Fitness training for the adult with chronic pulmonary disease

Dear Friend:

Today’s blog like so many before is inspired by the personal story of one of my training clients who was recently diagnosed with Idiopathic Pulmonary Fibrosis. I decided to expand on this and discuss Fitness Training for Adults with Chronic Pulmonary Diseases in general. I am going to cover the pros and possible cons of Fitness Training with this particular work-out group and put forward training suggestions that have proven to be helpful in managing Chronic Pulmonary Diseases. This blog combines literature research and experiences  I have gained in my own practice.

The most common chronic pulmonary diseases (CPDs) in adults develop generally as a result of poor respiratory or environmental conditions and/or genetic make-up.

• Smoking – 1st and 2nd Hand
• Poor working conditions – i.e. mining
• Exposure to high airborne particulates – Air Pollution
• Genetics and some Auto-Immune Diseases have been linked to Interstitial Lung Diseases. Continuous exposure to smoke and/or inhalation of irritants in the work- or living space causes inflammation and constriction of the lung tissue, a normal immune system response, resulting in breathing difficulties. One challenge in obstructive lung diseases is the exhalation of CO2 leading to an increase of CO2 levels and a decrease of O2 in the body which is ultimately harmful to heart and lung.

1. Asthma
   Asthma is one of the most common chronic lung diseases that causes airways to swell and surrounding muscles to tighten making breathing difficult. Asthma can’t be cured but can be managed. The symptoms often include wheezing, difficulty to take air in, coughing and chest tightness. We differentiate intermittent (using rescue inhaler 2 or fewer times per week) and persistent asthma.
   Persistent Asthma is separated into three categories, “Mild”, “Moderate” and “Severe” with an increase in symptomatic days and nights, decreased lung test scores and increased limitations to regular activities.
2. COPD ( Chronic Obstructive Pulmonary Disease)
   This disease is most often caused by cigarette smoking or less often by inhalation of other irritating gases and particulate matter that increases the patient’s risk for heart disease and lung cancer. Patients with COPD have typically Chronic Bronchitis and/or Emphysema. Symptoms of Chronic Bronchitis and Emphysema include shortness of breath, wheezing, mucus production, coughing and chest tightness.
3. Interstitial Lung Diseases
   There are approximately 150 different Interstitial Lung Diseases which include Sarcoidosis, Idiopathic Pulmonary Fibrosis. ILD leads to scarring, inflammation, and stiffness of the lung tissue in the Interstitium (space between air sacs. All Interstitial Lung Diseases are incurable but new treatment options show success in slowing the progress of the diseases. Symptoms include a dry cough, difficulty breathing and shortness of breath.
4. Pulmonary Hypertension
   Pulmonary Hypertension describes an increase in blood pressure limited to the blood vessels between your heart and lungs leading to increased pressure in the arteries and capillaries in the lung. Pulmonary Hypertension is commonly caused by gene mutations, drugs, and congenital heart disease. Interstitial Lung Disease can lead to secondary Pulmonary Hypertension. Symptoms include shortness of breath, fatigue,  dizziness, chest pain, tachycardia (rapid heartbeat) and edema (swelling) of the ankles.
5. Chronic Pneumonia/Chronic Pneumonitis
   Chronic Pneumonia is commonly caused by bacterial, viral or fungal infections that lead to inflammation along with mucus accumulation and fluid retention in the lungs. If antibiotics or antiviral medications fail to clear up an infection it can hang on for a long period of time. Chronic Pneumonia is often favored by smoking, weak immune system, surgery or other illness. The most common symptoms include coughing up blood, swollen lymph nodes, chills, and lasting fever.
6. Lung Cancer
   Lung Cancer is characterized by abnormal cell growth within the lung tissue forming tumors, neoplasms or leasions which reduce the ability of proper lung function as they grow. Lung Cancer is most commonly caused by smoking and air pollutants, genetics or as secondary cancer. Symptoms include coughing up blood, wheezing, unexplained weight loss and shortness of breath.

How can fitness training help adults with Chronic Pulmonary Diseases?

When searching the internet for exercises for Chronic Pulmonary Diseases you most commonly find respiratory exercises often presented by a Pulmonary Therapist (very valuable, but not covered here). This article will get into fitness training and physical exercises that have shown to impact disease management, outcome and Quality of Life (QoL) in positive ways. Some of the information shared here is based on scientific studies that have been published, other information is based on my own experience in working with this population.

Chronic Respiratory Diseases share the effect of shortness of breath especially during exertion known as exercise intolerance. That intolerance commonly leads to a self-prescribed exercise, and activity restriction and a reduced health-related Quality of Life (HRQoL). Exercise training is essential in improving symptoms, function, and QoL. Current research indicates that regular exercising and fitness training is effective in patients with COPD, Cystic Fibrosis and Interstitial Lung Diseases. There is much less research available on Pulmonary Arterial Hypertension (PAH) and Asthma. However, a recent study reported improvements in functional capacity and effective reductions in mean pulmonary arterial pressure in patients with PAH.
(Cochrane Review: https://www.cochrane.org/CD011285/AIRWAYS_exercise-based-rehabilitation-pulmonary-hypertension)

Exercises can be divided into three categories, Cardio-Vascular Endurance Training, Strength and Resistance Training and Flexibility – Mobility Training.

Cardio-Vascular Endurance Training:

Endurance training aims to improve cardio-respiratory fitness, increase exercise tolerance, reduce muscular discomfort and strengthen the musculature involved in breathing itself. Most folks with chronic lung disease are self-limiting due to low exercise tolerance and the negative feelings associated with shortness of breath (dyspnoea). Cardio-Vascular training can be performed in two ways, at low to moderate intensities, defined as intensities that increase depth and frequency of breathing but stop short of dyspnoea (aerobic exercise), or in form of  short high-intensity levels that create a high demand for oxygen on the muscular cell level that can’t be satisfied by the respiratory system and therefore leads to shortness of breath (anaerobic exercise). In order to achieve training goals, one has to apply a work-out intensity higher than the one used in day to day activities. To increase stamina exercising continuously at moderate workout intensities has been very successful, but isn’t suitable for patients with significant respiratory limitations. In those cases, short High-Intensity Intervals alternated with short bouts of rest or low-intensity activities provide a more successful form of training. High-Intensity Interval Training (HIIT) has shown in patients with COPD improvements in lowering ventilation frequency, reduce hyperinflation, and reduce dyspnoea and leg pain, resulting in greater exercise and activity readiness.  Asthma attacks are often triggered by cold dry air. To increase temperature and humidity levels we have our Asthma patients use a simple dust mask or train in the pool. Frequency and consistency matter. If possible train daily, but at least 3 days per week and for 30 minutes or more each time. Keep in mind these are goals. If you can’t exercise for prolonged periods of time early in your training don’t be discouraged. If oxygen is needed to train, please use it, it has no negative consequences on training success. Cardiovascular training has shown improvements in stamina and reduction in breathing difficulties across all groups of chronic pulmonary disease.

Continuous Aerobic Training or Anaerobic HIIT can be done in the form of:

• walking/jogging – treadmill
• skating
• dancing
• cycling – stationary cycle
• swimming, aqua aerobics etc.

Strength and Resistance Training

The goal of Strength and Resistance Training in Patients with Chronic Pulmonary Disease is to regain and maintain muscular strength and strength endurance (fatigue resistance) necessary to perform everyday activities. In patients that are self-restricting physical activity muscular atrophy, weakness, and more rapid muscular fatigue are common. Those secondary effects can exacerbate feelings of being disabled, feelings of dependency and lead to other problems such as poor balance and increased fall risk. Muscular strength can be improved utilizing body-weight exercises (calisthenics), free weights or resistance bands or gym based equipment. Strength Training can isolate muscles or can include full-body exercises that combine many major muscle groups. Resistance training prescriptions vary greatly in the number of repetitions, intensities, and methods across the literature. Both the American Thoracic Society (ATS) and the European Respiratory Society (ERS) suggest four sets of 6-12 repetitions per set at 50-85% of the patient’s one repetition max on two or three days per week for Pulmonary Rehabilitation.

(The program for Pulmonary Rehab at El Camino Hospital follows the ACSM guidelines of 1-3 sets of 10-15 repetitions on 2-3 non-consecutive days per week. The RPE chosen is 12-14 and workloads are increased once 15 repetitions can be completed with proper form)

To gage work-out intensities I commonly use the Borg Rate of Perceived Exertion Scale. This scale allows the client/patient to rate his/her fatigue throughout the training program.

Flexibility and Mobility Training

Exercises that stretch muscles and mobilize joints are a necessary part of any exercise program no matter the target group or desired outcome. Stretching of muscles that have been used during cardiovascular training and strength and resistance training allows us to return the muscle to the functional length preventing muscle tightness and related limitations to joint range of motion (ROM). Flexibility and Mobility Training is also a successful form of intervention for already existing muscle tightness and joint mobility restrictions including postural corrections. Indeed the latter part in coordination with properly chosen strength exercises is routinely used in my practice to improve postural impairment and thoracic mobility in an effort to increase the thoracic spacial capacity for inhalation and exhalation and increase Vital Capacity (Vital capacity is the maximum amount of air a person can expel from the lungs after a maximum inhalation). Vital Capacity is not increasing in every individual.

Other forms of Exercises

Yoga, Tai-Chi, and Waterbased exercise programs have proven to be valuable complementary forms of therapy that can improve exercise capacity and overall QoL in patients with Chronic Pulmonary Diseases. Low impact exercises are especially beneficial to patients with osteoarthritic conditions that have a low tolerance for high impact exercises.

In summation, nearly all patients with a variety of CPDs exhibited in scientific studies exercise-related improvements in either/and exercise capacity, functional capacity, shortness of breath and QoL. Different CPDs were benefitting from different exercise protocols with respect to the choice of types of exercises, frequency and intensities. For more details please see the table below and use the attached list of literature sources in the appendix to this article.

Understand that this table only provides a guideline and that all individuals should confer with their physician related to safe intensities.Table 2. Training modalities for patients with different chronic respiratory disease entities

	COPD	Cystic fibrosis	Pulmonary hypertension	ILD	Asthma
Modality	Aerobic (continuous or interval) and resistance	Aerobic or anaerobic or a combination of both	Aerobic (interval) and peripheral muscle training	Aerobic and resistance training	Aerobic conditioning using treadmill/bicycle ergometer or swimming
Intensity	60–80% of Peak work capacity for continuous exercise and 100–120% of peak work capacity for interval exercise	55–65% Maximum heart rate	<120 bpm, SpO2 > 85% and Borg score < 5/10	60–80% of Peak work capacity for continuous exercise	50–75% VO2 max aerobic exercise
Length	8–12 weeks	Minimum of 6 weeks	6–8 weeks	8–12 weeks	8–12 weeks
Duration	20–60 min	20–30 min	30–60 min	20–60 min	30–40 min
Frequency	3–5 days per week	3–5 days per week	2–3 Supervised exercise	3–5 days per week	2–3 Sessions per week
Outcomes	Improvements in exercise capacity, strength and QoL	Improvements in exercise capacity, strength and QoL; slower rate of decline in lung function	Improved exercise endurance, QoL, peak VO2, increased peak workload and increased peripheral muscle function	Improved 6MWD, dyspnoea and QoL	Improved physical fitness, asthma symptoms, anxiety, depression and QoL

Matthew Armstrong,  Ioannis Vogiatzis(https://onlinelibrary.wiley.com/doi/full/10.1111/resp.13639Chronic Pulmonary Diseases and ComorbiditiesA large percentage of adults with CPDs suffer from secondary health conditions (Comorbidities) either as a side effect or unrelated to the CPD. That is particularly true for those of advanced age. As mentioned earlier, the impact of a CPD on exercise tolerance and the feeling of shortness of breath often has patients with CPDs self restrict physical activity. That self-restriction often leads to typical sedentary lifestyle-related health problems such as Hyperlipidemia (high cholesterol and triglycerides), Metabolic Syndrome, Type 2 Diabetes, and Hypertension (elevated blood pressure), etc. Those comorbidities are often responsible for a significant decrease in QoL and life expectancy. Nearly all those health problems can be managed well by reintroducing regular fitness training into the patient’s life. In other words, regular fitness training for the patient with a Chronic Pulmonary Disease isn’t limited to positive outcomes directly related to the CPD such as exercise capacity, functional capacity, strength, QoL and anxiety, and depression, but additionally helps to prevent the development of-, or helps manage comorbidities.What precautions have to be taken when exercising with a CPD?All of the CPDs feature a variety of challenges when it comes to fitness training, but despite intensive online research, I was unable to find any true contraindications. This leads me to believe that the patient with CPD can safely engage in Fitness Training as long as the Fitness Instructor, a Physical Therapist or Personal Fitness Trainer is aware of the challenges the CPD trainee is faced with and demonstrates a sound understanding of the way the disease expresses itself and makes all accommodations necessary for a successful outcome. Patients with Pulmonary Hypertension and those with low oxygen levels will require physicians’ guidance for safe exercises. Many of the CPDs are not only chronic but also progressive. I do think it makes sense to cut training volume and intensities in patients with very advanced CPD in an effort to manage the quality of life. If the disease reaches a state in which training robs the patient of all energy necessary to enjoy other still much-desired activities I often limit the training to stretching and mobility keeping the patient comfortable and enable him/her to take part in social activities.I hope this article was able to shed some light on the “Fitness Training for the Adult with Chronic Pulmonary Disease”. Should you feel you have important information to share or have additional questions that haven’t been answered please feel free to leave your questions or remarks in the comment section.In good health,Hartmut Broring – M.S. PhysiotherapyA big Thank You for reviewing and editing to:Missy Von LuehrteRN, BSNPulmonary RehabilitationEl Camino HospitalMountain View CALiterature Appendix:https://www.healthline.com/health/copd/exercisehttps://onlinelibrary.wiley.com/doi/full/10.1111/resp.13639https://www.ncbi.nlm.nih.gov/pubmed/23723024?dopt=Abstracthttps://my.clevelandclinic.org/health/articles/9450-copd-exercise–activity-guidelineshttps://www.cochrane.org/CD011285/AIRWAYS_exercise-based-rehabilitation-pulmonary-hypertensionhttps://lunginstitute.com/blog/pulmonary-fibrosis-and-exercise/https://www.physiciansweekly.com/exercise-training-for-interstitial-lung-disease/https://www.asthma.com/what-is-asthma.html?bing=e_&rotation=71700000038361464&banner=58700004208867532&kw=34938313613&cc=278B16106D26&pid=43700012665322306&gclid=CKiszeunpuUCFYZhgQodNjUHvQ&gclsrc=dshttps://www.healthline.com/health/breathe-deeper-improve-health-and-posturehttps://www.thebreatheffect.com/posture-breathing-physiological-effects/https://www.thebreatheffect.com/https://iowachiroclinic.com/2014/01/20/does-posture-really-affect-breathing-and-lung-capacity/https://www.ncbi.nlm.nih.gov/pubmed/24353107?dopt=Abstracthttps://www.ncbi.nlm.nih.gov/pubmed/22809999?dopt=Abstracthttps://www.ncbi.nlm.nih.gov/pubmed/27846347?dopt=Abstracthttps://www.ncbi.nlm.nih.gov/pubmed/15139572?dopt=Abstracthttps://www.cochrane.org/CD011434/AIRWAYS_arm-exercise-training-copdhttps://humankinetics.me/2017/07/20/common-medical-conditions-in-athletes/https://onlinelibrary.wiley.com/doi/10.1111/resp.13639https://www.researchgate.net/publication/245821977_Influence_of_Posture_on_Respiratory_Function_and_Respiratory_Muscle_Strength_in_Normal_Subjectshttps://www.healthline.com/health/understanding-idiopathic-pulmonary-fibrosis/chronic-lung-diseases-causes-and-risk-factors#9https://news.osu.edu/chronic-obstructive-pulmonary-disease-and-exercise/https://www.houstonlungdocs.com/lung-disease-exercise/