title: [Exercise training in chronic obstructive pulmonary disease. Comparative study of aerobic training of lower limbs vs. combination with upper limbs]. Supplemental oxygen during pulmonary rehabilitation in patients with COPD with exercise hypoxaemia Can ventilation-feedback training augment exercise tolerance in patients with chronic obstructive pulmonary disease? Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Inspiratory muscle training in pulmonary rehabilitation program in COPD patients. The effect of single set resistance training on strength and functional fitness in pulmonary rehabilitation patients. Tiotropium and exercise training in COPD patients: Effects on dyspnea and exercise tolerance The Effects of Controlled Breathing during Pulmonary Rehabilitation in Patients with COPD Nocturnal non-invasive ventilation in addition to rehabilitation in hypercapnic patients with COPD Effect of upper limb, lower limb and combined training on health-related quality of life in COPD Ambulatory oxygen improves the effectiveness of pulmonary rehabilitation in selected patients with chronic obstructive pulmonary disease Endurance and strength training in patients with COPD. L-carnitine as an ergogenic aid for patients with chronic obstructive pulmonary disease submitted to whole-body and respiratory muscle training programs. Exercise training decreases dyspnea and the distress and anxiety associated with it. Monitoring alone may be as effective as coaching. The impact of noninvasive ventilation during the physical training in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). Physical training with and without oxygen in patients with chronic obstructive pulmonary disease and exercise-induced hypoxaemia. Training with supplemental oxygen in patients with COPD and hypoxaemia at peak exercise. Polyunsaturated fatty acids improve exercise capacity in chronic obstructive pulmonary disease. Does a low-density gas mixture or oxygen supplementation improve exercise training in COPD? Creatine supplementation and physical training in patients with COPD: A double blind, placebo-controlled study Acupuncture as an Adjunct to Pulmonary Rehabilitation Ghrelin Treatment of Cachectic Patients with Chronic Obstructive Pulmonary Disease: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial Effects of training with heliox and noninvasive positive pressure ventilation on exercise ability in patients with severe COPD. Vitamin D supplementation during rehabilitation in COPD: a secondary analysis of a randomized trial Cycle ergometer and inspiratory muscle training in chronic obstructive pulmonary disease. Effect of respiratory muscle endurance training in patients with COPD undergoing pulmonary rehabilitation. Effects of unsupported upper extremity exercise training in patients with COPD: a randomized clinical trial. Training with inspiratory pressure support in patients with severe COPD Effects of Ghrelin Treatment on Exercise Capacity in Underweight COPD Patients: a substudy of a multicenter, randomized, double-blind, placebo-controlled trial of ghrelin treatment Sildenafil to improve respiratory rehabilitation outcomes in COPD: a controlled trial Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Effectiveness and safety of hypertonic saline inhalation combined with exercise training in patients with chronic obstructive pulmonary disease: a randomized trial. Effects of combined inspiratory muscle and cycle ergometer training on exercise performance in patients with COPD. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. The Effect of Strength Training on Functional Fitness in Older Patients with Chronic Lung Disease Enrolled in Pulmonary Rehabilitation [Functional effects of different training in patients with COPD]. Creatine supplementation during pulmonary rehabilitation in chronic obstructive pulmonary disease Randomized controlled trial of dietary creatine as an adjunct therapy to physical training in chronic obstructive pulmonary disease. Ventilatory support during training improves training benefit in severe chronic airway obstruction. Effects of whole body vibration in patients with chronic obstructive pulmonary disease--a randomized controlled trial. Aerobic and strength training in patients with chronic obstructive pulmonary disease. Osteopathic manipulative treatment effectiveness in severe chronic obstructive pulmonary disease: a pilot study. Effects of ubidecarenone in an exercise training program for patients with chronic obstructive pulmonary diseases. Combining triple therapy and pulmonary rehabilitation in patients with advanced COPD: a pilot study. Combined effect of dietary supplementation with pressurized whey and exercise training in chronic obstructive pulmonary disease: a randomized, controlled, double-blind pilot study. The influence of 6 months of oral anabolic steroids on body mass and respiratory muscles in undernourished COPD patients. Effects of nutritional supplementation combined with conventional pulmonary rehabilitation in muscle-wasted chronic obstructive pulmonary disease: a prospective, randomized and controlled study. Proportional assist ventilation as an aid to exercise training in severe chronic obstructive pulmonary disease Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease. Strength training increases maximum working capacity in patients with COPD--randomized clinical trial comparing three training modalities. Is Harmonica Playing an Effective Adjunct Therapy to Pulmonary Rehabilitation? A randomized controlled trial of the effect of psychotherapy on anxiety and depression in chronic obstructive pulmonary disease. Target-flow inspiratory muscle training during pulmonary rehabilitation in patients with COPD. Does unsupported upper limb exercise training improve symptoms and quality of life for patients with chronic obstructive pulmonary disease? The effectiveness of different combinations of pulmonary rehabilitation program components: a randomized controlled trial. Administration of growth hormone to underweight patients with chronic obstructive pulmonary disease. A prospective, randomized, controlled study. Branched-chain aminoacids and retraining of patients with chronic obstructive lung disease. Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients. Improvement in quadriceps strength and dyspnea in daily tasks after 1 month of electrical stimulation in severely deconditioned and malnourished COPD. Eccentric exercise training in patients with chronic obstructive pulmonary disease Inspiratory muscle training and whole-body reconditioning in chronic obstructive pulmonary disease. Inspiratory muscle training combined with general exercise reconditioning in patients with COPD. A role for anabolic steroids in the rehabilitation of patients with COPD? A double-blind, placebo-controlled, randomized trial. Written Disclosure Therapy for Patients With Chronic Lung Disease Undergoing Pulmonary Rehabilitation Helium-hyperoxia: a novel intervention to improve the benefits of pulmonary rehabilitation for patients with COPD.
abstract: A prospect i ve , r and omized and controlled study has been performed in 28 patients with severe COPD . A group of 14 has been trained with their lower limbs ( LL ) , while another similar group of 14 patients was also trained with their upper limbs ( UL ) . Results showed improvement in both groups in the endurance test for LL , dyspnea scale , efficiency and muscular working capacity . A considerable improvement was observed in the oxygen uptake at the anerobic threshold ( VO2AT ) which suggests a training effect , expressed through an improvement in exercise tolerance . Only the group who trained UL showed a remarkable improvement in the dyspnea scale , endurance test and maximal static mouth pressure , showing a better intrinsic working capacity and participation of the UL muscles producing those manoeuvres . At the end of training , quality of life was significantly increased and the hospitalization rate was lower in both groups . According to these findings , it is suggested that patients with severe COPD included in training programmes add UL exercises to the LL usually carried out BACKGROUND Supplemental oxygen in patients with chronic obstructive pulmonary disease ( COPD ) and exercise hypoxaemia improves exercise capacity and dyspnoea . However , the benefit of oxygen during pulmonary rehabilitation in these patients is still unknown . METHODS Twenty five patients with stable COPD ( mean ( SD ) forced expiratory volume in one second ( FEV1 ) 0.76 ( 0.29 ) l and 30.0 (9.89)% predicted , arterial oxygen tension ( Pao 2 ) 8.46 ( 1.22 ) kPa , arterial carbon dioxide tension ( Paco 2 ) 6.32 ( 1.01 ) kPa ) and significant arterial desaturation on exercise ( 82.0 (10.4)% ) were entered onto a pulmonary rehabilitation programme . Patients were r and omised to train whilst breathing oxygen ( OT ) ( n = 13 ) or air ( AT ) ( n = 12 ) , both at 4 l/min . Assessment s included exercise tolerance and associated dyspnoea using the shuttle walk test ( SWT ) and Borg dyspnoea score , health status , mood state , and performance during daily activities . RESULTS The OT group showed a significant reduction in dyspnoea after rehabilitation compared with the AT group ( Borg mean difference –1.46 ( 95 % CI –2.72 to –0.19 ) ) but there were no differences in other outcome measures : SWT difference –23.6 m ( 95 % CI –70.7 to 23.5 ) , Chronic Respiratory Disease Question naire 3.67 ( 95 % CI –7.70 to 15.1 ) , Hospital Anxiety and Depression Scale 1.73 ( 95 % CI –2.32 to 5.78 ) , and London Chest Activity of Daily Living Scale –2.18 ( 95 % CI –7.15 to 2.79 ) . At baseline oxygen significantly improved SWT ( mean difference 27.3 m ( 95 % CI 14.7 to 39.8 ) and dyspnoea ( –0.68 ( 95 % CI –1.05 to –0.31 ) ) compared with placebo air . CONCLUSIONS This study suggests that supplemental oxygen during training does little to enhance exercise tolerance although there is a small benefit in terms of dyspnoea . Patients with severe disabling dyspnoea may find symptomatic relief with supplemental oxygen RATIONALE Exercise-induced dynamic hyperinflation contributes to decreased exercise tolerance in chronic obstructive pulmonary disease ( COPD ) . It is unknown whether respiratory retraining ( ventilation-feedback [ VF ] training ) can affect exercise-induced dynamic hyperinflation and increase exercise tolerance . OBJECTIVES To determine whether patients with COPD would achieve longer exercise duration if r and omized to a combination of exercise training plus VF training than either form of training on its own . METHODS A total of 64 patients r and omized to 1 of 3 groups : VF plus exercise ( n = 22 ) , exercise alone ( n = 20 ) , and VF alone ( n = 22 ) . MEASUREMENTS AND MAIN RESULTS Exercise duration before and after 36 training sessions and exercise-induced dynamic hyperinflation and respiratory pattern before and after training were measured . In the 49 patients who completed training , duration of constant work-rate exercise was 40.0 ( + /- 20.4 ) minutes ( mean + /- SD ) with VF plus exercise , 31.5 ( + /- 17.3 ) minutes with exercise alone , and 16.1 ( + /- 19.3 ) minutes with VF alone . Exercise duration was longer in VF plus exercise than in VF alone ( P < 0.0001 ) , but did not reach predetermined statistical significance when VF plus exercise was compared with exercise alone ( P = 0.022 ) ( because of multiple comparisons , P < /= 0.0167 was used for statistical significance ) . After training , exercise-induced dynamic hyperinflation , measured at isotime , in VF plus exercise was less than in exercise alone ( P = 0.014 for between-group changes ) and less than in VF alone ( P = 0.019 for between-group changes ) . After training , expiratory time was longer in VF plus exercise training ( P < 0.001 ) , and it was not significantly changed in the other two groups . CONCLUSIONS The combination of VF plus exercise training decreases exercise-induced dynamic hyperinflation and increases exercise duration more than VF alone . An additive effect to exercise training from VF was not demonstrated by predetermined statistical criteria Supplemental oxygen improves exercise tolerance of normoxemic and hypoxemic chronic obstructive pulmonary disease ( COPD ) patients . We determined whether nonhypoxemic COPD patients undergoing exercise training while breathing supplemental oxygen  achieve higher intensity and therefore improve exercise capacity more than patients breathing air . A double-blinded trial was performed involving 29 nonhypoxemic patients ( 67 years , exercise SaO2 > 88 % ) with COPD ( FEV1 = 36 % predicted ) . All exercised on cycle ergometers for 45 minutes , 3 times per week for 7 weeks at high-intensity targets . During exercise , they received oxygen ( 3 L/minute ) ( n = 14 ) or compressed air ( 3 L/minute ) ( n = 15 ) . Both groups had a higher exercise tolerance after training and when breathing oxygen . However , the oxygen-trained group increased the training work rate more rapidly than the air-trained group . The mean + /- SD work rate during the last week was 62 + /- 19 W ( oxygen-trained group ) and 52 + /- 22 W ( air-trained group ) ( p < 0.01 ) . After training , endurance in constant work rate tests increased more in the oxygen-trained group ( 14.5 minutes ) than in the air-trained group ( 10.5 minutes ) ( p < 0.05 ) . At isotime , the breathing rate decreased four breaths per minute in the oxygen-trained group and one breath per minute in the air-trained group ( p = 0.001 ) . We conclude that supplemental oxygen provided during high-intensity training yields higher training intensity and evidence of gains in exercise tolerance in laboratory testing Most pulmonary rehabilitation ( PR ) programs do not currently incorporate IMT in their PR programs for COPD patients . The aim of the present study was to assess the influence of adding IMT to the patients already involved in a rehabilitation program . Thirty-four patients with significant COPD were recruited for the study . All patients participated in a general exercise reconditioning ( GER ) program for 12 weeks . The patients were then r and omized to receive IMT or sham IMT , in addition to GER for the next 6 months . Following three months of GER training there was a significant increase in the 6-min walk test ( 6MWT ) ( from mean+/-SEM 254+/-38 to 322+/-42 m , p<0.01 ) , and small but non-significant decreases in the perception of dyspnea ( POD ) , and in the St. George Respiratory Question naire score ( SGRQ ) . Following the addition of IMT to the GER program there was a significant increase in the PI(max ) in the GER+IMT group ( from 66+/-4.7 to 78+/-4.5 cm H(2)O , p<0.01 ) . This was accompanied by a significant improvement in the POD and a further significant improvement in the SGRQ score . IMT provides additional benefits to patients undergoing PR program and is worthwhile even in patients who have already undergone a GER program PURPOSE The primary goal of pulmonary rehabilitation ( PR ) is for patients to achieve and maintain their maximum level of independence and functioning in the community . Traditional PR uses a predominantly aerobic/endurance approach to rehabilitation with little or no inclusion of exercises to increase strength . Few studies have investigated the impact of resistance training on PR despite growing evidence supporting its efficacy to improve physical function ( functional fitness ) in both healthy individuals and those with chronic disease . The purpose of this study was to investigate the effect of single-set resistance training on strength and functional fitness outcomes in PR patients . METHODS Twenty PR patients , 60 to 81 years old , were r and omly assigned to an 8-week endurance-based PR program ( ET ) or an ET plus resistance training program ( RT ) . RESULTS Strength increased in RT ( P < .05 ) and decreased in  ET for both upper and lower body . Functional fitness improved ( P < .05 ) in 5 of 7 tests for RT compared with 2 tests for ET . CONCLUSIONS Single set RT can elicit significant improvements in both strength and functional fitness , which is not obtained by traditional PR alone . Our results are comparable to other studies with similar outcomes using multiple-set RT protocol s. These findings may have important implication s for program design , application , and adherence in PR Background Exercise training improves exercise tolerance in chronic obstructive pulmonary disease ( COPD ) . Tiotropium 18 μg once daily induces sustained bronchodilation throughout the day and reduces hyperinflation , one of the pathophysiological factors contributing to exertional dyspnea in COPD patients . Aim To determine whether tiotropium enhances the effects of exercise training in patients with COPD . Design Multicenter , 25 week r and omized , double-blind , placebo-controlled , parallel-group study . Setting Twelve Italian Pulmonary Units practicing pulmonary rehabilitation . Patients and intervention Two hundred thirty four COPD patients ( 196 males ; mean age : 67.4 ± 7.6 ; forced expiratory volume at 1 second ( FEV1 ) : 41.4 ± 13.0 % predicted ) were r and omised to tiotropium 18 μg or placebo inhalation capsules  taken once daily . Both groups underwent a 8 week pulmonary rehabilitation program ( PR ) consisting of 3 exercise training session per week . Measurements Baseline , at the end of PR and after 12 weeks , patients completed pulmonary function testing , six minute walking test ( 6MWT ) , the Baseline and Transition Dyspnea Index ( BDI and TDI ) , and the St. George ’s Respiratory Question naire ( SGRQ ) . Results Relative to placebo , tiotropium had larger trough and post- study drug FEV1 responses on all test days . At the end of and 12 weeks following PR , patients on tiotropium showed no statistically significant differences in 6MWT compared to patients on placebo . Compared to the period immediately prior to PR , the mean improvement in 6MWT was only 29.7 meters ( 7.1 % ) for the combined cohort . Mean TDI focal scores at the end of PR were 3.60 for tiotropium and 2.25 for placebo ( p < 0.01 ) . At 12 weeks after PR , TDI focal scores were 2.71 for tiotropium and 2.11 for placebo ( p = 0.16 ) . Reduction in all four SGRQ component scores , indicating an improvement in health-related quality of life , was observed for the tiotropium group over the duration of the study compared to placebo but the differences were not statistically significant . During the study period , there were fewer exacerbations and exacerbation days in the tiotropium group . Conclusion Although significant improvements were observed with perceived dyspnea , compared to placebo , the addition of tiotropium to pulmonary rehabilitation did not improve the 6MWT Background : Conventional pulmonary rehabilitation programs improve exercise tolerance but have no effect on pulmonary function in patients with chronic obstructive pulmonary disease ( COPD ) . The role of controlled breathing using respiratory biofeedback during rehabilitation of patients with COPD remains unclear . Objectives : To compare the effects of a conventional 4-week pulmonary rehabilitation program with those of rehabilitation plus controlled breathing interventions . Methods : A r and omized controlled trial was performed . Pulmonary function ( FEV1 ) , exercise capacity ( 6-min walking distance , 6MWD ) , health-related quality of life ( chronic respiratory question naire , CRQ ) and cardiac autonomic function ( rMSSD ) were evaluated . Results : Forty COPD patients ( mean ± SD age 66.1 ± 6.4 , FEV1 45.9 ± 17.4 % predicted ) were r and omized to rehabilitation ( n = 20 ) or rehabilitation plus controlled breathing ( n = 20 ) . There were no statistically significant differences between the two groups regarding the change in FEV1 ( mean difference –0.8 % predicted , 95 % CI –4.4 to 2.9 % predicted , p = 0.33 ) , 6MWD ( mean difference 12.2 m , 95 % CI –37.4 to 12.2 m , p = 0.16 ) , CRQ ( mean difference in total score 0.2 , 95 % CI –0.1 to 0.4 , p = 0.11 ) and rMSSD ( mean difference 2.2 ms , 95 % CI –20.8 to 25.1 ms , p = 0.51 ) . Conclusions : In patients with COPD undergoing a pulmonary rehabilitation program  , controlled breathing using respiratory biofeedback has no effect on exercise capacity , pulmonary function , quality of life or cardiac autonomic function Background : Long-term non-invasive positive pressure ventilation ( NIPPV ) might improve the outcomes of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease ( COPD ) with chronic respiratory failure . A study was undertaken to investigate whether nocturnal NIPPV in addition to pulmonary rehabilitation improves health-related quality of life , functional status and gas exchange compared with pulmonary rehabilitation alone in patients with COPD with chronic hypercapnic respiratory failure . Methods : 72 patients with COPD were r and omly assigned to nocturnal NIPPV in addition to rehabilitation ( n = 37 ) or rehabilitation alone ( n = 35 ) . Outcome measures were assessed before and after the 3-month intervention period . Results : The Chronic Respiratory Question naire total score improved 15.1 points with NIPPV + rehabilitation compared with 8.7 points with rehabilitation alone . The difference of 7.5 points was not significant ( p = 0.08 ) . However , compared with rehabilitation alone , the difference in the fatigue domain was greater with NIPPV + rehabilitation ( mean difference 3.3 points , p<0.01 ) , as was the improvement in the Maugeri Respiratory Failure question naire total score ( mean difference −10 % , p<0.03 ) and its cognition domain ( mean difference −22 % , p<0.01 ) . Furthermore , the addition of NIPPV improved daytime arterial carbon dioxide pressure ( mean difference −0.3 kPa ; p<0.01 ) and daily step count ( mean difference 1269 steps/day , p<0.01 ) . This was accompanied by an increased daytime minute ventilation ( mean difference 1.4 l ; p<0.001 ) . Conclusion : Non-invasive ventilation augments the benefits of pulmonary rehabilitation in patients with COPD with chronic hypercapnic respiratory failure as it improves several measures of health-related quality of life , functional status and gas exchange . Trial registration number : NCT00135538 Objectives : To study the effect of unsupported upper limb and lower limb exercise training and their combined influence on the exercise performance and health-related quality of life in COPD patients . Material s and Methods : Thirty patients were r and omly assigned to one of the three groups , through block r and omization . Of the three groups , group A received upper limb training , group B received lower limb training , and group C received both upper and lower limb training . Patients in group A , B , and C underwent exercise training five times a week for four weeks . The outcome measures used in the study were unsupported upper limb endurance test ( UULEX ) , Six-Minute Walk Test ( 6-MWT ) , and a Chronic Respiratory Question naire . Statistical analysis was performed with analysis of variance , Wilcoxon scale , and a Kruskal Wallis one way ANOVA test , and a P value of .05 was used in the study . Conclusion : The combined upper limb and lower limb training group showed a significant improvement in the exercise performance and health-related quality of life The effect of ambulatory oxygen use during pulmonary rehabilitation ( PR ) has not yet been clearly established , but many studies have shown benefit from oxygen acutely . Two small studies to date demonstrated no clear benefit when oxygen was used in patients who desaturated on exertion during a PR programme . One study showed the benefit of using oxygen during PR in patients who were normoxic at rest and desaturated to a minimum of 88 % on exertion . We conducted a single-blind , r and omised controlled trial comparing PR undertaken either with or without ambulatory oxygen , in those with demonstrable benefit from oxygen at baseline . Subjects from three PR services were recruited who , during baseline assessment , desaturated by more than 4 % and to less than 90 % on exertion , and walked 10 % or more further with ambulatory oxygen on endurance shuttle walk test . Patients were r and omised to either room air or oxygen via portable cylinder , titrated to optimise pulse oxygen saturation but up to a maximum flow rate of 6 L/min . All patients then completed a twice weekly , 6- to 7-week PR programme . Data were analysed as per protocol . Totally 51 patients completed the study . At the end of PR , both groups improved with PR , with patients in the oxygen group demonstrating a highly statistically significantly greater mean improvement in endurance walking distance than the controls , 490 m ( 95 % confidence interval 228–750 ; p ≤ 0.001 ) , as well as clinical ly , although not statistically , significant changes in quality of life .  The use of ambulatory oxygen during a 6- to 7-week PR programme greatly improved endurance walking distance in patients who desaturated on exertion with a positive acute response to ambulatory oxygen at baseline STUDY OBJECTIVES The purpose of this study was to compare the effects of endurance training only to endurance plus strength ( combined ) training in a r and omized trial of patients with COPD . METHODS Twenty-four patients completed the study : 11 patients in the  combined training group ( FEV(1 ) 45 + /- 5 % predicted ) , and 13 patients in the endurance training group  ( FEV(1 ) 40 + /- 4 % predicted ) [ mean + /- SE ] . Muscle strength , quality of life , exercise performance , and quadriceps fatigability were measured before and after rehabilitation . RESULTS Combined training led to significant improvements in quadriceps ( 23.6 % ) , hamstring ( 26.7 ) , pectoralis major ( 17.5 % ) , and latissimus dorsi ( 20 % ) muscle strength . Endurance training alone did not produce significant improvements in muscle strength : quadriceps ( 1.1 % decrease ) , hamstring ( 12.2 % increase ) , pectoralis major ( 7.8 % increase ) , and latissimus dorsi ( 2.8 % decrease ) . The increase in strength after training was significantly greater in the combined group compared to the endurance group for the quadriceps and latissimus dorsi muscles but not for the hamstring and pectoralis major muscles . Six-minute walk distance , endurance exercise time , and quality of life ( as measured by the Chronic Respiratory Question naire ) significantly increased in both groups after rehabilitation with no significant differences in the extent of improvement between groups . The extent of improvement in quadriceps fatigability after training ( assessed by quadriceps twitch force before and after exercise ) was not significantly different between groups . CONCLUSION Strength training can lead to significant improvement in muscle strength in elderly patients with COPD . However , this improvement in muscle strength does not translate into additional improvement in quality of life , exercise performance or quadriceps fatigability compared to that achieved by endurance exercise alone The effects of adding L-carnitine to a whole-body and respiratory training program were determined in moderate-to-severe chronic obstructive pulmonary disease ( COPD ) patients . Sixteen COPD patients ( 66 + /- 7 years ) were r and omly assigned to L-carnitine ( CG ) or placebo group ( PG ) that received either L-carnitine or saline solution ( 2 g/day , orally ) for 6 weeks ( forced expiratory volume on first second was 38 + /- 16 and 36 + /- 12 % , respectively ) . Both groups participated in three weekly 30-min treadmill and threshold inspiratory muscle training sessions , with 3 sets of 10 loaded inspirations ( 40 % ) at maximal inspiratory pressure . Nutritional status , exercise tolerance on a treadmill and six-minute walking test , blood lactate , heart rate , blood pressure , and respiratory muscle strength were determined as baseline and on day 42 . Maximal capacity in the incremental exercise test was significantly improved in both groups ( P < 0.05 ) . Blood lactate , blood pressure , oxygen saturation , and heart rate at identical exercise levels were lower in CG after training ( P < 0.05 ) . Inspiratory muscle strength and walking test tolerance were significantly improved in both groups , but the gains of CG were significantly higher than those of PG ( 40 + /- 14 vs 14 + /- 5 cmH2O , and 87 + /- 30 vs 34 + /- 29 m , respectively ; P < 0.05 ) . Blood lactate concentration was significantly lower in CG than in PG ( 1.6 + /- 0.7 vs 2.3 + /- 0.7 mM , P < 0.05 ) . The present data suggest that carnitine can improve exercise tolerance and inspiratory muscle strength in COPD patients , as well as reduce lactate production STUDY OBJECTIVE To determine whether exercise training with coaching is more effective than exercise training alone in reducing dyspnea and the anxiety and distress associated with it and improving exercise performance , self-efficacy for walking , and dyspnea with activities of daily living . DESIGN R and omized clinical trial of 51 dyspnea-limited patients with COPD assigned to monitored ( n = 27 ) or coached ( n = 24 ) exercise groups . SETTING Outpatient area of university teaching hospital . INTERVENTION Both groups completed 12 supervised treadmill training sessions ( phase 1 ) over 4 weeks followed by 8 weeks of home walking ( phase 2 ) . The CE group also received coaching during training . MEASUREMENTS Perceived work of breathing , dyspnea intensity , distress associated with dyspnea , and anxiety associated with dyspnea were rated on a visual analog scale during incremental treadmill testing and after 6-min walks before and after phase 1 . Dyspnea with activities of daily living , self-efficacy for walking , state anxiety , and 6-min walks were measured before and after both phases . RESULTS Dyspnea and the associated distress and anxiety improved significantly for both groups relative to work performed and in relation to ventilation ( p < 0.05 ) . There were no significant differences between groups in any outcomes . The phase 1 improvement in laboratory dyspnea was accompanied by improvements in dyspnea with activities of daily living ( p < 0.01 ) and self-efficacy for home walking ( p < 0.01 ) that were sustained during the home phase . CONCLUSIONS Coaching with exercise training was no more effective than exercise training alone in improving exercise performance , dyspnea , and the anxiety and distress associated with it , dyspnea with activities , and self-efficacy for walking OBJECTIVE To evaluate the influence of physical training with or without noninvasive ventilation at 2 levels of pressure in the airways ( BiPAP ) in patients with chronic obstructive pulmonary disease . METHODS Eighteen patients with FEV(1 ) = 34 + /- 8 % of predicted values , mean age of 68 + /- 9 years were r and omly distributed into 2 groups , one group performing physical training on a treadmill and the other group performing physical training associated with BiPAP ( physical training+B ) , for 30 minutes , 3 times a week for 12 weeks . The training velocity was based on a test of cardiopulmonary force performed pre- and postintervention , which registered the values for heart rate , systolic blood pressure , diastolic blood pressure , peripheral oxygen saturation , blood lactate , sensation of dyspnea , respiratory muscle strength , and analysis of gases expired such as oxygen consumption and the production of carbon dioxide . RESULTS For both groups , there was a significant improvement in dyspnea and peripheral oxygen saturation at identical levels of physical exercise , in distance walked during the physical training , and in respiratory muscle strength ( P < 0.05 ) . Only the physical training+B group had a significant improvement in heart rate , systolic blood pressure , and oxygen consumption after training ( P < 0.05 ) . Significant reductions of blood lactate were observed at identical levels of exercise in physical training+B when compared to isolated physical training ( from 1.3 + /- 0.7 mMol/L versus 2.5 + /- 0.9 mMol/L , ( P < 0.05 ) , respectively ) . CONCLUSION Physical training associated with BiPAP enhanced the oxidative muscular capacity and could be an adjunctive recourse for physical rehabilitation in patients with chronic obstructive pulmonary disease A r and omized , controlled , single-blind study was performed on 20 patients with chronic obstructive pulmonary disease and exercise-induced hypoxaemia . Ten patients each were r and omly 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 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 r and omized 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 BACKGROUND Muscle wasting and decreased muscle oxidative capacity commonly occur in patients with chronic obstructive pulmonary disease ( COPD ) .  Polyunsaturated fatty acids ( PUFA ) have been shown to mediate several inflammatory and metabolic pathways which may be involved in the pathogenesis of muscle impairment in COPD . The aim of this study was to investigate the effect of PUFA modulation on systemic inflammation , reversal of muscle wasting , and functional status in COPD . METHODS Eighty patients with COPD ( 57 men ) with forced expiratory volume in 1 second ( FEV1 ) 37.3 (13.8)% predicted received 9 g PUFA or placebo daily in a double blind r and omised fashion during an 8 week rehabilitation programme . Body composition ( bioelectrical impedance ) , functional capacity ( lung function , incremental cycle ergometry test , submaximal cycle test , isokinetic quadriceps strength ) and inflammatory markers ( C-reactive protein ( CRP ) , interleukin (IL)-6 and tumour necrosis factor (TNF)-alpha ) were assessed at baseline and after 8 weeks . RESULTS Both groups had similar increases in weight , fat-free mass ( FFM ) , and muscle strength . The peak load of the incremental exercise test increased more in the PUFA group than in the placebo group ( difference in increase 9.7 W ( 95 % CI 2.5 to 17.0 ) , p = 0.009 ) even after adjustment for FFM . The duration of the constant work rate test also increased more in patients receiving PUFA ( difference in increase 4.3 min ( 95 % CI 0.6 to 7.9 ) , p = 0.023 ) . The positive effects of PUFA could not be attributed to a decrease in systemic levels of CRP , IL-6 and TNF-alpha . CONCLUSIONS This is the first study to show beneficial effects of PUFA on exercise capacity in patients with COPD BACKGROUND Low-density gas mixtures and oxygen ( O₂ ) supplementation are known to improve physical performance and ventilatory adaptation during incremental maximal exercise in COPD . We investigated whether their combined use during intense physical training is also effective in ameliorating exercise tolerance in patients affected by moderate to severe COPD . METHODS Thirty patients ( FEV₁ < 60 % of predicted ) underwent a 2-month rehabilitation program . Leg-cycle training was conducted thrice weekly at 80 % of the initial peak work rate for at least 20 min breathing room air , a 60 % helium and 40 % O₂ mixture , or supplemental O₂ ( 40 % ) inhaled from a Douglas bag . The study was r and omized with a double-blind design . Before and at the end of the training period the subjects were tested for spirometry , arterial gas tension , diffusing lung capacity for CO , and incremental and constant work rate exercise test on a cycle ergometer . RESULTS Physical training result ed in a significant improvement in peak oxygen consumption and power output ( P < .01 for both ) and in exercise endurance time ( P < .05 ) independently of the kind of inhaled gas during the rehabilitation program ( P ≥ .42 ) . No changes were observed in lung function tests or gas exchange . CONCLUSIONS We concluded that the use of a low-density gas mixture or O₂ supplementation does not contribute to improved exercise performance in patients with moderate to severe COPD without a significantly decreased diffusion lung capacity for CO who are able to tolerate intense physical training Study objectives Patients with chronic obstructive pulmonary disease ( COPD ) have low exercise capacity and low content of high energetic phosphates in their skeletal muscles . The aim of the present study was to investigate whether creatine supplementation together with exercise training may increase physical performance compared with exercise training in patients with COPD . Design In a r and omized , double-blind , placebo-controlled study , 23 patients with COPD ( forced expiratory volume in one second [ FEV1 ] < 70 % of predicted ) were r and omized to oral creatine ( n = 13 ) or placebo ( n = 10 ) supplementation during an 8-week rehabilitation programme including exercise training . Physical performance was assessed by Endurance Shuttle Walking Test ( ESWT ) , dyspnea and leg fatigue with Borg CR-10 , quality of life with St George ’s Respiratory Question naire ( SGRQ ) . In addition , lung function test , artery blood gases , grip strength test , muscle strength and fatigue in knee extensors were measured . Results COPD patients receiving creatine supplementation increased their average walking time by 61 % ( ESWT ) ( p < 0.05 ) after the training period compared with 48 % ( p = 0.07 ) in the placebo group . Rated dyspnea directly after the ESWT decreased significantly from 7 to 5 ( p < 0.05 ) in the creatine group . However , the difference between the groups was not statistically significant neither in walking time nor in rated dyspnea . Creatine supplementation did not increase the health related quality of life , lung function , artery blood gases , grip strength and knee extensor strength/fatigue . Conclusions Oral creatine supplementation in combination with exercise training showed no significant improvement in physical performance , measured as ESWT , in patients with COPD compared with exercise training alone PURPOSE : Chronic obstructive pulmonary disease ( COPD ) is characterized by airflow limitation and by both systemic and airway inflammation . In COPD , acupuncture has been shown to improve quality -of-life scores and decrease breathlessness ; similar findings have also been reported after pulmonary rehabilitation ( PR ) . The hypothesis of this study was that acupuncture in conjunction with pulmonary rehabilitation would improve COPD outcome measures compared to pulmonary rehabilitation alone . METHODS : The design was a r and omized prospect i ve study ; all subjects had COPD . There were 19 controls , 25 who underwent PR , and 16 who had both acupuncture and PR .  The primary outcome measure was a change in measures of systemic inflammation at the end of PR and at 3 month followup . Lung function , including maximum inspiratory pressure ( PiMax ) , quality -of-life scores , functional capacity including steps taken , dyspnea scores , and exercise capacity , were secondary endpoints . RESULTS : After PR , both groups had significantly improved quality -of-life scores , reduced dyspnea scores , improved exercise capacity , and PiMax , but no change in measures of systemic inflammation compared with the controls . There were no differences in most of the outcome measures between the 2 treatment groups except that subjects who had both acupuncture and PR remained less breathless for a longer period . CONCLUSION : The addition of acupuncture to PR did not add significant benefit in most of the outcomes measured Background Pulmonary cachexia is common in advanced chronic obstructive pulmonary disease ( COPD ) , culminating in exercise intolerance and a poor prognosis . Ghrelin is a novel growth hormone (GH)-releasing peptide with GH-independent effects . The efficacy and safety of adding ghrelin to pulmonary rehabilitation ( PR ) in cachectic COPD patients were investigated . Methodology /Principal Findings In a multicenter , r and omized , double-blind , placebo-controlled trial , 33 cachectic COPD patients were r and omly assigned PR with intravenous ghrelin ( 2 µg/kg ) or placebo twice daily for 3 weeks in hospital . The primary outcomes were changes in 6-min walk distance ( 6-MWD ) and the St. George Respiratory Question naire ( SGRQ ) score . Secondary outcomes included changes in the Medical Research Council ( MRC ) scale , and respiratory muscle strength . At pre-treatment , serum GH levels were increased from baseline levels by a single dose of ghrelin ( mean change , + 46.5 ng/ml ; between-group p<0.0001 ) , the effect of which continued during the 3-week treatment . In the ghrelin group , the mean change from pre-treatment in 6-MWD was improved at Week 3 ( + 40 m , within-group p = 0.033 ) and was maintained at Week 7 ( + 47 m , within-group p = 0.017 ) , although the difference between ghrelin and placebo was not significant . At Week 7 , the mean changes in SGRQ symptoms ( between-group p = 0.026 ) , in MRC ( between-group p = 0.030 ) , and in maximal expiratory pressure ( MEP ; between-group p = 0.015 ) were better in the ghrelin group than in the placebo group . Additionally , repeated- measures analysis of variance ( ANOVA ) indicated significant time course effects of ghrelin versus  placebo in SGRQ symptoms ( p = 0.049 ) and MEP ( p = 0.021 ) . Ghrelin treatment was well tolerated . Conclusions / Significance In cachectic COPD patients , with the safety profile , ghrelin administration provided improvements in symptoms and respiratory strength , despite the lack of a significant between-group difference in 6-MWD . Trial Registration UMIN Clinical Trial Registry Background : Pulmonary rehabilitation is effective in improving exercise performance and health status in chronic obstructive pulmonary disease ( COPD ) . However , the role of nutritional support in the enhancement of the benefits of exercise training has not been explored . A double blind , r and omised , controlled trial of carbohydrate supplementation was undertaken in patients attending outpatient pulmonary rehabilitation . Methods : 85 patients with COPD were r and omised to receive a 570 kcal carbohydrate rich supplement or a non-nutritive placebo daily for the duration of a 7 week outpatient pulmonary rehabilitation programme . Primary outcome measures were peak and submaximal exercise performance using the shuttle walk tests . Changes in health status , body composition , muscle strength , and dietary macronutrient intake were also measured . Results : Patients in both the supplement and placebo groups increased shuttle walking performance and health status significantly . There was no statistically significant difference between treatment groups in these outcomes . Patients receiving placebo lost weight whereas supplemented patients gained weight . In well nourished patients ( BMI > 19 kg/m2 ) improvement in incremental shuttle performance was significantly greater in the supplemented group ( mean difference between groups : 27 ( 95 % CI 1 to 53 ) m , p<0.05 ) . Increases in incremental shuttle performance correlated with increases in total carbohydrate intake . Conclusions : When universally prescribed , carbohydrate supplementation does not enhance the rehabilitation of patients with COPD . This study suggests that exercise training results in negative energy balance that can be overcome by supplementation and that , in selected patients , this may improve the outcome of training . The finding of benefit in well nourished patients may suggest a role for nutritional supplementation beyond the treatment of weight loss in COPD STUDY OBJECTIVES We sought to determine whether breathing heliox or using nasal noninvasive positive pressure ventilation ( NIPPV ) would produce immediate improvements in exercise capability in patients with COPD , and whether training for 6 weeks with one of these modalities would result in greater exercise improvement than with training unassisted . SETTING US military medical center . METHODS Thirty-nine patients with severe COPD ( mean FEV1 of 33.5 % predicted ) underwent three incremental treadmill tests to exhaustion unassisted , breathing heliox , or breathing with NIPPV . They were then r and omized to undergo 6 weeks of twice-weekly rehabilitation with unassisted exercise training ( UT group ) , training while breathing heliox ( HT group ) , or training while breathing with NIPPV ( NT group ) . The three exercise tests were then repeated . RESULTS Heliox treatment did not produce any immediate benefit in exercise time or maximum workload in the 39 patients initially tested , the 32 patients who completed the protocol , or the HT group . Furthermore , no training advantage was evident in the HT group ( n = 10 ) compared to the UT group ( n = 11 ) . NIPPV did not produce an immediate benefit in the initial tests , but produced a small increase in exercise time in the 32 patients completing the protocol in the final tests . This effect was primarily because of the NT group , who exercised significantly longer ( mean + /- SD , 16.8 + /- 4.9 min vs 14.2 + /- 5.6 min , p = 0.0045 ) and to a higher workload ( 4.46 + /- 1.55 metabolic equivalents [ METs ] vs 4.09 + /- 1.75 METs , respectively ; p = 0.038 ) when tested using the ventilator . Compared to the UT group , the NT group started out with a lower exercise time ( 7.9 + /- 3.5 min vs 12.3 + /- 5.2 min , p = 0.031 ) in preliminary testing , but the statistical difference was eliminated in the final tests ( 14.2 + /- 5.6 min vs 16.0 + /- 5.8 min , respectively ; p = 0.451 ) . The NT group actually slightly exceeded the UT group when they used the ventilator in final testing , although this was not statistically significant ( 16.8 + /- 4.9 min vs 16.0 + /- 5.8 min , respectively ) . CONCLUSION Heliox treatment does not appear to offer an immediate or training advantage with exercise in patients with COPD . For patients who have undergone regular exercise conditioning with NIPPV , use of the ventilator produces an immediate improvement in both exercise time and maximum workload attained , and it may confer a training advantage Rationale Pulmonary rehabilitation is an important treatment for patients with Chronic Obstructive Pulmonary Disease , who are often vitamin D deficient . As vitamin D status is linked to skeletal muscle function , we aim ed to explore if high dose vitamin D supplementation can improve the outcomes of rehabilitation in Chronic Obstructive Pulmonary Disease . Material and methods This study is a post-hoc subgroup analysis of a larger r and omized trial comparing a monthly dose of 100.000 IU of vitamin D with placebo to reduce exacerbations . 50 Subjects who followed a rehabilitation program during the trial are included in this analysis . We report changes from baseline in muscle strength and exercise performance between both study arms after 3 months of rehabilitation . Results Vitamin D intervention result ed in significantly higher median vitamin D levels compared to placebo ( 51 [ 44 - 62 ] ng/ml vs 15 [ 13 - 30 ] ng/ml ; p < 0.001 ) . Patients receiving vitamin D had significantly larger improvements in inspiratory muscle strength ( -11±12 cmH2O vs 0±14 cmH2O ; p = 0.004 ) and maximal oxygen uptake ( 110±211 ml/min vs -20±187 ml/min ; p = 0.029 ) . Improvements in quadriceps strength ( 15±16 Nm ) or six minutes walking distance ( 40±55 meter ) were not significantly different from the effects in the placebo group ( 7±19 Nm and 11±74 meter ; p>0.050 ) . Conclusion High dose vitamin D supplementation during rehabilitation may have mild additional benefits to training In patients with chronic obstructive pulmonary disease ( COPD ) the intensity of aerobic training is limited by dyspnea . Improving strength of the inspiratory muscles could enhance aerobic exercise training by reducing exercise-related dyspnea . We examined effects of home-based inspiratory muscle training ( IMT ) and cycle ergometry training ( CET ) in 53 patients with moderate to severe COPD ( FEV(1)% pred , 50 + /- 17 [ mean + /- SD ] ) . Patients were r and omly assigned to 4 mo of training in one of four groups : IMT , CET , CET + IMT , or health education ( ED ) . Patients were encouraged to train to the limits of their dyspnea . Inspiratory muscle strength and endurance increased in IMT and CET + IMT groups compared with CET and ED groups ( p < 0 . 01 ) . Peak oxygen uptake increased and heart rate , minute ventilation , dyspnea , and leg fatigue decreased at submaximal work rates in the CET and CET + IMT groups compared with the IMT and ED groups ( p < 0 . 01 ) . There were no differences between the CET and CET + IMT groups . Home-based CET produced a physiological training effect and reduced exercise-related symptoms while IMT increased respiratory muscle strength and endurance . The combination of CET and IMT did not produce additional benefits in exercise performance and exercise-related symptoms . This is the first study to demonstrate a physiological training effect with home-based exercise training BACKGROUND Respiratory muscle endurance training ( hyperpnea training ) has been shown to have beneficial effects in patients with COPD . STUDY OBJECTIVES The purpose of this study was to determine whether hyperpnea training , when added to an endurance exercise training program , would lead to additional benefits compared with endurance training alone in patients with COPD . SETTING AND PARTICIPANTS Patients with COPD entering an 8-week outpatient pulmonary rehabilitation program . Fifteen patients ( mean [ + /- SE ] FEV1 , 45 + /- 6 % predicted ) were r and omized to combined therapy , and 14 patients ( mean FEV1 , 44 + /- 4 % predicted ) were r and omized to endurance training .  METHODS  Peak exercise capacity , exercise endurance time during constant workload cycle exercise , 6-min walk distance , quality of life as measured by the chronic respiratory question naire , respiratory muscle strength and endurance , and quadriceps fatigability were measured before and after endurance or combined training . RESULTS After rehabilitation , peak exercise capacity , exercise endurance time , 6-min walk distance , and quality of life all increased in both groups , but there was no significant difference in the extent of improvement between groups . Mean respiratory muscle endurance increased to a significantly greater extent in the combined therapy group ( 17.5 + /- 2.7 vs 8.5 + /- 2.5 min , respectively ; p = 0.02 ) . Respiratory muscle strength was significantly increased , and quadriceps fatigability was significantly reduced after rehabilitation in the combined therapy group but not in the endurance training group , but the difference between groups did not reach statistical significance . CONCLUSION The endurance of the respiratory muscles can be improved by specific training beyond that achieved by endurance training alone in patients with COPD . However , this improvement did not translate into additional improvement in quality of life or exercise performance BACKGROUND Current guidelines on pulmonary rehabilitation ( PR ) recommend upper extremity exercise training ( UEET ) in patients with COPD . However , the literature still questions the effectiveness of systematic UEET in this population . We studied the effects of 15 sessions of unsupported UEET on functional exercise capacity , the ability to perform activities of daily living ( ADL ) , and symptoms perceived during activities involving arms in patients with COPD . METHODS We conducted a r and omized trial that consisted of 3 weeks of inpatient PR , comparing the short-term effects of unsupported UEET plus PR ( intervention group ) to those of PR alone ( control group ) . A change in the 6-min ring test ( 6MRT ) was the primary outcome ; the ADL field test ( four shuttle stations ) , the dyspnea score as assessed by the Medical Research Council scale , the London Chest Activity of Daily Living scale ( LCADL ) , and the distance walked in 6 min served as secondary outcomes of the study . At the 6-month follow-up , we repeated the 6MRT and the LCADL . RESULTS Fifty patients with COPD were r and omly assigned to the two groups and completed the study . At the end of the study period , patients in the intervention group improved in the 6MRT and ADL field test compared with those patients in the control group ( p = 0.018 and p = 0.010 , respectively ) with reduced perception of fatigue ( p < or= 0.006 ) . At the 6-month follow-up , 6MRT ( p = 0.001 ) and LCADL ( p = 0.039 ) scores were still significantly better in the intervention group compared with the control group . CONCLUSIONS Our trial corroborates the effectiveness of unsupported UEET in specifically improving functional exercise capacity of patients with COPD . Moreover , it also provides evidence that this training modality may ameliorate and maintain the patients ' autonomy over and above st and ard PR . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00825032 This study evaluates the effects of training with noninvasive ventilatory support in patients with chronic obstructive pulmonary disease in a r and omised , controlled , observer-blinded trial . Twenty-nine patients with chronic obstructive pulmonary disease and with a ventilatory limited exercise capacity ( forced expiratory volume in one second < 60 % predicted , breathing reserve at maximal exercise < 20 % of maximally voluntary ventilation , resting arterial oxygen tension ≥8 kPa ( 60 mmHg ) , end-exercise arterial oxygen saturation measured by pulse oximetry ≥85 % ) completed an 8-week supervised outpatient cycle exercise programme .  Fourteen patients were r and omised to training with inspiratory pressure support of 10 cmH2O and 15 patients to training with control ( sham ) inspiratory pressure support of 5 cmH2O . Outcome measures were the incremental shuttle walking test and a constant-load cycle endurance test at 75 % of peak work rate including the measurement of physiological responses , and health status measured using the St. George 's Respiratory Question naire . Statistically significant between-group differences were found in favour of the inspiratory pressure support of 10 cmH2O group for improvement in shuttle walking distance ( 16±17 versus 3±13 % ) , cycle endurance ( 164±124 versus 88±128 % ) , and the reduction in minute ventilation during exercise ( -11±10 versus -2±9 % ) . It was concluded that exercise training with inspiratory pressure support of 10 cmH2O result ed in statistically significantly larger improvements in exercise performance  than training with inspiratory pressure support of 5 cmH2O in patients with chronic obstructive pulmonary disease suffering from a ventilatory limited exercise capacity . Inspiratory pressure support of 10 cmH2O may be considered as adjunct during high-intensity exercise training Background The aim of this sub study of the ghrelin treatment , multicenter , r and omized , double-blind , placebo-controlled trial was to investigate the effects of ghrelin administration on exercise capacity and the underlying mechanisms in underweight patients with chronic obstructive pulmonary disease ( COPD ) using cardiopulmonary exercise testing . Methods Twenty underweight COPD patients were r and omized to pulmonary rehabilitation with intravenous ghrelin ( 2 μg/kg , n = 10 ) or placebo ( n = 10 ) twice daily for 3 weeks in a double-blind fashion . The primary outcome was changes in peak oxygen uptake V•o2 . Secondary outcomes included changes in exertional cardio-respiratory functions : O2-pulse , physiologic dead space/tidal volume-ratio ( VD/VT ) , ventilatory equivalent for oxygen V•E/V•o2 , and ventilatory equivalent for carbon dioxide V•E/V•co2 . Results With incremental exercise , at peak exercise , there was a significant difference in the mean difference ( ghrelin minus placebo ) , i.e. , treatment effect in : i ) peak V•o2 ( 1.2 mL/kg/min , 95 % CI : 0.2 - 2.3 mL/kg/min , between-group p = 0.025 ) ; ii ) V•E/V•o2 ( -4.2 , 95 % CI : -7.9 to -0.5 , between-group p = 0.030 ) ; iii ) V•E/V•co2 ( -4.1 , 95 % CI : -8.2 to -0.1 , between-group p = 0.045 ) ; iv ) VD/VT ( -0.04 , 95 % CI : -0.08 to -0.00 , between-group p = 0.041 ) ; and v ) O2-pulse ( 0.7 mL/beat , 95 % CI : 0.3 to 1.2 mL/beat , between-group p = 0.003 ) . Additionally , repeated- measures analysis of variance ( ANOVA ) indicated a significant time-course effect of ghrelin versus placebo in the peak V•o2 ( p = 0.025 ) . Conclusion Ghrelin administration was associated with improved exertional capacity and improvements in ventilatory-cardiac parameters . Trial registration UMIN ( University Hospital Medical Information Network in Japan ) Pulmonary hypertension is a serious complication of chronic obstructive pulmonary disease ( COPD ) that currently has no established pharmacological treatment . This study aim ed to assess whether concomitant treatment with sildenafil would enhance the results of pulmonary rehabilitation in patients with COPD and increased pulmonary arterial pressure ( PAP ) . In this double-blind , r and omised controlled trial patients received 20 mg sildenafil or placebo three times daily and underwent pulmonary rehabilitation for 3 months . The primary end-point was the gain in the cycle endurance time at a constant work-rate . Secondary end-points included performance in the incremental exercise test , 6-min walk distance and quality of life .  63 patients with severe COPD and moderately increased PAP were r and omised .  Cycle endurance time increased by 149 s ( 95 % CI 26–518 s ) in the sildenafil group and by 169 s ( 95 % CI 0–768 s ) in the placebo group ( median change difference -7 s , 95 % CI -540–244 s ; p=0.77 ) . Gains in the incremental exercise test , 6-min walk distance and quality of life at the end of the study did not differ between groups . Measurements of arterial oxygenation and adverse events were similar in both groups . In patients with severe COPD and moderately increased PAP , concomitant treatment with sildenafil does not improve the results of pulmonary rehabilitation in exercise tolerance . Sildenafil did not improve respiratory rehabilitation outcomes in patients with severe COPD and moderately increased PAP STUDY OBJECTIVES Pulmonary rehabilitation ( PR ) improves exercise tolerance in COPD patients .  Tiotropium is a once-daily , inhaled anticholinergic bronchodilator that provides sustained 24-h improvements in airflow and lung hyperinflation reduction . We hypothesized that ventilatory mechanics improvements from tiotropium would permit enhanced ability to train muscles of ambulation and therefore augment exercise tolerance benefits of PR . DESIGN In a r and omized , double-blind , placebo-controlled trial  ( tiotropium , n = 47 ; placebo , n = 44 ) ,  tiotropium  ( 18 microg qd ) was administered to COPD patients participating in 8 weeks of PR ( treadmill training three times a week ; > /= 30 min per session ) at 17 sites . Study drug was administered 5 weeks prior to , 8 weeks during , and 12 weeks following PR . The primary end point was treadmill walking ( 0 % incline ) endurance time at 80 % of maximum speed attained in an initial incremental test . The transition dyspnea index ( TDI ) , St. George 's respiratory question naire ( SGRQ ) , and rescue albuterol use were secondary end points . PARTICIPANTS Mean age of the 93 participants was 67 years , 57 % were men , and mean FEV(1 ) was 0.88 L ( 34 % predicted ) . RESULTS Mean endurance time differences  ( tiotropium minus placebo ) prior to PR , at the end of PR , and 12 weeks after PR were 1.65 min ( p = 0.183 ) , 5.35 min ( p = 0.025 ) , and 6.60 min ( p = 0.018 ) , respectively . Mean TDI focal scores at the end of PR were 1.75 for tiotropium and 0.91 for placebo ( p > 0.05 ) . At 12 weeks after PR , TDI focal scores were 1.75 for tiotropium and 0.08 for placebo ( p < 0.05 ) . Relative to placebo , tiotropium improved SGRQ total scores by 3.86 at the end of PR and 4.44 at 12 weeks after PR ( p > 0.05 ) . Mean albuterol use declined following PR plus tiotropium , compared to PR alone ( p < /= 0.05 for 17 of 25 weeks ) . CONCLUSIONS Tiotropium in combination with PR improved endurance of a constant work rate treadmill task and produced clinical ly meaningful improvements in dyspnea and health status compared to PR alone . Improvements with tiotropium were sustained for 3 months following PR completion BACKGROUND Inhaled hypertonic saline is used for bronchial challenge and sputum induction in patients with chronic obstructive pulmonary disease ( COPD ) . We studied the effects of saline aerosol inhalation before each exercise session in an 8-week pulmonary rehabilitation program . METHODS This was a double-blind r and omized parallel controlled trial , conducted at an out-patient clinic . Sixty-eight subjects with COPD ( mean age 67 + /- 6.5 y , percent of predicted FEV(1 ) 47 + /- 21 ) were r and omized to inhale either 3 % hypertonic saline ( 34 subjects ) or normal saline ( 34 subjects ) before each exercise session in an 8-week exercise program that had 3 sessions per week . We measured 6-min walk distance , dyspnea , and quality of life ( with the Medical Outcomes Study 36-item short-form health survey ) . RESULTS After the 8-week exercise program , both groups ' mean 6-min walk distance had significantly increased : from 195 + /- 92 m to 251 + /- 97 m ( P < .001 ) in the hypertonic-saline group , and from 237 + /- 93 m to 441 + /- 121 m in the normal-saline group ( P < .001 ) . The normal-saline group had greater improvement than the hypertonic-saline group ( P < .001 ) . Dyspnea score improved from 3.1 + /- 0.9 to 2.3 + /- 0.8 ( P < .01 ) in the hypertonic-saline group , and from 3.5 + /- 0.2 to 2.3 + /- 1.0 ( P < .01 ) in the normal-saline group . Quality of life also significantly improved , except for the physical-functioning and social aspect domains in the hypertonic-saline group . Adverse effects ( cough or bronchospasm ) occurred in 4 patients ( 12 % ) in the hypertonic-saline group . CONCLUSIONS The improvement in 6-min walk distance was greater with normal saline than with hypertonic saline . Hypertonic saline was associated with adverse effects . It is unclear whether the only predictor of improved functional exercise capacity was exercise training . ( Clinical Trials.gov number , NCT00639236 . ) Cycle ergometer training plays an important role in the rehabilitation of patients with chronic obstructive pulmonary disease ( COPD ) , but the usefulness of specific inspiratory muscle training as part of pulmonary rehabilitation remains uncertain . To determine whether inspiratory muscle training could intensify the known beneficial effects of cycle ergometer training on exercise performance in these patients , we compared the effect of an 8 week inspiratory muscle training combined with cycle ergometer training with that of an 8 week cycle ergometer training alone on inspiratory muscle performance and general exercise capacity . Patients were r and omly assigned to the two training groups ; 21 patients received additional inspiratory muscle training ( Group 1 ) and 21 did not ( Group 2 ) .  Maximal sniff assessed oesophageal and transdiaphragmatic pressures served as parameters for global inspiratory muscle strength and diaphragmatic strength , respectively . The duration for which the patient could breathe against a constant inspiratory pressure load was used as an index of inspiratory muscle endurance . Exercise capacity was determined by an incremental symptom-limited cycle ergometer test . After the training period , inspiratory muscle performance improved significantly in the patients with inspiratory muscle training , but not in those without . Both training regimens increased maximal power output and oxygen uptake , but this improvement was significantly greater in the patients with inspiratory muscle training than in those without . ( ABSTRACT TRUNCATED AT 250 WORDS QUESTIONS Does the PEDro scale measure only one construct ie , the method ological quality of clinical trials ? What is the hierarchy of items of the PEDro scale from least to most adhered to ? Is there any effect of year of publication of trials on item adherence ? Are PEDro scale ordinal scores equivalent to interval data ? DESIGN Rasch analysis of two independent sample s of 100 clinical trials from the PEDro data base scored using the PEDro scale . RESULTS Both sample s of PEDro data showed fit to the Rasch model with no item misfit . The  PEDro scale item hierarchy was the same in both sample s , ranging from the most adhered to item r and om allocation , to the least adhered to item therapist blinding . There was no differential item functioning by year of publication . Original PEDro ordinal scores were highly correlated with transformed PEDro interval scores ( r = 0.99 ) . CONCLUSION The PEDro scale is a valid measure of the method ological quality of clinical trials . It is valid to sum PEDro scale item scores to obtain a total score that can be treated as interval level measurement and subjected to parametric statistical analysis & NA ; The purpose of this study was to compare the effects of a strength training‐enhanced program and a traditional pulmonary rehabilitation ( PR ) program on functional fitness ( FF ) in older patients with chronic obstructive pulmonary disease ( COPD ) , using the Senior Fitness Test . Twenty patients were recruited from an outpatient PR program . After completing baseline measures , including muscular strength and the Senior Fitness Test , patients were r and omly assigned to the strength training program ( TR+ST , n = 10 ) or traditional PR program ( TR , n = 10 ) . Patients completed 16 exercise sessions that were conducted twice a week for 8–10 weeks , after which patients repeated outcome measurements . Independent t tests were conducted to determine whether groups differed between measures . Both the TR+ST and TR groups improved on all FF measures . Moderate effect sizes were found for two of the FF measures when the groups were compared . The addition of strength training to PR may have a favorable impact on FF in older patients with COPD Disability and exertional dyspnea associated with chronic obstructive pulmonary disease has led to the development of rehabilitation programmes that aim to increase exercise tolerance and relief of dyspnea . To evaluate whether aerobic training ( training groups P1 and P4 ) , strength training ( P2 and P5 ) or a combination of both ( P4 and P6 ) is useful , 69 patients ( 44 m/25 f ) with moderate to severe COPD were r and omised to a three week inpatient training program . The training consisted of three weekly twenty minute exercise sessions without ( P1 - P3 ) or with supplemental oxygen ( P4 - P6 ) on a calibrated ergocycle ( 70 % W(max ) ) or three weekly sessions of 20 - 25 repetitions of 2 - 4 training series ( 40 % W(max ) ) or a combination of both . In general , the programme failed to demonstrate significant changes in lung function and arterial blood gases . Evaluation of exercise capacity via the six-minute-walking test ( 6MT ) yielded a significant increase of the walking distance in all groups except P2 ( 60 - 83 m ) , The time to finish a test-set of daily activities ( TAF ) was reduced in all groups ( 5 - 58 sec ) and reached significance in P1 , P3 , P5 and P6 . After the 6MT , exertional dyspnea improved in all groups except P4 and was significant in P1 and P3 ; after the TAF , dyspnea again was reduced in all groups with a significant change in P2 and P5 . These data support the hypotheses that a short term inpatient training programme is suitable to improve exercise-capacity and dyspnea .  Patients with advanced disease ( P4 - P6 ) show greater benefits with strength training ( alone or in combination with aerobic training ) while for patients with moderate disease ( P1 - P3 ) aerobic training is favourable . These changes may translate into improved performance of daily activities and general well-being Background : Skeletal muscle wasting and dysfunction are strong independent predictors of mortality in patients with chronic obstructive pulmonary disease ( COPD ) .  Creatine nutritional supplementation produces increased muscle mass and exercise performance in health . A controlled study was performed to look for similar effects in 38 patients with COPD . Methods : Thirty eight patients with COPD ( mean ( SD ) forced expiratory volume in 1 second ( FEV1 ) 46 (15)% predicted ) were r and omised to receive placebo ( glucose polymer 40.7 g ) or creatine ( creatine monohydrate 5.7 g , glucose 35 g ) supplements in a double blind trial . After 2 weeks loading ( one dose three times daily ) , patients participated in an outpatient pulmonary rehabilitation programme combined with maintenance ( once daily ) supplementation . Pulmonary function , body composition , and exercise performance ( peripheral muscle strength and endurance , shuttle walking , cycle ergometry ) took place at baseline ( n = 38 ) , post loading ( n = 36 ) , and post rehabilitation ( n = 25 ) . Results : No difference was found in whole body exercise performance between the groups : for example , incremental shuttle walk distance mean −23.1 m ( 95 % CI −71.7 to 25.5 ) post loading and −21.5 m ( 95 % CI −90.6 to 47.7 ) post rehabilitation . Creatine increased fat-free mass by 1.09 kg ( 95 % CI 0.43 to 1.74 ) post loading and 1.62 kg ( 95 % CI 0.47 to 2.77 ) post rehabilitation . Peripheral muscle performance improved : knee extensor strength 4.2 N.m ( 95 % CI 1.4 to 7.1 ) and endurance 411.1 J ( 95 % CI 129.9 to 692.4 ) post loading , knee extensor strength 7.3 N.m ( 95 % CI 0.69 to 13.92 ) and endurance 854.3 J ( 95 % CI 131.3 to 1577.4 ) post rehabilitation . Creatine improved health status between baseline and post rehabilitation ( St George ’s Respiratory Question naire total score −7.7 ( 95 % CI −14.9 to −0.5 ) ) . Conclusions : Creatine supplementation led to increases in fat-free mass , peripheral muscle strength and endurance , health status , but not exercise capacity . Creatine may constitute a new ergogenic treatment in COPD RATIONALE Skeletal muscle strength and bulk are reduced in patients with chronic obstructive pulmonary disease ( COPD ) and influence quality of life , survival , and utilization of health care re sources . Exercise training during pulmonary rehabilitation ( PR ) can reverse some of these effects . In athletes and healthy elderly individuals , dietary creatine supplementation ( CrS ) has been shown to augment high-intensity exercise training , thereby increasing muscle mass . OBJECTIVES This article examines the effect of CrS on functional exercise capacity and muscle performance in people with COPD . METHODS One hundred subjects with COPD ( mean [ SD ] age , 68.2 [ 8.2 ] yr ; FEV(1 ) , 44.0 [ 19.6 ] % predicted ) were r and omized to a double-blind , placebo-controlled , parallel group trial of CrS during 7 weeks of PR encompassing aerobic and resistance exercises . Subjects ingested creatine ( 22 g/d loading for 5 d ; maintenance , 3.76 g/d throughout PR ) or placebo . Baseline , postloading , and postrehabilitation measurements included pulmonary function , body composition , peripheral muscle strength , and functional performance ( shuttle walking tests ) . A volunteer subgroup ( n = 44 ) had pre- and postloading quadriceps muscle biopsies . MEASUREMENTS AND MAIN RESULTS Eighty subjects completed the trial ( 38 creatine  , 42  placebo ) . All outcome measures significantly improved after PR . There were no significant differences between groups post-PR ( mean [ SD ] change in incremental shuttle walk distance , 84 [ 79 ] m in the creatine group vs. 83.8 [ 60 ] m in the placebo group ; P = 1.0 ; knee extensor work , 19.2 [ 16 ] Nm [ Newton meters ] in the creatine group vs. 19.5 [ 17 ] Nm in the placebo group ; P = 0.9 ) . Muscle biopsies showed evidence of creatine uptake . CONCLUSIONS This adequately powered , r and omized , placebo-controlled trial shows that CrS does not augment the substantial training effect of multidisciplinary PR for patients with COPD . Clinical trial registered with https://portal.nihr.ac.uk/Pages/NRRArchive Search .aspx ( NO123138126 ) BACKGROUND One mechanism that may limit training effect in chronic obstructive pulmonary disease is the ventilatory limitation and associated dyspnea . OBJECTIVES To minimize ventilatory limitation during training of patients with severe COPD by applying bi-level positive pressure ventilation during training in order to augment training intensity ( and effect ) . METHODS The study group comprised 19 patients ( 18 males , 1 female ) with a mean age of 64 + /- 9 years . Mean forced expiratory volume in 1 second was 32 + /- 4 % of predicted , and all were ventilatory-limited ( exercise breathing reserve 3 + /- 9 L/min , normal > 15 L/min ) . The patients were r and omized : 9 were assigned to training with BiPAP and 10 to st and ard training . All were trained on a treadmill for 2 months , twice a week , 45 minutes each time , at maximal tolerated load . Incremental maximal unsupported exercise test was performed before and at the end of the training period . RESULTS BiPAP result ed in an increment of 94 + /- 53 % in training speed during these 2 months , as compared to 41 + /- 19 % increment in the control group ( P < 0.005 ) . Training with BiPAP yielded an average increase in maximal oxygen uptake of 23 + /- 16 % ( P < 0.005 ) , anaerobic threshold of 11 + /- 12 % ( P < 0.05 ) and peak O2 pulse of 20 + /- 19 % ( P < 0.05 ) , while peak exercise lactate concentration was not higher after training . Interestingly , in the BiPAP group , peak exercise ventilation was also 17 + /- 20 % higher after training ( P < 0.05 ) . Furthermore , contrary to our expectation , at any given work rate , ventilation ( and tidal volume ) in the BiPAP group was higher in the post-training test as compared to the pre-training test , and the end tidal partial pressure of CO2 at 55 watts was lower , 40 + /- 4 and 38 + /- 4 mmHg respectively ( P < 0.05 ) . No improvement in exercise capacity was observed after this short training period in the control group . CONCLUSION Pressure-supported ventilation during training is feasible in patients with severe COPD and it augments the training effect . The improved exercise tolerance was associated with higher ventilatory response and therefore lower P(ET)CO2 at equal work rates after training INTRODUCTION To date endurance and strength training are established and evidence -based exercise methods in patients with chronic obstructive pulmonary disease ( COPD ) . There is an unmet need for further research in new and complementary exercise modalities . Additional whole body vibration training during pulmonary rehabilitation may be such a new approach that has not yet been investigated in patients with COPD . METHODS Eighty-two patients ( 65 ± 9 yrs , FEV(1 ) pred . 38 ± 11 % , female 51 % ) with COPD in GOLD stage III to IV assessed for a 3-week inpatient multidisciplinary rehabilitation program were on top r and omly assigned to one of two intervention groups : ( 1 ) 3 × 3 min of bilateral dynamic squat exercises on a side-alternating vibration platform at 24 - 26 Hz three times per week ( WBV ) and ( 2 ) a control group ( CON ) with the same amount of exercise time without WBV . RESULTS Thirty-six patients completed the study in each group . The improvement in 6-min walking distance was significantly higher in the WBV-group when compared to the CON-group ( WBV : 64 ± 59 m , CON : 37 ± 52 m with a between-group difference of 27 m [ 95 % CI , 1 - 53 ] , p = 0.046 ) . The time required for a sit-to-st and test also decreased more markedly in the WBV-group than in the CON-group ( WBV : -4.0 ± 4.8 s , CON : -2.0 ± 3.1 s with a between-group difference of -1.9 s [ 95 % CI , -4.0 to 0.1 ] , p = 0.067 ) . Improvements in health-related quality of life were similar in both groups . CONCLUSIONS WBV training seems to be a promising new exercise modality for patients with COPD and may enhance the effects of a multidisciplinary rehabilitation program The purpose of this study was to evaluate whether strength training is a useful addition to aerobic training in patients with chronic obstructive pulmonary disease ( COPD ) . Forty-five patients with moderate to severe COPD were r and omized to 12 wk of aerobic training alone ( AERO ) or combined with strength training ( AERO + ST ) . The AERO regimen consisted of three weekly 30-min exercise sessions on a calibrated ergocycle , and the ST regimen included three series of eight to 10 repetitions of four weight lifting exercises .  Measurements of peripheral muscle strength , thigh muscle cross-sectional area ( MCSA ) by computed tomographic scanning , maximal exercise capacity , 6-min walking distance ( 6MWD ) , and quality of life with the chronic respiratory question naire were obtained at baseline and after training . Thirty-six patients completed the program and constituted the study group . The strength of the quadriceps femoris increased significantly in both groups ( p < 0.05 ) , but the improvement was greater in the AERO + ST group ( 20 + /- 12 % versus 8 + /- 10 % [ mean + /- SD ] in the AERO group , p < 0.005 ) . The thigh MCSA and strength of the pectoralis major muscle increased in the AERO + ST group by 8 + /- 13 % and 15 + /- 9 % , respectively ( p < 0.001 ) , but not in the AERO group ( 3 + /- 6 % and 2 + /- 10 % , respectively , p > 0.05 ) . These changes were significantly different in the two study groups ( p < 0.01 ) . The increase in strength of the latissimus dorsi muscle after training was modest and of similar magnitude for both groups . The changes in peak exercise work rate , 6MWD , and quality of life were comparable in the two groups . In conclusion , the addition of strength training to aerobic training in patients with COPD is associated with significantly greater increases in muscle strength and mass , but does not provide additional improvement in exercise capacity or quality of life OBJECTIVES Few and contrastingly data are available about use of osteopathic manipulative treatment ( OMT ) in patients with chronic obstructive pulmonary disease ( COPD ) . DESIGN Comparing the effects of the combination of pulmonary rehabilitation and OMT compared with pulmonary rehabilitation ( PR ) in patients with severely impaired COPD . SETTING Rehabilitative pulmonary department . INTERVENTIONS Patients underwent exercise training , OMT , educational support and nutritional and psychological counselling . MAIN OUTCOMES MEASURES Exercise capacity through 6 min walk test ( 6MWT-- primary outcome ) and pulmonary function test ( secondary outcomes ) were evaluated at the beginning and at the end of the training . Patients were r and omly assigned to receive PR+soft manipulation ( G1 ) or OMT+PR ( G2 ) for 5 days/week for 4 weeks . RESULTS 20 stable COPD patients ( 5 female -- mean age , 63.8±5.1 years ; FEV1 26.9±6.3 % of predicted ) referred for in-patient pulmonary rehabilitation were evaluated . Respect to the baseline , 6 MWT statistically improved in both group . In particular , G2 group gained 72.5±7.5 m ( p=0.01 ) and G1 group 23.7±9.7 m. Between group comparison showed a difference of 48.8 m ( 95 % CI : 17 to 80.6 m , p=0.04 ) . Moreover , in G2 group we showed a decrease in residual volume ( RV -- from 4.4±1.5 l to 3.9±1.5 l , p=0.05 ) . Between group comparison showed an important difference ( -0.44 l ; 95 % CI : -0.26 to -0.62 l , p=0.001 ) . Furthermore , only in G2 group we showed an increase in FEV1 . CONCLUSIONS This study suggests that OMT+PR may improve exercise capacity and reduce RV in severely impaired COPD patients with respect to PR alone A study was undertaken to determine the usefulness of ubidecarenone in pulmonary rehabilitation in exercise training programs in the management of chronic obstructive pulmonary disease ( COPD ) . The subjects were 20 patients with COPD who had been participating in an exercise training program for at least four weeks . The patients were r and omly assigned either to receive 50 mg of oral ubidecarenone daily or to enter a control group during the program .  Oxygen consumption , expired volume , and heart rate were measured during exercise tests before and after training . Maximum oxygen consumption increased 13 % in the ubidecarenone-treated patients and 7 % in the controls , and maximum expired volume increased 10 % in each group . The increases were significant in the ubidecarenone group but not in the controls . Heart rate increased 2 % in both groups . It is concluded that ubidecarenone deserves further evaluation in exercise training programs for patients with COPD BACKGROUND The synergistic interactions between pharmacotherapy and pulmonary rehabilitation has been provided , but it remains to be established whether this may also apply to more severe patients . OBJECTIVES We have examined whether tiotropium enhances the effects of exercise training in patients with advanced COPD ( FEV(1)</=60 % predicted , hypoxemia at rest corrected with oxygen supplementation , and limitations of physical activity ) . METHODS We enrolled 22 patients that were r and omised to tiotropium 18mug or placebo inhalation capsules taken once daily . Both groups ( 11 patients in each group ) underwent an in patient pulmonary rehabilitation program and were under regular treatment with salmeterol/fluticasone twice daily . Each rehabilitation session was held 5 days per week ( 3h/day ) for a total of 4 weeks . RESULTS Compared to placebo , tiotropium had larger impact on pulmonary function ( FEV(1)+0.164L , FVC + 0.112L , RV -0.544L after tiotropium , FEV(1)+0.084L , FVC -0.039L , RV -0.036L after placebo ) . The addition of tiotropium allowed a longer distance walked in 6min ( 82.3 m vs. 67.7 m after placebo ) and reduced dyspnoea ( Borg score ) ( -0.4 vs. + 0.18 after placebo ) when compared with baseline ( pre pulmonary rehabilitation program ) . The changes in SGRQ from baseline to the end of treatment were : total score -28.3U , activity -27.8U , impact -14.5U , and symptoms -33.4U in the placebo group ; and total score -19.1U , activity -18.9U , impact -16.4U , and symptoms -33.8U in the tiotropium group . CONCLUSIONS Our study clearly indicates that there is an advantage in combining pulmonary rehabilitation with an aggressive drug therapy in more severe patients Pressurized whey supplementation , by its antioxidant and nutritional properties , may improve exercise tolerance and potentiate the effects of exercise training in patients with chronic obstructive pulmonary disease ( COPD ) . In this r and omized , double-blind , placebo-controlled study , 22 patients with COPD were allocated to receive active pressurized whey or placebo ( casein ) dietary supplementation for a 16-week period . Patients continued their usual physical activities for the first 8 weeks , whereas they were subjected to an exercise training program for the remaining 8 weeks of the study . Patients were evaluated at baseline , after 8 weeks of supplementation alone ( time point , 8 weeks ) , and after 8 weeks of its combination with exercise training ( time point , 16 weeks ) . The constant workrate cycle endurance test ( CET ) , potentiated quadriceps twitch force , mid-thigh cross-sectional area , and Chronic Respiratory Question naire ( CRQ ) were used to evaluate the effects of treatments . The inflammatory ( C-reactive protein and interleukin-6 ) and oxidant/antioxidant ( protein oxidation and glutathione ) blood profiles were also characterized . At week 8 , there was no increase in CET time in either group . At week 16 , there was a statistically significant increase in CET time in the whey-only group ( P < .05 ) . Further , at week 16 , there was clinical ly significant improvement in the Dyspnea and the Mastery scales of the CRQ in both groups . Also , the Fatigue and Emotional Control scales of the CRQ showed clinical ly significant improvement in the whey-only group . Study interventions did not modify significantly the systemic inflammatory and oxidative stress markers that were assessed . Thus dietary supplementation with pressurized whey may potentiate the effects of exercise training on exercise tolerance and quality of life in patients with COPD STUDY OBJECTIVE To evaluate the influence of oral anabolic steroids on body mass index ( BMI ) , lean body mass , anthropometric measures , respiratory muscle strength , and functional exercise capacity among subjects with COPD . DESIGN Prospect i ve , r and omized , controlled , double-blind study . SETTING Pulmonary rehabilitation program . PARTICIPANTS Twenty-three undernourished male COPD patients in whom BMI was below 20 kg/m2 and the maximal inspiratory pressure ( PImax ) was below 60 % of the predicted value . INTERVENTION The study group received 250 mg of testosterone i.m . at baseline and 12 mg of oral stanozolol a day for 27 weeks , during which time the control group received placebo . Both groups participated in inspiratory muscle exercises during weeks 9 to 27 and cycle ergometer exercises during weeks 18 to 27 . MEASUREMENTS AND RESULTS Seventeen of 23 subjects completed the study . Weight increased in nine of 10 subjects who received anabolic steroids ( mean , + 1.8+/-0.5 kg ; p<0.05 ) , whereas the control group lost weight ( -0.4+/-0.2 kg ) . The study group 's increase in BMI differed significantly from that of the control group from weeks 3 to 27 ( p<0.05 ) . Lean body mass increased in the study group at weeks 9 and 18 ( p<0.05 ) . Arm muscle circumference and thigh circumference also differed between groups ( p<0.05 ) . Changes in PImax ( study group , 41 % ; control group , 20 % ) were not statistically significant . No changes in the 6-min walk distance or in maximal exercise capacity were identified in either group . CONCLUSION The administration of oral anabolic steroids for 27 weeks to malnourished male subjects with COPD was free of clinical or biochemical side effects . It was associated with increases in BMI , lean body mass , and anthropometric measures of arm and thigh circumference , with no significant changes in endurance exercise capacity BACKGROUND AND OBJECTIVE Nutritional depletion in chronic obstructive pulmonary disease ( COPD ) adversely affects health status and mortality . We aim ed to evaluate the effects of nutritional supplementation ( NS ) with pulmonary rehabilitation ( PR ) on body composition , mid-thigh cross-sectional area ( CSA ) , dyspnoea , exercise capacity , health-related quality of life , anxiety and depression in advanced COPD patients . METHODS Forty-six patients were r and omized to PR and nutritional support ( PRNS ) , PR or the control group .  Dyspnoea was measured with Medical Research Council and BORG scales . Exercise capacity was measured through 6-min walk test and shuttle tests ; health-related quality of life was assessed with St. George 's Respiratory Question naire . Psychological status was measured with Hospital Anxiety and Depression Scale . Body weight and body mass indexes ( BMI ) were also evaluated . Fat-free mass was measured through bioelectrical impedance analyser . The CSA of quadriceps was calculated in mid-level of the thigh with magnetic resonance imaging . RESULTS Dyspnoea and total scores of St. George 's Respiratory Question naire improved in both groups ( P < 0.05 ) . Six-minute walk test and incremental shuttle walk test distances in PRNS and PR patients increased significantly as ( 62.6 ± 42.4 m , 43.3 ± 59.2 m , both P = 0.001 ; and 63.3 ± 70.1 m and 69.3 ± 69.7 m , both P = 0.001 ) . Although anxiety improved in both groups ( P < 0.05 ) , there was no change in depression . Body weight , BMI and fat-free mass index ( FFMI ) ( 1.1 ± 0.9 kg , 0.2 ± 1.4 kg/m(2 ) and 0.6 ± 0.5 kg/m(2 ) , P < 0.05 ) in PRNS , whereas body weight and FFMI ( 0.6 ± 0.7 kg , 0.1 ± 0.6 kg/m(2 ) P < 0.05 ) increased in PR after the intervention . There was a significant increase in mid-thigh CSA ( 2.5 ± 4.1 cm(2 ) ) only in PRNS ( P = 0.04 ) . CONCLUSION The combination of NS with PR result ed in improvements particularly in lean body mass and mid-thigh CSA . This study suggests combining NS with PR in reversing weight loss and muscle wasting in COPD Background : The effects of providing ventilatory assistance to patients with severe chronic obstructive pulmonary disease ( COPD ) during a high intensity outpatient cycle exercise programme were examined . Methods : Nineteen patients ( 17 men ) with severe COPD ( mean ( SD ) forced expiratory volume in 1 second ( FEV1 ) 27 (7)% predicted ) underwent a 6 week supervised outpatient cycle exercise programme . Ten patients were r and omised to exercise with ventilatory assistance using proportional assist ventilation ( PAV ) and nine ( two women ) to exercise unaided . Before and after training patients performed a maximal symptom limited incremental cycle test to determine peak work rate ( Wpeak ) followed by a constant work rate ( CWR ) test at 70 % of Wpeak achieved in the baseline incremental test . Minute ventilation ( Ve ) , heart rate , and arterialised venous plasma lactate concentration [ La+ ] were measured before and after each test . Results : Mean training intensity ( Wt/Wpeak ) at 6 weeks was 15.2 % ( 95 % CI 3.2 to 27.1 ) higher in the group that used ventilatory assistance ( p=0.016 ) . Peak work rate after training was 18.4 % ( 95 % CI 6.4 to 30.5 ) higher ( p=0.005 ) in the assisted group ( p=0.09 ) . [ La+ ] at an identical workload after training was reduced by 30 % ( 95 % CI 16 to 44 ) in the assisted group ( p=0.002 compared with baseline ) and by 11 % ( 95 % CI –7 to 31 ) ( p=0.08 compared with baseline ) in the unassisted group ( mean difference 18.4 % ( 95 % CI 3.3 to 40 ) , p=0.09 ) . A significant inverse relationship was found between reduction in plasma lactate concentration ( ΔL ) at an equivalent workload after training during the CWR test and Wt/Wpeak achieved during the last week of training ( r=–0.7 , p=0.0006 ) . Conclusions : PAV enables a higher intensity of training in patients with severe COPD , leading to greater improvements in maximum exercise capacity with evidence of true physiological adaptation The addition of noninvasive positive pressure ventilation ( NPPV ) to an exercise training ( ET ) program in severe chronic obstructive pulmonary disease ( COPD ) may produce greater benefits in exercise tolerance and quality of life than after training alone . Forty-five patients with severe stable COPD -mean ( SD ) FEV(1 ) 0.96 ( 0.31 ) L , Pa(O(2 ) ) 65.4 ( 9.07 ) mm Hg , Pa(CO(2 ) ) 45.6 ( 7.89 ) mm Hg-were r and omized to domiciliary NPPV + ET ( n = 23 ) or ET alone ( n = 22 ) . Exercise capacity and health status were assessed at baseline and after an 8-wk training program . There was a significant improvement in mean shuttle walk test ( SWT ) in the NPPV + ET group : from 169 ( 112 ) to 269 ( 124 ) m ( p = 0.001 ) , compared with the ET group : 205 ( 100 ) to 233 ( 123 ) m ( p = 0.19 ) ; mean difference ( 95 % confidence interval [ CI ] ) : 72 ( 12.9 to 131 ) m. Repeated measures analysis of variance ( ANOVA ) showed that the differences between the two groups became evident only in the final 4 wk of the training program with a mean end study difference ( 95 % 1CI ) of 65.8 ( 17.1 to 114 ) m. There was a significant improvement in the Chronic Respiratory Disease Question naire ( CRDQ ) of mean ( SD ) 24.0 ( 17.4 ) ( p = < 0.001 ) in the NPPV + ET group and 11.8 ( 15.8 ) ( p = 0.003 ) points in the ET group ; mean difference : 12.3 ( 1.19 to 23.4 ) . Only the NPPV + ET group demonstrated a significant improvement in arterial oxygenation ; mean difference : 3.70 mm Hg ( 0.37 to 7.27 ) . This study suggests that domiciliary NPPV can be used successfully to augment the effects of rehabilitation in severe COPD BACKGROUND AND OBJECTIVE Skeletal muscle dysfunction contributes to exercise limitation in patients with chronic obstructive pulmonary disease ( COPD ) .  Strength training increases muscle strength and muscle mass , but there is an ongoing debate on the additional effect concerning the exercise capacity . The purpose of this study was to compare the effects of three different exercise modalities in patients with COPD including endurance training ( ET ) , progressive strength training ( ST ) and the combination of strength training and endurance training ( CT ) . DESIGN A prospect i ve r and omized trial . METHODS Thirty-six patients with COPD were r and omly allocated either to ET , ST , or CT .  Muscle strength , cardiopulmonary exercise testing , lung function testing and quality of life were assessed before and after a 12-week training period . RESULTS Exercise capacity ( Wmax ) increased significantly in all three training groups with increase of peak oxygen uptake ( VO2peak ) in all three groups , reaching statistical significance in the ET group and the CT group . Muscle strength ( leg press , bench press , bench pull ) improved in all three training groups , with a higher improvement in the ST ( + 39.3 % , + 20.9 % , + 20.3 % ) and the CT group ( + 43.3 % , + 18.1 % , + 21.6 % ) compared to the ET group ( + 20.4 % , + 6.4 % , + 12.1 % ) . CONCLUSIONS Progressive strength training alone increases not only muscle strength and quality of life , but also exercise capacity in patients with COPD , which may have implication s in prescription of training modality . CLINICAL TRIALS.GOV IDENTIFIER : NCT01091623 Purpose : This r and omized controlled trial examined the effect harmonica playing has on various clinical , psychosocial , and functional outcomes among chronic obstructive pulmonary disease ( COPD ) patients in pulmonary rehabilitation ( PR ) . Method : Twenty‐eight participants ( Age 69.9 ± 1.8 ; FEV1 Predicted 41.9 ± 2.0 % ) were recruited from an outpatient PR program . Participants were r and omly assigned to one of two groups , traditional PR ( C ; n = 16 ) or traditional PR plus harmonica playing ( HT ; n = 9 ) . The HT group was provided a harmonica and one‐on‐one instruction by PR staff . Patients were given practice exercises to perform for at least 5 minutes , but not exceeding 20 minutes twice/day , 5 days/week . Results : No significant differences were found between groups . The combined sample improved significantly in their perception of shortness of breath , quality of life , and distance walked in 6 minutes . Conclusion : Harmonica playing does not significantly affect the clinical , psychosocial , or functional status of COPD patients enrolled in PR OBJECTIVE To assess the effect of psychotherapy on the anxiety and depression levels of patients with chronic obstructive pulmonary disease ( COPD ) . DESIGN A blind , r and omized , controlled trial . SETTING Outpatient university pulmonary rehabilitation program in Brazil . PARTICIPANTS Thirty patients with COPD ( mean age , 60.33y ; 22 men ) attending a pulmonary rehabilitation program were r and omized into 2 groups : experimental group ( G1 ) and control group ( G2 ) . Both groups underwent a 12-week treatment program . INTERVENTIONS Group 1 ( n=14 ) participated in 24 sessions of physical exercise , 24 sessions of physiotherapy , 12 psychologic sessions , and 3 educational sessions . Group 2 did not participate in psychotherapy sessions . MAIN OUTCOME MEASURES All patients were evaluated at baseline and at completion of the pulmonary rehabilitation program by using 3 instruments : the Beck Anxiety Inventory ( BAI ) , Beck Depression Inventory ( BDI ) , and 6-minute walk distance ( 6MWD ) . RESULTS Both groups showed statistically significant improvements on the 6MWD ( G1 , P<.001 ; G2 , P=.03 ) . Only G1 had a significant reduction in anxiety and depression levels ( G1 : BAI , P<.001 ; BDI , P<.001 ; G2 : BAI , P=.156 ; BDI , P=.142 ) . Statistically significant differences existed between G1 and G2 for BAI ( P<.001 ) and BDI ( P=.02 ) . CONCLUSIONS Including psychotherapy in a pulmonary rehabilitation program for COPD reduced patients ' anxiety and depression levels but did not modify 6MWD performance The effects of additional target-flow inspiratory muscle training ( TF-IMT ) on the performance of the inspiratory muscles , on general exercise capacity , and on psychologic parameters during a pulmonary rehabilitation program ( PR ) were studied in 40 patients with COPD selected for ventilatory limitation during exercise . The mean age of the patients was 59 years , and the mean FEV1 was approximately 50 percent of predicted . All patients participated in a ten-week PR program . They were r and omized to receive either additional TF-IMT ( PR + IMT ) or not ( PR ) . The TF-IMT was performed by means of a target-flow resistive device ; the generated mouth pressure and the duration of inspiration and of the respiratory cycle were imposed . After the training period , maximal inspiratory mouth pressure and EMG-fatigability of the diaphragm were significantly better in the PR + IMT group than in the PR group . Maximal work load and psychologic symptoms increased to the same extent in both groups . The 12-minute walking distance also increased in both groups , but it increased significantly more in the PR + IMT group than in the PR group . We believe that additional TF-IMT during PR in a selected group of patients with COPD who have ventilatory limitation has an extra beneficial effect on the performance of the inspiratory muscles and on exercise performance PURPOSE Many patients with chronic obstructive pulmonary disease ( COPD ) report dyspnea and fatigue when performing upper limb activities . Unsupported upper limb training has been shown to improve upper limb endurance , but its effects on symptoms and quality of life have not been examined . The aim of this study was to compare the effects of upper limb and lower limb training with lower limb training alone on exercise capacity , symptoms , and quality of life with COPD . METHODS For this study , 38 patients with moderate to severe COPD were r and omly allocated to unsupported upper limb endurance training or to a control group that completed a sham training task . All the patients underwent lower limb endurance training . The 6-minute walk test , the Incremental Unsupported Upper Limb Exercise Test , and the Chronic Respiratory Disease Question naire ( CRQ ) were completed before training and then 6 weeks afterward . Both patients and assessors were blinded to group allocation . RESULTS All the patients reported symptoms associated with upper limb activities on the initial CRQ . Both groups showed significant improvements in all domains of the CRQ and in the 6-minute walk test after training . Only the upper limb training group showed improvement in upper limb endurance time ( 57 + /- 75 vs 2 + /- 58 seconds ; P = .02 ) . There were no significant differences between the groups for 6-minute walk test or any domain of the CRQ . CONCLUSIONS Unsupported upper limb training for patients COPD improves upper limb exercise capacity , but has no additional effect on symptoms or quality of life , as compared with leg training alone . This type of upper limb training may not adequately address the complex interaction between respiratory mechanics and upper limb function STUDY OBJECTIVES To study the short-term and long-term effects of combining activity training or lectures to exercise training on quality of life , functional status , and exercise tolerance . DESIGN R and omized clinical trial . SETTING Outpatient pulmonary rehabilitation center . PARTICIPANTS Forty-three out patients with COPD . INTERVENTIONS Patients were r and omized to one of three treatment groups : exercise training alone , exercise training plus activity training , and exercise training plus a lecture series . The mean treatment period was 10 weeks . MEASUREMENT The Chronic Respiratory Disease Question naire , the modified version of the Pulmonary Functional Status and Dyspnea Question naire , and the COPD Self-Efficacy Scale were administered at baseline , and 6 , 12 , 18 , and 24 weeks from the beginning of the rehabilitation program . The 6-min walk test was used to measure exercise tolerance . RESULTS Benefits of activity training combined with exercise included less dyspnea ( p < or = 0.04 ) and fatigue ( p < or = 0.01 ) , and increased activity involvement ( p < or = 0.02 ) and total functional status ( p < or = 0.02 ) in the short term compared to comparison treatment groups for comparatively older participants . Compared to the lecture series adjunct , the activity training adjunct result ed in significantly higher gains in total quality of life ( p = 0.04 ) maintained at 24 weeks . Significantly worse emotional function and functional status result ed from the lecture series adjunct in the oldest participants ( p < or = 0.03 ) . Treatment groups did not differ significantly on exercise tolerance or self-efficacy . CONCLUSIONS Evidence for additional benefits of activity-specific training combined with exercise was found . A behavioral method emphasizing structured controlled breathing and supervised physical activity was statistically significantly more effective than didactic instruction in facilitating additional gains and meeting participants ' learning needs Patients with chronic obstructive pulmonary disease ( COPD ) often develop weight loss , which is associated with increased mortality . Recombinant human growth hormone ( rhGH ) treatment has been proposed to improve nitrogen balance and to increase muscle strength in these patients . The aim of this study was to assess the effects of rhGH administration on the nutritional status , resting metabolism , muscle strength , exercise tolerance , dyspnea , and subjective well-being of underweight patients with stable COPD . Sixteen patients attending a pulmonary rehabilitation program ( age : 66 + /- 9 yr ; weight : 77 + /- 7 % of ideal body weight ; FEV1 : 39 + /- 13 % of predicted ) were r and omly treated daily with either 0.15 IU/kg rhGH or placebo during 3 wk in a double-blind fashion . Measurements were made at the beginning ( DO ) and at the end ( D21 ) of treatment and 2 mo later ( D81 ) . Body weight was similar in the two groups during the study , but lean body mass was significantly higher in the rhGH group at D21 ( p < 0.01 ) and D81 ( p < 0.05 ) . The increase in lean body mass was 2.3 + /- 1.6 kg in the rhGH group and 1.1 + /- 0.9 kg in the control group at D21 and 1.9 + /- 1.6 kg in the rhGH group and 0.7 + /- 2.1 kg in the control group at D81 . At D21 , the resting energy expenditure was increased in the rhGH group ( 107.8 % of DO , p < 0.001 compared with the control group ) . At D21 and D81 , the changes in maximal respiratory pressures , h and grip strength , maximal exercise capacity , and subjective well-being were similar in the two groups . At D21 , the 6-min walking distance decreased in the rhGH group ( -13 + /- 31 % ) and increased in the control group ( + 10 + /- 14 % ; p < 0.01 ) . We conclude that the daily administration of 0.15 IU/kg rhGH during 3 wk increases lean body mass but does not improve muscle strength or exercise tolerance in underweight patients with COPD BACKGROUND The aim of this work was to improve the efficacy of rehabilitation by retraining , by oral supply in branched-chain aminoacids ( BCAA ) .  Patients with chronic respiratory insufficiency mainly suffer from obstructive bronchitis due to tobacco or asthma .  Nutritional assessment is one of the components of respiratory rehabilitation , with retraining . Intense physical training for several days negativates the nitrogen balance , the beginning of a training programme for sedentary patients increases their need in proteins . An additional supply in branched-chain aminoacids increases proteic anabolism , by synthesis increase and catabolism slackening of proteins . Moreover it is known that exposure to high altitude reduces lean mass by inducing a muscular atrophy , which can be avoided by the BCAA provided . This leads to wonder if extra supply of BCAA could play similar role in muscular mass loss induced by pathological chronic hypoxia . METHODS The prospect i ve and comparative survey carried out in Toki-Eder ( private hospital in Cambo ) consisted in supplying ( during five weeks or more ) 30 retrained patients suffering from chronic obstructive bronchitis , and in matching them with 30 witnesses ( obstructive patients retrained without additional supply in BCAA ) . Their  mean hypoxemia  amounted to 7 torr for age . RESULTS Each of them improved their reached maximal power , and their VO2 SL , very highly significantly . Each of them developed a moderate metabolic acidosis ( whose possible mechanisms are discussed ) and slightly increased their ventilation at rest . On the other h and only the supplied patients improved their PaO2 at rest highly significantly , a result which poses the question of the responsible mechanism , most likely a decrease of pulmonary shunt effect . The hypotheses concerning the acid load due to BCAA ingestion are discussed . Only the supplied patients developed hypocapnia expressing a gaseous alkalosis which might be due to a direct effect of BCAA on the respiratory centers . CONCLUSIONS This observation could have practical outcomes in the management of rehabilitation of chronic respiratory insufficiency : it should be useful to systematic ally supplement the patients with BCAA during their retraining in order to obtain a more effective improvement of their respiratory function Different modalities of assisted ventilation improve breathlessness and exercise tolerance in patients with chronic obstructive pulmonary disease ( COPD ) . The aim of this study was to evaluate the effects of the addition of assisted ventilation during exercise training on the outcome of a structured pulmonary rehabilitation programme ( PRP ) in COPD patients . Thirty-three male patients with stable COPD ( mean ( SD ) forced expiratory volume in 1 s ( FEV1 ) 44 ( 16 ) % pred ) , without chronic ventilatory failure , undergoing a 6-week multidisciplinary outpatient PRP including exercise training , were r and omised to training during either mask proportional assist ventilation ( PAV : 18 patients ) or spontaneous breathing ( SB : 15 patients ) . Assessment included exercise tolerance , dyspnoea , leg fatigue , and health-related quality of life ( HRQL ) . Five out of 18 patients ( 28 % ) in the PAV group dropped out due to lack of compliance with the equipment . Both groups showed significant post-PRP improvements in exercise tolerance ( peak work rate difference : 20 ( 95 % Cl 2.4 - 37.6 ) and 14 ( 3.8 % CI to 24.2 ) W in PAV and SB group , respectively ) , dyspnoea and leg fatigue , but not in HRQL , without any significant difference between groups . It is concluded that with the modality and in the patients assessed in this study assisted ventilation during training sessions included in a multidisciplinary PRP was not well tolerated by all patients and gave no additional physiological benefit in comparison with exercise training alone STUDY OBJECTIVES Low body weight in COPD patients is associated with worsening dyspnea , reduced leg strength , and poor prognosis . Classical rehabilitation strategies are then limited by reduced exercise tolerance . Thus , we proposed to evaluate whether electrostimulation ( ES ) was a beneficial technique in the rehabilitation programs for severely deconditioned COPD patients after an acute exacerbation . DESIGN R and omized , controlled study . SETTING Pulmonary rehabilitation center . PATIENTS Seventeen patients with severe COPD ( mean [ + /- SD ] FEV(1 ) , 30 + /- 3 % predicted ) and low body mass index ( BMI ) [ 18 + /- 2.5 kg/m(2 ) ] . METHODS Patients were r and omly assigned either to usual rehabilitation ( UR ) alone or to a UR-plus-ES program for 4 weeks . Quadriceps muscle strength , total muscle mass ( MM ) , exercise capacity , and health-related quality of life were measured before and after rehabilitation . RESULTS The training with ES plus UR induced a significant twofold improvement in the mean number of maximal voluntary contraction ( MVC ) compared to UR alone ( 97 + /- 71 vs 36 + /- 34 contractions , respectively ; p = 0.03 ) and result ed in a more significant improvement in dyspnea when performing daily tasks ( decrease in the dyspnea domain score of the 28-item Maugeri Foundation Respiratory Failure question naire , -1.7 + /- 1.0 vs -0.2 + /- 1.2 points , respectively ; p = 0.05 ) . There was also a significant increase in walking distance ( 63 + /- 40 m ; p = 0.01 ) and BMI ( 0.6 + /- 0.5 kg/m(2 ) ; p = 0.02 ) after training in the ES + UR group . A significant relationship was found between changes in MVC and changes in MM after training in the ES + UR group ( r = 0.94 ; p = 0.03 ) . CONCLUSIONS The combination of ES and UR was associated with greater improvement in quadriceps strength and dyspnea during the performance of daily tasks than UR alone in severely disabled COPD patients with low BMI . In this population , ES has been revealed as a useful procedure , complementing the usual pulmonary rehabilitation The oxygen cost of eccentric exercise is lower than that of concentric exercise at similar work-loads . In this study , the response to eccentric cycle exercise training ( EET ) in addition to general exercise training ( GET ) on exercise performance and quality of life was investigated in 24 patients with severe chronic obstructive pulmonary disease ( COPD ) . All patients had a normal resting PaO2 and an arterial oxygen saturation ( SaO2 ) below 90 % at Wmax , achieved during a maximal incremental concentric cycle exercise test . The patients participated in a comprehensive inpatient pulmonary rehabilitation programme of 10 weeks . They were r and omly assigned either to GET ( GET group : mean FEV1 38 % predicted ) or to GET and additional EET ( GET/EET group : FEV1 45 % predicted ) . During EET , the patients were able to cycle eccentrically for 15 min continuously at a mean of 160 ( 69 % ) of Wmax whereas the Borg dyspnoea score did not exceed 3.0 and SaO2 did not fall below 90 % . Parameters of cardiocirculatory fitness and gas exchange improved in the GET/EET group but no further improvement in exercise capacity occurred compared to GET . It is concluded that eccentric cycle exercise is a safe and attractive training modality for patients with severe COPD and can be performed at a high intensity without the patient becoming out of breath or needing supplemental oxygen To examine the efficacy of targeted inspiratory muscle training ( IMT ) , 25 patients with moderate COPD were r and omly assigned to one of three groups . Eight patients received IMT along with general exercise reconditioning , GER+IMT ; nine patients received general exercise reconditioning , GER ; eight patients received sham breathing exercises , CONTROL . All groups used a spring-loaded inspiratory muscle trainer ; however , the GER and CONTROL groups breathed through these devices at only 15 % of their maximal inspiratory pressure . The GER+IMT group increased the load on these devices until at 6 wk the load was equal to 80 % of their maximal inspiratory pressure . All patients exercised three times per week for a 12-wk period in supervised sessions . Analysis of covariance revealed no significant differences in spirometric measurements , maximal inspiratory pressure , or maximal oxygen consumption among any of the three groups after the intervention ( p > 0.05 ) . Twelve-minute walk distance was significantly greater in the GER+IMT and GER groups than in the CONTROL group ( p = 0.03 ) . After the intervention , there was a trend ( p = 0.08 ) for treadmill time to be greater for the GER+IMT and GER groups than for the CONTROL group . Dyspnea ratings at different exercise intensities were not found to be significantly different among the three groups after the intervention . These results demonstrate that GER+IMT and GER alone are equally effective in improving exercise performance in patients with COPD . Additionally , the combination of GER and IMT does not appear to provide any clinical ly significant improvements in exercise performance or perceptions of dyspnea during exercise when compared with GER alone We compared , in a controlled clinical trial , the effect of specific inspiratory muscle training combined with general exercise reconditioning , for six months , with that of general exercise reconditioning alone on inspiratory muscle strength , endurance , and exercise performance in patients with COPD . Thirty-six patients were recruited into three groups ; 12 patients received specific inspiratory muscle training combined with general exercise reconditioning , 12 patients underwent general exercise reconditioning alone , and the remaining 12 patients received no training . Specific inspiratory muscle training , for six months , improved the inspiratory muscle strength and endurance in patients with COPD . This training combined with general exercise reconditioning also provided improvement in exercise tolerance , and this improvement was significantly greater than that of general exercise reconditioning alone STUDY OBJECTIVES Skeletal muscle weakness commonly occurs in patients with COPD . Long-term use of systemic glucocorticosteroids further contributes to muscle weakness . Anabolic steroids could be an additional mode of intervention to improve outcome of pulmonary rehabilitation by increasing physiologic functioning , possibly mediated by increasing erythropoietic function . PATIENTS AND METHODS We r and omly assigned 63 male patients with COPD to receive on days 1 , 15 , 29 , and 43 a deep IM injection of 50 mg of n and rolone decanoate ( ND ) [ Deca-Durabolin ; N.V. Organon ; Oss , The Netherl and s ] in 1 mL of arachis oil , or 1 mL of arachis oil alone ( placebo ) in a double-blind design . All patients participated in a st and ardized pulmonary rehabilitation program . Outcome measures were body composition by deuterium and bromide dilution , respiratory and peripheral muscle function , incremental exercise testing , and health status by the St. George 's Respiratory Question naire . RESULTS Treatment with ND relative to placebo result ed in higher increases in fat-free mass ( FFM ; mean , 1.7 kg [ SD , 2.5 ] vs 0.3 kg [ SD , 1.9 ] ; p = 0.015 ) owing to a rise in intracellular mass ( mean , 1.8 kg [ SD , 3.1 ] vs - 0.5 kg [ SD , 3.1 ] ; p = 0.002 ) . Muscle function , exercise capacity , and health status improved in both groups to the same extent . Only after ND were increases in erythropoietic parameters seen ( erythropoietin : mean , 2.08 U/L [ SD , 5.56 ] , p = 0.067 ; hemoglobin : mean , 0.29 mmol/L [ SD , 0.73 ] , p = 0.055 ) . In the total group , the changes in maximal inspiratory mouth pressure ( PImax ) and peak workload were positively correlated with the change in hemoglobin ( r = 0.30 , p = 0.032 , and r = 0.34 , p = 0.016 , respectively ) , whereas the change in isokinetic leg work was correlated with the change in erythropoietin ( r = 0.38 , p = 0.013 ) . In the patients receiving maintenance treatment with low-dose oral glucocorticosteroids ( 31 of 63 patients ; mean , 7.5 mg/24 h [ SD , 2.4 ] ) , greater improvements in PImax ( mean , 6.0 cm H(2)O [ SD , 8.82 ] vs - 2.18 cm H(2)O [ SD , 11.08 ] , p = 0.046 ) , and peak workload ( mean , 20.47 W [ SD , 19.82 ] vs 4.80 W [ SD , 7.74 ] , p = 0.023 ) were seen after 8 weeks of treatment with ND vs placebo . CONCLUSIONS In conclusion , a short-term course of ND had an overall positive effect relative to placebo on FFM without exp and ing extracellular water in patients with COPD . In the total group , the improvements in muscle function and exercise capacity were associated with improvements in erythropoietic parameters . The use of low-dose oral glucocorticosteroids as maintenance medication significantly impaired the response to pulmonary rehabilitation with respect to respiratory muscle function and exercise capacity , which could be restored by ND treatment PURPOSE : Chronic lung diseases are typically associated with impaired quality of life , stress , and anxiety . Written disclosure therapy ( WDT ) reduces stress in patients with a variety of chronic illnesses . We sought to determine whether WDT benefits patients with chronic lung disease . METHODS : A prospect i ve , r and omized , controlled trial was performed to evaluate the effect of using WDT in patients ( N = 66 ) participating in a pulmonary rehabilitation program . Patients were r and omly assigned to write about a particularly traumatic life event ( WDT group ) or to write about an emotionally neutral subject ( control group ) .  Exercise capacity , dyspnea and quality of life , and values of spirometry were recorded at baseline , at the end of the program , and at 6 months . RESULTS : The 6-minute walk distance ( 6MWD ) significantly improved in both groups at 2 months , from 278 to 327 m in WDT and from 269 to 314 m in control groups ( P < .01 in both groups ) . There was no difference in improvement in 6MWD between groups ( P = .88 ) . At 6 months , the gains made in 6MWD were no longer present . Dyspnea severity , as well as most of the other domains of the Chronic Respiratory Disease Question naire and the St. George 's Respiratory Question naire , showed improvement within each group , but not between WDT and control groups . CONCLUSION : WDT did not add any additional benefit in patients with chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis when included as a component of pulmonary rehabilitation . These results are in contrast to previously seen benefits in patients with asthma BACKGROUND Helium-hyperoxia ( HH ) reduces dyspnea and increases exercise tolerance in patients with COPD . We investigated whether breathing HH would allow patients to perform a greater intensity of exercise and improve the benefits of a pulmonary rehabilitation program . METHODS Thirty-eight nonhypoxemic patients with COPD ( FEV(1)=47 + /- 17%(pred ) ) were r and omized to rehabilitation breathing HH ( 60:40 He : O(2 ) ; n = 19 ) or air ( n = 19 ) . Patients cycled for 30 min , 3 days/week for 6 weeks breathing the assigned gas . Exercise intensity was prescribed from baseline , gas-specific , incremental exercise tests and was advanced as tolerated . The primary outcome was exercise tolerance assessed as a change in constant-load exercise time ( CLT ) following rehabilitation . Secondary outcomes were changes in exertional symptoms , health related quality of life ( as assessed by the Short-form 36 and St George respiratory question naires ) , and peak oxygen consumption during an incremental exercise test . RESULTS The HH group had a greater change in CLT following rehabilitation compared to the air group ( 9.5 + /- 9.1 vs 4.3 + /- 6.3 min , p < 0.05 ) . At an exercise isotime , dyspnea was significantly reduced in both groups , while leg discomfort only decreased in the HH group . The changes in exertional symptoms and peak oxygen consumption were not different between groups . Health-related quality of life significantly improved in both groups ; however , the change in St. George respiratory question naire total score was greater with HH ( -7.6 + /- 6.4 vs -3.6 + /- 5.6 , p < 0.05 ) . During rehabilitation , the HH group achieved a higher exercise intensity and training duration throughout the program ( p < 0.05 ) . CONCLUSIONS Breathing HH during pulmonary rehabilitation increases the intensity and duration of exercise training that can be performed and results in greater improvements in CLT for patients with COPD
target: Meta- analysis revealed few clinical ly relevant and statistically significant benefits of " add-on " therapies on exercise performance compared with exercise training .
background: The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease ( COPD ) .