# Exercise as it relates to Disease/Is pulmonary rehabilitation beneficial for idiopathic pulmonary fibrosis patients?

This is an evaluation of article: Exercise training-based pulmonary rehabilitation program is clinically beneficial for idiopathic pulmonary fibrosis. By Vainshelboim, Oliveira, Yehoshua, Weiss, Fox, Fruchter and Kramer (2014). Created by U3090799

# Background

Idiopathic Pulmonary fibrosis (IPF) is a condition causing scarring of the air sacs in the lungs.,.
The scarring is permanent and rate of progression is highly individual, with an average prognosis of 2–5 years following diagnosis. In Australia an estimated 5,000 people have IPF, the risk increases with age, with men slightly more affected. IPF may remain undiagnosed due to the similarity of symptoms with other lung diseases, its cause is unknown, however is more common following a smoking history. Diagnosis is made after a physical exam, chest x-ray, lung function test, CT scan and occasionally lung biopsy.

## Symptoms

* Shortness of breath on exertion
* persistent dry cough
* fingernail and toenail clubbing.,,.

## Health Outcomes

* Increasing breathlessness
* loss of fitness and strength
* increasing lung scarring
* poor quality of life (QOL)
* mood disorders
* reduced life expectancy.,,

## Treatments

There is no cure for IPF and treatment options are limited:
* oxygen therapy
* structured exercise programs (Pulmonary Rehabilitation)
* medical treatment (eg for pneumonia)
* lung transplant
* palliative care.,,

# Research

This evidence assists in determining benefits of exercise for IPF. High quality evidence shows structured exercise programs significantly improve exercise capacity, breathlessness, fatigue, and quality of life for other chronic lung diseases,,. A number of articles on IPF and exercise benefits are previously published by these authors, this study adds significant supporting facts. Conflicts of interest are denied, with no conflict of obligations to conduct and report professionally apparent. Study conducted with ethics approval primarily at hospitals and universities in Israel where a history of good research funding and publications exist.

## Study

A Level II randomized controlled trial:
* participants were randomised into two groups, each receiving different treatments
* any effects measured to determine if one intervention was more effective.
Table 1: Evidence Levels for Intervention Questions.
| Level | Study Type | About |
| I | Meta-analysis | Best available |
| II | Randomised Controlled Trial | Particularly good |
| III-1 | Non-randomised Controlled Studies | Increased risk of bias |
| III-2,3 | Comparative Studies with and without Concurrent Controls | Known and unknown confounding factors |
| IV | Cohort & Case-control studies | Not effective |

## Method

32 participants diagnosed with moderate IPF.
Exercise group: 2 x 6 week blocks, 60minute, twice weekly supervised pulmonary rehabilitation:
* 5-8 minute warm-up
* 30 minutes aerobic interval training
* 5–8 minutes self-paced walking
* 10 minutes resistance training: upper and lower body
* 5 mins stretching
* stair climbing added and work intensity increased during second block.
Control group: continued regular medical treatment.
The method was appropriate with:
* concealed randomization for group allocation
* evidence based pulmonary rehabilitation program
* sufficient follow-up
* valid, reliable, appropriate outcome measures.

## Limitations

Although strong, study design faults include:
* small sample sizes may inflate true effect of results
* slight group diversity introducing allocation bias
* participants not blinded, increasing risk of placebo or Hawthorn effect
* therapists and assessors not blinded increasing risk of expectation bias.

## Results

The exercise training group showed significant improvements in:
* exercise tolerance
* functional capacity
* breathlessness
* quality of life.

## Researchers Interpretation

The authors interpreted the improvements in exercise tolerance as mostly due to greater volume of air breathed in when exercising, as the body is able to perform more efficiently. They acknowledge increased heart and skeletal muscle strength also contributes to physical improvements, with better walking ability generating more effective lungs, and therefore QOL. Suggesting further that advances in lung function with exercise acts to improve life expectancy.

## Conclusions

This studies implications are positive, align with similar research findings and are not over-emphasised. Showing short-term, supervised exercise training can improve physical functioning, decrease breathlessness and improve QOL in IPF, however improvements may vary significantly depending on the rate or stage of progression.
A recent IPF review, found meaningful health improvements comparable to this study, with new evidence recommending that due to the cost effectiveness, and positive health impacts, pulmonary rehabilitation should be offered early, and ongoing every 6–12 months.

# Considerations

Importantly, before starting new exercise routines with IPF, obtain a medical clearance from a respiratory specialist and consider other health conditions such as heart disease, high blood pressure and muscle or joint problems, and ensure the program is personalised. Distressing breathlessness can be experienced during exercise, symptoms should be monitored as supplemental oxygen may be needed., With pulmonary rehabilitation, IPF patients learn exercise pacing, movement and breathing coordination, disease education and prepararation for home/community maintenance exercise.

# Further Information

* Lung Foundation Australia http://lungfoundation.com.au/
* Pulmonary Fibrosis Foundation (US) http://www.pulmonaryfibrosis.org
* Healthline http://www.healthline.com/health/pulmonary-fibrosis#Treatments6

# References

* 1 2 3 4 5 6 7 8 9 10 11 12 Vainshelboim B, Oliveira J, Yehoshua L, Weiss I, Fox BD, Fruchter O, Kramer MR. Exercise training-based pulmonary rehabilitation program is clinically beneficial for idiopathic pulmonary fibrosis. Respiration. 2014 Oct 23;88(5):378-88.
* 1 2 3 4 5 6 7 8 9 10 11 Lung Foundation Australia [Internet]. Lungfoundation.com.au. 2016 [cited 14 September 2016]. Available from: http://lungfoundation.com.au/
* 1 2 3 4 5 Prasad J, Holland AE, Glaspole I, Westall G. Idiopathic pulmonary fibrosis: an Australian perspective. Internal medicine journal. 2016 Jun 1;46(6):663-8.
* 1 2 Yang IA, Dabscheck E, George J, Jenkins S, McDonald CF, McDonald V, Smith B, Zwar N. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2016. Version 2.46, June 2016
* 1 2 3 4 5 6 7 8 Hoffmann T, Bennett S, Del Mar C. Evidence-based practice across the health professions. Sydney: Churchill Livingstone Elsevier; 2013.
* ↑ Kozu R, Senjyu H, Jenkins SC, Mukae H, Sakamoto N, Kohno S. Differences in response to pulmonary rehabilitation in idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease. Respiration. 2010 May 27;81(3):196-205.
* ↑ Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. The Cochrane Library. 2014 Jan 1.