Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Respiratory rehabilitation improved exercise tolerance and quality of life

ACP J Club. 1995 May-June;122:63. doi:10.7326/ACPJC-1995-122-3-063


Source Citation

Goldstein RS, Gort EH, Stubbing D, Avendano MA, Guyatt GH. Randomised controlled trial of respiratory rehabilitation. Lancet. 1994 Nov 19; 344:1394-7.


Abstract

Objective

To determine the effectiveness of a respiratory rehabilitation program compared with conventional care in patients with chronic obstructive pulmonary disease (COPD).

Design

24-week randomized controlled trial.

Setting

Inpatient and outpatient services of a tertiary care center in Canada.

Patients

Of 244 patients screened, 89 (mean age 65 y, 45 women) had severe stable COPD, had not smoked for ≥ 2 months, had dyspnea in ≥ 3 activities of daily living (ADL), had no medical conditions limiting exercise tolerance or cognitive functioning, and spoke English. Patients who had participated in a supervised respiratory rehabilitation program within the previous 2 years were excluded. 78 patients (88%) completed the study.

Intervention

Patients were assigned to 2 months of inpatient rehabilitation plus 4 months of outpatient care (n = 45) or to conventional care (n = 44). The rehabilitation program included 30-minute stretching and breathing classes; alternating low- and high-power exercises for 40 minutes; treadmill and upper extremity training; leisure walking; lectures; relaxation classes; and recreational activities. Outpatient care included attendance at the outpatient clinic and home visits by a physiotherapist.

Main outcome measures

6-minute walking test; submaximal cycle time; and dyspnea, fatigue, emotional function, and mastery assessed by the Chronic Respiratory Disease Questionnaire (CRDQ).

Main results

At 24 weeks, patients in the rehabilitation program had superior 6-minute walking distance and submaximal cycle time compared with patients receiving conventional care (95% CI for the 37.9-m difference in walking distance, 10.8 to 65.0 m; CI for the 4.7-min difference in cycle time, 2.1 to 7.3 min). Rehabilitation group patients showed more improvement in CRDQ scores for dyspnea, fatigue, emotional function, and mastery than did conventional care patients (for each comparison, P ≤ 0.05).

Conclusion

A respiratory rehabilitation program promoted increased exercise tolerance and enhanced the quality of life in patients with chronic obstructive pulmonary disease.

Sources of funding: West Park Hospital Foundation; Ontario Ministry of Health; Respiratory Health Network of Centres of Excellence.

For article reprint: Dr. R.S. Goldstein, West Park Hospital, 82 Buttonwood Avenue, Toronto, Ontario M6M 2J5, Canada. FAX 416-243-8947.


Commentary

"Pulmonary rehabilitation is a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual's maximum level of independence and functioning in the community" (1).

A properly run pulmonary rehabilitation program can improve compliance and success with medical management. In the case of severe, irreversible pulmonary disease, this holistic approach may be more important than the medicines physicians prescribe in ensuring that patients have the highest possible functional capacity allowed by their pulmonary handicaps and overall life situations.

Patients with COPD often show anxiety, depression, fatigue, coping difficulty, and somatic preoccupation. They also may exhibit respiratory panic, in which dyspnea is worsened by emotional change. Fear of dyspnea can cause inactivity and isolation. The mechanism of improvement with pulmonary rehabilitation is not totally clear, but is this important as long as improved motivation, desensitization to dyspnea, or improved skills occur?

The goals of the comprehensive care of patients with pulmonary problems should be to prevent or treat reversible disease and complications using optimal standard medical care, to prolong life with chronic oxygen therapy when indicated, to prevent further damage through smoking cessation, and to improve quality of life. This is the essence of rehabilitation through exercise conditioning, physical and occupational therapy, nutritional counseling, psychosocial support, and education.

These Canadian authors achieved all of these goals in a highly motivated group of 78 persons who completed the comprehensive, fully supervised program. The program was expensive ($12 000/patient) and justifying the inpatient phase is difficult. This study, however, has confirmed the benefit of supervised outpatient care using the Respicare program (2). The findings were also confirmed in a subsequent meta-analysis (3). This approach is beneficial for patients with all lung diseases and is incorporated in the preoperative preparation for lung and heart-lung transplantation. The benefits are no longer in doubt; only the mechanism for reducing cost is still in question.

Michael F. Tenholder, MD
Veterans Affairs Medical Center at MemphisMemphis, Tennessee, USA


References

1. National Institute of Child Health and Human Development. Research plan for the National Center for Medical Rehabilitation Research. NIH publication no. 93-3509;1993.

2. Haggerty MC, Stockdale-Woolley R, Nair S. Respi-Care. An innovative home care program for the patient with chronic obstructive pulmonary disease. Chest. 1991;100:607-12.

3. Lacasse Y, Wong E, Guyatt GH, et al. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet. 1996;348:1115-9.