Exercise training modalities and strategies to improve exercise performance in patients with respiratory disease

array:25 ["pii" => "S0873215913001347" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2013.10.004" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "186" "copyright" => "Sociedade Portuguesa de Pneumologia" "copyrightAnyo" => "2013" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Pneumol. 2014;20:36-41" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8362 "formatos" => array:3 [ "EPUB" => 238 "HTML" => 6593 "PDF" => 1531 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S2173511514000128" "issn" => "21735115" "doi" => "10.1016/j.rppnen.2013.10.012" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "186" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "ssu" "cita" => "Rev Port Pneumol. 2014;20:36-41" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3831 "formatos" => array:3 [ "EPUB" => 271 "HTML" => 2599 "PDF" => 961 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Exercise training modalities and strategies to improve exercise performance in patients with respiratory disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "36" "paginaFinal" => "41" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Modalidades e Estratégias de Treino Físico para Melhorar o Desempenho durante o Exercício em Pacientes com Doenças Respiratórias" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 750 "Ancho" => 1001 "Tamanyo" => 138855 ] ] "descripcion" => array:1 [ "en" => "Neuromuscular electrical stimulation." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Almeida, F. Rodrigues" "autores" => array:2 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Almeida" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Rodrigues" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0873215913001347" "doi" => "10.1016/j.rppneu.2013.10.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001347?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000128?idApp=UINPBA00004E" "url" => "/21735115/0000002000000001/v1_201401230023/S2173511514000128/v1_201401230023/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0873215913000226" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2012.12.002" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "137" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2014;20:42-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 10079 "formatos" => array:3 [ "EPUB" => 272 "HTML" => 8411 "PDF" => 1396 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Case report" "titulo" => "Successful treatment of atelectasis with Dornase alpha in a patient with congenital muscular dystrophy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "42" "paginaFinal" => "45" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tratamento bem sucedido de atelectasia com Dornase alfa num doente com distrofia muscular congénita" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 93715 ] ] "descripcion" => array:1 [ "en" => "Chest CT scan at day 12: partial regression of the atelectasis." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Crescimanno, O. Marrone" "autores" => array:2 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Crescimanno" ] 1 => array:2 [ "nombre" => "O." "apellidos" => "Marrone" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173511514000098" "doi" => "10.1016/j.rppnen.2012.10.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000098?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913000226?idApp=UINPBA00004E" "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913000226/v2_201509041402/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0873215913001086" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2013.06.009" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "178" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2014;20:31-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6484 "formatos" => array:3 [ "EPUB" => 269 "HTML" => 4931 "PDF" => 1284 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "Publicação breve" "titulo" => "Associação entre a mecânica respiratória e função autonómica na obesidade mórbida" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "31" "paginaFinal" => "35" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Association between respiratory mechanics and autonomic function in morbid obesity" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2535 "Ancho" => 2451 "Tamanyo" => 210468 ] ] "descripcion" => array:1 [ "pt" => "Associação entre mecânica respiratória e variabilidade da frequência cardíaca. SDNN: desvio padrão de todos os intervalos RR normais; rMSSD: raiz quadrada das diferenças sucessivas entre intervalos RR normais adjacentes ao quadrado; R0: resistência extrapolada a 0Hz; R5: resistência em 5Hz; Rm: resistência média." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Sant’ Anna Junior, R.F. Carvalhal, J.R.I. Carneiro, M.S. Lapa, W.A. Zin, J.R. Lugon, F.S. Guimarães" "autores" => array:7 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Sant’ Anna Junior" ] 1 => array:2 [ "nombre" => "R.F." "apellidos" => "Carvalhal" ] 2 => array:2 [ "nombre" => "J.R.I." "apellidos" => "Carneiro" ] 3 => array:2 [ "nombre" => "M.S." "apellidos" => "Lapa" ] 4 => array:2 [ "nombre" => "W.A." "apellidos" => "Zin" ] 5 => array:2 [ "nombre" => "J.R." "apellidos" => "Lugon" ] 6 => array:2 [ "nombre" => "F.S." "apellidos" => "Guimarães" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173511513001012" "doi" => "10.1016/j.rppnen.2013.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511513001012?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001086?idApp=UINPBA00004E" "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913001086/v2_201509041402/pt/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Exercise training modalities and strategies to improve exercise performance in patients with respiratory disease" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "36" "paginaFinal" => "41" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Almeida, F. Rodrigues" "autores" => array:2 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "F." "apellidos" => "Rodrigues" "email" => array:1 [ 0 => "fatima.rodriguesed@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Medicina Física e de Reabilitação do Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Pneumologia do Centro Hospitalar Lisboa Norte – Hospital Pulido Valente, Faculdade de Medicina da Universidade de Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Modalidades e Estratégias de Treino Físico para Melhorar o Desempenho durante o Exercício em Pacientes com Doenças Respiratórias" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1540 "Tamanyo" => 133857 ] ] "descripcion" => array:1 [ "en" => "Cycling while on oxygen." ] ] ] "textoCompleto" => "IntroductionExercise training (ET) is a mandatory component of pulmonary rehabilitation (PR), it is at the core of PR programs and improves patients exercise tolerance and functional capacity, fatigue and dyspnea symptoms and health-related quality of life.<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a>Pulmonary rehabilitation also has benefits for health-related costs, reducing the number of exacerbations and hospitalizations, days in hospital and mortality in COPD patients.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Although highly recommended by scientific societies, at present, less than 5% of eligible patients have access to pulmonary rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> There is a need to optimize availability, accessibility and quality of PR in Europe, and that includes Portugal.According to GOLD, exercise training has benefits for all categories of COPD, but PR programs are mainly directed at the most symptomatic and severe patients: grades B, C and D.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Exercise intensity is a key element in improving outcomes. Therefore, high intensity training is recommended for its physiological benefits.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>In this article, authors describe a variety of modalities and strategies to overcome exercise limitations and improve the effects of exercise training.Exercise training componentsExercise training modalities include:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Endurance training:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010">(a)Lower and upper limbs</li><li class="elsevierStyleListItem" id="lsti0015">(b)Continuous or interval training</li><li class="elsevierStyleListItem" id="lsti0020">(c)High and moderate intensity. Relevance of total dose (combining training intensity, training session duration and frequency)</li></ul></li><li class="elsevierStyleListItem" id="lsti0025">2.Strength training: lower and upper extremities</li><li class="elsevierStyleListItem" id="lsti0030">3.Neuromuscular electrical stimulation (NMES)</li></ul>Limiting factors of exercise performance in COPD patients are multifactorial,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> but dynamic hyperinflation and peripheral muscle dysfunction are the most relevant ones, particularly in severe patients.Strategies to enhance exercise toleranceMultiple strategies to improve tolerance to high intensity exercise training in severe patients have been presented in literature<a class="elsevierStyleCrossRef" href="#bib0045">9</a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">•Pharmacological treatment optimization<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a></li><li class="elsevierStyleListItem" id="lsti0040">•Non-invasive ventilation (NIV)<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a></li><li class="elsevierStyleListItem" id="lsti0045">•Oxygen supplementation (O2)<a class="elsevierStyleCrossRefs" href="#bib0070">14–18</a></li><li class="elsevierStyleListItem" id="lsti0050">•Heliox<a class="elsevierStyleCrossRefs" href="#bib0095">19–21</a></li><li class="elsevierStyleListItem" id="lsti0055">•Aerobic training modalities: interval training,<a class="elsevierStyleCrossRefs" href="#bib0110">22–28</a> bicycle interval training,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> nonlinear exercise training<a class="elsevierStyleCrossRef" href="#bib0150">30</a></li><li class="elsevierStyleListItem" id="lsti0060">•Localized muscle training: a few muscle groups are active at each moment<a class="elsevierStyleCrossRefs" href="#bib0155">31–32</a> bicycle single-leg (unilateral),<a class="elsevierStyleCrossRef" href="#bib0160">32</a> progressive strength training (or isolated quadriceps training)<a class="elsevierStyleCrossRefs" href="#bib0165">33,34</a></li><li class="elsevierStyleListItem" id="lsti0065">•Neuromuscular electrical stimulation (NMES)<a class="elsevierStyleCrossRefs" href="#bib0175">35–37</a></li><li class="elsevierStyleListItem" id="lsti0070">•Eccentric exercise training (experimental)<a class="elsevierStyleCrossRefs" href="#bib0190">38,39</a></li><li class="elsevierStyleListItem" id="lsti0075">•Walking aids utilization<a class="elsevierStyleCrossRefs" href="#bib0200">40,41</a></li></ul>In all above strategies, pharmacological treatment optimization with inhaled bronchodilators is highly recommended to improve symptoms and dynamic lung hyperinflation and to enhance exercise tolerance. It is essential to prescribe them appropriately, to stimulate patient compliance and verify inhalation technique.Noninvasive ventilation, oxygen therapy and heliox supplements during exercise training are matters of debates. The real value of these exercise training adjuncts is not well established.Noninvasive ventilation and heliox supplements have been the subject of pilot studies that have shown evidence of exercise tolerance improvement in patients who have severely limited ventilation, but their efficacy and applicability has not been established.Use of supplemental oxygen in patients with exercise dessaturation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) is consensual in order to maintain an oxygen saturation of at least 90% during the training session (grade of recommendation 1C).<a class="elsevierStyleCrossRef" href="#bib0010">2</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Some studies have suggested the benefit of oxygen supplementation in exercise tolerance in non-hypoxemic patients,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> but the effects in improving activities of daily living, health status, morbidity or mortality are not yet documented. This therapy might be cost-effective in ventilatory limited patients where dyspnea due to dynamic hyperinflation prevents high intensity exercise training. Oxygen supplementation reduces dynamic hyperinflation through inhibition of carotid sinus stimulation, reducing ventilatory drive and respiratory rate. During exercise sessions it is also known to improve oxygen delivery to peripheral muscles, reducing muscle fatigue, which underpins its role as a training adjuvant and potentiating its effects.Exercise training is of paramount value in improving exercise tolerance. It reduces ventilatory demands for sub maximal efforts due to a lower lactic acid production in muscle fibers. This will reduce respiratory rate, and hence the dynamic hyperinflation for the same exercise intensity.Exercise intensity and session duration are determinants of the physiological response to training. However, continuous high intensity exercise is usually too hard for patients to achieve due to their ventilatory limitation, their muscle dysfunction with its premature lactic acidosis, their higher ventilatory demand and their dynamic hyperinflation.Some exercise training modalities are also good strategies for improvingThis is the case with interval training, which produces a high intensity peripheral muscle demand and at the same time, a lower ventilatory demand due to late lactic acidosis. Interval training with repeated short high intensity training periods (30 s to 3 min), interspersed with rest or low intensity periods, is well suited for patients with dynamic hyperinflation, and it delays its onset. Interval training is well suited for patients with dynamic hyperinflation, and it delays its onset. The benefits are well documented, it not only improves training tolerance, but it also enhances muscle fiber capillarity, metabolism, typology and size.Muscle training involving fewer muscle groups, namely quadriceps strength training, could be an alternative option, particularly in patients with a high risk of deconditioning (e.g. severe exacerbations with hospitalization).Neuromuscular electrical stimulation of ambulatory muscles (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) might be an additional or alternative strategy in very disabled patients, such as patients with acute exacerbations or patients on an active list for lung transplant.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>All the above strategies or training modalities could be either alternative or complementary and the clinician who prescribes pulmonary rehabilitation should be aware of them. Combinations of different but complementary strategies might be more beneficial than the cumulative effect of the benefits of each one.Dynamic hyperinflation reduction has a key role in the improvement of exercise tolerance and might be achieved by combining strategies that enhance expiratory flow (e.g. pharmacological optimization with inhaled bronchodilators) with a ventilatory demand and respiratory rate reduction (e.g. through oxygen supplementation and high intensity interval training). However, it should be noted that the eventual role of oxygen supplementation beyond the effects found in laboratory studies, in exercise training of non-hypoxemic patients, particularly those that do not desaturate while exercising, has not yet been demonstrated.Motivation in complying with medication, with an active lifestyle and regular exercise might generate positive reinforcement and could counteract the negative spiral of dyspnea, becoming sedentary, deconditioned and more dyspneic. It is well documented in the literature that there is an association between lower physical activity, the risk of exacerbation with hospitalization and mortality in patients with COPD<a class="elsevierStyleCrossRef" href="#bib0210">42</a>. Exercise training is the treatment that does most to improve and preserve the muscle mass and exercise performance, both relevant prognostic indexes in COPD.Exercise training adaptations due to comorbiditiesAn accurate and individualized exercise prescription should necessarily include some patient adaptation due to comorbidities. The prevalence of comorbidities, particularly multiple comorbidities, reflects the growing evidence of COPD as a complex disease that impacts on multiple organic systems. Systemic inflammation enhances the risk of developing and worsening conditions like coronary heart disease, congestive heart failure, diabetes mellitus, peripheral vascular disease, muscle dysfunction, cachexia and osteoporosis, among others.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>Although they influence patient prognosis, comorbidities should not preclude indication for pulmonary rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> On the contrary, PR programs should be adapted to comorbidities, not only in the evaluation settings but also in the prescription of PR modalities and monitoring PR programs. Exercise training, the core of PR programs, has also demonstrated well documented benefits in several comorbidities. Moreover, exercise training has a clear and high level of evidence-based benefits. The level of recommendation is IA for conditions like coronary heart disease, congestive heart failure, diabetes mellitus and peripheral vascular disease.<a class="elsevierStyleCrossRefs" href="#bib0225">45,46</a>The most relevant exercise training adaptations in patients with comorbidities are:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080">•Coronary heart disease: a moderate intensity training is recommended, being cautious in relation to intensity progression (start with intensities of 50 to 60% of maximal heart rate attained in previous maximal exercise test and, if well tolerated, gradually increase the intensity to a maximal threshold of 80% of peak heart rate); train below the anaerobic threshold, and if ischemic or arrhythmic thresholds are present, train below those limits; train under clinical surveillance and telemetric monitoring, at least in the first few weeks.</li><li class="elsevierStyleListItem" id="lsti0085">•Congestive heart failure: slow progression of exercise intensity, as tolerated; start with intensity of 40% peakVO2 and progress to 80% peakVO2; clinical and telemetric monitoring and active search for signs or symptoms of instability (central or peripheral edema, rapid weight gain, pulmonary congestion) are highly recommended.</li><li class="elsevierStyleListItem" id="lsti0090">•Diabetes mellitus: an accurate monitoring of glucose is recommended to improve metabolic control; prevention of hypoglycemia (with diet/nutritional counseling and pharmacological adjustments, if needed); search for metabolic derangements (exercise is contraindicated if glycemia>250mg/dL with ketonuria or if glycemia>300mg/dL); be aware of possible sub-clinical coronary disease; evaluate, prescribe and monitor evolution according to this information; diabetic foot surveillance is recommended, with particular attention to adequate hydration.</li><li class="elsevierStyleListItem" id="lsti0095">•Peripheral vascular disease: privilege gait training above ischemic threshold for lower limbs (training elicits claudicating symptoms; if intense pain is present, training is followed by a brief period of rest to permit symptoms to resolve; repeat for 30min to 1h); it should be noted that peripheral vascular disease is frequently associated with systemic vascular disease, including cerebral and coronary, though an active search for sub-clinical coronary disease is mandatory.</li></ul>ConclusionsAlthough strongly recommended by scientific societies, pulmonary rehabilitation programs still need to be more widely implemented. PR programs have shown high level of evidence of benefits in chronic respiratory patients, particularly those with COPD. Exercise training is an essential component of PR programs and its benefits are well documented in the literature. Clinicians should be aware of the different strategies available in order to optimize exercise training, patient security and compliance. Generalization and development of the existent PR programs and implementation of new strategies and modalities should be a constant preoccupation for all clinicians involved in the care of respiratory patients.Patients with advanced COPD show significant exercise intolerance due to severe muscle dysfunction and intense dyspnea. In these patients, exercise with interval training – repeated short high intensity training periods (30s to 3min), interspersed with rest or low intensity periods, and/or global strength training or localized to quadriceps, under oxygen supplementation if needed, might constitute suitable, applicable and efficacious exercise training strategies.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres547708" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec565588" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres547709" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec565589" "titulo" => "Palavras-chave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Exercise training components" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Strategies to enhance exercise tolerance" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Some exercise training modalities are also good strategies for improving" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Exercise training adaptations due to comorbidities" ] ] ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-11" "fechaAceptado" => "2013-10-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565588" "palabras" => array:3 [ 0 => "Pulmonary rehabilitation" 1 => "Exercise training" 2 => "Chronic obstructive pulmonary disease" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565589" "palabras" => array:3 [ 0 => "Reabilitação pulmonar" 1 => "Treino físico" 2 => "Doença pulmonar obstrutiva crónica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Pulmonary rehabilitation is an evidence-based, multidisciplinary, comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and whose daily living activities are often restricted.Pulmonary rehabilitation programs are designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote long-term adherence to health-enhancing behavior.Exercise training is at the core of pulmonary rehabilitation (PR) programs. The benefits of exercise training include decreased dyspnea, improved health-related quality of life, fewer days of hospitalization, and decreased health-care utilization.To gain PR benefits, patients should be able to complete an exercise training program, preferably with high intensity exercise, and it is likely that these benefits will translate into a change from a pattern of a sedentary lifestyle to a physically active lifestyle.Chronic respiratory patients, namely COPD patients, have a low exercise tolerance due to multiple factors, such as dynamic hyperinflation and peripheral muscle dysfunction.In this article, the authors describe a variety of modalities and strategies to overcome exercise limitations and improve the effects of exercise training." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "A reabilitação pulmonar é uma intervenção abrangente, multidisciplinar e baseada em evidências, para doentes com doenças respiratórias crónicas que são sintomáticas e cujas actividades da vida diária são frequentemente limitadas.Os programas de reabilitação pulmonar estão concebidos para melhorar a condição física e emocional de pessoas com doenças respiratórias crónicas e promover a adesão a longo prazo a comportamentos benéficos para a saúde.O exercício físico está no cerne dos programas de reabilitação pulmonar (RP). Os benefícios do exercício físico incluem redução da dispneia, melhor qualidade de vida em termos de saúde, menos dias de hospitalização, e utilização reduzida dos cuidados de saúde.Para obter os benefícios da RP, os doentes deverão ser capazes de completar um programa de exercício físico, de preferência com exercícios de alta intensidade, e é provável que esses benefícios se traduzam numa mudança de um padrão de estilo de vida sedentário para um estilo de vida fisicamente activo.Doentes com doenças respiratórias crónicas, nomeadamente com DPOC, têm uma baixa tolerância ao exercício devido a uma diversidade de factores, como a hiperinsuflação dinâmica e a disfunção muscular periférica.Neste artigo, os autores descrevem uma variedade de modalidades e estratégias para superar as limitações de exercício e melhorar os efeitos do treino físico." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1540 "Tamanyo" => 133857 ] ] "descripcion" => array:1 [ "en" => "Cycling while on oxygen." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 137104 ] ] "descripcion" => array:1 [ "en" => "Neuromuscular electrical stimulation." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:46 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Nici" 1 => "C. Donner" 2 => "E. Wouters" 3 => "R. Zuwallack" 4 => "N. Ambrosino" 5 => "J. Bourbeau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200508-1211ST" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "173" "paginaInicial" => "1390" "paginaFinal" => "1413" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16760357" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.L. Ries" 1 => "G.S. Bauldoff" 2 => "B.W. Carlin" 3 => "R. Casaburi" 4 => "C.F. Emery" 5 => "D.A. Mahler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.06-2418" "Revista" => array:7 [ "tituloSerie" => "Chest" "fecha" => "2007" "volumen" => "131" "numero" => "5 Suppl" "paginaInicial" => "4S" "paginaFinal" => "42S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17494825" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current best practice in pulmonary rehabilitation for chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. de Blasio" 1 => "M. Polverino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/1753465812444712" "Revista" => array:6 [ "tituloSerie" => "Ther Adv Respir Dis" "fecha" => "2012" "volumen" => "6" "paginaInicial" => "221" "paginaFinal" => "237" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22563010" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline update from the American College of Physicians, American College of Chest Physicians American Thoracic Society and European Respiratory Society" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Qaseem" 1 => "T.J. Wilt" 2 => "S.E. Weinberger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7326/0003-4819-155-3-201108020-00008" "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2011" "volumen" => "155" "paginaInicial" => "179" "paginaFinal" => "191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21810710" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.A. Puhan" 1 => "E. Gimeno-Santos" 2 => "M. Scharplatz" 3 => "T. Troosters" 4 => "E.H. Walters" 5 => "J. Steurer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Cochrane Database of Systematic Reviews" "fecha" => "2011" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Directing the future of lung health: the European Respiratory Roadmap" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "Y. Sibille" 1 => "M. Decramer" 2 => "L.P. Nicod" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00097111" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2011" "volumen" => "38" "paginaInicial" => "502" "paginaFinal" => "506" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21885412" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Global Initiative for Chronic Obstructive Lung Disease (GOLD) (Updated 2013), Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Available from <a href="http://www.goldcopd.org/">http://www.goldcopd.org</a>." ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Limiting factors of exercise capacity in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Rodrigues" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Port Pneumol" "fecha" => "2004" "volumen" => "X" "paginaInicial" => "9" "paginaFinal" => "61" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strategies of muscle training in very severe COPD patients in SERIES: “NOVELTIES IN PULMONARY REHABILITATION” edited by Clini E and Ambrosino N" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I. Vogiatzis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00075011" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2011" "volumen" => "38" "paginaInicial" => "971" "paginaFinal" => "975" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21737548" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improvement of endurance time with the combination of tiotropium and pulmonary rehabilitation in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Casaburi" 1 => "D. Kakafka" 2 => "C. Cooper" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.127.3.809" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2005" "volumen" => "127" "paginaInicial" => "809" "paginaFinal" => "817" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15764761" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of bronchodilators and oxygen alone and in combination on self-paced exercise performance in stable COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Cukier" 1 => "C. Ferreira" 2 => "R. Stelmach" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rmed.2006.08.013" "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "2007" "volumen" => "101" "paginaInicial" => "746" "paginaFinal" => "753" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17000096" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proportional assisted ventilation as an aid to exercise training in severe COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Hawkins" 1 => "L.C. Johnson" 2 => "D. Nikoletou" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2002" "volumen" => "57" "paginaInicial" => "853" "paginaFinal" => "859" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12324670" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Respiratory muscle unloading improves leg muscle oxygenation during exercise in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Borghi-Silva" 1 => "C.C. Oliveira" 2 => "C. Carrascosa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2007.090167" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2008" "volumen" => "63" "paginaInicial" => "910" "paginaFinal" => "915" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18492743" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dose-response effect of oxygen on hyperinflation and exercise endurance in nonhypoxaemic COPD patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Somfay" 1 => "J. Porszasz" 2 => "S.M. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2001" "volumen" => "18" "paginaInicial" => "77" "paginaFinal" => "84" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11510809" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of hyperoxia on gas exchange and lactate kinetics following exercise onset in nonhypoxemic COPD patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Somfay" 1 => "J. Porszasz" 2 => "S.M. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "121" "paginaInicial" => "393" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11834648" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of oxygen on lower limb blood flow and O2 uptake during exercise in COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "F. Maltais" 1 => "M. Simon" 2 => "J. Jobin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Sci Sports Exerc" "fecha" => "2001" "volumen" => "33" "paginaInicial" => "916" "paginaFinal" => "922" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11404656" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oxygen therapy during exercise training in chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.L. Nonoyama" 1 => "D. Brooks" 2 => "Y. Lacasse" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD005372.pub2" "Revista" => array:5 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2007" "volumen" => "2" "paginaInicial" => "CD005372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17443585" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Benefits of supplemental oxygen in exercise training in non-hypoxemic COPD patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Emtner" 1 => "J. Porszasz" 2 => "M. Bunrs" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2003" "volumen" => "68" "paginaInicial" => "1034" "paginaFinal" => "1042" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heliox improves oxygen delivery and utilization during dynamic exercise in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G.R. Chiappa" 1 => "F. Queiroga Jr." 2 => "E. Meda" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200811-1793OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2009" "volumen" => "179" "paginaInicial" => "1004" "paginaFinal" => "1010" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19299497" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of helium breathing on intercostals and quadriceps muscle blood flow during exercise in COPD patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vogiatzis" 1 => "H. Habazetl" 2 => "A. Aliverti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Physiol Regul Integr Comp Physiol" "fecha" => "2011" "volumen" => "300" "paginaInicial" => "1549" "paginaFinal" => "1559" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of heliox on heart rate kinetics and dynamic hyperinflation during high-intensity exercise in COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Laveneziana" 1 => "G. Valli" 2 => "P. Onorati" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00421-010-1643-z" "Revista" => array:6 [ "tituloSerie" => "Eur J Appl Physiol" "fecha" => "2011" "volumen" => "111" "paginaInicial" => "225" "paginaFinal" => "234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20852881" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effectiveness of interval exercise training in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E.A. Kortianou" 1 => "I.G. Nasis" 2 => "S.T. Spetsioti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cardiopulm Phys Ther J" "fecha" => "2010" "volumen" => "21" "paginaInicial" => "12" "paginaFinal" => "19" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20957074" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiopulmonary exercise testing in the functional and prognostic evaluation of patients with pulmonary diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.M. Ferrazza" 1 => "D. Martolini" 2 => "G. Valli" 3 => "P. Palange" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000186694" "Revista" => array:6 [ "tituloSerie" => "Respiration" "fecha" => "2009" "volumen" => "77" "paginaInicial" => "3" "paginaFinal" => "17" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19145106" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dynamic hyperinflation and tolerance to interval exercise in patients with advanced COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vogiatzis" 1 => "S. Nanas" 2 => "E. Kastanakis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.04.00128903" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2004" "volumen" => "24" "paginaInicial" => "385" "paginaFinal" => "390" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15358696" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skeletal muscle adaptations to interval training in patients with advanced COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vogiatzis" 1 => "G. Terzis" 2 => "S. Nanas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.128.6.3838" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2005" "volumen" => "128" "paginaInicial" => "3838" "paginaFinal" => "3845" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16354852" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of pulmonary rehabilitation on peripheral muscle fiber remodeling in patients with COPD in GOLD Stages II to IV" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vogiatzis" 1 => "G. Terzis" 2 => "G. Stratakos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.10-3058" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2011" "volumen" => "140" "paginaInicial" => "744" "paginaFinal" => "752" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21493697" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Interval training compared with continuous training in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.H. Arnardóttir" 1 => "G. Boman" 2 => "K. Larsson" 3 => "H. Hedenström" 4 => "M. Emtner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rmed.2006.11.004" "Revista" => array:7 [ "tituloSerie" => "Respir Med" "fecha" => "2007" "volumen" => "101" "paginaInicial" => "1196" "paginaFinal" => "1204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17188853" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0016508597001297" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Interval versus continuous training in individuals with COPD – a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.K. Beauchamp" 1 => "M. Nonoyama" 2 => "R. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2009.123000" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "157" "paginaFinal" => "164" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19996334" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilatory and metabolic adaptations to walking and cycling in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Palange" 1 => "S. Forte" 2 => "P. Onorati" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Appl Physiol" "fecha" => "2000" "volumen" => "88" "paginaInicial" => "1715" "paginaFinal" => "1720" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10797134" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nonlinear exercise training in advanced COPD is superior to traditional exercise training: a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Klijn" 1 => "A. van Keimpema" 2 => "M. Legemaat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201210-1829OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2013" "volumen" => "188" "paginaInicial" => "193" "paginaFinal" => "200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23449691" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Symptoms and quadriceps fatigability after walking and cycling in chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W.D. Man" 1 => "M.G. Soliman" 2 => "J. Gearing" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200302-162OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2003" "volumen" => "168" "paginaInicial" => "562" "paginaFinal" => "567" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12829456" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of one-legged exercise training of patients with chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.E. Dolmage" 1 => "R.S. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.07-1423" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2008" "volumen" => "133" "paginaInicial" => "370" "paginaFinal" => "376" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17925417" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Troosters" 1 => "V.S. Probst" 2 => "T. Crul" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200908-1203OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2010" "volumen" => "181" "paginaInicial" => "1072" "paginaFinal" => "1107" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20133927" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resistance training preserves skeletal muscle function in patients with COPD who are hospitalized with an acute exacerbation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Saey" 1 => "F. Ribeiro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1836-9553(11)70042-X" "Revista" => array:5 [ "tituloSerie" => "J Physiother" "fecha" => "2011" "volumen" => "57" "paginaInicial" => "194" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21843836" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with Chronic Heart Failure and COPD: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.J.H. Sillen" 1 => "C.M. Speksnijder" 2 => "Eterman R-MA" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.08-2481" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2009" "volumen" => "136" "paginaInicial" => "44" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19363213" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional and muscular effects of neuromuscular electrical stimulation in patients with severe COPD: a randomized clinical trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vivodzev" 1 => "R. Debigaré" 2 => "P. Gagnon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-0839" "Revista" => array:7 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "141" "paginaInicial" => "716" "paginaFinal" => "725" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22116795" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0016508507011614" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combination of pulmonary rehabilitation and neuromuscular electrical stimulation in copd patients: a randomized clinical trial of efficacy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Zanotti" 1 => "C. Bizarri" 2 => "R. Grasso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4172/2161-105X.1000112" "Revista" => array:3 [ "tituloSerie" => "J Pulmonar Respirat Med" "fecha" => "2012" "volumen" => "2" ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eccentric exercise in patients with chronic health conditions: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Roig" 1 => "B. Shadgan" 2 => "W.D. Reid" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3138/physio.60.2.146" "Revista" => array:6 [ "tituloSerie" => "Physiother Can" "fecha" => "2008" "volumen" => "60" "paginaInicial" => "146" "paginaFinal" => "160" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20145778" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eccentric cycle exercise in severe COPD: feasibility of application" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.S. Rocha Vieira" 1 => "J. Baril" 2 => "R. Richard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/15412555.2011.579926" "Revista" => array:7 [ "tituloSerie" => "COPD" "fecha" => "2011" "volumen" => "8" "paginaInicial" => "270" "paginaFinal" => "274" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21728805" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0016508502004560" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of a walking aid in COPD patients receiving oxygen therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Crisafulli" 1 => "S. Costi" 2 => "F. De Blasio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.06-2108" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2007" "volumen" => "131" "paginaInicial" => "1068" "paginaFinal" => "1074" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17426211" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effects of a “new” walking aid on exercise performance in patients with COPD: a randomized crossover trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.W. Vaes" 1 => "J. Annegarn" 2 => "K. Meijer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-1076" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "141" "paginaInicial" => "1224" "paginaFinal" => "1232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22116797" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Regular physical activity reduces hospital admission and mortality in COPD: a population based cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Garcia-Aymerich" 1 => "P. Lange" 2 => "M. Benet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2006.060145" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2006" "volumen" => "61" "paginaInicial" => "772" "paginaFinal" => "778" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16738033" "web" => "Medline" ] ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0215" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic manifestations and comorbidities of COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Barnes" 1 => "B. Celli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00128008" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2009" "volumen" => "33" "paginaInicial" => "1165" "paginaFinal" => "1185" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19407051" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0220" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of comorbidities in pulmonary rehabilitation outcomes in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Carreiro" 1 => "J. Santos" 2 => "F. Rodrigues" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rppneu.2012.12.004" "Revista" => array:6 [ "tituloSerie" => "Rev Port Pneumol" "fecha" => "2013" "volumen" => "19" "paginaInicial" => "106" "paginaFinal" => "113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23664247" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0225" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of European Association of Cardiovascular Prevention and Rehabilitation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Piepoli" 1 => "U. Corrà" 2 => "W. Benzer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/HJR.0b013e3283313592" "Revista" => array:6 [ "tituloSerie" => "Eur J Cardiovasc Prev Rehabil" "fecha" => "2010" "volumen" => "17" "paginaInicial" => "1" "paginaFinal" => "17" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19952757" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0230" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exercise prescription for hospitalized people with chronic obstructive pulmonary disease and comorbidities: a synthesis of systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W.D. Reid" 1 => "C. Yamabayashi" 2 => "D. Goodridge" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J COPD" "fecha" => "2012" "volumen" => "7" "paginaInicial" => "297" "paginaFinal" => "320" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913001347/v2_201509041402/en/main.assets" "Apartado" => array:4 [ "identificador" => "9597" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Revisão" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08732159/0000002000000001/v2_201509041402/S0873215913001347/v2_201509041402/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001347?idApp=UINPBA00004E"]

Statistics

Review

Exercise training modalities and strategies to improve exercise performance in patients with respiratory disease

Modalidades e Estratégias de Treino Físico para Melhorar o Desempenho durante o Exercício em Pacientes com Doenças Respiratórias

P. Almeidaa, F. Rodriguesb,

Corresponding author

fatima.rodriguesed@gmail.com

Corresponding author.

a Serviço de Medicina Física e de Reabilitação do Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Portugal

b Serviço de Pneumologia do Centro Hospitalar Lisboa Norte – Hospital Pulido Valente, Faculdade de Medicina da Universidade de Lisboa, Portugal

Read

13940

Times
was read the article

3332

Total PDF

10608

Total HTML

Share statistics

 array:25 [
  "pii" => "S0873215913001347"
  "issn" => "08732159"
  "doi" => "10.1016/j.rppneu.2013.10.004"
  "estado" => "S300"
  "fechaPublicacion" => "2014-01-01"
  "aid" => "186"
  "copyright" => "Sociedade Portuguesa de Pneumologia"
  "copyrightAnyo" => "2013"
  "documento" => "article"
  "crossmark" => 1
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "ssu"
  "cita" => "Rev Port Pneumol. 2014;20:36-41"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 8362
    "formatos" => array:3 [
      "EPUB" => 238
      "HTML" => 6593
      "PDF" => 1531
    ]
  ]
  "Traduccion" => array:1 [
    "en" => array:20 [
      "pii" => "S2173511514000128"
      "issn" => "21735115"
      "doi" => "10.1016/j.rppnen.2013.10.012"
      "estado" => "S300"
      "fechaPublicacion" => "2014-01-01"
      "aid" => "186"
      "copyright" => "Sociedade Portuguesa de Pneumologia"
      "documento" => "article"
      "crossmark" => 0
      "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
      "subdocumento" => "ssu"
      "cita" => "Rev Port Pneumol. 2014;20:36-41"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 3831
        "formatos" => array:3 [
          "EPUB" => 271
          "HTML" => 2599
          "PDF" => 961
        ]
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
        "titulo" => "Exercise training modalities and strategies to improve exercise performance in patients with respiratory disease"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "pt"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "36"
            "paginaFinal" => "41"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "Modalidades e Estrat&#233;gias de Treino F&#237;sico para Melhorar o Desempenho durante o Exerc&#237;cio em Pacientes com Doen&#231;as Respirat&#243;rias"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "pt" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0010"
            "etiqueta" => "Figure 2"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr2.jpeg"
                "Alto" => 750
                "Ancho" => 1001
                "Tamanyo" => 138855
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Neuromuscular electrical stimulation&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "P&#46; Almeida, F&#46; Rodrigues"
            "autores" => array:2 [
              0 => array:2 [
                "nombre" => "P&#46;"
                "apellidos" => "Almeida"
              ]
              1 => array:2 [
                "nombre" => "F&#46;"
                "apellidos" => "Rodrigues"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S0873215913001347"
          "doi" => "10.1016/j.rppneu.2013.10.004"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001347?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000128?idApp=UINPBA00004E"
      "url" => "/21735115/0000002000000001/v1_201401230023/S2173511514000128/v1_201401230023/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:20 [
    "pii" => "S0873215913000226"
    "issn" => "08732159"
    "doi" => "10.1016/j.rppneu.2012.12.002"
    "estado" => "S300"
    "fechaPublicacion" => "2014-01-01"
    "aid" => "137"
    "copyright" => "Sociedade Portuguesa de Pneumologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Pneumol. 2014;20:42-5"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 10079
      "formatos" => array:3 [
        "EPUB" => 272
        "HTML" => 8411
        "PDF" => 1396
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Successful treatment of atelectasis with Dornase alpha in a patient with congenital muscular dystrophy"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "pt"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "42"
          "paginaFinal" => "45"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Tratamento bem sucedido de atelectasia com Dornase alfa num doente com distrofia muscular cong&#233;nita"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 713
              "Ancho" => 950
              "Tamanyo" => 93715
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan at day 12&#58; partial regression of the atelectasis&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "G&#46; Crescimanno, O&#46; Marrone"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "G&#46;"
              "apellidos" => "Crescimanno"
            ]
            1 => array:2 [
              "nombre" => "O&#46;"
              "apellidos" => "Marrone"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2173511514000098"
        "doi" => "10.1016/j.rppnen.2012.10.008"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000098?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913000226?idApp=UINPBA00004E"
    "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913000226/v2_201509041402/en/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S0873215913001086"
    "issn" => "08732159"
    "doi" => "10.1016/j.rppneu.2013.06.009"
    "estado" => "S300"
    "fechaPublicacion" => "2014-01-01"
    "aid" => "178"
    "copyright" => "Sociedade Portuguesa de Pneumologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Pneumol. 2014;20:31-5"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 6484
      "formatos" => array:3 [
        "EPUB" => 269
        "HTML" => 4931
        "PDF" => 1284
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Publica&#231;&#227;o breve</span>"
      "titulo" => "Associa&#231;&#227;o entre a mec&#226;nica respirat&#243;ria e fun&#231;&#227;o auton&#243;mica na obesidade m&#243;rbida"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "31"
          "paginaFinal" => "35"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Association between respiratory mechanics and autonomic function in morbid obesity"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figura 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 2535
              "Ancho" => 2451
              "Tamanyo" => 210468
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Associa&#231;&#227;o entre mec&#226;nica respirat&#243;ria e variabilidade da frequ&#234;ncia card&#237;aca&#46; SDNN&#58; desvio padr&#227;o de todos os intervalos RR normais&#59; rMSSD&#58; raiz quadrada das diferen&#231;as sucessivas entre intervalos RR normais adjacentes ao quadrado&#59; R0&#58; resist&#234;ncia extrapolada a 0<span class="elsevierStyleHsp" style=""></span>Hz&#59; R5&#58; resist&#234;ncia em 5<span class="elsevierStyleHsp" style=""></span>Hz&#59; Rm&#58; resist&#234;ncia m&#233;dia&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "M&#46; Sant&#8217; Anna Junior, R&#46;F&#46; Carvalhal, J&#46;R&#46;I&#46; Carneiro, M&#46;S&#46; Lapa, W&#46;A&#46; Zin, J&#46;R&#46; Lugon, F&#46;S&#46; Guimar&#227;es"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Sant&#8217; Anna Junior"
            ]
            1 => array:2 [
              "nombre" => "R&#46;F&#46;"
              "apellidos" => "Carvalhal"
            ]
            2 => array:2 [
              "nombre" => "J&#46;R&#46;I&#46;"
              "apellidos" => "Carneiro"
            ]
            3 => array:2 [
              "nombre" => "M&#46;S&#46;"
              "apellidos" => "Lapa"
            ]
            4 => array:2 [
              "nombre" => "W&#46;A&#46;"
              "apellidos" => "Zin"
            ]
            5 => array:2 [
              "nombre" => "J&#46;R&#46;"
              "apellidos" => "Lugon"
            ]
            6 => array:2 [
              "nombre" => "F&#46;S&#46;"
              "apellidos" => "Guimar&#227;es"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2173511513001012"
        "doi" => "10.1016/j.rppnen.2013.06.006"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511513001012?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001086?idApp=UINPBA00004E"
    "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913001086/v2_201509041402/pt/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
    "titulo" => "Exercise training modalities and strategies to improve exercise performance in patients with respiratory disease"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "36"
        "paginaFinal" => "41"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "P&#46; Almeida, F&#46; Rodrigues"
        "autores" => array:2 [
          0 => array:3 [
            "nombre" => "P&#46;"
            "apellidos" => "Almeida"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "F&#46;"
            "apellidos" => "Rodrigues"
            "email" => array:1 [
              0 => "fatima&#46;rodriguesed&#64;gmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Servi&#231;o de Medicina F&#237;sica e de Reabilita&#231;&#227;o do Hospital Pedro Hispano&#44; Unidade Local de Sa&#250;de de Matosinhos&#44; Portugal"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servi&#231;o de Pneumologia do Centro Hospitalar Lisboa Norte &#8211; Hospital Pulido Valente&#44; Faculdade de Medicina da Universidade de Lisboa&#44; Portugal"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Modalidades e Estrat&#233;gias de Treino F&#237;sico para Melhorar o Desempenho durante o Exerc&#237;cio em Pacientes com Doen&#231;as Respirat&#243;rias"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 896
            "Ancho" => 1540
            "Tamanyo" => 133857
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Cycling while on oxygen&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Exercise training &#40;ET&#41; is a mandatory component of pulmonary rehabilitation &#40;PR&#41;&#44; it is at the core of PR programs and improves patients exercise tolerance and functional capacity&#44; fatigue and dyspnea symptoms and health-related quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Pulmonary rehabilitation also has benefits for health-related costs&#44; reducing the number of exacerbations and hospitalizations&#44; days in hospital and mortality in COPD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although highly recommended by scientific societies&#44; at present&#44; less than 5&#37; of eligible patients have access to pulmonary rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> There is a need to optimize availability&#44; accessibility and quality of PR in Europe&#44; and that includes Portugal&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">According to GOLD&#44; exercise training has benefits for all categories of COPD&#44; but PR programs are mainly directed at the most symptomatic and severe patients&#58; grades B&#44; C and D&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Exercise intensity is a key element in improving outcomes&#46; Therefore&#44; high intensity training is recommended for its physiological benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In this article&#44; authors describe a variety of modalities and strategies to overcome exercise limitations and improve the effects of exercise training&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Exercise training components</span><p id="par0035" class="elsevierStylePara elsevierViewall">Exercise training modalities include&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Endurance training&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Lower and upper limbs</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Continuous or interval training</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">High and moderate intensity&#46; Relevance of total dose &#40;combining training intensity&#44; training session duration and frequency&#41;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Strength training&#58; lower and upper extremities</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Neuromuscular electrical stimulation &#40;NMES&#41;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Limiting factors of exercise performance</span> in COPD patients are multifactorial&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but dynamic hyperinflation and peripheral muscle dysfunction are the most relevant ones&#44; particularly in severe patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Strategies to enhance exercise tolerance</span><p id="par0075" class="elsevierStylePara elsevierViewall">Multiple strategies to improve tolerance to high intensity exercise training in severe patients have been presented in literature<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Pharmacological treatment optimization<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Non-invasive ventilation &#40;NIV&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Oxygen supplementation &#40;O<span class="elsevierStyleInf">2</span>&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Heliox<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Aerobic training modalities&#58; interval training&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;28</span></a> bicycle interval training&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> nonlinear exercise training<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Localized muscle training&#58; a few muscle groups are active at each moment<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;32</span></a> bicycle single-leg &#40;unilateral&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> progressive strength training &#40;or isolated quadriceps training&#41;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Neuromuscular electrical stimulation &#40;NMES&#41;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Eccentric exercise training &#40;experimental&#41;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Walking aids utilization<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p></li></ul></p><p id="par0125" class="elsevierStylePara elsevierViewall">In all above strategies&#44; <span class="elsevierStyleItalic">pharmacological treatment optimization</span> with inhaled bronchodilators is highly recommended to improve symptoms and dynamic lung hyperinflation and to enhance exercise tolerance&#46; It is essential to prescribe them appropriately&#44; to stimulate patient compliance and verify inhalation technique&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Noninvasive ventilation</span>&#44; <span class="elsevierStyleItalic">oxygen therapy</span> and <span class="elsevierStyleItalic">heliox supplements</span> during exercise training are matters of debates&#46; The real value of these exercise training adjuncts is not well established&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Noninvasive ventilation and heliox supplements have been the subject of pilot studies that have shown evidence of exercise tolerance improvement in patients who have severely limited ventilation&#44; but their efficacy and applicability has not been established&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Use of supplemental oxygen in patients with exercise dessaturation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; is consensual in order to maintain an oxygen saturation of at least 90&#37; during the training session &#40;grade of recommendation 1C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Some studies have suggested the benefit of oxygen supplementation in exercise tolerance in non-hypoxemic patients&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> but the effects in improving activities of daily living&#44; health status&#44; morbidity or mortality are not yet documented&#46; This therapy might be cost-effective in ventilatory limited patients where dyspnea due to dynamic hyperinflation prevents high intensity exercise training&#46; Oxygen supplementation reduces dynamic hyperinflation through inhibition of carotid sinus stimulation&#44; reducing ventilatory drive and respiratory rate&#46; During exercise sessions it is also known to improve oxygen delivery to peripheral muscles&#44; reducing muscle fatigue&#44; which underpins its role as a training adjuvant and potentiating its effects&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Exercise training is of paramount value in improving exercise tolerance&#46; It reduces ventilatory demands for sub maximal efforts due to a lower lactic acid production in muscle fibers&#46; This will reduce respiratory rate&#44; and hence the dynamic hyperinflation for the same exercise intensity&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Exercise intensity and session duration are determinants of the physiological response to training&#46; However&#44; continuous high intensity exercise is usually too hard for patients to achieve due to their ventilatory limitation&#44; their muscle dysfunction with its premature lactic acidosis&#44; their higher ventilatory demand and their dynamic hyperinflation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Some exercise training modalities are also good strategies for improving</span><p id="par0160" class="elsevierStylePara elsevierViewall">This is the case with <span class="elsevierStyleItalic">interval training</span>&#44; which produces a high intensity peripheral muscle demand and at the same time&#44; a lower ventilatory demand due to late lactic acidosis&#46; Interval training with repeated short high intensity training periods &#40;30 s to 3 min&#41;&#44; interspersed with rest or low intensity periods&#44; is well suited for patients with dynamic hyperinflation&#44; and it delays its onset&#46; Interval training is well suited for patients with dynamic hyperinflation&#44; and it delays its onset&#46; The benefits are well documented&#44; it not only improves training tolerance&#44; but it also enhances muscle fiber capillarity&#44; metabolism&#44; typology and size&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Muscle training involving fewer muscle groups</span>&#44; namely <span class="elsevierStyleItalic">quadriceps strength training</span>&#44; could be an alternative option&#44; particularly in patients with a high risk of deconditioning &#40;e&#46;g&#46; severe exacerbations with hospitalization&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Neuromuscular electrical stimulation</span> of ambulatory muscles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; might be an additional or alternative strategy in very disabled patients&#44; such as patients with acute exacerbations or patients on an active list for lung transplant&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">All the above strategies or training modalities could be either alternative or complementary and the clinician who prescribes pulmonary rehabilitation should be aware of them&#46; Combinations of different but complementary strategies might be more beneficial than the cumulative effect of the benefits of each one&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Dynamic hyperinflation reduction has a key role in the improvement of exercise tolerance and might be achieved by combining strategies that enhance expiratory flow &#40;e&#46;g&#46; pharmacological optimization with inhaled bronchodilators&#41; with a ventilatory demand and respiratory rate reduction &#40;e&#46;g&#46; through oxygen supplementation and high intensity interval training&#41;&#46; However&#44; it should be noted that the eventual role of oxygen supplementation beyond the effects found in laboratory studies&#44; in exercise training of non-hypoxemic patients&#44; particularly those that do not desaturate while exercising&#44; has not yet been demonstrated&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Motivation in complying with medication&#44; with an active lifestyle and regular exercise might generate positive reinforcement and could counteract the negative spiral of dyspnea&#44; becoming sedentary&#44; deconditioned and more dyspneic&#46; It is well documented in the literature that there is an association between lower physical activity&#44; the risk of exacerbation with hospitalization and mortality in patients with COPD<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>&#46; Exercise training is the treatment that does most to improve and preserve the muscle mass and exercise performance&#44; both relevant prognostic indexes in COPD&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Exercise training adaptations due to comorbidities</span><p id="par0190" class="elsevierStylePara elsevierViewall">An accurate and individualized exercise prescription should necessarily include some patient adaptation due to comorbidities&#46; The prevalence of comorbidities&#44; particularly multiple comorbidities&#44; reflects the growing evidence of COPD as a complex disease that impacts on multiple organic systems&#46; Systemic inflammation enhances the risk of developing and worsening conditions like coronary heart disease&#44; congestive heart failure&#44; diabetes mellitus&#44; peripheral vascular disease&#44; muscle dysfunction&#44; cachexia and osteoporosis&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Although they influence patient prognosis&#44; comorbidities should not preclude indication for pulmonary rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> On the contrary&#44; PR programs should be adapted to comorbidities&#44; not only in the evaluation settings but also in the prescription of PR modalities and monitoring PR programs&#46; Exercise training&#44; the core of PR programs&#44; has also demonstrated well documented benefits in several comorbidities&#46; Moreover&#44; exercise training has a clear and high level of evidence-based benefits&#46; The level of recommendation is IA for conditions like coronary heart disease&#44; congestive heart failure&#44; diabetes mellitus and peripheral vascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The most relevant exercise training adaptations in patients with comorbidities are&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Coronary heart disease</span>&#58; a moderate intensity training is recommended&#44; being cautious in relation to intensity progression &#40;start with intensities of 50 to 60&#37; of maximal heart rate attained in previous maximal exercise test and&#44; if well tolerated&#44; gradually increase the intensity to a maximal threshold of 80&#37; of peak heart rate&#41;&#59; train below the anaerobic threshold&#44; and if ischemic or arrhythmic thresholds are present&#44; train below those limits&#59; train under clinical surveillance and telemetric monitoring&#44; at least in the first few weeks&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Congestive heart failure</span>&#58; slow progression of exercise intensity&#44; as tolerated&#59; start with intensity of 40&#37; peakVO<span class="elsevierStyleInf">2</span> and progress to 80&#37; peakVO<span class="elsevierStyleInf">2</span>&#59; clinical and telemetric monitoring and active search for signs or symptoms of instability &#40;central or peripheral edema&#44; rapid weight gain&#44; pulmonary congestion&#41; are highly recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diabetes mellitus</span>&#58; an accurate monitoring of glucose is recommended to improve metabolic control&#59; prevention of hypoglycemia &#40;with diet&#47;nutritional counseling and pharmacological adjustments&#44; if needed&#41;&#59; search for metabolic derangements &#40;exercise is contraindicated if glycemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>250<span class="elsevierStyleHsp" style=""></span>mg&#47;dL with ketonuria or if glycemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#59; be aware of possible sub-clinical coronary disease&#59; evaluate&#44; prescribe and monitor evolution according to this information&#59; diabetic foot surveillance is recommended&#44; with particular attention to adequate hydration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Peripheral vascular disease</span>&#58; privilege gait training above ischemic threshold for lower limbs &#40;training elicits claudicating symptoms&#59; if intense pain is present&#44; training is followed by a brief period of rest to permit symptoms to resolve&#59; repeat for 30<span class="elsevierStyleHsp" style=""></span>min to 1<span class="elsevierStyleHsp" style=""></span>h&#41;&#59; it should be noted that peripheral vascular disease is frequently associated with systemic vascular disease&#44; including cerebral and coronary&#44; though an active search for sub-clinical coronary disease is mandatory&#46;</p></li></ul></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0225" class="elsevierStylePara elsevierViewall">Although strongly recommended by scientific societies&#44; pulmonary rehabilitation programs still need to be more widely implemented&#46; PR programs have shown high level of evidence of benefits in chronic respiratory patients&#44; particularly those with COPD&#46; Exercise training is an essential component of PR programs and its benefits are well documented in the literature&#46; Clinicians should be aware of the different strategies available in order to optimize exercise training&#44; patient security and compliance&#46; Generalization and development of the existent PR programs and implementation of new strategies and modalities should be a constant preoccupation for all clinicians involved in the care of respiratory patients&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Patients with advanced COPD show significant exercise intolerance due to severe muscle dysfunction and intense dyspnea&#46; In these patients&#44; exercise with interval training &#8211; repeated short high intensity training periods &#40;30<span class="elsevierStyleHsp" style=""></span>s to 3<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; interspersed with rest or low intensity periods&#44; and&#47;or global strength training or localized to quadriceps&#44; under oxygen supplementation if needed&#44; might constitute suitable&#44; applicable and efficacious exercise training strategies&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Protection of human and animal subjects</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Confidentiality of data</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:9 [
        0 => array:3 [
          "identificador" => "xres547708"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec565588"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres547709"
          "titulo" => "Resumo"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec565589"
          "titulo" => "Palavras-chave"
        ]
        4 => array:3 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Exercise training components"
            ]
            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Strategies to enhance exercise tolerance"
            ]
            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Some exercise training modalities are also good strategies for improving"
            ]
            3 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Exercise training adaptations due to comorbidities"
            ]
          ]
        ]
        5 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conclusions"
        ]
        6 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-10-11"
    "fechaAceptado" => "2013-10-14"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec565588"
          "palabras" => array:3 [
            0 => "Pulmonary rehabilitation"
            1 => "Exercise training"
            2 => "Chronic obstructive pulmonary disease"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec565589"
          "palabras" => array:3 [
            0 => "Reabilita&#231;&#227;o pulmonar"
            1 => "Treino f&#237;sico"
            2 => "Doen&#231;a pulmonar obstrutiva cr&#243;nica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary rehabilitation is an evidence-based&#44; multidisciplinary&#44; comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and whose daily living activities are often restricted&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pulmonary rehabilitation programs are designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote long-term adherence to health-enhancing behavior&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Exercise training is at the core of pulmonary rehabilitation &#40;PR&#41; programs&#46; The benefits of exercise training include decreased dyspnea&#44; improved health-related quality of life&#44; fewer days of hospitalization&#44; and decreased health-care utilization&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To gain PR benefits&#44; patients should be able to complete an exercise training program&#44; preferably with high intensity exercise&#44; and it is likely that these benefits will translate into a change from a pattern of a sedentary lifestyle to a physically active lifestyle&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chronic respiratory patients&#44; namely COPD patients&#44; have a low exercise tolerance due to multiple factors&#44; such as dynamic hyperinflation and peripheral muscle dysfunction&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In this article&#44; the authors describe a variety of modalities and strategies to overcome exercise limitations and improve the effects of exercise training&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A reabilita&#231;&#227;o pulmonar &#233; uma interven&#231;&#227;o abrangente&#44; multidisciplinar e baseada em evid&#234;ncias&#44; para doentes com doen&#231;as respirat&#243;rias cr&#243;nicas que s&#227;o sintom&#225;ticas e cujas actividades da vida di&#225;ria s&#227;o frequentemente limitadas&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os programas de reabilita&#231;&#227;o pulmonar est&#227;o concebidos para melhorar a condi&#231;&#227;o f&#237;sica e emocional de pessoas com doen&#231;as respirat&#243;rias cr&#243;nicas e promover a ades&#227;o a longo prazo a comportamentos ben&#233;ficos para a sa&#250;de&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">O exerc&#237;cio f&#237;sico est&#225; no cerne dos programas de reabilita&#231;&#227;o pulmonar &#40;RP&#41;&#46; Os benef&#237;cios do exerc&#237;cio f&#237;sico incluem redu&#231;&#227;o da dispneia&#44; melhor qualidade de vida em termos de sa&#250;de&#44; menos dias de hospitaliza&#231;&#227;o&#44; e utiliza&#231;&#227;o reduzida dos cuidados de sa&#250;de&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Para obter os benef&#237;cios da RP&#44; os doentes dever&#227;o ser capazes de completar um programa de exerc&#237;cio f&#237;sico&#44; de prefer&#234;ncia com exerc&#237;cios de alta intensidade&#44; e &#233; prov&#225;vel que esses benef&#237;cios se traduzam numa mudan&#231;a de um padr&#227;o de estilo de vida sedent&#225;rio para um estilo de vida fisicamente activo&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Doentes com doen&#231;as respirat&#243;rias cr&#243;nicas&#44; nomeadamente com DPOC&#44; t&#234;m uma baixa toler&#226;ncia ao exerc&#237;cio devido a uma diversidade de factores&#44; como a hiperinsufla&#231;&#227;o din&#226;mica e a disfun&#231;&#227;o muscular perif&#233;rica&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Neste artigo&#44; os autores descrevem uma variedade de modalidades e estrat&#233;gias para superar as limita&#231;&#245;es de exerc&#237;cio e melhorar os efeitos do treino f&#237;sico&#46;</p></span>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 896
            "Ancho" => 1540
            "Tamanyo" => 133857
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Cycling while on oxygen&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 750
            "Ancho" => 1000
            "Tamanyo" => 137104
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Neuromuscular electrical stimulation&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:46 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American Thoracic Society&#47;European Respiratory Society statement on pulmonary rehabilitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Nici"
                            1 => "C&#46; Donner"
                            2 => "E&#46; Wouters"
                            3 => "R&#46; Zuwallack"
                            4 => "N&#46; Ambrosino"
                            5 => "J&#46; Bourbeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200508-1211ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "173"
                        "paginaInicial" => "1390"
                        "paginaFinal" => "1413"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16760357"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary Rehabilitation&#58; Joint ACCP&#47;AACVPR Evidence-Based Clinical Practice Guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;L&#46; Ries"
                            1 => "G&#46;S&#46; Bauldoff"
                            2 => "B&#46;W&#46; Carlin"
                            3 => "R&#46; Casaburi"
                            4 => "C&#46;F&#46; Emery"
                            5 => "D&#46;A&#46; Mahler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.06-2418"
                      "Revista" => array:7 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2007"
                        "volumen" => "131"
                        "numero" => "5 Suppl"
                        "paginaInicial" => "4S"
                        "paginaFinal" => "42S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17494825"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current best practice in pulmonary rehabilitation for chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; de Blasio"
                            1 => "M&#46; Polverino"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/1753465812444712"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ther Adv Respir Dis"
                        "fecha" => "2012"
                        "volumen" => "6"
                        "paginaInicial" => "221"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22563010"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease&#58; A Clinical Practice Guideline update from the American College of Physicians&#44; American College of Chest Physicians American Thoracic Society and European Respiratory Society"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Qaseem"
                            1 => "T&#46;J&#46; Wilt"
                            2 => "S&#46;E&#46; Weinberger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-155-3-201108020-00008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2011"
                        "volumen" => "155"
                        "paginaInicial" => "179"
                        "paginaFinal" => "191"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21810710"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;A&#46; Puhan"
                            1 => "E&#46; Gimeno-Santos"
                            2 => "M&#46; Scharplatz"
                            3 => "T&#46; Troosters"
                            4 => "E&#46;H&#46; Walters"
                            5 => "J&#46; Steurer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database of Systematic Reviews"
                        "fecha" => "2011"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Directing the future of lung health&#58; the European Respiratory Roadmap"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Y&#46; Sibille"
                            1 => "M&#46; Decramer"
                            2 => "L&#46;P&#46; Nicod"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00097111"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2011"
                        "volumen" => "38"
                        "paginaInicial" => "502"
                        "paginaFinal" => "506"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21885412"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Global Initiative for Chronic Obstructive Lung Disease &#40;GOLD&#41; &#40;Updated 2013&#41;&#44; Global strategy for the diagnosis&#44; management&#44; and prevention of chronic obstructive pulmonary disease&#46; Available from <a href="http://www.goldcopd.org/">http&#58;&#47;&#47;www&#46;goldcopd&#46;org</a>&#46;"
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Limiting factors of exercise capacity in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "F&#46; Rodrigues"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Port Pneumol"
                        "fecha" => "2004"
                        "volumen" => "X"
                        "paginaInicial" => "9"
                        "paginaFinal" => "61"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Strategies of muscle training in very severe COPD patients in SERIES&#58; &#8220;NOVELTIES IN PULMONARY REHABILITATION&#8221; edited by Clini E and Ambrosino N"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "I&#46; Vogiatzis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00075011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2011"
                        "volumen" => "38"
                        "paginaInicial" => "971"
                        "paginaFinal" => "975"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21737548"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Improvement of endurance time with the combination of tiotropium and pulmonary rehabilitation in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Casaburi"
                            1 => "D&#46; Kakafka"
                            2 => "C&#46; Cooper"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.127.3.809"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2005"
                        "volumen" => "127"
                        "paginaInicial" => "809"
                        "paginaFinal" => "817"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15764761"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of bronchodilators and oxygen alone and in combination on self-paced exercise performance in stable COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Cukier"
                            1 => "C&#46; Ferreira"
                            2 => "R&#46; Stelmach"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rmed.2006.08.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2007"
                        "volumen" => "101"
                        "paginaInicial" => "746"
                        "paginaFinal" => "753"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17000096"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Proportional assisted ventilation as an aid to exercise training in severe COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Hawkins"
                            1 => "L&#46;C&#46; Johnson"
                            2 => "D&#46; Nikoletou"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2002"
                        "volumen" => "57"
                        "paginaInicial" => "853"
                        "paginaFinal" => "859"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12324670"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Respiratory muscle unloading improves leg muscle oxygenation during exercise in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Borghi-Silva"
                            1 => "C&#46;C&#46; Oliveira"
                            2 => "C&#46; Carrascosa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2007.090167"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2008"
                        "volumen" => "63"
                        "paginaInicial" => "910"
                        "paginaFinal" => "915"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18492743"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dose-response effect of oxygen on hyperinflation and exercise endurance in nonhypoxaemic COPD patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Somfay"
                            1 => "J&#46; Porszasz"
                            2 => "S&#46;M&#46; Lee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2001"
                        "volumen" => "18"
                        "paginaInicial" => "77"
                        "paginaFinal" => "84"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11510809"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of hyperoxia on gas exchange and lactate kinetics following exercise onset in nonhypoxemic COPD patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Somfay"
                            1 => "J&#46; Porszasz"
                            2 => "S&#46;M&#46; Lee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "121"
                        "paginaInicial" => "393"
                        "paginaFinal" => "400"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11834648"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of oxygen on lower limb blood flow and O<span class="elsevierStyleInf">2</span> uptake during exercise in COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46; Maltais"
                            1 => "M&#46; Simon"
                            2 => "J&#46; Jobin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Sci Sports Exerc"
                        "fecha" => "2001"
                        "volumen" => "33"
                        "paginaInicial" => "916"
                        "paginaFinal" => "922"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11404656"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxygen therapy during exercise training in chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;L&#46; Nonoyama"
                            1 => "D&#46; Brooks"
                            2 => "Y&#46; Lacasse"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD005372.pub2"
                      "Revista" => array:5 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2007"
                        "volumen" => "2"
                        "paginaInicial" => "CD005372"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17443585"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Benefits of supplemental oxygen in exercise training in non-hypoxemic COPD patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Emtner"
                            1 => "J&#46; Porszasz"
                            2 => "M&#46; Bunrs"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "68"
                        "paginaInicial" => "1034"
                        "paginaFinal" => "1042"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Heliox improves oxygen delivery and utilization during dynamic exercise in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46;R&#46; Chiappa"
                            1 => "F&#46; Queiroga Jr&#46;"
                            2 => "E&#46; Meda"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200811-1793OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2009"
                        "volumen" => "179"
                        "paginaInicial" => "1004"
                        "paginaFinal" => "1010"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19299497"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of helium breathing on intercostals and quadriceps muscle blood flow during exercise in COPD patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Vogiatzis"
                            1 => "H&#46; Habazetl"
                            2 => "A&#46; Aliverti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Physiol Regul Integr Comp Physiol"
                        "fecha" => "2011"
                        "volumen" => "300"
                        "paginaInicial" => "1549"
                        "paginaFinal" => "1559"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of heliox on heart rate kinetics and dynamic hyperinflation during high-intensity exercise in COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Laveneziana"
                            1 => "G&#46; Valli"
                            2 => "P&#46; Onorati"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00421-010-1643-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Appl Physiol"
                        "fecha" => "2011"
                        "volumen" => "111"
                        "paginaInicial" => "225"
                        "paginaFinal" => "234"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20852881"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of interval exercise training in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46;A&#46; Kortianou"
                            1 => "I&#46;G&#46; Nasis"
                            2 => "S&#46;T&#46; Spetsioti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Cardiopulm Phys Ther J"
                        "fecha" => "2010"
                        "volumen" => "21"
                        "paginaInicial" => "12"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20957074"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiopulmonary exercise testing in the functional and prognostic evaluation of patients with pulmonary diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;M&#46; Ferrazza"
                            1 => "D&#46; Martolini"
                            2 => "G&#46; Valli"
                            3 => "P&#46; Palange"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000186694"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respiration"
                        "fecha" => "2009"
                        "volumen" => "77"
                        "paginaInicial" => "3"
                        "paginaFinal" => "17"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19145106"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dynamic hyperinflation and tolerance to interval exercise in patients with advanced COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Vogiatzis"
                            1 => "S&#46; Nanas"
                            2 => "E&#46; Kastanakis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.04.00128903"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2004"
                        "volumen" => "24"
                        "paginaInicial" => "385"
                        "paginaFinal" => "390"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15358696"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skeletal muscle adaptations to interval training in patients with advanced COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Vogiatzis"
                            1 => "G&#46; Terzis"
                            2 => "S&#46; Nanas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.128.6.3838"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2005"
                        "volumen" => "128"
                        "paginaInicial" => "3838"
                        "paginaFinal" => "3845"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16354852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of pulmonary rehabilitation on peripheral muscle fiber remodeling in patients with COPD in GOLD Stages II to IV"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Vogiatzis"
                            1 => "G&#46; Terzis"
                            2 => "G&#46; Stratakos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.10-3058"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2011"
                        "volumen" => "140"
                        "paginaInicial" => "744"
                        "paginaFinal" => "752"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21493697"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Interval training compared with continuous training in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46;H&#46; Arnard&#243;ttir"
                            1 => "G&#46; Boman"
                            2 => "K&#46; Larsson"
                            3 => "H&#46; Hedenstr&#246;m"
                            4 => "M&#46; Emtner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rmed.2006.11.004"
                      "Revista" => array:7 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2007"
                        "volumen" => "101"
                        "paginaInicial" => "1196"
                        "paginaFinal" => "1204"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17188853"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0016508597001297"
                          "estado" => "S300"
                          "issn" => "00165085"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Interval versus continuous training in individuals with COPD &#8211; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;K&#46; Beauchamp"
                            1 => "M&#46; Nonoyama"
                            2 => "R&#46; Goldstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2009.123000"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2010"
                        "volumen" => "65"
                        "paginaInicial" => "157"
                        "paginaFinal" => "164"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19996334"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilatory and metabolic adaptations to walking and cycling in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Palange"
                            1 => "S&#46; Forte"
                            2 => "P&#46; Onorati"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Appl Physiol"
                        "fecha" => "2000"
                        "volumen" => "88"
                        "paginaInicial" => "1715"
                        "paginaFinal" => "1720"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10797134"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nonlinear exercise training in advanced COPD is superior to traditional exercise training&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Klijn"
                            1 => "A&#46; van Keimpema"
                            2 => "M&#46; Legemaat"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201210-1829OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2013"
                        "volumen" => "188"
                        "paginaInicial" => "193"
                        "paginaFinal" => "200"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23449691"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Symptoms and quadriceps fatigability after walking and cycling in chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "W&#46;D&#46; Man"
                            1 => "M&#46;G&#46; Soliman"
                            2 => "J&#46; Gearing"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200302-162OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "168"
                        "paginaInicial" => "562"
                        "paginaFinal" => "567"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12829456"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of one-legged exercise training of patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46;E&#46; Dolmage"
                            1 => "R&#46;S&#46; Goldstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.07-1423"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2008"
                        "volumen" => "133"
                        "paginaInicial" => "370"
                        "paginaFinal" => "376"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17925417"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "T&#46; Troosters"
                            1 => "V&#46;S&#46; Probst"
                            2 => "T&#46; Crul"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200908-1203OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2010"
                        "volumen" => "181"
                        "paginaInicial" => "1072"
                        "paginaFinal" => "1107"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20133927"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Resistance training preserves skeletal muscle function in patients with COPD who are hospitalized with an acute exacerbation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Saey"
                            1 => "F&#46; Ribeiro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1836-9553(11)70042-X"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Physiother"
                        "fecha" => "2011"
                        "volumen" => "57"
                        "paginaInicial" => "194"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21843836"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with Chronic Heart Failure and COPD&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;J&#46;H&#46; Sillen"
                            1 => "C&#46;M&#46; Speksnijder"
                            2 => "Eterman R-MA"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.08-2481"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2009"
                        "volumen" => "136"
                        "paginaInicial" => "44"
                        "paginaFinal" => "61"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19363213"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Functional and muscular effects of neuromuscular electrical stimulation in patients with severe COPD&#58; a randomized clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Vivodzev"
                            1 => "R&#46; Debigar&#233;"
                            2 => "P&#46; Gagnon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.11-0839"
                      "Revista" => array:7 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2012"
                        "volumen" => "141"
                        "paginaInicial" => "716"
                        "paginaFinal" => "725"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22116795"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0016508507011614"
                          "estado" => "S300"
                          "issn" => "00165085"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combination of pulmonary rehabilitation and neuromuscular electrical stimulation in copd patients&#58; a randomized clinical trial of efficacy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Zanotti"
                            1 => "C&#46; Bizarri"
                            2 => "R&#46; Grasso"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4172/2161-105X.1000112"
                      "Revista" => array:3 [
                        "tituloSerie" => "J Pulmonar Respirat Med"
                        "fecha" => "2012"
                        "volumen" => "2"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eccentric exercise in patients with chronic health conditions&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Roig"
                            1 => "B&#46; Shadgan"
                            2 => "W&#46;D&#46; Reid"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3138/physio.60.2.146"
                      "Revista" => array:6 [
                        "tituloSerie" => "Physiother Can"
                        "fecha" => "2008"
                        "volumen" => "60"
                        "paginaInicial" => "146"
                        "paginaFinal" => "160"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20145778"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eccentric cycle exercise in severe COPD&#58; feasibility of application"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "D&#46;S&#46; Rocha Vieira"
                            1 => "J&#46; Baril"
                            2 => "R&#46; Richard"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3109/15412555.2011.579926"
                      "Revista" => array:7 [
                        "tituloSerie" => "COPD"
                        "fecha" => "2011"
                        "volumen" => "8"
                        "paginaInicial" => "270"
                        "paginaFinal" => "274"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21728805"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0016508502004560"
                          "estado" => "S300"
                          "issn" => "00165085"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of a walking aid in COPD patients receiving oxygen therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Crisafulli"
                            1 => "S&#46; Costi"
                            2 => "F&#46; De Blasio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.06-2108"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2007"
                        "volumen" => "131"
                        "paginaInicial" => "1068"
                        "paginaFinal" => "1074"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17426211"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effects of a &#8220;new&#8221; walking aid on exercise performance in patients with COPD&#58; a randomized crossover trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;W&#46; Vaes"
                            1 => "J&#46; Annegarn"
                            2 => "K&#46; Meijer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.11-1076"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2012"
                        "volumen" => "141"
                        "paginaInicial" => "1224"
                        "paginaFinal" => "1232"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22116797"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Regular physical activity reduces hospital admission and mortality in COPD&#58; a population based cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Garcia-Aymerich"
                            1 => "P&#46; Lange"
                            2 => "M&#46; Benet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.060145"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "772"
                        "paginaFinal" => "778"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16738033"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systemic manifestations and comorbidities of COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Barnes"
                            1 => "B&#46; Celli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00128008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2009"
                        "volumen" => "33"
                        "paginaInicial" => "1165"
                        "paginaFinal" => "1185"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19407051"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of comorbidities in pulmonary rehabilitation outcomes in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Carreiro"
                            1 => "J&#46; Santos"
                            2 => "F&#46; Rodrigues"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rppneu.2012.12.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Pneumol"
                        "fecha" => "2013"
                        "volumen" => "19"
                        "paginaInicial" => "106"
                        "paginaFinal" => "113"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23664247"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Secondary prevention through cardiac rehabilitation&#58; from knowledge to implementation&#46; A position paper from the Cardiac Rehabilitation Section of European Association of Cardiovascular Prevention and Rehabilitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Piepoli"
                            1 => "U&#46; Corr&#224;"
                            2 => "W&#46; Benzer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/HJR.0b013e3283313592"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Cardiovasc Prev Rehabil"
                        "fecha" => "2010"
                        "volumen" => "17"
                        "paginaInicial" => "1"
                        "paginaFinal" => "17"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19952757"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exercise prescription for hospitalized people with chronic obstructive pulmonary disease and comorbidities&#58; a synthesis of systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "W&#46;D&#46; Reid"
                            1 => "C&#46; Yamabayashi"
                            2 => "D&#46; Goodridge"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J COPD"
                        "fecha" => "2012"
                        "volumen" => "7"
                        "paginaInicial" => "297"
                        "paginaFinal" => "320"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913001347/v2_201509041402/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "9597"
    "tipo" => "SECCION"
    "pt" => array:2 [
      "titulo" => "Revis&#227;o"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "pt"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/08732159/0000002000000001/v2_201509041402/S0873215913001347/v2_201509041402/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001347?idApp=UINPBA00004E"
]

Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppneu.2013.10.004

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	16	6	22
2024 October	71	48	119
2024 September	76	45	121
2024 August	89	48	137
2024 July	65	29	94
2024 June	62	44	106
2024 May	48	31	79
2024 April	51	36	87
2024 March	45	17	62
2024 February	40	29	69
2024 January	39	31	70
2023 December	52	19	71
2023 November	40	35	75
2023 October	36	43	79
2023 September	36	32	68
2023 August	33	17	50
2023 July	37	29	66
2023 June	34	18	52
2023 May	63	33	96
2023 April	50	23	73
2023 March	101	27	128
2023 February	69	22	91
2023 January	33	18	51
2022 December	102	16	118
2022 November	66	45	111
2022 October	110	29	139
2022 September	63	26	89
2022 August	75	40	115
2022 July	82	49	131
2022 June	31	25	56
2022 May	50	46	96
2022 April	51	26	77
2022 March	34	58	92
2022 February	49	33	82
2022 January	47	34	81
2021 December	62	42	104
2021 November	74	39	113
2021 October	90	40	130
2021 September	59	42	101
2021 August	62	25	87
2021 July	39	21	60
2021 June	67	26	93
2021 May	88	36	124
2021 April	128	98	226
2021 March	163	28	191
2021 February	60	22	82
2021 January	54	24	78
2020 December	50	20	70
2020 November	76	22	98
2020 October	64	29	93
2020 September	76	25	101
2020 August	115	31	146
2020 July	132	24	156
2020 June	126	24	150
2020 May	165	35	200
2020 April	148	15	163
2020 March	129	22	151
2020 February	133	37	170
2020 January	131	24	155
2019 December	106	23	129
2019 November	155	27	182
2019 October	130	25	155
2019 September	99	24	123
2019 August	194	9	203
2019 July	224	20	244
2019 June	229	23	252
2019 May	219	25	244
2019 April	242	29	271
2019 March	275	14	289
2019 February	273	10	283
2019 January	263	33	296
2018 December	180	13	193
2018 November	70	0	70
2018 October	69	6	75
2018 September	44	5	49
2018 August	55	26	81
2018 July	61	24	85
2018 June	58	17	75
2018 May	100	24	124
2018 April	57	9	66
2018 March	65	9	74
2018 February	42	8	50
2018 January	36	27	63
2017 December	62	23	85
2017 November	66	24	90
2017 October	45	13	58
2017 September	44	16	60
2017 August	42	14	56
2017 July	39	14	53
2017 June	45	33	78
2017 May	56	21	77
2017 April	25	9	34
2017 March	34	28	62
2017 February	29	3	32
2017 January	27	8	35
2016 December	26	17	43
2016 November	26	10	36
2016 October	20	12	32
2016 September	24	6	30
2016 August	42	5	47
2016 July	28	8	36
2016 May	2	16	18
2016 April	56	4	60
2016 March	62	15	77
2016 February	72	34	106
2016 January	56	18	74
2015 December	64	13	77
2015 November	47	25	72
2015 October	60	23	83
2015 September	52	19	71
2015 August	37	15	52
2015 July	60	18	78
2015 June	45	12	57
2015 May	91	14	105
2015 April	81	21	102
2015 March	74	16	90
2015 February	94	19	113
2015 January	84	20	104
2014 December	109	25	134
2014 November	125	30	155
2014 October	148	30	178
2014 September	116	48	164
2014 August	109	23	132
2014 July	107	26	133
2014 June	104	16	120
2014 May	111	26	137
2014 April	120	49	169
2014 March	144	61	205
2014 February	99	82	181
2014 January	116	62	178

Show all

Indexed in:

Follow us:

Statistics

Indexed in:

Follow us:

Statistics

Subscribe to our newsletter