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Nonlinear Periodized Exercise Training in Pulmonary Rehabilitation: the devil is in the details!

Authors: Dr. Peter Klijn, clinical exercise physiologist

Merem Medical Rehabilitation, department of Pulmonary Rehabilitation

Hilversum, The Netherlands

Exercise training is a cornerstone of pulmonary rehabilitation (PR) with the combination of aerobic endurance training and strength training as major parts. [1] The prevailing PR exercise paradigm could be characterized as a multimodal, continuous program, i.e. similar whole-body endurance exercises (walking and cycling) and number of resistance training (RT) exercises with constant sets and repetitions for the duration of the program. However, the use of such a concurrent exercise paradigm, especially performed in the same session (i.e. cycling, walking and  strength training), could hamper physiological adaptations. [2-11]

Improving different physical fitness characteristics (e.g. muscular strength, anaerobic endurance, power, speed, muscular endurance, aerobic endurance) within a timeframe is common practice in the athletic population. It is therefore crucial to properly organize the training plan. Athletes use exercise periodization to achieve peak performance at a predetermined point in time. [8] There is, however, a major difference in time frames of athletic training and PR.  An in-depth discussion of athletic periodization theory, [8, 12, 13] however, is beyond the scope of this quarterly bite.

Periodization is characterized by a division in interrelated periods, i.e. smaller, distinct and more easy manageable phases each with specific goals and characteristics. [14-16] Each phase contains microcycles (typically one week). The objectives of these phases and cycles all contribute to the overall training plan. [8] The microcycle consists of several training sessions (typically 3/week during PR). The training session is the smallest functional unit and determines the characteristic and focus of the microcycle. [8] Figure 1 illustrates an example of a training plan during PR divided into phases and cycles.

figure 1

Moreover, the concept of periodization involves the process of systematic planning of short- and long-term training by manipulating acute training variables to optimize the fundamental exercise principle of overload, i.e. gradual increase in the stimulus placed on the body to stimulate continual adaptation.
Variation, i.e. appropriate sequencing and integration of different acute training variables, is a key tenet of periodization. By incorporating variation of training variables the body is regularly challenged to restore the disruption of (muscle) homeostasis, thereby preventing stagnation and ultimately, optimize adaptations (i.e. supercompensation). [17, 18]

The planning process (i.e. training phases) aims to develop specific physical fitness characteristics (e.g. muscular strength, anaerobic endurance, power, muscular endurance, aerobic endurance) that contribute to the specific goal. The training program typically starts with a base training phase. This is a physiological and psychological adaptation phase characterized by a low load:
- to familiarize patients with the exercises
- to become accustomed to the combination of exercises
- to improve neuromuscular function
- to develop or improve training technique (e.g. breathing technique, speed of muscle action, adequate time-under-tension, duration of concentric and eccentric phases)
- to teach patients the theory and methodology of goal specific training

In the preparation phase patients are prepared for more intense exercise. The use and appropriate structuring of selected acute training variables (i.e. programming) elicits the required adaptations (e.g. musculoskeletal, neuromuscular, metabolic). [19] An example preplanned 4-week preparation phase is shown in Figure 2. During the optimization phase protocols are used to induce goal specific adaptations. Figure 3 shows an example of a preplanned 4-week optimization phase. The duration of each training phase is, however, not fixed, but depends on the time needed by the individual patient for adequate preparedness or improvement of the physical fitness attribute(s). Appropriate planning and programming prevents overtraining, modulate accumulative fatigue and attain an optimal training effect. [20, 21] As shown in table 1 there is a multitude of possible combinations between program variables and hence, many possible periodized programs. [18]  

figure 2

figure 2

figure 2

As stated above, periodization is a fundamental strategy to organize exercise training in athletic populations. [21, 23] However, during the last decade exercise periodization has also received considerable interest as a defining principle in health-indices, the rehabilitation setting and the old. [24-33] Although there are different types of periodization, this quarterly bite will focus on non-linear periodization. [21]

Nonlinear or undulating periodization is a type of periodization characterized by frequent manipulation of training variables and often dramatic alterations in the exercise intensity, repetition volume and number of exercises. [20] The undulating model makes these changes daily, weekly, or biweekly. Recently, nonlinear periodized exercise training (NLPE) with a daily undulating model was compared with traditional endurance and progressive resistance training (EPR) in patients with severe to very severe COPD. [20] Superior statistical significant and clinical relevant larger improvement in endurance cycling and all domains of the Chronic Respiratory Questionnaire, was achieved with NLPE compared to EPR. EPR was a traditional, multimodal continuous program. In this regard, it is important to  emphasize again that concurrent and continuous, high-intensity linear loads, absent of variation may increase the risk of maladaptation. [8-10, 34]

The development of an individual training program during PR requires a realistic, achievable goal and goal specific exercise assessment (i.e. consistency between training and testing). Moreover, it is paramount to perform a needs analysis of the required physical activity (e.g. walking, stair climbing, carrying groceries, cycling). The needs analysis includes a physiological and biomechanical analysis, and an analysis of individual deficiencies. [16, 35]
-physiological analysis:  to determine, among others, which energy sources are used and what are the determining muscle attributes (e.g. strength, power, endurance) distinctive to the physiological profile of the physical activity.
- biomechanical analysis: involved joints, joint range of motion, muscle groups and types of movement to choose activity-specific training. 

The resultant of the performance needs analysis therefore, dictates the building blocks of individual training programs. The needs analysis and, physiological and biomechanical building blocks of the recent NLPE intervention is shown in table 2.

figure 5

A building block (e.g. aerobic endurance) consists of several protocols composed of different combinations of the training variables (e.g. duration of work phase, intensity, duration of rest phase, number of series). The focus of the aerobic endurance training session can be achieved with different acute training variables (Table 1) determined by the needs of a patient pertaining to cycling with 75% Wmax

The analysis of deficiencies provides information on the individual causes of exercise intolerance and biopsychosocial factors that mediate the training response, and should therefore be addressed in the individual training plan. As can be observed in Figure 1, there is myriad of factors that could influence the response to exercise training. Furthermore, these factors are prevalent in many combinations. Based on the needs analysis (i.e. physiological and biomechanical building blocks) a global preplanned individual training plan (i.e. training phases) should be developed. The preplanned programming (i.e. exercise protocols) is determined by the analysis of exercise intolerance and non-training factors. In this respect it is important to emphasize that physical activity during daily life has implications for the recovery-adaptation relationship, since every physical activity  is a challenge to homeostasis. Clearly, outpatient PR is more likely to be influenced by non-training factors.

figure 6

Next to the needs analysis, the actual programming is determined by emerging information from the training sessions (i.e. monitoring). Monitoring is an imperative  element in exercise periodization that unveils how patients respond to the training, thereby enhancing individualization and recovery. [42] The  monitoring process actually starts before the training session with an assessment of prevalent symptoms: global fatigue (i.e. highly prevailing and disabling symptom in COPD), [43] level of dyspnea (i.e. day-to-day variability) and sympathetic stress (i.e. heart rate and percutaneous oxygen saturation [SpO2]). [20] During a training session emerging symptoms (exercise-induced dyspnea and muscle fatigue, sense of effort) should be assessed and after the training session the transient training stress is evaluated (i.e. residual fatigue, dyspnea, heart rate and  SpO2). [20] These detailed monitoring records are necessary to establish individual patterns for further planning and programming, and eliciting desired goal specific training effects. [15] In this respect it is important to consider the high level of subjectivity that is characteristic of bodily symptoms (e.g. dyspnea, fatigue, exertion or heaviness, pain). [44-47] Clearly, the preplanned format determines the basics of the program. Exercise protocols, however, are adapted based on the emerging information from the training sessions.

A multitude of factors play a role in the variable adaptation to exercise training in patients with COPD. Clearly, there is a need for personalized exercise training based upon a comprehensive assessment and systematic research on the individual exercise response to establish the interfering factors of exercise adaptation. Nonlinear exercise periodization might provide a template for the organization of exercise training in the heterogenous COPD population.


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