Yet, limiting activity and avoiding exercise then causes people to be "out of shape," or deconditioned. Deconditioning places more demand on the lungs and heart, which in turn causes more shortness of breath during the activity, making it hard to be active.
In PR, educational classes will help you better understand and manage your breathing problem, and supervised exercise classes will gradually help you be more active and "get in shape" — so that you can complete your daily activities and exercise more easily with less shortness of breath. The educational classes are designed to help you understand your breathing and learn how to manage and live better with your condition. They also serve as a forum to ask questions and discuss topics that arise when dealing with a chronic condition.
These classes also allow you to speak with others with similar lung problems and get useful tips from them. PR has been shown to decrease these feelings as you become more physically fit, learn more about your condition, and speak with others. The exercise sessions are designed for your specific needs and abilities. Prior to starting the program, you will be evaluated to find out the best and safest exercises for you. Reports from PR programs worldwide have shown that PR is safe.
The sessions are supervised by trained health care professionals; they will monitor you as you exercise and ensure you are safe. PR is a complement, not an alternative to, existing medical therapy such as inhaled or pill forms of medicines. In the United States, individuals enrolled in a PR program typically meet at the program site times a week for weeks. Learning about your specific lung problem from a team of health care experts, will help empower you to be a better manager of your disease in collaboration with your own health care team.
It should also help you learn to communicate your health issues more effectively with your provider. Talking about your breathing problems with others who have similar problems may help you deal with the many emotions often experienced by those with a chronic health problem. If you feel in control of your lung problem, you may feel less stress and have a more positive outlook about your health and life. Individuals with breathing problems can have shortness of breath during exercise or even regular activity.
Unfortunately, people try to avoid this feeling by becoming less and less active. This plan may work at first, but in time leads to a vicious circle of avoiding activities which leads to getting out of shape or becoming deconditioned. This can result in even more shortness of breath with activities. PR exercise training interrupts this cycle and helps you get in shape and be more active with less shortness of breath.
Generally, PR programs accept insurance if you have been given a prescription to attend it, but insurance coverage varies between different programs and insurance policies. Therefore, the out of pocket cost to you, including any co-pays, can vary greatly.
Before you enroll in a PR program, ask the staff to help you determine what your out of pocket costs will be, including any extras, such as transportation or parking. You may also want to check with your insurance company about the co-pay costs.
Some programs offer help with quitting. Other PR programs require that you stop smoking before beginning the program.
PR, medications, and quitting smoking cannot reverse whatever permanent lung damage you may have from cigarettes, but it can prevent further damage. If you smoke, make a serious effort to quit. Get help if needed. Stopping smoking is an important part of getting stronger and healthier. PR is the beginning of a lifestyle change. All patients should receive disease education to improve their compliance with medication regimens, 10 oxygen therapy, smoking cessation, nutritional interventions, exercise, and health preservation, all of which contribute to the overall autonomy of the patient.
Patient education aims to equip the patient with the knowledge and skills they need to manage their disease and to change their lifestyle, which is the ultimate aim of PR. All the multidisciplinary team members participate in educational programs. Chest physiotherapy represents a nonessential component of PR but proves its usefulness in patients with a marked bronchial hypersecretion.
They also educate the oxygen-dependent patient. In COPD, nutritional depletion is common and has a negative impact on respiratory as well as on skeletal muscle functions, and contributes to the morbidity and mortality of COPD patients.
Underweight patients may require nutritional advice caloric supplements may be required prior to commencing a PR program to ensure that the extra physical activity does not lead to further weight loss. Overweight patients may also need nutritional advice regarding weight loss, but the challenge here, is to not lose fat-free mass. Anxiety and depression are important comorbidities of COPD, 3 , 12 , 13 , 75 and a significant proportion of COPD patients referred to PR centers suffer from these psychiatric disorders.
Psychological support helps in overcoming addictions, especially tobacco smoking and, along with medical treatment for smoking cessation, is an important intervention in PR programs. The benefits of a PR program tend to diminish over the months following its discontinuation.
PR programs are usually not associated with sustained benefits beyond 12 months. Many centers currently offer maintenance programs in the hope of consolidating and prolonging the benefits of a successful rehabilitation program. However, the optimal strategy to meet this aim has not yet been described.
Among the available options, we find telephone contacts and monthly supervised reinforcement sessions, 83 , 84 home exercise training with or without a weekly supervised outpatient session , 85 and recurrent PR programs.
A systematic review concluded that after 8 weeks of supervised physical exercise training, maintenance programs consisting of weekly telephone calls and monthly reinforcement sessions for 1 year were unsuccessful in altering behavior and maintaining the treatment effects.
The best and the most effective maintenance program currently remains to be found. Beyond post-PR exercise programs, the PR center staff, as well as family members and general practitioners, should encourage and motivate the patient to follow the maintenance program and continue with a more active lifestyle, in order to retain the gains.
This advice is supported by the month follow-up data taken from a cohort of COPD patients who had completed a week comprehensive PR program and who were invited to follow a structured home program at the end of the PR program. Patients with COPD are typically less active in daily life than are healthy older adults.
However, there is currently no strong evidence that patients translate the benefits obtained from PR into a more active lifestyle in real life. Cindy et al 92 recently published the first meta-analysis evaluating the effect of exercise training on measures of physical activity. This meta-analysis pointed out that supervised exercise training confers a significant but small effect on physical activity.
The principal limitation of the meta-analysis was that the majority of the included studies did not use the same method to measure physical activity; moreover, it is well known that questionnaires and pedometers are an insufficiently sensitive means of detecting changes in physical activity in this particular clinical slow-walking population. Two parameters appear to be crucial to enhancing physical activity in COPD patients after PR: the frequency of supervised exercise training and the duration of the program.
Indeed, in the meta-analysis by Cindy et al, 92 the studies that proposed an exercise training regimen of three times per week showed a significant increase in physical activity, in contrast with those that offered exercise only two times a week. Moreover, in a study measuring physical activity with an accelerometer, Pitta et al 93 showed that a 6-month, supervised exercise training program was required to obtain a significant effect on physical activity, while three months was shown to be insufficient.
This is consistent with the recent concept that 6 months are needed for most people to change behavior. Daily activity and the completion of domestic tasks are more important for the patient than an improvement in the 6-minute walk test, total CRQ score, or maximal load achieved during ergospirometry. Thus clinicians should take into account what people actually do eg, walking, climbing stairs, dressing, etc , rather than what they are capable of doing since it is the natural level of physical activity that seems to best determine the prognostic benefit.
Notes: A An accelerometer worn on the arm. As mentioned above, a study showed that a better outcome of PR can be obtained by its association with long-acting anticholinergic bronchodilators. Finally, new studies using accelerometers are needed to validate their use 98 and to go further in this crucial domain linking PR and physical activity, since we know that physical activity levels determine the survival in COPD patients.
PR has certainly been demonstrated to provide beneficial effects on dyspnea, improvement in muscle strength and endurance, improvement of psychological status, reduction of hospital admissions, and improvement of HRQoL in COPD patients, with a gradual increase in daily physical activity and autonomy.
Successful PR therefore requires behavioral changes. These changes rest on the following: exercise training; psychosocial support; nutritional intervention; self-management; and education, as well as pacing and energy conservation strategies, all of which are intended for motivated COPD patients. Therefore, PR embodies a very important and safe therapeutic option that aims to reverse the systemic manifestations of COPD and which, along with pharmacological therapy, can be used to obtain optimal patient management, leading to a favorable change in the daily life of our COPD patients.
Accordingly, with the increasing burden of COPD patients in the world, there is an urgent need for advocacy with the concerned authorities, for a more widespread reimbursement of PR programs worldwide. We would like to thank Mark Denham for his assistance in reviewing the English for this article.
National Center for Biotechnology Information , U. Published online Dec Author information Copyright and License information Disclaimer. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Keywords: chronic obstructive pulmonary disease, exercise training, physical activity, quality of life.
COPD: a systemic disease with effort limitation For a long time, COPD was considered to be a respiratory disease, mainly caused by tobacco smoking and leading to progressive dyspnea. Open in a separate window. Figure 1. Abbreviation: COPD, chronic obstructive pulmonary disease. What is pulmonary rehabilitation? Who should attend a pulmonary rehabilitation program?
Contraindications and barriers to pulmonary rehabilitation The main contraindications are lack of motivation and nonadherence, psychiatric illness or dementia, uncontrolled cardiovascular diseases, inability to do exercise for orthopedic or other reasons , and unstable diseases eg, hepatic, diabetes.
Components in pulmonary rehabilitation PR is a comprehensive, multidisciplinary Figure 2 , multicomponent, patient-centered intervention, consisting of a prerehabilitation assessment program, exercise and muscle training, self-management education, occupational therapy, psychosocial support, and nutritional intervention. Figure 2. Figure 3. Summary of the steps and benefits of pulmonary rehabilitation. Setting and length for pulmonary rehabilitation programs The structure and the setting of PR vary widely around the world.
Prerehabilitation assessment program Assessment of the patient, prior to initiation of PR but also, during and at the end of PR, is an essential element in the practice of PR. Exercise training Continuous and interval training as well as strength training may be regarded as the major exercise components of PR. Strength training Strength training resistance exercises would be particularly indicated for patients with significant muscle atrophy and marked dyspnea on minimal exertion. Upper limb training PR programs have traditionally focused on the lower extremities, but many patients report dyspnea during daily activities that involve use of their arms, such as dressing, washing, and carrying groceries.
Adjunct to the exercise training Neuromuscular electrical stimulation Neuromuscular electrical stimulation NMES may be an adjunctive therapy for patients with severe chronic respiratory diseases who are bedbound or suffering from extreme skeletal muscle weakness.
Respiratory muscle training Inspiratory muscle training IMT is not recommended as a routine component of a PR program 9 but should be considered in COPD patients with ventilatory muscle weakness. Alternative treatment Beyond the classical modes of training, such as walking, cycling, stepping, and arm training, there have been a few recently published papers on the effects of alternative exercise training modalities, in people with COPD.
Education Patient education, incorporating self-management training, remains an important component of any comprehensive PR program, despite the difficulties in measuring its direct contribution to overall outcome. Disease education All patients should receive disease education to improve their compliance with medication regimens, 10 oxygen therapy, smoking cessation, nutritional interventions, exercise, and health preservation, all of which contribute to the overall autonomy of the patient.
Physiotherapy skills Chest physiotherapy represents a nonessential component of PR but proves its usefulness in patients with a marked bronchial hypersecretion.
Nutritional intervention In COPD, nutritional depletion is common and has a negative impact on respiratory as well as on skeletal muscle functions, and contributes to the morbidity and mortality of COPD patients. Psychosocial support Anxiety and depression are important comorbidities of COPD, 3 , 12 , 13 , 75 and a significant proportion of COPD patients referred to PR centers suffer from these psychiatric disorders.
Maintenance program The benefits of a PR program tend to diminish over the months following its discontinuation. Pulmonary rehabilitation and effect on physical activity Patients with COPD are typically less active in daily life than are healthy older adults. Figure 4. Use of a multisensory accelerometer. Acknowledgments We would like to thank Mark Denham for his assistance in reviewing the English for this article. Footnotes Disclosure The authors report no conflicts of interest in this work.
References 1. Alternative projections of mortality and disability by cause — Global Burden of Disease Study. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Louis R, Corhay JL. Health status instrument vs prognostic instrument for assessing chronic obstructive pulmonary disease in clinical practice.
Int J Clin Pract. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Hill NS. Pulmonary rehabilitation. Proc Am Thorac Soc. Pulmonary rehabilitation for chronic obstructive pulmonary disease [review] Cochrane Database Syst Rev. Pulmonary rehabilitation in chronic obstructive pulmonary disease. American College of Physicians.
American College of Chest Physicians. American Thoracic Society. Ann Intern Med. Agusti A, Soriano JB. COPD as a systemic disease. Systemic manifestations and comorbidities of COPD.
After 90 days, 2 The readmission rate showed a nonsignificant decline in patients participating in rehabilitation. Conclusion: This case study showed that the referral rate of patients with COPD to early municipal rehabilitation is extremely low without a targeted effort and still insufficient in spite of a focused intervention. We showed that completion of a municipal rehabilitation program shortly after discharge is possible even for patients with severe COPD. The findings from our pilot study can guide further investigations into the effect of implementation strategies for handovers between health-care sectors to secure early-onset rehabilitation of patients with COPD.
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