Pulmonary Rehabilitation Exercise

Prescription in Chronic Obstructive

Lung Disease
US SURVEY AND REVIEW OF GUIDELINES AND
CLINICAL PRACTICES

Chris Garvey, FNP, MSN, MPA; M. Dot Fullwood, MS; Julia Rigler, RRT, BA

Chronic obstructive pulmonary disease is a common, progressive disorder associated with disabling symptoms, skeletal muscle dysfunction, and substantial morbidity and mortality. Current national guidelines recommend pulmonary rehabilitation (PR) to improve dyspnea,
functional capacity, and quality of life. Many PR exercise programs are
based on guidelines from the American College of Sports Medicine.
Recommendations have also been published by the American
Association of Cardiovascular and Pulmonary Rehabilitation and the
American Thoracic Society. Translating exercise science into effective
training and clinical care requires interpretation and the use of diverse
national PR guidelines and recommendations. Pulmonary rehabilitation clinicians often vary in their education and background, with
most nurses and respiratory care practitioners lacking formal training
in exercise physiology. Patients often have comorbidities that may further complicate exercise provision and prescription. This article
describes the results of an informal, nonscientific survey of the
American Association of Cardiovascular and Pulmonary Rehabilitation
members exploring current PR exercise prescription practices as a
basis for discussion and reviews current national exercise recommendations for chronic obstructive pulmonary disease. Further, it describes
areas of uncertainty regarding exercise prescription in PR and suggests
strategies for providing effective exercise training, given the diversity of
guidelines, clinician preparedness, and patient complexity.

Chronic obstructive pulmonary disease (COPD) is a common, progressive disorder associated with disabling
symptoms, skeletal muscle dysfunction, and substantial
morbidity and mortality. Current national guidelines recommend pulmonary rehabilitation (PR) to improve dyspnea, functional capacity, and quality of life.1-3 In addition,
the American Association of Cardiovascular and
Pulmonary Rehabilitation (AACVPR) has a national PR
certification that requires specific elements of exercise

K E Y

W O R D S

chronic obstructive pulmonary disease

clinical practices
exercise prescription
pulmonary rehabilitation

Author affiliations: Seton Pulmonary and

Cardiac Rehabilitation, Daly City, California
(Mrs Garvey, Mr Fullwood, and Ms Rigler);
and Department of Sleep Disorders,
University of California Medical Center,
San Francisco (Mrs Garvey).
The authors declare no conflicts of interest.
Correspondence: Chris Garvey, FNP, MSN,
MPA, Seton Pulmonary and Cardiac
Rehabilitation, 1900 Sullivan Ave, Daly
City, CA 94015 (chrisgarvey@dochs.org).
DOI: 10.1097/HCR.0b013e318297fea4

prescription, including documentation of mode, frequency, duration, and methodology of progression of exercise. Translating exercise science into effective training
and clinical care requires interpretation and the use of
diverse national PR guidelines and recommendations.
Pulmonary rehabilitation clinicians often vary in their
education and background. Nurses and respiratory care
practitioners may lack formal training in exercise physiology. Patients often have comorbidities that further

314 / Journal of Cardiopulmonary Rehabilitation and Prevention 2013;33:314-322

www.jcrpjournal.com

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 314

22/08/13 4:19 PM

complicate exercise provision and prescription. The purpose of this article is to review current national exercise
recommendations for COPD, explore areas of uncertainty regarding exercise prescription, describe results of
an informal nonscientific survey of PR programs in the
United States, and suggest strategies for providing effective exercise training, given the diversity of guidelines,
clinician preparedness, and patient complexity.

PR EXERCISE PRESCRIPTION
An extensive evidence base supporting the effectiveness of PR has emerged since the first ATS PR statements were published in 19994 and American College
of Chest Physicians and AACVPR PR guidelines were
first published in 1997.5 On the basis of this original
document and subsequent updates,1,6 the 3 available
PR guidelines offer clinicians a framework for developing the exercise prescription in PR settings. The
American Thoracic Society (ATS) guidelines provide
an international, scholarly approach to PR exercise,
although they lack practical tools for clinical program
operations.1 The American College of Sports Medicine
(ACSM) offers in-depth clinical information and
exercise recommendations for patients of various
ages and comorbid conditions,2 yet lack the use of
international Global Initiative for Chronic Obstructive
Lung Disease COPD criteria7 for disease severity
levels. The AACVPR provides a framework for clinical
care and PR program operations,3 yet some exercise
recommendations may be challenging for entry-level
practitioners to use, for example, estimating exerciseintensity levels that target patient activity goals.
Clinical challenges include staff training and competencies, as well as standardization of the practice of
exercise training in the PR setting. These challenges
include lack of formal exercise science training for
nurses and respiratory care practitioners, diversity of
national PR exercise guidelines recommendations,
and comorbidities commonly associated with chronic
lung disease that may require adapting exercise training and prescription. Although this review focuses on
PR for COPD, PR clinicians must be prepared to provide safe, effective, individualized care for a range of
chronic lung diseases in the PR setting.

EXERCISE PRESCRIPTION IN PR
The American College of Sports Medicine
The ACSM recommends that persons with mild, moderate, and severe COPD participate in aerobic exercise,
resistance training, flexibility training, and muscular
www.jcrpjournal.com

fitness activities (Table 1). This approach can reduce

pulmonary symptoms and improve skeletal muscle
function through musculoskeletal and cardiovascular
adaptations that occur with exercise. Initial patient
evaluation should include either indirect or direct
assessment of cardiopulmonary exercise capacity, pulmonary function, and arterial oxygen saturation (SaO2).

Aerobic Training
The ACSM exercise prescription guidelines are based
on frequency, intensity, time, and type methodology.
Aerobic training recommendations for mild COPD follow the general principles of exercise prescription
guidelines.2 Exercise duration may be only a few minutes initially. Intermittent exercise, using short intervals of rest, may be used initially until the patient
tolerates sustained exercise. Although there is no
consensus on optimal exercise intensity in persons
with lung disease, aerobic training intensity should be
primarily based on a rating of perceived exertion,
although an intensity of 60% to 80% of peak work rate
based on graded exercise testing, if available, is also
appropriate, as tolerated.

Resistance Training
Resistance training recommendations for patients with
mild COPD are identical to those for healthy adults,
that is, multijoint or compound exercises (such as
bench or leg presses), focusing on training of major
muscle groups of the chest, shoulders, upper and
lower back, abdomen, hips, and legs. Single muscle
group training includes biceps curls, triceps extensions, calf raises, and so on. Training of agonistic and
antagonistic (opposing) muscle groups, such as lower
back and abdomen or quadriceps and hamstrings, can
be used. Each set should be performed to the point
of muscle fatigue but not failure. Progressive weight
lifting or weight bearing calisthenics should involve
the major muscle groups for 10 to 15 repetitions each;
alternatives include stair climbing or other strengthening activity using major muscle groups.
Techniques recommended to enhance resistance
training include proper body positioning and controlled
breathing, for example, exhaling during work phase
and inhaling during release phase. A full, controlled
range of motion of the joint(s) should be used. As muscles adapt to the training, greater stimuli or progressive
overload is recommended, for example, increasing the
weight or the number of sets per muscle group.

Range of Motion and Flexibility Training

The ACSM flexibility training recommendations include
the use of stretching options, including static, ballistic,
and proprioceptive neuromuscular facilitation stretching. Static stretching involves stretching and elongating
PR Exercise Prescription / 315

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 315

22/08/13 4:19 PM

T a b l e 1 Exercise Recommendations Summary

ACSM

AACVPR

ATS

General recommendations: Use FITT

framework

Upper and lower extremity training

Upper and lower extremity training

Walking (treadmill, track, supported

walking via walker or wheelchair),
cycling, stationary bike, arm ergometry,
arm-lifting exercises with or without
weights, step exercises, rowing, water
exercises, swimming, modified aerobic
dance, and seated aerobics
Warm-up before and cool-down after
exercise

Cycling (cycle ergometer) or walking

(treadmill)

3-5 d/wk

3 d/wk

20-90 min a session

If debilitated, initial sessions can be shorter,
with more frequent rest breaks

>30 min
Interval training if the patient cannot
achieve time and/or intensity

High intensity (60%-80% of peak work

rate)
Interval training is effective for those who
cannot sustain continuous high intensity
exercise
Intensity should be designed to accomplish
patient activity goals
Intensity may be at certain level on the
Dyspnea Scale or to a predetermined
MET level

60% of peak work rate/exercise capacity

RPE 4-6/10 for dyspnea or fatigue or
predetermined MET level
High-intensity exercise yields greater
physiological effect; lower-intensity
exercise is able to improve symptoms,
HRQOL, and some ADL performance

Involves large muscle groups: Walking,

cycling, stair climbing, and swimming

Treadmill or cycle ergometer

Recommended in conjunction with lower

extremity training
Training is task specific
Note: Direct exercise training to muscles
involved in functional living

Arm cycle ergometer, free weights, and

elastic bands

Hand and ankle weights, free weights, and

machine weights
Elastic resistance, using body weight, eg,
stairs or squats
Intensity: Begin with lower resistance and
higher reps to work on muscle endurance
On individual basis, higher resistance and
fewer reps may be indicated to promote
strength development

2-4 sets of 6-12 reps at 50%-85% of

1-RM intensity

Modes of aerobic exercise

Walking (preferred) or cycle ergometer

Frequency
>3-5 d/wk of continuous or intermittent
exercise
Duration
20-60 min/d

Intensity
For mild COPD:
RPE 5-6/10 (moderate)
RPE 7-8/10 (vigorous)
For moderate to severe COPD: 60%-80%
of peak work rate or RPE 3-5/10 for
dyspnea from graded exercise test

Lower extremity training

NA
Upper extremity training
NA

Strength training
Train each muscle group (may be multiple
groups) 2-4 sets, 2-3 times per week,
at least 48-h apart; rest intervals of
2-3 min between sets
Intensity: 60%-80% of 1 RM; if goal
is increased muscle endurance,
15-25 reps at 50% 1 RM
Older and/or deconditioned patients:
10-15 reps at RPE 5-6/10

(continues)

316 / Journal of Cardiopulmonary Rehabilitation and Prevention 2013;33:314-322

www.jcrpjournal.com

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 316

22/08/13 4:19 PM

T a b l e 1 Exercise Recommendations Summary (Continued )

ACSM

AACVPR

ATS

Balance training and stretching to increase

range of motion, eg, modified yoga for
whole body stretching with coordinated
breathing

NA

Flexibility, posture, and body mechanics

Minimum of 2-3 d/wk targeting major
muscle tendon groups for 4 reps per
muscle group; stretching options
include static, ballistic, and
proprioceptive neuromuscular
facilitation stretching

Abbreviations: AACVPR, American Association of Cardiovascular and Pulmonary Rehabilitation; ACSM, American College of Sports Medicine;
ATS, American Thoracic Society; ADL, activities of daily living; COPD, chronic obstructive lung disease; FITT, frequency, intensity, time, and type;
HRQOL, health-related quality of life; MET, metabolic equivalents; RPE, Rating of Perceived Exertion; RM, repetition maximum.

target muscles for 20 to 30 seconds for 1 to 2 repetitions. Ballistic stretching involves using momentum to
force joints beyond their range of motion, with a
bouncing action. Proprioceptive neuromuscular facilitation involves positioning the target muscle group to
be stretched so that it is stretched and under tension.
The individual then contracts the stretched muscle
group for 5 to 6 seconds while a partner, or immovable object, applies sufficient resistance to inhibit
movement. The contracted muscle group is then
relaxed and a controlled stretch is applied for about
20 to 30 seconds, followed by a 30-second recovery.
The process is repeated 2 to 4 times. Static stretching
is generally a safer and more effective way of improving flexibility. Ballistic and proprioceptive neuromuscular facilitation stretching should only be used by
clinicians skilled in these techniques, and caution
should be used to avoid risk of muscle injury.

Summary
The clinician should closely monitor initial exercise
sessions and adjust intensity and duration according to
patient responses and tolerance. Heart rate and blood
pressure assessments are generally the traditional
method of monitoring exercise intensity. The ACSM
describes most patients with COPD as having the ability to accurately and reliably produce a dyspnea rating
during incremental exercise testing as a target to
monitor and regulate exercise intensity. Symptoms,
particularly dyspnea, should supersede objective
methods of exercise prescription. Inspiratory muscle
training is recommended for 30 minutes, or two
15-minute sessions, a minimum of 4 to 5 days a week,
at 30% of maximal inspiratory pressure measured at
functional residual capacity.

The American Association of Cardiovascular

and Pulmonary Rehabilitation
The AACVPR identifies exercise as the cornerstone of
a comprehensive, interdisciplinary PR program.
www.jcrpjournal.com

Aerobic Training
Improvements in functional capacity resulting from
aerobic training are likely, even in those patients with
more severe limitations. The principles of exercise training include upper and lower extremity endurance and
strength training, and possibly respiratory muscle training. Mode, frequency, duration, and intensity should be
included in the individualized exercise prescription and
training (Table 1). These should be based on disease
severity, level of conditioning, functional status, and
results of exercise testing.
An appropriate level of exercise intensity training, for
example, 60% to 80% of peak work rate, is needed for
optimal conditioning. This may be achieved with sustained exercise, for example, a continuous 20-minute
bout, but improvement can also be attained with interval training (alternating periods of greater and lower
intensity or rest), particularly in patients who are more
deconditioned initially. Oxygen saturation should be
monitored and maintained above 88%. Patients may
also be evaluated at exercise intensities associated with
activities of daily living, including the use of their own
portable oxygen systems.

Strength Training
Upper and lower extremity muscle groups involved in
activities of daily living should undergo training exercises that enhance neuromuscular ability. Strength
training recommendations include beginning with
lighter weights and higher repetitions to increase local
muscular endurance. In some individuals, heavier
weights and fewer repetitions may be appropriate to
promote muscle strength.

Balance and Flexibility Training

The AACVPR recommends assessment of functional
performance, balance, orthopedic and musculoskeletal
limitations, strength, range of motion, posture, and
flexibility. Functional performance evaluation should
PR Exercise Prescription / 317

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 317

22/08/13 4:19 PM

include assessment of respiratory muscle function,

breathing mechanics, and thoracic mobility (ie, diaphragmatic excursion, accessory breathing patterns, and
rib cage flexibility). Balance assessment should include
the evaluation of activities of daily living, for example,
lying to stand and climbing steps, and fall risk.

The American Thoracic Society

The use of endurance and strength training generally
translates into multiple beneficial effects (Table 1).
Aerobic exercise sessions at appropriate intensity levels, for example, 60% of maximal work rate, exceeding 30 minutes, are ideal. Interval training offers an
alternative for those who are at lower functional
capacity. Both upper and lower extremity training
should be used. In addition, resistance training, using
various modalities, is recommended.

SPECIAL CONSIDERATIONS FOR

EXERCISE PRESCRIPTION
Comorbidities are common in chronic lung diseases
and may go undiagnosed. A comprehensive assessment, including history and focused physical examination, baseline exercise testing, and assessment of
comorbidities, is an important approach to effective
and safe PR. Particular attention should be paid to
screening for neurological and orthopedic conditions,
including bone-density abnormalities.

EXERCISE PRESCRIPTION AND

PROGRAMMING IN THE UNITED
STATESSURVEY RESULTS
A nonscientific survey was developed to gain information regarding PR exercise prescription in the United
States. The survey was developed by the authors, with
consultation for the tool development from several
international experts in exercise physiology, PR clinical practice, and the AACVPR program certification.
The survey included 15 questions related to PR exercise prescription practice, PR clinical staff disciplines,
program setting (hospital-based, free standing, and
academic affiliation), phase II PR patient volume per
year, and patient diagnoses.
The exact number of PR providers in the United
States is not known but is estimated at 1000 programs
by the AACVPR. Given the lack of the exact number of
US PR programs and the potential that cardiac rehabilitation providers may also be providing PR, the present
survey was sent to the entire AACVPR membership
(approximately 3000 individuals) via an e-mail message
with invitation to complete via surveymonkey.com.

Participation and response were voluntary. Three hundred eighty-one responses were returned (12.7%). Low
return rate could reflect the large number of AACVPR
members providing exclusively cardiac rehabilitation.
Limitations of the survey tool included low return rate
and sample size, uncertainty of the actual number of US
PR programs, characteristics of noncompleters, and lack
of a written option for survey and responses. Survey
responses are summarized in Table 2.
Survey results indicate that the majority of respondents use an exercise evaluation to establish the exercise prescription. The 6-Minute Walk Test (6MWT) is
the most commonly used evaluation tool. The exercise prescription is most often developed by a staff
respiratory care practitioner, a registered nurse, an
exercise physiologist, and/or a physician. Most exercise prescriptions are derived from frequency, intensity, time, and type methodology. Exercise goals most
often target exercise duration versus intensity or distance. Most patients are offered a formal exercise
education class during the PR program. Programs
commonly perform oxygen titration during treadmill
walking, and less often during stationary bicycle use.
Continuous-flow oxygen is most commonly used during titration; however, 47% of responders use the
patient ambulatory oxygen system.
While the majority of programs include intensity
and progression as part of the exercise prescription,
there is considerable variability regarding specific
methods used. A modified 10-point Dyspnea Scale8,9
and a 20-point Rating of Perceived Exertion (RPE)
Scale10 are the most commonly reported exerciseintensity measures. The modified 10-point Dyspnea
Scale is widely used in chronic lung disease and is a
standardized measure of dyspnea intensity during
6MWT.11 The RPE Scale numerically characterizes the
patient subjective description of physical activity
intensity level.10 Ninety-nine survey respondents
described various intensity measures, methodologies,
or formulas for measuring exercise intensity, including
the 20-point RPE Scale,10 the modified 10-point
Dyspnea Scale,8,9 target heart rate, oxygen saturation,
metabolic equivalents (MET), 6MWT, Shuttle Walk
Test, blood pressure, respiratory rate, electrocardiogram, blood glucose, fatigue, muscle fatigue, and
pain. Formulas used for exercise prescription development include the 10-point dyspnea rating of 3 to 5
of 10, the 20-point RPE of 13 to 15 of 20, and progression to an established MET level.
General descriptions of exercise progression methodology include the use of time increments, risk
stratification, patient goals, what the patient can tolerate, and when the patient and staff feel the patient
is ready. Specific descriptions of exercise progression
methodology include increasing exercise by a given

318 / Journal of Cardiopulmonary Rehabilitation and Prevention 2013;33:314-322

www.jcrpjournal.com

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 318

22/08/13 4:19 PM

T a b l e 2 Pulmonary Rehabilitation Exercise Prescription Survey Questions and Responses, % (n)

Questions
Do you develop an exercise prescription for your PR patients? (n = 381, 100%)

Yes

No

97.1 (370)

2.9 (11)

If so, which components are included? Check all that apply (n = 339)
Mode

95.3 (323)

Frequency

95.6 (324)

Duration

94.7 (321)

Training intensity

84.7 (287)

Progression

81.7 (277)

Continuous exercise

41.0 (139)

Interval exercise

42.5 (144)

Resting intervals

34.8 (118)

Training intensity at baseline and progression over time

46.3 (157)

Supervision

49.9 (169)

If intensity is measured, check which measure is used (n = 323)

Borg 10-point Dyspnea Scale

30.3 (98)

Rating of perceived exertion

29.1 (94)

Target heart rate

7.7 (25)

Metabolic equivalents

10.5 (34)

Percentage of maximum target heart rate

2.8 (9)

Percentage of maximum work rate

0.3 (1)

Percentage of heart rate reserve

Watts

1.5 (5)

Incremental cardiopulmonary exercise test

1.5 (5)

6-Minute Walk Test

15.8 (51)

Constant work rate cardiopulmonary exercise test

Do you use any protocol for resistance training? (n = 334)

0.3 (1)
40.4 (135)

59.6 (199)

61.3 (193)

38.7 (122)

Describe indicators or methodology used to determine progression of exercise. (n = 264)

Do you use exercise testing to establish exercise prescription? (n = 315)
6-Minute Walk Test

91.4 (170)

Endurance Shuttle Walk Test

0.5 (1)

Incremental Shuttle Walk Test

0.5 (1)

Constant work rate cardiopulmonary exercise test

0.5 (1)

Incremental cardiopulmonary exercise test

7.0 (13)

How do you determine exercise goals for patients? (n = 292)

Duration

87.3 (255)

Distance

35.3 (103)

Metabolic equivalents (intensity)

45.9 (134)

Is a formal exercise class that addresses physical activity and concepts of exercise
prescription offered to patients? (n = 312)

70.5 (220)

29.5 (92)
(continues)

www.jcrpjournal.com

PR Exercise Prescription / 319

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 319

22/08/13 4:19 PM

T a b l e 2 Pulmonary Rehabilitation Exercise Prescription Survey Questions and Responses, % (n)

(Continued)
Questions
Do you perform oxygen titration during exercise? (n = 314)

Yes

No

92.7 (291)

7.3 (23)

If yes, describe method or exercise used during titration (n = 197)

Treadmill

95.4 (188)

Cycle

48.2 (95)

What oxygen system(s) are used? Check all that apply (n = 280)
Continuous flow oxygen

92.5 (259)

Pulse

29.6 (83)

Patient ambulatory oxygen system

46.8 (131)

Who develops exercise prescription? Check all that apply (n = 308)

RT

57.5 (177)

RN

45.1 (139)

Exercise physiologist

44.2 (136)

Physician

37.0 (114)

PT

6.2 (19)

NP

1.0 (3)

Mix of your core PR team members. Check all that apply. (n = 302)
RT

81.1 (249)

RN

66.4 (204)

NP

1.6 (5)

EP

53.1 (163)

PT

15.6 (48)

Physician

66.8 (205)

OT

13.7 (42)

Social worker

18.9 (58)

Dietitian

49.2 (151)

Psychologist

8.5 (26)

Which disorders receive care in your PR program? (n = 306)

COPD

99.7 (305)

Asthma

88.6 (271)

Interstitial lung disease (includes IPF, sarcoid, scleroderma, etc)

95.4 (292)

Lung cancer

75.5 (231)

Chest wall abnormalities (scoliosis, kyphosis, etc)

48.7 (149)

Thoracic surgery

54.6 (167)

Neuromuscular disorders (ALS, Parkinson disease, etc)

25.2 (77)

What best describes your PR program? (n = 303)

Hospital-based

94.7 (287)

Free-standing

4.6 (14)

Academic affiliation

0.7 (2)
(continues)

320 / Journal of Cardiopulmonary Rehabilitation and Prevention 2013;33:314-322

www.jcrpjournal.com

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 320

22/08/13 4:19 PM

T a b l e 2 Pulmonary Rehabilitation Exercise Prescription Survey Questions and Responses, % (n)

(Continued)
Questions

Yes

No

Approximate number of phase II patients seen per year? (n = 306)

<10

6.9 (21)

10-25

17.0 (52)

26-50

35.6 (109)

51-100

28.4 (87)

>100

12.1 (37)

Abbreviations: AACVPR, American Association of Cardiovascular and Pulmonary Rehabilitation; ACSM, American College of Sports Medicine; ALS, amyotrophic
lateral sclerosis; ATS, American Thoracic Society; COPD, chronic obstructive lung disease; EP, exercise physiologist; IPF, idiopathic pulmonary fibrosis; NP, nurse
practitioner; OT, occupational therapist; PR, pulmonary rehabilitation; PT, physical therapist; RN, registered nurse; RT, respiratory therapist.

percentage per session or weekly, or after a specific

number of sessions based on clinical evaluation, adding minutes on each mode based on oxygen saturation or Borg rating, increasing exercise duration to 15
to 45 minutes, then increasing intensity, using MET
goals from a 6MWT or graded exercise test, and
increasing by a specified MET level over time. Less
than half of the responders use a resistance training
protocol.

APPLICATION TO PRACTICE
Individual responses and general survey results
described in Table 2 suggest approaches to exercise
prescription in PR that include exercise science, clinical judgment, and patient objective and subjective
findings. The varied responses and practices may be
influenced by diverse national recommendations,
exercise prescription requirements of AACVPR national PR certification, lack of formal exercise science
training of many PR clinicians, and various models of
PR used throughout the United States and possibly
regional variations. It is unclear whether diverse practices reflect the heterogeneity of PR patients. The
results are from a small sample size, and caution
should be used in applying the results to program
exercise recommendations.
The AACVPR program certification requirements
indicate that the PR exercise prescription be individualized; contain exercise mode, frequency, duration,
intensity, and progression; and oxygen saturation and
oxygen titration. Intensity targets must comply with
the ACSM or AACVPR guidelines. Initial exercise
assessment, reassessment, followup, and discharge
assessment must be included in the patient individualized treatment plan (from https://www.aacvpr.org/
www.jcrpjournal.com

Portals/0/certification/2013/Copy%20of%202013%20
Pulmonary%20App%2001.10.13%20-%20REFERENCE
%20ONLY.pdf, accessed April 19, 2013).
Initial and ongoing assessment of exercise, oxygenation, and symptoms are central to PR exercise
prescription. Optimizing oxygenation and bronchodilation in obstructive lung disease may enhance exercise training. Comorbidities should be evaluated and
when appropriate, exercise training should be adapted
to enhance training and safety. Long-term adherence
to exercise is a major priority in PR, particularly translating gains from PR into increased physical activity.

SUMMARY
Comprehensive PR results in improvement in exercise
capacity, dyspnea, and quality of life. Exercise recommendations are available from at least 3 major US
organizations. Table 1 compares and contrasts exercise
recommendations from the ACSM, the AACVPR, and
the ATS. All guidelines recommendations include exercise frequency, duration, and intensity and recommend
aerobic and resistance training. Areas of inconstancy
include recommendations for flexibility training and
specifics regarding duration and intensity. The ACSM
categorizes COPD severity as mild or moderate to
severe, whereas the ATS and the Global Initiative for
Chronic Obstructive Lung Disease6 guidelines describe
mild, moderate, severe, and very severe COPD corresponding with pulmonary function impairment. The
ACSM includes emphysema, chronic bronchitis, and
cystic fibrosis as COPD disorders, in contrast to the
ATS7 and Global Initiative for Chronic Obstructive
Lung Disease,6 which do not include cystic fibrosis as
a COPD disorder. The American College of Chest
Physicians and AACVPR evidence-based PR guidelines
PR Exercise Prescription / 321

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 321

22/08/13 4:19 PM

do not recognize inspiratory muscle training as an

essential component of PR. Guideline differences may
reflect variations in backgrounds, composition, and
mission of national organization leadership and membership. Clinicians should be familiar with all major,
evidence-based PR guidelines and use clinical judgment and a collaborative, multidisciplinary team
approach to individualized exercise training and prescription. A baseline and ongoing assessment that
includes disease and symptom severity, comorbidities,
and patient goals should be emphasized. This should
be coupled with individual and aggregate measurement and analysis of patient-centered outcomes,
including exercise performance. Finally, PR should
emphasize sustainable exercise that translates into
increased physical activity. Future research considerations include evaluating and comparing efficacy of
various PR guidelines to aid clinicians in selecting
optimal practice strategies.

Acknowledgments
The authors thank the following individuals for their
support and assistance in the development, review, and
testing of the exercise prescription survey: P. Joanne Ray;
Gayla Oakley, RN; Bonnie Anderson, MS, RCEP,
FAACVPR; Susan O. Carter, RN, BC, FAACVPR; David
Verrll, MS, RCEP, FAACVPR; Cristy Baldwin, BSN, RN,
FAACVPR; Richard Casaburi, PhD, MD, FAACVPR;
Thierry Troosters, PT, PhD; and Martijn Spruit, PT, PhD.

References
1. Nici L, Donner C, Wouters E, et al. American Thoracic Society/
European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173:1390-1413.
2. Thompson WR, Gordon EF, Pescatello LS. ACSM's Guidelines
for Exercise Testing and Prescription. 8th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2010.
3. ZuWallack R, Crouch R. American Association of Cardiovascular
and Pulmonary Rehabilitation Guidelines for Pulmonary
Rehabilitation Programs. 4th ed. Champaign, IL: Human
Kinetics; 2011.
4. Lareau S, ZuWallack R, Carlin BW, et al. Pulmonary rehabilitation. Am J Respir Crit Care Med. 1999;159:1666-1682.
5. Ries AL, Carlin BW, Carrieri-Kohlman V, et al. American College
of Chest Physicians, American Association of Cardiovascular and
Pulmonary Rehabilitation. Pulmonary rehabilitation: joint ACCP/
AACVPR evidence-based guidelines. Chest. 1997;112:13631396.
6. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation:
joint ACCP/AACVPR evidence-based guidelines. Chest.
2007;131:4S-42S.
7. Rodriguez Roisin R, Vestbo J, Anzueto A, et al. Global strategy
for diagnosis, management, and prevention of COPD. http://
www.goldcopd.org. Accessed February 20, 2012.
8. Borg G. Psychophysical basis of perceived exertion. Med Sci
Sports Exerc. 1982;14:377-381.
9. Elliott MW, Adams L, Cockcroft A, Macrae KD, Murphy K, Guz A.
The language of breathlessness. Am Rev Respir Dis. 1991;144:
826-832.
10. Borg G. Borgs Perceived Exertion and Pain Scales. Champaign,
IL: Human Kinetics; 1998.
11. Crapo R, Casaburi R, Coates W, et al. ATS statement: guidelines
for the Six-Minute Walk Test. Am J Respir Crit Care Med. 2002;166:
111-117.

322 / Journal of Cardiopulmonary Rehabilitation and Prevention 2013;33:314-322

www.jcrpjournal.com

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HCR200302.indd 322

22/08/13 4:19 PM