A recent Japanese study examined the relationship of folic acid intake and degree of breathlessness and functional capacity among COPD patients and concluded that the lower a COPD patient’s daily folic acid intake, the more prevalent the symptoms of breathlessness. (Hirayama F, et al. Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010; 19(1):103-9)
So what is folic acid? According to the National Institutes of Health Office of Dietary Supplements folic acid (also known as folate) is defined as, “a water-solubleB vitamin that occurs naturally in food. Folic acid is the synthetic form of folate that is found in supplements and added to fortified foods…Folate helps produce and maintain new cells . This is especially important during periods of r apid cell division and growth such as infancy and pregnancy. Folate is needed to make DNA and RNA, the building blocks of cells. It also helps prevent changes to DNA that may lead to cancer. Both adults and children need folate to make normal red blood cells and prevent anemia. Folate is also essential for the metabolism of homocysteine, and helps maintain normal levels of this amino acid …Leafy green vegetables (like spinach and turnip greens), fruits (like citrus fruits and juices), and dried beans and peas are all natural sources of folate.”
On average, the Japanese COPD patients in the study consumed 231 micrograms of folic acid each day. By comparison, the National Institutes of Health recommends 400 micrograms daily for adults over the age of 19. Ironically, even the control subjects of the study (a random selection of Japanese adults without COPD) only consumed 261 mcg on average each day.
What is most interesting about the study is that even with the modest spread between the folic acid intake of the control subjects and COPD patients (30 microgram difference in daily consumption), the researchers found statistically significant variances in symptoms of breathlessness. Among COPD patients alone, the researchers found that the COPD patients with the highest levels of folic acid intake reported the least amount of breathlessness symptoms and vice versa. The researchers conclude that COPD patients would be well served by supplementing their dietary sources of folic acid.
In our opinion, current and former smokers would be well advised to also boost their folic acid intake. Depressed levels of folic acid and other key B-Vitamins in smokers have been reported in other studies. Low folic acid levels have been shown in these studies to be a causal element of developing a condition known as hyperhomocysteinaemia – a condition where the body produces too much of a chemical called homocysteine. Too much homocysteine in the blood has been linked to blot clots, heart attacks and stroke.
In the US, nearly all multivitamins contain at least 400 micrograms of folic acid given that this level has been deemed by the Institute of Medicine of the National Academy of Sciences as the recommended daily allowance (now referred to as dietary reference intake). In addition, many leafy green vegetables and even fortified cereals contain notable levels of folic acid. For more information about folic acid, its benefits, and food source content, click here to visit the National Institutes of Health’s Office of Dietary Supplements web site.
Friday, May 28, 2010
Wednesday, May 26, 2010
Outpatient pulmonary rehab for COPD patients cuts hospital attendance/readmits by 52%
A study published this month in the journal Thorax demonstrated that administering pulmonary rehabilitation to COPD patients immediately after hospital discharge related to an acute exacerbation (a significant shortness of breath event) cut subsequent readmission and hospital attendance for a re-exacerbation by 52%.
The UK based study examined 60 COPD patients who had been admitted to one of two different UK hospitals for an acute exacerbation event. The research team divided the 60 patients into two groups. One group received “usual care” post-discharge (post-discharge usual care is a term meaning providing patients basic instructions and medication prescriptions, but no specific follow-on therapy). The other group, denoted here as the rehab group, participated in an 8 week outpatient pulmonary rehab program. (Seymour JM, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010 May; 65(5):423-428)
The pulmonary rehab program involved twice weekly visits of 2 hours each over the 8 week period. In those sessions, patients participated in aerobic exercise and strength training exercise under the supervision of respiratory care professionals and received education counseling regarding breathing techniques and nutrition among other subjects.
The research team then evaluated how many COPD patients in each group were either readmitted to a hospital or visited a hospital emergency department for a subsequent exacerbation event during the 3 months from their initial hospital admission (during the 3 month period the rehab group was actively participating in the pulmonary rehab program).
Their data showed that only 2 of the 30 patients in the pulmonary rehab group were readmitted during the 3 month period following their initial exacerbation-related admission while 10 of the 30 COPD patients in the usual care group were readmitted. With regard to emergency department visits related to a subsequent exacerbation, the rehab group reported 6 of 30 and the usual care group reported 7 of 30. All together 8 of the 30 rehab group COPD patients were either readmitted or visited an emergency room in comparison to 17 of the 30 usual care group patients, hence the reported 52% fewer admissions/ED visits.
The researchers concluded, “Outpatient pulmonary rehabilitation immediately following an acute COPD exacerbation can reduce the risk of re-exacerbation requiring hospital attendance in the following 3 months.”
Interestingly, though the purpose of the study was to specifically examine hospital readmission/ED visit rates, the researchers also evaluated both groups for physical conditioning and quality of life measures. In doing so, they took baseline measurements of physical conditioning and recorded quality of life survey responses at the outset of the study for both groups. At the end of the 8 week pulmonary rehab program, both groups were evaluated again for physical conditioning and quality of life.
Consistent with other pulmonary rehab studies, the COPD patients who participated in the rehab program experienced significant improvements in physical conditioning and patient-reported quality of life compared to the usual care group. For example, on the endurance shuttle walk test (similar to the 6 minute walk test), COPD patients in the rehab group saw their average distance walked rise 88% between their pre-rehab and post-rehab evaluations. By comparison, the usual care group showed no improvement.
So, as we’ve related in previous articles, pulmonary rehab works. It improves physical conditioning, reduces shortness of breath, improves quality of life, reduces hospital admissions and reduces overall health care costs. We’re guessing that this study will catch the attention of US hospital administrators. Why? Because the quasi-government body that administers Medicare payments is tightening reimbursement eligibility/amounts for hospitalizations that result in a re-admission within 30 days of discharge. To these hospital administrators, the cost of offering reimbursable pulmonary rehab to COPD patients admitted with an exacerbation is surely lower than eating the cost of a subsequent hospital admission/emergency room visit.
One hopes that more doctors will prescribe pulmonary rehab for COPD patients as the evidence of its efficacy mounts so that one day pulmonary rehab will be considered “usual care” instead of an experimental therapy.
The UK based study examined 60 COPD patients who had been admitted to one of two different UK hospitals for an acute exacerbation event. The research team divided the 60 patients into two groups. One group received “usual care” post-discharge (post-discharge usual care is a term meaning providing patients basic instructions and medication prescriptions, but no specific follow-on therapy). The other group, denoted here as the rehab group, participated in an 8 week outpatient pulmonary rehab program. (Seymour JM, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010 May; 65(5):423-428)
The pulmonary rehab program involved twice weekly visits of 2 hours each over the 8 week period. In those sessions, patients participated in aerobic exercise and strength training exercise under the supervision of respiratory care professionals and received education counseling regarding breathing techniques and nutrition among other subjects.
The research team then evaluated how many COPD patients in each group were either readmitted to a hospital or visited a hospital emergency department for a subsequent exacerbation event during the 3 months from their initial hospital admission (during the 3 month period the rehab group was actively participating in the pulmonary rehab program).
Their data showed that only 2 of the 30 patients in the pulmonary rehab group were readmitted during the 3 month period following their initial exacerbation-related admission while 10 of the 30 COPD patients in the usual care group were readmitted. With regard to emergency department visits related to a subsequent exacerbation, the rehab group reported 6 of 30 and the usual care group reported 7 of 30. All together 8 of the 30 rehab group COPD patients were either readmitted or visited an emergency room in comparison to 17 of the 30 usual care group patients, hence the reported 52% fewer admissions/ED visits.
The researchers concluded, “Outpatient pulmonary rehabilitation immediately following an acute COPD exacerbation can reduce the risk of re-exacerbation requiring hospital attendance in the following 3 months.”
Interestingly, though the purpose of the study was to specifically examine hospital readmission/ED visit rates, the researchers also evaluated both groups for physical conditioning and quality of life measures. In doing so, they took baseline measurements of physical conditioning and recorded quality of life survey responses at the outset of the study for both groups. At the end of the 8 week pulmonary rehab program, both groups were evaluated again for physical conditioning and quality of life.
Consistent with other pulmonary rehab studies, the COPD patients who participated in the rehab program experienced significant improvements in physical conditioning and patient-reported quality of life compared to the usual care group. For example, on the endurance shuttle walk test (similar to the 6 minute walk test), COPD patients in the rehab group saw their average distance walked rise 88% between their pre-rehab and post-rehab evaluations. By comparison, the usual care group showed no improvement.
So, as we’ve related in previous articles, pulmonary rehab works. It improves physical conditioning, reduces shortness of breath, improves quality of life, reduces hospital admissions and reduces overall health care costs. We’re guessing that this study will catch the attention of US hospital administrators. Why? Because the quasi-government body that administers Medicare payments is tightening reimbursement eligibility/amounts for hospitalizations that result in a re-admission within 30 days of discharge. To these hospital administrators, the cost of offering reimbursable pulmonary rehab to COPD patients admitted with an exacerbation is surely lower than eating the cost of a subsequent hospital admission/emergency room visit.
One hopes that more doctors will prescribe pulmonary rehab for COPD patients as the evidence of its efficacy mounts so that one day pulmonary rehab will be considered “usual care” instead of an experimental therapy.
Tuesday, May 25, 2010
Vitamin C supplementation a possible defense against atherosclerosis for smokers
This month a group of Indian researchers reported their findings that supplementation of Vitamin C in guinea pigs exposed to cigarette smoke developed significantly less atherosclerosis (sometimes referred to as hardening of the arteries) than guinea pigs exposed to smoke without Vitamin C. (Ray T, et al. Vitamin C Prevents Cigarette Smoke Induced Atherosclerosis in Guinea Pig Model. J Atheroscler Thromb. 2010 May 13. [Epub ahead of print])
Prolonged exposure to cigarette smoke has previously been shown to be a significant risk factor in the development of atherosclerosis in humans. Atherosclerosis is characterized by thickening of artery walls and build-up of cholesterol plaques in the arteries which over time can block blood flow and cause cardiac events.
You might ask – what does a Vitamin C study about cigarette smoking guinea pigs have to do with humans who smoke? A good question. According to the study authors, guinea pigs are a good proxy for humans when it comes to atherosclerosis due to the fact that cholesterol is distributed in the arteries in very similar ways in both species. Further, similar inflammatory responses to cigarette smoke in humans and guinea pigs has been previously studied and documented. Finally, guinea pigs apparently cannot synthesize Vitamin C from their diet and so nutritional supplementation is the only source of Vitamin C a guinea pig can absorb which makes it easier to isolate its effects.
Cigarette smoke contains massive numbers of free radicals which are considered pro-oxidants (chemicals which damage human tissue unless counteracted by antioxidants such as Vitamin C). Over time, if a person does not have adequate antioxidant levels in their body to overcome the presence of free radicals, diseases such as atherosclerosis can develop. It is clear from past research studies that smokers have depressed antioxidant levels due to the pro-oxidants inhaled in smoke and it is equally clear that atherosclerosis is common among smokers.
So with that in mind, the researchers discovered that cigarette smoke increased the thickness of the guinea pig aortas and increased a body mechanism known as apoptosis (in simple terms, programmed cell death) in the epithelium (lining of the arteries). This, according to the researchers, led to a notable build-up of cholesterol deposits in the guinea pig arteries and proved a clear diagnosis of atherosclerosis after 21 days of cigarette smoke exposure.
By contrast, guinea pigs that were exposed to cigarette smoke for 21 days and provided a Vitamin C supplement each day had significantly less aortic wall thickening, significantly less shedding of epithelial cells, and significantly less cholesterol plaque build-up in the arteries. Indeed, the researchers concluded that those guinea pigs who consumed Vitamin C each day had not developed atherosclerosis.
The study authors conclude, “Therefore, our findings provide insight into some critical atherogenic events triggered by cigarette smoke in the guinea pig model, which is one of the first of its kind and also establishes the preventative role of Vitamin C in the development of the disease.”
The guinea pigs in the study were provided either 1mg or 5 mg of Vitamin C each day. That obviously is inadequate for humans. The National Academy of Sciences (NAS) recommended Vitamin C daily intake (now referred to as Dietary Reference Intake) for average adults is 90mg but given the huge amount of pro-oxidant chemicals inhaled in cigarette smoke, this level is not protective for smokers. We are unaware of any specific dosage recommended for smokers but the tolerable upper level limit recommended by the NAS is 2,000 mg each day. A number of studies on Vitamin C for its antioxidant protection have been done on dosages between 500mg and 1,000mg per day. Supplemental Vitamin C, in the form of ascorbic acid, is widely available online and in retail stores for $3-$10 per 30 day supply depending on the dosage level chosen.
Prolonged exposure to cigarette smoke has previously been shown to be a significant risk factor in the development of atherosclerosis in humans. Atherosclerosis is characterized by thickening of artery walls and build-up of cholesterol plaques in the arteries which over time can block blood flow and cause cardiac events.
You might ask – what does a Vitamin C study about cigarette smoking guinea pigs have to do with humans who smoke? A good question. According to the study authors, guinea pigs are a good proxy for humans when it comes to atherosclerosis due to the fact that cholesterol is distributed in the arteries in very similar ways in both species. Further, similar inflammatory responses to cigarette smoke in humans and guinea pigs has been previously studied and documented. Finally, guinea pigs apparently cannot synthesize Vitamin C from their diet and so nutritional supplementation is the only source of Vitamin C a guinea pig can absorb which makes it easier to isolate its effects.
Cigarette smoke contains massive numbers of free radicals which are considered pro-oxidants (chemicals which damage human tissue unless counteracted by antioxidants such as Vitamin C). Over time, if a person does not have adequate antioxidant levels in their body to overcome the presence of free radicals, diseases such as atherosclerosis can develop. It is clear from past research studies that smokers have depressed antioxidant levels due to the pro-oxidants inhaled in smoke and it is equally clear that atherosclerosis is common among smokers.
So with that in mind, the researchers discovered that cigarette smoke increased the thickness of the guinea pig aortas and increased a body mechanism known as apoptosis (in simple terms, programmed cell death) in the epithelium (lining of the arteries). This, according to the researchers, led to a notable build-up of cholesterol deposits in the guinea pig arteries and proved a clear diagnosis of atherosclerosis after 21 days of cigarette smoke exposure.
By contrast, guinea pigs that were exposed to cigarette smoke for 21 days and provided a Vitamin C supplement each day had significantly less aortic wall thickening, significantly less shedding of epithelial cells, and significantly less cholesterol plaque build-up in the arteries. Indeed, the researchers concluded that those guinea pigs who consumed Vitamin C each day had not developed atherosclerosis.
The study authors conclude, “Therefore, our findings provide insight into some critical atherogenic events triggered by cigarette smoke in the guinea pig model, which is one of the first of its kind and also establishes the preventative role of Vitamin C in the development of the disease.”
The guinea pigs in the study were provided either 1mg or 5 mg of Vitamin C each day. That obviously is inadequate for humans. The National Academy of Sciences (NAS) recommended Vitamin C daily intake (now referred to as Dietary Reference Intake) for average adults is 90mg but given the huge amount of pro-oxidant chemicals inhaled in cigarette smoke, this level is not protective for smokers. We are unaware of any specific dosage recommended for smokers but the tolerable upper level limit recommended by the NAS is 2,000 mg each day. A number of studies on Vitamin C for its antioxidant protection have been done on dosages between 500mg and 1,000mg per day. Supplemental Vitamin C, in the form of ascorbic acid, is widely available online and in retail stores for $3-$10 per 30 day supply depending on the dosage level chosen.
Tuesday, May 11, 2010
Home based pulmonary rehab improves physical conditioning, emotional well being and shortness of breath among COPD patients
For COPD patients, proactive self-management is likely the most important success factor in limiting the impact of lung disease symptoms over the long-term. One proven method for improving shortness of breath, physical conditioning and quality of life/sense of well being among COPD patients is a treatment option known as pulmonary rehabilitation. Pulmonary rehabilitation involves guided aerobic and strength training exercise, learning/practicing breathing techniques that are helpful when exerting yourself or managing a shortness of breath event, and nutrition counseling among other activities. Of these elements, the guided exercise is considered the centerpiece of such a program.
However, pulmonary rehab is prescribed to an excruciatingly small slice of the COPD population (1-2%) and is typically only offered for a modest period of time (6-12weeks) before insurance/Medicare reimbursement ceases. At that point, COPD patients who were lucky enough to gain entry to such a program are on their own to self-manage their condition for the rest of their lives. For COPD patients who never gain entry to pulmonary rehab, there are few self-management guidance/support offered to help improve how they feel and slow the progression of lung disease.
We are convinced that COPD patients can employ many of the principles and practices of pulmonary rehabilitation at home or at a local fitness center. It’s the main reason we created our Breathe Better for Life guide and companion CD-ROM (http://www.breathebetterforlife.com/). We examined many pulmonary rehab studies, visited several pulmonary rehab facilities, spoke with a slew of leading pulmonary rehab practitioners & researchers, and reviewed the pulmonary rehab program guidelines established by the two main thoracic medicine societies. From these resources, we constructed an at-home better breathing program that incorporates the key successful elements of pulmonary rehabilitation. Whether you follow our program or one your doctor recommends, we would encourage any COPD patient who either can’t gain access to a hospital based rehab program in their area or who has been discharged from a rehab program to consider implementing a home based or fitness center based pulmonary rehab-style exercise program for the long-term.
For an example of the power of a home-based pulmonary rehab program, we direct your attention to an Egyptian study published earlier this year in the Annals of Thoracic Medicine that showed the dramatic benefits achieved through a home based pulmonary rehab program.
This particular study involved moderate to severe COPD patients who had recently been admitted to a hospital due to an acute exacerbation (doctor-speak for a shortness of breath attack intense enough to require a hospital admission). The researchers split the study subjects into two groups after their medical treatment and discharge from the hospital. One group received what the researchers call “usual standard of care” which typically means patients are sent home with some basic materials and instruction to take better care of themselves and are advised to visit their pulmonologist for periodic follow up visits. The second group was given in-hospital instruction on aerobic & strength training exercises as well as breathing techniques and then asked to self-manage their own at-home pulmonary rehab program every other day over a two month period. The patients in the pulmonary rehab group were not supervised in their at-home programs.
In our view the results were dramatic. In the researcher’s view the results were deemed clinically significant (such a designation means that the degree of observed improvement is large enough to demonstrate efficacy of the studied approach).
After two months, the home-based pulmonary rehab group experienced a 60% improvement in the distance walked in 6 minutes (a standard evaluation measure for assessing COPD patient physical conditioning) while the usual care group experienced a 18% decline in distance walked in 6 minutes. The home-based pulmonary rehab group reported a 66% improvement in perceived shortness of breath while the usual care group reported an 8% improvement. Self-reported improvement in fatigue, energy levels, and emotional well being for the home-based pulmonary rehab group ranged from 48-77% while the usual care group reported 7-13% improvements on the same measures. (Ghanem M, et al. Home-based pulmonary rehabilitation program: Effect on exercise tolerance and quality of life in chronic obstructive pulmonary disease patients. Ann Thorac Med. 2010 Jan; 5(1):18-25)
In our view, this study points out that with some level of instruction/information, a COPD patient can successfully implement a pulmonary rehab program at home. Other, earlier studies have reached similar conclusions.
For COPD patients who do proactively practice self-management techniques such as pulmonary rehab, the health benefits are substantial as another recent study noted, “Current estimates indicate that 70–80% of older individuals living with a chronic condition can reduce disease burden and preventable hospital admissions through the implementation of appropriate self-management. For instance, older adults who have participated in self-management programs experience significantly less dyspnea (shortness of breath attacks) and a 36% reduction in the chance of a hospital admission relating to COPD.” (Warwick M, et al. Self-management and symptom monitoring among older adults with chronic obstructive pulmonary disease. Journal of Advanced Nursing. 2010: 66(4), 784–793)
Therefore, we would encourage you to consider asking your doctor to refer you for admission to a pulmonary rehab program in your area to learn the principles and practices of this valuable therapy option that you can in turn practice for a lifetime.
If you can’t gain admission to a program in your area, ask your doctor to at least recommend an at-home pulmonary rehab-style exercise & nutrition program suited for your particular circumstance. If they can’t help design a program for you, consider visiting a local fitness center and ask to speak to a fitness instructor who is certified in designing exercise programs for people with chronic health conditions. They can not only design a program well suited for your condition, they can also guide you regarding how to do the specific exercises.
To educate yourself more about pulmonary rehab and/or to review our recommended at-home exercise program, consider purchasing our Breathe Better for Life guide and companion CD-ROM by visiting http://www.breathebetterforlife.com/ for ordering information.
However, pulmonary rehab is prescribed to an excruciatingly small slice of the COPD population (1-2%) and is typically only offered for a modest period of time (6-12weeks) before insurance/Medicare reimbursement ceases. At that point, COPD patients who were lucky enough to gain entry to such a program are on their own to self-manage their condition for the rest of their lives. For COPD patients who never gain entry to pulmonary rehab, there are few self-management guidance/support offered to help improve how they feel and slow the progression of lung disease.
We are convinced that COPD patients can employ many of the principles and practices of pulmonary rehabilitation at home or at a local fitness center. It’s the main reason we created our Breathe Better for Life guide and companion CD-ROM (http://www.breathebetterforlife.com/). We examined many pulmonary rehab studies, visited several pulmonary rehab facilities, spoke with a slew of leading pulmonary rehab practitioners & researchers, and reviewed the pulmonary rehab program guidelines established by the two main thoracic medicine societies. From these resources, we constructed an at-home better breathing program that incorporates the key successful elements of pulmonary rehabilitation. Whether you follow our program or one your doctor recommends, we would encourage any COPD patient who either can’t gain access to a hospital based rehab program in their area or who has been discharged from a rehab program to consider implementing a home based or fitness center based pulmonary rehab-style exercise program for the long-term.
For an example of the power of a home-based pulmonary rehab program, we direct your attention to an Egyptian study published earlier this year in the Annals of Thoracic Medicine that showed the dramatic benefits achieved through a home based pulmonary rehab program.
This particular study involved moderate to severe COPD patients who had recently been admitted to a hospital due to an acute exacerbation (doctor-speak for a shortness of breath attack intense enough to require a hospital admission). The researchers split the study subjects into two groups after their medical treatment and discharge from the hospital. One group received what the researchers call “usual standard of care” which typically means patients are sent home with some basic materials and instruction to take better care of themselves and are advised to visit their pulmonologist for periodic follow up visits. The second group was given in-hospital instruction on aerobic & strength training exercises as well as breathing techniques and then asked to self-manage their own at-home pulmonary rehab program every other day over a two month period. The patients in the pulmonary rehab group were not supervised in their at-home programs.
In our view the results were dramatic. In the researcher’s view the results were deemed clinically significant (such a designation means that the degree of observed improvement is large enough to demonstrate efficacy of the studied approach).
After two months, the home-based pulmonary rehab group experienced a 60% improvement in the distance walked in 6 minutes (a standard evaluation measure for assessing COPD patient physical conditioning) while the usual care group experienced a 18% decline in distance walked in 6 minutes. The home-based pulmonary rehab group reported a 66% improvement in perceived shortness of breath while the usual care group reported an 8% improvement. Self-reported improvement in fatigue, energy levels, and emotional well being for the home-based pulmonary rehab group ranged from 48-77% while the usual care group reported 7-13% improvements on the same measures. (Ghanem M, et al. Home-based pulmonary rehabilitation program: Effect on exercise tolerance and quality of life in chronic obstructive pulmonary disease patients. Ann Thorac Med. 2010 Jan; 5(1):18-25)
In our view, this study points out that with some level of instruction/information, a COPD patient can successfully implement a pulmonary rehab program at home. Other, earlier studies have reached similar conclusions.
For COPD patients who do proactively practice self-management techniques such as pulmonary rehab, the health benefits are substantial as another recent study noted, “Current estimates indicate that 70–80% of older individuals living with a chronic condition can reduce disease burden and preventable hospital admissions through the implementation of appropriate self-management. For instance, older adults who have participated in self-management programs experience significantly less dyspnea (shortness of breath attacks) and a 36% reduction in the chance of a hospital admission relating to COPD.” (Warwick M, et al. Self-management and symptom monitoring among older adults with chronic obstructive pulmonary disease. Journal of Advanced Nursing. 2010: 66(4), 784–793)
Therefore, we would encourage you to consider asking your doctor to refer you for admission to a pulmonary rehab program in your area to learn the principles and practices of this valuable therapy option that you can in turn practice for a lifetime.
If you can’t gain admission to a program in your area, ask your doctor to at least recommend an at-home pulmonary rehab-style exercise & nutrition program suited for your particular circumstance. If they can’t help design a program for you, consider visiting a local fitness center and ask to speak to a fitness instructor who is certified in designing exercise programs for people with chronic health conditions. They can not only design a program well suited for your condition, they can also guide you regarding how to do the specific exercises.
To educate yourself more about pulmonary rehab and/or to review our recommended at-home exercise program, consider purchasing our Breathe Better for Life guide and companion CD-ROM by visiting http://www.breathebetterforlife.com/ for ordering information.
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