Pulmonary Rehabilitation Maintenance Interventions: A Systematic Review Andrea K. Busby, PhD; Rebecca L. Reese, PhD; Steven R. Simon, MD, MPH

Objective: To examine existing research on pulmonary exercise rehabilitation (PR) maintenance interventions. Methods: Authors conducted a systematic review of PR maintenance interventions. The primary outcome of interest was physical endurance. Results: Eight studies met inclusion criteria. Most showed initial positive intervention effects, which declined to non-significance within 3-12 months after completion of maintenance. Only one of the 8 studies described a theoretical framework underlying the maintenance intervention.

C

hronic lung diseases are a significant cause of morbidity and mortality. Chronic obstructive pulmonary disease (COPD), the most common of these conditions, is the sixth leading cause of death worldwide1 and is expected to be the third leading cause of death by 2020.2 COPD is a progressive, incurable condition, making effective disease management strategies paramount in the effort to decrease patient and societal burden of COPD. The primary symptom of COPD is dyspnea, which contributes to decreased physical activity, and thus, muscle atrophy, loss of cardiovascular fitness, and further increased shortness of breath. Pulmonary exercise rehabilitation (PR) is a strategy that intervenes in this downward spiral via exercise training.3 Broadly speaking, PR is an intervention aimed at improving functional status and decreasing/managing symptoms among patients with chronic lung disease, as well as reducing disease-related healthcare system burden.4 Whereas PR length and setting (inpatient vs outpatient) tend to vary across programs,4 the typical Andrea K. Busby, Medical Informatics fellow, Emergency Service, Rebecca L. Reese, Behavioral Medicine fellow, Behavioral Medicine Service, and Steven R. Simon, Chief, Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA. Dr. Busby is now with Lifespan Physician Group, Behavioral Medicine Clinical Services, The Miriam Hospital, Providence, RI. Correspondence Dr Busby; [email protected]

Am J Health Behav.™ 2014;38(3):321-330

Conclusions: Existing interventions generally fail to maintain benefits derived from PR programs. Future studies should evaluate maintenance interventions that are theoretically-based and seek to impact known maintenance mediators. Evaluation of these interventions should include substantial follow-up periods and adherence measurements. Key words: exercise, physical activity, chronic obstructive pulmonary disease, behavior change Am J Health Behav. 2014;38(3):321-330 DOI: http://dx.doi.org/10.5993/AJHB.38.3.1

outpatient program lasts 8-12 weeks, and includes a combination of assessment, cardiovascular exercise and strength training, education on disease management, medications, and/or nutrition, and psychosocial support.5 Due to the comprehensive nature of the intervention, PR programs are interdisciplinary, and typically involve a combination of physicians, nurses, respiratory therapists, exercise specialists, and/or psychologists as healthcare providers.6 Although PR programs are becoming increasingly available to those who could benefit, only a small fraction of those who have access to PR actually attend,7 and up to 31.8% of participants drop-out prior to completion of rehabilitation for a variety of reasons, such as medical complications, transportation issues, smoking, depressed mood, poor social support, and lack of perceived benefit.8 Therefore, there is still a need to improve delivery of PR for management of chronic lung disease. Evidence suggests that for those who attend and complete PR, program participation contributes to improved quality of life and exercise capacity, as well as decreased symptoms, exacerbations, and financial burden.9-12 Unfortunately, improvements made during PR decay over time, with most patients returning to pre-rehabilitation levels of physical endurance within 6-24 months of program discharge.13,14 Therefore, there is increasing interest in developing maintenance interventions for use following PR to preserve functional gains and delay future exacerbations and declines.

321

Pulmonary Rehabilitation Maintenance Interventions: A Systematic Review

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)57 Flow Diagram Records identified through database searches (N = 1080)

Records after duplicates removed (N = 1059)

Records screened (N = 99)

Records excluded (N = 77)

Full-text articles assessed for eligibility (N = 22)

Full-text articles excluded (N = 14) -­‐ -­‐ -­‐

Studies included in qualitative synthesis (N = 8)

Over the past decade, the importance of effective maintenance strategies for behavior change has been recognized by both behavioral scientists and funding agencies. For example, a special issue of the American Journal of Health Behavior summarized work from the Health Maintenance Consortium, a collection of 21 National Institutes of Health (NIH) funded investigators conducting theory-driven research on maintenance of health behavior change.15 However, there is no current consensus or guideline on the use of any particular maintenance program, either for PR, or for health behavior change in general. Therefore, the purpose of this review is to examine existing research on maintenance interventions following PR and to evaluate long-term durability of these interventions. In addition, this review seeks to summarize common methodological issues and comment on future directions for exercise maintenance research in patients with chronic lung disease. METHODS The authors conducted a systematic review of

322

-­‐

Reasons excluded: Lack of randomization to groups (5) No or inappropriate control group (2) Not all subjects received the same initial PR (5) Maintenance intervention did not fit inclusion criteria (2)

PR maintenance interventions, adhering to established procedures.16,17 Appropriate studies were defined as those that tested a maintenance intervention after an initial PR program. Inclusion criteria included: English language articles; randomized, controlled trials; participants with chronic lung disease; and a primary outcome measure of physical endurance. This review was limited to randomized, controlled trials because this type of study design allows investigators to make inferences regarding the relationship between treatment and outcome. Studies without a measure of physical endurance were excluded. Although comprehensive PR programs seek to impact multiple diseaserelevant variables, physical endurance was chosen as the variable of primary interest because exercise intolerance has been identified as having primary impact in limiting functional status in chronic lung disease patients,5 and because exercise training is the only specific component of PR considered to be “essential” and “mandatory” in building a comprehensive, multidisciplinary program.4 Two authors (AKB and RLR) independently

Busby et al

Table 1 Characteristics of the Maintenance Interventions Study

Bauldoff et al, 200235

Brooks et al, 200234

Du Moulin et al, 200936

Ries et al, 200341

Ringbaek et al, 201037

Spencer et al, 201038

Samplea

- N = 24 enrolled - Unknown # of completers - Moderate to severe COPD - N = 109 enrolled - N = 41 completed - inpatients & outpatients with severe, stable COPD

- N = 20 enrolled - N = 11 completed - Moderate COPD

- N = 172 enrolled - N = 138 completed - Chronic lung disease

Mean Age in Years + SD

68.1 ± 8

68 ± .8 Intervention group: 68 ± ? Comparison group: 72 ± ?

67.1 ± 8.2

Intervention group: 66.7 ± - N = 96 enrolled 10.6 - N = 78 completed Comparison - Stable COPD group: 69.2 ± 8.5

- N = 59 enrolled - N = 48 completed - Moderate COPD

Intervention group: 65 ± 8 Comparison group: 67 ± 7

Components of Maintenance Intervention

20:4

- Unsupervised walking program - Instructions to walk 20-45 mins in flat area or on treadmill, at pace to dyspnea 2-3 on Borg scale - Use of portable audiocassette player and 2 tapes with 45 minutes of upbeat music - Pedometer and log

35:50

- Written home exercise prescription - Group sessions with physical therapist: supervised exercise & discussion of any concerns - Telephone call between visits using standardized questions to address adherence and/or concerns

6:14

- Individualized training plan to walk 3 times per day a distance of 125% of last 6MW distance (15 mins or less) - Pedometer & training diary - Telephone contacts for motivation

75:89

Waterhouse et al, 201033

- Chronic lung disease - N = 161 enrolled - N = 103 completed - COPD

67 ± ?

68.6 ± 7.7

- Recommended home care plan - Semistructured telephone interview to assess adherence and provide advice - Supervised reinforcement sessions (1.5 hours of exercise, 1 hour topic review, 30 mins social time)

33:63

- Unsupervised training at home: exercise at 85% based on ISWT - Supervised training sessions tapering off in frequency over time to gradually increase unsupervised activity

26:22

- Supervised sessions (20 mins walking, 20 mins cycling, 10 mins arm cycling, upper/ lower limb strength training) - Unsupervised home exercise using illustrated home exercise booklet (30 mins walking & 30 mins limb strength)

13:98

- Home & community based exercise program: walking ≥ 20mins./day & encouragement to exercise outside of home - Self-monitoring, development of problemsolving skills - Semistructured telephone interview to assess adherence, engage in problem solving, make recommendations, and provide encouragement - 1 home visit to assist in establishing home and community exercise - Pedometer & exercise handbook

- N = 111 enrolled - N = 102 completed Steele et al, 200840

Intervention Duration in Weeks

Female: Male Ratio

73:88

- Scripted telephone follow-up calls giving encouragement to exercise

8

52

Intervention Frequency

Comparison Group Activities

- “Control group” - Unsupervised walking program - Instructions to walk 20-45 mins in flat area or on treadmill, at pace to dyspnea 2-3 on Borg scale 2-5 times per - Pedometer and log week - Monthly session - Monthly phone call

Outcome Measure

6MWT

- “Conventional follow-up” - Written home exercise prescription - Visited physical therapist and physician every 3 months for 1 year - Asked about health and exercise program & encouraged to adhere 6MWT

- Daily exercise - Monthly phone call

- “Control group” - Instructions to return to normal activities of daily living - No instructions re: physical activity after PR

6MWT

- Weekly phone call - Monthly session

- “Standard care control” - Referred back to primary care physician for continuing care - Provided with recommendations for home rehab - Invitation to monthly alumni group

6MWT

52

- Weekly sessions for 6 months, then - “Control group” twice monthly - Unsupervised training at home: sessions for 6 exercise at 85% based on ISWT months

ISWT & ESWT

52

- Weekly sessions - 4 times per week home exercise

12

- 4 times per week home exercise - “Usual care” - Weekly ex- Return to care with referring ercise outside provider the home - Individual recommendations for - Weekly exercise phone calls - Invited to attend the “lung club”

26

52

64

- Monthly calls for 6 months, then one call every 3 months

- “Control group” - Unsupervised home exercise 5 times per week using illustrated home exercise booklet 6MWT and - Exercise diary ESWT

- “Usual care” - No other details provided

6MWT

ESWT

Note. a Number completed is defined as the number of participants who were still enrolled and were assessed immediately following the maintenance intervention period.

searched the following databases: PubMed, CINAHL, and PsycInfo (through 25 April 2012, updated 22 May 2013) using identical Medical Subject Heading (MeSH) and key word search terms (Appendix A).  Articles retrieved were screened by title, and relevant abstracts were reviewed. If deemed appropriate, full text articles were obtained to determine if studies met inclusion criteria. To reduce bias against unpublished research, the following resources were examined using the same search terms: Cochrane Library of Systemat-

ic Reviews; NIH Research Portfolio Online Reporting Tools: Expenditures and Results (RePORTER); and clinicaltrials.gov. The authors then searched PubMed to identify relevant articles published by authors of articles already identified as relevant. The reference section of each included article was also reviewed for any additional studies that met criteria. Two authors (AKB and RLR) independently reviewed all articles. The authors compared methods, findings, conclusions, strengths, and weaknesses of each article, and resolved disagree-

Am J Health Behav.™ 2014;38(3):321-330

DOI:

http://dx.doi.org/10.5993/AJHB.38.3.1

323

Pulmonary Rehabilitation Maintenance Interventions: A Systematic Review

Table 2 Study Quality Assessment: Risk of Bias

Study

Selection bias: Random sequence generation

Selection bias: Allocation concealment

Performance bias: Blinding of participants and personnel

Detection bias: Blinding of outcome assessment

Attrition bias: Incomplete outcome data

Reporting bias: Selective reporting

Other sources of bias

Bauldoff et al, 200235

Unclear risk

Unclear risk

High risk

Unclear risk

Unclear risk

Low risk

Low risk

1

Brooks et al, 200234

Low risk

Unclear risk

High risk

Low risk

High risk

Low risk

Low risk

2

Du Moulin et al, 200936

Low risk

Low risk

High risk

Low risk

Low risk

Low risk

Low risk

1

Ries et al, 200341

Low risk

Low risk

High risk

Low risk

Low risk

Low risk

Low risk

1

Unclear risk

Unclear risk

High risk

Unclear risk

Low risk

High risk

Low risk

2

Low risk

Low risk

High risk

High risk

Low risk

Low risk

Low risk

2

Unclear risk

Unclear risk

High risk

Unclear risk

Low risk

Low risk

Low risk

1

Low risk

Unclear risk

High risk

Low risk

Low risk

Low risk

Low risk

1

Ringbaek et al, 201037

Spencer et al, 201038

Steele et al, 200840

Waterhouse et al, 201033

ments through discussions with the third author (SRS). Methodological quality was independently assessed using Cochrane’s tool for assessing quality and risk of bias18 by 2 authors (AKB and RLR). There was high agreement among the authors regarding assessments of bias, and any disagreements were resolved through discussion. A total of 22 articles on PR maintenance interventions were found (Figure 1). Eleven studies were excluded for not meeting inclusion/exclusion criteria: lack of randomization,19-23 lack of comparison group,24 not all participants received initial PR,25-28 and the maintenance program was simply an extended version of the initial PR program.29 Three additional articles were strongly considered for inclusion but were ultimately excluded following discussion among reviewers. In the first study, the intervention and control groups did not receive the same initial pulmonary rehabilitation.30 In the second study, the control group received more than usual care.31 In the third study, intervention

324

Total High Risk

participants who experienced a disease exacerbation received repeat PR within 12 months of the initial program.32 In total, 8 articles were judged as meeting the above inclusion/exclusion criteria (Figure 1). Of note, 2 of these studies included 2 types of premaintenance PR. Waterhouse et al33 randomized participants to either hospital-based or community-based PR, and then randomized both groups to either a maintenance program or usual care (2 x 2 design). The authors found no differences in the initial impact of the PR programs, and pooled the results of the initial PR program when analyzing maintenance data. Therefore, this study was deemed eligible for the present review. Brooks et al34 recruited participants from inpatient and outpatient-based PR programs. These programs differed in length (6 weeks vs 8 weeks) and number of contacts per week (5 vs 3), but were described as having the same curriculum (patient education, psychosocial support, and supervised exercise).

Busby et al

Figure 2 Study Timelines

Note. Ÿ Represent data collection timepoints

Participants from both programs were pooled and randomized to receive either a maintenance intervention or conventional follow-up. There were no baseline differences between the maintenance and comparison groups on disease-relevant or other demographic variables, indicating that randomization was effective. Therefore, this study was also deemed eligible for the present review. RESULTS The 8 studies included in this systematic review were conducted in North America, Europe, and Australia. Date of publication ranged from 2002 to 2010. Characteristics of each study, including features of the maintenance interventions, are summarized in Table 1. All studies included patients with chronic lung disease; 6 of the 8 studies were limited to COPD patients.33-38 Sample sizes were small (ranging from N = 24 to N = 164), and predominantly male (60.4% across studies). Mean age ranged from 65 to 68 years. All studies were judged to have at least some methodological quality issues. All studies were found to have high risk of performance bias, which is common among exercise interventions, where participants cannot be blinded to group assignment. Three studies were found to have additional areas of high risk of bias,34,37,38 and the risk of bias in other areas was unclear in several studies due to incomplete information on study methods (Table 2).

Length of initial PR ranged from 3-14 weeks. The initial PR program in each study included supervised exercise and education, although the education topics were not described in most cases, nor were the frequency, intensity, or type of exercise. Whereas all studies reported the inclusion of participants who had completed an initial PR, none of the studies provided details of how completion of initial PR was defined. Length of maintenance rehabilitation ranged from 8 to 64 weeks, and included various combinations of supervised exercise (walking, cycling, strength training), unsupervised exercise (primarily walking), in-person or telephone-based motivational/problem-solving sessions, and use of measurement or informational tools (pedometer, training diary, exercise handbook). Six of the 8 studies used the 6-minute walk test (6MWT) as the primary measure of physical endurance. The 6MWT is a measure of functional capacity indicated for measuring response to interventions for moderate to severe lung disease, and is commonly used in both clinical and research settings with chronic lung disease patients.39 The 6MWT is particularly useful for assessing exercise level for activities of daily living.39 Other measures used were the incremental shuttle walk test (ISWT)37,38 and the endurance shuttle walk test (ESWT),33,37,38 which are similar to the 6MWT, but are less commonly used and have less validation.39 In addition, 3 of the 8 studies included second-

Am J Health Behav.™ 2014;38(3):321-330

DOI:

http://dx.doi.org/10.5993/AJHB.38.3.1

325

Pulmonary Rehabilitation Maintenance Interventions: A Systematic Review

Table 3 Physical Endurance Results Studies That Reported 6MWT Outcomes Change Scorea (Baseline toPost-Intervention), Meters

Study Bauldoff et al, 200235

Intervention Group

+136b

Comparison Group

-52

Net Effect of Intervention

+188

Change Score (Baseline to Follow-Up), Meters

No follow-up

Intervention Group Brooks et al, 200234 Du Moulin et al, 200936 Ries et al, 200341 Spencer et al, 201038 Steele et al, 200840

Comparison Group Net Effect of Intervention

Exact figures not provided

Intervention Group

+33.9

Comparison Group

-11.5

Net Effect of Intervention

+45.4

No follow-up

Intervention Group

-17.9

-42.5

Comparison Group

-42.2

-45.1

Net Effect of Intervention

+24.3

+2.96

Intervention Group

-11

Comparison Group

-6

Net Effect of Intervention

-5

No follow-up

Intervention Group

-8.2

-18.3

Comparison Group

-33.5

-39.6

Net Effect of Intervention

+25.3

+21.3

Studies That Reported ESWT Outcomes Intervention Group Ringbaek et al, 201037 Spencer et al, 201038

Comparison Group Net Effect of Intervention

Exact figures not provided

Intervention Group

+105

Comparison Group

-26

Net Effect of Intervention

+131

Intervention Group Waterhouse et al, 201033

-225.6

Comparison Group Net Effect of Intervention

No follow-up -136.2

No data pointc

-89.4

Note. a Change scores are based on means provided in article; Numbers of patients at each time point may vary b Data for this study were reported in feet, and were converted to meters for comparability with other studies c Authors took measurements 3 months prior, and 3 months after the end of the intervention. There is no immediate post-maintenance measurement time point

ary measures of physical activity, such as pedometers,35 exercise diaries,35,38,40 and accelerometers.40 Data collection time points varied from monthly to every 6 months. Four studies did not include any post-maintenance follow-up.34-36,38 In the 4 studies that collected post-maintenance data,33,37,40,41 follow-up time periods ranged from 3 to 12 months

326

(Figure 2). One study35 described a clear theoretical framework to explain the mechanism by which the intervention was hypothesized to promote exercise maintenance (use of distractive auditory stimuli to reduce the perception of dyspnea and enhance exercise persistence). The other studies provided minimal information regarding theoreti-

Busby et al cal underpinnings and focused primarily on number and type (in-person vs telephone) of contacts with health professionals. Compared to no intervention or usual care control, 6 of the 8 studies found at least some evidence for positive maintenance intervention effects on primary outcomes of physical endurance (6MWT, ISWT, ESWT). However, most intervention effects were relatively short-lived. Of the 6 studies that found positive intervention effects, 2 studies34,37 showed initial positive maintenance intervention effects, which then declined to non-significance by the end of the intervention period. Two studies40,41 showed positive maintenance intervention effects throughout the intervention period, which then deteriorated during the 12-month follow-up period. Two studies35,36 provided no post-maintenance follow-up data, thereby prohibiting any inference regarding the persistence of maintenance behavior. Table 3 contains change scores and net effect sizes for studies that reported these data. Results for secondary measures of objective and self-reported physical activity were similarly limited. Bauldoff et al35 found that intervention participants walked more miles during the intervention period based on self-reported pedometer data, but this difference was not statistically significant. Steele et al40 found that the intervention group reported more minutes of exercise immediately after the intervention, but this difference was not significant at 9-month follow-up. They also found no difference between groups in accelerometer activity at any time point. Exercise diary data from Spencer et al38 appeared to indicate that the intervention group exercised more frequently at the 3-month time point. However, the authors did not provide information on statistical significance due to poor rates of diary completion, and the differences eroded considerably by the 12-month time point. DISCUSSION This systematic review identified 8 studies evaluating interventions to improve the maintenance of PR effects in patients with chronic lung disease. Although most of the reviewed studies showed at least some favorable results during the maintenance intervention period, there was limited evidence of durability of any intervention effects on physical endurance during follow-up. There are several possible explanations for these results, including the apparent atheoretical nature of the interventions, the expected progressive course of COPD and other chronic lung diseases, variable intervention and follow-up periods, variable handling of participant drop-out, and poor adherence measurement. Although much remains unknown about mechanisms of behavior change maintenance, theoretically-driven research exists and should be used to inform interventions. Several researchers have articulated the differences between adoption and maintenance, which may explain why physical ac-

tivity interventions demonstrate an initial effect but not a lasting one. For example, the physical activity adoption environment is often protected and supervised, whereas the physical activity maintenance environment is unsupervised, exposing participants to a variety of moods, stresses, and temptations.42 To persist with physical activity in the maintenance period successfully, one must cultivate skills to cope with the challenges of the fluctuating, unsupervised environment, above and beyond physical skills associated with exercise. Other researchers have distinguished between initial behavior change and maintenance by examining what drives decision-making for each process.43 Behavioral initiation is oriented towards reducing the discrepancy between the current state and a desired future state (approach-based self-regulatory system); conversely, behavioral maintenance is oriented towards preserving the current state to avoid an alternative, undesired state (avoidancebased self-regulatory system).43 Therefore, the results of behavioral change must meet or exceed expectations to sustain motivation for maintenance. Several studies have examined determinants of physical activity maintenance. Among the most common predictors of exercise maintenance are high self-efficacy,44,45 positive affect,44,45 lower perceived stress,46 exercise adoption interventions preceding maintenance that are long and structured,42,47-49 social and physical environments that are supportive of exercise,42,44 high intrinsic motivation,42,50 and perceived moderate intensity effort.44,51,52 However, questions remain regarding which type of intervention can best promote maintenance via these mediators/moderators. Over the past 10 years, funding for health maintenance research has increased substantially,15 and researchers have begun to test maintenance theories43,53 and maintenance interventions systematically.15 Although there is no consensus on which physical activity maintenance interventions are most successful, strategies common to successful maintenance interventions include relapse prevention strategies, follow-up prompts, and self-monitoring.47 In addition, some suggest that environmental change (eg, availability of locations in which to exercise) is integral to successful maintenance.54 Most of the reviewed studies involved follow-up prompts to promote physical activity maintenance.33,34,36,40,41 One study explicitly included selfmonitoring, relapse prevention, and functional analysis of the environment in the maintenance intervention;40 no other studies addressed these correlates of maintenance in their interventions. In fact, most studies in the current review focused on frequency and type (ie, in-person vs telephone) of therapeutic contact, rather than therapeutic content. Therefore, it is possible that the reviewed interventions were not appropriately directed at maintenance-relevant beliefs, behaviors, emotional states, and environments to promote persistence of physical activity behavior. Another possible reason for lack of durability of

Am J Health Behav.™ 2014;38(3):321-330

DOI:

http://dx.doi.org/10.5993/AJHB.38.3.1

327

Pulmonary Rehabilitation Maintenance Interventions: A Systematic Review maintenance intervention effects is the expected course of chronic lung diseases. COPD is, by definition, chronic and progressive, and is often punctuated by periods of acute illness, even in patients with relatively well-managed disease. Therefore, it would be unrealistic to expect chronic lung disease patients to maintain a steady level of physical activity/endurance indefinitely. Rather, a successful maintenance intervention in this population would contribute to a slowing of declines in physical activity and endurance, and provide patients with skills to resume physical activity safely after acute exacerbations. In the reviewed studies, intervention and comparison group participants were largely indistinguishable by the end of the study periods, indicating that any intervention gains were shortlived, and intervention participants returned to their original downward trajectories. Only 3 studies37,38,41 reported group differences in disease exacerbations and/or healthcare utilization during the intervention period, and these variables were not used in any predictive modeling. Therefore, the overall impact of disease exacerbations and/ or healthcare utilization on the efficacy of the interventions is not known in this group of studies. Other factors impacting ability to draw conclusions from the studies include differences in intervention and follow-up periods, handling of participant drop-out, and adherence measurements. The variability in intervention and follow-up time periods makes comparing interventions across studies or defining length of durability of interventions challenging. Interestingly, longer maintenance interventions were not associated with more favorable results, indicating that intervention content may be just as important as intervention length, if not more so. Regarding participant drop-out, some studies excluded drop-outs or did not indicate how drop-outs were addressed in analyses,34,37,40,41 whereas others performed intent-to-treat analyses,33,35,36,38 making these studies somewhat difficult to compare. Regarding adherence, most studies included a measurement of adherence, but data type was variable. Some studies provided adherence data on intervention contacts and self-reported home exercise,33,34 but others provided adherence data on intervention contacts only,37,41 or self-reported home exercise only.35,40 Of the remaining studies, one did not provide any adherence data,36 and one reported such low completion of self-report exercise diaries that the authors were unable to comment on adherence to at-home exercise.38 Given the variability of adherence reporting, even when intervention adherence is known, it is difficult to determine if the interventions themselves (eg, telephone calls, in-person sessions, music) had the intended effect of maintaining physical activity level in the home environment. Two recent systematic reviews/meta-analyses used similar methods and, despite including a slightly different sample of articles for review,

328

reached conclusions similar to the present review.55,56 However, there are important differences worth highlighting. First, Soysa et al55 focused on the immediate impact of the maintenance interventions, but did not review maintenance followup data, providing no information on the durability of the maintenance interventions. In contrast, the present review focuses both on the immediate and long-term impact of the maintenance interventions, providing a more complete assessment of intervention durability. Second, Beauchamp et al56 focused on supervised exercise programs only, whereas the present review includes studies with both supervised and unsupervised exercise interventions. The inclusion of studies with unsupervised interventions is a strength of the current review in that the unsupervised environment requires participants to use maintenance skills more intensively. Therefore, examining the results of unsupervised exercise interventions provides vital information regarding maintenance of behavior change. Both previous reviews were limited to COPD-only studies,55,56 whereas the present review includes studies with disease heterogeneity, more accurately representing the clinical PR environment. Third, neither of the prior reviews identified the apparent atheoretical nature of most studies as a limitation to address in future research. The purpose of maintenance interventions is both to lengthen the impact of initial interventions and to foster skills necessary to preserve behavior change when all outside intervention is removed. Therefore, the importance of thoughtfully designing interventions and rooting them in an established theoretical framework cannot be overstated. The present review contributes to the literature by identifying limitations of maintenance interventions in facilitating lasting behavior change, and suggesting methods of designing more durable, theoretically-driven interventions. The reviewed studies provide a useful base for future PR maintenance research, both in the data they provide and in the questions that remain unanswered. Future studies should build upon past physical activity maintenance research to create interventions that are theoretically based and seek to influence known maintenance mediators. Interventions that are likely to be effective will include components of relapse prevention, self-monitoring, follow-up prompts, and a focus on other variables previously shown to be associated with maintenance of health behavior change. In addition, future intervention studies should include substantial follow-up periods to determine durability of the maintenance intervention, adherence measurements for the maintenance behavior of interest (ie, daily physical activity), and measurements of other relevant variables, such as disease exacerbations and costs of intervention. Human Subjects Statement This systematic review did not involve the use of human subjects.

Busby et al Conflict of Interest Statement The authors declare no conflicts of interest.

  1. Rennard A, Decramer M, Calverley PMA, et al. Impact of COPD in North America and Europe in 2000: subjects’ perspective of confronting COPD international survey. Eur Respir J. 2002;20(4):799-805.   2. Murray CJ, Lopez AD. Alternative projection of mortality by cause 1990-2020: global burden of disease study. Lancet. 1997;349(9064):1498-1504.   3. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy for chronic disease. Scand J Med Sci Sports. 2006;16(S1):3-63.   4. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(Suppl 5):4S-42S.   5. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390-1413.   6. Ries AL, Squier HC. The team concept in pulmonary rehabilitation. In Fishman A (Ed). Pulmonary Rehabilitation. New York, NY: Marcel Dekker; 1996:55-65.   7. Yohannes AM, Connolly MJ. Pulmonary rehabilitation programmes in the UK: a national representative survey. Clin Rehabil. 2004;18(4):444-449.   8. 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(2):89-99.   9. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;4:CD003793. 10. Salman GF, Mosier MC, Beasley BW, Calkins DR. Rehabilitation for patients with chronic obstructive pulmonary disease: meta-analysis of randomized controlled trials. J Gen Int Med. 2003;18(3):213-221. 11. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomized controlled trial. Lancet. 2000;355(9211):362-368. 12. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001;56(10):779-784. 13. Foglio K, Bianchi L, Bruletti G, et al. Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction. Eur Respir J. 1999;13(1):125-132. 14. Troosters T, Gosselink R, Decramer M. Short and longterm effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Am J Med. 2000;109(3):207-212. 15. Ory MG, Smith ML, Mier N, Wericke MM. The science of sustaining health behavior change: the health maintenance consortium. Am J Health Behav. 2010;34(6):647659. 16. Oxman A, Guyatt G, Cook D, Montori V. Summarizing the evidence. In Guyatt G, Rennie D (Eds). User’s Guides to the Medical Literature: A Manual For Evidence-Based Clinical Practice. Chicago, IL: American Medical Association Press; 2002:155-173.

17. Wieseler B, McGauran N. Reporting a systematic review. Chest. 2010;137(5):1240-1246. 18. Higgins JPT, Green S (Eds). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration 2011. 19. Moullec G, Ninot G. An integrated programme after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: effect on emotional and functional dimensions of quality of life. Clin Rehabil. 2009;24(2):122-136. 20. Moullec G, Ninot G, Varray A, et al. An innovative maintenance follow-up program after a first inpatient pulmonary rehabilitation. Respir Med. 2008;102(4):556-566. 21. Cockram J, Cecins N, Jenkins S. Maintaining exercise capacity and quality of life following pulmonary rehabilitation. Respirology. 2006;11(1):98-104. 22. Grosbois JM, Lamblin C, Lemaire B, et al. Long-term benefits of exercise maintenance after outpatient rehabilitation program in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 1999;19(4):216-225. 23. Vale F, Reardon JZ, ZuWallack RL. The long-term benefits of pulmonary rehabilitation on exercise endurance and quality of life. Chest. 1993;103(1):42-45. 24. Cooke M, Moyle W, Griffiths S, Shields L. Outcomes of a home-based pulmonary maintenance program for individuals with COPD: a pilot study. Contemp Nurse. 20092010;34(1):85-97. 25. Van Wetering CR, Hoogendoorn M, Mol SJ, et al. Shortand long-term efficacy of a community-based COPD management programme in less advanced COPD: a randomised controlled trial. Thorax. 2010;65(1):7-13. 26. Behnke M, Taube C, Kirsten D, et al. Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease. Respir Med. 2000;94(12):1184-1191. 27. Ries L, Kaplan RM, Limberg TM, Prewitt LM. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med. 1995;122(11):823-832. 28. Wijkstra PJ, Ten Vergert EM, van Altena R, et al. Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patient with chronic obstructive pulmonary disease. Thorax. 1995;50(8):824-828. 29. Berry MJ, Rejeski WJ, Adair NE, et al. A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2003;23(1):60-68. 30. Puente-Maestu L, Luisa Sanz ML, Sanz P, et al. Longterm effects of a maintenance program after supervised or self-monitored training programs in patients with COPD. Lung. 2003;181(2):67-78. 31. Nguyen HQ, Gill DP, Wolpin S, et al. Pilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD. Int J Chron Obstruct Pulmon Dis. 2009;4:301-313. 32. Carr SJ, Hill K, Brooks D, Goldstein RS. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulm Rehabil Prev. 2009;29(5):318-324. 33. Waterhouse JC, Walters SJ, Oluboyede Y, Lawson RA. A randomized 2x2 trial of community versus hospital pulmonary rehabilitation for chronic obstructive pulmonary disease followed by telephone or conventional follow-up. Health Technol Assess. 2010;14(6):1-140. 34. Brooks D, Krip B, Mangovski-Alzamora S, Goldstein RS. The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. Eur Respir J. 2002;20(1):20-29. 35. Bauldoff GS, Hoffman LA, Zullo TG, Sciurba FC. Exercise maintenance following pulmonary rehabilitation. Chest. 2002;122(3):948-954.

Am J Health Behav.™ 2014;38(3):321-330

DOI:

Acknowledgements Dr Busby and Dr Reese were supported by grants from the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affairs during the writing of this article. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. REFERENCES

http://dx.doi.org/10.5993/AJHB.38.3.1

329

Pulmonary Rehabilitation Maintenance Interventions: A Systematic Review 36. Du Moulin M, Taube K, Wegscheider K, et al. Homebased exercise training as maintenance after outpatient pulmonary rehabilitation. Respiration. 2009;77(2):139145. 37. Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year maintenance training on physical functioning and health status in patients with COPD. J Cardiopulm Rehabil Prev. 2010;30(1):47-52. 38. Spencer LM, Alison JA, McKeough ZJ. Maintaining benefits following pulmonary rehabilitation: a randomized controlled trial. Eur Respir J. 2010;35(3):571-577. 39. 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):111-117. 40. Steele BG, Belza B, Cain KC, et al. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease. Arch Phys Med Rehabil. 2008;89(3):404-412. 41. Ries AL, Kaplan RM, Myers R, Prewitt LM. Maintenance after pulmonary rehabilitation in chronic lung disease. Am J Respir Crit Care Med. 2002;167(6):880-888. 42. Laitakari J, Vuori I, Oja P. Is long-term maintenance of health-related physical activity possible? An analysis of concepts and evidence. Health Educ Res. 1996;11(4):463477. 43. Rothman AJ. Toward a theory-based analysis of behavioral maintenance. Health Psychol. 2000;19(1S):64-69. 44. Dishman RK, Sallis JF. Determinants and interventions for physical activity and exercise. In Bouchard C, Shephard RJ, Stephens T (Eds). Physical Activity, Fitness, and Health: International Proceedings And Consensus Statement. Champaign, IL: Human Kinetics; 1994:77-88. 45. McAuley E, Morris KS, Motl RW, et al. Long-term followup of physical activity behavior in older adults. Health Psychol. 2007;26(3):375-380. 46. King AC, Kiernan M, Oman RF, et al. Can we identify who will adhere to long-term physical activity? signal detection methodology as a potential aid to clinical decision

making. Health Psychol. 1997;16(4):380-389. 47. Fjeldsoe B, Neuhaus M, Winkler E, Eakin E. Systematic review of maintenance of behavior change following physical activity and dietary interventions. Health Psychol. 2011;30(1):99-109. 48. Emery CF, Hanck ER, Blumenthal JA. Exercise adherence of maintenance among older adults: 1-year followup study. Psychol Aging. 1992;7(3):466-470. 49. Keefe FJ, Blumenthal JA. The life fitness program: a behavioral approach to making exercise a habit. J Behav Ther Exp Psychiatry. 1980;11:31-34. 50. Thompson CE, Wankel LM. The effects of perceived activity choice upon frequency of exercise behavior. J App Soc Psychol. 1980;10:436-443. 51. Pollock M. Prescribing exercise for fitness and adherence. In Dishman RK (Ed). Exercise Adherence: Its Impact on Public Health. Champaign, IL: Human Kinetics; 1988:259-277. 52. Epstein LH, Wing RR, Koeske R, Voloski A. A comparison of lifestyle exercise, aerobic exercise, and calisthenics on weight loss in obese children. Behav Ther. 1985;16(4):345-356. 53. Nigg CR, Borrelli B, Maddock J, Dishman RK. A theory of physical activity maintenance. Appl Psychol Int Rev. 2008;57(4):544-560. 54. Seymour RB, Hughes SL, Ory MG, et al. A lexicon for measuring maintenance of behavior change. Am J Health Behav. 2010;34(6):660-668. 55. Soysa S, McKeough Z, Spencer L, Alison J. Effects of maintenance programs on exercise capacity and quality of life in chronic obstructive pulmonary disease. Phys Ther Rev. 2012;17(5):335-345. 56. Beauchamp MK, Evans R, Janaudis-Ferreira T, et al. Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with COPD. Chest. 2013;Feb 21: doi:10.1378/chest.12-2421. 57. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;6(5):336-341.

Appendix A Search Strategies: (Pulmonary Disease, Chronic Obstructive/rehabilitation OR Respiration Disorders/rehabilitation OR Lung Diseases, Obstructive/rehabilitation OR Respiratory Therapy[MeSH Terms]) AND (Patient Compliance OR Self Care OR Follow-Up Studies OR Aftercare OR Time Factors OR Home Care Services[MeSH Terms]) AND (maintenance OR home rehabilitation OR postrehabilitation OR exercise persistence OR adherence)

330

Copyright of American Journal of Health Behavior is the property of PNG Publications and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Pulmonary rehabilitation maintenance interventions: a systematic review.

To examine existing research on pulmonary exercise rehabilitation (PR) maintenance interventions...
739KB Sizes 0 Downloads 2 Views