Effects of a Supervised Home Exercise Program on Patients with Severe Chronic Obstructive Pulmonary Disease

Transcription

1 Effect of a Supervied Home Exercie Program on Patient with Severe Chronic Obtructive Pulmonary Dieae ANGELA J. BUSCH and JAMES D. McCLEMENTS The purpoe of thi tudy wa to analyze the effect of a home exercie program on phyical work capacity and dypnea during activitie of daily living in patient with evere chronic obtructive pulmonary dieae. Twenty patient with evere repiratory impairment were aigned in a tratified, random manner to an Exercie Group (n = 0) or a Control Group (n = 0). Patient in the Exercie Group performed the upervied home exercie program of daily mobility, trengthening, and endurance exercie. Patient in the Control Group were viited regularly by a phyical therapit but did not follow the exercie program. Six patient were eliminated from the tudy, either becaue of death (n = ) or noncompliance with experimental condition (n = 5), leaving each group with even patient. The reult of a progreive bicycle ergometer tet after 8 week howed a ignificant between-group difference in phyical work capacity. The phyical work capacity of patient in the Exercie Group had improved 3% and had deteriorated 28% for patient in the Control Group (p <.05). The ymptom-limited multitage tep tet and the Chronic Repiratory Dieae Quetionnaire howed no difference in the patient' phyical work capacity or dypnea during ADL. Although not concluive, thi tudy yielded ome evidence for the beneficial effect of home exercie training on patient with evere chronic obtructive pulmonary dieae. Key Word: Dypnea; Phyical therapy; Pulmonary, chronic obtructive pulmonary dieae. Exercie training ha emerged in the lat three decade a a new treatment modality for patient with chronic obtructive pulmonary dieae (COPD). Many reearcher have reported improved exercie performance and phyical work capacity in patient with COPD after exercie training in controlled tudie. -6 Some reearcher have alo reported improvement in patient' performance of activitie of daily living 4-7 and pychological well-being after exercie training. 8 Mot reearcher, however, have hopitalized patient A. Buch, MSc, i Deputy Charge Phyiotherapit, Univerity Hopital, Sakatoon, Sakatchewan, Canada S7N OXO. She wa a tudent in the mater' degree program, College of Phyical Education, College of Graduate Studie and Reearch, Univerity of Sakatchewan, Sakatoon, Sakatchewan, Canada S7N OWO, when thi tudy wa completed. J. McClement, PhD, i Profeor, College of Phyical Education, Univerity of Sakatchewan. Thi tudy wa completed in partial fulfillment of the requirement for M. Buch' Mater of Science degree in phyical education, Univerity of Sakatchewan. Thi article wa ubmitted November 2, 986; wa with the author for reviion 0 week; and wa accepted June, 987. Potential Conflict of Interet: 4. with COPD for at leat part of their exercie training program. Thi tudy ued a completely home-baed exercie program, a did the tudy by Sinclair and Ingram. 5 If a home-baed exercie program can be hown to effectively reduce diability in patient with evere COPD, the benefit of exercie training will be acceible to more patient with COPD. The cot of delivering a homebaed exercie program i much le than the cot of an exercie program that require patient hopitalization. Phyical therapit at the Rehabilitation Home Care Program of Univerity Hopital, Univerity of Sakatchewan, uggeted the topic of thi tudy. They wanted to initiate a program of endurance exercie training for their patient with COPD. The patient were everely diabled, mot were houebound, and everal (including ome patient with no expectoration problem) were pychologically dependent on the exiting bronchial drainage and percuion maintenance program. Rather than withdraw treatment altogether, the phyical therapit decided to initiate a rehabilitative program in which patient had a more active role in their treatment. The purpoe of thi tudy wa to meaure the effect of the upervied home exercie program (SHEP) on the diability level of patient with COPD. Our hypothei wa that, in patient with evere repiratory impairment caued by COPD, the SHEP would ) limit deterioration of patient' phyical work capacity and 2) decreae patient' dypnea perceived during ADL. METHOD Subject Selection. Twenty patient with evere, irreverible airway obtruction and without apparent or ymptomatic ichemic heart dieae or diablement from medical condition other than COPD gave their informed conent to participate in thi tudy. The patient were between 44 and 80 year of age. We aigned the patient by tratified random ampling to either the Control Group (n = 0) or the Exercie Group (n = 0). A phyician ued pertinent Volume 68 / Number 4, April

2 patient data (ie, ex, ue of upplemental oxygen, FEV a a percentage of predicted normal FEV, dypnea at ret, and power output achieved on a pretet progreive bicycle ergometer tet [PBET]) to group the patient into imilar trata and randomly aigned them from each tratum to either the Control Group or the Exercie Group. One patient in the Control Group died after an exacerbation of COPD, and two patient in the Control Group began exerciing progreively of their own volition. Three patient in the Exercie Group did not perform the trengthening or endurance exercie regularly, depite intruction and encouragement. Thu, the ample ize wa reduced to 4 patient (7 patient in each group). Characteritic. The ix men and one woman in the Control Group were an average age of 65.6 ± 5.5 year; the five men and two women in the Exercie Group were an average age of 64.6 ± 5.5 year. Five patient in the Control Group and ix patient in the Exercie Group ued upplemental oxygen on a daily bai. One patient from each group had marked dypnea at ret. The average FEV, at pretet wa 0.79 ± 0.30 L and 0.75 ± 0.33 L for patient in the Control Group and the Exercie Group, repectively. No ignificant difference exited between group in pulmonary function variable (Tab. ), upplemental oxygen ue, or dypnea at ret. Intercurrent illne. Four of the even patient in the Exercie Group recorded five dicrete illne epiode in their daily exercie diarie during the tudy. The illnee were influenza, exacerbation of COPD, low back pain, chet infection, and rib pain. Baed on patient data collected at 6-week interval, we determined that at leatfiveof the even patient in the Control Group experienced dicrete epiode of illne during the 8-week tudy. Deign The tudy involved a repeated meaure reearch deign over an 8-week period. We conducted creening tet (including the PBET) on all patient before the tudy began. Meaurement of pretet level of the other dependent variable coincided with the onet of the SHEP. The teter did not know whether the patient were aigned to the Exercie Group or the Control Group. Patient in the Exercie Group were given the SHEP and intructed to exercie a minimum of five day a week TABLE Pretet Pulmonary Function Tet Reult of Patient with Chronic Obtructive Pulmonary Dieae by Group Meaurement Volume Reidual volume (L) Total lung volume (L) RV/TLV (%) b Flow c FVC (L) FEV (L) FEV /FVC (%) FEV % predicted d Control Group (n = 7) for an 8-week period. Patient in the Control Group were not given the SHEP and were intructed not to change their cutomary life tyle and activity level. A phyical therapit contacted or viited patient in the Exercie Group every two week to monitor and progre exercie. A phyical therapit viited patient in the Control Group every three week, alternating viit for teting with viit to monitor activity level. Both group continued any previou management or therapy regimen. Patient who ued upplemental oxygen more than 2 hour a day exercied and were teted with upplemental oxygen. The tudy deign wa approved by the Univerity of Sakatchewan Preident' Adviory Committee on Ethic in Human Experimentation. Supervied Home Exercie Program Decription. The SHEP conited of three ection of daily exercie to improve ) thoracic mobility (trunk flexion and extenion, houlder girdle circumduction, and trunk-ide flexion), 2) extremity and trunk mucle trength, and 3) exercie endurance. Patient in the Exercie Group performed the mucle trengthening ection in the morning, the endurance ection in the afternoon, and the mobility ection in the morning and the afternoon a a warm-up routine. Breathing control wa incorporated into each exercie. Patient performed the mobility and mucle trengthening exercie in a itting poition. Intenity. Both the mucle trengthening and the endurance ection of the Exercie Group (n = 7) t a Progreive bicycle ergometer tet. The PBET, a ymptom-limited exercie laboratory tet, wa ued ) to creen potential tudy patient for advere cara df=2. b RV/TLV = ratio of reidual volume to total lung volume. c All flow meaurement except FEV % predicted were obtained after adminitration of a bronchodilator. d FEV % predicted = forced expiratory volume in one econd a a percentage of predicted normal. SHEP were graded progreively. We determined the tarting level for each mucle trengthening exercie by aking patient to perform repetition of the exercie (without reitance) to their tolerance level (a maximum of 20) in the preence of the phyical therapit. If the patient could perform 20 exercie repetition without exceive effort, reitance wa added in pecified gradient. During the two-week interval between viit by the phyical therapit, patient attempted to increae the number of repetition in their tolerance level to a maximum of 20 repetition per exercie. The duration of endurance exercie wa alo determined on an individual bai. Patient exercied to their ymptom-limited level and were intructed to top exerciing if they experienced exceive dypnea, leg pain, general fatigue, angina, dizzine, or nauea. Patient choe either walking or tair tepping a their endurance exercie, depending on the layout of their home. We intructed the patient to meaure and record their potexercie pule rate, but mot patient did not do thi reliably becaue they were too haky on completing the exercie. At the biweekly home viit, the phyical therapit aeed patient' progre, collected exercie diarie, increaed mucle trengthening exercie repetition, and monitored the endurance exercie. Evaluation Procedure 470 PHYSICAL THERAPY

3 diovacular repone to exercie and 2) to meaure patient' pretet and pottet level of phyical work capacity. In thi tet, a decribed by Jone and Campbell, 9 work load i incremented at oneminute interval, and cardiovacular, repiratory, and ubjective repone (ie, heart rate, repiratory rate, electrocardiographic repone, blood preure, tidal volume, percentage of aturation of hemoglobin with oxygen in arterial blood, minute ventilation, and repone on the Borg Scale of Perceived Exertion) are monitored uing noninvaive technique. The PBET continue until patient either reach their ymptom-limited level or exhibit a phyiological reaon for topping (eg, cardiac arrhythmia, exceive drop in oxygen aturation). We calculated patient' phyical work capacity in joule by umming the product of power output and duration for each one-minute work interval. Symptom-limited multitage tep tet. We ued the ymptom-limited multitage tep tet (SLMST) to meaure phyical work capacity in the patient' home at pretet and at 6, 2, and 8 week pottet. The SLMST wa modeled after the Canadian Home Fitne Tet (CHFT) 0 and involve one or more 3-minute interval of tair tepping at pecified rate on a double 5-cm tair. If, at the completion of an exercie interval, the patient' heart rate i le than 85% of hi predicted maximum heart rate and if the patient agree to continue, the tet proceed to the next interval and the cadence (ie, rate of tepping) i increaed. We calculated patient' phyical work capacity uing the formula Phyical work capacity (J) = total number of tep climbed height of the tep (m) body weight (kg) J/kg The CHFT in it original form wa hown to be reliable with a tet-retet correlation coefficient of.79 (N = 03, p <.00) (D. A. Bailey, unpublihed data, 973). Shephard et al tudied the concurrent validity of the CHFT and reported a correlation coefficient of.72 ±.02 (N =,52) when they compared the reult of the CHFT and the Atrand Rhyming tet. 0 We ued the home-adminitered SLMST becaue we could collect data frequently without impoing additional hardhip on the patient (eg, tranportation difficultie during the winter). More frequent teting would provide greater detail regarding the patient' re- TABLE 2 Type, Compliance, and Quantity of Endurance Exercie Performed by Patient in Exercie Group Patient Exercie tair tair walking walking walking tair tair Compliance (%) Average Duration of Exercie Seion for Each Six-Week Period (ec) Week Week pone to training, uch a length of time required to repond to the exercie program. Chronic Repiratory Dieae Quetionnaire. Guyatt et al developed the Chronic Repiratory Dieae Quetionnaire (CRDQ) to meaure phyical and emotional repone to treatment intervention in patient with chronic cardiac or repiratory condition. We ued the dypnea cale core of the CRDQ at pretet and at 6, 2, and 8 week pottet to meaure degree of dypnea during ADL. Patient ued a 7-point cale ( = extreme hortne of breath, 7 = no hortne of breath) to rate the degree of dypnea experienced while performing activitie that they had deignated at pretet a having produced dypnea in the lat two week. Guyatt et al etimated the reliability of the dypnea cale by applying the CRDQ to 43 ubject ix time at twoweek interval. They reported a coefficient of variation (ie, the within-peron tandard deviation divided by the mean) of.095. Regarding the validity of the tet, they alo reported that change in CRDQ core correlated well with change in phyiological function, patient' global rating, and phyician' opinion about the degree of improvement. Data Analyi We analyzed three dependent variable (work capacity uing the PBET, SLMST reult, and dypnea during ADL) uing an analyi of variance (AN- OVA) for repeated meaure (BMDP- 2V6 tatitical oftware program 2 ). We calculated F ratio for ) the variance attributable to grouping alone (Exercie Group v Control Group), 2) the variance attributable to the time factor Week Minimum Range (ec) Maximum , RESEARCH Average Duration of All Exercie Seion (ec) alone, and 3) the variance attributable to the interaction between the grouping factor and the time factor. The differential effect produced by exercie training on the group over time wa the phenomenon of interet. We analyzed patient' dypnea cale core (at the ordinal level of meaurement) uing Friedman' nonparametric two-way ANOVA (BMDP-2S2 2 ). Again, the phenomenon of interet wa a differential effect on the group over time. Two trend would upport the hypothei that the SHEP i a beneficial program: ) the Exercie Group improved in phyical work capacity or ADL relative to the Control Group, or 2) the Exercie Group did not deteriorate in phyical work capacity but the Control Group did. We ued a ignificance level of.05 for all hypothei teting. RESULTS Performance of Endurance Exercie and Compliance The daily exercie diarie of patient in the Exercie Group howed that the maximum duration of endurance exercie achieved wa le than three minute for three patient, between three and ix minute for two patient, and greater than ix minute for two patient. We calculated compliance rating and ix-week average for the duration of the endurance exercie for each patient in the Exercie Group to decribe the quantity of exercie performed in thi tudy (Tab. 2). Phyical Work Capacity The phyical work capacity reult for patient and group are hown in Table Volume 68 / Number 4, April

4 3. One patient in each group wa unavailable for the pottet PBET becaue of illne. The ample, therefore, wa reduced to 2 patient for the PBET. The phyical work capacity of the Control Group on the PBET decreaed 2,465 J (28%), from a pretet level of 8,738 ± 5,68 J to a pottet level of 6,273 ± 4,026 J. The phyical work capacity of the Exercie Group, however, increaed by 79 J (3%), from a pretet level of 5,538 ± 2,745 J to a pottet level of 5,77 ± 2,584 J (Fig., Tab. 3). We found a ignificant interaction of group with time (F = 7.57; df-,0; p <.05) that upported the hypothei that the SHEP would produce a poitive effect on the phyical work capacity of patient in the Exercie Group (Tab. 4). The SLMST reult are hown in Table 3 and illutrated in Figure 2. The initial phyical work capacity of the Control Group (2,297 ± 2,605 J) wa greater than that of the Exercie Group (4,76 ± 4,654 J), but the difference wa not tatitically ignificant (t =.48, df = 2, p >.05). The phyical work capacity of one patient in the Exercie Group improved markedly (828% and 44% increae at 2 and 8 week, repectively). Thi increae far urpaed that of any other patient in the tudy and wa upported by the clinical phyical therapit, who ubjectively noted improvement in the patient' mental outlook and general activity level. The ANOVA reult howed a ignificant difference over time (F = 3.38; df = 3,36; p <.05), but the interaction of time with group wa not tatitically ignificant (F = 0.0; df= 3,36; p >.05) (Tab. 5). Thi finding indicated that both group improved in phyical work capacity over time but the difference attributed to the SHEP wa not ignificant. TABLE 3 Individual and Group Work Output on the Progreive Bicycle Ergometer Tet (PBET) and Symptom-Limited Multitage Step Tet (SLMST) Patient Control Group a 6 7 Exercie Group a Pretet,700,625 8,00 4,200,500 5,300 8, ,68.3,500 7,450 7,500 5,825 2,850 8,00 5, ,745.3 PBET (J) 8 Week 6,275 0,40 4,850 4, ,550 6, , ,625 8,725 8,00 4,200 3,525 7,25 5,76.7 2,583.6 Pretet 8,964 22,806 5,844 2,385 8,023,956 36,02 2,297. 2,605.,638 4,987,50 4,472 2,942 4,43 3,633 4, , Week 3,636 26,363 4,558 3,02 7,440,365 36,02 5, ,958.,603 7,325 5,44 2,399 3,330 5,869 2,348 6,898. 5,826.7 SLMST (J) a Patient did not perform the PBET at 8 week becaue of illne. 2 Week 22,97 25,356 6,3 3,237 7,76,488 49,22 6, ,56.0,2 7,325 4,009 5,244 3,556 6,24 2,962 8, , Week 9,3 25,593 6,08 5,793 7,00,62 39,502 4, ,77.9 2,992 7,324 7,757 6,707 3,653 4,592,928 6, ,223.2 Activitie of Daily Living The median pretet dypnea cale core in the Control Group wa 5 (range = 9-2) compared with a median of 3 (range = 8-3) in the Exercie Group. The Friedman' two-way AN OVA reult howed no change in dypnea during ADL over time in either the Control Group (X r 2 = 0.64, df= 3, n = 7, p >.05) or the Exercie Group (X r 2 = 0.56, df= 3, n = 7, p >.05) uing Friedman' two-way ANOVA. The SHEP, therefore, had no effect on dypnea during ADL. Fig.. Pretet and pottet phyical work capacity of patient with chronic obtructive pulmonary dieae in the Control and Exercie Group on the progreive bicycle ergometer tet. DISCUSSION Three of the 0 patient in the Exercie Group were noncompliant in thi tudy. We do not know whether thi number i inordinately high. Merten et al reported that "of the 3 patient recruited, only five exercied a regularly a precribed," but their exercie intervention program included a weekly exercie cla at the hopital, and the duration of the program wa two year PHYSICAL THERAPY

5 TABLE 4 Analyi of Variance for Repeated Meaure of Work Output on Progreive Bicycle Ergometer Tet Source Between group Time Time x group a p<.05. df 0 0 2,68,87 27,788,50 7,83,838 0,480,87 3,849,640 MS 2,68,87 27,78,85 7,83,838 0,480,87,384,964 F a 7.57 a Fig. 2. Phyical work capacity of patient with chronic obtructive pulmonary dieae in the Control and Exercie Group on the ymptom-limited multitage tep tet at pretet (initial) and at 6,2, and 8 week. Given the nature of COPD, the everity of the dieae in our patient, and their age, we had anticipated intercurrent illne. Only rarely have training effect been tudied in patient with COPD a elderly 5,7 or with uch evere repiratory impairment a the patient in thi tudy. 4,7 Becaue our method of obtaining illne data for the two patient group differed, we do not know whether the Exercie Group and the Control Group differed in the quantity or everity of illne they experienced. The quantity of illne recorded in the diarie of patient in the Exercie Group averaged 0.5 day a week. Although the quantity of illne i rarely reported in the literature, McGavin et al reported that their ubject, who exercied for an average of 9 week, had an average of 0 day of illne per ubject, which i comparable to our finding. 4 The data from the PBET howed that although the patient in the Exercie Group had made only marginal gain in their phyical work capacity, the patient in the Control Group had deteriorated in phyical work capacity. Thi finding agree with McGavin et al 4 and Cockcroft et al 6 who oberved the ame repone pattern in the reult of cycle ergometer tet. They reported little or no change in maximum oxygen uptake in the Exercie Group and ignificant deterioration in the Control Group. The SLMST reult revealed that both group had improved ignificantly in phyical work capacity over time and that no difference in phyical work capacity exited between the two group. RESEARCH We know of no previou attempt to tet the phyical work capacity of patient with COPD in their own home. The SLMST reult did not concur with the reult we obtained with the laboratorybaed PBET, and we doubt that both group actually improved in phyical work capacity. The increae in phyical work capacity on the SLMST probably wa due to the effect of habituation (ie, adjutment to teting procedure). Patient appeared to be le anxiou about the SLMST at each ubequent teting. We do not know the reaon for the dicrepancy between the PBET reult and the SLMST reult. Although the patient eemed to puh themelve harder on the PBET than they did on the SLMST, thi obervation wa not confirmed by the rating the patient aigned to their effort uing the Borg Scale of Perceived Exertion. We ued the Wilcoxon matched-pair ignedrank tet 4 to analyze the Borg Scale data and found no difference in effort a perceived by the patient on the two exercie tet (T= 9, n = 7, two-tailed p >.05). The fundamental difference between the two exercie tet probably account for the conflicting phyical work capacity reult. The PBET i a cycling tet; the SLMST i a tair-tepping tet. The PBET i a continuou exercie tet; the SLMST i an interrupted exercie tet. Becaue the PBET i a continuou tet, it may be more enitive to change than the SLMST. Thi greater enitivity might explain why we detected change uing the PBET but not with the SLMST and i upported by the comparatively maller variance in PBET data; however, the one-minute veru three-minute increment alo poibly contributed to the difference. The coefficient of variation (in order of pretet and pottet) wa 8% and 78% in the PBET data and 9% and 08% in the SLMST data. Exercie training did not affect patient' dypnea during ADL a meaured by the CRDQ. Dypnea can fluctuate from hour to hour and i difficult to meaure. Neverthele, Moer et al, who alo tudied dypnea during ADL in an elderly, diabled group of patient with COPD, reported "ubtantial improvement" in ADL core after a ix-week training program. 7 In their tudy, which lacked a control group, the ADL index wa ued to meaure dypnea experienced by patient while performing 6 activitie. Although we found no exercie training effect on ADL, we tudied only one Volume 68 / Number 4, April

6 TABLE 5 Analyi of Variance for Repeated Meaure of Work Output on Symptom-Limited Multitage Step Tet Source Between group Time Time group a p<.05. df apect of ADL. We cannot comment on the effect of home exercie training on other variable related to ADL (eg, range of activitie, level of independence at a given activity, quantity of activity performed on a daily bai). Some reearcher have reported a poitive effect of exercie on ADL uing a three-category cale (ie, improvement, no change, and deterioration) to decribe change in overall performance of ADL. 4-6 Intrumentation with atifactory pychometric propertie for meaurement of more pecific apect of ADL i carce. The SLMST ha potential a an aement tool for clinician. It i eay to ue and can be ued in patient' home. The lack of agreement between the reult of the SLMST and the PBET, however, ugget that further development i neceary to tandardize and validate the SLMST. The SHEP wa trictly an exercie intervention and did not addre patient education or pychological iue. The effectivene of an exercie intervention would be enhanced by adding thee dimenion. CONCLUSIONS SS 946,820,897 5,528,453,772 22,82,486 3,776, ,67,763 MS 946,820, ,704,48 40,937,495,258,762 2,0,993 F a 0.0 We tudied the effect of the 8-week SHEP on the phyical work capacity and dypnea during ADL in patient with evere COPD. We found a tatitically ignificant effect on phyical work capacity uing the PBET. Thi finding upported the hypothei that the SHEP would limit deterioration of phyical work capacity in patient with evere COPD. We could not, however, ubtantiate thi finding with the SLMST data, nor did we find any pottet difference between the two patient group in performance of ADL. Thee reult are not overwhelming evidence of the effectivene of exercie training, but the patient in thi tudy belong to a everely diabled population with a progreive dieae and a grim outlook. Very little can be done to improve or even retard the progreive deleteriou effect of COPD. We oberved no eriou training complication in the Exercie Group during the 8-week SHEP. Some patient in the Exercie Group made urpriing and extraordinary improvement. Depite the lack of concluive evidence, therefore, we believe that the SHEP may be beneficial for ome patient with evere COPD. Acknowledgment. We thank Dr. V. H. Hoeppner, Dr. D. W. Cockcroft, and Dr. L. Tan for their adviory aitance; Dr. M. Kehmeri for diagnotic ervice and aitance with exercie teting; Ken Waller and other volunteer who helped with exercie teting; Marilyn Mc- Pheron and Dorothy Yate for adminitrative aitance; JoAnn Nilon and the phyical therapit at the Rehabilitation Home Care Program for their important contribution in planning and conducting the tudy; and Anne Lehure and the phyical therapit of Univerity Hopital for their cooperation and clinical aitance. REFERENCES. Cheter EH, Belman MJ, Bahler RC, et al: Multidiciplinary treatment of chronic pulmonary inufficiency: 3. The effect of phyical training on cardiopulmonary performance in patient with chronic obtructive pulmonary dieae. Chet 72:695-70, Degre S, Sergyel R, Mein R, et al: Hemodynamic repone to phyical training in patient with chronic lung dieae. Am Rev RepirDi 0: , Sergyel R, DeCoter A, Degre S, et al: Functional evaluation of a phyical rehabilitation program including breathing exercie and bicycle training in chronic obtructive dieae. Repiration 38:05-, McGavin CR, Gupta SP, Lloyd EL, et al: Phyical rehabilitation for the chronic bronchitic: Reult of a controlled trial of exercie in the home. Thorax 32:307-3, Sinclair DJM, Ingram CG: Controlled trial of upervied exercie training in chronic bronchiti. Br Med J 23:59-52, Cockcroft AE, Saunder MJ, Berry G: Randomized controlled trial of rehabilitation in chronic repiratory diability. Thorax 36: , Moer KM, Bokinky GE, Savage RT, et al: Reult of a comprehenive rehabilitation program: Phyiologic effect on patient with chronic obtructive pulmonary dieae. Arch Intern Med 40:596-60, Fihman DB, Petty TL: Phyical, ymptomatic, and pychological improvement in patient receiving comprehenive care for chronic airway obtruction. J Chronic Di 24: ,97 9. Jone NL, Campbell EJM: Clinical Exercie Teting, ed 2. Philadelphia, PA, W B Saunder Co, Shephard RJ, Bailey DA, Mirwald RL: Development of the Canadian Home Fitne Tet. Can Med Aoc J 4: ,976. Guyatt GH, Berman LB, Pugley SO, et al: Development of a reponive meaure of quality of life for patient with chronic cardiorepiratory dieae. Abtract. Clin Re 32:222a, Dixon WJ, et al (ed): BMDP Statitical Software 983 Manual. Berkeley, CA, Univerity of California Pre, Merten DJ, Shephard RJ, Kavanaugh T: Long-term exercie therapy for chronic obtructive lung dieae. Repiration 35:96-07, Siegel S: Nonparametric Statitic for the Behavioral Science. New York, NY, McGraw-Hill Book Co, PHYSICAL THERAPY