Fig. 12.5 Quality of life. Group A (rehabilitation group follow-up once a week); Group B (rehabilitation group follow-up once a month); Group C (control group, no rehabilitation at all). *, P < 0.05; **, P < 0.01 compared with baseline; #, P < 0.05 compared with the control group .
was no difference between the rehabilitation group (n=99) and the control group (n = 101) in the number of hospitalizations, but a significant difference was found in the number of days spent in hospital (mean 10.4 ± 9.7 vs. 20.7 ± 20.7; P=0.022). Compared with the control group, the rehabilitation group also showed greater improvements in walking distance and in both general and specific health status.
Another randomized controlled trial was conducted in patients with moderate to severe COPD (FEV1 35% of predicted) . Thirty patients randomized to rehabilitation received 3months of outpatient breathing retraining and chest physiotherapy, 3 months of daily supervised exercise and 6 months of weekly supervised breathing exercises. Significant differences were found between the groups in perception of dyspnoea, 6-minute walking distance, and day-to-day dyspnoea, fatigue and emotional function measured by the Chronic Respiratory Questionnaire. The improvements were maintained for a total period of 2years. In addition, the rehabilitation group experienced a significant reduction in exacerbations.
At present only two studies have been published investigating the effects of pulmonary rehabilitation after 5 years. In the study by Ries et al., 119 patients with COPD (FEVj 1.2L) were randomly assigned to either an 8-week comprehensive outpatient rehabilitation programme or an 8-week education programme . Rehabilitation consisted of 12 4-h sessions including education, physical and respiratory care instruction, psychosocial support and supervised exercise training. Monthly supervision was given during the first year. The education group received four 2-h sessions about education. After 2 months, maximal exercise tolerance, endurance capacity, perceived breath-lessness, and muscle fatigue all improved significantly compared to the education group. However, although these effects were still present after 1 year, they tended to diminish afterwards. A recently published abstract reported positive effects 5 years after home rehabilitation . In this study, Strijbos et al. presented follow-up data from an earlier study  comparing home-based rehabilitation, outpatient rehabilitation, and a control group. After 5years, the walking distance in the home rehabilitation group was still increased compared to the control group.
In summary, there is now enough evidence that rehabilitation leads to short-term benefits in quality of life, exercise tolerance and dyspnoea in patients with COPD. However, the long-term benefits are less clear. Home-based rehabilitation may be an attractive approach for maintaining long-term benefits, as the patients can incorporate what they learn into their daily lives more easily . On the other hand, some patients with severe disability and handicap need a more multidisciplinary approach. These patients may be better candidates for rehabilitation in a centre (in-patient or outpatient).
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