Pulmonary Rehabilitation in Lung Disease Other Than Chronic Obstructive Pulmonary Disease1- 3
STEVEN FOSTER and HENRY M. THOMAS III
Introduction
T he benefit of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPO) has been well documented (1-6). However, the benefit of similar rehabilitation in patients with severe pulmonary impairment who have diagnoses other than COPO has not been demonstrated. The great majority of patients who have been referred to our intensive pulmonary rehabilitation program have COPO (7). However, a small number of patients who do not have COPO have been admitted to our institution on the basis of their referring physicians' assessment that rehabilitation was required. Although our bias has always been that these patients benefited, it was possible that their limitation in some way differed from that of COPO patients. Thus, their functional capacity may not improve, and could even worsen, with an intensive rehabilitation program. Therefore, we reviewedour records to see if non-COPO patients improved with pulmonary rehabilitation and, if so, how the improvement compared to that of patients with copo. It should be noted that these non-COPO patients have a wide variety of diseases, mostly with severerestrictive pulmonary function test results. Since the improvement in walking distance with rehabilitation appears consistent across subgroups, we have grouped them for this analysis. Methods We reviewed the records of all patients who completed the pulmonary rehabilitation program at the Burke Rehabilitation Center from 1983 to 1987. There were 32 admissions for a pulmonary diagnosis other than COPD. The diagnostic groups were Pulmonary Fibrosis (n = 7), Bronchiectasis (n = 7), Fibrothorax (n = 3), Scoliosis (n = 4), Neuromuscular Disease (n = 4), and Other (n = 7). The neuromuscular group includes Charcot-MarieTooth syndrome (n = 2, one patient with two admissions 1.5 yr apart), multiple sclerosis (n = 1),and polyneuropathy of unknown etiology (n = 1). The other group included pa-
SUMMARY The benefit of pulmonary rehabilitation Is well documented for patients with chronic obstructive pulmonary disease (COPO). However, such benefit has not been demonstrated for severely impaired patients with other chronic pulmonary diseases. Occasional non-COPO patients have been admitted to our 4-wk inpatient program. We compared the improvement of these nonCOPO patients with that of COPO patients in the same program. Improvement is assessed by a 6-min walk test done at admission and discharge. On the admission 6-min walk test, 32 non-eOPD patients had an ambulation distance of 276 ± 219ft (SO). At completion of the program, their ambulation distance increased to 574 ± 367 ft (increase in ambulation 298 ± 290 ft, P < 0.0001).Diagnostic subgroups improved to essentially the same extent. The increase in ambulation was not statistically different between non-COPOpatients and a series of 317patients with COPO.Patients severely impaired with chronic pulmonary disease other than COPO benefit from intensive pulmonary rehabilitation, and the degree of improvement is similar to that of COPO patients. AM REV RESPIR DIS 1990; 141:601-604
tients with a history of adult respiratory distress syndrome (n = 2), lung resection (n = 3), motor vehicle accident with lung trauma (n = 1), and thoracoplasty (n = 1). Each patient underwent an intensive, inpatient pulmonary rehabilitation program with an average length of stay of 4 wk. On admission and discharge, patients had pulmonary function tests and arterial blood gases, which were measured as described previously (7). Those patients with hypoxemia (Po, < 55 mm Hg on room air or after exercise) received supplementary oxygen during exercise and for 12 h/day or more. The program consists of multiple daily therapy sessions. There are two 45-min physical therapy sessions a day, emphasizing lower extremity function. Included are floor walking, treadmill walking, and stationary bicycle riding; each of these is performed to the patient's tolerance. There is one 45-min occupational therapy session a day, emphasizing upper extremity resistive exercise to tolerance and improvement in activities of daily living. There are daily education or relaxation programs. Respiratory therapy provides the patient with chest physiotherapy and education in the use of nebulizers and inhalers. Patients are seen four times a week by the physician for standard medical management. Progress is assessedat a weeklymultidisciplinaryconference. A 6-min walk test and pulmonary function tests were performed at both the time of admission and discharge. For comparison with the results of patients in this study, it should be noted that a person walking at 4 miles/h covers 2112 ft in 6 min. A total of 21 patients had measurements of arterial blood gases after exercise. The ex-
ercise performed was the 6-min walk test, and arterial blood gases were measured immediately after exercise with a separate arterial puncture. Statistical analyses of the effects of the rehabilitation program wereperformed. The results of these analyses in non-COPD patients were then compared to our previous data in patients with COPD (7). Statistical computations were done on a Macintosh Plus computer using Statview 512+ software. Analyses included Student's t tests for paired data and one-way analysis for variance (8).
Results
In general, pulmonary function tests on admission showed a severerestrictiveventilatory defect with decreased respiratory muscle strength (table 1). There is no change in spirometry and only minor improvement in respiratory muscle strength from admission to discharge. Mean val(Received in original form June 16, 1989 and in revised form August 3, 1989) 1 From the Division of Pulmonary and Critical Care Medicine, Cornell University Medical College, New York, New York, and the Will Rogers Pulmonary Research Laboratory, Burke Rehabilitation Center, White Plains, New York. 2 Supported by the Will Rogers Institute and the Potts Foundation. 3 Correspondence and requests for reprints should be addressed to Henry M. Thomas, III, M.D., Will Rogers Pulmonary Research Laboratory, Burke Rehabilitation Center, 785 Mamaroneck Avenue, White Plains, NY 10605.
601
602
FOSTER AND THOMAS
TABLE 1 ADMISSION VERSUS DISCHARGE PULMONARY FUNCTION TESTS IN NON-GOPD PATIENTS· Admission (% Predicted)
Discharge (% Predicted)
P
FVC.L
1.20 (39
0.45 16)
1.30 ± 0.54 (41 ± 14)
NS
FEV" L
0.66 ± 0.35 (41 ± 22)
0.99 ± 0.49 (44 % 19)
NS
FEV,/FVC. Gib
75
% %
%
14
76
%
14
NS
P1max. em H.O
39 ± 22 (41 ± 24)
44±22 (47 % 25)
NS
PEmax. em H.O
43 ± 23 (27 ± 13)
58 % 28 (36 ± 16)
< 0.005 NS
7.41 ± 0.03
7.41 ± 0.04
PCO•• mm Hg
43 ± 8
43 ± 9
PO•• mm Hg
67 ± 12
72 ± 15
pH, units
De"nltlon 01 abbrllV/stIons: FVC
c
NS
< 0.02
forced vitalcapacity (L); FEV, - forced expiratory volums In 1 s
(L); FEV,IFVC, % - ratio ofFEV, toforced v"aIcapac"y expressed aspercentage; P1max - maximum inspiratory pressure, emH20 ; PEmax - maximum expiratory pressure. emH,O. • Values aremean ± SO.
Distance walked in 6 min, feet
Fig. 1. Admission versusdischargeambulation in 32 non-GOPDpatients. The meanimprovementwasstatisticallysignificant (P < 0.001).
ues of arterial blood gases are shown in table l. Ten patients had Pco. values greater than 45 mm Hg. Six patients had POIvalues of 55 mm Hg or less. Arterial blood gases after exercisewere measured in 21 patients. POI fell more than 2 mm Hg in 16ofthose patients, and the mean decrease was -7.1 ± 8.8 (SO) mm Hg (P < 0.(05). At the end of the rehabilitation program, Pco. and pH were unchanged compared to admission and Pol was slightly higher (table 1; P < 0.02). On admission 6-min walk test, the nonCOPO patients had an average ambulation distance of 276 ± 219ft. Atthe completion of their program, their ambulation distance increased to 574 ± 376 ft (P < 0.001; figure 1). All groups improved, some more than others (figure 2 and table 2). However, the differences between diagnostic groups was not significant by analysis of variance. Wethen compared these results to our series of 317 patients with advanced COPO. These patients (7) had moderate to very severe obstructive ventilatory defects (table 3). Arterial blood gases on admission were quite similar to those of the non-COPD patients (table 1). The walk tests showed that non-COPD patients were able to ambulate somewhat less than COPO patients both on admission and at discharge (figure 3). The increase in ambulation was also less in the non-COPD group. However, none of the differences in walking distance was statistically significant (table 4). Discussion
Admission
Discharge
1200 1000 Distance walked in 6 min, feet
800 600 400 200
Pulmonary Bronchiectasis Neuromuscular Fibrosis Fibrothorax Scoliosis Disease Other Fig. 2. Increase in ambulation with rehabilitation by diagnosis group. Each group showed an improvement in ambulation when comparing admission with discharge values. The differences between diagnostic groups were not significant by analysis of variance.
We have attempted in this study to evaluate whether patients who have not traditionally been considered candidates for pulmonary rehabilitation can benefit from such a program. Pulmonary rehabilitation is an established method of care for advanced stages of COPO (9). Pulmonary rehabilitation does improve the quality (5), functional capacity (4, 10), and, possibly, the duration of life in COPO patients (11, 12).However, a similar benefit has not previously been demonstrated in non-COPO patients. We have received an increasing number of referrals for rehabilitation of patients severely impaired with lung diseases other than COPO. This indicates to us a growing need for services to this group. Pulmonary rehabilitation did not produce a substantial improvement in pulmonary function tests from admission to discharge in this group (table 1). This correlates with the finding in COPO pa-
603
REHABILITATION IN NON-eOPD PATIENTS
TABLE 2 AMBULATION MEASUREMENTS BY DIAGNOSIS GROUP*
Pulmonary fibrosis Fibrothorax Bronchiectasis Scoliosis Neuromuscular disease Other • Values are mean ±
n
Admission Ambulation
Discharge Ambulation
Increase in Ambulation
7 3 7 4 4 7
231 240 284 441 179 289
506 ± 422 967 ± 189 583 ± 330 520 ± 464 439±268 573 ± 396
275 727 299 79 260 284
± ± ± ± ± ±
217 104 204 372 178 206
± ± ± ± ± ±
368 270 196 135 127 307
so. All distances measured in feet.
tients that rehabilitation. does not significantly effect pulmonary function tests (13, 14). Ambulation distance was used as an objective measure of functional status (1, 13, 15). Ambulation distance is a simple test widely used in COPO patients and is correlated, but not closely, to maximal O 2 consumption (16). Owing to the limited exercise tolerance of our patients, we used the 6-min walk test (17). The nonCOPO patients were able to significantly improve their walking distance from an average on admissionof 276 ft to 574 ft upon discharge (figure 1 and table 3). Our clinical impression is that the patients' ability to perform activities of daily living changed in parallel with the walking distance. The number of patients in each group is small. It appears that patients with scoliosis tend to improve less than other
patients and patients with fibrothorax do better than the group as a whole. Since the analysis of variance showed that the difference between groups is not significant, these differences are only a trend and a larger group of patients must be studied to evaluate this finding. When wecompared these results to our previously reported seriesof patients with advanced COPO (7), we found that the non-COPO patients did not differ significantly in ambulation distance at admission or discharge from COPO patients. Improvement in ambulation also was not significantly different between
the COPO and non-COPO categories (table 4). From this, weconclude that although non-COPO patients who were admitted to our program were as severely impaired as the COPO patients, if not slightly more so, they tended to improve similarly to the COPO patients. In a multidisciplinary rehabilitation program, many components contribute to the improvement in quality of life (6). However, our opinion, based on close observation of these patients, is that the physical exercise, specifically multiple sessions of upper and lower extremity exercise to tolerance, is the core of improvement in these patients. Both COPO and nonCOPO patients appear to benefit from this program of substantially increased activity. Therefore, we conclude that patients with severe pulmonary disease and diagnoses other than COPO can and do benefit from an inpatient, multidisciplinary pulmonary rehabilitation program. Their improvement is similar to that obtained by COPO patients.These fmdings mayencourage admission of non-COPO patients to pulmonary rehabilitation programs.
1400 1200 1000
TABLE 3 ADMISSION PULMONARY FUNCTION TESTS AND ARTERIAL BLOOD GASES FOR 317 PATIENTS WITH COPD* Admission
(% Predicted) FVC, L
1.58 ± 0.62 (47 ± 16)
FEV" L
0.65 ± 0.28 (29 ± 12)
FEV 1/FVC, %
42 ± 10
P1max, cm H2O
38 ± 17 (44 ± 18)
PEmax, cm H2O
51 ± 28 (31 ± 15)
pH, units
7.42 ± 0.04
Pco2 , mm Hg
44 ± 8
Po2 , mm Hg
63 ± 14
Distance walked in6min, feet
800 600 400 200 0 Admission Discharge COPO
Fig. 3. Comparison of ambulation distances on a 6-min walk test for COPD versus non-COPO patients. The nonCOPO patients walked less at admission than COPD patients (P = 0.06), suggesting a more impaired population. However, their improvement with rehabilitation was only slightly less than in COPO patients (P = 0.3).
TABLE 4 AMBULATION DISTANCES ON A 6-MIN WALK TEST: COPO VERSUS NON-COPO PATIENTS*
n Definition 01 abbnwistions: FVC == forced vital capacity (L); FEV1 - forcedexpiratory volumein 1 s (L); FEV1/FVC, % == ratioof FEV1 to forcedvital capacityexpressed as percentage; Plmax - maximum inspiratory pressure, cm H2 0 ; PEmax maximum expiratory pressure, cm H20. • Valuesare mean ± SO.
Admission Discharge non-COPO
COPO Non-COPO Non-COPO versus COPD • Values are mean ±
317 32
Admission Ambulation
Discharge Ambulation
Increase in Ambulation
380 ± 313 276 ± 219 p = 0.06
751 ± 562 574 ± 367 p = 0.08
371 ± 419 298 ± 290 p = 0.3
so. All distancesmeasured in feet.
604
FOSTER AND THOMAS
Acknowledgment The writers thank Pierre Saadeh for his help in compiling these data. We also thank Barbara Bruce for expert typing of the manuscript. References 1. Nicholas J J, Gilbert R, Gabe R, Auchincloss JW Jr. Evaluation of an exercise therapy program for patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1970; 102:1-9. 2. MoserKM, Bokinsky GE, SavageRT,Archibald CJ, Hansen PRo Results of a comprehensive rehabilitation program. Physiologic and functional effects on patients with chronic obstructive pulmonary disease. Arch Intern Med 1980; 140: 1596-1601. 3. Lustig FM, Haas A, Castillo R. Clinical and rehabilitation regime in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehab 1972; 52:315-22. 4. Fishman DB, Petty TL. Physical, symptomatic and psychologicalimprovement in patients receiv-
ing comprehensive care for chronic airway obstruction. J Chron Dis 1971; 24:775-85. 5. McSweeneyAS, Grant I, Heaton R, Adams K, Timms R. Life quality of patients with chronic obstructive pulmonary disease.Arch Intern Med 1982; 142:473-9. 6. Make BJ. Introduction to pulmonary rehabilitation. Clin Chest Med 1986; 7:519-40. 7. Foster S, Lopez D, Thomas HM III. Pulmonary rehabilitation in COPD patients with elevated Peal. Am Rev Respir Dis 1988; 138:1519-23. 8. Snedecor GW, Cochran WG. Statistical methods. 6th 00. Ames: Iowa State UniversityPress, 1967. 9. Petty, TL. Pulmonary rehabilitation for COPD. In: Petty TL, ed. Intensive and rehabilitative respiratory care. 3rd ed. Philadelphia: Lea & Febiger, 1982; 385-413. 10. Carter R, Nicastro MD. Newer insights into the management and rehabilitation of the patient with pulmonary disease. Semin Respir Med 1986; 8:113-23. 11. Sahn SA, Petty TL. Results of a comprehensive rehabilitation program for severe COPD. In: Petty TC, ed. Chronic obstructive pulmonary dis-
ease. New York: Marcel Dekker, 1978; 203-20. 12. Sahn SA, Nett LM, Petty TC. Tenyear followup of a comprehensive rehabilitation for severe COPD. Chest 1980; 77(2 Suppl:311-4). 13. Petty TL, Nett LM, Finigan MM, Brink GA, Corsello PRo A comprehensive care program for chronic airway obstruction. Ann Intern Med 1969; 70:1109-20. 14. Unger KM, Moser KM, Hansen RN. Selection of exercise program for patients with chronic obstructive pulmonary disease. Heart Lung 1980; 9:68-76. 15. Swinburn CR, Wakefield JM, Jones PW. Performance, ventilation, and oxygen consumption in three different types of exercise test in patients with chronic obstructive lung disease. Thorax 1985; 40:581-6. 16. McGavin CR, Gupta SP, McHardy GJR. 1\velve-minute walking test for assessing disability in chronic bronchitis. Br Med J 1976; 1:822-3. 17. Butland RJA, Pang J, Gross ER, Woodstock AA, Geddes DM. Two-, six-, and 12minute walking tests in respiratory disease. Br Med J 1982; 284:1607-8.
STEVEN FOSTER and HENRY M. THOMAS III
Introduction
T he benefit of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPO) has been well documented (1-6). However, the benefit of similar rehabilitation in patients with severe pulmonary impairment who have diagnoses other than COPO has not been demonstrated. The great majority of patients who have been referred to our intensive pulmonary rehabilitation program have COPO (7). However, a small number of patients who do not have COPO have been admitted to our institution on the basis of their referring physicians' assessment that rehabilitation was required. Although our bias has always been that these patients benefited, it was possible that their limitation in some way differed from that of COPO patients. Thus, their functional capacity may not improve, and could even worsen, with an intensive rehabilitation program. Therefore, we reviewedour records to see if non-COPO patients improved with pulmonary rehabilitation and, if so, how the improvement compared to that of patients with copo. It should be noted that these non-COPO patients have a wide variety of diseases, mostly with severerestrictive pulmonary function test results. Since the improvement in walking distance with rehabilitation appears consistent across subgroups, we have grouped them for this analysis. Methods We reviewed the records of all patients who completed the pulmonary rehabilitation program at the Burke Rehabilitation Center from 1983 to 1987. There were 32 admissions for a pulmonary diagnosis other than COPD. The diagnostic groups were Pulmonary Fibrosis (n = 7), Bronchiectasis (n = 7), Fibrothorax (n = 3), Scoliosis (n = 4), Neuromuscular Disease (n = 4), and Other (n = 7). The neuromuscular group includes Charcot-MarieTooth syndrome (n = 2, one patient with two admissions 1.5 yr apart), multiple sclerosis (n = 1),and polyneuropathy of unknown etiology (n = 1). The other group included pa-
SUMMARY The benefit of pulmonary rehabilitation Is well documented for patients with chronic obstructive pulmonary disease (COPO). However, such benefit has not been demonstrated for severely impaired patients with other chronic pulmonary diseases. Occasional non-COPO patients have been admitted to our 4-wk inpatient program. We compared the improvement of these nonCOPO patients with that of COPO patients in the same program. Improvement is assessed by a 6-min walk test done at admission and discharge. On the admission 6-min walk test, 32 non-eOPD patients had an ambulation distance of 276 ± 219ft (SO). At completion of the program, their ambulation distance increased to 574 ± 367 ft (increase in ambulation 298 ± 290 ft, P < 0.0001).Diagnostic subgroups improved to essentially the same extent. The increase in ambulation was not statistically different between non-COPOpatients and a series of 317patients with COPO.Patients severely impaired with chronic pulmonary disease other than COPO benefit from intensive pulmonary rehabilitation, and the degree of improvement is similar to that of COPO patients. AM REV RESPIR DIS 1990; 141:601-604
tients with a history of adult respiratory distress syndrome (n = 2), lung resection (n = 3), motor vehicle accident with lung trauma (n = 1), and thoracoplasty (n = 1). Each patient underwent an intensive, inpatient pulmonary rehabilitation program with an average length of stay of 4 wk. On admission and discharge, patients had pulmonary function tests and arterial blood gases, which were measured as described previously (7). Those patients with hypoxemia (Po, < 55 mm Hg on room air or after exercise) received supplementary oxygen during exercise and for 12 h/day or more. The program consists of multiple daily therapy sessions. There are two 45-min physical therapy sessions a day, emphasizing lower extremity function. Included are floor walking, treadmill walking, and stationary bicycle riding; each of these is performed to the patient's tolerance. There is one 45-min occupational therapy session a day, emphasizing upper extremity resistive exercise to tolerance and improvement in activities of daily living. There are daily education or relaxation programs. Respiratory therapy provides the patient with chest physiotherapy and education in the use of nebulizers and inhalers. Patients are seen four times a week by the physician for standard medical management. Progress is assessedat a weeklymultidisciplinaryconference. A 6-min walk test and pulmonary function tests were performed at both the time of admission and discharge. For comparison with the results of patients in this study, it should be noted that a person walking at 4 miles/h covers 2112 ft in 6 min. A total of 21 patients had measurements of arterial blood gases after exercise. The ex-
ercise performed was the 6-min walk test, and arterial blood gases were measured immediately after exercise with a separate arterial puncture. Statistical analyses of the effects of the rehabilitation program wereperformed. The results of these analyses in non-COPD patients were then compared to our previous data in patients with COPD (7). Statistical computations were done on a Macintosh Plus computer using Statview 512+ software. Analyses included Student's t tests for paired data and one-way analysis for variance (8).
Results
In general, pulmonary function tests on admission showed a severerestrictiveventilatory defect with decreased respiratory muscle strength (table 1). There is no change in spirometry and only minor improvement in respiratory muscle strength from admission to discharge. Mean val(Received in original form June 16, 1989 and in revised form August 3, 1989) 1 From the Division of Pulmonary and Critical Care Medicine, Cornell University Medical College, New York, New York, and the Will Rogers Pulmonary Research Laboratory, Burke Rehabilitation Center, White Plains, New York. 2 Supported by the Will Rogers Institute and the Potts Foundation. 3 Correspondence and requests for reprints should be addressed to Henry M. Thomas, III, M.D., Will Rogers Pulmonary Research Laboratory, Burke Rehabilitation Center, 785 Mamaroneck Avenue, White Plains, NY 10605.
601
602
FOSTER AND THOMAS
TABLE 1 ADMISSION VERSUS DISCHARGE PULMONARY FUNCTION TESTS IN NON-GOPD PATIENTS· Admission (% Predicted)
Discharge (% Predicted)
P
FVC.L
1.20 (39
0.45 16)
1.30 ± 0.54 (41 ± 14)
NS
FEV" L
0.66 ± 0.35 (41 ± 22)
0.99 ± 0.49 (44 % 19)
NS
FEV,/FVC. Gib
75
% %
%
14
76
%
14
NS
P1max. em H.O
39 ± 22 (41 ± 24)
44±22 (47 % 25)
NS
PEmax. em H.O
43 ± 23 (27 ± 13)
58 % 28 (36 ± 16)
< 0.005 NS
7.41 ± 0.03
7.41 ± 0.04
PCO•• mm Hg
43 ± 8
43 ± 9
PO•• mm Hg
67 ± 12
72 ± 15
pH, units
De"nltlon 01 abbrllV/stIons: FVC
c
NS
< 0.02
forced vitalcapacity (L); FEV, - forced expiratory volums In 1 s
(L); FEV,IFVC, % - ratio ofFEV, toforced v"aIcapac"y expressed aspercentage; P1max - maximum inspiratory pressure, emH20 ; PEmax - maximum expiratory pressure. emH,O. • Values aremean ± SO.
Distance walked in 6 min, feet
Fig. 1. Admission versusdischargeambulation in 32 non-GOPDpatients. The meanimprovementwasstatisticallysignificant (P < 0.001).
ues of arterial blood gases are shown in table l. Ten patients had Pco. values greater than 45 mm Hg. Six patients had POIvalues of 55 mm Hg or less. Arterial blood gases after exercisewere measured in 21 patients. POI fell more than 2 mm Hg in 16ofthose patients, and the mean decrease was -7.1 ± 8.8 (SO) mm Hg (P < 0.(05). At the end of the rehabilitation program, Pco. and pH were unchanged compared to admission and Pol was slightly higher (table 1; P < 0.02). On admission 6-min walk test, the nonCOPO patients had an average ambulation distance of 276 ± 219ft. Atthe completion of their program, their ambulation distance increased to 574 ± 376 ft (P < 0.001; figure 1). All groups improved, some more than others (figure 2 and table 2). However, the differences between diagnostic groups was not significant by analysis of variance. Wethen compared these results to our series of 317 patients with advanced COPO. These patients (7) had moderate to very severe obstructive ventilatory defects (table 3). Arterial blood gases on admission were quite similar to those of the non-COPD patients (table 1). The walk tests showed that non-COPD patients were able to ambulate somewhat less than COPO patients both on admission and at discharge (figure 3). The increase in ambulation was also less in the non-COPD group. However, none of the differences in walking distance was statistically significant (table 4). Discussion
Admission
Discharge
1200 1000 Distance walked in 6 min, feet
800 600 400 200
Pulmonary Bronchiectasis Neuromuscular Fibrosis Fibrothorax Scoliosis Disease Other Fig. 2. Increase in ambulation with rehabilitation by diagnosis group. Each group showed an improvement in ambulation when comparing admission with discharge values. The differences between diagnostic groups were not significant by analysis of variance.
We have attempted in this study to evaluate whether patients who have not traditionally been considered candidates for pulmonary rehabilitation can benefit from such a program. Pulmonary rehabilitation is an established method of care for advanced stages of COPO (9). Pulmonary rehabilitation does improve the quality (5), functional capacity (4, 10), and, possibly, the duration of life in COPO patients (11, 12).However, a similar benefit has not previously been demonstrated in non-COPO patients. We have received an increasing number of referrals for rehabilitation of patients severely impaired with lung diseases other than COPO. This indicates to us a growing need for services to this group. Pulmonary rehabilitation did not produce a substantial improvement in pulmonary function tests from admission to discharge in this group (table 1). This correlates with the finding in COPO pa-
603
REHABILITATION IN NON-eOPD PATIENTS
TABLE 2 AMBULATION MEASUREMENTS BY DIAGNOSIS GROUP*
Pulmonary fibrosis Fibrothorax Bronchiectasis Scoliosis Neuromuscular disease Other • Values are mean ±
n
Admission Ambulation
Discharge Ambulation
Increase in Ambulation
7 3 7 4 4 7
231 240 284 441 179 289
506 ± 422 967 ± 189 583 ± 330 520 ± 464 439±268 573 ± 396
275 727 299 79 260 284
± ± ± ± ± ±
217 104 204 372 178 206
± ± ± ± ± ±
368 270 196 135 127 307
so. All distances measured in feet.
tients that rehabilitation. does not significantly effect pulmonary function tests (13, 14). Ambulation distance was used as an objective measure of functional status (1, 13, 15). Ambulation distance is a simple test widely used in COPO patients and is correlated, but not closely, to maximal O 2 consumption (16). Owing to the limited exercise tolerance of our patients, we used the 6-min walk test (17). The nonCOPO patients were able to significantly improve their walking distance from an average on admissionof 276 ft to 574 ft upon discharge (figure 1 and table 3). Our clinical impression is that the patients' ability to perform activities of daily living changed in parallel with the walking distance. The number of patients in each group is small. It appears that patients with scoliosis tend to improve less than other
patients and patients with fibrothorax do better than the group as a whole. Since the analysis of variance showed that the difference between groups is not significant, these differences are only a trend and a larger group of patients must be studied to evaluate this finding. When wecompared these results to our previously reported seriesof patients with advanced COPO (7), we found that the non-COPO patients did not differ significantly in ambulation distance at admission or discharge from COPO patients. Improvement in ambulation also was not significantly different between
the COPO and non-COPO categories (table 4). From this, weconclude that although non-COPO patients who were admitted to our program were as severely impaired as the COPO patients, if not slightly more so, they tended to improve similarly to the COPO patients. In a multidisciplinary rehabilitation program, many components contribute to the improvement in quality of life (6). However, our opinion, based on close observation of these patients, is that the physical exercise, specifically multiple sessions of upper and lower extremity exercise to tolerance, is the core of improvement in these patients. Both COPO and nonCOPO patients appear to benefit from this program of substantially increased activity. Therefore, we conclude that patients with severe pulmonary disease and diagnoses other than COPO can and do benefit from an inpatient, multidisciplinary pulmonary rehabilitation program. Their improvement is similar to that obtained by COPO patients.These fmdings mayencourage admission of non-COPO patients to pulmonary rehabilitation programs.
1400 1200 1000
TABLE 3 ADMISSION PULMONARY FUNCTION TESTS AND ARTERIAL BLOOD GASES FOR 317 PATIENTS WITH COPD* Admission
(% Predicted) FVC, L
1.58 ± 0.62 (47 ± 16)
FEV" L
0.65 ± 0.28 (29 ± 12)
FEV 1/FVC, %
42 ± 10
P1max, cm H2O
38 ± 17 (44 ± 18)
PEmax, cm H2O
51 ± 28 (31 ± 15)
pH, units
7.42 ± 0.04
Pco2 , mm Hg
44 ± 8
Po2 , mm Hg
63 ± 14
Distance walked in6min, feet
800 600 400 200 0 Admission Discharge COPO
Fig. 3. Comparison of ambulation distances on a 6-min walk test for COPD versus non-COPO patients. The nonCOPO patients walked less at admission than COPD patients (P = 0.06), suggesting a more impaired population. However, their improvement with rehabilitation was only slightly less than in COPO patients (P = 0.3).
TABLE 4 AMBULATION DISTANCES ON A 6-MIN WALK TEST: COPO VERSUS NON-COPO PATIENTS*
n Definition 01 abbnwistions: FVC == forced vital capacity (L); FEV1 - forcedexpiratory volumein 1 s (L); FEV1/FVC, % == ratioof FEV1 to forcedvital capacityexpressed as percentage; Plmax - maximum inspiratory pressure, cm H2 0 ; PEmax maximum expiratory pressure, cm H20. • Valuesare mean ± SO.
Admission Discharge non-COPO
COPO Non-COPO Non-COPO versus COPD • Values are mean ±
317 32
Admission Ambulation
Discharge Ambulation
Increase in Ambulation
380 ± 313 276 ± 219 p = 0.06
751 ± 562 574 ± 367 p = 0.08
371 ± 419 298 ± 290 p = 0.3
so. All distancesmeasured in feet.
604
FOSTER AND THOMAS
Acknowledgment The writers thank Pierre Saadeh for his help in compiling these data. We also thank Barbara Bruce for expert typing of the manuscript. References 1. Nicholas J J, Gilbert R, Gabe R, Auchincloss JW Jr. Evaluation of an exercise therapy program for patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1970; 102:1-9. 2. MoserKM, Bokinsky GE, SavageRT,Archibald CJ, Hansen PRo Results of a comprehensive rehabilitation program. Physiologic and functional effects on patients with chronic obstructive pulmonary disease. Arch Intern Med 1980; 140: 1596-1601. 3. Lustig FM, Haas A, Castillo R. Clinical and rehabilitation regime in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehab 1972; 52:315-22. 4. Fishman DB, Petty TL. Physical, symptomatic and psychologicalimprovement in patients receiv-
ing comprehensive care for chronic airway obstruction. J Chron Dis 1971; 24:775-85. 5. McSweeneyAS, Grant I, Heaton R, Adams K, Timms R. Life quality of patients with chronic obstructive pulmonary disease.Arch Intern Med 1982; 142:473-9. 6. Make BJ. Introduction to pulmonary rehabilitation. Clin Chest Med 1986; 7:519-40. 7. Foster S, Lopez D, Thomas HM III. Pulmonary rehabilitation in COPD patients with elevated Peal. Am Rev Respir Dis 1988; 138:1519-23. 8. Snedecor GW, Cochran WG. Statistical methods. 6th 00. Ames: Iowa State UniversityPress, 1967. 9. Petty, TL. Pulmonary rehabilitation for COPD. In: Petty TL, ed. Intensive and rehabilitative respiratory care. 3rd ed. Philadelphia: Lea & Febiger, 1982; 385-413. 10. Carter R, Nicastro MD. Newer insights into the management and rehabilitation of the patient with pulmonary disease. Semin Respir Med 1986; 8:113-23. 11. Sahn SA, Petty TL. Results of a comprehensive rehabilitation program for severe COPD. In: Petty TC, ed. Chronic obstructive pulmonary dis-
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