Evaluating the benefit of performing two 6-min walk tests after pulmonary rehabilitation to improve assessment of functional capacity.

Introduction and Objectives Approximately 1.2 million people in the UK are diagnosed with chronic obstructive pulmonary disease (COPD), which costs the NHS over £800 million per year in direct healthcare...

This study aims to compare the effects of pulmonary rehabilitation (PR) in patients with mild-to-moderate and severe-to-very severe chronic obstructive pulmonary disease (COPD). Between January 2005 and December 2010, a total of 76 patients with mild-to-moderate (Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stages I+II, n=33, mean age 66.0±8.6 years) and severe-to-very severe (GOLD Stages III+IV, n=43, mean age 63.5±8.8 years) COPD completed an eight-week outpatient PR program. Incremental and endurance shuttle walk tests (ISWT, ESWT), St. George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Hospital Anxiety and Depression Scale were assessed before and after PR. Changes after the intervention were compared between two groups. There were significant improvements in the ISWT and median 60 m [(-150)-(400)] in mild-to-moderate group and 70 m [(0)-(270)] in severe-to-very severe group (both, p<0.001). The ESWT time improved in both groups, 122s [(-279)-(665)] (p=0.002) and 61s [(-180)- (878)] (p<0.001), respectively. Significant effects were observed in all domains of the SGRQ except the impact score in mild-to-moderate patients. There were significant improvements in all domains except the symptoms score in severe-to-very severe patients. Using the CRQ, a significant improvement was shown in all domains of CRQ except the dyspnea score of mild-to-moderate patients. Anxiety and depression scores decreased after PR in both groups (p<0.05). According to changes in outcomes, there was no difference in any parameters between two groups. This study demonstrates that patients with mild-to-moderate COPD benefit from PR comparably to patients with severe-to- very-severe COPD. Although patients with mild-to-moderate COPD are not usually symptomatic, our findings suggest that they should be included in PR.

Pulmonary rehabilitation reduces daily symptoms and improves functional exercise performance and health status in patients with moderate to very severe chronic obstructive pulmonary disease (COPD). Moreover, post-exacerbation pulmonary rehabilitation in COPD can reduce re-exacerbation events that require admission or hospital attendance over a 3-month period. Consequently, pulmonary rehabilitation is recommended to be integrated in the management of symptomatic patients with COPD. Even though pulmonary rehabilitation can be considered a beneficial non-pharmacological intervention for patients with COPD, a considerable proportion of the COPD patients who have been referred for pulmonary rehabilitation decline participation. For example, Young et al. reported a decline rate of 34% of the initial group of 88 COPD patients referred for pulmonary rehabilitation. The main reasons given by the patients for non-participation included work commitments, transport difficulties, considered themselves to be too ill, considered the programme to be too difficult, considered the programme unlikely to be helpful and ‘other reasons.’ Similar reasons are reported for drop out during a pulmonary rehabilitation programme. So, medical specialists referring COPD patients for pulmonary rehabilitation should ensure that individual patients’ information needs about various aspects in pulmonary rehabilitation are adequately met. Key aspects include individualizing information concerning transportation difficulties, health care costs, service provision (setting and timing of the program), the content of the program, the burden of the program, the importance of the program and possible communication difficulties. For patients with work commitments, pulmonary rehabilitation programs may be offered out of working hours. Moreover, for patients with transportation difficulties, community transportation needs to be arranged to the rehabilitation centre or pulmonary rehabilitation programs should be offered in health care facilities near the patients’ home. Indeed, specialised rehabilitation centres can increase their capacity by sharing their knowledge with general hospitals through decentralization, including resource allocation, which will provide an appropriate response to the increasing interest in pulmonary rehabilitation for disabled patients with COPD. Also pre-rehabilitation instruction videos on the internet may be considered an appropriate and low-threshold tool. For example, colleagues from Imperial College (London, United Kingdom) provide information on pulmonary rehabilitation via www.youtube.com (search terms: ‘copd AND rehabilitation’). Nevertheless, the internet does not specifically address the individual needs of COPD patients that have been referred for pulmonary rehabilitation. Indeed, a pre-rehabilitation face-to-face contact may be necessary to address the individual needs and problems that patients with COPD may experience before the start of a pulmonary rehabilitation program. In the current issue of Chronic Respiratory Disease, Graves et al. report the effects of a ‘group optin session’ on the uptake and graduation rates for a pulmonary rehabilitation program for patients with COPD. COPD patients referred for pulmonary rehabilitation were invited to attend a 1.5-hours group optin session run by psychologist and physiotherapist. The concept of pulmonary rehabilitation was introduced in a supportive environment using a case study of a patient with COPD. Moreover, the pulmonary rehabilitation course was discussed in detail. Indeed, reasons for individual unsuitability for the pulmonary

Objectives: The aim of this study was to determine current awareness about the chronic obstructive pulmonary disease (COPD) and pulmonary rehabilitation among patients with COPD. Materials-Methods: A total of 200 patients who were diagnosed as COPD according to the Gold criteria and followed up at Pamukkale University Department of Chest Diseases were included in this cross-sectional study. Demographic and clinical characteristics of patients with COPD were recorded. Previously implemented awareness of COPD and pulmonary rehabilitation questionnaire consisting of 22 questions formed via examining the earlier awareness surveys was completed, face to face with patients. Results: In our study there were 186 men (93%), 14 women (7%) patients diagnosed with COPD. The mean age of the subjects was 65.11±10 years, the mean period of the disease was 7.8±6.69 years. The rate of awareness in the questions about COPD ranges from 40 to 86%. Only 29(14.5%) patients answered yes to the question Is there any other treatment options rather than drugs in COPD?. Only 15(7.5%) patients replied yes to the question have you ever heard about pulmonary rehabilitation?. The awareness rate ranges from 13 to 47% in the parameters questioning exercises of pulmoner rehabilitation. 55(27.5%) of the patients had been proposed to take pulmonary rehabilitation programme, but only 43(21.5%) patient had participated in such a programme. Conclusion: We found that the awareness of pulmonary rehabilitation is very low. Therefore, in our opinion it is essential to find out new methods novel strategies to increase the awareness of pulmonary rehabilitation in COPD patients.

The procedure of lung parenchyma resection may result in impairment of physical capacity and quality of life. In patients with operable non-small cell lung cancer (NSCLC), lobectomy is an elective procedure. Chronic obstructive pulmonary disease (COPD) is a common coexisting condition in patients with NSCLC. Effectiveness of post-operative pulmonary rehabilitation (PR) in patients who underwent lobectomy due to NSCLC and suffering from COPD as compared to individuals without COPD has not been determined yet. The aim of the study was to compare effectiveness of post-operative PR in patients with COPD after lobectomy due to NSCLC (COPD[+] L [+]) with individuals with COPD without lung parenchyma resection (COPD(+) L(-)) and those who underwent lobectomy due to NSCLC and not suffering from COPD (COPD[-] L[+]). Thirty-seven patients with non-small cell lung cancer (21 patients with and 16 patients without COPD) who underwent lobectomy and 29 subjects with COPD referred to the Lung Diseases Treatment and Rehabilitation Centre in Lodz in 2018-2019 were included in this retrospective analysis. The patients participated in a 3-week inpatient pulmonary rehabilitation (PR) program which included breathing exercises, physical workout, relaxation exercises, education, psychological support and nutrition consulting. The evaluation included lung function measurements, six-minute walking test (6MWT) and the St. George's Respiratory Questionnaire (SGRQ) score. The results obtained before the rehabilitation were compared to those achieved after the 3-week PR program and compared between the study groups. A significant increase in the distance covered during 6MWT was observed in all the three groups studied: COPD(+) L(+) (Δ = 62.52 ± 14.58 m); COPD(-) L(+) (Δ = 73.67 ± 11.58 m); and COPD(+) L(-) (Δ = 59.93 ± 10.02 m) (p < 0.001 for all). Similarly, a statistically and clinically significant improvement in the total SGRQ score was recorded: COPD(+) L(+) ∆ = -12.05 ± 3.96 points; p < 0.05 and COPD(-) L(+) ∆ = -12.30 ± 4.85 points; p < 0.01 and COPD(+) (L-) ∆= -14.07 ± 3.36 points (p < 0.001). No significant differences in the outcome improvement between the study groups were identified. The results of the study show that COPD(+) L(+) patients gained benefits from post-operative PR comparable to COPD(+) L(-) and COPD(-) L(+) subjects by improving their physical capacity and quality of life.

Background: The six-minute stepper test (6MST) validity and reproducibility have already been demonstrated in patients with chronic obstructive pulmonary disease (COPD). Aims: To evaluate the responsiveness of the 6MST to pulmonary rehabilitation (PR) in patients with COPD and to objectively compare 6MST and six-minute walk test (6MWT). Methods: 62 patients with COPD were included in this prospective cohort study. Participants underwent a three weeks inpatient PR program. Two 6MST and two 6MWT were performed before PR and one 6MST and one 6MWT were performed after the program. The primary outcome was the evolution of the number of steps during the 6MST before and after PR. Secondary outcome included the evolution of the six-minute walk distance (6MWD) pulse oxymetry, heart rate, dyspnea and leg discomfort during the tests before and after PR. Results: A significant increase in the number of steps during the 6MST was observed after PR (22.5 steps; 95% CI: 13.8-31.3; p&amp;lt;0.0001) and in the 6MWD after PR (26.6 m; 95% CI: 17.6-35.5; p&amp;lt;0.0001). 6MST and 6MWT improved by 10.1% and 6.5%, respectively. The number of steps during the 6MST was significantly correlated with the 6MWD before (r=0.72; p&amp;lt;0.0001) and after PR (r=0.66; p&amp;lt;0.0001). Conclusion: The 6MST appears to be as responsive as the 6MWT in order to assess functional improvement during PR in patients with COPD. The 6MST is low cost and requires limited space.

Background: While the efficacy of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) has been well established, emerging evidence also suggests its benefit in idiopathic pulmonary fibrosis (IPF). However, the differences and similarities between how PR affects diseases with different physiologies remain unknown. Objective: This study aimed to compare the efficacy of PR in COPD and IPF patients by performing multifactorial evaluation with various exercise capacity measurements, and dyspnea and health-related quality of life (QoL) assessment. Methods: Twenty-two IPF patients (%vital capacity: 72%) and 27 COPD patients (%forced expiratory volume1: 43%) were recruited. Subjects who completed a 10-week outpatient PR program were analyzed. We assessed five exercise capacity indicators (6-minute walking distance, incremental shuttle walking distance, endurance time, peak work rate, and peak values for oxygen uptake [peak VO2]), dyspnea (Baseline Dyspnea Index: BDI), and health-related QoL (St. George's Respiratory Questionnaire: SGRQ) at baseline and immediately following completion of the PR program. Results: After 10 weeks of PR, all exercise capacity measurements, except VO2, as well as BDI and SGRQ score improved significantly (p<0.05) in both disease groups. The magnitude of the observed changes in each outcome, assessed by the effect size, was comparable between IPF and COPD patients. This was also true for endurance time, the measurement most responsive to PR, with a large effect size. Conclusions: PR can result in comparable improvements in exercise capacity, including endurance time, and dyspnea and HRQoL in both IPF and COPD patients after 10 weeks of exercise training. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 283-289).

Pulmonary rehabilitation (PR) has been shown to be an effective intervention in patients with very severe chronic obstructive pulmonary disease (COPD) awaiting lung transplantation (LTx). The objective of this study was to characterize the prevalence of acute exacerbations (AEs) during PR and their impact on the outcomes of pre-LTx PR. In this retrospective analysis, 559 patients with COPD awaiting LTx who were referred to a 4-wk inpatient PR program were evaluated. A total of 114 patients (20%) acquired an AE during PR and continued in an adapted fashion. Pulmonary function testing, 6-min walk test (6MWT), and a health-related quality-of-life questionnaire (SF-36) were administered on admission and on discharge of PR. Following PR, both groups, patients with and without AE, increased their 6MWT significantly (P < .001) to a clinically relevant amount (58 ± 72 and 52 ± 64 m, respectively). The sum scores of the SF-36 also improved significantly without any between-group differences. No observed changes were different between the two groups. No relevant predictors for PR outcomes could be detected by logistic regression. Our data show that patients with end-stage COPD listed for LTx can achieve clinically relevant improvements in functional exercise capacity and quality of life even if they develop an AE during PR.

This study aimed to measure changes in different properties of skeletal muscles and evaluate their contribution and relationship to changes in functional performance after pulmonary rehabilitation (PR) in patients with chronic obstructive pulmonary disease (COPD). COPD outpatients attending 5 weeks of conventional PR were recruited. Functional performance [5-repetitions sit-to-stand (5STS), and 4-m gait speed (4mGS)], and muscle function (maximal isometric strength, power, force control, and relative concentric and eccentric activation during 5STS) were assessed after PR and 3 months of follow-up. Twenty patients (71 years; 52% of predicted FEV1) completed the study. 4mGS and relative concentric activation during 5STS decreased respectively by 7.7% and 26% between the beginning of PR and follow-up. Quadriceps strength, power, and force control improved by 10.4%, 27.3%, and 15.2%, respectively, from the beginning of PR to follow-up the relative eccentric activation during 5STS explained 31% of the variance in 4mGS changes. In conclusion, functional performance appeared to decline after conventional PR, whereas several properties of skeletal muscles were maintained at follow-up in COPD outpatients. Of note, eccentric contractions might play a role in the improvement of functional performance. Therefore, future studies with interventional design should include eccentric training in PR programs during clinical COPD practice.

Objective The present systematic review and meta-analysis of randomized clinical trials (RCTs) aimed to investigate the effects of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease (COPD). Methods The RCTs of pulmonary rehabilitation programs published between 1999 and 2021 were retrieved from electronic databases (PubMed, Cochrane Library, and Embase). Two reviewers independently assessed the topical relevance and trial quality and extracted data for meta-analysis using the Stata software version 14.0. Results A total of 39 trials involving 2,397 participants with COPD were evaluated. We found that patients who received pulmonary rehabilitation program had significant improvement in the 6-min walk test (6MWT), St. George Respiratory Questionnaire score, and the modified British Medical Research Council score as compared to those who received usual care. Yoga and Tai Chi showed significant improvement in the forced expiratory volume (FEV1)% in 1 s predicted value. However, no significant difference was detected in the modified Borg score, forced vital capacity (FVC), and FEV1/FVC predicted value between the pulmonary rehabilitation and usual care groups. Conclusion Yoga and Tai Chi showed a significant improvement in the FEV1% predicted value. Also, pulmonary rehabilitation program improved the exercise capacity, the quality of life, and dyspnoea in patients with COPD. Key messages A total of 39 trials involving 2,397 participants with COPD were evaluated. We found that patients who received pulmonary rehabilitation program had significant improvement in the 6MWT, St. George Respiratory Questionnaire score, and the modified British Medical Research Council score as compared to those who received usual care. Yoga and Tai Chi showed significant improvement in the FEV1% predicted value. No significant difference was detected in the modified Borg score, FVC, and FEV1/FVC predicted value between the pulmonary rehabilitation and usual care groups.

Exercises Commonly Used in Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Cardiopulmonary Responses and Effect Over Time

Pulmonary rehabilitation (PR) is recognized as a cost-effective non-pharmacological treatment modality to promote quality of life and delay disease progression in patients with chronic obstructive pulmonary disease (COPD). Although PR has been shown to be effective, it is underutilized in clinical practice. This study aimed to investigate the factors associated with affecting compliance with PR in stable COPD patients. This study is a cross-sectional survey. Patients with stable COPD were included using convenience sampling method. Data were collected using questionnaires including the demographic questionnaire, PR Compliance Questionnaire, mMRC dyspnea Scale, Family Support Scale, and Chronic Disease Self-Efficacy Scale (SES6G). Univariate analysis and multiple linear regression analysis were used to analyze the data. The 100 patients with stable COPD were moderately compliant with PR (3.51 ± 0.65), with the highest compliance with medication (4.10 ± 0.86) and the lowest with exercise (3.03 ± 1.16). Univariate analysis showed statistically significant influences on PR compliance were gender (P = 0.029), educational level (P = 0.021), exercise habits (P < 0.01), willingness to PR (P < 0.01), difficulty of PR (P = 0.030), mMRC (P = 0.002), and SES6G (P = 0.002). The following equation represents the multiple linear regression model: PR compliance = 0.235 × exercise habits + 0.609 × willingness to PR + 0.325 × difficulty of PR (P < 0.0001), adjusted R2 = 0.330, F=7.974, and Durbin-Watson ratio = 2.049. Patients' good exercise habits in regular life, stronger willingness to PR, and easier PR programs may contribute to improved PR compliance. This study suggested that stable COPD patients were not sufficiently compliant with PR and revealed related important factors affecting the compliance. Exercise habits, willingness to PR, and PR difficulty were found to be significant influencing factors. The results of this study can provide evidence for developing a more appropriate PR program and promoting PR compliance in the future.

Previous researchers have identified that participation in a pulmonary rehabilitation program improves health outcomes yet, continuation in a weekly maintenance program yielded mixed results. Self-management programs have had reported use in chronic obstructive pulmonary disease (COPD). A meta analysis has identified that no self-management program had evaluated the effect of this type of intervention on the functional status of the participant with COPD. Reduced functional status is well reported as an indicator of disease progression in COPD. Adjuvant therapies for people with COPD need to demonstrate an effect in this domain. The Stanford model chronic disease self-management program (CDSMP) had been reported as a program that may optimise the health of people with chronic health conditions. However, its utility has not been formally evaluated for people with COPD. There have not been any reports of a comparison of the Stanford model CDSMP with pulmonary rehabilitation via a randomised controlled study in COPD. Aim: To compare and evaluate the health outcomes from participation in nurse ledwellness-promoting interventions conducted in the ambulatory care setting of a metropolitan hospital. Participants were randomised to either a six-week behavioural intervention: the Stanford model CDSMP or, a six-week pulmonary rehabilitation program and results compared to usual care (a historical control group). The efficacy of the interventions was measured at week seven and repeated at week 26 and 52. Following the week seven evaluation, the pulmonary rehabilitation program participants were rerandomised to usual care or, weekly maintenance pulmonary rehabilitation for 18 weeks and, followed up until the study completion at week 52.Little is reported about the costs of care for people with COPD in Australia. This study prospectively evaluated the costs of the interventions and health resource for the 52 weeks and undertook a cost utility analysis.;Methods: Walking tests (The Incremental Shuttle Walking Test) and questionnaires asking participants about their health related quality of life, mood status, dyspnoea and self efficacy were assessed prior to randomisation to either six week intervention and repeated at weeks 7, 26 and 52. The implementation of these adjuvant therapies enabled all costs associated with the interventions to be prospectively examined and compared. Results: During the two years of recruitment 252 people (54% males) with a mean age 71 years (SD 11, range 39-93 years) were referred to the study. Student's ttests identified that there were no statistically significant differences (P=0.16) between all those referred by age and gender as compared to all those admitted to Hospital A with an exacerbation of COPD. Ninety-seven people (51% male) with a mean age of 68 years (SD 9, range 39-87 years) agreed to participate in the study. Follow up in the study continued for 12 months following enrolment with only a modest level of attrition by week seven (3%) and week 52 (25%). Following the six-week interventions, both the pulmonary rehabilitation and CDSMP groups recorded statistically significant increases in functional capacity, self-efficacy and health related quality of life.Functional performance was additionally evaluated in the intervention arms with participants wearing pedometers for the six-week period of the interventions. There were no statistically significant differences between steps per week (P=0.15) and kilometres per week (P=0.17) walked between these two groups in functional performance. The Spearman rho statistic identified no statistically significant relationship between functional performance and the severity of COPD (rs (33) = 0.19, P = 0.26). No significant correlation between functional capacity and functional performance was identified (rs (32) = 0.19, P = 0.29). This suggests that other factors contribute to daily functional performance.;The largest cost of care for people with COPD has been reported to be unplanned admissions due to an exacerbation of COPD.In this study there were no statistically significant differences between the three intervention groups in the prospective measurement of ambulatory care visits, Emergency Department presentations and admissions to hospital. The calculation of costs illuminated the costs of care in COPD are greater than the population norm. In addition, maintenance pulmonary rehabilitation generated a greater quality adjusted life year (QALY) than a six-week program. Despite the strength of the participants preferences (as measured by the QALY) for maintenance PRP, there were no significant differences in use of hospital resources throughout the study period by the three intervention groups, which suggests some degree of equivalence.

PH Professional Network: “Just Do It”: Practical Aspects of Pulmonary Rehabilitation Programs

Pulmonary rehabilitation (PR) is effective in patients with moderate to severe chronic obstructive pulmonary disease (COPD). However, the effects of PR in patients with mild COPD have not yet been established. Thus, this study investigated the short- and long-term effects of PR in patients with mild COPD in comparison with patients with moderate to severe disease. A total of 32 patients with mild (group 1) and 29 with moderate to severe (group 2) COPD completed the study. Both groups participated in a 12-week PR program with exercise training and psychosocial support and education. Outcome measures at baseline, 3 (post-PR), 6, and 9 months later included 6-minute walk test (6MWT); Modified Medical Research Council Dyspnea Scale; 1-repetition maximum chest press and knee extension; a brief physical activity assessment; the number of exacerbations in the past 3 months and the St. George Respiratory Questionnaire (SGRQ). Improvements in the 6MWT, chest press, knee extension, and physical activity were observed post-PR (P < .001), with no differences between the 2 groups. Reduction in the number of exacerbations (P < .001) and improvements in the SGRQ total (P < .001) were also observed, however, with greater magnitude in group 2 (P = .029 and P < .001, respectively). Except for peripheral muscle strength (P < .002), all the achieved benefits were sustained at 6 and 9 months (P > .05). Pulmonary rehabilitation improves exercise tolerance, muscle strength, physical activity, and health-related quality of life and reduces exacerbations in patients with mild COPD as it does in patients with moderate to severe COPD. Moreover, most of these benefits were maintained at 9-month follow-up, suggesting that PR could be part of the management of mild COPD.