Alan Hamilton
Kay Tetzlaff- 1COPD Foundation, Miami, FL, United States
- 2Department of Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- 3Department of Sports Medicine, University of Tübingen, Tübingen, Baden-Württemberg, Germany
Editorial on the Research Topic
Exercise intervention for prevention, management of and rehabilitation from chronic obstructive pulmonary disease (COPD)
Following the inclusion of “physical reconditioning” in several COPD comprehensive care programs, as well as early studies exploring the benefits of endurance training in COPD (Petty et al., 1969; Make, 1986), the American Thoracic Society (ATS) included exercise conditioning as an “essential” component in their first pulmonary rehabilitation (PR) statement in 1981 (Hodgkin et al., 1981). Since then, exercise training has maintained a central position in the various updates to the ATS PR statement (1999 (Lareau et al., 1999), 2006 (Nici et al., 2006), 2013 (Spruit et al., 2013)). In the 1990s, the physiological mechanisms explaining the benefits of endurance training in patients with COPD began to emerge, with evidence of reduced ventilatory requirements during exercise secondary to morphologic and biochemical adaptations in skeletal muscle (Casaburi et al., 1991; Maltais et al., 1996; Maltais et al., 1997). At the same time, the recognition that many COPD patients have peripheral muscle weakness (Hamilton et al., 1995; Gosselink et al., 1996; Bernard et al., 1998) led to exploration of resistance training as an alternative form of exercise training (Simpson et al., 1992; Bernard et al., 1999; Spruit et al., 2002). Consistent with key physiological principles, adjunct therapies within exercise-based interventions have been explored to optimize the stimulus for physiological adaptations during endurance training (bronchodilators, oxygen, helium, and non-invasive ventilation) and resistance training (anabolic hormonal supplementation) (Spruit et al., 2013).
Studies included in the present Research Topic have focused on endurance training, resistance training and adjunct therapies. In exploring clinical phenotyping of exercise limitation, Gelinas et al. observed differential physiological responses to incremental exercise and proposed that patient-specific exercise limitation phenotypes may assist practitioners in prescribing a more appropriate exercise program to target the ventilatory and/or cardiovascular exercise limitation and optimize physiological adaptations. To support exercise prescription and progression in resistance training studies, Calatayud et al. evaluated the neuromuscular responses to progressive elastic band resistance in patients with COPD. With a focus on the potential respiratory/locomotor muscle interplay with adjunct therapy, Labeix et al. explored the effects of pressure ventilatory support during exercise on peripheral skeletal muscle endurance before and after an endurance training program.
Future directions in the development and evaluation of exercise-based interventions: a perspective from the editors. The multidisciplinary nature of exercise-based intervention development and evaluation is highlighted by Zhou et al. who conducted a bibliometric analysis as a resource for investigators seeking research collaborators. In recent years, the development, evaluation and implementation of exercise-based interventions has become increasingly complex: there is a growing need to increase the applicability and accessibility of exercise-based interventions such as pulmonary rehabilitation; novel forms of exercise-based interventions are being developed using newer technologies that facilitate intervention delivery via teleconferencing and apps, and incorporate wearables (e.g., for physical activity) and remote monitoring (Holland et al., 2021); there is an increasing exploration of novel forms of exercise training in COPD, including interval training, upper limb training, and transcutaneous neuromuscular electrical stimulation (Spruit et al., 2013); with improvements in breathlessness and activity limitation in daily life as the ultimate target, exercise-based interventions are including behavior change techniques to influence the ability, motivation and confidence to engage in physical activity and maintain outcomes (Bourbeau et al., 2015).
In recognition of this complexity, development and evaluation of exercise-based interventions in COPD may benefit from an integrative, interdisciplinary approach embedded within a complex intervention framework (Brighton et al., 2020; Trompette et al., 2020; Skivington et al., 2021). For example, the development of the exercise-based intervention included in the PHYSACTO (Troosters et al., 2018) study was accomplished by an interdisciplinary team comprised of experts in exercise/respiratory physiology (with knowledge of the physiological principles of exercise training) and behavioural psychology (with experience in developing behaviour change interventions), with intervention development guided by a psychophysiological model of breathlessness and activity limitation in patients with COPD.
- With exercise endurance as a proximal target, intervention development was grounded in a physiological model of progressive limitation in exercise endurance over time in COPD. With expiratory flow limitation, the respiratory response to support increased metabolic demands of muscular work results in disproportionate breathlessness; to avoid breathlessness, patients reduce the intensity and/or amount of activity performed during daily life (Jones et al., 2009; Dobbels et al., 2014); reduced activity leads to muscular de-conditioning; early onset of lactic acidosis during exercise stimulates breathing, increases breathing work, increases breathlessness, and creates a downward spiral of disability (Ramon et al., 2018).
- With physical activity as a downstream target, intervention development was also grounded in behavioural theory to develop a mechanistic model of key causal assumptions connecting the included behaviour change techniques to the psychological target and downstream behavioural outcomes (Michie and Johnston, 2012). Importantly, to support sustained behaviour change in the context of a chronic disease, intervention delivery was informed by postulates from Self-Determination Theory (SDT) (Ryan and Deci, 2017) that explain the internalization of motivational regulation towards autonomous motivation (volitional engagement in an activity important and concordant with one’s values), which has positive cognitive, affective and behavioural consequences (in contrast to controlled motivation, with pressure to engage in an activity dictated by others’ expectations, monetary incentives or a sense of guilt or obligation). In accordance with SDT, motivational communication (MC) (Dragomir et al., 2021) techniques (non-judgmental, non-confrontational, collaborative and empathic) were included in the intervention to support internalization by facilitating the satisfaction of the basic psychological needs of autonomy (feeling that one is empowered and has choice), competence (feeling that one can be effective and capable), and relatedness (feeling close to, and valued by others) (Ntoumanis et al., 2021). The MC component of the intervention empowered patients to take greater responsibility for their health and wellbeing, with healthcare professionals serving as guides in the behaviour change process.
For researchers seeking to improve the physical and psychological condition of people with COPD and promote long-term adherence to health-enhancing behaviours (Spruit et al., 2013), we encourage exploration of the value gained by grounding exercise intervention research within a complex intervention framework, and adopting an integrated, interdisciplinary approach, using well-described psychophysiological mechanistic models to guide intervention development and evaluation.
Author contributions
AH and KT contributed to conception of the editorial. AH wrote the first draft of the editorial. AH and KT contributed to editorial revision, read, and approved the submitted version. All authors contributed to the article and approved the submitted version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
Bernard, S., LeBlanc, P., Whittom, F., Carrier, G., Jobin, J., Belleau, R., et al. (1998). Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 158, 629–634. doi:10.1164/ajrccm.158.2.9711023
Bernard, S., Whittom, F., LeBlanc, P., Jobin, J., Belleau, R., Bérubé, C., et al. (1999). Aerobic and strength training in patients with chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 159, 896–901. doi:10.1164/ajrccm.159.3.9807034
Bourbeau, J., Lavoie, K., and Sedeno, M. (2015). Comprehensive self-management strategies. Semin. Respir. Crit. Care Med. 36 (4), 630–638. doi:10.1055/s-0035-1556059
Brighton, L., Evans, C., Man, W., and Maddocks, M. (2020). Improving exercise-based interventions for people living with both COPD and frailty: A realist review. Int. J. Chron. Obstruct Pulmon Dis. 15, 841–855. doi:10.2147/COPD.S238680
Casaburi, R., Patessio, A., Ioli, F., Zanaboni, S., Donner, C. F., and Wasserman, K. (1991). Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am. Rev. Respir. Dis. 143, 9–18. doi:10.1164/ajrccm/143.1.9
Dobbels, F., Corina de Jong, C., Drost, E., Elberse, J., Feridou, C., Jacobs, L., et al. (2014). The PROactive innovative conceptual framework on physical activity. Eur. Respir. J. 44, 1223–1233. doi:10.1183/09031936.00004814
Dragomir, A., Boucher, V., Bacon, S., Gemme, C., Szczepanik, G., Corace, K., et al. (2021). An international delphi consensus study to define motivational communication in the context of developing a training program for physicians. Transl. Behav. Med. 11 (2), 642–652. doi:10.1093/tbm/ibaa015
Gosselink, R., Troosters, T., and Decramer, M. (1996). Peripheral muscle weakness contributes to exercise limitation in COPD. Am. J. Respir. Crit. Care Med. 153, 976–980. doi:10.1164/ajrccm.153.3.8630582
Hamilton, A., Killian, K., Summers, E., and Jones, N. (1995). Muscle strength, symptom intensity, and exercise capacity in patients with cardiorespiratory disorders. Am. J. Respir. Crit. Care Med. 152, 2021–2031. doi:10.1164/ajrccm.152.6.8520771
Hodgkin, J. E., Farrell, M. J., Gibson, S. R., Kanner, R. E., Kass, I., Lampton, L. M., et al. (1981). American Thoracic Society. Medical Section of the American Lung Association. Pulmonary rehabilitation. Am. Rev. Respir. Dis. 124, 663–666.
Holland, A., Cox, N., Houchen-Wolloff, L., Rochester, C. L., Garvey, C., ZuWallack, R., et al. (2021). Defining modern pulmonary rehabilitation. An official American Thoracic Society workshop report. Ann. Am. Thorac. Soc. 18 (5), 12–29. doi:10.1513/AnnalsATS.202102-146ST
Jones, P., Harding, G., Wiklund, I., Berry, P., and Leidy, N. (2009). Improving the process and outcome of care in COPD: Development of a standardised assessment tool. Prim. Care Respir. J. 18 (3), 208–215. doi:10.4104/pcrj.2009.00053
Lareau, S., ZuWallack, R., Carlin, B., Celli, B., Fahy, B., Gosselink, R., et al. (1999). Pulmonary rehabilitation-1999. American Thoracic Society. Am. J. Respir. Crit. Care Med. 159, 1666–1682.
Make, B. (1986). Pulmonary rehabilitation: Myth or reality? Clin. Chest Med. 7, 519–540. doi:10.1016/s0272-5231(21)00449-4
Maltais, F., LeBlanc, P., Jobin, J., Bérubé, C., Bruneau, J., Carrier, L., et al. (1997). Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 155, 555–561. doi:10.1164/ajrccm.155.2.9032194
Maltais, F., LeBlanc, P., Simard, C., Jobin, J., Bérubé, C., Bruneau, J., et al. (1996). Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 154, 442–447. doi:10.1164/ajrccm.154.2.8756820
Michie, S., and Johnston, M. (2012). Theories and techniques of behaviour change: Developing a cumulative science of behaviour change. Health Psychol. Rev. 6 (1), 1–6. doi:10.1080/17437199.2012.654964
Nici, L., Donner, C., Wouters, E., Zuwallack, R., Ambrosino, N., Bourbeau, J., et al. (2006). American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am. J. Respir. Crit. Care Med. 173 (12), 1390–1413. doi:10.1164/rccm.200508-1211ST
Ntoumanis, N., Ng, J., Prestwich, A., Quested, E., Hancox, J. E., Thøgersen-Ntoumani, C., et al. (2021). A meta-analysis of self-determination theory-informed intervention studies in the health domain: Effects on motivation, health behavior, physical, and psychological health. Health Psychol. Rev. 15 (2), 214–244. doi:10.1080/17437199.2020.1718529
Petty, T., Nett, L., Finigan, M., Brink, G. A., and Corsello, P. R. (1969). A comprehensive care program for chronic airway obstruction. Methods and preliminary evaluation of symptomatic and functional improvement. Ann. Intern Med. 70 (6), 1109–1120. doi:10.7326/0003-4819-70-6-1109
Ramon, M., Ter Riet, G., Carsin, A-E., Gimeno-Santos, E., Agustí, A., Antó, J. M., et al. (2018). The dyspnoea-inactivity vicious circle in COPD: Development and external validation of a conceptual model. Eur. Respir. J. 52, 1800079. doi:10.1183/13993003.00079-2018
Ryan, R., and Deci, E. (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness. New York: Guilford Publishing.
Simpson, K., Killian, K., McCartney, N., Stubbing, D. G., and Jones, N. L. (1992). Randomised controlled trial of weightlifting exercise in patients with chronic airflow limitation. Thorax 47, 70–75. doi:10.1136/thx.47.2.70
Skivington, K., Matthews, L., Simpson, S., Craig, P., Baird, J., Blazeby, J. M., et al. (2021). A new framework for developing and evaluating complex interventions: Update of medical research council guidance. BMJ 374, n2061. doi:10.1136/bmj.n2061
Spruit, M., Gosselink, R., Troosters, T., De Paepe, K., and Decramer, M. (2002). Resistance versus endurance training in patients with COPD and peripheral muscle weakness. Eur. Respir. J. 19 (6), 1072–1078. doi:10.1183/09031936.02.00287102
Spruit, M., Singh, S., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., et al. (2013). An official American Thoracic Society/European Respiratory Society statement: Key concepts and advances in pulmonary rehabilitation. Am. J. Respir. Crit. Care Med. 188 (8), 13–64. Erratum in: Am J Respir Crit Care Med 2014; 189 (12), 1570. doi:10.1164/rccm.201309-1634ST
Trompette, J., Kivits, J., Minary, L., and Alla, F. (2020). Dimensions of the complexity of health interventions: What are we talking about? A review. Int. J. Environ. Res. Public Health 17 (9), 3069. doi:10.3390/ijerph17093069
Troosters, T., Maltais, F., Leidy, N., Lavoie, K. L., Sedeno, M., Janssens, W., et al. (2018). Effect of bronchodilation, exercise training, and behavior modification on symptoms and physical activity in chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 198 (8), 1021–1032. doi:10.1164/rccm.201706-1288OC
Keywords: COPD-chronic obstructive pulmonary disease, exercise intervention approaches, endurance training, resistance training, non-invasive ventilation (NIV), complex intervention development, self-determination theory, behaviour change techniques
Citation: Hamilton A and Tetzlaff K (2023) Editorial: Exercise intervention for prevention, management of and rehabilitation from chronic obstructive pulmonary disease (COPD). Front. Physiol. 14:1228431. doi: 10.3389/fphys.2023.1228431
Received: 24 May 2023; Accepted: 31 May 2023;
Published: 06 June 2023.
Edited and reviewed by:
Giuseppe D'Antona, University of Pavia, ItalyCopyright © 2023 Hamilton and Tetzlaff. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Alan Hamilton, ZHIuaGFtaWx0b24uYWxhbkBnbWFpbC5jb20=