Influence of Aerobic Exercise Training on Bone Mineral Status among Chronic Obstructive
Pulmonary Disease Patients
Shehab M Abd El Kader1* and Osama H Al-Jiffri2
1Department of Physical therapy, King Abdulaziz University, Saudi Arabia
2Department of Medical Laboratory Technology, King Abdulaziz University, Saudi Arabia
Submission: February 16, 2017; Published: July 14, 2017
*Corresponding author: Prof. Shehab M. Abd El- Kader, Faculty of Applied Medical Sciences, Department of Physical Therapy, King Abdulaziz University, P.O. Box 80324, Jeddah, 21589, Saudi Arabia, Email: [email protected]
How to cite this article: Shehab M A E K, Osama H A J. Influence of Aerobic Exercise Training on Bone Mineral Status among Chronic Obstructive
pulmonary Disease Patients. Int J Pul & Res Sci. 2017; 2(1): 555577. DOI:10.19080/IJOPRS.2017.02.555577
Background: Chronic obstructive pulmonary disease (COPD) characterized with abnormal bone mineral status with high risk for fracture and poor pulmonary function. Aerobic exercise was proved to improve bone mineral density (BMD) and bone geometry.
Objective: The aim of this study was to measure the impact of aerobic exercise on bone mineral status among COPD patients. Methods: Eighty patients with COPD involved in this study who were enrolled in two equal groups: group (A) received 3 sessions of treadmill aerobic exercise training every week for 6 months, while group (B) was considered as a control group who received no training intervention.
Results: The mean values of bone marrow density (BMD) of the femoral neck, lumbar spine & total hip were improved significantly in group (A) at the end of the study, but group (B) had non-significant changes. However, the differences between mean value of the investigated parameters in both groups were significant at the end of the study (p<0.05).
Conclusion: Aerobic exercise is an effective treatment policy to improve bone mineral status in chronic obstructive pulmonary disease patients.
Keywords: Aerobic exercise training; Bone mineral density; Chronic obstructive pulmonary disease
Chronic Obstructive Pulmonary Disease (COPD) is an incomplete reversible progressive disorder due to its pathological manifestations [1-3] one of the extra-pulmonary manifestations is skeletal muscle dysfunction which affects patients with COPD more than health subjects by two to five folds [4-6], the decline in bone mineral density (BMD) was found to be correlated with the decline in the lung functions . Moreover, about 6-70% of COPD patients affected with osteoporosis according to the severity of illness . The strength of the handgrip strength was found to be closely related to body lean mass, percentage of fat, fat mass composition and BMD .
Globally, COPD is a prevalent disorder  with high risk of osteoporosis along with high economic burden of the disease medical care [8-12]. COPD is the third cause of death in America . By 2030 it is expected to have 9 million subject die from COPD every year [14,15]. Currently COPD is the 5th leading cause of death and 3rd economic burden of disease care [16,17].
About 10% drug-related complications and 141,000 of USA hospital stays were related to corticosteroids in 2004 . In addition, corticosteroids-induced osteoporosis via bone formation suppression and enhanced bone resorption  which is usually associated with intake of moderate or high doses of inhaled corticosteroids (ICS) . Long-term low-dose ICS use increases the rate of bone marrow density (BMD) loss in patients with chronic obstructive pulmonary disease [21-23].
The regular pharmacological agents for osteoporosis have high cost and unlimited side-effects specially with long term intake which limit their use [24,25], these side-effects of the pharmacological therapy forced the medical care members
to the non-pharmacological treatment for COPD . Weight
bearing exercises of moderate to high intensity have a good role
in maintenance of bone mineral status among adult populations
, therefore exercise training is widely accepted treatment
strategy for osteoporosis prevention . The purpose of this
study was to measure the impact of aerobic exercise on BMD
among COPD patients.
Eighty patients with moderate severity of COPD according
to GOLD  were enrolled in this study. Patients with
exacerbations in the last 4 weeks were either rescheduled or
excluded; their age ranged from 36 to 57 years. Exclusion criteria
included smokers, hepatic disorders, cardiac disorders, renal
disorders, diabetes, musculoskeletal disorders. Participants
were enrolled in two equal groups, the first group (A) received
their traditional treatment in addition to treadmill aerobic
exercises, while the second group (B) was considered as a
control group and received only their traditional treatment for
six months. The CONSORT diagram clearly outline the screening
details and phases of randomization phases (Figure 1). Informed
consent was signed by all participants. This study was approved
by the Scientific Research Ethical Committee, Faculty of Applied
Medical Sciences at King University.
Overnight fasting venous blood samples were added to
Ethylene diamine tetra acetic acid (EDTA), and centrifuged for
10 min at 1000 ×g. Samples stored at − 80 °C until analysis.
Parathyroid hormone (PTH) and serum blood calcium were
measured with an Enzyme Linked Immuno Sorbent Assay (ELISA)
(Diagnostics Systems Laboratories, Inc., Webster, TX). However,
measurements of BMD of total hip, lumbar spine and the femoral
neck were taken by Dual Energy X-Ray Absorptiometry ((DXA)
GE Lunar Prodigy enCORE software version 8.80, GE Medical
Systems, Madison WI).
Participants were randomly included into two equal groups
Group (A) received treadmill aerobic exercise training with a five minutes warming-up phase done on the treadmill
(Track master 400E, gas fitness system, England) with
low load, actual training time was thirty minutes with an
intensity of 70–80% of HRmax and finally five minutes
of cooling down that was done in the form of running or
Group (B) was considered as a control group and
received no training intervention for six months.
SPSS (Chicago, IL, USA) version 17 was used in statistical
analysis, where the investigated parameters of both groups
obtained before and at the end of the study were compared.
However, comparison between the investigated parameters of
both groups done using independent “t”. All data were expressed
as the mean ± SD (P<0.05).
BMI: Body Mass Index; FVC: Forced Vital Capacity; FEV1: Forced Expiratory volume in the First Second; FEV1/FVC: Ratio between Forced
Expiratory Volume in the First Second and Forced Vital Capacity; MVV: Maximum Voluntary Ventilation.
The baseline characteristics of all participants are shown in
Table 1. Most participants (65 %) were men. Forty participants
were assigned to the aerobic exercise group (n = 40; 26 males
and 14 females), while the resistance exercise group (n = 40;
25 males and 15 females). None of the baseline characteristics
differed significantly between the two groups is listed in Table 1.
The mean values of bone marrow density (BMD) of
the femoral neck, lumbar spine & total hip were improved
significantly in group (A) at the end of the study (Table 2), but
group (B) had non-significant changes (Table 3). However, the
differences between mean values of the investigated parameters
in both groups were significant at the end of the study (Table
4). These results confirm that aerobic exercise is appropriate
to modulate handgrip strength and bone mineral density in
patients with COPD.
BMD: Bone Marrow Density; (*) indicates a significant difference between the two groups, P < 0.05.
BMD: Bone Marrow Density
BMD: Bone Marrow Density; (*) indicates a significant difference between the two groups, P < 0.05.
The American College of Sports Medicine (ACSM)
recommended regular weight-bearing to preserve bone mass
. However, Greendale and colleagues stated that exercise can
prevent osteoporosis . Therefore, this study was designed
to measure the impact of aerobic exercise on bone mineral
status among COPD patients. The main finding of our study
indicated that aerobic exercise training improves bone mineral
status among patients with COPD. These findings approved by
Lester et al.  stated that only long term exercise training
for a period more than 6 months was enough to improve bone
mineral density . Also, Nordstrom et al.  reported that
BMD improved among athletes who participate in weightbearing
activities . While Bonaiuti  and colleague’s
recommended walking exercise for prevention and treatment
of osteoporosis in postmenopausal women . However, Hind
et al.  reported that BMD improve in cystic fibrosis children
after 6 months of regular weight-bearing exercise . While,
Remes et al.  said that exercise is essential for middle-aged
men to have peak bone mass . Also, Lin et al. stated that
weight-bearing exercise had a greater positive effect on BMD
than the non-weight-bearing exercise . Moreover, Douchi et
al.  confirmed that strength training significantly increased
BMD of lumbar spine in postmenopausal women .
The possible mechanism by which exercise maintains the
skeletal integrity are: changes in the biochemical structure of
the blood by altering the level of its component which has a
role in the integrity of normal skeletal and mechanical load of
the exercise which can modify and increase bone mass .
The increase in bone mineral density after exercise may be
due to increase in serum calcium associated with decreased
parathyroid hormone following exercise training .
The present study has important limitations and strengths.
The supervised nature of the study is a point of strength as it
limit the need to rely on activity questionnaires or to have a
dubiety regarding compliance and adherence of participants
in training. Moreover, the study was randomized; hence, we
can ensure adherence to the general population. While, the
possibility of findings generalization may be limited by the
small sample size in both groups. Finally, based on the present
study findings, treadmill walking exercise training is an effective treatment policy to modulate bone mineral status in COPD
patients. Further researches are needed to explore the impact
of exercise training upon quality of life and other biochemical
parameters among COPD patients.
This project was funded by the Deanship of Scientific
Research (DSR) at King Abdulaziz University, Jeddah, under
grant no. (G-56-142-34). The authors, therefore, acknowledge
with thanks DSR for technical and financial support.