Maximum Heart Rate:
One of the most common ways that we can represent the intensity of exercise or activity is by the percentage of your maximum heart rate (HR Max%). This method is often very effective, but it can also be equally ineffective depending upon how the numbers are derived. Let me explain why I say this.

Your maximum heart rate is the maximum number of times your heart can beat per minute when you are working at your highest level of exertion or activity. It is based primarily on your age and level of conditioning. As a general rule, as we age, our maximum heart rate decreases and as another general rule, the more conditioned we are, the lower your heart rate will be, both at rest and at any given workload.

The Theoretical, The Actual and the “Actual” Actual

Your theoretical age-predicted maximum heart rate is most often calculated using the formula 220 minus your age (220-age). For example, a 60-year-old person has
a theoretical age-predicted maximum heart rate of 160 beats per minute (bpm).

However, it is important to understand that this age-predicted formula for maximum heart rate is a theoretical approximation based upon general population data. It is not an individually established calculation based on your or any one person’s distinct set of medical, physical, or other physiological characteristics.

Furthermore, this approximation should only be used as a predictor in “normal, healthy individuals.” It does not apply to and therefore, should not be used for “high risk” populations, including anyone with any type of cardiovascular, pulmonary, metabolic, or otherwise significant medical condition that might impair normal exercise physiology or compromise safety.

In clinical or medical settings, we cannot and should not be using the theoretical maximum heart rate. Instead, we need to establish an actual maximum heart rate for each individual patient. For that reason, it is strongly recommended that the patient undergo a comprehensive cardiovascular workup prior to beginning an exercise or rehabilitation program, especially in these special cardiopulmonary populations.

At a minimum, depending on the number and degree of risk factors, some type of clinical exercise evaluation or stress test (preferably, with an echocardiogram) should be performed in order to determine the patient’s actual maximum heart rate as well as to establish safe parameters for exercise. However, here is where things get interesting (and tricky and confusing). When it comes to pulmonary patients, even the actual maximum heart rate does not always apply either.

During a traditional stress test, the exercise would typically be terminated when the patient reaches what we call a hemodynamic or physiologic endpoint. Usually, these endpoints are based on the patient’s age, gender, fitness level, and medical condition, particularly the presence of any potential cardiac risk factors. These endpoints most frequently include heart rate (HR) or pulse in beats per minute (bpm), heart rhythm via electrocardiogram (ECG or EKG), blood pressure (BP) in millimeters of mercury (mm Hg), aerobic capacity or peak oxygen consumption (VO2 max) and in the case of pulmonary patients, oxygen saturation (O2 Sat%).

The test is usually stopped once any one of these pre-determined endpoints is reached, or for any number of other reasons including chest pain, tachycardia (high heart rate), hyper- or hypotension (high or low blood pressure respectively), equipment malfunction, or at the patient’s request.

However, it is important to understand that patients with pulmonary disease are often prevented from reaching their true maximum because they are limited by shortness of breath and/or lower extremity fatigue, long before they reach any of these physiologic endpoints. For example, that 60-year-old man might have to stop the test because he is too short of breath to continue even though his heart rate is only 120 as opposed to his age-predicted maximum heart rate of 160. In this scenario, instead of an actual maximum heart rate, we get what we call a symptom-limited maximum heart rate.

In traditional cardiac rehabilitation programs, an exercise prescription might include a target heart rate (THR) somewhere between 50% and 90% of maximum, depending on the individual’s medical history, their current level of conditioning and their personal health and fitness goals. However, this is not effective in a pulmonary population or in any patient who is limited by their symptoms prior to being limited by their cardiovascular condition or hemodynamic performance.

Another point to make is that many of the medications used to treat pulmonary patients can have a stimulant effect. As a result, in addition to the increased work of breathing and deconditioning, pulmonary patients can sometimes have elevated heart rates, both at rest as well as during exercise.

Metabolic Equivalents (METs)

A Measure of Exercise Tolerance or Metabolic Equivalent (MET) is a unit of measure used to describe cardiovascular workload. One MET equals 3.5 ml O2·kg−1·min−1. In English, this means that for each metabolic equivalent or MET, your body utilizes 3.5 milliliters of oxygen per kilogram of body weight per minute. To take this one step further, each person’s body uses a certain amount of oxygen per minute, depending upon the activity they are doing, their body weight and composition, and their fitness level.

We can determine the exact MET level at which a person is working either by direct measurement (using what we call expired gas analysis) or by using predicted values. During a cardiopulmonary stress test, the actual milliliters of oxygen that are consumed by that patient per minute are measured. When we plug that number into a formula that adjusts for that patient’s weight, we are able to determine their actual MET level.

We can also reasonably predict the approximate MET level of various activities, including different treadmill intensities, based upon data that has been collected from thousands of exercise tests and activity measurements from thousands of subjects.

For every 1.0 MET (which is consistent with being at rest), a person will use 3.5 ml of oxygen per minute for every kilogram of body weight. Therefore, if a person’s body weight is 50 kilograms (approximately 110 pounds), at rest or at 1.0 MET, they use 3.5 ml of oxygen per minute multiplied by 50 kg. In other words, they use 175 ml of oxygen per minute under resting conditions, or at 1.0 MET.

If that 50 kg person exercises for 1 minute and uses 350 ml of oxygen, their body uses double the amount of oxygen as it did at rest. In other words, this person was exercising at twice the level of exertion as compared to resting conditions, or 2.0 METs.

Thankfully, we have averages for each treadmill level (intensity), so we don’t have to figure it out every time. Instead, you can use the treadmill MET chart and age-predicted treadmill intensities I have provided for this purpose in chapter 6: Treadmill 101.

Subjective Measures of Exercise Intensity

Rating of Perceived Exertion (RPE) Scale

Named for its creator, Dr. Gunnar Borg, the Borg Scale or Rating of Perceived Exertion (RPE) Scale is simple to use and can be an invaluable tool for creating, monitoring and modifying an exercise program. The original scale ranges from 6-20 and represents a subjective measure of how hard the person is working. A rating of 6 is equal to rest or very, very light exertion and a rating of 20 is equivalent to maximum exertion. Each number also corresponds to a description in words ranging from very, very light all the way to very, very hard.

Multiplying each number by 10 will give us an approximate heart rate range where 60 corresponds to the person’s heart rate at rest and 200 corresponds to their heart rate at maximum exertion. There is also a modified version of this scale that ranges from 0-10, but in my opinion, the 6-20 scale works better and is the one we use at PWRC.

The majority of your workout should take place in the “somewhat hard” range, increasing from fairly light at the beginning, working up to somewhat hard for the majority of the workout, and finally working hard at the peak, followed by a short cool-down period.

Perceived Dyspnea (Breathlessness) Scale

As compared to factors that can be observed by another person, like respiratory rate or increased work of breathing, dyspnea refers to a person’s own internal perception of breathlessness. Similar to the RPE Scale, the Dyspnea (Breathlessness) Scale can be used to quantify the degree of shortness of breath a person is experiencing. This scale also ranges from 6-20, where a rating of 6 corresponds to none or very, very mild breathlessness and 20 corresponds to very, very strong breathlessness. This information can then be correlated with more objective measures, like heart rate, blood pressure and oxygen saturation in order to determine safe and effective exercise parameters.

At PWRC, we continuously monitor our patients’ heart rate and rhythm by EKG and their blood pressure and oxygen saturation are measured in five-minute intervals. We can also determine the percentage of your age- and gender-predicted maximum workload you’re working at. That’s what we mean by objective data.

As a point of reference, below are the general parameters that we use with our patients. This is assuming all things being equal, which they almost never are. As an example, if someone has known heart disease or pulmonary hypertension, we might make an adjustment to the below numbers to minimize the risk of a problem. Again, to be clear, these are general guidelines only. Your guidelines and limits should come from your physician.

Heart Rate: We will generally allow most of our patients to go up to a maximum heart rate of 200 minus their age (200-age). So, as an example, if we had an 80-year-old patient, we would allow him to go to a maximum heart rate of 120. The reason we use 200 instead of 220 is that it gives us a built-in 20 beat per minute safety zone, although most people don’t reach that due to other factors like SOB or fatigue.

Blood Pressure: As far as blood pressure, if you are under eighty years of age, we will generally allow your systolic blood pressure go to a maximum of 200 millimeters of mercury. If you are eighty years of age or older, we will generally allow your systolic blood pressure go to a maximum of 180 millimeters of mercury. We generally try to keep diastolic pressures under 95 mm Hg.

Oxygen Saturation: As far as oxygen saturation goes, we try to keep our patients at 93% plus during exercise. In many cases, this means that we have to use supplemental oxygen but in doing so, our patients are able to get a much better workout, as compared to room air and it is these more challenging workouts that lead to the greatest short- and long-term benefits.

Rating of Perceived Exertion (RPE): Again, when it comes to RPE, we generally want our patients to warm up in the “fairly light” to “somewhat hard” range, with most of the workout being in the “somewhat hard” range and “hard” range at the peak. Exercise in the “very light” or “very very light” range is too easy and exercise in the “very hard” to very very hard” range is too intense.

Perceived Dyspnea (Breathlessness): Similarly to RPE, when it comes to breathlessness, we generally want our patients to warm up in the “fairly mild” to “somewhat strong” range with most of the workout being in the “somewhat strong” range and “strong” range at the peak.

TIME (DURATION) OF EXERCISE

How much time you spend exercising is going to be dependent upon multiple factors and can vary from person to person, and sometimes even day to day. It will depend on your medical condition, your current level of fitness, and your degree of motivation (which, as you know, can be either your best friend or your worst enemy). And then there are those million and one other factors like going to work, picking up the grandkids from school, doctor’s appointments, cooking and cleaning, etcetera, etcetera, etcetera. As John Lennon of the Beatles says: “Life is what happens while we’re busy making other plans.”

In an ideal world, we should exercise for a minimum of 20 minutes per day with an ultimate goal of 45 to 90 minutes per day. I know this is a big range, but it will make more sense later, when I give you sample workouts for 20 minutes, 30 minutes, 45 minutes, 60 minutes, and even a 90-minute workout for you exercise junkies.

In my experience with patients, the most effective workouts are between 30 and 60 minutes in duration with short rest breaks interspersed throughout the workout. If you can only tolerate 10 minutes of exercise (or less) at a time, you really need to be exercising two to three times per day. The good news is that there is evidence that suggests three 10- minute workouts per day are almost as effective as one 30-minute workout. Keep in mind that these workout times are in addition to all of the other activities you do in your daily life.

TYPE OF EXERCISE

When we talk about the type of exercise, we are referring to the broad, general categories into which exercise can be divided. For the purposes of this book and my “typical” patient, I have included the five categories that we have found to be the most beneficial for people living with pulmonary disease. These five categories include breathing retraining, aerobic exercise, strength training, flexibility exercises, and balance training.

We will consider each of these categories from the perspective of both their physiologic impact on the body and their functional impact on the individual as a whole, during everyday activity. For example, when we talk about strength training, the physiological impact involves increasing the size of the muscles and the force with which they can contract.

When we talk about the functional impact, we are referring to the application of this force during everyday activities (e.g. getting up from a chair or lifting up your grandchild). I will try to make this connection between physiologies and function whenever possible so that you have a clear understanding of how different exercises impact your everyday life. Then, you can decide which ones are most important for you.

Another key point is that whether it’s in the physiology lab, at pulmonary rehab or in fitness magazines at the local supermarket, people often rigidly discuss and classify the types of exercise into distinct physiological and functional categories as if they somehow exist solely as independent entities and to the exclusion of all other categories. In reality, the majority of exercises and activities that we do involve a combination of two or more types of exercise.

In other words, even when you are doing what is traditionally considered to be aerobic exercise, you will still get secondary gains in strength, flexibility, and balance as well. Similarly, when doing strength training, you can also gain some aerobic and balance benefits, and finally, when you are doing stretching or flexibility exercises, you can also gain strength and aerobic benefits.

For example, walking is usually considered to be an aerobic activity, with elements of balance, strength, flexibility and breath control required as well. However, when walking uphill or climbing stairs, a greater degree of muscle force is required making it more strength-intensive. My point in mentioning this is to say that you will get at least some benefit in multiple areas during most physical activities.

With this in mind, our goal is to create a program that incorporates each of these types of exercise that will give you the maximum benefit in the most areas with the least amount of time and effort. In other words, we want you to work smarter, not necessarily harder.

BREATHING RETRAINING

Breathing retraining includes diaphragmatic breathing, pursed-lip breathing, paced breathing, and recovery from shortness of breath. Although they are covered in Chapter 3, I wanted to mention them here in the context of exercise in order to keep things in their proper perspective (and chronologic order). These techniques provide you with greater breath control, which is why they are the first thing we teach our patients during their initial exercise session.

When you first begin learning and practicing these breathing methods, the techniques themselves are the actual exercises. However, as you become more skilled in their application, you will use them as a tool that will allow you to do more vigorous exercise. It is this vigorous exercise that will ultimately decrease your shortness of breath, allowing you to walk more and potentially improving your lung function in the process. If you haven’t done it yet, read about them, study them, practice them and use them both during your workouts and in your everyday life.

AEROBIC EXERCISE

When people hear the words “aerobic exercise” or simply, “aerobics,” their minds usually conjure up images of Jane Fonda or a room full of sweaty—I mean glowing women—in neon spandex jumping around, flailing their arms and legs to 80’s disco music—
and a few sweaty men. While that certainly qualifies, for the purposes of this chapter, I will define aerobic exercise as any activity that is cardiovascular in nature or what some people refer to simply as “cardio.” In most cases, aerobic exercise involves rhythmic exercises that use large muscle groups and that can be sustained for relatively long periods of time. They will typically be lower in intensity than anaerobic exercise. Think tortoise, rather than hare, because if the intensity of the exercise is too great, you will be unable to sustain it long enough for it to be aerobic.

For anyone living with a cardiovascular or pulmonary disease, aerobic exercise is, by far, the single most important type of exercise. Aerobic exercise helps your body become more efficient at using oxygen and you, less short of breath. This can occur by:

1. Improving the mechanics of your respiratory system, allowing you to move air in and out more efficiently.
2. Improving the ability of your heart to pump blood to the lungs and throughout all of the organs and tissues of the body.
3. Improving the efficiency with which your peripheral (or skeletal) muscles utilize oxygen, making them more efficient at extracting oxygen from the blood, and delivering waste products to the blood for removal.

In the context of our “supply and demand” conversation, aerobic exercise increases your body’s oxygen supply while reducing its demand during physical activity, at rest and even while you sleep.

Examples of aerobic exercise include walking, jogging, cycling, swimming, and dancing, among others. If you’re in the gym (or pulmonary rehab), cardio machines include the treadmill, stationary bicycle, upper body ergometer (UBE) and many others. To help you make the best choices for your own workout, I will take you through the pros and cons of each type and tell you what and why we do what we do with our patients.

Walking

Walking is one of the best possible exercises you can do, for a number of reasons. Most importantly, as human beings, walking is our primary mode of locomotion. If you cannot walk, this will severely limit your ability to get around and to participate in various activities of daily living, diminishing your overall quality of life. Walking can be done almost anywhere; indoors or outdoors and requires no special equipment other than comfortable clothing and a good pair of sneakers or walking shoes (and if you’ve seen some of the getups people work out in, you know that’s not even entirely true).

Walking is multi-systemic and involves all exercise modes, not only enhancing aerobic capacity but also improving your strength, flexibility and balance and decreasing your shortness of breath in the process. It is also easily modifiable with respect to speed and duration, based on the individual.

Be sure to walk in a safe place like a gym, track, mall or supermarket. Walk where the air is clean and avoid temperature extremes. If you are in a hot climate, walk early in the morning before the sun is at its strongest, or in the evening when the sun is starting to go down. If you live in a cold environment, walk indoors if the temperature is below approximately 36 degrees. Finally, if you are supposed to be using an assistive device like a walker or cane, please do. The same goes for any prescribed orthotics, where applicable.

Jogging/Running

Jogging and running have many of the same benefits of walking, but with a few caveats. The biggest difference between walking and jogging or running is that when you walk (even quickly), you always have at least one foot on the ground. When you jog or run there is at least a brief period during each stride (actually two) when both feet (and the rest of your body) are off the ground. As a result, there is a greater mechanical load every time your foot hits the floor. These factors increase the impact and potential stress on your body, particularly the musculoskeletal system (joints, tendons, ligaments), significantly increasing your chances of injury.

Both of these activities can range from fairly mild to very vigorous, so they can potentially generate even greater benefits with respect to aerobic capacity. However, this increased intensity also comes with some increased risk, which is why we usually recommend walking instead of jogging or running for the majority of our patients.

Treadmill

The treadmill is my single favorite piece of exercise equipment for many reasons. First, the treadmill is highly effective, mainly because its intensity can be easily adjusted with respect to speed and incline, making it a consistently measurable and “dose-controllable” activity.

Second, the treadmill provides mechanical assistance to ambulation (walking) by bringing your leg backward with each stride. This reduces the amount of force needed to overcome the resistance exerted on your body by the ground. For this reason, many people can do more on the treadmill than they can when walking, which ultimately helps you do more off the treadmill. As a point of reference, walking on a flat surface is equivalent to walking at approximately a 2% incline on a treadmill.

Finally, and this is so important, holding on to the arm rails closes the chain, allowing the muscles of the thorax and the entire upper body (pecs, lats, traps, serratus) to work in their reverse actions, assisting the diaphragm and allowing you to breathe easier.

I will address the treadmill in much greater detail as well as give you several sample workouts in Chapter 8: Treadmill 101. That’s how valuable I think it is.

Bicycling

Riding a bicycle is another great exercise that most people can participate in (in one form or another). As they say, “it is like riding a bike.” The bike is a relatively versatile and user-friendly piece of equipment. Its various parameters (body position, speed and resistance) can all be modified based upon your cardio-respiratory fitness and any musculoskeletal limitations you may have, making it an effective workout tool for almost anybody.

Depending upon your body type and/or any physical or physiologic limitations you may have, you may find one bicycle to be more comfortable than another. As an example, because your back is supported, many people find the recumbent bike to be more comfortable and easier to use than an upright bike. However, this also makes the recumbent bike less physically (and metabolically) demanding than the upright bike.

Compared to the recumbent bike, there is also a strong postural component to the upright bike. In addition to the work of the lower body, the muscles of the thorax (chest, back and abdominals) have to work harder to keep you upright, balancing anterior (front) and posterior (back) and left and right to prevent you from falling over. As a result the upright bike is more physically (and metabolically) demanding than the recumbent

bike. In other words, the upright bike requires more muscle activity, thereby increasing its value as an aerobic exercise.

Another consideration in choosing one bike versus another is the impact of body position on respiratory mechanics. When you’re on the recumbent bike as compared to the upright, your knees come up a bit higher, bringing your thighs closer towards your upper body, compressing the abdominal and thoracic contents. As a result, the diaphragm has less room to contract (downward) and in fact, can be pushed upwards, further increasing the intra-abdominal and intra-thoracic pressures. These increased intra-abdominal and intra-thoracic pressures further compress the lungs, making it more difficult for you to take a deep breath. This is particularly true for overweight individuals, especially if they have a lot of soft tissue (fat) in the midsection.

Using a stationary bike indoors can eliminate the risks of outdoor cycling while still allowing you to develop both strength and aerobic capacity and if we set up a fan in front of you, you can still get that nice wind-blowing-through-your-hair feeling as you ride.

Elliptical Machine

Another one of my favorites, the elliptical machine is one of the most popular exercise machines on the market and for good reason. The elliptical offers a very effective full- body workout with many of the same aerobic benefits as jogging or walking with far less impact on the joints. Elliptical machines can be done using only the lower body (while holding on with the arms) or upper and lower body at the same time.

It is significantly more strenuous to do both arms and legs as opposed to just using your legs and requires a greater balance and coordination. Beginners should start using the lower body only for a less intense workout. As you feel more comfortable, you can add the arms, increasing the time and intensity as your fitness level improves. Be careful especially when getting on and off the machine.

Nu-Step

The Nu-Step is a semi-recumbent/recumbent cross trainer that combines forward and back arm motion (like the elliptical), with an up and down stepping motion in the legs (like a stepper), all in a seated or semi-reclining position. One of the greatest benefits of this type of design is that people of all fitness levels can use it, even if they are not capable of full weight bearing. The Nu-Step is extremely comfortable and consistently a favorite among patients.

Upper Body Ergometer (UBE)

The upper body ergometer (UBE) or “arm bike” is essentially a bicycle that you pedal with your arms. In most cases, you can pedal forwards or backward and the resistance can be adjusted in order to increase or decrease the tension, increasing or decreasing the intensity of the workout. The UBE is one of the best exercise machines on the market and almost always the first exercise we introduce our patients to in their initial session.

As human beings, we conduct the majority of activities in front of us. As a result, the muscles on the front of the body are typically stronger (and consequently tighter) than those on the back, which are usually weaker (and looser). This muscle imbalance can lead to that round-shouldered, forward-bending posture that is so common as we age and even more so in people with respiratory disease.

For this reason, we usually have people pedal backward first, while they have the most energy in order to prioritize the back muscles. In this way, we strive to restore the body’s natural muscle balance and upright posture. For patients with a significant forward bend (kyphosis), we may have them do the entire exercise backward. The UBE is also very effective in relaxing the muscles of the upper body and the airways, increasing ribcage mobility, decreasing muscle tension and allowing you to take a deeper breath.

Arm-R-Size

Arm-R-Size is a series of 10-20 upper body movements that I believe I first learned at the UCSD pulmonary rehab program more than 20 years ago. We’ve been using it ever since and even added a few moves of our own. Essentially, these exercises simulate everyday activities, and each one can be done for 15-60 seconds (or more) in succession for a total exercise time of 5-15 minutes. One of the best things about this program is that it can be performed almost anywhere and doesn’t require any special machines or equipment, making Arm-R-Size an invaluable addition to your overall workout or on its own.

For many people with pulmonary disease, upper body and particularly overhead (open chain) activities, are especially difficult—think washing your hair. These activities put the diaphragm and the rest of your respiratory muscles at a significant mechanical disadvantage for breathing, thereby causing you to become shorter of breath and your muscles (and you) to fatigue more quickly.

Arm-R-Size can help to prevent and reverse these effects increasing the strength and endurance of your upper body, improving the mechanics of your respiratory system and desensitizing you to dyspnea, making your upper body muscles more efficient and you, less short of breath.

Swimming

Swimming is an excellent full-body, aerobic exercise for those that are able to do it. It has many of the same benefits of other aerobic exercise but creates less impact on the body due to the buoyancy of the water. However, swimming also requires a great deal of breath control and coordination, and the workout will vary depending upon which stroke you choose. Be aware that people whose respiratory triggers include strong odors or irritants may have increased sensitivity to the chemicals used in pools.

Water Aerobics

Water Aerobics combine various upper and lower body movements into a full-body aerobic workout. Working out in the water uses buoyancy to assist or resist the motion, reducing impact and increasing or decreasing the resistance depending on the muscles used. Again, be aware that people whose respiratory triggers include strong odors or irritants may have increased sensitivity to the chemicals used in pools.

Aerobic Dance

Aerobic Dance is an excellent full-body workout that combines various dance movements into a full-body aerobic workout. Besides the overall health benefits for your cardiovascular fitness and endurance; aerobic dance develops balance, coordination, and flexibility. It also adds a mental component to your workout as you learn and remember new dance steps and sequences throughout the class—and it’s fun!!!

Aerobic dance classes vary from instructor to instructor and from class to class, depending on the style and many other factors. So please be sure to choose a class that is appropriate for your fitness level.

Stairmaster/Stair Climber/Stepper/Stepmill

Although there are slight variations from machine to machine, the stepper allows you to utilize the same muscles as during stair climbing, which is one of the most challenging activities for people, especially if you have difficulty breathing. When you use the stepper with your hands free, you get the added benefit of working on balance and stability. However, holding on increases your safety and assists with respiration by allowing the upper extremities to work in a closed chain, improving respiratory mechanics. Be careful especially when getting on and off the machine.

If you can, try to use your arms for balance and stability only. Putting too much weight on your arms significantly decreases the effectiveness of the workout and increases your chance of developing a repetitive use injury, particularly at the shoulders, elbows and wrists.

Ski Machine/NordicTrack

A ski machine is an exercise machine that, as the name suggests, is designed to replicate the act of cross-country skiing, one of the best-known aerobic workouts. Your arms and legs move through the forward and backward motion of cross-country skiing, offering a very effective full-body workout, providing many of the same benefits as jogging or walking, but with less impact on the joints.

It is significantly more strenuous to do both the arms and legs as opposed to using your legs only. It also requires greater balance and coordination. Beginners should start using the lower body only for a less intense workout. As you feel more comfortable, you can add the arms, increasing the time and intensity as your fitness level improves. Be careful especially when getting on and off the machine.

Versa-Climber

The Versa-Climber is another full-body; sitting or standing cross-trainer that combines a climbing motion of the upper body with a stepping motion of the legs. It can be used either as an upper and lower body exercise, in either seated or standing; or as a lower body exercise only, while seated. Because of the comfort of the seat and the simple stepping motion, people of all fitness levels can use it.

Rowing Machine

A Rowing Machine replicates the act of rowing a boat (or more accurately, a racing shell). Stroke! Stroke! It’s used in a seated position and is a full body exercise that combines a pushing (extension) motion with the legs and a pulling (flexion) motion with the arms. The rowing machine is an excellent workout for pulmonary patients and can be very beneficial in terms of posture. However, it may be difficult for people with limited joint motion, particularly in the lower back, hips, knees and ankles.

STRENGTH TRAINING

The goal of strength or resistance training is to increase the size (mass) of your muscles and the amount of force that they can generate. This is accomplished by exercising the muscles in a way that incrementally demands greater exertion, gradually increasing the resistance over time. This can be done using a variety of exercises, including free weights (barbells, dumbbells, wrist and ankle weights), machines, therapeutic bands, isometric exercises and activities that use your own body weight as resistance.

For pulmonary patients, we usually begin with aerobic exercise and gradually add strength training once you’ve improved your level of aerobic conditioning sufficiently. Generally, when you can do 15 minutes of arm exercises, 15 minutes of biking or Nu- Step and 25 minutes on the treadmill, we will then begin adding specific strength training exercises. However, as mentioned earlier, even an aerobic workout will help to improve your strength. For instance, if you are very weak, and you have been inactive, then going out for a walk—which is primarily an aerobic activity—will also increase your strength.

Strengthening exercises can be divided into compound and isolation movements. Compound movements are exercises that work several different muscle groups at the same time in order to achieve a specific motion or action, whereas isolation exercises focus on one muscle or muscle group at a time. As an example, the bench press is a compound movement whose primary muscle group is the chest or pectoral muscles, but they are assisted by the muscles on the front of the shoulder (anterior deltoid) and the triceps muscles on the back of the arms. The “pectoral fly” on the other hand, focuses on the chest muscles or pectorals alone, in isolation. Ideally, you would use a combination of compound and isolation movements depending upon your personal fitness goals.

FLEXIBILITY EXERCISE

Flexibility or stretching exercises can increase your range of motion, decrease joint and muscle stiffness, and help prevent injury. While you may not need to be able to put your foot behind your head or twist yourself into a pretzel, flexibility is crucial to being able to breathe well and is essential to maintaining and improving your ability to perform a broad range of activities of daily living (ADL).

Due to poor respiratory mechanics and increased work of breathing, many people with pulmonary disease often develop muscle imbalances, particularly between the diaphragm and accessory muscles of breathing, as well as between anterior and posterior muscles of the body. Some muscles become tighter and shorter due to overuse, while others become weaker and overstretched. When this happens people may experience pain, particularly in the muscles of the neck, shoulders, back, chest and abdominals. This can further lead to skeletal adaptations of the spine and thorax.

Flexibility exercises can help correct or even prevent these imbalances, preserving diaphragmatic excursion and thoracic mobility and maximizing expansion of the lungs. In other words, flexibility exercises can help keep the respiratory muscles pliable, allowing the diaphragm to move freely and the chest and lungs to expand fully, decreasing the work of breathing.

Flexibility can also play an important role in everyday activities. For people living with a pulmonary condition, upper body, particularly overhead activities can be especially challenging. If you think back to our discussion of open chain vs. closed chain activities, you will recall that overhead (open chain) activities put the diaphragm at a significant mechanical disadvantage. In fact, people are often advised to avoid these activities altogether in the name of “energy conservation.”

As an example, people are often told to avoid storing things on high shelves. However, if you don’t use it, you lose it and avoiding these activities can lead to significantly decreased range of motion in the upper body, particularly, the shoulders. So, in spite of conventional wisdom, don’t be so quick to avoid the activities that cause you discomfort.

Like aerobic exercise and strength training, there are several different types of flexibility or stretching exercises including static (stationary, including both active and passive), dynamic (moving), ballistic and isometric. Stretches can be used as part of your warm- up, mid-workout, or cool-down. For our purposes some combination of static and dynamic stretching would likely provide the greatest benefit while minimizing your risk of injury.

For those adventurous types who want to take your flexibility training to the next level you might consider alternative modalities such as Yoga, Pilates, Tai Chi or Qigong.

BALANCE & STABILITY TRAINING

Balance and stability training should be an essential part of any exercise program. Good balance requires the interaction of the musculoskeletal system (strength and flexibility) and the neurologic system (coordination, proprioception and sensation), among others. As we age, our balance and stability decrease, particularly if we have other conditions that diminish our strength, flexibility and neurologic function.

Improving your balance enables you to maximize the benefits of your exercise routine and overall health and wellness program. More importantly, having good balance is essential for everyday activities.

Think about the role that balance plays in the following:

• Walking on uneven surfaces
• Walking up or down stairs
• Getting in and out of bed
• Getting into and out of the shower/bath
• Bending over to pick up something from the floor
• Overhead activities such as getting off a high shelf or changing a light-bulb
• Getting in and out of a car
• Getting up and down from the floor
• Being able to stand while riding the bus
• Line dancing or doing the conga at your niece’s wedding!

There are a broad variety of balance and stability exercises and some types may be more suitable for you than others. Balance activities can be divided into static (stationary) and dynamic (moving) activities. Some balance exercises can be performed at home, using only your own body, whereas others utilize specialized equipment such as stability balls, balance pads, foam rollers or wobble boards. In addition, there are a wealth of books, videos and classes that offer specific examples of individual or group balance exercises including alternative modalities such as Yoga, Pilates, Tai Chi or Qigong.

FINAL NOTE:
As with any exercise program, please remember that safety is our number one priority. With that in mind, please check with your physician or health care provider before beginning any exercise program.