Results of an 8-week, outpatient pulmonary rehabilitation program on patients with and without chronic obstructive pulmonary disease

PURPOSE: To determine whether there is any difference in the effect of pulmonary rehabilitation (PR) on outcomes in patients with and without chronic obstructive pulmonary disease (COPD). METHODS: Retrospective analysis of medical records of all patients enrolling in PR over a 5-year period. RESULTS: A total of 422 patients enrolled in a multidisciplinary PR program from August 1999 to April 2004. Three hundred nine patients had COPD and 113 patients had diagnoses other than COPD. Three hundred seventy-nine patients completed the program. PR was conducted according to currently accepted guidelines. Measurements included the 6-minute walk distance (6MW) performed at the beginning and end of the program and quality of life as determined by the Chronic Respiratory Questionnaire (CRQ) at the beginning and end of the program. Both groups had significant improvements in the 6MW and all domains of the CRQ following PR. There was no significant difference in any of these outcomes between the 2 groups. The baseline forced expiratory volume in 1 second (FEV1) was not correlated with improvement in the 6MW in either group. CONCLUSIONS: There is no significant difference in improvement in exercise tolerance or quality of life following PR in COPD versus non-COPD patients. Baseline lung function does not predict improvement in exercise tolerance. PR is effective for patients with disability due to any chronic respiratory disease and not just COPD.     

Comprehensive pulmonary rehabilitation according to severity of COPD

A new classification for the severity of COPD was proposed at GOLD 2003: stage I: FEV(1) > or = 80% predicted; stage II: 50% < or = FEV(1)<80%; stage III: 30% < or = FEV(1)<50%; and stage IV: FEV(1) < 30%. To elucidate the acute effects of pulmonary rehabilitation (PR) on patients with different stages of COPD, data on pulmonary function, arterial blood gas analysis, the 6-min walk test, respiratory muscle strength, and activities of daily living were analyzed before and after our comprehensive 4- to 8-week inpatient PR program between 1992 and 2003. A total of 225 patients (201 men and 24 women; 21 with stage II, 79 with stage III, and 125 with stage IV COPD) was assessed. There were significant differences in FEV(1)% predicted and % residual volume in stages III and IV, in % vital capacity in stages II, III and IV, and in % total lung capacity in stage II when comparing the changes between pre- and post-PR. Significant differences of PaO(2) in stages III and IV and PaCO(2) in stage IV were found when comparing the changes between pre- and post-PR. The 6-min walk distance was significantly increased after PR by an average of approximately 50m for all staged patients. Respiratory muscle strength was also significantly increased in stages III and IV. Activities of daily living were significantly improved in all stages. These results showed that patients with COPD had benefited from PR regardless of disease severity. The effects included improvement in pulmonary function, arterial blood gas analysis, 6-min walk distance, respiratory muscle strength, and activities of daily living although there were some differences among the three stages.     

Anxiety and depression in severe chronic obstructive pulmonary disease: the effects of pulmonary rehabilitation

BACKGROUND: Previous studies have demonstrated high levels of anxiety and depression among patients with chronic obstructive pulmonary disease (COPD). The effects of an outpatient pulmonary rehabilitation (PR) program on psychological morbidity were examined in patients with severe COPD. METHODS: Levels of anxiety and depression in 95 patients with severe COPD (FEV1 < 40% predicted) were measured on entry to an outpatient PR program using the Hospital Anxiety and Depression (HAD) scale. HAD scores were remeasured at the completion of PR (3 months) and at 6 month follow-up. The effects of PR on mean HAD scores and on the number of patients with significant anxiety or depression were determined. Improvements in exercise capacity after PR were compared in patients with high and low HAD scores. RESULTS: Of patients, 35 (29.2%) had significant anxiety at screening and 18 (15%) significant depression. PR produced statistically significant falls in mean HAD scores for anxiety and depression, both of which remained significantly lowered at 6-month follow-up. PR also reduced the number of patients with significant anxiety or depression. Patients with high anxiety levels showed significantly greater improvements in shuttle walk distance than those with low HAD scores. CONCLUSIONS: Levels of anxiety and depression were high in a significant minority of this group of patients with severe COPD and were significantly improved by PR. Patients with higher HAD scores had lower baseline shuttle walk distances than those with low HAD scores. Anxious patients showed statistically greater improvements in exercise capacity following PR.     

低分子肝素钙对慢性肺源性心脏病急性加重期临床研究

目的 观察低分子肝素钙(LMWH)对继发于COPD的肺心病急性加重期患者肺动脉压(PASP)及六分钟步行试验(6MWT)的影响.方法 将152例继发于COPD的肺心病急性加重期患者,随机分为LMWH治疗组及对照组,两组均给予控制感染、氧疗等常规治疗,LMWH治疗组加用LMWH皮下注射10天.记录两组入院及住院10天时PASP及6MWT结果.结果 治疗10天后,治疗组PASP下降明显,差异具有统计学意义(u=3.37,P＜0.01);治疗组6MWT距离增加明显,差异具有统计学意义(u =3.47,P＜0.01).结论LMWH对继发于COPD的肺心病急性加重期可明显降低PASP.提高6 MWT距离.     

The functional impact of an individualized, graded, outpatient pulmonary rehabilitation in end-stage chronic obstructive pulmonary disease

OBJECTIVE: To evaluate the functional impact of an individualized outpatient pulmonary rehabilitation program in end-stage chronic obstructive pulmonary disease (COPD). METHODS: Patients with end-stage COPD were admitted into a 6-week comprehensive outpatient pulmonary rehabilitation program that was "packaged" for each patient. We compared spirometric parameters, exercise tolerance, level of breathlessness, and intensity of work before and after rehabilitation. RESULTS: Of 45 eligible patients, only 14 consented to participate in the study. All 14 patients had forced expiratory volume in 1 second <35% of predicted, and 10 patients (72%) had a 6-minute walk test <180 m. The level of breathlessness was between 7 (moderate to severely breathless) and 10 (maximally breathless) on the Visual Analogue Scale in all patients. After the program, there was significant improvement in the FEV 1 P = 0.04), forced vital capacity P = 0.0045), 6-minute walk test P = 0.00047), and shuttle-walk test (9 of 14 patients). All patients had some improvement in level of dyspnea. CONCLUSIONS: Individualized outpatient pulmonary rehabilitation in end-stage COPD can produce a measurable improvement in spirometry and exercise tolerance with a favorable impact on the level of physical activity.     

Managing chronic obstructive pulmonary disease in the community. A randomized controlled trial of home-based pulmonary rehabilitation for elderly housebound patients

PURPOSE: Pulmonary rehabilitation is essential for managing chronic obstructive pulmonary disease (COPD). Housebound COPD patients are frequently excluded from this treatment because they are unable to access outpatient pulmonary rehabilitation programs because of the severity of their disease. This randomized controlled trial assesses the effects of a 12-week home-based pulmonary rehabilitation program for 60 housebound COPD patients older than 60 years. METHODS: Intervention patients received an individually tailored supervised walking and arm exercise program as well as individual multidisciplinary education sessions on COPD and its management. Outcomes were assessed using the 6-minute walk test, St George's respiratory questionnaire, and Borg score of perceived breathlessness. Healthcare utilization was assessed using hospital admission rates with exacerbation of COPD and average length of stay at readmission. RESULTS: Complete data for 23 patients in each group were available for analysis. There was no significant difference between groups on baseline measures. Compared with the control group, intervention patients demonstrated a significant improvement in 6-minute walk test (P = .023), Borg score of perceived breathlessness (P = .024), St George's respiratory questionnaire total score (P = .020), and impact subscore (P = .024). At 6 months, the intervention group had a significantly shorter average length of stay at readmission to hospital with exacerbation (P = .035). CONCLUSION: A 12-week home-based pulmonary rehabilitation is effective in improving exercise tolerance, perception of breathlessness, and quality of life for housebound COPD patients. To manage COPD in the community more effectively, health services should focus on expanding home-based pulmonary rehabilitation.     

Neurobehavioral improvement after brief rehabilitation in patients with chronic obstructive pulmonary disease

PURPOSE: Depressive symptoms, physiologic function, and cognition were examined in patients with chronic obstructive pulmonary disease (COPD) after 3 weeks of rehabilitation. METHODS: Patients with COPD completed measures of depression, neuropsychological function, exercise, and spirometry before and after a 3-week rehabilitation program. The 30 rehabilitation patients with COPD were compared with 29 untreated patients with COPD and 21 healthy controls similar in age, education, and gender. RESULTS: A significant group by time interaction effect was found on the Beck Depression Inventory (BDI). A significant interaction effect was also found on the 6-minute walk. Patients in the COPD rehabilitation program had decreased depressive symptoms and increased 6-minute walk distance compared with the untreated groups. Across the 3 groups, no significant interaction effects were found on neuropsychological tests. However, clinically significant improvement in sustained visual attention, verbal retention, and visuospatial ability were reported in the most impaired patients with COPD in the rehabilitation group. CONCLUSION: Compared with control groups, decline in depressive symptoms and increased exercise capacity occurred in patients with COPD after brief rehabilitation. Clinical improvement in visual attention, verbal memory, and visuospatial functions occurred in the impaired patients with COPD participating in treatment. Neurobehavioral improvements after such a brief rehabilitation intervention are relevant for clinical care and warrant continued investigation in well-designed clinical trials.     

Effects of pulmonary rehabilitation in bronchiectasis: A retrospective study

There is limited information about the benefits of pulmonary rehabilitation (PR) in patients with bronchiectasis. This study aimed to evaluate the effects of an out-patient PR program in patients with a primary diagnosis of bronchiectasis and to compare them with a matched COPD group who completed the same PR program. A retrospective review was conducted of patients with bronchiectasis or COPD who completed 6 to 8 weeks of PR at two tertiary institutions. The outcome measures were the 6-minute walk distance (6MWD) and Chronic Respiratory Disease Questionnaire (CRQ). Ninety-five patients with bronchiectasis completed the PR (48 male; FEV(1) 63 [24] % predicted; age 67 [10] years). Significant improvements in 6MWD (mean change 53.4 m, 95% CI 45.0 to 61.7) and CRQ total score (mean change 14.0 units, 95% CI 11.3 to 16.7) were observed immediately following PR. In patients with complete follow-up (n = 37), these improvements remained significantly higher than baseline at 12 months (20.5 m, 95% CI 1.4 to 39.5 for 6MWD; 12.1 points, 95% CI 5.7 to 18.4 for CRQ total score). The time trend and changes in the 6MWD and CRQ scores were not significantly different between the bronchiectasis and the COPD groups (all p > 0.05). This study supports the inclusion of patients with bronchiectasis in existing PR programs. Further prospective RCTs are warranted to substantiate these findings.     

Distance and oxygen desaturation in 6-min walk test predict prognosis in COPD patients

The aim of the present study was to predict the prognosis of Chronic obstructive pulmonary disease (COPD) patients who underwent comprehensive pulmonary rehabilitation (PR). A total of 144 patients who performed PR between 1992 and 1999 was assessed. After PR, 67 patients underwent lung volume reduction surgery (LVRS). Baseline data before PR consisted of body mass index, serum albumin levels, use of supplement oxygen at home, pulmonary function, arterial blood gas analysis, and distance and fall of hemoglobin oxygen saturation (DeltaSpO(2)) in 6-min walk test. In addition to pre-PR factors, treatment with LVRS was taken into the analysis. The prognostic significance of variables influencing survival was determined by univariate analysis with Log rank test or multivariate analysis using Cox's proportional hazard model. By a median follow-up time of 8.4 years, the median survival time was 8.1 years (95% confidence interval: 6.9-9.4 years). Albumin level, PaCO(2), distance and DeltaSpO(2) were significant prognostic factors in univariate analysis. LVRS did not affect the prognosis. The multivariate analysis showed short distance and increase of DeltaSpO(2) as significant independent predictors of the risk of death. 6-min walk test was very useful for predicting the prognosis of the COPD patients.     

Effect of pulmonary rehabilitation on quality of life in patients with COPD: the use of SF-36 summary scores as outcomes measures

PURPOSE: Pulmonary rehabilitation (PR) is an accepted therapy for patients with chronic obstructive pulmonary disease (COPD), improving both exercise capacity and quality of life (QOL). Generic measures of QOL have been criticized as being insensitive to detecting the improvement in QOL after PR in contrast to disease-specific instruments. The authors looked at the Medical Outcomes Survey Short Form 36-item questionnaire (SF-36), a generic QOL measure, to detect changes in QOL in COPD patients after completion of PR. METHODS: Patients with COPD who participated in a PR program completed the QOL questionnaire before and after completion of PR. Exercise tolerance was assessed by the 6-minute walking test. Quality of life was assessed by the SF-36; the authors calculated its eight dimensions as well as mental (MCS) and physical (PCS) component summary scores. RESULTS: The patients realized a significant improvement in exercise tolerance; 6-minute walking test distance increased from 470 +/- 104 m (mean +/- standard deviation) to 536 +/- 133 m (P = 0.0006) after PR. Quality of life also improved in nearly all dimensions and in both summary scores; PCS improved from 26.1 +/- 8.0 before PR to 30.5 +/- 9.0 after PR (P = 0.008) and MCS improved from 27.9 +/- 7.0 before PR to 34.1 +/- 5.0 after PR (P = 0.0002). CONCLUSION: The SF-36 and its summary scores are sensitive instruments to detect improvement in QOL in COPD patients after PR.     

Comparison of Recording Positions of Physical Activity in Patients with Severe COPD Undergoing LTOT

Abstract

Background: Accelerometry is increasingly used to assess physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD). It is not known how the relationship of PA to clinical results depends on the position of the PA sensor. Methods: We assessed the effect of monitor position by measuring lower extremity (ankle), upper extremity (wrist) and total body movement (hip) in 52 patients with severe COPD (mean [± SD] age, 62 ± 10 years; FEV₁, 38 ± 12% predicted) undergoing long-term oxygen therapy with and without walkers during a pulmonary rehabilitation (PR) program. Sensors were worn 8.5 ± 3.1 days and data was compared to the BODE score and the 6-minute walk distance (6MWD) assessed at the beginning and end of the PR. Results: Mean ankle PA was moderately related to the 6MWD, irrespective of patients being equipped with a walker or not (p < 0.05). Mean PA values were considerably lower in COPD patients with walker compared to patients without for all sensor positions. No significant association was observed between mean hip PA data and 6MWD; however, hip and ankle PA data were moderately related in walker-free and strongly related in walker patients (p < 0.01). In a multivariate regression model only ankle activity was significantly associated with the BODE score (p < 0.01). Conclusion: The sensor position had a significant impact on the association between PA recordings and the 6MWD in very severe COPD. In our setting, ankle measurement seemed to best reflect the clinical state of patients.     

The Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD

Abstract

Chronic pain affects up to 88% of people with chronic obstructive pulmonary disease (COPD) and has been associated with comorbidities. However, with pain not evaluated during pulmonary rehabilitation (PR) assessments, it is unclear whether PR impacts pain intensity and coping ability. This study aimed to 1) determine the effect of PR on pain qualities, coping behavior and psychological symptoms in those with COPD and chronic pain; and 2) assess the impact of PR on exercise capacity and quality of life in individuals with COPD and chronic pain compared to those without pain. Patients with COPD and comorbidities enrolling in outpatient PR were assessed for chronic pain. Those with chronic pain completed the Brief Pain Inventory, Coping Strategies Questionnaire-24, Fear Avoidance Behavior Questionnaire and measures of anxiety and depression. Changes in HRQOL and 6-minute walk distance (6MWD) following PR were compared between participants with and without chronic pain. Thirty-four participants with chronic pain and 34 participants without pain were included (mean?±?SD, FEV₁ 47?±?19% predicted). In those with chronic pain, PR did not affect pain intensity (median[IQR] pre/post PR 3[2–5] vs. 4[2–6] points, p?=?0.21), anxiety (7[2–9] vs. 5[3–8] points, p?=?0.82) or depression (4[2–8] vs. 3[1–6] points, p?=?0.38) and did not change pain coping strategies. Both groups improved in 6MWD (mean difference [95% CI] 17[?39 to 72] m), and those without pain had greater improvement in mastery (p?=?0.013). PR was effective in patients with moderate to severe COPD whether or not they reported chronic pain at the time of their initial assessment.     

Does unsupported upper limb exercise training improve symptoms and quality of life for patients with chronic obstructive pulmonary disease?

PURPOSE: Many patients with chronic obstructive pulmonary disease (COPD) report dyspnea and fatigue when performing upper limb activities. Unsupported upper limb training has been shown to improve upper limb endurance, but its effects on symptoms and quality of life have not been examined. The aim of this study was to compare the effects of upper limb and lower limb training with lower limb training alone on exercise capacity, symptoms, and quality of life with COPD. METHODS: For this study, 38 patients with moderate to severe COPD were randomly allocated to unsupported upper limb endurance training or to a control group that completed a sham training task. All the patients underwent lower limb endurance training. The 6-minute walk test, the Incremental Unsupported Upper Limb Exercise Test, and the Chronic Respiratory Disease Questionnaire (CRQ) were completed before training and then 6 weeks afterward. Both patients and assessors were blinded to group allocation. RESULTS: All the patients reported symptoms associated with upper limb activities on the initial CRQ. Both groups showed significant improvements in all domains of the CRQ and in the 6-minute walk test after training. Only the upper limb training group showed improvement in upper limb endurance time (57 +/- 75 vs 2 +/- 58 seconds; P = .02). There were no significant differences between the groups for 6-minute walk test or any domain of the CRQ. CONCLUSIONS: Unsupported upper limb training for patients COPD improves upper limb exercise capacity, but has no additional effect on symptoms or quality of life, as compared with leg training alone. This type of upper limb training may not adequately address the complex interaction between respiratory mechanics and upper limb function.     

The endurance shuttle walk test: an alternative to the six-minute walk test for the assessment of ambulatory oxygen

UK guidelines for domiciliary oxygen have suggested the six-minute walk test or shuttle walk tests as suitable functional measures for the clinical assessment of ambulatory oxygen (AO). To date, there is limited evidence that would support the use of shuttle walk tests as assessment tools for AO. The endurance shuttle walk test (ESWT) is used increasingly as an assessment tool within pulmonary rehabilitation (PR) but its potential as an investigative test for AO has not been explored. Using the same test for both PR and AO assessment is appealing since it would improve efficiency and act to standardise outcome measures in this patient population. The aim of this study was to examine the responsiveness and repeatability of the ESWT to AO and to compare the response with that of the six-minute walk test (6MWT). Twenty-three patients with chronic obstructive pulmonary disease (COPD) performed, in random order, the ESWT and the 6MWT on air and whilst breathing AO. Oxygen saturation and Borg ratings of breathlessness and perceived exertion were recorded. On a third day, eleven patients repeated the ESWT with AO in order to measure repeatability. There was a significantly greater change in the ESWT with oxygen than the change recorded from the 6MWT (66 [91] vs 6 [28] m respectively; P < .05). When repeated on a separate day, the mean difference (95% CI) between distances walked on the ESWT with AO was 0.91 (-47, 49) m. The ESWT was more responsive than the 6MWT for detecting improvements in walking endurance whilst breathing AO.     

信必可都保干粉吸入治疗慢性阻塞性肺疾病的疗效评价

目的 观察信必可都保干粉(信必可)吸入治疗慢性阻塞性肺疾病(COPD)稳定期患者的疗效.方法 对40例处于稳定期的中、重度COPD患者在常规治疗基础上,给予吸入信必可(160.0/4.5ug),每次l吸,2次/d,记录治疗前、后肺功能及6分钟步行距离、住院次数、呼吸困难变化等,治疗前后进行比较.结果 治疗后肺功能指标、临床症状改善情况、6分钟步行距离、住院次数等均明显优于治疗前(P＜0.05).结论 对于稳定期COPD患者,信必可能减轻临床症状,明显改善肺功能,降低住院次数,提高生活质量.     

Pulmonary rehabilitation in lung disease other than chronic obstructive pulmonary disease

The benefit of pulmonary rehabilitation is well documented for patients with chronic obstructive pulmonary disease (COPD). However, such benefit has not been demonstrated for severely impaired patients with other chronic pulmonary diseases. Occasional non-COPD patients have been admitted to our 4-wk inpatient program. We compared the improvement of these non-COPD patients with that of COPD patients in the same program. Improvement is assessed by a 6-min walk test done at admission and discharge. On the admission 6-min walk test, 32 non-COPD patients had an ambulation distance of 276 +/- 219 ft (SD). At completion of the program, their ambulation distance increased to 574 +/- 367 ft (increase in ambulation 298 +/- 290 ft, P less than 0.0001). Diagnostic subgroups improved to essentially the same extent. The increase in ambulation was not statistically different between non-COPD patients and a series of 317 patients with COPD. Patients severely impaired with chronic pulmonary disease other than COPD benefit from intensive pulmonary rehabilitation, and the degree of improvement is similar to that of COPD patients.     

Do the Benefits Gained Using a Short-Term Pulmonary Rehabilitation Program Remain in COPD Patients After Participation?

The aim of this study was to evaluate the short-term benefits of a pulmonary rehabilitation program in chronic obstructive pulmonary disease (COPD) patients. The study was a randomized controlled trial that included 54 mild and moderate COPD patients. Patients were assigned to either an 8-week-long pulmonary rehabilitation program, which consisted of exercise plus education (rehabilitation group), or were controls. All the patients were evaluated at baseline at the completion of the 8th week of the program and one month after the completion of the pulmonary rehabilitation program using five instruments: arterial blood gas analysis, postbronchodilator pulmonary function test, 6-minute walk test (6MWT), Saint George Respiratory Questionnaire (SGRQ), and the dyspnea visual analog scale (VAS) There were no statistically significant differences in the pulmonary functions and pulmonary gas analysis between baseline, discharge (8th week), and the 12th-week visit in both groups (p > 0.05). Rehabilitation resulted in significant improvements in both the VAS and the 6MWT at the 8th week, but by the 12th week all of these improvements had deteriorated. All of the SGRQ domains improved both at the 8th and the 12th week, with a significant difference between the groups (p < 0.05). We conclude that rehabilitation resulted in improvements in exercise capacity, health status, and dyspnea. All of these benefits, however, tend to deteriorate in the first month after rehabilitation. Therefore, it is strongly recommended that all patients with COPD be kept motivated in order to continue with rehabilitation and maintain the benefits gained.     

Inspiratory muscle training in pulmonary rehabilitation program in COPD patients

Most pulmonary rehabilitation (PR) programs do not currently incorporate IMT in their PR programs for COPD patients. The aim of the present study was to assess the influence of adding IMT to the patients already involved in a rehabilitation program. Thirty-four patients with significant COPD were recruited for the study. All patients participated in a general exercise reconditioning (GER) program for 12 weeks. The patients were then randomized to receive IMT or sham IMT, in addition to GER for the next 6 months. Following three months of GER training there was a significant increase in the 6-min walk test (6MWT) (from mean+/-SEM 254+/-38 to 322+/-42 m, p<0.01), and small but non-significant decreases in the perception of dyspnea (POD), and in the St. George Respiratory Questionnaire score (SGRQ). Following the addition of IMT to the GER program there was a significant increase in the PI(max) in the GER+IMT group (from 66+/-4.7 to 78+/-4.5 cm H(2)O, p<0.01). This was accompanied by a significant improvement in the POD and a further significant improvement in the SGRQ score. IMT provides additional benefits to patients undergoing PR program and is worthwhile even in patients who have already undergone a GER program.