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


Therapeutics

Meta-analysis: Respiratory rehabilitation relieves dyspnea in COPD

ACP J Club. 1997 Mar-Apr;126:38. doi:10.7326/ACPJC-1997-126-2-038


Source Citation

Lacasse Y, Wong E, Guyatt GH, et al. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet. 1996 Oct 26;348:1115-9.


Abstract

Objective

To assess the effectiveness of respiratory rehabilitation on exercise capacity and health-related quality of life (HRQL) in patients with chronic obstructive pulmonary disease (COPD).

Data sources

Randomized controlled trials were identified by searching MEDLINE (1966 to October 1995) and Cumulated Index to Nursing and Allied Health (1982 to October 1995) using the keywords lung diseases, obstructive; rehabilitation; exercise therapy; research design; longitudinal studies; evaluation study; and randomized controlled trial. Reference lists of retrieved articles were also scanned, abstracts presented at international meetings were searched, and experts were contacted.

Study selection

Studies were selected if they included patients with a clinical diagnosis of COPD and evaluated inpatient, outpatient, or home-based rehabilitation programs (including exercise therapy with or without any form of education or psychological support) that lasted ≥ 4 weeks. The respiratory rehabilitation program had to have been compared with conventional community care or other interventions that were unlikely to affect exercise capacity or quality of life.

Data extraction

Data were extracted on patient characteristics; the setting, components, and duration of the respiratory rehabilitation program; exercise capacity; and HRQL (assessed in most studies by use of a questionnaire about chronic respiratory problems).

Main results

14 studies met the selection criteria. Most patients were elderly and had severe COPD. Statistically significant improvements were found for all outcomes. The effect of respiratory rehabilitation on maximum exercise capacity was assessed in 11 trials involving 309 patients. The pooled effect size was 0.3 SD units (95% CI 0.1 to 0.6 SD), which corresponds to 8.3 W (CI 2.8 to 16.5 W) in natural units of the incremental cycle ergometer test. The effect of respiratory rehabilitation on functional exercise capacity was assessed in 11 trials involving 413 patients. For the 6-minute walk test, a difference of 55.7 m (CI 27.8 to 92.8 m) was found between the treatment and control groups. The overall effect of treatment was compared with its minimum clinically important difference (MCID), defined as the smallest difference considered important by the average patient. For 2 features of HRQL, dyspnea and mastery, the overall treatment effect was larger than the MCID: 1.0 (CI 0.6 to 1.5) and 0.8 (CI 0.5 to 1.2), respectively, compared with an MCID of 0.5.

Conclusion

Respiratory rehabilitation that includes at least 4 weeks of exercise training relieves dyspnea and improves control over chronic obstructive pulmonary disease.

Source of funding: No external funding.

For article reprint: Dr. R.S. Goldstein, Department of Medicine, Division of Respiratory Medicine, University of Toronto, West Park Hospital, Toronto, Ontario M6M 2J5, Canada. FAX 416-243-8947.


Commentary

Although much of the damage caused by COPD is irreversible, many treatments are valuable. The meta-analysis by Lacasse and colleagues shows that a rehabilitation program can increase functional capacity, reduce dyspnea, and improve mastery. The patients in the studies (mean age 60 y) had severe COPD with a mean forced expiratory volume in 1 second that was 30% to 40% of the predicted value. The rehabilitation programs varied greatly, from 6 weeks to 6 months in duration; from inpatient to either outpatient or home settings; and from lower-limb exercises alone to lower- and upper-limb exercises, breathing exercises, and inspiratory muscle training. The programs also included psychological support, education, or combinations of these interventions. Although a post hoc analysis suggested more effect from longer courses, shorter, simpler outpatient or home-based programs will be most practical for those seeking respiratory rehabilitation.

Rehabilitation programs require enthusiasm and resources. Many elements, including nutrition and use of therapy, can be addressed during rehabilitation sessions. We need to sort out the most important parts of the programs and determine how they should be adapted for individual participants. This meta-analysis deals with the patient's status at the end of the rehabilitation program. To justify the work involved, the benefits must be maintained; this is likely to require continued exercise and motivation. 1 study showed that a visit to a physiotherapist each month maintained the effect on quality of life for 18 months (1).

The benefits of rehabilitation are not dramatic, but they are above and beyond those of conventional therapy and they improve physical performance and relevant quality-of-life measures. This meta-analysis provides encouragement for the wider development and evaluation of respiratory rehabilitation programs, their longer term effects, and their cost benefits.

P. John Rees, MD
Guy's HospitalLondon, England, UK


Reference

1. Wijkstra PJ, TenVergert EM, van Altena R, et al. Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease. Thorax. 1995;50: 874-8.