2015 Summer Continuing Care/Rehabilitation Section Bulletin

Summer 2015 Continuing Care/Rehabilitation Section Bulletin

Gerilynn Connors, BS, RRT, FAARC
Inova Fairfax Hospital
Falls Church, VA

Arianna Villa, BS, RRT
UCSD Medical Center
San Diego, CA

Pamela Neuenfeldt, MPH, RRT
HealthPartners Institute for Education and Research
Arden Hills, MN

How Should We Help Our COPD Patients Get the Most Out of Their Exercise Time in Pulmonary Rehab?

Pamela Neuenfeldt, MPH, RRT, and Natalie Nutting, CRT, Regions Cardiopulmonary Rehabilitation, St. Paul, MN

We have been interested in motivating people to exercise harder during their time in rehab. The notion of high-intensity interval training (HIIT) is not new in the world of fitness, yet it is still somewhat controversial.

A recent posting on the My Fitness Pal blog recognized that HIIT and steady-state cardio are effective in their own ways. The authors compared the benefits of both in healthy people and their conclusion was to alternate the two: “Training in blocks is ideal . . . you can’t get good at aerobic performance and HIIT at the same time. A better approach is to ‘periodize’ your workouts, or switch them on a regular basis. You’ll reduce your chance of injury, stave off boredom and fitness plateaus, and stay lean and healthy.”1

Some of you may recall a very entertaining debate between Drs. Bart Celli and Richard Casaburi at an AARC Congress back in the late 1990s on whether we should “be mean” by pushing patients to go faster and harder or “be nice” and let them go at their own pace. Dr. Casaburi and colleagues have published extensively on the benefits of appropriate intensity exercise.2-8

Our section members have written about this in the past as well. A word search for “interval training” on AARConnect brings up a brief discussion between Edwards, Fayle, and Mangus. There are many discussions about exercise testing, forms, and reimbursement, but few on how to make the patient experience beneficial.

Are we paying enough attention to each patient to get them to do their best? Can our approach to and expectations of our patients set the stage for a few seconds of heavy breathing and working harder followed by a couple minutes of slower, self-paced exercise?

It is a difficult and complicated task to motivate COPD patients to exercise. Not only is the discomfort and fear of shortness of breath a limiting factor but co-morbid anxiety, obesity, osteoporosis, and depression are also associated with reduced physical performance.9 Yet an accepted therapy for all these co-morbidities is exercise.

While HIIT is not for every rehab patient, perhaps short bursts of moderately high intensity would be acceptable for many. In the absence of cardiac abnormalities or recent cardiac events, with adequate oxygenation, pre-medication, a seated mode of exercise for starters, a pleasant form of distraction, and some coaching, perhaps there is a way to maximize our patients’ potential.


  1. What’s More Beneficial: Steady-State or High Intensity Cardio? My Fitness Pal; 2015. http://blog.myfitnesspal.com/whats-more-beneficial-steady-state-or-high-intensity-cardio/?native_client=1.
  2. Casaburi R. A brief history of pulmonary rehabilitation. Respir Care 2008;53:1185-1189.
  3. Casaburi R. Boosting the effectiveness of rehabilitative exercise training. Am J Respir Crit Care Med 2008;177:805-806.
  4. Casaburi R, Porszasz J. Reduction of hyperinflation by pharmacologic and other interventions. Proc Am Thorac Soc 2006;3:185-189.
  5. Casaburi R, ZuWallack R. Pulmonary rehabilitation for management of chronic obstructive pulmonary disease. N Engl J Med 2009;360:1329-1335.
  6. Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Am J Respir Crit Care Med 2003;168:1034-1042.
  7. Porszasz J, Rambod M, van der Vaart H, et al. Sinusoidal high-intensity exercise does not elicit ventilatory limitation in chronic obstructive pulmonary disease. Exp Physiol 2013;98:1102-1114.
  8. Varga J, Porszasz J, Boda K, Casaburi R, Somfay A. Supervised high intensity continuous and interval training vs. self-paced training in COPD. Respir Med 2007;101:2297-2304.
  9. Li LS, Caughey GE, Johnston KN. The association between co-morbidities and physical performance in people with chronic obstructive pulmonary disease: a systematic review. Chron Respir Dis 2014;11:3-13.

From the Literature: Studies Highlight Key Issues in PR

The following abstracts were authored or co-authored by Bulletin editor Pam Neuenfeldt and may help inform the ongoing debate on why chronic lung disease patients refuse pulmonary rehabilitation — and how to keep them motivated to exercise when they do enroll in our programs. Email Pam for a copy of the full paper for the first abstract below.

Implementation of physical activity programs after COPD hospitalizations: Lessons from a randomized study.

Benzo R, Wetzstein M, Neuenfeldt P, McEvoy C.

Pulmonary rehabilitation (PR), following an acute exacerbation of chronic obstructive pulmonary disease (COPD), has been found effective in some studies in reducing readmission rates and has recently been recommended by the PR guidelines. However, very recent reports suggested that PR is not feasible after a hospital admission for a COPD exacerbation. The objective of this study is to investigate the knowledge gap on the underlying reasons for nonparticipation in PR in the posthospitalization period.

We qualitatively analyzed the responses of 531 patients hospitalized for a COPD exacerbation who were not interested in participating in either PR (home or center based) or physical activity monitoring program after being discharged from the hospital. The responses were coded thematically, and independent reviewers compiled the raw data into themes.

The characteristics of the 531 subjects (45% male) who declined the intervention are as follows: age was 70 ± 10 years, mean forced expiratory volume in one second (FEV1%) predicted 40 ± 16, and age, dyspnea, and airflow obstruction index 6.0 ± 1.6 (scale 0-10). The themes for not attending include lack of interest (39%), the perception of “being too ill or frail or disabled” (24%), the perception of being “too busy or having too much to do” (11%), distance or the need of travel (11%), commitment issues (7%), comorbidities (6%), and lack of social support (2%).

We identified barriers for PR or just physical activity programs after a hospitalization that may affect implementation of such programs. Implementing posthospitalizations program in COPD may require patient engagement and mindful and compassionate professionals who may individualize program components to focus specific deficits and particularly patients’ preferences. — Chron Respir Dis. 2015 Feb;12(1):5-10

Effects of Music on Exercise Experience of Cardiac and Pulmonary Rehabilitation Participants (EMUSE)

Pamela J. Neuenfeldt, MPH, RRT, LRT


Patients with heart and lung disease participate in cardiopulmonary rehabilitation programs to improve or regain the stamina lost due to sedentary lifestyles and exacerbating events. Though beneficial, exercise can be unpleasant. Music, as a form of distraction, has been used to make the activity more enjoyable. Adherence to regular exercise is related to enjoyment. This study examined the effect of favorite music on the exercise experience of cardiopulmonary rehab patients.


In a crossover trial, 45 patients from cardiopulmonary rehabilitation programs were randomized to a sequence of three music and three control sessions during exercise once per week over a period of six-weeks. The primary outcome measure was MET-minutes of exercise and secondary outcome was enjoyment measured by a visual analog scale. Percent target heart rate, rates of perceived exertion and perceived dyspnea, and steps per minute were also measured. General well-being was assessed prior to exercise sessions.


Mixed-effects model showed no statistical difference in MET-minutes for music and control sessions (p=0.199). Music had a significant positive effect on enjoyment of exercise (p <.0001) and percent target heart rate (p=0.02). Perceived exertion and dyspnea were not significantly different (p =0.08 and p=0.16 respectively) for music versus control sessions. There was no association between steps per minute of exercise and music tempi. Feelings of general well-being were positively associated with enjoyment.


Listening to favorite music resulted in higher levels of exercise enjoyment and target heart rate but did not show significant difference in MET-minutes, perceived exertion or dyspnea. — Presented at AARC Congress 2014 in Las Vegas.

Section Connection

Specialty Practitioner of the Year: Use our online nomination form to nominate a fellow section member for our 2015 Specialty Practitioner of the Year award.

Recruit a new member: Know an AARC member who could benefit from section membership? Direct them to section sign up. It’s the easiest way to add section membership to their overall membership package.

Section discussion list: Go to the section website and click on “Discussion List” to start networking with your peers via the AARC’s social networking site, AARConnect.

Attention all budding authors: Got an interesting story? Have an abstract you would like to share? Want to tell a funny story about your program? (Names changed to protect the innocent and HIPAA laws, of course.) Email your contributions to Gerilynn Connors or Pamela Neuenfeldt by the deadlines stated below.

Bulletin deadlines: Winter Issue: December 1; Spring Issue: March 1; Summer Issue: June 1; Fall Issue: September 1