programme . The programme involved 2 hours of supervised exercise and education sessions each week and two unsupervised exercise sessions each week for 6 weeks . Assessment s took place 1 week before and 1 week after completing the programme . Primary outcome measures were changes in exercise capacity measured using the 6-minute walk test ( 6MWT ) and incremental shuttle walk test ( ISWT ) . Secondary outcome measures were changes in anxiety and depression scores using the Hospital Anxiety and Depression Scale ( HADS ) . Median distance covered in the 6MWT improved by 160 metres ( p<0.001 ) , and median distance covered in the ISWT also improved by 160 metres ( p < 0.001 ) . Significant improvement in anxiety ( p = 0.001 ) and depression ( p = 0.001 ) scores were also seen . Outpatient , physiotherapy-lead rehabilitation appears to improve both exercise capacity and anxiety and depression scores in a cohort of intensive care survivors . A similar programme should be tested in a r and omised controlled trial This study was design ed to test the effects of pursed lips breathing ( PLB ) during exercise in patients with chronic obstructive pulmonary disease ( COPD ) who did not spontaneously perform PLB . Sixtynine COPD patients , mean FEV , ( SD ) 1.09 ( 0.5 ) , age 68 ( 51 - 83 ) were recruited to the study . They performed three incremental shuttle walk tests ( ISWT ) . The first walk was design ed to identify natural PLBs and the next two walks were performed in a r and om order ; ISWT + PLB or ISWT whilst breathing normally . Measures of respiratory rate ( RR ) , breathlessness and oxygen saturation were taken before and after walks . Data was analysed using the t-test . Fifteen patients demonstrated PLB on baseline ISWT and were therefore excluded from further walking tests although baseline data was included in the analysis . There was no significant difference between walks , mean ( SD ) , 298.5 (173.7)PLB and non-PLB ; 292.5 ( 161.9 ) nor any difference in dyspnoea . There was a significant reduction in end exercise RR and recovery time with PLB , mean difference ( 95 % CI ) ; 6.2 ( 4.5 - 7.9 ) and 24.9 ( 2.8 - 47.0 ) seconds , respectively . Patients who showed a good response with the PLB walk ( 41 % ) had significantly higher baseline breathlessness , Borg score , mean ( SD ) , 1.5 ( 1.0 ) versus 0.74 (0.96)(P = 0.02 ) . Natural PLB patients demonstrated lower exercise tolerance on the baseline walk(P = 0.01 ) and a trend towards greater resting breathlessness than those who did not . This study shows PLB during exercise and recovery results in lower post exercise RR and speeds return to pre exercise breathlessness , compared with exercise and non-PLB . Reductions in RR appear to be greatest in those patients with resting breathlessness OBJECTIVE To evaluate the applicability of the incremental ( shuttle ) walk test in patients with chronic obstructive pulmonary disease and compare the performance of those patients on the shuttle walk test to that of the same patients on the encouraged 6-minute walk test . METHODS A cross-sectional study was conducted , in which 24 patients with chronic obstructive pulmonary disease were selected . In r and om order , patients were , after an initial practice period , su bmi tted to a shuttle walk test and an encouraged 6-minute walk test . RESULTS The patients obtained a higher heart rate ( expressed as a percentage of that predicted based on gender and age ) on the encouraged 6-minute walk test ( 84.1 + /- 11.4 % ) than on the shuttle walk test ( 76.4 + /- 9.7 % ) ( p = 0.003 ) . The post-test sensation of dyspnea ( Borg scale ) was also higher on the encouraged 6-minute walk test . On average , the patients walked 307.0 + /- 89.3 meters on the shuttle walk test and 515.5 + /- 102.3 meters on the encouraged 6-minute walk test ( p < 0.001 ) . There was a good correlation between the two tests in terms of the distance walked ( r = 0.80 , p < 0.001 ) . CONCLUSION The shuttle walk test is simple and easy to implement in patients with chronic obstructive pulmonary disease . The encouraged 6-minute walk test produced higher post-test heart rate and greater post-test sensation of dyspnea than did the shuttle walk test Background : The evidence of benefit for pulmonary rehabilitation ( PR ) programmes is established . However , the optimal duration of a PR programme is not known . A r and omised controlled trial was undertaken in patients with chronic obstructive pulmonary disease ( COPD ) to assess whether a 4 week PR programme was equivalent to our conventional 7 week PR programme at equivalent time points of 7 weeks and 6 months . Methods : One hundred patients ( 56 men ) with stable COPD of mean ( SD ) age 70 ( 8) years and forced expiratory volume in 1 second ( FEV1 ) 1.13 ( 0.50 ) litres were r and omised to either a 7 week ( n = 50 ) or 4 week ( n = 50 ) supervised PR programme . Patients were assessed at baseline , at completion of the supervised PR programme , and 6 months later . Patients r and omised to the 4 week group were also assessed at the 7 week time point . Outcome measures were the Incremental Shuttle Walk Test , Endurance Shuttle Walk Test ( ESWT ) , Chronic Respiratory Question naire-Self Reported , and the Breathing Problems Question naire . Results : Forty one patients in each group completed the PR programme . Patients made significant within group improvements after supervised rehabilitation . There were no statistically significant differences between the groups for any other measure at the 7 week or 6 month time points , except that patients in the 4 week group attained higher ESWT times ( mean difference 124 seconds ( 95 % CI 17.00 to 232.16 ) , p = 0.024 ) at the 7 week time point . Conclusions : A shortened 4 week supervised PR programme is equivalent to a 7 week supervised PR programme at the comparable time points of 7 weeks and 6 months 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 PURPOSE : The Incremental Shuttle Walk Test ( ISWT ) is an important functional and prognostic marker in chronic disease . Aging has a detrimental effect on exercise performance . The objective of this study was to produce normal age-specific values for the ISWT in a healthy British population and to explore whether additional variables improve the accuracy of a predictive equation . METHODS : Healthy subjects ( N = 152 ) , aged 40 to 90 years , were recruited . Data collection occurred over 2 study visits . Anthropometric and demographic data were collected , and lung function and quadriceps maximal voluntary contraction were measured . An accelerometer was worn for 2 consecutive days at home . The Duke Activity Status Index was completed , and the greatest distance from 2 ISWTs was recorded . RESULTS : One hundred forty subjects ( 56 men ) with mean age ( SD ) of 59.4 ( 11.0 ) years completed 2 ISWTs . Forced expiratory volume in 1 second ( FEV1 ) was 109.1 % ( 14.56 % ) predicted and ISWT distance was 737 m ( 183 m ) . Age-specific normal values for the ISWT were observed : mean ( lower limit of normal)—40 to 49 years , 824 m ( 765 m ) ; 50 to 59 years , 788 m ( 730 m ) ; 60 to 69 years , 699 m ( 649 m ) ; and 70 years and older , 633 m ( 562 m ) . A predictive equation was developed from 114 subjects . Age , body mass index , FEV1 , quadriceps maximal voluntary contraction , and Duke Activity Status Index contributed to ISWT distance predicting 50.4 % of the variation in performance . CONCLUSION : We have developed age-specific normal values for performance on the ISWT in a healthy British population . However , even using practical , clinical ly relevant variables , it is not possible to accurately predict exercise capacity from a regression equation 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 The purpose of this study was to investigate the relationship between performance on the shuttle walking test and maximal oxygen uptake ( VO2max ) during a conventional treadmill test in patients with chronic airflow limitation . Two different techniques were used to measure oxygen consumption , i.e. conventional Douglas bag techniques ( treadmill test ) and a portable oxygen consumption meter ( shuttle test ) . Initially , 19 patients performed a shuttle walking test ( after one practice walk ) and a maximal treadmill walking test , in a r and omized , balanced design . Subsequently , 10 patients , ( after one practice ) completed an unencumbered shuttle walking test and one supporting the portable oxygen consumption meter , in r and om order . The results of the first experiment revealed a strong relationship between performance during the shuttle walking test and VO2max during the treadmill walking test ( r = 0.88 ) . The results of the second experiment consistently demonstrated an incremental increase in oxygen consumption and ventilation in response to the increasing intensity of the shuttle walking test . Again , a strong relationship between VO2max and performance on the shuttle test was demonstrated ( r = 0.81 ) . We concluded that the shuttle walking test is a valid field exercise test of functional capacity . Performance on the test relates strongly to VO2max , the traditional indicator of cardiorespiratory capacity Objective : To evaluate how spontaneously used pursed lips breathing influences walking endurance , oxygen saturation and dyspnoea in patients with moderate to severe chronic obstructive pulmonary disease . Design : A r and omized open-label , cross-over study of chronic obstructive pulmonary disease patients participating in a rehabilitation programme . Setting : Outpatient pulmonary rehabilitation centre at a university hospital . Subjects : Thirty-two patients with moderate to severe chronic obstructive pulmonary disease . Intervention : All patients performed two endurance shuttle walking tests in r and om order . During endurance shuttle walking test I a mouthpiece was used in order to prevent spontaneous pursed lips breathing . During endurance shuttle walking test II spontaneous pursed lips breathing was used freely . Heart rate , oxygen saturation and the patients ' estimated dyspnoea and leg fatigue on a Borg Category Ratio 10 scale were recorded before , directly after , and 5 and 10 minutes after the tests . Results : When spontaneous pursed lips breathing was used the patients walked on an average for 37 seconds ( 16 % ) longer ( P<0.01 ) than when pursed lips breathing was prevented . The patients desaturated considerably during both walking tests but the average drop in oxygen saturation was 1.2 % less when spontaneous pursed lips breathing was employed . There were no significant differences in rated degree of dyspnoea or leg fatigue with or without pursed lips breathing . Conclusion : Spontaneous pursed lips breathing can be a useful technique to increase walking endurance and reduce oxygen desaturation during walking in patients with moderate to severe chronic obstructive pulmonary disease Aim : The purpose of this study was to investigate whether adding neuromuscular electrical stimulation ( NMES ) to a comprehensive pulmonary rehabilitation ( cPR ) program would have additive effects on clinical -functional outcomes . Methods : Twenty-seven chronic obstructive pulmonary disease patients participating in a 10-week cPR program were r and omly allocated to NMES + cPR ( n = 13 ) or Sham + cPR ( n = 14 ) groups . Quadriceps strength , exercise capacity , symptoms , mood , activities of daily living and quality of life were evaluated pre- and post- interventions . Results : There were no significant differences in any of the physiological and subjective improvements induced by NMES + cPR versus Sham + cPR ( p > 0.05 ) . In fact , the NMES + cPR group showed lower increases in incremental shuttle walk test ( ISWT ) distance ( 38.4 vs 69.2 m , respectively ) and % ISWT distance ( 5.1 vs 9 % , respectively ) compared with the Sham + cPR group ( p < 0.05 ) . Conclusion : The increase in exercise capacity is less important when NMES is used as an adjunct to the cPR Background . Exertional dyspnoea limits level of physical activity in people with Chronic Obstructive Pulmonary Disease ( COPD ) . This r and omized , double-blinded , crossover study evaluated the effect of Acu-TENS , application of Transcutaneous Electrical Nerve Stimulation on acupoints , on breathlessness during exercise in people with COPD . Methods . Twenty-one participants , mean% predicted FEV1 50 ± 21 % , attended assessment followed by two intervention days , one week apart . On each intervention day , participants performed two  endurance shuttle walk tests  ( ESWT ) ( Walk 1 and Walk 2 ) . Walk 1 was performed without intervention and Walk 2 was performed with either Acu-TENS or Sham-TENS , in r and om order , for 45 minutes before and during Walk 2 . Duration of each ESWT and dyspnoea score at isotime of Walk 1 and Walk 2 on each intervention day were compared . Between-group differences in ESWT duration and isotime dyspnoea were also compared . Results . At isotime of Walk 1 and Walk 2 , Acu-TENS showed significant reduction in dyspnoea of −0.8 point ( 95 % CI −0.2 to −1.4 ) but not in Sham-TENS [ 0.1 point ( 95 % CI −0.4 to 0.6 ) ] . Compared to Sham-TENS , Acu-TENS showed significant reduction in dyspnoea of −0.9 point ( 95 % CI −0.2 to −1.6 ) while no between-group significance was found in ESWT duration . Conclusion . Acu-TENS  alleviated dyspnoea during walking in people with COPD but did not increase walking duration RATIONALE There is no consensus regarding which exercise test to use to evaluate the functional impact of bronchodilators in patients with chronic obstructive pulmonary disease . OBJECTIVE AND METHODS Bronchodilator-induced changes in endurance time were evaluated during cycling and walking in 17 patients with chronic obstructive pulmonary disease who completed two cycle endurance tests and two endurance shuttle walks at 80 % of peak capacity . Each endurance test was preceded by the nebulization of a placebo or 500 microg of ipratropium bromide using a r and omized , double-blind , crossover design . Quadriceps twitch force was measured with magnetic stimulation of the femoral nerve before and after each endurance test . RESULTS Cycling endurance time did not improve significantly after bronchodilation despite a significant increase in FEV1 ( delta endurance time ipratropium bromide - placebo : 51 + /- 255 s , p = 0.42 ) . A similar change in FEV1 was associated with a significant improvement in walking endurance time ( delta endurance time ipratropium bromide - placebo : 164 + /- 177 s , p < 0.01 ) . A 22 + /- 17 % fall in quadriceps twitch force was observed after cycling , whereas no significant change was seen after walking . CONCLUSION The endurance shuttle walk is a sensitive test to detect changes in exercise tolerance after bronchodilation . Differences in the occurrence of quadriceps muscle fatigue may explain , in part , the different responsiveness to change between cycling and walking OBJECTIVE This pilot study investigated whether a home exercise video programme could improve exercise tolerance and breathlessness in patients with moderate to severe chronic obstructive pulmonary disease . METHODS Twenty subjects completed the study after being r and omized to intervention or control . The intervention group ( n=10 ) , watched a 19-min video on the benefits of exercise for patients with chronic obstructive pulmonary disease and were given a 30-min exercise video , an illustrated exercise diary and an educational booklet about chronic obstructive pulmonary disease , for use at home . They were advised to follow the exercise video programme 4 times a week for 6 weeks . The control group ( n=10 ) received the chronic obstructive pulmonary disease educational booklet only .  Exercise tolerance was measured using the Incremental Shuttle Walk Test and breathlessness by the self-reported Chronic Respiratory Question naire . RESULTS The median change in the Incremental Shuttle Walk Test and breathlessness score significantly improved in the intervention group compared with the control ( + 45 m vs -15 m , p=0.013 and + 0.5 vs -0.1 Chronic Respiratory Question naire units , p=0.042 ) . The other findings for the self-reported Chronic Respiratory Question naire showed significant improvements in the intervention group for emotion ( p<0.001 ) and fatigue ( p=0.012 ) , but not mastery ( p=0.253 ) . CONCLUSION This pilot study suggests that participation in a home exercise video programme may benefit people with chronic obstructive pulmonary disease PURPOSE To compare treadmill and shuttle walk tests for assessing functional capacity in patients with intermittent claudication , with respect to test-retest reliability , cardiovascular responses , and patient preferences . METHODS Patients with stable intermittent claudication ( N = 55 , ages 52 - 85 yr , median age 68 yr ) were recruited from the Sheffield Vascular Institute at the Northern General Hospital , Sheffield , UK . Each patient performed an incremental shuttle walk test , a constant-pace shuttle walk test , and a st and ardized treadmill test ( 3.2 km x h(-1 ) , 12 % gradient ) , each on three occasions . The incremental shuttle walk began at 3 km x h(-1 ) and increased by 0.5 km x h(-1 ) every minute , whereas the constant-pace shuttle walk was performed at the fixed pace of 4 km x h(-1 ) . Claudication distance ( CD ) , maximum walking distance ( MWD ) , heart rate ( HR ) , and blood pressure were assessed in each testing session . The patients also completed a test preference question naire . RESULTS CD and MWD for both shuttle walks were greater than the corresponding walking distances achieved in the treadmill test ( P < 0.001 ) . Average coefficients of variation for repeated incremental shuttle walk , constant-pace shuttle walk , and treadmill tests were 15.9 % , 21.1 % , and 18.7 % , respectively , for MWD , corresponding to average intraclass correlation coefficients of 0.87 , 0.82 , and 0.87 . Treadmill walking evoked greater increases in HR and blood pressure ( P < 0.001 ) , and fewer patients expressed a preference for it ( 24 vs 43 % for shuttle walking ) . CONCLUSION These findings indicated that shuttle walk testing exhibits similar test-retest reliability as treadmill testing , but that it evoked a lower level of cardiovascular stress and is preferred to treadmill testing by a large proportion of patients 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 Background : The relationship between the shuttle walk test and peak oxygen consumption in patients with lung cancer has not previously been reported . A study was undertaken to examine this relationship in patients referred for lung cancer surgery to test the hypothesis that the shuttle walk test would be useful in this clinical setting . Methods : 125 consecutive patients with potentially operable lung cancer were prospect ively recruited . Each performed same day shuttle walking and treadmill walking tests . Results : Shuttle walk distances ranged from 104 m to 1020 m and peak oxygen consumption ranged from 9 to 35 ml/kg/min . The shuttle walk distance significantly correlated with peak oxygen consumption ( r = 0.67 , p<0.001 ) . All 55 patients who achieved more than 400 m on the shuttle test had a peak oxygen consumption of at least 15 ml/kg/min . Seventy of 125 patients failed to achieve 400 m on the shuttle walk test ; in 22 of these the peak oxygen consumption was less than 15 ml/kg/min . Nine of 17 patients who achieved less than 250 m had a peak oxygen consumption of more than 15 ml/kg/min . Conclusion : The shuttle walk is a useful exercise test to assess potentially operable lung cancer patients with borderline lung function . However , it tends to underestimate exercise capacity at the lower range compared with peak oxygen consumption . Our data suggest that patients achieving 400 m on the shuttle walk test do not require formal measurement of oxygen consumption . In patients failing to achieve this distance we recommend assessment of peak oxygen consumption , particularly in those unable to walk 250 m , because a considerable proportion would still qualify for surgery as they had an acceptable peak oxygen consumption Study objectives Patients with chronic obstructive pulmonary disease ( COPD ) have low exercise capacity and low content of high energetic phosphates in their skeletal muscles . The aim of the present study was to investigate whether creatine supplementation together with exercise training may increase physical performance compared with exercise training in patients with COPD . Design In a r and omized , double-blind , placebo-controlled study , 23 patients with COPD ( forced expiratory volume in one second [ FEV1 ] < 70 % of predicted ) were r and omized to oral creatine ( n = 13 ) or placebo ( n = 10 ) supplementation during an 8-week rehabilitation programme including exercise training . Physical performance was assessed by Endurance Shuttle Walking Test ( ESWT ) , dyspnea and leg fatigue with Borg CR-10 , quality of life with St George ’s Respiratory Question naire ( SGRQ ) . In addition , lung function test , artery blood gases , grip strength test , muscle strength and fatigue in knee extensors were measured . Results COPD patients receiving creatine supplementation increased their average walking time by 61 % ( ESWT ) ( p < 0.05 ) after the training period compared with 48 % ( p = 0.07 ) in the placebo group . Rated dyspnea directly after the ESWT decreased significantly from 7 to 5 ( p < 0.05 ) in the creatine group . However , the difference between the groups was not statistically significant neither in walking time nor in rated dyspnea . Creatine supplementation did not increase the health related quality of life , lung function , artery blood gases , grip strength and knee extensor strength/fatigue . Conclusions Oral creatine supplementation in combination with exercise training showed no significant improvement in physical performance , measured as ESWT , in patients with COPD compared with exercise training alone 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 Abstract The use of rhythmic music is beneficial in assisting with the exercise intensity at home . This paper investigated the effects of paced walking to music at home with an 80 % VO2 peak for patients with COPD . A prospect i ve r and omized clinical trial consisting of a treatment group ( n = 20 ) assigned to a 12-week period of paced walking to music at home , while the patients in the control group ( n = 21 ) were only given educational information . The treatment response was measured based on the patient 's score in the maximal exercise capacity test using the incremental shuttle walking test ( ISWT ) , lung function , health- related quality of life ( HRQOL ) using the Saint George Respiratory Question naire ( SGRQ ) and their health care utilization during baseline , 4 , 8 , 12 and 16 weeks . The treatment group increased their distance in the ISWT from 243.5 ± 135.4 at baseline to 16 weeks ( 306.0 ± 107.3 , p < 0.001 ) , Borg RPE-D decreased from 2.2 ± 1.3 at baseline to 0.8 ± 1.1 ( p < 0.001 ) at 16 weeks , and Borg RPE-L decreased from 1.2 ± 1.4 at baseline to 0.3 ± 0.7 ( p < 0.05 ) at 16 weeks , and improved all of the domains of the SGRQ , compared to the control group . The paced walking to music at home program helps patients to achieve a higher-intensity exercise . It is easily incorporated into the care of COPD patients , providing them with a convenient , safe and enjoyable exercise Abstract Purpose : To evaluate the effectiveness of a home-based inspiratory muscle training ( IMT ) programme using multiple inspiratory muscle tests . Method : Sixty-eight patients ( 37 M ) with moderate to severe chronic obstructive pulmonary disease ( COPD ) ( Mean [ SD ] , FEV1 36.1 [13.6]% pred . ; FEV1/FVC 35.7 [11.2]% ) were r and omised into an experimental or control group and trained with a threshold loading device at intensity > 30 % maximum inspiratory pressure ( PImax ) or < 15 % PImax , respectively , for 7 weeks . Thirty-nine patients ( 23 M ) completed the study . The following measures were assessed pre- and post-IMT : PImax , sniff inspiratory nasal pressure ( SNIP ) , diaphragm contractility ( Pdi , tw ) , incremental shuttle walk test ( ISWT ) , respiratory muscle endurance ( RME ) , chronic respiratory disease question naire ( CRDQ ) , the hospital anxiety and depression scale ( HADS ) and the SF-36 . Between-group changes were assessed using one-way analysis of variance ( ANOVA ) . Results : PImax and perception of well-being improved significantly post-IMT [ p = 0.04 and < 0.05 in four domains , respectively ] . This was not reflected in SNIP [ p = 0.7 ] , Pdi , tw [ p = 0.8 ] , RME [ p = 0.9 ] or ISWT [ p = 0.5 ] . Conclusions : A seven-week , community-based IMT programme , with realistic use of health-care re sources , improves PImax and perception of well-being but a different design may be required for improvement in other measures . Multiple tests provide a more comprehensive evaluation of changes in muscle function post-IMT . Implication s for Rehabilitation A seven-week , home-based inspiratory muscle training programme improves maximal inspiratory pressure and perception of well-being in patients with moderate to severe COPD but not sniff nasal inspiratory pressure or diaphragm contractility , respiratory muscle endurance and exercise capacity . Multiple tests are recommended for a more comprehensive assessment of changes in muscle function following inspiratory muscle training programmes . Therapists need to explore different community-based inspiratory muscle training regimes for COPD patients and identify the optimal exercise protocol that is likely to lead to improvements in diaphragm contractility and exercise capacity AIM The aim of our study was to assess the efficacy of pulmonary rehabilitation in addition to regular chest physiotherapy in non cystic fibrosis bronchiectasis . METHODS Thirty patients with clinical ly significant bronchiectasis and limited exercise tolerance were r and omized into either the control group receiving chest physiotherapy ( 8 weeks ) or into the  intervention group , receiving pulmonary rehabilitation in addition to chest physiotherapy ( 8 weeks ) . Both groups were encouraged to maintain their exercise program and or chest physiotherapy , following completion of the study . RESULTS End of training ( 8 weeks ) No improvement in control group . In the intervention group , incremental shuttle walk test ( ISWT ) improved by 56.7 m ( p = 0.03 ) , endurance walk test ( EWT ) by 193.3 m ( p = 0.01 ) , Leicester Cough Question naire ( LCQ ) improved by 2.6 units ( p < 0.001 ) and St. George 's Respiratory Question naire ( SGRQ ) by 8 units ( p < 0.001 ) . At 20 weeks ( 12 weeks post end of training ) No improvement in control group . In the intervention group , ISWT improved by 80 m ( p = 0.04 ) and EWT by 247.5 m ( p = 0.003 ) . LCQ improved by 4.4 units ( p < 0.001 ) and SGRQ by 4 units ( p < 0.001 ) . CONCLUSION Pulmonary rehabilitation in addition to regular chest physiotherapy , improves exercise tolerance and health related quality of life  in non cystic fibrosis bronchiectasis and the benefit was sustained at 12 weeks post end of pulmonary rehabilitation . Clinical trials regn no. NCT00868075 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 Background : Bariatric surgery is effective for the treatment of stage II and III obesity and its related diseases , although increasing evidence is showing weight regain ~12–24 months postsurgery . Weight regain increases the risk of physical function decline , which negatively affects an individual 's ability to undertake activities of daily living . The study assessed the effects of a 12-week supervised exercise intervention on physical function and body composition in patients between 12 and 24 months post bariatric surgery . Methods : Twenty-four inactive adult bariatric surgery patients whose body mass index remained ⩾30 kg m2 12 to 24 months post surgery were r and omised to an exercise intervention ( n=12 ) or control group ( n=12 ) . Supervised exercise consisted of three 60-min gym sessions per week of moderate intensity aerobic and resistance training for 12 weeks . Control participants received usual care .  The incremental shuttle walk test ( ISWT ) was used to assess functional walking performance after the 12-week exercise intervention , and at 24 weeks follow-up . Measures of anthropometric , physical activity , cardiovascular and psychological outcomes were also examined . Using an intention-to-treat protocol , independent t-tests were used to compare outcome measures between groups . Results : Significant improvements in the exercise group were observed for the ISWT , body composition , physical function , cardiovascular and self-efficacy measures from baseline to 12 weeks . A large baseline to 12-week change was observed for the ISWT ( exercise : 325.00±117.28 m ; control : 355.00±80.62 m , P<0.001 ) . The exercise group at 24 weeks recorded an overall mean improvement of 143.3±86.6 m and the control group recorded a reduction of −32.50±75.93 m. Findings show a 5.6 kg difference between groups in body mass change from baseline to 24 weeks favouring the exercise group . Conclusions : A 12-week supervised exercise intervention led to significant improvements in body mass and functional walking ability post intervention , with further improvements at the 24-week follow-up The 6-min walking test ( 6MWT ) is frequently used to assess functional capacity in chronic cardiopulmonary disorders because of its simplicity . The study examines the physiological responses during encouraged 6MWT in patients with chronic obstructive pulmonary disease . Pulmonary oxygen ( O2 ) uptake ( V′O2 ) was measured in 20 male patients ( age 66±6 yrs , forced expiratory volume in one second 45±14 % predicted ) during 6MWT and incremental cycling  , in r and om order  . O2 tension in arterial blood , carbon dioxide tension in arterial blood and arterial lactate concentration ( [La]art ) were obtained in the last 10 patients . During the 6MWT  , V′O2 showed a plateau after the 3rd min ( 1.39±0.28 , 1.42±0.31 , and 1.40±0.30 L·min−1 , 4th , 5th and 6th min , respectively ) , and minute ventilation ( V′E ) ( 42±8 L·min−1 ) was 91 % maximal voluntary ventilation . No differences were shown between 6MWT ( 6th min ) and peak cycling exercise in V′O2 ( 1.40±0.30 versus 1.41±0.28 L·min−1 , respectively ) , cardiac frequency ( 126±13 versus 130±12 beats·min−1 ) , or arterial respiratory blood gases . The two tests were significantly different in V′E ( 42±8 versus 47±8 L·min−1 , 6MWT versus cycling , respectively ) , carbon dioxide production ( 1.30±0.31 versus 1.45±0.18 L·min−1 ) and [La]art ( 2.9±1.99 versus 5.9±1.51 M ) . The study demonstrates that an encouraged 6-min walking test  generates a high but sustainable oxygen uptake . Since the oxygen uptake plateau reflects the integrated response of the system , it may explain the high prognostic value of the 6-min walking test The aims of the study were to determine the effect of short-form Sun-style t’ai chi ( SSTC ) ( part A ) and investigate exercise intensity of SSTC ( part B ) in people with chronic obstructive pulmonary disease ( COPD ) . Part A : after confirmation of eligibility , participants were r and omly allocated to either the t’ai chi group or control group ( usual medical care ) . Participants in the t’ai chi group trained twice weekly for 12 weeks . Part B : participants who had completed training in the t’ai chi group performed a peak exercise test ( incremental shuttle walk test ) and SSTC while oxygen consumption ( VO2 ) was measured . Exercise intensity of SSTC  was determined by the per cent of VO2 reserve . Of 42 participants ( mean±sd forced expiratory volume in 1 s 59±16 % predicted ) , 38 completed part A and 15 completed part B. Compared to control , SSTC significantly increased endurance shuttle walk time ( mean difference 384 s , 95 % CI 186–510 ) ; reduced medial-lateral body sway in semi-t and em st and ( mean difference -12.4 mm , 95 % CI -21– -3 ) ; and increased total score on the chronic respiratory disease question naire ( mean difference 11 points , 95 % CI 4–18 ) . The exercise intensity  of SSTC  was 53±18 % of VO2 reserve . SSTC  was an effective training modality in people with COPD achieving a moderate exercise intensity which meets the training recommendations Study objectives The aims of this study were to establish whether pulmonary rehabilitation ( PR ) improves domestic function and daily activity levels in COPD and whether individually targeted exercise is more effective than general exercise . Design Prospect i ve r and omized , controlled trial . Setting Outpatient PR program in secondary care . Participants One-hundred eighty patients ( mean [ ±SD ] age , 68.3 ± 8.6 years ; FEV 1 , 0.95 ± 0.4 L ; FEV 1 /FVC ratio , 0.51 ± 0.15 ; 111 male patients ; 69 female patients ) with stable COPD . One hundred twenty-one patients completed the study . Interventions Patients were r and omized to a conventional 7-week general exercise program ( [ GEP ] n=90 ) or an individually targeted exercise program ( [ ITEP ] n=90 ) . Measurement and results Daily activity was measured using ambulatory activity monitors ( Z80 –32k V1 Int ; Gaehwiler Electronics ; Hombrechtikon , Switzerl and ) . These were lightweight devices , which contained a uniaxial accelerometer . Domestic function was assessed by the Canadian Occupational Performance Measure ( COPM ) . Exercise performance was assessed by the incremental shuttle walk test ( ISWT ) and the endurance shuttle walk test and health status by the chronic respiratory question naire – self-reported . Activity monitor counts increased by 29.18 % ( 95 % confidence interval [ CI ] , 3.19 to 55.17 ; p=0.03 ) for the GEP and 40.63 % ( 95 % CI , 7.42 to 73.83 ; p=0.02 ) for the ITEP . Mean COPM performance scores increased by 1.71 ( 95 % CI , 1.37 to 2.05 ; p=0.0001 ) for the GEP and 1.46 ( 95 % CI , 1.05 to 1.87 ; p=0.0001 ) for the ITEP . Mean COPM satisfaction scores increased by 2.27 ( 95 % CI , 1.74 to 2.81 ; p=0.0001 ) for the GEP and 2.04 ( 95 % CI , 1.56 to 2.52 ; p=0.0001 ) for the ITEP . ISWT scores increased by 81.72 m ( range , 63.83 to 99.62 ) for the GEP and by 85.52 m ( range , 67.62 to 103.42 ) for the ITEP . No statistically significant difference was found between the general exercise group and the individually targeted exercise group for any outcome measure . Conclusions Pulmonary rehabilitation improves domestic function and physical activity . This study also demonstrates that general exercise training is as effective as individually targeted training Background : Despite widespread use of the incremental shuttle walk distance ( ISWD ) , there are no reference equations for predicting it . Objectives : We aim ed to evaluate ISWD in healthy subjects and to establish a reference equation for its prediction . Methods : 131 Brazilian individuals ( 61 males ; 59 ± 10 years ) performed 2 walk tests in a 10-m long corridor . We assessed height , weight , body mass index , forced expiratory volume in 1 s , forced vital capacity and self-reported physical activity  . Results : Mean ISWD was greater in males than in females ( 606 ± 167 vs. 443 ± 117 m ; p < 0.001 ) . ISWD correlated significantly ( p < 0.05 ) with age ( r = –0.51 ) , height ( r = 0.54 ) and weight ( r = 0.20 ) . A predictive model including age , height , weight and gender explained 50.3 % of the ISWD variance . In an additional group of 20 subjects prospect ively studied , the difference between measured and predicted ISWD was not statistically significant ( 534 ± 84 vs. 552 ± 87 m , respectively ) , representing 97 ± 12 % of the predicted value calculated with our reference equation for ISWD . Conclusions : This reference equation including demographic and anthropomorphic attributes could be useful for interpreting the walking performance of patients with chronic diseases that affect exercise capacity 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 PURPOSE To examine whether maintenance training ( MT ) for 1 year improved the long-term effects of a 7-week chronic obstructive pulmonary disease ( COPD ) rehabilitation program . METHODS After a 7-week outpatient rehabilitation program , 96 patients with COPD were r and omized to either an MT group ( n = 55 ) or a control group ( n = 41 ) . Both groups were requested to continue unsupervised training at home . The MT group received weekly supervised training the first 6 months , supervised training every second week the next 6 months , and finally no supervised training the last 6 months of the 18-month study period . Primary effect parameters were Endurance Shuttle Walk Test ( ESWT ) time and health status ( St. George 's Respiratory Question naire , SGRQ ) . Secondary effect parameters were adherence to supervised training , dropout rates , and hospitalization . RESULTS Compared with the control group , the MT group had significantly better ESWT times at 3 and 6 months ( + 43.9 seconds ; P= .03 , and + 75.1 seconds ; P= .02 ) and insignificantly higher ESWT time at 12 months ( + 66.6 seconds ; P= .40 ) . SGRQ total score declined gradually after the 7-week program with no difference between the 2 groups , and after 18 months , the score was 1.7 units ( 95 % confidence interval : −0.7 to 4.1 ) worse than at r and omization . There was no difference between the 2 groups regarding dropout rates or hospitalization . DISCUSSION Weekly MT for 12 months improved walking time but had no influence on health-related quality of life or hospital admissions , compared with unsupervised daily training at home . The effect of the MT was closely related to adherence to the program OBJECTIVE Surgery remains the treatment of choice in patients with potentially resectable lung carcinoma . Both the British Thoracic Society and American Chest Physician guidelines for the selection of patients with lung cancer surgery suggest the use of a shuttle walk test to predict outcome in patients with borderline lung function . The guidelines suggest that if the patient is unable to walk 250 m during a shuttle walk test , they are high risk for surgery . However , there is no published evidence to support this recommendation . Therefore , we undertook a prospect i ve study to examine the relationship between shuttle walk test  and surgical outcome in 139 patients undergoing assessment for possible lung cancer surgery . METHODS The shuttle walk test was performed in 139 potentially resectable patients , recruited over a 2 year period , prior to surgery . One hundred and eleven patients underwent surgery . Outcome of surgery , including duration of hospital stay , complication and mortality rates was recorded . Student 's t-test was used to compare the shuttle walk distance in patients with good and poor outcome from surgery . RESULTS Mean age of patients undergoing surgery was 69 years ( 42 - 85 ) .  Mean shuttle walk distance was 395 m ( 145 - 780 ) , with a mean oxygen desaturation of 4 % ( 0 - 14 ) during the test . Sixty nine patients had a good surgical outcome and 34 had a poor outcome . The shuttle walk distance was not statistically different in the two outcome groups . CONCLUSION Shuttle walk distance  should not be used to predict poor surgical outcome in lung cancer patients , contrary to current recommendations . It is therefore advisable to perform a formal cardiopulmonary exercise test if at all possible . The usefulness of a shuttle walk test might be improved . It could be compared to a predicted value , as for a formal cardiopulmonary exercise test BACKGROUND The acute consumption of dietary nitrate has been shown to improve exercise capacity in athletes , healthy adults and subjects with peripheral vascular disease . Many COPD patients have reduced exercise capacity . We hypothesized that acute nitrate consumption might increase incremental shuttle walk test ( ISWT ) distance in COPD subjects . METHODS Eleven COPD subjects were r and omly assigned to consume either a high nitrate or a matched , low nitrate beverage in a double-blind , r and omized , placebo-controlled , crossover design . ISWT distance was measured both before and 3 h after the beverage and change was recorded . After a 7-day washout , ISWT distances were re-measured before and 3 h after the alternate beverage and changes were recorded . RESULTS We observed an increase in ISWT distance after consuming the high nitrate juice ( 25 m ) compared with a reduction after the low nitrate juice ( 14 m ) ( p < 0.01 ) . This improvement in exercise capacity was associated with significant increases in serum nitrate ( p < 0.000005 ) and nitrite ( p < 0.01 ) levels and a significant lowering of resting blood pressure ( < 0.05 ) . CONCLUSIONS In patients with stable COPD , the acute consumption of dietary nitrate increased serum nitrate/nitrite levels and exercise capacity and was associated with a decrease in resting blood pressure .  Nitrate consumption might alter exercise capacity in COPD patients QUESTION Among people who are hospitalised for community-acquired pneumonia , does an inpatient exercise-based rehabilitation program improve functional outcomes , symptoms , quality of life and length of hospital stay more than a respiratory physiotherapy regimen ? DESIGN R and omised trial with concealed allocation , intention-to-treat analysis and blinding of some outcomes . PARTICIPANTS Forty-nine adults hospitalised for community-acquired pneumonia . INTERVENTION The experimental group ( n=32 ) underwent a physical training program that included warm-up , stretching , peripheral muscle strength training and walking at a controlled speed for 15 minutes . The control group ( n=17 ) underwent a respiratory physiotherapy regimen that included percussion , vibrocompression , respiratory exercises and free walking . The intervention regimens lasted 8 days . OUTCOME MEASURES The primary outcome was the Glittre Activities of Daily Living test , which assesses the time taken to complete a series of functional tasks ( eg , rising from a chair , walking , stairs , lifting and bending ) . Secondary outcomes were distance walked in the incremental shuttle walk test , peripheral muscle strength , quality of life , dyspnoea , lung function , C-reactive protein and length of hospital stay . Measures were taken 1 day before and 1 day after the intervention period . RESULTS There was greater improvement in the experimental group than in the control group on the Glittre Activities of Daily Living test ( mean between-group difference 39 seconds , 95 % CI 20 to 59 ) and the incremental shuttle walk test ( mean between-group difference 130 m , 95 % CI 77 to 182 ) . There were also significantly greater improvements in quality of life , dyspnoea and peripheral muscle strength in the experimental group than in the control group . There were no between-group differences in lung function , C-reactive protein or length of hospital stay . CONCLUSION The improvement in functional outcomes after an inpatient rehabilitation program was greater than the improvement after st and ard respiratory physiotherapy . The exercise training program led to greater benefits in functional capacity , peripheral muscle strength , dyspnoea and quality of life . REGISTRATION Clinical Trials.gov , NCT02103400 Background Exercise training is known to be beneficial in chronic heart failure ( CH F ) patients but there is a lack of studies following patient groups for longer duration with maintenance training programs to defer deconditioning . Methods Study base consisted of all patients diagnosed with CHF in a 3-year period . Sixty-six patients with systolic CHF ( ejection fraction < 45 , New York Heart Association II-III ) were r and omized to 12 months of either usual care or home-based maintenance exercise with group training sessions  every 2 weeks after an initial 8-week training program . The primary endpoint was maximum workload ; secondary endpoints were 6-min walk test , incremental shuttle walk test , sit-to-st and test , quality of life , and serological markers . Results Six patients died and 43 completed the study . The initial 8-week training was associated with small but significant improvement in all of the functional tests . In both groups there was a significant decline in the maximum workload the next 12 months ( P = 0.03 and P < 0.001 , respectively ) but after an adjustment for difference between groups in baseline characteristics , maintenance intervention reduced the decline in the maximum workload by 8.0W ( 95 % CI : 3.0–13.0 , P = 0.002 ) . No effect of maintenance intervention was observed for 6-min walk test , incremental shuttle walk test , sit-to-st and test , or quality of life . After 14 months changes in most markers of inflammation , endothelial damage , and glycemic control were more beneficial in the intervention group . Conclusion A low-cost maintenance intervention  in CHF patients reduced the decline in the maximum workload compared with usual care but not in other measures of physical function . Results suggest beneficial effects of long-term maintenance training on glycemic control , inflammation , and endothelial function AIM To assess the feasibility and acceptability of swimming pool-based exercise as pulmonary rehabilitation ( PR ) for COPD sufferers . METHOD 101 patients with mild or moderate COPD registered with a South London general practice were invited to a swimming pool-based PR programme . Participants completed spirometry , the Chronic Respiratory Question naire ( CRQ-SR ) , and the Incremental Shuttle Walk Test ( ISWT ) before and after the programme . A qualitative interview was used to assess participants ' views . RESULTS 24 patients ( 24 % ) expressed interest ; 18 were recruited and 16 ( 16 % ) completed the PR programme . Their mean age was 69 yrs , seven were female , and mean % predicted FEV1 was 59 % . The mean number of sessions attended was 10.6 out of 12 . Significant improvements in dyspnoea score ( difference 4.9 ; 95 % CI -8.27 to -1.48 ) and walking distance ( difference 32 metres ; 95 % CI -52.63 to -11.36 ) were observed , and all other findings were in the direction of improvement . Most patients enjoyed being in the water , were happy to expose themselves in swimsuits , overcame their fears , valued learning about COPD and socializing with fellow sufferers , and were positive about their physical improvement . CONCLUSION The swimming pool is a feasible and positive alternative venue for PR for COPD patients in primary care Background Symptomatic relief is an important treatment goal for patients with COPD . To date , no diary for evaluating respiratory symptoms in clinical trials has been developed and scientifically-vali date d according to FDA and EMA guidelines . The EXACT – Respiratory Symptoms ( E-RS ) scale is a patient-reported outcome ( PRO ) measure design ed to address this need . The E-RS utilizes 11 respiratory symptom items from the existing and vali date d 14-item EXACT , which measures symptoms of exacerbation . The E-RS total score quantifies respiratory symptom severity , and 3 domains assess breathlessness , cough and sputum , and chest symptoms . Methods This study examined the performance of the E-RS in each of 3 controlled trials with common and unique validation variables : one 6-month ( N = 235 , US ) and two 3-month ( N = 749 ; N = 597 ; international ) . Subjects completed the E-RS as part of a daily eDiary . Tests of reliability , validity , and responsiveness were conducted in each data set . Results In each study , RS-Total score was internally consistent ( Cronbach α ) ( 0.88 , 0.92 , 0.92 ) and reproducible ( intra-class correlation ) in stable patients ( 2 days apart : 0.91 ; 7 days apart : 0.71 , 0.74 ) . RS-Total scores correlated significantly with the following criterion variables ( Spearman 's rho ; p < 0.01 , all comparisons listed here ) : FEV1 % predicted ( -0.19 , -0.14 , -0.15 ) ; St. George 's Respiratory Question naire ( SGRQ ) ( 0.65 , 0.52 , 0.51 ) ; Breathlessness , Cough , and Sputum Scale ( BCSS ) ( 0.89 , 0.89 ) ; modified Medical Research Council dyspnoea scale ( mMRC ) ( 0.40 ) ; rescue medication use ( 0.43 , 0.42 ) ; Functional Performance Inventory Short-Form ( FPI-SF ) ( 0.43 ) ; 6-minute walk distance ( 6-MWT ) ( -0.30 , -0.14 ) and incremental shuttle walk ( ISWT ) ( -0.18 ) tests . Correlations between these variables and RS-Breathlessness , RS-Cough and Sputum , RS-Chest Symptoms scores supported subscale validity . RS-Total , RS-Breathlessness , and RS-Chest Symptoms differentiated mMRC levels of breathlessness severity ( p < 0.0001 ) . RS-Total and domain scores differentiated subjects with no rescue medication use and 3 or more puffs ( p < 0.0001 ) . Sensitivity to changes in health status ( SGRQ ) , symptoms ( BCSS ) , and exercise capacity ( 6MWT , ISWT ) were also shown and responder definitions using criterion- and distribution-based methods are proposed . Conclusions Results suggest the E-RS is a reliable , valid , and responsive measure of respiratory symptoms of COPD suitable for use in natural history studies and clinical trials . Trial registration MPEX : NCT00739648 ; AZ1 : NCT00949975 ; AZ 2 : BACKGROUND : Although pulmonary rehabilitation ( PR ) has been reported to improve exercise capacity in patients with idiopathic pulmonary fibrosis , it is unknown which exercise measurement is the most responsive for evaluation of PR efficacy . The purpose of this study was to compare the responsiveness of 5 exercise measurements by evaluating the efficacy of PR in subjects with idiopathic pulmonary fibrosis . METHODS : We conducted a prospect i ve observational study in which 53 subjects with idiopathic pulmonary fibrosis were enrolled . The PR group underwent a 10-week out-patient PR program . The control group was observed without any additional intervention , including PR . Five exercise measurements  ( endurance time [ ET ] , peak work rate , peak oxygen consumption [ V̇O2 ] , 6-min walk distance , and incremental shuttle walk distance ) were evaluated at baseline and after 10 weeks . The effect size was used for the assessment of responsiveness . RESULTS : In each group , 24 subjects completed the 5 measurements at baseline and after 10 weeks . The changes in ET ( PR : 181.6 % ; control : −8.2 % ) , peak V̇O2 ( PR : 7.6 % ; control : −5.4 % ) , peak work rate ( PR : 15.1 % ; control : −5.1 % ) , 6-min walk distance ( PR : 6.0 % ; control : −3.8 % ) , and incremental shuttle walk distance ( PR : 9.1 % ; control : −5.1 % ) were significantly different between the groups after 10 weeks ( P < .05 ) . In the PR group , ET showed the most striking improvement among the 5 measurements ( P < .05 ) , and its effect size was as large as 2.96 , whereas those of the others were all < 0.5 . CONCLUSIONS : ET is the most responsive exercise measurement for evaluating PR efficacy in patients with idiopathic pulmonary fibrosis Question For patients with bronchiectasis , does pulmonary rehabilitation either with or without inspiratory muscle training ( IMT ) improve exercise tolerance ? Design R and omised controlled trial . Setting Outpatient-based pulmonary rehabilitation program of a UK hospital . Patients Patients with bronchiectasis confirmed by highresolution computer tomography . Exclusion criteria included concomitant emphysema , an acute exacerbation in the previous six weeks , long-term oral corticosteroid use , and significant co-morbidities . Thirty-two patients were r and omised to pulmonary rehabilitation plus IMT  ( PRIMT ) ( n = 12 ) , pulmonary rehabilitation plus sham IMT ( PR-Sham ) ( n = 11 ) , or a control group with no intervention ( n = 9 ) . Interventions Pulmonary rehabilitation consisted of exercise training and multidisciplinary education sessions for eight weeks . Exercise consisted of three 45- minute periods per week with a target exercise intensity of 80 % of the peak heart rate achieved on an initial maximal incremental exercise test . Two sessions per week were performed at the hospital and involved cycling , treadmill walking , and stair climbing . A third session of walking was performed at home , using the Borg dyspnoea scale to guide intensity . IMT was performed for 15 minutes twice daily over the eight-week period using a pressure threshold device . Pressure was set at 30 % of the patient 's maximal inspiratory pressure and increased by 5 % each week to a maximum of 60 % . Sham IMT followed the same regimen except that the pressure was always 7 cmH 2 O. Outcomes The incremental shuttle walk test , endurance exercise capacity , and respiratory muscle strength were assessed in all groups at baseline and at the end of the program . The endurance exercise test involved walking on a treadmill at 85 % of peak oxygen uptake . Results Over the eight weeks , improvement in the incremental shuttle walk test was significantly greater in the PR-IMT group ( by 113 m , 95 % CI 45 to 182 ) and PRSham group ( by 86 m , 95 % CI 42 to 130 ) than the control group . Similarly , change in endurance exercise capacity was significantly better in the PR-IMT group ( by 720 m , 95 % CI 342 to 1098 ) and PR-Sham group ( by 505 m , 95 % CI 128 to 883 ) than the control group . Change in maximal inspiratory pressure was significantly better in the PR-IMT group ( by 23 cmH 2 O , 95 % CI 10 to 36 ) and the PR-Sham group ( by 14 cmH 2 O , 95 % CI 2 to 25 ) than that seen in the control group . The inclusion of IMT did not produce a statistically significant benefit over pulmonary rehabilitation alone for these outcomes during the training period . Conclusion Pulmonary rehabilitation with or without IMT  improves exercise tolerance and inspiratory muscle strength in subjects with bronchiectasis AIMS Chronic heart failure is associated with maladaptive and prolonged neurohormonal and pro-inflammatory cytokine activation causing a metabolic shift favouring catabolism , vasodilator incapacity , and loss of skeletal muscle bulk and function . In men , and rogens are important determinants of anabolic function and physical strength and also possess anti-inflammatory and vasodilatory properties . METHODS AND RESULTS We conducted a r and omized , double-blind , placebo-controlled parallel trial of testosterone replacement therapy ( 5 mg And roderm ) at physiological doses in 76 men ( mean+/-SD , age 64+/-9.9 ) with heart failure ( ejection fraction 32.5+/-11 % ) over a maximum follow-up period of 12 months . The primary endpoint was functional capacity as assessed by the incremental shuttle walk test ( ISWT ) . At baseline , 18 ( 24 % ) had serum testosterone below the normal range and bioavailable testosterone correlated with distance walked on the initial ISWT ( r=0.3 , P=0.01 ) . Exercise capacity significantly improved with testosterone therapy compared with placebo over the full study period ( mean change + 25+/-15 m ) corresponding to a 15+/-11 % improvement from baseline ( P=0.006 ANOVA ) . Symptoms improved by at least one functional class on testosterone in 13 ( 35 % ) vs. 3 ( 8 % ) on placebo ( P=0.01 ) . No significant changes were found in h and grip strength , skeletal muscle bulk by cross-sectional computed tomography , or in tumour necrosis factor levels .  Testosterone therapy was safe with no excess of adverse events although the patch preparation was not well tolerated by the study patients . CONCLUSION Testosterone replacement therapy improves functional capacity and symptoms in men with moderately severe heart failure Background : There is a concern that comorbidity or frailty in older people could limit the usefulness of currently available exercise tests for chronic lung disease . This study evaluated the feasibility and reproducibility of the incremental shuttle walking test ( SWT ) in people aged 70 years or over , compared exercise tolerance with other disability markers , and assessed whether the SWT is responsive to change after bronchodilators . Methods : Fifty elderly patients with chronic airflow limitation ( CAL ) and 32 controls without airflow limitation attempted the SWT before and after combined nebulised salbutamol/ipratropium bromide . Subjects also completed the Nottingham Extended Activities of Daily Living index ( NEADL ) and the London H and icap score ( LHS ) . Results : Forty four subjects with CAL ( 88 % ) and 29 controls ( 84 % ) completed the SWT , including many with co-morbidities . Two week repeatability was good and the SWT was strongly associated with EADL ( r=0.51 , p<0.001 ) and LHS ( r=0.43 , p<0.004 ) , but only weakly with forced expiratory volume in 1 second ( FEV1 ) ( r=0.31 , p=0.05 ) . Subjects with CAL walked a mean distance of 177.7 m compared with 243.3 m in controls ( p<0.001 ) ; following bronchodilator therapy the distance walked increased in the CAL group by 13.2 % ( p=0.009 ) . Conclusion : The SWT is a feasible and reproducible measure of exercise tolerance in elderly people with and without airflow obstruction and correlates with other markers of disability . It is sensitive to change following bronchodilation in subjects with CAL , although the change correlates less well with improvements in FEV1 . Overall , these results suggest that the SWT might be an appropriate measure to assess interventions in elderly people 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 BACKGROUND : Arterial oxygen desaturation frequently occurs in patients with COPD during daily activities at home . Oxygen flow is usually set at fixed and low rates for ambulatory patients . We evaluated an innovative closed-loop system ( FreeO2 ) that automatically adjusts the oxygen flow to the patient 's needs in subjects with COPD during walking followed by recovery time , such as during ambulatory conditions . METHODS : Patients with COPD who exhibited oxygen desaturation on exertion were included in the study . Subjects performed endurance shuttle walk tests followed by 10 min of recovery . The tests were conducted in a r and om order and in crossover with the 3 following conditions : subjects breathing ( 1 ) air at 2 L/min , ( 2 ) oxygen at 2 L/min , or ( 3 ) FreeO2 ( variable oxygen flow ) . SpO2 , pulse rate , PETCO2 , breathing frequency , and oxygen flow  were continuously recorded during the 3 conditions . The primary outcome was the percentage of time within the SpO2 target of 92–96 % . Secondary outcomes included the endurance shuttle walk test time and distance .  RESULTS : Sixteen subjects with COPD were recruited . The percentage of time with SpO2 in the target range ( 92–96 % ) was higher while using the FreeO2 , and time with severe oxygen desaturation ( SpO2 < 88 % ) was lower with FreeO2 in comparison with constant-flow oxygen and air testing conditions ( 0.6 % vs 23.9 % vs 52.2 % , P < .001 ) . In comparison with air , walking distance was increased by 35 % with oxygen ( P = .045 ) and by 63 % with FreeO2 ( P < .001 ) . The walking distance was increased by 17 % with FreeO2 in comparison with constant oxygen , but the difference was not statistically significant ( P = .22 ) . CONCLUSIONS : Automatic titration of oxygen flow during walking to maintain oxygen saturation in a specified range improves oxygenation and may improve exercise tolerance during daily activity , such as walking , in patients with COPD in comparison with room air and fixed oxygen administration . ( Clinical Trials.gov registration : NCT02150434 . This study investigated the use of an incremental , externally-paced 10 m shuttle walk test ( SWT ) as an objective , reliable and predictive test of functional capacity in patients with heart failure ( CHF ) . The SWT was compared to a 6 minute walk test ( 6WT ) and a maximal symptom-limited treadmill peak oxygen consumption ( VO2peak ) test . Experiment 1 examined the reproducibility of the SWT . Two SWF trials were performed and distance ambulated ( DA ) , heart rate ( HR ) and  rate of perceived exertion ( RPE ) results compared . In experiment 2 , SWT , 6WT , and VO2 peak tests were performed and HR . RPE and ambulatory VO2 compared . The SWT demonstrated strong test/retest reliability for DA ( r = 0.98 ) . HR ( r = 0.96 ) and RPE ( r = 0.89 ) . Treadmill VO2 peak was significantly correlated with DA during the SWT ( r = 0.83 , P < 0.05 ) , but not the 6WT . SWT peak VO2 ( 18.5 + /- 1.8 ml.kg(-1 ) x min(-1 ) ) and treadmill VO2 peak ( 18.3 + /-2.0 ml.kg(-1 ) x min(-1 ) ) were also highly correlated ( r = 0.78 , P < 0.05 ) . Conversely , 6WT peak VO2 and treadmill VO2 peak were not significantly correlated . This study suggests the SWT is a reliable , objective test , highly predictive of VO2 peak which may be a more optimal field exercise test than the self paced 6WT Background Pulmonary rehabilitation programs have been shown to increase functional exercise capacity and quality of life in COPD patients . However , following the completion of pulmonary rehabilitation the benefits begin to decline unless the program is of longer duration or ongoing maintenance exercise is followed . Therefore , the aim of this study is to determine if supervised , weekly , hospital-based exercise compared to home exercise will maintain the benefits gained from an eight-week pulmonary rehabilitation program in COPD subjects to twelve months . Methods Following completion of an eight-week pulmonary rehabilitation program , COPD subjects will be recruited and r and omised ( using concealed allocation in numbered envelopes ) into either the maintenance exercise group ( supervised , weekly , hospital-based exercise ) or the control group ( unsupervised home exercise ) and followed for twelve months . Measurements will be taken at baseline ( post an eight-week pulmonary rehabilitation program ) , three , six and twelve months . The exercise measurements will include two six-minute walk tests , two incremental shuttle walk tests , and two endurance shuttle walk tests . Oxygen saturation , heart rate and dyspnoea will be monitored during all these tests . Quality of life will be measured using the St George 's Respiratory Question naire and the Hospital Anxiety and Depression Scale .  Participants will be excluded if they require supplemental oxygen or have neurological or musculoskeletal co-morbidities that will prevent them from exercising independently . Discussion Pulmonary rehabilitation plays an important part in the management of COPD and the results from this study will help determine if supervised , weekly , hospital-based exercise can successfully maintain functional exercise capacity and quality of life following an eight-week pulmonary rehabilitation program in COPD subjects in Australia BACKGROUND AND OBJECTIVE Nutritional depletion in chronic obstructive pulmonary disease ( COPD ) adversely affects health status and mortality . We aim ed to evaluate the effects of nutritional supplementation ( NS ) with pulmonary rehabilitation ( PR ) on body composition , mid-thigh cross-sectional area ( CSA ) , dyspnoea , exercise capacity , health-related quality of life , anxiety and depression in advanced COPD patients . METHODS Forty-six patients were r and omized to PR and nutritional support ( PRNS ) , PR or the control group .  Dyspnoea was measured with Medical Research Council and BORG scales . Exercise capacity was measured through 6-min walk test and shuttle tests ; health-related quality of life was assessed with St. George 's Respiratory Question naire . Psychological status was measured with Hospital Anxiety and Depression Scale . Body weight and body mass indexes ( BMI ) were also evaluated . Fat-free mass was measured through bioelectrical impedance analyser . The CSA of quadriceps was calculated in mid-level of the thigh with magnetic resonance imaging . RESULTS Dyspnoea and total scores of St. George 's Respiratory Question naire improved in both groups ( P < 0.05 ) . Six-minute walk test and incremental shuttle walk test distances in PRNS and PR patients increased significantly as ( 62.6 ± 42.4 m , 43.3 ± 59.2 m , both P = 0.001 ; and 63.3 ± 70.1 m and 69.3 ± 69.7 m , both P = 0.001 ) . Although anxiety improved in both groups ( P < 0.05 ) , there was no change in depression . Body weight , BMI and fat-free mass index ( FFMI ) ( 1.1 ± 0.9 kg , 0.2 ± 1.4 kg/m(2 ) and 0.6 ± 0.5 kg/m(2 ) , P < 0.05 ) in PRNS , whereas body weight and FFMI ( 0.6 ± 0.7 kg , 0.1 ± 0.6 kg/m(2 ) P < 0.05 ) increased in PR after the intervention . There was a significant increase in mid-thigh CSA ( 2.5 ± 4.1 cm(2 ) ) only in PRNS ( P = 0.04 ) . CONCLUSION The combination of NS with PR result ed in improvements particularly in lean body mass and mid-thigh CSA . This study suggests combining NS with PR in reversing weight loss and muscle wasting in COPD This study reports on the development and test-retest reproducibility of a modified shuttle walking and step testing protocol s to assess exertional dyspnea in patients with COPD . Patients with COPD r and omly performed four externally paced 3-min bouts of shuttle walking at 1.5 , 2.5 , 4.0 and 6.0 km·h− 1 or stepping at constant rate of 18 , 22 , 26 and 32 steps·min− 1 . Walking and stepping procedures were repeated once , on a separate occasion . Ventilation , heart rate , gas exchange parameters and dyspnea Borg scores were obtained at the end of each exercise bout . Most patients completed walking or stepping at the slow and middle speed cadences but only 33 % completed walking at 6.0 km·h− 1 and 40 % completed stepping at 32 steps·min− 1 . Walking and stepping at progressively faster pace caused a progressive increase in ventilation and dyspnea . Test-retest Pearson correlation coefficients for ventilation , heart rate , gas exchange parameters and dyspnea scores over the four exercise bouts , all exceeded 0.80 . Intra-class correlation coefficients were at least as strong as Pearson coefficients . Bl and & Altman representation showed that for repeated Borg scores , 92 and 96 % of points lied within 2 SD of the mean difference between test-retest values for walking and stepping . The majority of moderate and severe COPD patients completed the 3-min shuttle waking testing at 1.5 to 4.0 km·h− 1 and the 3-min of step testing at rates between 18 and 26 steps·min− 1 . Both field tests were highly reproducible in patients with COPD Background : Pulmonary rehabilitation is effective in improving exercise performance and health status in chronic obstructive pulmonary disease ( COPD ) . However , the role of nutritional support in the enhancement of the benefits of exercise training has not been explored . A double blind , r and omised , controlled trial of carbohydrate supplementation was undertaken in patients attending outpatient pulmonary rehabilitation . Methods : 85 patients with COPD were r and omised to receive a 570 kcal carbohydrate rich supplement or a non-nutritive placebo daily for the duration of a 7 week outpatient pulmonary rehabilitation programme . Primary outcome measures were peak and submaximal exercise performance using the shuttle walk tests . Changes in health status , body composition , muscle strength , and dietary macronutrient intake were also measured . Results : Patients in both the supplement and placebo groups increased shuttle walking performance and health status significantly . There was no statistically significant difference between treatment groups in these outcomes . Patients receiving placebo lost weight whereas supplemented patients gained weight . In well nourished patients ( BMI > 19 kg/m2 ) improvement in incremental shuttle performance was significantly greater in the supplemented group ( mean difference between groups : 27 ( 95 % CI 1 to 53 ) m , p<0.05 ) . Increases in incremental shuttle performance correlated with increases in total carbohydrate intake . Conclusions : When universally prescribed , carbohydrate supplementation does not enhance the rehabilitation of patients with COPD . This study suggests that exercise training results in negative energy balance that can be overcome by supplementation and that , in selected patients , this may improve the outcome of training . The finding of benefit in well nourished patients may suggest a role for nutritional supplementation beyond the treatment of weight loss in COPD BACKGROUND Peak oxygen uptake ( peak VO(2 ) ) is a reference parameter in the assessment of functional capacity of patients with chronic heart failure , but the procedure for cardiopulmonary exercise testing with expired gas analysis is complex and expensive , so more simple and available methods are desirable . METHODS We compared the usefulness of a time-limited walk test , the 6-minute walk test ( 6-MT ) , with that of a symptom-limited walk test , the shuttle walk test ( SWT ) , in the evaluation of patients with moderate to severe chronic heart failure . We prospect ively studied 46 clinical ly stable patients in New York Heart Association class II to IV heart failure with left ventricular ejection fraction < 40 % ( aged 53 + /- 10 years , ejection fraction 23 % + /- 8 % , New York Heart Association functional class 2.8 + /- 0.7 ) . Each patient performed two 6-MT , two SWT and a cardiopulmonary exercise testing within 2 weeks . RESULTS We found a close correlation between distance walked in SWT and peak VO(2 ) ( r = 0.83 , P < .001 ) and a moderate correlation between distance in 6-MT and peak VO(2 ) ( r = 0.69 , P < .001 ) . Both walk tests showed to be reproducible after just one practice walk . All patients who walked > 450 m in SWT had a peak VO(2 ) > 14 mL/kg/min . The overall discriminatory accuracy for SWT distance was greater than that for 6-MT distance for predicting a peak VO(2 ) < 14 mL/kg/min ( area under receiver operator characteristic curves 0.97 and 0.83 respectively , P = .02 ) . Stepwise multivariate regression analysis , including clinical , exercise testing , echocardiographic , radionuclide-angiographic , and rest hemodynamic data , showed that distance walked in SWT was the only independent predictor of peak VO(2 ) ( P < .001 ) and the strongest predictor of percent achieved of age- and sex-predicted peak VO(2 ) ( % PVO(2 ) ) ( P < .001 ) , with only age offering additional information ( P = .02 ) . CONCLUSIONS The SWT shows to be a feasible and safe method to evaluate patients with chronic heart failure that strongly and independently predicts peak VO(2 ) and % PVO(2 . ) This symptom-limited walk test seems to be more useful than 6-MT in the assessment of functional capacity in these patients Objectives Pulmonary rehabilitation ( PR ) provides benefit for patients with chronic obstructive pulmonary disease ( COPD ) in terms of quality of life ( QoL ) and exercise capacity ; however , the effects diminish over time . Our aim was to evaluate a maintenance programme for patients who had completed PR . Setting Primary and secondary care PR programmes in Norfolk . Participants 148 patients with COPD who had completed at least 60 % of a st and ard PR programme were r and omised and data are available for 110 patients . Patients had greater than 20 pack year smoking history and less than 80 % predicted forced expiratory volume in 1 s but no other significant disease or recent respiratory tract infection . Interventions Patients were r and omised to receive a maintenance programme or st and ard care . The maintenance programme consisted of 2 h ( 1 h individually tailored exercise training and 1 h education programme ) every 3 months for 1 year . Primary and secondary outcome measures The Chronic Respiratory Question naire ( CRQ ) ( primary outcome ) , endurance shuttle walk test ( ESWT ) , EuroQol ( EQ5D ) , hospital anxiety and depression score ( HADS ) , body mass index ( BMI ) , body fat , activity levels ( overall score and activity diary ) and exacerbations were assessed before and after 12 months . Results There was no statistically significant difference between the groups for the change in CRQ dyspnoea score ( primary end point ) at 12 months which amounted to 0.19 ( −0.26 to 0.64 ) units or other domains of the CRQ . There was no difference in the ESWT duration ( −10.06 ( −191.16 to 171.03 ) seconds ) , BMI , body fat , EQ5D , MET-minutes , activity rating , HADS , exacerbations or admissions . Conclusions A maintenance programme of three monthly 2 h sessions does not improve outcomes in patients with COPD after 12 months . We do not recommend that our maintenance programme is adopted . Other methods of sustaining the benefits of PR are required . Trial registration number NCT00925171 Little is known about effects of community-based physiotherapeutic exercise programmes incorporated in COPD self-management programmes . In a r and omised trial , the effect of such a programme ( COPE-active ) on exercise capacity and various secondary outcomes including daily activity as a marker of behaviour change was evaluated . All patients attended four 2-h self-management sessions . In addition the intervention group participated in the COPE-active programme offered by physiotherapists of private practice s , consisting of a 6-month " compulsory " period ( 3 sessions/week ) and subsequently a 5-month " optional " period ( 2 sessions/week ) . Because COPE-active was intended to change behaviour with regard to exercise , one session/week in both periods consisted of unsupervised home-based exercise training .  Of 153 patients , 74 intervention and 68 control patients completed the one-year follow-up . Statistically significant between-group differences in incremental shuttle walk test-distance ( 35.1 m ; 95 % CI ( 8.4 ; 61.8 ) ) and daily activity ( 1190 steps/day ; 95 % CI ( 256 ; 2125 ) ) were found in favour of the intervention group . Over the 12-month period a significant difference of the chronic respiratory question naire ( CRQ ) dyspnoea-score ( 0.33 points ; 95 % CI ( 0.01 ; 0.64 ) ) and a non-significant difference of the endurance shuttle walk test ( 135 m ( 95 % CI ( -29 ; 298 ) ) was found . No differences were found in the other CRQ-components , anxiety and depression scores and percentage of fat free mass . This study demonstrates that a community-based reactivation programme improves exercise capacity in patients with moderately to severe COPD . Even more important , the programme improves actual daily activity after one-year which indicates behaviour change with regard to daily exercise . Registered trail number : IS RCT N81447311 OBJECTIVES To determine whether pulmonary rehabilitation carried out in a community setting is more effective than that carried out in a st and ard hospital setting and which is more cost-effective ; also whether telephone follow-up is both cost-effective and useful in prolonging the beneficial effects of a pulmonary rehabilitation programme . DESIGN A r and omised trial . Participants were r and omised in 2 x 2 factorial fashion to hospital or community rehabilitation and telephone or st and ard follow-up with review . SETTING Hospitals or community sites in Sheffield . The community venues were selected to be close to public transport routes and have good parking and level access . The two hospital venues were the physiotherapy gym and a staff gym within the grounds of the hospital . PARTICIPANTS Patients with chronic obstructive pulmonary disease diagnosed by respiratory physicians according to Global Initiative for Chronic Obstructive Lung Disease guidelines . INTERVENTIONS Participants were r and omised to one of four groups : hospital rehabilitation with no telephone follow-up ; hospital rehabilitation with telephone follow-up ; community rehabilitation with no telephone follow-up ; or community rehabilitation with telephone follow-up . All were blinded to the telephone intervention arm until 1 month post rehabilitation , when only the assessment team and research participants were unblinded . MAIN OUTCOME MEASURES The primary outcome measure was the difference in improvement in endurance shuttle walking test ( ESWT ) between hospital and community pulmonary rehabilitation groups post rehabilitation , and the difference in ESWT during 18 months ' follow-up between those receiving telephone encouragement and those receiving st and ard care . A secondary measure was health-related quality of life . RESULTS A total of 240 participants had evaluable data . Of these , 129 were r and omised to hospital rehabilitation ( 64 with telephone follow-up and 65 with no telephone follow-up ) and 111 to community rehabilitation ( 55 with telephone follow-up and 56 with no telephone follow-up ) . For the primary outcome measure , there were 162 patients with data for analysis : hospital rehabilitation with no telephone follow-up ( n = 38 ) ; hospital rehabilitation with telephone follow-up ( n = 48 ) ; community rehabilitation with no telephone follow-up ( n = 43 ) ; and community rehabilitation with telephone follow-up ( n = 33 ) . For the acute phase post-rehabilitation outcomes , before patients had the opportunity for telephone follow-up , we compared outcomes between the 76 patients in the community rehabilitation group and the 86 patients in the hospital rehabilitation group . Patients in the hospital rehabilitation group increased the distance they could walk at the post-rehabilitation follow-up by 283 m ( SD 360 m ) , an increase relative to baseline of 109 % ( SD 137 % ) . Patients in the community rehabilitation group increased the distance they could walk at the post-rehabilitation follow-up by 216 m ( SD 340 m ) , an increase relative to baseline of 91 % ( SD 133 % ) . There was no statistically significant difference between the groups [ 17.8 % ( 95 % CI -24.3 to 59.9 , p = 0.405 ) ] . For longer term outcomes at 6 , 12 and 18 months post rehabilitation there was no evidence of a rehabilitation group effect . After allowing for the initial post-rehabilitation baseline distance walked , time ( follow-up visit ) and the factorial design ( telephone follow-up group ) , the average difference in the post-rehabilitation follow-up distance walked on the ESWT between the hospital and community rehabilitation groups was 1.5 m ( 95 % CI -82.1 to 97.2 , p = 0.971 ) , and between the telephone and no-telephone groups it was 56.9 m ( 95 % CI -25.2 to 139 , p = 0.174 ) . There was no difference between hospital or community groups in terms of acute effect or persistence of effect . Health economic analysis favoured neither hospital nor community setting s , nor did it clearly favour telephone follow-up or routine care . CONCLUSIONS Pulmonary rehabilitation delivered in a community setting has similar efficacy to that produced in a more traditional hospital-based setting , both setting s producing significant improvements in terms of exercise capacity and quality of life acutely and after long-term follow-up . Health economic analysis showed that neither hospital nor community programmes were greatly favoured . The choice of model will depend on local factors of convenience , existing availability of re sources and incremental costs . Staff characteristics may be important in gaining optimal outcome , and care should be taken in staff recruitment and training . TRIAL REGISTRATION Current Controlled Trials IS RCT N86821773
Method ological factors affecting 6MWD include track length , encouragement , supplemental oxygen and walking aids .
Supplemental oxygen also affects ISWT and ESWT performance .
Responsiveness was moderate to high for all tests , with greater responsiveness to interventions that included exercise training .
The findings of this review demonstrate that the 6MWT , ISWT and ESWT are robust tests of functional exercise capacity in adults with chronic respiratory disease
This systematic review examined the measurement properties of the 6-min walk test ( 6MWT ) , incremental shuttle walk test ( ISWT ) and endurance shuttle walk test ( ESWT ) in adults with chronic respiratory disease .