What are the shortterm effects of pulmonary rehabilitation

A number of randomized controlled trials have shown that rehabilitation leads to short-term effects in patients with COPD [29,30,32,34]. In this chapter, we consider studies with a duration of a maximum of 6 months to be short-term. Important in this respect is to interpret these results in the light of the minimal clinically important difference (MCID). Looking at the MCID, it has been shown that rehabilitation relieves dyspnoea and improves control over COPD [35]. Although most rehabilitation studies do also report increased exercise tolerance, the value of this improvement is less clear (Fig. 12.3). In contrast, Celli concluded on basis of a number of controlled randomized trials that rehabilitation does improve exercise tolerance, dyspnoea and quality of life [36].

Positive results have been shown in different settings. Goldstein et al. set up a randomized controlled trial in which they assigned 89 patients (FEV1 35% of predicted) to either an in-patient rehabilitation programme for 8weeks, followed by an outpatient programme of 16 weeks, or to a conventional care programme consisting of medication alone [34]. Patients in the rehabilitation group showed an improved endurance capacity compared to the control group. In addition, they found a decrease in dyspnoea, fewer complaints with regard to emotional function and better control over the disease. Wijkstra et al. showed that patients after 12 weeks of home rehabilitation (FEV1 44% of predicted; n=30) had significantly better exercise tolerance, a better quality of life, and fewer dyspnoea complaints during exercise compared to the controls [29]. It seems, therefore, that rehabilitation is equally successful in different settings. One Dutch study is important in this respect. Strijbos et al. compared home rehabilitation (n = 15), outpatient rehabilitation (n = 15)

and a control group (n = 15) in COPD (FEV141% of predicted) [32]. Patients received a 12-week programme consisting of visiting the physiotherapist twice weekly either at the outpatient clinic (outpatient group) or in their home town (home group). In addition, a nurse and a physician supervised the patients once a month. After 12weeks, improved exercise tolerance and decreased dyspnoea were observed in both rehabilitation groups compared to the control group. In addition, both Dutch studies found a clinically relevant improvement in health status after 12weeks of training. In contrast to the studies by Wijkstra and Strijbos, Wedzicha et al. showed that health status did not improve after home-based rehabilitation in patients with a FEV1 of 0.9L, which is lower than in the above-mentioned studies [37]. In this study, the patients were stratified according to their disability assessed by the MRC dyspnoea scale. The patients were randomized to receive outpatient rehabilitation if their dyspnoea was graded 3-4. They received home rehabilitation if their dyspnoea was graded as 5, meaning that they were too breathless to leave the house. Sixty patients were randomly assigned to the outpatient group, 30 received rehabilitation and 30 patients were included in the control group. Another 60 were included for home-based rehabilitation—i.e. 30 patients received exercise training by a local physiotherapist, while 30 patients were randomized to the control group. Patients receiving outpatient rehabilitation significantly improved their exercise tolerance and health status, assessed using the SGRQ, compared to the control group after 8 weeks of training. Although it is debatable whether the training intensity in the home rehabilitation group was high enough to achieve benefits, no significant improvements were shown in this group. This is the only study that has stratified patients according the severity of disability on the MRC dyspnoea scale, which makes this study unique. The study shows that the level of disability may influence the effects of rehabilitation, although it may be arguable whether these patients with complex problems (MRC dyspnoea scale 5) are the best candidates for home-based rehabilitation. Such patients might be better candidates for inpatient rehabilitation, as a multidisciplinary approach is needed. Still, the study by Wedzicha raises an important point, which may be particularly helpful in developing strategies to find good candidates for adequate rehabilitation in an appropriate setting.

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