SECTION IX
AIRWAY DISEASES
42 Pulmonary Rehabilitation
THIERRY TROOSTERS  RIK GOSSELINK 
DANIEL LANGER  MARC DECRAMER
INTRODUCTION
Generally, rehabilitation is defined as “restoration of human
functions to the maximum degree possible in a person or per-
sons suffering from disease or injury.” Rehabilitation, there-
fore, is not confined to a specific organ or structure but
rather to the functioning and interaction of a person in his or
her environment. Pulmonary rehabilitation is a form of reha-
bilitation dealing with patients primarily with respiratory
disorders and limited participation in daily life. The rehabilita-
tion process, however, is not oriented at improving lung
function but is aimed at improving the long-term systemic
consequences patients with lung diseases may suffer. These
so-called systemic consequences include, but are not limited
to, muscle weakness, nutritional depletion, impaired mental
state, exercise intolerance, and symptoms that are often out
of proportion of the lung function abnormality.
The goals of pulmonary rehabilitation are patient and soci-
ety centered in the sense that rehabilitation aims at improving
symptoms, exercise tolerance, patient participation in daily
life, and health-related quality of life, as well as at reducing
the overall cost of care in these patients by reducing or post-
poning use of health care resources. To be efficient, rehabilita-
tion programs should be an integral part of the overall care
plan. Ideally, they facilitate communication between health
care providers across lines of health care. In a recent document
of the American Thoracic Society and the European Respira-
tory Society, pulmonary rehabilitation was explicitly put
within the context of integrated care and was defined as “an
evidence-based, multidisciplinary, and comprehensive inter-
vention for patients with chronic respiratory diseases who are
symptomatic and often have decreased daily life activities.
Integrated into the individualized treatment of the patient,
pulmonary rehabilitation is designed to reduce symptoms,
optimize functional status, increase participation, and reduce
health care costs through stabilizing or reversing systemic
manifestations of the disease.”
This definition acknowledges the significant evidence base
for rehabilitation programs and recognizes that its primary
aim is not enhancing lung function. The definition, however,
is rather comprehensive, and it follows that a thorough dis-
cussion of all components of pulmonary rehabilitation is out-
side the scope of this chapter. Rather, after discussing the
outcomes of pulmonary rehabilitation, this chapter focuses
on one intervention, often referred to as the cornerstone of
rehabilitation programs for patients with respiratory diseases:
exercise training. In addition, most of the discussion pertains
to patients with chronic obstructive pulmonary disease
(COPD). Indeed, most research has been conducted in this
large patient population. Finally, most of the discussed techni-
ques can be transposed to patients with other lung diseases. In
fact, many of the techniques are also used in other diseases,
such as frailty, osteoporosis, and congestive heart failure.
OUTCOMES AFTER PULMONARY
REHABILITATION
The success of achieving the goals of rehabilitation can be
assessed through physiologic, psychosocial, and economic
outcome measures. In a recent meta-analysis, the effects of
pulmonary rehabilitation programs on exercise tolerance were
systematically reviewed. In incremental tests, peak work rate
improves on the average by approximately 20% compared
with baseline, whereas peak oxygen uptake improves by 10%
when the rehabilitation groups are compared with the res-
pective controls. The effect of pulmonary rehabilitation on
whole-body constant work rate exercise tolerance is much
larger (80–100%). Exertional dyspnea is consistently reported
to be reduced after pulmonary rehabilitation.
The clinical relevance of the benefit of pulmonary rehabili-
tation is illustrated by the improved functional capacity, as
measured by the 6-min walk test. The pooled effect size of
all randomized controlled studies of the results of pulmonary
rehabilitation is approximately 50 m, with a 95% confidence
interval of 26–72 m2. The minimal clinically important differ-
ence (MCID) of the 6-min walking test has been estimated to
be approximately 50 m. We calculated that the number
needed to have one patient with a clinically significant benefit
was 3 (95% CI, 1.7–6.4).
A review of the published literature shows that the
improvement in health-related quality of life after pulmonary
rehabilitation clearly exceeds the MCID. When disease-
specific instruments were used, the lower limit of the 95%
confidence interval exceeded the minimal clinically important
difference. This means that almost all patients benefit to a clin-
ically important extent from pulmonary rehabilitation in terms
of health-related quality of life. To improve health-related
quality of life, the effects of adding pulmonary rehabilitation
to the treatment of a patient with COPD may be greater than
adding another drug.
Interestingly enough, improved health-related quality of
life is sometimes observed even in the absence of clinically
significant improvements in exercise capacity. It is clear that
the enhanced health-related quality of life is surely not only
influenced by the physiologic benefits. Improved mental
state, enhanced self-efficacy, enhanced symptom control, and
ameliorated perception of symptoms are among the non-
physiologic pathways likely to contribute to an enhanced
543
544 SECTION IX Airway Diseases
health-related quality of life. Long-term follow-up has shown
that quality-of-life benefits are maintained above control levels
if rehabilitation yields clinically significant effects on exercise
tolerance.
Effects of rehabilitation on psychologic well-being (e.g., anxi-
ety and depression) are less studied. Obviously, the effects of
pulmonary rehabilitation on psychologic morbidity should be
expected only in the 20–40% of patients referred for pulmonary
rehabilitation with significant psychologic morbidity.
Few randomized controlled studies have examined the
effectiveness of pulmonary rehabilitation programs on use of
health care resources and assessed the cost-effectiveness of
this intervention. To assess the cost-effectiveness of pulmonary
rehabilitation, long-term follow-up is mandatory. In one well-
conducted study, Griffiths and co-workers reported that
patients with COPD spent fewer days in the hospital during
a 1-year follow-up period. In fact, it was concluded from this
study that it is very likely that pulmonary rehabilitation can
be organized without an additional health care cost to
society. Smaller recent studies of outpatient rehabilitation
showed similar trends in reducing hospital days but lacked
statistical power to confirm significance. Because several non-
controlled studies also support the propensity of pulmonary
rehabilitation to reduce hospital in-patient days, the main cost
driver in COPD, we believe that the evidence is good enough
to conclude that pulmonary rehabilitation is cost-effective.
This benefit of rehabilitation programs may be attributed to
the physiologic improvements or, alternately, to the improved
knowledge of the disease and enhanced self-management. In a
recent randomized controlled trial, hospital admissions were
reduced by 40% in patients with a history of hospital admis-
sions who followed a self-management program and in whom
a “case manager” was assigned to follow-up the patients.
Interestingly, the effect of pulmonary rehabilitation pro-
grams on physical activity levels in daily life has been poorly
investigated with objective measures. Clearly, objective assess-
ment of physical activities is the “gold standard” for investigat-
ing the patients’ engagement in everyday physical activities.
Questionnaires have been shown to be inaccurate for objective
analysis of the involvement of patients in activities. The results
of studies that used activity monitors have, so far, been
conflicting. All studies, so far, had unequivocally a number of
patients that did not increase their physical activity levels, as
is indicated by the variability in the outcome. Taken together
the need for better insight on the effect of pulmonary rehabil-
itation on physical activity levels seems to be crucial, because
enhanced activity levels may have a protective effect on mor-
bidity and may be effective in maintaining the physiologic
effects gained from an exercise training program. It may be
that specific interventions are needed to enhance physical
activity levels in patients with COPD. Giving patients feed-
back on their physical activity levels may enhance their
engagement in daily physical activities. This is clearly an
important avenue for future research.
THE EXERCISE TRAINING INTERVENTION
Rationale
From the definition of pulmonary rehabilitation it follows that
“reversing the systemic consequences” of the lung disease
renders the benefits of rehabilitation programs. As expected,
exercise training does impact on cardiovascular function.
Working at either a constant (steady state) work rate or at
progressive, high-intensity exercise training, the heart rate
reduces for a given energy output with repetitive training.
It has also been suggested that baroreflex sensitivity is altered
favorably after exercise training. Whether exercise training also
has favorable effects on vascular function, as in patients with
heart failure or cardiac structure, has not been investigated.
Exercise training aims at reversing the skeletal muscle abnorm-
alities. Clinically, skeletal muscle strength has been reported to
be reduced in severe COPD, in proportion to the skeletal mus-
cle mass. Local endurance is even more impaired than skeletal
muscle strength. The skeletal muscle of patients with COPD is
also more rapidly fatigued during exercise, compared with
healthy muscle, and deranged muscle bioenergetics have been
reported. At the microscopic level, generalized skeletal muscle
atrophy with a predominance of glycolytic fibers is seen. This
pattern is slightly different from that observed with aging,
where typically type II fiber atrophy is present. In addition,
the number of capillary to fiber contacts is reduced. In the
context of pulmonary rehabilitation two important findings
at the molecular level deserve to be mentioned. First, the
activity of two important enzymes, citrate synthase and
HADH, is reduced in patients with COPD. These enzymes
play an important role in the oxidative energy processes in
skeletal muscle. As a result, the skeletal muscle has to rely
on anaerobic glycolysis at abnormally low work rates. The pro-
duced lactate provides an additional drive to the compromised
ventilatory system and leads to early ventilatory limitation
(maximum exercise ventilation). Second, the skeletal muscle
is more vulnerable to oxidative stress. In a subset of patients
with a low body mass index (BMI), this may compromise the
benefits of exercise training.
Most, if not all, skeletal muscle consequences of COPD are
also seen after severe deconditioning. It seems likely that inac-
tivity is the main driver of the skeletal muscle abnormalities
seen in most patients. In subgroups of patients, however, other
mechanisms may further impair skeletal muscle function. Such
subgroups of patients include those with hypoxemia or hyper-
capnia, those rapidly losing body weight, or those treated with
high doses of oral corticosteroids. Most of the deconditioning-
induced abnormalities are at least partially reversible. After
exercise training, skeletal muscle force is increased and the
limb muscles are less prone to exercise-induced contractile
fatigue. At the molecular and fiber level, oxidative enzyme
capacity is enhanced and skeletal muscle fibers do hypertrophy
and the number of capillary contacts per fiber increases.
Exercise Training, Practical Aspects
In general, exercise training in patients with COPD follows the
principles of exercise training in the healthy elderly. Programs
generally consist of a warmup, a core program in which at least
30 min of exercise is included, and a cooling down period.
Close supervision and proper monitoring will ensure safety
during the program. In fact, very few exercise-related events,
and as far as the authors are aware, no fatal events have
been reported after pulmonary rehabilitation in the published
literature. Tables 42-1, A–C summarize a suggested training
schedule in patients with COPD used in the authors’ center.
Whole-Body Exercise
Exercise training has been included in virtually all studies
investigating the benefits of pulmonary rehabilitation. To suc-
cessfully increase skeletal muscle properties and render mea-
surable physiologic benefits, it is important that patients do
 42 Pulmonary Rehabilitation 545

exercise at relative high work loads. To do so, the exercise
training intervention can be adapted to the individual exercise
potential of the patient. The conventionally used form to
deliver exercise training to COPD patients is endurance train-
ing. In COPD patients with primarily moderate disease, exer-
cise training conducted at approximately 75% of the peak
work rate (60% of the difference between the lactate threshold
and peak oxygen uptake) results in significant physiologic
effects in patients across disease stages.
Interval exercise training has been shown to result in
physiologic benefits comparable to those of endurance train-
ing. The advantage of interval training is that the ventilatory
requirements remain relatively limited. In our center, interval
training is used in patients with severe ventilatory limitation
or those not able to sustain long exercise bouts. It is important
to adjust and increase the training load in every session.
Trained personnel should be available to ensure close super-
vision on the training intensity. Training intensity can be
monitored by use of Borg symptom scales. A score of approxi-
mately 4–6 is generally advised as an appropriate training
intensity, provided the patients are familiar with the scale.
Interestingly a given Borg symptom score is generally chosen
by a patient at a fixed relative work rate relative to the peak
work rate. Hence, as patients improve during training, the

TABLE 42-1A Training Scheme for the Treadmill Exercises Used in the Authors’ Institute
(A) Endurance Training, Proposed Schedule on the Treadmill
WK Duration Training Load
1 10 min 75% 6 MWs
2 12 min 75% 6 MWs
3 12 min 80% 6 MWs
4 14 min 80% 6 MWs
5 14 min 85% 6 MWs
6 14 min 90% 6 MWs
7 16 min 90% 6 MWs
8 16 min 95% 6 MWs
9 16 min 100% 6 MWs
10 16 min 105% 6 MWs
11 16 min 110% 6 MWs
12 16 min 110% 6 MWs

6 MWs is the speed obtained during a 6-min walking test. Training week (WK) is displayed along with the duration of the block of exercise and
the intensity relative to the maximal training load.

TABLE 42-1B Training Scheme for the Cycling Exercises Used in the Authors’ Institute
(B) Interval Training Proposed Training Schedule on the Bicycle
WK Duration Number Blocks Training Load
1 2 min 5 60% Wmax
2 2 min 6 60% Wmax
3 2 min 6 65% Wmax
4 2 min 7 65% Wmax
5 2 min 7 70% Wmax
6 2 min 7 70% Wmax
7 2 min 7 75% Wmax
8 2 min 8 75% Wmax
9 2 min 8 80% Wmax
10 2 min 8 80% Wmax
11 2 min 8 85% Wmax
12 2 min 8 85% Wmax

In between the different blocks patients are allowed to rest or they can continue cycling at reduced work rate.
Continued
546 SECTION IX Airway Diseases

TABLE 42-1C Training Scheme for the Resistance Training Exercises Used in the Authors’ Institute
(C) Schedule for the Resistance Training Program
WK Load Reps
1 70% 1 R.M. 38
2 70% 1 R.M 38
3 76% 1 R.M 38
4 82% 1 R.M 38
5 88% 1 R.M 38
6 94% 1 R.M 38
7 100% 1 R.M 38
8 106% 1 R.M 38
9 112% 1 R.M 38
10 115% 1 R.M 38
11 118% 1 R.M 38
12 121% 1 R.M 38

1 RM is the maximal weight a patient can lift once over the whole range of motion without compensatory movements. The number of repetitions (Reps)
remains three series of eight repetitions throughout the training program.

same Borg rating will be achieved at higher absolute work
rates. Because most patients are not limited by the cardiovas-
cular system, use of the heart rate to guide exercise training
is not advised.
Interventions to minimize the ventilatory burden during
exercise training include the use of supplemental oxygen, the
use of noninvasive ventilation, and the use of light-density
gas mixtures (helium-oxygen). Oxygen reduces the ventilation
for a given exercise intensity, hence application of supplemen-
tary oxygen may allow training at higher intensity at accept-
able levels of pulmonary ventilation. Noninvasive mechanical
ventilation reduces the work of breathing and has been used
successfully in severe COPD as an adjunct to exercise training.
In less severe COPD, however, the impact of the use of nonin-
vasive mechanical ventilation is not significant. The use of non-
invasive mechanical ventilation may increase the complexity of
the training regimen disproportionally to the anticipated bene-
fits, and this intervention should be restricted to very carefully
selected patients. Last, the required ventilation can be reduced
simply by reducing the amount of muscles put to work.
If exercise is confined to one leg, ventilation is considerably
reduced, allowing a significant increase in training load to
those muscles. During cycling, for example, fewer muscles are
recruited than with walking exercises, and it is not surprising
that for a given oxygen consumption, cycling is more fatiguing
to the skeletal muscles involved. It would be interesting to
conduct a head-to-head comparison study on the physiologic
effects of cycling versus walking exercises when applied in a
rehabilitation program to check whether, on the basis of
the larger potential to elicit muscle fatigue, cycling would be
a form of exercise training that results in larger physiologic
effects than walking.
Obviously, optimal bronchodilator therapy also allows for
better pulmonary ventilation during exercise. In one study, a
potent long-acting anticholinergic drug, tiotropium, enhanced
exercise training effects compared with the use of short-acting
bronchodilators only.
Resistance Training
Another form of conventional training is resistance training.
This form of exercise generally consists of weightlifting or—
in less controlled forms—may consist of exercises against grav-
ity (squat exercises or rising from a chair) or exercises with
elastic bands. They can be used as the only form of training
or in combination with whole-body exercises. Skeletal muscle
strength was consistently increased more when resistance
training was added to the exercise regimen. Increased muscle
strength is an important treatment objective in patients with
COPD who have muscle weakness. Indeed, many activities
of daily life do require strength on top of muscle endurance.
As mentioned previously, muscle weakness is an important
factor related to morbidity and even mortality in COPD. It fol-
lows that patients with muscle weakness may be particularly
good candidates to a resistance training program.
Resistance training is easy to apply in clinical practice.
Patients are instructed to lift weights (generally on a multigym
device). The weight imposed and the number of repetitions
ensure overload of the skeletal muscle. In patients with COPD
and several other chronic diseases, resistance training is started
at approximately 70% of the weight a patient can lift once
 42 Pulmonary Rehabilitation 547

(i.e., the one repetition maximum). Proper warmup exercises
are advised to prevent damage to joints and tendons in frail
patients. The effects of resistance training programs may be
enhanced in male hypogonadal patients by testosterone replace-
ment therapy. Weekly intramuscular injections with testoster-
one, aiming at restoring testosterone levels to normal values,
did enhance skeletal muscle force more than either of the
interventions alone. Further studies, however, are required to in-
vestigate the long-term safety of this intervention. However,
because skeletal muscle dysfunction is in itself a negative prognos-
tic factor, short-term use of testosterone may be beneficial to
result in a rapid restoration of this potentially harmful situation.
Another intervention used to specifically stimulate the
peripheral muscles is neuromuscular electrical stimulation
(NMES). Skeletal muscle force seems to increase more in
patients treated with NMES, as monotherapy or in combina-
tion with general exercise training. It is important that the
increased muscle function is engaged in functional exercises
respecting the contraction time and intensity of daily life.
Hence, we would advise the use of NMES only in combina-
tion with regular exercise training. NMES, however, may be
a first approach to enhance skeletal muscle function in the
most frail patients, who are too weak to take part in regular
rehabilitation.
In summary, exercise training programs can be adjusted
to the individual exercise limitations of patients with COPD.
In individual patients, endurance training, interval training, or
resistance training can be offered to keep the training stimulus
attractive and with acceptable symptoms. Several interven-
tions can be considered to further alleviate the ventilatory
burden or specifically stimulate the peripheral muscles. An
empirical flowchart that may guide the clinician to design the
exercise intervention is given in Figure 42-1. It should be
recognized that this flowchart is not directly validated but
rather compiles the available knowledge and clinical expertise.
SPECIFIC RESPIRATORY MUSCLE TRAINING
The respiratory muscles have been specifically targeted for
training in COPD. Inspiratory muscle training programs can
be conducted at home by use of resistive breathing with target
inspiratory pressures or target inspiratory flows or with thresh-
old loading devices. Normocapnic hyperpnea has also been
applied, albeit less frequently, in COPD. When the training
load is appropriate (controlled and more than 30–40% of
PImax), inspiratory muscle training leads consistently to reduc-
tions in dyspnea and improved measures of inspiratory muscle
performance. Programs are relatively inexpensive but require
regular supervision. Whether inspiratory muscle training trans-
lates to increased exercise tolerance and quality of life is much
less clear. Therefore, there has been some debate as to whether
inspiratory muscle training should be part of rehabilitation
programs in COPD, with most evidence-based guidelines
concluding that it should not be a routine component.

Optimal bronchodilatation and safety to perform exercise

Predominantly Predominantly Desaturation? Skeletal muscle

cardiovascular limitation ventilatory limitation weakness?
No Yes

Exercise tolerance Respir. muscle Exercise tolerance Hypogonadism?

enhanced by NIMV weakness enhanced by O2?

Yes
Yes Yes

Consider TR O2 supplements Consider

with NIMV testosterone
supplements
Yes
Constant work rate
test @ 70% Wmax

>10 min <10 min

Whole body Whole body Add IMT Resistance training

endurance TR interval TR

FIGURE 42-1 Empirical algorithm that could help the clinician to prescribe exercise therapy in individual patients on the basis of the exercise
limitation of the patient (investigated in an incremental exercise test). With further clinical findings different training strategies or combina-
tions can be prescribed. Typical cutoffs are: respiratory muscle weakness, PImax <60% predicted; hypogonadism: total serum testosterone,
<400 ng/dL 1; desaturation, saturation on exercise <85%. Constant work rate test at 70% Wmax is an exercise performed at 70% of the peak
work rate from the incremental test. IMT, Inspiratory muscle training; NIMV, noninvasive mechanical ventilation; TR, training.
548 SECTION IX Airway Diseases
In patients with inspiratory muscle weakness, one can
speculate that increasing respiratory muscle function may
transform into functional benefits. Therefore, in patients with
inspiratory muscle weakness, the prescription of strictly
standardized inspiratory muscle training may be justified as
an adjunct to exercise training, with the aim of improving
exercise-induced symptoms of dyspnea. It should be noted,
however, that whole-body exercise training, by itself, has
improved inspiratory muscle force in some studies. Inspiratory
muscle training as a stand-alone treatment is clearly inferior to
general exercise training in COPD if the goal is to improve
function or health-related quality of life.
OTHER INTERVENTIONS THAT ARE OFTEN
PART OF PULMONARY REHABILITATION
PROGRAMS
Given the prevalence of abnormalities in body composition
(both overweight and underweight), psychologic morbidity,
social isolation, poor self-management skills, and inappropriate
management of daily life activities, other health care providers
are crucial as members of a multidisciplinary rehabilitation
team. Clearly, it is beyond the scope of this chapter to provide
detail on the precise content of the interventions offered by
these health care providers. Their actions are—as those offered
by the exercise training specialists—structured and fit with the
overall aims of the individualized rehabilitation program.
Nutritional specialists will focus on problems of under-
weight or overweight and will give advice as to balanced nutri-
tional intake, taking into account the caloric and protein load of
meals. Eventually, nutritional supplements can be considered in
carefully selected patients. Meta-analysis clearly showed that
providing nutritional supplements to unselected patients did
not result in clinically meaningful improvements. If these inter-
ventions are successful, however, they contribute importantly
to the enhanced survival. It remains challenging to identify
which patients would benefit most from nutritional supple-
ments. Although it is thought that patients with systemic
inflammation are less responsive to nutritional interventions,
more research is needed.
Psychologic counseling can focus on several issues. First,
psychiatric morbidities, such as anxiety and depression, are
potential targets for therapy. Compared with patients with
chronic heart failure, patients with severe lung disease were
shown to be more likely to have psychologic risk factors
such as a psychiatric history, comorbid psychiatric illness,
and stressful life events. Second, the psychologist may assist
in achieving the desired behavioral changes in patients with
COPD. In those who still smoke at the onset of the program,
smoking behavior should clearly be tackled. Patients who are
inactive could be assisted to achieve a more active lifestyle.
Behavioral change toward a more active lifestyle is difficult
and may require the use of several models and techniques to
achieve this goal. Reliance on one specific theoretical construct
is not likely to be successful in all patients. Changing physical
activities depends on the physiologic capacities of the patient,
psychological aspects such as mood state and self-efficacy,
logistic, and cultural aspects.
Occupational therapists focus on the daily life situation of
the patient. Home visits may reveal potentially nonergonomic
physical activities. Improving the ergonomy does result in an
enhanced efficiency with daily life tasks, which may result in
fewer symptoms on performing activities. An occupational
therapy intervention carried out at the home of severely
disabled patients may improve the ability of patients to carry
out daily tasks. This is obviously the core of any rehabilitation
process, as mentioned previously. Specific training of physical
activities of daily life has also been suggested to alleviate
dyspnea more than just with exercise training alone. The occu-
pational therapist could also investigate the pace at which
patients perform their daily life activities. This pace should
be adjusted to the physiologic possibilities (i.e., exercise toler-
ance, lung function, and hyperinflation) of the patient. Last,
the occupational therapist may discuss tools to aid the patient
in his or her daily life, for example, wheeled walking aids.
These enhance the walking distance, reduce symptoms of dys-
pnea, and improve oxygen saturation, particularly in patients
with poor walking efficiency and those walking at a slow pace.
During exacerbations, wheeled walking aids may be used to
assist in early mobilization of the patients.
Finally, patients often lack self-management skills to deal
with their chronic condition. This is particularly true for
patients after a recent hospital admission. Programs aimed at
enhancing self-management have been shown to be successful
in reducing hospital readmissions. These programs, in combi-
nation with a case manager, are cost-effective if a case manager
could manage 50–70 patients. In these programs, patients get
personalized advice on how to deal with issues related to their
disease. The programs provide customer-tailored “action
plans” specifying the steps to follow in particular situations,
such as an exacerbation. In mild and stable patients, the bene-
fits of acquiring self-management skills are less certain. Obvi-
ously, self-management programs can be integral part of a
pulmonary rehabilitation program. A nurse specialist, for
example, would have the ideal professional profile to integrate
such a program.
SUMMARY
Pulmonary rehabilitation programs have been shown to be an
“evidence-based” intervention. This is reflected in the most
recent guideline on pulmonary rehabilitation and in a regularly
updated meta-analysis. It has become clear over the past few
decades that pulmonary rehabilitation is an essential corner-
stone in the treatment of patients with reduced physical activ-
ity levels or with unresolved symptoms despite medical
treatment. The program should be individually tailored and
may vary in complexity from patient to patient. This chapter
elaborated on the exercise training intervention, but it should
be emphasized that rehabilitation involves, by definition, mul-
tiple disciplines of health care providers. Adequate and multi-
disciplinary assessment of patients is crucial to set out the
rehabilitation track in individual patients. This review focused
on the exercise training intervention, which should also be
designed for each individual patient. To do so, knowledge of
the exercise tolerance, exercise limitation, and muscle function
seems crucial.
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