Exercise training in COPD patients: the basic questions

Pulmonary rehabilitation programmes aim at improving exercise capacity, activities of daily living, quality of life and perhaps survival in patients with chronic obstructive pulmonary disease (COPD). Recently, well-designed studies investigated and confirmed the efficacy of comprehensive pulmonary rehabilitation programmes, including exercise training, breathing exercises, optimal medical treatment, psychosocial support and health education. In the present overview, the contribution of exercise training in clinical practice to the demonstrated effects of pulmonary rehabilitation is discussed by means of six basic questions. These include: 1) the significance of exercise training; 2) the optimal intensity for exercise training; 3) prescribing training modalities; 4) the effects of exercise training combined with medication, nutrition or oxygen; 5) how training effects should be maintained; and 6) where the rehabilitation programme should be performed: in-patient, out-patient or homecare? First, exercise training has been proven to be an essential component of pulmonary rehabilitation. Training intensity is of key importance. High-intensity training (>70% maximal workload) is feasible even in patients with more advanced COPD. In addition, the effects on peripheral muscle function and ventilatory adaptations are superior to low-intensity training. There is, however, no consensus on the optimal training modalities. Both walking and cycling improved exercise performance. Since peripheral muscle function has been recognized as an important contributor to exercise performance, specific peripheral muscle training recently gained interest. Improved submaximal exercise performance and increased quality of life were found after muscle training. The optimal training regimen (strength or endurance) and the muscle groups to be trained, remain to be determined. Training of respiratory muscles is recommended in patients with ventilatory limitation during exercise. The additional effects of anabolic-androgenic drugs, oxygen and nutrition are not well-established in COPD patients and need further research. In order to maintain training effects, close attention of the rehabilitation team is required. The continuous training frequency necessary to maintain training effects remains to be defined. At this point in time, out-patient-based programmes show the best results and guarantee the best supervision and a multidisciplinary approach. Future research should focus on the role of homecare programmes to maintain improvements.     

Effects of a multidisciplinary rehabilitation programme on health-related quality of life in patients with prolonged musculoskeletal disorders: a 6-month follow-up of a prospective controlled study

PURPOSE: The aim of this prospective, controlled, follow-up study (6 months) was to examine the effects of a multidisciplinary rehabilitation programme on perceived health-related quality of life (HRQL) in patients with prolonged musculoskeletal disorders (PMSD). The programme focused on body awareness therapy and cognitive and relaxation treatment. METHOD: The rehabilitation group comprised 122 patients, and there were 114 patients in the matched control group (CG). Both groups of patients had access to primary health care. Baseline data were compared with 6-month follow-up data within and between the groups. The following measurements were employed: HRQL (Nottingham Health Profile), body awareness, postural control, pain (VAS), pain-related medicine consumption, isometric arm muscle endurance, aerobic capacity, psychosomatic symptoms, physical and psychosocial working environment and sick leave. RESULTS: Variables that improved significantly as compared with the CG were: HRQL, anxiety, pain related to movements, psychosomatic symptoms and need for pain-related medicines. CONCLUSIONS: The multidisciplinary rehabilitation programme used here improved HRQL in patients with PMSD to a greater extent than the standard treatment provided within primary heath care (p = 0.01) at least in the short term.     

The effects of body composition changes to observed improvements in cardiopulmonary parameters after exercise training with cardiac rehabilitation

STUDY OBJECTIVE: To discriminate the effects of body fat reduction on improvements in peak aerobic capacity made following exercise training during cardiac rehabilitation. DESIGN: Observational, prospective study. SETTING: Outpatient cardiovascular health center at regional academic center. PATIENT INTERVENTIONS: Peak oxygen uptake (pkVO2), percent body fat, lean body mass (LBM), and other anthropometric measures were assessed before and after a 3-month program of cardiac rehabilitation and exercise training in 500 consecutive cardiac patients following a major coronary event. Baseline pkVO2 was corrected for LBM (pk/VO2 lean) and compared with posttraining values. RESULTS: Following exercise training, percent body fat decreased 5% from 26.2+/-8.0 to 24.8+/-7.5 (p<0.0001), and LBM increased 1% from 61.3+/-12.5 to 61.7+/-11.8 kg (p=0.02). pk/VO2 increased 16% from 16.0+/-4.1 to 18.5+/-4.8 mL/kg/min (p<0.0001), and pkVO2 lean increased 13% from 21.7+/-5.3 to 24.6+/-6.0 mL/kg/min (p<0.0001). Isolating the effects of reduction in body fat, we discern that these changes contributed to 0.3 of the 2.5 mL/kg/min increase in pkVO2 or 12% of the increase in pkVO2 observed. CONCLUSIONS: Changes in body composition, as a consequence of dietary and exercise modification, contribute to 12% of the "observed" improvement noted in weight-adjusted peak aerobic capacity following cardiac rehabilitation and exercise training. Changes in pkVO2 lean should be used by investigators to assess the singular effects of exercise conditioning alone.     

The stress connection. Women and coronary heart disease

Assessment and treatment of the stressors associated with major medical illness such as CHD without regard to gender overlooks women's issues in some extremely fundamental ways. To ensure that rehabilitation formats are relevant for women, more qualitative studies are needed so that women can give voice to the story of an MI recovery from a feminine perspective. It is vital to understand the psychologic contribution to the development and treatment of CHD both as described by women in their own words and as evaluated by distinctly feminine constructs. Assessment of psychosocial factors should be an essential component of a CHD diagnostic evaluation. Although little can be done about a genetic predisposition to CHD, education and personal support can help women make needed lifestyle changes to forestall further cardiac damage and to improve a woman's level of functioning. The capacity to take charge of one's life and social support are strong counterpoints to negative psychosocial symptoms of CHD. There is a strong need to make rehabilitation programs for women with CHD contextually congruent. Strategies to involve women in cardiac rehabilitation must take into account a woman's needs, providing both age-appropriate physical exercise and psychologic social support for women at times convenient to their schedules. Women must be given permission to let go of normally performed duties after a major cardiac event and to seek out what is meaningful. Group formats that offer women essential social support, an opportunity to verbally process the meaning of a life-threatening diagnosis, an opportunity to share their experiences with other women, and the ability to reconstruct a new sense of self based on feminine constructs may be as important for women as other lifestyle structural components in effective rehabilitation programs. Society must reclassify the CHD disease process as one that equally affects women. Research studies with women as primary subjects and key informants can provide needed direction in the identification of psychosocial risk factors and appropriate treatments to reduce alarming morbidity and mortality of CHD in women. More data are needed about the psychosocial mechanisms that aggravate and mediate physiologic responses in CHD in women.     

Maximizing functional capacity. Pulmonary rehabilitation and adjunctive measures

Pulmonary rehabilitation has become an important adjunct to standard medical therapy, with the primary goal of restoring patients to the highest possible functional state using a combination of exercise training, education, respiratory and chest physiotherapy techniques, and psychosocial support. Evidence supports the use of this combined modality therapy for motivated patients with disability from chronic lung disease. Although pulmonary function generally does not change, exercise tolerance can improve, together with decreased symptoms of breathlessness, improved quality of life, and less need for health care services. Patients are empowered with a better understanding of their disease and the proper usage of medications, oxygen therapy, and chest physiotherapy techniques. Thus, pulmonary rehabilitation enables patients to make the most of their lungs and their life.     

Psychosocial interventions for patients with coronary artery disease: a meta-analysis

BACKGROUND: Narrative review strategies and meta-analyses have shown that drug treatment and exercise rehabilitation regimens can reduce psychological distress and postmyocardial infarction mortality and recurrence. OBJECTIVE: To question whether the addition of psychosocial interventions improves the outcome of a standard rehabilitation regimen for patients with coronary artery disease. METHODS: We performed a statistical meta-analysis of 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation from documented coronary artery disease. Anxiety, depression, biological risk factors, mortality, and recurrence of cardiac events were the clinical end points that were studied. Mortality data were available from 12 studies, and recurrence data were available from 10 of the 23 studies. RESULTS: The studies had evaluated 2024 patients who received psychosocial treatment vs 1156 control subjects. The psychosocially treated patients showed greater reductions in psychological distress, systolic blood pressure, heart rate, and cholesterol level (with effect size differences of -0.34 [corrected], -0.24, -0.38, and -1.54, respectively). Patients who did not receive psychosocial treatment showed greater mortality and cardiac recurrence rates during the first 2 years of follow-up with log-adjusted odds ratios of 1.70 for mortality (95% confidence interval [CI], 1.09 to 2.64) and 1.84 for recurrence (CI, 1.12 to 2.99). CONCLUSIONS: The addition of psychosocial treatments to standard cardiac rehabilitation regimens reduces mortality and morbidity, psychological distress, and some biological risk factors. The benefits were clearly evident during the first 2 years and were weaker thereafter. At the clinical level, it is recommended to include routinely psychosocial treatment components in cardiac rehabilitation. The findings also suggest an urgent need to identify the specific, most effective types of psychosocial interventions via controlled research.     

Rehabilitation in children with juvenile chronic arthritis

Chronic childhood arthritis impairs joint function and may result in severe physical handicap. Joint pain and inflammation trigger a vicious cycle that often ends in joint damage and fixed deformities. A comprehensive rehabilitation programme must start early to restore loss of function and prevent permanent handicap. It is dominated by a physiotherapeutic regimen consisting of pain relief, movement expansion, training of muscular coordination and finally re-integration of a physiological movement pattern. The approaches of occupational therapy become integrated into the treatment programme, concentrating on joint protection and self-care training. Additional aids support the aim of joint restoration. They include individual splinting, adapted footwear and walking aids. Depending on the child's age and developmental status different aspects of rehabilitation dominate. Small children need adequate mobility to promote their psychosocial development. In later years integration into school life and the peer group becomes important. Adolescents require help for an adequate vocational training and self-care support. Last but not least, parental education and integration of the whole family into the rehabilitation programme markedly improve the patient's prognosis.     

Adaptational behaviour of peripheral and central acoustic responses in guinea pigs under the influence of various fractions of an extract from Gingko biloba (author''s transl)

Cardiopulmonary function studies at rest and during submaximal and maximal exercise were performed in 21 children and adolescents who had undergone surgical correction of tetralogy of Fallot. Maximal oxygen uptake of the patients was 84.6% of healthy peers matched for age and height. The reduced aerobic capacity can mainly be attributed to a reduction in stroke volume. In the presence of a reduced stroke volume normal cardiac output during submaximal exercise was achieved and maintained by an increase in heart rate. During maximal exercise, however, the heart rate did not exceed that of the healthy controls and the results for the children in this series are about 20% higher than those reported in the literature for adults who had undergone surgical repair of a tetralogy. Persistent impairment of cardiac function in patients with tetralogy of Fallot who have undergone corrective surgery may represent a residual outflow tract obstruction in the right ventricle, impaired function of the left ventricle or the result of restricted physical activity.     

Rehabilitation after myocardial infarction or coronary surgery: elderly patients may benefit as much as the younger ones

At most Swedish hospitals participation in cardiac rehabilitation programmes is restricted to patients of working age, although coronary patients predominately belong to the higher age groups. The article consists in a review of the benefits of cardiac rehabilitation to the elderly, such as enhanced quality of life and lower readmission rates, improvement in co-ordination, muscular strength and bone mineral constant, and a cardioprotective effect on risk factors. Cardiac rehabilitation programmes for the elderly, preferably organised in close so-operation between local hospitals, primary care facilities and patient organisations, might yield considerable individual and general health economic benefits.     

The efficacy and safety of exercise programs in cardiac rehabilitation

Physical activity performed by patients with coronary heart disease is a two-edged sword. A number of biological changes produced by regular exercise may reduce the risk of future cardiac events, while the increase in cardiac work produced by this same exercise can predispose the patient to sudden cardiac death. Data from observational studies as well as randomized clinical trials demonstrate a lower cardiac mortality rate for men participating in exercise rehabilitation programs vs nonparticipants. Overall, exercise program participants appear to experience a reduction of approximately 25% in cardiac and all-cause mortality, but no single study has provided definitive results. During medically supervised exercise, the risk of cardiac death based on reports of programs in the United States is approximately one event in every 60,000 participant-hours of exercise. At this rate, a typical rehabilitation program that has 95 patients exercising 3 h.wk-1 could expect a sudden cardiac death during an exercise session once every 4 yr. No data have been published on the morbidity or mortality benefits or risks of home-based exercise or for women participants. Also, the contribution of continuous electrocardiographic monitoring to the safety of exercise training of cardiac patients is yet to be defined.     

Effect of ambulatory sports therapy on bronchial asthma in children

Exercise-induced asthma (EIA) is very common in children with asthma. For this reason they avoid every strenuous exercise because they fear a new asthma attack. Working capacity and maturation of motor performance can be insufficient as a consequence. We investigated whether a special training programme in an asthma sports group has positive effects not only on asthma, but also on working capacity and motor performance. 11 children with extrinsic asthma (4 girls, 7 boys), 8 to 14 years old, were studied before and after a 6-month out-patient rehabilitative sports therapy (sports group) with regard to their degree of bronchial hyperreactivity (BHR), frequency of EIA, cardiopulmonary capacity for exercise; knowledge about their asthma, level of coordination and condition, and their movement-related anxiety. There were 9 children with extrinsic asthma (2 girls, 7 boys), 8 to 15 years old, in a control group. They did not take part in any special training programme. After the sports therapy we found in 3 children of the sports group a decrease in BHR, EIA was now present in only 2 of formerly 4 children. Physical working capacity (PWC) at the aerobic/anaerobic threshold improved in the sports group by about 1 W/kg body weight (p = 0.008), efficiency of work from 23.7% to 27.9% (p = 0.009). We also found a remarkable improvement of motor abilities. Movement-related anxiety decreased in the sports group both in Indoor sports (p = 0.0089) and aquatics (p = 0.026). In the control group there was no significant change. Physical training in children with asthma has many positive effects on lung function and motor performance. We believe that the limit for an EIA release is shifted to a higher PWC. The reduction of the anxiety over sports at a higher level of PWC contributes to an improved quality of life for children with asthma.     

Trends along the debt-income axis: implications for medical students'' selections of family practice careers

Even elderly patients > or = 75 years of age with coronary artery disease have modest improvements in lipid levels and marked improvements in exercise capacity, behavioral characteristics, and quality-of-life parameters after cardiac rehabilitation and exercise training programs. These data support that even very elderly patients with coronary artery disease should be routinely referred to and vigorously encouraged to pursue formal outpatient cardiac rehabilitation and exercise training programs following major coronary events.     

Common and specific process factors in cardiac rehabilitation: Independent and interactive effects of the working alliance and self-efficacy.

Objective: Therapeutic processes in cardiac rehabilitation programs are virtually unexamined. Models were tested by which changes in the working alliance between patient and staff (agreement on goals/tasks; emotional bond) may affect outcomes in conjunction with changes in patient self-efficacy to change their diets and increase exercise. Design: Cardiac patients (n = 79) participated in a 12-week program, and completed assessments at early, mid, and late treatment. Main Outcome Measures: Changes in cardiac depression, physical health, perceived exertion during exercise, rate/pressure product at submaximal exercise tolerance, weight loss, return to work, total fat intake. Results: Early-treatment changes in agreement on goals/tasks were related to changes in psychosocial factors and perceived exertion during exercise independent of effects of changes in self-efficacy. Early-treatment changes in goals/tasks and self-efficacy interacted to predict changes in cardiorespiratory fitness, weight loss, and return to work such that patients high on both goals/tasks and self-efficacy showed the most gains. Conclusion: Sound therapeutic relationships between patients and staff may play an important role in facilitating the achievement of a wide-range of salutary outcomes during cardiac rehabilitation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Need for psycho-oncologic management in Germany--a comparison of present status and future needs

A comparison of acute care, inpatient rehabilitation and outpatient aftercare in Germany reveals significant differences in the quality and spreading of psychosocial services for cancer patients. Planning psychosocial care for cancer patients, we have to consider patients' need for psychosocial care as well as the health professionals' estimation of patients' needs and the demand for health care services. Analyses of patients' requirements have shown that the needs which patients defined themselves differ from the needs estimated by experts. Therefore, decisions made in health care must be based on systematic data acquired by various approaches. Within the frame of evaluation performed in the research program "Rehabilitation of Cancer Patients" funded by the German Ministry of Research (the former BMFT), data from two studies are presented investigating the need for psychosocial care in oncology using two different approaches. In one study we investigated the status quo of psychosocial care for cancer patients in acute hospitals (n = 585) and rehabilitation centers (n = 42). By use of the Delphi technique, the second study focuses on an analysis of patients' need estimated by health professionals (n = 34). Comparing both studies, deficits in psychosocial care for cancer patients were found especially in acute hospitals and outpatient aftercare services. Methodological problems of the two approaches are discussed and further research strategies are suggested.     

Rehabilitation by physical exercise in chronic heart failure

The aim of rehabilitation is to improve exercise capacity and, thereby, the autonomy of patients with cardiac failure. For many years, these patients were considered inapt to perform physical exercise and they are in the same situation at the dawn of the year 2000 as patients with myocardial infarction forty years ago. The symptoms of cardiac failure (dyspnoea of effort and muscular fatigue) are not only the consequence of pulmonary hypertension and decreased muscular perfusion. Prolonged interruption of exercise and long stays in bed or in a chair lead to anatomical and functional amyotrophy, which, in turns, incites to further inactivity. Deconditioned respiratory muscles cannot tolerate the increased load of hyperventilation. Neurohormonal changes cause vasoconstriction which reduces muscular perfusion. Physical training can significantly improve these abnormalities, though it does not seem to have a measurable effect on cardiac function; based on segmental work which enables performance of substantial efforts with a minimum of haemodynamic changes, it provides a 20 to 30% gain in capacity, mainly increasing the duration of submaximal exercise rather than maximum performance. Muscular fatigue is the symptom which is the most improved. Unfortunately the organisation, which is more difficult than in the post-infarction period, and the generalisation of the practice of long-term, well adapted physical training remains marginal although hundreds of thousands of patients could benefit; more than the inertia of the official instances concerning anything related to cardiac rehabilitation, it is the lack of interest shown by cardiologists and the absence of flexible structures within the health care organisation for elderly people which are responsible.     

Cognitive-behavioural interventions in cardiac rehabilitation

Evidence pertaining to the efficacy of cognitive-behavioural interventions, broadly defined, in cardiac rehabilitation is reviewed. Primary concerns lie with risk reduction and with the amelioration of psychological distress following myocardial infarction. The available data permit few definitive conclusions. The available data, on balance, suggest that programmes targeted at reducing Type A behaviours, smoking cessation, increasing exercise, or which teach stress management techniques, may be effective in reducing psychological distress and increasing effective coping, although frequently only in the short-term; it is more difficult to point to long-lasting advantage in this context. In addition, psychological interventions of this sort would seem to be associated with positive behavioural change. However, there is, as yet, little concerted evidence that such changes afford benefits in terms of coronary heart disease mortality or morbidity. Nevertheless, the pessimism of these conclusions may reflect shortcomings in study design and the failure to optimally match patients to programmes rather than an intrinsic lack of efficacy of the interventions.