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BrazJMedBiolRes42(3)2009

ThreeexerciseprogramsinpatientswithCOPD

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BrazilianJournalofMedicalandBiologicalResearch(2009)42:263-271

ISSN0100-879X

Effectofthreeexerciseprogramson

patientswithchronicobstructivepulmonarydisease

V.Z.Dourado1,S.E.Tanni3,L.C.O.Antunes4,S.A.R.Paiva3,A.O.Campana3,A.C.M.Renno2andI.Godoy3

1DepartamentodeCinciasdaSade,LaboratriodeEstudosdaMotricidadeHumana,2Departamento

deBiocincias,UniversidadeFederaldeSoPaulo,CampusBaixadaSantista,Santos,SP,Brasil3DisciplinadePneumologia,DepartamentodeClnicaMdica,4SeoTcnicadeReabilitao,

FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,Botucatu,SP,Brasil

Correspondenceto:V.Z.Dourado,DepartamentodeCinciasdaSade,Av.Alm.SaldanhadaGama,89,11030-400Santos,SP,Brasil

Fax:+55-13-3221-8058.E-mail:,

Wecomparedtheeffectofthreedifferentexerciseprogramsonpatientswithchronicobstructivepulmonarydiseaseincluding

strengthtrainingat5080%ofone-repetitionmaximum(1-RM)(ST;N=11),low-intensitygeneraltraining(LGT;N=13),or

combinedtraininggroups(CT;N=11).Bodycomposition,musclestrength,treadmillendurancetest(TEnd),6-minwalktest

(6MWT),SaintGeorgesRespiratoryQuestionnaire(SGRQ),andbaselinedyspnea(BDI)wereassessedpriortoandafterthe

trainingprograms(12weeks).Thetrainingmodalitiesshowedsimilarimprovements(P>0.05)inSGRQ-total(ST=1314%;

CT=1214%;LGT=1110%),BDI(ST=1.84;CT=1.83;LGT=12),6MWT(ST=4351m;CT=4850m;LGT

=3175m),andTEnd(ST=1120min;CT=1111min;LGT=75min).IntheSTandCTgroups,anadditionalimprovement

in1-RMvalueswasshown(P


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ingishigherthanthatobtainedwithendurancetraining(5),

buttheimportanceofthisincrease,mainlyregardingthe

health-relatedqualityoflifeinCOPDpatients,isunclear.

Pulmonaryrehabilitationshouldbeincorporated intoCOPDtreatmentstrategiesaspartoflong-termdisease

management (3).However, some barriers to treatment

adherence byCOPD patients include the monotonyof

exerciseprogramsandthelimitedexercisetolerance.In

addition,therearealimitednumberofstructuredprograms

available.Therefore,theefficacyofmakingtrainingpro-

gramsaccessibletoagreaternumberofCOPDpatients

warrantsfurtherinvestigation.

Somerandomizedcontrolledclinicaltrialshaveshown

thathigh-intensityintervaltraining resultsin benefitsre-

latedtodyspnea,health-relatedqualityoflifeandexercise

capacity,similartothoseobtainedby continuousendur-

anceexercise(6,7).However,arecentsystematicreviewconcludedthatthereisalackofevidencethathigh-intensity

exerciseissuperiortolow-intensityexercise(8).Therefore,

furtherstudiesarenecessarytoinvestigatethishypothesis.

Low-intensity exerciseprogramsare easy to imple-

mentandhavebeenusedasthestandardrehabilitation

programattheBotucatuMedicalSchoolformanyyears.

Theireffectsonexercisetoleranceandthesensationof

dyspnea have been previously described (9,10). Low-

intensitytraining(aerobicandstrength)iswelltoleratedby

COPDpatientsandisparticularlysuitedtothosewiththe

severeformofthedisease(11).Inthiscontext,wehypoth-

esizedthatacombinationofstrengthtraining(ST)andour

current program of low-intensity general training (LGT)

couldresultinadditionalbenefitstoCOPDpatients.Thus,

theaimofthepresentstudywastocomparethreedifferent

physicalexerciseprogramsinpatientswithCOPD:moder-

ate-tohigh-intensityST,LGT,andcombinedtraining(CT).

Patients and Methods

Patients and design

Fifty-oneconsecutivepatientsadmittedto theReha-

bilitation Center of Paulista State University (UNESP),

SchoolofMedicineatBotucatu,SP,Brazil,wereinvitedto

participateinthestudy.Patientswereincludedinthestudyiftheymettheglobalinitiativeforchronicobstructivelung

diseasecriteria fora diagnosisof COPD (12).Patients

consideredclinicallyunstable(i.e.,whopresentedchanges

inmedicationdoseorfrequency,diseaseexacerbation,or

hospitaladmissionsinthepreceding8weeks)wereex-

cluded.Theoccurrenceofexacerbationwasevaluatedby

self-reportingduring clinic visits and was confirmed by

reviewingthemedicalrecord.Thefollowingfactorswere

alsoconsideredgroundsforexclusion:chronicdiseases

suchasmalignantdisorders,cardiovasculardisease,in-

sulin-dependentdiabetesmellitus, osteoarthritis, useof

oralcorticosteroids,treatmentnon-compliance,andinabil-

itytoperformthelungfunctiontest.Ingroupsof3,patientswererandomlyassignedtoone

ofthetrainingmodalities(ST,LGT,orCT).Eachprogram

consistedofthree1-hsessionsperweekoveraperiodof

12weeks.

Fourpatientsdidnotcompletethebaselineevaluation

andwere excludedfrom the study. Therefore, the final

samplewascomposedof47patients.Uponthearrivalof

eachsubject,thepurposeandproceduresinvolvedinthe

studywereexplainedandwritteninformedconsentwas

obtained.AllprocedureswereapprovedbytheResearch

EthicsCommittee of theUNESPSchoolofMedicineat

Botucatu.

Pulmonary function and arterial blood gas analysis

Spirometrywasperformedbeforeandafter15minof

inhalationof400mgsalbutamol(Med-Graph1070;Medi-

calGraphicsCorporation,USA).Forcedexpiratoryvolume

inthefirstsecondisreportedasliters,aspercentforced

vital capacityand aspercent of reference values (13).

Bloodwasdrawnfromthebrachialarterywiththepatients

atrestandbreathingroomair.Arterialoxygentensionand

carbon dioxide tension (PaO2 andPaCO2) were deter-

minedwithabloodanalyzer (StatProfile5 Plus;Nova

Biomedical,USA).

Nutritional assessment

Body weight and height were measured, and body

massindex(BMI=weight/height 2)wascalculated.Body

compositionwasevaluatedusingbioelectricalimpedance

(BIA101A;RJLsystems,USA).Resistancewasmeas-

uredontherightsideofthebodyinthesupineposition.

Fat-freemass (FFM,kg)was calculatedusingagroup-

specificregressionequationdevelopedbyKyleetal.(14).

TheFFMindex(FFMI=FFM/height2)wasalsocalculated.

LeanbodymassdepletionwasdefinedasanFFMI


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Respiratory pressures, handgrip and peripheral muscle

strength

Wemeasured maximal inspiratory pressure by the

methodofBlackandHyatt(21).Forearmmusclestrengthwasmeasuredon thebasisofhandgripstrengthof the

dominanthandmeasuredwithadynamometer(TEC-60;

TechnicalProducts,USA).

Peripheralmusclestrengthwasassessedbythedeter-

minationoftheone-repetitionmaximum(1-RM).Theagreed

convention for1-RM is theheaviestweight that canbe

liftedthroughoutthecompleterangeofmotionrelatedto

theexerciseperformed.The1-RMwasassessedforexer-

cisescarriedouton weight trainingequipment (22): leg

press(quadriceps,gluteus,hamstrings,andcalfmuscles),

legextension(quadriceps),latpull-down(latissimusdorsi,

trapezius,andbiceps),benchpress(pectoralsmajorand

triceps), seated rowing (latissimus dorsi, trapezius andtriceps),tricepspulley(triceps),andbicepscurl(biceps).A

warm-upof3-5minfollowedby10repetitionswithalight

loadwasperformedpriortothetestinordertominimizethe

effectsoflearning.The1-RMtestwasinitiatedataweight

nearthe suspectedmaximumtominimizerepetition fa-

tigue. All participants attained the 1-RM within 3-5 at-

tempts.Twoto3minofrestwereallowedbetweenrepeti-

tions.TheValsalvamaneuverwasavoided,andtheproper

exerciseperformance technique foreachmusclegroupwasemphasized.

Exercise tolerance

Amaximalexercisetolerancetestwasperformed.The

test consisted ofsymptom-limitedgradedexerciseon a

treadmillwithpatientbreathingroomairanditsobjective

wastodeterminedpossiblecardiovascularcontraindica-

tionsofexerciseprogramsusingamodifiedBruceprotocol

(23).Aconstantworkloadtreadmilltest,usedtoassess

endurancecapacity,was performedon aseparateday,

subsequenttothatonwhichtheincrementalexercisetest

wasperformed.After3minofwarm-up,thetreadmillwas

setat80%ofthemaximuminclinationandatthespeedachievedduringthebaselinemaximalincrementalexer-

cisetest.Patientswereinstructedtowalkat80%oftheir

maximumpoweroutput(i.e.,exerciseintensityprobably

abovethelactatethreshold)foraslongastheycould.

A6-minwalktest(6MWT)wasalsoconductedaftera

Table1.Table1.Table1.Table1.Table1.Low-intensitygeneraltraining.

Walking

Indoorwalking:Walkingfor30minataself-determinedvelocity.

Parallelbar

Thoracicandupper-limbstrengthtraining:Patientinuprightpositionwithbothhandsontheparallelbar.Bringingthechesttothe

barandreturningtotheinitialpositionusingthethoracicandupper-limbmuscles(25repetitions).Squat:Patientinuprightpositionwithbothhandsontheparallelbar.Squattingtoapproximately50ofhipandkneeflexionand

returningtotheinitialposition(15repetitions).

Diagonalupper-limbstrengthtraining:Patientinuprightposition.Raisingonearmdiagonallywithoutanyaddedweight

(20repetitions/arm).

Freeweights

Diagonalupper-limbstrengthtraining:Patientinuprightposition.Raisingonearmdiagonallywhileholdingdumbbells

(20repetitions/arm).

Bicepscurl:Patientlyingcomfortablyonamat,holdingdumbbellswiththepalmsofthehandsturnedupward.Flexingtheforearms

toapproximately90andreturningtotheinitialposition(25repetitions).

Shoulderflexorstrengthtraining:Patientlyingcomfortablyonamat,holdingdumbbellswiththepalmsofthehandsturneddown.

Flexing theshouldersto approximately45withthe groundwith forearmextensionand returningto theinitialposition (25

repetitions).

Pectoralisstrengthtraining:Patientlyingcomfortablyonamatwithshouldersabducted,holdingdumbbellswiththepalmsofthe

handsturnedupward.Horizontaladductionofthearmstothemediallineofthetrunkandreturningtotheinitialposition(25repetitions).

Tricepscurl:Patientlyingcomfortablyonamat,armsandshouldersflexingto90andforearmintotalflexingandneutralposition,

holdingdumbbells.Extendingtheforearmcompletelyandslowlyreturningtothepositionnearthehead(25repetitionseacharm).

Matwork

Hipabductorstrengthtraining:Patientinlateraldecubituswiththelegclosesttothegroundinkneeflexionto90andtheotherleg

inkneeextension.Abductingthesuperiorhipinkneeextensionandreturningtotheinitialposition(25repetitionsforeachleg).

Hipandlumbarextensorstrengthtraining:Patientonallfours.Performinghyperextensionofthehipinoneofthelowerlimbsand

returningtotheinitialposition(25repetitionsforeachleg).

Abdominalexercises:Patientinsupinepositionwiththekneesin90flexionandthehipsin45flexion.Tighteningofabdominal

muscles,witheyesfixedonthenavel,holdingfor2s.Returntostartingposition(50repetitions).


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fewminutesofpractice,withthepatientsbeinginstructed

towalkonanoval33.12-mcourse,attemptingtocoverthe

greatestdistancepossiblein6min.Aresearchassistant

timedthewalk,andstandardizedverbalencouragementwasgiventoeachpatient.Peripheraloxygensaturation

(SpO2)wasmonitoredthroughoutthetestusingapulse

oximeter(OhmedaBiox3700;Ohmeda,USA).Patients

whopresentedhypoxiaatbaseline,aswellasthosewhose

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grouppresentedasignificantpost-trainingimprovementin

theSGRQsymptomsdomain,activitiesdomainandtotal

scores,aswellasintheAQ20totalscore.ThoseintheCT

grouppresentedasignificantpost-trainingimprovementintheSGRQactivitiesdomain,impactdomain,totalscores,

and in the AQ20 total score. Those in the LGT group

presenteda significantpost-trainingimprovementin the

SGRQ symptoms domain and total scores. In addition,

minimalclinicallysignificantimprovementinthetotalSGRQ

scorewasfoundfor7patientsintheSTgroup(63.6%),9

patientsintheCTgroup(72.7%),and9patientsintheLGT

group(69.2%;P>0.05).Althoughsignificantimprovement

inBDIwasfoundonlyintheSTgroup,therewas

a minor, though consistent, trend towards im-

provementinBDIscoreintheCTandLGTgroups.

Effects of exercise training on functionalexercise tolerance

Results related to functional exercise toler-

anceareshowninTable4.Itcanbeobservedthat

therewasasignificantincreaseinthe6-minwalked

distanceandintheendurancetimeintheCTand

ST groups. A minimal clinically significant im-

provementinthe6MWTwasobservedin6pa-

tientsintheSTgroup(54.5%)andin4patientsin

theCTgroup(36.4%).Inaddition,weobserveda

tendencytoasignificantincreasein6MWTvalues

andinthetreadmillendurancetimeintheLGT

group.FourLGTpatients(30.8%)presentedmini-

malclinicallysignificantimprovementsinthe6MWT

results.

Effects of training on respiratory and peripheral

muscle strength

Pre- and post-training values of respiratory

Table3.Table3.Table3.Table3.Table3.Pre-andpost-trainingmeanvaluesofqualityoflifeanddyspneaforpatientsinthestrengthtraining(ST),combinedtraining

(CT),andlow-intensitygeneraltraininggroups(LGT).

SGRQsymptoms(%) SGRQactivities(%) SGRQimpact (%) SGRQtotal (%) AQ20total(%) BDI

Pre-trainingST 59 28 63 20 42 21 48 19 55 23 1.8 1.4

CT 42 24 61 22 36 20 45 20 45 23 1.9 1.2

LGT 55 22 61 16 42 16 50 13 48 21 1.6 0.8

Post-training

ST 36 24* 44 27* 32 22 35 20* 39 19* 2.4 1.2*

CT 32 22 48 23* 24 19* 33 17* 32 16* 2.5 1.3

LGT 30 14* 51 19 34 21 39 17* 44 25 2.0 1.3

DataarereportedasmeanSD.SGRQ=SaintGeorgesRespiratoryQuestionnaire;AQ20=AirwaysQuestionnaire20;BDI=

baselinedyspneaindex.*P


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distancepresentedsignificant positive correlations with

changesin1-RMinthelatpulldown(r=0.64;P=0.0452),

1-RMinthebenchpress(r=0.62;P=0.0395),and1-RM

inthelegextension(r=0.60;P=0.0467).

Discussion

The aim of the present study was to compare the

resultsofthreedifferentexerciseprogramsregardingbody

composition,quality of life, dyspnea,peripheralmuscle

strength, andexercise toleranceof COPDpatients.We

foundthatthestrength-trainingcomponentproducedaddi-

tionalimprovementsinperipheralmusclestrength.How-

ever,thistypeoftrainingdidnotpromoteanyadditional

benefit inexercise tolerance, dyspneaor health-related

qualityoflife.

Inthepresentstudy,ST,aloneorcombinedwithLGT,

was effective in increasing the strength of the muscle

groups trained. Supporting this finding, there is strong

evidencethatSTaloneorcombinedwithendurancetrain-

ingcanleadtoasignificantimprovementinmusclestrength

inCOPDpatients(5,8,27,28). In contrast withprevious

studiesthatshowedincreasedmusclestrengthandhigher

enduranceinCOPDafterlow-intensityresistancetraining,wedidnotfindasignificantincreaseinmusclestrengthin

the LGT group (9,10). Studies using cycling and arm

cranking asa trainingmodality have shown significant

increasesinlowerandupperlimbmusclestrength(5,23,24).

Ontheotherhand,Madoretal.(29)didnotobserveany

change in peripheral muscle strength after endurance

training.Thesediscrepanciesmaybe attributableto the

differencesin themodalitiesand theintensityoftraining

employed.

No significant changes inBMI, FFM or FFMI were

foundinourstudyinanygroupevaluated.Thisfindingisin

agreementwithpreviousreportsofincreasesintotalFFM

onlywhen therehabilitationprocess includednutritional

supportorsupplementationwithspecificagents,suchas

testosteroneor creatine (3032).Moreover, body impe-

danceisnotaccurateenoughtodetectsmallchangesin

bodymasscomposition(14).

TheST andCTmodalitiesproducedsignificantand

similarchangesinhealth-relatedqualityoflifeinthepres-

entstudy.Themagnitudeoftheimprovementsshownin

thepresentstudy(SGRQtotalchange=1110to13

14%)has beenreportedbyothers inBrazilianpatients

(33).ThedyspneaintheSTgroupimprovedsignificantly,

whereasitdidnotchangesignificantlyintheCTorLGT

groups.Thebetween-groupdifferenceforthechangein

dyspnea,however,wasnot significant.In fact,a recent

systematicreviewofrandomizedcontrolledtrialscompar-

ingdifferentexerciseprogramsforCOPDshowedthatST

producedgreater improvementsin thedyspneadomain

andinthetotalscoreoftheChronicRespiratoryDisease

Questionnairewhencomparedtoendurancetraining(8).

The6-minwalkingdistanceandtheendurancetime

werehigherintheSTandCTgroups,inagreementwithother reports (5,28). In thepresentstudy, themean in-

creaseinthe6-mindistancewalkedwaslessthan54m.

However,forsomeofthepatients,theabsolutevaluewas

greaterthan54m(54.4%intheST,36.4%intheCT,and

30.8% in the LGT). Mador et al. (29) reported similar

resultsinpatientssubmittedtoacombinedexercisepro-

gram(strengthandaerobicexercises).Moreover,Spruitet

al.(28)andOrtegaetal.(5)alsoshowedanimprovement

in endurance time in COPD patients after an exercise

Table4.Table4.Table4.Table4.Table4.Pre-andpost-trainingmeanvaluesoffunctionalexercisetolerance,aswellasrespiratoryandperipheralmusclestrengthfor

patientsinthestrengthtraining(ST),combinedtraining(CT),andlow-intensitygeneraltraininggroups(LGT).

6MWT(m) TEnd(min) Meanvaluesofonerepetitionmaximum(kg)

Leg Leg Bench Latpull HGS PImax

press extension press down (kgF) (cmH2O)

Pre-training

ST 601 85 18 8 98 26 36 12 35 11 44 12 38 7 -80 26

CT 511 62+ 17 10 78 23 33 8 34 7 39 8 33 8 -63 25

LGT 560 109 12 5 68 15 34 8 34 8 41 10 36 5 -64 20

Post-training

ST 645 73* 29 19* 155 60*+ 52 11* 46 11* 56 13* 38 7 -81 26

CT 559 52*+ 28 15* 116 32*# 46 13*# 40 8* 50 11*# 35 8 -74 22

LGT 592 76 19 4 85 20 37 9 36 10 42 12 39 7 -66 27

DataarereportedasmeanSD.6MWT=6-minwalktest;TEnd=constantworkloadtreadmillendurancetest;HGS=handgrip

strength; PImax = maximal inspiratory pressure. *P


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program. The continuous (oval) tracks and number of

practicetestsrelatedto6MWTinthepresentstudymight

haveinfluencedourresults(34).Recently, thedistance

walkedonacontinuouscirculartrackexceededthedis-tancewalkedonastraighttrackby1317minpatients

withCOPD(34).Thecoefficientofrepeatabilityfor3-day

sessionswas51and 65m for the straightandcircular

tracks,respectively.Thus, foran individualpatient,per-

formingthetestindifferentlayoutsresultsinlessvariability

in 6-min walk distance then performing the test on a

differentday.Regardingtheexecutionofapracticewalk

test,thedistancewalkedisonlyslightlygreaterinasecond

testaccordingtoATSrecommendations(35).

Wefoundatendencytowardsincreasedexercisetol-

eranceintheLGTgroup.Clarketal.(9),comparingthe

resultsobtainedforagroupof patientsfollowinga low-

intensityexerciseprogramwiththosefoundforacontrolgroup,alsoobservedasignificantincreaseinendurance

timeinthetrainedgroup.Similarresultswerereportedby

Normandinetal.(10).ThelowintensityoftheLGTpro-

gramandthereducednumberofpatientsperformingthis

trainingmodalityinourstudymightexplainthelackofa

statisticaleffect.Nevertheless,all exercise trainingpro-

gramsstudiedwereabletoproducesignificantandsimilar

changesinhealth-relatedqualityoflife,inagreementwith

previousreports(5,10,27,29).

Intheliterature,twodifferentmodalitiesofCT,shorter

andlongersessionsofendurancetrainingcombinedwith

ST, have been compared to endurance training alone

(5,27,29). The longer CTsession protocols resulted in

increased muscle strengthbut providednogreater im-

provementinexercisetoleranceorhealth-relatedquality

oflifethandidendurancetrainingalone(27,29).Interest-

ingly,theshorterCTsessionprotocolsprovidedthebest

benefits for the patients and have been suggested to

representanoptionalstrategyforpatientswithCOPD(5).

This is in agreement with our findings showing that a

combinationof trainingmodalitiesiseffectivewithoutin-

creasingthedurationofthesessions.

An interesting finding of the present studywas the

correlationbetweenchangesinmusclestrengthandin6-

minwalkdistance.Wewereabletofindonlyonestudy(36)that showed a significant correlation between percent

changes in leg muscle function and constantworkload

treadmillendurancetestperformanceafterstrengthtrain-

ingalone.However,thecitedstudydidnotassesstrunk

muscle strength (latissimus dorsi, trapezius, pectoralis

major)asassessedinthepresentstudy.Someofthese

trunkmusclesmaytakeonanaccessoryrespiratoryfunc-

tionwhen theprimary respiratorymusclesare dysfunc-

tionalorcannotmeettheventilatorydemand(37).There-

fore, improvement oftrunkmusclestrengthmaybenefit

respiratorymechanics,resultinginbetterexercisecapac-

ity(38).

Thepresent study has some methodological limita-tions.Althoughweusedreliabletoolstoevaluatepatient

abilitytocarryoutdailylifeactivities,suchasthe6MWT

(39),wewereunabletodirectlyassessmaximaloxygen

uptake due to equipment limitations. Moreover, the re-

ducednumber ofpatients in the LGT groupmay have

influencedtheamountofbenefitsofthistypeoftraining.As

previously mentioned, the sample size was calculated

considering minimal clinically important differences in

health-relatedqualityoflife (SGRQtotalscoreimprove-

ment4%),thatindicatedN=10ineachtraininggroup.It

ispossiblethatthenumberofpatientsstudied(ST=11;CT

=11;LGT=13)wasnotsufficienttoobservedifferences

relatedtoothervariablesintheLGTgroup,probablyduetoatypeIIerror.However,itisunlikelythatincludingmore

patientsinthestudywouldhavechangedtheconclusion

that, except for theperipheralmuscle strength, the im-

provementsweresimilarforthethreestudygroups.Ina

systematicreview,OSheaetal.(40)showedthatstrength

trainingwasfoundtohavestrongevidenceforimproving

peripheralmusclestrength;however,nostrongevidence

forstrengthtrainingwasfoundforoutcomemeasuressuch

asexercisecapacity,dyspneaorhealth-relatedqualityof

life. Further investigationsare required to evaluate the

impactofstrengthtrainingprogramsonactivitiesofdaily

living,balance,upper-limbfunction,andself-careinpa-

tientswithCOPD.

The low-intensity training regarding LGT may also

haveinfluencedourresults.However,theliteratureshows

thatthistrainingtypecanresultinsignificantbenefitsfor

patientswithCOPD(6,9,10).Rehabilitationprogramsare

scarceandjustasmallnumberofpatientshaveaccessto

thistreatment,mainlyinBrazil,whereresourcesarelim-

ited.Theavailablestructureallowstrainingwithmats,free

weights,parallelbars,andfreewalkingandthishasbeen

ourrehabilitationstrategyformanyyears.Therefore,the

present study was designed to determine whether the

additionofstrengthtrainingperformedongymequipment

can maximize the benefits of our current program. Inaddition,althoughthevariousCTprogramshaveyielded

significantbenefits,ourdesigndidnotallowustoassess

patientmotivation or preference for any of the training

modalities.Fourofthe6patientswhodroppedoutofthe

LGTstatedalackofmotivation.Sincethestatisticalanal-

ysisdidnotshowsignificantdifferencesamongthegroups,

no conclusions can be drawn regarding the effects of

different exercise modalities and session durations on

COPDpatientadherencetothetrainingprograms.Finally,


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anunblindedassessmentwasnecessary,similartosome

previousstudies(5,28,36).

Theresultsofthepresentstudysupporttheviewthat

theadditionofastrength-trainingcomponenttoanendur-ancetrainingprogramofCOPDpatientsincreasesmuscle

strength.However,itcannotpromoteadditionalincreases

inexerciseendurance,dyspnea,orhealth-relatedquality

oflife.Moreover,arelativelysimpletrainingprogramcom-

biningLGTandSTcanproducesignificantimprovements

inmusclestrength, inexercisetolerance andin health-

related quality of life, even when the sessions are of

standardduration.Finally,thebenefitsofphysicalcondi-tioningforhealthystatusinpatientswithCOPDseemtobe

independent of themodalityor intensity of theexercise

trainingundertaken.

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