Magnitude of exercise capacity and quality of life improvement following repeat pulmonary rehabilitation in patients with COPD

Maintenance Pulmonary Rehabilitation: An Update and Future Directions

The Global Initiative for Chronic Obstructive Lung Disease guidelines recommend pulmonary rehabilitation (PR) for individuals with COPD to improve exercise capacity and health-related quality of life (HRQOL) and reduce symptoms of dyspnea. For cost-effectiveness in COPD care, PR is second only to smoking cessation. However, PR programs typically last 9-12 weeks. The benefits of PR in terms of exercise capacity and HRQOL often decrease toward pre-PR levels as early as 3-6 months after completing PR if patients do not continue to engage in exercise. This review will (1) briefly summarize the efficacy data that informed the 2023 American Thoracic Society (ATS) clinical practice guidelines for maintenance PR, (2) discuss exercise components of maintenance PR studied since 2020 when the last papers were included in the ATS guidelines, (3) explore future directions for delivery of maintenance PR using technology-mediated models, and (4) examine the need for behavior change techniques informed by theoretical models that underpin long-term behavior change. This review will focus on persons with COPD who have completed an out-patient core initial PR program as most of the data on maintenance PR have been published in this patient population. Core PR typically implies a facility-based initial intensive structured program. All patients who complete a core initial PR program should be counseled by PR staff at the discharge visit to engage in ongoing exercise. This usual care is equally as important as referral to a formal PR maintenance program. It is critical to emphasize that usual care after core initial PR means all patients should be supported to participate in regular ongoing exercise, regardless of whether supervised maintenance PR is available. Currently, the optimal frequency, exercise and/or physical activity content, and delivery mode for maintenance PR in persons with COPD and other chronic respiratory diseases remain unknown. Patient safety and degree of in-person supervision required due to the severity of the underlying lung disease need to be considered. Future research of maintenance PR should be underpinned by behavior change techniques. Finally, in the setting of finite resources, balancing the competing priorities of core initial programs with those of maintenance PR programs needs to be achieved.

Barriers and Facilitators to Exercise Compliance for Community Elders with COPD: A Cross-Sectional Study

Background and Aim

Exercise compliance was known as important to improve long-term health conditions for Chronic obstructive pulmonary disease (COPD) patients, however, little was known about the determinants which affect their exercise compliance. This study aimed to investigate factors related to exercise compliance of COPD elderly patients.

Methods

This cross-sectional study included elderly patients with stable COPD participants. Random cluster sampling and a survey, including the Exercise Compliance Scale, mMRC Dyspnea Index Scale, Social Support Scale, Anxiety Self-Assessment Scale, and Self-rating Depression Scale, were used. Data were analyzed using Spearman correlation and backward logistic regression.

Results

124 participants (45.90%) had poor exercise compliance while 146 had good compliance (54.10%). The backward logistic regression showed household monthly income (¥501-¥1500: OR=21.54, P<0.05; ¥3001-¥5000: OR=32.76, P<0.05), two chronic comorbidities (OR=17.13, P<0.05), and the moderate dyspnea (OR=16.87, P<0.05) might help to improve exercise compliance. While female COPD patients (OR=0.11, P<0.01) who had server dyspnea (OR=0.02, P<0.05) and depression (OR=0.84, P<0.05) might have more difficulties adhering to exercise.

Conclusion

Low exercise compliance in community-dwelling elderly COPD patients could be affected by sex, monthly income level, number of chronic comorbidities, dyspnea, and depression.

Efficacy of Repeating Pulmonary Rehabilitation in People with COPD: A Systematic Review

Background

Pulmonary rehabilitation is an effective intervention for people with chronic obstructive pulmonary disease (COPD). People with COPD undertake repeat programs, but synthesis of evidence regarding such practice has not been undertaken. The aim of this systematic review was to establish the effects of repeating pulmonary rehabilitation subsequent to an initial program in people with COPD.

Methods

Studies where participants with COPD undertook >1 pulmonary rehabilitation program were included, incorporating RCT (randomized controlled trial) and non-randomized studies. Electronic database searches were undertaken. Two authors independently undertook study identification, data extraction and risk of bias assessment. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were exercise capacity, hospitalizations and exacerbations, adherence, mortality and adverse events. Narrative synthesis was undertaken for clinically heterogeneous trials. Data from RCTs and non-randomized studies were not combined for analysis.

Results

Ten included studies (2 RCTs) involved 907 participants with COPD (n=653 had undertaken >1 program). The majority of studies were at high risk of bias. One RCT (n=33) reported no difference in HRQol after a repeat program vs usual care following exacerbation (Chronic Respiratory Disease Questionnaire dyspnea domain score MD 0.4, 95% CI -0.5 to 3). In stable patients, clinically important and statistically significant improvements in HRQoL and exercise capacity were reported after repeat programs, but of a smaller magnitude than initial programs. There was evidence for reductions in exacerbations and hospitalizations, and shorter hospital length of stay for patients who repeated a program twice in 12 months compared to those who repeated once. No data for mortality or adverse events were available.

Conclusion

This systematic review provides limited evidence for benefits of repeating pulmonary rehabilitation in people with COPD, including improved HRQoL and exercise capacity, and reduced hospitalizations. However, most studies have high risk of bias, which reduces the certainty of these conclusions.

Study Registration

PROSPERO (CRD42020215093).

Trajectories of COPD patients' response to repeated pulmonary rehabilitation programs

BACKGROUND AND OBJECTIVE

Pulmonary rehabilitation (PR) is essential in the management of chronic obstructive pulmonary disease (COPD), but the long-term effects and the outcomes of repeated programs especially in non-responders remain to be clarified. The aim of this study is to evaluate the long-term effect of PR 12 months after and the effect of repeated PR depending on the patient's response to the first PR.

METHODS

This is a single center retrospective analysis of COPD patients admitted to two or three PR programs between January 2012 and December 2017, using the 6-min walking distance (6MWD) to determine the functional response to PR.

RESULTS

One hundred ninety patients completed PR twice and 62 completed PR three times with 10-14 months delay between programs. The effect of the first PR program (PR1) on 6MWD was mostly lost after one year. The 6MWD change after the second PR program (PR2) was smaller than after PR1 (+65 ± 30 m post-PR1, +44 ± 20 m post-PR2; p = 0.001). Out of the 149 responders post-PR1, 44 (30%) became non-responders post-PR2. Out of the 41 non-responders post-PR1, 23 (56%) became responders post-PR2. Patients with long term oxygen therapy and severe exercise dyspnea were most likely to remain non-responders to repeated PR.

CONCLUSION

This study showed that most of the 6MWD improvement following PR disappears over 12 months and emphasized the clinical relevance of repeating PR including for non-responders to initial PR. However, some patients did not respond systematically to PR and may require specific PR modalities to improve their functional status.

Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.

OBJECTIVES

This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.

RESULTS

We included 267 studies (43153 individuals with COPD). A broad range of domains (n=22), outcomes (n=163) and measures (n=217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n=218) assessed with the 6-min walk test (n=140), health-related quality of life (n=204) assessed with the Saint George's respiratory questionnaire (n=99), and symptoms (n=158) assessed with the modified Medical Research Council dyspnea scale (n=56). The least reported outcomes were comorbidities, adverse events and knowledge.

CONCLUSIONS

This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.

PROSPERO ID

CRD42017079935.

Benefits of different intensities of pulmonary rehabilitation for patients with moderate-to-severe COPD according to the GOLD stage: a prospective, multicenter, single-blinded, randomized, controlled trial

Purpose

Pulmonary rehabilitation (PR) is essential to manage patients with COPD. The aim of this study was to investigate the appropriate intensity of PR exercise training for patients with moderate-to-severe COPD.

Patients and methods

A prospective multicenter randomized controlled trial was conducted from January 2014 to October 2018. The subjects were randomly assigned to three groups with different intensities of PR, according to their maximum oxygen uptake percentage determined by cardiopulmonary exercise testing. After 20 weeks of exercise training, the effects of low-, moderate-, and high-intensity exercise interventions on patients were compared to determine the most appropriate PR prescription.

Results

For patients with moderate COPD, all the measured parameters were significantly improved in the moderate- and high-intensity PR groups (P<0.01), while there was no significant difference in the frequency of acute exacerbations and the mMRC questionnaire after 20 weeks of PR exercise in the low-intensity PR group. For patients with severe COPD, all variables were also improved in the high-intensity PR group (P<0.05), while the mean differences of pre- and post-PR were lower than those in patients with moderate COPD. Moreover, the Hamilton Anxiety Scale and body mass index showed no significant difference in low-intensity PR group (P>0.05).

Conclusion

High-intensity PR exercise is helpful for patients with moderate to severe COPD. Moderate COPD patients need to receive intensive PR training; the improvement degrees from PR intervention were higher than those of the severe COPD patients. For patients with severe COPD, high-intensity PR exercise may be more beneficial if patients can tolerate it.

Pulmonary rehabilitation, physical activity, respiratory failure and palliative respiratory care

The CIRO Academy in Horn (the Netherlands) organised a 2-day meeting to present and discuss the studies published in 2017 pertaining to key priority areas of respiratory and critical care medicine. This review summarises studies focussing on pulmonary rehabilitation and exercise training, physical activity, chronic respiratory failure and palliative respiratory care published in 2017.

The use of patient-reported preoperative activity levels as a stratification tool for short-term and long-term outcomes in patients with adult spinal deformity

OBJECTIVE Given the recent shift in health care toward quality reporting requirements and a greater emphasis on a cost-quality approach, patient stratification with respect to long-term outcomes and the use of health care resources is of increasing value. Stratification tools may be effective if they are simple and evidence based. The authors hypothesize that preoperative patient-reported activity levels might independently predict postoperative outcomes in patients with adult spinal deformity. METHODS This is a retrospective cohort. A total of 575 patients in a prospective adult spinal deformity surgical database were identified with complete data regarding the preoperative level of activity. Answers to question 5 of the Scoliosis Research Society-22r Patient Questionnaire (SRS-22r) were used to stratify patients into active and inactive groups. Outcomes were length of hospital stay (LOS), level of activity, and reaching the minimum clinically important difference (MCID) for SRS-22r domains and the Physical Component Summary (PCS) of the SF-36 at 2 years postoperatively. The 2 groups were compared with respect to several potential confounders. Covariates with p < 0.1 were controlled for. The impact of activity on LOS was assessed using multivariate negative binomial regression analysis. Multivariate logistic regression models additionally controlling for the respective baseline health-related quality of life (HRQOL) scores were used to assess the association between preoperative activity levels and reaching the MCID at 2 years postoperatively. RESULTS A total of 420 (73%) of the 575 patients who met the inclusion criteria had complete data at 2 years postoperatively. The inactive group was more likely to be significantly older, have a higher Charlson Comorbidity Index, worse baseline radiographic deformity, and greater correction of most radiographic parameters. After controlling for possible confounders, the active group had a significantly shorter LOS (incidence risk ratio 0.91, p = 0.043). After adding respective baseline HRQOL scores to the models, active patients were significantly more likely to reach the MCID for the SRS-22r pain domain (OR 1.72, p = 0.026) and PCS (OR 1.94, p = 0.013). Active patients were also significantly more likely to be active at 2 years postoperatively on multivariate analysis (OR 8.94, p < 0.001). CONCLUSIONS The authors' results show that patients who belong to the inactive group are likely to have a longer LOS and lower odds of reaching the MCID in HRQOL or being active at 2 years postoperatively. Inquiring about patients' preoperative activity levels might be a reliable and simple stratification tool in terms of long- and short-term outcomes in ASD patients.

The relationship between exercise capacity and different functional markers in pulmonary rehabilitation for COPD

Rationale

The relationship of functional parameters such as lung mechanics, chest kinematics, metabolism and peripheral and respiratory muscle function with the level of exercise tolerance remains a controversial subject. While it has been previously shown that pulmonary rehabilitation is capable of improving exercise tolerance in patients afflicted by COPD, as expressed by values of 6-minute walking test (6MWT), the degree of contribution to this change by each of the aforementioned parameters remains unclear.

Aims

To investigate the correlation between changes in exercise capacity and other functional markers following pulmonary rehabilitation in COPD and to determine which parameters are more closely related to improvements of exercise tolerance.

Materials and methods

Three hundred and twenty-seven patients with COPD (with average, 95% CI for forced expiratory volume in the first second [FEV₁]: 45% [25%–83%] predicted, age: 64 [48–80] years, and BMI: 27 [13.5–40.4] kg/m²) participated in this study. Thirty percent of the patients had pulmonary hypertension as comorbidity. Patients underwent a pulmonary rehabilitation program with 20–30 minutes sessions two to three times per day for 4 weeks. The program was composed of chest wall-stretching, controlled breathing exercises, and a personalized training schedule for cycling and treadmill use. Measurements of 6MWT, lung function, chest wall expansion, grip strength, maximal inspiratory pressure, and breath holding time were taken. The Body mass index, airflow Obstruction, Dyspnea and Exercise capacity (BODE-index), body mass index [BMI], FEV₁, 6MWT, modified Medical Research Dyspnea Scale score, and an alternative scale score (for BMI, FEV₁, 6MWT, and COPD Assessment Test) were calculated.

Results

Rehabilitation resulted in a generalized improvement in 6MWT among patients (average: 360 [95% CI: 178–543 m] vs average: 420 [95% CI: 238–601 m], p<0.05). Improvements in exercise tolerance were found to be most closely associated with changes in composite BODE-index (R²=−0.6), Alternative Scale (R²=−0.56), dyspnea score (modified Medical Research Dyspnea Scale R²=−0.54), and health status (COPD Assessment Test R²=−0.4, p<0.05). In addition, improvements in exercise tolerance were found to moderately correlate with improvements in inspiratory vital capacity (IVC, R²=0.34, p<0.05). Post-rehabilitation changes in IVC displayed a connection with grip strength (R²=0.6) and chest expansion (R²=0.48).

Conclusion

Enhancements in exercise tolerance had correlation with changes in IVC, BODE-index, and the new Alternative Scale. However, comprehensive assessment needs to include considerations of chest kinematics and peripheral and respiratory muscle function as well.