**8. Pulmonary rehabilitation program**

### **8.1 Pre-rehab assessment**

Every patient referred for pulmonary rehabilitation should be thoroughly evaluated prior to initiation of the program. Majority of the patients have a regular pulmonary physician managing the lung disease. As a part of the management, pulmonary physicians refer the patient for pulmonary rehabilitation to supplement the pharmacological treatment. These patients when present to the pulmonary rehabilitation have already undergone an evaluation of symptoms and physical examination. Regardless, it is a good practice to perform a thorough evaluation of patient's medical problems, laboratory results, social habits and specific medications. This should be accompanied by a comprehensive physical examination with estimation of patient's functional capacity. In most of the pulmonary rehabilitation program, this assessment is performed by the physical therapists. If a pulmonologist is an integral part of the program, the physician can do this work up.

Prior to initiation of the pulmonary rehabilitation program, a careful appraisal of patient's pulmonary disease and current severity should be done. For COPD patients this will include the duration of their symptoms, current symptomatology, mMRC score [46], smoking history, pulmonary function testing, arterial blood gas analysis, inhaler therapy, oxygen supplementation and non-invasive ventilation prescription. It is imperative that a special attention should be paid to patient's co morbidities. This is essential as several other medical problems may have impact on patient's disease course and exercise capacity. These may include obesity, OSA, diabetes, cardiovascular co morbidities, hypertension, osteoarthritis, pulmonary hypertension, peripheral vascular disease and malignancy.

A detailed pre rehab assessment enables the physical therapist to devise an individualized treatment plan for the patients. This strategy is particularly helpful for patients with advanced disease, low exercise tolerance, special healthcare needs such as high oxygen requirements, pacemaker or defibrillators, walkers and cane. Information gathered at the beginning of the program will help set realistic individualized goals and alert the provider regarding the possibility of adverse effects.

Physical examination at the beginning of the pulmonary rehabilitation program is centered on measurements of patient's functional status and capacity to handle additional physical stress. Most relevant for COPD patients will be an examination

**7**

*Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease*

vidual patient's tolerance and potential areas of improvement.

of muscle wasting, joint mobility, postural deformities, and cardio-respiratory examination. Results of this examination allows physical therapist to gauge indi-

An important component of physical examination is nutritional assessment. This commonly includes measurement of weight, height and BMI. Both being underweight and overweight in a COPD patient can be detrimental. Excess weight can lead to extrinsic restriction on lung capacity as well as increased work of breathing. Weight loss and muscle wasting is a poor prognostic factor in COPD patients

Pertinent respiratory examination in patients with COPD is directed at ability of the patients to clear their respiratory secretions, use of accessory muscles of respiration, breathing pattern, adventitious sounds on auscultation such as wheezing and crepitation. A knowledge of patients' respiratory status will help develop an educational plan regarding self-management, medication compliance and respira-

Reduced functional capacity due to physical deconditioning is widespread in COPD patients. This is multifactorial with poor nutritional status, systemic inflammation, cardiovascular comorbidities, postural deformities and osteoporosis [62] Interviewing the patient to ascertain their capacity to perform ADLs, sustained exercise and risk of falls is essential. Several questionnaires have also been used to objectively measure individual patient's baseline functionality. A few examples include: the Functional Independence Measure (FIM), the Assessment of Motor and Process Skills (AMPS), and a Functional Capacity Evaluation (FCE) [63].

Apart from questionnaire, various exercise tests can be used to gauge individual

If in addition to the functional limitation specific problems are identified by the physical therapists, various other tests may need to be performed. These tests address the muscle weakness, gait disturbances, and include balance testing and

After an initial assessment, patient is enrolled into a pulmonary rehabilitation program. The basic aim of such a program in any COPD patient is to assist them in performing essential daily activities with independence. Independence comes from reduction in dyspnea and fatigue. COPD patient are inadvertently caught in a downward spiral where dyspnea is leading to inactivity, which in turn leads to physical deconditioning and decreased capacity to handle day-to-day stress. To save the patient from this downward spiral a pulmonary rehabilitation program focuses

patient's functional capacity. These exercise tests can be done as field walking tests, on bicycle ergometer or on treadmill. In most hospital, simple walk testing can be cost effective and practical. Walk tests are considered more reflective of daily functionality of a COPD patient. Some of the commonly employed walk tests include the 6-minute walk test (6MWT) and the incremental shuttle walk testing. Standardized protocols have been established for performing the 6MWT. If done as per the set protocol, this walk test is highly reproducible and reliable test for both diagnostic and prognostic purposes. In this test, patient walk back and forth on a 30-m distance marked hallway at their own pace for 6 minutes. During the test, distance walked, vital signs, oxygen desaturation, development of dyspnea using a visual analog scale is measured [64]. The incremental shuttle walk test is performed on a 10 m marked course. It is a paced walk test to assess symptom limited maximal exercise capacity. Test is continued until patient develops symptoms of dyspnea or for 20 minutes, whichever occurs first. This is a valid and popular testing in various

*DOI: http://dx.doi.org/10.5772/intechopen.81742*

[59–61].

tory muscle training.

resource limited clinical settings [45].

**8.2 Components of pulmonary rehabilitation**

sit-to-stand tests [65].

### *Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.81742*

*Cardiorespiratory Fitness*

prior to pulmonary rehabilitation.

• Depression and social isolation.

• Cost of pulmonary rehabilitation.

**8. Pulmonary rehabilitation program**

**8.1 Pre-rehab assessment**

can do this work up.

• Lower quadriceps strength*.*

• Even though current smokers obtain the same benefits from pulmonary rehabilitation, smokers generally have poor adherence to pulmonary rehab than ex-smokers. Active smoking status is not an absolute contraindication for pulmonary rehabilitation. Patients are encouraged to undergo smoking cessation

• COPD patients with higher mMRC score and frequent exacerbations.

Every patient referred for pulmonary rehabilitation should be thoroughly evaluated prior to initiation of the program. Majority of the patients have a regular pulmonary physician managing the lung disease. As a part of the management, pulmonary physicians refer the patient for pulmonary rehabilitation to supplement the pharmacological treatment. These patients when present to the pulmonary rehabilitation have already undergone an evaluation of symptoms and physical examination. Regardless, it is a good practice to perform a thorough evaluation of patient's medical problems, laboratory results, social habits and specific medications. This should be accompanied by a comprehensive physical examination with estimation of patient's functional capacity. In most of the pulmonary rehabilitation program, this assessment is performed by the physical therapists. If a pulmonologist is an integral part of the program, the physician

Prior to initiation of the pulmonary rehabilitation program, a careful appraisal of patient's pulmonary disease and current severity should be done. For COPD patients this will include the duration of their symptoms, current symptomatology, mMRC score [46], smoking history, pulmonary function testing, arterial blood gas analysis, inhaler therapy, oxygen supplementation and non-invasive ventilation prescription. It is imperative that a special attention should be paid to patient's co morbidities. This is essential as several other medical problems may have impact on patient's disease course and exercise capacity. These may include obesity, OSA, diabetes, cardiovascular co morbidities, hypertension, osteoarthritis, pulmonary

A detailed pre rehab assessment enables the physical therapist to devise an individualized treatment plan for the patients. This strategy is particularly helpful for patients with advanced disease, low exercise tolerance, special healthcare needs such as high oxygen requirements, pacemaker or defibrillators, walkers and cane. Information gathered at the beginning of the program will help set realistic individualized goals and alert the provider regarding the possibility of adverse effects. Physical examination at the beginning of the pulmonary rehabilitation program is centered on measurements of patient's functional status and capacity to handle additional physical stress. Most relevant for COPD patients will be an examination

hypertension, peripheral vascular disease and malignancy.

• Long commute to pulmonary rehabilitation and lack of transport.

**6**

of muscle wasting, joint mobility, postural deformities, and cardio-respiratory examination. Results of this examination allows physical therapist to gauge individual patient's tolerance and potential areas of improvement.

An important component of physical examination is nutritional assessment. This commonly includes measurement of weight, height and BMI. Both being underweight and overweight in a COPD patient can be detrimental. Excess weight can lead to extrinsic restriction on lung capacity as well as increased work of breathing. Weight loss and muscle wasting is a poor prognostic factor in COPD patients [59–61].

Pertinent respiratory examination in patients with COPD is directed at ability of the patients to clear their respiratory secretions, use of accessory muscles of respiration, breathing pattern, adventitious sounds on auscultation such as wheezing and crepitation. A knowledge of patients' respiratory status will help develop an educational plan regarding self-management, medication compliance and respiratory muscle training.

Reduced functional capacity due to physical deconditioning is widespread in COPD patients. This is multifactorial with poor nutritional status, systemic inflammation, cardiovascular comorbidities, postural deformities and osteoporosis [62] Interviewing the patient to ascertain their capacity to perform ADLs, sustained exercise and risk of falls is essential. Several questionnaires have also been used to objectively measure individual patient's baseline functionality. A few examples include: the Functional Independence Measure (FIM), the Assessment of Motor and Process Skills (AMPS), and a Functional Capacity Evaluation (FCE) [63].

Apart from questionnaire, various exercise tests can be used to gauge individual patient's functional capacity. These exercise tests can be done as field walking tests, on bicycle ergometer or on treadmill. In most hospital, simple walk testing can be cost effective and practical. Walk tests are considered more reflective of daily functionality of a COPD patient. Some of the commonly employed walk tests include the 6-minute walk test (6MWT) and the incremental shuttle walk testing. Standardized protocols have been established for performing the 6MWT. If done as per the set protocol, this walk test is highly reproducible and reliable test for both diagnostic and prognostic purposes. In this test, patient walk back and forth on a 30-m distance marked hallway at their own pace for 6 minutes. During the test, distance walked, vital signs, oxygen desaturation, development of dyspnea using a visual analog scale is measured [64]. The incremental shuttle walk test is performed on a 10 m marked course. It is a paced walk test to assess symptom limited maximal exercise capacity. Test is continued until patient develops symptoms of dyspnea or for 20 minutes, whichever occurs first. This is a valid and popular testing in various resource limited clinical settings [45].

If in addition to the functional limitation specific problems are identified by the physical therapists, various other tests may need to be performed. These tests address the muscle weakness, gait disturbances, and include balance testing and sit-to-stand tests [65].

### **8.2 Components of pulmonary rehabilitation**

After an initial assessment, patient is enrolled into a pulmonary rehabilitation program. The basic aim of such a program in any COPD patient is to assist them in performing essential daily activities with independence. Independence comes from reduction in dyspnea and fatigue. COPD patient are inadvertently caught in a downward spiral where dyspnea is leading to inactivity, which in turn leads to physical deconditioning and decreased capacity to handle day-to-day stress. To save the patient from this downward spiral a pulmonary rehabilitation program focuses

on improving the cardiorespiratory endurance, muscle strength, body flexibility and respiratory muscle training. With an individualized patient's clinical analysis and examination, a specific therapy plan can be built for each patient. This plan is intended to establish patient specific goals and focus on areas of functional limitation, which need to improve to achieve those goals. As the COPD patients undergo pulmonary rehabilitation, improvement in their physical deconditioning and exercise capacity needs to be measured and documented. This is achieved by using a variety of parameters, such as quantity of exercise performed or improvement in perception of dyspnea, symptoms, heart rate during exertion. Any changes seen in these parameters will be suggestive of patient's improved capacity to handle the physical stress. As discussed earlier in the chapter walk tests and questionnaires can provide an objective measure of functional improvement for COPD patients undergoing pulmonary rehabilitation.

### *8.2.1 Endurance training*

Physical exercise training in COPD patients can be delivered in two forms: Continuous high intensity aerobic endurance training or an interval training, which alternates high intensity aerobics with low intensity exercises [66]. Continuous high intensity regimen of endurance training can be administered with constant load or incremental load. It has been shown that high intensity aerobic training (70–80% of peak work rate), will result in maximal improvement in physical fitness by increasing oxygen consumption, delaying anaerobic threshold and decreasing heart rate for a given exercise rate [27, 62, 67–69].

In patients with advanced COPD and persistent dyspnea a high intensity endurance training is difficult to sustain. These patients can be provided with interval endurance training. In this approach, high intensity aerobic training in short bouts (30–180 s) is alternated with low intensity exercises (leading to a subjective experience of exertion between 4 and 6 on the modified Borg scale) or rest [70–74].

Even though there may be less appreciable gains in aerobic parameters, this training approach has proven to be effective in improving exercise endurance in COPD patients [42, 75]. Interval endurance training leads to lesser degree of pulmonary hyperinflation allowing patients to exercise longer without excessive dyspnea. COPD patients may more easily adapt a lower intensity exercise regimen in their daily life. The choice of regimen is ultimately based on both therapist and patient preference.

Endurance training is delivered using various modalities including walking (treadmill or supported ground walking with walker or wheelchair), cycling, rowing, and swimming or modified aerobic dancing. It is recommended to provide this training 3–5 times per week at an intensity aimed at a Borg Dyspnea score of 4–6 (moderate level of exercise) [26, 44, 48, 67, 69, 76–79]. Exercise sessions can last from 30 to 120 minutes, with at least 30 minutes of continuous aerobic activity, based on each patient's capacity [26, 46, 79, 80]. General recommendation for the frequency of pulmonary rehabilitation is two supervised exercise sessions a week with third unsupervised session based on the available resources [44, 81, 82]. A minimum of 12 exercise sessions or 4 weeks of rehabilitation program is essential to achieve any improvement in physical fitness. Program length can be increased up to 72 weeks if patient is inclined and insurance coverage is favorable [48, 83, 84]. While shorter (6–8 weeks) pulmonary rehabilitation programs are more cost effective and widespread, longer duration programs have shown sustained beneficial effects. This is mostly due to fact that longer duration programs not only lead to physiological changes but also behavioral changes [85].

**9**

*Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease*

patients to tolerate higher intensity workout for longer duration.

More specific for COPD patients it is recommended to check oxyhemoglobin saturation both prior to the start of the exercise and at peak work rate. This will not only help to ascertain the need for oxygen supplementation but also guide both therapist and the patient to know appropriate level to use with different intensity of work. Similarly, a careful attention on patient's bronchodilator therapy, both long acting and short acting, is essential during the program. Patients may require administration of short acting bronchodilator at the beginning of the exercises or during the workout. For a successful outcome of endurance training it is important that patient gets trained on similar oxygen delivery device that they use at home and are on optimal management of COPD. A stable respiratory function will allow the

Apart from improvement in endurance, COPD patients benefit from increase in their muscle strength [26, 83, 86, 87] . Increased muscle strength provides the patients with an ability to handle the ADLs better, improves their gait and reduce fall risk, thereby making them more independent [88]. A recent meta-analysis investigating different methods of PR in COPD showed greater improvement in HRQoL by adding strength training than endurance training alone [89]. Physiologically improving muscle strength in COPD patients can lead to increase in physical endurance, 6-minute walk distance and maximum oxygen consumption [90, 91]. Strength training is most beneficial if directed at muscles involved in functional living. This involves training muscles in upper and lower extremities as

It has been well proven that exercise training of the lower extremities leads to significant improvement in ambulatory stamina in COPD patients [42, 67, 92–94]. This is because lower extremities suffer most from disease-related muscular dystrophy in COPD patients. Additionally increasing lower extremity strength can reduce falls and maintain bone mineral density in COPD patients [45]. General recommendation to improve lower extremity strength is to provide resistance training with 2–4 sets of 10–15 repetitions of each exercise, for 2–3 days per week. Selection of weight for this type of resistance training workout is individualized based on patient's capacity. Increment in the weight is done gradually once patient is able to accomplish all sets of exercise with a prescribed weight [45]. Lower extremity training can be achieved using walking, bicycling with incremental loads, stair climbing, swimming, weight machines or elastic bands. Choice is driven by available resources

Patients suffering from COPD who have hyperinflation and flattened diaphragm have limitation in using their upper extremities to perform ADLs. Elevation of arms can result in increased ventilatory and metabolic demands in COPD patients with low respiratory reserves. This is thought to be because some of the upper extremity muscles also serve as accessory muscles of respiration [95–97]. Majority of the published literature on pulmonary rehabilitation suggests beneficial effect of upper extremity training in COPD patients. Some of the observed benefits of this training include improved upper extremity strength, which is task specific, decreased ventilatory demands and more independence in performing ADLs. Despite these observed benefits, optimal prescription of upper extremity training remains unclear. Physical therapists have to be mindful that in training the upper extremities, COPD patients may have elevated ventilatory work, asynchronous breathing and more dyspnea for the level of work. It is prudent to start with low resistance and frequent repetitions before gradually increasing the weight [81]. Upper extremity

*DOI: http://dx.doi.org/10.5772/intechopen.81742*

*8.2.2 Strength training*

well as the trunk.

at the training site.

### *Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.81742*

More specific for COPD patients it is recommended to check oxyhemoglobin saturation both prior to the start of the exercise and at peak work rate. This will not only help to ascertain the need for oxygen supplementation but also guide both therapist and the patient to know appropriate level to use with different intensity of work. Similarly, a careful attention on patient's bronchodilator therapy, both long acting and short acting, is essential during the program. Patients may require administration of short acting bronchodilator at the beginning of the exercises or during the workout. For a successful outcome of endurance training it is important that patient gets trained on similar oxygen delivery device that they use at home and are on optimal management of COPD. A stable respiratory function will allow the patients to tolerate higher intensity workout for longer duration.

### *8.2.2 Strength training*

*Cardiorespiratory Fitness*

undergoing pulmonary rehabilitation.

for a given exercise rate [27, 62, 67–69].

changes but also behavioral changes [85].

*8.2.1 Endurance training*

on improving the cardiorespiratory endurance, muscle strength, body flexibility and respiratory muscle training. With an individualized patient's clinical analysis and examination, a specific therapy plan can be built for each patient. This plan is intended to establish patient specific goals and focus on areas of functional limitation, which need to improve to achieve those goals. As the COPD patients undergo pulmonary rehabilitation, improvement in their physical deconditioning and exercise capacity needs to be measured and documented. This is achieved by using a variety of parameters, such as quantity of exercise performed or improvement in perception of dyspnea, symptoms, heart rate during exertion. Any changes seen in these parameters will be suggestive of patient's improved capacity to handle the physical stress. As discussed earlier in the chapter walk tests and questionnaires can provide an objective measure of functional improvement for COPD patients

Physical exercise training in COPD patients can be delivered in two forms: Continuous high intensity aerobic endurance training or an interval training, which alternates high intensity aerobics with low intensity exercises [66]. Continuous high intensity regimen of endurance training can be administered with constant load or incremental load. It has been shown that high intensity aerobic training (70–80% of peak work rate), will result in maximal improvement in physical fitness by increasing oxygen consumption, delaying anaerobic threshold and decreasing heart rate

In patients with advanced COPD and persistent dyspnea a high intensity endurance training is difficult to sustain. These patients can be provided with interval endurance training. In this approach, high intensity aerobic training in short bouts (30–180 s) is alternated with low intensity exercises (leading to a subjective experience of exertion between 4 and 6 on the modified Borg scale) or rest [70–74]. Even though there may be less appreciable gains in aerobic parameters, this training approach has proven to be effective in improving exercise endurance in COPD patients [42, 75]. Interval endurance training leads to lesser degree of pulmonary hyperinflation allowing patients to exercise longer without excessive dyspnea. COPD patients may more easily adapt a lower intensity exercise regimen in their daily life. The choice of regimen is ultimately based on both therapist and patient

Endurance training is delivered using various modalities including walking (treadmill or supported ground walking with walker or wheelchair), cycling, rowing, and swimming or modified aerobic dancing. It is recommended to provide this training 3–5 times per week at an intensity aimed at a Borg Dyspnea score of 4–6 (moderate level of exercise) [26, 44, 48, 67, 69, 76–79]. Exercise sessions can last from 30 to 120 minutes, with at least 30 minutes of continuous aerobic activity, based on each patient's capacity [26, 46, 79, 80]. General recommendation for the frequency of pulmonary rehabilitation is two supervised exercise sessions a week with third unsupervised session based on the available resources [44, 81, 82]. A minimum of 12 exercise sessions or 4 weeks of rehabilitation program is essential to achieve any improvement in physical fitness. Program length can be increased up to 72 weeks if patient is inclined and insurance coverage is favorable [48, 83, 84]. While shorter (6–8 weeks) pulmonary rehabilitation programs are more cost effective and widespread, longer duration programs have shown sustained beneficial effects. This is mostly due to fact that longer duration programs not only lead to physiological

**8**

preference.

Apart from improvement in endurance, COPD patients benefit from increase in their muscle strength [26, 83, 86, 87] . Increased muscle strength provides the patients with an ability to handle the ADLs better, improves their gait and reduce fall risk, thereby making them more independent [88]. A recent meta-analysis investigating different methods of PR in COPD showed greater improvement in HRQoL by adding strength training than endurance training alone [89]. Physiologically improving muscle strength in COPD patients can lead to increase in physical endurance, 6-minute walk distance and maximum oxygen consumption [90, 91]. Strength training is most beneficial if directed at muscles involved in functional living. This involves training muscles in upper and lower extremities as well as the trunk.

It has been well proven that exercise training of the lower extremities leads to significant improvement in ambulatory stamina in COPD patients [42, 67, 92–94]. This is because lower extremities suffer most from disease-related muscular dystrophy in COPD patients. Additionally increasing lower extremity strength can reduce falls and maintain bone mineral density in COPD patients [45]. General recommendation to improve lower extremity strength is to provide resistance training with 2–4 sets of 10–15 repetitions of each exercise, for 2–3 days per week. Selection of weight for this type of resistance training workout is individualized based on patient's capacity. Increment in the weight is done gradually once patient is able to accomplish all sets of exercise with a prescribed weight [45]. Lower extremity training can be achieved using walking, bicycling with incremental loads, stair climbing, swimming, weight machines or elastic bands. Choice is driven by available resources at the training site.

Patients suffering from COPD who have hyperinflation and flattened diaphragm have limitation in using their upper extremities to perform ADLs. Elevation of arms can result in increased ventilatory and metabolic demands in COPD patients with low respiratory reserves. This is thought to be because some of the upper extremity muscles also serve as accessory muscles of respiration [95–97]. Majority of the published literature on pulmonary rehabilitation suggests beneficial effect of upper extremity training in COPD patients. Some of the observed benefits of this training include improved upper extremity strength, which is task specific, decreased ventilatory demands and more independence in performing ADLs. Despite these observed benefits, optimal prescription of upper extremity training remains unclear.

Physical therapists have to be mindful that in training the upper extremities, COPD patients may have elevated ventilatory work, asynchronous breathing and more dyspnea for the level of work. It is prudent to start with low resistance and frequent repetitions before gradually increasing the weight [81]. Upper extremity

### *Cardiorespiratory Fitness*

and trunk muscle strength training is achieved by using light weights (dumbbells, elastic bands), weight machines for stronger patients, rowing machines etc. Several of these instruments can also provide aerobic exercise training thereby improving both strength and endurance in the upper extremities.

Physical therapists may provide training of upper and lower extremities on alternate days to improve patient tolerance. Progressive improvement in muscle strength is documented using standardized lifting tests, incremental resistive load tolerated by the patient and increased capacity in performing ADLs efficiently [86].
