Exercise Training

Other Possible Program Inclusions

There has been considerable interest over the past decade regarding the ways exercise training can be adapted to suit individuals’ needs and optimise benefits. Many options now exist with each having a different purpose and/or application including enhancement of the physiological stimulus on skeletal muscles, optimisation of engagement or cultural appropriateness, and the targeting of treatable traits via distinct adjunctive components (or ‘co-interventions’). The potential suitability of any adjunct modality for a patient undertaking PR should be made on the basis of several factors including the individual’s circumstances,  factors specific to your setting including staff expertise and familiarity with the technique/literature, patient abilities, safety, equipment etc.

Examples of some of these approaches are listed below as well as some potentially useful literature for further reading.

Broad reviews:

– Bisca, G. W., Camillo, C. A., Cavalheri, V., Pitta, F., & Osadnik, C. R. (2017). Peripheral muscle training in patients with chronic obstructive pulmonary disease: novel approaches and recent advances. Expert review of respiratory medicine, 11(5), 413-423.

– Gloeckl, R, Osadnik, C.R. (2021). Alternative training strategies for patients with chronic respiratory disease. ERS Monograph. 93 (chapter 5). pp. 67-82. DOI: 10.1183/2312508.X.10019720

Partitioning: Involves reducing the volume of muscle mass being used at one time to reduce associated metabolic demand. Examples include unilateral resistance training (strength or endurance) or single-leg cycling.

References:

– Nyberg A, Lindstrom B, Rickenlund A, et al. Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial. Clin Respir J. 2015;9(3):278–288.

– Evans RA, Dolmage TE, Mangovski-Alzamora S, et al. One-legged cycle training for chronic obstructive pulmonary disease. A prag- matic study of implementation to pulmonary rehabilitation. Ann Am Thorac Soc. 2015;12(10):1490–1497.

– Robles, P., Araujo, T., Brooks, D., Zabjek, K., Janaudis‐Ferreira, T., Marzolini, S., … & Mathur, S. (2017). Does limb partitioning and positioning affect acute cardiorespiratory responses during strength exercises in patients with COPD?. Respirology, 22(7), 1336-1342.

Eccentric training: Involves training with increased emphasis on eccentric rather than concentric muscle contractions due to energy/force efficiencies. Examples include eccentric resistance training, downhill treadmill walking, eccentric cycling.

References:

– Rooyackers JM, Berkeljon DA, Folgering HT. Eccentric exercise train- ing in patients with chronic obstructive pulmonary disease. Int J Rehabil Res. 2003;26:47–49.

– Camillo, C. A., Osadnik, C. R., Burtin, C., Everaerts, S., Hornikx, M., Demeyer, H., … & Troosters, T. (2020). Effects of downhill walking in pulmonary rehabilitation for patients with COPD: a randomised controlled trial. European Respiratory Journal, 56(3).

Adjunct/co-interventions: includes specific ‘add-on’ modalities targeting treatable traits. Common examples of adjunct co-interventions include inspiratory muscle training (IMT) for respiratory muscle weakness, airway clearance techniques (ACTs) for excessive sputum production, balance retraining for impaired balance and so on.

References:

– Camillo, C. A., Osadnik, C. R., van Remoortel, H., Burtin, C., Janssens, W., & Troosters, T. (2016). Effect of “add-on” interventions on exercise training in individuals with COPD: a systematic review. ERJ open research, 2(1), 00078-2015. https://doi.org/10.1183/23120541.00078-2015

– Charususin, N., Gosselink, R., Decramer, M., Demeyer, H., McConnell, A., Saey, D., … & Langer, D. (2018). Randomised controlled trial of adjunctive inspiratory muscle training for patients with COPD. Thorax, 73(10), 942-950.

– Tymkew, H., Burlis, T., Baidy, M., Bennett, D., Hooper, S., Leidner, M., … & Arroyo, C. (2019). Balance training in pulmonary rehabilitation to reduce fall risk. Cardiopulmonary Physical Therapy Journal, 30(4), 162-170.

Neuromuscular electrical stimulation (NMES): Involves the application of a portable electrical stimulator to muscle groups such as quadriceps to trigger motor contractions. May be used initially for people with severe disease who experience considerable difficulty engaging actively in physical exercise. This is not regularly used in Australia.

References:

– Jones S, Man WDC, Gao W, Higginson IJ, Wilcock A, Maddocks M. Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD009419. DOI: 10.1002/14651858.CD009419.pub3.

– Maddocks, M., Nolan, C. M., Man, W. D., Polkey, M. I., Hart, N., Gao, W., … & Higginson, I. J. (2016). Neuromuscular electrical stimulation to improve exercise capacity in patients with severe COPD: a randomised double-blind, placebo-controlled trial. The Lancet Respiratory Medicine, 4(1), 27-36.

Non-invasive ventilation: Involves exercising with concurrent use of bi-level positive airways pressure, often via mouthpiece or nasal interface. May be appropriate for people who experience significant ventilatory limitations to exercise.

References:

– Menadue C, Piper AJ, van ‘t Hul AJ, Wong KK. Non-invasive ventilation during exercise training for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014(5): CD007714.

– Gloeckl R, Andrianopoulos V, Stegemann A, Oversohl J, Schneeberger T, Schoenheit-Kenn U, Hitzl W, Dreher M, Koczulla AR, Kenn K. High-pressure non-invasive ventilation during exercise in COPD patients with chronic hypercapnic respiratory failure: A randomized, controlled, cross-over trial. Respirology 2019: 24(3): 254-261.

Whole-body vibration training (WBVT): Involves performing lower limb strength training while standing on a whole-body vibration platform to increase muscle stimulus (through additional involuntary contractions).

References:

– Zhou J, Pang L, Chen N, Wang Z, Wang C, Hai Y, Lyu M, Lai H, Lin F. Whole-body vibration training – better care for COPD patients: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2018: 13: 3243-3254.

– Gloeckl R, Jarosch I, Bengsch U, Claus M, Schneeberger T, Andrianopoulos V, Christle JW, Hitzl W, Kenn K. What’s the secret behind the benefits of whole-body vibration training in patients with COPD? A randomized, controlled trial. Respir Med 2017: 126: 17-24.

Other examples examined in studies involving people with chronic lung disease include the use of inhaled heliox gas mixtures, non-linear periodisation, exercising in water, tai chi, yoga and use of music during exercise.