Benefits of Long-Term Pulmonary Rehabilitation Maintenance Program in Patients with Severe Chronic Obstructive Pulmonary Disease. Three-Year Follow-up.

RATIONALE: In chronic obstructive pulmonary disease (COPD), the benefits of pulmonary rehabilitation (PR) tend to wane over time. Whether maintenance techniques may help sustain the benefits achieved after completion of the initial PR program remains controversial. OBJECTIVES: To determine whether a long-term (3-yr) maintenance program after PR preserves the short-term effects on outcomes in patients with COPD. METHODS: This was a multicenter prospective randomized trial including 143 patients with moderate-severe COPD, with 3 years of PR maintenance following an 8-week outpatient PR program. Patients were randomized to maintenance intervention group (IG) and standard monitoring program or control group (CG). The effects on BODE index, 6-minute-walk test distance (6MWD), and health-related quality of life were compared at 12, 24, and 36 months. MEASUREMENTS AND MAIN RESULTS: A total of 138 (96.5%) completed the 8-week program. At this time, all outcomes (BODE, 6MWD, and health-related quality of life) showed clinically and statistically significant improvements (P ≤ 0.001). During the follow-up period, the magnitude of change in 6MWD differed between IG and CG (P = 0.042), with a slight initial increase in the IG during the first year and smaller decline afterward. The BODE index changes differed between baseline and measurements at Month 24 (P = 0.043). At 3 years, the adherence rate of IG patients was 66% and 17% for the CG group (P < 0.001). CONCLUSIONS: This study shows a 2-year beneficial effect of a program of rehabilitation maintenance on the BODE index and 6MWD when compared with a standard strategy. This effect vanishes after the second year of follow-up. Clinical trial registered with www.clinicaltrials.gov (NCT 01090999).

Muscle training with repetitive magnetic stimulation of the quadriceps in severe COPD patients.

BACKGROUND: Previous studies have used electrical neuromuscular stimulation as a physical training method in patients with severe COPD. We introduce the use of the more tolerable magnetic stimulation for the same purpose, investigating the effectiveness of an eight-week protocol. METHODS: Eighteen patients with severe COPD were randomly assigned to a magnetic stimulation training protocol, n=10, FEV(1)=30% (SD: 7) or to parallel clinical monitoring, control group, n=8, FEV(1)=35% (SD: 8). During eight weeks, patients were stimulated for 15min on each quadriceps femoris, three times per week. Quadriceps muscle strength and endurance measurements, quality-of-life questionnaires (SF36, SGRQ) and a six-minute walking test were all carried out before and after the training period in the stimulated and control subjects. RESULTS: All patients completed the training with increasing intensity of stimulation, displaying a significant improvement in voluntary quadriceps strength (17.5% of the baseline value) and exercise capacity, with a mean increase of 23m in the six-minute walking test. The questionnaire scores showed greater increases in quality-of-life scores in the trained subjects compared to the controls, particularly in the physical function areas: mean increments in SF36 in "physical function": +26, "role limitations due to physical problems": +40 and "vitality": +17.5, while +13, -4 and +1, respectively in controls. Saint George's "Activity" score improved by 19.6 points, for 11.5 in controls. CONCLUSIONS: In COPD patients who are limited due to dyspnoea, magnetic neuromuscular stimulation of the quadriceps constitutes a feasible training method for the lower limbs, with positive effects on the muscle function, effort capacity and perception areas.

[Home vs hospital-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a Spanish multicenter trial]. / Comparación de un programa de rehabilitación domiciliario con uno hospitalario en pacientes con EPOC: estudio multicéntrico español.

OBJECTIVE: To compare the effects of a simple home pulmonary rehabilitation program and an intensive hospital-based program in terms of the exercise tolerance and health-related quality of life (HRQL) of patients with severe chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Patients in this prospective, multicenter trial were randomized to 2 groups to receive hospital or home pulmonary rehabilitation. Patients in both groups attended 2 informative sessions about the disease and 4 physical therapy sessions. Patients in the hospital group then carried out a structured exercise program while home group patients performed low intensity exercises at home without supervision. RESULTS: Twenty-eight patients were randomized to the hospital rehabilitation group and 23 to the home group. Both groups showed a similar improvement on the 6-minute walk test (mean difference, 8.7 m; P=.61). HRQOL measured with the Chronic Respiratory Questionnaire also improved in both groups, but the change was greater on the emotional function domain in the hospital rehabilitation group (mean difference between groups, 0.58 on a scale for which the smallest clinically relevant difference is 0.5 points). The benefits were maintained in both groups 6 months after the programs ended. CONCLUSIONS: This study demonstrates that the improvement in exercise tolerance achieved by COPD patients with an unsupervised home pulmonary rehabilitation program is similar to the gains of patients in an intensive hospital-based program. However, the hospital program afforded greater benefit on the HRQOL emotional function domain.

Comparación de un programa de rehabilitación domiciliario con uno hospitalario en pacientes con EPOC: estudio multicéntrico español / Home vs hospital-based pulmonary rehabilitation for patients with Chronic Obstructive Pulmonary Disease: a spanish multicenter trial

OBJETIVO: Estudiar el impacto de un programa simple de rehabilitación respiratoria domiciliario, comparado con uno intensivo hospitalario, sobre la capacidad de esfuerzo y la calidad de vida relacionada con la salud (CVRS) de los pacientes con enfermedad pulmonar obstructiva crónica. PACIENTES Y MÉTODOS: Se ha realizado un estudio prospectivo y multicéntrico en el que se aleatorizó a pacientes con EPOC grave en 2 grupos: hospital (GH) o domicilio (GD). En ambos los pacientes recibieron 2 sesiones de educación y 4 de fisioterapia. Los del GH realizaron un programa estructurado de ejercicio en el hospital y los del GD, un programa de ejercicio de baja intensidad en el domicilio, sin supervisión. RESULTADOS: Se aleatorizó a 28 pacientes en el GH y a 23 en el GD. Ambos grupos mostraron una mejoría similar en la prueba de la marcha de 6 min (diferencia media de 8,7 m; p = 0,61). A pesar de que en ambos grupos mejoró la CVRS, medida con el Cuestionario de Enfermedad Respiratoria Crónica (CRQ), se objetivó un incremento mayor en el área de función emocional para el GH (diferencia media entre grupos: 0,58, en una escala donde un valor de 0,5 representa la diferencia mínima importante). Los beneficios del programa se mantuvieron en ambos grupos hasta 6 meses después de finalizarlo. CONCLUSIONES: El estudio muestra que un programa domiciliario de rehabilitación respiratoria sin supervisión produce una mejoría similar en la capacidad de esfuerzo de los pacientes con EPOC que un programa intensivo hospitalario. Sin embargo, éste alcanza mayores beneficios en el área de la función emocional de la CVRS

OBJECTIVE: To compare the effects of a simple homepulmonary rehabilitation program and an intensivehospital-based program in terms of the exercise toleranceand health-related quality of life (HRQL) of patients withsevere chronic obstructive pulmonary disease (COPD).PATIENTS AND METHODS: Patients in this prospective,multicenter trial were randomized to 2 groups to receivehospital or home pulmonary rehabilitation. Patients in bothgroups attended 2 informative sessions about the disease and4 physical therapy sessions. Patients in the hospital groupthen carried out a structured exercise program while homegroup patients performed low intensity exercises at homewithout supervision.RESULTS: Twenty-eight patients were randomized to thehospital rehabilitation group and 23 to the home group. Bothgroups showed a similar improvement on the 6-minute walktest (mean difference, 8.7 m; P=.61). HRQOL measured withthe Chronic Respiratory Questionnaire also improved in bothgroups, but the change was greater on the emotional functiondomain in the hospital rehabilitation group (mean differencebetween groups, 0.58 on a scale for which the smallestclinically relevant difference is 0.5 points). The benefits weremaintained in both groups 6 months after the programs ended.CONCLUSIONS: This study demonstrates that theimprovement in exercise tolerance achieved by COPD patientswith an unsupervised home pulmonary rehabilitation programis similar to the gains of patients in an intensive hospital-basedprogram. However, the hospital program afforded greaterbenefit on the HRQOL emotional function domain

[Benefits of a home-based pulmonary rehabilitation program for patients with severe chronic obstructive pulmonary disease]. / Beneficios de un programa de rehabilitación respiratoria domiciliaria en pacientes con EPOC grave.

OBJECTIVE: The benefits of a domiciliary program of pulmonary rehabilitation for patients with severe to very severe chronic obstructive pulmonary disease (COPD) are uncertain. We aimed to assess the short- and medium-term efficacy of such a program in this clinical setting. PATIENTS AND METHODS: Patients with severe COPD (stages III-IV, classification of the Global Initiative for Chronic Obstructive Lung Disease) and incapacitating dyspnea (scores 3-5, Medical Research Council [MRC] scale) were randomized to a control or domiciliary rehabilitation group. The 9-week supervised pulmonary rehabilitation program included educational sessions, respiratory physiotherapy, and muscle training in weekly sessions in the patient's home. We assessed the following variables at baseline, 9 weeks, and 6 months: lung function, exercise tolerance (3-minute walk test), dyspnea (MRC score), and health-related quality of life with the Chronic Respiratory Questionnaire (CRQ). RESULTS: Thirty-eight patients with a mean (SD) age of 68 (6) years were enrolled. The mean MRC score was 4 (0.8) and mean forced expiratory volume in 1 second was 29% of reference. Twenty-nine patients completed the study (6 months). Distance covered on the walk test increased significantly in the rehabilitation group (P=.001) and the difference was maintained at 6 months. Dyspnea also improved significantly with rehabilitation (P<.05), but the reduction was not evident at 6 months. Statistically significant improvements in symptoms related to 2 CRQ domains were detected between baseline and 9 weeks: dyspnea (3.1 [0.8] vs 3.6 [0.7]; P=.02) and fatigue (3.7 [0.8] vs 4.2 [0.9]; P=.002). A clinically relevant but not statistically significant change in mastery over disease was detected (from 4.3 to 4.9). All improvements were maintained at 6 months. CONCLUSIONS: Home-based pulmonary rehabilitation for patients with severe to very severe COPD and severe functional incapacity leads to improvements in exercise tolerance and health-related quality of life that are maintained at 6 months.

Beneficios de un programa de rehabilitación respiratoria domiciliaria en pacientes con EPOC grave / Benefits of a home-based pulmonary rehabilitation program for patients with severe Chronic Obstructive Pulmonary Disease

Objetivo: Los beneficios de la rehabilitación respiratoria domiciliaria (RRD) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) de grado grave-muy grave son controvertidos. Nuestro objetivo ha sido evaluar la eficacia a corto y medio plazo de un programa de RRD en pacientes con EPOC grave. Pacientes y métodos: Se trata de un estudio prospectivo y aleatorizado en pacientes con EPOC grave (estadios III y IV de la clasificación GOLD) y disnea invalidante --puntuación de 3 a 5 en la escala del Medical Research Council (MRC)--, distribuidos en grupo control y grupo RRD. El programa de rehabilitación respiratoria fue de 9 semanas y consistía en educación, fisioterapia respiratoria y entrenamiento muscular con supervisión semanal en domicilio. Evaluamos en situación basal, a las 9 semanas y a los 6 meses la función pulmonar, la capacidad de ejercicio (prueba de la marcha de 3 min), la disnea (MRC) y la calidad de vida relacionada con la salud, determinada con el Chronic Respiratory Questionnaire (CRQ). Resultados: Participaron en el estudio 38 pacientes, con una edad media ± desviación estándar de 68 ± 6 años (puntuación MRC: 4 ± 0,8; volumen espiratorio forzado en el primer segundo: 29% del valor de referencia), y 29 completaron el seguimiento a los 6 meses. En el grupo RRD se incrementó significativamente la distancia recorrida en la prueba de la marcha de 3 min (p = 0,001), resultado que se mantuvo a los 6 meses. La disnea mejoró significativamente tras la RRD (p < 0,05), pero dicha mejoría desapareció a los 6 meses. Se observó una mejoría clínica y estadísticamente significativa en 2 dominios del CRQ, el de disnea (3,1 ± 0,8 frente a 3,6 ± 0,7; p = 0,02) y el de fatiga (3,7 ± 0,8 frente a 4,2 ± 0,9; p = 0,002), y tan sólo clínica (4,3 frente a 4,9) en el control de la enfermedad, mejorías que se mantuvieron a los 6 meses. Conclusiones: La RRD en pacientes con EPOC grave-muy grave y alta incapacidad funcional aporta beneficios en la calidad de vida relacionada con la salud y la capacidad de ejercicio, que pueden mantenerse hasta los 6 meses

Objective: The benefits of a domiciliary program of pulmonary rehabilitation for patients with severe to very severe chronic obstructive pulmonary disease (COPD) are uncertain. We aimed to assess the short- and medium-term efficacy of such a program in this clinical setting. Patients and methods: Patients with severe COPD (stages III-IV, classification of the Global Initiative for Chronic Obstructive Lung Disease) and incapacitating dyspnea (scores 3-5, Medical Research Council [MRC] scale) were randomized to a control or domiciliary rehabilitation group. The 9-week supervised pulmonary rehabilitation program included educational sessions, respiratory physiotherapy, and muscle training in weekly sessions in the patient´s home. We assessed the following variables at baseline, 9 weeks, and 6 months: lung function, exercise tolerance (3-minute walk test), dyspnea (MRC score), and health-related quality of life with the Chronic Respiratory Questionnaire (CRQ). Results: Thirty-eight patients with a mean (SD) age of 68 (6) years were enrolled. The mean MRC score was 4 (0.8) and mean forced expiratory volume in 1 second was 29% of reference. Twenty-nine patients completed the study (6 months). Distance covered on the walk test increased significantly in the rehabilitation group (P=.001) and the difference was maintained at 6 months. Dyspnea also improved significantly with rehabilitation (P<.05), but the reduction was not evident at 6 months. Statistically significant improvements in symptoms related to 2 CRQ domains were detected between baseline and 9 weeks: dyspnea (3.1 [0.8] vs 3.6 [0.7]; P=.02) and fatigue (3.7 [0.8] vs 4.2 [0.9]; P=.002). A clinically relevant but not statistically significant change in mastery over disease was detected (from 4.3 to 4.9). All improvements were maintained at 6 months. Conclusions: Home-based pulmonary rehabilitation for patients with severe to very severe COPD and severe functional incapacity leads to improvements in exercise tolerance and health-related quality of life that are maintained at 6 months

Comparison of the distances covered during 3 and 6 min walking test.

AIMS: To determine the reproducibility of the distance covered in 3 min and its correlation with the 6 min walking test, as well as compare the distances covered at different time intervals. Secondly, to evaluate the relationship between the distances covered during these time periods and the maximum oxygen intake obtained during a bicycle ergometer test. METHODS: Forty-five Chronic Obstructive Pulmonary Disesase patients were included in the study. Subjects who were either physically limited or familiar with the test, or those with acute exacerbation in the month prior to the study, were excluded. Three walking tests were carried out each day. In 30 patients for three consecutive days, and the distances covered in periods of 3 and 6 min were measured with 20 min rest between each walk. No incentive was given and the patients knew that the distances covered in 3 and 6 min would be quantified. Oxygen saturation, heart rate and degree of breathlessness (modified Borg scale) were registered at baseline. After 3 min, the distance covered and degree of breathlessness were also measured. After 6 min, oxygen saturation, heart rate, degree of breathlessness and distance covered in meters were registered. Spirometry was performed daily on each patient, and those with an FEV1 variation of less than 10% were considered clinically and functionally stable. An exercise test using bicycle ergometer was carried out to determine maximum oxygen intake. A 3 min walking test was performed in 15 patients, independently on the same day, which was followed after 20 min rest with a 6 min walking test. RESULTS: A significant increase was observed in the distance covered over 3 and 6 min in the first 5 walks, with the greatest increase seen in the first 3 walks. The correlation between the distance covered in 3 and 6 min was 0.98. The correlation between the distance covered in 3 min and oxygen intake was 0.64. No significant differences were observed between the distances covered in the 0-3 and 3 to 6 min periods. During the walking test, breathlessness was measured using the modified Borg scale, which was 1.8 after 3 min, and 3.2 after six min and 8.6 at the end of bicycle ergometer test. No significant differences were observed between the distance covered during the 3 minute test and the distance in the first 3 min of the 6 min walking test. CONCLUSIONS: A learning effect was observed when the walking test is carried out repeatedly over short time periods, with a significant increase in the first 5 walks. Correlation between the distances covered in 3 and 6 min is very good, and acceptable when the distance covered over these periods is compared with oxygen intake and walking speed is constant.