NIHR Signal Pulmonary rehabilitation improves quality of life and exercise capacity

Published on 24 February 2015

This Cochrane systematic review found that pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD) improved quality of life and exercise capacity compared to usual care. It also relieved shortness of breath and fatigue. This updated review provides stronger evidence to support NICE's recommendation that pulmonary rehabilitation should be available to everyone who is disabled by COPD. The optimal length, number of sessions and type of staff delivering the pulmonary rehabilitation programmes is not yet clear.

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Why was this study needed?

Three million people live with COPD in England, which includes diseases like chronic bronchitis and emphysema. The NHS spends about £1 billion a year on treatment. Pulmonary rehabilitation is a treatment package that involves exercise training and often educational and psychological support, normally lasting for at least four weeks. A 2006 Cochrane review showed that, compared with usual care, pulmonary rehabilitation improved quality of life, but not exercise capacity. This 2015 Cochrane review updates that work to include 34 newer trials. These have taken a more focussed look at disease related quality of life focussing on walking distance, a measure of exercise capacity.

What did this study do?

This was a systematic review of randomised controlled trials (RCTs) comparing the effect of pulmonary rehabilitation or usual care on quality of life and exercise capacity in people with COPD. Quality of life measurements included shortness of breath and fatigue up to three months after the completion of the intervention. Standard Cochrane systematic review methods were used and the RCTs were generally at low risk of bias, so the results should be reliable.

What did it find?

Sixty five RCTs were included, with a total of 3,822 participants. Pulmonary rehabilitation improved overall quality of life, shortness of breath and exercise capacity, compared with usual care. These improvements were large enough to be considered clinically significant.

  • Shortness of breath improved by 0.8 on a scale of 1 to 7
  • Overall quality of life improved by 8 points on a 100 point scale
  • Walking distance improved by 40 metres

What does current guidance say on this issue?

The current 2010 NICE guideline states that pulmonary rehabilitation should be made available to all patients who consider themselves “functionally disabled” by COPD, including those needing recent hospital care. Rehabilitation programmes should be held at a time and place that suit patients, and include “multicomponent, multidisciplinary interventions” (physical training, disease education, nutritional, psychological and behavioural intervention) tailored to the individual’s needs. Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required.

The NICE guideline states that there is good evidence that pulmonary rehabilitation is cost-effective in the outpatient setting compared to usual care.

What are the implications?

The findings of this latest review add further support to NICE guidance that pulmonary rehabilitation is effective and should be made available to all eligible people with COPD. The authors suggested that future research studies should focus on identifying which components of pulmonary rehabilitation are essential and how long treatment effects last.

In a 2011 audit of 239 UK respiratory units, only 58% provided pulmonary rehabilitation for all eligible patients. This suggests a gap in clinical practice or commissioning of this service.

Pulmonary rehabilitation is a complex intervention, incorporating physical training, disease education, and nutritional, psychological and behavioural intervention. Implementation support from NICE is available. The University Hospitals of Leicester NHS Trust has also published a QIPP case study of a successful implementation of a pulmonary rehabilitation programme, in this case led by a team of COPD specialist nurses.

Some evidence suggests that any programme should include at least four weeks of exercise training; NICE recommends six weeks. However the optimal duration of programmes, number of sessions offered per week, and type of staff required to deliver pulmonary rehabilitation programmes remains unclear. Subgroup analysis in this review suggested that exercise only interventions were as effective as other, more complex interventions. Focussing on the critical components of the programme may therefore lead to improvements in cost-effectiveness.

Citation

McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;2:CD003793.

Bibliography

Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. British Thoracic Society Standards of Care Committee 2013

National Clinical Guideline Centre. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Update Guideline. London: National Clinical Guideline Centre - Acute and Chronic Conditions; 2010

NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). CG101. London: National Institute of Health and Care Excellence; 2010

NICE. Implementation Programme: NICE support for commissioners and others using the quality standard for Chronic obstructive pulmonary disease (COPD). London: National Institute of Health and Care Excellence; 2011

Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13-64

The Development and Implementation of a COPD Discharge Care Bundle at University Hospitals of Leicester NHS Trust. QIPP Case study. [Leicester]: University Hospitals of Leicester NHS Trust; 2012

Yohannes A, Stone R, Lowe D, et al. Pulmonary rehabilitation in the United Kingdom. Chron Respir Dis 2011;8:193–9.

Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. British Thoracic Society Standards of Care Committee 2013

Why was this study needed?

Three million people live with COPD in England, which includes diseases like chronic bronchitis and emphysema. The NHS spends about £1 billion a year on treatment. Pulmonary rehabilitation is a treatment package that involves exercise training and often educational and psychological support, normally lasting for at least four weeks. A 2006 Cochrane review showed that, compared with usual care, pulmonary rehabilitation improved quality of life, but not exercise capacity. This 2015 Cochrane review updates that work to include 34 newer trials. These have taken a more focussed look at disease related quality of life focussing on walking distance, a measure of exercise capacity.

What did this study do?

This was a systematic review of randomised controlled trials (RCTs) comparing the effect of pulmonary rehabilitation or usual care on quality of life and exercise capacity in people with COPD. Quality of life measurements included shortness of breath and fatigue up to three months after the completion of the intervention. Standard Cochrane systematic review methods were used and the RCTs were generally at low risk of bias, so the results should be reliable.

What did it find?

Sixty five RCTs were included, with a total of 3,822 participants. Pulmonary rehabilitation improved overall quality of life, shortness of breath and exercise capacity, compared with usual care. These improvements were large enough to be considered clinically significant.

  • Shortness of breath improved by 0.8 on a scale of 1 to 7
  • Overall quality of life improved by 8 points on a 100 point scale
  • Walking distance improved by 40 metres

What does current guidance say on this issue?

The current 2010 NICE guideline states that pulmonary rehabilitation should be made available to all patients who consider themselves “functionally disabled” by COPD, including those needing recent hospital care. Rehabilitation programmes should be held at a time and place that suit patients, and include “multicomponent, multidisciplinary interventions” (physical training, disease education, nutritional, psychological and behavioural intervention) tailored to the individual’s needs. Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required.

The NICE guideline states that there is good evidence that pulmonary rehabilitation is cost-effective in the outpatient setting compared to usual care.

What are the implications?

The findings of this latest review add further support to NICE guidance that pulmonary rehabilitation is effective and should be made available to all eligible people with COPD. The authors suggested that future research studies should focus on identifying which components of pulmonary rehabilitation are essential and how long treatment effects last.

In a 2011 audit of 239 UK respiratory units, only 58% provided pulmonary rehabilitation for all eligible patients. This suggests a gap in clinical practice or commissioning of this service.

Pulmonary rehabilitation is a complex intervention, incorporating physical training, disease education, and nutritional, psychological and behavioural intervention. Implementation support from NICE is available. The University Hospitals of Leicester NHS Trust has also published a QIPP case study of a successful implementation of a pulmonary rehabilitation programme, in this case led by a team of COPD specialist nurses.

Some evidence suggests that any programme should include at least four weeks of exercise training; NICE recommends six weeks. However the optimal duration of programmes, number of sessions offered per week, and type of staff required to deliver pulmonary rehabilitation programmes remains unclear. Subgroup analysis in this review suggested that exercise only interventions were as effective as other, more complex interventions. Focussing on the critical components of the programme may therefore lead to improvements in cost-effectiveness.

Citation

McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;2:CD003793.

Bibliography

Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. British Thoracic Society Standards of Care Committee 2013

National Clinical Guideline Centre. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Update Guideline. London: National Clinical Guideline Centre - Acute and Chronic Conditions; 2010

NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). CG101. London: National Institute of Health and Care Excellence; 2010

NICE. Implementation Programme: NICE support for commissioners and others using the quality standard for Chronic obstructive pulmonary disease (COPD). London: National Institute of Health and Care Excellence; 2011

Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13-64

The Development and Implementation of a COPD Discharge Care Bundle at University Hospitals of Leicester NHS Trust. QIPP Case study. [Leicester]: University Hospitals of Leicester NHS Trust; 2012

Yohannes A, Stone R, Lowe D, et al. Pulmonary rehabilitation in the United Kingdom. Chron Respir Dis 2011;8:193–9.

Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. British Thoracic Society Standards of Care Committee 2013

Pulmonary rehabilitation for chronic obstructive pulmonary disease

Published on 24 February 2015

McCarthy, B.,Casey, D.,Devane, D.,Murphy, K.,Murphy, E.,Lacasse, Y.

Cochrane Database Syst Rev Volume 2 , 2015

BACKGROUND: Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise capacity) attributable to the programmes. This review updates the review reported in 2006. OBJECTIVES: To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal exercise capacity in persons with COPD. SEARCH METHODS: We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were current as of March 2014. SELECTION CRITERIA: We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. We defined 'pulmonary rehabilitation' as exercise training for at least four weeks with or without education and/or psychological support. We defined 'usual care' as conventional care in which the control group was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered best practice at the start of the trial for all participants. DATA COLLECTION AND ANALYSIS: We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary study. We used standard methods as recommended by The Cochrane Collaboration. MAIN RESULTS: Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.We noted no significant demographic differences at baseline between members of the intervention group and those who received usual care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were community based (at community centres or in individual homes) and one study had both a hospital component and a community component. Most programmes were of 12 weeks' or eight weeks' duration with an overall range of four weeks to 52 weeks.The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition, it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by several studies, this impacted the overall risk of bias.We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies = 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19; low-quality evidence). Statistically significant improvements were noted in all domains of the St. George's Respiratory Questionnaire (SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15, 95% CI -7.95 to -2.36; N = 572; studies = 7).Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95% CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference. Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution. AUTHORS' CONCLUSIONS: Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.

The joint American Thoracic Society and European Respiratory Society define pulmonary rehabilitation as: "a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health enhancing behaviours."

Commentary

This review confirms the place of pulmonary rehabilitation, a supervised programme of exercise training and education delivered by a multidisciplinary team, as one of the most important and highest value elements in the management of COPD. Trials show consistently that pulmonary rehabilitation improves breathlessness, exercise capacity and quality of life. These improvements are clinically as well as statistically significant. Despite existing strong recommendations in NICE guidance many patients still have difficulty accessing or are unable to access pulmonary rehabilitation programmes and this needs to be addressed urgently.

Dr Nicholas Hopkinson, Clinical Senior Lecturer, Imperial College & Honorary Consultant Chest Physician, The Royal Brompton Hospital