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1
Pulmonary Rehabilitation
Pulmonary Rehabilitation
Second Edition

Edited by

Claudio F. Donner
Nicolino Ambrosino
Roger S. Goldstein
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2021 by Taylor & Francis Group, LLC

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Library of Congress Cataloging-in-Publication Data

Names: Donner, C. F. (Claudio F.), editor. | Ambrosino, N. (Nicolino), 1948- editor. | Goldstein, Roger, editor. |
Donner, C. F. (Claudio F.). Pulmonary rehabilitation.
Title: Pulmonary rehabilitation / edited by Claudio F. Donner, Nicolino Ambrosino, Roger S. Goldstein.
Other titles: Pulmonary rehabilitation (Donner)
Description: Second edition. | Boca Raton : CRC Press, [2020] | Preceded by Pulmonary rehabilitation /
Claudio F. Donner, Nicolino Ambrosino, Roger Goldstein. 2005. | Includes bibliographical references and index. |
Summary: “The new edition includes new sections on the development of PR as a discipline, global perspectives on quality control,
early PR post exacerbation and personalized rehabilitation, innovative approaches to exercise, PR in interstitial lung disease and
lung transplantation, and the latest research into the application of music, dance and yoga”-- Provided by publisher.
Identifiers: LCCN 2020002769 (print) | LCCN 2020002770 (ebook) | ISBN 9781138498815 (hardback) |
ISBN 9781351015592 (ebook)
Subjects: MESH: Pulmonary Disease, Chronic Obstructive--rehabilitation | Respiratory Therapy--methods | Treatment Outcome
Classification: LCC RC776.R38 (print) | LCC RC776.R38 (ebook) | NLM WF 600 | DDC 616.2/4--dc23
LC record available at https://lccn.loc.gov/2020002769
LC ebook record available at https://lccn.loc.gov/2020002770

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents

Foreword ix
About the Book xi
Preface xiii
Editors xv
Contributors xvii

Part 1 THE FOUNDATION OF PULMONARY REHABILITATION 1

1 A framework for medical rehabilitation: Restoring function and improving quality of life 3
Julia Warden and Mark Bayley
2 Pulmonary rehabilitation: The development of a scientific discipline 11
Linda Nici and Roger S. Goldstein
3 Key concepts in pulmonary rehabilitation 21
Felipe V.C. Machado, Frits M.E. Franssen and Martijn A. Spruit
4 Enhancing use and delivery of pulmonary rehabilitation 29
Emily Hume, Carolyn L. Rochester and Ioannis Vogiatzis
5 Pathophysiological basis, evaluation and rationale of exercise training 41
Pierantonio Laveneziana and Paolo Palange
6 Education: Realizing the potential for learning in pulmonary rehabilitation 53
Felicity Blackstock and Suzanne C. Lareau
7 Self-management 63
Jean Bourbeau and Tanja W. Effing
8 Dual therapy: Pharmacologic management in pulmonary rehabilitation 75
J. Michael Nicholson and Richard Casaburi

Part 2 EVALUATION AND MANAGEMENT 87

9 Respiratory muscle function in rehabilitation 89

Thierry Troosters, Michael I. Polkey and Rik Gosselink
10 Peripheral muscles 99
Luis Puente-Maestu, François Maltais, André Nyberg and Didier Saey
11 Anxiety and depression in patients with chronic respiratory disease 115
Abebaw Mengistu Yohannes
12 Dyspnoea 125
Pierantonio Laveneziana and Donald A. Mahler
13 Nutritional management in pulmonary rehabilitation 135
Rosanne J.H.C.G. Beijers, Emiel F.M. Wouters and Annemie M.W.J. Schols
14 Balance impairment 145
Marla K. Beauchamp

v
vi Contents

15 Monitoring of physical activity 153

Heleen Demeyer, Thierry Troosters and Henrik Watz
16 Monitoring health status 163
Claire M. Nolan, William D.-C. Man and Richard L. ZuWallack

Part 3 HOW, WHO AND WHERE? 171

17 Establishing a pulmonary rehabilitation programme 173

Michael D.L. Morgan and Sally J. Singh
18 Quality assurance and control in pulmonary rehabilitation 183
Michael Steiner, Chris Garvey, Sally J. Singh and Gerene Bauldoff
19 The ideal candidate 195
Francesca de Blasio, Rafael Mesquita and Enrico Clini
20 Rehabilitation team 203
Inês Machado Vaz, Sofia Viamonte and João Carlos Winck
21 Modalities of exercise training 209
Matthew Armstrong, Rebecca Crouch and Ioannis Vogiatzis
22 Physiotherapy and airway clearance 219
Miguel R. Gonçalves and Amanda J. Piper
23 Smoking cessation 231
Francesco Pistelli, Stefania Brogi and Laura Carrozzi
24 Early rehabilitation following exacerbation of COPD 241
William D.-C. Man, Claire M. Nolan and Milo A. Puhan
25 Personalized rehabilitation 247
Nicolino Ambrosino and Annia Schreiber
26 Pulmonary rehabilitation and primary care 253
Jonathan M. Raskin
27 Home rehabilitation 257
Sally J. Singh and Linzy Houchen-Wolloff
28 Telerehabilitation 271
Michele Vitacca and Michael K. Stickland
29 Living with chronic lung disease: The experiences and needs of patients and caregivers 281
Alda Marques and Roger S. Goldstein

Part 4 NEW APPROACHES TO EXERCISE TRAINING 295

30 Partitioned aerobic exercise training of ventilatory-limited patients with chronic respiratory disease 297
Thomas E. Dolmage and Roger S. Goldstein
31 Whole-body vibration training 309
Rainer Gloeckl
32 Neuromuscular electrical stimulation 317
Matthew Maddocks and Isabelle Vivodtzev
33 A role for water-based rehabilitation 327
Renae J. McNamara and Jennifer A. Alison
34 Sedentarism and light-intensity physical activity (in COPD) 335
Kylie Hill, Zoe McKeough and Daniel F. Gucciardi

Part 5 DISEASES OTHER THAN COPD 347

35 The multi-morbidity patient 349

Roberto Tonelli, Ernesto Crisafulli, Stefania Costi and Enrico Clini
36 Is there any role for pulmonary rehabilitation in asthma? 359
Elisabetta Zampogna, Martina Zappa, Antonio Spanevello and Dina Visca
37 Neuromuscular disorders 363
Miguel R. Gonçalves and John R. Bach
 Contents vii

38 Interstitial lung diseases 373

Nicolino Ambrosino
39 Management of suppurative lung diseases 379
J. Michael Nicholson, Roger S. Goldstein and Dmitry Rozenberg
40 Rehabilitation in the intensive care unit 391
Piero Ceriana and Nicolino Ambrosino
41 Chronic respiratory failure – pathophysiology 399
Mafalda Vanzeller, Marta Drummond and João Carlos Winck
42 Lung transplantation 409
Daniel Langer
43 Lung volume reduction − old and new approaches 419
Nathaniel Marchetti and Gerard Criner

Part 6 ADD-ON INTERVENTIONS 439

44 Supplemental oxygen and heliox 441

Paolo Palange and Richard Casaburi
45 Noninvasive ventilation during exercise training 447
Nicolino Ambrosino and Lara Pisani
46 COPD patients requiring chronic nocturnal noninvasive ventilation 455
Marieke L. Duiverman and Peter J. Wijkstra
47 More tools in the toolbox 463
Annemarie L. Lee and Dina Brooks
48 Palliative care and end of life 473
Michele Vitacca and Nicolino Ambrosino
49 Economical evaluation 483
Roberto W. Dal Negro and Claudio F. Donner
50 Pulmonary rehabilitation in the integrated care of the chronic respiratory patient 491
Linda Nici and Richard L. ZuWallack
51 Pulmonary rehabilitation in post-acute patients with COVID-19 503
Michele Vitacca, Mara Paneroni, and Nicolino Ambrosino

Index 511
Foreword

There is no field in the therapy of patients with respira- expanded in the fourth section, where new approaches to
tory diseases that has shown more practical evidence for this crucial component are explored. This section serves as
its benefit than that of pulmonary rehabilitation. This has an excellent base for those interested in exploring new areas
occurred over the last several decades because of the persis- of research. The subsequent section is also novel in provid-
tence of some unique health care professionals devoted to ing actualized information about the value of pulmonary
improving the quality of life of patients suffering from these rehabilitation in diseases different from chronic obstructive
illnesses. The scientific method has been applied to answer pulmonary disease. This is extremely important because
the many questions that in previous decades labeled the most of the solid evidence upon which we have built the
field of pulmonary rehabilitation as simple ‘art’. The new programs is based on experience gained in patients with
edition of this already classic book summarizes the result COPD. Once again, how effective the basic program is and
of hundreds of studies, many of which have been authored how to modify it, if we have to, is ripe for more research and
by the chapter writers since 2005 and complemented by should stimulate younger generations of caregivers to plan
their extensive personal experience in treating the ultimate the studies needed to expand the applicability of this highly
beneficiaries—symptomatic patients with respiratory ail- effective therapy. The last section gathers several specific
ments. Unique to the readers of this book is the important areas of importance that are often forgotten and should be
contribution by a group of Italian colleagues who sum- in the minds of health care providers who participate in the
marized their experience and recommendations related to care of these patients. This section includes the crucial issue
pulmonary rehabilitation in this era of the COVID-19 pan- of palliative care for compromised patients and the novel
demic. Even though we expect this pandemic to decrease experience with rehabilitation in the COVID-19 era.
and eventually disappear, the lessons learned should be The modern world in which we live allows us to access
extremely helpful and instructive, as it is likely that epi- novel information from almost anywhere in the world.
demics such as the one we have suffered will reappear in This has led to the narrow view that books are no longer
the future. One lesson gained from this experience is that needed. Nothing could be further from the truth, as this
we should always be prepared. edition proves. There is a need to have an updated reference
A special recognition must be given to Drs Claudio at hand, to summarize in one single volume the knowledge
Donner, Nicolino Ambrosino and Roger Goldstein, who that arises from the wide-angle vision of experience. This
gathered not only the most respected authorities in the field book is a must for anyone interested in caring for patients
to contribute to this book, but had the foresight to orga- with respiratory disease who are symptomatic with compro-
nize its contents along an easy-to-grasp series of impor- mise in their lifestyle. Pulmonary rehabilitation has been
tant headings. It starts with the foundation of the specialty, proven to result in the largest potential impact on objective
authored by several modern pioneers of the field and laying outcomes such as dyspnea, quality of life, and functional
the ground work for subsequent major headings. The book capacity in patients who qualify for the treatment. Its wide
then guides the reader in the appropriate tools to evaluate application still remains an elusive goal, and this book is
patients in those areas where the therapy will have its effect, one excellent effort to increase not only knowledge about
or that will be needed to monitor during and after the pro- the benefits of pulmonary rehabilitation, but also to spark
gram. In the third section, various experts review the basic an expansion in the number of champions ready to make
questions of who, where, and when with excellent reviews rehabilitation a routine tool in treating their patients.
on how to develop a program and expand areas such as the
use of the home for rehabilitation and the potential use of Bartolome R. Celli, MD
telemedicine. The same section reviews the solid science that Professor of Medicine
has proven to be the most important component of pulmo- Harvard Medical School
nary rehabilitation, that of exercise training. This is further Boston, Massachusetts

ix
About the Book

On the wall in my office is a letter from a gentleman with advances that have occurred since 2005. These include
COPD received in 2005, the same year the first edition of new approaches to exercise training (e.g. partitioning,
this important text on pulmonary rehabilitation was pub- water-based training and neuromuscular stimulation)
lished. He opens the letter by telling me that his recent pul- and a broader range of program components (e.g. physi-
monary rehabilitation program had ‘worked wonders for cal activity monitoring and balance training). Pulmonary
me – I would not have believed it possible’. He goes on to rehabilitation is extended into new settings and modes of
describe the new knowledge he had gained, and how he had delivery (primary care, home, telerehabilitation), and the
been particularly struck by the critical role of the alveoli in importance of quality assurance is addressed. The voices
lung health and disease. He was a mathematician, so he had of patients and caregivers are incorporated into this new
gone home and calculated the surface area of a single alveo- edition to enhance our understanding of the experience of
lus. He included those results in his letter (by his calculation living with chronic lung disease and of undertaking pul-
each alveolus 0.23 mm2, giving rise to over 70 m2 of surface monary rehabilitation. Emerging knowledge on rehabilita-
area for gas exchange in the lung). This story will be famil- tion of COVID-19 survivors is included. The authors bring
iar to many pulmonary rehabilitation practitioners using expertise from across the globe, and their work confirms
this book, who will have numerous testimonials (perhaps that pulmonary rehabilitation is an essential component of
without the maths) from people who experienced similar comprehensive and integrated care. I am confident that the
benefits. Pulmonary rehabilitation is an intervention that scientific rigor, clinical expertise, and insights contained in
can transform the lives of people with chronic lung disease these pages will contribute to better lives for people with
and has transformed the understanding of healthcare pro- chronic lung disease.
fessionals about the extraordinary things that people with
chronic lung disease can do. Anne E Holland PT PhD FThorSoc
In this second edition of Pulmonary Rehabilitation, Professor Physiotherapy
the authors have presented the well-established scien- Monash University and Alfred Health
tific foundations of this treatment along with the many Melbourne, Australia

xi
Preface

Since publication of the first edition of this book in 2005, society-centred and has to be modified within the context
there has been growing interest in the role of pulmonary of local clinical and financial resources. Programmes must
rehabilitation (PR) for the management of chronic respira- also be quality controlled to ensure fidelity to the model
tory disease, which continues to increase as a major cause used. There is an increasing awareness of the importance of
of global mortality and morbidity. Health providers and the impact of respiratory disease on caregiver burden. Newer
healthcare professionals, having become more aware of the modalities of distance monitoring, such as telemedicine-
improvements in function and quality of life associated with supported rehabilitation and web-based learning modules,
PR, are increasingly including it as an integral part of their are being encouraged to increase access and capacity as well
approach to disease management. Since the joint European as prolong the benefits of PR. With the increased interest
Respiratory Society and American Thoracic Society’s 2013 in collaborative integrated care, clinicians are challenged
major statements on PR, published guidelines from profes- to map the pathways that site PR in the patients’ journey
sional associations around the world have endorsed PR as the between community services and acute care admissions.
prevailing standard of care for those with chronic respiratory The increasing interest in PR has paralleled the advances
conditions. in the development of patient-reported outcomes as well as
PR substantially helps clinicians extend the pharmaco- patient-reported experiences. Although proven to improve
logical approach to chronic disease management by tackling quality of life and exercise capacity as well as reduce health-
some of the many associated non-respiratory impairments care utilization, the possibility that PR may offer a survival
such as peripheral muscle dysfunction, cardiovascular dis- advantage remains of interest.
ease, nutritional limitations and mental health disorders The authors have condensed information from reports
that are associated with chronic diseases. PR reduces exacer- spanning 2005 to 2019, published since the last edition.
bation frequency and healthcare resource utilization. It also There are key points, take-home learning messages and
offers clinically important symptom relief and functional chapter summaries. We have been fortunate in attracting
improvements for those with non-COPD respiratory condi- some of the world’s most recognized experts in the field and
tions such as pulmonary fibrosis, pulmonary hypertension, we hope that this text serves as a learning tool and resource
suppurative lung disease and in the population preparing for the next generation of healthcare providers interested in
for and following lung transplantation, lobar resection or participating and increasing learning in this evolving field.
volume reduction surgery.
Despite the rich fabric of information reported in excel- Claudio F. Donner
lent peer-reviewed publications, there are exciting ongo- Nicolino Ambrosino
ing challenges in relation to the location, duration, timing Roger S. Goldstein
and content of PR. Clearly it must be both patient- and

xiii
Editors

Claudio F. Donner, FERS is currently medical director of Nicolino Ambrosino, FERS is a specialist in internal
Mondo Medico Multidisciplinary and Rehabilitation Clinic, ­medicine, pulmonary diseases and physiokinesitherapy and
Borgomanero (NO), Italy, prior to which he served as chief occupational medicine. He is a research consultant at Istituti
of the Division of Pulmonary Disease, Scientific Institute of Clinici Maugeri, Pavia, Italy. He is also chief editor of the
Veruno, ‘S. Maugeri’ Foundation (1985–2006) and director Pulmonology journal. He was formerly research and clini-
of the Department of Pulmonary Rehabilitative Medicine cal department director of Auxilium Vitae Rehabilitation
of the ‘S. Maugeri’ Foundation throughout Italy. He has also Center Volterra, director of the Pulmonary and Respiratory
been on the faculty of medical schools in Ferrara, Turin, Intensive Care Unit, Cardio-Thoracic Department, University
and Novara. Hospital, Pisa and director of the Pulmonary Division and
Dr Donner has served professional associations in a Intermediate Intensive Care, S. Maugeri Foundation, Medical
number of capacities including as president of the Italian Center of Gussago. He has been also appointed professor at
Association of Hospital Pulmonologists (AIPO) (1995–1997) several Italian universities.
and of the Italian Interdisciplinary Association for Research Dr Ambrosino is one of the earliest contributors to the
in Lung Disease (AIMAR) (2003–2012). He has also been development of the use of noninvasive mechanical venti-
president of the non-profit Italian Foundation ‘World of lation techniques in acute and chronic respiratory failure,
Breath’ since 2013. Additional professional activities include pulmonary rehabilitation and respiratory intensive care
service as head of the ERS Clinical Assembly (1996–1998), units. His research activity has been devoted to respiratory
secretary general of the European Respiratory Society (ERS) critical care, pulmonary rehabilitation and home respira-
(1998–2004), president (2002–2006) of the Pneumology tory care.
Section & Board of the European Union of Medical Specialists He has received several life achievement awards such
(UEMS) (2002–2006), and member the UEMS Management as the ERS educational award and those from the ATS
Council (2004–2006). He was also international governor of Pulmonary Rehabilitation Assembly, the ERS Assembly II,
the American College of Chest Physicians’ Italian Chapter the Italian Association of Pulmonologist and Livorno Oscar.
(2009–2012). Commended for his involvement, Dr Donner
has been honored with numerous awards, most recently Roger S. Goldstein, FRCP (C), FRCP (UK) is a professor of
receiving a fellowship of the European Respiratory Society medicine and physical therapy at the University of Toronto.
and special recognition by AIPO He held the founding National Sanitarium Association’s
Dr Donner is past editor-in-chief of the scientific journal Chair in Respiratory Rehabilitation Research from 2002–
Monaldi Archives for Chest Disease (1993–2002) and associ- 2019. He is a senior scientist and heads the Respiratory
ate editor since 2017 as well as past co-editor (1990–2004) of Division at West Park Healthcare Centre, Toronto, Ontario,
the Italian Review of Respiratory Disease (1990–2004) and of Canada, which specializes in the management of chronic
Multidisciplinary Respiratory Medicine (2006–2016). He has respiratory conditions. Together with Dr Dina Brooks, he
been associate editor of Respiratory Medicine since 2005. co-leads the postgraduate respiratory research programme
He is also author of several textbooks and numerous at West Park, which has welcomed fellows from Canada and
original scientific papers (208 indexed in MEDLINE) on around the world. He was the founding scientific chair of
a wide range of topics including pathophysiologic mecha- the first Canadian Respiratory Conference. He has made
nisms of exercise and CO2 retention, follow-up of chronic numerous presentations and has published more than 200
respiratory failure (CRF), lung mechanics in critical care, articles in his field of research. He co-edited the first edition
pulmonary rehabilitation, COPD genetics, sleep respiratory of Pulmonary Rehabilitation in 2005 and is the co-editor of
disorders and QoL in patients with CRF. the current second edition.

xv
Contributors

Jennifer A. Alison and

Sydney School of Health Sciences Division of Physical Medicine and Rehabilitation
Faculty of Medicine and Health Department of Medicine
The University of Sydney University of Toronto
and Toronto, Ontario, Canada
Sydney Local Health District
NSW Ministry of Health Marla K. Beauchamp
Sydney, Australia School of Rehabilitation Science
Department of Medicine
Nicolino Ambrosino McMaster University
Istituti Clinici Scientifici Maugeri IRCCS Hamilton, Ontario, Canada
U.O. di Pneumologia Riabilitativa
Istituto Scientifico di Montescano (PV) and
Montescano, Italy
West Park Healthcare Centre
Toronto, Ontario, Canada
Matthew Armstrong
Department of Sport, Exercise and
Rehabilitation Rosanne J.H.C.G. Beijers
School of Health & Life Sciences Department of Respiratory Medicine
Northumbria University NUTRIM School of Nutrition and Translational
Newcastle, United Kingdom Research in Metabolism
Maastricht University Medical Centre
John R. Bach Maastricht, The Netherlands
Department of Physical Medicine and Rehabilitation and
Department of Neurosciences Felicity Blackstock
Center for Ventilator Management Alternatives Department of Physiotherapy
University Hospital School of Science and Health
Rutgers New Jersey Medical School Western Sydney University
Newark, New Jersey Sydney, Australia

Gerene Bauldoff Jean Bourbeau

Clinical Nursing Respiratory Epidemiology and
The Ohio State University Clinical Research Unit
Columbus, Ohio Research Institute of the McGill University
Health Centre
Mark Bayley Department of Medicine
Toronto Rehabilitation Institute McGill University
University Health Network Montreal, Quebec, Canada

xvii
xviii Contributors

Stefania Brogi Gerard Criner

Pulmonary Unit Department of Thoracic Medicine and Surgery
Cardiothoracic and Vascular Department Lewis Katz School of Medicine at Temple University
University Hospital of Pisa Philadelphia, Pennsylvania
Pisa, Italy
Ernesto Crisafulli
Dina Brooks Department of Medicine and Surgery
Department of Respiratory Medicine Respiratory Disease and Lung Function Unit
West Park Healthcare Centre University of Parma
and Parma, Italy
Department of Physical Therapy
University of Toronto
Toronto, Ontario, Canada Rebecca Crouch
College of Pharmacy and Health Sciences
and Campbell University
School of Rehabilitation Sciences Buies Creek, North Carolina
Faculty of Health Sciences
McMaster University Roberto W. Dal Negro
Hamilton, Ontario, Canada National Centre for Respiratory Pharmacoeconomics and
Pharmacoepidemiology
Laura Carrozzi CESFAR
Department of Surgery, Medicine, Verona, Italy
Molecular Biology and Critical Care
University of Pisa Francesca de Blasio
and Department of Medical Science
Respiratory Pathophysiology and Rehabilitation University of Turin
Section Turin, Italy
Cardiothoracic and Vascular Department
University Hospital of Pisa and
Pisa, Italy Department of Medicine and Health Sciences
‘V.Tiberio’ University of Molise and Clinic Center
Richard Casaburi S.p.A.
Rehabilitation Clinical Trials Center Private Hospital
Los Angeles Biomedical Research Institute at Campobasso, Italy
Harbor UCLA Medical Center
Torrance, California
Heleen Demeyer
Department of Rehabilitation Sciences
Piero Ceriana
Ghent University
Istituti Clinici Scientifici Maugeri IRCCS
Ghent, Belgium
U.O. di Pneumologia Riabilitativa
Istituto Scientifico di Pavia and
Pavia, Italy
University Hospitals Leuven
Respiratory Division
Enrico Clini
Leuven, Belgium
Department of Medical and Surgical Sciences
University of Modena Reggio Emilia and
University Hospital of Modena Thomas E. Dolmage
Modena, Italy Respiratory Diagnostic & Evaluation Services
West Park Healthcare Centre
Stefania Costi Toronto, Ontario, Canada
Department of Surgical Medical and Dental
Department of Morphological Sciences related to Claudio F. Donner
Transplants, Oncology and Regenerative Medicine Mondo Medico
University of Modena and Reggio Emilia Multidisciplinary and Rehabilitation Outpatient Clinic
Modena, Italy Borgomanero (NO), Italy
 Contributors xix

Marta Drummond Miguel R. Gonçalves

Faculty of Medicine Noninvasive Ventilatory Support Unit
Porto University Pulmonology Department
and Emergency and Intensive Care Medicine Department
Pulmonology Department Center for Home Mechanical Ventilation
São João Hospital São João University Hospital
Porto, Portugal and
Faculty of Medicine
Marieke L. Duiverman University of Porto
Department of Pulmonary Diseases/Home Mechanical Porto, Portugal
Ventilation
and Rik Gosselink
Groningen Research Institute for Asthma and COPD Department of Rehabilitation Sciences
University of Groningen KU Leuven
University Medical Center Groningen and
Groningen, The Netherlands Pulmonary Rehabilitation, Respiratory Division
University Hospital Leuven
Leuven, Belgium
Tanja W. Effing
Department of Respiratory Medicine Daniel F. Gucciardi
Southern Adelaide Local Health Network School of Physiotherapy and Exercise Science and Physical
and Activity and Well-Being Research Group
School of Medicine Faculty of Health Science
Flinders University Curtin University
Adelaide, Australia Perth, Western Australia, Australia

Frits M.E. Franssen Kylie Hill

Department of Research and Development School of Physiotherapy and Exercise Science
CIRO+ Faculty of Health Science
Horn, The Netherlands Curtin University
and
and Institute for Respiratory Research
Department of Respiratory Medicine Sir Charles Gairdner Hospital
Maastricht University Medical Centre Perth, Western Australia, Australia
NUTRIM School of Nutrition and Translational
Linzy Houchen-Wolloff
Research in Metabolism
Department of Respiratory Science
Maastricht, The Netherlands
University of Leicester
and
Chris Garvey Centre for Exercise and Rehabilitation Science
Pulmonary Rehabilitation and Sleep Disorders NIHR Leicester Biomedical Research Centre – Respiratory
University of California San Francisco Glenfield Hospital
San Francisco, California Leicester, United Kingdom

Emily Hume
Rainer Gloeckl
Department of Sport, Exercise and Rehabilitation
Institute for Pulmonary Rehabilitation Research
Northumbria University
Schoen Klinik Berchtesgadener Land
Newcastle, United Kingdom
Schönau am Königssee, Germany
Daniel Langer
Roger S. Goldstein KU Leuven Faculty of Movement and
Respiratory Rehabilitation Research Rehabilitation Sciences
Medicine and Physical Therapy and
University of Toronto Department of Rehabilitation Sciences
and Research Group for Rehabilitation in Internal Disorders
Respiratory Services Respiratory Rehabilitation and Respiratory Division
West Park Healthcare Centre University Hospital
Toronto, Ontario, Canada Leuven, Belgium
xx Contributors

Suzanne C. Lareau François Maltais

College of Nursing Institut universitaire de cardiologie et de
University of Colorado pneumologie de Québec
Anschutz Medical Center Université Laval
Aurora, Colorado Québec, Canada

Pierantonio Laveneziana William D.-C. Man

Sorbonne Université Harefield Respiratory Research Group
INSERM Royal Brompton and Harefield NHS Foundation Trust
UMRS1158 Neurophysiologie Respiratoire and
Expérimentale et clinique National Heart and Lung Institute
and Imperial College
Département Médico-Universitaire and
AP-HP Sorbonne Université Harefield Pulmonary Rehabilitation and Muscle Research
Service des Explorations Fonctionnelles de la Respiration, Laboratory
de l’Exercice et de la Dyspnée des Hôpitaux London, United Kingdom
Pitié-Salpêtrière
Tenon et Saint-Antoine Nathaniel Marchetti
Paris, France Department of Thoracic Medicine and Surgery
Lewis Katz School of Medicine at Temple University
Annemarie L. Lee Philadelphia, Pennsylvania
Department of Physiotherapy
Monash University Alda Marques
and Lab3R-Respiratory Research and Rehabilitation
Institute for Breathing and Sleep Laboratory of the School of Health Sciences (ESSUA)
Austin Health and
and Institute of Biomedicine (iBiMED)
Physiotherapy, Rehabilitation, Nutrition and Sport University of Aveiro
La Trobe University Aveiro, Portugal
Victoria, Australia
Zoe McKeough
Felipe V.C. Machado Discipline of Physiotherapy
Department of Research and Development Sydney School of Health Sciences
CIRO+ Faculty of Medicine and Health
Horn, The Netherlands The University of Sydney
and Sydney, New South Wales, Australia

Department of Physiotherapy Renae J. McNamara

Laboratory of Research in Respiratory Physiotherapy (LFIP) Department of Physiotherapy
State University of Londrina Prince of Wales Hospital
Londrina, Brazil and
Sydney School of Health Sciences
Matthew Maddocks Faculty of Health Sciences
King’s College London The University of Sydney
London, United Kingdom and
Woolcock Institute of Medical Research
Donald A. Mahler The University of Sydney
Geisel School of Medicine at Dartmouth Sydney, Australia
Hanover, New Hampshire
Rafael Mesquita
and
Department of Physiotherapy
Valley Regional Hospital Federal University of Ceará
Claremont, New Hampshire Fortaleza, Brazil
 Contributors xxi

Michael D.L. Morgan Francesco Pistelli

Department of Respiratory Science Pulmonary Unit
University of Leicester Cardiothoracic and Vascular Department
and University Hospital of Pisa
Centre for Exercise and Rehabilitation Science Pisa, Italy
NIHR Leicester Biomedical Research Centre – Respiratory
Glenfield Hospital
Michael I. Polkey
Leicester, United Kingdom
Department of Respiratory Medicine
Royal Brompton & Harefield NHS Foundation Trust
J. Michael Nicholson
London, United Kingdom
Division of Respirology
Western University
London, Ontario, Canada Luis Puente-Maestu
Department of Respiratory Medicine
Linda Nici University Hospital Gregorio Marañón
The Warren Alpert Medical School of Brown University Universidad Complutense de Madrid Medical School
and Madrid, Spain
Providence Veterans Affairs Medical Center
Providence, Rhode Island
Milo A. Puhan
Epidemiology, Biostatistics and Prevention Institute
Claire M. Nolan
University of Zurich
Harefield Respiratory Research Group and
Zurich, Switzerland
Harefield Pulmonary Rehabilitation Unit
Royal Brompton and Harefield NHS Foundation Trust
London, United Kingdom Jonathan M. Raskin
Mount Sinai Beth Israel Medical Center
André Nyberg Lenox Hill Hospital
Department of Community Medicine and Rehabilitation Mount Sinai Medical Center
Section of Physiotherapy New York, New York
Umeå University
Umeå, Sweden
Carolyn L. Rochester
Paolo Palange Section of Pulmonary, Critical Care and Sleep Medicine
Department of Public Health and Infectious Diseases Department of Medicine
Sapienza University of Rome Yale University School of Medicine
and New Haven, Connecticut
Lorillard-Spencer Foundation
Sapienza University of Rome Dmitry Rozenberg
Rome, Italy Department of Medicine
Division of Respirology
Amanda J. Piper University of Toronto
Department of Respiratory and Sleep Medicine and
Royal Prince Alfred Hospital Sandra Faire & Ivan Fecan Professorship
Camperdown, Australia in Rehabilitation Medicine
and Toronto General Hospital Research Institute
Faculty of Medicine and Health Science University Health Network
University of Sydney Toronto, Ontario, Canada
Sydney, New South Wales, Australia

Lara Pisani Didier Saey

Respiratory and Critical Care Unit Centre de Recherche
Alma Mater Studiorum Institut universitaire de cardiologie et de
University of Bologna pneumologie de Québec
Sant’Orsola Malpighi Hospital Université Laval
Bologna, Italy Québec, Canada
xxii Contributors

Annemie M.W.J. Schols Michael K. Stickland

NUTRIM School of Nutrition and Translational Research in Pulmonary Division
Metabolism Department of Medicine
Department of Respiratory Medicine Faculty of Medicine and Dentistry
Maastricht University Medical Centre University of Alberta
Maastricht, The Netherlands and
G.F. MacDonald Centre for Lung Health
Annia Schreiber Covenant Health
Division of Respirology Edmonton, Alberta, Canada
Department of Medicine
University Health Network
Toronto, Ontario, Canada Roberto Tonelli
Department of Medical and Surgical
Sally J. Singh Sciences
Department of Respiratory Science University of Modena Reggio Emilia
University of Leicester and
and University Hospital of Modena
Centre for Exercise and Rehabilitation Science Modena, Italy
NIHR Leicester Biomedical Research Centre – Respiratory
Glenfield Hospital
Thierry Troosters
Leicester, United Kingdom
Departement of Rehabilitation Sciences
KU Leuven
Antonio Spanevello
and
Dipartimento di Medicina e Chirurgia
Pulmonary Rehabilitation
Malattie dell’Apparato Respiratorio Università degli Studi
Respiratory Division
dell’Insubria
University Hospital Leuven
Varese, Italy
Leuven, Belgium
and

Dipartimento di Medicina e Riabilitazione Cardio Mafalda Vanzeller

Respiratoria U.O. di Pneumologia Riabilitativa Istituti Faculty of Medicine
Clinici Scientifici Maugeri, IRCCS Tradate Porto University
Tradate, Italy and
Pulmonology Department
Martijn A. Spruit São João Hospital
Department of Research and Development Porto, Portugal
CIRO+
Horn, The Netherlands
Inês Machado Vaz
and Centro de Reabilitação do Norte/Centro
Department of Respiratory Medicine Hospitalar Vila Nova de Gaia-Espinho
Maastricht University Medical Centre Valadares, Portugal
NUTRIM School of Nutrition and Translational Research in
Metabolism
Sofia Viamonte
Maastricht, The Netherlands
Centro de Reabilitação do Norte/Centro
and Hospitalar Vila Nova de Gaia-Espinho
Valadares, Portugal
Rehabilitation Research Center (REVAL)
Biomedical Research Institute (BIOMED)
Faculty of Rehabilitation Sciences Dina Visca
UHasselt Istituti Clinici Scientifici Maugeri IRCCS
Diepenbeek, Belgium Respiratory Rehabilitation of the Institute
of Tradate (VA)
Michael Steiner and
Leicester Biomedical Research Centre-Respiratory Department of Medicine and Surgery
Institute for Lung Health Respiratory Diseases
University of Leicester University of Insubria
Leicester, United Kingdom Varese-Como, Italy
 Contributors xxiii

Michele Vitacca João Carlos Winck

Istituti Clinici Scientifici Maugeri IRCCS Centro de Reabilitação do Norte/Centro Hospitalar Vila
U.O. di Pneumologia Riabilitativa Nova de Gaia-Espinho
Institute of Lumezzane (Brescia) Valadares, Portugal
and
and
Respiratory Rehabilitation Division
Istituti Clinici Scientifici Maugeri Faculdade de Medicina do Porto
IRCCS Lumezzane (BS) Porto, Portugal
Lumezzane, Italy
Emiel F.M. Wouters
Isabelle Vivodtzev
NUTRIM School of Nutrition and Translational
Department of Physical Medicine & Rehabilitation
Research in Metabolism
Harvard Medical School
Department of Respiratory Medicine
Boston, Massachusetts
Maastricht University Medical Centre
Maastricht, The Netherlands
Ioannis Vogiatzis
VA Connecticut Healthcare System
West Haven, Connecticut Abebaw Mengistu Yohannes
Azusa Pacific University
and Department of Physical Therapy
Department of Sport, Exercise and Rehabilitation School of Behavioral and Applied Sciences
School of Health & Life Sciences Azusa, California
Northumbria University
Newcastle, United Kingdom Elisabetta Zampogna
Istituti Clinici Scientifici Maugeri IRCCS
Julia Warden Respiratory Rehabilitation of the Institute
Toronto Rehabilitation Institute of Tradate (VA)
University Health Network Tradate (VA), Italy
and
Division of Physical Medicine and Rehabilitation
Martina Zappa
Department of Medicine
University of Insubria
University of Toronto
Department of Medicine and Surgery
Toronto, Ontario, Canada
Respiratory Diseases
Varese-Como, Italy
Henrik Watz
Pulmonary Research Institute at Lungen Clinic
Grosshandorf Richard L. ZuWallack
Airway Research Center North Pulmonary and Critical Care
German Center for Lung Research St Francis Hospital (Trinity)
Grosshansdorf, Germany Hartford, Connecticut

and
Peter J. Wijkstra
Department of Pulmonary Diseases/Home Mechanical University of Connecticut School of Medicine
Ventilation Farmington, Connecticut
and
and
Groningen Research Institute for Asthma and COPD
University of Groningen Frank H. Netter MD School of Medicine at Quinnipiac
University Medical Center Groningen University
Groningen, The Netherlands North Haven, Connecticut
 1
Part    

The foundation of pulmonary

rehabilitation

1 A framework for medical rehabilitation: Restoring function and improving quality of life 3
Julia Warden and Mark Bayley
2 Pulmonary rehabilitation: The development of a scientific discipline 11
Linda Nici and Roger S. Goldstein
3 Key concepts in pulmonary rehabilitation 21
Felipe V.C. Machado, Frits M.E. Franssen and Martijn A. Spruit
4 Enhancing use and delivery of pulmonary rehabilitation 29
Emily Hume, Carolyn L. Rochester and Ioannis Vogiatzis
5 Pathophysiological basis, evaluation and rationale of exercise training 41
Pierantonio Laveneziana and Paolo Palange
6 Education: Realizing the potential for learning in pulmonary rehabilitation 53
Felicity Blackstock and Suzanne C. Lareau
7 Self-management 63
Jean Bourbeau and Tanja W. Effing
8 Dual therapy: Pharmacologic management in pulmonary rehabilitation 75
J. Michael Nicholson and Richard Casaburi
 1
A framework for medical rehabilitation:
Restoring function and improving quality of life

JULIA WARDEN AND MARK BAYLEY

Introduction 3 Measuring the benefits of rehabilitation 7

A unifying model for rehabilitation: The International Summary 8
Classification of Functioning, Disability and Health 4 Conflict of interest 8
The approach to rehabilitation assessment 5 References 8
Unpacking the black box of rehabilitation: Important
service delivery considerations and questions 6

KEY MESSAGES

• The WHO International Classification of Functioning is a in remediation or compensation for an impaired

unifying framework for rehabilitation that addresses the function.
impact of the health condition on body structure and • The ideal dose, timing, type, location and delivery
function, activities of life and participation in usual roles. model of rehabilitation should be based on the
• Rehabilitation treatment is goal oriented, individual patient and address their unique physical,
interdisciplinary and is focused on training functional and psychological issues.

INTRODUCTION and it complements the other three health strategies, that

include prevention, cure and support (2).
Advances in curative medicine combined with demo- To put the four key health strategies in context, the pri-
graphic and epidemiological trends of population mary goal of the preventive strategy is to prevent health
ageing and the shift to a higher incidence of chronic, non-­ conditions by targeting risk factors, for example controlling
communicable diseases, require that healthcare systems tobacco to reduce the incidence of lung cancer. The primary
be able to respond to the increasing needs of people living goal of the curative strategy is to cure health conditions,
with chronic conditions and impairments (1). Individuals such as achieving remission in cancer, or controlling dis-
are living longer, but with more disability, and what affects eases such rheumatoid arthritis, typically with the use of
people more are the limitations in their independence biologically active medications. The primary goal of the
and functioning arising from their health conditions. rehabilitative strategy is to restore or optimize function, for
Rehabilitation is the field of medicine that focuses on example rehabilitating an individual with hemiparesis after
improving quality of life and optimizing independence in stroke so that they are able to manage their basic activities
daily activities. of daily living independently, with or without the use of
Based in the WHO International Classification of adaptive aids, and so that they are able to mobilize indepen-
Functioning, Disability and Health (ICF), rehabilitation can dently, whether it be with or without a gait aid. The primary
be defined as the health strategy that aims to enable people goal of the supportive strategy is to optimize quality of life,
with health conditions experiencing or likely to experience for example achieving pain control and relieving mental
disability to achieve and maintain optimal functioning in distress in a palliative care patient with terminal cancer (1).
interaction with the environment (2). It is a strategy that is Although conceptually distinct, the four health strate-
relevant to all medical specialties and health professions (3), gies have many related outcomes. For example, although the
3
4 A framework for medical rehabilitation: Restoring function and improving quality of life

rehabilitative strategy focuses on function, similar to the sup- or action by an individual, and activity limitation represents
portive strategy, it is also concerned with quality of life as a the difficulties an individual may have in executing activities.
closely related outcome. Rehabilitation medicine also aims to Participation is involvement in a life situations, and restric-
optimize disease management, similar to the curative strat- tion refers to the problems an individual may experience
egy, and it has a focus on minimizing the effects of the initial with involvement in their usual roles in life, i.e. employment,
health problem, which is similar to a preventive strategy. parenting and recreation (4,5). Contextual factors in this
The objective of this chapter, therefore, is to provide the model represent the complete background of an individual’s
reader with (a) a unifying model for the discipline of reha- life and living and include two components: environmental
bilitation, (b) an overview of the rehabilitation assessment, factors (i.e. external to the individual) and personal factors
(c) a peek into the black box of rehabilitation interventions (i.e. features of the individual such as gender, education or
and (d) insights into how rehabilitation outcomes are mea- coping style). In the framework, an individual’s functioning
sured. It concludes with some of the key remaining research in a specific domain is a complex interaction between their
questions in the field. health condition and contextual factors (4).

A UNIFYING MODEL FOR The discipline of rehabilitation

REHABILITATION: THE INTERNATIONAL
CLASSIFICATION OF FUNCTIONING, Rehabilitation is an inter-professional discipline, which
DISABILITY AND HEALTH deals with various disease entities with functional limita-
tions (3). The first step involves diagnosing health conditions
The ICF is the WHO framework for measuring health and assessing their impact on body structures, functioning
and disability of individuals and populations. It has been and participation. Treatment can be focused on remedia-
described as a unifying model for the conceptual descrip- tion, which refers to reducing impairments and stabilizing,
tion of the rehabilitation strategy (2). The overall purpose of improving or restoring function. However, in many cases
the classification is to provide a framework for the descrip- it is focused on compensation for the absence or loss of
tion of health and health-related states, and the unit of body functions and structures, such as by providing assis-
classification is categories within health and health-related tive technology or teaching the individual to change their
domains (4). environment. Regardless of which of these two treatment
The classification is based on a model of functioning approaches is most predominant, an individual will need
and disability (Figure 1.1), in which Health condition is training in remediation and/or compensation techniques to
defined as a disease (acute or chronic), disorder, injury or improve their function and wellbeing (Figure 1.2).
trauma. Functioning is an umbrella term for body func-
tions and structures and activities, and Participation signi- The rehabilitation team
fies the positive aspects of the complex interaction between
an individual with a health condition and their contextual In rehabilitation, the various practitioners on the team work
factors (environmental and personal factors). Disability is collaboratively to assist individuals in achieving as much
an umbrella term for impairments, activity limitations and independence as possible based on personal goals. The
participation restrictions. It refers to the negative aspects of interdisciplinary rehabilitation team frequently includes:
the classification. Body function and structure refers to physi-
ological functions and anatomic parts of the body systems, ●● Medical doctors, for example those who specialize in
and impairment is a loss or deviation from normal body physical medicine and rehabilitation, such as in stroke,
functions and structures. Activity is the execution of a task brain injury, spinal cord, musculoskeletal or amputee

Health condition

Body functions Remediation Compensation

Activity Participation
and structures

Environmental Personal
Training
factors factors

Figure 1.1 Interactions between the components of the

International Classification of Functioning, Disability and
Health (ICF) (4). Figure 1.2 Rehabilitation management.
Another random document with
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The Project Gutenberg eBook of Narrative of the
residence of Fatalla Sayeghir among the
wandering Arabs of the great desert
This ebook is for the use of anyone anywhere in the United States
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Title: Narrative of the residence of Fatalla Sayeghir among the

wandering Arabs of the great desert

Author: Alphonse de Lamartine

Release date: November 17, 2023 [eBook #72150]

Language: English

Original publication: Philadelphia: Carey, Lea & Blanchard, 1836

Credits: Carla Foust, Brian Coe and the Online Distributed

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Library of Congress)

*** START OF THE PROJECT GUTENBERG EBOOK NARRATIVE

OF THE RESIDENCE OF FATALLA SAYEGHIR AMONG THE
WANDERING ARABS OF THE GREAT DESERT ***
 Transcriber’s note
New original cover art included with this eBook is
granted to the public domain.
 DE LAMARTINE.

NARRATIVE
OF THE RESIDENCE OF
FATALLA SAYEGHIR
AMONG THE
WANDERING ARABS OF THE
GREAT DESERT:
COLLECTED AND TRANSLATED BY THE CARE OF

M. DE LAMARTINE.

PHILADELPHIA:
CAREY, LEA & BLANCHARD.
1836.
 ADVERTISEMENT
OF THE AMERICAN PUBLISHERS.
In presenting to the public the curious and interesting Narrative of
Fatalla Sayeghir, it is proper to explain that it formed an appendix to
the English edition of “De Lamartine’s Pilgrimage to the Holy Land;”
but having no immediate connexion with it, the publishers thought, it
proper to defer the publication of this work (as mentioned in their
advertisement) until they should know what reception the
“Pilgrimage” would meet with. A second edition being called for and
nearly expended, it has induced the publication of the “Narrative” in a
separate volume, which they hope will be acceptable to the public.
 INTRODUCTION.
BY ALPHONSE DE LAMARTINE.
We were encamped in the midst of the desert which extends from
Tiberias to Nazareth, and were speaking of the Arab tribes we had
met in the day, of their manners, and the connexions between them
and with the great population by whom they are surrounded. We
endeavoured to elucidate the mystery of their origin, their destiny,
and that astonishing endurance of the spirit of race, which separates
this people from all other human families, and keeps them, like the
Jews, not without the pale of civilization, but within a civilization of
their own, as unchangeable as granite.
The more I have travelled, the more I am convinced that races of
men form the great secret of history and manners. Man is not so
capable of education as philosophers imagine. The influence of
governments and laws has less power, radically, than is supposed,
over the manners and instincts of any people, while the primitive
constitution and the blood of the race have always their influence,
and manifest themselves, thousands of years afterwards, in the
physical formations and moral habits of a particular family or tribe.
Human nature flows in rivers and streams into the vast ocean of
humanity: but its waters mingle but slowly, sometimes never; and it
emerges again, like the Rhone from the Lake of Geneva, with its
own taste and colour. Here is indeed an abyss of thought and
meditation, and at the same time a grand secret for legislators. As
long as they keep the spirit of race in view, they succeed; but they
fail when they strive against this natural predisposition: nature is
stronger than they are. This sentiment is not that of the philosophers
of the present time, but it is evident to the traveller; and there is more
philosophy to be found in a caravan journey of a hundred leagues,
than in ten years’ reading and meditation. I felt happy in thus
wandering about among deserts and unknown countries, with no
route before me but my caprice; and I told my friends, and M.
Mazolier, my interpreter, that if I were alone and without family ties, I
would lead this manner of life for years and years. I would never
sleep where I had arisen: I would transport my tent from the shores
of Egypt to the Persian Gulf, and wish no aim for the evening but
evening itself. I would wander on foot, and dwell with eye and heart
on these unknown lands, these races of men so different from my
own, and contemplate humanity, this most beautiful work of God,
under all its forms. To effect this, what would be requisite?—a few
slaves or faithful servants, arms, a little gold, two or three tents, and
some camels. The sky of these countries is almost always warm and
pure, life easy and economical, and hospitality certain and
picturesque. I should prefer, a hundred times, years passed under
different skies, with hosts and friends ever new, to the barren and
noisy monotony of the life of our capitals. It is undoubtedly more
difficult to lead the life of a man of the world in Paris or London, than
to visit the universe as a traveller. The results of two such lives are,
however, very different. The traveller either dies, or he returns with a
treasure of thoughts and wisdom. The domesticated inhabitant of our
capitals grows old without knowledge, without experience, and dies
as much entrammelled, as much immersed in false notions, as when
he first begins to exercise his senses. I should like, said I to my
dragoman, to cross those mountains, to descend into the great
desert of Syria, accost some of the large unknown tribes that
traverse it, receive their hospitality for months, pass on to others,
study their resemblances and differences, follow them from the
gardens of Damascus to the banks of the Euphrates and the
confines of Persia, and raise the veil which still hangs over the
civilization of the desert,—a civilization where our chivalry had its
birth, and where it must still exist: but time presses, and we may see
but the borders of that ocean whose whole no one has yet crossed.
No traveller has penetrated amidst those innumerable tribes, whose
tents and flocks cover the plains of the patriarchs; one only man
attempted it, but he is no more, and the notes which he had collected
during ten years’ residence amongst the people were lost with
himself. I desired to introduce M. de Lascaris to my readers: the
following is a sketch of his character.
M. de Lascaris was born in Piedmont, of one of those Greek families
which settled in Italy after the conquest of Constantinople: he was a
knight of Malta when Napoleon conquered the island. M. de Lascaris
was then a very young man; he followed him to Egypt, attached
himself to his fortunes, and was fascinated by his genius. Highly
gifted himself, he was one of the first to perceive the lofty eminence
reserved by Providence for the young man who was imbued with all
the spirit of Plutarch, when the human character seemed worn out,
shattered, or false. He perceived more: he perceived that the great
work to be accomplished by his hero was not perhaps the restoration
of power in Europe; an effect which the reaction of men’s minds
rendered necessary, and therefore easy; he felt that Asia presented
a far wider field for the renovating ambition of a hero; that that was
the scene for conquering, for founding, and for renovating on a scale
incomparably more gigantic; that despotism, brief in Europe, would
be lasting, eternal, in Asia; that the great man who could there apply
the principles of organization and unity would effect more than
Alexander,—more than Bonaparte in France. It appears that the
young warrior of Italy, whose imagination was luminous as the East,
undefined as the desert, wide as the world, held some confidential
conversations with M. de Lascaris on this subject; and directed one
ray of thought towards that horizon which was opening to him his
destiny. It was but a ray, and I lament it: it is evident that Bonaparte
was the man for the East, not the man for Europe. This will provoke
a smile; it will appear paradoxical to the world. But consult travellers.
Bonaparte, who is looked upon as the man of the French revolution
and of liberty, never understood liberty, and wrecked the French
revolution. History will prove it in every page, when written under
other impulses than those which at present dictate it. He was the
incarnation of reaction against the liberty of Europe: glorious and
brilliant, it is true; but no more. What proof shall I advance? Ask what
remains of Bonaparte in the world, beyond a page of warfare, and a
page to record an unskilful restoration. But as for a monument, a
basis for expectation, a future, a something that may live after him
besides his name—nothing exists but an immense reminiscence. In
Asia he would have stirred men by millions; and, himself a man of
simple ideas, he would with two or three facts have built up a
monument of civilization which would have survived him a thousand
years. But the mistake was made: Napoleon chose Europe; he only
chose to leave behind him one explorer to examine what might be
done, and to trace out the road to India, if ever fortune should lay it
open to him. M. de Lascaris was the man; he set out with secret
instructions from Bonaparte, received the necessary sums for his
undertaking, and established himself at Aleppo, to complete his
knowledge of Arabic. Being a man of merit, talent, and knowledge,
he feigned a sort of enthusiasm to account for his continuance in
Syria, and his unceasing intercourse with the Arabs of the desert
who came to Aleppo. At length, after some years’ preparation, he
commenced his grand and perilous enterprise; he passed with
various risks, and under different disguises, through all the tribes of
Mesopotamia and of the Euphrates; and returned to Aleppo, rich in
the knowledge he had acquired, and in the political relations he had
prepared for Napoleon. But whilst accomplishing the mission, fortune
overthrew his hero; and he learned his downfall the very day on
which he was about to bring him the fruits of seven years’ danger
and devotion. This unforeseen stroke was fatal to M. de Lascaris; he
went into Egypt, and died at Cairo, alone, unknown, abandoned, and
leaving behind him his notes, his only bequest. It is said that the
English consul obtained these valuable documents, which might
have become injurious to his government, and that they were either
destroyed or sent to London.
“What a pity,” said I to M. Mazolier, “that we should have lost the
result of so many years’ labour and patience!” “There is something
yet remaining,” said he; “I was attached at Latakia, my country, to a
young Arab, who accompanied M. de Lascaris during all his travels.
After his death, being without resources, and deprived even of the
arrears of his small salary, which M. de Lascaris had promised him,
he returned poor and plundered to his mother. He is now living in
some small employ with a merchant of Latakia. I knew him there,
and he has often spoken to me of a series of notes that he wrote at
the instigation of his patron in the course of their wandering life.” “Do
you think,” said I to M. Mazolier, “the young man would consent to
sell them?” “I should think so,” he replied; “and the more so, as he
has often expressed his desire to present them to the French
government. But nothing is so easy as to know this; I will write to
Fatalla Sayeghir, which is the name of the young Arab. Ibrahim
Pacha’s Tartar will deliver him my letter, and we shall have an
answer on his return to Said.” “I commission you,” said I, “to
negotiate the affair, and to offer him two thousand piastres for his
manuscript.”
Some months elapsed before the answer of Fatalla Sayeghir
reached me. Returning to Byrauth, I sent my interpreter to negotiate
directly for the MS. at Latakia. The terms were accepted, the sum
was paid, and the Arabic MS. brought me by M. Mazolier. In the
course of the winter, I got them translated with infinite difficulty into
the Frank language, and thence translated them into French myself;
the public are thus enabled to enjoy the fruits of a ten years’
journeying, which no other traveller has hitherto effected. The
extreme difficulty of this triple translation must be an excuse for the
style of the notes. The style indeed is of little importance in such
works; facts and manners are everything. I am fully satisfied that the
first translator has altered nothing; he has only suppressed some
tedious details consisting of idle repetitions which availed nothing.
Should this recital possess any interest in a scientific, a
geographical, or a political point of view, I have only one wish to
form; it is that the French government, which such a period of peril
and exile was intended to enlighten and serve, should show a tardy
gratitude towards the unfortunate Fatalla Sayeghir, whose services
might even still be useful. In this wish I include too the young and
skilful interpreter, M. Mazolier, who has translated these notes from
the Arabic, and who accompanied me for a year in my travels in
Syria, Galilee, and Arabia. Versed in the knowledge of Arabic, the
son of an Arab mother, nephew of one of the most powerful and
revered sheiks of Lebanon, having already traversed all those
countries with me, familiar with the manners of the tribes, a man of
courage, intelligence and honour, heartily devoted to France, this
young man might be of the utmost service to the government in our
relations with Syria. French nationality terminates not with our
frontiers. Our country has sons as attached upon shores whose
name she scarcely knows. M. Mazolier is one of those sons. France
should not forget him. No one could serve her better than he, in
countries in which the effects of our activity of civilization, protection,
and even of policy, must soon be necessarily felt. The following is
the narrative of Fatalla Sayeghir, literally translated.
 NARRATIVE
OF
FATALLA SAYEGHIR.
At eighteen years of age I quitted Aleppo, my country, with a stock of
merchandise, to establish myself in Cyprus. Being tolerably fortunate
in the first year of my commercial speculations, I took a liking to the
business, and adopted the fatal idea of taking to Trieste a cargo of
the productions of the island. In a short time my goods were
embarked; they consisted of cotton, silk, wine, sponge, and
colocynth. On the 18th March, 1809, my ship, commanded by
Captain Chefalinati, set sail. I was already calculating the profits of
my venture, and rejoicing at the idea of the gross returns, when, in
the midst of my delightful illusions, the fatal news arrived of the
capture of the vessel by an English ship of war, which had taken her
to Malta. In consequence of such a loss, I was obliged to strike my
balance, and retire from trade; and I quitted Cyprus totally ruined,
and returned to Aleppo. Some days after my arrival I dined at one of
my friends’ with several persons, amongst whom was a stranger,
very ill-dressed, but to whom much consideration was shown. After
dinner there was music; and the stranger sitting beside me,
conversed with much affability: we spoke of music, and after a long
conversation, I rose to ask him his name. I learned that it was M.
Lascaris de Ventimiglia, and that he was a knight of Malta. The
following day, I saw him coming to my house, holding in his hand a
violin. “My good young man,” said he on entering, “I remarked
yesterday how much you like music; I already look upon you as my
son, and bring you a violin, of which I beg your acceptance.” I
received with much pleasure the instrument, which was exactly to
my taste, and gave him very many thanks. After an animated
conversation of two hours, during which he questioned me upon all
sorts of subjects, he retired. The next day he returned, and
continued in this manner his visits for a fortnight; he then proposed
to me to give him lessons in Arabic for an hour every day, for which
he offered me a hundred piastres a month. I gladly accepted this
advantageous proposal; and after six months’ teaching he began to
read and speak Arabic tolerably well. One day he said to me, “My
dear son, (he always addressed me thus,) I see that you have a
great inclination for commerce; and as I wish to remain some time
with you, I should like to employ you in a manner agreeable to
yourself. Here is money: purchase goods, such as are saleable at
Homs, at Hama, and the neighbourhood. We will trade in the
countries least frequented by merchants; you will find we shall
succeed well.” My desire of remaining with M. de Lascaris, and the
persuasion that the undertaking would be successful, determined me
to accept the proposal without hesitation; and I began, according to a
note which he sent me, to make the purchases, which consisted of
the following articles: red cloth, amber, corals in chaplets, cotton
handkerchiefs, silk handkerchiefs black and red, black shirts, pins,
needles, box combs and horn, rings, horses’ bits, bracelets of glass
beads, and other glass ornaments; to these we added chemical
products, spices, and drugs. M. Lascaris paid for these different
articles eleven thousand piastres, or two thousand tallaris.
The people of Aleppo, who saw me purchasing the goods, told me
that M. Lascaris was become mad. Indeed his dress and his
manners made him pass for mad. He wore his beard long and ill-
combed, a white turban very dirty, a shabby robe or gombaz, with a
vest beneath, a leather belt, and red shoes without stockings. When
spoken to, he pretended not to understand what was said. He spent
the greater part of the day at the coffee-house, and ate at the
bazaar, which was never done by the higher people. This behaviour
had an object, as I afterwards discovered; but those who knew it not
thought his mind was deranged. As to myself, I found him full of
sense and wisdom; in short, a superior man. One day when all the
goods were packed, he called me to him, to ask what was said of
him at Aleppo. “They say,” replied I, “that you are mad.” “And what
do you think yourself?” said he. “I think that you are full of sense and
knowledge.” “I hope in time to prove it so,” said he; “but I must have
you engage to do all I shall order, without reply or asking a reason; to
obey me in every thing; in short, I must have a blind obedience; you
will have no occasion to repent.” He then told me to fetch him some
mercury; I instantly obeyed: he mixed it with grease and two other
drugs, of which I was ignorant, and assured me, that a thread of
cotton dipped in this preparation and tied round the neck was a
security against the bite of insects. I thought to myself there were not
insects enough at Homs, or at Hama, to require such a preservative;
that therefore it was destined for some other country; but as he had
interdicted every remark, I merely asked him on what day we should
depart, that I might order the moukres (camel drivers.) “I allow you,”
he replied, “thirty days to divert yourself; my chest is at your
disposal; enjoy yourself, spend what you like, spare nothing.” This is,
thought I, for a farewell to the world which he wishes me to make:
but the strong attachment I already felt for him stifled this reflection; I
thought no longer but of the present, and availed myself of the time
he allowed to enjoy myself. But alas! the time for pleasure soon
passes! it soon came to an end. M. Lascaris pressed me to depart; I
submitted to his orders, and profiting by a caravan that set out for
Hama, Thursday the 18th of February, 1810, we left Aleppo, and
arrived at the village of Saarmin, after twelve hours’ march. The next
day we set out for Nuarat el Nahaman, a pretty little town, distant six
hours. It is celebrated for the salubrity of the air and the goodness of
its waters; it is the native place of the celebrated Arabian poet Abu el
Hella el Maari, who was blind from his birth. He had learned to write
by a singular method. He remained in a vapour bath while they
traced on his back the form of the Arabic letters with iced water.
Many are the traits of sagacity related of him; among others the
following:—Being at Bagdad with a calife, to whom he was
continually boasting of the air and water of his native place, the calife
procured some water from the river Nuarat, and without any
intimation gave it him to drink. The poet, immediately recognising it,
exclaimed, “Here is its limpid water, but where its air so pure!” To
return to the caravan: it remained two days at Nuarat, to be present
at a fair that was held there on Sundays. We went to walk about, and
in the multitude I lost sight of M. Lascaris, who had disappeared in
the midst. After looking for him a long while, I at last discovered him
in a solitary spot conversing with a ragged Bedouin. I asked him with
surprise what pleasure he found in the conversation of such a
person, who could neither understand his Arabic, nor make him
understand his. “The day,” said he, “when I have first had the honour
of speaking with a Bedouin, is one of the happiest days of my life.”
“In that case,” I replied, “you will often be at the summit of happiness,
for we shall be continually meeting with this sort of people.”
He made me buy some galettes (the bread of the country) and some
cheese, and gave them to Hettall, (the name of the Arab,) who
thanked us and took leave. The 20th February we left Nuarat el
Nahaman, and, after six hours’ march, we arrived at Khrau
Cheikhria, and the next day, after nine hours, at Hama, a
considerable town, where we were known to nobody, as M. Lascaris
had brought no letters of recommendation. We passed the first night
in a coffee-house; and, the next day, hired a room in the khan of
Asshad Pacha. As I was beginning to open the bales, and prepare
the goods for sale, M. Lascaris said to me with a dissatisfied air, “You
are only thinking of your miserable commerce! If you knew how
many more useful and interesting things there are to be done!” After
that I thought no more of selling, and went to survey the town. On
the fourth day, M. Lascaris, walking by himself, proceeded as far as
the castle, which is falling to ruins. Having examined it attentively, he
had the imprudence to begin taking its dimensions. Four vagabonds,
who were concealed under a broken arch, threw themselves upon
him with threats to denounce him for wishing to carry off treasures,
and introduce the giaours into the castle. With a little money all might
have been ended without noise; but M. Lascaris defended himself,
and with difficulty escaped from their hands and came to me. He had
not finished telling me his adventure, when we saw two men from the
government enter with one of the informers. They took the key of our
room, and led us away, driving us with sticks like felons. Being
brought into the presence of the mutzelim, Selim Beg, known for his
cruelty, he thus questioned us: “Of what country are you?” “My
companion is from Cyprus,” I replied, “and myself from Aleppo.”
“What object leads you to this country?” “We are come to trade.”
“You lie; your companion was seen about the castle, taking its
dimensions and drawing plans; it is to obtain treasure, and deliver
the place to the infidels.” Then turning to the guards, “Take the two
dogs,” said he, “to the dungeon.”—We were not allowed to say
another word. Being brought to the prison, we were loaded with
chains from the neck to the feet, and shut up in a dark dungeon,
which was so small that we could hardly turn. After a time we
obtained a light, and some bread, for a tallari; but the immense
quantity of bugs and other insects that infested the prison prevented
us from closing our eyes. We had scarcely courage to think of
means to get out of the horrible place. At length I recollected a
Christian writer, named Selim, whom I knew by reputation as a
useful person. I gained over one of our guards, who went for him;
and the following day Selim arranged the matter by means of a
present of sixty tallaris to the mutzelim, and fifty piastres to his
people. At this price we obtained our liberty. This imprisonment
procured for us the acquaintance of Selim, and several other
persons at Hama, with whom we passed three weeks very
agreeably.
The town is charming; the Orontes crosses it, and renders it gay and
animated; its abundant waters keep up the verdure of numerous
gardens. The inhabitants are amiable, lively, and witty. They admire
poetry and cultivate it with success. They have been well
characterised with the epithet of speaking birds. M. Lascaris having
asked Selim for a letter of recommendation to a man of humble
condition at Homs, who might serve us as guide, he wrote the
following note: “To our brother Yakoub, health! They who will present
you this letter are pedlers, and come to you to sell their wares in the
neighbourhood of Homs; assist them as far as you are able. Your
pains will not be lost; they are honest people. Farewell!”
M. Lascaris, well satisfied with this letter, wished to take advantage
of a caravan that was going to Homs. We departed on the 25th
March, and arrived after six hours at Rastain, which is at present
only the ruin of an ancient considerable town. It contains nothing
remarkable. We continued our route, and at the end of another six
hours we reached Homs. Yakoub, to whom we delivered our letter,
received us admirably, and gave us a supper. His trade was making
black cloaks, called machlas. After supper, some men of his own
rank came to pass the evening with him, drinking coffee and
smoking. One of them, a locksmith named Naufal, appeared very
intelligent. He spoke to us of the Bedouins, of their manner of living
and making war; he told us that he passed six months of the year
with these tribes to arrange their arms, and that he had many friends
among them. When we were alone, M. Lascaris said to me that he
had that night seen all his relatives; and as I expressed my wonder
at learning that there were any of the people of Ventimiglia at Homs,
“My meeting with Naufal,” said he, “is more valuable to me than that
with my whole family.”
It was late when we retired, and the master of the house gave a
mattress and covering for us both. M. Lascaris had never slept with
any one; but, out of kindness, he insisted that I should share the bed
with him: not wishing to contradict him, I placed myself beside him;
but as soon as the light was out, wrapping myself in my machlas, I
crept out to the ground, where I passed the night. The next morning,
on waking, we found ourselves lying in the same manner; M.
Lascaris having done as I had. He came and embraced me, saying,
“It is a good sign that we had the same idea, my dear son; for I like
to call you so, as it pleases you, I hope, as well as me.” I thanked
him for the interest he showed me, and we went out together to
prevail on Naufal to accompany us through the town, and show us
what curiosity it contained, promising to pay him for the loss of the
day. The population of Homs is about eight thousand. The character
of the people is quite different from that of the inhabitants of Hama.
The citadel, situated in the centre of the town, is falling to ruins; the
ramparts still preserved are watered by a branch of the Orontes. The
air is pure. We bought for forty piastres two sheep-skin cloaks like
those of the Bedouins: these cloaks are water-proof. To be the more
at liberty, we hired a room at the khan, and begged Naufal to stay
with us, engaging to pay him as much as he would have earned in
his shop,—about three piastres a day. He was of the greatest use.
M. Lascaris questioned him dexterously, and obtained from him all
the information he wished: getting him to describe the manners,
usages, and character of the Bedouins, their mode of receiving
strangers and treating them. We stayed thirty days at Homs, to wait
the return of the Bedouins, who commonly quit the neighbourhood of
that city in October, to proceed to the south, according to the
weather, and the water and pasturage; progressing one day, and
halting five or six. Some go as far as Bagdad, others to Chatt el
Arab, where the Tigris and the Euphrates join. In February they
commence their return to Syria, and at the end of April they are
found again in the deserts of Damascus and Aleppo. Naufal gave us
all this intelligence, and told us that the Bedouins made constant use
of cloaks like ours, black machlas, and above all of cafiés. M.
Lascaris accordingly made me buy twenty cloaks, ten machlas, and
fifty cafiés, of which I made a bale. This purchase amounted to
twelve hundred piastres. Naufal having proposed to us to visit the
citadel, the recollection of the adventure at Hama made us at first
hesitate; but, on his assurance that nothing disagreeable could
happen, and that he would be responsible, we consented, and went
with him to view the ruins seated at the top of a small hill in the
middle of the town. The castle is in better preservation than that of
Hama. We observed in it a deep and concealed grotto, in which was
an abundant spring; the water escaped by an opening four feet by
two, and passed through bars of iron into a second opening. It is
excellent. An old tradition was told us, that the passage being once
stopped up, there came a deputation from Persia, which, for a
considerable sum paid to the government, procured it to be re-
opened, and that for the future the water should not be obstructed.
The entrance into the grotto is now forbidden, and it is very difficult to
get in.
Returning home, M. Lascaris asked me, if I had noted down what we
had seen, and what had occurred since our departure; and on my
answer in the negative, he begged that I would do so, making me
promise to keep an exact journal in Arabic of all that had occurred,
that he might himself translate it into French. From that time I took
notes, which he carefully transcribed every day and returned to me
the day following. I have now put them together in the hope that they
may one day prove useful, and obtain for me a slight compensation
for my fatigues and sufferings.
M. Lascaris having determined to go to the village of Saddad, I
engaged Naufal to accompany us; and joining some other persons,
we quitted Homs with all our merchandise. After five hours’ march,