Effectiveness of pulmonary rehabilitation performed through exercise training for patients with stable COPD: A meta-analysis of randomized controlled trials

Zerbo Šporin, Dorjana; Domjanič, David; Žvanut, Boštjan

doi:10.2478/sjph-2022-0031

Abstract

Background

The application of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) improves functional capacity and health-related quality of life (HRQoL) at all stages of disease severity. The aim of this study was to determine the effects of PR, performed through exercise training (PR-ET), on functional capacity and HRQoL in patients with stable COPD.

Methods

The meta-analysis was performed by including randomized controlled trials (RCTs) involving patients with stable COPD who participated in different types of PR-ET in which six-minute walk distance (6MWD) and/ or St. George’s Respiratory Questionnaire total scores (SGRQ) were measured. The data search was conducted in December 2020 and January 2021.

Results

The first meta-analysis showed a statistically significant positive effect (MD=31.73m; p<0.00001) of PR-ET on 6MWD. Similarly, the second meta-analysis found a statistically significant favourable effect of pulmonary rehabilitation through exercise training on SGRQ total scores (MD=-8.09; p=0.002).

Conclusions

PR, which includes several different types of exercise training, has a positive effect on the functional capacity and HRQoL of patients with stable COPD. Further studies should be conducted to determine the effects of home-based PR-ET and PR-ET >8 weeks on SGRQ total scores.

References

Barnes PJ. Inflammatory mechanisms in patients with chronic obstructive pulmonary disease. J Allergy Clin Immunol. 2016;138(1):16–27. doi: 10.1016/j.jaci.2016.05.011.
Open DOI Search in Google Scholar Back to article
Müllerova H, Agusti A, Erqou S, Mapel DW. Cardiovascular comorbidity in COPD. Chest. 2013;144(4):1163–78.
Search in Google Scholar Back to article
World Health Organisation. Chronic obstructive pulmonary disease (COPD). Accessed Spetember 1st, 2022 at: https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)
Search in Google Scholar Back to article
Global initiative for chronic obstructive lung disease: global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2019 report. Accessed February 23th, 2021 at: https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf
Search in Google Scholar Back to article
Adeloye D, Chua S, Lee C, Basquill C, Papana A, Theodoratou E, et al. Global and regional estimates of COPD prevalence: systematic review and meta-analysis. J Glob Health. 2015;5(2):020415. doi: 10.7189/ jogh.05-020415.
Open DOI Search in Google Scholar Back to article
World Health Organisation. COPD predicted to be third leading cause of death in 2030. Accessed February 23, 2021 at: https://www.who.int/respiratory/copd/World_Health_Statistics_2008/en/
Search in Google Scholar Back to article
Wouters EF, Posthuma R, Koopman M, Liu W-Y, Sillen MJ, Hajian B, et al. An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease. Expert Rev Respir Med. 2020;14(2):149–61. doi: 10.1080/17476348.2020.1700796.
Open DOI Search in Google Scholar Back to article
Škrgat S, Triller N, Košnik M, Poplas Susič T, Petek D, Vodopivec Jamšek V, et al. Priporočila za obravnavo bolnika s kronično obstruktivno pljučno boleznijo na primarni in specialistični pulmološki ravni v Sloveniji. Zdrav Vest. 2017;86(1–2):65-75. doi: 10.6016/ ZdravVestn.2471.
Open DOI Search in Google Scholar Back to article
Maltais F, Decramer M, Casaburi R, Barreiro E, Burelle Y, Debigaré R, et al. An official American Thoracic Society/European Respiratory Society statement: update on limb muscle dysfunction in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2014;189(9):e15-62. doi: 10.1164/rccm.201402-0373ST.
Open DOI Search in Google Scholar Back to article
Zamzam MA, Azab NY, El Wahsh RA, Ragab AZ, Allam EM. Quality of life in COPD patients. Egypt J Chest Dis Tuberculosis. 2012;61(4):281–9. doi: 10.1016/j.ejcdt.2012.08.012.
Open DOI Search in Google Scholar Back to article
Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-complete measure of health status for chronic airflow limitation: the St. George’s Respiratory Questionnaire. Am Rev Respir Dis. 1992;145(6):1321–7. doi: 10.1164/ajrccm/145.6.1321.
Open DOI Search in Google Scholar Back to article
Jones PW. Quality of life, symptoms and pulmonary function in asthma: long-term treatment with nedocromil sodium examined in a controlled multicentre trial: Nedocromil Sodium Quality of Life Study Group. Eur Respir J. 1994;7(1):55–2. doi: 10.1183/09031936.94.07010055.
Open DOI Search in Google Scholar Back to article
Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester 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. doi: 10.1164/ rccm.201309-1634ST.
Open DOI Search in Google Scholar Back to article
Sievi N, Franzen D, Kohler M, Clarenbach C. Physical inactivity and arterial stiffness in COPD. Int J Chron Obstruct Pulmon Dis. 2015;10:1891-7. doi: 10.2147/COPD.S90943.
Open DOI Search in Google Scholar Back to article
Reis LFF, Guimarães FS, Fernandes SJ, Cantanhede LA, Dias CM, Lopes AJ, et al. A long-term pulmonary rehabilitation program progressively improves exercise tolerance, quality of life and cardiovascular risk factors in patients with COPD. Eur J Phys Rehabil Med. 2013;49(4):491–7.
Search in Google Scholar Back to article
Polverino F, Celli BR, Owen CA. COPD as an endothelial disorder: endothelial injury linking lesions in the lungs and other organs? (2017 Grover Conference Series). Pulm Circ. 2018;8(1):1–18. doi: 10.1177/2045894018758528.
Open DOI Search in Google Scholar Back to article
Clarenbach CF, Senn O, Sievi NA, Camen G, van Gestel AJR, Rossi VA, et al. Determinants of endothelial function in patients with COPD. Eur Respir J. 2013;42(5):1194–204. doi: 10.1183/09031936.00144612.
Open DOI Search in Google Scholar Back to article
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111–7. doi: 10.1164/ ajrccm.166.1.at1102.
Open DOI Search in Google Scholar Back to article
Porszasz J, Emtner M, Goto S, Somfay A, Whipp BJ, Casaburi R. Exercise training decreases ventilatory requirements and exercise-induced hyperinflation at submaximal intensities in patients with COPD. Chest. 2005;128(4):2025–34. doi: 10.1378/chest.128.4.2025.
Open DOI Search in Google Scholar Back to article
American College of Sports Medicine. General Principles of Exercise Prescription. In: Pescatello LS, Arena R, Riebe D, Thompson PD, editors. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013: 162-193.
Search in Google Scholar Back to article
Spruit MA, Gosselink R, Troosters T, De Paepe K, Decramer M. Resistance versus endurance training in patients with COPD and peripheral muscle weakness. Eur Respir J. 2002;19(6):1072–8. doi: 10.1183/09031936.02.00287102.
Open DOI Search in Google Scholar Back to article
Garvey C, Bayles MP, Hamm LF, Hill K, Holland A, Limberg TM, et al. Pulmonary rehabilitation exercise prescription in chronic obstructive pulmonary disease: review of selected guidelines: an official statement from the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2016;36(2):75–83. doi: 10.1097/HCR.0000000000000171.
Open DOI Search in Google Scholar Back to article
Mänttäri A, Suni J, Sievänen H, Husu P, Vähä-Ypyä H, Valkeinen H, et al. Six-minute walk test: a tool for predicting maximal aerobic power (VO 2 max) in healthy adults. Clin Physiol Funct Imaging. 2018;38(6):1038–45. doi: 10.1111/cpf.12525.
Open DOI Search in Google Scholar Back to article
Holland AE, Spruit MA, Troosters T, Puhan MA, Pepin V, Saey D, et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J. 2014;44(6):1428–46. doi: 10.1183/09031936.00150314.
Open DOI Search in Google Scholar Back to article
Malamud AL, Ricard PEH. Feasibility of the six-minute walk test for patients who have cystic fibrosis, are ambulatory, and require mechanical ventilation before lung transplantation. Phys Ther. 2016;96(9):1468–76. doi: 10.2522/ptj.20150235.
Open DOI Search in Google Scholar Back to article
Seoane L, Alex S, Pirtle C, Gupta M, Taylor DE, Valentine VG, et al. Utility of the 6-minute walk test following lung transplantation. Ochsner J. 2010;10(4):227–30.
Search in Google Scholar Back to article
Brooks D, Solway S, Weinacht K, Wang D, Thomas S. Comparison between an indoor and an outdoor 6-minute walk test among individuals with chronic obstructive pulmonary. Arch Phys Med Rehabil. 2003;84(6):873–6. doi: 10.1016/S0003-9993(03)00011-X.
Open DOI Search in Google Scholar Back to article
Valeiro B, Hernández C, Barberán-Garcia A, Rodríguez DA, Aibar J, Llop L, et al. Viabilidad de la evaluación domiciliaria del estado funcional de pacientes con enfermedad pulmonar obstructiva crónica en fase de recuperación de una exacerbación. Arch Bronconeumolog. 2016;52(5):256–61. doi: 10.1016/j.arbres.2015.10.010.
Open DOI Search in Google Scholar Back to article
Physiotherapy Evidence Database. PEDro scale. Accessed February 15, 2021 at: https://staging-pedro.neura.edu.au/english/resources/pedro-scale/
Search in Google Scholar Back to article
de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129–33. doi: 10.1016/S0004-9514(09)70043-1.
Open DOI Search in Google Scholar Back to article
Cashin AG, McAuley JH. Clinimetrics: Physiotherapy Evidence Database (PEDro) Scale. J Physiother. 2020;66(1):59. doi: 10.1016/j. jphys.2019.08.005.
Open DOI Search in Google Scholar Back to article
Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687–8. doi: 10.1136/bmj.g1687.
Open DOI Search in Google Scholar Back to article
Austin TM, Richter RR, Sebelski CA. Introduction to the GRADE approach for guideline development: considerations for physical therapist practice. Phys Ther. 2014;94(11):1652–9. doi: 10.2522/ ptj.20130627.
Open DOI Search in Google Scholar Back to article
GRADEpro GDT: GRADEpro guideline development tool. McMaster University and Evidence Prime, 2022. Accessed August 30th, 2021 at: https://gdt.gradepro.org/app/
Search in Google Scholar Back to article
Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. doi: 10.1136/bmj.327.7414.557.
Open DOI Search in Google Scholar Back to article
Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Statist Med. 2002;21(11):1539–58. doi: 10.1002/sim.1186.
Open DOI Search in Google Scholar Back to article
Farias CC, Resqueti V, Dias FAL, Borghi-Silva A, Arena R, Fregonezi GAF. Costs and benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease: a randomized controlled trial. Braz J Phys Ther. 2014;18(2):165–73. doi: 10.1590/s1413-35552012005000151.
Open DOI Search in Google Scholar Back to article
Hospes G, Bossenbroek L, Ten Hacken NHT, van Hengel P, de Greef MHG. Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: results of an exercise counseling program. Patient Educ Couns. 2009;75(2):274–8. 10.1016/j.pec.2008.10.005
Search in Google Scholar Back to article
Lahham A, McDonald CF, Moore R, Cox NS, Rawlings S, Nichols A, et al. The impact of home-based pulmonary rehabilitation on people with mild chronic obstructive pulmonary disease: a randomised controlled trial. Clin Respir J. 2020;14(4):335–44. doi: 10.1111/crj.13138.
Open DOI Search in Google Scholar Back to article
Li Y, Feng J, Li Y, Jia W, Qian H. A new pulmonary rehabilitation maintenance strategy through home-visiting and phone contact in COPD. Patient Prefer Adherence. 2018;12:97–104. doi: 10.2147/PPA. S150679.
Open DOI Search in Google Scholar Back to article
Pradella CO, Belmonte GM, Maia MN, Delgado CS, Luise APT, Nascimento OA, et al. Home-based pulmonary rehabilitation for subjects with COPD: a randomized study. Respir Care. 2015;60(4):526–32. doi: 10.4187/respcare.02994.
Open DOI Search in Google Scholar Back to article
Tsai LLY, McNamara RJ, Moddel C, Alison JA, McKenzie DK, McKeough ZJ. Home-based telerehabilitation via real-time videoconferencing improves endurance exercise capacity in patients with COPD: the randomized controlled TeleR study. Respirology. 2017;22(4):699–707. doi: 10.1111/resp.12966.
Open DOI Search in Google Scholar Back to article
Wijkstra PJ, van der Mark TW, Kraan J, van Altena R, Koeter GH, Postma DS. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD). Eur Respir J. 1996;9(1):104–10. doi: 10.1183/09031936.96.09010104.
Open DOI Search in Google Scholar Back to article
Xi F, Wang Z, Qi Y, Brightwell R, Roberts P, Stewart A, et al. Longterm effect of respiratory training for chronic obstructive pulmonary disease patients at an outpatient clinic: a randomised controlled trial. Clin Transl Med. 2015;4(1):31. doi: 10.1186/s40169-015-0073-2.
Open DOI Search in Google Scholar Back to article
Yekefallah L, Zohal MA, Keshavarzsarkar O, Barikani A, Gheraati M. Comparing the effects of upper limb and breathing exercises on six-minute walking distance among patients with chronic obstructive pulmonary disease: a three-group randomized controlled clinical trial. Adv Respir Med. 2019;87(2):77–82. doi: 10.5603/ARM.2019.0013.
Open DOI Search in Google Scholar Back to article
Breyer M-K, Breyer-Kohansal R, Funk G-C, Dornhofer N, Spruit MA, Wouters EFM, et al. Nordic walking improves daily physical activities in COPD: a randomised controlled trial. Respir Res. 2010;11:112. doi: 10.1186/1465-9921-11-112.
Open DOI Search in Google Scholar Back to article
Finnerty JP, Keeping I, Bullough I, Jones J. The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease: a randomized controlled trial. Chest. 2001;119(6):1705–10. doi: 10.1378/ chest.119.6.1705.
Open DOI Search in Google Scholar Back to article
Gallo-Silva B, Cerezer-Silva V, Ferreira DG, Sakabe DI, Kel-Souza LD, Bertholo VC, et al. Effects of water-based aerobic interval training in patients with COPD: a randomized controlled trial. J Cardiopulm Rehabil Prev. 2019;39(2):105–11. doi: 10.1097/HCR.0000000000000352.
Open DOI Search in Google Scholar Back to article
Gottlieb V, Lyngsø AM, Nybo B, Frølich A, Backer V. Pulmonary rehabilitation for moderate COPD (GOLD 2) - does it have an effect? COPD. 2011;8(5):380–6. doi: 10.3109/15412555.2011.610393.
Open DOI Search in Google Scholar Back to article
McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA. Water-based exercise in COPD with physical comorbidities: a randomised controlled trial. Eur Respir J. 2013;41(6):1284–91. doi: 10.1183/09031936.00034312.
Open DOI Search in Google Scholar Back to article
Ringbaek TJ, Broendum E, Hemmingsen L, Lybeck K, Nielsen D, Andersen C, et al. Rehabilitation of patients with chronic obstructive pulmonary disease: exercise twice a week is not sufficient! Respir Med. 2000;94(2):150–4. doi: 10.1053/rmed.1999.0704.
Open DOI Search in Google Scholar Back to article
Román M, Larraz C, Gómez A, Ripoll J, Mir I, Miranda EZ, et al. Efficacy of pulmonary rehabilitation in patients with moderate chronic obstructive pulmonary disease: a randomized controlled trial. BMC Fam Pract. 2013;14:21. doi: 10.1186/1471-2296-14-21.
Open DOI Search in Google Scholar Back to article
Wadell K, Webb KA, Preston ME, Amornputtisathaporn N, Samis L, Patelli J, et al. Impact of pulmonary rehabilitation on the major dimensions of dyspnea in COPD. COPD. 2013;10(4):425–35. doi: 10.3109/15412555.2012.758696.
Open DOI Search in Google Scholar Back to article
Yudhawati R, Rasjid Hs M. Effect of yoga on FEV1, 6-minute walk distance (6-MWD) and quality of life in patients with COPD group B. Adv Respir Med. 2019;87(5):261–8. doi: 10.5603/ARM.2019.0047.
Open DOI Search in Google Scholar Back to article
Zhu S, Shi K, Yan J, He Z, Wang Y, Yi Q, et al. A modified 6-form Tai Chi for patients with COPD. Complement Ther Med. 2018;39:36–42. doi: 10.1016/j.ctim.2018.05.007.
Open DOI Search in Google Scholar Back to article
Kessler R, Faller M, Fourgaut G, Mennecier B, Weitzenblum E. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159(1):158–64. doi: 10.1164/ajrccm.159.1.9803117.
Open DOI Search in Google Scholar Back to article
Holland AE, Nici L. The return of the minimum clinically important difference for 6-minute-walk distance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013;187(4):335–6. doi: 10.1164/rccm.201212-2191ED.
Open DOI Search in Google Scholar Back to article
Santiworakul A, Piya-amornphan N, Jianramas N. A home-based multimedia pulmonary rehabilitation program improves clinical symptoms and physical performance of patients with chronic obstructive pulmonary disease. Int J Environ Res Public Health. 2021;18(21):11479. doi: 10.3390/ijerph182111479.
Open DOI Search in Google Scholar Back to article
de Souza Y, da Silva KM, Condesso D, Figueira B, Noronha Filho AJ, Rufino R, et al. Use of a home-based manual as part of a pulmonary rehabilitation program. Respir Care. 2018;63(12):1485–91. doi: 10.4187/ respcare.05656.
Open DOI Search in Google Scholar Back to article
Imamura S, Inagaki T, Terada J, Nagashima K, Katsura H, Tatsumi K. Long-term efficacy of pulmonary rehabilitation with home-based or low frequent maintenance programs in patients with chronic obstructive pulmonary disease: a meta-analysis. 2020;9(5):2606–15. doi: doi: 10.21037/apm-19-581.
Open DOI Search in Google Scholar Back to article
Gallefoss F, Bakke PS, Rsgaard PK. Quality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159(3):812–7. doi: 10.1164/ajrccm.159.3.9804047.
Open DOI Search in Google Scholar Back to article
Dong J, Li Z, Luo L, Xie H. Efficacy of pulmonary rehabilitation in improving the quality of life for patients with chronic obstructive pulmonary disease: evidence based on nineteen randomized controlled trials. Int J Surg. 2020;73:78–86. doi: 10.1016/j.ijsu.2019.11.033.
Open DOI Search in Google Scholar Back to article
Rugbjerg M, Iepsen UW, Jørgensen KJ, Lange P. Effectiveness of pulmonary rehabilitation in COPD with mild symptoms: a systematic review with meta-analyses. Int J Chron Obstruct Pulmon Dis. 2015;10:791–801. doi: 10.2147/COPD.S78607.
Open DOI Search in Google Scholar Back to article
Wu W, Liu X, Wang L, Wang Z, hu jun, Yan J. Effects of Tai Chi on exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. COPD. 2014;1253. doi: 10.2147/COPD.S70862.
Open DOI Search in Google Scholar Back to article
Jackson D, Turner R. Power analysis for random-effects meta-analysis: power analysis for meta-analysis. Res Syn Meth. 2017;8(3):290–302. doi: 10.1002/jrsm.1240.
Open DOI Search in Google Scholar Back to article