**10.2 Respiratory muscle training**

*Cardiorespiratory Fitness*

involvement.

**9. Location of the training**

**10. Adjuncts to exercise training**

**10.1 Neuromuscular electrical training**

**8.4 Psychosocial support**

Many COPD patients who are referred to pulmonary rehabilitation suffer from

Various models of PR have been adopted worldwide. An outpatient or hospital based-outpatient setting is the most widely used model to deliver PR to COPD patient in the developed countries [126]. Current body of evidence regarding effectiveness of PR in COPD patients is based on this model. In recent years an alternative model where the site of delivery of PR is at home has been studied. Home based PR setting provides the benefit of exercise training in a familiar setting to a larger patient population. Specifically for patients with severe COPD dependent on long term oxygen therapy, this model of PR has been shown to be both safe and effective [127, 128]. While home based PR model offers convenience, it lacks the group dynamics which an outpatient model can offer. Group therapy leads to socialization, mood elevation and positive reinforcement. Additionally a home based program does not have a multidisciplinary and comprehensive structure of a hospital based outpatient setting. At the present time, choice of location of PR is dependent on patient preference, disease severity and regional availability of resources.

Several COPD patients with advanced lung disease who are bed bound or wheelchair bound are unable to participate in a conventional pulmonary rehabilitation program. To help these patients, a new modality of transcutaneous neuromuscular electrical stimulation (NMES) has been devised recently [129–131]. This technology involves application of low amplitude electric current via electrodes transcutaneously to the targeted muscle groups by depolarizing motor neurons. Low intensity electric current (10–100 mA) is delivered at stimulation frequencies between 8 and 120 Hz for duration of 250–400 ms. Although no large RCTs are available, a recent meta-analysis did report improvement in quadriceps strength and exercise capacity with NMES. Unfortunately, no significant improvement in HRQoL in moderate to

depression and anxiety [45, 122]. Recent studies have estimated prevalence of depressed mood in about 45% and anxiety in 32% of patients with moderate to advanced COPD [123–125]. Dyspnea on exertion leads to fear and anxiety anytime a COPD patient has to exercise. This severely limits their social interaction and eventually leads to depression. COPD patients can suffer from hopelessness, sense of isolation and lack of motivation. It is essential to assess the presence of depressed mood during initial evaluation in a pulmonary rehabilitation program. Family and caregiver involvement is advisable to assess the social support system for the patient. Identifying the mood disorders and deficit in the social support is an integral part of the program [114]. Patients in need can be provided with psychological and social support, which works to elevate mood, positive thinking and adaptive behavior towards disease and its management. This also improves the compliance with the pulmonary rehabilitation program. Psychological support can be provided by the physical therapist but often require a psychologist or a psychiatrist

**12**

A pulmonary rehabilitation programs for COPD patients usually includes respiratory muscle training. The goal of this training is to improve the abnormal breathing pattern, which may result due to increased work of breathing, chest wall changes and poor breathing habits in COPD patients [135–138]. The most commonly applied approach is through the endurance and strength training. [26]. Exercise training can lead to increase in minute ventilation, which leads to an increase in work of breathing. Constant controlled aerobic exercises of upper and lower extremities can lead to a recurrent stimulation to respiratory muscles. This helps the COPD patients to modify their breathing patterns on a day-to-day basis as well as be better prepared for an exacerbation.

Apart from exercise training, specific breathing exercises such as diaphragmatic breathing, paced breathing with exercises and pursed lip breathing has been proven to be beneficial in COPD patients. Diaphragm, which is the main inspiratory muscle, is flattened and ineffective in patients with hyperinflated lungs. This puts these patients at a mechanical disadvantage to adequately maintain and increase their minute ventilation. COPD patients who undergo the training to improve the coordination of their diaphragmatic muscle tend to fare better overall [139].

Many patients with emphysema self-discover the method of purse lip breathing for faster recovery from shortness of breath post exercise. Other patients can be instructed regarding this method. It helps patients to increase alveolar ventilation, tidal volume and CO2 removal. It also leads to slow expiratory flow and decreased respiratory rate [140]. Using the same principle, respiratory muscles can be trained by using resistive breathing devices. This can be particularly useful in patients who continue to have dyspnea despite optimal medical management.

Additionally COPD patients specifically with chronic bronchitis occasionally have ineffectual cough leading to difficulty in respiratory secretion clearance. Instructions on special coughing techniques (huffing, autogenic drainage) combined with oscillating expiratory breathing devices (Acapella, In-exsufflator) can prove effective [141]. Patients can be instructed to perform daily chest physiotherapy to assist in respiratory secretion clearance through postural drainage techniques [142]. A meta-analysis of 32 studies focusing on respiratory muscle training showed that it leads to improvement in respiratory muscle strength, exercise capacity and perception of exertional dyspnea [143].
