Abstract
Pulmonary rehabilitation incorporating exercise training is an effective method of enhancing physiological function and quality of life for patients with chronic obstructive pulmonary disease (COPD). Despite the traditional belief that exercise is primarily limited by the inability to adequately increase ventilation to meet increased metabolic demands in these patients, significant deficiencies in muscle function, oxygen delivery and cardiac function are observed that contribute to exercise limitation. Because of this multifactorial exercise limitation, defining appropriate exercise training intensities is difficult. The lack of a pure cardiovascular limitation to exercise prohibits the use of training guidelines that are based on cardiovascular factors such as oxygen consumption or heart rate.
Current recommendations for exercise training intensity for patients with COPD include exercising at a ‘maximally tolerable level’, at an intensity corresponding with 50% of peak oxygen consumption (VO2peak), or at 60–80% of peak power output obtained on a symptom-limited exercise tolerance test. In general, it appears that higher intensity training elicits greater physiological change than lower intensity training; however, there is no consensus as to the exercise training intensity that elicits the greatest physiological benefit while remaining tolerable to patients.
The ‘optimal’ intensity of training likely depends upon the individual goals of each patient. If the goal is to increase the ability to sustain tasks that are currently able to be performed, lower to moderate-intensity training is likely to be sufficient. If the goal of training, however, is to increase the ability to perform tasks that are above the current level of tolerance, higher intensity training is likely to elicit greater performance increases. In order to perform higher intensity exercise, an interval training model is likely required. High-intensity interval training involves significant anaerobic energy utilisation and, therefore, may better mimic the physiological requirements of activities of daily living. Also, high-intensity interval training is tolerable to patients and may, in fact, reduce the degree of dyspnoea and dynamic hyperinflation through a reduced ventilatory demand. Another factor that will determine the optimal intensity of training is the relative contribution of ventilatory limitation to exercise tolerance. If peak exercise tolerance is limited by a patient’s ability to increase ventilation, it is possible that interval training at an intensity higher than peak will elicit greater muscular adaptation than an intensity at or below peak power on an incremental exercise test. More research is required to determine the optimal training intensity for pulmonary rehabilitation patients.
Similar content being viewed by others
References
American Thoracic Society. Pulmonary rehabilitation — 1999: an official statement of the American Thoracic Society. Am J Respir Crit Care Med 1999; 159: 1666–1682
Noseda A, Capiaux J-P, Schmerber J, et al. Dyspnea and flow-volume curve during exercise in COPD patients. Eur Respir J 1994; 7: 279–285
Ries AJ, Archibald CJ. Endurance exercise training at maximal targets in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 1987; 7: 594–601
Gigliotti F, Coli C, Bianchi R, et al. Exercise training improves exertional dyspnea in patients with COPD. Chest 2003; 123: 1794–1802
Casaburi R. Exercise training in chronic obstructive pulmonary disease. In: Casaburi R, Petty TL, editors. Principles and practice of pulmonary rehabilitation. Philadelphia (PA): WB Saunders Co., 1993: 204–224
Casaburi R. Special considerations for exercise training. In: American College of Sports Medicine. ACSM’s resource manual for guidelines for exercise testing and prescription. 4th ed. Baltimore (MD): Lippincott Williams and Wilkins, 2001: 346–354
Cherniak EP. Pulmonary rehabilitation in the elderly. In: Cherniak NS, Altose MD, Homma I, editors. Rehabilitation of the patient with respiratory disease. New York: McGraw-Hill, 1999: 445–454
Casaburi R, Patessio A, Ioli F, et al. Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis 1991; 143: 9–18
Casaburi R, Porszasz J, Burns MR, et al. Physiologic benefits of exercise training in rehabilitation of patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155: 1541–1551
Vogiatzis I, Nanas S, Roussos CH. Interval training as an alternative modality to continuous exercise in patients with COPD. Eur Respir J 2002; 20: 12–19
Rooyackers JM, Folgering HTM. Cardio-respiratory load of exercise training in patients with severe COPD. Int J Rehabil Res 1998; 21: 259–271
Neder JA, Jones PW, Nery LE, et al. Determinants of the exercise endurance capacity in patients with chronic obstructive pulmonary disease: the power-duration relationship. Am J Respir Crit Care Med 2000; 162: 497–504
Gimenez M, Servera E, Vergara P, et al. Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity. Arch Phys Med Rehabil 2000; 81: 102–109
Wasserman K, Casaburi R. Acid-base regulation during exercise in humans. In: Whipp BJ, Wasserman K, editors. Exercise: pulmonary physiology and pathophysiology. New York: Marcel Dekker Inc., 1991: 405–448
Wasserman K, Stringer WW. Homeostasis of exercise gas exchange: coupling of pulmonary and cardiovascular function to cellular respiration during exercise. In: Scharf SM, Pinsky MR, Magder S, editors. Respiratory-circulatory interactions in health and disease. New York: Marcel Dekker Inc., 2002: 219–255
Nici L. Mechanisms and measures of exercise intolerance in chronic obstructive pulmonary disease. Clin Chest Med 2000; 21: 693–704
Maltais F, Jobin J, Sullivan MJ, et al. Metabolic and hemodynamic responses of lower limb during exercise in patients with COPD. J Appl Physiol 1998; 84: 1573–1580
Simon M, LeBlanc P, Jobin J, et al. Limitation of lower limb VO2 during cycling exercise in COPD patients. J Appl Physiol 2001; 90: 1013–1019
Richardson RS, Sheldon J, Poole DC, et al. Evidence of skeletal muscle metabolic reserve during whole body exercise in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 881–885
Bernard S, LeBlanc P, Whittom F, et al. Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158: 629–634
Serres I, Gautier V, Varray A, et al. Impaired skeletal muscle endurance related to physical inactivity and altered lung function in COPD patients. Chest 1998; 113: 900–905
Maltais F, Simard AA, Simard C, et al. Oxidative capacity of the skeletal muscle and lactic acid kinetics during exercise in normal subjects and in patients with COPD. Am J Respir Crit Care Med 1996; 153: 288–293
Aliverti A, Macklem PT. How and why exercise is impaired in COPD. Respiration 2001; 68: 229–239
American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 6th ed. Philadelphia (PA): Lippincott Williams and Wilkins, 2000
Alpert JS, Bass H, Szucs MM, et al. Effects of physical training on hemodynamics and pulmonary function at rest and during exercise in patients with chronic obstructive pulmonary disease. Chest 1974; 66: 647–651
Casaburi R. Limitation to exercise tolerance in chronic obstructive pulmonary disease: look to the muscles of ambulation. Am J Respir Crit Care Med 2003; 168: 409–414
Saey D, Debigare R, LeBlanc P. Contractile leg fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2003; 168: 425–430
O’Donnell DE, Revill SM, Webb KA. Dynamic hyperinflation and exercise intolerance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 164: 770–777
Foglio K, Carone M, Pagani M, et al. Physiological and symptom determinants of exercise performance in patients with chronic airway obstruction. Resp Med 2000; 94: 256–263
Johnson BD, Weisman IM, Zeballos RJ, et al. Emerging concepts in the evaluation of ventilatory limitation during exercise: the exercise tidal flow-volume loop. Chest 1999; 116: 488–503
Sietsema K. Cardiovascular limitations in chronic pulmonary disease. Med Sci Sports Exerc 2001; 33 Suppl. 7: 656–661
Maltais F, LeBlanc P, Jobin J, et al. Peripheral muscle dysfunction in chronic obstructive pulmonary disease. Clin Chest Med 2000; 21: 665–677
Casaburi R. Skeletal muscle dysfunction in chronic obstructive pulmonary disease. Med Sci Sports Exerc 2001; 33 Suppl. 7: 662–670
Killian KJ, LeBlanc P, Martin DH, et al. Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. Am Rev Respir Dis 1992; 146: 935–940
O’Donnell DE. Ventilatory limitations in chronic obstructive pulmonary disease. Med Sci Sports Exerc 2001; 33 Suppl. 7: 647–655
American Thoracic Society, American College of Chest Physicians. ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 2003; 167: 211–277
Oelberg DA, Kacmarek RM, Pappagianopoulos PP, et al. Ventilatory and cardiovascular responses to inspired He-O2 during exercise in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158: 1876–1882
Jobin J, Maltais F, Doyon J-F, et al. Chronic obstructive pulmonary disease: capillarity and fiber-type characteristics of skeletal muscle. J Cardiopulm Rehabil 1998; 18: 432–437
Matthews JI, Bush BA, Ewald FW. Exercise responses during incremental and high intensity and low intensity steady state exercise in patients with obstructive lung disease and normal control subjects. Chest 1989; 96: 11–17
Carter R, Holiday DB, Stocks J, et al. Peak physiologic responses to arm and leg ergometry in male and female patients with airflow obstructions. Chest 2003; 124: 511–518
Lewis MI, Belman MJ, Monn SA, et al. The relationship between oxygen consumption and work rate in patients with airflow obstruction. Chest 1994; 106: 366–372
Levison H, Cherniak RM. Ventilatory cost of exercise in chronic obstructive pulmonary disease. J Appl Physiol 1968; 25: 21–27
Brooks GA, Fahey TD, White TP, et al. Exercise physiology: human bioenergetics and its applications. 3rd ed. London: Mayfield Publishing Company, 2000
Oelberg DA, Medoff BD, Markowitz DH, et al. Systemic oxygen extraction during incremental exercise in patients with severe chronic obstructive pulmonary disease. Eur J Appl Physiol 1998; 78: 201–207
Killian KJ. Dyspnea: implications for rehabilitation. In: Casaburi R, Petty TL, editors. Principles and practice of pulmonary rehabilitation. Philadelphia (PA): WB Saunders Co., 1993: 103–114
Marin JM, Carrizo SJ, Gascon M, et al. Inspiratory capacity, dynamic hyperinflation, breathlessness, and exercise performance during the 6 minute walk test in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 163: 1395–1399
Medoff BD, Oelberg DA, Kanarek DJ, et al. Breathing reserve at the lactate threshold to differentiate a pulmonary mechanical from cardiovascular limit to exercise. Chest 1998; 113: 913–918
Diaz O, Villafranca C, Ghezzo H, et al. Role of inspiratory capacity on exercise tolerance in COPD patients with and without tidal expiratory flow limitation at rest. Eur Respir J 2000; 16: 269–275
Sliwinski P, Kaminski D, Zielinski J, et al. Partitioning of the elastic work of inspiration in patients with COPD during exercise. Eur Respir J 1998; 11: 416–421
American Thoracic Society, European Respiratory Society. Skeletal muscle dysfunction in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159 Suppl.: 1–40
Zacarias EC, Neder JA, Cendom SP, et al. Heart rate at the estimated lactate threshold in patients with chronic obstructive pulmonary disease: effects on the target intensity for dynamic exercise training. J Cardiopulm Rehabil 2000; 20: 369–376
Gosselink R, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med 1996; 153: 976–980
Troosters T, Gosselink R, Rollier H, et al. Change in lower limb muscle strength contributes to altered six minute walking distance in COPD. Eur Respir J 1996; 9: 144s
Harms CA, Wetter TJ, McClaran SR, et al. Effects of respiratory muscle work on cardiac output and its distribution during maximal exercise. J Appl Physiol 1998; 85: 609–618
Harms CA, Babcock MA, McClaran SR, et al. Respiratory muscle work compromises leg blood flow during maximal exercise. J Appl Physiol 1997; 82: 1573–1583
Maltais F, Simon M, Jobin J, et al. Effects of oxygen on lower limb blood flow and O2 uptake during exercise in COPD. Med Sci Sports Exerc 2001; 33: 916–922
Simmons DN, Berry MJ, Hayes SI, et al. The relationship between %HRpeak and %VO2peak in patients with chronic obstructive pulmonary disease. Med Sci Sports Exerc 2000; 32: 881–886
Brolin SE, Cecins NM, Jenkins SC. Questioning the use of heart rate and dyspnea in the prescription of exercise in subjects with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2003; 23: 228–234
Horowitz MB, Mahler DA. Dyspnea ratings for prescription of cross modal exercise in patients with COPD. Chest 1998; 113: 60–64
Punzal PA, Ries AL, Kaplan RM, et al. Maximum intensity exercise training in patients with chronic obstructive pulmonary disease. Chest 1991; 100: 618–623
Vellos M, Garcia Stella S, Cendon S, et al. Metabolic and ventilatory parameters of four activities of daily living accomplished with arms in COPD patients. Chest 2003; 123: 1047–1053
Serres I, Varray A, Vallet G, et al. Improved skeletal muscle performance after individualized exercise training in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 1997; 17: 232–238
Vogiatzis I, Williamson AF, Miles J, et al. Physiological response to moderate exercise workloads in a pulmonary rehabilitation program in patients with varying degrees of airflow obstruction. Chest 1999; 116: 1200–1207
Ries AL, Kaplan RM, Limberg TM, et al. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995; 122: 823–832
Maltais F, LeBlanc P, Simard C, et al. Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 154: 442–447
Maltais F, LeBlanc P, Jobin J, et al. Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155: 555–561
Otsuka T, Kurihara N, Fujii T, et al. Effect of exercise training and detraining on gas exchange kinetics in patients with chronic obstructive pulmonary disease. Clin Physiol 1997; 17: 287–297
Bernard S, Whittom F, LeBlanc P, et al. Aerobic and strength training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 896–901
Puente-Maestu L, Tena T, Trascasa C, et al. Training improves muscle oxidative capacity and oxygenation recovery kinetics in patients with chronic obstructive pulmonary disease. Eur J Appl Physiol 2003; 88: 580–587
Patesso A, Carone M, Ioli F, et al. Ventilatory and metabolic changes as a result of exercise training in COPD patients. Chest 1992; 101 Suppl. 5: 274–278
Clark CJ, Cochrane L, Mackay E. Low intensity peripheral muscle conditioning improves exercise tolerance and breath- lessness in COPD. Eur Respir J 1996; 9: 2590–2596
Vallet G, Ahmaidi S, Serres I, et al. Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols. Eur Respir J 1997; 10: 114–122
McArdle WD, Katch FI, Katch VL. Essentials of exercise physiology. 2nd ed. Philadelphia (PA): Lippincott Williams and Wilkins, 2000
Puente-Maestu L, Sanz ML, Sanz P, et al. Reproducibility of the parameters of the on-transient cardiopulmonary responses during moderate exercise in patients with chronic obstructive pulmonary disease. Eur J Appl Physiol 2001; 85: 434–441
Puente-Maestu L, Sanz ML, Sanz P, et al. Effects of two types of training on pulmonary and cardiac responses to moderate exercise in patients with COPD. Eur Respir J 2000; 15: 1026–1032
Coppoolse R, Schols AMWJ, Baarends EM, et al. Interval versus continuous training in patients with severe COPD: a randomized clinical trial. Eur Respir J 1999; 14: 258–263
Laursen PB, Jenkins DG. The scientific basis for high-intensity interval training. Sports Med 2002; 32: 53–73
Poole DC, Gaesser GA. Response of ventilatory and lactate thresholds to continuous and interval training. J Appl Physiol 1985; 58: 1115–1121
Tabata I, Nishimura K, Kouzaki M, et al. Effects of moderate intensity endurance and high intensity intermittent training on anaerobic capacity and VO2max. Med Sci Sports Exerc 1996; 28: 1327–1330
Burke J, Thayer R, Belcamino M. Comparison of effects of two interval training programmes on lactate and ventilatory thresholds. Br J Sports Med 1994; 28: 18–21
Vogiatzis I, Nanas S, Kastanakis E, et al. Dynamic hyperinflation and tolerance to interval exercise in patients with advanced COPD. Eur Respir J 2004; 24: 385–390
Meyer K, Samek L, Schwaibold M, et al. Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures. Med Sci Sports Exerc 1997; 29: 306–312
Gosker HR, Lencer NHMK, Franssen FME, et al. Striking similarities in systemic factors contributing to decreased exercise capacity in patients with severe chronic heart failure or COPD. Chest 2003; 123: 1416–1424
Bompa TO. Periodization: theory and methodology of training. 4th ed. Champaign (IL): Human Kinetics, 1999
Acknowledgements
Mr Butcher is supported by a Canadian Lung Association — Canadian Physiotherapy Cardiorespiratory Society Fellowship. The authors disclose that they have no conflicts of interest related to the contents of this manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Butcher, S.J., Jones, R.L. The Impact of Exercise Training Intensity on Change in Physiological Function in Patients with Chronic Obstructive Pulmonary Disease. Sports Med 36, 307–325 (2006). https://doi.org/10.2165/00007256-200636040-00003
Published:
Issue Date:
DOI: https://doi.org/10.2165/00007256-200636040-00003