Physical rehabilitation for lung transplant candidates and recipients: An evidence-informed clinical approach

Table 1 Physical assessment of lung transplant candidates and recipients

Measuredconstruct	Clinical tests	Clinical utility
Exercise capacity	Lab-based test: Cardiopulmonary exercise test on cycle or treadmill Field-based walk tests: 6MWT, ISWT[19,27] Upper extremity endurance capacity: UULEX[28]	Cause of exercise limitation Assess need for oxygen Assess functional capacity Outcome measure pre-post rehab and pre-post transplant Exercise prescription
Muscle function (strength, endurance)	Peripheral muscles: Manual muscle testing or hand held dynamometry Handgrip force 1-repetition maximum Respiratory muscles: MIP/MEP	Assess muscle strength and/or muscle endurance Outcome measure Exercise prescription (1-RM for peripheral muscles, MIP for IMT)
Physical performance and mobility	Gait speed (over 4 m)[110] Sit-stand tests (e.g., 30 s sit to stand; 5 times sit to stand)[111,112] Short Physical Performance Battery[113] Timed Up and Go[114] Balance tests (e.g., Berg balance scale, BESTest)[115,116] FIM[117] Tests specifically for ICU/inpatients: Egress test[118] Various ICU physical function tests[119-121]	Assess mobility, balance and physical function Assess need for gait aid Outcome measure Exercise prescription Discharge planning
Physical activity	Physical Activity questionnaires, e.g., PASE[122]; IPAQ[123]; DASI[124] Pedometers or accelerometers	Assess physical activity Outcome measure Set activity goals (e.g., target daily step count)

CPET: Cardiopulmonary exercise test; 6MWT: Six-minute walk test; ISWT: Incremental shuttle walk test; UULEX: Unsupported upper limb exercise test; MMT: Manual muscle testing; 1RM: One repetition maximum; HGF: Handgrip force; HHD: Hand-held dynamometry; MIP: Maximal inspiratory pressure, MEP: Maximal expiratory pressure; IMT: Inspiratory muscle testing; SPPB: Short physical performance battery; TUG: Timed Up and Go; FIM: Functional independence measure; PASE: Physical activity scale for the elderly; IPAQ: International physical activity questionnaire; DASI: Duke activity status questionnaire.

Table 2 Guidelines for pre-transplant exercise prescription in stable outpatients

	Aerobic	Resistance	Flexibility
Frequency	2-5 d/wk	2-3 d/wk	3-5 d/wk
Intensity	50%-80% HR reserve Dyspnea > leg fatigue: Moderate to hard (3-5 on modified Borg scale)[48] SpO2 > 85%-90% Continuous or intermittent training1: 60%-80% 6MWT speed for walking[41,49] 60% peak workload for cycling[39,43] or just above anaerobic threshold[40] Interval training2: 100%: 0% peak work rate (cycle)[39]	30%-80% 1-RM or use 8-15-RM[125]
Type	Walking (treadmill, corridor, Nordic poles)[42] Cycling (leg and/or arm ergometer)	Major muscle groups of upper and lower body (quadriceps, hamstrings, plantar flexors, gluteals, biceps, triceps, pectorals, latissimus dorsi) Training modalities: Free weights/dumbbells Elastic bands Pulleys Gym equipment Body weight (stairs, squats, heel raises, wall push-ups)	Major muscle groups of upper and lower body Thoracic cage and chest wall mobility
Time/ Training Volume	Continuous: 15-30 min Intermittent: 5-10 min × 2-3 bouts Interval2: 30 s exercise: 30 s rest (12-36 min)[39]	1-2 sets × 8-15 reps	Hold up to 10-30 s each, repeat 2-4 times
Progression	Progress time up to 20-30 min continuous Perform regular 6MWTs and adjust speed accordingly for treadmill training; and increase Watts on cycle Higher level patients may tolerate a treadmill incline of 1%-4%	Increase weights based on tolerance; (approximately 0.5 kg or 1 lb. per week, as tolerated)[41] Body weight exercises: Can add hand or ankle weights	Hold stretches to point of tightness/slight discomfort

¹Intermittent training is regular or irregular intervals of the same low to moderate intensity vs interval training, which involves pre-set, alternating, short intervals of high intensity to intervals of rest or lower intensity;

²There are several different interval training protocols described in chronic lung disease[126]. SpO₂: Oxygen saturation measured by pulse oximetry; HRR: Heart rate reserve; 6MWT: Six-minute walk test; ISWT: Incremental shuttle walk test; HR: Heart rate; BP: Blood pressure; RR: Respiratory rate; ESWT: Endurance shuttle walk test; reps: Repetitions; RM: Repetition maximum.

Table 3 Exercise and mobility for hospitalized lung transplant candidates and recipients

Setting	Interventions/prescription	Considerations for a complicated hospital course
Intensive care unit	Upright positioning AROM for upper extremities Acupuncture for incisional pain Progressive mobility program, consisting of: Bed mobility > dangling > transfer to chair > standing > marching on spot > ambulation with HWW up to 100-200 m with or without MV In sitting or lying: Resistance training using light weights, elastic resistance bands	PROM, A/AROM for those who are sedated/not actively moving Trunk control and sitting balance prior to standing and walking Specialized equipment to facilitate mobility, such as: Standing frames, sit-stand lifts or mechanical lifts, standing and walking slings, portable treadmills, portable ventilators for ambulation in ICU (with appropriate settings to facilitate exercise), manual resuscitation bag with PEEP valve Bedside cycle ergometer or treadmill for aerobic training Video gaming system (e.g., Nintendo Wii™) for balance and strengthening exercises[127]
Step-down unit/ward	AROM upper extremities Progressive mobility program: Up to chair 1-3 ×/day; supervised walking 1 × /day building up to 100 m; progress to 4-5 ×/day for 10-15 min bouts and increase distance > 100 m Stair climbing Resistance training: Up to 5 lbs. (1 set × 10 reps) Education re: Lifting restrictions Postural correction/re-education Oxygen titration: Maintain SpO2 > 88% on exertion	Transfer training Gait training Gait aids: Progress from HWW > rollator > no gait aids, if able Specialized seating Referral to inpatient rehabilitation for those who are not independent for discharge home

ROM: Range of motion; HWW: High-wheeled walker; MV: Mechanical ventilation; AROM: Active range of motion; PROM: Passive range of motion; A/AROM: Active/assisted range of motion; PEEP: Positive end expiratory pressure.

Table 4 Guidelines for early post-transplant exercise prescription in stable outpatients

	Aerobic	Resistance	Flexibility
Frequency	3-5 d/wk	2-3 d/wk	3-5 d/wk
Intensity	50%-80% HR reserve or < 85% age-predicted HRmax[4,23] Leg fatigue > dyspnea: Moderate to hard (3-4 on Borg scale) SpO2 > 88% Continuous training: 75%-100% 6MWT speed for walking[24,25] 50%-80% peak workload for cycling[24,59,128]	60%-80% 1RM[24,26] 10-RM No upper extremity lifting/pulling/pushing > 10 lbs. first 3 month Extra restrictions if sternal instability	Hold stretches to point of tightness/slight discomfort
Type	Walking (treadmill, corridor) Cycling (leg); avoid arm ergometry in first 3 month to allow for incision healing	See pre-transplant Avoid abdominal muscle exercises for first 3 month	Major muscle groups of upper and lower body Thoracic cage and chest wall mobility Postural re-education
Time/ Training Volume	Continuous: 20-30 min	1-3 sets × 8-15 reps	Hold up to 10-30 s each, repeat 2-4 times
Progression	Progress time to 30 min, then progress speed on treadmill; increase incline after approximately 6 wk post-transplant (if tolerated) Increase Watts on cycle Walk: Run program for some high level patients (at least 6 wk post-transplant) 30-60 s running bouts interspersed with walking for 20-30 min	Start with sit-stands and when able to perform without arm support progress to squats with hand weights Weekly increase weights based on tolerance; (approximately 0.5 kg or 1 lb. per week, as tolerated) within lifting guidelines (e.g., < 10 lbs. for upper extremities for first 3 month) Body weight exercises: Can add hand or ankle weights (e.g., squats and stair climbing)	Hold stretches to point of tightness/slight discomfort Extra restrictions if sternal instability (e.g., avoid chest expansion stretches)

6MWT: Six-minute walk test; CPET: Cardiopulmonary exercise test; HR: Heart rate; HRR: Heart rate reserve; SpO₂: Oxygen saturation measured by pulse oximetry; RR: Respiratory rate; BP: Blood pressure; ISWT: Incremental shuttle walk test; ESWT: Endurance shuttle walk test.