Time to adapt exercise training regimens in pulmonary rehab
Exercise intolerance, exertional dyspnea, reduced health-related quality of life, and acute exacerbations are features characteristic of chronic obstructive pulmonary disease (COPD). Patients with a primary diagnosis of COPD often report comorbidities (notably cardiovascular disease, diabetes, depression, osteoporosis, and osteoarthritis) and other secondary manifestations (nutritional deficits, body composition) which diversifies the clinical presentation.
Pulmonary rehabilitation that includes whole body exercise training is a critical part of management, and core programs involve endurance and resistance training for the upper and lower limbs.
Positive outcomes in maximal and submaximal exercise capacity, dyspnea, fatigue, health-related quality of life, and psychological symptoms are well known and widely implemented as standard care across the world.
However, The varying clinical profile of COPD may direct the need for modification to traditional training strategies for some patients.
Pulmonary rehabilitation (PR) is a cornerstone of management of COPD. It is defined as a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education and behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours”.
This article discusses the various traditional exercise modalities (endurance, interval and resistance training) and proposes novel ways to individualize training and optimize clinical outcomes. Periodization, partitioning (ie one-legged cycling), inspiratory muscle training, balance training are promising components of PR programs.
The authors propose for clinicians to look at strategies to optimize adherence and outcome of PR: to provide supplemental oxygen or even NIV to selected patients, improve self-efficacy, increase program duration up to 12-18 months, vary settings from hospital to home- or community based programs, consider water-based training for patients with comorbidities and introduce maintenance programs.
Failure to attend initial PR is attributed to inconvenient timing, disruption to usual routine, and influence of their primary health care provider. Suboptimal attendance is commonly related to transport, lack of perceived benefit as well as hospitalization and social isolation. The authors stress the importance of a positive attitude of the referring professional, and involving the patient actively in solutions.
COPD is a heterogeneous condition, with patients demonstrating physical, psychological, and functional disability in addition to comorbidities and complications which increase the complexity of clinical presentation.
PR ideally should be offered in a stable clinical state and immediately following AE, and training strategies should consider the potential role of comorbidities in exercise training prescription and outcomes.
> From: Lee et al., Int J Chron Obstruct Pulm Dis 9 (2014) 1275-1288. All rights reserved to The Author(s). Click here for the Pubmed summary.