Approaches to outcome assessment in pulmonary rehabilitation

Effectiveness of 12-week inspiratory muscle training with manual therapy in patients with COPD: A randomized controlled study

The benefits of inspiratory muscle training (IMT) in patients with COPD were reported. However, its effects are limited in severe COPD patients. Further researches are required in new and complementary modalities demonstrating IMT efficacy in severe COPD patients. This study aims to investigate effects of manual therapy (MT) additional over IMT on functional capacity, respiratory muscle strength, pulmonary function, dyspnea, fatigue, and quality of life in severe COPD patients. Sixty patients with COPD in GOLD stage III-IV were included in this prospective single-blind randomized trial. Patients were randomly assigned to receive either MT additional over IMT at 40% of maximal inspiratory pressure (MIP) (n = 30) or only IMT (n = 30) for 12 weeks. MT group received MT during 12 weeks for 30 min additional to IMT. Pulmonary function, respiratory muscle strength, functional capacity, dyspnea, fatigue, and quality of life were evaluated by spirometry, mouth pressure device, six-minute walk test, Modified Medical Research Council (mMRC) dyspnea scale, fatigue severity scale, and St. George's Respiratory Questionnaire (SGRQ), respectively. MT group had significantly greater improvement in FEV1%, FVC%, PEF%, respiratory muscle strength, function, dyspnea, fatigue, and quality of life compared with IMT group (p < 0.05). 6MWT (p < 0.001, effect size Cohen's d: 0.915), MIP (p < 0.001, effect size Cohen's d: 1.235), and mMRC score (p < 0.001, effect size Cohen's d: 0.982) were significantly improved in IMT with MT group. This study demonstrated that subjects in IMT with MT group had improved outcomes in functional capacity, respiratory muscle strength, pulmonary function, dyspnea, fatigue perception, and quality of life compared with alone IMT group.

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.

Triangulated perspectives on outcomes of pulmonary rehabilitation in patients with COPD: a qualitative study to inform a core outcome set

Introduction:

Pulmonary rehabilitation implies a comprehensive assessment. Although several outcomes are commonly measured, those are selected mainly by health professionals and researchers, with the voice of patients and informal caregivers being minimally captured. Qualitative studies are fundamental to enhance our knowledge on perspectives of different stakeholders involved in pulmonary rehabilitation.

Objective:

This study aimed to explore the views of different stakeholders on outcomes of pulmonary rehabilitation, contributing to one of the stages of a core outcome set for pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

Methods:

Semi-structured interviews were conducted with 12 patients with COPD, 11 informal carers and 10 health professionals. Data were analysed with content analysis, followed by thematic analysis to gain deeper understanding of the different perspectives.

Results:

A total of 44 outcomes were identified, being the most reported ‘improving functional performance’ (67%) and ‘reducing and taking control over dyspnoea’ (64%). Five relevant themes across stakeholders were generated: having a healthy mind in a healthy body; I can(’t) do it; feeling fulfilled; knowing more, doing better and avoiding doctors and expenses. Although perspectives were mostly consensual, some outcomes were only valued by health professionals (e.g. pulmonary function) or by patients and informal carers (e.g. quality of sleep).

Conclusion:

Views of the different stakeholders on outcomes of pulmonary rehabilitation were similar although, some specificities existed. Comprehensive assessments are needed to reflect what is valued by the different stakeholders in pulmonary rehabilitation. This study contributed to a future core outcome set in this field.

Utility of ultrasound assessment of diaphragmatic function before and after pulmonary rehabilitation in COPD patients

Background

Pulmonary rehabilitation (PR) may improve respiratory symptoms and skeletal muscle strength in patients with COPD. We aimed to evaluate changes in ultrasound (US) measurements of diaphragmatic mobility and thickness after PR in COPD patients and to test its correlation with PR outcomes.

Methods

Twenty-five COPD patients were enrolled and underwent a diaphragm US assessment before and after a 12-week PR program.

Results

We found a correlation between the intraindividual percentage of change in the diaphragmatic length of zone of apposition at functional residual capacity (ΔLzapp%) and the change in 6-minute walking distance (6MWD) after PR (rho=0.49, P=0.02). ΔLzapp% was significantly higher in patients with improved 6MWD and COPD Assessment Test (CAT) score (mean rank=12.03±2.57 vs 6.88±4.37; P=0.02). A ΔLzapp% of ≥10% was able to discriminate among patients with improved 6MWD, with a sensitivity of 83% and a specificity of 74%. The area under the receiver operating characteristic curve for ΔLzapp% was 0.83. A cutoff value of ≥9% of ΔLzapp% had a positive predictive value in discriminating a reduction in ≥2 points of CAT score after PR, with a sensitivity and a specificity of 80% and 62%, respectively.

Conclusion

Diaphragm US assessment represents a useful prognostic marker of PR outcomes in COPD patients.