CONCISE CLINICAL REVIEW

Pulmonary Rehabilitation and Physical Activity in Patients with Chronic

Obstructive Pulmonary Disease
Martijn A. Spruit1,2, Fabio Pitta3, Edward McAuley4, Richard L. ZuWallack5, and Linda Nici6
1
Department of Research and Education, CIRO1, Center of Expertise for Chronic Organ Failure, Horn, the Netherlands; 2REVALRehabilitation
Research Center, BIOMEDBiomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek,
Belgium; 3Laboratory of Research in Respiratory Physiotherapy (LFIP), Department of Physiotherapy, Universidade Estadual de
Londrina, Londrina, Brazil; 4Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana,
Illinois; 5Department of Pulmonary/Critical Care Medicine, Saint Francis Hospital, Hartford, Connecticut; and 6Pulmonary/Critical
Care Section, Providence VA Medical Center, Providence, Rhode Island
ORCID ID: 0000-0003-3822-7430 (M.A.S.).

Abstract capacity to greater participation in activities involving physical

Physical inactivity is common in patients with chronic obstructive
pulmonary disease (COPD) compared with age-matched healthy
individuals or patients with other chronic diseases. Physical
inactivity independently predicts poor outcomes across several
aspects of this disease, but it is (at least in principle) treatable in
patients with COPD. Pulmonary rehabilitation has arguably the
greatest positive effect of any current therapy on exercise capacity in
COPD; as such, gains in this area should facilitate increases in
physical activity. Furthermore, because pulmonary rehabilitation
also emphasizes behavior change through collaborative self-
management, it may aid in the translation of increased exercise
activity. Both increased exercise capacity and adaptive behavior
change are necessary to achieve signicant and lasting increases in
physical activity in patients with COPD. Unfortunately, it is readily
assumed that this translation occurs naturally. This concise clinical
review will focus on the effects of a comprehensive pulmonary
rehabilitation program on physical activity in patients with COPD.
Changing physical activity behavior in patients with COPD needs an
interdisciplinary approach, bringing together respiratory medicine,
rehabilitation sciences, social sciences, and behavioral sciences.
Keywords: COPD; pulmonary rehabilitation; self-efcacy;
physical activity; behavior change

Lack of activity destroys the good
condition of every human being, while
movement and methodical physical
exercise save it and preserve it. This
frequently quoted phrase (13), attributed
to Plato, tells us that the association
between physical inactivity and poor
outcome, including the benecial effects of
its treatment, has been known since
antiquity. More recently, the World Health
Organization noted that physical inactivity,
which is unfortunately present in 1 of 3
adults (4), is among the 10 leading risk
factors for death worldwide (5). The
importance of a focus on the problem of
physical inactivity in chronic obstructive
pulmonary disease (COPD) is based on
several factors: (1) COPD is a major public
health problem that is highly prevalent (6),
and is currently the third leading cause of
death worldwide (7); (2) physical inactivity
appears to be more common in patients
with COPD compared with age-matched
healthy individuals (8) or even patients
with other chronic diseases (e.g., coronary
artery disease or rheumatoid arthritis) (9);
(3) physical inactivity independently
predicts poor outcomes across several
aspects of this disease (10, 11); (4) physical
inactivity (at least in principle) is treatable
in patients with COPD (12), although
a causal link between increases in physical
activity and improvements in health
outcome has not been established (13); (5)
physical activity substantially decreases
over time in patients with COPD and to
a greater extent than in non-COPD subjects
(11); (6) a sustained low level of physical
activity over time is associated with an
accelerated progression of exercise
intolerance and muscle depletion (14); and
(7) clinicians may underappreciate the

( Received in original form May 13, 2015; accepted in final form July 9, 2015 )
Author Contributions: M.A.S., F.P., E.M., R.L.Z., and L.N. all contributed to the conception and design of this work; they all participated in writing, revising, and
approving the manuscript; and they are in agreement as to the integrity of the work and the contributions of all the authors.
Correspondence and requests for reprints should be addressed to Martijn A. Spruit, Ph.D., P.T., Department of Research and Education, CIRO, Hornerheide 1,
6085 NM Horn, the Netherlands. E-mail: martijnspruit@ciro-horn.nl
CME will be available for this article at www.atsjournals.org
Am J Respir Crit Care Med Vol 192, Iss 8, pp 924933, Oct 15, 2015
Copyright 2015 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201505-0929CI on July 10, 2015
Internet address: www.atsjournals.org

924 American Journal of Respiratory and Critical Care Medicine Volume 192 Number 8 | October 15 2015
CONCISE CLINICAL REVIEW
importance of physical inactivity in their
respiratory patients.
This concise clinical review will rst
cover the denition of physical activity
(which is a different construct than exercise
capacity), its prevalence and signicance
in COPD, its objective measurement, risk
factors for physical inactivity, and potential
ways to improve or maintain one or
more components of physical tness.
Pulmonary rehabilitation has arguably the
greatest positive effect of any current therapy
on exercise capacity in COPD (15). As such,
gains in this area should facilitate increases
in physical activity. Furthermore, because
pulmonary rehabilitation also emphasizes
behavior change through collaborative self-
management, it may aid in the translation of
increased exercise capacity to greater
participation in activities involving physical
activity. Accordingly, the second part of
this review will focus on the effects of this
comprehensive intervention on this
important outcome.
Pulmonary Rehabilitation
The 2013 Statement on Pulmonary
Rehabilitation from the American Thoracic
Society (ATS) and European Respiratory
Society (ERS) denes pulmonary
rehabilitation as a comprehensive
intervention based on a thorough patient
assessment followed by patient-tailored
therapies, which include, but are not
limited to, exercise training, education,
and behavior change, designed to improve
the physical and psychological condition
of people with chronic respiratory disease
and to promote the long-term adherence
of health-enhancing behaviors (16). This
denition clearly states that optimization of
functional status and increased participation
are prominent goals for this intervention.
Physical activity is a prominent component
of functional status. Participation, which is
an important aspect of quality of life,
indicates the abandonment of a sedentary,
home-bound lifestyle for a more active
involvement in activities of daily living.
Exercise training and collaborative self-
management education, which are
integral components of comprehensive
pulmonary rehabilitation (17), both
directly and indirectly promote physical
activity and participation. Exercise training
increases physical exercise tolerance (18),
allowing patients to have the capacity to
Concise Clinical Review
do more things, whereas self-efcacy
teaching encourages patients to go out and
do more (19).
Although pulmonary rehabilitation
has no direct effect on the physiologic
derangements in lung function, it provides
the greatest improvements in dyspnea,
exercise tolerance, and health-related
quality of life of any intervention available
for patients with chronic respiratory disease
(16). It also decreases subsequent
healthcare use, especially when provided
following an exacerbation of COPD (20).
The benets from pulmonary rehabilitation
result from a decrease in the negative
effects of comorbidities (e.g., physical
deconditioning resulting from sedentary
behavior and reductions in anxiety and
depression) and from enhanced self-efcacy
(e.g., the early recognition and appropriate
treatment of exacerbation of COPD) (21).
Physical Activity
Physical activity can be dened as any
bodily movement produced by skeletal
muscles that results in energy expenditure
(22, 23). Therefore, physical activity in daily
life can be considered as the totality of
voluntary movement produced by skeletal
muscles during every day functioning (24,
25) and is assessed by the quantication
of this totality of movements during daily
life. In distinction, exercise is a subset of
physical activity that is planned, structured,
repetitive and purposeful (22) and has its
own assessment methods (e.g., maximal
and submaximal exercise tests) (26, 27).
Physical activity is a complex behavior
inuenced by a combination of individual,
sociocultural, and environmental factors
(23). It can be characterized by type,
intensity, duration, patterns, routines, and
activity-related symptoms (28). Types of
physical activity include, but are not
limited to, leisure time, domestic, and
occupational activities (29). Activities of
daily living refers to a subset of physical
activity that encompasses basic, everyday
tasks required for personal self-care and
independent living (29, 30). Performance
of activities of daily living has its own
assessment methods, such as specic
activities of daily living questionnaires and
functional tests (3135).
Questionnaires and motion sensors
are the more commonly used assessment
methods to quantify physical activity in
patients with COPD (36). Despite their
widely recognized usefulness, questionnaires
are prone to inaccuracy when used on an
individual level (23). Motion sensors, which
are small devices worn on the body to
detect movement, and therefore, are used to
quantify physical activity over a period of
time, are becoming increasingly available.
These devices include pedometers (step
counters) and accelerometers (detection of
body acceleration). Pedometers quantify
steps in a given period (despite a considerable
misdetection in slow-walking subjects)
(3740), provide a rough estimate of energy
expenditure, and can also be successfully
used as a motivational tool to increase
physical activity (4143). Accelerometers
have the advantage of being more sensitive
to detection of physical activity differences in
inactive and slowly moving individuals,
and are more accurate and sensitive to light
activities (25). Different devices provide
a variety of outcomes, such as time spent
above a certain intensity threshold (e.g.,
moderate or vigorous physical activity),
time spent in sedentary behavior, average
metabolic equivalent of task, physical
activity level index, vector magnitude units,
and/or energy expenditure estimation.
Output from the various types of
accelerometers varies considerably, making
it difcult to compare devices (44).
Physical Activity in COPD
Patients with COPD have signicantly lower
levels of daily physical activity compared
with healthy control subjects; they spend
signicantly less time walking, walk at
a lower intensity than their healthy
counterparts, and most do not meet current
recommendations for levels of physical
activity (8, 4552). Physical inactivity is not
only a feature of advanced COPD; it is
already reduced in subjects with a new
spirometry-based diagnosis of mild or
moderate COPD (53), even preceding the
onset of breathlessness (54).
Physical activity in patients with COPD
is dependent on many factors, including
physiologic, behavioral, social,
environmental, and cultural factors. See
Watz and colleagues for all details about
factors associated with physical activity in
patients with COPD (23). In brief, daily
physical activity is only weakly associated
with post-bronchodilator FEV1 (23).
However, there is a strong inverse
925

association between daily physical activity
and dynamic hyperination (55), which
correlates strongly with exertional dyspnea
in COPD (56). In contrast to resting lung
function testing, performance on lower
limb muscle function tests and (eld)
exercise tests correlates better with physical
activity in COPD (27, 50, 57, 58). Daily
symptoms (i.e., dyspnea and fatigue) are
associated with lower physical activity levels
in patients with COPD (45, 50, 59). Impaired
health status is weakly-to-moderately
related to physical activity in patients with
COPD (50, 6063). Interestingly, this
association was conrmed in a 5-year
longitudinal observational study that showed
that a decline in physical activity was
associated with a decline in health status in
patients with COPD (64). Self-efcacy
(i.e., individuals belief in their capacity to
execute behaviors necessary to produce
specic outcomes [65]) is only weakly
associated with daily physical activity in
patients with COPD (60, 66, 67). In addition,
sociodemographic and environmental factors
all have the potential to inuence daily
physical activity among patients with COPD
(6875). Physical activity levels may also be
inuenced by the day of the week, with
activity lower on weekends compared with
weekdays (28, 45, 76). Exacerbations
clearly reduce physical activity levels in
patients with COPD (77, 78), in particular,
in very severe exacerbations that
necessitate hospitalization (79, 80).
Medical comorbidities may also
independently or synergistically affect
physical activity levels (50, 51, 59, 61,
8188).
Physical activity levels predict
important outcomes in COPD. Lower
physical activity levels are associated with
a higher risk of an exacerbation-related
hospitalization (79, 8994). In addition to
baseline levels of physical activity predicting
COPD-related hospitalization, a decline in
physical activity over time also predicts this
outcome, also after adjustment for age,
FEV1, and previous hospitalizations (95).
Lower physical activity levels also increase
the risk of all-cause mortality in patients
with COPD after controlling for relevant
confounding factors (10, 93, 94). A decline
in physical activity over time also predicts
mortality (11). Reecting these strong
associations, physical activity has been
included as a factor in multidimensional
prognostic scores for all-cause and
respiratory mortality (96) or exacerbations
926 American Journal of Respiratory and Critical Care Medicine Volume 192 Number 8 | October 15 2015
and COPD-related hospitalization in
patients with stable COPD (97). These
outcome studies underscore the importance
of promoting physical activity in the earliest
stages of COPD, with a goal of more than
2 hours per week.
Effects of Pulmonary
Rehabilitation on Physical
Activity in COPD
The cornerstones of pulmonary
rehabilitation are exercise training and
education, which are aimed at behavior
change through promoting self-efcacy
(21). For pulmonary rehabilitation to have
its greatest long-term impact, the increases
in exercise capacity demonstrated in the
rehabilitation center would ideally translate
into increases in physical activity in the
home and community settings (16). Both
exercise capacity increase and adaptive
behavior change are necessary to achieve
signicant and lasting increases in daily
physical activity in patients with COPD
(Figure 1). Unfortunately, it is readily
assumed that this translation occurs naturally.
Twelve studies have evaluated the effects of
pulmonary rehabilitation on physical activity
and have had inconsistent results.
Positive Studies
In a randomized controlled trial, Sewell and
colleagues (98) compared the effects of two
approaches to exercise training on physical
activity in 180 patients with COPD. Physical
activity was measured over 2 consecutive
days using an activity monitor (Z80-32k V1
Int; Gaewiler Electronics; Hombrechtikon,
Switzerland). The pulmonary rehabilitation
(7 wk, 2 sessions/wk) consisted of a weekly
1-hour session of supervised aerobic training
and a weekly 1 hour of supervised circuit
training exercises, and twice weekly
educational sessions. The circuit training
differed between groups; there was either
a conventional program of general
strengthening exercises or a program of
goal-directed exercise based on problematic
daily activities. Exercise performance,
performance of problematic daily activities,
and health status all improved signicantly
compared with baseline. Physical activity
expressed as total activity counts increased
signicantly after both interventions,
without any difference between groups. This
study was the rst to demonstrate that
CONCISE CLINICAL REVIEW
directly measured physical activity improved
after pulmonary rehabilitation. However, in
a secondary analysis, the authors reported
that the response in physical activity might
be susceptible to seasonal variation, with the
best results in the winter (75).
Mercken and colleagues (99) evaluated
the effects of an 8-week inpatient
pulmonary rehabilitation program on
physical activity in 11 patients with
moderate-to-very severe COPD. Physical
activity was measured over 9 consecutive
days using an uniaxial accelerometer
(Physical Activity Monitor AM 100; Pam
BV, Oosterbeek, the Netherlands). The
pulmonary rehabilitation (8 wk, 5 sessions/wk)
consisted of exercise training of the upper
and lower extremities (aerobic and strength
exercise training, education, and when
appropriate, psychosocial and behavioral
interventions. Exercise performance and
exercise-induced oxidative stress improved
signicantly compared with baseline.
Physical activity (measurement unit was not
reported) increased signicantly compared
with baseline.
Walker and colleagues (51) evaluated the
effects of an 8-week outpatient pulmonary
rehabilitation program on physical activity in
24 patients with moderate-to-very severe
COPD. Physical activity was measured over 7
consecutive days using an accelerometer
(Dynaport Activity Monitor; McRoberts
BV, The Hague, the Netherlands). The
pulmonary rehabilitation (8 wk, 2 supervised
sessions/wk, 1 unsupervised session/wk)
consisted of exercise training of the upper
and lower extremities (aerobic and strength
exercise training), and educational sessions.
Lower limb muscle function, exercise
performance, performance of problematic
daily activities, symptoms of anxiety and
depression, and health status all improved
signicantly compared with baseline.
Physical activity expressed as a percentage
of time spent mobile, mean activity score
(3103 counts/h), or as mean intensity of
activity score (3103 counts/h) also increased
signicantly compared with baseline.
Improvement in leg activity counts was
positively correlated with baseline lung
function; those with better pulmonary
function had greater increases in activity
after rehabilitation. Interestingly, changes
in physical activity were not signicantly
related to changes in muscle strength or
walking distance, although these variables
improved with pulmonary rehabilitation.
This discord in outcomes points to the
CONCISE CLINICAL REVIEW

Educational Collaborative Occupational walking. Lower limb muscle function,

sessions self-management therapy exercise performance, mood status, and
health status increased signicantly. The
percentage of total time spent in medium-
Disease-specific Self-management Energy-conservation intensity activity increased signicantly
knowledge skills techniques compared with baseline, but did not
remain after exclusion of training
Psychological Physical activity Exercise Nutritional
periods.
counseling coaching training modulation
Dallas and colleagues (39) evaluated
the effects of a 6- to 12-week, hospital-
based outpatient pulmonary rehabilitation
Symptoms of Self-efficacy Limb muscle function
program on physical activity in 54 patients
anxiety with severe COPD. Physical activity was
Symptoms of measured over 7 consecutive days using
Dynamic hyperinflation
depression a pedometer (NL-2000 Activity Monitor;
Adaptation to
Behavior New Lifestyles Inc., Lees Summit, MO)
limitations
change Exercise-induced symptoms during the rst and last week of the
pulmonary rehabilitation program. The
pulmonary rehabilitation (612 wk, 23
Light intensity sessions/wk) consisted of exercise training
physical activities Optimal Smoking
pharmacological
of the upper and lower extremities (aerobic
cessation
therapy (including and strengthening exercises), educational
comorbidities) sessions, and psychosocial support.
Active Symptoms, exercise performance, and
living health status all improved signicantly
compared with baseline. Physical activity
level expressed in pedometer counts per
Exacerbation and/or hospitalization
hour did not change.
Saunders and colleagues (101) assessed
Figure 1. Components of a comprehensive pulmonary rehabilitation program (blue rectangles) have
a direct positive effect on disease-specific knowledge and disease-management skills, via improvements the effects of seven pulmonary
in the physical and psychological extrapulmonary features of patients with chronic obstructive pulmonary rehabilitation programs (community-based
disease (yellow rectangles), or via a reduction in dynamic hyperinflation (red rectangle). These positive or hospital-based) on physical activity in
effects also translate into a higher self-efficacy. The increase in self-efficacy will induce a behavior change 294 patients with moderate-to-severe
and, in turn, an increase in time in light-intensity physical activities and active living. The active living will COPD. Physical activity was measured over
reduce the risk of exacerbations and/or hospitalizations (white rectangles). The improvements in the 7 consecutive days using a step counter
physical and psychological extrapulmonary features, the smoking cessation, and the optimization of the (Yamax Digiwalker, Warminster, PA). The
pharmacological therapy will also have a direct impact on exacerbations and/or hospitalizations. pulmonary rehabilitation (612 wk, 23
sessions/wk) consisted of exercise training
(aerobic and strengthening exercises) and
inuence of other components of pulmonary magnitude units per minute differed educational sessions. Changes in exercise
rehabilitation, such as promoting self- between a preprogram non-exercise day and performance were not reported. Physical
efcacy, in achieving positive outcome in a supervised exercise day in the last week of activity level expressed in steps per day did
physical activity. the pulmonary rehabilitation program. not change.
Nevertheless, physical activity did not Mador and colleagues (102) evaluated
Negative Studies change signicantly when pre- and post- the effects of an 8-week pulmonary
Steele and colleagues (100) assessed the program nonexercising days were compared rehabilitation program on physical activity in
effects of an 8-week, hospital-based, or for the full 5 days of activity assessment. 24 patients with moderate-to-severe COPD.
outpatient pulmonary rehabilitation Coronado and colleagues (52) assessed Physical activity was measured over 7
program in 41 patients with mild-to-very- the effects of 3-week inpatient pulmonary consecutive days using a triaxial accelerometer
severe COPD. Physical activity was rehabilitation program in 15 patients with (RT3; Stay Healthy Inc.). The pulmonary
measured 5 days before entry into the mild-to-very-severe COPD. Physical activity rehabilitation (8 wk, 3 sessions/wk) consisted
pulmonary rehabilitation program and was measured on the rst and last day of the of calisthenics (with and without weights),
during the nal week of the program using pulmonary rehabilitation program using an ergometry cycling, treadmill walking, and
a triaxial accelerometer (RT3; Stay Healthy uniaxial accelerometer (The Self-Contained multidisciplinary educational sessions. Lower
Inc., Monrovia, CA). The pulmonary Activity Monitor, ADXL05; Analog Devices, limb muscle function, exercise performance,
rehabilitation (8 wk, 2 sessions/wk) was not Norwood, MA). The pulmonary and health status all improved signicantly
described in detail. Changes in exercise rehabilitation (3 wk, 67 sessions/wk) compared with baseline. Physical activity level
performance have not been reported. consisted of exercise training (aerobic and expressed in vector magnitude units per
Physical activity expressed as vector strengthening exercises) and outdoor minute did not change.

Concise Clinical Review 927


Mixed-Result Studies
Pitta and colleagues (103) studied the
impact of a 12- to 24-week, hospital-based
outpatient pulmonary rehabilitation
program on physical activity in 41 patients
with severe COPD. Physical activity was
measured over 5 consecutive weekdays
using an accelerometer (Dynaport Activity
Monitor; McRoberts BV). The pulmonary
rehabilitation (12 wk, 3 sessions/wk,
followed by 12 wk, 2 sessions/wk) consisted
of supervised exercise training (endurance/
strengthening exercises), educational sessions,
and visits for support and/or counseling with
a pulmonary physician, a nutritionist, a
psychologist, an occupational therapist,
a respiratory nurse, and a social assistant.
Symptoms, lower limb muscle function,
exercise performance, performance of
problematic daily activities, and health
status were signicantly better at 12 and
24 weeks compared with baseline. Mean
walking time was only signicantly better
after 24 weeks, not at 12 weeks. Mean
movement intensity during walking was
signicantly better at 12 and 24 weeks
after compared with baseline. The time
spent standing, sitting, and lying down,
and the number of blocks of continuous
walking done per day did not change.
Demeyer and colleagues (104)
evaluated the effects of a similar pulmonary
rehabilitation program as Pitta and colleagues
(103) on physical activity in 57 patients
with moderate-to-severe COPD. Physical
activity was measured over 7 consecutive
days using a biaxial accelerometer (Sensewear
Pro Armbands; BodyMedia, Inc., Pittsburgh,
PA). The possible change in exercise
performance was not described. The number
of steps per day increased signicantly
12 weeks after baseline (with 47 d of
measurement), whereas time spent in at
least moderate physical activity or the
mean metabolic equivalents of task level
did not change.
Egan and colleagues (105) studied the
short-term improvements in physical activity
in 47 patients with severe COPD after
a 7-week, hospital-based outpatient
pulmonary rehabilitation program. Physical
activity was measured over 5 consecutive
days using a biaxial accelerometer
(Sensewear Pro Armbands; BodyMedia,
Inc.). The pulmonary rehabilitation (7 wk,
2 sessions/wk, with a recommended 3 further
days of 30 min of moderate intensity
exercise) consisted of a progressive exercise
circuit (strength/exibility/endurance),
928 American Journal of Respiratory and Critical Care Medicine Volume 192 Number 8 | October 15 2015
multidisciplinary interactive educational
sessions, and home inspiratory muscle
training program. Symptoms, exercise
performance, and health status all improved
signicantly compared with baseline. Total
energy expenditure decreased signicantly
compared with baseline, whereas there was
no change in the average number of daily
steps, time spent sedentary, or time spent in
active exercise.
In summary, a randomized controlled
trial comparing the effects of a pulmonary
rehabilitation program on daily physical
activity with usual care in patients with
COPD is lacking. Most studies were
noncontrolled, small-sized, and observational.
All pulmonary rehabilitation programs
consisted of a supervised exercise training
program and educational (multidisciplinary)
sessions. Only a few also contained
psychological counseling, occupational
therapy, and dietary counseling. Interestingly,
exercise performance improved signicantly
after pulmonary rehabilitation in all
studies (if reported), whereas physical
activity did not. This suggests a differing
trajectory in exercise and activity
outcomes. An editorial writer, who
commented on the differing trajectories,
quipped insightfully, one needs 3 months
to train the muscle, but 6 months to train
the brain (106).
Which Pieces of the Puzzle
Are Missing?
Although pulmonary rehabilitation
improves exercise performance in patients
with COPD (107), this is not always
accompanied by an increase in physical
activity in daily life (108). The reasons for
this are not clear, because a comprehensive
pulmonary rehabilitation program arguably
contains the necessary ingredients to
improve physical activity in patients with
COPD (Figure 1).
Because self-reported physical activity
is unreliable (109), attention has focused on
using physical activity monitors in patients
with COPD (76, 110112). Pedometers,
which are insensitive to detecting activity in
slowly moving individuals with COPD,
have had negative results (39); more
sensitive motion detectors, such as triaxial
accelerometers, are more likely to detect
changes in activity (103).
The choice of physical activity outcome
assessment may determine the success or
CONCISE CLINICAL REVIEW
failure of the pulmonary rehabilitation
programs demonstrable effect on the
physical activity. Most COPD trials have
focused on the impact of pulmonary
rehabilitation on the total number of steps
per day, walking time, and/or the time
spent in moderate to vigorous intensity
(108). Demeyer and colleagues reported
a signicant increase in steps per day
following a 3-month outpatient pulmonary
rehabilitation program, which was not
accompanied by increases in metabolic
equivalents or time spent in moderate- or
high-intensity physical activity (104).
In some of the observational studies,
physical activity was measured while
patients were already/still participating in
the pulmonary rehabilitation program (39,
52, 100). Preferably, physical activity should
be measured in free-living conditions
before and after a pulmonary rehabilitation
program (not during). This will increase the
validity of the ndings.
Patients with COPD do not appear to
increase the amount of time in moderate-to-
vigorous intense activities after pulmonary
rehabilitation (104), but they can still adopt
a more active lifestyle, through engaging in
leisure activities or doing more domestic
household activities (98). Therefore, we
may need to transition our thinking from
physical activity to active living. This
concept includes leisure, occupational, and
household activities, as well as active
transportation (walking and bicycling)
(113), most of which many may not be
detected by the currently available physical
activity measurements. In addition, it is
important to better understand physical
activity patterns. Which is more important:
more time spent in higher intensity
physical activity or less time spent in
a sedentary state? This latter approach is in
line with the philosophy of Sparling and
colleagues, who argue that a reduction in
sedentary time and an increase in light
activities may prove more realistic and pave
the way to more intense exercise in older
adults than just focusing on moderate to
vigorous intense physical activities (114).
Even a slight increase in physical activity in
the most sedentary subjects may have
signicant health benets (Figure 1) (115).
The duration and content of
pulmonary rehabilitation services, which
vary widely among pulmonary
rehabilitation trials, may explain some of the
variance in change in physical activity (17).
This is brought out in the results of the
CONCISE CLINICAL REVIEW
previously described study by Pitta and
colleagues (103). Moreover, the differences
in behavior change strategies among
centers may also explain some of this
variance (116). For example, a pulmonary
rehabilitation program, with a lifestyle
physical activity counseling program
incorporating feedback from a pedometer,
increased the number of patients steps per
day to a greater extent than did pulmonary
rehabilitation without this counseling (42).
Also, specicity of the exercise training
modality seems to play an important
role. Twelve weeks of Nordic walking
increased walking time and walking
intensity in patients with COPD and
was still present 6 months after the
intervention (117).
Changing a complex health behavior
such as physical activity is very difcult, so
interventions should be guided by sound
theoretical models. This seems lacking in the
current pulmonary rehabilitation construct.
One of the most commonly applied theories
is social cognitive theory (SCT) (118). The
active agent in SCT is self-efcacy, which
is theorized to have both direct and indirect
effects on behavior. Although there is
evidence of pulmonary rehabilitation
programs increasing self-efcacy (19), this
is not always the case. It has been
empirically demonstrated that the time
point at which self-efcacy is measured
inuences the extent to which it increases
or decreases across the intervention period
(119). Efcacy expectations assessed at
baseline are likely overestimations that are
recalibrated in the early stages of the
exercise program. Thus, generally weak, but
consistent relationships with physical
activity may be a function of poor temporal
measurement or self-efcacy measures that
do not accurately reect the actual
behavior. Because interventions do not
appear to be able to change moderate-to-
vigorous physical activities in patients with
COPD, measures reecting moderate-to-
vigorous physical activities are likely to be
weakly related to behavior. A recent self-
efcacy enhancing intervention improved
light physical activity by approximately
21 minutes per day, as measured by
accelerometry. This was substantially
greater than two exercise interventions
without the efcacy enhancement
component (120, 121). Targeting the
primary sources of efcacy as integral parts
of pulmonary rehabilitation for COPD
might bring about important changes in
Concise Clinical Review
light physical activity that, if maintained,
could lead to more intense active living.
Other self-regulatory approaches to
increasing adherence behavior in older
adults hold promise for COPD. For
example, higher levels of executive function
and use of self-regulatory strategies were
associated with greater self-efcacy, which
led to greater exercise adherence (122).
However, reliance on individual-level
approaches to behavior change is unlikely
to have potent effects on physical activity.
Consideration of how individual
factors interact within the social and
environmental milieu in which
individuals exist is warranted (123).
Socioecological variables may also
modulate the effect of pulmonary
rehabilitation on physical activity (124).
These include intrapersonal, interpersonal/
cultural, organizational, physical
environment, and policy variables (125,
126). For example, walking is related to
pedestrian infrastructure and concerns
for safety in older adults (127).
Moreover, neighbors social support and and optimizing patients treatment.
positive neighborhood satisfaction will
increase the likelihood of walking (128),
whereas a lower socioeconomic status
will lower walking activity in older adults
(129). Outdoor air quality also needs to
be taken into consideration, because
physical activity in clean air has larger
health benets compared with physical
activity in trafc-related polluted areas
(130, 131). To date, neighborhood
walkability, and the inuence of
interpersonal relationships, formal
community engagement, and outdoor air
quality on physical activity have not been
studied in patients with COPD. Several
studies do report that COPD patients
surroundings and transport/nance have
been identied as barriers to participation
in physical activity (132134). In
contrast, health benets (65%),
enjoyment (44%), continuation of an
active lifestyle in the past (28%), and
functional reasons (i.e., daily activities,
transportation, and so on) (26%) have
been identied as reasons for patients
with COPD to stay/become physically
active (133).
Future Approaches
Changing physical activity behavior in
patients with COPD needs an
interdisciplinary approach, bringing
together respiratory medicine, rehabilitation
sciences, social sciences, and behavioral
sciences. This concise clinical review has
presented data that patients with COPD are
generally very inactive, and that this
physical inactivity is detrimental to both
quality and quantity of life. Therefore,
increased efforts to better understand the
determinants of physical activity, as well as
effective strategies to improve this variable,
must be a prominent goal in pulmonary
rehabilitation. Physical activity is now listed
as one of the main outcome measures of
pulmonary rehabilitation programs by
the ATS/ERS Ofcial Statement on
Pulmonary Rehabilitation (107).
Despite this, only a minority of
healthcare professionals have identied
physical activity as one of the main
outcomes of pulmonary rehabilitation
(33.5% in Europe; and 21.9% in North
America) (17).
Future research in this area should
include both advancing the science
The following are suggested areas to
focus on:
The science:
1. The potential disease-modifying effects
of increased physical activity (light/
moderate/vigorous intensity) in patients
with COPD;
2. The determinants of physical activity
(light/moderate/vigorous intensity) in
patients with COPD;
3. Self-management strategies that best
promote physical activity (light/
moderate/vigorous intensity),
including long-term increases in
activity;
4. The interaction of pharmacological and
non-pharmacological interventions on
physical activity (light/moderate/
vigorous intensity);
5. The relationship between changes in
the traditional outcomes of pulmonary
rehabilitation (exercise capacity,
dyspnea, and functional and health
status) and changes in physical
activity (light/moderate/vigorous
intensity);
6. The best instruments to measure
physical activity in clinical practice
(light/moderate/vigorous intensity);
7. The minimal important difference for
physical activity measures, as they
relate to health status, healthcare use,
929
 CONCISE CLINICAL REVIEW

and mortality (light/moderate/
vigorous intensity); and
8. Randomized, adequately powered,
controlled trials that evaluate whether
increases in physical activity resulting
from the therapeutic intervention lead
to improvements in health outcome,
including healthcare use and mortality.
This would establish the needed
causality link.
The patient:
1. Introduce physical activity early on in
the pulmonary rehabilitation curriculum
and incorporate it as a standard
outcome measure;
2. Tailor physical activity to the individual
patient, taking into account exercise
capacity, morbidities and/or disabilities,
home and community environment,
and behavioral and cultural
factors;
3. Focus on resumption of exercise
and physical activity after an
exacerbation of COPD, including
establishing realistic goals and
maintaining support by the
professional team; and
4. Maintain and foster ongoing lines of
communication among the patient
and the healthcare team to detect
changes in the patients condition
that interfere with ongoing
exercise and activity, thereby
allowing for an early intervention. n
Author disclosures are available with the text
of this article at www.atsjournals.org.
Acknowledgment: The authors thank the
anonymous reviewers for their excellent
suggestions.

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