Exercise training and pulmonary rehabilitation: new insights and remaining challenges

A virtual reality-based endurance training program for COPD patients: acceptability and user experience

PURPOSE

To investigate the acceptability and user experience of an in-hospital endurance training program based on the Virtual Park, a semi-immersive Virtual Reality (VR) system for patients with Chronic Obstructive Pulmonary Disease (COPD).Materials and methodsPatients performed 20 min of cycling two times/day for around ten days. The evaluation included adherence, exercise capacity, physical performance, and user experience.

RESULTS

Fourteen patients (6 F/8 M; age = 71.29 ± 6.93 years) with mild/moderate COPD participated. The adherence rate was satisfying: 85.71% of patients attended the program without adverse events; the individual attendance rate (86.85% ± 27.43) was also high. The exercise capacity assessed before and after the training significantly improved in our group (6MWT pre-post: t(11)= -5.040, p < 0.05), as happens in standard PR programs. The physical performance metrics of each session indicate that all participants could sustain the proposed training protocol over the whole period. Patients judged the VR experience positively (User Experience Questionnaire = 1.84 ± 0.22) and were highly engaged in the activity for the whole period (Short Flow State Scale pre-post: 4.61 ± 0.27/4.40 ± 0.36).

CONCLUSIONS

Our preliminary results open the possibility for further investigations on long-term motivation and clinical effectiveness of more immersive VR interventions for COPD.

Association of Frailty with Patient-Report Outcomes and Major Clinical Determinants in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

This study aimed to explore the correlation of frailty status with disease characteristics and patient-reported outcomes (PROs) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and determine the sensitivity and specificity of modified COPD PRO scale (mCOPD-PRO) for detecting frailty.

Patients and Methods

This cross-sectional study surveyed 315 inpatients with AECOPD from a tertiary hospital in China from August 2022 to June 2023. Patient frailty and PROs were assessed using the validated FRAIL scale and mCOPD-PRO, respectively. Spearman's ρ was used to assess the relevance of lung disease indicators commonly used in clinical practice, and ordinal logistic regression analyses were used to identify the variables associated with frailty status. The validity of mCOPD-PRO in discriminating frail or non-frail individuals was determined using the receiver operating characteristic curve.

Results

The participants (N=302, mean age 72.4±9.1 years) were predominantly males (73.2%). Among them, 43 (14.3%) patients were not frail, whereas 123 (40.7%) and 136 (45.0%) patients were pre-frail and frail, respectively. The FRAIL scale was moderately correlated with the mCOPD-PRO scores (Spearman's rank correlation coefficient [Rs]=0.52, P<0.01) for all dimensions (Rs=0.43-0.49, P<0.01). Patients residing in rural areas (odds ratio [OR], 1.67; 95% confidence interval [95% CI], 1.01-2.76) and with higher mCOPD-PRO scores (OR, 4.78; 95% CI, 2.75-8.32) were more likely to be frail. Physically active patients (OR, 0.42; 95% CI, 0.21-0.84) were less likely to be frail. In addition, mCOPD-PRO had good discriminate validity for detecting frailty (area under the curve=0.78), with a sensitivity and specificity of 84.6% and 60.8%, respectively. The optimal probability threshold for mCOPD-PRO was ≥1.52 points.

Conclusion

In patients with AECOPD, frailty is closely related to PROs and disease characteristics. Additionally, the mCOPD-PRO score can distinguish well between frail and non-frail patients. Our findings provide support for interventions targeting frail populations with AECOPD.

Feasibility and Design Factors for Home-Based Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease and Chronic Lung Diseases Based on a People-Object-Environment Framework: Qualitative Interview Study

BACKGROUND

The feasibility of implementing home-based pulmonary rehabilitation (PR) can be assessed from the perspectives of patients with chronic lung disease and health care professionals involved in PR.

OBJECTIVE

Through a qualitative inquiry using interviews and the adoption of the people-object-environment framework, this study aims to understand the influences of interpersonal, environmental, and situational factors on the perceptions and considerations of individuals involved in home-based PR for patients with chronic lung disease.

METHODS

One-on-one interviews were conducted with 20 patients with chronic lung disease and 20 health care professionals for investigating their attitudes and opinions based on their experiences regarding home-based PR as well as for identifying the key factors affecting the benefits and drawbacks of such therapies. This study further evaluates the feasibility of using digital tools for medical diagnosis and treatment by examining the technology usage of both parties.

RESULTS

The 4 key issues that all participants were the most concerned about were as follows: distance to outpatient medical care, medical efficiency, internet connectivity and equipment, and physical space for diagnosis and treatment. Interviews with patients and health care professionals revealed that the use of technology and internet was perceived differently depending on age and area of residence. Most participants reported that digital tools and internet connectivity had many benefits but still could not solve all the problems; moreover, these same digital tools and network transmission could lead to problems such as information security and digital divide concerns. This study also emphasizes the significant impact of human behavior and thinking on shaping the design of health care interventions and technologies. Understanding user perspectives and experiences is crucial for developing effective solutions for unmet needs.

CONCLUSIONS

The results of this study indicate that despite the different perspectives of patients and health care professionals, their considerations of the key issues are very similar. Therefore, the implementation of plans related to telemedicine diagnosis, treatment, or rehabilitation should take the suggestions and considerations of both parties into account as crucial factors for telehealth care design.

Utility of rehabilitation prior to bronchoscopic lung volume reduction: post hoc analysis of the VENT trial

Background and objective

Rehabilitation programmes are a valuable treatment modality for patients with COPD to increase exercise capacity and quality of life. The utility of pulmonary rehabilitation prior to bronchoscopic lung volume reduction (BLVR) is unclear.

Methods

We performed a post hoc analysis of the Valve for Emphysema Palliation Trial (VENT) trial, the first multicentre randomised trial comparing the safety and efficacy of BLVR. Patients completed a pulmonary rehabilitation programme prior to BLVR over 6-10 weeks and maintained by daily practice, consisting of endurance training, strength training and upper/lower limb exercise. Lung function and exercise parameters (6-min walk distance (6MWD)) were assessed before and after rehabilitation and we tried to identify predictors for pulmonary rehabilitation benefit.

Results

Lung function and exercise capacity of 403 patients (mean±sd age 63.3±7.4 years, 37.5% female, mean±sd forced expiratory volume in 1 s 30.1±7.6 L) were analysed. Exercise capacity significantly improved from 331.6±98.8 m to 345.6±95.3 m (p<0.001) in 6-min walk testing (6MWT), with 40.3% showing clinically meaningful improvements. Patients also experienced less dyspnoea after 6MWT, while pulmonary function parameters did not change significantly overall. Patients with lower exercise capacity at screening (6MWD <250 m) benefited more from pulmonary rehabilitation. The indication and prerequisites for BLVR were still present in all patients after pulmonary rehabilitation.

Conclusion

The national mandatory requirements for rehabilitation prior to BLVR, which apply to all COPD patients, should be reconsidered and specified for COPD patients who really benefit.

Hybrid delivery of cluster-set resistance training for individuals previously treated for lung cancer: the results of a single-arm feasibility trial

BACKGROUND

Individuals with non-small cell lung cancer (NSCLC) are burdened by long-lasting symptoms (e.g., dyspnea and fatigue) post-treatment. These symptoms often reduce physical activity levels and increase the risk of functional decline. Though we have previously proposed cluster-set resistance training to mitigate symptom burden in lung cancer, there is currently no data on the feasibility or acceptability of this mode of exercise in cancer. Therefore, the purpose of this study was to investigate the feasibility and acceptability of a hybrid-delivery home-based cluster-set resistance training program in individuals with NSCLC stages I-III (i.e., early stage).

METHODS

This study aimed to recruit individuals with NSCLC stages I-III post-treatment to participate in 8 weeks of home-based resistance training, 3 days per week. The program included supervised sessions in the participants' homes and virtual supervision via videoconferencing. The primary outcome measure of feasibility was evaluated through recruitment, retention, and intervention fidelity (i.e., proportion of exercise completed, relative to what was prescribed). Intervention acceptability (i.e., ease and quality of virtual delivery, level of difficulty, and home-based approach) was assessed using a 4-point Likert-type scale from "strongly disagree" to "strongly agree".

RESULTS

Fourteen participants were recruited over a 6-month period, with 11 completing the intervention (2 withdrew due to unrelated illness, 1 withdrew due to requiring active treatment), yielding a retention rate of 79%. Characteristics of the participants who completed the intervention (n = 11) were as follows: mean age: 71 ± 10 years, mean BMI: 29.1 ± 6.5, and average time since diagnosis was 62 ± 51 months. Of completers, 27% were male, and 36% were Black; 10 were stage I (91%), and one was stage II (9%). Mean session attendance was 86.4 ± 9.5%. Mean intervention fidelity was 83.1 ± 13.1%. With regard to acceptability,  > 90% of participants positively rated all aspects of the intervention delivery. No adverse events related to exercise were recorded.

CONCLUSIONS

The hybrid delivery of a home-based resistance exercise program for individuals previously treated for early-stage NSCLC was found to be safe and feasible. Adaptations to the program for future interventions are required, particularly surrounding resistance exercise programming, and intervention delivery with home visits.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05014035 . Registered January 20, 2021.

Measurement properties of physical activity in adults with bronchiectasis: A systematic review protocol

People with bronchiectasis reduce their physical activity (PA) due to muscle weakness, dyspnea, fatigue, reduced exercise capacity and frequent cough with expectoration. Patient-reported and objective physical assessment methods have been used to evaluate PA in people with bronchiectasis. In the literature, significant differences in the PA measured using patient-reported outcome measures when compared with the objective methods. Given the availability of many PA assessment tools, it is tedious for the clinician or researcher to choose an outcome measure for clinical practice or research. The evidence on validity and reliability in bronchiectasis are unclear. Objectives: To identify the PA assessment tools, describe and evaluate the literature on psychometric properties of instruments measuring and analyzing PA. Methods: The search will be conducted in PubMed/Medline, Cochrane Central Register of Controlled Studies, Scopus and EMBASE databases. The keywords, index terms and synonyms of the following words will be used: bronchiectasis, physical activity, and outcome measures. Published studies of adult with clinical and/ or radiologically diagnosed bronchiectasis, aged >18 years, any gender and studies that assessed PA and/or if there are reports on measurement properties of PA will be included in the review. Studies using qualitative research methods, narrative reviews, letters to editors and editorials will be excluded. The quality of the study will be assessed and data will be extracted. Any disagreement will be resolved in the presence of an author not involved in the screening or selecting studies. Discussion: By assessing the quality of studies on measurement properties, this review will help researchers choose the outcome measure to evaluate the effects of interventions on PA. This review will identify the suite of outcome measures of PA for people with bronchiectasis that can be used for research and clinical purpose.

A Web-Based Mind-Body Intervention (Mindful Steps) for Promoting Walking in Chronic Cardiopulmonary Disease: Insights From a Qualitative Study

Background

Given the deleterious effects of physical inactivity in persons with chronic obstructive pulmonary disease (COPD) and/or heart failure (HF), interventions that promote long-term daily physical activity are needed. Mindful Steps, designed to promote walking behaviors in COPD and HF, is a multicomponent intervention that integrates mind-body content with other self-regulatory components. The aim of the current qualitative study was to characterize participants' experiences with Mindful Steps and understand the perceived influence of the intervention on walking and health.

Method

In the context of a pilot randomized controlled feasibility trial comparing the year-long Mindful Steps program to usual care among individuals with COPD and HF, semi-structured qualitative interviews were administered at 6- and 12-months. Interviews were audio recorded and transcribed. The constant comparative method was used to code transcripts, identify categories, and develop interrelated themes.

Results

Nineteen participants (63% female; Mage = 70.2 years, SD = 6.95) who were randomized to the intervention group completed the 6-month interview and 17 completed the 12-month interview. The pedometer with feedback, live group classes, and mind-body videos were described as the most helpful intervention components. Participants learned several strategies that helped their walking (e.g., breathing regulation and awareness, body awareness, mind-body techniques, pacing), described walking as enjoyable, and identified internal reasons for walking (e.g., to feel good). They also reported several physical and mental health benefits of the intervention. Some participants reported limited influence of the intervention on walking or health. Many participants continued to use the strategies they learned in the first half of the intervention at 12-months.

Conclusions

The mind-body content of Mindful Steps appeared to positively influence walking behaviors. Participants' experiences with the intervention helped to identify areas for future intervention refinement. Future quantitative work is needed to corroborate these qualitative findings and assess the efficacy of the intervention on long-term physical activity engagement.

Trial Registration

This trial is registered in Clinical Trials.gov, ID number NCT01551953.

Exercise Capacity and Physical Activity in Non-Cystic Fibrosis Bronchiectasis after a Pulmonary Rehabilitation Home-Based Programme: A Randomised Controlled Trial

BACKGROUND

Patients with chronic respiratory disease have low exercise capacity and limited physical activity (PA), which is associated with worsening dyspnoea, exacerbations, and quality of life. The literature regarding patients with non-cystic fibrosis bronchiectasis (non-CF BQ) is scarce, especially regarding the use of cardiopulmonary exercise tests (CPET) to assess the effects of home-based pulmonary rehabilitation programmes (HPRP). The aim was to evaluate the effect of an HPRP on the exercise capacity of non-CF BQ patients using CPET and PA using an accelerometer.

METHODS

Our study describes a non-pharmacological clinical trial in non-CF BQ patients at the Virgen Macarena University Hospital (Seville, Spain). The patients were randomised into two groups: a control group (CG), which received general advice on PA and educational measures, and the intervention group (IG), which received a specific 8-week HPRP with two hospital sessions. The variables included were those collected in the CPET, the accelerometer, and others such as a 6 min walking test (6MWT) and dyspnoea. The data were collected at baseline and at an 8-week follow-up.

RESULTS

After the intervention, there was a significant increase in peak VO₂ in the IG, which was not evidenced in the GC (IG 66.8 ± 15.5 mL/min p = 0.001 vs. CG 62.2 ± 14.14 mL/min, p = 0.30). As well, dyspnoea according to the mMRC (modified Medical Research Council), improved significantly in IG (2.19 ± 0.57 to 1.72 ± 0.05, p = 0.047) vs. CG (2.07 ± 0.7 to 2.13 ± 0.64, p = 0.36). In addition, differences between the groups in walked distance (IG 451.19 ± 67.99 m, p = 0.001 vs. CG 433.13 ± 75.88 m, p = 0.981) and in physical activity (IG 6591 ± 3482 steps, p = 0.007 vs. CG 4824 ± 3113 steps, p = 0.943) were found.

CONCLUSION

Participation in a specific HPRP improves exercise capacity, dyspnoea, walked distance, and PA in non-CF BQ patients.

Effects of a new respiratory muscle training device in community-dwelling elderly men: an open-label, randomized, non-inferiority trial

Background

Respiratory muscle training (RMT) has various clinical benefits in older adults; however, the low adherence to training remains a challenging issue. The present study aimed to confirm the efficacy of a new device that combines inspiratory muscle training and a positive expiratory pressure (IMT/PEP) compared to that of a Threshold IMT device (Philips Respironics Inc), and to determine whether home-based training differed from rehabilitation center training.

Methods

This four-arm, multicenter, parallel, non-inferiority trial randomized 80 active community-dwelling older men (mean age = 72.93 ± 5.02 years) to center-based groups (new IMT/PEP device or Threshold IMT device; 16 supervised sessions) or home-based groups (new IMT/PEP device or Threshold IMT device; 2 supervised sessions and individual sessions). Participants in all groups performed RMT twice a day for 8 weeks. Assessments were performed at baseline and post-training. The primary outcomes were maximum inspiratory pressure and maximal expiratory pressure. The secondary outcomes included forced vital capacity and forced expiratory volume in the first second, peak cough flow, diaphragm thickness, VO₂ peak, the International Physical Activity Questionnaire score, electromyographic activities of the sternocleidomastoid muscle, and skeletal muscle mass and phase angle as measured by bioimpedance analysis. In addition, rates of adherence to each protocol were also compared.

Results

Among all groups, the maximal inspiratory pressure was improved post-training, while the maximal expiratory pressure showed improvement only in the IMT/PEP groups. The overall non-inferiority of the IMT/PEP device was thus validated. A statistically significant improvement in diaphragm thickness was found. However, no consistent improvement was shown in other secondary outcomes. No significant difference in training adherence rate between protocols was observed (mean adherence rate of 91–99%).

Conclusion

Compared to the Threshold IMT, the new IMT/PEP device did not result in a significant difference in maximal inspiratory pressure but did improve maximal expiratory pressure in older men. The IMT/PEP device’s improved usability, which is associated with exercise adherence, provided distinct advantages in this cohort. If proper education is first provided, home-based RMT alone may provide sufficient effects in older individuals.

Trial registration

This trial was registered in the database cris.nih.go.kr (registration number KCT0003901) on 10/05/2019.

Pulmonary rehabilitation for COPD: A narrative review and call for further implementation in Saudi Arabia

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable condition, in which outcomes can be improved with careful management. Pulmonary rehabilitation (PR) comprises exercise and education, delivered by multidisciplinary teams. PR is a cost-effective management strategy in COPD patients which improves exercise performance, reduces dyspnea, reduces the risk of exacerbation, and improves health-related quality of life. All COPD patients appear to benefit irrespective of their baseline function, and PR has also been shown to be a clinically and cost-effective management approach following an acute exacerbation. COPD patients with greater disability and those recovering postexacerbation should be specifically targeted for PR. Due to limited current capacity, the latter group may not currently be able to benefit from PR. Therefore, there is a need for the wider implementation of PR services in Saudi Arabia, requiring us to address challenges including capacity and workforce competency.

Application of Inspiratory Muscle Training to Improve Physical Tolerance in Older Patients with Ischemic Heart Failure

Regardless of the management regime for heart failure (HF), there is strong evidence supporting the early implementation of exercise-based cardiac rehabilitation (CR). Respiratory therapy is considered to be an integral part of such secondary prevention protocols. The aim of the study was to evaluate the effect of inspiratory muscle training (IMT) on exercise tolerance and the functional parameters of the respiratory system in patients with heart failure involved in cardiac rehabilitation. The study included 90 patients with HF who took part in the second-stage 8-week cycle of cardiac rehabilitation (CR). They were randomly divided into three groups: Group I underwent CR and IMT; Group II only CR; and patients in Group III underwent only the IMT. Before and after the 8-week cycle, participants were assessed for exercise tolerance and the functional parameters of respiratory muscle strength. Significant statistical improvement concerned the majority of the hemodynamic parameters, lung function parameters, and respiratory muscle strength in the first group. Moreover, the enhancement in the exercise tolerance in the CR + IMT group was accompanied by a negligible change in the HR_peak. The results confirm that the addition of IMT to the standard rehabilitation process of patients with heart failure can increase the therapeutic effect while influencing some of the parameters measured by exercise electrocardiography and respiratory function.

Targeting exertional breathlessness to improve physical activity: the role of primary care

Primary care physicians (PCPs) play a crucial role in the diagnosis and management of chronic obstructive pulmonary disease (COPD). By working together with patients to target exertional breathlessness and increase physical activity, PCPs have an important role to play, early in the disease course, in improving patient outcomes in both the short and long term. In this article, we consider how physical activity affects disease progression from the PCP perspective. We discuss the role of pharmacological therapy, the importance of an holistic approach and the role of PCPs in assessing and promoting physical activity. The complexity and heterogeneity of COPD make it a challenging disease to treat. Patients' avoidance of activity, and subsequent decline in capacity to perform it, further impacts the management of the disease. Improving patient tolerance of physical activity, increasing participation in daily activities and helping patients to remain active are clear goals of COPD management. These may require an holistic approach to management, including pulmonary rehabilitation and psychological programmes in parallel with bronchodilation therapy, in order to address both physiological and behavioural factors. PCPs have an important role to optimise therapy, set goals and communicate the importance of maintaining physical activity to their patients. In addition, optimal treatment that addresses activity-related breathlessness can help prevent the downward spiral of inactivity and get patients moving again, to improve their overall health and long-term prognosis.

Strengthening the Case for Cluster Set Resistance Training in Aged and Clinical Settings: Emerging Evidence, Proposed Benefits and Suggestions

Resistance training (RT) is a fundamental component of exercise prescription aimed at improving overall health and function. RT techniques such as cluster set (CS) configurations, characterized by additional short intra-set or inter-repetition rest intervals, have been shown to maintain acute muscular force, velocity, and 'power' outputs across a RT session, and facilitate positive longer-term neuromuscular adaptations. However, to date CS have mainly been explored from a human performance perspective despite potential for application in health and clinical exercise settings. Therefore, this current opinion piece aims to highlight emerging evidence and provide a rationale for why CS may be an advantageous RT technique for older adults, and across several neurological, neuromuscular, cardiovascular and pulmonary settings. Specifically, CS may minimize acute fatigue and adverse physiologic responses, improve patient tolerance of RT and promote functional adaptations (i.e., force, velocity, and power). Moreover, we propose that CS may be a particularly useful exercise rehabilitation technique where injury or illness, persistent fatigue, weakness and dysfunction exist. We further suggest that CS offer an alternative RT strategy that can be easily implemented alongside existing exercise/rehabilitation programs requiring no extra cost, minimal upskilling and/or time commitment for the patient and professional. In light of the emerging evidence and likely efficacy in clinical exercise practice, future research should move toward further direct investigation of CS-based RT in a variety of adverse health conditions and across the lifespan given the already demonstrated benefits in healthy populations.

[Group Training of Patients with Chronic Lung Diseases under Outpatient Conditions - Recommendations of the Working Group Lung Sports in Germany and the German Airways League]

To improve acceptance and use of physical training by patients with chronic lung diseases, recommendations for performing lung exercises on an outpatient basis in a group setting are given by experts in physical training, sports therapists and pulmonologists. The evidence-based positive effects of physical training were analyzed for asthma , COPD, interstitial lung diseases, cystic fibrosis, lung carcinoma, and pulmonary hypertension. The requirements for lung exercises in outpatient groups as well as compensation by care providers were given on the basis of legal regulations. Furthermore, the main items of the training units as well as supervision by specially trained group leaders in relation to the severity of the underlying lung disease are described. Finally, aspects of safety of the participating patients are discussed, including the prevention of infection with corona-2-virus.

Systematic review of clinical effectiveness, components, and delivery of pulmonary rehabilitation in low-resource settings

Pulmonary rehabilitation (PR) is a guideline-recommended multifaceted intervention that improves the physical and psychological well-being of people with chronic respiratory diseases (CRDs), though most of the evidence derives from trials in high-resource settings. In low- and middle-income countries, PR services are under-provided. We aimed to review the effectiveness, components and mode of delivery of PR in low-resource settings. Following Cochrane methodology, we systematically searched (1990 to October 2018; pre-publication update March 2020) MEDLINE, EMBASE, CABI, AMED, PUBMED, and CENTRAL for controlled clinical trials of adults with CRD (including but not restricted to chronic obstructive pulmonary disease) comparing PR with usual care in low-resource settings. After duplicate selection, we extracted data on exercise tolerance, health-related quality of life (HRQoL), breathlessness, included components, and mode of delivery. We used Cochrane risk of bias (RoB) to assess study quality and synthesised data narratively. From 8912 hits, we included 13 studies: 11 were at high RoB; 2 at moderate RoB. PR improved functional exercise capacity in 10 studies, HRQoL in 12, and breathlessness in 9 studies. One of the two studies at moderate RoB showed no benefit. All programmes included exercise training; most provided education, chest physiotherapy, and breathing exercises. Low cost services, adapted to the setting, used limited equipment and typically combined outpatient/centre delivery with a home/community-based service. Multicomponent PR programmes can be delivered in low-resource settings, employing a range of modes of delivery. There is a need for a high-quality trial to confirm the positive findings of these high/moderate RoB studies.

An Evaluation of Service Provision and Novel Strength Assessment on Patient Outcomes in a UK-Based Pulmonary Rehabilitation Setting

This study's purpose was to (i) assess the impact of a 7-week pulmonary rehabilitation (PR) programme upon patient outcomes; incremental shuttle walk test (ISWT), COPD assessment tool (CAT), Clinical COPD Questionnaire (CCQ) and the Hospital Anxiety and Depression Scale (HADS); (ii) assess the impact of COPD severity on ISWT, psychological functioning and quality of life measures following PR; (iii) assess the feasibility of incorporating individually prescribed one repetition maximum (1RM) training loads into the existing strength training programme. Patients were people with COPD enrolled onto one of three versions (locations A, B and C) of a 7-week PR programme, which consisted of group exercise sessions and a social plus education element. Two locations incorporated individually prescribed training loads. Minimal clinically important changes (MCICs) are reported for the ISWT across all locations. Statistically significant changes in both CAT and the CCQ were found, with MCIC's evident for CAT score overall and individually at location B. MCIC's were not found for the CCQ. No statistically significant or MCICs were evident for the HADS. MCIC's were present only in patients with mild to moderate severity for the ISWT. For the CAT, moderate, severe and very severe patients with COPD experienced MCIC's. MCIC's and statistically significant increases in 1RM strength were seen at both locations. These findings evidence an effective PR service. Basic strength exercise programming and assessment are feasible and should be implemented in PR services to maximise patient outcomes.

Interventions to Improve the Quality of Life of Patients with Chronic Obstructive Pulmonary Disease: A Global Mapping During 1990-2018

Chronic obstructive pulmonary disease (COPD) has been considered a significant health challenge globally in recent years, which affects different aspects of the quality-of-life (QoL). A review was conducted of research output, research topics, and landscape to have a global view of the papers mentioning the interventions to increase QoL of patients with COPD. A total of 3242 research items from Web of Science during the period 1990-2018 were downloaded and analyzed. Analyses based on the different levels of data and methods using using VOSviewer software tool (version 1.16.15, Centre for Science and Technology Studies (CWTS), Leiden University, Leiden, The Netherlands) and Latent Dirichlet allocation. By exploring the trends in research productivity and topics, an increase was found in the number of papers mentioning non-pharmacological interventions as well as mental health illness and QoL among patients with COPD. In conclusion, the research on the interventions to increase the QoL of patients with COPD has attracted scientists globally. It is suggested that more research should be conducted on the effectiveness of non-pharmacological therapies to increase QoL of patients with COPD that can be applied broadly in the community. The collaboration and support from developed countries to developing countries are needed to increase the QoL of people living with COPD.

Pulmonary rehabilitation for chronic obstructive pulmonary disease: effects of a high versus low intensity programme

Background/Aims

Pulmonary rehabilitation is known to facilitate improvements in chronic obstructive pulmonary disease symptoms, exercise tolerance and quality of life. Despite this, there is no consensus on the ideal programme intensity. This article aims to explore and compare the benefits of a high intensity and low intensity pulmonary rehabilitation programme.

Methods

A total of 30 patients with a diagnosis of chronic obstructive pulmonary disease were randomly and blindly allocated to either a high intensity or low intensity 12-week pulmonary rehabilitation programme.

Results

Significant improvements in functional and health-related quality of life measures were obtained in both groups. Most of the significant changes for the high intensity group were achieved by week 8. The low intensity group required a further 4 weeks of rehabilitation in order to reach a significant difference.

Conclusions

Results show that both low and high intensity pulmonary rehabilitation programmes were beneficial. However, the high intensity programme was more efficient in achieving these improvements than the low intensity group.

Participation in Pulmonary Rehabilitation by Veterans Health Administration and Medicare Beneficiaries After Hospitalization for Chronic Obstructive Pulmonary Disease

BACKGROUND

Hospitalization with acute exacerbation of chronic obstructive pulmonary disease (COPD) is common and costly to the health care system. Pulmonary rehabilitation (PR) can improve symptom burden and morbidity associated with COPD. The use of PR among Medicare beneficiaries is poor, and the use by Veterans Health Administration (VHA) beneficiaries is unknown. We sought to determine whether participation in PR was similarly poor among eligible veterans compared with Medicare beneficiaries.

METHODS

We performed a retrospective study using national VHA and Medicare data to determine the proportion of eligible patients who participated in PR after hospitalization for an acute exacerbation of COPD between January 2007 and December 2011. We also evaluated patient characteristics including demographic factors and comorbid medical history associated with participation.

RESULTS

Over the 5-year study period, 485 (1.5%) of 32 856 VHA and 3199 (2.0%) of 158 137 Medicare beneficiaries hospitalized for COPD attended at least 1 session of PR. Among both VHA and Medicare beneficiaries, participation was higher in those who had had comorbid pneumonia or pulmonary hypertension and was lower in older patients. Although participation increased in both groups over time, it remained exceedingly low overall.

CONCLUSION

Pulmonary rehabilitation is significantly underused in both the VHA and Medicare populations. Although comorbid pulmonary disease is associated with higher use, the proportion of eligible patients who participate remains extremely low.

The application of "upper-body yoga" in elderly patients with acute hip fracture: a prospective, randomized, and single-blind study

Purposes

Hip fracture leads to decreased activity and an increased risk of pulmonary complications. The main purpose of this study was to observe the lung capacity, cough capacity of the elderly patient with acute hip fracture, and assess the effects and the feasibility of using a special-designed “upper-body yoga” training to treat elderly patients with hip fracture.

Methods

This was a prospective, randomized, and single-blind study. Eighty-four subjects aged over 65 years were randomly divided into either a control group or a yoga group to undergo an abdominal breathing program or an “upper-body yoga” program until 4 weeks after surgery. The primary outcomes were forced vital capacity/predicted value (FVC%), peak cough flow (PCF), Barthel Index (BI), and the incidence of pneumonia. The secondary outcomes were the rates of right skills and inclination.

Results

Thirty-nine subjects in the yoga group and 40 subjects in the control group completed this study. At the end of the first training week, FVC% (74.14% ± 13.11% vs. 70.87% ± 10.46%, P = 0.231) showed no significant difference between the two groups, while the value of PCF (204.80 ± 33.45 L/min vs. 189.06 ± 34.80 L/min, P = 0.048) and BI (38.59 ± 8.66 vs. 33.00 ± 9.32, P = 0.009) in the yoga group was higher. After 4 weeks of treatment, FVC%, PCF, and BI were higher in the yoga group (78.83% ± 13.31 % vs. 72.20% ± 10.53%, P = 0.016; 216.16 ± 39.29 L/min vs. 194.95 ± 31.14 L/min, P = 0.008; 70.77 ± 10.23 vs. 65.75 ± 11.30, P = 0.019). One in the control group and nobody in the yoga group was diagnosed with pneumonia. There was no significant difference between the two groups in terms of the rates of right skills, whereas more elderly people preferred the training program of the “upper-body yoga.”

Conclusion

Elderly patients with acute hip fractures are at risk of impaired lung capacity and inadequate cough. “Upper-body yoga” training may improve the quality of daily life, vital capacity, and cough flow in elderly patients, making it a better choice for bedridden patients with hip fracture.

Effects of core stabilization exercises on pulmonary function, respiratory muscle strength, and functional capacity in adolescents with substance use disorder: Randomized controlled trial

BACKGROUND

Adolescent substance abuse is a serious and growing problem worldwide. The aim of this study was to investigate the effects of core stabilization exercises on pulmonary function, respiratory muscle strength, and functional capacity in adolescents with substance use disorder (SUD).

METHODS

This was a prospective randomized controlled trial. A total of 49 adolescent male patients with SUD were randomly assigned to either the exercise group (n = 25; mean age 16.6 years) or the control group (n = 24; mean age 16.7 years), for 6 weeks. All participants underwent a medical and behavioral therapy program 5 days a week for 6 weeks. The exercise group received five core stabilization exercises combined with deep breathing as a group training for 45 to 60 minutes, twice a week for 6 weeks, and the control group received recreational activities in addition to the usual care for 45 to 60 minutes, twice a week for 6 weeks. Spirometry, maximal inspiratory and expiratory pressures, and the 6-minute walk test were performed and measured at baseline and after training.

RESULTS

There were significant improvements in maximal inspiratory pressure (24.16 cm H₂ O; P < 0.0001), maximal expiratory pressure (30.28 cm H₂ O; P < 0.0001), forced vital capacity (5.80% predicted, P < 0.0001), forced expiratory volume in 1 second (7.34% predicted; P = 0.002), peak expiratory flow (13.32% predicted; P = 0.0003), forced expiratory flow 25%-75% (11.84% predicted; P = 0.027), and the 6-minute walking distance (65.84 m; P < 0.0001) in the exercise group compared with the control group.

CONCLUSIONS

Core stabilization exercise can improve pulmonary function, respiratory muscle strength, and functional capacity in adolescents with SUD.

Direct and Indirect Costs of Chronic Obstructive Pulmonary Disease in Korea

Background

Understanding the burden of disease is important to establish cost-effective treatment strategies and to allocate healthcare resources appropriately. However, little reliable information is available regarding the overall economic burden imposed by chronic obstructive pulmonary disease (COPD) in Korea.

Methods

This study is a multicenter observational research on the COPD burden in Korea. Total COPD costs were comprised of three categories: direct medical, direct non-medical, and indirect costs. For direct medical costs, institutional investigation was performed at 13 medical facilities mainly based on the claims data. For direct non-medical and indirect costs, site-based surveys were administered to the COPD patients during routine visits. Total costs were estimated using the COPD population defined in the recent report.

Results

The estimated total costs were approximately 1,245 million US dollar (1,408 billion Korean won). Direct medical costs comprised approximately 20% of the total estimated costs. Of these, formal medical costs held more than 80%. As direct non-medical costs, nursing costs made up the largest percentage (39%) of the total estimated costs. Costs for COPD-related loss of productivity formed four fifths of indirect costs, and accounted for up to 33% of the total costs.

Conclusion

This study shows for the first time the direct and indirect costs of COPD in Korea. The total costs were enormous, and the costs of nursing and lost productivity comprised approximately 70% of total costs. The results provide insight for an effective allocation of healthcare resources and to inform establishment of strategies to reduce national burden of COPD.

Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis

Background

Pulmonary rehabilitation (PR), delivered as a supervised multidisciplinary program including exercise training, is one of the cornerstones in the chronic obstructive pulmonary disease (COPD) management. We performed a systematic review and meta-analysis to assess the effect on mortality of a supervised early PR program, initiated during or within 4 weeks after hospitalization with an acute exacerbation of COPD compared with usual post-exacerbation care or no PR program. Secondary outcomes were days in hospital, COPD related readmissions, health-related quality of life (HRQoL), exercise capacity (walking distance), activities of daily living (ADL), fall risk and drop-out rate.

Methods

We identified randomized trials through a systematic search using MEDLINE, EMBASE and Cocharne Library and other sources through October 2017. Risk of bias was assessed regarding randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases using the Cochrane Risk of Bias tool.

Results

We included 13 randomized trials (801 participants). Our meta-analyses showed a clinically relevant reduction in mortality after early PR (4 trials, 319 patients; RR = 0.58 (95% CI: [0.35 to 0.98])) and at the longest follow-up (3 trials, 127 patients; RR = 0.55 (95% CI: [0.12 to 2.57])). Early PR reduced number of days in hospital by 4.27 days (1 trial, 180 patients; 95% CI: [− 6.85 to − 1.69]) and hospital readmissions (6 trials, 319 patients; RR = 0.47 (95% CI: [0.29 to 0.75])). Moreover, early PR improved HRQoL and walking distance, and did not affect drop-out rate. Several of the trials had unclear risk of bias in regard to the randomization and blinding, for some outcome there was also a lack of power.

Conclusion

Moderate quality of evidence showed reductions in mortality, number of days in hospital and number of readmissions after early PR in patients hospitalized with a COPD exacerbation. Long-term effects on mortality were not statistically significant, but improvements in HRQoL and exercise capacity appeared to be maintained for at least 12 months. Therefore, we recommend early supervised PR to patients with COPD-related exacerbations. PR should be initiated during hospital admission or within 4 weeks after hospital discharge.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0718-1) contains supplementary material, which is available to authorized users.

Clinician-Facilitated Physical Activity Intervention Versus Pulmonary Rehabilitation for Improving Physical Activity in COPD: A Feasibility Study

Pulmonary rehabilitation (PR) may not suit all individuals with chronic obstructive pulmonary disease (COPD) and may not result in increased physical activity. Higher levels of physical activity are associated with reduced mortality and morbidity. The aim of this study was to assess the feasibility of conducting a trial to investigate the effectiveness of a clinician-facilitated physical activity intervention (PAI) versus PR in improving physical activity in patients with COPD referred to PR. In this randomised controlled mixed methods feasibility study, all patients referred to PR who were eligible and willing were assessed at baseline and then randomised to the PAI or to PR. The assessments were repeated post-intervention and at 3-month follow-up. The main outcome was step count measured by Actigraph. Semi-structured interviews were conducted post-intervention. The N = 50 patients; mean (SD) age, 64.1(8.6) years, 24M were recruited and randomised; N = 23 (PAI) and n = 26 (PR): one patient was excluded from the analysis as that person did not meet the GOLD diagnostic criteria. Key feasibility criteria were met; recruitment was 11%, dropouts in PAI were 26% (n = 6) and 50% (n = 13/26) PR. Participants in both groups experienced a range of health benefits from their respective programmes. The PAI appears to be effective in increasing step counts in people with COPD: mean change (standard deviation) [confidence interval] for the PAI group was 972.0(3230.3)[-1080.3 to 3024.4], n = 12 and 4.3(662.7)[-440.9 to 449.5], n = 11 for the PR group. The PAI met all domains of fidelity. This study provides key information to inform a future-randomised controlled trial in physical activity.

Exercise Testing, Supplemental Oxygen, and Hypoxia

Cardiopulmonary exercise testing (CPET) in hyperoxia and hypoxia has several applications, stemming from characterization of abnormal physiological response profiles associated with exercise intolerance. As altered oxygenation can impact the performance of gas-concentration and flow sensors and pulmonary gas exchange algorithms, integrated CPET system function requires validation under these conditions. Also, as oxygenation status can influence peak [Formula: see text]o₂, care should be taken in the selection of work-rate incrementation rates when CPET performance is to be compared with normobaria at sea level. CPET has been used to evaluate the effects of supplemental O₂ on exercise intolerance in chronic obstructive pulmonary disease, interstitial pulmonary fibrosis, and cystic fibrosis at sea level. However, identification of those CPET indices likely to be predictive of supplemental O₂ outcomes for exercise tolerance at altitude in such patients is lacking. CPET performance with supplemental O₂ in respiratory patients residing at high altitudes is also poorly studied. Finally, CPET has the potential to give physiological and clinical information about acute and chronic mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema. It may also translate high-altitude acclimatization and adaptive processes in healthy individuals into intensive care medical practice.

Using Exploratory Focus Groups to Inform the Development of a Peer-Supported Pulmonary Rehabilitation Program: DIRECTIONS FOR FURTHER RESEARCH

PURPOSE

There has been limited research on the role of peer support in self-management for patients with chronic obstructive pulmonary disease (COPD) attending pulmonary rehabilitation (PR) programs. This research explored patient acceptability of "peer supporters" in promoting sustained self-management practices after PR and to assess their perceived self-efficacy to manage their disease.

METHODS

This qualitative study used focus groups and individual interviews to identify perspectives of peer supporters and benefits of participation in a PR program. The analysis included systematically reading and reviewing transcripts of the sessions, establishing themes, and sorting responses into thematic categories.

RESULTS

A total of 28 patients with COPD (15 males) participated in either a focus group or interview. The majority of participants considered peer supporters to be good facilitators for motivating ongoing exercise after completing PR. Exercise sessions were viewed as extremely beneficial for disease management, and many were satisfied with the care they had received. Most subjects wanted to receive followup sessions with either a professional or peer after the intensive phase of PR. Overall, the concept of having a peer supporter involved in ongoing maintenance of self-management efforts after PR was generally viewed as positive.

CONCLUSIONS

Integrating a peer support model into PR programs may improve better long-term health outcomes for COPD management as many participants endorsed the need for continued support after the program. It also improved our understanding of the role of "peer supports" in exercise and self-care maintenance after PR. The selection of peers and the specific model used warrants further investigation in a randomized controlled trial.

Efficacy of patients' preferred exercise modalities in chronic obstructive pulmonary disease: A parallel-group, randomized, clinical trial

INTRODUCTION

Physical exercise effectively improves health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). However, application of this medical intervention is problematic, due to poor adherence to the exercise program or unawareness of the significance of this intervention.

OBJECTIVE

To determine whether COPD patients who adopted personal-preferred exercise modalities (PPEMs) for daily training would demonstrate sustained benefits due to improved adherence.

METHODS

Stable COPD patients were randomly assigned to the daily PPEMs group or the control group (without extra exercise apart from daily life activities). All other treatments were similar. The primary outcome was the health-related quality of life (HRQoL), measured with St. George's Respiratory Questionnaire (SGRQ) score at 12 months. Other measures included the Borg dyspnea score, 6-min walking distance (6MWD) and lung function variables.

RESULTS

The intention-to-treat (ITT) population included 94 patients, 68 of them completed the study protocol over 12 months (the PP-population). A greater decline of SGRQ score (improvement of HRQoL) in the PPEMs group than that in the controls was demonstrated over 12 months (-19.1 vs -9.0 in the ITT population and -19.1 vs -8.7 in the PP population, P ≤ .001 for all comparisons), the reduction exceeded the minimal clinically important difference of ≥ 4 points. The PPEMs group also showed a greater reduction than the control group in Borg score at 12 months in the ITT and the PP population as well (P < .01). No significant improvement was found in 6MWD or in lung function variables.

CONCLUSIONS

COPD patients could benefit from extra daily PPEMs, and the gain may sustain at least for 1 year.

A pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion And Morphine Sulfate (BEAMS) study protocol

INTRODUCTION

Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended- release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD.

METHODS AND ANALYSIS

The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0-10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used.

ETHICS AND DISSEMINATION

Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness.

TRIAL REGISTRATION NUMBER

NCT02720822; Pre-results.

Whole-Body Vibration Training During a Low Frequency Outpatient Exercise Training Program in Chronic Obstructive Pulmonary Disease Patients: A Randomized, Controlled Trial

BACKGROUND

The aim of the study was to investigate whether whole-body vibration training (WBVT) can be applied beneficially within an outpatient low frequency exercise program.

METHODS

In a prospective, controlled, randomized study, WBVT effectiveness and safety were investigated in COPD stage II-IV patients undergoing a 3-month training program. Participants took part in a 90-min circuit training once a week. On top patients were randomized to either perform squats with WBVT, or without (conventional training group (CTG)). Before and after the intervention, a sit-to-stand test (STST), a 6-min walk test (6-MWT), the COPD assessment test (CAT), and the chronic respiratory disease questionnaire (CRQ) were evaluated.

RESULTS

Twenty-eight out of 55 patients completed the study (n = 12 WBTV, n = 16 CTG). The STST time remained nearly constant for the CTG (Δ -0.8 ± 3.1 s) and the WBVT (Δ 1.4 ± 3.2 s; P = 0.227), respectively. Similarly, for both WBVT and CTG, the 6-min walk distance remained unchanged (Δ 7 ± 55 m vs. 9 ± 45 m, P = 0.961). In three out of four categories, the CRQ scores showed a significant improvement within WBVT, and in one category when comparing across groups. The CAT score dropped by -0.8 ± 2.9 points within CTG and by 2.4 ± 2.7 points within WBVT (P = 0.105). There were no adverse events related to WBVT.

CONCLUSION

The implementation of WBVT in the context of an outpatient low frequency exercise program did not significantly improve the patients' exercise capacity. An improvement in CAT and partially in CRQ was shown within WBVT. However, regarding the high dropout rate (49%), these results must be interpreted with caution.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Guidelines have provided positive recommendations for pulmonary rehabilitation after exacerbations of chronic obstructive pulmonary disease (COPD), but recent studies indicate that postexacerbation rehabilitation may not always be effective in patients with unstable COPD.

OBJECTIVES

To assess effects of pulmonary rehabilitation after COPD exacerbations on hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life (HRQL) and exercise capacity).

SEARCH METHODS

We identified studies through searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PEDro (Physiotherapy Evidence Database) and the Cochrane Airways Review Group Register of Trials. Searches were current as of 20 October 2015, and handsearches were run up to 5 April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing pulmonary rehabilitation of any duration after exacerbation of COPD versus conventional care. Pulmonary rehabilitation programmes had to include at least physical exercise (endurance or strength exercise, or both). We did not apply a criterion for the minimum number of exercise sessions a rehabilitation programme had to offer to be included in the review. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS

We expected substantial heterogeneity across trials in terms of how extensive rehabilitation programmes were (i.e. in terms of number of completed exercise sessions; type, intensity and supervision of exercise training; and patient education), duration of follow-up (< 3 months vs ≥ 3 months) and risk of bias (generation of random sequence, concealment of random allocation and blinding); therefore, we performed subgroup analyses that were defined before we carried them out. We used standard methods expected by Cochrane in preparing this update, and we used GRADE for assessing the quality of evidence.

MAIN RESULTS

For this update, we added 11 studies and included a total of 20 studies (1477 participants). Rehabilitation programmes showed great diversity in terms of exercise training (number of completed exercise sessions; type, intensity and supervision), patient education (from none to extensive self-management programmes) and how they were organised (within one setting, e.g. pulmonary rehabilitation, to across several settings, e.g. hospital, outpatient centre and home). In eight studies, participants completed extensive pulmonary rehabilitation, and in 12 studies, participants completed pulmonary rehabilitation ranging from not extensive to moderately extensive.Eight studies involving 810 participants contributed data on hospital readmissions. Moderate-quality evidence indicates that pulmonary rehabilitation reduced hospital readmissions (pooled odds ratio (OR) 0.44, 95% confidence interval (CI) 0.21 to 0.91), but results were heterogenous (I² = 77%). Extensiveness of rehabilitation programmes and risk of bias may offer an explanation for the heterogeneity, but subgroup analyses were not statistically significant (P values for subgroup effects were between 0.07 and 0.11). Six studies including 670 participants contributed data on mortality. The quality of evidence was low, and the meta-analysis did not show a statistically significant effect of rehabilitation on mortality (pooled OR 0.68, 95% CI 0.28 to 1.67). Again, results were heterogenous (I² = 59%). Subgroup analyses showed statistically significant differences in subgroup effects between trials with more and less extensive rehabilitation programmes and between trials at low and high risk for bias, indicating possible explanations for the heterogeneity. Hospital readmissions and mortality studies newly included in this update showed, on average, significantly smaller effects of rehabilitation than were seen in earlier studies.High-quality evidence suggests that pulmonary rehabilitation after an exacerbation improves health-related quality of life. The eight studies that used St George's Respiratory Questionnaire (SGRQ) reported a statistically significant effect on SGRQ total score, which was above the minimal important difference (MID) of four points (mean difference (MD) -7.80, 95% CI -12.12 to -3.47; I² = 64%). Investigators also noted statistically significant and important effects (greater than MID) for the impact and activities domains of the SGRQ. Effects were not statistically significant for the SGRQ symptoms domain. Again, all of these analyses showed heterogeneity, but most studies showed positive effects of pulmonary rehabilitation, some studies showed large effects and others smaller but statistically significant effects. Trials at high risk of bias because of lack of concealment of random allocation showed statistically significantly larger effects on the SGRQ than trials at low risk of bias. High-quality evidence shows that six-minute walk distance (6MWD) improved, on average, by 62 meters (95% CI 38 to 86; I² = 87%). Heterogeneity was driven particularly by differences between studies showing very large effects and studies showing smaller but statistically significant effects. For both health-related quality of life and exercise capacity, studies newly included in this update showed, on average, smaller effects of rehabilitation than were seen in earlier studies, but the overall results of this review have not changed to an important extent compared with results reported in the earlier version of this review.Five studies involving 278 participants explicitly recorded adverse events, four studies reported no adverse events during rehabilitation programmes and one study reported one serious event.

AUTHORS' CONCLUSIONS

Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.

Effects on pulmonary rehabilitation in patients with COPD or ILD: A retrospective analysis of clinical and functional predictors with particular emphasis on gender

BACKGROUND

The response of patients in a pulmonary rehabilitation (PR) is essentially good. However, not all patients benefit from PR to the same extent. In this analysis we wanted to identify the impact of gender and other factors on PR outcomes in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD).

METHODS

Patients suffering from COPD (n = 1492) or ILD (n = 599), treated during an inpatient PR between 1997 and 2015, were analysed according to the effects of PR on exercise capacity and quality of life with regard to the impact of gender or other predictors by univariate and multivariate analyzes.

RESULTS

In the group of COPD patients, 30% did not achieve the expected physical performance during the 6-min walk test (28% of female and 32% of male patients). However, the non-responders initially have had a higher 6-min walking distance (6-MWD) (p < 0.001) and both male and female showed a significant lower BODE index (p = 0.025) in the multivariate analysis. In the ILD-group, 37% females and 43% males were classified as non-responders with regard to the 6-MWD. Also in this group, the non-responders initially have had a higher 6-MWD (p < 0.001). All other variables (age, BMI, lung function, blood gases, C-reactive Protein, Haemoglobin or rehabilitation duration) had no influence on the outcome.

CONCLUSION

Our study supports the positive effects of PR in COPD and ILD patients. In both groups, patients with the biggest limitations benefit most from PR. However, relevant gender differences or other predictors could not be found.

Physical Activity Counselling during Pulmonary Rehabilitation in Patients with COPD: A Randomised Controlled Trial

Background

Pulmonary rehabilitation programs only modestly enhance daily physical activity levels in patients with chronic obstructive pulmonary disease (COPD). This randomised controlled trial investigates the additional effect of an individual activity counselling program during pulmonary rehabilitation on physical activity levels in patients with moderate to very severe COPD.

Methods

Eighty patients (66±7 years, 81% male, forced expiratory volume in 1 second 45±16% of predicted) referred for a six‐month multidisciplinary pulmonary rehabilitation program were randomised. The intervention group was offered an additional eight-session activity counselling program. The primary outcomes were daily walking time and time spent in at least moderate intense activities.

Results

Baseline daily walking time was similar in the intervention and control group (median 33 [interquartile range 16–47] vs 29 [17–44]) whereas daily time spent in at least moderate intensity was somewhat higher in the intervention group (17[4–50] vs 12[2–26] min). No significant intervention*time interaction effects were observed in daily physical activity levels. In the whole group, daily walking time and time spent in at least moderate intense activities did not significantly change over time.

Conclusions

The present study identified no additional effect of eight individual activity counselling sessions during pulmonary rehabilitation to enhance physical activity levels in patients with COPD.

Trial Registration

clinicaltrials.gov NCT00948623

Pulmonary Rehabilitation and Palliative Care for the Lung Cancer Patient

Pulmonary rehabilitation, as a quality of life intervention, has a role to play in palliative care for lung cancer patients. Combining the art and skills of clinical care, physiological, and behavioral tools, pulmonary rehabilitation can serve to rebuild the functional capacity of patients limited by breathlessness and deconditioning. Exercise programs are the primary tool used to restore and rebuild the patient's endurance by challenging the entire pathway of oxygen transport and improving gas exchange. Other tools of pulmonary rehabilitation include breathing retraining, self-management skills, airway clearance techniques, bronchodilitation, smoking cessation and oxygen therapy. Pulmonary rehabilitation is now becoming a part of supportive care for patients undergoing chemotherapy and radiation therapy. The ability to be more active without suffering the consequences of dyspnea on exertion boosts the patient's self-efficacy and allows for an improved quality of life, so that lung cancer patients can participate in their family lives during this therapeutic challenge.

Effects of complementary whole-body vibration training in patients after lung transplantation: A randomized, controlled trial

BACKGROUND

In recent years, some studies have shown that whole-body vibration training (WBVT) may be a beneficial training mode in patients with chronic obstructive pulmonary disease (COPD). However, the effects of WBVT in patients after lung transplantation (LTx) have not yet been investigated.

METHODS

Eighty-three LTx patients (56 ± 7 years of age, 51% male, 10 ± 12 weeks post-LTx, forced expiratory volume in 1 second [FEV1] 68 ± 20 percent predicted [% pred], baseline 6-minute walk distance [6MWD] 350 ± 120 meters) admitted to a 4-week inpatient multidisciplinary program of pulmonary rehabilitation (PR) performed supervised endurance and strength training on 5 days per week. In addition, patients were randomly assigned to 1 of 2 supervised intervention groups on 3 days/week: (1) 4 × 2 minutes of bilateral dynamic squat exercises on a side-alternating vibration platform at 24 to 26 Hz (WBVT); and (2) a control group (CON) with the same amount of exercise time on the floor.

RESULTS

Seventy patients completed the study (WBVT: n = 34; CON: n = 36). Improvement in 6MWD was significantly (p = 0.029) higher in the WBVT group (83.5 meters [95% CI 65.4 to 101.7]) compared with the CON group (55.2 m [95% CI 37.5 to 72.8]). Also, peak work rate increased significantly (p = 0.042) more in the WBVT group (16.8 W [95% CI 13.5 to 20.5]) than in the CON group (12.6 W [95% CI 9.0 to 16.1]). No adverse events related to the intervention occurred during the study.

CONCLUSIONS

A complementary WBVT on top of conventional endurance and strength training seems to be a feasible and safe exercise modality in patients after LTx. Furthermore, it may even enhance the benefits of a comprehensive PR on exercise capacity.

Principles of rehabilitation and reactivation

Skeletal muscle dysfunction and physical inactivity are two clinically important features of a wide range of acute and chronic respiratory conditions. Optimisation of both of these features is important in order to improve physical function, prevent clinical deterioration and maximise community participation. One of the most potent and evidence-based interventions to address these physical deficits is pulmonary rehabilitation (PR). Whilst the majority of PR research has been conducted in patients with chronic obstructive pulmonary disease, there is widespread recognition that PR can benefit many other respiratory patient groups. These include patients with interstitial lung diseases, asthma, pulmonary hypertension, pre-/post-lung surgery (e.g. lung cancer, transplantation) and cystic fibrosis to name a few. Exercise training must be appropriately prescribed by a skilled healthcare professional with comprehensive knowledge of the pathology and physiology of these conditions, as well as a sound understanding of the exercise physiology and core principles of exercise prescription, monitoring and progression. It has also become increasingly recognised that people with respiratory conditions, particularly those with chronic disease, are considerably less active than those of good health. PR should therefore aim to induce behavioural change to facilitate the adoption and maintenance of an active lifestyle. In addition, PR should pay attention to the psychological well-being of patients and self-management of their lung disease in all its aspects. To that end, multidisciplinary individualised programs should be offered. This review sets the scene of PR principles for a series of papers that will focus on specific diseases other than chronic obstructive pulmonary disease where rehabilitation may offer a clinically important aspect of care over and above conventional pharmacological treatment.

Lung hyperinflation in chronic obstructive pulmonary disease: mechanisms, clinical implications and treatment

Lung hyperinflation is highly prevalent in patients with chronic obstructive pulmonary disease and occurs across the continuum of the disease. A growing body of evidence suggests that lung hyperinflation contributes to dyspnea and activity limitation in chronic obstructive pulmonary disease and is an important independent risk factor for mortality. In this review, we will summarize the recent literature on pathogenesis and clinical implications of lung hyperinflation. We will outline the contribution of lung hyperinflation to exercise limitation and discuss its impact on symptoms and physical activity. Finally, we will examine the physiological rationale and efficacy of selected pharmacological and non-pharmacological 'lung deflating' interventions aimed at improving symptoms and physical functioning.

Standardizing the analysis of physical activity in patients with COPD following a pulmonary rehabilitation program

BACKGROUND

There is a wide variability in measurement methodology of physical activity. This study investigated the effect of different analysis techniques on the statistical power of physical activity outcomes after pulmonary rehabilitation.

METHODS

Physical activity was measured with an activity monitor armband in 57 patients with COPD (mean ± SD age, 66 ± 7 years; FEV1, 46 ± 17% predicted) before and after 3 months of pulmonary rehabilitation. The choice of the outcome (daily number of steps [STEPS], time spent in at least moderate physical activity [TMA], mean metabolic equivalents of task level [METS], and activity time [ACT]), impact of weekends, number of days of assessment, postprocessing techniques, and influence of duration of daylight time (DT) on the sample size to achieve a power of 0.8 were investigated.

RESULTS

The STEPS and ACT (1.6-2.3 metabolic equivalents of task) were the most sensitive outcomes. Excluding weekends decreased the sample size for STEPS (83 vs 56), TMA (160 vs 148), and METS (251 vs 207). Using 4 weekdays (STEPS and TMA) or 5 weekdays (METS) rendered the lowest sample size. Excluding days with < 8 h wearing time reduced the sample size for STEPS (56 vs 51). Differences in DT were an important confounder.

CONCLUSIONS

Changes in physical activity following pulmonary rehabilitation are best measured for 4 weekdays, including only days with at least 8 h of wearing time (during waking hours) and considering the difference in DT as a covariate in the analysis.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00948623; URL: www.clinicaltrials.gov.