Benefits of home-based endurance training in lung transplant recipients
Introduction
Lung transplantation is a recognized treatment for end-stage cardiopulmonary diseases, since it has been shown to be viable (Christie et al., 2009), to enhance survival (Hosenpud et al., 1998) and to improve quality of life (Vermuelen et al., 2007). However, despite the significant improvement in lung function, exercise capacity is still limited in these patients (Williams et al., 1990, Williams et al., 1992).
Peripheral muscular deconditioning may be responsible for the low exercise tolerance in lung transplant recipients (LTR) (Miyoshi et al., 1990, Orens et al., 1995, Tirdel et al., 1998, Lands et al., 1999, Pantoja et al., 1999, Pinet et al., 2004). Although the benefits of exercise training to enhance exercise tolerance and quality of life have been clearly established in chronic heart and lung diseases (Lacasse et al., 2006, van Tol et al., 2006), pulmonary rehabilitation has been poorly investigated in LTR. To our knowledge, two previous studies have shown that supervised endurance training could enhance functional capacity, muscle strength and quality of life in the first months following the surgery (Maury et al., 2008, Munro et al., 2009). Yet, in numerous patients, exercise tolerance remains abnormally low even years after transplantation (Orens et al., 1995, Lands et al., 1999). Only one study has shown that exercise training could improve exercise capacity and ventilatory response within 6–18 months after surgery in LTR (Stiebellehner et al., 1998). The paucity of the literature on rehabilitation in this population may be a sign of troubles to design a controlled study on rehabilitation in the context of post transplant care and follow-up. There is however a clear interest on pulmonary rehabilitation after transplantation in LTR (Rochester, 2008).
In chronic obstructive pulmonary disease (COPD) patients, Maltais et al. suggested that home-based training is an equivalent alternative to outpatient rehabilitation in patients with COPD. The authors reported similar improvements in exercise tolerance and quality of life after outpatient and home-based exercise training (Maltais et al., 2008).
We thus wonder whether home-based exercise training could be a strategy to increase access to rehabilitation in LTR. In this study, we aimed at investigate the benefits of 3-month home-based endurance training in LTR. We hypothesized that, even performed at home, exercise training may improve exercise tolerance, muscle strength and quality of life in LTR.
We further hypothesized that not all the patients would be able to benefit from unsupervised training at home. In a secondary objective, we thus aimed at identifying the patients who are either responders or non-responders to home-based exercise training. We distinguished the patients depending on their ability to improve exercise tolerance after training. To do that, endurance time was measured and compared to the mean change observed in a group of aged-matched healthy subjects. Differences at baseline between responders and non-responders to exercise training were studied.
Section snippets
Subjects
Procedures were approved by our institutional review board and all participants gave informed consent. Twelve lung transplant recipients (LTR) and 7 age-matched healthy subjects were recruited. All LTR had performed a 4-week inpatient rehabilitation program immediately after transplantation but none of them had performed home-based exercise training later on. Healthy subjects were included when their spontaneous physical activity did not exceed 2 h per week in the last 2 months before inclusion
Patients studied
Anthropometrics and pulmonary function in LTR are shown in Table 1. FEV1 forced expiratory volume in 1 s was under normal value at 74 ± 24% of predicted value. Two patients (patients 9 and 12) had a single lung transplantation and showed moderate obstruction after transplantation. Two double lung transplant patients (patients 5 and 10), one HLT (patient 11) showed also moderate to severe obstruction pattern because of chronic dysfunction.
A comparison of LTR and healthy subjects in anthropometrics,
Discussion
The main result of this study is that 3-month endurance training could improve endurance time, muscle strength and quality of life in LTR in a home based setting. Changes in endurance time were independently associated with a decrease in minute ventilation during exercise and an increase in type II fibers diameter. Furthermore, half of the patients improved endurance time to the same absolute extent than age-matched healthy subjects after training, and they significantly improved peak oxygen
Funding
Grants from Conseil Scientifique of Association Nationale de Traitement à Domicile Innovation et Recherche, Conseil Scientifique of AGIR-à-dom, «Délégation à la Recherche Clinique du Centre Hospitalier Universitaire de Grenoble», awarded to Dr Bernard Wuyam. Centre d’Investigation Clinique, Inserm, CHU Grenoble, and, «Programme Interdisciplinaire Complexité du Vivant et Action STIC-Inserm» awarded to Pr Christophe Pison, Bourse «André Dion» (ATRIR) awarded to Dr Isabelle Vivodtzev.
Conflict of interest statement
Mrs Isabelle Vivodtzev has no conflict of interest to disclose. Pr Christophe Pison has conflicts of interest to disclose: he received honorarium from Astellas, Novartis and Roche companies. The study sponsors had no involvement in the collection, analysis and interpretation of data, in the writing of the manuscript and in the decision to submit the manuscript for publication. The authors Karen Guerrero, Paulette Mezin, Elisabeth Maclet, Jean-Christian Borel, Phillipe Chaffanjon, Rachid Hacini,
Acknowledgements
The authors are grateful to the scientific council of AGIR-à-dom (Meylan, France) for its financial support to this study and for the management of the rehabilitation program. The authors are also grateful to Mr Patrice Flore for scientific advices and to Mrs Chrystèle Deschaux for statistical advices.
References (34)
- et al.
The registry of the international society for heart and lung transplantation: twenty-sixth official adult lung and heart-lung transplantation Report-2009
J. Heart Lung Transpl.
(2009) - et al.
Effect of diagnosis on survival benefit of lung transplantation for end-stage lung disease
Lancet
(1998) - et al.
Validation of a bioelectrical impedance analysis equation to predict appendicular skeletal muscle mass (ASMM)
Clin Nutr.
(2003) - et al.
Maximal exercise capacity and peripheral skeletal muscle function following lung transplantation
J. Heart Lung Transpl.
(1999) - et al.
Skeletal muscle force and functional exercise tolerance before and after lung transplantation: a cohort study
Am. J. Transpl.
(2008) - et al.
Cardiopulmonary exercise testing after single and double lung transplantation
Chest
(1990) - et al.
Pulmonary rehabilitation following lung transplantation
Transpl. Proc.
(2009) - et al.
Cardiopulmonary exercise testing following allogeneic lung transplantation for different underlying disease states
Chest
(1995) - et al.
Aerobic endurance training program improves exercise performance in lung transplant recipients
Chest
(1998) - et al.
Long-term functional follow-up of lung transplant recipients
Clin. Chest Med.
(1990)
Training induced changes in the subgroups of human type II skeletal muscle fibres
Acta Physiol. Scand.
Chronic lung allograft rejection: mechanisms and therapy
Proc. Am. Thorac. Soc.
Aerobic and strength training in patients with chronic obstructive pulmonary disease
Am. J. Respir. Crit. Care Med.
Psychophysical bases of perceived exertion
Med. Sci. Sports Exerc.
French-Canadian version of the Chronic Respiratory and St George's Respiratory questionnaires: an assessment of their psychometric properties in patients with chronic obstructive pulmonary disease
Can. Resp. J.
Muscle Biopsy: A Practical Approach
Functional coupling of adenine nucleotide translocase and mitochondrial creatine kinase is enhanced after exercise training in lung transplant skeletal muscle
Am. J. Physiol. Regul. Integr. Comp. Physiol.
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