The influence of comorbidities on outcomes of pulmonary rehabilitation programs in patients with COPD: a systematic review

Major depressive disorder plays a vital role in the pathway from gastroesophageal reflux disease to chronic obstructive pulmonary disease: a Mendelian randomization study

Background: Observational studies have shown a bidirectional association between chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease (GERD), but it is not clear whether this association is causal. In our previous study, we found that depression was a hot topic of research in the association between COPD and GERD. Is major depressive disorder (MDD) a mediator of the association between COPD and GERD? Here, we evaluated the causal association between COPD, MDD, and GERD using Mendelian randomization (MR) study. Methods: Based on the FinnGen, United Kingdom Biobank, and Psychiatric Genomics Consortium (PGC) databases, we obtained genome-wide association study (GWAS) summary statistics for the three phenotypes from 315,123 European participants (22,867 GERD cases and 292,256 controls), 462,933 European participants (1,605 COPD cases and 461,328 controls), and 173,005 European participants (59,851 MDD cases and 113,154 controls), respectively. To obtain more instrumental variables to reduce bias, we extracted relevant single-nucleotide polymorphisms (SNPs) for the three phenotypes from published meta-analysis studies. Bidirectional MR and expression quantitative trait loci (eQTL)-MR were performed using the inverse variance weighting method to assess the causal association between GERD, MDD, and COPD. Results: There was no evidence of a causal effect between GERD and COPD in the bidirectional MR analysis [forward MR for GERD on COPD: odds ratios (OR) = 1.001, p = 0.270; reverse MR for COPD on GERD: OR = 1.021, p = 0.303]. The causal effect between GERD and MDD appeared to be bidirectional (forward MR for GERD on MDD: OR = 1.309, p = 0.006; reverse MR for MDD on GERD: OR = 1.530, p < 0.001), while the causal effect between MDD and COPD was unidirectional (forward MR for MDD on COPD: OR = 1.004, p < 0.001; reverse MR for COPD on MDD: OR = 1.002, p = 0.925). MDD mediated the effect of GERD on COPD in a unidirectional manner (OR = 1.001). The results of the eQTL-MR were consistent with those of the bidirectional MR. Conclusion: MDD appears to play a vital role in the effect of GERD on COPD. However, we have no evidence of a direct causal association between GERD and COPD. There is a bidirectional causal association between MDD and GERD, which may accelerate the progression from GERD to COPD.

The impact of Virtual Reality on Anxiety and Functional Capacity in Cardiac Rehabilitation: A Systematic Review and Meta-analysis

BACKGROUND

The overall utilization of cardiac rehabilitation (CR) is low despite its proven benefits in secondary prevention. Virtual reality (VR), a novel method of rehabilitation, may increase overall compliance. The purpose of this systematic review and meta-analysis is to synthesize evidence and report whether the addition of VR leads to an improvement in anxiety and functional capacity (FC) compared to standard CR.

METHODS

A comprehensive search strategy was used to search the online databases for the randomized controlled trials (RCTs) on VR-CR. Statistical analysis was performed using Stata SE version 17.0 (College Station, TX) and RevMan5.

RESULTS

A total of 747 study participants were part of 7 studies included in the meta-analysis. Three studies were part of the narrative synthesis. Anxiety showed significant improvement in VR-CR compared to standard CR (SMD -0.32, 95% CI -0.61, -0.03). There was no significant improvement in FC between VR-CR and the standard CR (SMD 0.077, 95% CI -1.24, 1.32).

CONCLUSION

VR-CR significantly improved CR-related anxiety compared to standard CR. However, no significant improvement in FC was found in VR-CR compared to the standard CR. Further studies are needed to assess the impact of non-immersive and immersive VR on FC.

Exploring the prevalence and impact of hip and knee pain in pulmonary rehabilitation: a propensity-matched cohort study

BACKGROUND

Musculoskeletal pain is more common in individuals with chronic respiratory diseases than the aged-matched general population. This investigation aimed to understand the prevalence and impact of hip and knee pain on pulmonary rehabilitation outcomes and completion rates.

METHODS

Participants who experienced hip/knee pain in the 4 weeks prior to pulmonary rehabilitation completed an Oxford Hip and/or Knee Score alongside a routine pulmonary rehabilitation assessment. Participants engaged in a twice-weekly, 6-week outpatient pulmonary rehabilitation programme. A 1:1 propensity score match for age, sex, BMI, sessions attended and MRC score was completed prior to group comparison for a pulmonary rehabilitation cohort without hip/knee pain.

RESULTS

6.5% (n = 97) of pulmonary rehabilitation participants reported pain: hip (n = 27), knee (n = 40) or hip and knee pain (n = 30). 75 participants with hip/knee pain provided sufficient data for pre pulmonary rehabilitation matching and were propensity matched with a pulmonary rehabilitation group without hip/knee pain. The average Oxford Score across all reported joints was 28.7 (8.5) indicating moderate/severe pain at baseline. Statistically significant improvements were made in Oxford Scores for the left hip, left knee and right knee (P < 0.01) but not the right hip following pulmonary rehabilitation. There was no statistically significant difference between groups for improvements in quadriceps strength, walking tests or depression scores, both groups achieved within group significance. There were no significant differences in pulmonary rehabilitation completion rates between groups.

CONCLUSIONS

Prevalence of hip/knee pain in individuals presenting to pulmonary rehabilitation is 6.5%. Pain improved in the majority of joints following pulmonary rehabilitation and pain did not impact the effectiveness or completion of the programme.

TRIAL REGISTRATION

This trial was an evaluation of a clinical service and has not been registered in a public domain.

Quali-quantitative analysis of adherence and perceived satisfaction of individuals with COPD after high-intensity training on land and in water: additional analysis from a randomized clinical trial

ABSTRACT Although patients with chronic obstructive pulmonary disease (COPD) benefit in many ways after participating in pulmonary rehabilitation programs, high dropout rates are still observed among participants. This study aims to analyze the adherence rate and perceived satisfaction in individuals with chronic obstructive pulmonary disease who underwent high-intensity physical training on land (LG) and in water (WG). This study is an additional analysis from a randomized controlled trial. In total, 36 subjects (51%) completed the intervention. All participants underwent six months of high-intensity endurance and strength training. Adherence was assessed by the proportion of patients who completed the training program. Perceived satisfaction was evaluated using a questionnaire composed of structured and semi-structured questions. The interviews were recorded, transcribed, and analyzed according to the criteria of our thematic analysis. The Shapiro-Wilk test was used to assess data normality, and dropout rates were compared using the chi-square test. Statistical significance was set at 5%. Regarding adherence, 59% of WG participants and 44% of LG participants completed the program, with no difference between the groups (p>0.05). Individuals from both groups were equally satisfied after six months of physical training (<90%); the therapist-patient relationship and treatment effectiveness being important factors for this perception. Qualitative analysis also showed that WG participants reported a more prominent improvement in their respiratory symptoms, leisure, sensation of pain, and sleep. In conclusion, patients with COPD were satisfied after six months of high-intensity physical training in water and on land, noting that water exercising promoted additional benefits compared to land exercising. There seems to be no superiority to any of the regimens (water or land) regarding the adherence to the training programs.

Risk factors as outcome predictors of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Introduction/Objective. Chronic obstructive pulmonary disease (COPD) is a primary lung disease. Today, pulmonary rehabilitation (PR) is the basis of non-pharmacological treatment of these patients, with numerous confirmed effects on the most significant symptoms of the disease and quality of life (QoL). The aim of this study was to determine the relationship between certain risk factors and the outcome of PR, as well as to determine the percentage of respondents who had a positive outcome of PR. Methods. The study included 500 patients with COPD, determined according to the guidelines of the GOLD, all stages I-IV, in the stable phase of the disease, who completed the outpatient PR program. Disease stage, comorbidities, forced expiratory volume in the first second, 6-minute walk test (6MWT), COPD Assessment Test (CAT) and Medical Research Council dyspnea scale, BODE index, were measured before and after the program. The last four parameters have been observed as risk factors that affect the outcome of PR, but also as parameters by which we monitor the outcome of PR. Results. A successful outcome of PR was achieved by as many as 452 (90.4%) patients. As independent predictors of a positive outcome of PR were determined: lower number of comorbidities, absence of heart failure, higher BMI and CAT ? 10. Conclusions. PR in our group of patients leads to statistically significant improvements in most of the examined subjective and objective parameters, in patients at all stages of the disease.

Long-Term Effectiveness of a Home-Based Pulmonary Rehabilitation in Older People with Chronic Obstructive Pulmonary Disease: A Retrospective Study

Background

Long-term effectiveness of pulmonary rehabilitation (PR) is still uncertain in older people with severe chronic obstructive pulmonary disease (COPD). The objective was to compare the effects of home-based PR in people with COPD above and below the age of 70 years.

Methods

In this retrospective study, 480 people with COPD were recruited and divided into those ≤70 (n=341) and those >70 years of age (n=139). All participants underwent an 8 weeks of home-based PR, consisting of a weekly supervised 90-minute home session. Six-minute stepper test (6MST), timed-up and go test (TUG), Hospital Anxiety and Depression Scale, and Visual Simplified Respiratory Questionnaire (VSRQ) were assessed at baseline (M0), at 2 (M2), 8 (M8), 14 (M14) months after baseline.

Results

The older group was described by fewer current smokers (p <0.001), more long-term oxygen therapy use (p = 0.024), higher prevalence of comorbidities (p<0.001), lower 6MST score and higher TUG score (p<0.001), compared to the younger group. Both groups improved every outcome at M2 compared to baseline. At M2, 88% of people ≤70 years of age and 79% of those above 70 were considered as responders in at least one evaluated parameter (p = 0.013). Both groups maintained the benefits at M14, except for the VSRQ score and the number of responders to this outcome in the older group.

Conclusion

Regardless of the age, personalized home-based PR was effective for people with COPD in the short term. Above 70 years, an ageing effect appeared on the long-term effectiveness of quality of life benefit.

The effect of comorbidity severity on pulmonary rehabilitation outcomes in chronic obstructive pulmonary disease patients

CLINICAL TRIAL NUMBER

NCT03319108.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Impact of comorbidities on anti-TNFα response and relapse in patients with inflammatory bowel disease: the VERNE study

Objective

To evaluate the impact of comorbidities and extraintestinal manifestations of inflammatory bowel disease on the response of patients with inflammatory bowel disease to antitumour necrosis factor alpha (anti-TNFα) therapy.

Design

Data from 310 patients (194 with Crohn’s disease and 116 with ulcerative colitis) treated consecutively with the first anti-TNFα in 24 Spanish hospitals were retrospectively analysed. Univariate and multivariate logistic regression analyses were performed to assess the associations between inflammatory bowel disease comorbidities and extraintestinal manifestations with anti-TNFα treatment outcomes. Key clinical features, such as type of inflammatory bowel disease and concomitant treatments, were included as fixed factors in the model.

Results

Multivariate logistic regression analyses (OR, 95% CI) showed that chronic obstructive pulmonary disease (2.67, 1.33 to 5.35) and hepato-pancreato-biliary diseases (1.87, 1.48 to 2.36) were significantly associated with primary non-response to anti-TNFα, as was the use of corticosteroids and the type of inflammatory bowel disease (ulcerative colitis vs Crohn’s disease). It was also found that myocardial infarction (3.30, 1.48 to 7.35) and skin disease (2.73, 1.42 to 5.25) were significantly associated with loss of response, along with the use of corticosteroids and the type of inflammatory bowel disease (ulcerative colitis vs Crohn’s disease).

Conclusions

Our results suggest that the presence of some comorbidities in patients with inflammatory bowel disease, such as chronic obstructive pulmonary disease and myocardial infarction, and of certain extraintestinal manifestations of inflammatory bowel disease, such as hepato-pancreato-biliary conditions and skin diseases, appear to be related to failure to anti-TNFα treatment. Therefore, their presence should be considered when choosing a treatment.

Trial registration number

NCT02861118.

Prevalence of comorbidities and impact on pulmonary rehabilitation outcomes

Background

The presence of comorbid conditions could impact performance in pulmonary rehabilitation (PR) programmes. We aimed to compare the comorbidity prevalence among those with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) and evaluate the impact on PR response.

Methods

We performed a retrospective cohort study, recording comorbidities for all patients with COPD or ILD referred to PR. Participants were classified as responders to PR if they met the minimal important difference for exercise capacity and health-related quality of life (HRQoL). The prevalence of comorbidities and impact on PR outcomes were compared by lung disease and by sex using a univariate analysis and multivariate logistic regression.

Results

The mean number of comorbidities was similar among those with COPD (3.3±2.1, n=242) and ILD (3.2±1.9, n=66) (p>0.05). Females had a higher number of comorbidities than males in both COPD (p=0.001) and ILD (p=0.017) populations. Circulatory (64%) and endocrine/metabolic (45%) conditions were most common in COPD. In ILD, digestive (55%) and circulatory (53%) comorbidities were most prevalent. In people with ILD, those over 65 years, with musculoskeletal/connective tissue disease or circulatory disease were less likely to obtain meaningful improvements in exercise capacity. There was no impact of comorbidities on exercise capacity in COPD or on HRQoL in ILD.

Conclusions

The majority of patients with COPD or ILD enrolled in PR programmes have multiple comorbidities that may affect improvements in exercise capacity. PR programmes may be less effective for older adults with ILD and comorbid circulatory or musculoskeletal disease.

Effectiveness of pulmonary rehabilitation in elderly patients with COPD: A systematic review and meta-analysis of randomized controlled trials

AIM

The review aimed to evaluate the effects of pulmonary rehabilitation in elderly patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

With an increase in published reports on pulmonary rehabilitation, there is a need for a meta-analysis to measure the effects of pulmonary rehabilitation in elderly COPD patients.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

The Cochrane library (Issue 4, 2018), Web of Science (1975 to April 2018), Embase (1974 to April 2018), Pubmed (1966 to April 2018), CINAHL (1982 to April 2018), JBI (The Joanna Briggs Institute) (1996 to April 2018), CNKI (China National Knowledge Infrastructure) (1979 to April 2018), CBM (SinoMed) (1982 to April 2018), and Wanfang Data (1900 to April 2018) were searched.

REVIEW METHODS

Six outcome indicators were utilized for the effects of pulmonary rehabilitation. Two reviewers selected trials, evaluated the quality, and extracted data. Meta-analysis was performed by using the RevMan 5.3 software.

RESULTS

Eight studies recruited 414 elderly patients. Pulmonary rehabilitation resulted in significantly improved exercise capacity and quality of life in elderly people but with no influence on oxygen saturation compared with the control group.

CONCLUSION

There is a need to provide more detailed pulmonary rehabilitation programs for elderly patients with COPD.

Patient assessment and selection for pulmonary rehabilitation

Pulmonary rehabilitation (PR) is beneficial for people with several forms of chronic respiratory disease. Given the existing limitations on availability of PR services, it is important to identify participants who are most likely to benefit from it. Identification of criteria for patient referral to PR is challenging, as chronic respiratory diseases and their medical and psychosocial co-morbidities place a complex and multifaceted burden on patients. Although research studies have attempted to identify key parameters predictive of 'responsiveness to PR', to date no firm physiological, psychosocial or other criteria exist by which optimal patient candidacy can be determined. Moreover, individual factors do not reliably predict successful multidimensional PR outcomes. In general, individuals who remain symptomatic with dyspnoea, fatigue and exercise intolerance; who have difficulty performing activities of daily living (ADL); and who are having difficulty coping with or managing their disease despite optimized pharmacological therapy are potential candidates for PR. Patient assessment and outcome measurement are core essential features of PR. To be considered as a PR programme, rehabilitation programmes must demonstrate, at a minimum, assessment and outcome measurement in regard to exercise capacity, dyspnoea and health-related quality of life. Additional parameters, including physical activity, nutritional status, tobacco use status, patient knowledge and self-efficacy, performance of ADL, fatigue, disease exacerbations, hospitalizations and other urgent healthcare utilization, and behavioural outcomes, including coping styles, patient satisfaction and programme metrics, are other relevant and important aspects of patient assessment and outcome measurement that should be considered and undertaken in PR, where feasible.

Predictors of response to pulmonary rehabilitation in stable chronic obstructive pulmonary disease patients: A prospective cohort study

Context:

Pulmonary rehabilitation (PR) has become a standard of care in the management of chronic obstructive pulmonary disease (COPD). However, a significant proportion of the patients do not show benefit after the PR program.

Aims:

The study was planned to find different patient- and/or disease-related factors that may predict response to PR in stable COPD.

Subjects and Methods:

A total of 102 stable COPD patients were prospectively enrolled. Baseline evaluation and investigations, including spirometry, arterial blood gas analysis, and bone mineral density assessment, were done. Thereafter, all patients underwent an 8-week comprehensive outpatient PR program that consisted of exercise training, education, nutritional, and psychological counseling. The response to PR was dichotomously (yes/no) defined by the combined improvement in exercise tolerance (6-min walk distance [6MWD] +54 m) and quality of life (St. George's Respiratory Questionnaire [SGRQ] score - 4 points) measured before and after the program. Thereafter, different predefined factors were analyzed for their possible association with the PR response.

Results:

A total of 80 patients (78.4%) completed the PR program and were subjected for analysis. Out of them, 42 (52.5%) showed improvement in both 6MWD and SGRQ score (46 in 6MWD and 54 in SGRQ score). After application of multivariate logistic regression analysis, forced expiratory volume in 1 s <50% predicted (odds ratio [OR]: 2.9; 95% confidence interval [CI]: 1.1–8.3; P = 0.04) and osteoporosis (OR: 0.26; 95% CI: 0.13–0.53; P < 0.001) were found as independent factors predicting PR efficacy.

Conclusions:

Poor baseline lung function predicts a short-term improvement in exercise capacity and quality of life in COPD patients, whereas osteoporosis is a negative predictor of PR response. Active search for these factors may help in better patient selection, thus leading to improved outcome after PR.

The impact of pulmonary rehabilitation on severe physical inactivity in patients with chronic obstructive pulmonary disease: a pilot study

Introduction

In patients with COPD, severe physical inactivity (SPI, which is defined as total daily energy expenditure/resting energy expenditure; physical activity level [PAL] ratio, <1.4) is associated with increased morbidity and mortality. Pulmonary rehabilitation (PR) increases physical capacity in COPD, but the impact on SPI is unknown. In this study, we aimed at elucidating the prevalence of SPI in COPD patients attending standard PR, the impact of PR on SPI prevalence, and the relationship between SPI and time spent in moderate physical activity thus whether American College of Sports Medicine (ACSM) recommendations are clinically useful in excluding SPI in COPD.

Methods

This is a prospective non-interventional pilot study on patients with COPD completing PR, consenting to wear an accelerometer (Sensewear^© Armband) for a week before and after completing PR to assess changes in energy expenditure, time spent in physical activity, and number of daily steps. Low level of daily physical activity was not an inclusion criterion.

Results

In total, 57 patients completed the study and 31 (54%) had SPI at baseline. In patients with SPI, baseline median FEV₁ was 48 (range, 28–86) % of predicted and GOLD B, n=11 (35%)/GOLD D, n=20 (65%). Surprisingly, 31 of SPI patients (97%) spent ≥150 minutes/week in moderate physical activity. After rehabilitation, 24 (78%) did not change activity level and were persistently SPI. We observed no differences at baseline between patient responding (n=7) vs not responding (n=24) to PR. Responders increased number of daily steps and time spent in lighter but not moderate physical activity during rehabilitation.

Conclusion

In this pilot study, SPI was prevalent, and PR had limited impact. Contraintui-tively, most patients with SPI complied with general recommendations of weekly hours spent in moderate physical activity. Our study highlights that increasing time spent in light activity rather than improving time spent in moderate activity is important in COPD patients with chronic dyspnea.

Home discharge following critical illness: A qualitative analysis of family caregiver experience

BACKGROUND

Few studies have longitudinally explored the experience and needs of family caregivers of ICU survivors after patients' home discharge.

METHODS

Qualitative content analysis of interviews drawn from a parent study that followed family caregivers of adults ICU survivors for 4 months post-ICU discharge.

RESULTS

Family caregivers (n = 20, all white, 80% woman) viewed home discharge as positive progress, but reported having insufficient time to transition from family visitor to the active caregiver role. Caregivers expressed feelings of relief during the steady recovery of family members' physical and cognitive function. However, the slow pace of improvement conflicted with their expectations. Even after patients achieved independent physical function, emotional needs persisted and these issues contributed to caregivers' anxiety, worry, and view that recovery was incomplete.

CONCLUSION

Family caregivers of ICU survivors need information and skills to help managing patients' care needs, pacing expectations with actual patients' progress, and caregivers' health needs.

Comorbidities in Patients With Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation Outcomes

PURPOSE

The objective of this study was to evaluate the impact of comorbidities as potential predictors of the response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

METHODS

The study included 165 patients with COPD with exercise limitations. Comorbidity was classified as cardiac, metabolic, orthopedic, behavioral health problems, or other diseases. Number of comorbidities was grouped as 0, 1, or ≥2. Outcomes were defined as improvement in exercise capacity (maximal exercise capacity, 6-minute walk test, and constant workload cycle exercise duration) and quality of life (Chronic Respiratory Questionnaire). We assessed the effect of comorbidities on improvement in outcomes and the impact of the number of comorbidities on the percentage of patients reaching the minimal clinically important difference for each outcome.

RESULTS

Most patients (n = 160; 96%) were elderly males (mean age 70 years) with COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages II to IV. Sixty-four percent of patients had at least 1 comorbidity. The ≥2 comorbidity group (n = 29) had a higher modified Charlson index and more patients required continuous supplemental oxygen. Absolute differences in dyspnea scores in patients with cardiac disease and orthopedic problems compared with those without these comorbidities were 2.6 ± 0.87; 95% CI 0.89 to 4.32; p = .003, and -3.25 ± 1.23; 95% CI -5.69 to -0.82; p = .009, respectively. Comorbidities had no significant effect on other exercise outcomes or quality of life.

CONCLUSION

Patients with cardiac disease experienced greater improvement in the dyspnea score compared with patients with no cardiac disease, whereas patients with orthopedic problems had a smaller but also clinically significant improvement in dyspnea after pulmonary rehabilitation.

A Systematic Review of Comorbidity Measurement Methods for Patients With Nontraumatic Brain Injury in Inpatient Rehabilitation Settings

This review summarizes comorbidity measurements used on patients with nontraumatic brain injury in inpatient rehabilitation and describes findings on measurement validation and comorbidity profiles. MEDLINE and MEDLINE In-Process, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews, Health, and Psychosocial Measurement Instruments were searched. Two reviewers screened results according to predefined inclusion and exclusion criteria. Population, statistical methods, comorbidity measurement, justification of its use, and results involving comorbidity were extracted using a standard table. Of 9476 articles retrieved, 16 were included. Comorbidity has been measured using various methods including the following: number and type within various classification systems, such as the International Disease Classification system, the Charlson comorbidity index, Centers for Medicare and Medicaid Services comorbidity tiers and patient comorbidity and complexity level values and subsets of diagnoses within nonadministrative data studies. No studies have assessed the predictive ability of the comorbidity measurements for inpatient rehabilitation outcomes in this population. Because comorbidities are common among the nontraumatic brain injury population, the predictive validity of comorbidity measurements should be assessed to determine the most appropriate measure to predict or risk adjust rehabilitation outcomes, which has implications for the development of clinical guidelines, and to inform health service research, planning, and delivery.

A narrative review of the impact of medical comorbidities on stroke rehabilitation outcomes

PURPOSE

Medical comorbidities in stroke patients influence acute mortality, but may also affect participation of survivors in rehabilitation. There is limited research investigating the impact of comorbidities on stroke rehabilitation outcomes. The review will explore the literature on the impact of comorbidities on stroke rehabilitation outcome.

MATERIALS AND METHODS

The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome.

RESULTS

Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes.

CONCLUSIONS

There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes. Implications for rehabilitation Benefit of rehabilitation after stroke in improving functional outcome is well-established. Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation. The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.

Coordination of care for patients with COPD: Clinical points of interest

The management of care of chronic obstructive pulmonary disease improved over the last years but is still very complex. Both over- and underdiagnosis are often reported and misclassification of disease severity is common. Differentiating between chronic obstructive pulmonary disease, asthma and asthma-chronic obstructive pulmonary disease overlap syndrome remains difficult. Much is known about the effectiveness of treatment approaches in chronic obstructive pulmonary disease, but patients are often not treated according to the guidelines, and we need more evidence on effectiveness in phenotypes of chronic obstructive pulmonary disease. Care coordination is of great importance and can help to further improve care for chronic obstructive pulmonary disease patients. Pulmonary rehabilitation and self-management are considered important aspects of chronic obstructive pulmonary disease care. In our opinion, there is a major role for eHealth to improve coordination of care of chronic obstructive pulmonary disease.

Influence of comorbidities on the efficacy of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

AIM

To evaluate the influence of comorbidities and aging on pulmonary rehabilitation (PR) efficacy in patients with chronic obstructive pulmonary disease (COPD).

METHODS

This was a retrospective cohort study of patients with COPD attending an outpatient PR program. Comorbidity information was collected with the Charlson Index, BODE index and COPD-specific comorbidity test, and also included other common conditions not included in these indexes. The efficacy of PR was defined as a 54-m increase in 6-min walk distance or a four-point decrease in St. George's Respiratory Questionnaire score. Patients were divided into two age groups according to the median age of 72 years.

RESULTS

A total of 21 of 52 patients (40%) showed a clinically significant benefit by the 6-min walk distance, and 29 patients (55.8%) by the St. George's Respiratory Questionnaire score. PR efficacy was not different between the elderly group and the younger group by either parameter. A total of 98% of the patients had at least one chronic comorbidity. Hypertension was the most frequently reported comorbidity (28.5%). Higher body mass index, Hospital Anxiety and Depression Scale anxiety score and St. George's Respiratory Questionnaire total score were associated with a good response to PR by the 6-min walk distance. None of the individual comorbidities or indexes were correlated with the efficacy of PR. Multiple logistic regression analysis showed that body mass index was independently associated with the response to PR.

CONCLUSIONS

PR is equally effective in elderly and younger patients with COPD, with efficacy influenced by body mass index and anxiety. Geriatr Gerontol Int 2016; 16: 934-941.

Maintaining Gains Following Pulmonary Rehabilitation

PURPOSE

Pulmonary rehabilitation (PR) is an accepted intervention for individuals with chronic obstructive pulmonary disease. Despite initial improvements following PR, many patients eventually return to baseline function or decline even further. The aim of this study is to look at long-term (>1 year) outcomes following PR.

METHODS

This was a prospective cohort study of patients who had completed PR. Participants were invited for an assessment consisting of participant interviews and clinical assessments using standardised instruments.

RESULTS

129 patients between 2003 and 2012 completed rehabilitation and were eligible. 88 patients were included in the analysis. The mean time of the long-term assessment was 22 months following PR. The mean age was 71 years. Mean FEV1 was 46%. There was a statistically significant (p < 0.001) increase in the incremental shuttle walk test distance of 29.0 m following PR but this gain was lost at the long-term reassessment. Chronic Respiratory Questionnaire (CRQ) scores showed a statistically significant (p < 0.001) increase in all four domains but only the domains of dyspnoea and fatigue remained statistically significant (p < 0.001, p < 0.01, respectively) at the long-term reassessment. Hospital Anxiety and Depression Scale scores reduced following rehabilitation but only the anxiety component was statistically significant (p < 0.01). These improvements persisted at the long-term reassessment but were not statically significant.

CONCLUSIONS

This study confirms that many of the functional gains achieved in PR are lost in the longer term. Regular surveillance or monitoring of these patients post-PR is important to identify those requiring further intervention.

Improvement in Pulmonary Function of Chronic Obstructive Pulmonary Disease (COPD) Patients With Osteoporotic Vertebral Compression Fractures (OVCFs) After Kyphoplasty Under Local Anesthesia

To investigate the changes in respiratory function of COPD patients with osteoporotic vertebral compression fractures (OVCFs) after kyphoplasty (KP). Pain scores, pulmonary function parameters (PFT), and local kyphotic angle (LKA) were measured in 31 older patients (25 women, 6 men) with OVCFs before, 3 days after and 3 months after kyphoplasty. The preoperative and postoperative (3 days, 3 months) PFT parameters were as follows: % pred FVC, 74.33 ± 12.35, 85.23.8 ± 13.23, and 84.86 ± 14.01; % pred FEV1, 60.23 ± 11.2, 60.02 ± 11.90, and 60.78 ± 12.70; FEV1/FVC ratio (%), 68.22 ± 16.74, 59.56 ± 13.23, and 60.77 ± 12.28, % pred MVV 52.46 ± 14.37, 55.23 ± 15.68, and 62.12 ± 14.48, respectively. The preoperative mean VAS score was 8.01 ± 1.41 and significantly decreased to 2.52 ± 0.89 and 2.34 ± 0.78 at 3 days, 3 months after kyphoplasty, respectively. The preoperative local kyphotic angle degree was 21.96 ± 5.75°, significantly decreased to 13.48 ± 6.12° 3 days after KP, and maintained 3 month after KP. The decrease in the VAS scores correlated with the PFT parameters; however, there were no significant correlations between the PFT parameters and the LKA, the VAS scores and the LKA. Kyphoplasty under local anesthesia is a safety treatment for the COPD patients with OVCFS, and is able to improve the lung function impaired by OVCFs.

Time to adapt exercise training regimens in pulmonary rehabilitation--a review of the literature

Exercise intolerance, exertional dyspnea, reduced health-related quality of life, and acute exacerbations are features characteristic of chronic obstructive pulmonary disease (COPD). Patients with a primary diagnosis of COPD often report comorbidities and other secondary manifestations, which diversifies the clinical presentation. Pulmonary rehabilitation that includes whole body exercise training is a critical part of management, and core programs involve endurance and resistance training for the upper and lower limbs. Improvement in maximal and submaximal exercise capacity, dyspnea, fatigue, health-related quality of life, and psychological symptoms are outcomes associated with exercise training in pulmonary rehabilitation, irrespective of the clinical state in which it is commenced. There may be benefits for the health care system as well as the individual patient, with fewer exacerbations and subsequent hospitalization reported with exercise training. The varying clinical profile of COPD may direct the need for modification to traditional training strategies for some patients. Interval training, one-legged cycling (partitioning) and non-linear periodized training appear to be equally or more effective than continuous training. Inspiratory muscle training may have a role as an adjunct to whole body training in selected patients. The benefits of balance training are also emerging. Strategies to ensure that health enhancing behaviors are adopted and maintained are essential. These may include training for an extended duration, alternative environments to undertake the initial program, maintenance programs following initial exercise training, program repetition, and incorporation of approaches to address behavioral change. This may be complemented by methods designed to maximize uptake and completion of a pulmonary rehabilitation program.