Peter Klijn PhD Clinical exercise physiologist Human movement scientist Physical education teacher
Asthma Centre Heideheuvel
Part of Merem Treatment Centres
Exercise training in COPD: the
devil is in the details!
VVMi < 16 kg/m2 mannen
VVMi < 15 kg/m2 vrouwen
VVMi ≥ 16 kg/m2 mannen
VVMi ≥ 15 kg/m2 vrouwen
Randomisatie
NLPE EPR
Randomisatie
COPD
FEV1% < 50%
FEV1/VC <70%
N=110
Stratificatie
N=33
60±7.1jaar
FEV1%pred 30.6±9.2
FFMi (kg/m2) 13.7±1.0
N=21
61.3±6jaar
FEV1%pred 31.2±9
FFMi (kg/m2) 17.4±1.6
N=22
61.9±5.3jaar
FEV1%pred 34.6±9
FFMi (kg/m2) 18.1±1.6
N=34
61.3±5.8jaar
FEV1%pred 32.7±9.7
FFMi (kg/m2) 13.9±1.0
NLPE EPR
http://www.merem.nl/heideheuvel/
Aim
• To compare the effects of NLPE training and traditional endurance and progressive resistance training on cycle endurance in patients with severe COPD and depleted or nondepleted FFM.
Exercise training
• 3 times/wk for 10 weeks • Alternate days
• 45-90 min/session
• Supervised exercise training
Workout logs
• ET segment • Intensity / duration
• RT segment • Intensity / number of reps
• Constant Work rate Test (CWT)
– 75% peak work rate (CPET)
• Quality of life • Chronic Respiratory
Questionnaire
• Isotonic 1-RM strength – Leg press
– Leg extension, pull down, chest press
• Bio-impedance analysis – Fat Free Mass
Measurements
Endurance and Progressive
Resistance training
• Treadmill walking – 60% 6MWTspeed, 10 min
– Progression: week 12, 15 min, 75% 6MWTspeed
• Cycle ergometer – 30% Wpeak first week
– Progression: week 12, 20-24min, 70-80% Wpeak
• leg press, leg extension, chest press,
pull down, – first week: 2 series, [8-10] repetitions, 50%1-RM
– Progression: 3 series, 60- >70% 1-RM
• BorgAH < 5: intensity increase
• BorgAH 5-6: intensity unchanged
• BorgAH ≥ 7 intensity decrease
Bernard et al. Am. J. Respir. Crit. Care Med. 159(3) 1999
Spruit et at., Eur .Respir. J. 19(6) 2002.
Ortega et al. Am. J. Respir. Crit . Care Med. 166(5) 2002
Mador et al. Chest 125(6) 2004.
Maltais et al. Am. J. Respir. Crit. Care Med. 155(3) 1997
0
200
400
600
800
1000
1200
Baseline 6 w eeks 12 w eeks
Measurement
Cycle
en
du
ran
ce (
seco
nd
s)
EPR-depleted
NLPE-depleted
0
200
400
600
800
1000
1200
Baseline 12 weeks
Measurement
Cy
cle
en
du
ran
ce
(s
ec
on
ds
)
EPR-nondepleted
NLPE-nondepleted
CWT Depleted patients
EPR (n=34)
NLPE (n=33)
First training period 15% (n=5)
42% (n=14)
Second training period
25% (n=7)
52% (n=16)
399
395
+414
+114
+569
+262
431
426
+528
+198
CWT Non-depleted
patients
EPR (n=21)
NLPE (n=22)
End of training
24% (n=5)
64% (n=14)
CWT EPR (n=55) NLPE (n=55) Difference (95%CI)
Time, s +238 s +539 s 300.6(197 - 404)
Peak SpO2 90.7 89.2 -1,5 (-5.2 – 2.2)
dyspnea 6,4 5,5 -0,9 (-1,6 - -0,1)
leg fatigue 6.5 4.7 -1.8 (-2.6 - -1.0)
CRQ-score
dyspnea +0.94 +1.90 0.96 (0.57 – 1.35)
fatigue +0.90 +1.64 0.74 (0.39 – 1.10)
emotions +0.83 +1.32 0.48 (0.19 – 0.78)
mastery +0.87 +1.39 0.52 (0.21 – 0.84)
Total group
Background
Exercise training
• The aim of exercise prescription in PR is to address the multiple contributors to exercise limitation. (Hill and Holland., Int J COPD 2014)
• Dyspnea
• Fatigue
• Anxiety
• Gas exchange abnormalities
• Altered respiratory mechanics
• Cardiovascular limitations
• Respiratory and peripheral muscle dysfunction
• Fat-free mass depletion
http://www.merem.nl/heideheuvel/
Background
Exercise training
• The aim of exercise prescription in PR is to address the multiple contributors to exercise limitation. (Hill and Holland., Int J COPD 2014)
• Do the right thing.
• Do the right thing right.
• Evidence based efficacy (Grade A).
http://www.merem.nl/heideheuvel/
A program of exercise training of the muscles of ambulation is recommended as a mandatory
component of pulmonary rehabilitation for patients with COPD.
Grade of recommendation, 1A.
Lower extremity exercise training at higher exercise intensity produces greater physiologic benefits
than lower intensity training in patients with COPD.
Grade of recommendation, 1B.
Both low-intensity and high-intensity exercise training produce clinical benefits for patients with
COPD. Grade of recommendation, 1A.
The addition of a strength-training component to a program of pulmonary rehabilitation increases
muscle strength and muscle mass.
Strength of evidence, 1A
Ries et al. Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007;131(5, Suppl):4S–42S.
Recommendations
Garber et al. American College of Sports Medicine. American College of Sports Medicine position stand: quantity and quality of exercise for
developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for
prescribing exercise. Med Sci Sports Exerc 2011;43:1334–1359.
Recommendations
Background
Exercise training
• Cornerstone of pulmonary rehabilitation. (Spruit et al., AJRCCM 188 (8), 2013)
• Both low-intensity and high-intensity exercise training produce clinical benefits for patients with COPD (Ries et al., Chest 131, 2007)
• Optimal resistance training prescription for patients with COPD is not determined. (O’Shea et al., Chest 2009)
• Non-responders – 1/3 to 1/4 do not improve their exercise capacity following pulmonary rehab
– Noise, Nuisance or Normal phenomenon?
• Individual needs
http://www.merem.nl/heideheuvel/
Highly variable training-induced strength and endurance adaptations in healthy individuals undergoing the same training plans.
high-responders
low-responders
nonresponders
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Background
Exercise training
Skinner et al., the HERITAGE Family Study. J Appl Physiol 90 (5) 2001
633 inactive persons
17-65 yr
Cyclo ergometer
20 weeks, 3x/week
30 min 50 min
HR 55% VO2max HR 75% VO2max
http://www.merem.nl/heideheuvel/
Skinner et al., the HERITAGE Family Study. J Appl Physiol 90 (5) 2001 http://www.merem.nl/heideheuvel/
Hubal et al., Variability in muscle size and strength Med Sci Sports Exerc 37 2005 http://www.merem.nl/heideheuvel/
Davidsen et al., High responders to resistance training. J Appl Physiol 110 2011
http://www.merem.nl/heideheuvel/
Resistance
training
http://www.merem.nl/heideheuvel/
Overload
Progression Specificity
Variation
Fleck and Kraemer; Designing resistance training programs. 2004;
ACSM position stand. Progression models in RT for healthy adults. Med Sci Sports Exerc 2009
Resistance training
• Serres et al., Chest 113(4), 1998
• Mador et al., Am J Respir Crit Care Med 168(1) 2003
• Van‘t Hul et al., Muscle Nerve 29(2) 2004
• Janaudis-Ferreira et al., Respir Med 100(8) 2006
Beachle and Earle. Essentials of strength training and conditioning. 2008 http://www.merem.nl/heideheuvel/
Type IIx Type IIa
Type I
Traditional endurance and
progressive resistance training
Bernard et al 1999 – Endurance
• 80% Wpeak (HI)
– Strength • 60-80% 1-RM; 2-3 x (8-10) reps
• >10 reps / set increase in load
Ortega et al 2002 – Endurance
• 70% Wpeak
– Strength • 70-85% 1-RM; 4 x (6-8) reps;
1-RM every 2-wks
– Combined
• 70% Wpeak / 70-85% 1-RM;
2 x (6-8) reps
Spruit et al 2002 – Endurance
• 30-75% Wpeak; 10->25 min
• 60% 6MWDspeed; 10->20 min
– Strength • 70% 1-RM; 3 x 8 reps
• 2min walk 60% 6MWDspeed
Mador et al 2004 – Endurance
• Cycling: 50% Wpeak;
20 min 10% increase workload
• Walking: 1.1-2.0 mph
– Combined • Cycling: 50% Wpeak; 20 min
• Walking: 1.1-2.0 mph
• Strength: 60% 1-RM; 1-> 3 sets x 10
reps
– 3 sets without difficulty 5lb
increase
http://www.merem.nl/heideheuvel/
Nonlinear (Undulating) Model of Periodization
• Variation in intensity & volume by rotating different protocols (daily, weekly, biweekly) – Attempts to train various components of neuromuscular system
– Only one characteristic is trained in each workout
http://www.merem.nl/heideheuvel/
• An assessment of factors that determine the specific training program appropriate for an individual.
– Physiological requirements
– Biomechanical requirements
– Individual needs and deficiencies
Program design Needs analysis
http://www.merem.nl/heideheuvel/
• Physiological requirements • Aerobic energy system
• Anaerobic energy system
• Leg endurance
• Leg strength
• Biomechanical requirements • Knee and hip muscles
• Many submaximal contractions
• Individual deficiencies • FFM depletion
• Dyspnea
• Oxygen desaturation
• Fatigue
http://www.merem.nl/heideheuvel/
Needs analysis cycle endurance 75% Wmax
Volume Intensity Rest
• 1-2 series ≥20 Reps 30-39% 1-RM 1 min
• 2-3 series 12-15 Reps 40-49% 1-RM 1 min
• 3-4 series 8-10 Reps 50-65% 1-RM 2 min
• 4-5 series 5-6 Reps 70-80% 1-RM 2-3 min
• 4-5 series 1-3 Reps 85-90% 1-RM 3-4 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2) http://www.merem.nl/heideheuvel/
Nonlinear (undulating) RT
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-49% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Volume Exercise Intensity Rest Training 1
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 2
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 3
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 4
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 5
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear RT
Volume Exercise Intensity Rest Training 6
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 7
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 8
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 9
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 10
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear RT
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-50% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Volume Exercise Intensity Rest Training 6
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 7
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 8
• 1-2 series 20-30 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 9
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 10
• 1-2 series 20-30 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear RT
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-50% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Volume Exercise Intensity Rest Training 11
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 12
• 1-2 series 30-40 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 13
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 14
• 1-2 series 30-40 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 15
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear RT
Volume Exercise Intensity Rest Training 16
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 17
• 1-2 series 40-50 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 18
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 19
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 20
• 1-2 series 40-50 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear RT
Volume Exercise Intensity Rest Training 21
• 1-2 series 40-50 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 22
• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 23
• 3-4 series 8-10 Reps LP PD LE CP 50-65% 1-RM 2 min
Training 24
• 1-2 series 50-60 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 25
• 1-2 series 50-60 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear RT
Klijn et al; Ned Tijdschr Geneesk 2013, 135(57).
Nonlinear periodized resistance training
http://www.merem.nl/heideheuvel/
No. of sessions
Traditional progressive training
Klijn et al; Ned Tijdschr Geneesk 2013, 135(57).
http://www.merem.nl/heideheuvel/
No. of sessions
Klijn et al; Am J Resp Crit Care Med 2013, 188(2) http://www.merem.nl/heideheuvel/
Training characteristics
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-50% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Volume Intensity Rest
• 1-3 x (3-10) min 50-60% Wpeak 1-3 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized cycle exercise
Hickson et al., Eur J Appl Physiol 1980
http://www.merem.nl/heideheuvel/
Lundberg et al., J Appl Physiol 116 2014
http://www.merem.nl/heideheuvel/
Lundberg et al., J Appl Physiol 114 2013
Background
Concurent exercise training
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-50% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Volume Intensity Rest
• 1-3 x (3-10) min 50-60% Wpeak 1-3 min
• 2-8 x (2-5)min 65-80% Wpeak 2-4 min
Compensation cycling following an anaerobic exercise session
• 1 x (5-10) min 50% Wpeak
Klijn et al; Am J Resp Crit Care Med 2013, 188(2) http://www.merem.nl/heideheuvel/
Nonlinear periodized cycle exercise
Volume Intensity Rest
1-3 x (3-10) min 50-60% Wpeak 1-3 min
• (2-3) x 3 min 1 min
• (2-4) x 4 min 1-2 min
• (2-3) x 5 min 1-2 min
• (1-3) x 6 min 1-2 min
• (1-2) x 7 min 1-3 min
• (1-2) x 8 min 1-3 min
• 1 x 9-10 min
2-8 x (2-5)min 65-80% Wpeak 2-3 min
• (4-8) x 2 min 1½-2 min
• (3-5) x 3 min 2 min
• (2-3) x 4 min 3 min
• (2-3) x 5 min 3-4 min
Klijn et al; Am J Resp Crit Care Med 2013, 188(2) http://www.merem.nl/heideheuvel/
Nonlinear periodized cycle exercise
Nonlinear Periodized Exercise
Energy system cycle training Resistance training
Repetition range
Aerobic
≥ 20 Muscular endurance
Strength
12-15
Anaerobic
8-10
4-6
1-3
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Volume Exercise Intensity Rest Training 1
• 2 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min
Training 2
• 2-3 series 4 min cycling 50% 2 min
• 2 series 12-15 Reps LP PD LE 40-49% 1-RM 1 min
Training 3
• 2-3 series 4 min cycling 50% 2 min
• 2 series 12-15 Reps LP CP LE 40-49% 1-RM 1 min
Training 4
• 3-5 series 3 min cycling 65% 2 min
• 3 series 8-10 Reps LP PD LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized exercise training
Volume Exercise Intensity Rest Training 5
• 2-4 series 4 min cycling 50% 2 min
• 2 series 12-15 Reps LP PD LE 40-49% 1-RM 1 min
Training 6
• 3-5 series 3 min cycling 65% 2 min
• 3 series 8-10 Reps LP CP LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Training 7
• 2-4 series 4 min cycling 50% 2 min
• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps PD LE 40-49% 1-RM 1 min
Training 8
• 3-5 series 3 min cycling 70% 2 min
• 3 series 8-10 Reps LP PD LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized exercise training
Volume Exercise Intensity Rest Training 9
• 2-4 series 4 min cycling 50% 2 min
• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps CP LE 40-49% 1-RM 1 min
Training 10
• 3-5 series 3 min cycling 70% 2 min
• 3 series 8-10 Reps LP CP LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Training 11
• 2-4 series 4 min cycling 50% 2 min
• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps PD LE 40-49% 1-RM 1 min
Training 12
• 3-5 series 3 min cycling 70% 2 min
• 3 series 8-10 Reps LP PD LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized exercise training
Lower volume, shorter work phase duration, lower intensity and/or longer rest
• Dyspnea
• Anxiety
• Fatigue
Shorter work phase duration and/or longer rest
• Oxygen desaturation
Progression
• Intensity
• Volume
• Shorter rest
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized cycle exercise
Volume Exercise Intensity Rest Training 9
• 2-3 series 6 min cycling 50% 2 min
• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps CP LE 40-49% 1-RM 1 min
Training 10
• 3-5 series 3 min cycling 75% 2 min
• 3 series 8-10 Reps LP CP LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Training 11
• 2-3 series 6 min cycling 50% 2 min
• 2 series 30-40 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps PD LE 40-49% 1-RM 1 min
Training 12
• 2-3 series 5 min cycling 70% 3½ min
• 3 series 8-10 Reps LP PD LE 50-65% 1-RM 2 min
• 1 series 5-10 min cycling 50% Wmax
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized exercise training
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-50% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Volume Intensity Rest
• 1-2 x (8-10) min 50-60% Wpeak 1-3 min
• (15-30) x 30 sec >95% Wpeak 30 sec
• HI 4x4 min 80-90% Wpeak 3 min active rest 50%Wpeak
• 2 x 7 min 65-80% Wpeak 3-5 min
• 6-10 x (90-120)sec 85-95% Wpeak 2-3 min
Compensation cycling following an anaerobic exercise session
• 1 x (5-10) min 50% Wpeak
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized cycle exercise
Volume Exercise Intensity Rest Training 13
• 2 series 8 min cycling 60% Wmax 3 min
• 2 series 40-50 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps CP 40-49% 1-RM 1 min
Training 14
• 10 series 90 sec cycling 85% 2 min
• 4 series 4-6 Reps LP PD LE 70-80% 1-RM 2-3 min
• 1 serie 5-10 min cycling 50% Wmax
Training 15
• 2 series 50-60 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min
Training 16
• 2 series 7 min cycling 70% Wmax 4 min
• 3 series 8-10 Reps LP CP LE 50-65% 1-RM 2 min
• 1 serie 5-10 min cycling 50% Wmax
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
http://www.merem.nl/heideheuvel/
Nonlinear periodized exercise training
†
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Training characteristics
http://www.merem.nl/heideheuvel/
‡ ‡
Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Training characteristics
http://www.merem.nl/heideheuvel/
Table 1. General outline of NLPE program design and adaptations.
Pro
gram
de
sign
Physiological and psychological adaptation phase (Base training). First two to three training sessions
-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-50% 1-RM
Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high
repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and
repetition zones.
Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and
number of sessions during the last week prior to exercise testing, while maintaining training intensity.
Pro
gre
ssiv
e
ove
rlo
ad
Criteria for adaptation and progression through the training program
Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*
- prolonging the anaerobic work phase: 2-3 series, 5 min
- increasing the anaerobic work intensity: 70-80% Wmax
Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)
- increasing the intensity (repetition-load) within the 1-RM range
Ind
ivid
ual
pat
ien
t ch
arac
teri
stic
s
Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or
muscle efficiency relative to muscle mass.
In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or
fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are
used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.
Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity
exercise.
- prolonging the anaerobic work phase: 2 series, 7 min
- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax
- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax
- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.
http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)
Take home message
The prescription of an “optimal” exercise training program that works for every individual is not possible as substantial variation exists in the ability of individuals to respond to a training stimulus!
http://www.merem.nl/heideheuvel/
Training smart!