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


Therapeutics

Review: Exercise and psychosocial support may improve quality of life in COPD

ACP J Club. 1997 Sep-Oct;127:40. doi:10.7326/ACPJC-1997-127-2-040


Source Citation

Lacasse Y, Guyatt GH, Goldstein RS. The components of a respiratory rehabilitation program. A systematic overview. Chest. 1997 Apr;111:1077-88.


Abstract

Objective

To determine the effect of various components of respiratory rehabilitation on exercise capacity and health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD).

Data sources

Studies were identified by searching MEDLINE (1966 to April 1996) using the keywords lung diseases, obstructive and (exercise therapy or rehabilitation); or (patient education or health education); or (psychotherapy, counseling, or social support) combined with (research design, longitudinal studies, evaluation study, or randomized controlled trial). Bibliographies of relevant articles, a statement by the American Thoracic Society, and abstracts presented at international meetings were scanned. Experts in respiratory rehabilitation were also contacted.

Study selection

Randomized controlled trials that evaluated the use of exercise therapy, education, psychological support, and breathing exercises for COPD were selected if the treatment effect of a specific component of rehabilitation could be isolated and exercise capacity, HRQL, compliance, and knowledge about the disease were measured.

Data extraction

Data were extracted on patient characteristics, number and distribution of patients who withdrew, a full description of the rehabilitation program, exercise capacity, and HRQL outcome measures and their corresponding results.

Main results

22 trials met the selection criteria. 2 studies found that patients can achieve physiologic training by exercising at or above their anaerobic threshold. 1 study compared the effects of upper limb training with lower limb training and a combination of both and showed that training was muscle specific. Addition of inspiratory muscle training to general exercise training was studied in 7 trials, but the results were equivocal. Few trials have been done on education alone or as an adjunct to exercise training for COPD. 2 trials studied the effects of progressive relaxation on dyspnea and anxiety and found that the treatment group had less dyspnea and anxiety than control patients. Behavioral modification as an adjunct to exercise training was examined in 1 trial. At 3-month follow-up, the experimental groups showed improvements in the time spent walking, exercise tolerance, quality of well-being scores, and walking self-efficacy.

Conclusion

Exercise training and psychosocial support as components of a respiratory rehabilitation program may improve functional exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease.

Source of funding: Not stated.

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


Commentary

The major reason patients with COPD seek medical attention is exertional breathlessness. Typically, these individuals decide to see a physician because dyspnea limits their ability to perform daily activities and affects HRQL (1). Most patients with advanced lung disease are deconditioned, which further contributes to progressive breathlessness.

Why is pulmonary rehabilitation important? Evidence from randomized controlled trials proves that pulmonary rehabilitation is beneficial; it reduces the severity of dyspnea, improves HRQL, and increases exercise endurance. Based on these studies, exercise training is an essential component of pulmonary rehabilitation. In a 1995 statement, the American Thoracic Society recommended that pulmonary rehabilitation be prescribed for patients with COPD who have "severe symptoms or decreased functional capacity" after optimal bronchodilator and medical therapy (2). In addition, lung volume reduction surgery for patients with emphysema has further renewed interest in pulmonary rehabilitation.

Presently, pulmonary rehabilitation is underprescribed for the 14 million patients with COPD and the many other patients with advanced lung disease. Appropriate outcome measures are available to examine the numerous important questions regarding types of training, exercise intensity, and inspiratory muscle training raised by Lacasse and colleagues. It is likely that rehabilitation programs, particularly maintenance activities, will occur in the home (3).

Donald A. Mahler, MD
Dartmouth-Hitchcock Medical CenterLebanon, New Hampshire, USA

Donald A. Mahler, MD
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire, USA


References

1. Mahler DA, Faryniarz K, Tomlinson D, et al. Impact of dyspnea and physiologic function on general health status in patients with chronic obstructive pulmonary disease. Chest. 1992;102:395-401.

2. American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;152(Suppl): S77-120.

3. Wijkstra PJ, van der Mark TW, Kraan J, et al. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD). Eur Respir J. 1996;9:104-10.