[NOTE: This article has been posted prior to peer review for use in an active research program. This content will be updated with a peer reviewed version as soon as it is available.]
People with chronic obstructive pulmonary disease (COPD) can become less active as breathing grows more difficult, yet this inactivity worsens shortness of breath, muscle weakness, and overall health.1,2 Regular exercise improves the body’s use of oxygen, strengthening muscles, and reducing the effort needed for daily activities.3 Clinical practice guidelines recommend that those with COPD maintain regular physical activity to improve exercise capacity, symptoms, and quality of life across all grades of COPD severity with exact goals of frequency and intensity individualized to patients.Guidelines also support the use of home-based and community programs which can help expand access and encourage patients to exercise.1,4,5 Patients completing exercise programs have reported positive effects on multiple outcomes, ranging from daily symptoms and exercise tolerance to a return to gainful employment and decrease in healthcare utilization.4,6,7
In clinical studies, patients completing structured training programs demonstrated marked improvements in exercise tolerance. One study from 1970 (n=11) found that after an 18-week exercise program, all participants reported they could do more in their daily lives and all had increased maximal workload.8 Another study from 2002 (n=47) found that strength training, endurance training, or a combination of both were all effective at improving exercise capacity and dyspnea, although unsurprisingly, endurance training was superior for exercise endurance and strength training was superior for muscle strengthening.9 After a 12-week program of either, participants saw an improvement in distance walked while maintaining speed (104, 39, and 59 meters, respectively) and endurance (8.3, 33.6, and 24.0, respectively). Scores from the Chronic Respiratory Questionnaire (each question scored on a Likert scale from 0-7) found that participants had improved dyspnea, (0.8, 0.8, and 0.7, respectively), fatigue, (0.9, 0.1, and 0.4, respectively), and emotion (0.8, 0.1, and 0.6, respectively).
Hospitalization
Patients who remain active are less likely to be hospitalized and have shorter stays when hospitalized. The same 2010 analysis NETT data found that those who were hospitalized reported getting less physical activity each week (94 vs 109 minutes, p=0.01).10 They were also less physically fit, with shorter 6-minute walk distances (355.05 vs 377.14 meters, p=0.01) and lower maximal workload (36.52 vs 41.29, p=0.01). A randomized controlled trial from 2000 (n=200) found over one year of follow up, those who completed a 6-week program spent an average of 9.4 days in the hospital due to respiratory illness compared to 18.1 days for controls (p=0.021).11
Even light daily movement like household chores or stretching can provide measurable benefits.7 One 2010 analysis of data from the National Emphysema Treatment Trial (NETT), a large randomized controlled trial, found that just two or more hours of light activity each week decreased the risk of hospitalization. The analysis examined 597 patients, 394 of whom had no hospital admission over a 12-month period and 203 of whom did.10 Among those who had no hospitalization, 42% reported exercising 2 hours or more each week compared to only 30% of patients who had been hospitalized at least once (p=0.003).
Mortality
Additionally, long-term data confirm that declining physical activity is one of the strongest predictors of mortality in COPD. A 2011 prospective cohort study of 170 patients with stable COPD found over four years, the absolute risk of all-cause mortality for very inactive patients was 31% compared to 9% for sedentary and 0% for active (overall mortality 15.4%).12 Analysis showed that after adjustment, each 0.14 increase in physical activity level was independently associated with a lower risk of death (Hazard Ratio [HR] 0.46, Confidence Interval [CI] [0.33-0.64), p=0.001) and that physical activity was most predictive of mortality risk (other attributes examined included lung function, nutritional and muscular status, systemic inflammation, and cardiovascular status).
Mood, Sleep, and Quality of Life
Exercise improves mood, mediating symptoms of depression and anxiety.13 A 2000 randomized controlled trail (n=200) found that pulmonary rehabilitation was more effective than standard care in reducing anxiety and depression as reported on a self-assessment scale (scored 0-21). After a 6-week program, average depression scores were 5.6 compared to 7.9 for controls, and anxiety scores 7.3 vs 8.9 for controls.
Exercise also improves sleep and health-related quality of life. A 2014 study (n=34) found that pulmonary rehabilitation improved sleep quality (assessed by Pittsburgh Sleep Quality Index [PSQI], scored 0-21 with scores >5 indicating poor sleep) and quality of life (assessed by St Geroge Respiratory Questionnaire [SGRQ], scored 0-100 with lower scores indicating better quality of life).14 After pulmonary rehabilitation, PSQI scores decreased from 9.41 to 7.82 (p<0.001), and the number of participants with poor quality sleep decreased from 85.3% to 64.7% (p=0.006). Quality of life also improved, with SGRQ scores decreasing from 50 to 40 (p<0.001).
References
- Agustí A, Celli BR, Criner GJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, 2024 Report. 2024. https://goldcopd.org/2024-gold-report/
- Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. May 1 2005;171(9):972-7. doi:10.1164/rccm.200407-855OC
- Patel H, Alkhawam H, Madanieh R, Shah N, Kosmas CE, Vittorio TJ. Aerobic vs anaerobic exercise training effects on the cardiovascular system. World J Cardiol. Feb 26 2017;9(2):134-138. doi:10.4330/wjc.v9.i2.134
- Watz H, Pitta F, Rochester CL, et al. An official European Respiratory Society statement on physical activity in COPD. Eur Respir J. Dec 2014;44(6):1521-37. doi:10.1183/09031936.00046814
- Xiang X, Huang L, Fang Y, Cai S, Zhang M. Physical activity and chronic obstructive pulmonary disease: a scoping review. BMC Pulm Med. Aug 5 2022;22(1):301. doi:10.1186/s12890-022-02099-4
- Spruit MA, Burtin C, De Boever P, et al. COPD and exercise: does it make a difference? Breathe (Sheff). Jun 2016;12(2):e38-49. doi:10.1183/20734735.003916
- Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. Sep 2006;61(9):772-8. doi:10.1136/thx.2006.060145
- Bass H, Whitcomb JF, Forman R. Exercise training: therapy for patients with chronic obstructive pulmonary disease. Chest. Feb 1970;57(2):116-21. doi:10.1378/chest.57.2.116
- Ortega F, Toral J, Cejudo P, et al. Comparison of effects of strength and endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Sep 1 2002;166(5):669-74. doi:10.1164/rccm.2107081
- Benzo RP, Chang CC, Farrell MH, et al. Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease. Respiration. 2010;80(1):10-8. doi:10.1159/000296504
- Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet (London, England). Jan 29 2000;355(9201):362-8. doi:10.1016/s0140-6736(99)07042-7
- Waschki B, Kirsten A, Holz O, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest. Aug 2011;140(2):331-342. doi:10.1378/chest.10-2521
- Coventry PA, Hind D. Comprehensive pulmonary rehabilitation for anxiety and depression in adults with chronic obstructive pulmonary disease: Systematic review and meta-analysis. J Psychosom Res. Nov 2007;63(5):551-65. doi:10.1016/j.jpsychores.2007.08.002
- Lan CC, Huang HC, Yang MC, Lee CH, Huang CY, Wu YK. Pulmonary rehabilitation improves subjective sleep quality in COPD. Respir Care. Oct 2014;59(10):1569-76. doi:10.4187/respcare.02912