By Jacqueline Pierce, PT, CCS, CCRP, FAACVPR, and Ryan Arruda, MS

One of the central challenges in prescribing exercise for the pulmonary rehabilitation population is that when breathing itself feels like strenuous work, any added demand — whether strength, mobility, or endurance training — can quickly become overwhelming.

This is exactly why exercise becomes so essential. The body of someone with chronic lung disease isn’t just deconditioned — it’s operating under a constant respiratory workload that changes how they move, how long they can sustain activity, and how confident they feel doing it. Altered breathing mechanics, such as dynamic hyperinflation, make movement feel harder than it objectively is. This means that traditional exercise guidelines still apply, but the initial prescription and progression must be tailored to the individual’s respiratory tolerance.

Every movement needs to have a specific purpose, and every movement should include breathing strategies and energy conservation techniques. Purpose-driven exercise prescription helps patients understand why they’re doing an exercise. That focus on function/goals can dramatically improve adherence and lessen the barriers for home exercise. Energy conservation practices can be utilized to improve activity tolerance and dyspnea management. The goal is to not just improve fitness, but also to help make our patients more confident with their ability to move and breathe efficiently.

While the focus of this article is on respiratory conditions, energy conservation/home exercise is certainly applicable to all populations, including our cardiac patients. Consider the functional limitations of the heart failure population who may also have decreased strength and endurance and increased dyspnea. Chronic disease management is vital to quality of life for both populations, and regular exercise is a major component.

Basic energy conservation principles include:

• Exercise at the time of day when energy level is highest
• Exercise at a comfortable pace and allow rest breaks if needed
• Sitting up straight with good posture encourages better ventilation
• Sitting versus standing will conserve energy, if appropriate
• Coordinate the exhale with the most strenuous part of the exercise using pursed-lips breathing

Chair-Based Exercise Programs

Chair-based exercise programs are a safe and effective form of functional training for cardiopulmonary rehabilitation patients. These programs can be designed to help improve specific real-life tasks/activities that are essential in the patient’s daily routine, such as cooking, making the bed, vacuuming, showering/bathing, dressing, walking, transferring, etc. Often, this form of training is used in our more functionally limited patients, where safety, compliance, and energy conservation are priorities. Despite limitations, chair-based exercise can be an effective way of improving ADL [activities of daily living] performance and exercise compliance in these populations.

Chair-Based Aerobic Exercise

Movements focused on continuous, rhythmic action of the upper/lower body targeting endurance and coordination to improve walking/ADL performance. Examples of such exercises include:

• Seated marching
• Arm pedaling
• Floor pedaling
• Alternating heel/toe taps

Chair-Based Resistance Exercise

Single or multi-joint movements of the major upper- and lower-body muscle groups target strength building and coordination to improve ADL/task-specific performance. Examples of modalities include:

• Hand weights
• Resistance bands
• Bodyweight exercises
• Household items (e.g., using water bottles as hand weights)

Task-Oriented Functional Training Examples

• Walking and Transferring
  • Sit-to-stands, seated marching, seated weight-shifting
• Overhead reaching (Showering, Meal Prepping, Grooming)
  • Alternating overhead reach, seated shoulder press, seated wall slides
• Household Chores (Vacuuming, Mopping the Floor, Cooking)
  • Seated trunk rotations, bicep curls, lateral reaching
• Stair Climbing
  • Seated marching, seated leg extensions, seated heel taps

Real Patient Story

While chair-based exercise is an effective tool for improving physical function and ADL performance, it can also improve the ability of patients to return to meaningful and enjoyable daily activities. Mary is a 70-year-old woman who was diagnosed with interstitial lung disease (ILD). As the disease progressed and daily activities became more challenging, she found herself too exhausted to engage in the activities she finds most enjoyable, such as quilting. When entering pulmonary rehab, one of her goals was to return to quilting, as she previously had done for two to three hours at a time. Quilting demands upper-extremity strength, endurance, and coordination, which can all be diminished in a deconditioned individual with ILD. To specifically help improve her ability to quilt, she was given the following chair-based functional routine: 

• Arm ergometer – 7 minutes @12 watts
• Seated band rows
• Front/lateral raises
• Alternating overhead reach
• Seated trunk rotations

These exercises were selected to replicate the movements that Mary needed to perform while quilting. Pursed-lips breathing and pacing skills were emphasized with each exercise. She performed the exercises during the early afternoon, which was when she felt more energetic, and she was coached on appropriate posture and quality of movement.

By regularly engaging in this chair-based program designed to improve a specific activity, Mary regained the strength to return to her hobby. She was able to return to quilting daily for 2-4 hours at a time, donating her finished products to a community-based organization that provides bedding items for families in need.

As evident in Mary’s story, chair-based functional exercise can be an effective tool to help our patients meet their goals.  As pulmonary and cardiac rehab clinicians, designing a home program is a chance to improve patient outcomes and challenge the clinician’s creativity in prescribing exercise that directly translates to activities and the movements they require.   

Ultimately, chair-based home exercise programs empower patients to improve independence in essential daily tasks while re-establishing the ability to participate in the activities that bring them the greatest meaning and enjoyment.

Jackie Pierce is an APTA clinical specialist in cardiopulmonary physical therapy. She has 27 years of service at the Miriam Hospital's Center for Cardiac, Pulmonary, and Vascular Fitness in Providence, Rhode Island, where she is currently the pulmonary rehab program coordinator. Pierce is an adjunct faculty member at URI in the physical therapy program and the current MACVPR president.

Ryan Arruda is a clinical exercise physiologist at the Miriam Hospital's Center for Cardiac, Pulmonary, and Vascular Fitness in Providence, Rhode Island. He holds an MS in kinesiology from the University of Rhode Island and is passionate about improving patient outcomes through evidence-based exercise interventions, with a focus on increasing long-term exercise adherence in cardiac and pulmonary rehabilitation populations.