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COPD – Increased Independence

Evidence Summary (Updated 2022)
A large body of good quality randomised controlled trial study data shows an improvement in physical and functional capacity as measured by mean walking distance.(1–3)
A 12 study (n = 689) SR/MA concluded that HIIT could improve pulmonary function, exercise capacity (improved estimate 30.31m 6MWD (MD = 30.31, 95% CI [14.52, 46.10], P = 0.0002) (GRADE: high)), and quality of life (CRQ score improvement (SMD = 0.3, 95% CI [0.06, 0.54], P = 0.01) (GRADE: moderate)) but may not decrease dyspnoea in patients with COPD.(4)
This SR/MA looking at land and water-based aerobic training shows that aerobic exercise can effectively improve dyspnoea (MD –0.61 [–1.08, –0.15]; P=0.01)) and exercise capacity (land and water-based groups improved 6MWT (MD: 56.37, 95% CI [32.61, 80.13], P < .05) and ESWT (MD: 254.81, 95% CI [166.41, 343.22], P < .05)) in COPD patients. Compared with land-based aerobic exercise, water-based aerobic exercise had a significant additional effect in improving the endurance exercise capacity of COPD patients.(5)
An 11 study (n = 405) meta-analysis on the effects of resistance training in elderly COPD patients. The results such as improved 6-min walking distance (WMD, 54.52; 95% CI 25.47–83.56; I2 = 43%; P = 0.14), transfer numbers for the 6-min pegboard and ring test (WMD, 25.17; 95% CI 10.17–40.16; I2 = 0%; P = 0.55), and tolerance time for the unsupported upper-limb exercise test (SMD, 0.41; 95% CI 0.03–0.79; I2 = 0%; P = 0.83). indicate that resistance training could improve functional, endurance and maximum exercise capacity of elderly COPD patients.(6)
Another 8 study (n= 332) SR/MA looking at elastic resistance training. Compared to resistance training with weight machines, there were similar effects on improved muscle strength (similar knee extensor strength (SMD = −0.14, 95% CI = −0.58 to 0.29, I2 = 0%; low certainty), shoulder flexor strength (MD = 4.02 N, 95% CI = −7.81 to 15.84 N, I2 = 42%; very low certainty) and elbow flexor strength (SMD = 0.07, 95% CI = −0.36 to 0.50, I2 = 0%; moderate certainty), functional exercise capacity (MD = 10.94, 95% CI = −8.65 to 30.53, I2 = 0%; low certainty), HRQoL and dyspnoea.(7)
The review (15 studies, n = 842) concluded that exercise-based interventions have a positive effect on balance in COPD patients. Incorporation of balance training into PR seems to have the most beneficial effect on balance, although the effects on fall risk and longer-term intervention effects are understudied.(8)
Early PR interventions, through meta-analysis, were found to improve functional exercise capacity (higher 6MWD (MD = 97.58, 95%CI 17.21 to 177.96, Z = 2.38, p = 0.02)), dyspnoea (mMRC was significantly lower in the PR group (MD = −0.36, 95%CI −0.52 to −0.21, Z = 4.56, p ˂ 0.00001)), QoL (lower SGRQ (MD = −9.67, 95%CI −16.23 to −3.11, Z = 2.89, p = 0.004)) and SF-36 physical questionnaires.(9)
A SR/MA looking at the effects of upper limb training in COPD. They found improved functional exercise capacity (SMD=0.60; 95% CI, 0.26 to 0.94; p<0.001), dyspnoea l (SMD=-0.44; 95% CI, -0.64 to -0.23; p<0.001), reduced upper limb fatigue (4 studies, SMD=-0.41; 95% CI, -0.83 to -0.00; p=0.05) but no statistically significant differences in QoL questionnaire measures such as SGRQ (SMD=-0.32; 95% CI, -0.75 to 0.11; p=0.15).(10)
A large 39 study (n= 2397) systematic review and meta-analysis on the effects of PR, including those based on Yoga, Tai Chi. Meta-analysis showed improvements in exercise capacity (6MWT WMD, 36.34; 95% CI 26.51–46.17; p < .001; I2 = 91.6%), QoL (SGRQ total score (WMD, −6.66; 95% CI: −8.38 to −4.94; p < .001; I2 = 78%), lung function (significant changes in the FEV1% predicted value (WMD, 0.20; 95% CI: 0.03–0.36; p < .001; I2 = 92.7%) and dyspnoea (WMD, −0.59; 95% CI: −0.81 to −0.37; p < .001; I2 = 76.8%).(11)
Similar positive effects on variables of independence were found with traditional Chinese exercises in systematic review and meta-analysis performed by Yang, et al (2020), Xiao, et al (2020), Guo, et al (2020), Wu, et al (2018), Liu, et al (2018), Cramer, et al (2019) and Gao, et al (2021)
Improvements were seen with the following researched modalities: unsupported upper limb exercise, Continuous/ Interval Training, aerobic, resistance – both machine based and elastic band, HIT, LIT, Yoga & Tai Chi
Recent review of evidence strengthens the recommendation

Quality of Evidence
Grade A – High quality.

Strength of recommendation
Grade 1 – strong recommendation.

Clinical and patient consensus is that physical activity can improve physical and exercise capacity. On the basis of the existing evidence, clinical opinion is that all or most patients will be best served by following this piece of evidence .


  1. Zwerink M, Brusse-Keizer M, van der Valk PDLPM, Zielhuis GA, Monninkhof EM, van der Palen J, et al. Self management for patients with chronic obstructive pulmonary disease. Cochrane database Syst Rev [Internet]. 2014 Mar 24 [cited 2022 Oct 5];2014(3). Available from:
  2. Mador MJ, Krawza M, Alhajhusian A, Khan AI, Shaffer M, Kufel TJ. Interval training versus continuous training in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev [Internet]. 2009 Mar 1 [cited 2022 Oct 4];29(2):126–32. Available from:
  3. Arnardóttir RH, Boman G, Larsson K, Hedenström H, Emtner M. Interval training compared with continuous training in patients with COPD. Respir Med [Internet]. 2007 Jun [cited 2022 Oct 5];101(6):1196–204. Available from:
  4. Gao M, Huang Y, Wang Q, Liu K, Sun G. Effects of High-Intensity Interval Training on Pulmonary Function and Exercise Capacity in Individuals with Chronic Obstructive Pulmonary Disease: A Meta-Analysis and Systematic Review. Adv Ther [Internet]. 2022 Jan 1 [cited 2022 Oct 4];39(1):94–116. Available from:
  5. Chen H, Li P, Li N, Wang Z, Wu W, Wang J. Rehabilitation effects of land and water-based aerobic exercise on lung function, dyspnea, and exercise capacity in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Medicine (Baltimore) [Internet]. 2021 Aug 20 [cited 2022 Oct 5];100(33). Available from:
  6. Li N, Li P, Lu Y, Wang Z, Li J, Liu X, et al. Effects of resistance training on exercise capacity in elderly patients with chronic obstructive pulmonary disease: a meta-analysis and systematic review. Aging Clin Exp Res [Internet]. 2020 Oct 7 [cited 2022 Oct 5];32(10):1911–22. Available from:
  7. de Lima FF, Cavalheri V, Silva BSA, Grigoletto I, Uzeloto JS, Ramos D, et al. Elastic Resistance Training Produces Benefits Similar to Conventional Resistance Training in People With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis. Phys Ther [Internet]. 2020 Nov 1 [cited 2022 Oct 5];100(11):1891–905. Available from:
  8. Delbressine JM, Vaes AW, Goërtz YM, Sillen MJ, Kawagoshi A, Meijer K, et al. Effects of Exercise-Based Interventions on Fall Risk and Balance in Patients With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW. J Cardiopulm Rehabil Prev [Internet]. 2020 May 1 [cited 2022 Oct 5];40(3):152–63. Available from:
  9. Du Y, Lin J, Wang X, Zhang Y, Ge H, Wang Y, et al. Early Pulmonary Rehabilitation in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Meta-Analysis of Randomized Controlled Trials. [Internet]. 2022 [cited 2022 Oct 5];19(1):69–80. Available from:
  10. Kruapanich C, Tantisuwat A, Thaveeratitham P, Lertmaharit S, Ubolnuar N, Mathiyakom W. Effects of Different Modes of Upper Limb Training in Individuals With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Ann Rehabil Med [Internet]. 2019 [cited 2022 Oct 5];43(5):592–614. Available from:
  11. Zhang H, Hu D, Xu Y, Wu L, Lou L. Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Ann Med [Internet]. 2022 [cited 2022 Oct 5];54(1):262–73. Available from: