Effectiveness and safety of exercise training and rehabilitation in pulmonary hypertension: a systematic review and meta-analysis

"A new realization of what I'm able to do": exercise interventions can impact knowledge, confidence and daily activity for people with pulmonary arterial hypertension (PAH)

PURPOSE

Exercise-based rehabilitation interventions can improve functional outcomes in pulmonary arterial hypertension (PAH), but barriers to participation are common and little is known about the patient-reported experience. This study evaluated the patient experience of participating in structured, outpatient exercise interventions for PAH, and explored how participation may impact knowledge, attitudes and engagement in physical activity.

METHODS

A mixed-methods evaluation was conducted alongside a pilot trial (ExPAH). Semi-structured interviews were completed with participants who undertook a 12-week, outpatient exercise-based intervention for PAH. Interview data were analyzed via descriptive and inductive thematic analyses.

RESULTS

Fourteen participants were included (mean 53 ± 14.9 years, 79% females). Formal therapy programs were reported to be enjoyable and increased participant's knowledge, confidence to exercise, and daily physical activity. Six dominant themes described the subjective experience of undertaking a structured program: confronting a sense of loss and limitation through exercise; "permission to try" built knowledge and confidence; finding joy and empowerment through physical activity; the importance of motivation; reframing exercise as part of daily life; and exercise as liberating.

CONCLUSIONS

Structured therapy programs can increase knowledge, confidence, and positive perceptions of physical activity for people with PAH. Structured programs were reported to be enjoyable, empowering and increased functional independence.

Expanding horizons in pulmonary hypertension management: A systematic review and meta-analysis of non-pharmacological interventions

BACKGROUND

Pulmonary hypertension (PH) is a progressive and life-threatening disorder characterized by elevated pulmonary arterial pressure, leading to right heart failure and reduced exercise capacity. Traditional pharmacological and surgical treatments offer limited efficacy and significant side effects, necessitating the exploration of alternative therapeutic options.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the efficacy and safety of non-pharmacological interventions, including exercise, dietary modifications, and psychosocial therapies, in the management of pulmonary hypertension.

METHODS

Comprehensive searches were conducted in PubMed, Cochrane Library, and Scopus up to 2024, identifying randomized controlled trials and observational studies examining non-pharmacological interventions for PH. Primary outcomes assessed included pulmonary arterial pressure, right heart function, exercise capacity, and quality of life, with secondary analysis on safety and adverse effects. Data synthesis was performed using random-effects meta-analysis.

RESULTS

The review included 30 studies, totaling 2000 participants with various forms of PH. Meta-analysis demonstrated significant improvements in exercise capacity as measured by the 6 min walk distance (mean increase of 45 meters, 95 % CI: 30-60, p<0.001), enhanced quality of life scores, and reduction in pulmonary arterial pressure (mean reduction of 5 mmHg, 95 % CI: 3-7, p<0.01). Non-pharmacological therapies also showed a favorable safety profile, with minor adverse effects reported.

CONCLUSION

Non-pharmacological interventions provide a viable and effective complement to traditional treatments for pulmonary hypertension, significantly improving functional capacity and hemodynamic parameters without severe adverse effects. These findings support the integration of tailored non-pharmacological strategies into the therapeutic regimen for PH patients, emphasizing the need for broader implementation and further research to optimize intervention protocols.

Assessing the Barriers and Facilitators to Pulmonary Rehabilitation Referrals Using the Consolidated Framework for Implementation Research (CFIR)

Chronic obstructive pulmonary disease (COPD) is a global health issue causing significant illness and death. Pulmonary Rehabilitation (PR) offers non-pharmacological treatment, including education, exercise, and psychological support which was shown to improve clinical outcomes. In both stable COPD and after an acute exacerbation, PR has been demonstrated to increase exercise capacity, decrease dyspnea, and enhance quality of life. Despite these benefits, referrals for PR for COPD treatment remain low. This study aims to evaluate the perceptions of healthcare providers for referring a COPD patient to PR. Semi-structured qualitative interviews were conducted with pulmonary specialists, hospitalists, and emergency department physicians. Domains and constructs from the Consolidated Framework for Implementation Research (CFIR) were applied to the qualitative data to organize, analyze, and identify the barriers and facilitators to referring COPD patients. The findings from this study will help guide strategies to improve the referral process for PR.

Impression life with pulmonary hypertension: clinically relevant characteristics and quality of life among patients in Gansu, China

BACKGROUND

The adverse effects of pulmonary arterial hypertension (PAH) on physical, emotional, and health-related quality of life (HRQoL) remain primarily unrecognized, especially in resource-limited settings.

OBJECTIVES

This study aims to characterize the HRQoL of patients with PAH in this area and also identify the potential role of clinically relevant characteristics, including the 6-min walk distance test (6MWD), WHO-Functional Classification (WHO-FC), and mental health in the occurrence of lowering quality of life.

DESIGN

This was a cross-sectional observational study.

METHODS

Inpatients with PAH were chosen from a tertiary hospital located in Gansu province, China. All participants were interviewed face-by-face by using questionnaires, including items from the 36-Item Short Form Health Survey (SF-36), the self-rating anxiety scale, and the self-rating depression scale. Data on demographic and clinically relevant characteristics, including WHO-FC and 6MWD, were also collected by tracing medical recorders. Multiple linear regression analysis was used to determine the association between demographic, clinically relevant characteristics data, and physical component summary (PCS) or mental component summary (MCS) in SF-36.

RESULTS

Of the 152 participants, SF-36 differed significantly from Chinese norms in all eight domains, with role-physical (21.55 ± 9.87) less than one-third of the norm (88.79 ± 28.49). Multiple linear regression results showed that the factors with the greatest impact on PCS were anxiety scores (β = -0.22, p = 0.001), followed by WHO-FC (β = -0.16, p = 0.014) and 6MWD (β = 0.15, p = 0.036). The factors with the greatest impact on MCS were WHO-FC (β = -0.30, p < 0.001), followed by anxiety (β = -0.23, p = 0.001) and depression scores (β = -0.16, p = 0.013).

CONCLUSION

HRQoL was substantially reduced among PAH patients in the resource-limited area, mainly the physiological functions. WHO-FC and anxiety scores were independently associated with both PCS and MCS in SF-36. Clinicians should make reasonable rehabilitation programs and plans for patients according to their cardiac function grade and the severity of clinical symptoms. In addition, psychological interventions should also be taken, especially for those with anxiety symptoms, so as to improve their HRQoL.

Safety, feasibility and effectiveness of the remotely delivered Pulmonary Hypertension and Home-Based (PHAHB) physical activity intervention

Background

Pulmonary hypertension (PH) is a heterogeneous condition, associated with a high symptom burden and a substantial loss of exercise capacity. Despite prior safety concerns regarding physical exertion, exercise training as a supportive therapy is now recommended for PH patients. Currently, most programmes are hospital-based, which limits accessibility. There is a need to provide alternative approaches for physical activity engagement for PH patients. The aim of this research was to develop, implement and evaluate the safety, feasibility and effectiveness of home-based physical activity intervention for PH.

Methods

An entirely remotely delivered home-based physical activity intervention underpinned by behaviour change theory and informed by end-users, was assessed using a single-arm feasibility study design. Participants (n=19; 80% female) with a mean±sd age of 49.9±15.9 years with a diagnosis of PH undertook a 10-week, home-based physical activity intervention with induction training, support materials, telecommunication support, health coaching, exercise training and assessments, all remotely delivered. Training involved respiratory training along with a combination of aerobic and resistance exercises.

Results

The intervention was deemed safe as no adverse events were reported. A high level of feasibility was demonstrated as the protocol was implemented as intended, sustained a high level of engagement and adherence and was well accepted by participants in terms of enjoyment and utility. There was a significant improvement in functional capacity, physical activity, exercise self-efficacy and quality of life, between baseline and post-training.

Conclusion

The study demonstrates that an entirely remotely delivered home-based physical activity programme is safe, feasible and effective in improving functional capacity, physical activity and quality of life in PH patients.

Lung Transplantation for Pulmonary Artery Hypertension

This manuscript discusses the role of lung transplantation in patients with pulmonary hypertension. The indications and timing for referral to a transplant unit and timing for wait-listing for lung transplantation are discussed. The type of transplantation—isolated (single or double) lung transplantation and situations when combined heart and double lung transplantation is indicated—will be elaborated. Escalation of medical therapy with the need and timing for bridging therapies such as extracorporeal membrane oxygenation until an appropriate organ becomes available will be discussed. Challenges in the postoperative period, specific to lung transplantation for pulmonary artery hypertension, will be reviewed. The outcomes following lung transplantation will also be considered in greater detail.

Exercise Training in Pulmonary Hypertension: AN UPDATED SYSTEMATIC REVIEW WITH META-ANALYSIS

PURPOSE

Given that previous reviews on exercise training in pulmonary hypertension (PH) were largely based on a small number of randomized controlled trials (RCT), their conclusions are subject to bias. This review sought to identify the impact of exercise training on functional capacity and health-related quality of life (HRQoL) in PH using advanced statistical approaches such as meta-analysis by stratification according to study design.

REVIEW METHODS

Five databases were searched from January 2015 to April 2020 to update a previous review. Included articles had data extracted, risk of bias (ROB) assessed, and quality rating performed. Data were analyzed using meta-analysis with a random-effects model for 6-min walk test (6MWT) distance and HRQoL. Heterogeneity was explored using stratified meta-analysis, within patient correlation and meta-regression.

RESULTS

A total of 28 studies (11 RCT, 12 pre-/post-studies, 2 two-group non-RCT, and three case series) consisting of 1264 patients were included. Meta-analysis of six RCT demonstrated an improved 6MWT distance by 49.5 m (95% CI, 27.2-71.8: I2 = 73%; 254 participants; low-moderate ROB) with a low correlation coefficient of 0.34, while the 12 pre-/post-non-RCT showed an improvement of 68.36 m (95% CI, -86.78 to -49.94: I2 = 37%; 746 participants; high ROB) along with improvements in V˙ o2peak (weighted mean difference [WMD] = 3.03 mL/kg/min, 95% CI, 2.17-3.90: I2 = 0%, P = .82), and HRQoL (WMD = 2.74: 95% CI, -0.82 to 6.30). Metaregression showed that the benefit of exercise on 6MWT distance did not significantly vary across the trial study characteristics.

CONCLUSION

This updated review identified an additional body of evidence supporting the efficacy of exercise training on 6MWT distance and HRQoL in stable PH patients. These benefits appeared to be consistent across models of delivery.

Individually tailored home-based physiotherapy program makes sustainable improvement in exercise capacity and daily physical activity in patients with pulmonary arterial hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare, chronic, progressive, and life-threatening cardiopulmonary disease. This study investigated the impact of an individually tailored 12 weeks home-based physiotherapy program in PAH patients, with the aim to evaluate change in exercise capacity and daily physical activity level.

METHODS

This was an analysis of secondary outcomes from a prospective, randomized, controlled intervention study. Twenty-one participants were recruited from the Latvian PH registry based on inclusion criteria and randomized in a training group (TG) and control group (CG). Both groups continued a medical target therapy, but for TG, the individually tailored home-based physiotherapy program was added including physical exercises, relaxation, self-control, education, and supervision with telehealth elements. Outcomes included a 6-min walk test (6MWT) (m) and daily physical activity based on accelerometry results assessed at baseline, after 12 weeks, and at follow-up 6 months after commencement of intervention.

RESULTS

6MWT distance significantly (p < 0.05) and clinically (>33 m) increased within TG after 12 weeks (51.8 m, 95% CI = 25.7-77.9 m, Cohen's d = 1.7) and at follow-up (75.5 m, 95% CI = 46.1-104.8 m, Cohen's d = 2.1). A significant difference in 6MWT results between the groups at 12 weeks and follow-up was approved. In TG, low-intensity activities significantly (p < 0.05) increased both after 12 weeks (Cohen's d = 1.6) and at follow-up (Cohen's d = 1.2), moderate-intensity activities significantly (p < 0.05) increased at follow-up (Cohen's d = 1.3), and no significant improvements were present in CG.

CONCLUSION

The individually tailored 12 weeks home-based physiotherapy program comprising comprehensive physical exercise training, relaxation, self-control skills training, and education, added to stable medical target therapy and supervised by physiotherapist through telehealth elements, is effective in improving exercise capacity and increasing daily time in low or moderate physical activities 6 months after commencement of the intervention in patients with PAH.

Individually Tailored Remote Physiotherapy Program Improves Participation and Autonomy in Activities of Everyday Life along with Exercise Capacity, Self-Efficacy, and Low-Moderate Physical Activity in Patients with Pulmonary Arterial Hypertension: A Randomized Controlled Study

Background and Objectives: Pulmonary arterial hypertension (PAH) is a rare, chronic, progressive, and life-threatening disease; however, the appropriate target medical treatment today allows patients with PAH not only to survive but also to live a relatively normal life. However, patients face the challenge of adapting and maintaining a good quality of life, thus it is important to consider complex interventions related not only to medical treatment. Methods: This was a prospective, randomized, controlled, single-blind study. Twenty-one (21) patients diagnosed with PAH were included and randomly assigned to training or control group. All participants continued target medical therapy. Furthermore, TG underwent the individually tailored 12-week remote physiotherapy program. As a primary outcome measurement, the Impact on Participation and Autonomy Questionnaire (IPA) was used. Secondary outcome included aerobic capacity (6MWT), accelerometery and general self-efficacy (GSE). Data were collected at baseline, after 12 weeks and at follow-up 6 months after the beginning of the intervention. Results: A significant difference between the groups was found in the follow-up assessment on three of the four IPA subscales analyzed, AO, RF, and AI. The total IPA score decreased significantly in TG after the program, indicating an improved participation. In addition, in TG a significant increase in 6MWT results, daily time in low- or moderate-intensity physical activities, and GSE was observed. Conclusions: In summary, the individually tailored physiotherapy program investigated added to stable target medical therapy in patients with PAH encourages improvement and prevents possible deterioration of perceived participation of patients in activities of their everyday life in the context of one’s health condition in the long term, along with improved exercise capacity and increased time spent in low- or moderate-intensity physical activities. Future studies are needed to develop and evaluate long-term intervention to support patients living with this rare, chronic, and life-threatening disease.

Comparison of Alexa Voice and Audio Video Interfaces for Home-Based Physical Telerehabilitation

The goal of this pilot study was to compare Alexa voice and video interfaces for home-based telerehabilitation dialog by conducting cognitive walkthrough testing. All task performance scores were higher in video interface as compared to the audio interface. The overall task score was significantly higher for video interface (42.4±4.6) as compared to the audio score (41.3±5.9). Comparative usability survey demonstrated higher preference of the video interface as compared to the audio interface. Based in the comparative survey, 85.7% stated they definitely prefer video interface, 85.7% felt that video introduction was simpler to understand, 71.4% felt that exercise instructions were simpler to understand with the video interface, and 78.6% felt that overall navigation was easier with the video interface. The overall time to accomplish all three tasks was significantly shorter (p<0.05) for the video interface (170.5±12.2 seconds) as compared to the audio interface (194.2±10.3 seconds). This is the first study systematically comparing two major Alexa interfaces in a telerehabilitation system. These results are instrumental for future development of Alexa-based telerehabilitation systems.

Effectiveness and safety of a simple home-based rehabilitation program in pulmonary arterial hypertension: an interventional pilot study

BACKGROUND

Rehabilitation plays an important role in the management of patients with pulmonary arterial hypertension (PAH) and current guidelines recommend implementation of a monitored individualized exercise training program as adjuvant therapy for stable PAH patients on optimal medical treatment. An optimal rehabilitation model for this group of patients has not yet been established. This randomized prospective study assessed the effectiveness and safety of a 6-month home-based caregiver-supervised rehabilitation program among patients with pulmonary arterial hypertension.

METHODS

A total of 39 patients with PAH were divided into two groups: intervention group (16 patients), subjected to a 6-month home-based physical training and respiratory rehabilitation program adapted to the clinical status of participants, and control group (23 patients) who did not perform physical training. The 6-min walk test (6MWT), measurement of respiratory muscle strength, quality of life assessment (SF-36, Fatigue Severity Scale - FSS) were performed before study commencement, and after 6 and 12 months. Adherence to exercise protocol and occurrence of adverse events were also assessed.

RESULTS

Physical training significantly improved 6MWT distance (by 71.38 ± 83.4 m after 6 months (p = 0.004), which remained increased after 12 months (p = 0.043), and respiratory muscle strength after 6 and 12 months (p < 0.01). Significant improvement in quality of life was observed after the training period with the use of the SF-36 questionnaire (Physical Functioning, p < 0.001; Role Physical, p = 0.015; Vitality, p = 0.022; Role Emotional, p = 0.029; Physical Component Summary, p = 0.005), but it did not persist after study completion. Adherence to exercise protocol was on average 91.88 ± 14.1%. No serious adverse events were noted.

CONCLUSION

According to study results, the home-based rehabilitation program dedicated to PAH patients is safe and effective. It improves functional parameters and quality of life. Strength of respiratory muscles and 6MWD remain increased 6 months after training cessation.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03780803 . Registered 12 December 2018.