Effectiveness of Pulmonary Rehabilitation in Reducing Health Resources Use in Chronic Obstructive Pulmonary Disease

A pulmonary rehabilitation program reduces hospitalizations in chronic obstructive pulmonary disease patients: A cost-effectiveness study

BACKGROUND

Although pulmonary rehabilitation (PR) is recommended in patients with chronic obstructive pulmonary disease (COPD), there is a scarcity of data demonstrating the cost-effectiveness and effectiveness of PR in reducing exacerbations.

METHODS

A quasi-experimental study in 200 patients with COPD was conducted to determine the number of exacerbations 1 year before and after their participation in a PR program. Quality of life was measured using the COPD assessment test and EuroQol-5D. The costs of the program and exacerbations were assessed the year before and after participation in the PR program. The incremental cost-effectiveness ratio (ICER) was estimated in terms of quality-adjusted life years (QALYs).

RESULTS

The number of admissions, length of hospital stay, and admissions to the emergency department decreased after participation in the PR program by 48.2%, 46.6%, and 42.5%, respectively (P < 0.001 for all). Results on quality of life tests improved significantly (P < 0.001 for the two tests). The cost of PR per patient and the cost of pre-PR and post-PR exacerbations were €1867.7 and €7895.2 and €4201.9, respectively. The PR resulted in a cost saving of €1826 (total, €365,200) per patient/year, and the gain in QALYs was+0.107. ICER was -€17,056. The total cost was <€20,000/QALY in 78% of patients.

CONCLUSIONS

PR contributes to reducing the number of exacerbations in patients with COPD, thereby slowing clinical deterioration. In addition, it is cost-effective in terms of QALYs.

Occupational therapy in adults with chronic respiratory conditions: A scoping review

INTRODUCTION

Chronic respiratory diseases have a clear impact on occupational performance and engagement. Although occupational therapists have long provided services to this population, evidence regarding the unique role and true impact of occupational therapy is emerging.

AIMS/OBJECTIVES

The purpose of this scoping review was to explore the range, context, and outcomes of occupational therapy services for adults with chronic respiratory conditions.

METHODS

A scoping review guided by the methodological framework of Arksey and O'Malley was completed. To be included articles needed to be peer reviewed primary studies published in English between 2000 and September 2022 describing occupational therapy service delivery for people with chronic respiratory conditions.

RESULTS

Twenty-six articles met inclusion criteria including 12 cohort studies, seven randomised control trials, four qualitative, two case reports, and one service evaluation. Interventions were targeted at body functions and structures (n = 18), activities and participation (n = 17), and environmental factors (n = 14). Ten studies reported impacts of occupational therapy ranging from physiological responses through to quality of life.

CONCLUSION

Occupational therapy service delivery is common for this population, often occurring as part of multidisciplinary programs, and is inclusive of a range of assessments and interventions. Further details in future primary research are needed to describe the mode and unique occupational nature of service delivery.

Effects of creative dance on functional capacity, pulmonary function, balance, and cognition in COPD patients: A randomized controlled trial

BACKGROUND

Exercise training is key to the comprehensive management of patients with chronic obstructive pulmonary disease (COPD). Creative dance can be an innovative approach as effective as traditional exercise training.

OBJECTIVES

This study aimed to investigate effect of creative dance-based exercise (CDE) training on functional capacity, postural stability and balance, pulmonary and cognitive functions, respiratory and peripheral muscle strength in COPD patients.

METHODS

Twenty-four patients with COPD were randomly allocated to either "chest physiotherapy and home-based walking program" (PT) or "CDE alongside home-based chest physiotherapy group" (PT+CDE). Both groups performed chest PT program twice a day for 5 days per week for 8 weeks. PT+CDE group received CDE training 2 days a week for 8 weeks. Primary outcome was six minute walk test (6MWT). Secondary outcomes were postural stability and balance, pulmonary function, maximum inspiratory (MIP) and expiratory (MEP) pressure, peripheral muscle strength, Montreal Cognitive Assessment (MoCA), COPD Assessment Test (CAT), and BODE index. Outcome measures were assessed at baseline and after 8 weeks of training.

RESULTS

Both groups showed statistically significant improvements in 6MWT distance, MIP, MEP, MoCA score, CAT, and BODE index (p < 0.05). Only with CDE training was achieved improvements in postural stability and balance scores, pulmonary function, and peripheral muscle strength (p < 0.05). The improvements in 6 MWT distance, MEP, MoCA score, and CAT were greater in PT+CDE group (p < 0.05).

CONCLUSION

Use of creative dance training in addition to home-based chest PT program was more effective than chest PT program regarding primary and secondary outcomes in COPD patients.

Occupational therapy in pulmonary rehabilitation programs: A scoping review

Pulmonary rehabilitation (PR) is a multidisciplinary intervention forming the cornerstone of chronic respiratory disease management, improving individuals' exercise capacities and abilities to complete activities of daily living (ADLs). Although the occupational therapy (OT) scope of practice focuses on similar outcomes as PR, the tasks/roles and benefit of including OT in PR has not been reviewed. This scoping review synthesized the i) tasks/roles, ii) recommendations of guidelines, iii) prevalence and iv) effects of OT as part of PR programs. Searching of four databases (MEDLINE, EMBASE, CINAHL and Cochrane), OT association websites, and hand searching was performed, and 51 records were included. The OT tasks/roles most reported include teaching energy conservation techniques (n = 23), addressing ADLs (n = 17), and assisting with breathlessness management (n = 10). Using the Canadian Model of Occupational Performance and Engagement these tasks/roles were grouped into person (n = 16 unique tasks/roles), occupation (n = 6 tasks/roles), environment (n = 5 tasks/roles), and other (n = 3 tasks/roles) domains and were endorsed by two available practice guidelines addressing OT in PR programs. From 13 PR surveys across four continents, 17-92% of PR programs included OT. Inclusion of OT in PR resulted in positive effects on ADLs, pulmonary function, dyspnea, quality of life, and mortality. Although an increasing number of PR programs include occupational therapists in their multidisciplinary teams, there is a paucity of original studies and guidelines reporting on the tasks/roles and benefits of OT in PR. Further research is needed to clearly define the tasks/roles of OT in multidisciplinary PR teams and contributions to enhancing patient outcomes.

The Long-Term Maintenance Effect of Remote Pulmonary Rehabilitation via Social Media in COPD: A Randomized Controlled Trial

Background

Although the benefits of conventional pulmonary rehabilitation (PR) maintenance are well documented, it is challenged by many difficulties. We investigated whether remote home-based PR maintenance strategy via social media (WeChat) is effective on clinical improvements and reducing the risk for acute exacerbation of chronic obstructive pulmonary disease (COPD).

Methods

The eligible stable COPD patients completing an initial 8-week PR were allocated into three groups randomly. Group A: PR maintenance via social media supervision at home. Group B: PR maintenance at hospital. Group C: Usual care. During a 12-month follow-up, the frequency of acute exacerbation of COPD (AECOPD), 6 minutes walking test (6MWT), COPD assessment test (CAT), and modified Medical Research Council scale (mMRC) were evaluated every 3 months.

Results

At the end of the follow-up, compared to the decline in the usual care group (n = 49), the clinical improvements of 6MWD, CAT, and mMRC were sustained in both the home-based group (n = 47) and the hospital-based maintenance group (n = 44) (p < 0.001), no difference was observed between these two groups (p > 0.05). In multivariate analysis, the home-based PR maintenance and hospital-based PR maintenance were independent predictors of lower risk for AECOPD (incidence rate ratio (IRR) 0.712, 95% CI 0.595-0.841, p < 0.001 and IRR 0.799, 95% CI 0.683-0.927, p = 0.002), respectively.

Conclusion

Remote PR maintenance via social media is effective in reducing the risk for AECOPD and keeping the clinical improvement from decline. Remote PR maintenance via social media might be used to deliver alternatives to conventional PR.

Pulmonary Rehabilitation in Management of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is an obstructive and progressive airway disorder that is linked with a significant loss in daily physical activity as well as psychological issues that contribute to the patient's impairment and poor health-related quality of life. Over the last two decades, however, the research and application of nonpharmacologic therapies such as lung rehabilitation have been expedited with increasing evidence of systemic events in COPD patient groups and their nugatory impact on their functioning pulmonary rehabilitation (PR). It is a key part of integrated treatment for COPD and other chronic breathing disorders and is helpful in supporting the recovery of patients following COPD hospitalization. In this paper, we summarize current evidence regarding the effectiveness of PR in the management of chronic COPD. A systematic review was carried out during June 2021, searching databases PubMed, Google Scholar, and EBSCO. The authors extracted qualitative data, and then the author's names, year, study type, methodology, and the result were reported. The search of the aforementioned databases returned a total of 127 studies that were included for title, abstract, and full-text screening, and nine studies were enrolled for final data extraction. PR alleviates tiredness and dyspnea, improves emotional function, and increases the ability to do daily activities. These benefits are relatively extensive and substantial clinically. Rehabilitation acts as an important component of COPD management and helps to improve the quality of life and training linked to health.

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.

Operational Modeling with Health Economics to Support Decision Making for COPD Patients

OBJECTIVE

To assess the impact of interventions for improving the management of chronic obstructive pulmonary disease (COPD), specifically increased use of pulmonary rehabilitation (PR) on patient outcomes and cost-benefit analysis.

DATA SOURCES

We used the national Hospital Episode Statistics (HES) datasets in England, local data and experts from the hospital setting, National Prices and National Tariffs, reports and the literature around the effectiveness of PR programs.

STUDY DESIGN

The COPD pathway was modeled using discrete event simulation (DES) to capture the patient pathway to an adequate level of detail as well as randomness in the real world. DES was further enhanced by the integration of a health economic model to calculate the net benefit and cost of treating COPD patients based on key sets of interventions.

DATA COLLECTION/EXTRACTION METHODS

A total of 150 input parameters and 75 distributions were established to power the model using the HES dataset, outpatient activity data from the hospital and community services, and the literature.

PRINCIPAL FINDINGS

The simulation model showed that increasing referral to PR (by 10%, 20%, or 30%) would be cost-effective (with a benefit-cost ratio of 5.81, 5.95, and 5.91, respectively) by having a positive impact on patient outcomes and operational metrics. Number of deaths, admissions, and bed days decreased (ie, by 3.56 patients, 4.90 admissions, and 137.31 bed days for a 30% increase in PR referrals) as well as quality of life increased (ie, by 5.53 QALY among 1540 patients for the 30% increase).

CONCLUSIONS

No operational model, either statistical or simulation, has previously been developed to capture the COPD patient pathway within a hospital setting. To date, no model has investigated the impact of PR on COPD services, such as operations, key performance, patient outcomes, and cost-benefit analysis. The study will support policies around extending availability of PR as a major intervention.

Effect of home-based pulmonary rehabilitation on health-related quality of life, lung function, exercise tolerance, and dyspnea in chronic obstructive pulmonary disorder patients in a tertiary care center in South India

Context:

Home-based pulmonary rehabilitation (PR) can increase compliance in chronic obstructive pulmonary disorder (COPD). There is paucity of data on this in India.

Aims:

To study the effectiveness of home-based PR on lung function, health-related quality of life, exercise tolerance and dyspnea among patients with COPD.

Setting:

The Department of Pulmonary Medicine, Christian Medical College, Vellore.

Subjects and Methods:

This was a quasi-experimental study which included COPD patients who found hospital-based PR impractical. Those willing for home-based PR constituted the intervention group and those unwilling, constituted the control group. Both groups received standard of care otherwise. At 6 weeks, forced expiratory volume in 1 sec (FEV1), St. George Respiratory Questionnaire (SGRQ), six-minute walk test distance (6MWD), COPD assessment test (CAT) score and modified Borg dyspnea scale were compared with their baseline values.

Statistical Analysis:

Student paired t-test.

Results:

A total of 42 patients completed the study, 21 in each arm. The baseline characteristics were comparable. The improvement in FEV1 was 90 ml in the intervention group and 4 ml in the control group (P = 0.01). There was no significant difference in 6MWD change. SGRQ score, Borg scale and CAT score improved significantly by 10.4, 2.4, and 3.4, respectively, in the intervention group when compared to the control group (P = 0.01).

Conclusions:

Home-based PR effectively provides tangible benefits in FEV1, QOL, exercise tolerance and dyspnea. It should be offered to those who are unable to avail institution-based PR, especially in this era of COVID pandemic.

Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Objective

Hospital-outreach pulmonary rehabilitation (PR) can improve health status and reduce health-care utilization by patients with chronic obstructive pulmonary disease (COPD). However, its long-term effects and costs versus benefits are still not clear. This study was conducted to develop, deliver, and evaluate the effects and monetary savings of a hospital-outreach PR program for patients with COPD.

Methods

A randomized controlled trial was conducted. Patients with COPD (n=208) were randomly assigned to the hospital-outreach PR program (treatment) or treatment as usual (control). The treatment group received a 3-month intensive intervention, including supervised physical exercise, smoking cessation, self-management education, and psychosocial support, followed by long-term access to a nurse through telephone follow-up and home visits up to 24 months. The control group received routine care, including discharge education and a self-management education brochure. Main outcomes were collected at 3, 6, 12, and 24 -months postrandomization. Primary outcomes included health-care utilization (ie, readmission rates, times, and days, and emergency department visits) and medical costs. Secondary outcomes included lung function (ie, FEV1, FEV1% predicted, FVC), dyspnea (mMCR), exercise capacity (6MWD), impact on quality of life (CAT), and self-management (CSMS).

Results

At the end of 24 months, 85 (81.7%) in the treatment group and 89 (85.6%) in the control group had completed the whole program. Compared with the control group, patients in the treatment group had lower readmission rates, times, and days at 6 and 12 months and during 12-24 months. Regarding costs during the 2 years, the program achieved CN¥3,655.94 medical  savings per patient per year, and every ¥1 spent on the program led to ¥3.29 insavings. Patients in the treatment group achieved improvements in FEV1, FEV1% predicted, exercise capacity, and self-management. It also achieved relief of dyspnea symptoms and improvement in COPD's impact on quality of life.

Conclusion

The hospital-outreach PR program for patients with COPD achieved reductions in health-care utilization, monetary savings, and improvements in patient health outcomes. The effects of the program were sustained for at least 2 years.

Trial Registration

This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-TRC-14005108).

Short- and Long-term Effects of Pulmonary Rehabilitation in Patients With Mild COPD: A COMPARISON WITH PATIENTS WITH MODERATE TO SEVERE COPD

PURPOSE

Pulmonary rehabilitation (PR) is effective in patients with moderate to severe chronic obstructive pulmonary disease (COPD). However, the effects of PR in patients with mild COPD have not yet been established. Thus, this study investigated the short- and long-term effects of PR in patients with mild COPD in comparison with patients with moderate to severe disease.

METHODS

A total of 32 patients with mild (group 1) and 29 with moderate to severe (group 2) COPD completed the study. Both groups participated in a 12-week PR program with exercise training and psychosocial support and education. Outcome measures at baseline, 3 (post-PR), 6, and 9 months later included 6-minute walk test (6MWT); Modified Medical Research Council Dyspnea Scale; 1-repetition maximum chest press and knee extension; a brief physical activity assessment; the number of exacerbations in the past 3 months and the St. George Respiratory Questionnaire (SGRQ).

RESULTS

Improvements in the 6MWT, chest press, knee extension, and physical activity were observed post-PR (P < .001), with no differences between the 2 groups. Reduction in the number of exacerbations (P < .001) and improvements in the SGRQ total (P < .001) were also observed, however, with greater magnitude in group 2 (P = .029 and P < .001, respectively). Except for peripheral muscle strength (P < .002), all the achieved benefits were sustained at 6 and 9 months (P > .05).

CONCLUSIONS

Pulmonary rehabilitation improves exercise tolerance, muscle strength, physical activity, and health-related quality of life and reduces exacerbations in patients with mild COPD as it does in patients with moderate to severe COPD. Moreover, most of these benefits were maintained at 9-month follow-up, suggesting that PR could be part of the management of mild COPD.

Pulmonary Rehabilitation Utilization in Older Adults With Chronic Obstructive Pulmonary Disease, 2003 to 2012

PURPOSE

To assess the trends in pulmonary rehabilitation (PR) utilization and factors associated with its use in older adults with chronic obstructive pulmonary disease (COPD).

METHODS

We examined data for Medicare beneficiaries with COPD who received PR from January 1, 2003, to December 31, 2012. Persons with COPD were identified by (1) ≥2 outpatient visits >30 days apart within 1 year with an encounter diagnosis of COPD or (2) an acute care hospitalization with COPD as the primary diagnosis or a primary diagnosis of acute respiratory failure with a secondary discharge diagnosis of COPD. PR utilization was the study outcome identified by health care common procedure coding system codes G0237, G0238, G0239, and G0424 (after year 2010) or current procedural terminology codes (97001, 97003, 97110, 97116, 97124, 97139, 97150, 97530, 97535, and 97537) in a calendar year.

RESULTS

Patients with COPD who received PR increased from 2.6% in 2003 to 3.7% in 2012 (P = .001). In a multivariable analysis, factors associated with receipt of PR were younger age, non-Hispanic white race, high socioeconomic status, multiple comorbidities (OR = 1.20; 95% CI = 1.13-1.27), and evaluation by a pulmonary physician (OR = 2.23; 95% CI = 2.13-2.33). Increased use of PR was attributed to prior users rather than new users of PR.

CONCLUSIONS

Utilization of PR during the study period increased only 1.1% in these Medicare beneficiaries with COPD and remained low.

Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits

Pulmonary rehabilitation (PR) remains grossly underutilised by suitable patients worldwide. We investigated whether home-based maintenance tele-rehabilitation will be as effective as hospital-based maintenance rehabilitation and superior to usual care in reducing the risk for acute chronic obstructive pulmonary disease (COPD) exacerbations, hospitalisations and emergency department (ED) visits.

Following completion of an initial 2-month PR programme this prospective, randomised controlled trial (between December 2013 and July 2015) compared 12 months of home-based maintenance tele-rehabilitation (n=47) with 12 months of hospital-based, outpatient, maintenance rehabilitation (n=50) and also to 12 months of usual care treatment (n=50) without initial PR.

In a multivariate analysis during the 12-month follow-up, both home-based tele-rehabilitation and hospital-based PR remained independent predictors of a lower risk for 1) acute COPD exacerbation (incidence rate ratio (IRR) 0.517, 95% CI 0.389–0.687, and IRR 0.635, 95% CI 0.473–0.853), respectively, and 2) hospitalisations for acute COPD exacerbation (IRR 0.189, 95% CI 0.100–0.358, and IRR 0.375, 95% CI 0.207–0.681), respectively. However, only home-based maintenance tele-rehabilitation and not hospital-based, outpatient, maintenance PR was an independent predictor of ED visits (IRR 0.116, 95% CI 0.072–0.185).

Home-based maintenance tele-rehabilitation is equally effective as hospital-based, outpatient, maintenance PR in reducing the risk for acute COPD exacerbation and hospitalisations. In addition, it encounters a lower risk for ED visits, thereby constituting a potentially effective alternative strategy to hospital-based, outpatient, maintenance PR.

Healthcare Resource Use and Costs in Long-Term Survivors of Acute Respiratory Distress Syndrome: A 5-Year Longitudinal Cohort Study

OBJECTIVE

To evaluate the time-varying relationship of annual physical, psychiatric, and quality of life status with subsequent inpatient healthcare resource use and estimated costs.

DESIGN

Five-year longitudinal cohort study.

SETTING

Thirteen ICUs at four teaching hospitals.

PATIENTS

One hundred thirty-eight patients surviving greater than or equal to 2 years after acute respiratory distress syndrome.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Postdischarge inpatient resource use data (e.g., hospitalizations, skilled nursing, and rehabilitation facility stays) were collected via a retrospective structured interview at 2 years, with prospective collection every 4 months thereafter, until 5 years postacute respiratory distress syndrome. Adjusted odds ratios for hospitalization and relative medians for estimated episode of care costs were calculated using marginal longitudinal two-part regression. The median (interquartile range) number of inpatient admission hospitalizations was 4 (2-8), with 114 patients (83%) reporting greater than or equal to one hospital readmission. The median (interquartile range) estimated total inpatient postdischarge costs over 5 years were $58,500 ($19,700-157,800; 90th percentile, $328,083). Better annual physical and quality of life status, but not psychiatric status, were associated with fewer subsequent hospitalizations and lower follow-up costs. For example, greater grip strength (per 6 kg) had an odds ratio (95% CI) of 0.85 (0.73-1.00) for inpatient admission, with 23% lower relative median costs, 0.77 (0.69-0.87).

CONCLUSIONS

In a multisite cohort of long-term acute respiratory distress syndrome survivors, better annual physical and quality of life status, but not psychiatric status, were associated with fewer hospitalizations and lower healthcare costs.

Long-term integrated telerehabilitation of COPD Patients: a multicentre randomised controlled trial (iTrain)

BACKGROUND

Pulmonary rehabilitation (PR) is an effective intervention for the management of people with chronic obstructive pulmonary disease (COPD). However, available resources are often limited, and many patients bear with poor availability of programmes. Sustaining PR benefits and regular exercise over the long term is difficult without any exercise maintenance strategy. In contrast to traditional centre-based PR programmes, telerehabilitation may promote more effective integration of exercise routines into daily life over the longer term and broaden its applicability and availability. A few studies showed promising results for telerehabilitation, but mostly with short-term interventions. The aim of this study is to compare long-term telerehabilitation with unsupervised exercise training at home and with standard care.

METHODS/DESIGN

An international multicentre randomised controlled trial conducted across sites in three countries will recruit 120 patients with COPD. Participants will be randomly assigned to telerehabilitation, treadmill and control, and followed up for 2 years. The telerehabilitation intervention consists of individualised exercise training at home on a treadmill, telemonitoring by a physiotherapist via videoconferencing using a tablet computer, and self-management via a customised website. Patients in the treadmill arm are provided with a treadmill only to perform unsupervised exercise training at home. Patients in the control arm are offered standard care. The primary outcome is the combined number of hospitalisations and emergency department presentations. Secondary outcomes include changes in health status, quality of life, anxiety and depression, self-efficacy, subjective impression of change, physical performance, level of physical activity, and personal experiences in telerehabilitation.

DISCUSSION

This trial will provide evidence on whether long-term telerehabilitation represents a cost-effective strategy for the follow-up of patients with COPD. The delivery of telerehabilitation services will also broaden the availability of PR and maintenance strategies, especially to those living in remote areas and with no access to centre-based exercise programmes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02258646 .

Moderate Aerobic Training Improves Cardiorespiratory Parameters in Elastase-Induced Emphysema

Aim: We investigated the therapeutic effects of aerobic training on lung mechanics, inflammation, morphometry and biological markers associated with inflammation, and endothelial cell damage, as well as cardiac function in a model of elastase-induced emphysema.

Methods: Eighty-four BALB/c mice were randomly allocated to receive saline (control, C) or 0.1 IU porcine pancreatic elastase (emphysema, ELA) intratracheally once weekly for 4 weeks. After the end of administration period, once cardiorespiratory impairment associated with emphysema was confirmed, each group was further randomized into sedentary (S) and trained (T) subgroups. Trained mice ran on a motorized treadmill, at moderate intensity, 30 min/day, 3 times/week for 4 weeks.

Results: Four weeks after the first instillation, ELA animals, compared to C, showed: (1) reduced static lung elastance (Est,L) and levels of vascular endothelial growth factor (VEGF) in lung tissue, (2) increased elastic and collagen fiber content, dynamic elastance (E, in vitro), alveolar hyperinflation, and levels of interleukin-1β and tumor necrosis factor (TNF)-α, and (3) increased right ventricular diastolic area (RVA). Four weeks after aerobic training, ELA-T group, compared to ELA-S, was associated with reduced lung hyperinflation, elastic and collagen fiber content, TNF-α levels, and RVA, as well as increased Est,L, E, and levels of VEGF.

Conclusion: Four weeks of regular and moderate intensity aerobic training modulated lung inflammation and remodeling, thus improving pulmonary function, and reduced RVA and pulmonary arterial hypertension in this animal model of elastase-induced emphysema.

Loss of Dignity in Severe Chronic Obstructive Pulmonary Disease

CONTEXT

The maintenance of dignity is an important concept in palliative care, and the loss of dignity is a significant concern among patients with advanced cancer.

OBJECTIVES

The goals of this study were to examine whether loss of dignity is also a concern for patients receiving interdisciplinary rehabilitation for Stage III or IV chronic obstructive pulmonary disease. We examined the prevalence and correlates of loss of dignity and determined whether it improves with treatment.

METHODS

Inpatients underwent a structured interview inquiry around their sense of dignity and completed measures of pulmonary, physical, and psychological function at admission (n = 195) and discharge (n = 162).

RESULTS

Loss of dignity was identified as a prominent ongoing concern for 13% of patients. It was correlated with measures of depression and anxiety sensitivity, but not with pulmonary capacity or functional performance. A robust improvement in loss of dignity was demonstrated, with 88% of those who reported a significant problem at admission no longer reporting one at discharge.

CONCLUSION

The prevalence of a problematic loss of dignity among patients with severe chronic obstructive pulmonary disease is at least as high as among those receiving palliative cancer care. Loss of dignity may represent a concern among people with medical illnesses more broadly, and not just in the context of "death with dignity" at the end of life. Furthermore, interdisciplinary care may help to restore a sense of dignity to those individuals who are able to participate in rehabilitation.

Long-term effect of respiratory training for chronic obstructive pulmonary disease patients at an outpatient clinic: a randomised controlled trial

OBJECTIVE

To assess the effect of respiratory training (RT) on lung function, activity tolerance and acute exacerbation frequency with chronic obstructive pulmonary disease (COPD).

DESIGN

A randomised controlled trial.

SETTING

Outpatient clinic and home of the COPD patients, Zhengzhou City, China.

SUBJECTS

Sixty participants with COPD were randomised into two groups: an intervention group (n = 30) which received the RT in self-management and a control group (n = 30) that received an education program during the study.

INTERVENTION

Pulmonary function, activity tolerance and frequency of acute exacerbation of these COPD patients were evaluated before and after the program. The intervention and control programs were delivered at monthly outpatient clinic visits over a period of 12 months. The pulmonary rehabilitation (PR) program was conducted by a physiotherapist (who delivered RT to the participant over a minimum of 1 h per visit) for the intervention group, whereas the control group received routine health education provided by physiotherapists. The intervention group patients were then instructed to perform exercises at home as taught in the RT at least 5 days per week at home.

RESULTS

After 12 months of RT, the lung function and the activity tolerance of the COPD patients in the intervention group were significantly improved and the exacerbation frequency was also decreased.

CONCLUSION

Long-term RT can improve lung function and activity tolerance while decreasing the frequency of acute exacerbation for COPD patients.

Veterans with chronic obstructive pulmonary disease achieve clinically relevant improvements in respiratory health after pulmonary rehabilitation

PURPOSE

To measure respiratory health and respiratory-related (RR) health care utilization in veterans with chronic obstructive pulmonary disease referred to pulmonary rehabilitation (PR) at the Cincinnati Veterans Administration (VA) Medical Center.

METHODS

We reviewed the records of 430 patients referred for PR from 2008 to 2010: 78 met inclusion criteria and completed PR (PR group); 92 qualified for PR but declined participation (referral group). All PR participants completed the St. George's Respiratory Questionnaire (SGRQ), BODE index, 6-minute walk test (6MWT), UCSD Shortness of Breath Questionnaire (UCSDSOBQ), Pulmonary Disease Knowledge Test, and self-reported use of short-acting bronchodilators before and after PR. All VA health care encounters during the 12 months before and after PR (PR group) or referral (referral group) were reviewed.

RESULTS

Respiratory health improved after PR: SGRQ (60.6 ± 15.1, 51.1 ± 16.7), BODE (4.65 ± 1.93, 3.41 ± 1.84), 6MWT (497 ± 367 m, 572 ± 397 m), UCSDSOBQ (68.3 ± 21.1, 61.0 ± 20.9), Pulmonary Disease Knowledge Test (75.9 ± 12.4%, 85.9 ± 11.1%), short-acting bronchodilator (22.5 ± 25.3, 12.8 ± 15.6 inhalations per week) (before, after PR; P < .001 for all comparisons). The RR emergency department (ED) visits (0.71 ± 1.44, 0.44 ± 0.86; P = .04) and RR hospitalizations (0.41 ± 0.73, 0.23 ± 0.51; P = .03) (visits/patient/year; pre-PR, post-PR) decreased following PR. RR ED visits and hospitalizations were the same for the PR and referral groups prior to PR but declined post-PR (0.44 ± 0.86, 0.78 ± 1.36 ED visits/patient/year; P = .05) and (0.23 ± 0.51, 0.59 ± 1.20 hospitalizations/patient/year; P = .01). Ninety-four percent of PR participants achieved the minimal clinically important difference in at least 1 univariate scale (Modified Medical Research Council, UCSDSOBQ, SGRQ, and 6MWT); 82%, 2 scales; 59%, 3 scales; and 24%, all 4 scales.

CONCLUSIONS

Pulmonary rehabilitation improves respiratory health in veterans with chronic obstructive pulmonary disease and decreases RR health care utilization.

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.

Improving understanding of and adherence to pulmonary rehabilitation in patients with COPD: a qualitative inquiry of patient and health professional perspectives

OBJECTIVES

Although patients with Chronic Obstructive Pulmonary Disease (COPD) who adhere to a pulmonary rehabilitation program are better able to manage their illness and experience a better health-related quality of life, pulmonary rehabilitation remains underused. This study aims to describe the experiences of patients who are in a pulmonary rehabilitation program, and explore the perceptions of both patients and health professionals about what improves effective pulmonary rehabilitation.

METHODS

A qualitative research design, including focus groups and individual interviews with 25 patients and 7 program health professionals, was used to obtain combined perspectives about the factors underpinning the COPD patient's reasons for participation in a rehabilitation program.

RESULTS

Three themes were derived from the descriptive content analysis: (1) building confidence, (2) a perception of immediate tangible results, and (3) being ready and having access to the program.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Qualitative findings from this study suggest that a patient's adherence to a COPD rehabilitation program can be improved by quickly building up the participant's confidence, promoting tangible results, and by timely recognizing and responding to the issues of readiness and access. Based on these findings, health care providers could develop strategies to better serve COPD patients who face multiple barriers to access and successfully complete a pulmonary rehabilitation program.

Ground-based walking training improves quality of life and exercise capacity in COPD

This study was designed to determine the effect of ground-based walking training on health-related quality of life and exercise capacity in people with chronic obstructive pulmonary disease (COPD). People with COPD were randomised to either a walking group that received supervised, ground-based walking training two to three times a week for 8-10 weeks, or a control group that received usual medical care and did not participate in exercise training. 130 out of 143 participants (mean±sd age 69±8 years, forced expiratory volume in 1 s 43±15% predicted) completed the study. Compared to the control group, the walking group demonstrated greater improvements in the St George's Respiratory Questionnaire total score (mean difference -6 points (95% CI -10- -2), p<0.003), Chronic Respiratory Disease Questionnaire total score (mean difference 7 points (95% CI 2-11), p<0.01) and endurance shuttle walk test time (mean difference 208 s (95% CI 104-313), p<0.001). This study shows that ground-based walking training is an effective training modality that improves quality of life and endurance exercise capacity in people with COPD.

Self-reported quality of ADL task performance among patients with COPD exacerbations

OBJECTIVE

Patients suffering from chronic obstructive pulmonary disease (COPD) experience problems in the performance of activities of daily living (ADL) tasks. The objective was to examine the self-reported quality of ADL task performance among COPD patients, and to investigate whether age, gender, and routine COPD characteristics correlate with the self-reported ADL ability.

METHODS

Eighty patients admitted to hospital with COPD exacerbations participated. In a cross-sectional study, the patients' self-reported ADL ability was assessed using the ADL-Interview (ADL-I) instrument. Data concerning age, gender, and routine COPD characteristics were drawn from the patients' medical records.

RESULTS

The patients reported being inefficient to markedly inefficient when performing ADL tasks within the personal hygiene, toileting, dressing, household, mobility, and transportation domains. While more than 90% of the participants reported increased effort and/or fatigue when performing the ADL tasks, up to 88% of the participants relied on help from others in the performance of general household chores like cooking and shopping. Self-reported ADL ability did not correlate with age, gender, or routine COPD characteristics.

CONCLUSIONS

Decreased quality of ADL task performance seemed to be extremely common among COPD patients. Therefore, addressing the problems in individually tailored pulmonary rehabilitation programmes may be advantageous.

Benefits and costs of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease - a multi-centre randomised controlled equivalence trial

BACKGROUND

Pulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease (COPD) to improve exercise capacity, symptoms and quality of life, however only a minority of individuals with COPD are able to participate. Travel and transport are frequently cited as barriers to uptake of centre-based programs. Other models of pulmonary rehabilitation, including home-based programs, have been proposed in order to improve access to this important treatment. Previous studies of home-based pulmonary rehabilitation in COPD have demonstrated improvement in exercise capacity and quality of life, but not all elements of the program were conducted in the home environment. It is uncertain whether a pulmonary rehabilitation program delivered in its entirety at home is cost effective and equally capable of producing benefits in exercise capacity, symptoms and quality of life as a hospital-based program. The aim of this study is to compare the costs and benefits of home-based and hospital-based pulmonary rehabilitation for people with COPD.

METHODS/DESIGN

This randomised, controlled, equivalence trial conducted at two centres will recruit 166 individuals with spirometrically confirmed COPD. Participants will be randomly allocated to hospital-based or home-based pulmonary rehabilitation. Hospital programs will follow the traditional outpatient model consisting of twice weekly supervised exercise training and education for eight weeks. Home-based programs will involve one home visit followed by seven weekly telephone calls, using a motivational interviewing approach to enhance exercise participation and facilitate self management. The primary outcome is change in 6-minute walk distance immediately following intervention. Measurements of exercise capacity, physical activity, symptoms and quality of life will be taken at baseline, immediately following the intervention and at 12 months, by a blinded assessor. Completion rates will be compared between programs. Direct healthcare costs and indirect (patient-related) costs will be measured to compare the cost-effectiveness of each program.

DISCUSSION

This trial will identify whether home-based pulmonary rehabilitation can deliver equivalent benefits to centre-based pulmonary rehabilitation in a cost effective manner. The results of this study will contribute new knowledge regarding alternative models of pulmonary rehabilitation and will inform pulmonary rehabilitation guidelines for COPD.

The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

BACKGROUND

As fiscal constraints dominate health policy discussions across Canada and globally, priority-setting exercises are becoming more common to guide the difficult choices that must be made. In this context, it becomes highly desirable to have accurate estimates of the value of specific health care interventions.Economic evaluation is a well-accepted method to estimate the value of health care interventions. However, economic evaluation has significant limitations, which have lead to an increase in the use of Multi-Criteria Decision Analysis (MCDA). One key concern with MCDA is the availability of the information necessary for implementation. In the Fall 2011, the Canadian Physiotherapy Association embarked on a project aimed at providing a valuation of physiotherapy services that is both evidence-based and relevant to resource allocation decisions. The framework selected for this project was MCDA. We report on how we addressed the challenge of obtaining some of the information necessary for MCDA implementation.

METHODS

MCDA criteria were selected and areas of physiotherapy practices were identified. The building up of the necessary information base was a three step process. First, there was a literature review for each practice area, on each criterion. The next step was to conduct interviews with experts in each of the practice areas to critique the results of the literature review and to fill in gaps where there was no or insufficient literature. Finally, the results of the individual interviews were validated by a national committee to ensure consistency across all practice areas and that a national level perspective is applied.

RESULTS

Despite a lack of research evidence on many of the considerations relevant to the estimation of the value of physiotherapy services (the criteria), sufficient information was obtained to facilitate MCDA implementation at the local level.

CONCLUSIONS

The results of this research project serve two purposes: 1) a method to obtain information necessary to implement MCDA is described, and 2) the results in terms of information on the benefits provided by each of the twelve areas of physiotherapy practice can be used by decision-makers as a starting point in the implementation of MCDA at the local level.

Physical inactivity in COPD and increased patient perception of dyspnea

OBJECTIVE

To study patients' levels of exercise activity and the clinical characteristics that relate to physical activity and inactivity among patients with chronic obstructive pulmonary disease (COPD).

METHODS

A postal questionnaire was administered to 719 patients with COPD in 2010; patients were recruited from the Helsinki and Turku University Central Hospitals in Finland and have been followed since 2005. The questionnaire asked participants about their exercise routines and other daily activities, potential restrictions to exercise, health-related quality of life, and subjective sensations of dyspnea upon exertion.

RESULTS

A total of 50% of the participants reported exercising>2 times a week throughout the year. The proportion of the exercise inactive patients increased in parallel with disease progression, but the participants exhibited great variation in the degree of activity as well as in sport choices. Year-round activity was better maintained among patients who exercised both indoors and outdoors. Training activity was significantly correlated with patients' reported subjective dyspnea (r=0.32, P<0.001), health-related quality of life (r=0.25, P<0.001), mobility score (r=0.37, P<0.001), and bronchial obstruction (r=0.18, P<0.001). Active patients did not differ from inactive patients in terms of sex, age, smoking status, somatic comorbidities, or body mass index. Irrespective of the level of severity of patients' COPD, the most significant barrier to exercising was the subjective sensation of dyspnea.

CONCLUSION

When a patient with COPD suffers from dyspnea and does not have regular exercise routines, the patient will most likely benefit from an exercise program tailored to his or her physical capabilities.

Long-term efficacy of pulmonary rehabilitation: a state-of-the-art review

PURPOSE

While the short-term efficacy of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) is well documented, less is known about its sustainability and long-term effects in non-COPD patients, as well as secondary effects on exacerbation rates and the use of health care resources.

METHODS

We conducted a MEDLINE literature search on studies of pulmonary rehabilitation from the years 2000 to 2010. For each study, design, modalities, and outcomes were tabulated.

RESULTS

Design, group size, and duration of followup varied considerably between studies. Fifteen studies assessed physical performance, quality of life, or dyspnea in patients with COPD up to 24 months after rehabilitation. Six studies conducted followup evaluations in patients with interstitial lung disease, and 1 study considered asthma. Exacerbation rates and the use of health care resources were assessed in 20 studies in COPD and in 1 study in asthma. Results indicated the maintenance of the primary effects up to 1 year after pulmonary rehabilitation in COPD, while such effects were less pronounced in patients with interstitial lung disease. Secondary improvements regarding exacerbation rates and the use of health care resources were not consistent throughout studies and diseases.

CONCLUSIONS

Pulmonary rehabilitation has positive short- and long-term functional effects in COPD and more recent research supports improvements of exacerbation rates and the use of health care resources as secondary outcomes of pulmonary rehabilitation. Additional research on long-term efficacy regarding secondary effects and non-COPD patients is essential.

State of the art: how to set up a pulmonary rehabilitation program

Pulmonary rehabilitation plays an essential role in the management of symptomatic patients with COPD. The benefits of rehabilitation include a decrease in dyspnoea and fatigue, and improvements in exercise tolerance and health-related quality of life. Importantly, rehabilitation reduces hospitalization for acute exacerbations and is cost-effective. Although most of the evidence for pulmonary rehabilitation has been obtained in patients with COPD, symptomatic individuals with other respiratory diseases have been shown to benefit. In this review we outline a stepwise approach to establish, deliver and evaluate a pulmonary rehabilitation program (PRP) that would be feasible in most settings. Throughout the review we have specified the minimum requirements for a PRP to facilitate the establishment of programs using limited resources. Recommendations for staffing and other resources required for a PRP are presented in the first section. Exercise training is a focus of the section on program delivery as this is the component of rehabilitation that has the strongest level of evidence for benefit. Program considerations for patients with respiratory conditions other than COPD are described. Different approaches for delivering the education component of a PRP are outlined and recommendations are made regarding topics for group and individual sessions. The problems commonly encountered in pulmonary rehabilitation, together with recommendations to avoid these problems and strategies to assist in their resolution, are discussed. The review concludes with recommendations for evaluating a PRP.