Abstract and Introduction
Abstract
Background Most pulmonary rehabilitation programmes currently involve 2–3 sessions per week as recommended by international guidelines. We aimed to investigate whether relevant improvements in physical capabilities and quality of life in patients with chronic obstructive pulmonary disease (COPD) could be achieved by a long-term, low intensity, once weekly rehabilitation programme using limited resources.
Methods 100 patients with moderate to severe COPD were randomised to a continuous outpatient interdisciplinary rehabilitation programme or standard care. Physiotherapy-led supervised outpatient training sessions were performed once weekly in addition to educational elements. Outcome measures at baseline and after 26 weeks were 6-minute-walk-test, cycle ergometry, and health-related quality of life.
Results 37 patients in the training group and 44 patients in the control group completed the study. After 26 weeks there were clinically significant differences between the groups for 6 minute-walk-distance (+59 m, 95% CI 28–89 m), maximum work load (+7.4 Watt, 95% CI 0.5–13.4 Watt) and St. George's Respiratory Questionnaire score (−5 points, 95% CI −10 to −1 points). Total staff costs of the programme per participant were ≤ €625.
Conclusion Clinically meaningful improvements in physical capabilities and health-related quality of life may be achieved using long-term pulmonary rehabilitation programmes of lower intensity than currently recommended. Trial registration: clinicaltrials.gov NCT01195402.
Introduction
There is considerable evidence of the beneficial effects of pulmonary rehabilitation on exercise capabilities and health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). Clinically relevant effects may be achieved by rehabilitation programmes of differing designs in terms of setting (inpatient vs. outpatient vs. home-based), duration (short-term vs. long-term), and intensity (high vs. low intensity). As it is well known that achieved improvements decline following short-term programmes, efforts have been made to improve long-term maintenance.
Although the evidence for the efficacy of pulmonary rehabilitation is strong and it is highly recommended by current guidelines, only a minority of eligible COPD patients is included in rehabilitation programmes. Reasons for this discrepancy may be lack of belief in the efficacy of such programmes, lack of local access, and concerns about the cost. While the first aspect should be addressed by intensified promotion on the beneficial effects of pulmonary rehabilitation in the medical community, the other two may be answered by the design of simple and locally available programmes using a minimum amount of resources that still produce clinically relevant effects.
Current guidelines on pulmonary rehabilitation recommend interventions with a frequency of at least 2–3 supervised sessions of high-intensity training per week. This facilitates optimal short-term results, but may lead to lower adherence rates and higher costs in the long-term.
Ambulatory 'lung sport' groups with 15–20 participants and weekly sessions, which are fairly common in Germany, have shown long-term effects on cardiopulmonary fitness in mild to moderate obstructive airways diseases. However, patients with more severe limitations may find it difficult to exercise with those with less severe disease. Therefore, we developed the concept of physiotherapist-lead training groups of 6–10 members where it is possible to tailor training intensity to the different, and often very limited, physical capabilities of the participants.
The purpose of the present study was to evaluate whether a continuous, low-intensity, long-term, physiotherapist-lead outpatient pulmonary rehabilitation programme can induce significant improvements in the exercise capabilities and HRQoL in patients with moderate to severe COPD using less resources than previously published programmes.