Exercise Training in Pulmonary Rehabilitation

  • Chris Burtin
  • Richard ZuWallackEmail author


Higher levels of exercise capacity and physical activity are each independently related to health in individuals in general and COPD patients in particular [1]. Exercise and physical activity, however, while sharing some features, are separate concepts: exercise is considered a subset of physical activity. Physical activity refers to any bodily movement produced by skeletal muscles that results in energy expenditure. In contrast, exercise is planned, structured, typically repetitive, and done with a particular goal in mind [2]. Increases in both exercise capacity and physical activity are important goals of pulmonary rehabilitation, although the methods (and success) of achieving these goals are different.


  1. 1.
    Garcia-Rio F, Rojo B, Casitas R, Lores V, Madero R, Romero D, Galera R, Villasante C. Prognostic value of the objective measurement of daily physical activity in copd patients. Chest. 2012;142(2):338–46.CrossRefPubMedGoogle Scholar
  2. 2.
    Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100:126–31.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Spruit MA, Singh SJ, Garvey C, Zuwallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, Pitta F, Sewell L, Raskin J, Bourbeau J, Crouch R, Franssen FM, Casaburi R, Vercoulen JH, Vogiatzis I, Gosselink R, Clini EM, Effing TW, Maltais F, van der Palen J, Troosters T, Janssen DJ, Collins E, Garcia-Aymerich J, Brooks D, Fahy BF, Puhan MA, Hoogendoorn M, Garrod R, Schols AM, Carlin B, Benzo R, Meek P, Morgan M, Rutten-van Molken MP, Ries AL, Make B, Goldstein RS, Dowson CA, Brozek JL, Donner CF, Wouters EF. An official american thoracic society/european respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188:e13–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Breyer MK, Breyer-Kohansal R, Funk GC, Dornhofer N, Spruit MA, Wouters EF, Burghuber OC, Hartl S. Nordic walking improves daily physical activities in copd: A randomised controlled trial. Respir Res. 2010;11:112.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Andrianopoulos V, Klijn P, Franssen FM, Spruit MA. Exercise training in pulmonary rehabilitation. Clin Chest Med. 2014;35:313–22.CrossRefPubMedGoogle Scholar
  6. 6.
    Normandin EA, McCusker C, Connors M, Vale F, Gerardi D, ZuWallack RL. An evaluation of two approaches to exercise conditioning in pulmonary rehabilitation. Chest. 2002;121:1085–91.CrossRefPubMedGoogle Scholar
  7. 7.
    Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF, Wasserman K. 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.CrossRefPubMedGoogle Scholar
  8. 8.
    Mador MJ, Patel AN, Nadler J. Effects of pulmonary rehabilitation on activity levels in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 2011;31:52–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Polkey MI, Rabe KF. Chicken or egg: Physical activity in copd revisited. Eur Respir J. 2009;33:227–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Sala E, Roca J, Marrades RM, Alonso J, Gonzalez De Suso JM, Moreno A, Barbera JA, Nadal J, de Jover L, Rodriguez-Roisin R, Wagner PD. Effects of endurance training on skeletal muscle bioenergetics in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159:1726–34.CrossRefPubMedGoogle Scholar
  11. 11.
    Bernard S, Whittom F, Leblanc P, Jobin J, Belleau R, Berube C, Carrier G, Maltais F. Aerobic and strength training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159:896–901.CrossRefPubMedGoogle Scholar
  12. 12.
    Maltais F, LeBlanc P, Simard C, Jobin J, Berube C, Bruneau J, Carrier L, Belleau R. Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1996;154:442–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Franssen FM, Broekhuizen R, Janssen PP, Wouters EF, Schols AM. Effects of whole-body exercise training on body composition and functional capacity in normal-weight patients with copd. Chest. 2004;125:2021–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Spruit MA, Gosselink R, Troosters T, De Paepe K, Decramer M. Resistance versus endurance training in patients with copd and peripheral muscle weakness. Eur Respir J. 2002;19:1072–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Maltais F, Simard AA, Simard C, Jobin J, Desgagnes P, LeBlanc P. 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;153:288–93.CrossRefPubMedGoogle Scholar
  16. 16.
    O’Donnell DE. Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2006;3:180–4.CrossRefPubMedGoogle Scholar
  17. 17.
    Somfay A, Porszasz J, Lee SM, Casaburi R. Effect of hyperoxia on gas exchange and lactate kinetics following exercise onset in nonhypoxemic copd patients. Chest. 2002;121:393–400.CrossRefPubMedGoogle Scholar
  18. 18.
    Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Am J Respir Crit Care Med. 2003;168:1034–42.CrossRefPubMedGoogle Scholar
  19. 19.
    Aliverti A, Macklem PT. The major limitation to exercise performance in copd is inadequate energy supply to the respiratory and locomotor muscles. J Appl Physiol. 2008;105:749–51; discussion 755–747CrossRefPubMedGoogle Scholar
  20. 20.
    Debigare R, Maltais F. The major limitation to exercise performance in copd is lower limb muscle dysfunction. J Appl Physiol. 2008;105:751–3. discussion 755-757CrossRefPubMedGoogle Scholar
  21. 21.
    O’Donnell DE, Webb KA. The major limitation to exercise performance in copd is dynamic hyperinflation. J Appl Physiol. 2008;105:753–5; discussion 755-757CrossRefPubMedGoogle Scholar
  22. 22.
    Garcia-Aymerich J, Hernandez C, Alonso A, Casas A, Rodriguez-Roisin R, Anto JM, Roca J. Effects of an integrated care intervention on risk factors of copd readmission. Respir Med. 2007;101:1462–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Nici L, ZuWallack R. They can’t bury you while you’re still moving: A review of the european respiratory society statement on physical activity in chronic obstructive pulmonary disease. Pol Arch Med Wewn. 2015;125:771–8.PubMedGoogle Scholar
  24. 24.
    Nici L, ZuWallack R. Chronic obstructive pulmonary disease-evolving concepts in treatment: advances in pulmonary rehabilitation. Semin Respir Crit Care Med. 2015;36:567–74.CrossRefPubMedGoogle Scholar
  25. 25.
    Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal oxygen therapy trial group. Ann Intern Med 1980;93:391–398.Google Scholar
  26. 26.
    Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B, Rochester CL, Zuwallack R, Herrerias C. Pulmonary rehabilitation: Joint accp/aacvpr evidence-based clinical practice guidelines. Chest. 2007;131:4S–42S.CrossRefPubMedGoogle Scholar
  27. 27.
    Somfay A, Porszasz J, Lee SM, Casaburi R. Dose-response effect of oxygen on hyperinflation and exercise endurance in nonhypoxaemic copd patients. Eur Respir J. 2001;18:77–84.CrossRefPubMedGoogle Scholar
  28. 28.
    Hill KHA. Strategies to enhance the benefits of exercise training in the respiratory patient. Clin Chest Med. 2013;35:323–36.CrossRefGoogle Scholar
  29. 29.
    Ferreira IM, Verreschi IT, Nery LE, Goldstein RS, Zamel N, Brooks D, Jardim JR. The influence of 6 months of oral anabolic steroids on body mass and respiratory muscles in undernourished copd patients. Chest. 1998;114:19–28.CrossRefPubMedGoogle Scholar
  30. 30.
    Schols AM, Soeters PB, Mostert R, Pluymers RJ, Wouters EF. Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary disease. A placebo-controlled randomized trial. Am J Respir Crit Care Med. 1995;152:1268–74.CrossRefPubMedGoogle Scholar
  31. 31.
    Yeh SS, DeGuzman B, Kramer T. Reversal of COPD-associated weight loss using the anabolic agent oxandrolone. Chest. 2002;122:421–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Burdet L, de Muralt B, Schutz Y, Pichard C, Fitting JW. Administration of growth hormone to underweight patients with chronic obstructive pulmonary disease. A prospective, randomized, controlled study. Am J Respir Crit Care Med. 1997;156:1800–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Pape GS, Friedman M, Underwood LE, Clemmons DR. The effect of growth hormone on weight gain and pulmonary function in patients with chronic obstructive lung disease. Chest. 1991;99:1495–500.CrossRefPubMedGoogle Scholar
  34. 34.
    Dolmage TE, Goldstein RS. Response to one-legged cycling in patients with copd. Chest. 2006;129:325–32.CrossRefPubMedGoogle Scholar
  35. 35.
    Dolmage TE, Goldstein RS. Effects of one-legged exercise training of patients with copd. Chest. 2008;133:370–6.CrossRefPubMedGoogle Scholar
  36. 36.
    Evans RA, Dolmage TE, Mangovski-Alzamora S, Romano J, O’Brien L, Brooks D, Goldstein RS. One-legged cycle training for chronic obstructive pulmonary disease. A pragmatic study of implementation to pulmonary rehabilitation. Ann Am Thorac Soc. 2015;12:1490–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Corner E, Garrod R. Does the addition of non-invasive ventilation during pulmonary rehabilitation in patients with chronic obstructive pulmonary disease augment patient outcome in exercise tolerance? A literature review. Physiother Res Int. 2010;15:5–15.PubMedGoogle Scholar
  38. 38.
    Janaudis-Ferreira T, Hill K, Goldstein R, Wadell K, Brooks D. Arm exercise training in patients with chronic obstructive pulmonary disease: a systematic review. J Cardiopulm Rehabil Prev. 2009;29:277–83.CrossRefPubMedGoogle Scholar
  39. 39.
    Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP. American college of sports medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43:1334–59.CrossRefPubMedGoogle Scholar
  40. 40.
    Probst VS, Kovelis D, Hernandes NA, Camillo CA, Cavalheri V, Pitta F. Effects of 2 exercise training programs on physical activity in daily life in patients with copd. Respir Care. 2011;56:1799–807.CrossRefPubMedGoogle Scholar
  41. 41.
    Vogiatzis I, Nanas S, Roussos C. Interval training as an alternative modality to continuous exercise in patients with copd. Eur Respir J. 2002;20:12–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Sabapathy S, Kingsley RA, Schneider DA, Adams L, Morris NR. Continuous and intermittent exercise responses in individuals with chronic obstructive pulmonary disease. Thorax. 2004;59:1026–31.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Varga J, Porszasz J, Boda K, Casaburi R, Somfay A. Supervised high intensity continuous and interval training vs. Self-paced training in copd. Respir Med. 2007;101:2297–304.CrossRefPubMedGoogle Scholar
  44. 44.
    Kortianou EA, Nasis IG, Spetsioti ST, Daskalakis AM, Vogiatzis I. Effectiveness of interval exercise training in patients with copd. Cardiopulm Phys Ther J. 2010;21:12–9.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Vogiatzis I, Terzis G, Nanas S, Stratakos G, Simoes DC, Georgiadou O, Zakynthinos S, Roussos C. Skeletal muscle adaptations to interval training in patients with advanced copd. Chest. 2005;128:3838–45.CrossRefPubMedGoogle Scholar
  46. 46.
    Tidball JG. Mechanisms of muscle injury, repair, and regeneration. Compr Physiol. 2011;1:2029–62.PubMedGoogle Scholar
  47. 47.
    Rocha Vieira DS, Baril J, Richard R, Perrault H, Bourbeau J, Taivassalo T. Eccentric cycle exercise in severe copd: feasibility of application. COPD. 2011;8:270–4.CrossRefPubMedGoogle Scholar
  48. 48.
    Camillo CA, Burtin C, Hornikx M, Demeyer H, De Bent K, van Remoortel H, Osadnik CR, Janssens W, Troosters T. Physiological responses during downhill walking: a new exercise modality for subjects with chronic obstructive pulmonary disease? Chron Respir Dis. 2015;12:155–64.CrossRefPubMedGoogle Scholar
  49. 49.
    Klijn P, van Keimpema A, Legemaat M, Gosselink R, van Stel H. Nonlinear exercise training in advanced chronic obstructive pulmonary disease is superior to traditional exercise training. A randomized trial. Am J Respir Crit Care Med. 2013;188:193–200.CrossRefPubMedGoogle Scholar
  50. 50.
    Gloeckl R, Marinov B, Pitta F. Practical recommendations for exercise training in patients with copd. Eur Respir Rev. 2013;22:178–86.CrossRefPubMedGoogle Scholar
  51. 51.
    Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14:377–81.PubMedGoogle Scholar
  52. 52.
    Probst VS, Troosters T, Pitta F, Decramer M, Gosselink R. Cardiopulmonary stress during exercise training in patients with copd. Eur Respir J. 2006;27:1110–8.CrossRefPubMedGoogle Scholar
  53. 53.
    O’Shea SD, Taylor NF, Paratz J. Peripheral muscle strength training in copd: a systematic review. Chest. 2004;126:903–14.CrossRefPubMedGoogle Scholar
  54. 54.
    Gloeckl R, Heinzelmann I, Kenn K. Whole body vibration training in patients with copd: a systematic review. Chron Respir Dis. 2015;12:212–21.CrossRefPubMedGoogle Scholar
  55. 55.
    Ortega F, Toral J, Cejudo P, Villagomez R, Sanchez H, Castillo J, Montemayor T. Comparison of effects of strength and endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2002;166:669–74.CrossRefPubMedGoogle Scholar
  56. 56.
    McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2:CD003793.Google Scholar
  57. 57.
    Iepsen UW, Jorgensen KJ, Ringbaek T, Hansen H, Skrubbeltrang C, Lange P. A combination of resistance and endurance training increases leg muscle strength in copd: an evidence-based recommendation based on systematic review with meta-analyses. Chron Respir Dis. 2015;12:132–45.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Sillen MJ, Speksnijder CM, Eterman RM, Janssen PP, Wagers SS, Wouters EF, Uszko-Lencer NH, Spruit MA. Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with chronic heart failure or copd: a systematic review of the english-language literature. Chest. 2009;136:44–61.CrossRefPubMedGoogle Scholar
  59. 59.
    Beauchamp MK, O’Hoski S, Goldstein RS, Brooks D. Effect of pulmonary rehabilitation on balance in persons with chronic obstructive pulmonary disease. Arch Phys Med Rehabil. 2010;91:1460–5.CrossRefPubMedGoogle Scholar
  60. 60.
    Troosters T, Probst VS, Crul T, Pitta F, Gayan-Ramirez G, Decramer M, Gosselink R. Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2010;181:1072–7.CrossRefPubMedGoogle Scholar
  61. 61.
    Neder JA, Sword D, Ward SA, Mackay E, Cochrane LM, Clark CJ. Home based neuromuscular electrical stimulation as a new rehabilitative strategy for severely disabled patients with chronic obstructive pulmonary disease (copd). Thorax. 2002;57:333–7.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;1:CD005305.Google Scholar
  63. 63.
    Vanfleteren LE, Spruit MA, Groenen M, Gaffron S, van Empel VP, Bruijnzeel PL, Rutten EP, Op’t Roodt J, Wouters EF, Franssen FM. Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013;187:728–35.CrossRefPubMedGoogle Scholar
  64. 64.
    Divo M, Cote C, de Torres JP, Casanova C, Marin JM, Pinto-Plata V, Zulueta J, Cabrera C, Zagaceta J, Hunninghake G, Celli B, Group BC. Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186:155–61.CrossRefPubMedGoogle Scholar
  65. 65.
    Mesquita R, Vanfleteren LE, Franssen FM, Sarv J, Taib Z, Groenen MT, Gaffron S, Bruijnzeel PL, Pitta F, Wouters EF, Spruit MA. Objectively identified comorbidities in copd: Impact on pulmonary rehabilitation outcomes. Eur Respir J. 2015;46:545–8.CrossRefPubMedGoogle Scholar
  66. 66.
    Maltais F, Bourbeau J, Lacasse Y, Shapiro S, Perrault H, Penrod JR, Baltzan M, Rouleau M, Julien M, Paradis B, Audet R, Hernandez P, Levy RD, Camp P, Lecours R, Picard D, Bernard S. A canadian, multicentre, randomized clinical trial of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease: rationale and methods. Can Respir J. 2005;12:193–8.CrossRefPubMedGoogle Scholar
  67. 67.
    Troosters T, Gosselink R, Janssens W, Decramer M. Exercise training and pulmonary rehabilitation: new insights and remaining challenges. Eur Respir Rev. 2010;19:24–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Caron MATM, Debigare R, Maltais F. Skeletal muscle dysfunction. In: Nici L, Richard ZW, editors. Chronic obstructive pulmonary disease: co-morbidities and systemic consequences. New York: Humana Press; 2012. p. 137–60.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Faculty of Medicine and Life SciencesRehabilitation Research Centre, Biomedical Research Institute, Hasselt UniversityDiepenbeekBelgium
  2. 2.Saint Francis Hospital and Medical Center, University of ConnecticutFarmingtonUSA

Personalised recommendations