# Exercise as it relates to Disease/The significance of exercise in patients with chronic obstructive pulmonary disease

This is a critique of the article looking at the effectiveness of incorporating inspiratory muscle training in an exercise training program for patients living with chronic obstructive pulmonary disease.
Critique article: Elmorsi A, Eldesoky M, Mohsen M, Shalaby N, Abdalla D. Effect of inspiratory muscle training on exercise performance and quality of life in patients with chronic obstructive pulmonary disease. Egyptian Journal of Chest Diseases and Tuberculosis. (2016) 65, 41-46.

### What is the background to this research?

The World Health Organisation defines Chronic Obstructive Lung Disease as an “umbrella team term used to describe chronic lung diseases that cause limitations in lung airflow”.According to the National Health Survey conducted in 2014-15, 600,000 Australians were estimated to have been effected by chronic obstructive pulmonary disease. COPD is the third leading cause of death worldwide. This raises a global concern as the numbers increase each year due to smoking, exposure to dust, chemicals and pollution.
Some of the most common COPD conditions include chronic bronchitis, chronic asthma and emphysema
An intervention strategy for COPD would be inspiratory muscle training (IMT). IMT are breathing exercises that targets respiratory muscles in our body to strengthen and increase the lung capacity used which results in easier breathing. It is cost effective, easily accessible and a convenient method which has shown to reduce dyspnea. This training is beneficial for individuals who are suffering from asthma, bronchitis, emphysema and COPD. Research in inspiratory muscle training for patients with chronic obstructive pulmonary disease have found positive outcomes.

### Where is the research from?

This research took place at the Chest Medicine and Rheumatology and Rehabilitation Department under the Mansoura University Hospital in Egypt. This study is relevant in Australia as the number of individuals with COPD is increasing and has been reported to be the 2nd leading cause of avoidable hospital admissions.

### What kind of research was this?

This is a prospective comparative interventional study.

### What did the research involve?

This study consisted of 60 male patients aged between 45-65 years old. All patients were exsmokers who currently have a moderate to very severe COPD. The severity was classified based upon Global Initiative for Chronic Obstructive Lung Disease (GOLD).
Inclusion Criteria:
Male Patient
* 45 and 65 years of age
* Moderate to very severe Chronic Obstructive Pulmonary Disease
* Exsmokers
* Stable Clinical condition
Exclusion Criteria:
* Unstable cardiac diseases
* Uncontrolled Hypertension
* Recent Pneumothorax
* Recent abdominal or thoracic surgery
* Advanced Liver diseases
Participants were classified into 3 groups:
| Group | Criteria |
| Group A (study group) | 20 patients treated with pharmacological therapy, peripheral muscle exercise training and inspiratory muscle training |
| Group B (control positive group) | 20 patients treated with pharmacological therapy, peripheral muscle exercise training without inspiratory muscle training |
| Group C (control negative group) | 20 patients treated with pharmacological therapy. No form of pulmonary rehabilitation was applied |
Limitations of the method Group A and B were chosen randomly but Group C was not. Group C patients were chosen based upon distant localities who were facing transportation issues and their economic state. This was done as many patients dropped out of the study. They were asked to attend this study for one month. The results would be skewed as Group C was asked to attend for one month whilst Group A and B were scheduled 24 visits in a 8 week period.
This study was conducted to male patients who previously smoked cigarettes. As the researchers were targeting a specific group, this would need to be taken in consideration when interpreting the results as the study did not specify when they had last smoked a cigarette.

### What were the basic results?

This study found that COPD patients practicing inspiratory muscle training whilst undertaking some form of exercise resulted in respiratory muscle strength and an increase in exercise capacity. There was a significant improvement in Group A compared to Group B and C. Group A improved in the maximal inspiratory pressure, maximal expiratory pressure and the 6-min walking distance. This supports other studies who have found significant increase in groups that received IMT beside GER. Although Group C had a significant improvement in the 6-min walking distance, it was not translated as a clinical improvement in dyspnea or quality of life. The researchers concluded this may be due to the optimization of pharmacotherapy during the study.

### What conclusions can we take from this research?

This research concluded that the benefits of inspiratory muscle training (IMT) is significant for COPD patients. Combining IMT to the general exercise reconditioning (GER) does result in a significant improvement rather than GER on its own. Studies have shown inspiratory muscle training improves pulmonary oxygen uptake kinetics.
This study was conducted on male patients who previously smoked cigarettes. This would need to be taken in consideration when interpreting the results as the study did not specify when each participant had last smoked a cigarette. Another important factor is the participant selection. Group A and B were chosen randomly but Group C was not. Group C patients were chosen based upon distant localities who were facing transportation issues and their economic state. They were asked to attend this study for one month. The results would be skewed as Group C was asked to attend for one month whilst Group A and B were scheduled 24 visits in a 8 week period.
According to the WHO, COPD affects both male and females equally due to an increase in female smokers and air pollution. This is an important recognition as the study was focused on males. Further studies shown he conducted on females to ensure improvements are being made.
Although this article has concluded there are significant benefits for COPD patients to practice peripheral muscle exercise whilst undergoing inspiratory muscle exercise (Group A), it does state this does not improve dyspnea and quality of life compared to what is achieved by practicing peripheral training exercise on its own.(Group B) More recent studies in this area suggest that IMT is an effective treatment for patients suffering from COPD and improve the strength of their respiratory muscle, reduce dyspnoea and improvement in exercise capacity. IMT has also been linked to a number of other benefits, such as increasing physical activity which directly links with overall satisfaction with the quality of life

### Practical advice

Participants who are interested in testing out any exercise should complete the Pre- Screening tool prior to commencing the exercise. The aim of this tool is to identify individuals who may be at risk of having an adverse effect during the physical activity/ exercise. If the individual ticks yes to any of the questions, an approval needs to be made by the GP and/ or referral to an allied health professional to confirm the patient's well being and safety before commencing the physical activity/ exercise.
Please have a read through the COPD-X Australian and New Zealand guidelines for the diagnosis and management of COPD.
Please have a look through the Exercise Professionals under the Lung Foundation Australia.

### Further information/resources

* Lung Foundation Fact Sheet
* Exercising with Chronic Obstructive Pulmonary Disease (COPD).
* Risk Factors and Treatment for Chronic Obstructive Pulmonary Disease

### References

* 1 2 3 Elmorsi, A., Eldesoky, M., Mohsen, M., Shalaby, N., & Abdalla, D. (2016). Effect of inspiratory muscle training on exercise performance and quality of life in patients with chronic obstructive pulmonary disease. Egyptian Journal Of Chest Diseases And Tuberculosis, 65(1), 41-46. doi: 10.1016/j.ejcdt.2015.10.006
* ↑ Chronic obstructive pulmonary disease (COPD). Retrieved from http://www.who.int/respiratory/copd/en/
* 1 2 3 Department of Health | Chronic respiratory conditions - including asthma and chronic obstructive pulmonary disease (COPD). Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/chronic-respiratory
* ↑ COPD: The statistics | Lung Foundation Australia. (2018). Retrieved from https://lungfoundation.com.au/health-professionals/clinical-resources/copd/copd-the-statistics/
* 1 2 Gosselink, R., De Vos, J., van den Heuvel, S., Segers, J., & Decramer, M et al. (2011). Impact of inspiratory muscle training in patients with COPD: what is the evidence?. European Respiratory Journal, 37(2), 416-425. doi: 10.1183/09031936.00031810
* ↑ Larson, J., Covey, M., Wirtz, S., Berry, J., Alex, C et al. (1999). Cycle Ergometer and Inspiratory Muscle Training in Chronic Obstructive Pulmonary Disease. American Journal Of Respiratory And Critical Care Medicine, 160(2), 500-507. doi: 10.1164/ajrccm.160.2.9804067
* ↑ Ramírez-Sarmiento, A., Orozco-Levi, M., Güell, R., Barreiro, E., & Hernandez, N et al. (2002). Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease. American Journal Of Respiratory And Critical Care Medicine, 166, 1491–1497. doi: 10.1164/rccm.200202-075OC
* ↑ COPD: The statistics | Lung Foundation Australia. (2018). Retrieved from https://lungfoundation.com.au/health-professionals/clinical-resources/copd/copd-the-statistics/
* ↑ Chronic obstructive pulmonary disease (COPD). (2018). Retrieved from http://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)
* ↑ Chronic Obstructive Pulmonary Disease - Lung Foundation Australia. (2014). Retrieved from https://lungfoundation.com.au/wp-content/uploads/2013/12/COPD-Chronic-Obstructive-Pulmonary-Disease.pdf
* ↑ Exercising with Chronic Obstructive Pulmonary Disease (COPD). Retrieved from https://www.gwinnettmedicalcenter.org/media/file/17_12%20EIM%20Rx%20series_Exercising%20with%20COPD_2.pdf