# Exercise as it relates to Disease/The benefits of exercise in older adults with Idiopathic Pulmonary Fibrosis

This page explores the article ‘Exercise Training-Based Pulmonary Rehabilitation Program Is Clinically Beneficial for Idiopathic Pulmonary Fibrosis’ by Vainshelboim B, Oliveira J, Yehoshua L, Weiss I, Benjamin D, Fruchter O, Kramer O.

## What is the background to this research?

Idiopathic Pulmonary Fibrosis (IPF) is a chronic and progressing interstitial lung disease (ILD) with unknown aetiology. Usually affecting older adults and characterised as;
* Impaired gas exchange and ventilatory capacity
* Hypoxemia
* Progressive worsening of dyspnea and lung function
* Exercise intolerance
Individuals suffering from this disease are less physically active and more breathless, resulting in reduced functional capacity and quality of life (QOL). There is no current treatment for this disease however, interventions can be implemented to slow progression.
Exercise training (ET), a major component of pulmonary rehabilitation can help manage the effects of respiratory diseases. The implementation of ET has shown significant improvement in functional capabilities however, more research into this topic is required to draw definitive connections.
The aim of this intervention was to determine the effects of an ET program for pulmonary rehabilitation on; exercise tolerance, functional capacity, pulmonary function, dyspnea and QOL.

## Where is the research from?

This research was conducted in Israel at the Pulmonary Institute of the Rabin Medical Centre located at Beilinson Hospital. The article was published in Respiration: International Journal of Thoracic Medicine in 2014. This journal is an open access, peer reviewed journal indexed in PubMed and Science Citation Index Expanded (SCIE). It focused on respiratory, lung, heart, oesophageal, and mediastinal diseases.
The primary author of this article, Dr Baruch Vainshelboim has a Ph.D in Clinical Exercise Physiology and Pulmonary Rehabilitation. He has published 145 peer-reviewed scientific papers, received several reputed awards and funding for his academic efforts.

## What kind of research was this?

The study was conducted as a randomised control trial (RTC). The intervention evaluated the clinical and physiological outcomes of a 12-week ET program on individuals with IPF. RTC’s are used to measure the effectiveness of an intervention, or treatment, where participants are recruited and randomly assigned to either the intervention or the placebo group. This randomisation significantly reduces bias and offers an effective technique to explore the cause-effect relationship between an intervention and the outcome.

## What did the research involve?

Patient Recruitment and Selection
Patients from the Pulmonary Institute of the Rabin Medical Centre diagnosed with IPF, based on the American Thoracic Society (ATS) and European Respiratory Society (ERS) criteria, were recruited for the intervention. A clinical assessment on their medical history and IPF risk factors was performed with exclusion criteria being;
* - severe comorbid illnesses
* - unstable cardiac disease
* - neurological/orthopaedic contraindications for ET
* - exacerbation of IPF
* - participation in a pulmonary rehabilitation within 12 months prior to recruitment
A co-ordinator, uninvolved in-patient assessment or treatment randomised the 34 participants.
The ET group (n=18) participated in two, weekly, 60-minute supervised sessions over a 12-week period whilst continuing with care in the outpatient pulmonary rehabilitation program. The control group (n=16) did not participate in the ET program and continued with regular medical care in the outpatient pulmonary rehabilitation program.
The exercise program was broken up into two six-week progressive blocks.
Block 1
| Time | Activity | Instructions |
| 5 min | Warm up | Active stretching and breathing activities |
| 30 min | Aerobic interval training* | 1. treadmill walking @70–80% of individual average walking speed measured during the 6MWD test 2. Leg-cycling @50–60% of peak work rate (WR) achieved during the CPET |
| 8 min | Continuous walking | Self-paced walking in a 35m corridor to test for functional transfer adaptation. |
| 20 min | Dumbbell resistance training | 4-6 sets of 12–15 repetitions as directed at moderate intensity (3–5 on Borg CR 10 scale) – 1 min rest |
| 3 min | Flexibility training | 4–5 stretching exercises completed as directed for 15–30 seconds |
*When beginning the program exercise was performed in intervals of five minutes followed by one minute of passive rest, for five repetitions. Progression included an additional one minute of work, to each exercise interval, until participants reached 15 minutes of continuous exercise.
Block 2
In block two the duration of aerobic training was increased to 20 minutes of continuous aerobic endurance training. Intensity was increased to 60–70% of peak WR in cycling and 80–90% of individual average walking speed for treadmill walking. Stair climbing within the hospital for 3–5 minutes was added to each session. Resistance and flexibility training were maintained however, resistance sessions were altered to two sets of 10–12 repetitions with 45 seconds of rest.
Assessment
All participants were assessed at baseline and within 1-week post intervention. The assessment consisted of;
* 1. Pulmonary Function Tests
* 2. Cardiopulmonary Exercise Test (CPET)
* 3. 6MWD Test
* 4. 30-Second Chair-Stand Test of Leg Strength
* 5. Dyspnea questionnaire using the medical research council (mMRC) scale criteria for dyspnea evaluation
* 6. QOL questionnaire using a validated St. George's Respiratory Questionnaire (SGRQ)
During all sessions participants were periodically monitored for blood pressure, SpO$_2$, heart rate and symptoms. Supplementary oxygen was provided for patients on request or if SpO$_2$ fell below 88% during exercise.

## What were the basic results?

The intervention was completed by 32 of the 34 recruited participants, with an overall adherence rate of 90%. There were no differences between the intervention and control group in terms of patient characteristics, co-morbidities, physiological and clinical parameters, or medication at baseline.
The results from this study determined that the implementation of a supervised ET program in those with IPF resulted in improved:
* - Exercise tolerance (ΔVO$_2$ peak)
* - Functional capacity (Δ6MWD)
* - Leg strength (Δ30-second chair-stand test)
* - Pulmonary function (ΔFVC%)
* - Ventilatory response (ΔVO$_2$ peak)
* - Dyspnea (ΔmMRC)
* - QOL (ΔSGRQ)
A worsening trend in the progression of IPF was observed in the control group.

## What conclusions can we take from this research?

This intervention provides strong evidence that a short-term ET program can clinically improve several IPF manifestations and result in a better QOL. ET interventions should therefore be considered as standard care for IPF patients.
There were some limitations to this study. Sample size was only small which may have resulted in low statistical power. All recruited subjects had moderate pulmonary restriction meaning that these findings therefore cannot be extrapolated to those with a more severe progression of IPF.

## Practical advice

Whilst IPF is not a treatable or preventable disease there are steps that can be taken to mitigate the effects of moderate IPF and assist in reducing the rate of progression.
Exercise pre-screening is essential and constant monitoring of variables such as BP and SpO$_2$ is imperative when exercising to establish risk level. During exercise individuals with IPF should always be supervised.
Supplementary O$_2$ can be used to assist individuals to complete the training session if SpO$_2$ is low.

## Further information/resources

1. New and promising research into the treatment of IPF
2. IPF as a complication of COVID-19
3. Review: Regeneration or Repair? The Role of Alveolar Epithelial Cells in the Pathogenesis of IPF

## References

* 1 2 Barratt SL, Creamer A, Hayton C, Chaudhuri N. Idiopathic Pulmonary Fibrosis (IPF): An Overview. J Clin Med. 2018 Aug. 7(8):201-202
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 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;88(5):378-88
* 1 2 Journal of Thoracic Disease, About the Journal. JTD [Internet]. Hong Kong: JTD; 2009-2022 [cited 2022 September 12]. Available from: https://jtd.amegroups.com/about
* 1 2 Global Cardiology Experts, Baruch Vainshelboim. Global Cardiology Experts [Internet]. 2022 [cited 2022 September 12]. Available from: https://biography.omicsonline.org/israel/rabin-medical-center/baruch--vainshelboim-773668
* 1 2 Hariton E, Locascio JJ. Randomised controlled trials - the gold standard for effectiveness research: Study design: randomised controlled trials. BJOG. 2018 Dec;125(13):1716