Therapeutics
Review: Exercise programs after pulmonary rehabilitation preserve short-term exercise capacity in COPD
Beauchamp MK, Evans R, Janaudis-Ferreira T, Goldstein RS, Brooks D. Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with COPD. Chest. 2013;144:1124-33.
Clinical impact rating: F ★★★★★★✩ Question
Source of funding: No external funding.
In patients with chronic obstructive pulmonary disease (COPD), do supervised exercise programs after pulmonary rehabilitation preserve exercise capacity and health-related quality of life (HRQL)?
For correspondence: Dr. D. Brooks, University of Toronto, Toronto, ON, Canada. E-mail [email protected]. ■
Commentary
Review scope Included studies compared maintenance exercise programs delivered at least monthly for ≥ 6 months with usual care after pulmonary rehabilitation (supervised exercise training) in patients with COPD. Maintenance programs provided supervised exercise training (aerobic and/or resistance); could include education and psychological support; and occurred in outpatient, community, or home settings. Outcomes included exercise capacity and HRQL.
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, PEDro, and Cochrane Library (all to Dec 2012) were searched for randomized controlled trials (RCTs). Reference lists were searched. 6 RCTs (n = 619, mean age 67 y, mean FEV1 32% to 59% predicted) met the selection criteria. All exercise sessions included aerobic exercise, and duration of maintenance programs ranged from 9 to 15 months. 5 RCTs reported adequate random sequence generation, 3 reported allocation concealment, and 2 reported blinding of outcome assessors.
Main results Meta-analysis showed that maintenance exercise preserved exercise capacity more than usual care at 6 months but not at 12 months (Table). Groups did not differ for HRQL at 6 or 12 months (Table).
Conclusion In patients with chronic obstructive pulmonary disease, supervised exercise programs after pulmonary rehabilitation preserve 6-month exercise capacity but do not affect health-related quality of life or long-term exercise capacity. Maintenance exercise vs usual care after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease* Outcomes Exercise capacity Health-related quality of life
Assessment period (mo)
Number of trials (n)
Standardized mean difference (95% CI)†
6
5 (433)
−0.20 (−0.39 to −0.01)
12
5 (385)
−0.09 (−0.29 to 0.11)
6 12
4 (336) 5 (416)
−0.07 (−0.29 to 0.14) −0.15 (−0.42 to 0.13)
*CI defined in Glossary. †Negative standardized mean difference indicates greater improvement in maintenance group.
JC4
© 2014 American College of Physicians
The evidence that pulmonary rehabilitation improves important domains of quality of life and, to a lesser extent, exercise capacity in COPD is so compelling we suggested that additional randomized trials comparing pulmonary rehabilitation and conventional community care were not needed (1). Of note, our meta-analysis examined only the short-term effect of pulmonary rehabilitation (1). The systematic review by Beauchamp and colleagues addresses a different, but no less important, question on the effect of supervised exercise programs after primary pulmonary rehabilitation. Maintenance exercise programs had no effect on HRQL at 6or 12-month follow-up and only some effect on exercise capacity at 6 months. The clinical significance of this treatment effect remains unknown as it was reported only in terms of standard deviation units (standardized mean differences). The authors acknowledge that their meta-analysis was limited by the heterogeneity of rehabilitation and maintenance programs, various outcome measures, and timing of follow-up intervals. More important, the mean compliance rate to exercise interventions was only 60%. Accordingly, selection of participants to rehabilitation and maintenance programs is of utmost importance. Predictors of uptake and completion of pulmonary rehabilitation are not necessarily the same as those of exercise maintenance. Nevertheless, disruption to usual routine, program timing, and poor access to transportation affect uptake of pulmonary rehabilitation (2). Home-based pulmonary rehabilitation represents an alternative not only to improve access to rehabilitation, but also to increase adherence to maintenance programs (3). The available data regarding exercise maintenance may reflect failure to intervene (i.e., poor compliance to the intervention) rather than failure of the intervention itself. Patients should still be advised to engage in and continue pulmonary rehabilitation. Yves Lacasse, MD, MSc, FRCPC Institut universitaire de cardiologie et de pneumologie de Québec (Hôpital Laval), Université Laval Québec City, Québec, Canada References 1. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(4):CD003793. 2. Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis. 2011;8:89-99. 3. Maltais F, Bourbeau J, Shapiro S, et al; Chronic Obstructive Pulmonary Disease Axis of Respiratory Health Network, Fonds de recherche en santé du Québec. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008;149:869-78.
15 April 2014 | ACP Journal Club | Volume 160 • Number 8
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/929992/ by a Tufts University User on 07/20/2017
Review: Exercise programs after pulmonary rehabilitation preserve short-term exercise capacity in COPD
Beauchamp MK, Evans R, Janaudis-Ferreira T, Goldstein RS, Brooks D. Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with COPD. Chest. 2013;144:1124-33.
Clinical impact rating: F ★★★★★★✩ Question
Source of funding: No external funding.
In patients with chronic obstructive pulmonary disease (COPD), do supervised exercise programs after pulmonary rehabilitation preserve exercise capacity and health-related quality of life (HRQL)?
For correspondence: Dr. D. Brooks, University of Toronto, Toronto, ON, Canada. E-mail [email protected]. ■
Commentary
Review scope Included studies compared maintenance exercise programs delivered at least monthly for ≥ 6 months with usual care after pulmonary rehabilitation (supervised exercise training) in patients with COPD. Maintenance programs provided supervised exercise training (aerobic and/or resistance); could include education and psychological support; and occurred in outpatient, community, or home settings. Outcomes included exercise capacity and HRQL.
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, PEDro, and Cochrane Library (all to Dec 2012) were searched for randomized controlled trials (RCTs). Reference lists were searched. 6 RCTs (n = 619, mean age 67 y, mean FEV1 32% to 59% predicted) met the selection criteria. All exercise sessions included aerobic exercise, and duration of maintenance programs ranged from 9 to 15 months. 5 RCTs reported adequate random sequence generation, 3 reported allocation concealment, and 2 reported blinding of outcome assessors.
Main results Meta-analysis showed that maintenance exercise preserved exercise capacity more than usual care at 6 months but not at 12 months (Table). Groups did not differ for HRQL at 6 or 12 months (Table).
Conclusion In patients with chronic obstructive pulmonary disease, supervised exercise programs after pulmonary rehabilitation preserve 6-month exercise capacity but do not affect health-related quality of life or long-term exercise capacity. Maintenance exercise vs usual care after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease* Outcomes Exercise capacity Health-related quality of life
Assessment period (mo)
Number of trials (n)
Standardized mean difference (95% CI)†
6
5 (433)
−0.20 (−0.39 to −0.01)
12
5 (385)
−0.09 (−0.29 to 0.11)
6 12
4 (336) 5 (416)
−0.07 (−0.29 to 0.14) −0.15 (−0.42 to 0.13)
*CI defined in Glossary. †Negative standardized mean difference indicates greater improvement in maintenance group.
JC4
© 2014 American College of Physicians
The evidence that pulmonary rehabilitation improves important domains of quality of life and, to a lesser extent, exercise capacity in COPD is so compelling we suggested that additional randomized trials comparing pulmonary rehabilitation and conventional community care were not needed (1). Of note, our meta-analysis examined only the short-term effect of pulmonary rehabilitation (1). The systematic review by Beauchamp and colleagues addresses a different, but no less important, question on the effect of supervised exercise programs after primary pulmonary rehabilitation. Maintenance exercise programs had no effect on HRQL at 6or 12-month follow-up and only some effect on exercise capacity at 6 months. The clinical significance of this treatment effect remains unknown as it was reported only in terms of standard deviation units (standardized mean differences). The authors acknowledge that their meta-analysis was limited by the heterogeneity of rehabilitation and maintenance programs, various outcome measures, and timing of follow-up intervals. More important, the mean compliance rate to exercise interventions was only 60%. Accordingly, selection of participants to rehabilitation and maintenance programs is of utmost importance. Predictors of uptake and completion of pulmonary rehabilitation are not necessarily the same as those of exercise maintenance. Nevertheless, disruption to usual routine, program timing, and poor access to transportation affect uptake of pulmonary rehabilitation (2). Home-based pulmonary rehabilitation represents an alternative not only to improve access to rehabilitation, but also to increase adherence to maintenance programs (3). The available data regarding exercise maintenance may reflect failure to intervene (i.e., poor compliance to the intervention) rather than failure of the intervention itself. Patients should still be advised to engage in and continue pulmonary rehabilitation. Yves Lacasse, MD, MSc, FRCPC Institut universitaire de cardiologie et de pneumologie de Québec (Hôpital Laval), Université Laval Québec City, Québec, Canada References 1. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(4):CD003793. 2. Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis. 2011;8:89-99. 3. Maltais F, Bourbeau J, Shapiro S, et al; Chronic Obstructive Pulmonary Disease Axis of Respiratory Health Network, Fonds de recherche en santé du Québec. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008;149:869-78.
15 April 2014 | ACP Journal Club | Volume 160 • Number 8
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/929992/ by a Tufts University User on 07/20/2017
