Meta- analysis revealed few clinical ly relevant and statistically significant benefits of " add-on " therapies on exercise performance compared with exercise training .
The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease ( COPD ) .
Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD.
STUDY OBJECTIVES Pulmonary rehabilitation ( PR ) improves exercise tolerance in COPD patients .  Tiotropium is a once-daily , inhaled anticholinergic bronchodilator that provides sustained 24-h improvements in airflow and lung hyperinflation reduction . We hypothesized that ventilatory mechanics improvements from tiotropium would permit enhanced ability to train muscles of ambulation and therefore augment exercise tolerance benefits of PR . DESIGN In a r and omized , double-blind , placebo-controlled trial  ( tiotropium , n = 47 ; placebo , n = 44 ) ,  tiotropium  ( 18 microg qd ) was administered to COPD patients participating in 8 weeks of PR ( treadmill training three times a week ; > /= 30 min per session ) at 17 sites . Study drug was administered 5 weeks prior to , 8 weeks during , and 12 weeks following PR . The primary end point was treadmill walking ( 0 % incline ) endurance time at 80 % of maximum speed attained in an initial incremental test . The transition dyspnea index ( TDI ) , St. George 's respiratory question naire ( SGRQ ) , and rescue albuterol use were secondary end points . PARTICIPANTS Mean age of the 93 participants was 67 years , 57 % were men , and mean FEV(1 ) was 0.88 L ( 34 % predicted ) . RESULTS Mean endurance time differences  ( tiotropium minus placebo ) prior to PR , at the end of PR , and 12 weeks after PR were 1.65 min ( p = 0.183 ) , 5.35 min ( p = 0.025 ) , and 6.60 min ( p = 0.018 ) , respectively . Mean TDI focal scores at the end of PR were 1.75 for tiotropium and 0.91 for placebo ( p > 0.05 ) . At 12 weeks after PR , TDI focal scores were 1.75 for tiotropium and 0.08 for placebo ( p < 0.05 ) . Relative to placebo , tiotropium improved SGRQ total scores by 3.86 at the end of PR and 4.44 at 12 weeks after PR ( p > 0.05 ) . Mean albuterol use declined following PR plus tiotropium , compared to PR alone ( p < /= 0.05 for 17 of 25 weeks ) . CONCLUSIONS Tiotropium in combination with PR improved endurance of a constant work rate treadmill task and produced clinical ly meaningful improvements in dyspnea and health status compared to PR alone . Improvements with tiotropium were sustained for 3 months following PR completion
Meta- analysis revealed few clinical ly relevant and statistically significant benefits of " add-on " therapies on exercise performance compared with exercise training .
The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease ( COPD ) .