Pulmonary rehabilitation (PR) is a well-established evidence-based multidisciplinary programme of care for patients with symptomatic chronic respiratory impairment, targeting the extrapulmonary manifestations of the disease. The programme is individually tailored and should contain high-intensity progressive aerobic training, strength training, and self-management education. PR is probably the most cost-effective intervention for COPD. It interrupts the vicious cycle of dyspnoea leading to inactivity, subsequent deconditioning, and further worsening dyspnoea on more minimal exertion.
Aims of rehabilitation
• To reduce disability in people with chronic lung disease
• To improve QoL and restore independence
• To diminish the health care burden of disease.
demonstrated there were improvements in functional status with PR despite no change in severity of airflow obstruction.
of 23 RCTs, where PR included exercise training for at least 4 weeks (although the content was varied), confirmed the benefit of rehabilitation, with statistically and clinically significant improvements in functional or maximal exercise capacity and/or QoL. Symptoms of dyspnoea and fatigue are improved, and patients gain an enhanced sense of control over their condition.
Other benefits of PR
• Patients across the disease severity spectrum of COPD (including those with severe airflow obstruction) can benefit from PR
• Studies show patients who completed a rehabilitation course may have fewer hospital admissions for exacerbations than those who had not had rehabilitation, and hospital stays were shorter (10 days vs 21 days)
• Respiratory muscle training improves dyspnoea, but not exercise capacity or health-related QoL, above aerobic training
• High-intensity lower limb aerobic training is recommended, rather than low-intensity training
• Supplemental strength training improves muscle strength but does not provide additional benefit to exercise capacity or health-related QoL than aerobic training alone
• Early PR is recommended after a COPD exacerbation. It is safe and improves exercise tolerance, health-related QoL and reduces hospital admissions
• Short-term programmes achieve overall similar outcome benefits across the spectrum of patient disability. A minimum programme length of 6 weeks is recommended
• Decline in exercise tolerance and health status tends to occur between 6 and 12 months after completion of a course. Sustained improvement with ongoing rehabilitation sessions has yet to be evaluated.
• Anyone with chronic lung disease causing functional impairment despite receiving optimum medical treatment
• Well-motivated patients seem to benefit most
• Patients with poor lower limb mobility may still benefit from upper limb exercise and the education package
• O2 therapy is not a contraindication to rehabilitation
• Recent exacerbation of COPD is not a contraindication
• Stable ischaemic heart disease and heart failure are not contraindications
• Depression should be addressed prior to participation in PR, if possible, to increase the likelihood of benefit.
Candidates in whom rehabilitation may not be indicated
• Unstable ischaemic heart disease, severe valvular heart disease, severe cognitive impairment, or locomotor difficulties
• Poorly motivated people, with geographical or transport problems making attendance difficult, tend to do less well. It may be, however, that different locations (community or home-based) and different interfaces (manuals or web-based) may help these challenges of hospital-based programmes.
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Programmes are usually run on an outpatient basis but can be done in the community, home, or as an inpatient. They are run by a multiprofessional team—physician, physiotherapist, occupational therapist, dietician, nurse, pharmacist, social worker, and psychologist. A minimum programme length of 6 weeks is recommended. Programmes should be regularly audited by the department.
• Physical training The main component of the programme is progressive high-intensity aerobic exercise, such as walking and cycling, for a minimum of 2–3 times per week, with two supervised/class sessions. The prescription is individualized, and the benefits are improved with higher-intensity training. Upper or lower limb strength exercise with weights is often included. O2 supplementation may be required if significant desaturation occurs during exercise to below 80% and if exercise tolerance improves with O2
• Performance enhancement has been investigated. Improvements shown with: tiotropium, in addition to PR, vs PR alone, NIV, partitioned training (single leg cycling), testosterone (improves muscle strength). No improvement with: creatine, O2. Neutral or subgroups: helium hyperoxia, nutrition
• Disease education
• Psychological and social intervention with advice on anxiety and depression, smoking cessation, plus physiotherapy and occupational therapy input
• Nutritional education to optimize body weight and muscle mass.
• Optimize medical treatment
• O2 saturation on exercise
• ECG may be warranted, especially if history of cardiac disease.
Outcome assessment measures
• Exercise performance Often with SWT or 6MWT to assess ability and progress (see Box 60.1)
• Health status Disease-specific questionnaires:
• Chronic Respiratory Questionnaire (CRQ)
• St George’s Respiratory Questionnaire
• Generic questionnaires, e.g. the Short Form-36 (SF-36)
• Hospital Anxiety and Depression scores (HADS) are measured
• Practical Pedometers can be used for direct feedback and to improve performance.
• Access to PR for all who may benefit
• How to optimally maintain the improvements following a rehabilitation programme
• Using technology to enhance compliance and delivery of PR
• Expanding the potential population who may benefit from PR
• Further understanding the mechanisms of health benefits from improving physical activity
• Targeting exercise training earlier in the disease process.