Skip to main content
PMC home page
Thorax logoLink to Thorax
. 2005 May;60(5):367–375. doi: 10.1136/thx.2004.033274

How should COPD patients exercise during respiratory rehabilitation? Comparison of exercise modalities and intensities to treat skeletal muscle dysfunction

M Puhan 1, H Schunemann 1, M Frey 1, M Scharplatz 1, L Bachmann 1
PMCID: PMC1758898  PMID: 15860711

Abstract

Background: Physical exercise is an important component of respiratory rehabilitation because it reverses skeletal muscle dysfunction, a clinically important manifestation of COPD associated with reduced health-related quality of life (HRQL) and survival. However, there is controversy regarding the components of the optimal exercise protocol. A study was undertaken to systematically evaluate and summarise randomised controlled trials (RCTs) comparing different exercise protocols for COPD patients.

Methods: Six electronic databases, congress proceedings and bibliographies of included studies were searched without imposing language restrictions. Two reviewers independently screened all records and extracted data on study samples, interventions and methodological characteristics of included studies.

Results: The methodological quality of the 15 included RCTs was low to moderate. Strength exercise led to larger improvements of HRQL than endurance exercise (weighted mean difference for Chronic Respiratory Questionnaire 0.27, 95% CI 0.02 to 0.52). Interval exercise seems to be of similar effectiveness as continuous exercise, but there are few data on clinically relevant outcomes. One small RCT which included patients with mild COPD compared the effect of high and low intensity exercise (at 80% and 40% of the maximum exercise capacity, respectively) and found larger physiological training effects from high intensity exercise.

Conclusions: Strength exercise should be routinely incorporated in respiratory rehabilitation. There is insufficient evidence to recommend high intensity exercise for COPD patients and investigators should conduct larger high quality trials to evaluate exercise intensities in patients with moderate to severe COPD.

Full Text

The Full Text of this article is available as a PDF (304.3 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Anthonisen N. R., Wright E. C., Hodgkin J. E. Prognosis in chronic obstructive pulmonary disease. Am Rev Respir Dis. 1986 Jan;133(1):14–20. doi: 10.1164/arrd.1986.133.1.14. [DOI] [PubMed] [Google Scholar]
  2. Bernard S., LeBlanc P., Whittom F., Carrier G., Jobin J., Belleau R., Maltais F. Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998 Aug;158(2):629–634. doi: 10.1164/ajrccm.158.2.9711023. [DOI] [PubMed] [Google Scholar]
  3. Bernard S., Whittom F., Leblanc P., Jobin J., Belleau R., Bérubé C., Carrier G., Maltais F. Aerobic and strength training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999 Mar;159(3):896–901. doi: 10.1164/ajrccm.159.3.9807034. [DOI] [PubMed] [Google Scholar]
  4. Casaburi R., Patessio A., Ioli F., Zanaboni S., Donner C. F., Wasserman K. Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis. 1991 Jan;143(1):9–18. doi: 10.1164/ajrccm/143.1.9. [DOI] [PubMed] [Google Scholar]
  5. Celli B. R. Training in the rehabilitation of pulmonary patients with chronic obstructive pulmonary disease. Monaldi Arch Chest Dis. 1998 Aug;53(4):438–449. [PubMed] [Google Scholar]
  6. Celli Bartolome R., Cote Claudia G., Marin Jose M., Casanova Ciro, Montes de Oca Maria, Mendez Reina A., Pinto Plata Victor, Cabral Howard J. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004 Mar 4;350(10):1005–1012. doi: 10.1056/NEJMoa021322. [DOI] [PubMed] [Google Scholar]
  7. Coppoolse R., Schols A. M., Baarends E. M., Mostert R., Akkermans M. A., Janssen P. P., Wouters E. F. Interval versus continuous training in patients with severe COPD: a randomized clinical trial. Eur Respir J. 1999 Aug;14(2):258–263. doi: 10.1034/j.1399-3003.1999.14b04.x. [DOI] [PubMed] [Google Scholar]
  8. Decramer M., Gosselink R., Troosters T., Verschueren M., Evers G. Muscle weakness is related to utilization of health care resources in COPD patients. Eur Respir J. 1997 Feb;10(2):417–423. doi: 10.1183/09031936.97.10020417. [DOI] [PubMed] [Google Scholar]
  9. Donner C. F., Muir J. F. Selection criteria and programmes for pulmonary rehabilitation in COPD patients. Rehabilitation and Chronic Care Scientific Group of the European Respiratory Society. Eur Respir J. 1997 Mar;10(3):744–757. [PubMed] [Google Scholar]
  10. Goldstein R. S., Gort E. H., Stubbing D., Avendano M. A., Guyatt G. H. Randomised controlled trial of respiratory rehabilitation. Lancet. 1994 Nov 19;344(8934):1394–1397. doi: 10.1016/s0140-6736(94)90568-1. [DOI] [PubMed] [Google Scholar]
  11. Gosselink R., Troosters T., Decramer M. Exercise training in COPD patients: the basic questions. Eur Respir J. 1997 Dec;10(12):2884–2891. doi: 10.1183/09031936.97.10122884. [DOI] [PubMed] [Google Scholar]
  12. Griffiths T. L., Phillips C. J., Davies S., Burr M. L., Campbell I. A. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001 Oct;56(10):779–784. doi: 10.1136/thorax.56.10.779. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Hamilton A. L., Killian K. J., Summers E., Jones N. L. Muscle strength, symptom intensity, and exercise capacity in patients with cardiorespiratory disorders. Am J Respir Crit Care Med. 1995 Dec;152(6 Pt 1):2021–2031. doi: 10.1164/ajrccm.152.6.8520771. [DOI] [PubMed] [Google Scholar]
  14. Jaeschke R., Singer J., Guyatt G. H. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials. 1989 Dec;10(4):407–415. doi: 10.1016/0197-2456(89)90005-6. [DOI] [PubMed] [Google Scholar]
  15. Jones B., Jarvis P., Lewis J. A., Ebbutt A. F. Trials to assess equivalence: the importance of rigorous methods. BMJ. 1996 Jul 6;313(7048):36–39. doi: 10.1136/bmj.313.7048.36. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Kjaergard L. L., Villumsen J., Gluud C. Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses. Ann Intern Med. 2001 Dec 4;135(11):982–989. doi: 10.7326/0003-4819-135-11-200112040-00010. [DOI] [PubMed] [Google Scholar]
  17. Lacasse Y., Brosseau L., Milne S., Martin S., Wong E., Guyatt G. H., Goldstein R. S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002;(3):CD003793–CD003793. doi: 10.1002/14651858.CD003793. [DOI] [PubMed] [Google Scholar]
  18. Lake F. R., Henderson K., Briffa T., Openshaw J., Musk A. W. Upper-limb and lower-limb exercise training in patients with chronic airflow obstruction. Chest. 1990 May;97(5):1077–1082. doi: 10.1378/chest.97.5.1077. [DOI] [PubMed] [Google Scholar]
  19. Mador M. J., Bozkanat E. Skeletal muscle dysfunction in chronic obstructive pulmonary disease. Respir Res. 2001 May 2;2(4):216–224. doi: 10.1186/rr60. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Mador M. Jeffery, Bozkanat Erkan, Aggarwal Ajay, Shaffer Mary, Kufel Thomas J. Endurance and strength training in patients with COPD. Chest. 2004 Jun;125(6):2036–2045. doi: 10.1378/chest.125.6.2036. [DOI] [PubMed] [Google Scholar]
  21. Maltais F., LeBlanc P., Jobin J., Bérubé C., Bruneau J., Carrier L., Breton M. J., Falardeau G., Belleau R. Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1997 Feb;155(2):555–561. doi: 10.1164/ajrccm.155.2.9032194. [DOI] [PubMed] [Google Scholar]
  22. Maltais F., LeBlanc P., Simard C., Jobin J., Bérubé C., Bruneau J., Carrier L., Belleau R. Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1996 Aug;154(2 Pt 1):442–447. doi: 10.1164/ajrccm.154.2.8756820. [DOI] [PubMed] [Google Scholar]
  23. Marquis Karine, Debigaré Richard, Lacasse Yves, LeBlanc Pierre, Jobin Jean, Carrier Guy, Maltais François. Midthigh muscle cross-sectional area is a better predictor of mortality than body mass index in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2002 Sep 15;166(6):809–813. doi: 10.1164/rccm.2107031. [DOI] [PubMed] [Google Scholar]
  24. Martinez F. J., Vogel P. D., Dupont D. N., Stanopoulos I., Gray A., Beamis J. F. Supported arm exercise vs unsupported arm exercise in the rehabilitation of patients with severe chronic airflow obstruction. Chest. 1993 May;103(5):1397–1402. doi: 10.1378/chest.103.5.1397. [DOI] [PubMed] [Google Scholar]
  25. Normandin Edgar A., McCusker Corliss, Connors MaryLou, Vale Frederick, Gerardi Daniel, ZuWallack Richard L. An evaluation of two approaches to exercise conditioning in pulmonary rehabilitation. Chest. 2002 Apr;121(4):1085–1091. doi: 10.1378/chest.121.4.1085. [DOI] [PubMed] [Google Scholar]
  26. Ortega Francisco, Toral Javier, Cejudo Pilar, Villagomez Rafael, Sánchez Hildegard, Castillo José, Montemayor Teodoro. Comparison of effects of strength and endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2002 Sep 1;166(5):669–674. doi: 10.1164/rccm.2107081. [DOI] [PubMed] [Google Scholar]
  27. Redelmeier D. A., Bayoumi A. M., Goldstein R. S., Guyatt G. H. Interpreting small differences in functional status: the Six Minute Walk test in chronic lung disease patients. Am J Respir Crit Care Med. 1997 Apr;155(4):1278–1282. doi: 10.1164/ajrccm.155.4.9105067. [DOI] [PubMed] [Google Scholar]
  28. Ries A. L., Ellis B., Hawkins R. W. Upper extremity exercise training in chronic obstructive pulmonary disease. Chest. 1988 Apr;93(4):688–692. doi: 10.1378/chest.93.4.688. [DOI] [PubMed] [Google Scholar]
  29. Rooyackers J. M., Berkeljon D. A., Folgering H. T. M. Eccentric exercise training in patients with chronic obstructive pulmonary disease. Int J Rehabil Res. 2003 Mar;26(1):47–49. doi: 10.1097/00004356-200303000-00006. [DOI] [PubMed] [Google Scholar]
  30. Schulz K. F., Chalmers I., Hayes R. J., Altman D. G. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995 Feb 1;273(5):408–412. doi: 10.1001/jama.273.5.408. [DOI] [PubMed] [Google Scholar]
  31. Schünemann Holger J., Griffith Lauren, Jaeschke Roman, Goldstein Roger, Stubbing David, Guyatt Gordon H. Evaluation of the minimal important difference for the feeling thermometer and the St. George's Respiratory Questionnaire in patients with chronic airflow obstruction. J Clin Epidemiol. 2003 Dec;56(12):1170–1176. doi: 10.1016/s0895-4356(03)00115-x. [DOI] [PubMed] [Google Scholar]
  32. Schünemann Holger J., Puhan Milo, Goldstein Roger, Jaeschke Roman, Guyatt Gordon H. Measurement properties and interpretability of the Chronic respiratory disease questionnaire (CRQ). COPD. 2005 Mar;2(1):81–89. doi: 10.1081/copd-200050651. [DOI] [PubMed] [Google Scholar]
  33. Seemungal T. A., Donaldson G. C., Paul E. A., Bestall J. C., Jeffries D. J., Wedzicha J. A. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998 May;157(5 Pt 1):1418–1422. doi: 10.1164/ajrccm.157.5.9709032. [DOI] [PubMed] [Google Scholar]
  34. Sin Don D., Stafinski Tania, Ng Ying Chu, Bell Neil R., Jacobs Philip. The impact of chronic obstructive pulmonary disease on work loss in the United States. Am J Respir Crit Care Med. 2002 Mar 1;165(5):704–707. doi: 10.1164/ajrccm.165.5.2104055. [DOI] [PubMed] [Google Scholar]
  35. Spruit M. A., Gosselink R., Troosters T., De Paepe K., Decramer M. Resistance versus endurance training in patients with COPD and peripheral muscle weakness. Eur Respir J. 2002 Jun;19(6):1072–1078. doi: 10.1183/09031936.02.00287102. [DOI] [PubMed] [Google Scholar]
  36. Spruit Martijn A., Troosters Thierry, Trappenburg Jacob C. A., Decramer Marc, Gosselink Rik. Exercise training during rehabilitation of patients with COPD: a current perspective. Patient Educ Couns. 2004 Mar;52(3):243–248. doi: 10.1016/S0738-3991(03)00098-3. [DOI] [PubMed] [Google Scholar]
  37. Sullivan S. D., Ramsey S. D., Lee T. A. The economic burden of COPD. Chest. 2000 Feb;117(2 Suppl):5S–9S. doi: 10.1378/chest.117.2_suppl.5s. [DOI] [PubMed] [Google Scholar]
  38. Sívori M., Rhodius E., Kaplan P., Talarico M., Gorojod G., Carreras B., López C., Shimojo C. Entrenamiento muscular en la enfermedad pulmonar obstructiva crónica severa. Estudio comparativo del entrenamiento aerobico de miembros inferiores vs. combinacion con miembros superiores. Medicina (B Aires) 1998;58(6):717–727. [PubMed] [Google Scholar]
  39. Toral Marín J., Ortega F., Cejudo P., Elías T., Sánchez H., Montemayor T. Fuerza de los músculos periféricos en pacientes con EPOC estable: correlación con parámetros funcionales respiratorios y de calidad de vida. Arch Bronconeumol. 1999 Mar;35(3):117–121. [PubMed] [Google Scholar]
  40. Troosters T., Gosselink R., Decramer M. Short- and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Am J Med. 2000 Aug 15;109(3):207–212. doi: 10.1016/s0002-9343(00)00472-1. [DOI] [PubMed] [Google Scholar]
  41. Vallet G., Ahmaïdi S., Serres I., Fabre C., Bourgouin D., Desplan J., Varray A., Préfaut C. Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols. Eur Respir J. 1997 Jan;10(1):114–122. doi: 10.1183/09031936.97.10010114. [DOI] [PubMed] [Google Scholar]
  42. Vogiatzis I., Nanas S., Roussos C. Interval training as an alternative modality to continuous exercise in patients with COPD. Eur Respir J. 2002 Jul;20(1):12–19. doi: 10.1183/09031936.02.01152001. [DOI] [PubMed] [Google Scholar]
  43. Wijkstra P. J., Van Altena R., Kraan J., Otten V., Postma D. S., Koëter G. H. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. Eur Respir J. 1994 Feb;7(2):269–273. doi: 10.1183/09031936.94.07020269. [DOI] [PubMed] [Google Scholar]
  44. Würtemberger G., Bastian K. Funktionelle Effekte unterschiedlicher Trainingsformen bei Patienten mit COPD. Pneumologie. 2001 Dec;55(12):553–562. doi: 10.1055/s-2001-19001. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

[Web-only table]
thorax_60_5_367__index.html (1.2KB, html)
thorax_60_5_367__1.pdf (47.1KB, pdf)

Articles from Thorax are provided here courtesy of BMJ Publishing Group

RESOURCES