Functional and muscular effects of neuromuscular electrical stimulation in patients with severe COPD: a randomized clinical trial. Physical exercise and resistive breathing training in severe chronic airways obstruction--are they effective? Home based neuromuscular electrical stimulation as a new rehabilitative strategy for severely disabled patients with chronic obstructive pulmonary disease (COPD). Deep diaphragmatic breathing: rehabilitation exercises for the asthmatic patient. Randomised controlled trial of rehabilitation in chronic respiratory disability. Pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Randomized controlled pilot study of neuromuscular electrical stimulation of the quadriceps in patients with non-small cell lung cancer. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. A randomised trial of high vs low intensity training in breathing techniques for breathless patients with malignant lung disease: a feasibility study. Effect of a walking aid on disability, oxygenation, and breathlessness in patients with chronic airflow limitation. Non-pharmacological intervention for breathlessness in lung cancer. Comparison of effects of an intrapulmonary percussive ventilator to standard aerosol and chest physiotherapy in treatment of cystic fibrosis. Exercise training improves recovery in patients with COPD after an acute exacerbation. Skeletal muscle effects of electrostimulation after COPD exacerbation: a pilot study. The effects of biofeedback assisted breathing retraining on lung functions in patients with cystic fibrosis. Resistive inspiratory muscle training and exercise performance in COPD patients. A comparative study with conventional breathing retraining. Physical rehabilitation for the chronic bronchitic: results of a controlled trial of exercises in the home. Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease. Non-invasive ventilation assists chest physiotherapy in adults with acute exacerbations of cystic fibrosis. Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomized controlled trial. Skeletal muscle structure and function in response to electrical stimulation in moderately impaired COPD patients. Effects of a walking aid in COPD patients receiving oxygen therapy. Physical training with and without oxygen in patients with chronic obstructive pulmonary disease and exercise-induced hypoxaemia. [Physiotherapy in chronic obstructive pulmonary disease: oscillatory breathing with flutter VRP1]. Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation. Theophylline and salbutamol improve pulmonary function in patients with irreversible chronic obstructive pulmonary disease. Short- and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Comparison of high-frequency chest wall oscillation and oscillating positive expiratory pressure in the home management of cystic fibrosis: a pilot study. Low intensity peripheral muscle conditioning improves exercise tolerance and breathlessness in COPD. The usefulness of theophylline in nonasthmatic airway obstruction. Effect of chest wall vibration on dyspnea during hypercapnia and exercise in chronic obstructive pulmonary disease. Rehabilitation of patients with chronic obstructive pulmonary disease. Exercise twice a week is not sufficient! Asthma self-management education program by home monitoring of peak expiratory flow. Training with supplemental oxygen in patients with COPD and hypoxaemia at peak exercise. Inspiratory muscle training improves lung function and exercise capacity in adults with cystic fibrosis. Short term improvement in exercise capacity and symptoms following exercise training in interstitial lung disease.
The mechanisms through which neuromuscular electrical stimulation (NMES) training may improve limb muscle function and exercise tolerance in COPD are poorly understood. We investigated the functional and muscular effects of NMES in advanced COPD.
                Twenty of 22 patients with COPD were randomly assigned to NMES (n = 12) or sham (n = 8) training in a double-blind controlled study. NMES was performed on quadriceps and calf muscles, at home, 5 days per week for 6 weeks. Quadriceps and calf muscle cross-sectional area (CSA), quadriceps force and endurance, and the shuttle-walking distance with cardiorespiratory measurements were assessed before and after training. Quadriceps biopsy specimens were obtained to explore the insulin-like growth factor-1/AKT signaling pathway (70-kDa ribosomal S6 kinase [p70S6K] , atrogin-1).
                NMES training improved muscle CSA (P < .05), force, and endurance (P < .03) when compared with sham training. Phosphorylated p70S6K levels (anabolism) were increased after NMES as compared with sham (P = .03), whereas atrogin-1 levels (catabolism) were reduced (P = .01). Changes in quadriceps strength and ventilation during walking contributed independently to variations in walking distance after training (r = 0.77, P < .001). Gains in walking distance were related to the ability to tolerate increasing current intensities during training (r = 0.95, P < .001).
                In patients with severe COPD, NMES improved muscle CSA. This was associated with a more favorable muscle anabolic to catabolic balance. Improvement in walking distance after NMES training was associated with gains in muscle strength, reduced ventilation during walking, and the ability to tolerate higher stimulation intensity. Trial registry: ClinicalTrials.gov; No.: NCT00874965; URL: www.clinicaltrials.gov. Twenty-one patients with severe chronic irreversible airflow obstruction (FEV1 consistently less than 1.2 l) were allocated randomly to one of two training programmes designed to reduce respiratory disability or a placebo training control group. Daily structured physical exercise, twice daily inspiratory muscle training by resistive breathing, or daily placebo training were undertaken for 10 weeks, and the effects on lung function, exercise capacity, respiratory symptoms and psychological state compared. Maximal work achieved on a progressive bicycle exercise test was significantly increased in all groups (36%, 23% and 34% respectively) and global improvement in mood also occurred. There was no significant change in respiratory symptom score, static lung function tests or 12 min walking distance. Neither form of active treatment showed superiority over placebo training. Passive training of specific locomotor muscle groups by means of neuromuscular electrical stimulation (NMES) might be better tolerated than whole body exercise in patients with severe chronic obstructive pulmonary disease (COPD). It was hypothesised that this novel strategy would be particularly effective in improving functional impairment and the consequent disability which characterises patients with end stage COPD.
                Fifteen patients with advanced COPD (nine men) were randomly assigned to either a home based 6 week quadriceps femoris NMES training programme (group 1, n=9, FEV(1)=38.0 (9.6)% of predicted) or a 6 week control period before receiving NMES (group 2, n=6, FEV(1)=39.5 (13.3)% of predicted). Knee extensor strength and endurance, whole body exercise capacity, and health related quality of life (Chronic Respiratory Disease Questionnaire, CRDQ) were assessed.
                All patients were able to complete the NMES training programme successfully, even in the presence of exacerbations (n=4). Training was associated with significant improvements in muscle function, maximal and endurance exercise tolerance, and the dyspnoea domain of the CRDQ (p<0.05). Improvements in muscle performance and exercise capacity after NMES correlated well with a reduction in perception of leg effort corrected for exercise intensity (p<0.01).
                For severely disabled COPD patients with incapacitating dyspnoea, short term electrical stimulation of selected lower limb muscles involved in ambulation can improve muscle strength and endurance, whole body exercise tolerance, and breathlessness during activities of daily living. A new diaphragmatic breathing technique practiced without the aid of a physical corset is outlined, and the findings from a study of its application in the respiratory rehabilitation of asthmatic patients are presented. Sixty-seven asthmatic adults randomly assigned to either deep diaphragmatic breathing training, physical exercise training, or a waiting list control group participated in a 16-week program. Deep diaphragmatic training resulted in significant reductions in medication use and in the intensity of asthmatic symptoms. Importantly, a nearly 300% increase in time spent in physical activities also resulted from deep diaphragmatic training. A follow-up at two months found many patients had returned to earlier medication levels and sedentary habits. A strengthened musculature can replace the need for a physical aid in this respiratory habilitation; adherence to its use may require individually-tailored encouragement. A randomised controlled study of the effects of exercise training in 39 patients with chronic respiratory disability was performed. Exercise training began with six weeks in a rehabilitation centre and was continued at home. The original control group attended the rehabilitation centre after the controlled part of the study. The treated group experienced subjective benefit from rehabilitation. The 12-minute walking distance increased on average from 523 m to 643 m in the treatment group and from 564 m to 607 m in the control group. The treatment effect of 77 m (SE 33 m) was significant at the 5% level. Treadmill exercise performance changed little and resting lung function was unaltered after rehabilitation. The treatment group maintained most of their improvement seven months later and the original control subjects improved after their rehabilitation. The study confirms the beneficial effects of exercise training in the chronically breathless and it suggests that the 12-minute walking distance is a useful index of changes in everyday exercise tolerance. Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in India. Drug treatment alone does not optimize therapy. Pulmonary rehabilitation has been found to improve the physical efficiency of COPD patients. Therefore, we evaluated the effect of domiciliary pulmonary rehabilitation programme in patients of COPD.
                Forty patients of stable COPD having severe airflow obstruction were included in the study. They were divided into control and experimental groups randomly. Rehabilitation included walking, breathing exercises, postural drainage, controlled coughing and changes in life style activities. Exercises of 30 minutes duration were performed at home twice daily for four weeks supervision. Six-minute walking distance, forced expiratory volume in one seocond (FEV1) and various indices of chronic respiratory disease questionnaire (CRDQ) were measured in both experimental and control groups before and after completion of the study.
                In the experimental group, after four weeks, the mean (+/- SD) difference in six-minute walking distance, dyspnoea, mastery, fatigue and emotion scores were 54.2 (26.7) meters, 0.96 (0.26), 0.89 (0.44), 0.90 (0.40) and 0.91 (0.32) respectively. Changes in all these parameters were statistically significant (p < 0.001) as compared to the control group. There was no significant change in FEV1.
                It was concluded that domiciliary pulmonary rehabilitation for four weeks results in significant improvement in the quality of life and exercise tolerance, even without improvement in FEV1. Patients with lung cancer experience muscle wasting and weakness. Therapeutic exercise may be beneficial but is not always practical. An alternative approach may be neuromuscular electrical stimulation (NMES) of the quadriceps muscles, but this has not been formally examined in patients with cancer. Thus, we have undertaken this pilot study to assess feasibility and inform the design of future studies. Sixteen patients were randomized to receive usual care (control group) or usual care plus NMES for four weeks. NMES consisted of daily stimulation to both thighs for up to 30minutes (frequency 50Hz, "on" cycle 11%-25%). Adherence was assessed by a self-report diary and a semistructured evaluation form. Quadriceps muscle strength, exercise endurance, and free-living physical activity were assessed using a Cybex NORM dynamometer, an endurance shuttle walk test, and an ActivPAL accelerometer (mean daily step count), respectively. Changes in outcome from baseline were compared between groups by mean differences and their 95% confidence intervals using independent t-test (P=0.05). Median (range) adherence to the program was 80% (69%-100%). All patients found the NMES device easy to use. Changes in outcome favored the NMES group, with mean differences of 9.4 Nm (21%) in quadriceps muscle strength, 768 steps (15%) in free-living activity, and 138 m (8%) in exercise endurance, but none of the differences were statistically significant. In conclusion, NMES warrants further study in patients with lung cancer. To evaluate the effectiveness of nursing intervention for breathlessness in patients with lung cancer.
                Patients diagnosed with lung cancer participated in a multicentre randomised controlled trial where they either attended a nursing clinic offering intervention for their breathlessness or received best supportive care. The intervention consisted of a range of strategies combining breathing control, activity pacing, relaxation techniques, and psychosocial support. Best supportive care involved receiving standard management and treatment available for breathlessness, and breathing assessments. Participants completed a range of self assessment questionnaires at baseline, 4 weeks, and 8 weeks.
                Nursing clinics within 6 hospital settings in the United Kingdom.
                119 patients diagnosed with small cell or non-small cell lung cancer or with mesothelioma who had completed first line treatment for their disease and reported breathlessness.
                Visual analogue scales measuring distress due to breathlessness, breathlessness at best and worst, WHO performance status scale, hospital anxiety and depression scale, and Rotterdam symptom checklist.
                The intervention group improved significantly at 8 weeks in 5 of the 11 items assessed: breathlessness at best, WHO performance status, levels of depression, and two Rotterdam symptom checklist measures (physical symptom distress and breathlessness) and showed slight improvement in 3 of the remaining 6 items.
                Most patients who completed the study had a poor prognosis, and breathlessness was typically a symptom of their deteriorating condition. Patients who attended nursing clinics and received the breathlessness intervention experienced improvements in breathlessness, performance status, and physical and emotional states relative to control patients. The present multicentre study evaluates the differences in efficacy between a 3 month rehabilitation programme including drug treatment, and a 3 month control period of drug treatment only, for asthmatic patients and patients with chronic obstructive pulmonary disease (COPD). The programme was run by physiotherapists in eight local practices, and included exercise training, patient education, breathing retraining, evacuation of mucus, relaxation techniques, and recreational activities. In a randomized controlled trial with a cross-over design, the effects of rehabilitation were evaluated 3 and 6 months after baseline measurements in terms of exercise tolerance and quality of life (QOL). Exercise tolerance was assessed using submaximal cycle ergometer tests and 6 min walking tests. QOL was evaluated by means of the Chronic Respiratory Disease Questionnaire (CRDQ). After 3 months, the patients who started with rehabilitation showed significant improvements in endurance time (421 s) and cardiac frequency (6 beats.min-1) during cycling, walking distance (39 m), and total CRDQ score (17 points) compared to the control group. These improvements were still significant after 6 months. Additional analysis indicated that the asthmatic patients and the patients with COPD responded to rehabilitation in a similar way, with the exception that there was a greater improvement in walking distance for asthmatics. Improvements in exercise tolerance were not significantly correlated with improvements in QOL. Rehabilitation of patients with asthma or chronic obstructive pulmonary disease in local physiotherapy practices improves exercise tolerance and quality of life. Breathlessness remains a refractory symptom in malignant lung disease. Breathing training is an effective, non-pharmacological intervention but it is unclear how this should be delivered. This feasibility study aimed to assess recruitment and retention, best end point and variability of breathlessness scores in order to calculate sample size for a future study.
                This was a single centre, randomised controlled non-blinded parallel group feasibility study. Eligible participants (breathless patients with intrathoracic malignancy) received three breathlessness management training sessions or a single session only. Follow-up was for eight weeks and endpoints were: numerical rating scales (NRS) of breathlessness severity; breathlessness distress; HADS questionnaire; coping (BriefCOPE and our NRS coping question); EQ-5D and EQ-VAS.
                22 patients were randomised over 12 months; 55% of expected recruitment from pilot data. Screening logs indicated this resulted, in part, from excluding patients who were receiving or who had recently received chemotherapy or radiotherapy. There was 40% drop-out by week four. The most useful NRS scores for breathlessness severity were for "worst" and "average" over past 24h. From the variability data for "worst breathlessness", a sample size of 270 should allow detection of a 30% improvement in area under the curve in the three-session group compared with single-session, (90% power; p=0.05, two-tailed; 2:1 randomisation single:three sessions) allowing 50% drop out at four weeks.
                The follow-on study will test the hypothesis that three sessions of training improve breathlessness better than a single session. It will include patients undergoing palliative anti-cancer therapy. Stratification by centre will allow for differences in rates of chemotherapy or radiotherapy and variations in breathlessness service configuration.
                Copyright © 2010 Elsevier Ireland Ltd. All rights reserved. This study assessed the effect of a wheeled walking aid on disability, oxygenation, and breathlessness in patients with severe disability secondary to chronic irreversible airflow limitation.
                Eleven subjects with chronic irreversible airflow limitation, mean forced expired volume in 1 second (FEV1) 0.71 L +/- .33 L, were studied. Subjects performed four 6-minute walk tests, two on each of two study days, twice unaided and twice with the assistance of a wheeled walking aid. A randomized cross-over design was used. All subjects were oriented to 6-minute walk tests, use of bronchodilators was controlled, and standard encouragement was given during each walk test. Outcome measures were the distance walked in 6 minutes, change in oxyhemoglobin saturation during the walk, and breathlessness using a modified Borg Scale.
                The use of a wheeled walker resulted in a significant increase in 6-minute walking distance, a significant reduction in hypoxemia with walking and a significant reduction in breathlessness during the walk test.
                The use of a wheeled walker resulted in significant decreases in disability, hypoxemia, and breathlessness during a 6-minute walk test. By reducing disability and breathlessness, a wheeled walker may improve quality of life in individuals with severe impairment in lung function. To evaluate the effect of non-pharmacological intervention for breathlessness in lung cancer on breathlessness ratings and patient functioning.
                Randomised controlled pilot study.
                A nurse led clinic in a specialist cancer centre.
                20 patients with advanced small cell and non-small cell lung cancer.
                Weekly sessions with a nurse research practitioner over 3-6 weeks using counselling, breathing re-training, relaxation and teaching coping and adaptation strategies.
                Visual analogue scale ratings of breathlessness, distress caused by breathlessness, functional capacity, ability to perform activities of daily living and the Hospital Anxiety and Depression Scale.
                Improvements in median scores on all measures were observed in the intervention group with the exception of depression, compared with the control group where median scores were static or worsened. Distress from breathlessness was improved by a median of 53%, breathlessness at worst by 35% and functional capacity by 21%. In contrast, distress in the control group worsened by a median of 10%. Significant improvements compared with the control group were observed in breathlessness at best (p < 0.02), breathlessness at worst (p < 0.05), distress caused by breathlessness (p < 0.01), functional capacity (p < 0.02) and ability to perform activities of daily living (p < 0.03) but were not observed for anxiety or depression.
                Lung cancer patients suffering from breathlessness benefited from this rehabilitative approach to breathlessness management and strategies employed in this pilot study warrant further multicentre research. Macmillan nurses and palliative care teams are recommended to explore the potential of adopting similar approaches. Impaired mucociliary clearance due to defective ion and water transport and the effects of chronic airway infections lead to stasis of secretions and progressive pulmonary damage in patients with cystic fibrosis (CF). Methods to improve removal of tenacious lung secretions in CF patients contribute to slowing the decline in respiratory function. We have evaluated an intrapulmonary percussive ventilator (IPV), which is a device designed to enhance airway clearance and preserve lung function. A previous pilot study by us had determined that the device was acceptable to patients and is safe. We undertook a 6 month parallel comparative trial of the IPV versus standard, manual chest physiotherapy in 16 CF children and adults. No significant differences in spirometric measures, numbers of hospitalizations, use of oral or IV antibiotics, or anthropometric measurements were detected between the standard aerosol/chest physiotherapy group and the IPV group over the duration of the trial. Patient acceptance, as determined by participant survey, was good. The device appeared to be safe and durable. It was concluded that the IPV is as effective as standard aerosol and chest physiotherapy in preserving lung function and anthropometric measures, and there was no difference in the use of antibiotics and hospitalizations. Clinical experience suggests that exercise is beneficial for recovery after an acute exacerbation in patients with severe chronic obstructive pulmonary disease (COPD). The aim of this study was to quantify the clinical benefit of exercise in these patients. Twenty-nine inpatients were randomly assigned to a training group (n = 15, FEV1 34% pred) or a control group (n = 14, FEV1 38% pred). On ten consecutive days, patients in the training group performed a 6-min treadmill walking test and, in addition, five walking sessions per day at > or = 75% of the respective treadmill walking distance. Patients in the control group performed only treadmill walking tests on days 1, 5, and 10. To directly compare the possible benefit of exercise training all patients had an exercise test on day 11 at the same work load as on day 1. In the training group, 6-min walking distance increased from 237 to 420 m, in the control group from 230 to 255 m over the 10 day period which was significantly different (P < 0.0001). Minute ventilation and oxygen uptake increased significantly (P < 0.05) in the training but not in the control group. When comparing exercise tests on days 1 and 11, minute ventilation, oxygen uptake, PaCO2, lactic acid concentration, and Borg scale were significantly reduced to achieve the same work load (P < 0.01) only in the training group. Intrathoracic gas volume and residual volume decreased, and FEV1 and vital capacity increased in the training (P < 0.05) but not in the control group. Our data demonstrate that exercise training significantly improves the exercise capacity in patients with severe COPD after an acute exacerbation of their disease. Muscle dysfunction is a major problem in chronic obstructive pulmonary disease (COPD), particularly after exacerbations. We thus asked whether neuromuscular electrostimulation (NMES) might be directly useful following an acute exacerbation and if such a therapy decreases muscular oxidative stress and/or alters muscle fibre distribution. A pilot randomised controlled study of NMES lasting 6 weeks was carried out in 15 in-patients (n=9 NMES; n=6 sham) following a COPD exacerbation. Stimulation was delivered to the quadriceps and hamstring muscles (35 Hz). Primary outcomes were quadriceps force and muscle oxidative stress. At the end of the study, quadriceps force improvement was statistically different between groups (p=0.02), with a significant increase only in the NMES group (median (interquartile range) 10 (4.7-11.5) kg; p=0.01). Changes in the 6-min walking distance were statistically different between groups (p=0.008), with a significant increase in the NMES group (165 (125-203) m; p=0.003). NMES did not lead to higher muscle oxidative stress, as indicated by the decrease in total protein carbonylation (p=0.02) and myosin heavy chain carbonylation (p=0.01) levels. Finally, we observed a significant increase in type I fibre proportion in the NMES group. Our study shows that following COPD exacerbation, NMES is effective in counteracting muscle dysfunction and decreases muscle oxidative stress. This study examines the effects of respiratory muscle feedback and breathing retraining (BRT) on lung function in patients with cystic fibrosis (CF). Twenty-six patients with CF were matched for age and severity of disease. Standard respiratory spirometry was performed on all subjects before and after biofeedback training. Thirteen experimental subjects underwent eight sessions of pneumographic or strain-gauge feedback from the abdominal muscles and electromyogram feedback from accessory respiratory muscles to assist in learning diaphragmatic and pursed-lips breathing maneuvers. Control subjects received biofeedback-assisted (hand warming) relaxation training. Results revealed a significant improvement in FEV1 and mean forced expiratory flow during the middle half of forced vital capacity (FVC) for the biofeedback group, while the control group showed no change. A similar trend was noted for FVC. These data suggest that respiratory muscle feedback and BRT may improve lung function in patients with CF. Twenty patients with stable COPD (mean age 67.8 yr; mean FEV1 1.08 1), all limited by ventilation at maximum exercise, were randomly allocated after a four week control period, to an eight week programme of either inspiratory resistive training (IRT), with a P Flex device, or conventional breathing retraining (BR). Exercise performance was evaluated every four weeks, using a 12-min walking test, an incremental progressive exercise on a cycle ergometer and a cycle endurance test. Inspiratory muscle endurance was measured as the highest tolerated resistance for 10 min on a P Flex device. IRT produced a significant (p less than 0.05) increase in the highest tolerated resistance, but IRT and BR failed to improve lung function or exercise performance. The present study shows that in COPD patients with ventilatory limitation on exercise an IRT programme may fail to improve exercise performance, in spite of an efficient training effect on the endurance of the inspiratory muscles. Twenty-four men with chronic bronchitis participated in a controlled trial of a physical training scheme. The training involved progressive stair-climbing exercises carried out over a three-month period unsupervised at home. The twelve men in the exercise group benefited significantly in terms of general well-being and reduced breathlessness. Their exercise tolerance increased significantly as judged by increased walking speed in a simple 12-minute walking test and by a greater work load tolerated in a progressive work load test on a bicycle ergometer. The mean stride length during the walking test increased significantly with training. No significant changes occurred in body weight, ventilatory function tests or heart rate on exercise. There were no important changes in the control group. It is not clear whether the improvements noted were due to physiological changes such as improved neuromuscular coordination producing a more efficient walking pattern or to predominantly psychological factors such as increased tolerance of dyspnoea. The study demonstrates that a simple training scheme which can be administered from a hospital clinic or family doctor's surgery is safe, feasible, and of benefit to the chronic bronchitic. We examined the feasibility of home-based walking training to maintain the benefits of a short-term exercise training in patients with severe chronic obstructive pulmonary disease (COPD). After initial recovery from an exacerbation, 46 patients were randomized into a training and a control group, and 30 patients completed the programme (mean +/- SD FEV1, 36 +/- 7% predicted). The training group performed a 10-day walking training programme in the hospital, followed by a 6-month programme of supervised walking training at home, integrated into daily activities. The control group did not have exercise training in the hospital or at home. Until 6 months after discharge, lung function, exercise performance and symptom scores were assessed. Six-minute walking distance in the training group improved from day 1 to day 10 (P<0.001) and this effect was maintained over 6 months (P<0.001). On average, daily walking distance at home was 2308 m and walking was reported on 157 days. Quality of life (QoL) scores changed significantly over 6 months (P<0.001). The control group showed no significant changes in exercise performance or QoL scores throughout the whole study period. Therefore, (i) significant improvements in exercise performance and Chronic Respiratory Disease Questionnaire (CRQ) scores could be achieved after recovery from an exacerbation and (ii) these improvements were maintained after discharge, when supported by a home-based walking training. Chest physiotherapy is essential to the management of cystic fibrosis (CF). However, respiratory muscle fatigue and oxygen desaturation during treatment have been reported. The aim of this study was to determine whether non-invasive ventilation (NIV) during chest physiotherapy could prevent these adverse effects in adults with exacerbations of CF.
                Twenty six patients of mean (SD) age 27 (6) years and forced expiratory volume in 1 second (FEV1) 34 (12)% predicted completed a randomised crossover trial comparing standard treatment (active cycle of breathing technique, ACBT) with ACBT + NIV. Respiratory muscle strength (PImax, PEmax), spirometric parameters, and dyspnoea were measured before and after treatment. Pulse oximetry (SpO2) was recorded during treatment. Sputum production during treatment and 4 and 24 hours after treatment was evaluated.
                There was a significant reduction in PImax following standard treatment that was correlated with baseline PImax (r=0.73, p<0.001). PImax was maintained following NIV (mean difference from standard treatment 9.04 cm H2O, 95% confidence interval (CI) 4.25 to 13.83 cm H2O, p=0.006). A significant increase in PEmax was observed following the NIV session (8.04 cm H2O, 95% CI 0.61 to 15.46 cm H2O, p=0.02). The proportion of treatment time with SpO2 < or =90% was correlated with FEV1 (r=-0.65, p<0.001). NIV improved mean SpO2 (p<0.001) and reduced dyspnoea (p=0.02). There were no differences in FEV1, forced vital capacity (FVC) or sputum weight, but FEF(25-75) increased following NIV (p=0.006).
                Reduced inspiratory muscle strength and oxygen desaturation during chest physiotherapy are associated with inspiratory muscle weakness and severity of lung disease in adults with exacerbations of CF. Addition of NIV improves inspiratory muscle function, oxygen saturation and small airway function and reduces dyspnoea. To determine whether two types of exercise--breathing retraining (BRT) and inspiratory muscle training (IMT)--improve on cardiopulmonary functions and exercise tolerance in patients with stroke.
                A randomized controlled trial.
                Education and research hospital.
                Forty-five inpatients with stroke (24 men, 21 women) were recruited for the study. The subjects were randomized into three groups: 15 assigned to receive inspiratory muscle training (IMT); 15 assigned to received breathing retraining, diaphragmatic breathing and pursed-lips breathing (BRT); 15 assigned to a control group.
                All study groups participated in a conventional stroke rehabilitation programme. For the same period, the IMT and BRT groups trained daily, six times a week, with each session consisting of one half-hour of training for six weeks.
                Each subject underwent pulmonary function and cardiopulmonary exercise tests. Subjects were also assessed for exertional dyspnoea, stages of motor recovery, ambulation status, activity of daily living and quality of life.
                After the training programme, the IMT group had significantly improved forced expiratory volume at 1 second (FEV(1)), forced vital capacity (FVC), vital capacity (VC), forced expiratory flow rate 25-75% (FEF 25-75%) and maximum voluntary ventilation (MVV) values compared with the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.01). Peak expiratory flow rate (PEF) value was increased significantly in the BTR group compared with the IMT and control groups. The IMT group also had significantly higher peak oxygen consumption (Vo(2peak)) than the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.001). There was a statistically significant increase in maximum inspiratory pressure (PI(max)) and maximum inspiratory and expiratory pressure (PE(max)) in the BRT group and, PI(max) in the IMT group compared with baseline and the control group. In the IMT group, this was associated with improvements in exercise capacity, sensation of dyspnoea and quality of life.
                Significant short-term effects of the respiratory muscle training programme on respiratory muscle function, exercise capacity and quality of life were recorded in this study. To determine the structural and functional consequences of high-frequency neuromuscular electrical stimulation (hf-NMES) in a group of moderately impaired outpatients with chronic obstructive pulmonary disease (COPD).
                A prospective, cross-over randomized trial.
                An university-based, tertiary center.
                Seventeen patients (FEV(1)=49.6+/-13.4% predicted, Medical Research Council dyspnoea grades II-III) underwent 6-weeks hf-NMES (50Hz) and sham stimulation of the quadriceps femoris in a randomized, cross-over design. Knee strength was measured by isokinetic dynamometry (peak torque) and leg muscle mass (LMM) by DEXA; in addition, median cross-sectional area (CSA) of type I and II fibres and capillary-fibre ratio were evaluated in the vastus lateralis. The 6-min walking distance (6MWD) was also determined.
                At baseline, patients presented with well-preserved functional capacity, muscle strength and mass: there was a significant relationship between strength and type II CSA (P<0.05). NMES was not associated with significant changes in peak torque, LMM or 6MWD as compared to sham (P>0.05). At micro-structural level, however, electrical stimulation increased type II, but decreased type I, CSA; no change, however, was found in the relative fibre distribution or capillary:fibre ratio (P<0.05). There was no significant association between individual changes in structure and function with training (P>0.05). Post-NMES increase in type II CSA was inversely related to baseline mass and strength (P<0.05).
                NMES may promote a modest degree of type II muscle fibre hypertrophy in COPD patients with well-preserved functional status. These micro-structural changes, however, were not translated into increased volitional strength in this sub-population. To elucidate whether a simple walking aid may improve physical performance in COPD patients with chronic respiratory insufficiency who usually carry their own heavy oxygen canister.
                Randomized crossover trial.
                Physiopathology laboratory of three rehabilitation centers.
                We studied 60 stable COPD patients (mean age, 70.6 +/- 7.9 years; FEV(1), 44.8 +/- 14.3% of predicted [+/- SD]) with chronic respiratory insufficiency who randomly performed, on 2 consecutive days, a standardized 6-min walking test using two different modalities: a full-weight oxygen canister transported using a small wheeled cart and pulled by the patient (Aid modality) or full-weight oxygen canister carried on the patient's shoulder (No-Aid modality).
                The distance walked, peak effort dyspnea, and leg fatigue scores as primary outcomes, and other cardiorespiratory parameters as secondary outcomes were recorded during both tests. A significant difference (p < 0.05) between the two tests occurred for all the measured outcomes in favor of the Aid modality. Most importantly, significant changes for distance (+ 43 m, p < 0.001), peak effort dyspnea (- 2.0 points, p < 0.001), leg fatigue (- 1.4 points, p < 0.001), as well as for mean and nadir oxygen saturation and heart rate with the Aid modality (but not with the No-Aid modality) were recorded in the subgroup of patients walking < 300 m at baseline.
                This study suggests that a simple walking aid may be helpful in COPD patients receiving long-term oxygen therapy, particularly in those with lower residual exercise capacity. A randomized, controlled, single-blind study was performed on 20 patients with chronic obstructive pulmonary disease and exercise-induced hypoxaemia. Ten patients each were randomly assigned to one of two groups, one training with air and the other training with oxygen. There were no significant differences between the groups regarding values measured prior to the study. The patients trained 3 times per week for 30 minutes each time for a duration of 8 weeks. The training consisted of interval walking on a treadmill (intensity set according to Borg ratings) with either air or oxygen administered through a nasal cannula at a rate of 5 l/min. Training significantly improved the 6-minute walking distance by 20% and 14% in the air and oxygen group, respectively, when the patients were tested on air. In the same test the air group significantly decreased Borg ratings for perceived exertion. Borg ratings for dyspnoea and perceived exertion significantly decreased in the oxygen group when they were tested on oxygen. It was concluded that oxygen supplementation did not further improve the training effect, compared with training with air, in patients with chronic obstructive pulmonary disease and exercise-induced hypoxaemia. Chronic obstructive pulmonary disease (COPD) is characterized by sputum production and cough. It has been shown that mucus hypersecretion predisposes to recurrent bronchial infection and that reduction in airway secretions is associated with clinical improvement. Recently a new pipe-shaped device for chest physiotherapy, the flutter VRP1 ("VarioRaw:" Aubonne, Switzerland), was introduced in order to help clear bronchial hypersecretion. We determined the long-term efficacy of daily chest physiotherapy with the VRP1 in COPD and bronchial hypersecretion. 13 men and 7 women with COPD and sputum hypersecretion were studied; 10 were assigned to the physiotherapy group, and 10 to the control group getting sham therapy. After 3 months of physiotherapy, FVC, FEV1 and distance walked in 12 minutes increased in the treated group, but were almost unchanged in the sham-treated group. Arterial blood gases, the maximum voluntary ventilation, and respiratory rate at rest were unchanged in both groups. There was also an overall significant improvement in COPD symptoms in the physiotherapy group compared to baseline (p < 0.05). We conclude that long-term home physiotherapy with the flutter VRP1 is effective in COPD in improving airflow, functional ability and symptoms. A randomised controlled trial was undertaken to determine whether a respiratory health worker was effective in reducing the respiratory impairment, disability, and handicap experienced by patients with chronic airflow limitation attending a respiratory outpatient department. The 152 adults (aged 30-75 years) who participated had a prebronchodilator forced expiratory volume in one second (FEV1) below 60% predicted and no other disease. They were randomised to receive the care of a respiratory health worker or the normal services provided by the outpatient department. The respiratory health worker provided health education and symptom and treatment monitoring in liaison with primary care services. After one year there was little difference between the two groups in spirometric values (FEV1 and forced vital capacity before and after salbutamol 200 micrograms), disability (six minute walking distance and paced step test), and handicap (sickness impact profile, hospital anxiety and depression scale). Patients not looked after by the respiratory health worker were more likely to die (relative risk 2.9 (95% confidence limits 0.8, 10.2); when age and FEV1 were controlled for this risk increased to 5.5 (95% confidence limits 1.2, 24.5). Patients looked after by the respiratory health worker attended their general practitioner more frequently and were prescribed a greater range of drugs. This is the third study to have found limited measurable benefit in terms of morbidity from the intervention of a respiratory health worker. This may be due to the ability of such workers to keep frail patients alive. To investigate the efficacy of bronchodilators in patients with irreversible chronic obstructive pulmonary disease (COPD), we conducted a double-blind, randomized, four-phase, crossover comparison between placebo, oral theophylline, inhaled salbutamol, and a combination of both drugs in 12 patients with stable COPD (mean age, 63 years) whose increase in forced expiratory volume in 1 s (FEV1) was less than or equal to 15 percent following 200 micrograms of inhaled salbutamol. Patients received two weeks of therapy with each of the test regimens. Both theophylline and salbutamol resulted in statistically significant improvement in FEV1, forced vital capacity (FVC), slow vital capacity (SVC), residual volume (RV), airway resistance (Raw), and maximum expiratory flow rate at 50 percent of vital capacity (V50). In most instances, there were no significant differences between theophylline and salbutamol. Combination therapy produced significantly greater improvement in FEV1, FVC, V50, Raw, and RV than either agent alone. The two drugs interacted in an additive fashion. Neither of the drugs, used singly, significantly reduced the severity or incidence of symptoms. The reduction in dyspnea and wheeze during combination therapy approached statistical significance (p = 0.06) and patient preference was significantly in favor of the combination regimen. None of the active treatments produced significantly more side effects than placebo. We conclude that theophylline and inhaled salbutamol produce significant, and approximately equal, improvement in pulmonary function in patients traditionally classified as suffering from "irreversible" COPD. The combination of theophylline and inhaled salbutamol generally results in additional improvement over that obtained with either drug used alone and this improvement is reflected by reduced symptomatology and treatment preference. Pulmonary rehabilitation programs are effective in patients with severe chronic obstructive pulmonary disease (COPD) in the short term, but their long-term effects are not known. We investigated the short- and long-term effects of a 6-month outpatient rehabilitation program in patients with severe COPD.
                One hundred patients were randomly assigned to receive either an exercise training program that included cycling, walking, and strength training (n = 50) or usual medical care (n = 50). Thirty-four patients in the training group were evaluated after 6 months (end of training), and 26 were evaluated after 18 months of follow-up. In the control group, 28 patients were evaluated at 6 months and 23 after 18 months. We measured pulmonary function, 6-minute walking distance, maximal exercise capacity, peripheral and respiratory muscle strength, and quality of life (on a 20 to 140-point scale), and estimated the cost-effectiveness of the program.
                At 6 months, the training group showed improvement in 6-minute walking distance [mean difference (training - control) of 52 m; 95% confidence interval (CI), 15 to 89 m], maximal work load (12 W; 95% CI, 6 to 19 W), maximal oxygen uptake (0.26 liters/min; 95% CI, 0.07 to 0.45 liters/min), quadriceps force (18 Nm; 95% CI, 7 to 29 Nm), inspiratory muscle force (11 cm H(2)O; 95% CI, 3 to 20 cm H(2)O), and quality of life (14 points; 95% CI, 6 to 21 points; all P <0.05). At 18 months all these differences persisted (P <0.05), except for inspiratory muscle strength. For 6-minute walking distance and quality of life, the differences between the training group and controls at 18 months exceeded the minimal clinically-important difference.
                Among patients who completed the 6-month program, outpatient training resulted in significant and clinically relevant changes in 6-minute walking distance, maximal exercise performance, peripheral and respiratory muscle strength, and quality of life. Most of these effects persisted 18 months after starting the program. Enhanced airway clearance is thought to result in better-maintained pulmonary function in cystic fibrosis (CF). Postural drainage, percussion, and vibration (PDPV) have been the primary airway clearance technique (ACT) employed in CF for over 40 years. Two new airway clearance modalities are high-frequency chest wall oscillation (HFCWO) and oscillating positive expiratory pressure (OPEP). This pilot study was undertaken to evaluate the efficacy of these techniques during home use, assess patient satisfaction with them as compared to PDPV, and assess the feasibility of performing a definitive comparative trial. The prospective, randomized, multicenter crossover trial was conducted at three urban academic CF Care Centers. Twenty-nine CF patients, 9-39 years of age, participated. Subjects performed 4 weeks each of HFCWO and OPEP following 2-week lead-in/washout periods. Spirometry, lung volumes, National Institutes of Health and Petty Scores, and a satisfaction survey were performed at baseline and after each treatment period. An ACT preference survey was completed at the conclusion of the study. Twenty-four subjects completed both therapies. There were no statistically significant differences between therapies for spirometry, lung volumes, or clinical scores. No significant safety issues arose during the study period. Compliance between therapies was similar. Significant differences among therapies existed in patient satisfaction. Given a choice of therapy, 50% of subjects chose HFCWO, 37% OPEP, and 13% PDPV. This study suggests that HFCWO and OPEP are safe and as effective as patients' routine therapies when used for airway clearance in a home setting. Patient satisfaction and preference differ among ACTs and should be considered when prescribing home therapy. A definitive, multi-center, comparative study evaluating long-term efficacy of these techniques is feasible.
                Copyright 2001 Wiley-Liss, Inc. This randomized, controlled study investigated the physiological effects of a specially designed 12 week programme of isolated conditioning of peripheral skeletal muscle groups. The programme required minimal infrastructure in order to allow continued rehabilitation at home after familiarization within hospital. Forty eight patients, aged 40-72 yrs with chronic obstructive pulmonary disease (COPD) (mean (SD) forced expiratory volume in one second (FEV1) 61 (27)% of predicted normal) were randomly allocated into training (n = 32) and control (n = 16) groups. Physiological assessments were performed before and after the 12 week study period, and included peripheral muscle endurance and strength, whole body endurance, maximal exercise capacity (maximum oxygen consumption (V'O2,max)) and lung function. The training group showed significant improvement in a variety of measures of upper and lower peripheral muscle performance, with no additional breathlessness. Whole body endurance measured by free arm treadmill walking increased by 6,372 (3,932-8,812) 3 (p < 0.001). Symptom-limited maximal V'O2 was unchanged. However, the training group showed a reduction in ventilatory equivalents for oxygen and carbon dioxide, both at peak exercise and at equivalent work rate (Wmax). In summary, low intensity isolated peripheral muscle conditioning is well-tolerated, simple and easy to perform at home. The various physiological benefits should enable patients across the range of severity of chronic obstructive pulmonary disease to improve daily functioning. This study evaluated the effectivness of oral bronchodilator therapy using theophylline in patients with nonreversible chronic obstructive pulmonary disease. Twelve chronic obstructive pulmonary disease patients were entered into a doubleblind crossover study using either active drug theophylline in 200 mg capsules (Elixophyllin) or placebo for 3 months, followed by 3 months of the alternate capsule. At baseline and monthly visits, data were recorded, including history, physical examination, and pulmonary function testing. Clinically, 7 of 11 patients responded favorably to theophylline, 3 were unchanged, and 1 improved on placebo. Comparison of each sign and symptom individually revealed no statistically significant differences. Pulmonary function (FEV1 and FVC) showed slight deterioration with placebo, but not with active drug therapy. These findings suggest that nonasthmatic patients may improve clinically during theophylline therapy whereas their pulmonary function may deteriorate during placebo therapy. Vibration of chest wall inspiratory muscles during inspiration (in-phase) reduces breathlessness associated with hypercapnia and resistive loading in normal subjects and in patients with chronic obstructive pulmonary disease (COPD) at rest. To evaluate further the effect of chest wall vibration on breathlessness ("breathing discomfort") in patients, we studied 10 subjects 52 to 79 yr of age with severe dyspnea (mean FEV1, 0.75 L, 27% predicted). On a single day, we used two separate stimuli to produce mild to moderate breathlessness (BR): Protocol 1, steady-state hypercapnia; Protocol 2, exercise with a lower extremity ergometer. During each protocol, we applied in-phase chest wall vibration (CW) randomly alternating with one of two controls: deltoid vibration (DV) or no vibration (NV). During hypercapnia, CW significantly reduced BR (DV, 2.9 +/- 2.1; CW, 2.3 +/- 1.4; p < 0.05; NV, 3.3 +/- 2.1; CW, 2.6 +/- 2.0; p < 0.01) without significant changes in ventilation. During exercise, CW did not significantly alter BR relative to controls. These findings may be explained by the effect of vibration on the sense of respiratory effort and/or by improvement of the match between efferent motor commands and afferent information from the respiratory system. The lack of effect during exercise on BR suggests there may be a "therapeutic window" or range of conditions within which CW is effective in reducing dyspnea in patients with COPD. Several studies of chronic obstructive pulmonary disease (COPD) have shown that pulmonary rehabilitation, consisting of at least three training sessions a week, improves exercise performance and health status. This study investigates feasibility, effect and economic aspects of a rehabilitation programme consisting of two sessions a week for 8 weeks. Twenty-four patients with moderate COPD were randomized to rehabilitation and 21 to placebo. Patients were assigned to an 8-week programme of exercise plus education (Exercise group) or conventional community care (Placebo group). The rehabilitation program was carried out in a hospital outpatient setting and consisted of 16 h exercise and 13.5 h of education. The exercise group received physiotherapy and education twice a week. Seven patients did not complete the programme. The characteristics of the 38 COPD-patients at baseline were the following: (mean +/- SD) forced expiratory volume in 1 sec (FEV1) 1.1+/-0.4 1 (47% of predicted), 6-min walking distance (6MWD) 413+/-75 m, score of St. George's Respiratory Questionnaire (SGRQ) 44+/-21. Health-status, assessed by SGRQ and The Psychological General Well-being (PGWB) Index, did not improve. Rehabilitation resulted in an insignificant improvement in the 6MWD [29 m (95% confidence interval: -8 -66 m)]. We conclude that a rehabilitation program consisting of exercise and education twice a week for 8 weeks had no effect on exercise performance and well being in patients with moderate COPD. A prospective controlled trial of home monitoring of peak expiratory flow rate (PEFR) was conducted to determine the usefulness of an objective measure of lung function in association with an education program and a medication self-management plan in reducing morbidity in adult patients with asthma. Thirty-five patients managed themselves, using peak flow readings as the basis for the therapeutic plan coupled with educational intervention, whereas 35 control patients used symptoms and spirometric data for following physicians' treatment plans. After a 6-mo study period, patients in the experimental group showed statistically significant improvements in morbidity parameters (days lost from work, acute asthma attacks, days on antibiotic therapy, physician consultations, and emergency room admissions for asthma), increases in FVC, FEV1, and FEV1/FVC, mean PEFR and mean morning PEFR, decrease in percentage of the mean PEFR amplitude, and a reduction in the use of inhaled beta-agonists, oral theophylline, and oral prednisone. Although improvements in some of these parameters were also found in the control group, they did not reach the levels of significance obtained in the experimental group. The personal use of an objective measure of lung function in association with a medication self-management plan leads to improvement in the patient's condition. Supplemental oxygen has acute beneficial effects on exercise performance in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to investigate whether oxygen-supplemented training enhances the effects of training while breathing room air in patients with severe COPD. A randomized controlled trial was performed in 24 patients with severe COPD who developed hypoxaemia during incremental cycle exercise (arterial oxygen saturation (Sa,O2) <90% at peak exercise). All patients participated in an in-patient pulmonary rehabilitation programme of 10 weeks duration. They were assigned either to general exercise training while breathing room air (GET/RA group: forced expiratory volume in one second (FEV1) 38% of predicted; arterial oxygen tension (Pa,O2) 10.5 kPa at rest; Pa,O2 7.3 kPa at peak exercise), or to GET while breathing supplemental oxygen (GET/O2 group: FEV1 29% pred; Pa,O2 10.2 kPa at rest; Pa,O2 7.2 kPa at peak exercise). Sa,O2 was not allowed to fall below 90% during the training. The effects on exercise performance while breathing air and oxygen, and on quality of life were compared. Maximum workload (Wmax) significantly increased in the GET/RA group (mean (SD) 17 (15) W, p<0.01), but not in the GET/O2 group (7 (25) W). Six minute walking distance (6MWD), stair-climbing, weight-lifting exercise (all while breathing room air) and quality of life significantly increased in both groups. Acute administration of oxygen improved exercise performance before and after training. Training significantly increased Wmax, peak carbon dioxide production (V'CO2) and 6MWD while breathing oxygen in both groups. Differences between groups were not significant. Pulmonary rehabilitation improved exercise performance and quality of life in both groups. Supplementation of oxygen during the training did not add to the effects of training on room air. To investigate the effects of high-intensity inspiratory muscle training (IMT) on inspiratory muscle function (IMF), diaphragm thickness, lung function, physical work capacity (PWC), and psychosocial status in patients with cystic fibrosis (CF).
                Twenty-nine adult patients with CF were randomly assigned to three groups. Two groups were required to complete an 8-week program of IMT in which the training intensity was set at either 80% of maximal effort (group 1; 9 patients) or 20% of maximal effort (group 2; 10 patients). A third group of patients did not participate in any form of training and acted as a control group (group 3; 10 patients).
                In all patients, baseline and postintervention measures of IMF were determined by maximal inspiratory pressure (Pimax), and sustained Pimax (SPimax); pulmonary function, body composition, and physical activity status were also determined. In addition, diaphragm thickness was measured at functional residual capacity (FRC) and total lung capacity (TLC) [TDIcont], and the diaphragm thickening ratio (TR) was calculated (TR = thickness during Pimax at FRC/mean thickness at FRC). Subjects also completed an incremental cycle ergometer test to exhaustion and two symptom-related questionnaires, prior to and following training.
                Following training, significant increases in Pimax and SPimax (p < 0.05), TDIcont (p < 0.05), TR (p < 0.05), vital capacity (p < 0.05), TLC (p < 0.05), and PWC (p < 0.05) were identified, and decreases in anxiety scores (p < 0.05) and depression scores (p < 0.01) were noted in group 1 patients compared to group 3 patients. Group 2 patients significantly improved Pimax and SPimax (both p < 0.05) only with respect to group 3 patients. No significant differences were observed in group 3 patients.
                An 8-week program of high-intensity IMT resulted in significant benefits for CF patients, which included increased IMF and thickness of the diaphragm (during contraction), improved lung volumes, increased PWC, and improved psychosocial status. Interstitial lung disease (ILD) is characterised by exertional dyspnoea, exercise limitation and reduced quality of life. The role of exercise training in this diverse patient group is unclear. The aims of this study were to establish the safety of exercise training in ILD; its effects on exercise capacity, dyspnoea and quality of life; and whether patients with idiopathic pulmonary fibrosis (IPF) had similar responses to those with other types of ILD.
                57 subjects with ILD (34 IPF) were randomised to receive 8 weeks of supervised exercise training or weekly telephone support. The 6 min walk distance (6MWD), incremental exercise test, modified Medical Research Council (MRC) dyspnoea score and Chronic Respiratory Disease Questionnaire (CRDQ) were performed at baseline, following intervention and at 6 months.
                80% of subjects completed the exercise programme and no adverse events were recorded. The 6MWD increased following training (mean difference to control 35 m, 95% CI 6 to 64 m). A significant reduction in MRC score was observed (0.7 points, 95% CI 0.1 to 1.3) along with improvements in dyspnoea (p = 0.04) and fatigue (p<0.01) on the CRDQ. There was no change in peak oxygen uptake; however, exercise training reduced heart rate at maximum isoworkload (p = 0.01). There were no significant differences in response between those with and without IPF. After 6 months there were no differences between the training and control group for any outcome variable.
                Exercise training improves exercise capacity and symptoms in patients with ILD, but these benefits are not sustained 6 months following intervention.
Breathing training, walking aids, NMES and CWV appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.