Cochrane Database of Systematic Reviews (Reviews) || Physical training for interstitial lung disease

Physical training for interstitial lung disease (Review)

Holland AE, Hill C

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 3

http://www.thecochranelibrary.com

Physical training for interstitial lung disease (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

16DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

28INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iPhysical training for interstitial lung disease (Review)


[Intervention Review]

Physical training for interstitial lung disease

Anne E Holland1, Catherine Hill2

1Physiotherapy, Alfred Health / La Trobe University, Melbourne, Australia. 2Physiotherapy, Austin Hospital, Heidelberg, Australia

Contact address: Anne E Holland, Physiotherapy, Alfred Health / La Trobe University, Commercial Road, Melbourne, 3004, Australia.

[email protected]. [email protected].

Editorial group: Cochrane Airways Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 3, 2010.

Review content assessed as up-to-date: 1 February 2010.

Citation: Holland AE, Hill C. Physical training for interstitial lung disease. Cochrane Database of Systematic Reviews 2008, Issue 4.

Art. No.: CD006322. DOI: 10.1002/14651858.CD006322.pub2.


A B S T R A C T

Background

Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise-induced hypoxia. Physical training

is beneficial for people with other chronic lung conditions, however its effects in ILD have not been well characterised.

Objectives

To assess the effects of physical training on exercise capacity, symptoms, quality of life and survival compared to no physical training

in people with ILD.

Search methods

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 4), MEDLINE, EMBASE,

CINAHL and the Physiotherapy Evidence Database (PEDro) (all searched from inception to December 2009). The reference lists of

relevant studies were hand-searched for qualifying studies.

Selection criteria

Randomised or quasi-randomised controlled trials in which physical training was compared to no physical training or to other therapy

in people with ILD of any aetiology were included.

Data collection and analysis

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. Authors were contacted to

obtain missing data and information regarding adverse effects. A priori subgroup analyses were specified for participants with idiopathic

pulmonary fibrosis (IPF), severe lung disease and training modality.

Main results

Five studies were included, three of which were published as abstracts. Two studies were included in the meta-analysis (43 participants

who undertook physical training and 42 control participants). One study used a blinded assessor and intention-to-treat analysis. No

adverse effects of physical training were reported. Physical training improved the 6-minute walk distance with weighted mean difference

(WMD) 38.61 metres (95% confidence interval 15.37 to 61.85 metres). Improvement in 6-minute walk distance was also seen in

the subgroup of participants with IPF (WMD 26.55 metres, 2.81 to 50.30 metres). No effect of physical training on VO2peak was

evident. There was a reduction in dyspnoea (standardised mean difference (SMD) -0.47, 95% CI: -0.91 to -0.04) however this did not

reach significance in the IPF subgroup (SMD -0.43, 95% CI: -0.94 to 0.08). Quality of life improved following physical training in all

1Physical training for interstitial lung disease (Review)


mailto:[email protected]

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participants (SMD 0.58, 95% CI: 0.15 to 1.02) and in IPF (SMD 0.57, 95% CI: 0.06 to 1.09). Only one study reported longer-term

outcomes, with no significant effects of physical training on clinical variables or survival at six months. Insufficient data were available

to examine the impact of disease severity or training modality.

Authors’ conclusions

Physical training is safe for people with ILD. Improvements in functional exercise capacity, dyspnoea and quality of life are seen

immediately following training, with benefits also evident in IPF. There is little evidence regarding longer-term effects of physical

training.

P L A I N L A N G U A G E S U M M A R Y

Physical training for interstitial lung disease (ILD)

People with ILD often have reduced exercise capacity and shortness of breath during exercise. Physical training can improve well being

in people with other chronic lung diseases, but little is known regarding physical training in ILD. We conducted a review to establish

whether physical training is safe for people with ILD, and to examine the effects of physical training on exercise capacity, shortness

of breath and quality of life. We also looked at whether people with idiopathic pulmonary fibrosis, a type of ILD which can progress

rapidly, could benefit from physical training. Five studies were included, however only two studies contained sufficient information

for the analysis (43 participants receiving physical exercise and 42 participants not). There were no reports of unwelcome effects of

physical training. Immediately following training, participants could walk further than those who had not undertaken the training

(on average 39 metres further in six minutes), reported less shortness of breath and improved quality of life. People with idiopathic

pulmonary fibrosis also experienced improvements following physical training although these tended to be smaller. There was not

enough information to establish whether there were any ongoing effects once the training had stopped. Bigger studies are required to

determine which method of physical training is most beneficial and whether the severity of ILD influences the benefits of physical

training.

B A C K G R O U N D

Interstitial lung disease (ILD) is a highly disabling group of con-

ditions including idiopathic pulmonary fibrosis (IPF), acute and

chronic interstitial pneumonias, connective tissue diseases and sar-

coidosis. People with ILD frequently experience breathlessness on

exertion which limits their ability to undertake daily activities. Pa-

tients report low levels of physical functioning and vitality, and

high levels of dyspnoea and fatigue. Those with the greatest exer-

cise limitation have the worst quality of life (Chang 1999). Avail-

able treatments for ILD have proved largely ineffective, offering

no improvement in survival and demonstrating only limited im-

pact on quality of life.

The mechanisms of reduced exercise capacity in ILD are multi-

factorial. Impaired gas exchange occurs as a result of destruction

of the pulmonary capillary bed, resulting in ventilation-perfusion

mismatch and oxygen diffusion limitation (Agusti 1991). Circu-

latory limitation results from pulmonary capillary destruction and

pulmonary vasoconstriction, leading to pulmonary hypertension

and cardiac dysfunction in some patients (Hansen 1996). Ven-

tilatory limitation to exercise may also occur, although it is not

thought to be a major contributor in most patients (Harris-Eze

1996). Peripheral muscle dysfunction may also play a significant

role in limiting exercise capacity (Markovitz 1998), as a result of

physical deconditioning. Patients who experience dyspnoea and

fatigue with functional activity commonly reduce their activity

levels, leading to a vicious cycle of worsening exercise capacity

and increasing symptoms. In addition, treatments for ILD such as

corticosteroids and immunosuppressive therapy may lead to drug-

induced myopathy.

Physical training, involving regular participation in an exercise

programme, improves exercise performance and reduces symp-

toms in people with other chronic lung diseases such as chronic

obstructive pulmonary disease and bronchiectasis (Nici 2006). A

number of authors have postulated that there may be similar effects

of physical training in ILD. Markovitz 1998 advocates the use of

physical training in ILD to restore muscle strength and endurance,

maximise functional level and improve quality of life. Miki 2003

found that PaO2-slope, a marker of exercise-induced hypoxaemia

obtained from cardiopulmonary exercise testing, was significantly



related to both exercise capacity and survival in IPF. They postu-

lated that this factor was amenable to improvement with physical

training. Recently published guidelines for Pulmonary Rehabili-

tation, an intervention which includes physical training, have ad-

vocated its use in ’all patients in whom respiratory symptoms are

associated with diminished functional capacity or reduced health-

related quality of life’ (Nici 2006). The safety and efficacy of this

approach in ILD is unclear. The greater prevalence of exercise-

induced hypoxia, pulmonary hypertension and arrhythmia in this

patient population compared to other chronic lung diseases raises

the possibility that response to physical training may also differ

(ATS/ERS 2000).To date there has not been a systematic review

of the literature in this area.

This review was conducted to summarize the results of literature

evaluating the safety and efficacy of physical training in adult pa-

tients with ILD, and to determine the effects of physical training

on exercise capacity, symptoms, quality of life and survival in this

patient group.

O B J E C T I V E S

(1) To determine whether physical training in patients with ILD

has beneficial effects on exercise capacity, symptoms, quality of

life and survival compared to no physical training in patients with

ILD and (2) to assess the safety of physical training in patients

with ILD.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Only randomised or quasi -randomised controlled trials in which

a prescribed regimen of physical training was compared to no

physical training or to other therapy in patients with ILD were

considered for this review. Single blind and open studies were

considered for inclusion.

Types of participants

People with ILD of any aetiology, diagnosed according to the

investigators’ definition, were included. There were no exclusions

on the basis of age, gender or physiologic status.

Types of interventions

We considered any type of prescribed physical training, either

supervised or unsupervised. We recorded, wherever possible, the

precise nature of the training (intensity, frequency, duration and

whether supplemental oxygen was applied). Trials where physical

training was combined with another intervention (e.g. education

or pharmacological therapy) were eligible for inclusion.

Comparisons to be examined were:

1. Physical training versus no physical training

2. Physical training versus another intervention

3. Physical training combined with another intervention versus

no physical training

Types of outcome measures

Primary outcomes

Functional or maximal exercise capacity, measured during either

formal exercise tests (maximal oxygen uptake (VO2 max), peak

oxygen uptake (VO2 peak), maximal ventilation (Ve max), heart

rate ) or field exercise tests (increase in distance walked).

Secondary outcomes

1. Dyspnoea: all measures of dyspnoea used were considered

2. Quality of life: Quality of life as measured by generic or disease-

specific quality of life instruments. All quality of life instruments

used were considered.

3. Adverse effects: adverse cardiovascular events during training

were recorded, as well as fractures, skeletal muscle injuries and

death.

4. Survival

Search methods for identification of studies

Electronic searches

We searched the Cochrane Central Register of Controlled Trials

(CENTRAL), MEDLINE, EMBASE, CINAHL and the Physio-

therapy Evidence Database (PEDro). All databases were searched

from the period of their inception to December 2009. No lan-

guage restriction was used.

The full database search strategies are listed in the appendices

(Appendix 1, Appendix 2, Appendix 3, Appendix 4 and Appendix

5).



Searching other resources

The reference lists of relevant studies and any related review pa-

pers were hand-searched for qualifying studies. We also contacted

authors of randomised controlled trials for information on other

published and unpublished studies.

Data collection and analysis

Selection of studies

Two authors (AH and CH) independently coded studies identified

in the literature searches for relevance by examining titles, abstract

and keywords fields as follows:

1. INCLUDE: Study categorically meets all review criteria;

2. UNCLEAR: Study appears to meet some review criteria but

insufficient information available to categorically determine rele-

vance;

3. EXCLUDE: Study does not categorically meet all review criteria

Two authors (AH and CH) used a full text copy of studies in

categories 1 and 2 to decide on study inclusion. Disagreements

were resolved by consensus. A full record of decisions was kept

and simple agreement and kappa statistics calculated.

Data extraction and management

Data were extracted independently by two authors using a pre-

pared checklist before being entered into Review Manager by the

primary reviewer (AH), with random checks on accuracy. Dis-

agreements were resolved by consensus. Data included characteris-

tics of included studies (methods, participants, interventions, out-

comes) and results of the included studies. Authors of included

studies were asked to verify the data extracted for their study and

to provide details of missing data where applicable.

Assessment of risk of bias in included studies

Two authors assessed the internal validity of included studies using

a component approach (including sequence generation for ran-

domisation, allocation concealment, blinding of participants and

assessors, loss to follow-up, completeness of outcome assessment

and other possible bias prevention). Disagreements were resolved

by consensus. We wrote to study authors to seek clarification where

we had inadequate information to judge the risk of bias.

Measures of treatment effect

For continuous variables, we recorded either the mean change

from baseline or the mean post-intervention values and standard

deviation (SD) for each group. The mean difference (MD) for

outcomes measured with the same metrics or standardised mean

difference (SMD) for outcomes measured with different metrics

with 95% confidence intervals (95% CI) were calculated using

RevMan 5.0. For binary outcome measures, we recorded the num-

ber of participants with each outcome event, by allocated treated

group, to allow an intention-to-treat analysis. The odds ratio (OR)

with 95%CIs were calculated for each study.

Assessment of heterogeneity

Subgroup analyses were conducted to explore possible sources of

heterogeneity. Three subgroup analyses were specified a priori:

1. Type of interstitial lung disease - idiopathic pulmonary fibrosis

(IPF) vs other: due to the progressive nature of IPF, physical train-

ing may be less effective in this form of ILD

2. Severity of lung disease: patients with more advanced disease

may be less able to participate in physical training. Participants

were considered to have severe disease if diffusing capacity for car-

bon monoxide (TLCO) was less than 45% predicted. In addi-

tion, participants who desaturated during exercise testing (SpO2

less than or equal to 88%) were compared to those who do not

desaturate.

3. Type of exercise: aerobic exercise training programs may be more

effective in improving symptoms and functional exercise tolerance

than resistance training programs

Data synthesis

We performed a pooled quantitative analysis where trials were

clinically homogeneous. A fixed or random effects model was used

depending on assessment of heterogeneity.

Sensitivity analysis

The small number of studies precluded sensitivity analyses and the

creation of funnel plots to test for publication bias. If in future

updates there are more studies included, sensitivity analysis will

be performed to analyse the effects of allocation concealment and

use of intention to treat analysis on results.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

Results of the search

There were 4783 studies identified from the initial search of the

databases. From this list, 15 full text articles were retrieved for



closer inspection. No additional studies were identified follow-

ing hand searching of reference lists or contacting study authors.

Of the 15 full text articles, agreement between the authors was

achieved on 13 articles (87%) with kappa=0.74, indicating sub-

stantial agreement. Disagreement was resolved by consensus. Five

articles were deemed to meet the inclusion criteria for this review.

Common reasons for exclusion were that studies were not ran-

domised controlled trials (n=3), studies included subjects without

lung disease (n=3), studies included mixed disease groups (n=3) or

studies did not include physical training (n=1). Full details of ex-

cluded studies can be found in Characteristics of excluded studies.

An update search conducted in December 2009 did not identify

any relevant studies for inclusion in the review.

Included studies

Five studies met the inclusion criteria for this review and all were

parallel randomised controlled trials. Full details can be found

in the ’Characteristics of Included Studies’ table. Three studies

had been published in abstract form only (Baradzina 2005; Mejia

2000; Wewel 2005). Sample sizes ranged from 22 to 99 partic-

ipants. All studies compared physical training to a no physical

training or sham training control group (Data and analyses: Com-

parison 1). Four studies examined exercise training programs con-

ducted in the outpatient setting (Baradzina 2005; Holland 2008;

Mejia 2000; Nishiyama 2008) whilst one study evaluated a home-

based exercise training program (Wewel 2005). The length of the

training programs varied from 5-12 weeks for outpatient training

and six months for home-based training.

Most studies included participants with a variety of ILDs (Holland

2008; Mejia 2000; Wewel 2005), one of which was stratified for

IPF (Holland 2008). One study included only participants with

sarcoidosis (Baradzina 2005) whilst another only included those

with IPF (Nishiyama 2008). All participants were adults with a

mean age of 52 to 70 years, with the exception of the study that

included only participants with sarcoidosis where the mean age

was 36 years (Baradzina 2005). Three studies examined the effects

of aerobic training (Baradzina 2005; Mejia 2000; Wewel 2005)

whilst the remaining studies used a combination of aerobic and

resistance training (Holland 2008; Nishiyama 2008). No study

evaluated resistance training alone and therefore no subgroup anal-

yses for type of exercise were possible. Participants in two stud-

ies underwent additional interventions that were not offered to

the control group; these included educational lectures (Baradzina

2005; Nishiyama 2008), nutritional advice, stress management

and physiotherapy (Baradzina 2005).

All studies used a measure of functional exercise tolerance, most

commonly the 6-minute walk test (Holland 2008; Nishiyama

2008; Wewel 2005). Two studies also performed a cardiopul-

monary exercise test (Holland 2008; Wewel 2005). Quality of life

was assessed in all five studies, using either the Chronic Respiratory

Disease questionnaire (Holland 2008; Mejia 2000), the St George’s

Respiratory questionnaire (Nishiyama 2008; Wewel 2005) or the

WHO questionnaire (Baradzina 2005). Dyspnoea was assessed in

three studies using the modified Medical Research Council Scale

(Holland 2008), the Baseline Dyspnoea Index (Nishiyama 2008)

and an unspecified measure (Wewel 2005).

Risk of bias in included studies

An overview of the risk of bias for domains listed below is provided

in Figure 1.



Figure 1. Methodological quality summary: review authors’ judgements about each methodological quality

item for each included study.

Allocation

All studies reported random allocation to groups; no study speci-

fied the method by which the sequence was generated. Two studies

reported that the allocation sequence was concealed using sealed

envelopes (Holland 2008; Nishiyama 2008). The remaining stud-

ies, all of which were available only in abstract form, did not pro-

vide sufficient information to assess whether the allocation se-

quence was concealed, even after contacting the authors for clari-

fication (Baradzina 2005; Mejia 2000; Wewel 2005).

Blinding

One study (Holland 2008) reported use of a blinded assessor for all

outcome measures. Insufficient data were available to determine

whether the assessors were blinded in other studies. Blinding of

participants was not possible for any study due to the physical

nature of the intervention. No studies reported whether the data

analysts were blinded to treatment allocation.

Incomplete outcome data

Two studies reported dropouts and loss to follow up (Holland

2008; Nishiyama 2008). One of these reported that two subjects in

the exercise group withdrew prior to collection of baseline data and

therefore were not included in the analysis (Nishiyama 2008). The



other study reported a significant number of dropouts, with data

analysis performed according to the intention to treat principle and

using the last observation carried forward method where data were

not available (Holland 2008). The other studies did not report

whether there were any dropouts or losses to follow up.

Selective reporting

One study was listed on a clinical trial registry (Holland 2008)

and results were reported for all outcomes at all time points. It was

not possible to determine whether all data were available for the

other studies. As three studies were available only in abstract form

(Baradzina 2005; Mejia 2000; Wewel 2005) it is likely that not all

data are currently available.

Effects of interventions

Data and analyses tables summarize the results of the meta-analysis

for the comparison of physical training versus no physical training.

Sufficient data were available from two studies for pooling in a

meta-analysis (Holland 2008, Nishiyama 2008).

Functional exercise capacity

All five trials reported that physical training resulted in signifi-

cant improvement in functional exercise capacity immediately fol-

lowing training. Two trials provided sufficient data on 6-minute

walk test for meta-analysis, with a total of 43 participants in the

exercise training group and 42 participants in the control group

(Holland 2008, Nishiyama 2008). Results of the meta-analysis are

seen in Figure 2. The common effect (weighted mean difference)

for change in distance walked was 38.61 metres in favour of the

physical training group (95% CI 155.37 to 61.85 metres). A sig-

nificant effect of physical training was also seen in the subgroup of

participants with IPF (n=33 physical training, n=29 control) with

a common effect of 26.55 metres (95% CI 2.81 to 50.30 metres).

Only one study provided sufficient data to examine the effects of

physical training in subjects with severe lung disease (n=23) or

in subjects who desaturated (n=30) and no significant effects of

physical training were evident in these groups (Holland 2008).

Figure 2. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.1 Change in 6-

minute walk test immediately following training.



One study reported results of the 6-minute walk test at six month

follow up (Figure 3). No significant effect of physical training was

evident at this time.

Figure 3. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.2 6-minute walk

test at long-term follow-up. Mean change from baseline.

Tests of heterogeneity for all analyses of functional exercise capacity

were not significant.

Maximal exercise capacity

Two studies reported that cardiopulmonary exercise testing was

performed following physical training, however data were only

available from one study with 27 participants in the exercise train-

ing group and 25 participants in the control group (Holland

2008). There was a mean difference in VO2peak between base-

line and follow up of 0.69 ml.kg.min−1 in favour of the exercise

training group (Figure 4), however this did not reach statistical

significance (95% CI -0.25 to 1.63ml.kg.min−1). There were no

significant differences in VO2peak for any of the subgroup analy-

ses. Exercise training resulted in a significant increase in maximum

ventilation in the exercise training group (Figure 5) with a mean

difference between groups of 4.71L.min-1 (95% CI 0.10 to 9.32).

The effect was more pronounced in the subgroup of participants

with IPF (mean difference 6.97, 0.87 to 13.07). No significant

effects of exercise training on maximum exercise parameters were

seen in the subgroups of severe disease or de saturators. No sig-

nificant effect of physical training was evident on maximum heart

rate (Figure 6).



Figure 4. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.3 VO2peak

immediately following training - ml.kg.min.



Figure 5. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.4 Change in

VEmax immediately following training - Litres.min.




maximum heart rate immediately following training - beats per minute.

Dyspnoea

Dyspnoea was measured in four studies, with two reporting re-

duced dyspnoea immediately following training (Holland 2008;

Baradzina 2005) and two studies reporting no change (Nishiyama

2008, Wewel 2005). Data from two studies were pooled for meta-

analysis with a total of 43 participants in the exercise training

group and 42 participants in the control group (Figure 7). The

common effect (standardised mean difference) for change in dys-

pnoea was -0.47 in favour of the exercise training group (95% CI

-0.91 to -0.04). A similar effect was seen for participants with IPF

(33 participants in exercise training group and 29 participants in

control group), however this did not reach statistical significance

(mean difference -0.43, 95% CI -0.94 to 0.08). An effect in favour

of exercise training was seen in participants with severe disease and

those who desaturated, however this reached significance only for

the desaturators (Figure 7). One study reported dyspnoea at six

month follow up (Figure 8). No significant effect of physical train-

ing on dyspnoea was evident at this time.Tests of heterogeneity

for all analyses of dyspnoea were not significant.



Figure 7. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.6 Dyspnoea

score immediately following training.




dyspnoea score at long-term follow-up.

Quality of Life

Health-related quality of life was measured in all studies, with

significant differences between groups reported immediately fol-

lowing training in two studies (Holland 2008; Nishiyama 2008)

while in the remaining studies it was unclear whether there were

differences between groups. Data were available for pooling from

two studies, one of which utilised the Chronic Respiratory Dis-

ease questionnaire (Holland 2008) and the other the St George’s

Respiratory questionnaire (Nishiyama 2008). There was a com-

mon effect indicating an improvement in quality of life with ex-

ercise training (standardised mean difference 0.58, 95% CI 0.15

to 1.02). A similar effect in favour of exercise training was seen

in participants with IPF (Figure 9). Data regarding the effects on

quality of life in participants with severe disease and those who

desaturated was available from one study (Holland 2008) where

there were trends favouring exercise training that did not reach sta-

tistical significance. Data regarding longer-term effects on quality

of life were available from one study (Holland 2008). There were

no effects of exercise training at six months, except in the subgroup

with severe disease who had significantly improved quality of life

compared to controls (Figure 10).




quality of life immediately following training.



Figure 10. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.9 Quality of life

at long-term follow up.

Adverse Events

Information regarding adverse events was available from two stud-

ies (Holland 2008; Nishiyama 2008), neither of which reported

any adverse events during the study period.

Survival

Six month survival was reported in one study (Holland 2008)

where there were two deaths in each group (Figure 11)



Figure 11. Forest plot of comparison: 1 Physical training vs no physical training, outcome: 1.10 Six month

survival.

D I S C U S S I O N

This review identified five studies comparing physical training to a

no-training or sham control group in people with ILD. No adverse

effects of this treatment were identified. Physical training resulted

in a clear improvement in functional exercise capacity measured

by 6-minute walk test, however no effect on maximum exercise

capacity was evident. A significant reduction in dyspnoea and im-

provement in quality of life was also seen immediately following

training. Effects were similar in the subgroup of participants with

IPF, however insufficient data were available to draw conclusions

regarding the effects of physical training in those with severe dis-

ease and those who desaturated. To date there is insufficient data

to draw conclusions regarding the long-term effects of physical

training in ILD.

The mean improvement in 6-minute walk test following training

was 38.61 metres, compared to 50 metres in people with COPD

who have undergone Pulmonary Rehabilitation (Lacasse 2006).

The reasons for the smaller response in ILD are unclear. All studies

utilised training strategies that are well aligned with current guide-

lines for Pulmonary Rehabilitation (Nici 2006) and it is likely that

a sufficient training stimulus was delivered. Given the good qual-

ity of the exercise interventions, it is possible that differences in

pathophysiology may account for the differences in response. The

clinical significance of this modest increase in 6-minute walk dis-

tance is unclear. However, significant improvement was also seen

in dyspnoea and health-related quality of life, suggesting that the

observed improvement may be meaningful for patients.

The studies included participants with a range of ILDs, often with

mixed diagnoses (Holland 2008; Mejia 2000; Wewel 2005). This

recruitment strategy probably reflects the relatively uncommon

nature and shared pathophysiological features of many ILDs. Par-

ticipants with IPF often have more severe physiological derange-



ment and a more rapid disease course compared to other ILDs

(Lama 2004) and we hypothesised that physical training might be

less effective in people with IPF. However, this review indicated

that IPF participants did achieve significant improvements in 6-

minute walk test and health-related quality of life. It should be

noted however that of the two studies contributing to the meta-

analysis, one included IPF participants only (Nishiyama 2008)

whilst the other had a majority of participants with IPF (Holland

2008) and thus the overall results of the meta-analysis are heavily

influenced by the response of IPF participants.

All studies in this review utilised either aerobic exercise training

or a combination of aerobic and resisted exercise training. These

strategies are well aligned with current guidelines for Pulmonary

Rehabilitation (Nici 2006) and the results are therefore readily

applicable to clinical practice in Pulmonary Rehabilitation pro-

grams. However, we were unable to draw any inferences regard-

ing the most effective exercise training strategy for people with

ILD. Given the relatively modest improvements in exercise capac-

ity documented here, this may be an important area for future

research. The included studies used a range of program durations

(five weeks to six months) and training frequencies (2-5 sessions

per week). Longer programs and more frequent sessions appear to

yield greater benefits in people with other chronic lung diseases

(Nici 2006). To date the most effective dose of physical training

for people with ILD has not been established.

There are a number of potential sources of bias in this review.

Of the five studies identified, three were available only in abstract

form (Baradzina 2005; Mejia 2000; Wewel 2005). These publica-

tions provided little data regarding the outcomes of interest and it

was not possible to obtain additional data from the authors. The

remaining two studies therefore provided all the data that could

be pooled for meta-analysis. Despite this limitation, there was

consistency in most reported outcomes, with all studies reporting

improved functional exercise capacity following exercise training.

Assessment of study quality was also difficult due to the limited

availability of data. As exercise training is a physical intervention

it can be assumed that no participants were blinded, however only

one study reported blinding of the assessor (Holland 2008). Only

one study reported use of an intention-to-treat analysis (Holland

2008). Given the progressive nature of many ILDs, a significant

dropout rate is likely and may impact both on the size of the re-

ported treatment effect and the feasibility of the intervention.

A U T H O R S ’ C O N C L U S I O N SImplications for practice

This review indicates that physical training is safe for people with

ILD and results in significantly improved functional exercise ca-

pacity, dyspnoea and health-related quality of life immediately fol-

lowing training. It is appropriate to include people with ILD in a

standard Pulmonary Rehabilitation program. To date there is little

evidence of a long-term benefit of physical training in ILD.

Implications for research

Further studies are required to identify whether the magnitude of

improvement following physical training is greater in participants

who do not have IPF. The optimum exercise training method for

participants with ILD has not been established and requires fur-

ther investigation in light of the modest response to training docu-

mented here. Large studies are also required to determine whether

the benefits of physical training vary according to disease severity

and whether there are any longer term effects of physical training

in ILD. Future trials should ensure that assessors are blinded to

the intervention and that appropriate methods are used to account

for dropouts.

A C K N O W L E D G E M E N T S

We thank John White who was the contact editor for this review.

We would also like to thank Toby Lasserson for support and guid-

ance.

R E F E R E N C E S

References to studies included in this review

Baradzina 2005 {published data only}

Baradzina HL, Ponachevnaya NV. Pulmonary rehabilitation

programme in sarcoidosis (abstract). European Respiratory

Journal 2005;26(Suppl. 49):333s.

Holland 2008 {published and unpublished data}

Holland AE, Hill CJ, Conron M, Munro P, McDonald CF.

Short-term improvement in exercise capacity and symptoms

following exercise training in interstitial lung disease.

Thorax 2008;63:549–5.

Mejia 2000 {published data only}

Mejia RA, Sansores RH, Perez-Padilla R, Mahler DA.

Effects of exercise training on ’quality of life’ in patients with

interstitial lung diseases (abstract). European Respiratory

Journal 2000;16(Suppl. 31):330s.

Nishiyama 2008 {published and unpublished data}∗ Nishiyama O, Kondoh Y, Kimura T, Kato K, Kataoka

A, Ogawa T, et al.Effects of pulmonary rehabilitation in

patients with idiopathic pulmonary fibrosis. Respirology

2008;13:394–9.

Nishiyama O, Taniguchi H, Kondoh Y, Kimura T, Ogawa



T, Watanabe F, et al.Pulmonary Rehabilitation in Idiopathic

Pulmonary Fibrosis. American Thoracic Society 100th

International Conference, Orlando, May 21-26. 2004:D96

Poster 110.

Wewel 2005 {published data only}

Behnke M, Schwertfeger I, Zimmerman I, Kirsten D,

Joerres RAJ, Magnussen H. Home-based exercise training

in patients with interstitial lung disease (abstract). European

Respiratory Journal 2003;22(Suppl 45):Abstract No: [1081].∗ Wewel AR, Behnke M, Schwertfeger I, Eberhardt F,

Kroidl RF, Jorres RA, et al.Home-based walking training in

patients with interstitial lung diseases (abstract). European

Respiratory Journal 2005;26(Suppl. 49):528s.

References to studies excluded from this review

Cockcroft 1981 {published data only}

Cockcroft AE, Saunders MJ, Berry G. Randomised

controlled trial of rehabilitation in chronic respiratory

disability. Thorax 198;36:200–3.

Cockcroft 1982 {published data only}

Cockcroft AE, Berry G, Brown EB, Exall C. Psychological

changes during a controlled trial of rehabilitation in chronic

respiratory disability. Thorax 1982;37:413–6.

Daltroy 1995 {published data only}

Daltroy LH, Robb-Nicholson C, Iverson MD, Wright EA,

Liang MH. Effectiveness of minimally supervised home

aerobic training in patients with systemic rheumatic disease.

British Journal of Rheumatology 1995;34:1064–9.

Jastrzebski 2006 {published data only}

Jastrzebski D, Gumola A, Gawlik R, Kozielski J. Dyspnoea

and quality of life in patients with pulmonary fibrosis after

six weeks of respiratory rehabilitation. Journal of Physiology

and Pharmacology 2006;57(Suppl. 4):139–48.

Naji 2006 {published data only}

Naji NA, Connor MC. Donnelly SC, McDonnell TJ.

Effectiveness of Pulmonary Rehabilitation in Restrictive

Lung Disease. Journal of Cardiopulmonary Rehabilitation

2006;26:237–43.

Oh 2003 {published and unpublished data}

Oh E. The effects of home-based pulmonary rehabilitation

in patients with chronic lung disease. International Journal

of Nursing Studies 2003;40:873–9.

Ong 2001 {published data only}

Ong KC, Wong WP, Jailani AR, Sew S, Ong YY. Effects of

a pulmonary rehabilitation programme on physiologic and

psychosocial outcomes in patients wtih chronic respiratory

disorders. Annals of the Academy of Medicine, Singapore

2001;30:15–21.

Senstrom 1996 {published data only}

Senstrom CH, Arge B, Sundbom A. Dynamic training

vs relaxation training as home exercise for patients wtih

inflammatory rheumatic diseases. Scandinavian Journal of

Rheumatology 1996;25:28–33.

Senstrom 1997 {published data only}

Senstrom CH, Arge B, Sundbom A. Home exercise

and compliance in inflammatory rheumatic diseases - a

prospective clinical trial. Journal of Rheumatology 1997;24:

470–6.

Tryfon 2003 {published data only}

Tryfon SM, Mavrofridis E, Ilonidis G, Patakas D.

Cardiopulmonary effects of exercise, before and after oxygen

delivery, in patients with usual interstitial pneumonia.

European Respiratory Journal 2003;22(Suppl 45):Abstract

No: [P639].

Additional references

Agusti 1991

Agusti AG, Roca J, Gea J, Wagner PD, Xaubet A, Rodriguez-

Roisin R. Mechanisms of gas-exchange impairment

in idiopathic pulmonary fibrosis. American Review of

Respiratory Disease 1991;143(2):219–25.

ATS/ERS 2000

American Thoracic Society. Idiopathic pulmonary fibrosis:

diagnosis and treatment. International consensus statement.

American Thoracic Society (ATS), and the European

Respiratory Society (ERS). American Journal of Respiratory

and Critical Care Medicine 2000;161(2):646–64.

Chang 1999

Chang JA, Curtis JR, Patrick DL, Raghu G. Assessment of

health-related quality of life in patients with interstitial lung

disease. Chest 1999;116(5):1175–82.

Hansen 1996

Hansen JE, Wasserman K. Pathophysiology of activity

limitation in patients with interstitial lung disease. Chest

1996;109(6):1566–76.

Harris-Eze 1996

Harris-Eze AO, Sridhar G, Clemens RE, Zintel TA,

Gallagher CG, Marciniuk DD. Role of hypoxemia and

pulmonary mechanics in exercise limitation in interstitial

lung disease. American Journal of Respiratory & Critical Care

Medicine 1996;154(4 Pt 1):994–1001.

Lacasse 2006

Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary

rehabilitation for chronic obstructive pulmonary

disease. Cochrane Database of Systematic Reviews 2006,

Issue 4. [Art. No.: CD003793. DOI: 10.1002/

14651858.CD003793.pub2]

Lama 2004

Lama VN, Martinez FJ. Resting and exercise physiology in

interstitial lung diseases. Clinical Chest Medicine 2004;25:

435–53.

Markovitz 1998

Markovitz GH, Cooper CB. Exercise and interstitial lung

disease. Current Opinion in Pulmonary Medicine 1998;4(5):

272–80.

Miki 2003

Miki K, Maekura R, Hiraga T, Okuda Y, Okamoto T,

Hirotani A, et al.Impairments and prognostic factors for



survival in patients with idiopathic pulmonary fibrosis.

Respiratory Medicine 2003;97(5):482–90.

Nici 2006

Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N,

Bourbeau J, et al.American Thoracic Society / European

Respiratory Society statement on pulmonary rehabilitation.

American Journal of Respiratory & Critical Care Medicine

2006;173(12):1390–413.∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Baradzina 2005

Methods Randomised controlled trial

Participants Sarcoidosis, n=65

Exercise group - n=30, 12 male, mean age 38 years

Control group - n=35, 14 male, mean age 36 years

Interventions Exercise group - 5 week multidisciplinary exercise program. Included exercise training

(5 times weekly for 40 minutes), physiotherapeutic procedures, education, nutritional

advice and stress management

Control group - not specified

Outcomes Walking test - type unspecified

Health related quality of life - WHO questionnaire

All measures obtained pre and post intervention period.

Notes Abstract

Risk of bias

Item Authors’ judgement Description

Adequate sequence generation? Unclear Not specified

Allocation concealment? Unclear Not specified

Blinding?

All outcomes

Unclear Not specified

Incomplete outcome data addressed?

All outcomes


Free of selective reporting? Unclear Not specified

Holland 2008


Stratified for IPF

Participants ILD n=57, including IPF n=34

n=31 male

Exercise group n=30, age mean(SD) 70(8) years, TLCO 50(19)%predicted

Control group n=27, age 67(13) years, TLCO 49(18)%predicted



Holland 2008 (Continued)

Interventions Exercise group - 8 week outpatient exercise program, twice weekly supervised sessions

consisting of 30 minutes endurance exercise (cycling and walking) with initial intensity at

80% of walking speed on initial 6-minute walk test and progressed according to protocol.

Upper limb endurance and functional strength training for lower limbs also performed.

Supplemental oxygen provided for SpO2>85%. Unsupervised home exercise program

prescribed 3 times per week

Control group - weekly telephone calls for general health advice and support

Outcomes 6-minute walk test

Cardiopulmonary exercise test

Chronic Respiratory Disease questionnaire

Modified Medical Research Council scale

Measured pre and post intervention period. 6 minute walk test and questionnaires re-

peated at 6 month follow up

Notes Supported by the Victorian Tuberculosis and Lung Association

Risk of bias


Adequate sequence generation? Yes Computer generated random number se-

quence

Allocation concealment? Yes Central location, sealed opaque envelope

Blinding?

All outcomes

Yes Data collector blinded to treatment alloca-

tion.


All outcomes

Yes Intention to treat analysis, last observation

carried forward

Free of selective reporting? Yes All data available at all time points

Mejia 2000


Participants ILD n=22

FVC 61(19)%predicted, age 52(14) years

Interventions 12 week exercise program, three times weekly supervised sessions of 30-35 minutes each,

interval training

Exercise training group - exercised at 60% of maximal power output on cycle ergometer

Control group - sham exercise training at minimum workload achievable on cycle er-

gometer (no resistance)



Mejia 2000 (Continued)

Outcomes Chronic Respiratory Disease questionnaire

12-minute walk test

Measured at baseline and 12 weeks

Notes Abstract

Risk of bias




Blinding?

All outcomes



All outcomes



Nishiyama 2008


Participants Idiopathic pulmonary fibrosis n=28

Exercise group n=13, male n=12, age 68(9) years, DLCO 59.4(16.7)%predicted

Control group n=15, male n=9, age 65(9) years, DLCO 48.6(16.7)%predicted

Interventions Exercise group - 9 week outpatient exercise program, twice weekly supervised sessions.

Exercise on treadmill at 80% of walking speed on initial 6-minute walk test, or on cycle

ergometer at 80% of initial maximum workload. Strength training for limbs using elastic

bands for approximately 20 minutes. Supplemental oxygen administered to achieve

SpO2>90%. Some educational lectures included (content unspecified)

Control group - not specified


Baseline dyspnoea index

St George’s Respiratory Questionnaire

All measured at baseline and 10 weeks.

Notes Supported by the Japanese Ministry of Health, Labor and Welfare

Risk of bias




Nishiyama 2008 (Continued)


Allocation concealment? Yes Allocation concealed using sealed envelopes that had

been prepared prior to the study

Blinding?

All outcomes



All outcomes

Yes Two patients randomised to exercise training but with-

drew before baseline data collected


Wewel 2005


Participants Interstitial lung disease n=99

Usual interstitial pneumonia n=38, extrinsic allergic alveolitis n=8, nonspecific interstitial

pneumonia n=30, sarcoidosis n=23

Exercise group n=49, age 59 years, TLCO 49%predicted

Control group n=50, age 62 years, TLCO 44%predicted

Interventions Exercise group - 6-month home-based walking training, twice daily walking for 15

minutes

Control group - no scheduled walking


Cardiopulmonary exercise test

Walking distance at home (pedometer)

St George’s Respiratory Questionnaire

Dyspnoea - measure unspecified

Measured at baseline and 6 months.

Notes Abstract

Risk of bias




Blinding?

All outcomes




Wewel 2005 (Continued)


All outcomes



Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Cockcroft 1981 Mixed disease group - participants had chronic obstructive pulmonary disease as well as coal worker’s pneumoco-

niosis

Cockcroft 1982 Mixed disease group - participants had chronic obstructive pulmonary disease as well as coal worker’s pneumoco-

niosis

Daltroy 1995 Participants did not have ILD

Jastrzebski 2006 Not a randomised controlled trial

Naji 2006 Not a randomised controlled trial

Oh 2003 Mixed disease group - diagnoses not reported

Ong 2001 Not a randomised controlled trial

Senstrom 1996 Participants did not have ILD

Senstrom 1997 Participants did not have ILD

Tryfon 2003 Participants did not undergo exercise training



D A T A A N D A N A L Y S E S

Comparison 1. Physical training vs no physical training

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Change in 6-minute walk

distance immediately following

training. Mean change from

baseline - metres

2 Mean Difference (IV, Fixed, 95% CI) Subtotals only

1.1 All participants 2 85 Mean Difference (IV, Fixed, 95% CI) 38.61 [15.37, 61.85]

1.2 Idiopathic pulmonary

fibrosis only

2 62 Mean Difference (IV, Fixed, 95% CI) 26.55 [2.81, 50.30]

1.3 Severe lung disease 1 23 Mean Difference (IV, Fixed, 95% CI) 9.61 [-29.43, 48.65]

1.4 Desaturators 1 30 Mean Difference (IV, Fixed, 95% CI) 15.62 [-15.93, 47.

17]

2 Change in 6-minute walk test

at long-term follow-up. Mean

change from baseline - metres


2.1 All participants 1 57 Mean Difference (IV, Fixed, 95% CI) 7.40 [-36.42, 51.22]


fibrosis only

1 34 Mean Difference (IV, Fixed, 95% CI) -23.08 [-70.59, 24.

43]

2.3 Severe lung disease 1 23 Mean Difference (IV, Fixed, 95% CI) 13.49 [-62.30, 89.

28]

2.4 Desaturators 1 30 Mean Difference (IV, Fixed, 95% CI) -22.24 [-89.85, 45.

37]

3 Change in VO2peak immediately

following training - ml.kg.min




fibrosis only

1 30 Mean Difference (IV, Fixed, 95% CI) 0.7 [-0.52, 1.92]

3.3 Severe lung disease 1 18 Mean Difference (IV, Fixed, 95% CI) -0.03 [-89.86, 89.

80]

3.4 Desaturators 1 27 Mean Difference (IV, Fixed, 95% CI) 0.84 [-0.31, 1.99]

4 Change in VEmax immediately

following training - Litres.min


4.1 All participants 1 52 Mean Difference (IV, Fixed, 95% CI) 4.71 [0.10, 9.32]


fibrosis only

1 30 Mean Difference (IV, Fixed, 95% CI) 6.97 [0.87, 13.07]

4.3 Severe lung disease 1 20 Mean Difference (IV, Fixed, 95% CI) 4.16 [-3.34, 11.66]

4.4 Desaturators 1 27 Mean Difference (IV, Fixed, 95% CI) 6.95 [0.03, 13.87]

5 Change in maximum heart rate

immediately following training

- beats per minute


5.1 All participants 1 52 Mean Difference (IV, Fixed, 95% CI) -1.84 [-6.26, 2.58]


fibrosis only

1 30 Mean Difference (IV, Fixed, 95% CI) -1.91 [-5.92, 2.10]

5.3 Severe lung disease 1 20 Mean Difference (IV, Fixed, 95% CI) -5.38 [-11.46, 0.70]



5.4 Desaturators 1 27 Mean Difference (IV, Fixed, 95% CI) -0.45 [-6.07, 5.17]

6 Change in dyspnoea score


2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only

6.1 All participants 2 85 Std. Mean Difference (IV, Fixed, 95% CI) -0.47 [-0.91, -0.04]


fibrosis only

2 62 Std. Mean Difference (IV, Fixed, 95% CI) -0.43 [-0.94, 0.08]

6.3 Severe lung disease 1 23 Std. Mean Difference (IV, Fixed, 95% CI) -0.70 [-1.56, 0.15]

6.4 Desaturators 1 30 Std. Mean Difference (IV, Fixed, 95% CI) -0.85 [-1.61, -0.09]

7 Change in dyspnoea score at

long-term follow-up


7.1 All participants 1 57 Mean Difference (IV, Fixed, 95% CI) -0.13 [-0.81, 0.55]


fibrosis only


7.3 Severe lung disease 1 23 Mean Difference (IV, Fixed, 95% CI) -0.12 [-1.23, 0.99]


8 Change in quality of life


2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only

8.1 All participants 2 85 Std. Mean Difference (IV, Fixed, 95% CI) 0.58 [0.15, 1.02]


fibrosis only

2 62 Std. Mean Difference (IV, Fixed, 95% CI) 0.57 [0.06, 1.09]

8.3 Severe lung disease 1 23 Std. Mean Difference (IV, Fixed, 95% CI) 0.86 [-0.00, 1.73]

8.4 Desaturators 1 30 Std. Mean Difference (IV, Fixed, 95% CI) 0.42 [-0.31, 1.15]

9 Change in quality of life at long-

term follow-up




fibrosis only


9.3 Severe lung disease 1 23 Mean Difference (IV, Fixed, 95% CI) 14.93 [0.54, 29.32]


10 Six month survival 1 Odds Ratio (M-H, Fixed, 95% CI) Subtotals only

10.1 All participants 1 57 Odds Ratio (M-H, Fixed, 95% CI) 0.89 [0.12, 6.82]


fibrosis only

1 34 Odds Ratio (M-H, Fixed, 95% CI) 0.67 [0.08, 5.40]

10.3 Severe lung disease 1 23 Odds Ratio (M-H, Fixed, 95% CI) 1.64 [0.13, 21.10]

10.4 Desaturators 1 30 Odds Ratio (M-H, Fixed, 95% CI) 1.6 [0.13, 19.84]

W H A T ’ S N E W

Last assessed as up-to-date: 1 February 2010.

Date Event Description

2 February 2010 New search has been performed Updated search re-run; no new studies were identified.



H I S T O R Y

Protocol first published: Issue 1, 2007

Review first published: Issue 4, 2008

Date Event Description

28 January 2009 Amended Contact details changed

10 April 2008 Amended Converted to new review format.

11 October 2006 New citation required and major changes Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

Initiation of protocol: AH

Protocol development: AH and CH

Undertook search: AH

Retrieved papers : AH

Screened retrieved papers against eligibility criteria: AH and CH

Appraised quality: AH and CH

Extracted data: AH and CH

Wrote to authors for additional information: AH

Entered data into RevMan: AH

Analysis: AH and CH

Wrote review: AH and CH

Guarantor of the review: AH

D E C L A R A T I O N S O F I N T E R E S T

AH and CH conducted one of the studies included in this review.



S O U R C E S O F S U P P O R T

Internal sources

• No sources of support supplied

External sources

• Victorian Tuberculosis and Lung Association, Australia.

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

Subgroup analysis for exercise type could not be conducted as we did not identify any trials of resistance training. Sensitivity analysis

was not performed and funnel plots were not constructed due to the small number of included studies. If in future updates there are

more studies included then these analyses will be performed.

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Exercise; Exercise Therapy; Exercise Tolerance; Lung Diseases, Interstitial [physiopathology; ∗rehabilitation]; Randomized Controlled

Trials as Topic

MeSH check words

Humans



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Cochrane Database of Systematic Reviews (Reviews) || Physical training for interstitial lung disease