Comprehensive Pulmonary Rehabilitation Program Research Articles

The Impact of Early Pulmonary Rehabilitation on Dyspnea, Quality of Life, and Symptoms in Moderate to Severe COVID-19 Pneumonia Patients

Introduction: COVID-19 pneumonia leads to dyspnea, persistent symptoms and poor quality of life. Inpatient pulmonary rehabilitation (PR) has limited evidence of effectiveness. Therefore, we aimed to determine the effect of a comprehensive inpatient PR program on dyspnea symptoms and quality of life in patients with COVID-19 pneumonia. Methods: A group pretest-posttest design was conducted in patients with COVID-19 pneumonia. Comprehensive PR was administered during hospitalization. Baseline dyspnea index (BDI), Transitional dyspnea score (TDI), Modified Medical Research Council score (mMRC), and St. George’s Respiratory Questionnaire (SGRQ) were assessed at baseline, 4th week and 12th week after discharge. Results: In total, 28 patients were included (9 with oxygen supplementation, 19 without oxygen supplementation). The mean BDI at baseline was 7.82 ± 2.13. TDI scores at the 4th and 12th weeks were 5.14 ± 1.90 and 6.61 ± 1.59, respectively, with a significant difference observed between the 4th and 12th weeks (p < 0.001). Median mMRC scores at baseline, 4th week, and 12th week were 2(1.25 - 3), 1 (1 - 2) and 1 (0 - 1), respectively, showing a significant improvement between baseline vs 4th week, baseline vs 12th week, and 4th week vs 12th week (p < 0.001). The total SGRQ score exhibited a median (IQR) of 11.34 (7.88 - 8.58) at the 4th week and 6.93 (4.43 - 13.03) at the 12th week, demonstrating a statistically significant improvement (p < 0.001). No adverse events were reported during inpatient PR. Conclusion: Inpatient PR provides a safe and feasible profile, reduces dyspnea symptoms, and improves the quality of life in patients with moderate to severe COVID-19 pneumonia. HIGHLIGHTS COVID-19 pneumonia results in dyspnea and persistent symptoms, impacting quality of life. Early pulmonary rehabilitation, from inpatient to a 12-week outpatient program for moderate and severe cases, is safe and improves dyspnea, quality of life, and patient reported symptoms. GRAPHICAL ABSTRACT

Effectiveness of adequate chicken egg white consumption on dyspnea degree and exacerbation incidence in stable COPD patients practicing strength and endurance exercises.

Lack of physical exercise and inadequate nutritional intake in chronic obstructive pulmonary disease (COPD) patients could lead to low muscle mass and function, which causes reduced respiratory function, increased incidence of exacerbations, exercise intolerance, increased visits to health facilities, and low health status. Therefore, physical exercise and good nutritional intake are the main foundations of a comprehensive pulmonary rehabilitation program for COPD patients. The aim of the study was to determine the effect of chicken egg white supplementation on dyspnea degree and the incidence of exacerbations in stable COPD patients who perform physical exercise independently at home. A quasi-experimental study was conducted in 38 stable COPD patients based on the Global Initiative for Chronic Lung Disease (GOLD) 2021 classification criteria. The patients were divided into two groups: the control group who did smartphone application-assisted physical exercises and the intervention group who did the same physical exercises plus chicken egg white supplementation for 12 weeks. Performed physical exercises included both strength and endurance training. The degree of dyspnea was assessed with modified Medical Research Council (mMRC) dyspnea scale and the incidence of exacerbations was assessed by direct interviews at the beginning and at the end of the intervention. A Fisher's exact test was used to assess the association between the intervention with dyspnea degree and exacerbation incidence. In the intervention group, chicken egg white supplementation for 12 weeks lowered the dyspnea degree by 3.16 times than the control (relative risk 3.16 with p=0.001). Furthermore, the incidence of exacerbations was also reduced by 1.8 times compared to the control group (relative risk 1.8, p=0.001). This study highlights a significant improvement in dyspnea degree and exacerbation incidence in COPD patients with the combination of protein supplementation and physical exercise. Therefore, adding chicken egg white intake could be beneficial for stable COPD patients practicing physical exercises.

Functional capacity and quality of life improvement in stable chronic obstructive pulmonary disease (COPD) patients following physical exercise and chicken egg white supplementation.

The pillars of comprehensive pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD) patients include physical exercise and good nutrition. The aim of this study was to evaluate the efficacy of pulmonary rehabilitation, which included physical exercise and chicken egg white supplementation, on the quality of life (QoL) and functional capacity among patients with stable COPD. The COPD patients were enrolled prospectively in this quasi-experimental study and completed a 12-week smartphone-guided home-based physical exercise program that comprised strength and resistance training three times per week for 30 minutes each session. Participants were divided into two groups: the control group who underwent physical exercise only, and the intervention group who had physical exercise and chicken egg white supplementation as a protein source. Patient characteristics including sex, age, nutritional status, comorbidities, smoking status, and obstruction severity, were evaluated. The COPD assessment test (CAT) score and six-minute walk test (6MWT) were used as the parameters to evaluate QoL and functional capacity, respectively. Of the total 50 patients included in the study, 12 were excluded due to follow-up and adherence problems. Our data indicated there were significant CAT score reduction and 6MWT improvement in both control and intervention groups after 12 weeks compared to baseline data. However, reduction of mean CAT score was higher in intervention compared to control group (-13.47±6.49 vs -5.42±5.07, p<0.001). In addition, the improvement of 6MWT was also higher in intervention group compared to control group (145.47±69.2 vs 32.42±17.3 meters, p<0.001). In conclusion, chicken egg white supplement to male patients with stable COPD who exercise with resistance and strength training could improve the QoL and functional capacity.

Pulmonary Rehabilitation with and without a Cognitive Behavioral Intervention for Breathlessness in People Living with Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

(1) Background: Most controlled trials of cognitive behavior therapy (CBT) in people living with chronic obstructive pulmonary disease (COPD) have targeted anxiety and depression. (2) Methods: This pragmatic randomized controlled trial explored whether a comprehensive pulmonary rehabilitation program (CPRP) with CBT for breathlessness or social group control (CPRP + SC) significantly improved health outcomes. (3) Results: People with moderate-to-severe COPD were block randomized (CPRP + CBT n = 52 or CPRP + SC n = 49). Primary outcomes (Hospital Anxiety and Depression scale (HADs), six-minute walk distance (6MWD)) and secondary outcomes (breathlessness, quality of life and habitual physical activity) were assessed before and 1, 6 and 12 months post intervention. Between-group differences were calculated with mixed models for each time point to baseline (intention to treat (ITT)). Participants (n = 101, mean ± SD age 70 ± 8.5 years, 54 (53%) males, FEV1% pred 47.7 ± 16.3) were similar between groups. Post intervention, primary outcomes did not differ significantly between groups at 1 (6MWD mean difference −7.5 [95% CI −34.3 to 19.4], HADs-A −0.3 [−1.4 to 0.9], HADs-D 0.2 [−0.8 to 1.3]), 6 (6MWD −11.5 [−38.1 to 15.1], HADs-A 1.1 [0.0 to 2.2], HADs-D 0.2 [−0.9 to 1.3]), or 12 months (6MWD −3.8 [−27.2 to 19.6], HADS-A −0.4 [−1.5 to 0.6], HADs-D −0.7 [−1.7 to 0.4]). (4) Conclusions: In this cohort, combining CBT with a CPRP did not provide additional health benefits beyond those achieved by a standard CPRP.

FEV1 and pulmonary rehabilitation: Let's get the facts straight.

Pulmonary rehabilitation (PR) is a miracle intervention. Despite the lack of effect on resting lung function,1 symptomatic people with chronic obstructive pulmonary disease (COPD) generally have less symptoms (i.e., dyspnea, fatigue, anxiety and depression), better physical functioning and physiological exercise responses, less care dependency, an improved performance of activities of daily life, less healthcare use and an improved quality of life following a 8–12 weeks multidisciplinary PR program on top of the regular respiratory drug treatment.2-10 To date, post-bronchodilator forced expiratory volume in the first second (FEV1) is still often used as a selection criterion for referral for PR.11, 12 However, FEV1 is useless for this objective. Let us get the facts straight: Fact 1: Baseline FEV1 does not or only weakly correlate with physical, emotional and social functioning of people with COPD. Daily symptoms (such as dyspnea, fatigue, anxiety and depression), abnormal body composition, low exercise capacity, problematic activities of daily life, low physical activity and an impaired health status can occur in people with COPD, irrespective of the degree of airflow limitation.13-18 Moreover, FEV1 is only weakly correlated with the number of extra-pulmonary traits.18 So, FEV1 cannot be used to identify symptomatic people with limitations in daily functioning and extra-pulmonary traits, which can be addressed during a comprehensive PR program.2 Fact 2: Baseline FEV1 does not predict the likelihood of dropping out. PR programs report that 15%–40% of the participants drop out from the program.5, 19-25 Generally, people with COPD who drop out have similar baseline FEV1 compared to those who complete the PR program.19-22, 24 The presence of psychological factors (i.e., depressive symptoms, lack of motivation and/or distress arising from bodily perceptions), social factors (i.e., transportation difficulties, other duties or responsibilities, unsupportive remarks by staff or patients and/or conflict with other patients) and/or people's perception of insufficient improvements during the PR program, may partially explain why people with COPD drop out, irrespective of baseline FEV1.24, 26 So, baseline FEV1 cannot be used to identify people at risk of dropping out from a PR program. Fact 3: PR improves exercise capacity, symptoms and health status across all grades of COPD severity. Improvements in the abovementioned outcomes have been reported in people with a variety of baseline FEV1 values.27, 28 Moreover, baseline FEV1 (alone or in combination with other lung function attributes) does not predict whether or not people with COPD achieve the minimal important difference for exercise capacity, health status, fatigue, anxiety and/or depression following PR.5, 7, 29-31 So, baseline FEV1 cannot be used to identify responders or non-responders. To conclude, FEV1 has no added to value as selection criterion for PR in people with COPD. Therefore, the respiratory community needs to foster adequate referral to exercise-based interventions, including center-based pulmonary rehabilitation, without using FEV1 as a referral criterion.32 Consequently, an interdisciplinary assessment must go far beyond the regular lung function tests, and should include also patients' physical, emotional and social status.18, 33 Frits M. E. Franssen has received grants and personal fees from AstraZeneca, and personal fees from Boehringer Ingelheim, Chiesi, GSK and Novartis. Martijn A. Spruit received grant from Netherlands Lung Foundation, Stichting Astma Bestrijding, all paid to Ciro. Moreover, he received grants and/or personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi and Teva, all paid to Ciro.

Long-term efficiency of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease, bronchiectasis, and asthma: Does it differ?

The long-term effects of pulmonary rehabilitation (PR) and maintenance programs in obstructive pulmonary diseases have not been sufficiently investigated, particularly in diseases other than COPD. This retrospective study aimed to examine the long-term results of individualized comprehensive outpatient pulmonary rehabilitation in patients with obstructive pulmonary disease. This study is a single-center, retrospective cohort study. Between 2010 and 2019, 269 patients with chronic airway obstruction were treated in our multidisciplinary PR center at a tertiary training and research hospital, and they were divided into three groups based on their diagnosis: COPD, bronchiectasis, and asthma. Patients' perceptions of dyspnea, exercise capacity, inspiratory and peripheral muscle strength, body composition, quality of life, and psychosocial status were compared at the beginning, end, and 12th and 24th months of PR. Improvements in dyspnea perception remained longer in asthmatics than in the other two groups. The increases in exercisecapacity in the bronchiectasis and asthma groups lasted two years. All groups maintained their respiratory muscle strength gains at the end of the second year. Improvements in hand grip strength in the COPD and bronchiectasis groups have been sustained for two years, but in the asthma group, enhancements were lost in the second year. Even after the second year, quality of life was still better than the baseline in all groups, despite a worsening in the first year. However, groups anxiety and depression improvements were not sustained after the first year. The long-term effectiveness of PR in patients with bronchiectasis and asthma was similar to that of COPD patients. Therefore,multidisciplinary, comprehensive PR programs should be integrated into the management of patients with bronchiectasis and asthma. We also recommend structured follow-up programs to maintain gains and to detect the need for rerehabilitation.

Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis: A Chance for a Multidisciplinary Treatment Approach

Objectives: Idiopathic pulmonary fibrosis (IPF) is characterized by progressively worsening lung function, ventilation capacity, dyspnea, and finally reduced exercise intolerance. All of these have a significant negative impact on functional capacity and quality of life. In this study, we aim to evaluate the effects of pulmonary rehabilitation (PR) in IPF and assess the predictors of success. Methods: Data from 17 IPF patients who completed the program from the total of 27 patients who applied to PR were used in our study. We evaluated their pulmonary function tests, exercise capacity, peripheral-respiratory muscle strength, body composition, quality of life, and psychological states before and after PR. Results: Following the PR program, improvements over the minimal clinically important differences were observed in almost all parameters compared to the baseline; however, statistically significant improvements were only observed in the medical research council (P=0.020), the St. George respiratory questionnaire (P=0.002), the maximal inspiratory pressure (P=0.024), the anxiety score (P=0.001), the depression score (P=0.002), and the right quadriceps muscle strength (P=0.046). There was only a statistically significant negative correlation between the initial forced vital capacity and the forced expiratory volume in one-second value with the increase in patients’ maximal inspiratory pressure values after PR. Discussion: After a multidisciplinary, comprehensive PR program, dyspnea sensation, exercise capacity, endurance time, quality of life, respiratory and peripheral muscle strengths, and psychological status were improved regardless of age, gender, antifibrotic treatment, and comorbidities. Therefore, patients should be referred to PR units before the deterioration in the quality of life in the early stages of the disease.

Isokinetic testing of quadriceps function in COPD: feasibility, responsiveness, and minimal important differences in patients undergoing pulmonary rehabilitation

BackgroundIsokinetic testing of peripheral muscle function is valid and reliable in patients with chronic obstructive pulmonary disease (COPD). ObjectiveTo evaluate whether and to what extent isokinetic testing of quadriceps function meets pre-defined test criteria in patients with COPD; to determine the response to pulmonary rehabilitation (PR), and to calculate minimal important differences (MIDs) of isokinetic quadriceps function. MethodsRetrospective analysis of 2033 patients with COPD (age: 65±9 years, body mass index: 26±6 kg/m2, FEV1: 49±22% predicted) who followed a comprehensive PR program. Pre and post PR isokinetic quadriceps function was assessed with 30 maximal extension-flexion contractions at an angular speed of 90°/s on a computerized dynamometer. The chosen anchors were 6-min walk test and COPD assessment test. ResultsPre PR, 27% of the patients performed the isokinetic test incorrectly. In male and female patients with a correct pre and post PR isokinetic test, peak torque (Δ=10±13 Nm or 9% and Δ=7±9 Nm or 10%, respectively) and total work (Δ=263±270 J or 14% and Δ=198±190 J or 15%, respectively) improved significantly. There was no change in work fatigue index following PR. Using distribution-based calculations, MID estimates for peak torque and total work ranged between 6–7 Nm and 97–135 J in males and between 4–5 Nm and 62–99 J in females. ConclusionsBased on the current test criteria, three in four patients with COPD performed the isokinetic quadriceps test correctly during baseline PR assessment. Furthermore, peak torque and total work, but not work fatigue index, were responsive to PR and sex-specific MIDs were established.

Effects of Pulmonary Rehabilitation Including Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease after Stratification by the Degree of Static Hyperinflation

Inspiratory muscle training (IMT) improves inspiratory muscle strength, exercise capacity and health status in patients with chronic obstructive pulmonary disease (COPD). However, there is no additional effect on top of comprehensive pulmonary rehabilitation (PR). It is unclear whether patients with different baseline degrees of static hyperinflation respond differentially to IMT as part of a PR program. Therefore, the aim was to study the effects of IMT as an add-on on PR after stratification for baseline degrees of static hyperinflation. In this single center retrospective study data were extracted between June 2013 and October 2020 of COPD patients who participated in a comprehensive PR program including IMT. IMT was performed twice daily, one session consisted of 3 series of 10 breaths and training intensity was set initially at a load of approximately 50% of patients' maximal static inspiratory mouth pressure (MIP). The primary outcome measure was MIP. Secondary outcomes were the distance achieved on the 6-min walk test (6MWD), endurance cycling exercise capacity at 75% of the peak work rate (CWRT) and disease-specific health status using the COPD assessment test. 754 patients with COPD were screened for eligibility and 328 were excluded because of repeated PR programs, missing data or baseline residual volume (RV) > 350%. In total, 426 COPD patients were categorized into RV categories 50-130% (n = 84), 131-165% (n = 86), 166-197% (n = 86), 198-234% (n = 85) and 235-349% (n = 85). In the whole sample, MIP, endurance exercise capacity and health status improved significantly. The change in 6MWD was higher in the lowest baseline degree of static hyperinflation [+ 39 (9-92) m] compared with the baseline highest degree of static hyperinflation [+ 11 (- 18-54) m] (p < 0.05). IMT as part of a PR program in patients with COPD with different baseline degrees improved MIP irrespective of the degree of static lung hyperinflation. Improvement in functional exercise capacity was significantly higher in the group with the lowest degree of static hyperinflation compared with the patients with the highest degree of static hyperinflation.

An overview of Cochrane systematic reviews for pulmonary rehabilitation interventions in people with chronic obstructive pulmonary disease: a mapping synthesis.

There is a global unmet need for rehabilitation to meet which the World Health Organization, in collaboration with Cochrane Rehabilitation, is developing the Package of Interventions for Rehabilitation with the aim of identifying rehabilitation interventions relevant to a range of key health conditions, including chronic obstructive pulmonary disease (COPD). The purpose of this paper is to describe the best available evidence on pulmonary rehabilitation interventions for people with COPD. An Overview of Cochrane Systematic Reviews (CSRs). Through the search strategy, COPD-related systematic reviews published from January 2009 to November 2021 were identified. Data were extracted on each reported outcome related to an intervention and judgements about the quality of evidence were made, using the GRADE approach. Seventeen reviews were analyzed, for a total of 314 primary studies that included 22,206 participants. CSRs provided information on the effectiveness of rehabilitation on functioning, activity, quality of life, anxiety, depression, mortality, and health care resource utilization. Our findings report that comprehensive pulmonary rehabilitation programs and water exercises improve the exercise capacity and quality of life (QoL) in people with COPD. Different exercise modalities, intensities, and settings for different muscle groups, breathing exercises, and counseling can improve exercise capacity, QoL, dyspnea, hospitalizations, and physical activity. It is uncertain whether breathing exercise, low-intensity exercise, neuromuscular electrical stimulation, and psychological intervention have an effect on exercise capacity, dyspnea, QoL, and physical activity. The protocol was registered on OSF (registration DOI: 10.17605/OSF.IO/8A26Q).

The Korean-Lung Information Needs Questionnaire: Translation, validation and clinical implications in comprehensive pulmonary rehabilitation.

PurposeChronic obstructive pulmonary disease (COPD) is characterized by airflow limitation and persistent respiratory symptoms. Several symptom‐related questionnaires have been validated to improve understanding for patient with COPD. We aimed to systematically translate the English version of the Lung Information Needs Questionnaire (LINQ) into Korean and to verify the reliability, validity and clinical implications in comprehensive pulmonary rehabilitation (PR).MethodsThe original version of LINQ was translated into Korean by two translators and reviewed by the translation committee. It was then reverse translated back into English. The committee compared the reconciled version in Korean and the original version in English. A cognitive debriefing was performed on the pre‐final version, and a final version, K‐LINQ, was obtained. A test‐retest method for the analysis of reliability was performed within 2 weeks. Concurrent validity analysis was performed using Pearson correlation test of the K‐LINQ and other evaluation tools.ResultsA total of 110 patients were enrolled. The length, readability, understanding and suitability of the questionnaire rated well in scores for face validity of 52 Korean patients with COPD. No significant correlation was derived from the total K‐LINQ and each domain with other scales such as mMRC, K‐CAT and K‐LCADL. The intra‐class correlation coefficient of total score K‐LINQ showed high reliability. Patients who attended PR showed significantly poor pulmonary function or more severe symptoms. In addition, a significantly lower score in total score and exercise domain of K‐LINQ were confirmed in the group of PR attendees.ConclusionsWe translated the LINQ into Korean, implemented cross‐cultural adaptation and verified its validity and reliability. K‐LINQ can now be useful in various clinical and research fields in the Republic of Korea and could serve a complementary role and become an axis of successful treatment strategies, including a comprehensive PR programme.

Outcomes of pulmonary rehabilitation after lung resection in patients with lung cancer.

Background In this study, we aimed to examine the effectiveness of pulmonary rehabilitation applied after resection in patients with lung cancer. Methods Between October 2017 and December 2019, a total of 66 patients (53 males, 13 females; median age: 65 years; range, 58 to 70 years) who underwent lung resection for non-small cell lung cancer and who were not administered any chemotherapy or radiotherapy regimen were included in the study. An eight-week comprehensive outpatient pulmonary rehabilitation program was applied to half of the patients, while the other half received respiratory exercise training. After the intervention, the results of both groups were compared. Results In the pulmonary rehabilitation group, forced vital capacity value (p=0.011), six-minute walking distance (p<0.001), and Short Form-36 physical function, mental health, vitality scores increased significantly, while all scores of St. George's Respiratory Questionnaire, dyspnea (p<0.001) and anxiety score (p=0.041) significantly decreased. In the group given breathing exercise training, only dyspnea (p=0.046) and St. George's Respiratory Questionnaire symptom scores (p=0.038) were decreased. When the changes in the groups after pulmonary rehabilitation were compared, the decrease in dyspnea perception was significantly higher in the pulmonary rehabilitation group (p<0.001). Conclusion Pulmonary rehabilitation program applied after lung resection in patients with non-small cell lung cancer reduces dyspnea and psychological symptoms, increases exercise capacity, and improves quality of life. It should be ensured that patients with lung cancer who have undergone lung resection are directed to the pulmonary rehabilitation program and benefit from this program.

The Effectiveness of Pulmonary Rehabilitation on Pulmonary Function among Adults Patients of COVID-19 Survivors: A Systematic Review

Introduction: Corona Virus Infection Disease (COVID-19) refers to the infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Most of COVID-19 survivors have residual symptoms after being discharged from the hospital, it then leads to the decreased lung function and quality of life (QoL). Pulmonary rehabilitation is essential because it can reduce the impact of these sequelae. This study aimed to determine the effectiveness of pulmonary rehabilitation in improving lung function among adult patients of COVID-19 survivors.Methods: This study was conducted using 5 databases, namely: CINAHL, PubMed, SAGE, Science Direct, and Scopus from 1 April 2020 to 30 September 2021. The combination of keywords used was: "Pulmonary Rehabilitation", “Pulmonary Function", and "Post-COVID-19". In assessing the bias and methodological quality of the articles obtained, this study used the Joanna Briggs Institute (JBI) critical appraisal checklist tools.Results: From 678 articles, 11 research articles met the criteria. Pulmonary rehabilitation performed in post-COVID-19 patients included the provision of aerobic exercise, breathing exercises, strength training, balance exercises, relaxation, occupational therapy, psychological support, and nutrition consultation. Lung rehabilitation mainly was performed two sessions a week for 3-8 weeks with different proportions for each patient according to clinical conditions and ability limits. Spirometry and the 6-minute walk test (6MWT) revealed that patients who completed the pulmonary rehabilitation program experienced improvements in their lung function.Conclusion: Comprehensive pulmonary rehabilitation programs under supervision and psychotherapists are the right choice in improving lung function among COVID-19 survivor adult patients.

Effect of counselling during pulmonary rehabilitation on self-determined motivation to be physically active for people with chronic obstructive pulmonary disease: a pragmatic RCT

BackgroundCounselling is considered to be a promising approach to increasing physical activity (PA) in people with chronic obstructive pulmonary disease (COPD). The aim of the current study was to investigate whether a PA counselling program for people with COPD, when embedded in a comprehensive outpatient pulmonary rehabilitation (PR) program, increased their daily PA.MethodsA two-armed, single blind randomized controlled trial was conducted as a component of a 12-week outpatient pulmonary rehabilitation program. The participants randomized into the intervention group received five counselling sessions, based on the principles of motivational interviewing (MI), with a physiotherapist. The participants’ steps per day and other proxies of PA were measured using an accelerometer (SenseWear Pro®) at baseline, at the end of the PR program, and three months later. The group-by-time interaction effect was analyzed.ResultsOf the 43 participants,17 were allocated to the intervention group and 26 to the usual-care control group (mean age 67.9 ± 7.9; 21 (49%) males; mean FEV1 predicted 47.1 ± 18.6). No difference between groups was found for any measure of PA at any point in time.ConclusionsIn this study, counselling, based on MI, when embedded in a comprehensive PR program for people with COPD, showed no short-term or long-term effects on PA behavior. To investigate this potentially effective counselling intervention and to analyze the best method, timing and tailoring of an intervention embedded in a comprehensive outpatient PR program, further adequately powered research is needed.Trial registration: Clinical Trials.gov NCT02455206 (05/21/2015), Swiss National Trails Portal SNCTP000001426 (05/21/2015).

Feasibility of an Outpatient Training Program after COVID-19.

Long-term physical consequences of coronavirus disease 2019 (COVID-19) are currently being reported. As a result, the focus is turning towards interventions that support recovery after hospitalization. To date, the feasibility of an outpatient program for people recovering from COVID-19 has not been investigated. This study presents data for a physiotherapy-led, comprehensive outpatient pulmonary rehabilitation (PR) program. Patients were recruited after hospital discharge. Training consisted of twice weekly, interval-based aerobic cycle endurance (ACE) training, followed by resistance training (RT); 60–90 min per session at intensities of 50% peak work rate; education and physical activity coaching were also provided. Feasibility outcomes included: recruitment and dropout rates, number of training sessions undertaken, and tolerability for dose and training mode. Of the 65 patients discharged home during the study period, 12 were successfully enrolled onto the program. Three dropouts (25%) were reported after 11–19 sessions. Tolerability of interval-based training was 83% and 100% for exercise duration of ACE and RT, respectively; 92% for training intensity, 83% progressive increase of intensity, and 83% mode in ACE. We tentatively suggest from these preliminary findings that the PR protocol used may be both feasible, and confer benefits to a small subgroup of patients recovering from COVID-19.

Benefits of pulmonary rehabilitation in COVID-19: a prospective observational cohort study.

BackgroundCoronavirus disease 2019 (COVID-19) can result in a large variety of chronic health issues such as impaired lung function, reduced exercise performance and diminished quality of life. Our study aimed to investigate the efficacy, feasibility and safety of pulmonary rehabilitation in COVID-19 patients and to compare outcomes between patients with a mild/moderate and a severe/critical course of the disease.MethodsPatients in the post-acute phase of a mild to critical course of COVID-19 admitted to a comprehensive 3-week inpatient pulmonary rehabilitation programme were included in this prospective, observational cohort study. Several measures of exercise performance (6-min walk distance (6MWD)), lung function (forced vital capacity (FVC)) and quality of life (36-question short-form health survey (SF-36)) were assessed before and after pulmonary rehabilitation.Results50 patients were included in the study (24 with mild/moderate and 26 with severe/critical COVID-19). On admission, patients had a reduced 6MWD (mild: median 509 m, interquartile range (IQR) 426–539 m; severe: 344 m, 244–392 m), an impaired FVC (mild: 80%, 59–91%; severe: 75%, 60–91%) and a low SF-36 mental health score (mild: 49 points, 37–54 points; severe: 39 points, 30–53 points). Patients attended a median (IQR) 100% (94–100%) of all provided pulmonary rehabilitation sessions. At discharge, patients in both subgroups improved in 6MWD (mild/moderate: +48 m, 35–113 m; severe/critical: +124 m, 75–145 m; both p<0.001), FVC (mild/moderate: +7.7%, 1.0–17.8%, p=0.002; severe/critical: +11.3%, 1.0–16.9%, p<0.001) and SF-36 mental component (mild/moderate: +5.6 points, 1.4–9.2 points, p=0.071; severe/critical: +14.4 points, −0.6–24.5, p<0.001). No adverse event was observed.ConclusionOur study shows that pulmonary rehabilitation is a feasible, safe and effective therapeutic option in COVID-19 patients independent of disease severity.

Healthcare and Societal Costs in Patients with COPD and Breathlessness after Completion of a Comprehensive Rehabilitation Program

Breathlessness is one of the most frequent symptoms in chronic obstructive pulmonary disease (COPD). COPD may result in disability, decreased productivity and increased healthcare costs. The presence of comorbidities increases healthcare utilization. However, the impact of breathlessness burden on healthcare utilization and daily activities is unclear. This study’s goal was to analyze the impact of breathlessness burden on healthcare and societal costs. In this observational single-center study, patients with COPD were followed-up for 24 months after completion of a comprehensive pulmonary rehabilitation program. Every three months participants completed a cost questionnaire, covering healthcare utilization and impact on daily activities. The results were compared between participants with low (modified Medical Research Council (mMRC) grade <2; LBB) and high baseline breathlessness burden (mMRC grade ≥2; HBB). Healthcare costs in year 1 were €7302 (95% confidence interval €6476–€8258) for participants with LBB and €10,738 (€9141–€12,708) for participants with HBB. In year 2, costs were €8830 (€7372-€10,562) and €14,933 (€12,041–€18,520), respectively. Main cost drivers were hospitalizations, contact with other healthcare professionals and rehabilitation. Costs outside the healthcare sector in year 1 were €682 (€520–€900) for participants with LBB and €1520 (€1210–€1947) for participants with HBB. In year 2, costs were €829 (€662–€1046) and €1457 (€1126–€1821) respectively. HBB in patients with COPD is associated with higher healthcare and societal costs, which increases over time. This study highlights the relevance of reducing costs with adequate breathlessness relief. When conventional approaches fail to improve breathlessness, a personalized holistic approach is warranted.

Long-Term Benefits of Pulmonary Rehabilitation in Patients With COPD: A 2-Year Follow-Up Study

Pulmonary rehabilitation (PR) improves exercise capacity in patients with COPD in the short term. In patients with COPD, does 8weeks of PR confer long-term benefits on symptoms of dyspnea, anxiety, and depression, and on quality of life, 2 years after completion? One hundred and sixty-five patients with COPD completed an 8-week, community-based, comprehensive PR program, comprising 2-h sessions twice weekly. Sessions included aerobic exercise and an educational program. Patients were encouraged to perform daily walking exercise up to 30min at home. We evaluated a number of outcome measures at baseline, 8weeks, and 2 years, including the following: dyspnea measured with the modified Medical Research Council (mMRC) questionnaire, quality of life assessed with the St. George's Respiratory Questionnaire (SGRQ), and anxiety measured with the Anxiety Inventory for Respiratory Disease (AIR) and the Depression Anxiety Stress Scale (DASS). In addition, we measured exercise capacity, using the Incremental Shuttle Walk Test (ISWT), at baseline and 8weeks. Mean age (SD) was 72 (8.6) years; 55%were men. At 8weeks, improvements in mMRC, SGRQ, ISWT, DASS, and AIR were all statistically significant (P< .001). During the 2-year follow-up, changes observed at 8weeks were maintained for anxiety symptoms, and for symptoms, impact, and total SGRQ scores. In multivariate analysis, initial elevated levels of dyspnea, depression, anxiety, and decreased exercise capacity predicted greater quality of life improvement at 2 years (all P< .001). Over a 2-year period, an effective 8-week PR program provides sustained improvement in anxiety and quality of life. Short-term improvements in dyspnea, depression, and stress symptoms at 8weeks were not maintained at 2 years.

Incorporating Comprehensive Assessment Parameters to Better Characterize and Plan Rehabilitation for Persons with Chronic Obstructive Pulmonary Disease

ObjectivesThe current management of chronic obstructive pulmonary disease (COPD) largely ignores its heterogeneous pulmonary and extrapulmonary manifestations in the individual patient. This study aimed to identify clusters of patients with COPD based on a thorough traits assessment. DesignAn observational, prospective, single-center study. Setting and ParticipantsPatients with COPD referred by chest physicians for a comprehensive pulmonary rehabilitation program to CIRO (Horn, the Netherlands) were eligible to participate. CIRO is a specialized pulmonary rehabilitation center in the southern part of the Netherlands for patients with complex underlying respiratory diseases. MethodsClinically stable patients with COPD underwent a comprehensive assessment, including pulmonary traits (airflow limitation, static hyperinflation, gas transfer, respiratory pressures, and arterial blood gases), extrapulmonary functional traits, and health status (quadriceps muscle strength, physical functioning, body composition, comorbidities, symptoms perception, and social and emotional functioning). Clusters were generated using the SOM-Ward Cluster algorithm, a hybrid algorithm that applies the classical hierarchical method of Ward on top of the self-organizing map topology. ResultsBased on the abovementioned attributes of 518 patients with mild to very severe COPD (44% women, age 64.1 ± 9.1 years, forced expiratory volume in the first second 48.6% ± 20.0% of predicted), 7 clusters were identified. Clusters had unique patterns differing in demographics, pulmonary, extrapulmonary functional, and behavioral traits and/or health status. Conclusion and ImplicationsThe tremendous heterogeneity in pulmonary, extrapulmonary functional and behavioral traits, and health status in patients with COPD supports the need for an individual comprehensive assessment and a goal-directed personalized management strategy.

Changes in problematic activities of daily living in persons with COPD during 1 year of usual care.

Persons with chronic obstructive pulmonary disease (COPD) are often limited in performing their activities of daily living (ADLs). However, it remains unknown whether and to what extent problematic ADLs change over time and whether exacerbation-related hospitalisations affect problematic ADLs. Therefore, we investigated self-reported problematic ADLs of persons with COPD during 1year of usual care (i.e. without a specific experimental intervention). Stable persons with moderate to very severe COPD (n=137) were included in this longitudinal study (registered in the Dutch Trial Register [NTR 3941]). Participants were visited at home at baseline and after 1year. Participants with an exacerbation-related hospitalisation during follow-up were visited additionally within 2weeks after hospital discharge. During all visits, participants' personalised problematic ADLs were assessed using the Canadian Occupational Performance Measure (COPM), and perceived performance and satisfaction of important problematic ADLs were rated on a 10-point scale. In total, 90% of the participants reported at least one new important problematic ADL after 1year. In the subgroup of participants with an exacerbation-related hospitalisation (n=31), 92% of the participants reported new problematic ADLs 2weeks after discharge and 90% reported new problematic ADLs again after 1year. Only the satisfaction score of problematic ADLs as mentioned during baseline improved after 1-year follow-up in all participants (p=.002) and in participants without an exacerbation-related hospitalisation (n=106; p=.014). Problematic ADLs changed during 1year of usual care, which underlines the need for regular assessment of problematic ADLs and referral to treatment options like monodisciplinary occupational therapy and/or a comprehensive pulmonary rehabilitation programme.