FIG. 20:  The initial small study from Italy (Figures 17 and 18)^[14] was followed in 1995 by a randomized control trial in the United States that compared the effect of pulmonary rehabilitation with exercise training plus education versus education alone.^[17]  This Figure shows the principal results of this study, showing percent change over time from baseline in exercise capacity at a high level on a treadmill.  Pulmonary rehabilitation with education plus exercise training increased exercise capacity by 10.5 min, almost double the baseline level, versus almost no change in exercise capacity in the education alone group.  No pharmaceutical agent has been reported to double exercise capacity in COPD patients, although over a period of approximately 2 years the effect of exercise training waned and eventually was almost identical to that of education alone. 

In summary, this and the previous studies showed the good and the bad of exercise training in pulmonary rehabilitation.  Exercise training is associated with substantial improvements in exercise capacity over 1-2 years, but this effectiveness wears off.  As an optimist looking at the glass as half full, this means these patients have gained 2 years of increased exercise capacity; but looking at the result as a pessimist, the effect of exercise training wears off.  Clearly what pulmonary rehabilitation must do is try to extend the period of increased effectiveness of exercise training.  There is intense interest in this area, and probably the way to achieve this is to improve self-efficacy and collaborative strategies to encourage people to continue with the exercise training that they received during their pulmonary rehabilitation.  So far, we have not been able to do that.