Exercise assessments and trainings of pulmonary rehabilitation in COPD: a literature review

Figures & data

Table 1 Assessment of symptom evaluation in patients with COPD

Items	Assessment methods	Function	Advantage	Disadvantage	MCID
Dyspnea	mMRC^Citation25	Rates dyspnea and measures disability levels	Short completion time (30 seconds)	Only cover breathlessness	2 units
	Borg^Citation26	Measures intensity of the sensation of breathlessness and leg fatigue	Quick and easy, can be used over the phone	–	1 unit
	VAS^Citation29	Measures breathlessness	Within-subject repeated measurement	Not suitable to compare in different patients	10–20 units
	NRS^Citation31	Measures dyspnea	A valid measure of present dyspnea, and more repeatable than the VAS	Need smaller sample sizes to detect a change	–
	BDI/TDI^Citation32	Measures dyspnea and the change with time	Valid, responsive measures of acute changes	Only cover breathlessness	1 unit
OCD	A variation of the VAS^Citation33	Calculates oxygen cost at different activity levels	Simple and easy to administer	Responsiveness and validity are unproved	–

Abbreviations: MCID, minimal clinically important difference; mMRC, modifed Medical Research Council; VAS, Visual Analogue Scale; NRS, Numeric Rating Scale; BDI, Baseline Dyspnea Index; TDI, Transition Dyspnea Index; OCD, oxygen-cost diagram.

Table 2 Assessment of exercise endurance in patients with COPD

Assessment methods	Function	Advantage	Disadvantage	MCID
Field test
6MWT^Citation34	Evaluates functional capacity	Easy, cheap, better tolerated, and more reflective of activities of daily living	Very sensitive to variations in methodology and environment	30 m
ISWT^Citation36	Measures cardiopulmonary exercise capacity	Provokes a similar physiological response to CPET	Needs a prerecorded signal	48 m
ESWT^Citation37	Calculates endurance capacity	More sensitive to change than 6MWT	Must enforced after ISWT	65 seconds or 95 m
4MGS^Citation39	A marker of exercise capacity and a consistent risk factor for disability	Reliable and quick to perform	Usually used in older adults or frail individuals	0.11 m/s
6MST^Citation41,Citation42	An evaluation of exercise tolerance and used to individualize aerobic training	Avert the environmental constraints of the 6MWT	Safety concerns on the stepper	20 steps
STST^Citation43,Citation44 (1-minute)	An easy-to-use field test to evaluate exercise tolerance	A reliable, valid, and responsive test and comparable to 6MWT	Need to be more widespread	3 repetitions
CPET^Citation45	Identifies the reasons of exercise limitation, assesses maximal exercise capacity, and the prognosis	Standard aerobic exercise testing assessment	Carries an additional cost and competency requirements	–

Abbreviations: MCID, minimal clinically important difference; 6MWT, 6-minute walk test; ISWT, incremental shuttle walking test; ESWT, endurance shuttle walking test; 4MGS, 4-metre gait speed; 6MST, 6-minute stepper test; STST, sit-to-stand test; CPET, cardiopulmonary exercise testing.

Table 3 Assessments of muscle strength in patients with COPD

Regions	Assessment methods	Function	Advantage	Disadvantage	LNN/mean
Limb strength	MMT^Citation48	A rough assessment tool to calculate muscle strength	Easy and simple, without any equipment	Semiquantitative and imprecision	–
	Handheld dynamometry^Citation49	Evaluates knee and peak hip extension strength	Reliable, valid, portable, and inexpensive	Only in one angle. Not suitable to detect changes for one person	–
	Handgrip dynamometry^Citation50	Measures handgrip strength	Easy, simple, reliable, and valid	Measure only handgrip strength	–
	Computer dynamometry^Citation51	Measures isometric and isokinetic torque	Reliable, reproducible, and standardized. Measures various muscle groups at different joint angles and contraction velocities	Need cost and technique requirements	–
	Strain gauge^Citation52,Citation53	Measures maximal voluntary contraction of quadriceps and isometric knee extension tension	Easy, simple, portable, and inexpensive	Generally equipped with a purpose-built chair	–
	1RM^Citation54	Assesses muscle strength	Quick and easy Valid and reliable	Requires trained personnel and equipment	–
	Electrical or magnetic stimulation^Citation56	Non-volitional assessment to measure quadriceps and diaphragm muscle strength	Overcome some of the limitations of subjective factors	Discomfort and technical difficulty	–
Respiratory muscle	MIP/MEP^Citation58,Citation59	Measures respiratory muscle strength	Not complicated to perform and well tolerated by patients Easy, rapid, and portable to perform Noninvasive	Not objective. Depends on patient cooperation	MIP LLN: male = 62 − (0.15 × age) female = 62 − (0.50 × age), MEP LLN: male = 117 − (0.83 × age) female = 95 − (0.57 × age)
	Sniff Tests^Citation61	Measure respiratory muscle strength, especially the inspiratory muscle and diaphragm	Easily performed and more reproducible Need little practice	Need at least one unobstructed nostril and upper airway	Different sniff tests with various reference values
	ES^Citation58	Measures strength and fatigue of diaphragm through transcutaneous electrical stimulation	An original method for generating an isolated contraction of the diaphragm	Difficult to master Uncomfortable for patients	Mean: 10–26 cmH2O for COPD patients
	CMS^Citation58	Measures the strength and fatigue of diaphragm through magnetic stimulation	Easier and faster to apply and more accurate	May interfered by the upper rib cage and neck	Mean: 18.5 cmH2O for COPD patients

Abbreviations: LNN, lower limit of normal; MMT, Manual Muscle Testing; 1RM, one-repetition maximum; MIP, maximal inspiratory pressure; MEP, maximal expiratory pressure; ES, transcutaneous electrical stimulation; CMS, cervical magnetic stimulation.

Table 4 Assessment of life quality in patients with COPD

Assessment methods	Function	Advantage	Disadvantage	MCID/CID
SGRQ^Citation66,Citation70	A gold standardized self-completed questionnaire for measuring quality of life	Well validated and frequently used in COPD trials	Complicated and time consuming, especially for older patients Need special spreadsheets to calculate the scores Restricted in daily clinical practice	4 units
CCQ^Citation67,Citation71	A self-administered questionnaire specially developed to measure clinical control	Short and easy to complete, usually tested in mild-to-moderate COPD	Skewed distributions in functional and mental state domains	0.4
CAT^Citation68,Citation72	A patient-completed questionnaire for assessing and monitoring COPD	Easier and faster to complete, especially for patients with low education level	Need to testify in different patient population characteristics, such as females, patients with mild disease	2 points
CRQ^Citation69,Citation73	An established measure of health status including self-reported and interviewer-led versions	Demonstrates changes in disability in older patients	Lack of sensitivity in patients with minor symptoms Unable to make comparisons between populations	0.5 for each domain
SF-36, version 2.0^Citation75,Citation76	A self-administration 36-item short-form health survey	Has good construct validity and correlates well with objective assessments of health status. Completed in person or by telephone	Weak correlation with lung function tests Used less in clinical trials and practice	8.3 points
BODE^Citation77,Citation79	A simple multidimensional grading system to predict the risk of death and calculate the life quality	A better tool to predict mortality and a significant predictor of life quality in patients with severe COPD	Has not been widespread applied now	–

Abbreviations: SGRQ, St George’s Respiratory Questionnaire; CCQ, Clinical COPD Questionnaire; CAT, COPD Assessment Test; CRQ, Chronic Respiratory Questionnaire; BODE, body-mass index, airflow obstruction, dyspnea, and exercise capacity.

BestallJCPaulEAGarrodRGarnhamRJonesPWWedzichaJAUsefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary diseaseThorax199954758158610377201

 PubMed Web of Science ®Google Scholar

BorgGPsychophysical scaling with applications in physical work and the perception of exertionScand J Work Environ Health199016Suppl 155582345867

 PubMed Web of Science ®Google Scholar

MadorMJKufelTJReproducibility of visual analog scale measurements of dyspnea in patients with chronic obstructive pulmonary diseaseAm Rev Respir Dis1992146182871626820

 PubMed Web of Science ®Google Scholar

GiftAGNarsavageGValidity of the numeric rating scale as a measure of dyspneaAm J Crit Care1998732002049579246

 PubMedGoogle Scholar

WitekTJJrMahlerDAMinimal important difference of the transition dyspnoea index in a multinational clinical trialEur Respir J200321226727212608440

 PubMed Web of Science ®Google Scholar

McGavinCRArtvinliMNaoeHMcHardyGJDyspnoea, disability, and distance walked: comparison of estimates of exercise performance in respiratory diseaseBr Med J197826132241243678885

 PubMed Web of Science ®Google Scholar

ATS Committee on Proficiency Standards for Clinical Pulmonary Function LaboratoriesATS statement: guidelines for the six-minute walk testAm J Respir Crit Care Med2002166111111712091180

 PubMed Web of Science ®Google Scholar

SinghSJJonesPWEvansRMorganMDMinimum clinically important improvement for the incremental shuttle walking testThorax200863977577718390634

 PubMed Web of Science ®Google Scholar

RevillSMMorganMDSinghSJWilliamsJHardmanAEThe endurance shuttle walk: a new field test for the assessment of endurance capacity in chronic obstructive pulmonary diseaseThorax199954321322210325896

 PubMed Web of Science ®Google Scholar

KonSSPatelMSCanavanJLReliability and validity of 4-metre gait speed in COPDEur Respir J201342233334023222875

 PubMed Web of Science ®Google Scholar

CoquartJBLemaitreFCastresISaisonSBartFGrosboisJMReproducibility and sensitivity of the 6-Minute Stepper Test in patients with COPDCOPD201512553353825526322

 PubMedGoogle Scholar

PichonRCouturaudFMialonPResponsiveness and minimally important difference of the 6-Minute Stepper Test in patients with chronic obstructive pulmonary diseaseRespiration201691536737327216848

 PubMed Web of Science ®Google Scholar

VaidyaTChambellanAde BisschopCSit-to-stand tests for COPD: a literature reviewRespir Med2017128707728610673

 PubMed Web of Science ®Google Scholar

CrookSBuschingGSchultzKA multicentre validation of the 1-min sit-to-stand test in patients with COPDEur Respir J2017493

 Web of Science ®Google Scholar

American Thoracic SocietyAmerican College of Chest PhysiciansATS/ACCP statement on cardiopulmonary exercise testingAm J Respir Crit Care Med2003167221127712524257

 PubMed Web of Science ®Google Scholar

CieslaNDinglasVFanEKhoMKuramotoJNeedhamDManual muscle testing: a method of measuring extremity muscle strength applied to critically ill patientsJ Vis Exp201150

 Web of Science ®Google Scholar

O’SheaSDTaylorNFParatzJDMeasuring muscle strength for people with chronic obstructive pulmonary disease: retest reliability of hand-held dynamometryArch Phys Med Rehabil2007881323617207672

 PubMed Web of Science ®Google Scholar

BohannonRWMuscle strength: clinical and prognostic value of hand-grip dynamometryCurr Opin Clin Nutr Metab Care201518546547026147527

 PubMed Web of Science ®Google Scholar

RoblesPGMathurSJanaudis-FereiraTDolmageTEGoldsteinRSBrooksDMeasurement of peripheral muscle strength in individuals with chronic obstructive pulmonary disease: a systematic reviewJ Cardiopulm Rehabil Prev2011311112420724932

 PubMed Web of Science ®Google Scholar

EdwardsRHYoungAHoskingGPJonesDAHuman skeletal muscle function: description of tests and normal valuesClin Sci Mol Med1977523283290844260

 PubMedGoogle Scholar

SwallowEBReyesDHopkinsonNSQuadriceps strength predicts mortality in patients with moderate to severe chronic obstructive pulmonary diseaseThorax200762211512017090575

 PubMed Web of Science ®Google Scholar

LevingerIGoodmanCHareDLJerumsGToiaDSeligSThe reliability of the 1RM strength test for untrained middle-aged individualsJ Sci Med Sport200912231031618078784

 PubMed Web of Science ®Google Scholar

ManWDSolimanMGNikoletouDNon-volitional assessment of skeletal muscle strength in patients with chronic obstructive pulmonary diseaseThorax200358866566912885979

 PubMed Web of Science ®Google Scholar

American Thoracic Society/European Respiratory SocietyATS/ERS statement on respiratory muscle testingAm J Respir Crit Care Med2002166451862412186831

 PubMed Web of Science ®Google Scholar

EvansJAWhitelawWAThe assessment of maximal respiratory mouth pressures in adultsRespir Care200954101348135919796415

 PubMed Web of Science ®Google Scholar

LarocheCMMierAKMoxhamJGreenMThe value of sniff esophageal pressures in the assessment of global inspiratory muscle strengthAm Rev Respir Dis198813835986033202414

 PubMed Web of Science ®Google Scholar

JonesPWQuirkFHBaveystockCMThe St George’s Respiratory QuestionnaireRespir Med199185Suppl B25311759018

 PubMed Web of Science ®Google Scholar

JonesPWSt. George’s Respiratory Questionnaire: MCIDCOPD200521757917136966

 PubMedGoogle Scholar

van der MolenTWillemseBWSchokkerSTenHNPostmaDSJuniperEFDevelopment, validity and responsiveness of the Clinical COPD QuestionnaireHealth Qual Life Outcomes200311312773199

 PubMedGoogle Scholar

KocksJWTuinengaMGUilSMvan den BergJWStahlEvan der MolenTHealth status measurement in COPD: the minimal clinically important difference of the clinical COPD questionnaireRespir Res200676216603063

 PubMed Web of Science ®Google Scholar

JonesPWHardingGBerryPWiklundIChenWHKline LeidyNDevelopment and first validation of the COPD Assessment TestEur Respir J200934364865419720809

 PubMed Web of Science ®Google Scholar

KonSSCanavanJLJonesSEMinimum clinically important difference for the COPD Assessment Test: a prospective analysisLancet Respir Med20142319520324621681

 PubMed Web of Science ®Google Scholar

GuyattGHBermanLBTownsendMPugsleySOChambersLWA measure of quality of life for clinical trials in chronic lung diseaseThorax198742107737783321537

 PubMed Web of Science ®Google Scholar

SchunemannHJPuhanMGoldsteinRJaeschkeRGuyattGHMeasurement properties and interpretability of the chronic respiratory disease questionnaire (CRQ)COPD200521818917136967

 PubMedGoogle Scholar

MahlerDAMackowiakJIEvaluation of the short-form 36-item questionnaire to measure health-related quality of life in patients with COPDChest19951076158515897781351

 PubMed Web of Science ®Google Scholar

WyrwichKWFihnSDTierneyWMKroenkeKBabuANWolinskyFDClinically important changes in health-related quality of life for patients with chronic obstructive pulmonary disease: an expert consensus panel reportJ Gen Intern Med200318319620212648251

 PubMed Web of Science ®Google Scholar

CelliBRCoteCGMarinJMThe body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary diseaseN Engl J Med2004350101005101214999112

 PubMed Web of Science ®Google Scholar

OngKCLuSJSohCSDoes the multidimensional grading system (BODE) correspond to differences in health status of patients with COPD?Int J Chron Obstruct Pulmon Dis200611919618046907

 PubMedGoogle Scholar