# Exercise as it relates to Disease/Does combined aerobic strength training have a greater impact in COPD patients than fitness education programs?

This is a critique of the article; Effects of Combined Aerobic-Strength Training vs Fitness Education Program in COPD Patients.

### What is the Background to this research?

This study was designed to compare the effects that a new physical activity education program approach also known as (EDU). This study was conducted on patients who are stable with Chronic Obstructive Chronic Pulmonary (COPD) COPD is a progressive disease that makes it difficult for individuals to breathe, this is caused by abnormalities in airways of the lungs that lead to a reduced airflow coming in and out of the lungs. This study compared the effects of a new physical activity education program approach (EDU) with a traditional supervised combined strength and endurance training (CT). Research involving COPD patients in previous studies conducted has proven to be difficult, this is due to the lack of exercise programs that are specified towards these patients and their reluctance to participate and continue in a long-term program. There are also very few studies on the effects of different approaches to physical activity in relation to the specificity of COPD patients and their limitations. Physical activity is important for people that suffer from COPD to avoid deficiencies in their functional capacity and to prevent physical disability.

### Where is the research from?

The research was conducted in Verna, Italy at the University of Verona. The university is a research-intensive based university. There are a total of eight authors in the study. The four main authors are Elisabetta Bacchi, Francesca Vitali, Giuseppe Coratella and Chiara Milanese. The authors of this study have also worked on other studies including ‘The influence of testing modalities on the velocity at V02 max’ and ‘Promoting fitness enhancement and enjoyment for children through physical activity’. The authors have received no financial support for this study and the authors had no conflict of interests to declare.

### What kind of Research was this?

The study conducted was a Randomized Control Trial (RCT). In clinical research RCT’s are the most effective study design to safely and efficiently test new treatments. In a randomized and control study design the effects of the intervention are compared with a control group, in this study it is the CT training group. To ensure that there is unbiased comparison between the treatments, standardisation, and inclusion and exclusion criteria must be strictly controlled. RCT’s are ranked at the highest level of study hierarchy as they are designed to be unbiased and have the least risk of systematic errors. RCT’s should include randomisation and blinding with a description of both of those processes, a description of the number of subjects who completed the study and if any of whom dropped out or failed to complete the study and confidence intervals.

### What did the research involve?

The study was carried out at the Fitness Centre of the Exercise and Sport Science at the School of Verona University. The study was conducted in supervised training sessions that were monitored by exercise physiologists.
The participants in the physical activity education program approach were taught to slowly increase their rate of autonomous physical activity. This was done through different training methods including Nordic walking, group class and circuit training. The training occurred in both supervised and unsupervised sessions and the sessions lasted a minimum of sixty minutes. The clients filled in a self-reported intensity scale, the clients were instructed to maintain a level three to four out of ten.
The participants of the combined strength and endurance training program participated in fitness exercises three days a week with one rest day between sessions. The participants self-monitored the intensity and duration of the exercises to avoid shortness of breath. As the same in the new intervention group this group was instructed to maintain an intensity of three to four out of ten on the Borg Scale. The participants in this group were also instructed to continue their prescribed program during the fourteen week follow up period.
Body composition, walking capacity, muscle strength, flexibility and balance, total energy expenditure and quality of life were evaluated at baseline after 28 weeks of training (3days/week) and after a fourteen week follow up for both groups.
The participants for the study were recruited from the Cardiovascular and Thoracic Department in Verona Italy. The allocation and randomization were completed by one of the researchers without any contact or knowledge of the participants. They were ranked according to their forced expiratory volume and then a free online software was used to allocate the participants between the new intervention and traditional treatment group. The study design was approved by the ethics committee from the University and met the ethical criteria for studies involving human subjects.
Twenty eight participants who suffer from COPD were randomly assigned to receive either the EDU or CT treatment, however four participants dropped out of the study leaving the total at the end of the study to twenty four participants. Limitations of the study included the lack of a control group, the small sample size and the fact that only males were included in the study.

### What were the Basic Results?

Comparison of Results :
| CT | EDU |
| Improved walking capacity, body composition & quality of life *not maintained after 14 week follow up | Improved walking capacity, body composition & quality of life *not maintained after 14 week follow up |
| Improved muscle strength and flexibility *returned to baseline after 14 week follow up | Training adherence 100% |
| Training adherence 87% | Balance control improved |
| Chest press (1RM), leg extension (1RM) and sit-and reach *values worsened after the 14 week follow up | |
| Balance control improved | |
In line with the researcher’s hypothesis improvements were shown in 6MWT, balance, BMC and QOL were shown in both groups after twenty-eight weeks of training. However, at the fourteen week follow up body composition, 6MWT, balance, TEE and QOL were all impaired. The new physical activity program in COPD has overlapping results compared to the traditional combined protocol.

### What conclusions can we take this research?

As this was the first randomized study design that explored the effects of a new physical activity education program for COPD patients it provides and alternative method of physical activity. This type of program may be more convenient for patients or their practitioners to engage in. It is my understanding that any exercise that is both safe and client specified is beneficial for COPD patients.
A study conducted in France in 2021 over three years looked at the long-term results of following a maintenance program. The results showed that a maintenance program can extend the benefits of an initial exercise program

### Practical Advice

This research provides professional with insight into training programs and the different types of training programs that can be implemented for people of a specific population. The research provides the type of exercise programs and options of what can be included in the sessions. The session also provides a self-reported exertion scale that allows the patients to work towards their individual exertion rates.

### Further Information/Resources

1. https://my.clevelandclinic.org/health/articles/9450-copd-exercise--activity-guidelines
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933612/
3. https://err.ersjournals.com/content/22/128/178

### References

* 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 27 28 29 30 31 32 33 34 35 36 37 Rinaldo.N, Bacchi. E, Coratella. G, Vitali. F, etc, (2017) Effects of Combined Aerobic-Strength Training vs Fitness Education Program in COPD Patients International Journal of Sports Medicine 38(13)
* ↑ National Heart, Lung and Blood Institute (2019) COPD, U.S. Department of Health & Human Services
* ↑ World Health Organisation, (2021) Chronic Obstructive Pulmonary Disease (COPD) World Health Organisation Fact Sheet
* ↑ Top Universities (2021) Verona University
* ↑ Kabisch. M, Ruckes. C etc, (2011) Randomized Controlled Trials, Series on Evaluation of Scientific Publications, Part 17 (p661)
* 1 2 3 Burns. P, Rohrich. R, Chung. K (2011) The levels of Evidence and their role in Evidence-Based Medicine, Plastic Reconstruction Surgeries 128 (1), 305-310
* ↑ Bleraque.L, Prefaut.C, Forthin.H, etc (2021) Efficacy of a long-term pulmonary rehabilitation maintenance program for COPD patients in a real-life setting: a 5-year cohort study, Respiratory Research 22, Article 79