psychological and cognitive outcomes of a randomized trial of exercise among patients with chronic...

7/30/2019 Psychological and Cognitive Outcomes of a Randomized Trial of Exercise Among Patients With Chronic Obstructive…

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Ps y ch o lo g ica l a nd Co g n i t iv e O utco mes o f a Ra ndo m ized Tr ia l o f

Ex erc ise A m on g Patients W ith Chronic Obstruct ive Pulmonary Disea se

Charles E EmeryO h i o S t a t e U n i v e r s i t y

Rebecca L. ScheinD u k e U n i v e r s it y M e d i c a l C e n t e r

Emily R . HauckD e a n M e d i c a l C e n t e r

Neil R. MaclntyreD u k e U n i v e r s it y M e d i c a l C e n t e r

Exercise rehabilitation is recom men ded increasingly fo r patients with chronic obstructivepulm onary disease (COPD ). This study examined the effec t of exercise and education o n 79older adults (M age = 66.6 - 6.5 years; 53% female) with COPD, randomly assigned to 10weeks o f (a) exercise, education, and stress management (EXE SM; n = 29); (b) education andstress ma nag eme nt (ESM; n = 25); or (c) wait ing l ist (WL; n = 25 ). EXESM included 37sessions o f exercise, 16 educational lectures, and 10 weekly stress management classes. ESMincluded on ly the 16 lectures and 10 stress management classes. Before and after theintervention, assessments were conducted of physiological functioning (pulmon ary function,exercise enduran ce), psych ological w ell-being (depression, anx iety, quality of life), andcognit ive functioning (at tention, mo tor speed, mental efficiency, verbal processing). Repeatedmeasu res multivariate analysis of variance indicated that EX ESM participants expe riencedchanges not observed among ESM and WL part icipants, including improved endurance,reduced anxiety, and impro ved cognitive performance (verbal f luency).

Key words:chronic obstructive pulmonary disease, exercise, cognitive function,psychological well-being

P a t i e n t s w i t h c h r o n i c o b s t r u c t i v e p u l m o n a r y d i s e a s e

( C O P D ) t y p i c a l l y e x p e r i e n c e a p r o l o n g e d c o u r s e o f i l ln e s s

m a r k e d b y a g r a d u a l d e c r e a s e i n p h y s i c a l e n d u r a n c e ,

i n c r e a s e d s h o r t n e s s o f b r e a t h , a n d g r e a t e r r e li a n c e o n

m e d i c a t i o n s a n d m e d i c a l i n t e r v e n t i o n s ( C u g e l l , 1 9 8 8 ) . T h eC O P D p a t i e n t o f t en , i n tu r n , e x p e r i e n c e s r e d u c e d c a p a b i l i t y

f o r phys i ca l f unc t i on i ng , l i m i t a t i ons i n ac t i v i t ie s o f da i l y

l i v i ng , l os s o f t rad i t i ona l so c i a l ro l e s , and e mo t i ona l d i s tr e s s ,

e s p e c i a l l y d e p r e s s i o n a n d a n x i e t y ( A g l e & B a u m , 1 9 7 7 ;

M c S w e e n y , G r a n t , H e a to n , A d a m s , & T i m m s , 1 9 82 ). I n

a d d i t i o n , p a s t s t u d i e s h a v e r e v e a l e d i m p a i r e d c o g n i t i v e

Charles E Emery, Department o f Psychology, Ohio StateUniversi ty; Rebecca L. Schein, Department of Psychiatry andBehavioral Sciences, Duke Universi ty Medical Center; Emily R.Hauck, Department of Psychiatry, Dean Medical Center, Madison,Wisconsin; Neil R. Maclntyre, Department o f Medicine, Du keUniversity Medical Center.

This work w as supported by grants from the National H eart ,Lung, and B lood Institute (HIA5290) and the National Insti tute onAging (AG 00029). W e are indebted to staff me mb ers of thePulmonary Rehabil i tation Progra m at Du ke Unive rsi ty's Center forLiving for their hard work and expert ise, especially to RebeccaCrouch, who se support as Program Director was instrumental inthe implementation of this stu dy. We are also grateful fo r thedil igent effo rt of three students w ho w orked o n this project: JohnWilson, Merida Grant, and particularly Jennifer Egert.

Correspondence concerning this art icle should be addressed toCharles E Emery, Department o f Psychology, Ohio State Univer-si ty, 188 5 Neil Avenue, Columbus, Ohio 43210. Electronic m allma y be sent to emery.33 @osu.edu.

f u n c t i o n a m o n g a d u l t s w i t h C O P D . O n e p a s t s t u d y f o u n d

t h a t m i l d l y h y p o x e m i c ( m e a n P a O 2 = 6 6 . 3 + 7 . 0 ) C O P D

p a t i e n t s e x h i b i t e d d e c r e m e n t s o n t e s ts o f a b s t r a c t r e a s o n i n g ,

p s y c h o m o t o r sp e e d , an d m e m o r y w h e n c o m p a r e d to a g e -

a n d g e n d e r - m a t c h e d c o n t r o l s ( P r i g a t a n o , P a r s o n s , W r i g h t ,L e v i n , & H a w r y l u k , 1 9 8 3 ). I t h a s b e e n s u g g e s t e d th a t b l o o d

o x y g e n a t i o n l e v e l m a y p l a y a s u b s t a n t i a l r o l e i n th e d e g r e e

o f n e u r o p s y c h o l o g i c a l i m p a i r m e n t i n t h is p o p u l a t i o n ( G r a n t ,

P r i g a ta n o , H e a t o n , M c S w e e n y , W r i g h t , & A d a m s , 1 9 8 7 ) .

B e c a u s e e x e r c i se h a s b e c o m e m o r e w i d e ly a c c e p t e d a s a

s t a n d a r d t r e a t m e n t f o r p a t i e n t s w i t h C O P D , i t is o f i n t e r e s t to

e v a l u a t e t h e e f f e c t s o f e x e r c i s e n o t o n l y o n p h y s i c a l f u n c t io n -

i n g o f C O P D p a t i e n ts b u t a l s o o n i n d i c a to r s o f p s y c h o l o g i c a l

w e l l - b e i n g a n d c o g n i t i v e f u n c ti o n i n g . I t h a s b e e n s u g g e s t e d

t h a t e x e r c i s e m a y c o n t r i b u t e t o e n h a n c e d p s y c h o l o g i c a l

f u n c t i o n i n g v i a a n u m b e r o f p a t h w a y s , i n c l u d i n g ( a ) e n -

h a n c e d s e l f - e ff i c a c y r e s u l ti n g f r o m a b i l it y t o p e r f o r m p h y s i -

ca l ac t i v i t i e s , (b ) r e l ease o f na t u r a l op i a t e s i n t he b r a i n , and

( c ) soc i a l suppor t i nhe r en t i n t he exe r c i se s e t t i ng con t r i bu t -i n g t o p s y c h o l o g i c a l w e l l - b e i n g ( d e C o v e r l e y V e a le , 1 9 8 7 ).

C o g n i t i v e f u n c t i o n i n g i s t h o u g h t t o b e e n h a n c e d f o l l o w i n g

e x e r c i s e b y r e d u c t io n s i n s y m p a t h e t i c h y p e r a r o u s a l a n d

g r e a t e r o x y g e n - c a r r y i n g c a p a c i t y o f t h e b l o o d c o n t r i b u t i n g

t o e n h a n c e d n e u r o t r a n s m i t t e r r e g u l a t i o n ( D u s t m a n , E m m e r -

s o n , & S h e a r e r , 1 9 9 4 ) . C O P D p a t i e n t s a r e a n o p t i m a l

p o p u l a t i o n f o r f u r t h e r s t u d y o f e x e r c i s e - r e l a t e d c h a n g e s i n

p s y c h o l o g i c a l a n d c o g n i t i v e f u n c t io n i n g b e c a u s e t h e y a r e a t

r i sk f o r psycho l og i c a l d i s t r e s s and cogn i t i ve d i ff i cu l ti e s .

T h e s m a l l n u m b e r o f p r e v i o u s s t u d i es e v a l u a t i n g e x e r c i s e

o u t c o m e s a m o n g C O P D p a t i e n t s p r o v i d e e q u i v o c a l r e s u l t s .

P S Y C H O L O G I C A L A N D C O G N I T I V E O U T C O M E S O F E X E R C I S E 2 3 3

S e v e r a l p a s t s t u d i e s h a v e f o u n d t h a t e x e r c i s e i s a s s o c i a t e d

w i t h e n h a n c e d p s y c h o l o g i c a l f u n c t io n i n g , i n c l u d i n g d e -

c r e a s e d n e g a t i v e m o o d s t at e s ( D e k h u i j z e n , B e c k , F o l g e r i n g ,

& V a n H e r w a a r d e n , 1 9 9 0 ; E m e r y , L e a t h e r m a n , B u r k e r , &

M a c I n t y r e , 1 9 9 1 ) a n d i m p r o v e d s e l f - c o n c e p t ( K e r s t e n , 1 9 9 0 ) .

H o w e v e r , o t h e r s tu d i e s h a v e f o u n d f e w p s y c h o l o g i c a l b e n -

e f it s o f e x e rc i s e a m o n g C O P D p a t i en t s ( G a y l e , S p i t le r ,

K a r p e r , J a e g e r , & R i c e , 1 9 8 8 ; D . L e w i s & B e l l , 1 9 9 5 ;

T o s h i m a , K a p l a n , & R i e s , 1 9 9 0 ). A r e c e n t r a n d o m i z e d s t u d y

o f 1 1 9 C O P D p a t i e n t s a s s i g n e d e i t h e r t o a c o m p r e h e n s i v e

r e h a b i li t a ti o n p r o g r a m ( i n c lu d i n g e x e r c i s e a n d e d u c a t i o n ) o r

t o a n e d u c a t i o n - o n l y p r o g r a m r e v e a l e d s i g n i f i c a n t b e n e f i t s

o f e x e r c i s e r e h a b i l i ta t i o n f o r p h y s i c a l e n d u r a n c e , s h o r tn e s s

o f b r e a th , a n d w a l k i n g s e l f -e f f ic a c y b u t n o c h a n g e s i n

p u l m o n a r y f u n c t i o n , d e p r e s si o n , a n d s e l f - r a te d q u a l i t y o f l i fe

( R i e s , K a p l a n , L i m b e r g , & P r e w i t t , 1 9 9 5 ) . T h e s e r e s u l ts

p r o v i d e e v i d e n c e f o r t h e b e n e f it s o f e x e r c i s e t r a i n in g f o r

p h y s i c a l e n d u r a n c e a m o n g C O P D p a t i e n t s , d e s p i t e t h e

a b s e n c e o f c h a n g e s i n p u l m o n a r y f u n c ti o n o r p s y c h o l o g i c a l

w e l l - b e i n g . A l t h o u g h n o c h a n g e s i n p u l m o n a r y f u n c t i o nw e r e e x p e c t e d f o l l o w i n g e x e r c i se , t h e l a c k o f p o s i t iv e

c h a n g e i n p s y c h o l o g i c a l w e l l - b e i n g w a s a t t r ib u t e d t o o u t -

c o m e m e a s u r e s t h a t m a y n o t h a v e b e e n s e n s i t i v e t o c h a n g e

i n t h is p o p u l a t i o n .

T h i s s t u d y w a s d e s i g n e d t o e v a l u a t e p s y c h o l o g i c a l w e l l-

b e i n g w i t h a b a t t e r y o f m e a s u r e s s e n s it i v e t o c h a n g e s i n

p a r a m e t e r s r e l e v a n t t o p a ti e n t s w i t h C O P D . S p e c i fi c a ll y , th e

s t u d y i n c l u d e d m e a s u r e s o f d e p r e s s i o n a n d a n x i e ty , t h e m o s t

f r e q u e n t l y r e p o r t e d p s y c h o l o g i c a l c o n d i t i o n s a m o n g C O P D

p a t i e n t s , a s w e l l a s i n d i c a t o r s o f h e a l t h - r e l a t e d q u a l i t y o f l i fe

( i .e . , p e r c e i v e d c o n t r o l o f h e a l th , s e l f - r a t e d i m p a i r m e n t ) .

C o g n i t i v e m e a s u r e s w e r e s e l e ct e d t o a s s e ss a r e a s o f f u n c ti o n -

i n g i n w h i c h C O P D p a t i e n t s a r e l i k e l y t o d e m o n s t r a t e

i m p a i r m e n t a n d t h a t m a y b e c o m p r o m i s e d a m o n g o l d e r

a d u l t s ( i .e . , a t t e n ti o n , m o t o r s p e e d , m e n t a l e f f i c i e n c y , v e r b a l

p r o c e s s i n g ) . T h e s t u d y i n c l u d e d a c o n t r o l g r o u p r e c e i v i n g

e d u c a t i o n a n d s t r e s s m a n a g e m e n t a s w e l l a s a w a i t i n g - l i s t

c o n t r o l g r o u p .

I t w a s h y p o t h e s i z e d t h a t ( a ) n o n e o f t h e p a r ti c i p an t s

w o u l d a c h i e v e i m p r o v e m e n t s i n p u l m o n a r y f u n c t io n p e r s e ;

( b ) th e e x e r c i s e g r o u p w o u l d a c h i e v e s i g n if i c a n t i m p r o v e -

m e n t s i n c a r d i o p u l m o n a r y e n d u r a n c e b u t t h e c o n t r o l g r o u p s

w o u l d s h o w n o i m p r o v e m e n t i n e n d u r a n c e ; ( c ) b o t h t h e

e x e r c i s e g r o u p a n d t h e e d u c a t i o n - s t r e s s m a n a g e m e n t c o n -

t r o l g r o u p w o u l d a c h i e v e i m p r o v e m e n t s i n p s y c h o l o g i c a l

w e l l - b e i n g a n d C O P D k n o w l e d g e , b u t t h e w a i t i n g - l i s t

c o n t r o l g r o u p w o u l d n o t ; ( d ) e x e r c i s e p a r t i c i p a n t s w o u l de x p e r i e n c e e n h a n c e d h e a l t h - re l a t e d q u a l i t y o f l if e a n d i m -

p r o v e d c o g n i t i v e p e r f o r m a n c e , b u t c o n t r o l p a rt i c ip a n t s w o u l d

n o t e x p e r i e n c e c h a n g e s i n q u a l i ty o f li f e o r c o g n i ti v e

p e r f o r m a n c e ; ( e ) a m o n g e x e r c i s e p a r t i c i p a n t s , e n h a n c e d

p h y s i c a l e n d u r a n c e w o u l d b e a s s o c i a t e d w i t h i m p r o v e d

c o g n i t i v e p e r f o r m a n c e a n d q u a l i t y o f li f e; ( f ) a m o n g b o t h t h e

e x e r c i se p a r t ic i p a n ts a n d t h e e d u c a t i o n - s t r e s s m a n a g e m e n t

c o n t r o l p a r t ic i p a n ts , i n c r e a s e d C O P D k n o w l e d g e w o u l d b e

a s s o c i a t e d w i t h e n h a n c e d p s y c h o l o g i c a l w e l l -b e i n g ; a n d ( g )

a c r o s s t h e t o ta l s t u d y s a m p l e , i n d i c a t o r s o f p u l m o n a r y

d i s e a s e s t a t u s ( i .e . , b l o o d o x y g e n le v e l ) w o u l d b e a s s o c i a t e d

w i t h c o g n i t i v e p e r f o r m a n c e .

M e t h o d

Participants

Par tic ipants over age 50 w i th s table CO PD were recrui ted

through an nouncem ents a t loca l Bet ter Breathers Clubs, te levis ion

announcem ents , wo rd of mou th , adver ti sements in weekly newspa-pers for older adults, and physician referral . All potential partici-pants rece ived a pre l iminary te lephone screening to conf i rm thep r e s e nc e o f COPD s ympt om s a nd l e ng th o f d i a gnosi s a s we l l a s t o

rule out significant cardiac disease or other diseases that mightaffect exercise tolerance o r learning skil ls. Nin ety- two participants

met e l ig ib il ity requi rements for the s tudy and were scheduled forbaseline evaluation. Criteria f or study participa tion include d (a)age > 50 years , (b) ai rf low obst ruc t ion demonst ra ted on spi rometry

( i. e ., the ra t io of forced expi ra tory volum e in 1 s d iv ided by fo rcedvi ta l capaci ty [FE VI/FV C] < .70), and (c) c lin ica l sy mpto ms of

COPD ( i . e . , chronic cough or dyspnea , or both , l imi t ing someact iv i t ies) for more than 6 months . Individuals wi th pr imar i lyacute, reversible airway disease (asthma) without fixed airflow

obst ruct ion were ex cluded, as we re individuals wi th o ther s ignif i -

cant and disabl ing d iseases such as tuberculos is , pulm onaryfibrosis, or cancer; unstable cardiac disorder (e.g. , myocardialinfarction, unstable angina, or cong estive heart failure) du ring theprevious 3 months ; or o ther medica l condi t ions tha t would l imi tparticipation in a regu lar exercise p rogram . Base line spirome try

revealed tha t 9 part ic ipants had no rmal va lues (and thus w ereineligible for this study), and an additional 4 participants decid edthat they would be unable to mak e the comm itmen t to part ic ipa te inthe s tudy. Thus , a to ta l of 79 o lder adul ts wi th CO PD entered the

random ized s tudy. Characteri s tics of the samp le are inc luded inTable 1 . M ost par tic ipants were taking chronic pulmon ary medica-tions (e.g. , inhaled and oral bronchodilators or corticosteroids)

before s tudy ent ry . The m edica l appropr ia teness of these regimens

wa s r e v i e we d a nd a d ju s te d by me m be r s o f t he Duke Pu l mona r yRehabili tation Pro gra m staff , after wh ich no significant adjust-

me n t s we r e ma de du r i ng t he c ou r s e o f t he s t udy .

Procedures

Par tic ipants were rando mized to one of three groups: ( a )

exerc ise , educat ion , and s tress ma nagem ent (EXESM ; n = 29) ; (b)educat ion and s t ress management but no exerc ise t ra in ing (ESM;n = 25) , or (c) wai t ing li s t (WL ; n = 25) . Grou p ass ignments weretaken f rom a rand om nu mbe r schedule, pr in ted on a p iece of paper ,and placed in a sea led envelope . Par t ic ipants were no t g iven theenvelope conta in ing the i r group ass ignm ent unt il a f te r com ple t ing

the baseline assessment, and technic al staff con duc ting the assess-ments w ere not aware o f group ass ignments.

Bec ause of the l imited n um ber of participants available at onet ime, they entered the s tudy in smal l groups o f 1 to 5 par t ic ipants

pe r m on t h , a nd t he da t a we r e c o l l e ct e d ove r a pe r iod o f mor e t ha none year. Par tic ipants in the EXE SM group par tic ipa ted wi th o therCOPD patients in a clinical pulmonary exercise rehabili tationp r og r a m t ha t i nc l ude d t he s a me c ompone n t s a s t he EXESMcondi t ion . Part ic ipants in the ESM grou p engaged in the educa-t ional and s t ress m anagem ent comp onents but rece ived no exerc isetraining.

EX ESM par tic ipants met da i ly for 4 hr per day dur ing a 5-we ekper iod. Dal ly sess ions inc luded a to ta l of 45 min o f aerobic exerc iseas well as strength training on Nautilus equipment. Each exercisesess ion began w i th a 10-min warm -up per iod fo l lowed by aerobicexercise activit ies (i .e. , stationary bicycle, arm ergometry, andwalking) and ended w i th a cool -dow n per iod of s t re tching. T heEXESM sess ions a lso inc luded approximate ly four hour- long

234 E M E R Y , S C H E I N , H A U C K , A N D M A c I N T Y R E

T a b l e 1

Base l ine Charac ter i s t i c s o f the Sam ple

V a r ia b le E X E S M E S M W L T o t al

G e n d e rM ale 15 10 12 37

Fem ale 15 14 13 42A g e ( y e a r s )

M 65 .4 67 .4 67 .4 66 .6SD 6.4 5.9 7.1 6.5

FEV1 (L)M 1.24 1.13 1.02 1.14SD 0 .6 0 .5 0 .4 0 .5

% p r e d i c t e d F EV ~M 43 43 39 42SD 18 18 16 17

P a O2 ( m m H g )M 75 .4 76 .0 72 .5 74 .7SD 12.7 9.5 8.3 10.5

~rO2max (ml /kg /min)M 12.0 11.8 10.9 11.6SD 4 .0 3 .3 3 .4 3 .6

% us ing 02 20 8 8 13

% m e d i c a t i o n sT a k i n g a t l e a s t 1 p u l m o -

nary med ica t ion 86 95 81 87Predn is one 33 14 33 27T h e o p h y l l i n e 3 3 5 2 4 8 4 4A e r o s o l i z e d s t e r o id s 5 2 4 8 6 2 5 4Other b ronch od i la to r s 81 90 76 83

E d u c a t i o n< H i g h s c h o o l 2 0 2 9 2 8 2 5< C o l l e g e g r a d u a t i o n 5 7 3 8 4 0 4 6-->College grad uatio n 23 33 32 29

S C L - G S IM 57 .9 55 .8 58 .8 57 .5SD 8 .7 5 .4 7 .6 7 .5

Note. E X E S M = e x e r c i se , ed u c a t i o n , a n d s t r e ss m a n a g e m e n t ;E S M = e d u c a t i o n a n d s tr e s s m a n a g e m e n t ; W L = w a i t i n g l i st ; %p r e d i c t e d F E V I = f o r c e d e x p i r a t o r y v o l u m e i n 1 s ( F E V 0 d i v i d e db y p r e d i c t e d F E V 1 a c c o r d i n g t o a g e , g e n d e r, a n d h e i g h t n o r m s ; L =l i t e r s ; PaO2 = pa r t i a l p ressure o f oxygen in the a r te r ia l b lood ;~ 7 02 m ax = m a x i m u m o x y g e n co n s u m p t i o n ; 0 2 = o x y g e n ; S C L -G S I = s u m m a r y s c o r e o f p s y c h o l o g i c a l d i s t r es s f r o m t h e H o p k i n sS y m p t o m C h e c k l i s t - 9 0 - - - R e v i s e d .

e d u c a t i o n a l le c t u r e s p e r w e e k o n t o p i c s r e l e v a n t f o r C O P D p a t i e n ts

( e . g ., a n a t o m y a n d p h y s i o l o g y o f t h e l u n g s , m e d i c a t i o n s fo r c h r o n i c

lung d i sease , in te rp re t ing pu lmonary func t ion t e s t s , pa thophys io l -o g y o f C O P D , a n d u n d e r s t a n d i n g a r te r i a l b l o o d g a s e s ) . E X E S M

p a r t i c ip a n t s a l s o w e r e p r o v i d e d a w e e k l y 1 - h r g r o u p m e e t i n g f o rs t r e ss m a n a g e m e n t a n d p s y c h o s o c i a l s u p po r t . S t re s s m a n a g e m e n t

groups we re conduc ted by a c l in ica l psych o log is t us ing a cogn i t ive - -

b e h a v i o r a l f o r m a t . P a r t i c i p a n t s w e r e t a u g h t p r o g r e s s i v e m u s c l ere laxa t ion , s t r a teg ies to inc rease awa reness o f cogn i t ive d i s to r t ions

a s s o c i a t e d w i t h p h y s i c a l l i m i t a t io n s , a n d t h e n e g a t i v e e m o t i o n a lc o n s e q u e n c e s o f c o g n i t i v e d i s to r t io n s .

F o l l o w i n g t h e i n i t i a l i n t e n s iv e 5 - w e e k p e r i o d , E X E S M p a r t i c i -p a n t s t h e n p a r t i c i p a t e d i n 5 m o r e w e e k s o f a l e s s i n t e n s e r e g i m e n

c o n s i s ti n g o f e x e r c i s e s e s si o n s t h r e e ti m e s p e r w e e k f o r 6 0 - 9 0 r a i n

a n d o n e h o u r - l o n g w e e k l y s t r e s s m a n a g e m e n t c l a s s . T h u s , o v e r t h e

c o u r s e o f t h e 1 0 - w e e k i n t er v e n t i o n p e r i o d , E X E S M p a r t i c ip a n t s

were expec ted to a t t end 37 exerc i se sess ions , 16 educa t iona ls e s s io n s , a n d 1 0 s t r e ss m a n a g e m e n t c l a s s e s. A l l e x e r c i s e a n d

e d u c a t i o n a l c la s s e s w e r e c o n d u c t e d a t t h e D u k e C e n t e r f o r L i v i n g ,an eas i ly acce ssed rehab i l i t a t ion fac i l i ty a f fd ia ted wi th Duke

U n i v e r s i t y M e d i c a l C e n t e r . E S M p a r t i c i p a n t s a t t e n d e d t h e s a m e

schedu le o f l ec tu res (n = 16) and s t ress manag emen t sess ions

( n = 1 0 ) a s t h e E X E S M p a r t i c ip a n t s b u t w e r e n o t p r o v i d e d w i t h

any exerc i se t r a in ing . WL par t i c ipan t s were asked no t to a l t e r the i rac t iv i t i e s s ign i f i can t ly dur ing the 10-week s tudy pe r iod .

Assessments

Par t i c ipan t s underwent a ssessm ents o f phys io log ica l func t ion-

i n g , p s y c h o l o g i c a l w e l l- b e i n g , a n d c o g n i t i v e f u n c ti o n i n g a t b a s e -

l ine (T1) and a f te r the 10-week in te rven t ion pe r iod (T2) .

Physiological assessment. T h e p h y s i o l o g i c a l a ss e s s m e n t i n -

e l u d e d e v a l u a t i o n o f p u l m o n a r y f u n c t io n , w h i c h s e r v e s a s a m a r k e r

o f d i s e a s e s e v e r it y , a n d o f c a r d i o p u l m o n a r y f u n c t io n , w h i c h

ind ica tes phys ica l endurance dur ing a s tandard exerc i se p ro toco l .

( a ) P u l m o n a r y f u n c t i o n w a s e v a l u a t ed , u s i n g s t a n d a r d p u l m o n a r y

f u n c t i o n e q u i p m e n t ( S e n s o r m e d i c s 2 4 5 0 , Y o r b a L i n d a , C A ) t o

p e r f o r m s p i r o m e t r y i n a c c o r d a n c e w i t h A m e r i c a n T h o r a c i c S o c i e t y

s t a n d ar d s . M e a s u r e m e n t s d e r i v e d f r o m t h e s p i r o m e t r y a s s e s s m e n t

i n c l u d e d F E V 1 , p e r c e n t a g e o f p r e d i c t e d F E V I ( b a s e d o n n o r m s

ad jus ted fo r age , gender , and he igh t ) , FVC, and m axim al vo lun ta ry

v e n t i la t i o n ( M V V ) . F E V I a n d F V C p r o v i d e a m a r k e r o f p r o g re s -s i o n o f l u n g d i s e a s e a n d a r e u s e d i n t h e d i a g n o s is o f C O P D . M V V

p r o v i d e s a n i n d i c a t o r o f t h e m a x i m u m r a t e a t w h i c h t h e p a r t i c i p a n ti s a b l e t o i n h a le a n d e x p e l a i r f r o m t h e l u n g s a n d i s a c o m m o n t e s t

o f r e sp i ra to ry muscu la tu re and a i rway res i s tance . (b ) Card iopu lmo-

n a r y e n d u r a n c e w a s a s s e s s e d w i t h b i c y c l e e r g o m e t r y t e s t in g ,pe r fo rmed in the pos tabsorp t ive s ta te , w i th the pa r t i c ipan t s i t t ing

u p r i g h t o n a n i s o k i n e t i c , m a g n e t i c a ll y b r a k e d b i c y c l e e r g o m e t e r

( Q u i n t o n C o r i v a l 4 00 ) . E x e r c i s e b e g a n a t 0 W , a n d t h e l o a d w a s

inc reased 12 .5 W ev ery minu te , w i th exerc i se ra tes r emain ing

cons tan t a t 40- -60 rpm . Exe rc i se con t inued un t i l l imi ted byexcess ive fa t igue o r shor tness o f b rea th o r bo th . The con cen t ra t ion

o f e x p i r e d o x y g e n a n d c a r b o n d i o x i d e w a s a n a l y z e d o v e r 2 0 - s

in te rva l s (Sensorm edics ,2900 , Y orba L inda , C A) to ca lcu la te

o x y g e n c o n s u m p t i o n ( V O 2 ) a n d c a r b o n d i o x i d e p r o d u c t i o n

(VCO2) . . In the 9 pa r t i c ipan t s requ i r ing supp lem enta l oxygen wi the x e r c is e , V O 2 c o u l d n o t b e m e a s u r e d a n d o n l y V C O 2 w a s r e c o r d e d .

O t h e r m e a s u r e m e n t s i n c l u d e d h e a r t r a te ( H R ) a n d w o r k ( t he

m a x i m a l w o r k l o a d t h a t t h e p a r t i ci p a n t a c h ie v e d d u r i n g e x e r c i s etes t ing) . A t base l ine on ly , pa r t i c ipan t s had res t ing and maximal

exerc i se a r te r ia l b lood g as ana lys i s (PaO2) , p rov id ing an add i t iona l

i n d i c a t o r o f p u l m o n a r y d i s e a s e s t a t u s a n d b l o o d o x y g e n a t i o ndur ing exerc i se te s t ing .

Assessment of psychological well-being and health-related qual-i ty of l i fe . P s y c h o l o g i c a l w e l l - b e i n g w a s a s s e s s e d w i t h f o u rse l f - repor t sca les measur ing the dom ains o f depress ion and anx ie ty .

( a ) T h e C e n t e r f o r E p i d e m i o l o g i c a l S t u d i e s - - D e p r e s s i o n I n v e n t o r y

( C E S - D ) i s a 2 0 - i te m m e a s u r e o f d e p r e s s i v e s y m p t o m s d e v e l o p e df o r c o m m u n i t y u s e a n d v a l i d a t e d i n a n o l d e r a d u l t s a m p l e ( R a d l o ff ,

1977) . Scores range f rom 0 to 60 , wi th h igher scores ind ica t ing

grea te r symp toms o f depres s ion and a cu t -o f f score o f 16 re f lec t ing

s ign i f i can t depress ion . (b ) The Bradburn A f fec t -Ba lance Sca le i s a

10- i t em sca le t app ing bo th pos i t ive and nega t ive emot ions (Brad-bum , 1969) , w i th scores rang ing f rom 0 (most negative) to 10 (mostpositive). ( c ) T h e S t a t e - T r a i t A n x i e t y I n v e n t o r y ( S T A I ) i s a 4 0 - i t e m

a s s e s s m e n t o f b o t h i m m e d i a t e a n d l o n g e r - s ta n d i n g s y m p t o m s o fanx ie ty (Sp ie lbe rger , Gorsuch , & Lushene , 1970) . Only the S ta te

Anx ie ty sca le score (20 i t ems) was used in th i s s tudy because i t i s

more l ike ly to be respons ive to in te rven t ion ( range o f scores :

2 0 - 8 0 , w i t h h i g h e r s c o r e s i n d i c a t in g g r e a t e r s y m p t o m s o f a n x i e ty ) .( d ) T h e H o p k i n s S y m p t o m C h e c k l i s t (S C L - 9 0 - R ) i s a 9 0 - i t e m s c a l e

o f p s y c h i a t r i c a n d s o m a t i c s y m p t o m s p r o v i d i n g n i n e c l i n i c a lsubsca les and a summary score (Deroga t i s , 1983) . T scores a re

d e r i v e d f o r e a c h s u b s c a l e o f t h e S C L - 9 0 - R o n t h e b a s i s o f a d u l t

outpa t ien t norms . For purposes o f th i s s tudy , on ly the Depress ion

a n d A n x i e t y s u b s c a l e s c o r e s w e r e a n a l y z e d .

H e a l t h - r e l a te d q u a l it y o f l i f e w a s a s s e s s e d w i t h t w o s e l f - re p o r t

m e a s u r e s : ( a ) T h e M u l t i d i m e n s i o n a l H e a l th L o c u s o f C o n t r o l

(MHLC) inven to ry i s an 18- i t em sca le assess ing a t t r ibu t ions o f

con t ro l r egard ing hea l th ou tcome s (Wal l s ton , Wal l s ton , & DeVe! -

l i s , 1978) . Three subsca le scores a re de r ived f rom the MHLC (6i tems pe r subsca le ) t app ing in te rna l a t t r ibu t ions o f con t ro l a s we l l

as con t ro l a t t r ibu ted to power fu l o the rs ( e .g . , med ica l doc to rs ) and

to chance o r f a te . Pa r t i c ipan t s r espond to each i t em on a 6 -po in t

L iker t sca le , wi th scores fo r each o f the th ree subsca les rang ing

f r o m 6 (low) o 36 (high). (b) The Sickness Imp ac t P ro f i l e (SIP) i s a

1 3 6 - i te m c h e c k l i s t o f s y m p t o m s a n d p h y s i c a l l i m i t a ti o n s i n a c t i v i -

t i e s o f da l ly l iv ing (e .g . , s l eep , mobi l i ty , househo ld management ,

soc ia l in te rac t ion , and rec rea t ion ; Bergner , Bobbi t t , Car te r , &

Gi l son , 1981) . The SIP has been va l ida ted in mul t ip le s tud ies o f

medica l pa t i en t s , and pas t r e sea rch has demons t ra ted g rea te r

i m p a i r m e n t o n t h e S I P a m o n g C O P D p a t i en t s th a n a m o n g h e a l t h y

adu l t s (McSw eeny e t a l . , 1982). Th is s tudy eva lua ted the summ ary

s c o r e f r o m t h e S I P ( n u m b e r o f s y m p t o m s c h e c k e d d i v i d e d b y t o t a l

s y m p t o m s l i s te d ) .

Cognitive assessm ent. The cogn i t ive t e s t ba t t e ry eva lua tedsevera l domains , inc lud ing a t t en t ion , motor speed , men ta l e f f i -

c iency , and ve rba l p rocess ing . ( a ) At ten t ion was eva lua ted wi th the

Dig i t Vig i lance t e s t , which requ i res tha t pa r t i c ipan t s sea rch fo r and

c r o s s o f f a l l i n s t a n c es o f a g i v e n d i g i t o n a p a g e o f r a n d o m d i g i t s

(R . E Lew is & R ennick , 1979) . Co) The F inger Tapp ing te s t f rom

t h e H a l s t e a d - R e i ta n b a t te r y w a s u s e d a s a r e l i a b l e i n d i c a t o r o f

mo tor speed (Ha ls tead , 1947) . Sco res re f lec ted a mean o f f ive 10-s

t r i a l s fo r each hand . T es t s o f men ta l e f f i c iency inc luded (c ) the Tra i lM a k i n g T e s t ( P a rt s A a n d B ) , w h i c h i n c o r p o r a t e s c o m p o n e n t s o f

pe rcep tua l mo tor speed and sequenc ing (Re i tan , 1958) , and (d ) the

D i g i t S y m b o l s u b t e s t o f t h e W e c h s l e r A d u l t I n t e l l ig e n c e S c a l e - -

R e v i s e d , w h i c h i s a c o m m o n t e s t o f p s y c h o m o t o r p e rf o r m a n c e

sens i t ive to b ra in dys fu nc t ion (Wechs le r , 1981). ( e ) The Verba lF l u e n c y t e s t o f t h e H a l s t e a d - R e i t a n b a tt e r y i s a n i n d i c a t o r o f t h e

p a r t i c i p a n t s ' c a p a c i t y f o r o r g a n i z e d v e r b a l p r o c e s s i n g a n d i sthough t to be sens i t ive to f ron ta l lobe impa i rment (Es tes , 1974) .P a r t i c ip a n t s w e r e g i v e n 1 m i n t o n a m e a s m a n y w o r d s a s p o s s i b l e

s ta r t ing wi th a spec i f i ed l et t e r .Health knowledge. Par t i c ipan t s a l so comple ted a s t andard ized

p u l m o n a r y r e h a b i l it a t i o n h e a l t h k n o w l e d g e t e s t ( H o p p , L e e , &

Hills , 1989).

Data A na lys is

T h e p r i m a r y m o d e o f d a t a a n a l y s i s w a s r e p e a t e d m e a s u r e s

m u l t i v a r i a te a n a l y s is o f v a r i a n c e ( M A N O V A ) w i t h g r o u p a s s i g n -men t a s a be tween-pa r t i c ipan t s va r iab le and t ime as a wi th in -

par t i c ipan t s va r iab le . Var iab les were c lus te red accord ing to the

c o n c e p t u a l d o m a i n a s s e s s e d b y t h e i n s t r u m e n t s . F o r d o m a i n sassessed wi th a s ing le va r iab le (e .g . , hea l th - re la ted impa i rmen t o r

v e r b a l p r o c e s s in g ) u n i v a r i a t e a n a l y si s o f v a r i a n c e ( A N O V A ) w a s

used . P lanned con t ras t s were used to eva lua te in te rac t ions o f ( a )

E XF _,S M v e r s u s E S M + W L a n d t i m e a n d ( b ) E S M v e r s u s W L a n d

t i m e , f o r d o m a i n s i n w h i c h i t w a s h y p o t h e s i z e d t h a t o n l y E X E S M

p a r t i c i p a n t s w o u l d i m p r o v e a n d t h a t n o d i f f e r e n c e s w o u l d b e

o b s e r v e d i n t h e c o n t r o l g r o u p s ( i .e . , f o r c a r d i o p u l m o n a r y e n d u r -

ance , hea l th qua l i ty o f l i f e , and co gn i t ive func t ion) . Fo r domains in

w h i c h i t w a s h y p o t h e s i z e d t h a t b o t h E X E S M a n d E S M p a r t i c ip a n t sw o u l d i m p r o v e t o a s i m i l a r d e g r e e ( i . e. , f o r p s y c h o l o g i c a l w e l l -

b e i n g a n d C O P D k n o w l e d g e ) , p l a n n e d c o n t r as t s e v a l u a te d i n t e ra c -

t i o n s o f ( a ) E X E S M + E S M v e r s u s W L a n d t im e a n d ( b ) E X E S Mv e r s u s E S M a n d t i m e . W h e n s i g n if i c an t m u l t iv a r i a t e e f f ec t s w e r e

obse rved , un iva r ia te e f fec t s were then eva lua ted , us ing the sam e a

pr io r i con t ras t s used in the MANOVA. S ign i f i can t un iva r ia te

in te rac t ions were fo l lowed by pos t hoc con t ras t s o f T1 ve rsus T2

wi th in each o f the th ree g roups .

T h e s e c o n d a r y m o d e o f d a t a a n a l y s i s i n c l u d e d r e g r e s s i o n

ana lys i s to eva lua te the ex ten t to which inc rea sed phys ica l endur -

a n c e a m o n g t h e E X E S M p a r t i c ip a n t s a n d i n c r e a s e d k n o w l e d g e

a m o n g t h e E X E S M a n d E S M p a r t ic i p a n t s w e r e a s s o c i a t e d w i t hc h a n g e s i n p s y c h o l o g i c a l w e l l - b e in g , q u a l i ty o f l i f e , a n d c o g n i t i v e

func t ion . In add i t ion , co r re la t iona l ana lys i s was used to eva lua te

t h e e x t e n t t o w h i c h c o g n i t i v e o u t co m e s w e r e a s s o c i a te d w i t h b l o o d

o x y g e n a t i o n l e v e l s.

R e s u l t s

Effectiveness o f Randomization, An alysis o f Dropouts,and Adherence

A s s h o w n i n T a b l e 1 , r a n d o m a s s i g n m e n t w a s e f f e c t i v e i n

t h a t t h e r e w e r e n o s i g n i fi c a n t g r o u p d i f f e r e n c e s i n a g e ,

g e n d e r d i s t r i b u t i o n , o r i n d i c a t o r s o f p u l m o n a r y f u n c t i o n a n d

p h y s i c a l e n d u r a n c e . D i s t r i b u t i o n o f o x y g e n u s e a n d m e d i c a -t i o n s w e r e n o t s i g n i f i c a n t ly d i f fe r e n t a c r o s s g r o u p s . M o r e -

o v e r , th e r e w e r e n o g r o u p d i f f e r e n c e s in e d u c a t i o n o r o v e r a l l

p s y c h o l o g i c a l d i st r e s s (a s in d i c a t e d b y t h e s u m m a r y s c o r e

f o r t h e S C L - 9 0 - R ) .

D u r i n g t h e c o u r s e o f t h e s t u d y , a t o t a l o f 6 p a r t i c i p a n t s

d r o p p e d o u t o f t h e s t u dy . F o u r d r o p p e d o u t o f t h e E X E S M

c o n d i t i o n , a l l b e c a u s e o f i l l n es s , a n d 2 d r o p p e d o u t o f t h e

E S M c o n d i t i o n b e c a u s e o f t r a n s p o r t a t i o n p r o b l e m s . T h u s , a

t o t a l o f 7 3 p a r t i c i p a n t s c o m p l e t e d t h e i n t e r v e n t io n , w e r e

a s s e s s e d a t T 1 a n d T 2 , a n d w e r e i n c l u d e d i n t h e d a t a

a n a l y s i s . T o e v a l u a t e d i f f e r e n c e s b e t w e e n p a r t i c i p a n t s w h o

c o m p l e t e d t h e s tu d y ( n = 7 3 ) a n d s t u d y d r o p o u t s ( n = 6 ) , t

t e s ts w e r e c o n d u c t e d o n d e m o g r a p h i c , p h y s i o l o g i c a l , p s y c h o -

l o g i c a l , a n d c o g n i t i v e v a r i a b l e s a t T 1 . T h e d r o p o u t s w e r e

y o u n g e r ( M = 6 0 .2 v s . 6 7 . 2 y e a r s ) a n d w e r e m o s t l y m a l e

(~ = 8 3 % ) . T h e a n a l y s i s r e v e a l e d n o d i f f e r e n c e s in c a r d i o p u l -

m o n a r y f u n c ti o n o r p s y c h o l o g i c a l w e l l- b e i n g . H o w e v e r ,

d r o p o u t s h a d s i g n i f i c an t l y l o w e r s c o r e s o n t h e c o g n i t i v e t e s t

o f V e r b a l F l u e n c y , t ( 7 7 ) = 2 . 6 5 , p < . 0 1 .

A l m o s t a l l p a r t i c i p a n t s ( 9 2 % ) c o m p l e t e d t h e 1 0 - w e e k

s t u d y ( n = 7 3 ) , a l t h o u g h a s o m e w h a t l o w e r p r o p o r t i o n

c o m p l e t e d t h e e x e r c is e c o m p o n e n t ( 25 o f 2 9 ; 8 6 % ) . A m o n g

t h e 2 5 e x e r c i s e p a r t i c i p a n t s w h o c o m p l e t e d t h e s t u d y , t h e

m e a n n u m b e r o f s e s s i o n s a t t e n d e d w a s 2 9 (SD = _ 7 ) , o r

a p p r o x i m a t e l y t h r e e e x e r c i s e s e s s i o n s p e r w e e k , w h i c h i s

w e l l w i t h i n s t a n d a r d g u i d e l i n e s f o r c a r d i a c a n d p u l m o n a r y

r e h a b il i ta t i o n p r o g r a m m i n g ( A m e r i c a n A s s o c i a t io n o f C a r -d i o v a s c u l a r a n d P u l m o n a r y R e h a b i l i t a ti o n , 1 9 9 3 ) . T h e e x e r -

c i s e p a r t i c i p a n t s a tt e n d e d a p p r o x i m a t e l y 8 9 % o f t h e e d u c a -

t i o n c la s s e s a n d 8 0 % o f th e s t r e ss m a n a g e m e n t g r o u p s ,

w h e r e a s t h e e d u c a t i o n g r o u p a t t e n d e d a p p r o x i m a t e l y 8 8% o f

b o t h t h e e d u c a t i o n a n d s t re s s m a n a g e m e n t c l a s s e s .

Physiological Funct ioning

Pulmonary unction. P u l m o n a r y f u n c t io n o u t c o m e s w e r e

a n a l y z e d w it h a M A N O V A o f f o u r p u l m o n a r y f u n c t i o n

v a r i a b l e s (F E V 1 , % p r e d i c t e d F E V 1 , F V C , M V V ) . T h e

M A N O V A r e v e a l e d n o s i g n i fi c a nt e ff e ct s o f t i m e o r g r o u p

2 3 6 E M E RY , S C H E I N , H A U C K , A N D M A c I N T Y R E

a n d n o i n t e r a c ti o n . A s s h o w n i n T a b l e 2 , p u l m o n a r y f u n c t i o n

w a s n o t c h a n g e d d u r i n g t h e c o u r s e o f t h e i n te r v e n t i o n p e r i o d

f o r a n y o f t h e t h re e g r o u p s .

Cardiopulmonaryendurance. A M A N O V A o f tw o p h y si -

c a l e n d u r a n c e m e a s u r e s f r o m t h e e x e r c is e t e s ti n g ( m a x i m u m

H R a n d w o r k ) i n d i c a t e d a s i g n i f i c a n t ef f e c t o f t im e ,

F ( 2 , 6 8 ) = 4 . 0 7 , p < . 0 5 , a n d a n i n t e r a c t i o n o f T i m e x

G r o u p , F ( 2 , 6 6 ) = 3 . 4 5 , p < . 0 5 . U n i v a r i a t e a n a l y s e s

i n d i c a t e d a s i g n i f i c a n t t i m e e f f e c t, F ( 1 , 6 9 ) = 7 . 8 9 , p < . 0 1 ,

a n d a s ig n i f i c a n t i n t e r a c t i o n , F ( 2 , 6 7 ) = 6 . 0 8 , p < . 0 1 , f o r

w o r k b u t n o s i g n i f i c a n t u n i v a r i a t e e f f e c t s f o r H R . P a r t i c i -

p a n t s i n t h e E X E S M c o n d i t i o n i n c r e a s e d w o r k s i g n i fi c a nt l y,

w h e r e a s c o n t r o l p a r t i c i p a n t s d i d n o t , a s i s e v i d e n t i n T a b l e 3 .

B e c a u s e V O 2 m a x d a t a w e r e n o t o b t a i n a b l e f o r 9 p a r t ic i p a n ts

w h o w e r e u s i n g c o n t i n u o u s o x y g e n , a s e p a r a t e r e p e a t e d

m e a s u r e s A N O V A w a s c a l c u l a t e d f o r th e 6 4 p a r t ic i p a n ts

w i t h o u t o x y g e n . T h e A N O V A in d i c a t e d a s i g n if i c an t T i m e X

G r o u p i n t e r a c t i o n , F ( 2 , 6 1 ) = 9 . 8 9 , p < . 0 0 1 , a n d n o m a i n

e f f e cts . P a r t ic i p a n t s i n t h e E X E S M c o n d i t i o n a c h i e v e d g a i n s

i n V O 2 m a x t h a t w e r e n o t e v i d e n t i n t h e c o n t r o l g r o u p s , a ss h o w n i n T a b l e 3.

Psychological Well-Being

Depression. D e p r e s s e d m o o d w a s a n a l y z e d in a

M A N O V A o f C E S - D , S C L - D e p r e s s i o n , a n d A f f e c t -B a l a n c e

s c o r e s . T h e a n a l y s i s i n d i c a t e d a s i g n i f i c a n t t i m e m a i n e f f e c t ,

F ( 3 , 6 8 ) = 7 . 7 6 , p < . 0 0 1 , a n d a s i g n i f i c a n t T i m e × G r o u p

i n t e r a c t i o n , F ( 3 , 6 6 ) = 2 . 3 1 , p < . 0 5 . U n i v a r i a t e te s t s

i n d i c a t e d a s i g n i fi c a n t ti m e m a i n e f f e c t f o r C E S - D , F ( 1 ,

7 0 ) = 1 2 . 8, p < . 0 0 1 , S C L - D e p r e s s i o n , F ( 1 , 7 0 ) = 2 2 . 0 2 ,

p < . 0 0 1 , a n d A f f e c t B a i a n c e , F ( 1 , 7 0 ) = 9 . 0 3 , p < . 0 1 , w i t h

a s i g n i f ic a n t u n i v a r ia t e i n t e r a c t io n o n l y f o r S C L - D e p r e s s i o n ,

F ( 2 , 6 8 ) = 4 . 2 6 , p < . 0 5 . C o n t r a r y t o t h e e x p e r i m e n t a lh y p o t h e s i s , p l a n n e d g r o u p c o n t r a s t s i n d i c a t e d s i g n i f i c a n t

T a b l e 2Means and Standard Deviations for Pulmonary FunctionMeasures at Times I and 2

E X E SM E S M W L(n = 25) (n = 23) (n = 25)

T i m e T u n e T i m e T i m e T i m e T i m eMeasure 1 2 1 2 1 2

FEV 1 ( L )

M 1.29 1.31 1.15 1.07 1.02 1.04

SD 0.63 0.61 0.45 0.46 0.37 0.40% p r e d i c t e d

F E V IM 47 48 44 41 39 39SD 17 18 18 20 16 16

F V C ( L )

M 2.53 2.65 2.62 2.41 2.40 2.38SD 0.95 0 .96 0 .98 0 .85 0 .66 0 .96

M V VM 51.6 55.9 43.6 41.8 39.5 41.6SD 28.6 33.1 19.0 20.1 17.5 18.6

Note. EX ES M = exerc ise , educat ion , and s t ress managem ent ;ES M = educat ion and s t ress manage men t ; W L = wai t ing l is t ;FEV I = forced expi ra tory volum e in 1 s ; L = l ite rs ; FVC = forcedvi ta l capaci ty ; MV V = max imal voluntary venti la t ion .

T a b l e 3

Means and Standard Deviations for CardiopulmonaryEndurance Measures at Times I and 2

E X E S M E S M W L~ = 2 5 ) ( n = 2 3 ) ( n = 2 5 )

T i me T i me T i me T i me T i me T i meMe asure 1 2 1 2 1 2

Wor k ( k i lopond -meters)

M 66.3 77.6** 64.1 65.9 59.2 59.1SD 29.8 34.8 23.6 22.9 24.9 27.7

M a x H RM 135 138 127 131 125 122

. SD 24 29 16 16 18 17VO2ma x

( m l / k g / m i n )

M 12.4 14.4"* 12.0 11 .7 I1 .1 10.8SD 4.3 4.5 3.4 2.9 3.5 3.3

Note. EX ES M = exerc ise , education , and s tress managem ent ;ES M = educat ion and s t ress managem ent ; W L = wai t ing li s t;

wor k = ma x i m um w or k l oa d a c h ie ve d du ri ng b ic yc l ~ t es t; M a xHR = ma xim um hear t ra te dur ing b icycle test ; VO2max =ma x i ma l oxyge n c ons umpt i on du r i ng b i c yc l e t e st .**p < .01. The p va lues indica te wi th in-group compar ison s acrosstime.

d i ff e re n c es b e t w e e n t h e E X E S M a n d E S M g r o up s , F (1 ,

6 8 ) = 8 . 5 2 , p < . 0 1 . P o s t h o e a n a l y s i s o f w i t h i n - g r o u p

c h a n g e a c r o s s t i m e i n d i c a t e d s i g n i f i c a n t r e d u c t i o n s i n d e p r e s -

s iv e s y m p t o m s i n b o t h th e E X E S M a n d W L g r o u p s bu t n o

c h a n g e i n t h e E S M g r o u p , a s s h o w n i n T a b le 4 .

Anxiety. A n x i e t y w a s a n a l y z e d w i t h S t at e A n x i e t y f r o m

t h e S T A I a n d t h e A n x i e t y s u b s c a l e f r o m t h e S C L - 9 0 . R e s u l t s

i n d i c a t e d n o g r o u p o r t i m e m a i n e f f e c t s b u t a s i g n i f i c a n tT i m e × G r o u p i n t e r a c t io n , F ( 2 , 6 8 ) = 2 . 8 3 , p < . 0 5 .

U n i v a r i a t e t e s t s i n d i c a t e d t h a t t h e i n t e r a c t i o n w a s s i g n i f i c a n t

f o r S C L - A n x i e t y , F ( 2 , 6 9 ) = 3 . 1 3 , p < . 0 5 , a n d t h a t t h e r e

w a s a t r e n d f o r t h e S t a t e A n x i e t y s c a l e , F ( 2 , 6 9 ) = 2 . 8 1 , p <

. 0 7 . C o n t r a r y t o t h e h y p o t h e s e s , c o n t r a s t s i n d i c a t e d a

s i g n i f i c a n t d i f f e r e n c e b e t w e e n E X E S M a n d E S M , F ( 2 ,

6 8 ) = 3 . 1 3 , p < . 0 5 . P o s t h o e e v a l u a t i o n o f w i t h i n - g r o u p

c h a n g e a c r o s s t i m e i n d i c a t e d s i g n i f i c a n t r e d u c t i o n s i n a n x i -

e t y a m o n g E X E S M p a r ti c ip a n ts b u t n o t a m o n g E S M o r W L

p a r t i c i p a n t s , a s e v i d e n t i n T a b l e 4 .

Health Quality of Life

Generalized health attributions. A M A N O V A o f th et h r e e H e a l t h L o c u s o f C o n t r o l s u b s c a l e s ( I n te r n a l, o w e r f u l

O t h e r s, a n d C h a n c e ) r e v e a le d n o e f f ec t s o f g r o u p o r t i m e a n d

n o i n t e r a c t i o n f f e c t . t t r i b u t i o n s o f c o n t r o l r e m a i n e d s t a b l e

d u r i n g t h e i n t e r v e n t i o n , w i t h p a r t i c i p a n t s i n a l l t h r e e g r o u p s

a t t r i bu t i n g t h e g r e a t e s t d e g r e e o f c o n t r o l t o i n t e r n a l f a c t o r s

a n d t h e l e a st e g r e e o f c on t r o l t o c h a n c e f a ct o rs , s s h o w n i n

T a b l e 5 .

I l l n e s s - r e l at e d i m p a i r m e n t . A n a l y s i s o f t h e S I P t o t a l

s c o r e i n d i c a t e d a s i g n i f i c a n t t i m e m a i n e f f e ct , F ( I , 6 9 ) =

1 6 . 3 7 , p < . 0 0 1 , a n d a s i gn i fi c an t i m e × G r o u p i n te r ac t io n ,

F ( 2 , 6 9 ) = 3 . 8 6 , p < . 0 5 . H o w e v e r , c o n t r a ry t o t h e

h y p o t h e s i s , p l a n n e d c o n t r a s t s i n d i c a t e d s i g n i f i c a n t d i f fe r -

T a b l e 4

Means and Standard Deviations for Depression andAnxiety at Times 1 and 2

E X E S M E S M W L( n = 25 ) ( n = 23 ) ( n = 25 )

T i me T i me T i me T i me T i me T i meMe a s u r e 1 2 1 2 1 2

CES- De pr e s s i onM 14.2 9.4 13.0 11.9 14.0 12.5SD 9.8 7.3 8.3 9.3 7.4 7.9

Affec t -BalanceM 6.8 7.5 6.8 7.5 6.9 7.7SD 2.3 1.9 2.0 2.3 2.1 1.8

SCL- De pr e s s i onM 59.2 53.8*** 55.5 55.2 60.0 56.9*SD 7.6 5.7 5.3 4.8 7.7 6.9

S C L - A n x i e t yM 54.3 51.3"* 54.0 54.3 53.4 52.0SD 7.2 4.8 5.3 6.9 4.5 5.8

ST/ d - S t a t eAnx i e t y

M 36.9 33.2* 37.9 36.7 34.6 37.0SD 8.9 8.7 9.9 7.9 7.3 8.7

Note. Higher scores reflect greater distress for all measuresexcept Affec t -Balance . EX ESM = exerc ise , educat ion , and s tressma na ge me n t ; ESM = e duc a t i on a nd s t r e s s ma na ge me n t ; WL =wai t ing l is t ; CES = Center for Epidem iologica l Studies ; S CL =Hopk i ns Sympt om Che c k l i s t -90 - - - Re v i s e d ; ST / d = S t a t e -T r a i tAnx i e t y I nve n t o ry .*p < .05. **p < .01. ***p < .001. Th e p value s indicatewi th in-group com par isons across t ime.

e n c e s in c h a n g e s c o r es f o r E S M a n d W L g r o u ps , F ( 1 , 6 9 ) =

4 . 2 , p < . 05 . P o s t h o c a n a l y s i s o f w i t h i n - g r o u p c h a n g e

i n d i c a te d t h a t p ar t ic i p a n t s i n b o t h t h e E X E S M a n d W L

g r o u p s r e p o r t e d d e c r e a s e s i n i m p a i r m e n t o v e r t i m e , a s

s h o w n i n T a b l e 5.

Cognitive Functioning

Attention. A r e p e a t ed m e a s u r e s A N O V A o f D i g i t V ig i -

l a n c e p e r f o r m a n c e r e v e a l e d n o s i g n i f i c a n t e f f ec t s , as s h o w n

i n T a b l e 6 .

Motor speed. A r e p ea t e d m e a s u re s M A N O V A o f t h e

F i n g e r T a p p i n g t e s t r e v e a l e d n o s i g n i f i c a n t m a i n e f f e c t s o r

i n t e r a c t i o n e f f e c t s , a s s h o w n i n T a b l e 6 .

Mental efficiency. R e s u lt s o f a M A N O V A o f T r ai l

M a k i n g a n d D i g i t S y m b o l i n d i c a te d a s i g n i f ic a n t t i m e m a i ne f f e c t , F ( 3 , 7 0 ) = 2 1 . 9 4 , p < . 0 0 1 , w i t h p a r t i c i p a n t s i n a l l

t h r e e g r o u p s a c h i e v i n g i m p r o v e d p e r f o r m a n c e b u t n o i n t e r -

a c t i o n e f f e c t . U n i v a r i a t e t e s t s i n d i c a t e d t i m e e f f e c t s f o r a l l

t h r e e m e a s u r e s : T r a i l M a k i n g A , F ( 1 , 7 2 ) = 1 4 . 3 5, p < . 0 0 1 ;

T r a i l M a k i n g B , F ( 1 , 7 2 ) = 1 0 . 5 1 , p < . 0 1 ; a n d D i g i t

S y m b o l , F ( 1 , 7 2 ) = 5 1 . 2 2 , p < . 0 0 1 .

Organized verbal processing. A n A N O V A o f V e r b a l

F l u e n c y p e r f o r m a n c e i n d i c a t e d b o t h a t i m e m a i n e f f e c t , F ( 1 ,

7 0 ) = 9 . 0 5 , p < . 0 1 , a n d a T i m e × G r o u p i n t e r a c t i o n , F ( 2 ,

7 0 ) = 8 . 1 5 , p < . 0 0 1 . A s s h o w n i n T a b l e 6 , p a r t i c i p a n t s i n

t h e E X E S M c o n d i t i o n i m p r o v e d s i g n i f i c a n t l y , b u t t h o s e i n

t h e c o n t r o l c o n d i t i o n s d i d n o t c h a n g e .

Illness Knowledge

A r e p ea te d m e a s u re s A N O V A o f C O P D k n o w l e d g e

r e v e a l e d a t i m e m a i n e f f e c t, F ( 1 , 7 0 ) = 4 9 . 2 , p < . 0 0 1 , a s

w e l l a s a T i m e × G r o u p i n t e r a c t i o n , F ( 2 , 7 0 ) = 1 2 . 5 , p <

. 0 0 1 . P l a n n e d c o n t r a s t s w e r e c o n s i s t e n t w i t h t h e h y p o t h -

e s i z e d c h a n g e s . P o s t h o c w i t h i n - g r o u p c o m p a r i s o n s a c r o s s

t im e i n d i ca t e d t ha t b o t h E X E S M a n d E S M g r o u p s a c h i ev e d

s i g n i f i c a n t i n c r e a s e s i n t e s t s c o r e s ( E X E S M : 2 8 . 2 -+ 5 . 5 t o

31 . 9 - 5 . 2 , p < . 001 ; E SM : 23 . 7 _+ 7 . 4 t o 29 . 2 - 6 . 7 ,

p < . 0 01 ) , b u t t h e W L g r o u p d i d n o t c h a n g e ( 2 6 . 6 -+ 7 . 3 t o

27 . 8 - 5 . 8 , ns).

Evaluation o f Mediating Variables

T o e v a l u a t e t h e , e x t e n t t o w h i c h c h a n g e i n c a r d i o p u l m o -

n a r y e n d u r a n c e ( V O 2 m a x ) w a s a s s o c i a t e d w i t h c h a n g e i n

c o g n i t i v e f u n c t i o n a n d p s y c h o l o g i c a l w e U - b e i n g i n t h e

E X E S M g r o u p , a se r ie s o f m u l t i p l e re g r e s s i o n a n a l y s e s w a s

p e r f o r m e d . R e g r e s s i o n s w e r e c o n d u c t e d o n e a c h v a r i a b le f o r

w h i c h a s i g n i f ic a n t i n te r a c t io n h a d b e e n o b s e r v e d , i n c l u d i n g

S C L - D e p r e s s i o n , S C L - A n x i e t y , S T A I - S t a t e A n x i e t y , S IP ,

a n d V e r b a l F l u e n c y . F o r e a c h a n a l y s is , t h e T 2 s c o r e w a s f ir st

r e g r e s s e d o n t h e T 1 s c o r e , f o l l o w e d b y a c h a n g e s c o r e

c a l c u l a t e d f o r V O 2 m a x ( T 2 - T 1 ) . R e s u l t s i n d i c a te d t h a t

c h a n g e i n " ~ O 2 m a x w a s n o t a s i g n i fi c a n t p r e d ic t o r o f a n y o f

t h e o u t c o m e s .

A s i m i l a r s e t o f r e g r e s s i o n a n a l y s e s w a s t h e n p e r f o r m e d ,

r e g r e s s i n g c h a n g e o n t h e C O P D k n o w l e d g e t e s t o n T 2

i n d i c a t o r s o f p s y c h o l o g i c a l w e l l - b e i n g , a f t e r fi r st e n t e r in g

t h e T 1 v a l u e f o r e a c h i n d ic a t or . A m o n g t h e E X E S M

p a r t ic i p a n ts , C O P D k n o w l e d g e w a s n o t a s i g n if i c an t p re d i c -

T a b l e 5

Means and Standard Deviations for Health Qualityof Life at Times 1 and 2

E X E S M E S M W L( n = 2 5 ) ( n = 2 3 ) ( n = 25)

T i me T i me Tnne T i me T i me T i meMeasu re 1 2 1 2 1 2

M H L C - I n t e m a lM 25.5 24.5 22.6 21.9 23.5 24.1SD 4.0 3 .9 5 .8 7 .7 5 .0 5 .0

M H L C - P o w e r f u l

Others

M 21.1 19.2 20.8 19.3 22.1 21.1

SD 5.1 5.5 5.3 7.5 4.6 3.7M H L C - C h a n c e

M 15.7 14.7 16 .1 17.0 15.8 16.3SD 5.2 4.8 6.8 7.2 5.1 5.1

S i c kne ss I mp a c tProfile

M 11 .1 5 .8*** 10.9 10.7 14.2 10.4"**SD 8.1 5 .2 9 .9 7 .4 8 .6 7 .8

Note. Higher scores ref lec t s t ronger endorsement of MHLCat tr ibut ion and grea ter impai rm ent on the Sickness Im pact Profi le .EX ESM = exerc ise , education , and s tress mana geme nt ; ESM =

educat ion and s t ress management ; WL = wai t ing l i s t ; MHLC =Mul t id imensional Heal th Lo cus of Control .***p < .001. The p va lues indica te wi th in-group comp ar isonsacross t ime.

23 8 EMERY, SCHEIN, HAUCK , AND MAcINTYRE

Table 6

Means and Standard Deviations fo r CognitiveMeasures at 71rues I and 2

EXES M ES M WL(n = 25) (n = 23) (n = 25)

Time TimeMeasure 1 2 Time Time Time Time1 2 1 2

Digit VigilanceaM 196 . 0 198 . 6SD 54.5 45.9

Finger TappingDominant hand

M 41.8 43.3SD 1.8 2.1

Nondominanthand

M 37.3 37.4SD 1.3 1.4

Trail Making A ~M 40.5 33.5SD 16.2 9.7

Trail Making BaM 152 . 4 102 . 6SD 126.4 50.0

Digit SymbolM 46.0 51.0SD 1 3 . 4 1 2 . 3

Verbal FluencyM 28.6 33.9***SD 6.2 7.2

223 .3 220 . 3 192 . 6 195 .051.8 50.0 35.2 38.8

38.7 39.8 41.5 42.11.9 1.7 1 .4 1 .4

35 .1 35.4 36.9 37.71.5 1.6 1.3 1.1

46.6 40.5 38.6 34.52 2.7 1 6 . 2 1 7 . 7 1 3 . 5

175 . 5 149 . 3 131 . 4 111 . 0113.8 12 3.3 49.9 67.4

38.4 41.9 43.8 48.21 1 .1 1 0 . 1 1 2 . 4 1 2 .6

27.8 27.6 29.4 29.86.4 7.0 8.1 8.7

Note. Higher scores indicate better cognitive performance exc epton Digit Vigilance and Trail Making (A and B). EXESM =exercise, education, and stress manag ement; ESM = education andstress m anagement; W L = waiting list.aExpressed in seconds.***p < .00 1. The p value indicates within-group comparisonacross time.

t o r o f p s y c h o l o g i c a l w e l l - b e in g . H o w e v e r , w h e n t h e r e g r e s -

s i o n s w e r e r e p e a t e d w i t h t h e E S M p a r t i c i p a n t s , c h a n g e i n

C O P D k n o w l e d g e w a s s t r o n g l y a s s o c i a t e d w i t h S C L -

An xie ty ( [3 = .514, par t ia l r e = .26, p < .02) , b ut in a

n e g a t i v e d i r ec t i o n , s u g g es t i n g t h a t g r e a t e r C O P D k n o w l e d g e

was a s soc ia ted wi th inc r eased anx ie ty .

Interrelationship of Pulmonary Function and

Cognitive Function

T o e x p l o r e t h e h y p o t h e s i s th a t b l o o d o x y g e n a t i o n w o u l d

b e a s s o c i a t e d w i t h c o g n i t i v e p e r f o r m a n c e , P e a r s o n c o r r e l a-t i o n s w e r e c o n d u c t e d o f P a O 2 w i t h b a s e l in e v a l u e s f o r e a c hc o g n i t i v e m e a s u r e a s w e l l a s c h a n g e s c o re s ( T 1 - T 2 ) f o r

e a c h c o g n i t i v e m e a s u r e . T h e c o r r e l a t i o n s w e r e u n i f o r m l y

sm al l and wer e no t s t a t i s t i ca l ly s ign i f i can t . Cor r e la t ions o f

F EV1 wi th cog ni t ive va r iab le s wer e a l so r e la t ive ly sm a l l andnons ign i f i can t .

D i s c u s s i o n

T h e d a t a a r e c o n s i s t e n t w i t h p r e v i o u s s t u d i es d e m o n s t r a t-

ing the bene f ic ia l e f f ec t s o f exe r c i s e r ehab i l i t a t ion f o r

c a r d i o p u l m o n a r y e n d u r a n c e a m o n g p a t i e n t s w i t h C O P D .

F u r t h e r m o r e , c h a n g e s i n e n d u r a n c e o c c u r r e d d e s p i t e t h e

a b s e n c e o f s i g n if i ca n t c h a n g e i n p u l m o n a r y f u n c ti o n . T h u s ,

a l t h o u g h l u n g m e c h a n i c s o f C O P D p a t i en t s a r e s t ab l e a n d

the condi t ion i s i r r eve r s ib le , EXES M par t i c ipan ts ach ieved

s ign i f i can t f unc t iona l ga ins in the con tex t o f l im i ted pu lm o-

na r y capac i ty . The s ign i f i can t inc r ease o f appr ox im a te ly

1 6 % i n V O 2 m a x a m o n g E X E S M p a r t i c i p a n t s i s c o n s i s t e n t

wi th o the r t r a in ing s tud ies am ong hea l thy o lde r adu l t s

( Blum entha l e t a l ., 1989) and ind ica te s the e f f ec t ivenes s o f

t h e i n t e r v e n t i o n f o r e n h a n c i n g e n d u r a n c e l e v e l s . T h i s i n -

c r ease i s l a r ge r than the 9% inc r ease in VO2m ax r epor ted

r ecen t ly by Ries e t a l . ( 1995) , bu t i t m ay r e f lec t the

s o m e w h a t l o n g e r ( 1 0 w e e k s v s . 8 w e e k s ) a n d m o r e i n t e n s e

( 37 ses s ions vs . 12 ses s ions ) na tur e o f th is in te r ven t ion .

A s h y p o t h e s i z e d , E X E S M p a r ti c i p an t s e x p e r i e n c e d re d u c -

t ions in sym pto m s o f d is t r e ss , inc lud ing r educe d depr es s ion

a n d a n x i e ty . A l t h o u g h i t w a s h y p o t h e s i z e d t h a t E S M p a r ti c i -

p a n t s a l s o w o u l d e x p e r i e n c e d e c re a s e d s y m p t o m a t o l o g y a s a

r e s u l t o f i n c r ea s e d s o c i a l s u p p o r t a n d g r e a t e r k n o w l e d g e o f

d i sease p r oces ses , the da ta d id no t suppo r t the hypo thes i s . I nf ac t , the r egr es s ion ana lyses sugges ted tha t g r ea te r knowl-

e d g e m a y h a v e b e e n a s s o c ia t e d w i t h i n c r e a s e d d is t re s s i n t h e

E S M g r o u p . T h i s u n e x p e c t e d f i n d i n g i s c o n s i s t e n t w i t h

r e s u l t s o f o n e p r e v i o u s r e p o r t o f i n c r e a s e d p s y c h o l o g i c a l

d i s t r e s s a s soc ia ted wi th an educa t iona l in te r ven t ion am ong

CO P D pa t ien t s ( S cbe r e r , J ane l l i , & S chm iede r , 1989) . Thus ,

e d u c a t i o n a l o n e m a y h a v e l i m i t e d v a l u e f o r p h y s i c a l a n dp s y c h o l o g i c a l f u n c t io n i n g o f p a t ie n t s w i t h C O P D . H o w e v e r ,

f u r t h e r s tu d y o f e d u c a t i o n i n t e r v e n t i o n s a m o n g p a t ie n t s w i t h

C O P D w i l l h e l p t o c l a r i f y t h e e x t e n t t o w h i c h s u c h

i n t e r v e n ti o n s m a y b e u s e fu l .

EXES M par t i c ipan ts a l so ind ica ted r educ t ions in i l lnes s -

r e l a t e d p h y s i c a l a n d e m o t i o n a l i m p a i r m e n t t h a t w e r e n o to b s e r v e d a m o n g E S M p a r t i c i p a n t s , f u r t h e r s u p p o r t i n g t h e

v a l u e o f th e E X E S M i n t e r v e n ti o n o v e r t h e E S M c o n d i t io n .

I m p r o v e m e n t i n S I P s c o re s a m o n g W L p a r t ic i p a n ts m a y , i n

p a r t, r e f l e ct re g r e s s io n t o t h e m e a n b e c a u s e t h e m a g n i t u d e o f

T 2 s c o r e s in t h i s g r o u p w a s c o m p a r a b l e t o t h e T 1 s c o r es i n

t h e E X E S M a n d E S M g r ou p s . B e c a u se t h e W L g r o u p a l so

i n d i c a t e d r e d u c e d s y m p t o m s o f d e p r e s s i o n , h o w e v e r , i t i s

p o s s i b l e t h a t a w a r e n e s s o f b e i n g i n c l u d e d i n t h e r e s e a r c h

s t u d y c o n t r i b u t e d t o p o s i t i v e e x p e c t a t io n s l e a d i n g t o r e d u c e d

dis t r e ss and e nhan ced qua l i ty o f li f e .

Resu l t s f r om the cogni t ive t e s t ing ind ica ted tha t the r ew e r e n o e f f e c ts o n t e s t s o f a t t en t i o n a n d m o t o r s p e e d a n d

only p r ac t i ce e f f ec t s on t e s t s o f m enta l e f f i c iency . Ho we ver ,

the s ign i f i can t in te r ac t ion f o r the Ver ba l F luency te s t sug-g e s ts t h a t E X E S M w a s a s s o c ia t e d w i t h g r e a t e r e ff i c ie n c y o f

v e r b a l p r o c e ss i n g . T h e s e d a t a s u p p o r t t h e n o t i o n t h a t e x e r -

c i s e m a y h a v e a n e f f e c t o n t a s k s a s s e s si n g e x e c u t i v e

f unc t ion ( i . e . , s e l f - con t r o l and se l f - m oni to r ing) a s soc ia tedw i t h f r o n t a l l o b e f u n c t io n i n g .

E X E S M w a s a s s o c i a te d w i t h c h a n g e s n o t fo u n d i n e i t h e r

of the con t r o l condi t ions , sugges t ing tha t exe r c i s e - r e la tedp r o c e s s e s c o n t r i b u t e d t o t h e o b s e r v e d c h a n g e s . P o s s i b l e

m e c h a n i s m s b y w h i c h e x e r c i s e m i g h t a f f e c t m o o d a n d

c o g n i t i v e p r o c e s s e s a r e t h r o u g h c h a n g e s i n r e l e a s e a n d

u p t a k e o f b r a i n n e u r o t r a n s m i t t e r s a n d c h a n g e s i n s y m p a -

the t ic ne r vous sys tem ac t iv i ty ( Dus tm an e t a l . , 1990; S p i t -

P S YCHOLOGICAL AND COGNITIVE OUTCOMES OF EXERCISE 23 9

d .u so , 1 9 8 3 ) . H o w e v e r , c h a n g e s i n c a r d i o p u l m o n a r y f i t n e s s

( V O z m a x ) p e r s e w e r e n o t s i g n i f i c a n t l y a s s o c i a t e d w i t h

e i t h er m o o d o r c o g n i t iv e p e r f o r m a n c e , a n d b l o o d o x y g e n

l e v e l ( P a O 2 ) w a s n o t a s s o c i a t e d w i t h c o g n i t i v e p e r f o r m a n c e ,a s o b s e r v e d a m o n g m o r e i m p a i r e d C O P D p a t ie n ts ( G r a n t e t

a l . , 1987).

A d h e r e n c e t o t h e e x e r c i s e p r o g r a m m a y h a v e b e e n l i m i te d

b y t h e n a t u r e o f C O P D , w h i c h i s u n p r e d i c t a b l e a n d v a r i a b l e,

o f t e n r e n d e r i n g p a t i e n t s s e v e r e l y d e b i l i t a t e d . G i v e n t h e

o b s t a c l e s p o s e d b y t h e i l l n e s s , a d h e r e n c e r a t e s w e r e a d -

e q u a t e , a s i s s u b s t a n ti a t ed b y t h e i m p r o v e m e n t s i n e x e r c i s e

e n d u r a n c e a n d in C O P D k n o w l e d g e . T h e E X E S M i n te r v e n -

t i o n c o n t r i b u t e d t o s i g n i f i c a n t g a i n s i n f u n c t i o n , b u t t h e

l o n g e r - t e r m e f f e c t s o f t h e i n t e r v e n t i o n a r e u n k n o w n b e c a u s e

t h e s t u d y i n v o l v e d a r e l a t i v e l y b r i e f 1 0 - w e e k f o l l o w - u p .

I m p r o v e m e n t s i n c a r d i o p u l m o n a r y e n d u r a n c e a r e l i k e l y t o

d i s s ip a t e r a p i d l y w i t h o u t c o n t i n u e d e x e r c i s e , a n d r e c e n t d a t a

f r o m R i e s e t a l . ( 1 9 9 5 ) s u g g e s t t h a t b e n e f i t s o f e x e r c i s e

a m o n g C O P D p a t i e n t s a r e n o t l i k e l y t o b e m a i n t a i n e d o v e r a

l o n g e r - te r m , o n e - y e a r f o l l o w - u p . R e l i a b le m o d e l s f o r p r e d i c t-i n g e x e r c i s e a d h e r e n c e i n t h i s p o p u l a t i o n a r e n e e d e d b e c a u s e

a d h e r e n c e i s l i k e ly t o b e c o m p l i c a t e d b y n u m e r o u s f a c t o r s,

i n c l u d i n g s y m p t o m p e r c e p t i o n , s o c i a l s u p p o r t , a n d l i m i t a -

t i o n s i n t h e p a t i e n t 's c a p a c i t y t o c o m p r e h e n d t h e i n t e r v e n -

t i o n . P a s t w o r k b y K a p l a n a n d c o l l e a g u e s ( K a p l a n , A t k i n s , &

R e i n s c h , 1 9 8 4 ) s u g g e s ts t h a t c o m p l i a n c e w i t h w a l k i n g m a y

b e m e d i a t e d b y p e r c e i v e d s e l f - e ff i c a cy . R e s u l t s o f o u r s t u d y

i n d i c a t e t h a t e x e r c i s e b e h a v i o r m a y o f f e r i n tr i n s ic r e w a r d s

t h r o u g h r e d u c t i o n s i n s y m p t o m s o f d i s t r e s s a n d p h y s i c a l

im pa i rm ent a s we l l a s inc reases in func t iona l capac i ty . In

add i t ion , a t the T1 as ses sm ent , pa r t i c ipan t s in a l l g roup s had

high in te rna l hea l th - re la ted a t t r ibu t ions o f con t ro l ( re la t ive

t o a t t r ib u t i o n s o f c o n t r o l b y p o w e r f u l o t h e r s o r c h a n c e ) t h a t

m a y h a v e c o n t r i b u t e d t o s t u d y a d h e r e n c e . I t w a s s t ri k i n g t h a t

t h e 6 s t u d y d r o p o u t s h a d s i g n i fi c a n tl y l o w e r s c o r e s o n t h e

V e r b a l F l u e n c y t a s k t h a n d i d t h e 7 3 p a r t i c i p a n t s w h o

c o m p l e t e d t h e s t u d y , s u g g e s t i n g t h a t a s p e c t s o f c o g n i t i v e

f u n c t i o n m a y b e i m p o r t a n t t o i n c l u d e in m o d e l s o f a d h e r e n c e

a m o n g p a t ie n t s w i t h C O P D .

T h e r e s u l t s o f t h i s s t u d y d i v e r g e f r o m p a s t s t u d i e s i n

w h i c h m i n i m a l p s y c h o l o g i ca l c h an g e s w e r e o b s e r v e d a m o n g

exerc i s in g COP D pa t i en t s (e .g . , Ga yle e t a l ., 1988; Lewis &

Bel l , 1995; P ie s e t a l . , 1995) , pos s ib ly because the exe rc i s e

i n t e r v e n t i o n i n t h i s s t u d y w a s r e l a t i v e l y i n t e n s e . F u r t h e r

s t u d y i s n e e d e d t o e v a l u a t e o p t i m a l a m o u n t s o f e x e r c i s e f o r

p r o d u c i n g p h y s i o l o g i c a l , p s y c h o l o g i c a l , a n d c o g n i t i v e b e n -

e f i ts a m o n g p a t i e n t s w i t h C O P D , w i t h p a r t i c u l a r a t te n t i o n tom e c h a n i s m s u n d e r l y i n g e x e r c i s e - r e l a t e d p s y c h o l o g i c a l a n d

c o g n i t i v e c h a n g e .

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A M E R I C A N P S Y C H O L O G I C A L A S S O C I A T I O N

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