Start Of Pulmonary Rehabilitation Research Articles

Prediction of Low-intensity Physical Activity in Stable Patients with Chronic Obstructive Pulmonary Disease.

To develop an equation of the predicted amount of low-intensity physical activity (LPA) by analyzing clinical parameters in patients with chronic obstructive pulmonary disease (COPD). In this cross-sectional study, we analyzed the assessments of clinical parameters evaluated every 6 months from the start of pulmonary rehabilitation in 53 outpatients with stable COPD (age 77 ± 6 yrs; 46 men; body mass index 21.8 ± 4.1 kg/m2; forced expiratory volume in one second 63.0 ± 26.4% pred). An uniaxial accelerometer was used to measure the number of steps and the time spent in LPA of 1.8-2.3 metabolic equivalents during 14 consecutive days. We also evaluated body composition, respiratory function, skeletal muscle strength, inspiratory muscle strength, exercise capacity, and gait speed. Factors associated with the time spent in LPA were examined by multivariate regression analysis. Internal validity between the predicted amount of LPA obtained by the equation and the measured amount was examined by regression analysis. Multivariate regression analysis revealed that gait speed (β = 0.369, p = 0.007) and maximum inspiratory mouth pressure (PImax) (β = 0.329, p = 0.016) were significant influence factors on LPA (R2 = 0.354, p <0.001). The stepwise regression analysis showed a moderate correlation between the measured amount and predicted amount of LPA calculated by the regression equation (r = 0.609, p <0.001; LPA = 31.909 × gait speed + 0.202 × PImax - 20.553). Gait speed and PImax were extracted as influence factors on LPA, suggesting that the regression equation could predict the amount of LPA.

Inflammatory responses to acute exercise during pulmonary rehabilitation in patients with COPD

ObjectivePulmonary rehabilitation is a cornerstone treatment in the management of chronic obstructive pulmonary disease (COPD). Acute bouts of exercise can lead to short bursts of inflammation in healthy individuals. However, it is unclear how COPD patients respond to acute bouts of exercise. This study assessed inflammatory responses to exercise in COPD patients at the start (phase 1) and end (phase 2) of pulmonary rehabilitation.MethodsBlood samples were collected before and after an acute exercise bout at the start (phase 1, n = 40) and end (phase 2, n = 27) of pulmonary rehabilitation. The primary outcome was change in fibrinogen concentrations. Secondary outcomes were changes in CRP concentrations, total/differential leukocyte counts, markers of neutrophil activation (CD11b, CD62L and CD66b), and neutrophil subsets (mature, suppressive, immature, progenitor).ResultsAcute exercise (phase 1) did not induce significant changes in fibrinogen (p = 0.242) or CRP (p = 0.476). Total leukocyte count [mean difference (MD), 0.5 ± 1.1 (109 L−1); p = 0.004], neutrophil count [MD, 0.4 ± 0.8 (109 L−1); p < 0.001], and immature neutrophils (MD, 0.6 ± 0.8%; p < 0.001) increased post-exercise. Neutrophil activation markers, CD11b (p = 0.470), CD66b (p = 0.334), and CD62L (p = 0.352) were not significantly altered post-exercise. In comparison to the start of pulmonary rehabilitation (phase 2), acute exercise at the end of pulmonary rehabilitation led to a greater fibrinogen response (MD, 84 mg/dL (95% CI − 14, 182); p = 0.045).ConclusionAn acute bout of exercise does not appear to induce significant alterations in the concentrations of inflammatory mediators but can increase white blood cell subsets post-exercise. A greater fibrinogen response to acute exercise is seen at the end of pulmonary rehabilitation when compared to the start. Further research is required to understand the clinical context of these acute inflammatory responses to exercise.

Phenotypic Characteristics of Patients With Chronic Obstructive Pulmonary Disease After Stratification for the Short Physical Performance Battery Summary Score

ObjectiveTo assess the phenotypic characteristics of patients with chronic obstructive pulmonary disease (COPD) after stratification for Short Physical Performance Battery (SPPB) summary scores and to determine phenotypic characteristics of the SPPB summary score at the start of pulmonary rehabilitation (PR). DesignRetrospective, cross-sectional. SettingBaseline assessment for PR program. ParticipantsPatients with COPD (n=900; age 65±8y, 52% male, forced expiratory volume in the first second of expiration, 43% [interquartile range, 31%-62%] predicted). InterventionsNot applicable. Main Outcome MeasuresPatients were stratified according to their SPPB summary scores into low-performance (LP), moderate-performance (MP), or high-performance (HP) groups. Furthermore, lung function, arterial blood gases, body composition, physical capacity, lower limb muscle strength and endurance, and symptoms of anxiety and depression were assessed. ResultsGenerally, physical capacity and muscle function were lower and scores for symptoms of anxiety and depression were higher in LP patients than MP and HP patients (all values, P<.01). However, 25% of HP patients with COPD scored high on symptoms of anxiety and/or depression (≥10 points), and HP patients still had on average an impaired physical capacity (median, 6-minute walk test [6MWT] distance of 69% predicted). Furthermore, age and 6MWT distance (m) were the only independent predictors in a multivariate regression model, explaining 29% of the variance in SPPB summary score. ConclusionsIn COPD, LP patients have the worst physical and emotional functioning. However, HP patients can still exhibit physical and emotional impairments. Because the explained variance in SPPB summary score is low, SPPB should not be considered as a test to discriminate between patients with COPD with a low or preserved physical capacity and emotional status.

Physical Activity and Sedentary Behaviour Patterns in 326 Persons with COPD before Starting a Pulmonary Rehabilitation: A Cluster Analysis.

This study applies a cluster analysis to identify typical physical activity (PA) and sedentary behaviour (SB) patterns in people with chronic obstructive pulmonary disease (COPD) before starting pulmonary rehabilitation (PR). We implemented an observational design which assessed baseline data of objectively measured PA and SB from the STAR (Stay Active after Rehabilitation) study. A total of 355 persons wore an accelerometer (Actigraph wGT3X) for seven days before the start of their PR. Sociodemographic and disease-related parameters were assessed at the start of PR. We applied cluster analysis and compared clusters applying univariate variance analyses. Data was available for 326 persons (31.6% women; age ø = 58 years). Cluster analysis revealed four movement clusters with distinct PA and SB patterns: Sedentary non-movers (28.5%), sedentary occasional movers (41.7%), sedentary movers (19.6%), and sedentary exercisers (10.1%). The four clusters displayed varying levels of moderate PA before rehabilitation (Ø daily min: 9; 28; 38; 70). Notably, all four clusters displayed considerably long average sedentary time per day (Ø daily minutes: 644; 561; 490; 446). The clusters differed significantly in disease-related parameters of GOLD severity, FEV1, CAT, and 6-Min-Walk-Test. In addition to PA promotion, PR programs should consider the reduction of sedentary behaviour as a valuable goal.

The impact of disease-specific fears on outcome measures of pulmonary rehabilitation in patients with COPD.

Anxiety is a highly prevalent psychological comorbidity in patients with chronic obstructive pulmonary disease (COPD) and has detrimental effects on pulmonary rehabilitation (PR) outcomes. It has been suggested that disease-specific fears could play an even more important role in COPD patients' disease progression. However, little is known about how different disease-specific fears impact COPD. This study examined how different disease-specific fears relate to different PR outcome measures in COPD patients and how these relationships evolve over the course of PR. Before and after a 3-week inpatient PR program, COPD patients (N = 104) underwent a 6-min walking test to measure functional exercise capacity. Disease-specific fears (fear of physical activity, fear of dyspnea, fear of disease progression, fear of social exclusion) were assessed with the COPD-Anxiety-Questionnaire-Revised. Health-related quality of life (HQoL), COPD health status, dyspnea in daily life, depression, and anxiety were measured using validated questionnaires. Multiple regression showed that greater disease-specific fears at the start of PR were associated with worse functional exercise capacity, HQoL, health status, and depression at the start and end of PR (controlling for age, sex, lung function, smoking status, and general anxiety). Patients who showed a stronger decrease in disease-specific fears improved more in PR outcome measures over the course of PR. Furthermore, different disease-specific fears were related to different PR outcome measures. The results show that disease-specific fears are associated with treatment outcome measures, both cross-sectionally and prospectively. Therefore, disease-specific fears should be addressed in COPD patients as they might play a significant role in disease progression.

Feasibility of Immediate in-Intensive Care Unit Pulmonary Rehabilitation after Lung Transplantation: A Single Center Experience.

BackgroundPhysical function may influence perioperative outcomes of lung transplantation. We investigated the feasibility of a pulmonary rehabilitation program initiated in the immediate postoperative period at an intensive care unit (ICU) for patients who underwent lung transplantation.MethodsWe retrospectively evaluated 22 patients who received pulmonary rehabilitation initiated in the ICU within 2 weeks after lung transplantation at our institution from March 2015 to February 2016. Levels of physical function were graded at the start of pulmonary rehabilitation and then weekly throughout rehabilitation according to criteria from our institutional pulmonary rehabilitation program: grade 1, bedside (G1); grade 2, dangling (G2); grade 3, standing (G3); and grade IV, gait (G4).ResultsThe median age of patients was 53 years (range, 25 to 73 years). Fourteen patients (64%) were males. The initial level of physical function was G1 in nine patients, G2 in seven patients, G3 in four patients, and G4 in two patients. Patients started pulmonary rehabilitation at a median of 7.5 days (range, 1 to 29 days) after lung transplantation. We did not observe any rehabilitation-related complications during follow-up. The final level of physical function was G1 in six patients, G3 in two patients, and G4 in 14 patients. Fourteen of the 22 patients were able to walk with or without assistance, and 13 of them maintained G4 until discharge; the eight remaining patients never achieved G4.ConclusionsOur results suggest the feasibility of early pulmonary rehabilitation initiated in the ICU within a few days after lung transplantation.

The Impact of Cognitive Impairment on Efficacy of Pulmonary Rehabilitation in Patients With COPD

ObjectivesTo compare changes in pulmonary rehabilitation (PR) dropout and outcomes between chronic obstructive pulmonary disease (COPD) patients with and without cognitive impairment. DesignA cross-sectional observational study. SettingPatients with COPD were recruited from a PR centre in the Netherlands. ParticipantsThe study population consisted of 157 patients with clinically stable COPD who were referred for and completed PR. MeasurementsA comprehensive neuropsychological examination before start of PR was administered. Changes from baseline to PR completion in functional exercise capacity [6-minute walk test (6MWT)], disease-specific health status [COPD Assessment Test (CAT) and St George's Respiratory Questionnaire-COPD specific (SGRQ-C)], psychological well-being [Hospital Anxiety and Depression Scale (HADS)], COPD-related knowledge, and their need for information [Lung Information Needs Questionnaire (LINQ)] were compared between patients with and without cognitive impairment using independent samples t tests or Mann-Whitney U tests. ResultsOut of 157 patients with COPD [mean age 62.9 (9.4) years, forced expiratory volume in the first second 54.6% (22.9%) predicted], 24 patients (15.3%) did not complete PR. The dropout rate was worse in patients with cognitive impairment compared to those without cognitive impairment (23.3% and 10.3%, P = .03). Mean changes in PR outcomes after PR did not differ between completers with and without cognitive impairment. The proportion of patients with a clinically relevant improvement in 6MWT, CAT, SGRQ-C, HADS, and LINQ scores was comparable for patients with and without cognitive impairment. ConclusionPR is an effective treatment for patients with COPD and cognitive impairment. Yet patients with cognitive impairment are at increased risk for not completing the PR program.

Pulmonary Rehabilitation in Patients with Respiratory Disease

Background. Limited evidence suggests that pulmonary rehabilitation be included in the management of restrictive lung diseases. The purpose of this study was to document pulmonary rehabilitation outcomes in patients with respiratory diseases other than chronic obstructive pulmonary disease (COPD). Methods. Clinical outcomes of 31patients with respiratory diseases other than COPD and 190 patients with COPD, seen over a 35-month period, were reviewed retrospectively. Patients were evaluated for a 6-minute walk, arm curl strength, chair stand strength, the St. George’s Respiratory Questionnaire (SGRQ) total score, SGRQ symptom scores, SGRQ activity levels, and SGRQ impact of respiratory illness on the patient’s life. Outcome measures were obtained before the start of pulmonary rehabilitation and after a minimum of nine therapy visits. Results. Pre- and post-rehabilitation changes in the 6-minute walk, arm curl strength, chair stand strength, the St. George’s Respiratory Questionnaire (SGRQ) total score, SGRQ symptom scores, SGRQ activity levels, and SGRQ impact scores improved significantly for both groups. However, non-COPD patients achieved significantly higher mean SGRQ impact scores and arm curl strength than patients with COPD. Conclusions. Pulmonary rehabilitation should be recommended for all patients with respiratory disease, not only those with COPD.

A better response in exercise capacity after pulmonary rehabilitation in more severe COPD patients

Pulmonary rehabilitation (PR) has positive effects on exercise capacity in Chronic Obstructive Pulmonary Disease (COPD). However, not all COPD patients benefit from PR to the same extent. We investigated whether there is a patient profile, which is associated with the improvement in endurance exercise capacity. In this observational study, we included 102 COPD patients who followed PR (age 60±10 (mean±SD) years, FEV(1)%predicted 44±16%, 54 men). Lung function, maximal incremental cycle testing (Wpeak, VO(2)peak, Δlactate), quadriceps force and incremental and endurance shuttle walk test (ISWT/ESWT) were performed at the start of PR. The ESWT was repeated after 7 weeks of PR. Mean change in ESWT (ΔESWT) was 100±154%. Four variables showed a statistically significant negative correlation with ΔESWT: FEV(1)%pred. (ρ=-0.20), Wpeak (ρ=-0.24), Δlactate (ρ=-0.33) and incremental shuttle walk test (ISWT) (ρ=-0.31). A cluster analysis identified two patient profiles: A profile with high ΔESWT, TLC and RV and low FEV(1), VO(2)peak, quadriceps force, Δlactate, HR(peak)%pred. and ISWT distance and a profile with low ΔESWT, TLC and RV and high FEV(1), VO(2)peak, quadriceps force, Δlactate, HR(peak)%pred. and ISWT distance. Single variables from lung function or exercise testing at baseline have limited predictive value for response to exercise training. However, patients with worse disease status (i.e. a combination of lower FEV(1), more hyperinflation, lower exercise capacity and worse quadriceps force) improve more in endurance exercise capacity.