***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The aim of this study was to examine the effect of high intensity physical group training in water and on l and for patients with COPD with regard to physical capacity and health related quality of life ( HRQoL ) . A controlled , semi-r and omised study was conducted where 30 patients were r and omised to training either in water or on l and . Thirteen patients constituted a control group . Forty-three out patients , with moderate to severe COPD ( 27w/16 m ) , from two local hospitals in northern Sweden , were included in the study . High intensity physical group training in water ( water group ) or on l and ( l and group ) was performed for 12weeks , three times per week , 45min per session . The control group received no intervention . Pre- and post-intervention , all patients performed incremental and endurance shuttle walking tests ( ISWT and ESWT ) ,  cycle ergometer tests  and  responded question naires about HRQoL ( St. Georges Respiratory Question naire -- SGRQ and SF-36 ) . The patients trained with a mean heart rate of 80 - 90 % of peak heart rate . Both training groups increased the distance walked , i.e. l and group in ISWT ( 25 m ) and water group in ESWT ( 179 m ) . The water group increased the distance in ESWT significantly more that both the l and and the control groups . Both training groups increased the time cycled ( 40 - 85s ) and work load ( 10 - 20W ) in the cycle ergometer test . The control group deteriorated in HRQoL according to total score in SGRQ while the training groups remained constant . The water group improved their activity score in SGRQ and their physical health score in SF-36 and those improvements were significant as compared to the l and and the control groups . In conclusion , high intensity physical group training in water is of benefit for patients with COPD . It was in some areas found to be even more effective regarding improvements in physical capacity and experienced physical health compared to the same kind of training on l and L and -based exercise is often difficult for people with chronic obstructive pulmonary disease ( COPD ) who have coexisting obesity or musculoskeletal or neurological conditions . This r and omised controlled trial aim ed to determine the effectiveness of water-based exercise training in improving exercise capacity and quality of life compared to l and -based exercise training and control ( no exercise ) in people with COPD and physical comorbidities . Participants referred to pulmonary rehabilitation were r and omly allocated to a water-based exercise , l and -based exercise or the control group . The two exercise groups trained for 8 weeks , completing three sessions per week . 45 out of 53 participants ( mean±sd age 72±9 years ; forced expiratory volume in 1 s 59±15 % predicted ) completed the study . Compared to controls , water-based exercise training  significantly increased 6-min walking distance , incremental and endurance shuttle walk distances , and improved Chronic Respiratory Disease Question naire ( CRDQ ) dyspnoea and fatigue . Compared to l and -based exercise training , water-based exercise training significantly increased incremental shuttle walk distance ( mean difference 39 m , 95 % CI 5–72 m ) , endurance shuttle walk distance ( mean difference 228 m , 95 % CI 19–438 m ) and improved CRDQ fatigue  . Water-based exercise training was significantly more effective than l and -based exercise training and control in increasing peak and endurance exercise capacity and improving aspects of quality of life in people with COPD and physical comorbidities Purpose . To investigate effects of decreased training frequency in patients with COPD . Methods . Forty-three COPD patients participated in a controlled study . The intervention group ( 30 patients ) trained 3 times a week during 3 months and once a week during 6 months . Before , after 3 and 9 months all patients performed walking tests , cycle ergometer tests and responded question naires on health-related quality of life ( HRQoL ) ( SGRQ , SF-36 ) . Results . At 9 months compared to 3 months there were no changes in distance walked in the groups . Both groups decreased their VO2peak and the training group deteriorated in HRQoL. At 9 months compared to baseline the training group showed increased distance walked compared to the control group . In the disease-specific SGRQ the training group tended to improve their activity score while the control group tended to deteriorate in total score . In SF-36 the control group decreased their physical component score . Conclusion . Training once a week does not seem to be sufficient to maintain the level achieved after the 3-month period of training in COPD patients . However , training once a week during 6 months preceded by 3 months of high frequency training seems to prevent deterioration in physical capacity and HRQoL compared to baseline . Further studies are needed to investigate how to best sustain the benefits gained after physical training Kurabayashi H , Machida I , H and a H , Akiba T , Kubota K : Comparison of three protocol s for breathing exercises during immersion in 38 ° C water for chronic obstructive pulmonary disease . Am J Phys Med Rehabil 1998;77:145–148 Respiratory function test , arterial blood gas analysis , and ejection fraction were used to compare three protocol s of breathing exercises during immersion in 38 ° C water . Therapy was given for 2 mo to patients with stable chronic obstructive pulmonary disease . Protocol A consisted of a total exercise period of 20 min/wk ( 10 min/day , 2 days/wk ) and was performed by 7 patients ( 5 cases of asthma and 2 cases of emphysema ) . Protocol B consisted of a total exercise period of 120 min/wk ( 20 min x2 per day at 10:00 am and 3:00 pm , 3 days/wk ) and was performed by 9 patients ( 6 asthmas and 3 emphysemas ) . Protocol C consisted of a total exercise period of 120 min/wk ( 20 min/day , 6 days/wk ) and was performed by 8 patients ( 4 asthmas and 4 emphysemas ) . The ratio of forced expired volume in one second to forced vital capacity ( FEV10 % ) was significantly increased in protocol s B and C ( P < 0.01 ) . The ratio of forced vital capacity to the predicted normal value ( % FVC ) was not changed in any of the three protocol s. A significant increase in peak flow was observed in protocol s B and C ( P < 0.05 ) . The maximal expiratory flow at 25 % ( V25 ) was not changed in any of the three protocol s. Pao2 was significantly increased and Paco2 was significantly decreased in protocol B ( P < 0.01 and P < 0.05 , respectively ) , whereas only Paco2 was significantly decreased in protocol C ( P < 0.05 ) . Ejection fraction was increased in protocol s B and C. These results suggest that exercise for a total period of 120 min/wk is preferable to that of 20 min/wk in COPD OBJECTIVE The optimum method for sustaining the benefits gained from  pulmonary rehabilitation ( PR )  has not been determined . In this report the authors describe the 4-year referral and uptake patterns to a hospital-based outpatient PR programme , and the sustained benefits of PR in patients with COPD attending a community-based maintenance exercise programme .  METHODS Entry and exit data were mapped for all patients referred to the PR service over the review period . All eligible patients were offered a community-based maintenance exercise programme upon completion of PR . A total of 21 patients underwent follow-up assessment of functional exercise capacity , quality of life ( QOL ) and health-care utilization . RESULTS Over a 4-year period , 467 patients ( 80 % with COPD ) were referred to the programme , of whom 230 entered PR . In total , 172 patients completed PR , with attrition ( 25 % ) being mostly due to medical problems . Of the 84 patients who elected for the community-based programme , 46 were still attending at follow up and 21 patients with moderate-to-severe COPD ( 44.9 + /- 12.6 ( mean + /- SD ) FEV(1)% predicted ) were reassessed at 18.4 + /- 11.9 months post PR . Significant improvements ( mean change ( 95 % confidence interval ) ) persisted in 6-min walk distance ( 41.1 m ( 15.7 - 66.5 ) ) , distance walked in 20 min ( 195.1 m ( 82.3 - 308 ) ) and in QOL ( Chronic Respiratory Disease Question naire ) ( 11.0 points ( 4.4 - 17.6 ) ) ( P < 0.01 ) . The QOL improvements exceeded the minimum clinical ly important difference . A trend towards a reduction in COPD -related hospital admissions , bed-days and emergency department presentations was observed in the 12 months following PR . Self-reported adherence with the home exercise programme indicated that 67 % of patients were exercising at least 3 - 5 days each week in addition to attending a class . CONCLUSION For patients with moderate-to-severe COPD , a weekly community-based maintenance exercise class , supervised by a physiotherapist , combined with a home exercise programme is an effective intervention for maintaining improvements following PR OBJECTIVE To establish the minimal important difference ( MID ) for the six-minute walk distance ( 6MWD ) in persons with chronic obstructive pulmonary disease ( COPD ) . DESIGN Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD . SETTING Outpatient pulmonary rehabilitation program at 2 teaching hospitals . PARTICIPANTS Seventy-five patients with COPD ( 44 men ) in a stable clinical state with mean age 70 years ( SD 9 y ) , forced expiratory volume in one second 52 % ( SD 21 % ) predicted and baseline walking distance 359 meters ( SD 104 m ) . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Participants completed the  six-minute walk test  before and after a 7-week pulmonary rehabilitation program . Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD . RESULTS The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters , compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change ( P=.004 ) . Anchor-based methods identified an MID of 25 meters ( 95 % confidence interval 20 - 61 m ) . There was excellent agreement with distribution-based methods ( 25.5 - 26.5 m , kappa=.95 ) . A change in 6MWD of 14 % compared with baseline also represented a clinical ly important effect ; this threshold was less sensitive than for absolute change ( sensitivity .70 vs .85 ) . CONCLUSIONS The MID for 6MWD in COPD is 25 meters . Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline . These data support the use of 6MWD as a patient-important outcome in research and clinical practice AIM To assess the feasibility and acceptability of swimming pool-based exercise as pulmonary rehabilitation ( PR ) for COPD sufferers . METHOD 101 patients with mild or moderate COPD registered with a South London general practice were invited to a swimming pool-based PR programme . Participants completed spirometry , the Chronic Respiratory Question naire ( CRQ-SR ) , and the Incremental Shuttle Walk Test ( ISWT ) before and after the programme . A qualitative interview was used to assess participants ' views . RESULTS 24 patients ( 24 % ) expressed interest ; 18 were recruited and 16 ( 16 % ) completed the PR programme . Their mean age was 69 yrs , seven were female , and mean % predicted FEV1 was 59 % . The mean number of sessions attended was 10.6 out of 12 . Significant improvements in dyspnoea score ( difference 4.9 ; 95 % CI -8.27 to -1.48 ) and walking distance ( difference 32 metres ; 95 % CI -52.63 to -11.36 ) were observed , and all other findings were in the direction of improvement . Most patients enjoyed being in the water , were happy to expose themselves in swimsuits , overcame their fears , valued learning about COPD and socializing with fellow sufferers , and were positive about their physical improvement . CONCLUSION The swimming pool is a feasible and positive alternative venue for PR for COPD patients in primary care OBJECTIVE To determine the importance of a breathing out into water exercise during subtotal immersion for emphysematous patients . DESIGN Results of a respiratory function test and arterial blood gas analysis were examined to compare the programs of breathing exercise with and without the breathing out into water exercise . The breathing exercises in a pool filled with 38 degrees C water were performed 30 min/day , 5 days/wk , for 2 mo in 17 patients with stable chronic emphysema . Patients were r and omly assigned to breathing exercise programs including subtotal water immersion with the nose and mouth either immersed ( 9 patients ) or out of the water ( 8 patients ) during exhalation . RESULTS The ratio of % forced expired volume in 1 sec to forced vital capacity and % forced vital capacity at rest were significantly increased in the program with the breathing out into water exercise , but they did not change in the program without the breathing out into water exercise . A significant increase in peak flow was observed in the former program , although it did not change in the latter program . The maximal expiratory flow at 25 % did not change in either program . Pao2 was significantly increased and Paco2 was significantly decreased in the former program , although a trend for a decrease in Paco2 was observed in the latter program . CONCLUSIONS These results suggest that the breathing 
    Output:
    
There is limited quality evidence that water-based exercise training is safe and improves exercise capacity and quality of life in people with COPD immediately after training .
There is limited quality evidence that water-based exercise training offers advantages over l and -based exercise training in improving endurance exercise capacity , but we remain uncertain as to whether it leads to better quality of life .
Little evidence exists examining the long-term effect of water-based exercise training