The overall aim of this work was to examine the effects of depleted nutritional status on some aspects of Chronic Obstructive Pulmonary Disease (COPD). Morbidity. In paper І, we found that energy intake was lower than the calculated energy demand for all patients. A low body mass index (BMI) at inclusion and weight loss, during the one year follow-up period were independent risk factors for having a new exacerbation (p = 0.003 and 0.006, respectively). Mortality. Nineteen percent of the patients in paper ІІ, where underweight (BMI<20). A significant positive correlation was found between BMI and FEV1, and this correlation remained significant after adjustment for age, sex and pack years (p<0.0001). Being underweight was related to increased overall mortality and respiratory mortality but not to mortality of other causes, 19% of the patients had died within 2 years. The lowest mortality was found among the overweight patients (BMI 25-30 kg/m). Physical capacity and effect of training. In paper ІІІ we investigated baseline characteristics of patients that were starting physical training. We found that peak working capacity was positively related to BMI (r=0.35, p=0.02) and fat free mass index (FFMI) (r=0.49, p=0.004) and negatively related to S-Fibrinogen and serum C reactive protein (S-CRP). BMI and FFMI were significantly related to the 12 minutes walking distance when adjusted for body weight. Fifty to 76% of the variation in physical capacity was accounted for when age, gender, FEV1, FFMI and CRP were combined in a multiple regression model. In Paper ІV the median change in fat free mass (FFM), after 4 months of physical training was 0.5 kg. Old age, low FEV1 and high level of dyspnoea were independent negative predictors of FFM increase after the training period. In conclusion nutritional status is an important determinant of morbidity, mortality and physical capacity in COPD. Low FEV1 and high level of dyspnea are negative predictors for increased FFM after physical training.

Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

INTRODUCTION: Preoperative pulmonary rehabilitation (PPR) is an emerging therapy for transplant candidates who are awaiting surgery. Research indicates that PPR training has benefits for improving exercise tolerance, but little researcher exists on the association between PPR on post-transplant hospital outcomes. METHODS: The study was a non-probability cross-sectional analysis performed on data for post-transplant recipients who received either a single or bilateral lung transplant from February 8, 2007 to July 8, 2014. The study sample consisted of 207 transplant recipients. Analyses of the associations between independent variables: preoperative pulmonary rehabilitation and six-minute walk distance (6MWD) and covariates were performed by logistic regression analysis to examine the following outcomes: length of stay, hospital readmissions in the first 90 days post- transplant, and the number of hospital readmissions in the first 90 days. RESULTS: Transplant recipients who participated in preoperative pulmonary rehabilitation had 1.77 times greater odds of being readmitted in the first 90 days post-transplant compared to recipients who did not participated in preoperative pulmonary rehabilitation. Transplant recipients whose 6MWD was greater than 207 meters and who participated in preoperative pulmonary rehabilitation had 4.99 times greater odds of length of staying 12 days or less post- transplant surgery compared to transplant recipients whose walk distance was less than 207 meters and who did not participate in preoperative pulmonary rehabilitation. CONCLUSION: Pulmonary rehabilitation is an important part of the lung transplant. The results of this study indicate the importance of preoperative lung transplant on post-transplant outcomes for transplant recipients.

Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

A Doença Pulmonar Obstrutiva Crônica (DPOC) é uma doença caracterizada pela limitação ao fluxo aéreo, não totalmente reversível. Dentre as terapêuticas indicadas, a reabilitação pulmonar é uma estratégia de tratamento multidisciplinar, que tem por objetivo melhorar a qualidade de vida do paciente, reintegrando-o à sociedade. Objetivos: Descrever o processo e os custos de implantação na forma de um projeto de extensão universitária, os motivos da evasão e os resultados obtidos com um programa de reabilitação pulmonar. Material e Métodos: Após formar um grupo multidisciplinar no Centro Universitário Feevale e estabelecer uma parceria com a Secretaria Municipal da Saúde de Novo Hamburgo, os pacientes portadores de DPOC são encaminhados ao programa de reabilitação pulmonar (PRP). São avaliados pelo médico pneumologista, fisioterapeuta, nutricionista, psicólogo e educador físico. Após estas avaliações são formados grupos de até 16 pacientes que permanecem por um período de 4 meses, com três sessões semanais de treinamento físico, orientações nutricionais, encontros educativos e grupos de apoio psicológico. Foram avaliados o perfil destes pacientes, os custos para a implantação, as causas de evasão após o início do programa, bem como os resultados obtidos após o período de tratamento, medidos através do teste de caminhada dos seis minutos, do trabalho de caminhada através do produto distância-peso corporal e do questionário Saint George de qualidade de vida. Para a análise dos resultados foi utilizada a estatística descritiva, para comparação das médias o Teste t de Student. Resultados: O PRP foi implantado na forma de um projeto de extensão universitária, com um custo total de R$ 64 224,60. Foram avaliados 134 pacientes encaminhados dos postos de saúde do município de Novo Hamburgo e dos municípios vizinhos. Do total, 38 (28,4%) pacientes foram excluídos e 7(5,2%) foram a óbito antes de completar a avaliação. Desses, 89 (66,5%) portadores de DPOC de moderado a grave foram incluídos no PRP. A média de idade dos pacientes foi de 63,5±9,9 anos, predominou o sexo masculino 62(69%), com índice de massa corporal (IMC) médio de 23,5±5,3 Kg/m2, com média de Volume expiratório forçado no primeiro segundo (VEF1) de 1,16L(42,8±23,4% do previsto). Dos incluídos no PRP, 40 (44,9%) abandonaram, principalmente por problemas sócio-econômicos e 49 (55,1%) concluíram a reabilitação. Os dados para análise antes e depois do PRP estavam disponíveis para 37 pacientes que formaramo grupo para analisar os resultados do PRP. No teste de caminhada dos seis minutos, ocorreu uma variação significativa de 34,12m na média distância (367,15±101,93m vs. 401,27±95,55m; p <0,001). Ocorreu melhora significativa de 2,65 Km.Kg-1 (24,36±9,62 Km.Kg-1 vs. 27,01±10,0 Km.Kg-1) no trabalho de caminhada medido pelo produto distância-peso e uma melhora significativa com redução de 11% (46 vs. 35; p<0,001) no total do questionário Saint George de qualidade de vida. Conclusões: O PRP pode ser implantado na forma de um projeto de extensão universitária, com custo relativamente baixo pela sua abrangência e benefícios. A condição social dos pacientes foi o maior determinante da evasão, mas os pacientes que concluíram o PRP apresentaram uma melhora significativa na sua capacidade de exercício e na qualidade de vida. / Chronic obstructive pulmonary disease (COPD) is characterized by partially reversible airway obstruction. Pulmonary rehabilitation is one of the therapeutic interventions indicated for the treatment of COPD, and consists of a multidisciplinary treatment strategy whose purpose is to improve quality of life and to reintegrate patients into society. Objective: To describe the process and cost of implementing a university extension program for pulmonary rehabilitation, as well as the causes of patient dropout and the results achieved. Material and methods: After a multidisciplinary group was formed at Centro Universitário Feevale and a partnership was established with the Municipal Department of Health of Novo Hamburgo, patients with COPD were referred to the pulmonary rehabilitation program (PRP). They were examined by a pulmonologist, a physical therapist, a nutritionist, a psychologist and a physical education specialist. After evaluations, groups of up to 16 patients were formed and had 3 weekly meetings for 4 months. During meetings, patients participated in physical exercise training, nutritional counseling, educational meetings and psychological support groups. We evaluated patient data, costs of program implementation and causes of patient dropout. Also, the results obtained after PRP were measured by the 6-minute walk test, work calculated as the product of distance x body weight, and the St George respiratory questionnaire to assess quality of life. Descriptive statistics was used to analyze results, and the Student t test, to compare means. Results: PRP was implemented as a university extension program at a total cost of R$ 64,224.60. One hundred thirty-four patients referred by health stations in Novo Hamburgo and neighboring cities were evaluated; 38 (28.4%) of these patients were excluded and 7 (5.2%) died before they completed the initial evaluation. The other 89 (66.5%) patients with moderate to severe COPD were included in PRP. Mean patient age was 63.5±9.9, 62 (69%) were men, mean body mass index (BMI) was 23.5±5.3 kg/m2, and mean forced expiratory volume in one second (FEV1) was 1.16 L (42.8±23.4% of predict value). Forty (44.9%) patients dropped out, most of them due to socioeconomic problems, and 49 (55.1%) completed the rehabilitation program. Data for the analysis before and after PRP were available for 37 patients, who formed the group for analysis of PRP results. The 6-minute walk test showed a significant increase of 34.12 m in distance(367.15±101.93 m vs. 401.27±95.55 m; p <0.001). A significant improvement of 2.65 km.kg-1 (24.36±9.62 km.kg-1 vs. 27.01±10.0 km.kg-1) was observed in distance x body weight product, and total scores of the St. George questionnaire showed a reduction of 11% (46 vs. 35; p<0.001), which indicated a significant improvement in quality of life. Conclusion: PRP was implemented as a university extension program at a relatively low cost when considering its extent and benefits. Social condition was the main cause of patient dropout, but those that completed PRP had a significant improvement in their capacity for physical exercise and in quality of life.

A implantação de um programa de transplante pulmonar depende de uma ampla infraestrutura que garanta um atendimento multidisciplinar, que inicia sua atuação focalizando uma adequada seleção dos receptores e na reabilitação destes candidatos durante o tempo de espera. Objetivo: verificar o impacto do programa de reabilitação pulmonar pré-transplante (RPPTx) na capacidade funcional e na qualidade de vida dos pacientes em lista de espera para transplante pulmonar. Método: o estudo foi realizado no Serviço de Reabilitação Pulmonar do Pavilhão Pereira Filho do Complexo Hospitalar Santa Casa de Porto Alegre com pacientes em lista de espera para transplante pulmonar e que foram encaminhados para o RPPTx no período de junho 2007 a outubro 2009. Utilizou-se o teste de caminhada de 6 minutos (TC6) para avaliação da capacidade funcional e o questionário de qualidade de vida Medical Outcomes Study 36 – Item Short-Form Health Survey (SF36) antes e após 36 sessões de fisioterapia. As sessões tiveram em média 1 hora, com exercícios de fortalecimento e aeróbicos. Resultados: Dos 78 pacientes que iniciaram a RPPTx 30 transplantaram durante o programa, 2 desistiram, 8 morreram e foram excluídos. Completaram o programa proposto 38 pacientes que foram avaliados. Com relação à doença de base dos pacientes encaminhados ao programa (37)47% eram portadores de fibrose pulmonar, (27) 21% tinham enfisema pulmonar, (09)11% bronquiectasias, (07) 9% fibrose cística e (04)5% outras doenças pulmonares. Predominaram homens (45) 57,6 %; com idade média de 48,3 anos; IMC de 27,7 Os dados observados antes e depois da RPPTx demonstraram melhora no TC6 (antes do RPPTx 390,5 ± 145,1 metros ; após o RPPTx 463,7 ± 116, 5 metros com p <0,001). Em relação aos domínios do questionário SF-36, constatou-se uma melhora significativa em sete dos oito domínios comparando o início e o fim do RPPTx: na capacidade funcional(23,1 ± 17,5 para 59,6 ± 20,5; p< 0,001), limitações físicas (16,1 ± 12,0 para 27,8 ± 36,7; p= 0,012); estado geral de saúde (38,1 ± 21,7 para 42,5 ± 20,9; p < 0,001), na vitalidade (57,7 ± 21,3 para 65,9 ± 22,8; p < 0,001), limitação por aspectos sociais (56,62 ± 28,7 para 68,8 ± 22; p < 0,001); limitações emocionais (44,7 ± 42,1 para 57,8 ± 43,6; p < 0,001); e na saúde mental (73,1 ± 20,4 para 83,26 ± 11,7; p < 0,001). Conclusões: o programa de reabilitação foi capaz de melhorar a capacidade de exercício e a qualidade de vida destes pacientes. Estudos devem ser feitos no sentido de esclarecer se a RPPTx exerce alguma influência no pós operatório deste grupo de pacientes. / The deployment of a lung transplant program depends on a wide infrastructure to ensure the patient a multidisciplinary treatment, which begins focusing on a proper selection of recipients and rehabilitation of these candidates during waiting time. Objective: investigate the impact of the pre-operative pulmonary rehabilitation program (RPRx) on the functional capacity and quality of life of patients on the waiting list for lung transplantation. Method: The study was conducted in the Department of Pulmonary Rehabilitation Pereira Filho, Complexo Hospitalar Santa Casa de Porto Alegre with patients who entered the waiting list for lung transplant and who were referred to the RPPTx from June 2007 to October 2009. We used the 6-minute walk test (TC6) to evaluate functional capacity and a quality of life questionnaire, the Short-Form Health Survey (SF36), before and after 36 sessions of physical and functional training. Results: Of the 78 patients who started RPPTx, 30 were submitted to transplant during the program, 2 dropped out, 8 died and were excludet. 38 completed the proposed program. In regard to the underlying disease of the patients referred to the program (37), 47% suffered from pulmonary fibrosis, (27) 21% had pulmonary emphysema, (9) 11% bronchiectasis, (7) 9% cystic fibrosis and (4) 5% suffered from other lung diseases. There was a prevalence of men (45) 57.6%, about 48.3 years old, BMI of 27.7. The data observed before and after the RPPTx of the 38 patients who completed the program showed improvement in the TC6 (390.5 ± before RPPTx 145.1 meters; after RPPTx 463.7 ± 116, 5 meters with p <0.001). In regard to the domains of the SF-36 questionnaire, we found a significant improvement in seven of the eight domains by comparing the beginning and the end of RPPTx: in functional capacity (23.1 ± 17.5 to 59.6 ± 20.5, p <0.001), in physical limitations (16.1 ± 12.0 to 27.8 ± 36.7, p = 0.012), in general health (38.1 ± 21.7 to 42.5 ± 20.9, p <0.001), in vitality (57.7 ± 21.3 to 65.9 ± 22.8, p <0.001), in social aspects limitations (56.62 ± 28.7 to 68.8 ± 22, p <0.001 ); in emotional limitations (44.7 ± 42.1 to 57.8 ± 43.6, p <0.001) and in mental health (73.1 ± 20.4 to 11.7 ± 83.26, p <0.001 ). Conclusions: The rehabilitation program was able to improve the patients’ exercise capacity and quality of life. Further studies are required to clarify whether RPPTx exerts any influence on the post-operative period of this group of patients.

A Doença Pulmonar Obstrutiva Crônica (DPOC) é uma doença sistêmica prevenível e tratável que se caracteriza pela diminuição do fluxo aéreo não totalmente reversível, levando a intolerância ao exercício, interferindo na execução das atividades de vida diária e reduzindo a qualidade de vida dos pacientes. A reabilitação pulmonar é uma forma multidisciplinar de tratamento que tem como objetivo melhorar a qualidade de vida, aumentar a tolerância ao exercício, reduzindo os sintomas de fadiga e dispnéia. Já está bem demonstrado através de estudos controlados e randomizados a eficácia do treinamento da resistência para membros inferiores, porém existem dúvidas se trabalhar força e resistência de maneira combinada pode modificar os resultados. Objetivo: Comparar os treinamentos para os membros inferiores, de força e resistência com o de resistência, em pacientes portadores de DPOC que realizaram um programa de reabilitação pulmonar. Pacientes e métodos: Após a avaliação médica para confirmação do diagnóstico da doença, 27 pacientes, que participaram de um programa de reabilitação pulmonar, foram randomizados para um de dois grupos: o Grupo 1 (G1) (n=13) realizou apenas o treinamento de resistência dos membros inferiores, enquanto os pacientes do Grupo 2 (G2) (n=14), treinaram resistência e força combinadas para membros inferiores. As variáveis analisadas antes e após o treinamento foram obtidas através dos seguintes testes: teste de caminhada de seis minutos, teste de carga máxima, trabalho de caminhada, questionário Saint George de qualidade de vida, percepção de esforço pela escala de Borg, e circunferência de coxa e perna. Resultados: No teste de caminhada houve aumento da distância percorrida após o programa intragrupos [G1(distância pré: 343,38±136,11m vs. distância pós: 396,81±96,46; p=0,048)], e [G2 (distância pré: 367,28±125,11 vs. distância pós: 392,84±118,16, p=0,160)]. Nos testes de carga máxima obteve-se os seguintes resultados: G1 (extensão de joelhos pré: 32±13kg vs. peso pós: 38±14kg; p=0,016); (flexão de joelhos pré: 5,85±2,0kg vs. pós: 7,7±3,1kg; p=0,007); (flexão plantar direito pré: 20,75±4,78 repetições vs. pós:21,58±7,22 repetições; p=0,73), (flexão plantar esquerda pré:21,67±5,48 repetições vs. pós:20,92±7,36 repetições; p=0,74) e G2 (peso em extensão de joelhos pré: 33,43±16kg vs. peso pós: 44±16,40kg; p=0,0001); (flexão de joelhos pré: 5,23±3,19kg vs. pós: 7,92±3,75kg; p=0,0001); (flexão plantar direito pré: 20,17±5,82 repetições vs. pós: 29,33±11,59 repetições; p=0,001); (flexão plantar esquerda pré: 20,45±6,34 repetições vs. pós: 30,91±10,48 repetições; p=0,0001). Não foram observadas diferenças estatisticamente significativas no trabalho de caminhada tanto intragrupos quanto entre os grupos G1 e G2. Observou-se uma melhora com relação à qualidade de vida representada pela redução total de 21,77 pontos percentuais no G1 e 22,54 pontos percentuais no G2, sem diferença estatisticamente significativa entre os grupos. A percepção de dispnéia através da escala de Borg não mostra redução significativa tanto intragrupos quanto entre os grupos [ G1 (Borg pré: 4,27±2,71 vs. pós: 2,88±1,98; p=0,091)] e [G2 (Borg pré: 4,86±3,30 vs. pós: 3,79±2,63; p=0,24)]. Quando comparados os resultados após o programa entre os grupos (G1 e G2), houve diferença estatística no teste de carga máxima apenas no movimento de flexão plantar direita e esquerda, sendo na esquerda significativamente maior (G1 Δ: -0,75 repetições vs. G2 Δ: 10,46 repetições, p=0,001), nas demais variáveis estudadas não houve diferença estatística significativa. Conclusão: Nesta população estudada os dois grupos melhoraram a qualidade de vida e a força nos movimentos de flexão e extensão dos joelhos. No entanto, o treinamento combinado de força e resistência não se mostrou superior ao treinamento isolado da resistência para membros inferiores. / “Chronic Obstructive Pulmonary Diseases” is a systemic, preventable and treatable disease characterized by the decrease of the aerial flow not totally reversible, leading to exercise intolerance, interfering in daily activities and reducing the patients’ quality of life. Pulmonary rehabilitation is a multidisciplinary approach of treatment that aims to improve the patients’ quality of life, increasing exercise tolerance, decreasing the symptoms of tiredness and breathing difficulties. Controlled and randomized studies have already proved the effectiveness of leg resistance training. However, there are still doubts as to whether concomitant strength and resistance efforts can change the results. Objective: To establish whether resistance and strength training is superior to leg resistance training, in a pulmonary rehabilitation program. Patients and methods: After the medical evaluation in order to confirm the diagnosis of the disease, 27 patients were randomly divided into two groups: group 1 patients (G1) (13) were submitted only to leg resistance while, group 2 patients (G2) (14) trained concomitant resistance and strength tests. The variations analyzed before and after the training were achieved through the following tests: 6-min walk test, maximum load test, work walking, Saint George quality of life questionnaire, effort perception by the Borg scale, and thigh and calf measurement. Results: In the walking test there was increase in the distance covered after the grouping program [G1 (pre-distance: 343,38±136,11m vs. post-distance: 396,81±96,46; p=0,048)], and [G2 (pre-distance: 367,28±125,11 vs. post-distance: 392,84±118,16, p=0,160)]. The following results were obtained in the maximum load test: (knee pre-stretching: 32±13kg vs. post7 weight: 38±14kg; p=0,016); (knee pre-bending: 5,85±2,0kg vs. post: 7,7±3,1kg; p=0,007); (right sole pre-bending: 20,75±4,78 repetitions vs. post:21,58±7,22 repetitions; p=0,73), (left sole pre-bending:21,67±5,48 repetition vs. post:20,92±7,36 repetitions; p=0,74) and G2 (knee pre-stretching: 33,43±16kg vs. post-weight: 44±16,40kg; p=0,0001); (knee pre-bending: 5,23±3,19kg vs. post: 7,92±3,75kg; p=0,0001); (right sole pre-bending: 20,17±5,82 repetitions vs. post: 29,33±11,59 repetitions; p=0,001); (left sole pre-bending: 20,45±6,34 repetitions vs. post: 30,91±10,48 repetitions; p=0,0001). No statistically significant differences were observed in the walking exercise in both groups. Although an improvement was observed in the quality of life represented by the total decrease of 21,77% in G1 and 22,54% in G2, it does not demonstrate any statistically significant difference between the two groups. The breathing difficulty perception through the Borg scale does not show significant reduction in both groups [G1 (pre-Borg: 4,27±2,71 vs. post: 2,88±1,98; p=0,091)] e [G2 (pre-Borg: 4,86±3,30 vs. post: 3,79±2,63; p=0,24)]. When the results between the groups (G1 and G2) were compared after the program, statistically significant difference in the maximum load test was observed only in the right and left sole bending movement, expressively greater in the left one. (G1 Δ: - 0,75 repetitions vs. G2 Δ: 10,46 repetitions, p=0,001). In the other variations studied, no statistically significant difference was observed. Conclusion: Both groups studied had an improved their quality of life and their strength in the stretching and bending knee movements after the pulmonary rehabilitation program. Nevertheless, concomitant strength and resistance training did not seem superior to the isolated leg resistance training.

A Doença Pulmonar Obstrutiva Crônica (DPOC) é uma doença sistêmica prevenível e tratável que se caracteriza pela diminuição do fluxo aéreo não totalmente reversível, levando a intolerância ao exercício, interferindo na execução das atividades de vida diária e reduzindo a qualidade de vida dos pacientes. A reabilitação pulmonar é uma forma multidisciplinar de tratamento que tem como objetivo melhorar a qualidade de vida, aumentar a tolerância ao exercício, reduzindo os sintomas de fadiga e dispnéia. Já está bem demonstrado através de estudos controlados e randomizados a eficácia do treinamento da resistência para membros inferiores, porém existem dúvidas se trabalhar força e resistência de maneira combinada pode modificar os resultados. Objetivo: Comparar os treinamentos para os membros inferiores, de força e resistência com o de resistência, em pacientes portadores de DPOC que realizaram um programa de reabilitação pulmonar. Pacientes e métodos: Após a avaliação médica para confirmação do diagnóstico da doença, 27 pacientes, que participaram de um programa de reabilitação pulmonar, foram randomizados para um de dois grupos: o Grupo 1 (G1) (n=13) realizou apenas o treinamento de resistência dos membros inferiores, enquanto os pacientes do Grupo 2 (G2) (n=14), treinaram resistência e força combinadas para membros inferiores. As variáveis analisadas antes e após o treinamento foram obtidas através dos seguintes testes: teste de caminhada de seis minutos, teste de carga máxima, trabalho de caminhada, questionário Saint George de qualidade de vida, percepção de esforço pela escala de Borg, e circunferência de coxa e perna. Resultados: No teste de caminhada houve aumento da distância percorrida após o programa intragrupos [G1(distância pré: 343,38±136,11m vs. distância pós: 396,81±96,46; p=0,048)], e [G2 (distância pré: 367,28±125,11 vs. distância pós: 392,84±118,16, p=0,160)]. Nos testes de carga máxima obteve-se os seguintes resultados: G1 (extensão de joelhos pré: 32±13kg vs. peso pós: 38±14kg; p=0,016); (flexão de joelhos pré: 5,85±2,0kg vs. pós: 7,7±3,1kg; p=0,007); (flexão plantar direito pré: 20,75±4,78 repetições vs. pós:21,58±7,22 repetições; p=0,73), (flexão plantar esquerda pré:21,67±5,48 repetições vs. pós:20,92±7,36 repetições; p=0,74) e G2 (peso em extensão de joelhos pré: 33,43±16kg vs. peso pós: 44±16,40kg; p=0,0001); (flexão de joelhos pré: 5,23±3,19kg vs. pós: 7,92±3,75kg; p=0,0001); (flexão plantar direito pré: 20,17±5,82 repetições vs. pós: 29,33±11,59 repetições; p=0,001); (flexão plantar esquerda pré: 20,45±6,34 repetições vs. pós: 30,91±10,48 repetições; p=0,0001). Não foram observadas diferenças estatisticamente significativas no trabalho de caminhada tanto intragrupos quanto entre os grupos G1 e G2. Observou-se uma melhora com relação à qualidade de vida representada pela redução total de 21,77 pontos percentuais no G1 e 22,54 pontos percentuais no G2, sem diferença estatisticamente significativa entre os grupos. A percepção de dispnéia através da escala de Borg não mostra redução significativa tanto intragrupos quanto entre os grupos [ G1 (Borg pré: 4,27±2,71 vs. pós: 2,88±1,98; p=0,091)] e [G2 (Borg pré: 4,86±3,30 vs. pós: 3,79±2,63; p=0,24)]. Quando comparados os resultados após o programa entre os grupos (G1 e G2), houve diferença estatística no teste de carga máxima apenas no movimento de flexão plantar direita e esquerda, sendo na esquerda significativamente maior (G1 Δ: -0,75 repetições vs. G2 Δ: 10,46 repetições, p=0,001), nas demais variáveis estudadas não houve diferença estatística significativa. Conclusão: Nesta população estudada os dois grupos melhoraram a qualidade de vida e a força nos movimentos de flexão e extensão dos joelhos. No entanto, o treinamento combinado de força e resistência não se mostrou superior ao treinamento isolado da resistência para membros inferiores. / “Chronic Obstructive Pulmonary Diseases” is a systemic, preventable and treatable disease characterized by the decrease of the aerial flow not totally reversible, leading to exercise intolerance, interfering in daily activities and reducing the patients’ quality of life. Pulmonary rehabilitation is a multidisciplinary approach of treatment that aims to improve the patients’ quality of life, increasing exercise tolerance, decreasing the symptoms of tiredness and breathing difficulties. Controlled and randomized studies have already proved the effectiveness of leg resistance training. However, there are still doubts as to whether concomitant strength and resistance efforts can change the results. Objective: To establish whether resistance and strength training is superior to leg resistance training, in a pulmonary rehabilitation program. Patients and methods: After the medical evaluation in order to confirm the diagnosis of the disease, 27 patients were randomly divided into two groups: group 1 patients (G1) (13) were submitted only to leg resistance while, group 2 patients (G2) (14) trained concomitant resistance and strength tests. The variations analyzed before and after the training were achieved through the following tests: 6-min walk test, maximum load test, work walking, Saint George quality of life questionnaire, effort perception by the Borg scale, and thigh and calf measurement. Results: In the walking test there was increase in the distance covered after the grouping program [G1 (pre-distance: 343,38±136,11m vs. post-distance: 396,81±96,46; p=0,048)], and [G2 (pre-distance: 367,28±125,11 vs. post-distance: 392,84±118,16, p=0,160)]. The following results were obtained in the maximum load test: (knee pre-stretching: 32±13kg vs. post7 weight: 38±14kg; p=0,016); (knee pre-bending: 5,85±2,0kg vs. post: 7,7±3,1kg; p=0,007); (right sole pre-bending: 20,75±4,78 repetitions vs. post:21,58±7,22 repetitions; p=0,73), (left sole pre-bending:21,67±5,48 repetition vs. post:20,92±7,36 repetitions; p=0,74) and G2 (knee pre-stretching: 33,43±16kg vs. post-weight: 44±16,40kg; p=0,0001); (knee pre-bending: 5,23±3,19kg vs. post: 7,92±3,75kg; p=0,0001); (right sole pre-bending: 20,17±5,82 repetitions vs. post: 29,33±11,59 repetitions; p=0,001); (left sole pre-bending: 20,45±6,34 repetitions vs. post: 30,91±10,48 repetitions; p=0,0001). No statistically significant differences were observed in the walking exercise in both groups. Although an improvement was observed in the quality of life represented by the total decrease of 21,77% in G1 and 22,54% in G2, it does not demonstrate any statistically significant difference between the two groups. The breathing difficulty perception through the Borg scale does not show significant reduction in both groups [G1 (pre-Borg: 4,27±2,71 vs. post: 2,88±1,98; p=0,091)] e [G2 (pre-Borg: 4,86±3,30 vs. post: 3,79±2,63; p=0,24)]. When the results between the groups (G1 and G2) were compared after the program, statistically significant difference in the maximum load test was observed only in the right and left sole bending movement, expressively greater in the left one. (G1 Δ: - 0,75 repetitions vs. G2 Δ: 10,46 repetitions, p=0,001). In the other variations studied, no statistically significant difference was observed. Conclusion: Both groups studied had an improved their quality of life and their strength in the stretching and bending knee movements after the pulmonary rehabilitation program. Nevertheless, concomitant strength and resistance training did not seem superior to the isolated leg resistance training.

A implantação de um programa de transplante pulmonar depende de uma ampla infraestrutura que garanta um atendimento multidisciplinar, que inicia sua atuação focalizando uma adequada seleção dos receptores e na reabilitação destes candidatos durante o tempo de espera. Objetivo: verificar o impacto do programa de reabilitação pulmonar pré-transplante (RPPTx) na capacidade funcional e na qualidade de vida dos pacientes em lista de espera para transplante pulmonar. Método: o estudo foi realizado no Serviço de Reabilitação Pulmonar do Pavilhão Pereira Filho do Complexo Hospitalar Santa Casa de Porto Alegre com pacientes em lista de espera para transplante pulmonar e que foram encaminhados para o RPPTx no período de junho 2007 a outubro 2009. Utilizou-se o teste de caminhada de 6 minutos (TC6) para avaliação da capacidade funcional e o questionário de qualidade de vida Medical Outcomes Study 36 – Item Short-Form Health Survey (SF36) antes e após 36 sessões de fisioterapia. As sessões tiveram em média 1 hora, com exercícios de fortalecimento e aeróbicos. Resultados: Dos 78 pacientes que iniciaram a RPPTx 30 transplantaram durante o programa, 2 desistiram, 8 morreram e foram excluídos. Completaram o programa proposto 38 pacientes que foram avaliados. Com relação à doença de base dos pacientes encaminhados ao programa (37)47% eram portadores de fibrose pulmonar, (27) 21% tinham enfisema pulmonar, (09)11% bronquiectasias, (07) 9% fibrose cística e (04)5% outras doenças pulmonares. Predominaram homens (45) 57,6 %; com idade média de 48,3 anos; IMC de 27,7 Os dados observados antes e depois da RPPTx demonstraram melhora no TC6 (antes do RPPTx 390,5 ± 145,1 metros ; após o RPPTx 463,7 ± 116, 5 metros com p <0,001). Em relação aos domínios do questionário SF-36, constatou-se uma melhora significativa em sete dos oito domínios comparando o início e o fim do RPPTx: na capacidade funcional(23,1 ± 17,5 para 59,6 ± 20,5; p< 0,001), limitações físicas (16,1 ± 12,0 para 27,8 ± 36,7; p= 0,012); estado geral de saúde (38,1 ± 21,7 para 42,5 ± 20,9; p < 0,001), na vitalidade (57,7 ± 21,3 para 65,9 ± 22,8; p < 0,001), limitação por aspectos sociais (56,62 ± 28,7 para 68,8 ± 22; p < 0,001); limitações emocionais (44,7 ± 42,1 para 57,8 ± 43,6; p < 0,001); e na saúde mental (73,1 ± 20,4 para 83,26 ± 11,7; p < 0,001). Conclusões: o programa de reabilitação foi capaz de melhorar a capacidade de exercício e a qualidade de vida destes pacientes. Estudos devem ser feitos no sentido de esclarecer se a RPPTx exerce alguma influência no pós operatório deste grupo de pacientes. / The deployment of a lung transplant program depends on a wide infrastructure to ensure the patient a multidisciplinary treatment, which begins focusing on a proper selection of recipients and rehabilitation of these candidates during waiting time. Objective: investigate the impact of the pre-operative pulmonary rehabilitation program (RPRx) on the functional capacity and quality of life of patients on the waiting list for lung transplantation. Method: The study was conducted in the Department of Pulmonary Rehabilitation Pereira Filho, Complexo Hospitalar Santa Casa de Porto Alegre with patients who entered the waiting list for lung transplant and who were referred to the RPPTx from June 2007 to October 2009. We used the 6-minute walk test (TC6) to evaluate functional capacity and a quality of life questionnaire, the Short-Form Health Survey (SF36), before and after 36 sessions of physical and functional training. Results: Of the 78 patients who started RPPTx, 30 were submitted to transplant during the program, 2 dropped out, 8 died and were excludet. 38 completed the proposed program. In regard to the underlying disease of the patients referred to the program (37), 47% suffered from pulmonary fibrosis, (27) 21% had pulmonary emphysema, (9) 11% bronchiectasis, (7) 9% cystic fibrosis and (4) 5% suffered from other lung diseases. There was a prevalence of men (45) 57.6%, about 48.3 years old, BMI of 27.7. The data observed before and after the RPPTx of the 38 patients who completed the program showed improvement in the TC6 (390.5 ± before RPPTx 145.1 meters; after RPPTx 463.7 ± 116, 5 meters with p <0.001). In regard to the domains of the SF-36 questionnaire, we found a significant improvement in seven of the eight domains by comparing the beginning and the end of RPPTx: in functional capacity (23.1 ± 17.5 to 59.6 ± 20.5, p <0.001), in physical limitations (16.1 ± 12.0 to 27.8 ± 36.7, p = 0.012), in general health (38.1 ± 21.7 to 42.5 ± 20.9, p <0.001), in vitality (57.7 ± 21.3 to 65.9 ± 22.8, p <0.001), in social aspects limitations (56.62 ± 28.7 to 68.8 ± 22, p <0.001 ); in emotional limitations (44.7 ± 42.1 to 57.8 ± 43.6, p <0.001) and in mental health (73.1 ± 20.4 to 11.7 ± 83.26, p <0.001 ). Conclusions: The rehabilitation program was able to improve the patients’ exercise capacity and quality of life. Further studies are required to clarify whether RPPTx exerts any influence on the post-operative period of this group of patients.

A Doença Pulmonar Obstrutiva Crônica (DPOC) é uma doença caracterizada pela limitação ao fluxo aéreo, não totalmente reversível. Dentre as terapêuticas indicadas, a reabilitação pulmonar é uma estratégia de tratamento multidisciplinar, que tem por objetivo melhorar a qualidade de vida do paciente, reintegrando-o à sociedade. Objetivos: Descrever o processo e os custos de implantação na forma de um projeto de extensão universitária, os motivos da evasão e os resultados obtidos com um programa de reabilitação pulmonar. Material e Métodos: Após formar um grupo multidisciplinar no Centro Universitário Feevale e estabelecer uma parceria com a Secretaria Municipal da Saúde de Novo Hamburgo, os pacientes portadores de DPOC são encaminhados ao programa de reabilitação pulmonar (PRP). São avaliados pelo médico pneumologista, fisioterapeuta, nutricionista, psicólogo e educador físico. Após estas avaliações são formados grupos de até 16 pacientes que permanecem por um período de 4 meses, com três sessões semanais de treinamento físico, orientações nutricionais, encontros educativos e grupos de apoio psicológico. Foram avaliados o perfil destes pacientes, os custos para a implantação, as causas de evasão após o início do programa, bem como os resultados obtidos após o período de tratamento, medidos através do teste de caminhada dos seis minutos, do trabalho de caminhada através do produto distância-peso corporal e do questionário Saint George de qualidade de vida. Para a análise dos resultados foi utilizada a estatística descritiva, para comparação das médias o Teste t de Student. Resultados: O PRP foi implantado na forma de um projeto de extensão universitária, com um custo total de R$ 64 224,60. Foram avaliados 134 pacientes encaminhados dos postos de saúde do município de Novo Hamburgo e dos municípios vizinhos. Do total, 38 (28,4%) pacientes foram excluídos e 7(5,2%) foram a óbito antes de completar a avaliação. Desses, 89 (66,5%) portadores de DPOC de moderado a grave foram incluídos no PRP. A média de idade dos pacientes foi de 63,5±9,9 anos, predominou o sexo masculino 62(69%), com índice de massa corporal (IMC) médio de 23,5±5,3 Kg/m2, com média de Volume expiratório forçado no primeiro segundo (VEF1) de 1,16L(42,8±23,4% do previsto). Dos incluídos no PRP, 40 (44,9%) abandonaram, principalmente por problemas sócio-econômicos e 49 (55,1%) concluíram a reabilitação. Os dados para análise antes e depois do PRP estavam disponíveis para 37 pacientes que formaramo grupo para analisar os resultados do PRP. No teste de caminhada dos seis minutos, ocorreu uma variação significativa de 34,12m na média distância (367,15±101,93m vs. 401,27±95,55m; p <0,001). Ocorreu melhora significativa de 2,65 Km.Kg-1 (24,36±9,62 Km.Kg-1 vs. 27,01±10,0 Km.Kg-1) no trabalho de caminhada medido pelo produto distância-peso e uma melhora significativa com redução de 11% (46 vs. 35; p<0,001) no total do questionário Saint George de qualidade de vida. Conclusões: O PRP pode ser implantado na forma de um projeto de extensão universitária, com custo relativamente baixo pela sua abrangência e benefícios. A condição social dos pacientes foi o maior determinante da evasão, mas os pacientes que concluíram o PRP apresentaram uma melhora significativa na sua capacidade de exercício e na qualidade de vida. / Chronic obstructive pulmonary disease (COPD) is characterized by partially reversible airway obstruction. Pulmonary rehabilitation is one of the therapeutic interventions indicated for the treatment of COPD, and consists of a multidisciplinary treatment strategy whose purpose is to improve quality of life and to reintegrate patients into society. Objective: To describe the process and cost of implementing a university extension program for pulmonary rehabilitation, as well as the causes of patient dropout and the results achieved. Material and methods: After a multidisciplinary group was formed at Centro Universitário Feevale and a partnership was established with the Municipal Department of Health of Novo Hamburgo, patients with COPD were referred to the pulmonary rehabilitation program (PRP). They were examined by a pulmonologist, a physical therapist, a nutritionist, a psychologist and a physical education specialist. After evaluations, groups of up to 16 patients were formed and had 3 weekly meetings for 4 months. During meetings, patients participated in physical exercise training, nutritional counseling, educational meetings and psychological support groups. We evaluated patient data, costs of program implementation and causes of patient dropout. Also, the results obtained after PRP were measured by the 6-minute walk test, work calculated as the product of distance x body weight, and the St George respiratory questionnaire to assess quality of life. Descriptive statistics was used to analyze results, and the Student t test, to compare means. Results: PRP was implemented as a university extension program at a total cost of R$ 64,224.60. One hundred thirty-four patients referred by health stations in Novo Hamburgo and neighboring cities were evaluated; 38 (28.4%) of these patients were excluded and 7 (5.2%) died before they completed the initial evaluation. The other 89 (66.5%) patients with moderate to severe COPD were included in PRP. Mean patient age was 63.5±9.9, 62 (69%) were men, mean body mass index (BMI) was 23.5±5.3 kg/m2, and mean forced expiratory volume in one second (FEV1) was 1.16 L (42.8±23.4% of predict value). Forty (44.9%) patients dropped out, most of them due to socioeconomic problems, and 49 (55.1%) completed the rehabilitation program. Data for the analysis before and after PRP were available for 37 patients, who formed the group for analysis of PRP results. The 6-minute walk test showed a significant increase of 34.12 m in distance(367.15±101.93 m vs. 401.27±95.55 m; p <0.001). A significant improvement of 2.65 km.kg-1 (24.36±9.62 km.kg-1 vs. 27.01±10.0 km.kg-1) was observed in distance x body weight product, and total scores of the St. George questionnaire showed a reduction of 11% (46 vs. 35; p<0.001), which indicated a significant improvement in quality of life. Conclusion: PRP was implemented as a university extension program at a relatively low cost when considering its extent and benefits. Social condition was the main cause of patient dropout, but those that completed PRP had a significant improvement in their capacity for physical exercise and in quality of life.