Respiratory Medicine (2012) 106, 557e563

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/rmed

Strength training increases maximum working

capacity in patients with COPD e Randomized
clinical trial comparing three training modalities
Karin Vonbank a,*, Barbara Strasser b, Jerzy Mondrzyk a,
Beatrice A. Marzluf a, Bernhard Richter a, Stephen Losch c, Herbert Nell c,
Ventzislav Petkov a, Paul Haber a

a
Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18e20, 1090 Vienna, Austria
b
University of Health Sciences, Medical Informatics and Technology, Institute of Sports Medicine,
Alpine Medicine and Health Tourism, 6060 Hall in Tyrol, Austria
c
WGKK Gesundheitszentrum Wien Mariahilf, Vienna, Austria

Received 4 August 2011; accepted 9 November 2011

Available online 26 November 2011

KEYWORDS Summary
Strength training; Background and objective: Skeletal muscle dysfunction contributes to exercise limitation in
Aerobic exercise patients with chronic obstructive pulmonary disease (COPD). Strength training increases
training; muscle strength and muscle mass, but there is an ongoing debate on the additional effect
Chronic obstructive concerning the exercise capacity. The purpose of this study was to compare the effects of
pulmonary disease; three different exercise modalities in patients with COPD including endurance training
Pulmonary (ET), progressive strength training (ST) and the combination of strength training and endur-
rehabilitation; ance training (CT).
Exercise capacity Design: A prospective randomized trial.
Methods: Thirty-six patients with COPD were randomly allocated either to ET, ST, or CT.
Muscle strength, cardiopulmonary exercise testing, lung function testing and quality of life
were assessed before and after a 12-week training period.
Results: Exercise capacity (Wmax) increased significantly in all three training groups with
increase of peak oxygen uptake (VO2peak) in all three groups, reaching statistical significance
in the ET group and the CT group. Muscle strength (leg press, bench press, bench pull)
improved in all three training groups, with a higher improvement in the ST ( þ39.3%,
þ20.9%, þ20.3%) and the CT group (þ43.3%, þ18.1%, þ21.6%) compared to the ET group
(þ20.4%, þ6.4%, þ12.1%).

* Corresponding author. Tel.: þ43 01 40400 4774; fax: þ43 01 40400 4784.
E-mail address: karin.vonbank@meduniwien.ac.at (K. Vonbank).

0954-6111/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rmed.2011.11.005
558 K. Vonbank et al.

Conclusions: Progressive strength training alone increases not only muscle strength and
quality of life, but also exercise capacity in patients with COPD, which may have implications
in prescription of training modality.
ClinicalTrials.gov Identifier: NCT01091623.
ª 2011 Elsevier Ltd. All rights reserved.

Introduction Subjects

Chronic obstructive pulmonary disease (COPD) is a progres- Stable outpatients with COPD were considered for this
sive disorder that leads to substantial morbidity and study. COPD was diagnosed according to the GOLD
mortality. Treatment goals in COPD are prevention or consensus. Patients with evidence of other concomitant
deceleration of progression and increasing patients‘ quality lung diseases or other cardiovascular disorders were
of life.1 Limitation of exercise capacity is a significant excluded. Other exclusion criteria were any pathology
variable related to poor disease prognosis.1e3 which could possibly interfere with the ability to perform
Endurance and strength training are both essential exercise. Based on these inclusion and exclusion criteria
components of pulmonary rehabilitation in patients with forty-three patients were included in the study, 7 patients
COPD.4e7 There is, however, an ongoing debate on the optimal ceased training due to acute exacerbation. Thirty-six
exercise protocol. Several studies have compared different patients (11 women and 25 men) completed the study.
training modalities and training intensities in patients with According to the GOLD criteria, 4 patients were categorised
COPD, but there is substantial variation concerning the as GOLD stage I, 14 patients as stage II, 16 patients as stage
duration of training sessions and the results of improvement in III and 2 patients as stage IV. All 36 patients were receiving
muscle strength and exercise capacity. Endurance training is inhaled ß-agonists, 17 were receiving inhaled corticoste-
a key component of pulmonary rehabilitation and leads to roids, 2 were on oral theophylline. Smoking habits were not
clinically significant improvement in exercise performance.8,9 significantly different between all three training groups. 12
Low-intensity and high-intensity exercise training are both patients were randomly assigned to the endurance training
effective in patients with COPD with a tendency for greater group, 12 patients to the strength training group and 12
benefits after higher training intensity.10 The optimal training patients to a group with combined endurance and strength
duration for COPD patients with different impairment of training. In the endurance training group there was 1
exercise capacity is still unclear.11 patient in GOLD stage I, 6 patients in stage II, 4 patients in
Peripheral limb muscle strength is significantly reduced stage III and 1 patient in stage IV. In the strength training
in COPD patients compared to normal subjects.12 Muscle group there was 1 patient in stage I, 5 in stage II, 5 in stage
strength strongly correlates with symptom intensity and III and 1 in stage IV. In the combined training group there
work capacity.13,14 Despite the increasingly recognised role were 2 patients in stage I, 3 in stage II and 7 in stage III.
of skeletal muscle dysfunction in patients with COPD12e15 There was no difference with respect to GOLD stage
there are still conflicting results concerning the additional between the three training groups.
improvement attained with strength training.11 Resistance This study was approved by the Ethics Committee of the
training enhanced peripheral muscle force, muscle endur- Medical University of Vienna. All patients gave their
ance and whole- body endurance in COPD patients5,16e19 informed consent.
without significantly increasing peak exercise capacity. A
combination of endurance training and strength training Pulmonary function testing
can lead to a significant improvement in endurance exer-
cise time, muscle strength and quality of life, but does not Before exercise, each patient underwent routine lung
seem to be more effective than endurance training function studies. Predicted normal values were derived
alone.4,6,20 Studies comparing all three training modalities from the reference values of the Austrian Society of
are rare and differ in the duration of endurance training Pulmonary Medicine 23 which is in accordance with the ERS
and the intensity of strength training.6,21,22 recommendations.24 Each value represents the best of at
The aim of this study was to compare the effects of least three measurements. Spirometry and whole-body
endurance training, progressive strength training and plethysmography were performed with the Autobox DL
a combination of both endurance and strength training on 6200 (Sensor Medics, Vienna Austria) and blood gas was
the functional adaptations in COPD patients. measured with the gas analyzer (model ABL 510, Radiom-
eter, Copenhagen, Denmark). The results were expressed
as absolute values and as percent of the predicted values.
Methods
Incremental exercise test
A prospective randomized study design was utilized. All
patients performed a lung function test, a cardiopulmonary In order to determine the individual working capacity and
incremental exercise test, muscle strength test, quality of peak oxygen uptake (VO2peak), a symptom-limited
life assessment and a three-month training program maximal incremental cycle exercise test with gas
according to randomization. exchange measurements was performed. The load was
Strength training and COPD 559

increased every 2 min until maximum working capacity was following formula (Karvonen26): HR Z HRrest þ (HRmax 
reached, until exhaustion. Exhaustion was determined at HRrest)  0.6  5 beats/min, where HRrest was HR after
the point where the subject was unable to sustain a break of ten minutes, in supine position.
a pedaling rate of 60 rpm. The increment was adapted in
order to guarantee at least four but no more than six steps Strength training and endurance training (CT)
and varied from 5 to 15 W, depending on the maximum Patients in the combined training group performed endur-
working capacity. Pedaling rate was constant at 60e70/ ance training plus strength training program as described
min. above two times per week.
Maximum working capacity (Wmax) was calculated as
a percentage of predicted value depending on age, gender, Quality of life assessment
and body surface.25 ECG was continuously monitored during
CPET. The variables measured at each step and at Health-related quality of life was assessed by St. George
maximum working capacity were blood pressure and Respiratory Questionnaire, consisting of an impact score,
minute ventilation (VE). Oxygen uptake (VO2) and CO2 activity score, and symptoms score, as well as a total score.
output (VCO2) were measured using the breath-by- breath Each score ranges from 0 to 100, with lower values indi-
method (Sensormedics 2900 Metabolic Measurement Cart). cating a better quality of life.
Parameters relevant for maximum exercise were VO2peak
and Wmax.
Data analysis

Training program A sample size of 12 patients each group was calculated to

provide a power of 80% (alpha Z 0.05) to detect a differ-
Strength training (ST) ence in the training- induced changes of parameters
Strength training was performed two times per week between groups of 6% (assuming a standard deviation of
including eight different exercises per session. During the 5%).
first two weeks, the weight was kept to a minimal level so Continuous data are expressed as mean  SD. Differ-
that the patients could learn the exercise techniques, and ences of variables over time were evaluated using the
to allow the muscles to adapt to the training as well as to paired Student t-test. Differences between groups were
prevent muscle soreness and joint pains. From the third analyzed using a one-way analysis of variance (ANOVA) and
week two sets per muscle group per week were performed. post hoc Tukey’s multiple-comparison test. A value of
One set consisted of 8e15 repetitions without interruption, p < 0.05 (2-tailed) was considered statistically significant.
until severe fatigue occurred and completion of further Statistical analyses were carried out using the statistical
repetitions was impossible. The training load was individ- software package SPSS 12.0 (SPSS Inc., Chicago, USA).
ually and systematically adapted to keep the maximum
possible repetitions per set between 8 and 15. When more Results
than 15 repetitions were successfully performed at a given
weight, the weight was increased by an amount that Forty-three patients with COPD were included in the study
permitted approximately ten repetitions to be performed. and randomized to ET, ST or CT. Thirty-six patients
The numbers of sets for each muscle group were system- completed the study. Baseline parameters for all three
atically increased every 4 weeks from 2 at the beginning of training groups are shown in Table 1. The mean age of the
the program to 3 and finally 4 sets per week at the end of patients was 60.2  6.5 years. The mean FEV1 of all patients
the program. The ST program consisted of exercises for was 1.8  0.4 l with a ratio of FEV1 to FVC of 51.4  12.9%.
major muscle groups. Exercises to strengthen the upper No significant differences in respect of lung function
body included bench press (pectoralis), chest cross (hori- parameters were seen between the training groups.
zontal flexion of the shoulder joint), shoulder press
(trapezius), pull downs (latissimus dorsi), bicep curls, tri-
Cardiopulmonary exercise test at baseline
cep extensions and exercises for abdominal muscles (sit-
ups). Lower body exercises included leg press (quadriceps
femoris). No significant differences in baseline Wmax were found
between groups (Table 2). Wmax at baseline was
Endurance training (ET) 62.9  13.4% in the ET, 63.2  11.7% in the ST and
Systematic ET was performed on a cycle ergometer, two 57.1  21.2% in the CT. VO2peak in the ET at baseline was
times per week. During the first 4 weeks, participants 72.9  16.9%, 73.6  8.9% in the ST and 62.3  15.8% in the
trained for 20 min per session. Exercise sessions were CT. No significant differences concerning maximal lactate
increased by 5 min every four weeks. The total exercise increase, maximal heart rate, minute ventilation or blood
time per week, during the last four weeks, excluding warm gas analysis were detected between the training groups at
up and cool down, was 60 min. Heart rate (HR) was moni- baseline.
tored continuously throughout the training period (POLAR
Electro, Kempele, Finland). Cycle ergometer load during Cardiopulmonary exercise test after training period
training session was adjusted according to the heart rate
response of each patient, to a level corresponding to 60% of Maximum exercise capacity improved significantly in all
VO2peak. This was derived from ergometry by using the three training groups (Fig. 1). It increased from
560 K. Vonbank et al.

Table 1 Subject demographics and pulmonary function at baseline.

Mean  SD Mean  SD Mean  SD Mean  SD
All patients Endurance training Strength training Combined training
n Z 36 n Z 12 n Z 12 n Z 12
Age (yr) 60.2  6.5 61.8  5.4 60.0  6.4 59.2  7.7
Gender
Female 11 4 4 3
Male 25 8 8 9
BMI (kg/m2) 27.4  6.1 26.2  4.4 27.4  7.6 28.2  8.4
Weight (kg) 80.8  20.2 77.8  14.9 80.8  17.8 82.9  20.2
Height (cm) 171  10 172  10 171  10 170  10
VC (L) 3.5  0.7 3.5  0.4 3.3  0.7 3.6  1.0
FEV1 (L) 1.8  0.4 1.8  0.4 1.9  0.4 1.6  0.5
FEV1/FVC (%) 51.4  12.9 51.6  14.3 56.5  9.3 47.0  13.6
FEV1 (%pred.) 55.8  16.4 58.1  19.3 58.3  15.5 51.1  20.3
TLC (% predicted) 116  27 115  39 111  13 123  23
RV/TLC (%) 48.7  8.3 50.5  8.4 48.0  8.8 48.6  9.4
DLCO% predicted 67.7  22.3 69.8  21.4 66.5  13.5 67.2  28.1
PaO2 (mmHg) 71.8  9.8 71.6  8.0 68.2  7.4 69.7  10.6
PaCO2 (mmHg) 38.1  3.1 38.1  3.2 38.8  3.2 37.8  3.6
IC (L) 2.6  0.6 2.8  0.4 2.4  0.5 2.7  0.7
MVV (L/min) 69.0  18.6 70.7  20.4 69.6  13.8 66.3  21.4
Smoking habits (py) 28.9  8.8 29.7  9.2 27.4  9.3 28.4  9.3
BMI, body mass index; VC, vital capacity; FEV1, forced expiratory volume in one second; FEV1 /FVC, forced expiratory volume in one
second%vital capacity; TLC, total lung capacity; RV/TLC, residual volume%total lung capacity; DLCO, diffusing capacity of the lung for
carbon monoxide; PaO2 , partial arterial oxygen pressure; PaCO2 , partial arterial carbon dioxide pressure; IC, inspiratory capacity; MVV,
maximum voluntary ventilation.

62.9  13.4% to 69.3  12.0% (p < 0.005) in the ET, from Strength measurements and health-related quality
63.2  11.7% to 69.2  12.1% in the ST (p < 0.004) and from of life after training period
57.1  21.2% to 64.5  20.3% in the CT (p < 0.006). The
VO2peak significantly improved in the ET from 72.9  16.9% Muscle strength (leg press, bench press and bench pull)
to 79.2  21.3% (p < 0.04) and in the CT from 62.3  15.8% improved in all three training groups (Fig. 2) with a signifi-
to 68.8  19.7%, p < 0.02 (Table 2). In the ST the VO2peak cant higher improvement in the ST (þ39.3  27.7%,
improved after training period without reaching statistical þ20.9  19.8%, þ20.3  10.3%) and the CT (þ43.3  40.2%,
significance (from 73.6  8.9% to 76.3  12.9%, p Z 0.27). þ18.1  12.4%, þ21.6  26.6%) compared to the ET alone
The maximum lactate increase was greater after the (þ20.4  32.3%, þ6.4  16.3%, þ12.1  15.5%). Health-
training period in the ST and the CT, but only reached related quality of life improved significantly in all three
statistical significance in the ST (p Z 0.02). Ventilatory training groups (total score, p < 0.01), with a tendency to
equivalent for oxygen decreased significantly at the same a greater improvement in the CT group (Table 3).
submaximal work rate after training period in all three
training groups, reaching statistical significance in the ET
and the CT. Heart rate at submaximal exercise decreased Discussion
significantly in all three training groups (Table 2). No
significant differences were seen in pulmonary gas
In this study comparing three different training modalities
exchange and maximal heart rate in all three groups before
in patients with COPD, strength training alone increased
and after the training period.
the maximum exercise capacity to a similar extent as
endurance training and combined endurance and strength
Strength measurement at baseline training with significant increase of muscle strength.
Moreover, a significant decrease of heart rate and ventila-
The maximum muscle strength for leg press was tory parameters at submaximal exercise levels could be
82.1  26.6 kg in the ET, 84.6  25.9 kg in the ST and shown not only after endurance training and the combined
97.9  24.1 kg in the CT at baseline without statistically training, but also after strength training alone, which
significant differences. The maximum muscle strength for confirm, that an effective strength training not only
bench press was 41.3  12.9 kg in the ET, 44.3  15.8 kg in increase muscle strength, but also improve work efficiency.
the ST and 49.3  15.2 kg in the CT. Maximum muscle Peak oxygen uptake increased in all three training groups
strength for bench pull was 46.5  15.3 kg in the ET, reaching statistical significance in the endurance and the
49.6  16.5 kg in the ST and 49.4  11.6 kg in the CT (Table 3). combined training group. In prior studies, improvement of
Strength training and COPD 561

Table 2 Physiologic parameters at exercise before and after different training modalities.
Endurance training Strength training Combined training
Baseline End 12-week Baseline End 12-week Baseline End 12-week
training training training
Wattmax (Watt) 89.2  20.2 98.2  22.1** 91.9  19.8 101.0  22.6** 88.0  37.3 98.8  38.6*
Wmax (%pred.) 62.9  13.4 69.3  12.0** 63.2  11.7 69.2  12.1** 57.1  21.2 64.5  20.3**
VO2 (%pred.) 72.9  16.9 79.2  21.3* 73.6  8.9 76.3  12.9 62.3  15.8 68.8  19.7*
VO2 (ml/kg/min) 18.4  4.8 20.4  6.7* 18.2  2.1 18.8  2.9 15.7  3.4 17.4  4.9*
VE/VO2max 43.3  11.3 42.3  7.3 43.5 7.5 41.2  7.2 46.1  8.7 45.9  6.2
VE/VO2submax 36.4  7.1 33.1  5.5** 36.6  8.9 33.9  7.0 39.4  5.3 36.8  5.5**
VE/VCO2max 39.4  8.9 37.2  5.3 39.4  5.5 37.9  7.1 44.3  7.3 43.5  6.0
VE/VCO2submax 40.8  5.3 37.1  5.1* 39.8  6.8 38.3  5.3 44.8  4.9 43.0  4.9
Lactat (mmol/L) 3.8  1.7 4.2  1.5 3.9  1.5 4.9  1.6* 3.2  1.6 4.4  2.0
Vtmax (l) 1.8  0.4 1.7  0.3 1.8  0.3 1.77  0.4 1.8  0.5 1.71  0.6
Vtsubmax (l) 1.4  0.3 1.4  0.3 1.4  0.3 1.3  0.3 1.5  0.3 1.4  0.3
VEmax (L) 57.9  14.4 57.9  13.6 59.9  8.0 60.0  11.9 59.1  18.0 63.2  18.6
VEsubmax (L) 27.8  5.7 26.4  4.0 30.4  7.9 25.4  4.4* 28.7  5.6 27.5  6.2
F max (breaths/min) 35.7  10.2 34.3  6.7 34.3  6.9 34.1  3.9 36.7  9.9 38.0  10.3
F submax (breaths/min) 20.8  4.5 20.1  5.8 22.0  5.7 20.0  6.8 21.6  4.1 20.0  5.5
HR (beats/min) 145  26 147  25 133  13 135  12 136  29 135  15
HR submax (beats/min) 109  17 101  14** 104  13 95  8* 102  14 98  13*
Data are expressed as mean  SE.
Significant difference between baseline and end 12-week training: *p < 0.05, **p < 0.01.
Wmax, maximum working capacity; VO2 , peak oxygen uptake; VE/VO2 max, ventilatory equivalent for oxygen at maximum exercise, VE/
VO2 submax, ventilatory equivalent for oxygen at submaximal exercise; VE/VCO2 max, ventilatory equivalent for carbon dioxide at
maximum exercise; VE/VCO2 submax, ventilatory equivalent for carbon dioxide at submaximal exercise; Vt max, tidal volume at
maximum exercise; Vtsubmax, tidal volume at submaximal exercise; VEmax, maximum minute ventilation; VEsubmax, minute venti-
lation at submaximal exercise; F max, breath per minutes at maximum exercise; F submax, breath per minutes at submaximal exercise;
HR max, heart rate at maximum exercise; HR submax, heart rate at submaximal exercise.

maximum exercise capacity after strength training could endurance training consisting of 40 min three times per
only be shown by Spruit et al.20 after a 12-week training week at 60% of Wmax and strength training consisting of
period, where the patients were given the opportunity to five different exercises with 6e8 repetitions at 70e85% of
attend 36 sessions. In our study the patients attended only one repetition maximum and a combined training group
24 sessions at all. A study by Ortega et al.6 compared with half of the endurance and strength program for
a training period of 12-weeks. This study revealed that
a significant improvement of peak oxygen uptake and
maximum exercise capacity could only be shown in the
endurance group, whereas muscle strength and endurance
time could be improved in all three training groups. Mador
et al.7 did not observe a significant increase in maximum
workload and peak oxygen uptake after either endurance
training 20 min three times per week or combined endur-
ance and strength training. In our study, the patients per-
formed the same amount of endurance training in the
combined group as those in the endurance group. Inter-
estingly, despite a much shorter endurance training time in
our study compared to Ortega et al.,6 the measured extent
of improvement in maximum exercise capacity after
endurance training is similar. Several studies compared
different training intensities and modalities,10,11 but the
endurance training time varied widely in most studies.
Despite these variations in endurance training time per
week, an increase in exercise capacity could be seen in
most of the studies. The minimum relevant endurance
training time to improve exercise capacity in COPD patients
Figure 1 Increase in maximum working capacity after has not yet been established, but our study shows that even
strength training (ST), endurance training (ET) and combined starting with an endurance training time of only 20 minutes
strength and endurance training (CT). twice per week in the first month with an increase of 10
562 K. Vonbank et al.

Table 3 Muscle strength and health-related quality of life before and after different training modalities.
Endurance training Strength training Combined training
Baseline End 12-week Baseline End 12-week Baseline End 12-week
training training training
Leg press (1RM kg) 82.1  26.6 94.9  26.1 84.6  25.9 115.6  32.9** 97.9  24.1 136.2  40.3**
Bench press (1RM kg) 41.3  12.9 43.6  13.1 44.3  15.8 53.3  19.2** 49.3  15.2 58.3  19.0**
Bench pull (1RM kg) 46.5  15.3 50.3  15.5* 49.6  16.5 59.5  20.4** 49.4  11.6 61.0  24.1*
Total score 27.9  15.7 19.1  14.6** 42.3  14.8 30.1  13.2** 40.7  11.9 31.6  15.7**
Impact score 17.9  13.1 10.7  11.4 34.7  18.9 21.1  14.7* 33.0  12.0 25.1  15.3*
Activity score 38.8  21.0 26.9  21.4* 48.6  13.9 39.7  14.3* 49.9  16.3 38.7  18.8**
Symptom score 40.3  20.6 24.4  20.8** 54.9  22.4 41.4  16.6* 48.5  21.1 38.9  25.7*
Data are expressed as mean  SE.
*p-value < 0.05,**p-value < 0.01.

minutes every 4 weeks up to 40 minutes per week for the short comparing to other studies, but effective which could
last 4 weeks and a total amount of 24 training sessions leads be shown by similar improvement in maximum exercise
to a significant improvement of exercise capacity. Maximal capacity and oxygen uptake compared to others6 and
lactate at peak exercise increased in all three training decrease in submaximal heart rate and ventilatory param-
groups according to the increase in maximum exercise eters after the training period. The patients in the
capacity, reaching statistical significance only in the combined training group showed a more severe impairment
strength training group. of lung function compared to the other groups, which could
Health-related quality of life as measured using St. possibly interfere with the training results, but these
George Respiratory Questionnaire (SGRQ) improved signifi- differences between groups did not reach statistical
cantly in all three training groups with a greater improve- significance.
ment of the activity score in the combined training group. Impaired exercise tolerance is common even in early
No significant changes in lung function parameters could be COPD stages. Exercise training is an essential component of
shown after training, which is in line with previous studies. pulmonary rehabilitation in patients with COPD. Maximum
Muscle strength increased in all three training groups oxygen uptake and muscle strength are both independent
with a significantly higher improvement in the ST and CT factors associated with decreased survival rates. Whereas
group. The extent of improvement was similar to that endurance and strength training programs are strongly
achieved in previous studies of patients with COPD. scientific based in the last years, the optimal training
Strength training was well-tolerated, and no injuries duration and intensity is still not established.
occurred during training. In our study, a time sparing training program with strength
The limitations of our study are the small number of training alone is capable to significantly improve exercise
patients per group and the lack of data concerning capacity and muscle strength, which could have some
submaximal exercise tests, which could be already shown implication in training prescription in patients with COPD.
to improve even more after exercise training than
a symptom-limited maximum exercise test in these
patients. The duration of the endurance training is quite Author contributions

Dr. Vonbank: contributed to study design, data collection

and analysis, writing the manuscript and sharing scientific
discussions and revising the submitted manuscript.
Dr. Strasser: contributed to data collection and analysis,
sharing scientific discussions and revising the submitted
manuscript.
Mag Mondrzyk: contributed to data collection and
analysis.
Dr. Marzluf: contributed to data collection and analysis,
sharing scientific discussions and revising the submitted
manuscript.
Dr. Richter: contributed to data analysis, sharing scien-
tific discussions and revising the submitted manuscript.
Dr. Losch: contributed to data collection and revising the
submitted manuscript.
Dr. Nell: contributed to data collection and revising the
Figure 2 Increase in muscle strength after strength training submitted manuscript.
(ST), endurance training (ET) and combined strength and Dr. Petkov: contributed sharing scientific discussions and
endurance training (CT). revising the submitted manuscript.
Strength training and COPD 563

Prof. Haber: contributed to study design, sharing scien- disease: a comparison of high versus moderate intensity. Arch
tific discussions and revising the submitted manuscript. Phys Med Rehabil 2000;81:102e9.
11. Puhan MA, Schünemann HJ, Frey M, Scharplatz M,
Bachmann LM. How should COPD patients exercise during
Author disclosure information respiratory rehabilitation? Comparison of exercise modalitites
and intensities to treat skeletal muscle dysfunction. Thorax
None. 2005;60:367e75.
12. Gosselink R, Decramer M. Peripheral skeletal muscles and
exercise performance in patients with chronic obstructive
Conflict of interest disease. Monaldi Arch Chest Dis 1998;53:419e23.
13. Serres I, Hayot M, Prefaut C, Mercier J. Skeletal muscle
None. abnormalities in patients with COPD: contribution to exercise
intolerance. Med Sci Sports Exerc 1998;30:1019e27.
14. Gosselink R, Troosters T, Decramer M. Peripheral muscle
Acknowledgements weakness contributes to exercise limitation in COPD. Am J
Respir Crit Care Med 1996;153:976e80.
This work was supported by the Austrian National Research 15. Schols AM, Soeters PB, Dingemans AM, et al. Prevalence and
Fund [Grant 10992]. characteristics of nutritional depletion in patients with stable
COPD eligible for pulmonary rehabilitation. Am Rev Respir Dis
1993;147:1151e6.
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