Outpatient Pulmonary Rehabilitation Program Research Articles

Comprehensive out-patient pulmonary rehabilitation: Treatment outcomes in early and late stages of chronic obstructive pulmonary disease

BACKGROUND:The aim was to evaluate the outcomes of a comprehensive pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) and to establish whether in early disease stage PR is as effective as in late stages of disease.METHODS:A total of 55 stable COPD patients, 28 with early and 27 with late disease stages, were assessed. Patients underwent a comprehensive out-patient PR program for 8 weeks. To eluciate the effects of PR and compare the level of improvement; lung function, dyspnea sensation [Medical Research Council (MRC)], body composition [body mass index (BMI), fat free mass (FFM), fat free mass index (FFMI)], exercise capacity [incremental shuttle walking test, endurance shuttle walking test], health related quality of life (HRQoL) with St. George Respiratory Disease Questionnaire, psycohological status (Hospital anxiety–depression (HAD) scale) were evaluated before and after PR.RESULTS:At the end of PR in the early disease stage group, the improvement in forced vital capacity (FVC) reached a statistically significant level (P < 0.05). In both disease stages, there were no significant differences in BMI, FFM, and FFMI. The decrease in exertional dyspnea for the two groups evaluated with the modified BORG scale were not found statistically significant, though the dyspnea scores evaluated with MRC showed significant improvements (P < 0.001). HRQoL and exercise capacity were significantly improved for the two groups (P < 0.001). Psychological status evaluated with the HAD scale improved after PR (P < 0.001) both in early and late stages. Gainings in the study parameters did not differ in the early and the late disease stages.CONCLUSIONS:These results showed that patients with COPD had benefited from a comprehensive PR program in an out-patient setting regardless of disease severity. Even patients with earlier stage of disease should be referred and encouraged to participate in a PR program.

Outpatient vs. home-based pulmonary rehabilitation in COPD: a randomized controlled trial

&#x0D; &#x0D; &#x0D; Background: Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality affecting a large number of individuals in both developed and developing countries and it represents a significant financial burden for patients, families and society. Pulmonary rehabilitation (PR) is a multidisciplinary program that integrates components of exercise training, education, nutritional support, psychologi- cal support and self-care, resulting in an improvement in dyspnea, fatigue and quality of life. Despite its proven effectiveness and the strong scientific recommendations for its rou- tine use in the care of COPD, PR is generally underutilized and strategies for increasing access to PR are needed. Home- based self-monitored pulmonary rehabilitation is an alternative to outpatient rehabilitation. In the present study, patients with mild, moderate and severe COPD submitted to either an outpatient or at-home PR program for 12 weeks were analyzed.&#x0D; Methods: Patients who fulfilled the inclusion criteria were randomized into three distinct groups: an outpatient group who performed all activities at the clinic, a home-based group who performed the activities at home and a control group. PR consisted of a combination of aerobic exercises and strength- ening of upper and lower limbs 3 times a week for 12 weeks.&#x0D; &#x0D; &#x0D; Results: There was a significant difference in the distance cov- ered on the six-minute walk test (p &lt; 0.05) and BODE index (p &lt; 0.001) in the outpatient and at-home groups after partici- pating in the rehabilitation program compared to baseline.&#x0D; Conclusion: A home-based self-monitoring pulmonary reha- bilitation program is as effective as outpatient pulmonary rehabilitation and is a valid alternative for the management of patients with COPD.&#x0D; &#x0D; &#x0D;

S74 Effect of pulmonary rehabilitation on the Short Physical Performance Battery (SPPB) in COPD

IntroductionThe Short Physical Performance Battery (SPPB) is a simple objective assessment tool developed by the National Institute on Ageing for evaluating lower extremity function in older persons. It comprises tests...

P50 Facilitation of continued exercise via patient volunteers with chronic obstructive pulmonary disease (COPD) following a pulmonary rehabilitation programme: a feasibility study

IntroductionAfter pulmonary rehabilitation activity levels gradually decline, on average, back to baseline over 12–18 months. The NHS has highlighted the value of peer support for patients with chronic disease, but...

P52 Is a pulmonary rehabilitation (PR) programme effective in reducing severe symptoms of anxiety and depression in patients with COPD?

IntroductionPatients with COPD have a high prevalence of anxiety and depression which has been associated with poorer health outcomes. PR has been found to be successful in reducing anxiety and...

P53 The Effect of co-morbidities on response to pulmonary rehabilitation

<h3>Introduction</h3> Most patients with COPD are elderly, and the presence of co-morbidities is not uncommon. Co-morbidities are an important determinant of health related quality of life in patients with COPD. Although pulmonary rehabilitation (PR) is well known to improve exercise performance, health-related quality of life and symptoms, a proportion of patients are non-responders. We hypothesised that improvement in exercise capacity and health-related quality of life following PR may be limited in the presence of co-morbidities. <h3>Methods</h3> A structured history was taken from 128 patients referred to an 8-week supervised outpatient PR programme. Individuals9 self-reported co-morbidities were assessed by the Charlson index, which assigns to each disease a score that is proportional to the disease related risk of death. The calculated Charlson index did not include COPD in the individual9s score as suggested in the original description. In 115 patients completing the programme, changes in incremental shuttle walk (ISW) and chronic respiratory disease questionnaire (CRQ) domains following PR were calculated, and compared between those patients with and without co-morbidities (Charlson index 1 or more vs 0) using unpaired t-test or non-parametric equivalent. <h3>Results</h3> 84 patients (73%) had a Charlson index of 1 or more. No difference in age, gender, FEV1, or MRC Dyspnoea score was seen between those with and without co-morbidities. Mean (SD) change in ISW following PR was not significantly different between those with and without co-morbidities (63 (96) vs 33 (88); p=0.13). Similarly there were no significant differences in CRQ-D change (4.1 (6.4) vs 5.7 (7.1); p=0.26), CRQ-F change (2.6 (5.1) vs 4.4 (5.7); p=0.13), CRQ-E change (3.6 (7.8) vs 6.4 (7.7); p=0.09) or CRQ-M change (2.7 (4.8) vs 2.3 (6.9); p=0.75). No association was seen between Charlson index and change in ISW following PR (Spearman rank=0.09; p=0.32). <h3>Discussion</h3> The prevalence of co-morbidities in COPD patients undergoing PR is high. The presence of co-morbidities does not seem to affect patients9 response to pulmonary rehabilitation.

P48 Attendance rates and response to pulmonary rehabilitation

BackgroundAlthough randomised controlled trials and meta-analyses have demonstrated that pulmonary rehabilitation (PR) improves exercise capacity, there is a variability of response and a proportion of PR participants have not shown...

P43 Do changes in objective outcome measures match patient-reported experience of pulmonary rehabilitation?

<h3>Introduction</h3> There are a variety of different objective outcome measures that are currently used to assess patients′ response to pulmonary rehabilitation (PR) and the effectiveness of service delivery. Most of these measures have well defined minimal clinically important difference (MCID) thresholds, including the Incremental Shuttle Walk (ISW), Chronic Respiratory Questionnaire (CRQ) and the Hospital Anxiety and Depression scale (HAD). However, it is not clear how many outcome measures are needed to encapsulate patient-reported improvement following PR. <h3>Methods</h3> 101 patients, completing an 8 week supervised outpatient pulmonary rehabilitation programme, were asked to rate their response with the following question: ‘How do you feel your overall condition has changed after rehabilitation?’ Responses were categorised according to a Likert scale ranging from 1 ‘I feel much better’ to 5 ‘I feel much worse’. All patients were blinded to the results of their objective assessments. For every patient responding category 1, we determined whether the MCID was achieved for each of seven different outcome measures: the ISW (&gt;48 m), the four domains of the CRQ (mean change &gt;0.5 per domain), HAD-anxiety (&lt;−1.5) and HAD-depression (&lt;−1.5). <h3>Results</h3> 64 patients (63%) recorded a response of ‘I feel much better’. Of these, the proportion of patients achieving the MCID for the seven different outcome measures is seen in Abstract P43 Table 1 below. 6 patients (9%) achieved the MCID for all outcome measures tested, whilst one patient (1.6%) did not achieve the MCID in any of the outcome measures. Four patients (6.25%) did not achieve the MCID in either the ISW or any of the CRQ domains. <h3>Discussion</h3> Patient-reported positive response to PR is probably determined by several factors, which differ from individual to individual, and cannot be captured by use of only one outcome measure. More than 98% of patients who reported feeling much better following pulmonary rehabilitation achieve the MCID in at least one of ISW, CRQ domains or HAD.

Shuttle Walking Test as Predictor of Survival in Chronic Obstructive Pulmonary Disease Patients Enrolled in a Rehabilitation Program

The Incremental Shuttle Walking Test (ISWT) is used to assess exercise capacity in chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. We studied the value of this test in predicting survival in COPD patients enrolled in a rehabilitation program. A total of 416 patients performed an ISWT before entering a 7-week outpatient pulmonary rehabilitation program. Their survival was observed over a mean period of 4.5 years (range = 1.2-7.2 years). During the observation period, 169 (40.6%) patients died. Univariate analyses showed that the ISWT as well as age, gender, present and previous tobacco smoking, forced expiratory volume in 1 second, body mass index, oxygen saturation at rest, long-term oxygen therapy, Medical Research Council dyspnea score, and treatment with oral corticosteroids were significantly associated with survival. Multivariate analysis, including relevant confounders, revealed that low ISWT was independently associated with poor survival (P = .001). The association was not linear and the risk of dying increased markedly when ISWT was lower than 170 m (RR = 2.84, 95% CI: 2.05-3.93). This study shows that the ISWT is a strong and independent predictor of survival in patients with COPD enrolled in a rehabilitation program.

Exercise induced skeletal muscle metabolic stress is reduced after pulmonary rehabilitation in COPD

In COPD, skeletal muscle ATP resynthesis may be insufficient to meet demand during exercise due to excessive anaerobic and reduced oxidative (mitochondrial) energy production, leading to metabolic stress. We investigated the effect of outpatient pulmonary rehabilitation (PR) on the metabolic response (measured by exercise-induced accumulation of plasma ammonia) and determined whether this response predicted functional improvement following PR. 25 subjects with stable COPD [mean (SD) age 67 (8)years and FEV(1) 47 (18)% predicted] performed maximal cycling ergometry before and after PR. Plasma ammonia was measured at rest, during exercise and 2 min post-exercise. Following PR, there were significant increases in peak cycle WR and ISWT performance (Mean (SEM) changes 13.1 (2.0) W and 93 (15) m respectively, p < 0.001). Mean (SEM) rise in plasma ammonia was reduced at peak (Pre vs Post-PR: 29.0 (4.5) vs 20.2 (2.5) μmol/l, p < 0.05) and isotime (Pre vs Post-PR: 29.0 (4.5) vs 10.6 (1.7) μmol/l, p < 0.001) exercise. Improvements in exercise performance after PR were similar among subgroups who did versus those who did not show a rise in ammonia at baseline. The results suggest that muscle cellular energy production was better matched to the demands of exercise following PR. We conclude that a pragmatic outpatient PR programme involving high intensity walking exercise results in significant adaptation of the skeletal muscle metabolic response with a reduction in exercise-related metabolic stress. However, the outcome of PR could not be predicted from baseline metabolic response.

Six‐minute walk test in pulmonary rehabilitation: Do all patients need a practice test?

The six-minute walk test (6MWT) is widely used as an outcome measure in pulmonary rehabilitation programs (PRP). A learning effect for the test has been reported in COPD; however, limited data exist in patients with other respiratory diagnoses. The objectives of this study were to: (i) report the magnitude of change in 6MWD with test repetition in patients referred to an outpatient PRP, and (ii) compare the magnitude of change in 6MWD with test repetition in patients with COPD, interstitial lung disease (ILD), bronchiectasis and asthma. Retrospective study of 349 patients with stable COPD (n = 245), ILD (n = 21), bronchiectasis (n = 33) or asthma (n = 50) who performed two 6MWT at enrollment into a PRP. 6MWD increased in all groups on the second test (all P < 0.001). At least 80% of patients in each diagnostic group walked further on their second 6MWT. The magnitude of change (mean, 95% CI) was greater (P < 0.05) in the COPD (37 m, 95% CI: 33-41 m) and ILD (41 m, 95% CI: 27-55 m) cohorts compared with the bronchiectasis (22 m, 95% CI: 14-31 m) and asthma (19 m, 95% CI: 11-27 m) cohorts. Respiratory diagnosis influences the magnitude of the learning effect for the 6MWT. The findings support the recommendation of a practice 6MWT at baseline assessment in order to provide an accurate measure of the effects of rehabilitation on 6MWD.

The Norwegian version of the chronic obstructive pulmonary disease self-efficacy scale (CSES): a validation and reliability study

The aim of this study was to evaluate the feasibility, internal consistency and face and construct validity of the Norwegian version of the Chronic Obstructive Pulmonary Disease Self-Efficacy Scale (CSES). The CSES was translated into Norwegian according to standard procedures for forward and backward translation, and administered to 100 patients with chronic obstructive pulmonary disease (COPD) (51% men, mean age 66.1 years, range 42-82) prior to their participation in an outpatient pulmonary rehabilitation programme. The CSES-N (translated version) consists of 34 items comprising five subscales describing negative affect, intense emotional arousal, physical exertion, weather/environment and behavioural risk factors. Each scale ranges from 1 to 5, with higher scores indicating better self-efficacy. For validation purposes, we measured lung function (FEV(1) , FEV(1) % predicted) and exercise capacity (ISWT), and administered the St. George's Respiratory Questionnaire (SGRQ) and Hospital Anxiety and Depression Scale (HADS). A pilot study confirmed that the CSES-N was clear, understandable and easy to self-administer. Cronbach's alpha was 0.98 for the total score (0.80-0.96 for subscales). Results showed small to medium negative correlations between all CSES-N scales and anxiety, depression (HADS), physical activity, psychosocial impact of disease and total health status (SGRQ) (-0.20 to -0.49). Small or negligible negative correlations between different CSES-N scales and respiratory symptoms (SGRQ) (-0.03 to -0.23) were found. Any correlations among exercise capacity, lung function and different socio-demographic variables (age, gender and education) and CSES-N were also small or negligible (0.00 to 0.23). This study shows acceptable feasibility, internal consistency and face and construct validity for the CSES-N in a sample of Norwegian COPD patients.

Differences in Response to Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis and Chronic Obstructive Pulmonary Disease

Background: The benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) are well recognized. However, whether individuals with idiopathic pulmonary fibrosis (IPF) benefit is less clear. Objectives: To evaluate the effects of pulmonary rehabilitation in subjects with IPF and compare their responses with a group of COPD subjects who underwent an identical program. Methods: For- ty-five subjects with IPF and 45 age- and Medical Research Council grade-matched COPD subjects were recruited. Subjects completed an 8-week outpatient pulmonary rehabilitation program. Dyspnea, peripheral muscle force, exercise capacity (6-min walk distance, 6MWD), activities of daily living, and health status (36-item short-form survey, SF-36) were assessed at baseline, immediately following and at 6 months following completion of the program. Results: Adherence to the program was similar in both groups. Significant improvements in dyspnea, muscle force, exercise capacity and ADL were observed in both groups (all p < 0.05); however, the magnitude of improvement in all outcomes was less in the IPF group [mean (95% CI) improvement in 6MWD, IPF 16.2 (7.1–25.4); COPD 53.1 (44.9–61.2)]. All domains of SF-36, with the exception of social function, improved (all p < 0.05) in the COPD group; however, there were no changes in SF-36 scores in the IPF group. The benefits were well maintained in the COPD group at 6 months, but, with the exception of the ADL score, the benefits were no longer present in the IPF group. Conclusions: Pulmonary rehabilitation in IPF produces only modest short-term gains in dyspnea, exercise capacity and ADL, but does not improve health status.

Effectiveness of Pulmonary Rehabilitation in Reducing Health Resources Use in Chronic Obstructive Pulmonary Disease

Rubí M, Renom F, Ramis F, Medinas M, Centeno MJ, Górriz M, Crespí E, Martín B, Soriano JB. Effectiveness of pulmonary rehabilitation in reducing health resources use in chronic obstructive pulmonary disease. Objective To determine the effectiveness of a multidisciplinary, outpatient pulmonary rehabilitation (PR) program in patients with severe and very severe chronic obstructive pulmonary disease (COPD). PR is recommended in advanced COPD, but there is limited evidence on the effectiveness of PR in reducing health care resources when applied in outpatients. Design Before and after intervention, a prospective research trial of patients enrolled in a PR program. Setting Outpatient respiratory department in a specialized hospital. Participants We considered prospectively 82 consecutive patients with advanced COPD and finally studied 72 patients who completed the PR intensive phase. Intervention PR program. Main Outcome Measures The effectiveness of this PR program was assessed by comparing health resources use from the year before and the year after PR. Clinical variables including dyspnea; the body mass index, obstruction, dyspnea, exercise capacity (BODE) index; and the Chronic Respiratory Questionnaire and health resources use including the number of exacerbations, the number of hospitalizations, and days of hospitalization. Results Patients had a forced expiratory volume in the first second percentage predicted (mean ± SD) of 33.0±9.8 and a BODE index of 5.0±2.0. Significant improvements after PR were found in dyspnea, exercise capacity, and quality of life and on the BODE index ( P<.05). Compared with the 12 months before PR, there were also significant reductions during the year after PR on exacerbations (3.4±3.5 vs 1.9±2.0, P=.002), hospitalizations (2.4±2.0 vs 0.9±1.2, P<.001), and days of hospitalization (36.1±32.7 vs 16.1±31.3, P<.001) (ie, a reduction of 44%, 63%, and 55%, respectively; all P<.05). Conclusions We conclude that a multidisciplinary, outpatient PR program substantially reduces health resources use in patients with severe and very severe COPD.

Updating the Minimal Important Difference for Six-Minute Walk Distance in Patients With Chronic Obstructive Pulmonary Disease

Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Objective To establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD). Design Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD. Setting Outpatient pulmonary rehabilitation program at 2 teaching hospitals. Participants Seventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104m). Interventions Not applicable. Main Outcome Measures Participants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD. Results The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change ( P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20–61m). There was excellent agreement with distribution-based methods (25.5–26.5m, κ=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85). Conclusions The MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice.

Outpatient vs. home-based pulmonary rehabilitation in COPD: a randomized controlled trial.

BackgroundChronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality affecting a large number of individuals in both developed and developing countries and it represents a significant financial burden for patients, families and society. Pulmonary rehabilitation (PR) is a multidisciplinary program that integrates components of exercise training, education, nutritional support, psychological support and self-care, resulting in an improvement in dyspnea, fatigue and quality of life. Despite its proven effectiveness and the strong scientific recommendations for its routine use in the care of COPD, PR is generally underutilized and strategies for increasing access to PR are needed. Home-based self-monitored pulmonary rehabilitation is an alternative to outpatient rehabilitation. In the present study, patients with mild, moderate and severe COPD submitted to either an outpatient or at-home PR program for 12 weeks were analyzed.MethodsPatients who fulfilled the inclusion criteria were randomized into three distinct groups: an outpatient group who performed all activities at the clinic, a home-based group who performed the activities at home and a control group. PR consisted of a combination of aerobic exercises and strengthening of upper and lower limbs 3 times a week for 12 weeks.ResultsThere was a significant difference in the distance covered on the six-minute walk test (p < 0.05) and BODE index (p < 0.001) in the outpatient and at-home groups after participating in the rehabilitation program compared to baseline.ConclusionA home-based self-monitoring pulmonary rehabilitation program is as effective as outpatient pulmonary rehabilitation and is a valid alternative for the management of patients with COPD.

Health Care Utilization among Chronic Obstructive Pulmonary Disease Patients and the Effect of Pulmonary Rehabilitation

Objective: The present study aimed to analyze the utilization of health care resources among patients with chronic obstructive pulmonary disease (COPD) and to evaluate the effect of adherence to a pulmonary rehabilitation (PR) program on the utilization of these resources. Subjects and Methods: A retrospective review of medical charts of a group of patients with COPD who were enrolled in a standard outpatient PR program at a tertiary care teaching hospital was conducted. Eligible patients were above the age of 18 years with a history of dyspnea, chronic cough and/or exposure to a disease risk factor with a postbronchodilator FEV₁/FVC ratio <0.7. Results: Fifty patients were referred to the PR program. The average number of emergency department visits was 1.4 ± 1.6 days, the length of stay in the hospital was 1.7 ± 3.8 days, the pulmonary clinic scheduled visits were 3.9 ± 2.2, the use of combined inhalers was 9.0 ± 3.9 canisters, the use of short-acting bronchodilator was 9.0 ± 5.6 canisters, the cumulative prednisone doses were 427.5 ± 463 mg, and the use of antibiotic courses was 3.1 ± 2.9. Of the referred patients, 27 (54%) were adherent and 23 (46%) were not. Except for the use of combined inhalers, all parameters were significantly reduced in the adherent group. In contrast, the nonadherent group had increases in use of prednisone and antibiotics (p < 0.05). Conclusion: There was a reduction in the utilization of health care resources among adherent patients with COPD who completed a PR program as reflected in selected pharmacological and nonpharmacological parameters.

The Impact of Chronic Obstructive Pulmonary Disease Exacerbation on Pulmonary Rehabilitation Participation and Functional Outcomes

The purpose of this study was to determine the impact of chronic obstructive pulmonary disease exacerbation (COPDE) on pulmonary rehabilitation (PR) participation and completion and on PR outcomes of daily activity, self-reported daily exercise, and functional capacity. Participants in an 8-week outpatient PR program were studied pre- and post-PR. Variables included COPDE occurrence (computerized patient record system), self-reported exercise (daily activity diary), daily activity (accelerometer), exercise capacity (6-minute walk distance), dyspnea today and over the past 30 days (Lareau's Functional Status and Dyspnea Questionnaire), health status (The Medical Outcomes Study 36-Item Short-Form Health Survey adapted for Veterans), and quality of life (Seattle Obstructive Lung Disease Questionnaire). Outpatients with COPD (N = 146, 140 men) started PR; 112 completed the program and were studied. Of the 30 participants who had at least 1 COPDE during the program, 10 quit the program. Subjects who exacerbated had a lower body mass index than did patients without COPDE (28.4 compared with 30.8, respectively, P < .05), more severe COPD (percent-predicted forced expiratory volume in the first second of expiration, FEV1% predicted, 32%, compared with 40%, respectively, P< .05), and required supplemental oxygen (70% compared with 36%, respectively, P< .05). Exacerbators who completed PR were more likely to be nonsmokers, on oxygen, and have a higher FEV1% predicted than were exacerbators who quit. It was found that postprogram exercise capacity improved overall, with exacerbators performing better than nonexacerbators on the 6-minute walk test (P = .044). There were no significant differences in other outcomes. Findings suggest that COPD exacerbators who completed PR had similar outcomes as did nonexacerbators and should be encouraged to return to PR after COPDE.

Effects of Oxygen on Exercise Duration in Chronic Obstructive Pulmonary Disease Patients before and after Pulmonary Rehabilitation

Supplemental oxygen therapy has been shown to improve exercise performance in patients with chronic obstructive pulmonary disease (COPD). It is unknown whether the magnitude of this benefit would be affected by participation in a pulmonary rehabilitation program. To compare the effects of supplemental oxygen on exercise capacity in nonhypoxemic COPD patients before and after participation in a pulmonary rehabilitation program. Sixteen patients with COPD underwent two pairs of constant-load exercise tests before and after participation in a three-month outpatient pulmonary rehabilitation program. Each pair of exercise tests consisted of a test performed with room air and a second test performed with 50% supplemental oxygen, in random order. The primary outcome was the difference in exercise duration between tests performed with supplemental oxygen and with room air. This difference was compared before and after participation in a pulmonary rehabilitation program. Supplemental oxygen therapy improved exercise duration by 75 s before participation in a pulmonary rehabilitation program and by 153 s following pulmonary rehabilitation. Rehabilitation alone improved exercise duration by 28 s, but rehabilitation appeared to augment the exercise benefits of supplemental oxygen therapy by a mean of 78 s (95% CI 11 s to 145 s; P = 0.03). The effects of supplemental oxygen therapy were augmented after pulmonary rehabilitation. The improvement in exercise duration with supplemental oxygen following rehabilitation was greater than either supplemental oxygen or pulmonary rehabilitation alone.

Music: More than just a melody

Anxiety is one of the most persistent psychological findings in persons with chronic obstructive pulmonary disease (COPD). Anxiety is an emotional state characterized by subjective, consciously perceived feelings of tension and apprehension as well as heightened autonomic nervous system activity that may vary in intensity and fluctuate over time. As dyspnea is the most frequent symptom seen in patients with pulmonary disease, the development of concomitant anxiety is common. Dyspnea is anxiety provoking due to the suffocating sensations and other physiological factors that generate real fear. At the same time, dyspnea, a psychophysiologic phenomenon, may be triggered by non-ventilatory factors such as anxiety. More than 60 years ago, Altshuler theorized that music altered moods unconsciously through the stimulation of an autonomic response at the thalamic level. Brody believed that music influenced the right-hand side brain activity, causing the pituitary gland to release endorphins and generate a calming effect. The positive impact of music on anxiety has been described in multiple populations and settings including ambulatory surgery patients, myocardial infarction (MI) patients and mechanical ventilation. Music has been shown to reduce perceptions of dyspnea during exercise. In the current issue of Chronic Respiratory Disease, Vijay Singh and colleagues report the findings of their pilot study comparing the effectiveness of music versus progressive muscle relaxation (PMR) in hospitalized COPD patients experiencing an acute exacerbation. This randomized trial exposed participants to either music or PMR during two sessions within the same day. The authors report that both groups had significant reductions following both the first and second sessions for perceived dyspnea as measured by the Borg score and systolic blood pressure, heart and respiratory rates and anxiety as measured by the Spielberger State-Trait Anxiety Inventory State. These reductions were seen to increase following the second session. When the two groups were compared, the music group was shown to have significantly greater reductions for all outcomes compared to the PMR group ( p < .001). As dyspnea increases and activity tolerance declines in patients with COPD, anxiety commonly ensues. Often, patients with COPD develop anxiety with dyspnea when they believe the dyspnea episode is beyond their control. Because of the close interaction of dyspnea and anxiety, relief of one symptom often results in the relief of the other symptom. Desensitization, distraction and relaxation have been shown to be effective in reducing dyspnea and anxiety. The affective dimension of dyspnea has been well reported, with distraction shown to reduce the negative affective perception of dyspnea. Pulmonary rehabilitation (PR) has been shown to reduce anxiety in multiple studies using serial interviews and questionnaires related to psychological symptoms before and after PR. More than 20 years ago, Renfroe and colleagues described anxiety reduction over 4 weeks of PR sessions in 20 persons with COPD. In 40 moderate-to-severe COPD patients, Dekhuijzen and colleagues reported significant reductions in anxiety and depression components of the Symptoms Checklist (SCL-90) in persons assigned to PR exercise training. Gayle and colleagues noted reduction in anxiety scores as measured by the State-Trait Anxiety Inventory in 15 COPD patients enrolled in a 28-week outpatient PR program. The combination of behavioral therapy and PR has been shown to reduce anxiety.