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Physiotherapy Practice

for COPD


March 2000

Working Group Members

Derek Chan, GH
Galen Chan, HHH
Charles Cheung, TMH
Byran Chung, TPH
David Yu, KH
Annie Wu, ANNH
Alice Chiu, QMH

I. Goals of Physiotherapy Practice Guidelines for COPD

The goal of developing the physiotherapy practice guidelines for COPD is to provide evidence-
based supports to the physiotherapy practice in COPD management within the Hospital
Authority. It is an exercise of literature search and evaluation on related physiotherapy practices.
Due to various constraints, the guidelines do not cover all, but some common physiotherapy
assessments and treatment interventions used and studied in the field.

Currently, there are several evidence-based clinical practice guidelines available providing
generic disease management of COPD conditions (ATS, 1995; BTS, 1997; ERS, 1996).
Although these documents are not physiotherapy specific, they form the backbone of the overall
management model in this guideline. There are several reviews on pulmonary rehabilitation
(Lacasse et al, 1996; ACCP/AACVPR, 1997; Cambach W et al, 1999; ATS, 1999) which
constitute the base of this guideline on that particular subject. There are relatively few review on
physiotherapy practice, but some recent metaanalysis focused on physiotherapy interventions on
COPD (Jones & Rowe, 1999; Crockett AJ et al, 1999) are also included in this guidelines.
Besides, other non-COPD specific evidence-based physiotherapy techniques guidelines, and
COPD related primary studies are also cited and used in this guidelines, so as to compliment the
discussion details of a particular practice.

II. Epidemiology and Defintions of COPD

A. Epidemiology of COPD
There were total 10651 COPD patients admitted to the public hospitals throughout the territory
in the year 1997,(HAHO, 1997) and they occupied over 20000 bed days. In average, each
diagnosed patient admitted 2.31 times and their unplanned readmission rate was as high as
40.76%, which was the highest among all other disease groups. Unlike other chronic diseases
utilized mostly the rehabilitation hospitals, over 50 % of the total COPD admissions were to
acute hospitals. The data shown the huge demands of COPD patients on hospital services.

B. COPD Definitions
COPD is often used as a general term describing chronic lung disease, and its differentiation
from other common chest conditions e.g. chronic bronchitis, emphysema and adult asthma is
often confusing. Clarification of the terms is important, and the definitions used in the guideline
are listed:

Chronic obstructive pulmonary disease (COPD) is a chronic, slowly progressive disorder

characterized by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change
markedly over several months (BTS, 1997). The impairment of lung function is largely fixed but
is partially reversible. The causes of airflow obstruction may due to chronic bronchitis or
emphysema, or both.

Chronic bronchitis is defined as the presence of chronic productive cough for 3 months in each
of two successive years in a patient in whom other causes of chronic cough have been excluded
(ATS 1995).

Emphysema is defined as abnormal permanent enlargement of the air spaces distal to the
terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
(ATS 1995)

Adult asthma is characterized by inflammation with participation of complex cellular and

chemical mediators (ATS 1995), and the condition is reversible. Absolute clinical differentiation
of severe COPD from chronic severe asthma is difficult since some degree of improvement in
FEV1(reversibility)in COPD can often be produced by bronchodilator therapy(BTS, 1997).

B. COPD Staging of Disease

Severity of Symptoms

COPD conditions are clinically classified into 3 stages: mild, moderate and severe, according to
the patients' severity of symptoms (ERS 1995, BTS 1997). The stages are described as following
(BTS, 1997):

Mild stage : In patients with mild COPD there are few or no symptoms. A history of morning
cough, recurrent respiratory infections, or shortness of breath on vigorous exertion or manual
labour may happen.

Moderate stage: Moderate COPD can present with a wide range of respiratory symptoms
although there are few clinical signs. There is no single typical pattern but possibilities include
combinations of some or all of the following:
- cough and sputum production, especially if the sputum becomes discoloured;
- breathlessness(±wheeze) on moderate exertion such as physical work climbing hills;
- acute worsening of symptoms associated with an infective exacerbation

Severe stage: Patients with severe COPD are usually troubled by progressively disabling
breathlessness or with complications (such as the development of oedema) or with an acute
exacerbation with or without respiratory failure. Cough and wheeze are almost invariably present
but are poor predictors of severity.

Spirometry findings

Objective measurements of airways obstruction by FEV1 over predicted value is widely used as
the physiological and practical indices for COPD severity classification. (ATS 1995, ERS 1995,
BTS 1997) Table 1 illustrates COPD classifications according to FEV1 predicted values used by
major medical societies. The classifications are similar, but with different reference points for
management and treatment.

Table 1: Classification of severity of COPD based on FEV1 % of predicted value

British Thoracic Society European Respiratory Society American Thoracic society
Severity FEV1 % pred Severity FEV1 % pred Stage FEV1 % pred
Mild 60-79 Mild ≥70 I ≥50
Moderate 40-59 Moderate 50-69 II 35-49
Severe <40 Severe <50 III <35

Functional Status

Therapists may use patients' functional capacity as a reference for treatment interventions. Table
2 illustrate a commonly used functional classifications for COPD patients.(ATS, 1981)
Class Functional capacity Signs and Symptoms
A Full No dyspnoea on level walking
Dyspnoea on climbing 2 flight of stairs
Insignificant COPD symptoms
No restrictions imposed on the patient by his disease
B Slightly diminished No dyspnoea on level walking
Dyspnoea on climbing 1 fight of stairs
Mild COPD symptoms
Slight restrictions with respect to strenuous activities and stress
C Significantly diminished Dyspnoea on walking 1.5 level city blocks at own pace
Dyspnoea on some of the ADL
Moderate COPD symptoms
Considerable restrictions with respect to strenuous activities and
stress; prolonged walking and standing are contraindicated, as well as
lifting objects greater than 5 lbs
D Minimal remaining Dyspnoea on walking 0.5 level city block at own pace
Dyspnoea on most minimal stair climbing
Dyspnoea on most of the ADL
Marked COPD symptoms
Severe activity and environmental restriction, limiting patient to
sedentary activities and the less demanding aspects of self-care

E No remaining Dyspnoea at rest

Unable to carry out any of the ADL
Severe COPD symptoms
Maximal restrictions: patient is confined to wheelchair or bed; is
complelely dependent on others, and can tolerate no environmental
and emotional stress

III. Management of COPD

A. COPD Management Model
Early multidisplinary intervention is recommended for treating COPD patients (ATS 1995, BTS
1997). Once the diagnosis of COPD is established, the patient should be educated about the
disease and encouraged to actively participate in therapy (ATS 1995).

For stable COPD, the management varies according to the stages of the diseases. The COPD
Escalator summaries the therapies recommended, and its appropriate time of introduction
according to the stage of disease (BTS 1997) (Fig 1). Pulmonary rehabilitation is a generally
recommended as a major component in COPD management (ATS 1995, BTS 1997, ERS 1995)

The COPD Escalator



Healthy population

Smoker's cough
Little or no dyspnoea
Smoking cessation

No abnormal signs
Antibiotics for acute infections

Occasional bronchodilator as required

More frequent/combination

Dyspnoea on exertion
FEV1 as % predicted

Steroid reveersibility trial:

inhaled steroids if +ve

Cough and sputum

Pulmonary rehabilitation

Some abnormal signs


Influenza vaccination

Ambulatory oxygen
Assessment for

Dyspnoea on mild
Hyperinflation and


Increasing investigation and treatment

Fig 1 The COPD Escalator: Summary of the principal components of a management plan for
COPD (modified from BTS Guideline for COPD)

Acute exacerbation of COPD present as a worsening of previous stable situation. Mild cases can
be treated in the community or at Emergency Unit, and many others will be admitted as
inpatients (BTS 1997). As in-patient, drugs as bronchodilators, antibiotics and corticosteroids are
crucial in controlling the acute symptoms. Stepwise drug therapy with rapid response is
recommended for uses (ATS 1995). Oxygen therapy is introduced and adjusted to correct
hypoxemia, and aims SaO2>90% (BTS 1997). Physiotherapy is commonly referred to treat
patients' chest related impairments. Prior discharge, a comprehensive discharge plan for
individual patient is recommended, so as to facilitate the long term caring of the disease(ATS
1995, BTS 1997).

B. Objectives of Physiotherapy
1. Physiotherapy in unstable exacerbations
- to control symptoms
- to treat related chest problems e.g. sputum retention
- to minimize disability
- to recruit and plan for pulmonary rehabilitation

2. Physiotherapy in stable COPD

- to improve physical fitness and cardiopulmonary function
- to improve functional status and minimize disability
- to enhance life quality and social roles
- to educate and coach for activity modifications

C. Physiotherapy Assessment
Physiotherapy assessments of COPD patients include measures of impairments, disabilities and
handicaps. There is a wide spectrum of assessment tools available to evaluate the patients'
conditions. Choosing appropriate tools is important and the choice depends on the treatment
objectives and patients' disease status.

1. Chest Assessment

Chest assessment is widely used among physiotherapists as a means to evaluate the extent and
severity of respiratory impairments of COPD patients. It is extensively maneuvered for COPD
patients at all stages of the disease, whether stable or exacerbated. Chest assessment contains
package of assessment items (PTCOC, 1994), which are not tailored for COPD, but general lists
for chest conditions evaluations.

During exacerbation, chest assessment is important for physiotherapist to plan appropriate

interventions. Interventions like postural drainage therapy is not a routine treatment, but for
indicated cases(AARC, 1992). For stable patients or patients under rehabilitation programs, chest
assessment is still useful for cases having chest problems, likes(Singh SJ 1997) :

- recurrent chest infections

- difficulties with chest clearance
- inappropriate shortness of breath after exercise
- abnormal breathing patterns
- inappropriate inhaler technique

2. Assessment for pulmonary rehabilitation

Since pulmonary rehabilitation is a team program, the assessment for COPD patients should be a
collaborated process. Physiotherapist involves in the assessment process, but the practice and
extent of involvement varies among different program designs. American Thoracic Society
stated a comprehensive assessment of the rehabilitation candidate is necessary for the
development of an appropriate, individualized plan of care, and generally, the assessment should
include (ATS 1999):
1. Clinical history
2. Physical examination
3. Review of pertinent records e.g. spirometry
4. Educational assessment
5. Incremental exercise testing
6. Measurements of respiratory muscle strength
7. Measurements of peripheral muscle strength
8. Assessments of activities of daily living
9. Assessments of health status
10. Assessments of cognitive function, emotional and mood state
11. Assessments of nutritional status/body composition

3. HRQOL assessment

Disease specific and generic instruments are available to measure health-related QOL of
candidates of pulmonary rehabilitation program. The Outcomes Committee of the American
Association of Cardiovascular and Pulmonary Rehabilitation recommended the uses of Chronic
Respiratory Questionnaries(CRQ) and St. George's Respiratory Questionnaries (SGRQ)(Pashlow
et al, 1995). Although generic HRQOL instruments e.g. Short-form-36 Health Survey (SF-36)
may provide complementary information, they appear to be less responsive to therapeutic
interventions(Donald, 1998).

The CRQ developed by Guyatt and colleagues is a 20-items questionnaries evaluating four
dimensions of illness: dyspnea, fatigue, emotional function and mastery. Reliability and validity
estimates for the CRQ had been reported (Guyatt, 1987).

The SGRQ is a self-administrated 76-items questionnaries measuring three domains: symptoms,

activity and impact of disease on daily life. The "symptoms" category elicits information about
cough, sputum, wheeze and dyspnea. The "activities" reflects the activity limitation imposed by
the disease and the "impacts" reflect overall impact on daily life and well-being. The SGRQ has
been translated into several languages and reliability and validity estimates have been
reported(Jones, 1992).

4. Dyspnea Rating

According to ATS official statement, dyspnea is a term used to characterize a subjective

experience of breathing discomfort that consists of quantitatively distinct sensations that vary in
intensity (ATS, 1999). Often dyspnea is out of portion to the degree of impairment of lung
function and arterial blood gas analysis (Sweer & Zwillich, 1998), and is derived from
interactions among multiple physiological, psychological, social, and environmental factors, and
may induce secondary physiological and behavioral responses (ATS, 1999). Pathophysiologic
factors of dyspnoea is appended for reference (Appendix III). In assessing patient's severity or
evaluating treatment outcomes, both exertional and overall dyspnea should be measured.
Exertional dyspnea is usually rated during exercise testing, while overall dyspnea is commonly
assessed through its impact on daily activities.

Dyspnea during exercise is usually measured with a category scale as Borg scale of perceived
exertion or a visual analog scale(VAS).A modified version Borg 10-point scale with verbal
expression of severity (Borg, 1976) was widely used in pulmonary rehabilitation programs. A
Chinese version is attached for reference (Appendix IV). The Visual Analogue Scale (VAS)
consists of a line, usually 100 mm in length, placed either horizontally or vertically on a page
(Grit, 1989), with anchor to indicate extremes of a sensation. Scoring is accomplished by
measuring the distance from the bottom of the scale to the level indicated by the subject.

The day-to-day overall dyspnea can be measured by different instruments as the Medical
Research Coucil(MRC) dyspnea questionaire, the University of California San Diego Sortness of
Breath Questionnaire(UCSD-SOBQ), the dyspnea component of the Chronic Respiratory
Disease Questionnaire, the Baseline and Transitional Dyspnea Indexes(BDI and TDI), and the
Pulmonary Functional Status and Dyspnea Questionaire(PFSDQ) and its modified
version(PFSDQ-M) (ATS, 1999).

One of the most commonly used dyspnea instument is BDI. It is used to measure breathlessness
at a single point in time and is administered during a brief interview. BDI includes measurement
of functional impairment (the degree to which activities of daily living are impaired) and
magnitude of effort (the overall effort exerted to perform activities), in addition to magnitude of
task (Mahler et al, 1984).

Most recently, the University of California at San Diego Shortness of Breath Questionnaire
(USCDQ) was developed. The UCSDQ is a 24-item questionnaire measuring dyspnea during the
past week (Belman et al, 1996). In the modified version, patients are asked about the frequency
of dyspnea when performing 21 different activities inquire about activity limitations due to
shortness of breath, fear of harm from overexertion, and fear of shortness of breath (Eakin et al,

5. Walking Tests

Timed walking tests namely 6 Minutes Walk Test, 12 Minutes Walk Test and Shuttle Walk Test
are used to assess patient's functional ability of walking. These tests are simple and convenient to
perform. The tests correlate with peak exercise performance on graded exercise tests and self

reported data on functional test (ATS 1999). Standardization of test procedures is crucial to have
reliable findings (ATS 1999).

The progressive 10-m Shuttle Walk Test differ from ordinary timed walk tests in two aspects. It
is an incremental exercise test in nature, which rather measure exercise capacity than endurance.
Since the external sets the pace, self-pacing is eliminated. The Shuttle Walk Test is reproducible,
correlate with maximum oxygen consumption during incremental treadmill exercise and highly
responsive to therapeutic intervention (ATS 1999).

D. Physiotherapy Interventions
1. Bronchopulmonary Hygiene
2. Breathing retraining
3. Pulmonary Rehabilitation
3.1 Exercise Reconditioning
3.2 Education
4. Alternative treatment modalities

1. Bronchopulmonary Hygiene
A metaanalysis on the effectiveness of bronchopulmonary hygiene physiotherapy techniques
was conducted by Jones AP and Rowe BH in 1998(Jones & Rowe, 1998). The patient samples
include not just COPD, but also bronchiectasis patients.7 RCTs are included in the review, and
the results are summaried as following:

1. Demonstrable beneficial effects of bronchopulmonary hygiene physiotherapy techniques

BHPT have been confined to sputum production and radio-aerosol clearance only.
2. The impact of BHPT on lung function is not clearly established from studies includes in the
review. No study found a significant beneficial effect on pulmonary function or PaO2.
3. It is not possible from the trails reviewed to identify specific patients subgroups that might
benefit from BHPT.
4. Insufficient reporting in publications precludes any comments on the adverse effects or harm
associated with BHPT.
5. In view of the lack of functional improvement and sample sizes of the trials, the research on
BHPT is inconclusive. There is insufficient evidence to support or refute administration of
BHPT to patients with acute and stable COPD, chronic bronchitis or bronchiectasis.

Due to the limited quantity and quality of the reviewed RCTs, the review left many unanswered
questions. The review stated the research implications as:
1. there is a need to conduct RCTs of sufficient power that examine the effects of the various
forms of BHPT, both manual and mechanical
2. These trails should be conducted in clearly defined patient groups, with adequate controls,
randomization and blinding. In addition, such studies need to measure not only primary
function. They also should measure symptoms, exercise performance, health status(quality of
life), recovery time and relapse rate.

3. There also is a need to examine various BHPT regimens, rather than a single treatment.

The review searched the related RCTs till July 1997, and the types of the BHPT included in the
review: postural drainage, manual techniques, directed coughing and forced exhalation

1.1 Coughing/Forced expiratory technique

There are evidence that both cough and FET can clear radioaerosol particles induced to lungs
field (Bennett WD et al, 1981; Hasani A et al, 1991; Van der Schans 1990). Since the presence
of severe obstructive airways and bronchospasm may hamper the effectiveness of directed
cough(AARC, 1993), advantages of FET over cough had been suggested as less energy demand
(Langlands J, 1967), and better mucus transport effect(van der Schans et al, 1990 ). Directed
cough or FET can be readily used as an integral part other physiotherapy techniques as postural
drainage (Olseni L et al, 1994).

Indications of the coughing and FET was suggested (AARC, 1993):

- the need to aid in the removal of retained secretions from central airways
- the presence of atelectasis
- as prophylaxis against postoperative pulmonary complications
- as a routine part of bronchial hygiene in patients with cystic fibrosis,
bronchiectasis, chronic bronchitis, necrotizing pulmonary infection, or spinal
cord injury
- as an integral part of other bronchial hygiene therapies

1.2 Postural Drainage Therapy

In AARC Clinical Practice Guideline on Postural Drainage Therapy (PDT), PDT is defined to
include turning, postural drainage, percussion, vibration, and cough (AARC 1991). In actual
clinical practice, physiotherapist should select appropriate techniques for treating indicated
COPD patients. Although COPD is not the primary diagnosis that indicated for PDT, unlike
cystic fibrosis, bronchiectasis and cavitating lung disease(AARC, 1991), PDT still pertains its
roles in various chest problems and complications e.g. sputum retention.

Earlier studies support PDT can effectively clear secretion, without altering the pulmonary
parameters (Sutton et al, 1983; Newton & Stephenson, 1978; Bateman, 1979). Sutton et al (1983)
reported that a 30 minutes period of PD alone doubled the sputum production and improved
tracheobronchial clearance above control. Newton and Stephenson(1978) found that the PDT
including PD, percussion, vibration and breathing exercise significantly improve both functional
residual capacity and the airway conductance of acute patients with chronic bronchitis.
Improvement in airway conductance attributed to an altered distribution of sputum in the larger
airways. Bateman et al ((1979) showed that the PDT significantly increased clearance of sputum
from central, intermediate and peripheral lungs regions. There is no evidence PDT causing harm
to COPD patients. Buscaglia et al (1983) studied the oxygen saturation during PDT on acute
patients with COPD, and showed that PDT did not appear to produce dangerous hypoxaemia

even on acutely ill patients with severe COPD. Other studies on PDT is complied in Appendix
VI for reference.

2. Breathing Retraining
Breathing Retraining for COPD patients may be started early during the inpatient admission
period at excerabation, and continued throughout their rehabilitative and maintenance phases.
There are many techniques used by physiotherapists for such purposes, some common names
include breathing control, pursed-lip breathing, diaphragmatic breathing. The adjunct positioning
and relaxation skills are also important to achieve good training results.

2.1 Breathing Control/Active Control Breathing Technique

Breathing control at rest is defined as gentle breathing using the lower chest with relaxation of
the upper chest and shoulders; it is performed at normal tidal volume, at a natural rate, and
expiration should not be forced (Webber & Pryor, 1993). Slow and controlled breathing
produced an increase in tidal volume and a reduction in the arterial partial pressure of carbon
dioxide (PaCO2)(Mortley, 1963) . It is common that breathing control is taught and practiced
during activities in pulmonary rehabilitation. Few researches had, however, been done on this
technique and its usefulness during activities. Another commonly used breathing retraining
technique for COPD is Active Control Breathing Technique ACBT (Miller et al, 1995; White et
al, 1996). Its effectiveness reflected in some trials in treating cystic fibrosis, but with limited
evidence in managing COPD conditions.

2.2 Diaphragmatic Breathing

Diaphragmatic breathing is to consciously expand the abdominal wall during inspiratory

diaphragm descent. In theory, this would increase the efficiency of the diaphragm while reducing
the ineffective movement of upper chest wall and accessory muscle works. Despite the theory,
studies had demonstrated that taught diaphragmatic breathing increased the sensation of
dyspnoea and asynchrony of the chest wall, and reduced mechanical efficiency with COPD
(Vitacca et al, 1998; Gosselink et al, 1995). In view of the results, the routine use of
diaphragmatic breathing training in pulmonary rehabilitation is not recommended(ATS, 1999).

2.3 Pursed-lips breathing

Pursed-lips breathing is a technique commonly adopted by some COPD patients, typically those
with some degree of emphysema. The lips are pursed during expiration, creating some end-
expiratory pressure and thus maintaining small-airway patency. This technique has been
documented to reduce respiratory rate, and to increase tidal volume and oxygen saturation
(Webber & Pryor, 1993; Mueller et al, 1970; Tiep et al, 1986). Despite these physiologic
outcomes, the effectiveness of purse-lip breathing in reducing dyspnea in COPD is controversial,
with some studies actually demonstrating an increase in breathlessness at rest and during
exercise (ATS, 1999).

2.4 Positioning

Physiotherapists used to teach or help patients to adopt a relaxed position to relief dyspnea
during acute exacerbation of COPD. There are, however, limited studies on the efficacy of the
practise, and research study is rarely found in 1990s.

Positioning affect the efficiency of breathing mechanism. Most COPD patients prefers leaning
forward position. Such position had the greatest Pimax and least work of breathing in comparing
to other positions(O Neil & McCarthy, 1983), and effectively reduced the sensation of
breathlessness (Sharp et al, 1980). For COPD patients, sitting is usually more comfortable than
supine position, and the Pimax and Pemax is higher in sitting position (Heijdra e al, 1994).
Activities cause greater respiratory demand to COPD than healthy subjects( Baarends et al,
1995), hence mastering of comfortable and less demanding positions may be an important
teaching component in COPD management.

3. Pulmonary Rehabilitation
Pulmonary rehabilitation programs are used to be delivered in either in-patient or out-patient
models. Both delivery models of pulmonary rehabilitation showed promising result of patient's
outcomes. Recently, there were researches to study the feasibility and effectiveness of home-
based rehabilitation for COPD patients (Strijbos JH et al, 1996; Wiljkstra PJ et al, 1994, Bauldoff
Gs et al, 1996). At present, there is no consensus on optimal practices of pulmonary
rehabilitation (ATS, 1999). Questions on what are the essential components and cost-
effectiveness of pulmonary rehabilitation had been raised and remained unanswered
(ACCP/AACVPR, 1997).

Pulmonary rehabilitation is a multidisplinary program, and physiotherapists share roles as one of

the team member. Physiotherapists involve in education and some psychosocial interventions,
but exercise therapy remains the distinct contribution in pulmonary rehabilitation.

3.1 Exercise Reconditioning

3.1.1 Training Principles

Aims of Exercise reconditioning

- to improve muscle strength and endurance
- to improve cardiopulmonary fitness
- to minimize disabilities and maximize functional abilities
- to enhance psychological wellbeing

Tolerance training
Exercise tolerance training is often termed aerobic or endurance exercise training. Exercise
tolerance improvement is not just based upon the overall exercise regimes prescribed to the
patients, but also the synergy effects of all the elements in the rehabilitation program. In general
pulmonary rehabilitation practice, walking with or without treadmill, and stationary cycling are

two common exercises prescribed for cardiopulmonary and tolerance training. The frequency
and intensity of exercises prescribed vary among programs.

Strength Training

Peripheral muscle strength influence exercise performance of COPD patients, and its relation
was shown in 6 minutes walking performance(Troosters T et al, 1996). The strength of
Quadriceps contributes significantly to six minutes walking distance and maximal oxygen uptake
(Hamilton N et al, 1995; Gosselink R et al, 1996).

Relative few studies have evaluated the effectiveness of strength training in COPD patients.
Despite of this, there is evidence that peripheral strengthening exercises not only can improve
muscles functions (O'hara WJ et al, 1984; Simpson K et al, 1992; Clark CJ et al, 1996), but also
can have positive effects on overall exercise performance (O'hara WJ et al, 1984; Clark
CJ,1996)and quality of life(Simpson K et al,1992) as well.

Training Intensity
Use of heart rate as a descriptor of aerobic exercise intensity is widely applicable. In healthy
subjects, aerobic training is usually targeted at 60 to 90% of the predicted maximal heart rate
Recently, American Thoracic Society suggested higher training intensity of 60%-75% of
maximal heart rate as an effective training zone for COPD patients(ATS, 1999). For those who
cannot tolerate long period (20 to 30 minutes) of high intensity training, interval training with 2
to 3 minutes high intensity exercise and equal period of rest, may be an alternative(ATS, 1999).

Beside heart rate, use of dyspnea ratings (Borg-scale either for dyspnea or leg fatigue) obtained
from a maximal graded exercise test can also be reliably as a training target to produce specific
exercise intensities in symptom-guided exercise training (Horowitz et al, 1996).

American college of sports medicine considered the impairment level of different COPD patients
and suggested 4 different approaches in exercise prescription (ACSM, 1995):
1. Exercise at 50% of Maximum Oxygen Uptake (VO2max or VO2peak): for patients with
moderate to severe COAD who are deconditioned, training at this threshold intensity for
improvement of aerobic capacity should improve exercise performance.
2. Exercise at intensity above the anaerobic threshold (AT): for patients with mild COAD
to reduce VE and lactate. Use heart rate as a monitor. (AT and VO2max should be obtained
from Cardiopulmonary Exercise Test).
3. Exercise at a near-maximal intensity: for patients with moderate to severe COAD who can
sustain ventilation at a high percentage of their maximal minute ventilatory volume. It is
suggested that 95% of VO2peak for a few minutes can increase endurance.
4. Use ratings of dyspnea to define intensity: for patients with moderate to severe COAD who
are limited by exertional dyspnea. Target dyspnea rating is 3 (moderate) for exercise training
at an intensity of 50% VO2peak and 6 (between severe and very severe) for training at an
intensity of 85% VO2peak

3.1.2 Lower extremity training

In pulmonary rehabilitation, lower extremity training is often used as a major means for
endurance and cardiopulmonary training for COPD patients. The training effects is well
documented, and include improve peak oxygen consumption (Peak VO2) (Ries AL et al, 1995;
Wijkstra PJ et al,1994) reduce minute ventilation (VE) (O'Donnell DE et al, 1995), improve
timed walking distance (McGavin CR et al, 1977; Cockcroft AE et al, 1981; Lake FR, 1990;
Alison JA, 1981; Goldstenin RS, 1994), improve maximum working capacity (Alison JA et al,
1981) and decrease dyspnea ratings (Reardon J et al, 1994; Ries AL et al, 1995; O'Donnell DE et
al, 1995).

ACCP/AACVPR recommendations (Appendix VII)

The strength of evidence is graded A. COPD patients who undergo a program of lower extremity
exercise training consistently improve measures of exercise tolerance without evidence of
adverse outcome. A program of exercise training of the muscles of ambulation is recommended
as part of pulmonary rehabilitation.

Common lower extremities exercises include cycle ergometer training, treadmill walking,
ground-based walking, or combined exercises. Studies showed that all exercises are effective in
improving maximal work rate and endurance(ATS, 1999).Reviewed studies varied considerably
in training design: durarion, frequency, and intensity(ACCP/AACVPR, 1997). Only a few
studies describe their training regimen in great detail (Casaburi R et al, 1991; Maltais F et al,
1996). The optimal specific training regimens for patients with COPD still be
defined(ACCP/AACVPR, 1997).

3.1.3 Upper extremity training

Upper limbs endurance training is important to COPD patients for their daily activities, and it is
common for COPD patients report limitations of ADL involving the upper extremities(Tangri &
Woolf, 1973). Upper extremity training can improve exercise capacity of upper extremity (Ries
AL et al, 1988), and decrease ventilatory demand for similar arm work (O'Tiara WJ et al, 1984).
The effect of upper extremity training alone is less effective than lower extremity training in
improving overall function.(Ries Al et al, 1988; Lake FR et al, 1990) The addition of upper
extremity training to lower extremity training can significantly improve functional status when
compared to either exercise alone(Lake FR et al, 1990)

ACCP/AACVPR recommendations
The strength of evidence is graded B. Strength and endurance of the upper extremities improve
arm function in COPD patients. Arm exercises are safe, and should be included in rehabilitation
programs for COPD patients.

Patients can perform upper limbs exercises with arms supported or not. The supported arm
exercise commonly prescribed is upper limb ergometer, while unsupported arm exercises by free
weights, dowels and stretching elastic bands. Either training methods can effectively improve
arm endurance(ATS, 1999), though it was suggested that unsupported arms exercises have better

functional outcomes(Martinez FJ et al, 1993).

There is no standard way to train the arms, but ACCP/AACVPR had illustrated two forms of
common upper extremity training (ACCP/AACVPR, 1997).Upper extremity ergometer training
is achieved by having patients cycle at approximately 50 rpm. The load increases at 5-W
intervals from zero until 20 to 30 min of exercise. The arms can also be trained by lifting weight
up to shoulder level , the weights are increased as tolerated until 20 to 30 min of exercise . The
patient's performance is monitored with arms fatigue and dyspnea .

3.1.4 Inspiratory Muscle Training IMT

Inspiratory muscle function may be compromised in COPD, an impairment that may contribute
to dyspnea, exercise limitation and hypercapnia (ATS, 1999). Inspiratory muscle training (IMT)
is exercise specifically designed to build endurance and strength of the muscles powering the
ventilatory pump, aimed to minimize patients' disabilities.

ACCP/AACVPR recommendations
The strength of evidence is graded B. The scientific evidence at present time does not support the
routine use of IMT as an essential component of pulmonary rehabilitation. However, IMT may
be considered in selected patients with COPD who have decrased respiratory muscle strength
and breathlessness.

Echo to the ACCP/AACVPR recommendations, after reviewing 7 mixed interventions, Lacasse

concluded that the evidence of IMT confers any additional benefit to COPD pulmonary
rehabilitation is equivocal (Lacasse et al, 1996). The recent metaanalysis of long term pulmonary
effect on pulmonary rehabilitation also shared the same view (Cambach et al, 1999). Although
the beneficial effects of IMT alone on disabilities and handicaps of COPD patients remained
inconclusive (ATS 1999), there are clear evidence that IMT increase inspiratory muscle strength
(Gosselink R, 1997), reducing dyspnea and improving exercise tolerance of COPD patients
(Sonne et al, 1982; Falk et al, 1985; Goldstein et al, 1989; Reid & Dechman, 1995).

There have been large variations in IMT program and training methods. Respiratory muscle
strength is usually estimated by measuring maximal negative inspiratory pressure (Pimax), and
the minimal load required to achieve a training effect is 30% of the Pimax (Smith et al, 1992)
The 3 main types of IMT are sustained hyperpnea, resistive loading and threshold
loading(Appendix VIII). Training systems for sustained hyperpnea are institutional and require
monitoring, while the last 2 methods are convenient for patients self-practise and have been
studied more extensively.

3.2 Psychosocial and Education Interventions

Depression, anxiety and selected psychiatric symptoms are common in patients with COPD.
There is a positive association of psychological distress with pulmonary impairment, poor body
image, increased loneliness, reduced social support, dissatisfaction with social support and

negative self concept (Nicholas PK et al, 1992; Keele CG et al, 1993; Kersten L et al,
1990) .There is also documented impairment on tests of cognitive or neuropsychological
functioning among COPD patients, indicating deficits in higher-level cognitive tasks such as
attention, complex visual motor processes, abstraction ability and verbal tasks ( Incalzi Ra et al,
1993;Grant I et al, 1982; Fix AJ et al, 1982)

Pulmonary rehabilitation programs usually include psychosocial or behavioral components in

addition to exercise training. It can be in the forms of educational talks, patient support groups,
or stress management groups (Emery CF et al, 1991;Ries AL et al, 1995).There are
Multidisciplinary involvement in such service, and physiotherapy may share roles in such

ACCP/AACVPR recommendations
The strength of evidence is graded C. Evidence to date does not support the benefits of short-
term psychosocial interventions as single therapeutic modalities, but long-term interventions may
be beneficial. Although scientific evidence is lacking, expert opinion supports the inclusion of
educational and psychosocial interventions as components of comprehensive pulmonary
rehabilitation programs for COPD patients.

Exercise training itself is also a means to improve COPD patients' psychological wellbeing.
Benefits of exercises are both physiologic and psychological. Psychological benefits such as
increase motivation, antidepressant effects of exercise, loss of fear of dyspnea, desensitization to
dyspnea (Iiaas F et al, 1993), improve skill of performance (Paez PN et al, 1967; Pierce AK,

4. Alternative treatment modalities

4.1 Flutter

Aiding expectoration is an important factor for patients suffering form bronchial hypersecretion.
The Flutter valve was developed in Switzerland in the late 1980s as a hand-held mucus clearance
device designed to combine PEP with airway oscillation
Most of the evidence of effectiveness of Flutter was found in patients with cystic
fibrosis(Konstan M et al, 1994; Ernst M et al, 1998).

Weiner et al studied the effect of Flutter in COPD patients (n=20). After 3 months of treatment,
lung function (FEV1 and FVC) as well as 12 minutes walk test were higher than those
performing the placebo Flutter. Arterial blood gases, the maximum voluntary ventilation, and
respiratory rate at rest were unchanged in both groups. (Weiner P et al, 1996).

4.2 Long Term Oxygen Therapy LTOT

COPD patients usually develop progressive hypoxemia, which can rapidly lead to damaging
cellular hypoxia. The administration of domiciliary long term oxygen therapy (LTOT) can be life
preserving, and physiotherapist may share roles in the management. The Cochrane Group's

metaanalysis on 4 related RCTs concluded LTOT improves survival in a selected group of

COPD patients with severe hypoxaemia(arterial PO2 is less than 8.0kPa), and it does not appear
to improve survival in patients with moderate hypoaemia nor in COPD patients with nocturnal
desaturation only( Crockett et al, 1999).

Patients survival is one of the major outcome measures in evaluating LTOT effectiveness. Two
of the four RCTs included in the review, NOTT and MRC, demonstrated a significant survival
advantage for the selected COPD subjects receiving LTOT. In the NOTT study there was a
significant improvement in mortality for hypoxaemic COPD patients after 24 months of
treatment with continuous LTOT over nocturnal oxygen therapy group(NOTT, 1980). In the
MRC study LTOT produced a small but significant overall improvement in survival in patients
with chronic lung diseases(MRC, 1981). Beside survival, other outcome measures as HRQOL
and physiological parameters also found in related studies, but was not included in the

According to American Thoracic Society (ATS) statement 1995, COPD patients whose disease
is stable on a full medical regimen, with PaO2 < 55 mmHg (<7.3kPa or corresponding to an
SaO2 < 88%), should receive long term oxygen therapy LTOT. A patients whose PaO2 is
between 55 and 59 mmHg (SaO2 89%) and who exhibits signs of tissue hypoxia, such as cor
pulmonale, erythrocytosis, edema from right heart failure, or impaired mental status, should
receive LTOT (ATS, 1995).

Concerning the exercise-induced breathlessness, portable oxygen therapy should be

recommended only for patietns emonstrating a clear improvement of >50% in exercise tolerance
or breathlessness on exercise (Leach et al, 1994).

4.3 Non-invasive Positive Pressure Ventilation

Patients with acute exacerbation of COPD are prone to develop acute respiratory failure and is
associated with high mortality. Some patients are treated with intubation and mechanical
ventilation but this carries a high morbidity and may have difficulty in weaning off. These
problems have led to the use of non-invasive positive pressure ventilation (NIPPV) (Doherty &
Greenstone, 1998).

NIPPV was first introduced in 1987(Ellis et al, 1987). The benefit of NIPPV over conventional
treatment in selected exacerbated COPD patients with respiratory failure had been documented
in some RCTs (Bott et al, 1993; Brochard et al, 1995; Kramer et al, 1995). The proven benefits
includes improved arterial blood gas tensions, decreased breathlessness, reduced intubation
needs, reduced mortality and length of hospital stay. A metaanalysis of NIPPV in exacerbations
of respiratory failure due to COPD is developing by the Cochrane Group to evaluate its

4.4 Acupuncture

Acupuncture has traditionally been used in asthma (a condition overlaps with COPD) treatment
in China, and is increasingly applied in other countries. A recent Cochrane review stated there is
inconclusive evidence that short term(1-12 weeks) acupuncture treatment has a significant effect
on the course of asthma (Linde K et al, 1998), and there is an urgent need for quality research.
Few trials specifically evaluated the side-effect and morbidity profile of acupuncture treatments,
but the overall safety profile appears to be excellent (Linde K et al,1998). Despite of the
controversial on acupuncture for asthma, its development worth our concern. At present, there is
no review of acupuncture on COPD as the primary diagnosis. A RCT was conducted to compare
two group COPD patients received acupunture and placebo acupunture respectively, the
acupunture group had significant benefit in subjective breathlessness and six minutes walk scores.
( Jobst K et al, 1986)

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1. Pathophysiological factors of Dyspnoea

2. Chinese version of Modified Borg Scale
3. Summery table of Postural Drainage Therapy studies
4. Grading of ACCP/AACVPR Practice Guidelines
5. Training methods of IMT
6. Standardization of 6 minutes walk test

Appendix I : Pathophysiological factors of dyspnoea

Table illustrates the pathophysiologic factors in COPD that promotes breathlessness:

Increased airways resistance

Elevated minute ventilation due to inefficient gas exchange
Hyperinflation resulting in
Reduced ability of diaphragm to generate tension
Reduced efficiency of diaphragm in generation of negative intrathoracic pressure
Reduced outward recoil of chest wall
Respiratory muscle weakness
Respiratory muscle fatigue
Recruitment of needed accessory respiratory muscles during arm exercise
Hypoxemia and hypercapnea
Pulmonary hypertension

Appendix II: Chinese version of Modified Borg Scale

0 沒甚麼
0.5 非常, 非常輕微 (剛可感到)
1 非常輕微
2 輕微 (微量)
3 中量
4 稍為強烈
5 強烈 (沉重)
7 非常強烈
10 非常, 非常強烈 (接近頂點)

z 頂點

自我評估氣促表 (RPD). Borg Category Ratio Scale for Perceived Dyspnea

From: Borg, G. Medicine and science in sports and Exercise, 1982

Appendix III: Table of some Postural Drainage Therapy Studies

Investigators Patient Comparison Study Design Measurement Results

Postural Drainage (PD)

Olseni et al (1994) COPD z PD+FET RCT Mucus Clearance Both effective

z PD+PEP Patients preferred to use PEP
Newton & Stephenson Chronic Chest physio. RCT FEV1, VC, FRC, airways symbol 221 \f "Symbol" \s 12⇑} FRC
(1978) Bronchitis z PD resistance & conductance,
& airways conductance.
z vibration blood gases
Returned to baseline 40 min. after
z percussion
z Breathing ex.
Bateman et al (1979) Stable COPD Chest physio. RT cross-over Sputum clearance symbol 221 \f "Symbol" \s 12⇑}
z PD
sputum clearance
z vibration
z percussion

van-Hengstum et al (1988) Chronic z PEP+Br.+huffing+ RT cross-over Sputum clearance PD + FET is more effective than PEP +
bronchitis cough FET
z FET+PD+Br. Ex.
Buscaglia and St. Marie COPD Positioning Clinical trial O2 saturation No production of dangerous hypoxemia.
May and Munt (1979) Chronic z Percussion + PD Clinical trial z Sputum production. symbol 221 \f "Symbol" \s 12⇑}
bronchitis z Heat z Lung function.
sputum production.
z Blood gases.
Others- no change.

Stiller et al (1990) Lobar atelectasis z PD + vibration + bagging + RT Resolution of atelectasis PD group symbol 174 \f "Symbol" \s
z Bagging + suction 12→} symbol 221 \f "Symbol" \s 12⇑}
the efficacy of the treatment regime.
Mazzocco et al (1985) Bronchiectasis PD + percussion RCT FVC, SpO2, FEV1, HR, symbol 221 \f "Symbol" \s 12⇑}
PEF, sputum amount.
sputum production especially those large
sputum producer.
Mortensen et al (1991) CF z PD + FET RCT cross-over Sputum clearance Similar effect in both groups.

Percussion & Vibration

Newton & Stephenson Chronic Chest physio. RCT FEV1, VC, FRC, airways symbol 221 \f "Symbol" \s 12⇑} FRC
(1978) Bronchitis z PD resistance & conductance,
& airways conductance.
z vibration blood gases
Returned to baseline 40 min. after
z percussion
z Breathing ex.
May and Munt (1979) Chronic z Percussion + PD Clinical trial z Sputum production. symbol 221 \f "Symbol" \s 12⇑}
bronchitis z Heat z Lung function.
sputum production.
z Blood gases.
Others- no change.

Bateman et al (1979) Stable COPD Chest physio. RT cross-over Sputum clearance symbol 221 \f "Symbol" \s 12⇑}
z PD
sputum clearance
z vibration
z percussion

Bateman et al (1981) z PD + vibration + shaking + RCT cross-over Sputum clearance. Sputum yielded more during chest PT
percussion. than during cough.
z Cough.
Buscaglia and Marie (1983) COPD Positioning Clinical trial O2 saturation No production of dangerous hypoxemia.
Mazzocco et al (1985) Bronchiectasis PD + percussion RCT FVC, SpO2, FEV1, HR, symbol 221 \f "Symbol" \s 12⇑}
PEF, sputum amount.
sputum production especially those large
sputum producer.
Van der Schans (1991) CAO z Percussion. RCT cross-over Sputum clearance Percussion may be useful when patient is
z PD + percussion + coughing + not able to cough and cannot assume the
breathing ex.. appropriate position for PD.
z PD + coughing + breathing ex..
Gallon (1991) Bronchiectasis z PD + deep breathing ex. (DBE) + RCT cross-over Sputum clearance Both fast and slow manual percussion
FET increase the sputum production.
z PD + DBE + FET + fast manual
z PD + DBE + FET + slow manual
Rivington-Law et al (1984) Chronic z DBE RCT cross-over z FRC - ERV Vibration does not decrease ERV in
bronchitis z DBE + vibration RV patient with chronic bronchitis but DBE
z SpO2 does.

Appendix IV
Grading of ACCP/AACVPR Practice Guidelines

Grade Description
Scientific evidence provided by well-designed, well
A conducted, controlled trials (randomized and
nonrandomized) with statistically significant results
Scientific evidence provided by observational
B studies or by controlled trials with less consistent
Expert opinion. Scientific evidence available did not
C present consistent results or controlled trails were

Appendix V: Training methods of IMT

Inspiratory resistive loading

Patient inspires through a nonlinear resistive device, the resistance depends on the inspiratory
flow rate. Monitoring of patient's breathing pattern and flow rate is necessary.
The treatment regime suggested is 30 minutes (range = 15-50 min)daily for 4 weeks to 6 months
(Reid 1995). Some studies related to its effectiveness as: Dekhuijzen 1991, Belman 1988, Harver

Threshold Loading

Patient inspires against a threshold load and breathes out unimpeded. It was documented that
varying inspiratory flow rates did not appreciably alter inspiratory pressures, and thus threshold
loading devices functioned effectively (Larson JL et al, 1988; Goldstein R et al, 1989) Adequate
training stimulus is essential so as to provide a positive effect on inspiratory muscle function.
The pressure loads of at least 30% of maximal inspiratory mouth pressure (PImax or MIP) have
been suggested (Larson JL et al, 1988; Lisboa C et al, 1994) as a adequate training load. The
duration of training was 10 minutes to 1 hour; the frequency of training was 3 times per week to
daily, and the time course of training sessions ranged from 4 weeks to 6 months (Reid WD,

Isocapnic hyperventilation(Maximum sustained voluntary ventilation)

Isocapnic hyperventilation was introduced in 80s. Patient hyperventilate for 15 to 30 minutes
through a rebreathing device to maintain the partial pressure of arterial carbon dioxide (i.e.
isocapnia) at a target level. (Ries AL & Moser KM, 1986).The clinical usage of Isocapnic
hyperventilation is questionable for its inconvenience and costly. (Reid WD, 1995). Studies

supported the effectiveness of the isocapnic hyperventilation for COPD patients include as: Ries
AL & Moser KM, 1986; Belman MJ, 1980;Levine S, 1986.The duration of training was usually
15 to 30 minutes per session, the frequency of training was 3 to 6 times a week, and the time
course of training was 4 to 6 week (Reid WD, 1995).
- Dekhuijzen PNR, Folgering HTM, van Herwaarden CIA 1991. Target flow
inspiratory muscle training during pulmonary rehabilitation in patients with
COPD. Chest 99: 128-133.)
- Belman MJ, Shadmehr R 1988. Targeted resistive ventilatory muscle training
in chronic obstructive pulmonary disease. J Appl Physiol 65: 2726-2735.
- Harver A, mahler DA, Daubenspeck JA 1989. Targeted inspiratory muscle
function and reduces dyspnea in patients with chronic obstructive pulmonary
disease. Ann Intern Med 111: 117-124.
- Larson JL, Kim MJ, Sharp JT, et al (1988). Inspiratory muscle training with a
pressure threshold breathing device in patients with chronic obstructive
pulmonary disease. Am Rev Respir Dis. 138:689-696.
- Goldstein R, De Rosie J, Long S, et al (1989). Applicability of a threshold
loading device for inspiratory muscle training in patients with COPD. Chest
96: 564-571.
- Lisboa C, Munoz V, Beroiza T, Leiva A,Cruz E (1994). Inspiratory muscle
training in chronic airflow limitation: comparison of two different training
loads with a threshold device. Eur Respir J. 7: 1266-74.
- Reid WD, Samral B(1995). Respiratory muscle training for patients with
chronic obstructive pulmonary disease. Physical Therapy 75(11): 996-1006).
- Ries AL, Moser KM (1986). Comparison of isocapnic hyperventilation and
walking exercise training at home in pulmonary rehabilitation. Chest 90(2):
- Belman MJ, Mirtman C (1980). Ventatory muscle training improves exercise
capacity in chronic obstructive pulmonary disease patients. Am Rev Respir Dis
121: 273-280.
- Weiser P, Gillen J(1986). Evaluation of a ventilatory muscle endurance
training program in the rehabilitation of patients with chronic obstructive
pulmonary disease. Am Rev Respir Dis 133: 400-406.

Appendix VI: Six Minutes Walk Test

Method to measure walking distance (e.g., rolling distance marker); ideal walking distance at
least 100 feet in length with minimal traffic; stopwatch; cutaneous pulse oximeter; copy of the
10-point Borg scale in large print; sphygmomanometer; stethoscope; a walker, cart, or
wheelchair for patients who require supported walking (e.g., patients with severe dyspnea or
orthopedic conditions, etc.); chairs to be positioned along the walking course to be used if

1. Prior to the walk test following information may be documented: blood pressure, pulse,
oxyhemoglobin saturation, dyspnea level (show patient 10-point Borg Scale), medications,
oxygen, and assistive devices. Patients who use prescribed medications prior to
exercise/activity (e.g., inhaled beta agonist, nitroglycerin) should do so before performing
the test. Also patients who use oxygen with exercise/ activity should do so during the test at
their prescribed liter flow. The portable oxygen equipment may be carried by the staff, or it
may be placed in a cart or wheelchair for the patient to push as determined by the patient's
individual needs. The walker, cart, or wheelchair may also be used for the patients who
require supported walking.
2. If a team member accompanies the patient during the test, that member should walk behind
the patient so that she does not influence the patient's pace. During the test the team member
may provide words to encouragement (e.g., "you're doing great." "keep up the good work,"
"hang in there").
3. Oxyhemoglobin saturation should be assessed continuously during the test. Patients who
desaturate to levels below 88% may be allowed to continue the test if severe symptoms are
not present (e.g., increased dyspnea, chest pain). Realize that some patients may enter the
pulmonary rehabilitation program with severe hypoxemia who have been functioning with
these levels at home. The urgency to stop the test, therefore, may not be warranted unless the
patient is experiencing significant symptoms. We want to document what is truly happening
to the patient at home. If oxygen therapy is ordered and initiated these patients may then be
4. Documentation during the walk test may include oxyhemoglobin saturation, heart rate,
dyspnea level, patient symptoms and comments, and frequency and length of rest periods.
5. Documentation post walk test may include oxygenhomoglobin saturation; heart rate; blood
pressure; dyspnea level; symptoms; patient and team member comments: if test was
performed on room air or with oxygen (document liter flow); if patient required supported
walking via a cart, walker, or wheelchair. The total time for the test is 6 or 12 minutes,
which includes any rest stops. Example: Patient performed a 6-minute walk test and rested
twice for 30 seconds each, for a total rest time of 1 minute. Patient walked 5 minutes of the
6-minute test and covered a total distance of 1,050 feet.
6. The following instructions should be given to the patients:
"The purpose of this test is to assess your exercise ability and to obtain a baseline of
information (i.e., oxygen saturation, dyspnea level, blood pressure, heart rate, and distance

walked). You will begin at the designated starting point and follow the walking course as
directed, covering as much distance as possible or walking at your own pace in the 6- or 12-
minute period. If you need to, you may stop and rest. You will be asked to rate your
dyspnea level during the walk test and told to stop when the 6 or 12 minutes are up. To save
your breath for the test do not carry on a conversation while walking." Patients should then
be asked to repeat the instructions to verify that they understand them.
7. If two walk tests are performed, at least 10-15 minutes of rest between each test is advised.
Another option is to perform the tests on separate days.

Adapted from "Exercise Assessment and Training" by American Association of Cardiovascular

& Pulmonary Rehabilitation, 1998. In Guidelines for Pulmonary Rehabilitation Programs, 2nd ed.
(Champaign: Human Kinetics), p58.

Further Readings

Some major cited documents are attached as soft files in the floppy for references:

1. AARC Clinical Practise Guideline

1.1 Use of Positive Airway Pressure Adjuncts to Bronchial Hygiene Therapy
1.2 Postural Drainage Therapy
1.3 Directed Cough

2. Cochrane Reviews
2.1 Bronchopulmonary hygiene
2.2 Acupunture on chronic asthma
2.3 Domiliary Oxygen

3. Reviews/Guidelines
3.1 ACCP/AACVPR Pulmonary Rehabilitation Guidelines