New study shows 56% lower lung cancer risk among those with high levels of Vitamin B6

Vitamin deficiencies are highly common among current smokers, former smokers and COPD patients. The primary mechanism depressing levels of essential vitamins is exposure to cigarette smoke and the inflammation it causes throughout the human body.

Researchers continue to examine a range of vitamins and other naturally occurring food based nutrients (primarily antioxidants) to judge the impact of deficiencies in COPD patient and smoker outcomes. While very few studies have pointed to optimum dosages for most of these nutrients, researchers continue to look at these nutrients as potential solutions to help moderate the effects of cigarette smoke, airway inflammation and lung disease.

We’ve recently written about 2 such ingredients (folate and Vitamin E). Click here for our posting on folate and click here for our posting on Vitamin E.

Now you can add Vitamin B6 to the list. The Journal of the American Medical Association just published the results of a retrospective study to evaluate the connection between B Vitamin deficiency and lung cancer. They discovered that study participants with the highest levels of B6 in their blood serum had a 56% lower risk of developing lung cancer compared with those with the lowest level of B6 (Johansson, M, et al. Serum B Vitamin Levels and Risk of Lung Cancer. JAMA. 2010; 303 (23):2377-2385).

In explaining their results, the study’s authors indicated their belief that B Vitamin deficiencies increase the possibility of gene damage and mutation which in turn elevates cancer risk.

In the study itself, the research team accessed the medical records of nearly 400,000 people who had agreed to participate in a large, long-term study population known as the European Prospective Investigation into Cancer and Nutrition (EPIC). In particular the study group sought to determine if there were any statistically significant correlations between blood levels of 4 particular B Vitamins (B2, B6, folate, and B12) and lung cancer risk.

As mentioned above, the researchers discovered that of the four B Vitamins, there was a notable reduction in lung cancer incidence among participants who had higher levels of Vitamin B6 in their past blood work across all study participants (meaning both smokers and non-smokers). They also discovered a similar but lesser correlation with folate that appeared only among current smokers and former smokers.

For a detailed description about Vitamin B6, including food sources high in Vitamin B6 content, we recommend visiting the National Institutes of Health’s Office of Dietary Supplements web site by clicking here.

For a more detailed description of the JAMA study and its results, please click here.

Chinese herb dramatically reduces inflammation caused by cigarette smoke

A new study published online ahead of print in the journal Pharmacology and Pulmonology Therapeutics demonstrates the effectiveness of the Chinese herb known as scutellaria root in reducing airway inflammation caused by cigarette smoke exposure.

Scutellaria root, also known as Chinese Skull Cap, contains an extract called baicalin. According to the study’s authors, baicalin has been shown to possess anti-inflammatory, anti-bacterial and anti-viral properties in a number of other studies. However, the study authors note that baicalin has never been previously evaluated in relation to its impact on inflammation caused by cigarette smoke among COPD patients. (Lixuan Z, et al, Baicalin attenuates inflammation by inhibiting NF-kB activation in cigarette smoke induced inflammatory models, Pulmonary Pharmacology & Therapeutics 2010, doi:10.1016/j.pupt.2010.05.004)

Therefore, the research team set out to evaluate baicalin’s ability to reduce airway inflammation caused by exposure to cigarette smoke. The study was based on a “rat model” which simply means the researchers used laboratory rats instead of human subjects (this is a common practice for many dietary supplement studies because it is easier to control external variables in laboratory animals in comparison human subjects and such a study is less expensive to undertake). So while the results of the study are promising, more research will be required (preferably using live human subjects) before a wide cross section of pulmonology professionals will support the conclusions. Nevertheless, the results of the study are worth your attention in our opinion.

To begin, the study authors describe the impact of cigarette smoke on the lungs as follows: “Smoking is one of the main causes of COPD. CS (cigarette smoke) directly damages airway epithelium (lining of lung tissue) and activates macrophages and lymphocytes (white blood cells) to generate pre-inflammatory cytokines TNF-a, IL-6 and IL-8 (cytokines are proteins that signal the production of other white blood cells). It then activates neutrophils (white blood cells) leading to chronic bronchial inflammation and emphysema.” In other words, cigarette smoke triggers production of cytokines and neutrophils and the higher the level of cytokines and neutrophils, the higher the level of airway inflammation.

So in the study, the authors sought to evaluate the impact of varying dosages of baicalin on these immune response components (white blood cells and proteins that signal their production), and in turn determine baicalin’s impact on lung tissue inflammation.

The research team used 36 rats in the study and divided them into a control group which was not exposed to cigarette smoke and five other groups that were exposed to cigarette smoke over the 5 week study period (one group exposed to cigarette smoke with no treatment, another group given a prescription drug known to reduce inflammation called DMX or dexamethasone, a group given 20 milligrams of baicalin per 1 kilogram of body weight, a group given 40mg/1kg of baicalin, and the final group provided 80mg/1kg of baicalin).

After the 5 week period the rats were euthanized and their tissues were evaluated for the presence of inflammation and the specific immune response components mentioned above. They discovered that in every component measured, baicalin markedly reduced the precursors of inflammation and by extension the inflammation itself.

As the authors explained, “Our COPD rat models showed characteristic pathological changes of chronic bronchitis in the trachea and bronchi and the alveolar type of emphysema. These pathological changes in rats are consistent with human chronic bronchitis and obstructive pulmonary disease. Percentage of neutrophils of CS group was significantly higher than Control group. It indicated that CS exposure can induce a significant increase of neutrophil percentage. In addition, the difference of neutrophil percentage is the largest in the differential leukocyte counting items. Thus the COPD inflammation is mainly caused by neutrophil inflammation. According to Table 1, 20 mg, 40 mg and 80 mg dosage baicalin reduced total leukocyte count by 33%, 47% and 54% respectively. It revealed that baicalin has substantial anti-inflammatory effect on rats with COPD.”
There are no human dosage level recommendations available today for smokers and COPD patients but hopefully other researchers will follow up this research with human studies that provide better direction.

In the interim, there are some Chinese Skullcap dietary supplements available online and in health food retail stores. The most common dosage range we’ve seen advertised is between 100-200mg daily dosage. Be sure to look at the supplement facts box to ensure the formula contains the extract baicalin. Also be aware that just because a supplement facts box says there is 200mg of scutellaria root it does not mean that it has 200mg of the active ingredient baicalin. This is a common trick among supplement marketers to make it appear they have more of a particular herbal ingredient than is really present in the formula. Look for formulas which indicate the concentration of baicalin (such a label would say something like 200mg of scutellaria root, baicalin 20% concentration - meaning that there is actually only 40mg of baicalin in the formula). At least you will know the manufacturers of such products are being open and honest about what is in their product if they describe the baicalin concentration in the supplement facts box. Also, as always, please make sure you consult with your physician before taking any dietary supplement to ensure that there are no counter indications with your current medications or particular situation.

How Seasonality Impacts Pulmonary Rehabilitation Outcomes in COPD patients

Last week, a group of UK based researchers reported the results of a study that found notable differences in COPD patient physical activity achieved during pulmonary rehabilitation depending on what season of the year patients started their rehab. (Sewell L, et al. Seasonal Variations Affect Physical Activity and Pulmonary Rehabilitation Outcomes. J Cardiopulm Rehabil Prev. 2010 Jun 14. [Epub ahead of print])

The study findings shed light on a number of interesting differences in COPD patient conditioning and performance based on when patients start rehab (spring, summer, autumn or winter). The most noteworthy finding according to the study authors was that COPD patients who began a pulmonary rehab program during the winter months achieved the largest boost in subsequent physical activity – a 130% increase in mean “physical activity” compared to baseline measures taken prior to the rehab program (the term “physical activity” in this study means how much COPD patients move around doing normal every day activities outside of the pulmonary rehabilitation program – sometimes referred to as “activities of daily living” by respiratory care professionals). 

The pulmonary rehab program followed during the study lasted 7 weeks and involved 95 patients. COPD patients visited an outpatient rehab facility 2 times each week for 2 hours. In each session, patients participated in 1 hour of aerobic and strength training exercise and 1 hour of educational counseling on topics ranging from nutrition to breathing techniques to proper use of medications among other topics. Patients were also asked to exercise at home on a daily basis by walking and practicing some of the strength training exercises. Patients kept a log of their unsupervised at-home exercise and provided their data to the research team.

The fact that COPD patients who began rehab during the winter months saw the largest increase in physical activity did not surprise the researchers given that in geographic areas that experience cold winters (such as the UK), the incidences of COPD exacerbations that require hospitalization jump significantly.  The reigning belief is that when COPD patients are exposed to cold, inhospitable outdoor/indoor temperatures they become far more sedentary. The more sedentary a COPD patient is, the lower their level of physical conditioning.

By way of example, patients in the study who began rehab in the summer months averaged almost 9,000 activity units on the device used to measure physical activity (a uniaxial accelerometer – sort of a souped-up pedometer), while patients who began in the winter months averaged just over 3,000 activity units.  That’s obviously a huge difference and drives home the researchers point.

What seemed to surprise the researchers is how little the rehab program lifted the summer group’s physical activity (2% increase) in comparison to the winter group (130% increase – which translated to over 7,000 activity units for the winter group by the end of the study – still below the summer group but much closer).

Does this mean that pulmonary rehab is not effective for those who commence a program in the summer months?  Absolutely not. It just means that COPD patients who begin a rehab program during milder/warmer/dryer weather are more active at the outset of a rehab program compared to those who begin in the winter months and therefore don’t achieve as dramatic gains in their activity levels outside of rehab.

In support of this contention it is worthwhile to look at the improvement in exercise performance of the four seasonal groups reported in this study.  To assess exercise performance, the researchers used a test known as the Incremental Shuttle Walk Test (ISWT). In an ISWT patients are asked to walk as fast as they reasonably can for as long as they reasonably can before fatigue requires them to stop. The researchers asked patients to perform 2 ISWT tests, one at the outset of the program (baseline) and one at the end of the study.

Not surprisingly, the winter group had the lowest mean baseline ISWT at 146 meters walked before fatigue required them to stop, while the summer group had the highest mean baseline ISWT at 225 meters.  Both groups (in fact, all four groups) saw their end-of-study ISWT mean distance walked rise between 79-83 meters. This translated into a 54% improvement in exercise performance for the winter group and a 37% improvement in the summer group with the spring and autumn groups’ improvement falling between these two extremes.

While the researchers concluded there was not a statistically significant difference in the absolute increase in distance walked among the four seasonal groups, it seems clear to us that all four groups experienced statistically significant improvements in overall exercise performance regardless of seasonality.

So while seasonality does play a role in COPD patient physical conditioning at the outset of a pulmonary rehab program, and as a result can influence the degree of improvement experienced in rehab, all COPD patients can experience significant conditioning benefits by participating in such a program regardless of season.

Study shows potential risk of heart attack and stroke after COPD exacerbation

A recently published study indicated that approximately 1-2% of COPD patients following hospitalizations for an exacerbation (a shortness of breath attack severe enough to require hospitalization often triggered by a respiratory infection). For heart attacks, the risk was most pronounced within 1-5 days after an exacerbation, while the stroke risk was most pronounced 1-49 days after an exacerbation. (Donaldson GC, et al. Increased Risk of Myocardial Infarction and Stroke Following Exacerbation of COPD. Chest. 2010; 137(5):1091-1097)

The 1-2% range seems a very small number to us but the UK based researchers declared that even at these levels the results of their study are clinically significant because these risk levels are double those reported in stable COPD patients.

The study team suggested the reason for these increased risk levels for heart attack and stroke was that systemic inflammation associated with a COPD exacerbation event lingers beyond the event itself. Systemic inflammation is best described as persistent inflamed tissues in the lungs (and other parts of the body) that over long periods of time causes obstruction in the airways that make it difficult to breathe fully and makes it tougher for the body to fight off respiratory infections by depressing immune function.

Our only quibble with the study is the author’s conclusion that, “Knowledge of these risks would inform rational drug prescribing for prevention of cardiovascular disease, not only at exacerbation but also in stable COPD.”

What about smoking cessation? Pulmonary rehabilitation? Boosting antioxidant consumption (through diet and/or nutritional supplementation)? These three treatment strategies have been shown to reduce symptoms associated with airway inflammation (most notably reduced shortness of breath) and are not drug dependent. Further, smoking cessation and pulmonary rehab have been shown to reduce the number and intensity of subsequent exacerbation events among COPD patients. We think is in COPD patients’ best interests to discuss these other treatments options with their physicians in addition to exploring their recommendations for pharmaceutical support.  We have previously written a number of blog articles about the power of pulmonary rehabilitation and a range of antioxidant supplements that show promise for those who suffer from chronic shortness of breath. Check out our blog archive for more information on these treatment options.

General healthy eating tips for COPD patients and smokers

Poor dietary intake of important nutrients is common among COPD patients and smokers. Most pulmonology professionals believe that improving dietary intake can contribute to a reduction in shortness of breath symptoms and in slowing the progression of lung disease.

However, there is no current standard recommended diet offered by physicians for smokers and people with COPD. This is because there are two widely divergent ways poor diet is evidenced in COPD patients and smokers (underweight/overweight) that necessitate different recommendations. Further complicating matters to provide general dietary advice is the wide range of medications used by COPD patients. Some of these medications prevent absorption of key nutrients or otherwise deplete key nutrients in the body.

Most COPD patients/smokers are underweight and in many cases are considered malnourished. Diet recommendations for this audience typically focus on increasing consumption of calorie dense foods to add weight and improve access to vital base nutrients. According to a recent article, (Shepherd A. The nutritional management of COPD: an overview. British Journal of Nursing. 2010; 19(9): 559-562), respiratory care professionals believe the main causes driving underweight/malnourished COPD patients include: 

• Difficulty chewing because of chronic shortness of breath
• Chronic mouth breathing which alters the taste of food
• Excess mucus production depressing appetite
• Coughing spasms which can lead to retching and vomiting
• Depression
• Lack of motivation/effort to prepare meals
• Side effects of medication

On the other end of the spectrum, there is a segment of COPD patients who are obese but, according to the same British Journal of Nursing article, researchers have far less understanding of what drives the connection between COPD and obesity. The diet recommendations for this audience tend to focus on reduction of overall caloric intake and substitution of high fat/high carbohydrate foods with foods that provide a greater proportion of protein compared to fat/carbohydrates.

 

However, whether underweight or overweight, there are some valuable healthy eating tips for those who suffer from chronic shortness of breath offered in the British Journal of Nursing article that we’ve categorized into two different groupings:

 

Before eating:

• Rest prior to meals if possible
• Avoid consuming fluids prior to meals to avoid bloating
• Choose foods that are easy to prepare to conserve energy for eating
• Choose foods are soft and easy to chew
• For foods that are not naturally soft/easy to chew - cut or blend food into smaller, softer pieces
• Avoid foods that cause gas and bloating, which can cause abdominal/diaphragm discomfort

While eating:

• Maintain an upright position during/after meals to assist in digestion & reduce abdominal pressure 
• Eat meals when energy levels are at their highest 
• Eat several small meals/snacks throughout the day instead of a couple large meals 
• Eat slowly and avoid swallowing air 
• Limit salt intake as this can cause fluid retention, making breathing more difficult
• Limit caffeinated beverages and sugary foods as both contribute to inflammation & anxiety 
• Drink fluids at the end of the meal

Separately, there is a significant and growing body of evidence that people with COPD and smokers have dramatically reduced levels of antioxidants in their bodies. The significant depletion of antioxidants is believed to be mostly related to the pro-oxidative effects of cigarette smoke. Further, a number of studies have shown that the majority of COPD patients and smokers do not consume foods rich in antioxidant content (colorful fruits and vegetables are the typical sources of antioxidants in a traditional diet). The combination of pro-oxidative stress created by cigarette smoke and poor intake of anti-oxidative nutrients is believed to be a significant contributing factor to the degree of systemic inflammation present in COPD patients and smokers. In turn, systemic inflammation is believed to be a major cause of airway obstruction and the inability to breathe fully.

 

While researchers suggest that boosting antioxidant intake through diet and nutritional supplementation can raise blood levels of antioxidants there is not yet a standard recommendation regarding which foods/supplements to consume, and in what quantities/dosages to consume them. However, it is hard to imagine that a COPD patient or current smoker could consume enough antioxidant rich food to offset the effects of cigarette smoke/lung disease. Therefore, we recommend that COPD patients and smokers consider taking a high potency multi-nutrient in addition to consuming more antioxidant rich foods. It is worth at least discussing a high-potency multi-nutrient with your doctor. No individual ingredient in any supplement is a silver-bullet to prevent or cure lung disease, but a broad range of ingredients that have antioxidant properties may prove helpful in restoring your body’s natural antioxidant defenses.

Early use of antibiotics after COPD exacerbation improves patient outcomes

In late May, a group of Massachusetts based researchers published the results of a study examining the effectiveness of early antibiotic therapy for COPD patients hospitalized with an acute exacerbation. The researchers concluded that those patients who began receiving antibiotics within 2 days of admission to the hospital experienced significantly fewer inpatient complications and subsequent hospital readmission. (Rothberg M, et al. Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. JAMA. 2010; 303(20): 2035-2042)

An acute exacerbation is generally defined as a significant shortness of breath attack, often brought on by a respiratory infection and/or excess production of sputum. While it might seem commonsense to treat all COPD patients who are hospitalized due to an acute exacerbation with antibiotics, they are not consistently prescribed. According to the research team, current treatment guidelines only call for prescribing antibiotics when COPD patients are producing an increased amount of sputum. This study’s results challenge this guideline. In fact, the research team recommends providing early antibiotics to all COPD patients who are admitted to hospitals with an acute exacerbation.

In the study, the research team reviewed hospital admission records of over 80,000 COPD patients admitted over 400 U.S. hospitals between 2006 and 2007 and looked for differences in patient outcomes between those who received early antibiotics and those who did not.

While a large majority (79%) of the patients received at least 2 days of antibiotics during their hospital stay, there were notable differences in the outcomes of patients who began receiving antibiotics within the first 2 days of their stay versus those who began antibiotics later in their hospital stay. Those who received the antibiotics early in their hospital stay were less likely to be placed on mechanical ventilation, had lower inpatient mortality, and had fewer readmissions for subsequent exacerbations within the first 30 days after discharge.

The results, published in the Journal of the American Medical Association, were widely reported in media outlets around the globe. For a good synopsis of the study’s findings and some pull quotes from the research team leader, Dr. Michael Rothberg, click here.

Is ground walking better than cycling for COPD patients in pulmonary rehab programs?

A new research study published in the Journal of Physiotherapy revealed that COPD patients who “ground walked” (i.e. walking on the ground, not a treadmill) as part of a pulmonary rehabilitation exercise program reported significantly higher walking endurance capacity than COPD patients who cycled.

In many pulmonary rehab programs, stationary cycles are used for aerobic exercise due to space constraints (not many facilities have large indoor walking areas) and due to concerns about patient falls (many moderate to severe COPD patients have difficulty keeping their balance due to poor leg strength). In addition, a number of programs use treadmills as a substitute for indoor ground walking. A debate has gone back and forth over time as to which method is optimal. While this study does not resolve that debate, it does show that indoor ground walking should be considered as an additional form of aerobic exercise in pulmonary rehab programs.

The Australian research team that led the study divided 32 COPD patients into two groups. One group performed indoor ground walks 30-45 minutes 3 days a week for 8 weeks. The other group participated in indoor stationary cycle training for the same 30-45 minutes, 3 days a week during the 8 week study. The researchers evaluated exercise performance differences between the two groups on a variety of measures at the outset of the study (otherwise known as baseline measurements) and the end of the study. (Leung RW, et al. Ground walk training improves functional exercise capacity more than cycle training in people with chronic obstructive pulmonary disease (COPD): a randomised trial. J Physiother. 2010; 56(2):105-12).

The results of the study showed no significant differences between improvements in physical conditioning between the ground-walk group and the cycle group on most of the evaluated measures (including improving peak walking capacity, peak and endurance cycle capacity and quality of life).

However, in an endurance capacity test known as the endurance shuttle walk test (ESWT) the ground-walk group’s improvement between the baseline ESWT and the end of study ESWT was notably better than the cycle group’s improvement. In fact, the ground-walk group improvement exceeded the cycle group improvement by 279 seconds (or approximately 4.5 minutes).

The endurance shuttle walk test has two different components. First, patients are asked to walk a defined distance as fast as they reasonably can and a baseline measure of their speed/pace is recorded. This component of the test is known as an Incremental Shuttle Walk Test (ISWT). Then, in the second component of the ESWT, a patient is asked to walk at 75% to 95% of the maximum speed/pace exhibited in the ISWT for as long as they can before they need to stop and rest. During the ESWT, the patients are prompted to keep pace in the 75%-95% range by researchers.

Based on this outcome the research team concluded, “This study provides evidence for ground walking as a mode of exercise training in pulmonary rehabilitation programs.”

Getting ahead of the curve - pulmonary rehab for mild COPD patients

In late April 2010, the journal Nursing Times published a study review article that posed the question, “Do people with mild COPD benefit from early pulmonary rehabilitation programs?”

The study, conducted at a U.K. based outpatient medical services center known as a PCT (Primary Care Trust), involved a 3 week pre-pulmonary rehab program for 8 mild COPD patients. During the program, patients met twice a week for two hours to receive educational counseling from the researchers regarding exercise, breathlessness, relaxation techniques, smoking cessation, proper use of inhalers and nutrition among other topics. (Gulrajani R. Do people with mild COPD benefit from early pulmonary rehabilitation programmes? Nursing Times. 2010:106: 17, Epub ahead of print)

At the end of the program 50% of the patients in the study reported less dyspnea (shortness of breath episodes) and said they had more control over their condition. 25% of the study participants reported feeling less fatigued. 100% of the patients in the study felt the program was beneficial and would recommend it to other mild COPD patients.

While scientific researchers will likely discount the results of the study given its small size, construction, and duration, the article explores a critical question for both practitioners and patients – is there value in providing access to some of the core information provided in pulmonary rehabilitation programs for people who have yet to develop severe lung disease?

To fully appreciate this question, it is important to understand that today pulmonary rehabilitation is typically only offered to moderate to severe COPD patients in the U.K. (same is true in the U.S.), meaning mild COPD patients cannot gain access to such a program. Pulmonary rehabilitation is a treatment program which combines observed/managed aerobic and strength training exercise with counseling on nutrition, breathing techniques, airway clearing techniques, and proper use of medications among other topics. It has been proven time and time again as effective in improving COPD patient physical conditioning, reducing shortness of breath, reducing hospital admissions and improving overall patient quality of life.

According to the article author, people in the U.K. who visit a PCT complaining of chronic shortness of breath typically receive a spirometry test (to determine lung function quality). If mild COPD is suspected, a patient receives counseling on smoking cessation (if they smoke). They may also be prescribed rescue inhalers (which temporarily open airways during shortness of breath attacks) and provided instruction on the proper use of the inhalers. These counseling sessions typically last only 15 minutes and therefore a minimum of valuable information beyond these topics is communicated and, as mentioned above, pulmonary rehab is not offered. The same basic patient treatment scenario also occurs in U.S. medical practices.

To the researchers, this truncated practitioner/patient interaction leaves a lot to be desired especially when the practitioners know that pulmonary rehab has such a strong track record in improving symptoms and quality of life – even for those with mild COPD. So the researchers decided to investigate a novel approach to “try to prevent deteriorating lung function rather than wait until patients had moderate to severe disease and (then) could attend PRP (pulmonary rehabilitation program).”

Knowing it would not fly with their health care system administrators to simply offer a full scale pulmonary rehab program for mild COPD patients (pulmonary rehab services are only reimbursed for moderate to severe COPD patients), the U.K. based researchers sought to offer a mini-education program based on the core elements of pulmonary rehabilitation.

Intuition would suggest that offering a full scale pulmonary rehab as a treatment option earlier in the development of COPD might help slow or halt the progression of lung disease and reduce hospital admissions related to COPD exacerbation events. And indeed, there have been previously published studies that demonstrate efficacy of pulmonary rehab for those with mild COPD as well as more severe cases. However, despite the evidence that pulmonary rehab is helpful to people with mild COPD, it remains a treatment option largely only available to those with more advanced lung disease. And this reality is frustrating for the on the ground physicians, therapists and nurses who work in pulmonary rehab settings who believe they could make a bigger difference if they were given the opportunity to work with less severe COPD patients. This study attempts to fill the frustrating void with a mini-pre-rehab program and its results seem to demonstrate value in their approach (understanding that more rigorous follow on research is warranted).

This state of affairs is the primary reason we created the Breathe Better for Life guide and companion CD. We desired to expand awareness of pulmonary rehab and provide people who would otherwise have no access to its proven efficacy the opportunity to undertake a rehab-style program based on the principles of this powerful treatment option (in consultation with their doctor). For those interested in learning more about the guide and CD, visit http://www.breathebetterforlife.com./

We would encourage those who suffer from chronic shortness of breath to engage your physician (primary care or pulmonologist) about pulmonary rehab and whether it is appropriate to your situation. If the only weapons in your arsenal to manage your lung disease are rescue inhalers, antibiotics prescriptions, and/or supplemental oxygen, you are dramatically selling yourself short. These treatments do relieve short-term symptoms, but none of them improve physical conditioning, reduce shortness of breath on an ongoing basis, or improve long-term sense of quality of life like pulmonary rehabilitation.

Quadriceps resistance training after a COPD exacerbation improves muscular function

We have written often about the power of pulmonary rehabilitation in improving COPD patient physical conditioning, shortness of breath and quality of life. In most pulmonary rehabilitation studies, aerobic exercise (i.e. walking, cycling) is the primary exercise mode studied (although many studies also combine strength training with aerobic exercise).

So it was interesting to read a new study published in the journal Respiratory and Critical Care Medicine which showed 8 days of moderate strength training of the quadriceps muscles after an acute COPD exacerbation (doctor-speak for a shortness of breath attack significant enough to require hospital admission) improved muscular function and distance walked – even one month after discharge. (Troosters T, et al. Resistance Training Prevents Deterioration in Quadriceps Muscle Function During Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Respiratory and Critical Care Medicine. May 2010: 181; 1072-1077)

Unlike pulmonary rehabilitation, which (when prescribed) is typically administered post-hospital discharge, this study sought to evaluate the effects of strength training during the 8-day exacerbation-related hospital stay of 36 COPD patients who completed the study. The research team divided the 36 patients into two groups. One group (17 patients) received quadriceps muscle strength training during their hospital stay while the other group (19 patients) received no training.

The group that trained the quadriceps muscles (the large set of muscles on the top of the leg between the hip and knee) performed 3 sets of 8 repetitions each day of their 8-day hospital stay on a knee extension weight machine (a machine which isolates the quadriceps muscles for strengthening). For this particular exercise, a person sits on the back supported seat of the machine, placing their feet behind a padded arm connected to the weights. The patient then raises their feet upward pressing their lower shins against the weighted arm of the machine until their toes reach approximately knee height. Then the patient lowers their feet and the weighted arm almost all the way back down before repeating this movement. The repetitions during the study were performed at an average of 70% of each patient’s 1-rep maximum force. Basically this means that at the outset of the study each patient was tested to see how much weight they could comfortably lift one time on the machine and then the researchers conducted the exercise sessions at approximately 70% of that weight.

Among other measures, the research team evaluated maximum quadriceps force and distance walked in 6 minutes for both the quadriceps training group and the control group which received no training. These measurements were taken at the beginning the study, at the end of the 8-day hospitalization, and again 30 days after discharge.

The results showed that the quadriceps training group produced an average 10% increase in quadriceps muscle force and distance walked in 6 minutes at the end of the 8 day hospitalization and more remarkably maintained both measures of improvement 30 days after discharge. By contrast, the control group saw their quadriceps muscle force and distance walked in 6 minutes decline slightly at discharge and decline slightly further 30 days after discharge.

For the quadriceps group, the research team viewed the degree of increase in quadriceps force as significant but did not view the improvement in distance walked as significant (typically in pulmonary rehab studies, an improvement of 50 meters walked in 6 minutes is considered clinically significant – the trained group in this study increased by only 38 meters).

Still, that’s pretty amazing improvement considering these COPD patients did not go through a formal 6-8 week pulmonary rehab program where they would have participated in both aerobic and strength training exercises for about an hour a day, 3 days a week over 6-8 weeks. They simply performed 3 sets of 8 reps of 1 exercise – knee extensions – each day of their 8 day hospitalization (which likely took less than 15 minutes to complete each day). This low level of activity over a very short period of time nearly achieved a clinically significant improvement in walking distance.

The research team theorized that encouraging physical activity as soon as feasible after a hospitalization for a breathing attack would help COPD patients recover from the exacerbation more quickly. In testing this hypothesis, they further believed that moderate strength training of a large, lower extremity muscle group like the quadriceps would place less intense breathing burden on a hospitalized COPD patient versus attempting aerobic exercise. Their results seem to bear out both suppositions as muscle strength improved and there were no adverse events reported by the group who underwent the exercise program.

Interestingly, the study team seemed a little surprised that the quadriceps force and 6 minute walk distance were maintained 30 days after discharge given the low dose/duration of the strength training regimen. They speculated that the quadriceps group patients may have become more active in basic daily activities post-discharge given that their quadriceps muscles had strengthened (i.e. the quadriceps muscles are the dominant muscles used when walking). It is another example of the power of even simple exercise to improve the fortunes of COPD patients.