Effects of One-Legged Exercise Training of Patients With COPD

doi:10.1378/chest.07-1423

Chest

Volume 133, Issue 2, February 2008, Pages 370-376

https://doi.org/10.1378/chest.07-1423 Get rights and content

Background

Most patients with severe COPD are limited by dyspnea and are obliged to exercise at low intensity. Even those undergoing training do not usually have increased peak oxygen uptake (

o₂). One-legged exercise, at half the load of two-legged exercise, places the same metabolic demands on the targeted muscles but reduces the ventilatory load, enabling patients to increase work capacity. The purpose of this study was to determine whether one-legged exercise training would improve aerobic capacity compared with two-legged training in stable patients with COPD.

Methods

Eighteen patients with COPD (mean FEV₁, 38 ± 17% of predicted [± SD]) were randomized to two groups after completing an incremental exercise test. Both trained on a stationary cycle for 30 min, 3 d/wk, for 7 weeks. Two-legged trainers (n = 9) cycled continuously for 30 min, whereas one-legged trainers (n = 9) switched legs after 15 min. Intensity was set at the highest tolerated and increased with training.

Results

Both groups increased their training intensity (p < 0.001) and total work (p < 0.001). After training, the change in peak

o₂ of the one-legged group (0.189 L/min; confidence interval [CI], 0.089 to 0.290 L/min; p < 0.001) was greater than that of the two-legged group (0.006 L/min; CI, − 0.095 to 0.106 L/min; p = 0.91). This was accompanied by greater peak ventilation (4.4 L/min; CI, 1.8 to 7.1 L/min; p < 0.01) and lower submaximal heart rate (p < 0.05) and ventilation (p < 0.05) in the one-legged trained group.

Conclusion

Reducing the total metabolic demand by using one-legged training improved aerobic capacity compared with conventional two-legged training in patients with stable COPD.

Section snippets

Patients

Inclusion required a diagnosis of COPD¹⁰ based on standardized spirometry,¹¹ clinical stability, smoking abstinence, and willingness to enroll in an inpatient or outpatient pulmonary rehabilitation program that included supervised exercise, education, and psychosocial support. Patients were excluded if they were hypoxemic at rest (Pao₂ < 55 mm Hg), had comorbidities that limited their exercise tolerance, or were unable to provide informed consent. After baseline assessments, patients were

Results

Eighteen patients, 9 randomly allocated to each group, completed the study. Two patients withdrew: one allocated to the one-legged group, following an acute exacerbation; and the other patient, allocated to the two-legged group, was uncomfortable cycling. The baseline characteristics of each group are presented in Table 1; there were no significant differences between study groups. All of the nine patients allocated to the one-legged group could easily manage this technique after simple

Discussion

We evaluated whether exercising with one leg yielded physiologic changes consistent with a training effect. Such a study is an important precursor to larger clinical trials examining the influence of one-legged cycling on outcomes such as health-related quality of life. Peak

o₂ reflects the capacity and health of the component systems.¹⁷ Our main observation in this study was that COPD patients assigned to one-legged exercise training significantly improved their peak

o₂ as compared to those

ACKNOWLEDGMENT

The authors thank the patients of West Park Healthcare Center as well as Mika Nonoyama and Stefania Costi for help supervising the training sessions.

References (36)

DolmageTE et al.
Response to one-legged cycling in patients with COPD
Chest
(2006)
DolmageTE et al.
Repeatability of inspiratory capacity during incremental exercise in patients with severe COPD
Chest
(2002)
GoldsteinRS et al.
Randomised controlled trial of respiratory rehabilitation
Lancet
(1994)
JohnsonJE et al.
Effects of training with heliox and noninvasive positive pressure ventilation on exercise ability in patients with severe COPD
Chest
(2002)
BianchiL et al.
Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients
Respir Med
(2002)
PorszaszJ et al.
Exercise training decreases ventilatory requirements and exercise-induced hyperinflation at submaximal intensities in patients with COPD
Chest
(2005)
DempseyJA et al.
Consequences of exercise-induced respiratory muscle work
Respir Physiol Neurobiol
(2006)
MorganMDL et al.
Pulmonary rehabilitation
Thorax
(2001)
NiciL et al.
American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation
Am J Respir Crit Care Med
(2006)
American College of Sports Medicine
American College of Sports Medicine position stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults
Med Sci Sports Exerc
(1998)

AcevedoEO et al.

Increased training intensity effects on plasma lactate, ventilatory threshold, and endurance

Med Sci Sports Exerc

(1989)

CasaburiR et al.

Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease

Am Rev Respir Dis

(1991)

Rees, K, Taylor, R, Singh, S, et al Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev...

MaltaisF et al.

Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease

Am J Respir Crit Care Med

(1997)

Lacasse, Y, Goldstein, R, Lasserson, TJ, et al Pulmonary rehabilitation for chronic obstructive pulmonary disease....

O'DonnellDE et al.

Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease–2003

Can Respir J

(2003)

MillerMR et al.

Standardisation of spirometry

Eur Respir J

(2005)

BuchfuhrerMJ et al.

Optimizing the exercise protocol for cardiopulmonary assessment

J Appl Physiol

(1983)

Cited by (103)

Physiotherapy during and after acute exacerbation of COPD
2022, Revue des Maladies Respiratoires
Les exacerbations sont des évènements déterminants dans l’évolution et le pronostic de la BPCO. Au décours de ces épisodes, la récupération fonctionnelle n’est pas toujours complète, et le risque d’une nouvelle hospitalisation est élevé, nécessitant une prise en charge par anticipation.
Les conséquences pulmonaires et extrapulmonaires des exacerbations nécessitent une évaluation et une prise en charge globale et individualisée. Par ailleurs, la fonction musculaire et le statut nutritionnel sont des éléments clés de la prise en charge. La réadaptation respiratoire est une stratégie efficace pour prendre en charge ces éléments tout en permettant une approche globale du patient.
L’accès aux programmes de réadaptation est limité. L’identification des freins à l’accès aux programmes représente autant de leviers possibles à explorer. Les stratégies de maintien sur le long terme nécessitent également d’être évaluées.
Le masseur-kinésithérapeute est un acteur majeur dans la prise en charge de la BPCO en per- et post-exacerbation afin d’évaluer le patient, mettre en place un programme de réadaptation individualisé ainsi que pour accompagner le patient sur le long terme dans le maintien d’un style de vie actif et la gestion de sa pathologie chronique.
Exacerbations are major events in the course and prognosis of COPD. Following acute exacerbation of COPD (AECOPD), functional recovery is not always complete and the risk of relapse is high, requiring proactive management.
Pulmonary and extrapulmonary consequences of AECOPD require comprehensive and individualized care. Muscle function and nutritional status are key elements to target. Pulmonary rehabilitation is an effective strategy designed to deal with these aspects and to facilitate a comprehensive, patient-centered approach.
Access to pulmonary rehabilitation programs is limited, and existing barriers need to be more precisely identified as a first step toward their possible removal. Long-term exercise maintenance strategies likewise warrant further study.
The physiotherapist has a major role to assume in per- and post-exacerbation management of people with COPD; it is up to him to assess the patient and to put into place an individualized pulmonary rehabilitation program; it is also up to him to provide long-term support, helping the patient to maintain an active lifestyle while coping with a chronic pathology.
Effects of Low-Load/High-Repetition Resistance Training on Exercise Capacity, Health Status, and Limb Muscle Adaptation in Patients With Severe COPD: A Randomized Controlled Trial
2021, Chest
Citation Excerpt :
This difference in the design of the two resistance training modalities in combination with the known relevance of limb muscle endurance to exercise capacity12,13 highlight a potential advantage of this type of low-load resistance training compared with the traditional resistance training approach. We initially hypothesized that singe-limb LLHR-RT exercises would enable larger training volumes, resulting in more extensive physiological and functional adaptations than two-limb LLHR-RT.18,19 This hypothesis was based on the fact that training volume is paramount in the magnitude of physiological adaptations following resistance training.36,37 However, even though there seems to be a dose-response relationship between training volume and benefits of resistance training in healthy older adults,36 it is still unclear to what extent training volumes need to be increased for a further training effect to become notable.
Training volume is paramount in the magnitude of physiological adaptations following resistance training. However, patients with severe COPD are limited by dyspnea during traditional two-limb low-load/high-repetition resistance training (LLHR-RT), resulting in suboptimal training volumes. During a single exercise session, single-limb LLHR-RT decreases the ventilatory load and enables higher localized training volumes compared with two-limb LLHR-RT.
Does single-limb LLHR-RT lead to more profound effects compared with two-limb LLHR-RT on exercise capacity (6-min walk distance [6MWD]), health status, muscle function, and limb adaptations in patients with severe COPD?
Thirty-three patients (mean age 66 ± 7 years; FEV₁ 39 ± 10% predicted) were randomized to 8 weeks of single- or two-limb LLHR-RT. Exercise capacity (6MWD), health status, and muscle function were compared between groups. Quadriceps muscle biopsy specimens were collected to examine physiological responses.
Single-limb LLHR-RT did not further enhance 6MWD compared with two-limb LLHR-RT (difference, 14 [–12 to 39 m]. However, 73% in the single-limb group exceeded the known minimal clinically important difference of 30 m compared with 25% in the two-limb group (P = .02). Health status and muscle function improved to a similar extent in both groups. During training, single-limb LLHR-RT resulted in a clinically relevant reduction in dyspnea during training compared with two-limb LLHR-RT (–1.75; P = .01), but training volume was not significantly increased (23%; P = .179). Quadriceps muscle citrate synthase activity (19%; P = .03), hydroxyacyl-coenzyme A dehydrogenase protein levels (32%; P < .01), and capillary-to-fiber ratio (41%; P < .01) were increased compared with baseline after pooling muscle biopsy data from all participants.
Single-limb LLHR-RT did not further increase mean 6MWD compared with two-limb LLHR-RT, but it reduced exertional dyspnea and enabled more people to reach clinically relevant improvements in 6MWD. Independent of execution strategy, LLHR-RT improved exercise capacity, health status, muscle endurance, and enabled several physiological muscle adaptations, reducing the negative consequences of limb muscle dysfunction in COPD.
ClinicalTrials.gov; No.: NCT02283580; URL: www.clinicaltrials.gov
Pulmonary Rehabilitation for COPD
2021, Encyclopedia of Respiratory Medicine, Second Edition
COPD is associated with symptoms and non-pulmonary manifestations which are potentially amenable to exercise training, primarily through pulmonary rehabilitation. Pulmonary rehabilitation, an exercise and education program, is an integral component in the non-pharmacological strategy for COPD. This article outlines the evolution of pulmonary rehabilitation, the evidence-base for this intervention in people with COPD, the typical program format and content, the maintenance of pulmonary rehabilitation, and the implementation into clinical practice.
Single leg aerobic capacity and strength in individuals with surgically repaired anterior cruciate ligaments
2020, Physical Therapy in Sport
Compare single-leg aerobic capacity and strength differences between the surgically repaired ACL leg (injured) and the uninjured leg.
Cross-sectional study.
Laboratory.
Eight participants (5 female, 3 male, age = 23 ± 3.5 y, mass = 72.3 ± 17.3 kg, height = 169.7 ± 9.4 cm) that returned to play from ACL surgery between six and 18 months.
Participants performed an aerobically-based, single-leg cycling protocol to determine maximum oxygen consumption, ventilatory threshold, heart rate, rating of perceived exertion, and maximal watts cycled. Participants also performed isokinetic knee flexion and extension on a dynamometer to assess peak torque, total work, work fatigue, and power.
There were no statistical differences in single-leg aerobic capacity or strength outcomes between the injured and uninjured legs.
Individuals who have had an ACL surgically repaired six to 18 months after return to play do not appear to have aerobic capacity or strength deficits between the injured leg and uninjured leg.
Pulmonary Rehabilitation
2020, Clinics in Chest Medicine
Citation Excerpt :
One-legged exercise is based on a similar rationale: by isolating a smaller muscle mass during exercise, the leg being exercised can be exposed to a higher exercise intensity without being inhibited by the compromised ventilatory system.111 This approach has been demonstrated with good effect in COPD112 and appears to be an adjunct that is easy to incorporate into PR programs.113 Endurance cycle training using eccentric muscle actions (whereby the muscle lengthens while simultaneously producing force) is a potentially effective training strategy for patients with exercise intolerance.
Change in V˙O<inf>2peak</inf> in Response to Aerobic Exercise Training and the Relationship With Exercise Prescription in People With COPD: A Systematic Review and Meta-analysis
2020, Chest
Despite the wide-ranging benefits of pulmonary rehabilitation, conflicting results remain regarding whether people with COPD can improve their peak oxygen uptake ( $\dot{V}$ O_2peak) with aerobic training.
The goal of this study was to investigate the effect of aerobic training and exercise prescription on $\dot{V}$ O_2peak in COPD.
A systematic review was performed by using MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases for all studies measuring $\dot{V}$ O_2peak prior to and following supervised lower-limb aerobic training in COPD. A random effects meta-analysis limited to randomized controlled trials comparing aerobic training vs usual care was conducted. Other study designs were included in a secondary meta-analysis and meta-regression to investigate the influence of program and patient factors on outcome.
A total of 112 studies were included (participants, N = 3,484): 21 controlled trials (n = 489), of which 13 were randomized (n = 288) and 91 were uncontrolled (n = 2,995) studies. Meta-analysis found a moderate positive change in $\dot{V}$ O_2peak (standardized mean difference, 0.52; 95% CI, 0.34-0.69) with the intervention. The change in $\dot{V}$ O_2peak was positively associated with target duration of exercise session (P = .01) and, when studies > 1 year duration were excluded, greater total volume of exercise training (P = .01). Similarly, the change in $\dot{V}$ O_2peak was greater for programs > 12 weeks compared with those 6 to 12 weeks when adjusted for age and sex. However, reported prescribed exercise intensity (P = .77), training modality (P > .35), and mode (P = .29) did not affect $\dot{V}$ O_2peak. Cohorts with more severe airflow obstruction exhibited smaller improvements in $\dot{V}$ O_2peak (P < .001).
Overall, people with COPD achieved moderate improvements in $\dot{V}$ O_2peak through supervised aerobic training. There is sufficient evidence to show that programs with greater total exercise volume, including duration of exercise session and program duration, are more effective. Reduced effects in severe disease suggest alternative aerobic training methods may be needed in this population.
PROSPERO; No.: CRD42018099300; URL: https://www.crd.york.ac.uk/prospero/

View all citing articles on Scopus

This work was performed at West Park Healthcare Centre.

The authors have no conflicts of interest to disclose.

This study was supported in part by West Park Healthcare Centre Foundation.

View full text

Chest

Original ResearchPulmonary RehabilitationEffects of One-Legged Exercise Training of Patients With COPD

Background

Methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

ACKNOWLEDGMENT

Chest

Chest

Lancet

Chest

Respir Med

Chest

Respir Physiol Neurobiol

Pulmonary rehabilitation

Thorax

American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation

Am J Respir Crit Care Med

American College of Sports Medicine position stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults

Med Sci Sports Exerc

Increased training intensity effects on plasma lactate, ventilatory threshold, and endurance

Med Sci Sports Exerc

Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease

Am Rev Respir Dis

Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease

Am J Respir Crit Care Med

Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease–2003

Can Respir J

Standardisation of spirometry

Eur Respir J

Optimizing the exercise protocol for cardiopulmonary assessment

J Appl Physiol

Original Research
Pulmonary Rehabilitation
Effects of One-Legged Exercise Training of Patients With COPD