INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease, which is
largely attributed to lung-related death and disability. COPD is a very disabling disorder that is
accompanied by some extrapulmonary manifestations, but it can be prevented and treated [1]. The
breathlessness developed at rest and/or during daily living activities in patients with COPD can cause
an increasingly sedentary lifestyle, a progressive worsening in functional capacity, and may cause
home isolation. With progressive inactivity, cardiovascular function and skeletal muscle mass
decrease. The deterioration in aerobic fitness and strength creates a vicious cycle that leads to more
exertional dyspnea, muscular fatigue, an evitable loss of functional independence, and depression
[2]. Pulmonary rehabilitation (PR) is a comprehensive program that depends on a complete
assessment of patients and subsequent patient-tailored therapies, which consist of patient education
and exercise training, outlined to enhance both physical and psychological condition of patients with
chronic chest diseases and to encourage the long-term adherence to health-enhancing behaviors [3].
We aimed at evaluating the effectiveness of 8 weeks of outpatient PR on improving breathlessness,
quality of life, exercise tolerance, and functional ability in patients with stable COPD. (samah m
Shehata)

METHODOLOGY

Inclusion criteria

The following were the inclusion criteria:

(1) Cooperating patients with COPD.

(2) Presenting with a postbronchodilator 30% ≤

FEV1% predicted <80% (moderate and severe

airflow limitation only).

(3) Free from exacerbations 4 weeks before starting

PR.

Exclusion criteria

(1) Heart failure and unstable angina or recent (<6 months) myocardial infarction.

(2) Prior cardiac or pulmonary surgery.

(3) Patient was on long-term oxygen therapy or

received systemic steroid during the past 4 weeks.

(4) Presence of neuromuscular and orthopedic

diseases.

(5) Uncontrolled disabling diseases, for example,

diabetes, hypertension, and renal or hepatic

diseases.

(6) Patient was not interested in the program.

(7) Patient did not complete 85% of PR.

The patients were classified into two groups (test and control group) after taking an informed
consent from them:

(4) Spirometric pulmonary function test was performed by using computerized pulmonary function
apparatus (1999, ZAN 100 spirometer; ZAN Messgeraete GmbH Company, Germany) including
prebronchodilator/postbronchodilator forced expiratory volume in 1s (FEV1), forced vital capacity
(FVC), and FEV1/FVC to diagnose and assess degree of airway obstruction.

(6) Quality-of-life assessment by Saint George

respiratory questionnaire (SGRQ), which is a disease-specific questionnaire validated for measuring

impaired health in patients with respiratory disorders; scores range from 100, representing worst
possible health status, to 0, best possible. It consisted of two parts: part 1 (the symptom score)
covers the patients’ symptoms that occurred in the preceding period from 1 month to 1 year, and
part 2 addresses the patients’ current state (i.e. how they are these days), which consists of the
activity score (measures the disturbances in patient’s daily activity) and the impact score (measures
the disturbances in patient’s psychosocial condition) [6].

(7) Six-min walk test (6MWT): this test estimates the distance walked quickly by a patient on a hard
and flat surface for 6 min [the 6 min walk distance (6MWD)] [7].

Methods (pulmonary rehabilitation)

Patient health education [4]

It should help patients to acquire the following:

(1) Basic information about COPD, risk factors, recognition of symptoms, and management.

(2) Knowledge about the value of physical exercise for patients with COPD and the appropriate types
of exercise.

(3) Understanding the correct and proper use of medications.

(4) Advice about when to seek help and decision making during exacerbations.

Exercise training programs [8]

Different modes of training were used for both upper and lower limbs. They included endurance
(aerobic), strengthening (resistance) exercises, and breathing retraining technique.

(1) Endurance training:

(a) Cycle based using ergometer. (b) Walking based using treadmill. (c) Arm exercise using arm wheel.

(2) Strengthening training (resistance training):

(1)

(2)

Group 1 (test group): 40 patients were subjected to usual pharmacological therapy for COPD added
to it PR (exercise training, health education) which was conducted for 8 weeks.

Group 2 (control group): 40 patients were subjected to usual pharmacological therapy only for COPD.
All following:

patients in the study were subjected to the

(1) Clinical diagnosis depending on medical history, especially smoking and progressive dyspnea, with
irreversible airflow obstruction on spirometry, complete physical examination, and chest radiography
examination [4].

(3) Degree of dyspnea related to activities was assessed by modified-Medical Research Council
(mMRC) [5].

(a) Free weights. (b) TheraBand.

(c) Ball exercise.

(3) Breathing retraining (or breathing exercises).

Breathing retraining is a simple approach aiming to enhance respiratory muscle recruitment to

reduce dyspnea and improve respiratory muscle performance. They included the following:

(a) Pursed-lip breathing in which the patient inhales through the nose with mouth closed and exhales
through mouth lips pursed tightly, provided that the exhalation was twice as long as the inhalation.

(b) Diaphragmatic breathing in which the patient inhales slowly through the nose with the abdomen
expanded outward and exhales slowly through pursed lip while drawing the abdomen inward.

Physical exercise schedule during the study

(1) Warming up phase:this included stretching ,range of motion, and starting activities at low
intensity level.

(2) Physical exercise included the following:

(a) Breathing retraining in the form of pursed-lip

breathing and diaphragmatic breathing.

(b) Exercise training regarding frequency, intensity, time, and type (FITT) are shown

in Table 1.

The exercise training was tailored and selected to the patients depending on their ability to
withstand the exercise and their disease severity.

(3) Cool down phase:this allows the body to gradually recover from the training phase. Heart rate will
return to near-resting values. Best cool down was to decrease the exercise intensity and to perform
some stretching activities in the warm up.

At the end of 8 weeks, both groups were subjected to the following:

(1) Subjective methods including the following: (a) Assessment of SGRQ questionnaire. (b)
Assessment of dyspnea by mMRC.

(2) Objective methods including the following:

(a) 6MWT.
(b) Spirometry.

Statistical analysis

All data were collected, tabulated, and statistically

analyzed using SPSS 20.0 for windows (SPSS Inc.,
Chicago, Illinois, USA) and MedCalc 13 for
windows (MedCalc Software bvba, Ostend, Belgium).
Quantitative data were expressed as the mean±SD and
qualitative data were expressed as absolute frequencies
(number) and relative frequencies (percentage).
Continuous data were checked for normality by using
Shapiro–Wilk test. Independent Student’s t-test was
used to compare two groups of normally distributed
data whereas Mann–Whitney U was used for nonnormally
distributed data. Percentages of categorical
variables were compared using χ2-test or Fisher’s exact
test when appropriate. Spearman’s rank correlation
coefficient was calculated to assess relationship between
ΔSGRQ (Total), Δ6MWT, and baseline study parameters,
where values near to 1 were indicator of strong relationship
and values near 0 were indicator of weak relationship.