Exercise as it relates to Disease/Land or sea? Ideal exercise type for COPD patients with physical co-morbidities

This Wiki Fact Sheet critiques the article ‘Water-based exercise in COPD with physical comorbidities: a randomised controlled trial’, which was published in The European Respiratory Journal in 2013.

What is the background to this research?
Chronic Obstructive Pulmonary Disease (COPD) is a term for a group of disorders that cause an airway obstruction which limits gas exchange, and in-turn effects cardiac function. This progressive condition of the lungs and airways is characterised by the symptom of breathlessness, and is irreversible as permanent damage has occurred to the tissue of the lungs and airways. Land-based training has been proven to be an integral part of pulmonary rehabilitation for those suffering with COPD in order to improve physical wellbeing and decrease the breathlessness often experienced during daily activities. This type of exercise however can become difficult or impossible for those suffering from COPD and physical comorbidities that exist alongside the disease. This research was conducted as many people suffering from COPD are in the older age category, and are more likely to also be suffering from comorbid conditions, which tends to result in exclusion of these patients from many studies. McNamara’s study specifically aimed to determine if water-based exercise training could be a more effective intervention strategy than land-based exercise for this population in improving their quality of life, and their ability to perform everyday activities more easily.

Where is the research from?
This research was conducted by a team of researchers led by Dr Renae J. McNamara, from the Prince of Wales Hospital in NSW. McNamara has previous research experience within this area, as she has particular interest in COPD and using exercise to decrease severity of symptoms. She has also thoroughly researched how the type of exercise may effect the training adaptions acquired through pulmonary rehabilitation. Through a variety of research projects she has investigated how the way the exercise program is delivered (videoconferencing), and what the smallest worthwhile effect of these types of exercise (land and water based) was on those suffering from COPD.

What kind of research was it?
This study was a perspective randomised control trial in which participants with no contradictions to exercise were blindly randomised and allocated one of three clinical interventions (land-based exercise, water-based exercise and no exercise (control)). The control group did not undertake any exercise intervention and this group was used to compare the data acquired from the groups prescribed with a specific type of exercise. This type of controlled experiment allows quantitative comparison of interventions on a specific population who are randomly allocated in order to measure and compare outcomes. In this study, a total of 54 participants were randomly allocated into 3 groups to ensure 16 people per group would complete the study. This allowed for loss due to follow up or inability to complete the program due to unforeseen circumstances, but provided a big enough sample size for the comparison of training types.

What did the research involve?
This study comprised of participants that were referred to pulmonary rehabilitation in an ACT hospital who had confirmed COPD which was in a stable phase. Participants also had to have the presence of at least one physical comorbidity, which could include musculoskeletal conditions, neurological conditions, obesity (BMI > 32kg/m2) or mobility restricting conditions.

After being randomly allocated to an exercise group, trained for 8 weeks, completing 3 sessions per week, each of which was 60 minutes in duration. Participants trained to the best of their abilities at an intensity of 3-5 on a RPE scale, and intensity and muscle groups targeted were matched as closely as possible between the 2 exercise groups. Although the 2 exercise groups were matched closely in terms of amount and intensity of exercise performed, it should be noted that those who completed water-based exercise experienced much greater amounts of resistance as the movements they were performing were done so in water.

An endurance shuttle walk test (ESWT) was the main measure of endurance exercise capacity, and this was used alongside an incremental shuttle walk test (ISWT) and a 6 minute walk test (6MWT). In order to measure disease related quality of life all participants completed the chronic respiratory disease questionnaire (CRDQ) dyspnoea and fatigue. Participants in all 3 groups underwent all these tests before the intervention began and immediately post-intervention.

What were the basic results?
Through directly comparing the effect of land-based, water-based and no exercise on a group of patients suffering from COPD and physical comorbidities, this research collected data that showed water-based exercise improved the peak and endurance exercise capacity in this population significantly more than land-based training. This improvement is significant as in this study it was also seen that the group engaging in land-based exercise also saw improvements in exercise capacity to the control group who did not complete any exercise. This mode of training also saw large improvements in water-based training participants in the health-related quality of life self-reported CRDQ questionnaire, which shows an elevated response to participants self-perceived quality of life in relation to how the disease effects their everyday life.

McNamara’s Research in this population found that suggests that the addition of physical comorbidities alongside COPD may result in this specific population responding better to water-based exercise than those with COPD alone. It was highlighted that this may be due to the buoyancy experienced when submerged in water, which for people with musculoskeletal conditions, arthritis or mobility issues due to obesity or old age, may elevate some of the day to day pain they experience due to contact forces, which allows them to work at a higher intensity to that if they were exercising on land. This research is not overstated in the impact of its findings as although the effect of water and land-based training has been thoroughly researched with COPD patients, those suffering from additional diseases or conditions have been disregarded from research due to their other conditions interfering with compliance to the exercise and in turn the results.

What conclusions can we take from this research?
This study collected sufficient that water-based exercise was a more effective intervention for increasing exercise capacity and function in daily life than no exercise or land-based exercise for those suffering from COPD and comorbidities. When comparing the 3 types of training that participants undertook, it was evident that for this specific population, water-based training was more effective at improving patient function and wellbeing on land than land-based exercise. McNamara’s approach to this study involving those suffering from COPD was refreshing for this population and provided sufficient evidence of improvement in exercise capacity and showed how this type of physical activity benefited those suffering from additional comorbidities as attendance was higher in this exercise group when compared to the land-based exercise.

Practical advice
Caution should be taken when beginning exercise and an ESSA pre-exercise screening form should be completed to ensure the individual has no further contradictions to exercise, and GP approval is approved. Traditional pulmonary rehabilitation methods have been proven to be successful and are often implemented in COPD cases, with water-based exercise providing an alternative exercise method to land-based training. This could be more beneficial and more easily complied with if the patient does not have and contradictions to this form of exercise.

Further information/resources
For further information regarding COPD and pulmonary rehabilitation, please follow the links below:
 * What is COPD?: https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx
 * Pulmonary Rehabilitation: https://lungfoundation.com.au/wp-content/uploads/2014/02/Pulmonary-Rehabilitation-FS_May17.pdf