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Components of Pulmonary Rehabilitation

Comprehensive pulmonary rehabilitation generally includes exercise training, education, psychosocial and behavioural intervention, nutritional therapy and outcome assessment.

Exercise Training

Exercise training is an essential component of pulmonary rehabilitation. In general, two types of exercise training can be given: endurance (or aerobic) training and strength training (see ATS Statement on Pulmonary Rehabilitation).

Endurance training involves dynamic activity of large muscles, usually performed three to four times a week for 20-30 min per session at an intensity of ≥50% of maximal oxygen consumption. This induces structural and physiological adaptations that provide the trained individual with improved endurance for performance of high-intensity activity.

Lower extremity training is the mainstay of endurance training, although there is scientific rationale for incorporating upper extremity training. The optimal training duration for exercise training in COPD has not been established. Most programmes include exercise sessions of ≥30 min, two to five times a week, for 6-12 weeks. The effect of exercise training on exercise capacity and exertional dyspnoea in COPD is dose dependent [22]. However, many patients have difficulty sustaining prolonged high intensity (80% of maximum power output) for prolonged periods [23]. Despite this, lower intensity exercise training is at least as good as high intensity training in improving health-related quality of life [23, 24]. Interval exercise training (repeated periods of near-maximal exercise alternating with short intervals of rest) may give similar benefits as continuous training, but has less associated dyspnoea [25, 26].

Strength training has proven benefits in pulmonary rehabilitation and can be considered supplemental to endurance training [27-29]. While endurance training of the peripheral muscles is of proven benefit in COPD, ventilatory muscle training is also frequently given. While this probably improves respiratory muscle strength, its effect on symptoms and functional limitation has not yet been firmly established [30].

Education

Education is considered an important component of comprehensive pulmonary rehabilitation and is integrated into virtually all programmes. Because of this, its effect in isolation cannot be readily determined. Among the potential benefits of education are: active participation in healthcare [31, 32], increased coping skills [33, 34], a better understanding of the physical and psychological changes of chronic illness, more skill in collaborative self-management and better adherence to the treatment plan [35]. In addition to standard didactic sessions, education may also incorporate breathing strategies, such as pursed-lip and diaphragmatic breathing, energy conservation and work simplification, and advance directives (see Ethical and palliative care issues).

Psychosocial and Behavioural Intervention

Anxiety, depression and difficulties in coping with chronic disease are common in COPD patients and contribute to morbidity.

Psychosocial and behavioural intervention in pulmonary rehabilitation may include educational sessions or support groups focusing on specific problems such as stress management, or instruction in progressive muscle relaxation, stress reduction and panic control [36].

Informal discussions during rehabilitation sessions of symptoms, concerns and problems common to COPD patients may be beneficial. Participation by family members or friends in pulmonary rehabilitation support groups is encouraged. Motivation for pulmonary rehabilitation, which may be suboptimal at the onset, might improve during therapy.

Individuals with major psychiatric conditions should be referred to appropriate professionals.

Nutritional Therapy

Weight loss and muscle wasting, which are present in 20-35% of patients with stable COPD, contribute to morbidity and mortality in COPD, independent of the pulmonary physiological abnormality [20]. Nutritional intervention should be considered for these individuals, especially under conditions of increased exercise-related energy expenditure (see with Management of stable COPD: nutrition).


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