Background The widespread application pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function attributable to the programs. This review updates that reported by Lacasse et al Lancet 1996; 748:1115-1119. Objectives To determine the impact of rehabilitation on health-related quality of life (QoL) and exercise capacity in patients with COPD. Search strategy The 14 randomized controlled trials (RCTs) included in the original meta-analysis were included. Additional RCTs were identified from the Cochrane Airways Group's registry of COPD RCTs using the strategy: [exp, lung diseases, obstructive] and [exp, rehabilitation or exp, exercise therapy] and [research design or longitudinal studies or evaluation study or randomized controlled trial]. Abstracts presented at American Thoracic Society 1980-2000, American College of Chest Physicians 1980-2000 and European Respiratory Society 1987-2000 were also searched. Selection criteria RCTs of rehabilitation in patients with COPD in which quality of life (QoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. Rehabilitation was defined as exercise training for at least 4 weeks with or without education and/or psychological support. Control groups received conventional community care without rehabilitation. Data collection and analysis Weighted mean differences (WMD) were calculated using a random-effects model. Missing data from the primary study reports were requested from the authors. Main results 23 RCTs met the inclusion criteria. Statistically significant improvements were found for all the outcomes. In three important domains of QoL (Chronic Respiratory Questionnaire scores for Dyspnea, Fatigue and Mastery), the effect was larger than the minimal clinically important difference of 0.5 units using this instrument. For example Dyspnoea score: WMD 0.98 units, 95% Confidence Interval (95% CI) 0.74 - 1.22 units; n=9 trials. For FEC and MEC, the effect was small and a little below the threshold of clinical significance for the 6- minute walking distance: WMD 49 m, 95% CI: 26 - 72 m; n=10 trials. Reviewer's conclusions Rehabilitation relieves dyspnea and fatigue and enhances patients' sense of control over their condition. These improvements are moderately large and clinically significant. The average improvement in exercise capacity was modest. Rehabilitation forms an important component of the management of COPD.

Pulmonary rehabilitation for chronic obstructive pulmonary disease

Linda Nici, Claudio Donner, Emiel Wouters, Richard Zuwallack, Nicolino Ambrosino, Jean Bourbeau, Mauro Carone, Bartolome Celli, Marielle Engelen, Bonnie Fahy, Chris Garvey, Roger Goldstein, Rik Gosselink, Suzanne Lareau, Neil MacIntyre, Francois Maltais, Mike Morgan, Denis O’Donnell, Christian Prefault, Jane Reardon, Carolyn Rochester, Annemie Schols, Sally Singh, and Thierry Troosters, on behalf of the ATS/ERS Pulmonary Rehabilitation Writing Committee

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American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation

https://journal.chestnet.org/article/S0012-3692(16)30215-X/pdf

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

In this monograph, we ask whether various kinds of intellectual, physical, and social activities produce cognitive enrichment effects-that is, whether they improve cognitive performance at different points of the adult life span, with a particular emphasis on old age. We begin with a theoretical framework that emphasizes the potential of behavior to influence levels of cognitive functioning. According to this framework, the undeniable presence of age-related decline in cognition does not invalidate the view that behavior can enhance cognitive functioning. Instead, the course of normal aging shapes a zone of possible functioning, which reflects person-specific endowments and age-related constraints. Individuals influence whether they function in the higher or lower ranges of this zone by engaging in or refraining from beneficial intellectual, physical, and social activities. From this point of view, the potential for positive change, or plasticity, is maintained in adult cognition. It is an argument that is supported by newer research in neuroscience showing neural plasticity in various aspects of central nervous system functioning, neurochemistry, and architecture. This view of human potential contrasts with static conceptions of cognition in old age, according to which decline in abilities is fixed and individuals cannot slow its course. Furthermore, any understanding of cognition as it occurs in everyday life must make a distinction between basic cognitive mechanisms and skills (such as working-memory capacity) and the functional use of cognition to achieve goals in specific situations. In practice, knowledge and expertise are critical for effective functioning, and the available evidence suggests that older adults effectively employ specific knowledge and expertise and can gain new knowledge when it is required. We conclude that, on balance, the available evidence favors the hypothesis that maintaining an intellectually engaged and physically active lifestyle promotes successful cognitive aging. First, cognitive-training studies have demonstrated that older adults can improve cognitive functioning when provided with intensive training in strategies that promote thinking and remembering. The early training literature suggested little transfer of function from specifically trained skills to new cognitive tasks; learning was highly specific to the cognitive processes targeted by training. Recently, however, a new generation of studies suggests that providing structured experience in situations demanding executive coordination of skills-such as complex video games, task-switching paradigms, and divided attention tasks-train strategic control over cognition that does show transfer to different task environments. These studies suggest that there is considerable reserve potential in older adults' cognition that can be enhanced through training. Second, a considerable number of studies indicate that maintaining a lifestyle that is intellectually stimulating predicts better maintenance of cognitive skills and is associated with a reduced risk of developing Alzheimer's disease in late life. Our review focuses on longitudinal evidence of a connection between an active lifestyle and enhanced cognition, because such evidence admits fewer rival explanations of observed effects (or lack of effects) than does cross-sectional evidence. The longitudinal evidence consistently shows that engaging in intellectually stimulating activities is associated with better cognitive functioning at later points in time. Other studies show that meaningful social engagement is also predictive of better maintenance of cognitive functioning in old age. These longitudinal findings are also open to important rival explanations, but overall, the available evidence suggests that activities can postpone decline, attenuate decline, or provide prosthetic benefit in the face of normative cognitive decline, while at the same time indicating that late-life cognitive changes can result in curtailment of activities. Given the complexity of the dynamic reciprocal relationships between stimulating activities and cognitive function in old age, additional research will be needed to address the extent to which observed effects validate a causal influence of an intellectually engaged lifestyle on cognition. Nevertheless, the hypothesis that an active lifestyle that requires cognitive effort has long-term benefits for older adults' cognition is at least consistent with the available data. Furthermore, new intervention research that involves multimodal interventions focusing on goal-directed action requiring cognition (such as reading to children) and social interaction will help to address whether an active lifestyle enhances cognitive function. Third, there is a parallel literature suggesting that physical activity, and aerobic exercise in particular, enhances older adults' cognitive function. Unlike the literature on an active lifestyle, there is already an impressive array of work with humans and animal populations showing that exercise interventions have substantial benefits for cognitive function, particularly for aspects of fluid intelligence and executive function. Recent neuroscience research on this topic indicates that exercise has substantial effects on brain morphology and function, representing a plausible brain substrate for the observed effects of aerobic exercise and other activities on cognition. Our review identifies a number of areas where additional research is needed to address critical questions. For example, there is considerable epidemiological evidence that stress and chronic psychological distress are negatively associated with changes in cognition. In contrast, less is known about how positive attributes, such as self-efficacy, a sense of control, and a sense of meaning in life, might contribute to preservation of cognitive function in old age. It is well known that certain personality characteristics such as conscientiousness predict adherence to an exercise regimen, but we do not know whether these attributes are also relevant to predicting maintenance of cognitive function or effective compensation for cognitive decline when it occurs. Likewise, more information is needed on the factors that encourage maintenance of an active lifestyle in old age in the face of elevated risk for physiological decline, mechanical wear and tear on the body, and incidence of diseases with disabling consequences, and whether efforts to maintain an active lifestyle are associated with successful aging, both in terms of cognitive function and psychological and emotional well-being. We also discuss briefly some interesting issues for society and public policy regarding cognitive-enrichment effects. For example, should efforts to enhance cognitive function be included as part of a general prevention model for enhancing health and vitality in old age? We also comment on the recent trend of business marketing interventions claimed to build brain power and prevent age-related cognitive decline, and the desirability of direct research evidence to back claims of effectiveness for specific products.

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Enrichment Effects on Adult Cognitive Development: Can the Functional Capacity of Older Adults Be Preserved and Enhanced?

Physical activity is beneficial for healthy ageing. It may also help maintain good cognitive function in older age. Aerobic activity improves cardiovascular fitness, but it is not known whether this sort of fitness is necessary for improved cognitive function. Eleven studies of aerobic physical activity programmes for healthy people over the age of 55 years have been included in this review. Eight of these 11 studies reported that aerobic exercise interventions resulted in increased fitness of the trained group and an improvement in at least one aspect of cognitive function. The largest effects were on cognitive speed, auditory and visual attention. However, the cognitive functions which improved were not the same in each study and the majority of comparisons yielded no significant results. The data are insufficient to show that the improvements in cognitive function which can be attributed to physical exercise are due to improvements in cardiovascular fitness.

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Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment

The influence of specific training on benefits from caffeine (Caf) ingestion was examined during a sprint test in a group of highly trained swimmers (T) and compared with the response of a group of untrained occasional swimmers (UT). Seven T and seven UT subjects swam freestyle two randomly assigned 2 × 100 m distances, at maximal speed and separated by 20 min of passive recovery, once after Caf (250 mg) and once after placebo (Pla) ingestion. Anaerobic capacity was assessed by the mean velocity (meters per second) during each 100 m and blood was sampled from the fingertip just before and 1, 3, 5, 7, and 9 min after each 100 m for resting and maximal blood lactate concentration ([1a−]b, max) determination. The [[1a−]b, max was significantly enhanced by Caf in both T and UT subjects (P<0.01). However, only T subjects exhibited significant improvement in their swimming velocity (P<0.01) after Caf or any significant impairment during the second 100 m. In light of these results, it appears that specific training is necessary to benefit from the metabolic adaptations induced by Caf during supramaximal exercise requiring a high anaerobic capacity.

Benefits of caffeine ingestion on sprint performance in trained and untrained swimmers

The aim of this study was to specify the effects of caffeine on maximal anaerobic power (Wmax). A group of 14 subjects ingested caffeine (250 mg) or placebo in random double-blind order. The Wmax was determined using a force-velocity exercise test. In addition, we measured blood lactate concentration for each load at the end of pedalling and after 5 min of recovery. We observed that caffeine increased Wmax [964 (SEM 65.77) W with caffeine vs 903.7 (SEM 52.62) W with placebo; P less than 0.02] and blood lactate concentration both at the end of pedalling [8.36 (SEM 0.95) mmol.l-1 with caffeine vs 7.17 (SEM 0.53) mmol.l-1 with placebo; P less than 0.01] and after 5 min of recovery [10.23 (SEM 0.97) mmol.l-1 with caffeine vs 8.35 (SEM 0.66) mmol.l-1 with placebo; P less than 0.04]. The quotient lactate concentration/power (mmol.l-1.W-1) also increased with caffeine at the end of pedalling [7.6.10(-3) (SEM 3.82.10(-5)) vs 6.85.10(-3) (SEM 3.01.10(-5)); P less than 0.01] and after 5 min of recovery [9.82.10(-3) (SEM 4.28.10(-5)) vs 8.84.10(-3) (SEM 3.58.10(-5)); P less than 0.02]. We concluded that caffeine increased both Wmax and blood lactate concentration.

Caffeine increases maximal anaerobic power and blood lactate concentration.

This study tested the effect of two methods of training, one individualized at the heart rate corresponding to the gas exchange threshold (GET) and the other at the heart rate corresponding to 50% of maximal heart rate reserve, on maximal and submaximal cardiorespiratory response in 24 patients with chronic airway limitation (CAL). The patients were randomly assigned to either the individualized training group (IT; n = 12) or the standardized training group (ST; n = 12). The training programme consisted of 4 weeks of stationary bicycle exercise, 5 days.week-1. Before reconditioning began, the target level based on heart rate was not significantly different between groups (109 +/- 4 versus 110 +/- 3 beats.min-1, in IT and ST, respectively). Post-training, a significant increase in symptom-limited oxygen uptake (V'O2.sl) and maximal O2 pulse was found in IT, whereas ST exhibited no significant change. In each group, GET was statistically increased in much the same way as V'O2,sl, with a higher increase in IT (p < 0.01) than ST (p < 0.05). Nevertheless, IT exhibited a concomitant and gradual decrease in minute ventilation (V'E), carbon dioxide production (V'CO2), and venous lactate concentration ([La]), whereas ST presented no significant change in these parameters (intergroup p < 0.01). Breathing pattern was also altered after IT, at the same metabolic level and at the same ventilation level (intergroup p < 0.05). Cardiac responses were modified in the two groups. At the same metabolic level, a significantly lower cardiac frequency was found both for IT and ST (intragroup p < 0.05 after training). In contrast, the increase in O2 pulse was only significantly higher in It after training. These data show the greater efficiency of an individualized training protocol based on determination of gas exchange threshold as compared to a standardized protocol, in improving exercise performance, when applied to a patient group. Despite an apparently similar target training level, the individualized method clearly optimized the physiological training effects in patients with chronic airway limitation and, more particularly, decreased their ventilatory requirement.

https://erj.ersjournals.com/content/erj/10/1/114.full.pdf

Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols

In order to determine the effects of caffeine ingestion on performance and metabolic responses during supramaximal exercise, six healthy volunteers performed the Wingate Anaerobic Test twice. Sixty min before each trial, while in a fasting state, they took capsules containing either caffeine (5 mg/kg) or a placebo, according to a single blind and randomized procedure. Caffeine administration did not significantly change either maximal anaerobic capacity (AC) or power (AP) and power decrease (PD). It did, however, induce significant (p less than 0.05) increases in both catecholamine and blood lactate levels as compared to values obtained after placebo administration. Moreover, maximal blood lactate occurred earlier (p less than 0.05), and lactate output seemed to be greater with caffeine (p less than 0.01). There was a strong correlation, both with and without caffeine, between epinephrine and lactate levels (r = 0.81) and between both AP and AC and lactate levels. These data suggest that caffeine, essentially via epinephrine, modifies glycolytic metabolism but fails to improve performance during the Wingate Anaerobic Test in nonspecifically trained subjects.

Effects of caffeine ingestion on performance and anaerobic metabolism during the Wingate Test.

This study was undertaken to determine which of the two commonly used field tests, the 20-meter shuttle run test (20-MST) or the University of Montreal track test (UM-TT), provides the most accurate assessment of maximal and functional aerobic capacity in moderately trained athletes. Eleven male subjects aged from 18 to 30 years were studied in triple incremental and continuous running tests carried out until exhaustion both in laboratory and field conditions. They underwent a laboratory treadmill test and completed the outdoor 20-MST and UM-TT. During the three randomly assigned tests, maximal velocity (Vmax), maximal oxygen uptake (VO2max), maximal heart rate (HRmax), and post-exercise peak blood lactate (P[La]) measurements were made. The results indicate a significant difference in the mean Vmax (F = 9.26, p less than 0.001). Vmax determined by the 20-MST revealed a lower value than by treadmill (16.3%) and the UM-TT (19.3%). In contrast, there was no difference with regard to VO2max (F = 2.95, p = 0.06), HRmax (F = 2.72, p = 0.08), and P[La] (F = 2.79, p = 0.07). These results confirm that the UM-TT is a valid field test of maximal and functional aerobic capacity in moderately trained subjects and suggest that it can be additionally used for exercise prescription.

Maximal and functional aerobic capacity as assessed by two graduated field methods in comparison to laboratory exercise testing in moderately trained subjects.

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Papers

Benefits of caffeine ingestion on sprint performance in trained and untrained swimmers

Caffeine increases maximal anaerobic power and blood lactate concentration.

Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols

Effects of caffeine ingestion on performance and anaerobic metabolism during the Wingate Test.

Maximal and functional aerobic capacity as assessed by two graduated field methods in comparison to laboratory exercise testing in moderately trained subjects.