Community-based pulmonary rehabilitation is effective for people with chronic obstructive pulmonary disease (COPD)

Question

Does community-based pulmonary rehabilitation improve quality of life, respiratory exacerbations, exercise performance, and lung function in people with COPD?

Design

Randomised, controlled trial with concealed allocation and blinded outcome assessment.

Setting

Two hospitals in The Netherlands.

Participants

People with COPD (GOLD Stages 2 or 3) and impaired exercise capacity (< 70% of predicted peak work during incremental cycle ergometry). Prior rehabilitation and major co-morbidities were exclusion criteria. Randomisation of 199 participants allotted 102 to an intervention group and 97 to a control group.

Interventions

All participants had their medications optimised before randomisation. Over 4 months, the intervention group visited a local physiotherapist twice a week for 30-minute intensive exercise training (endurance cycling and walking, upper and lower limb strength/endurance exercises). They were instructed to do the exercises for 30 minutes twice daily at home and to walk and cycle outside. They also completed an individualised education program using a booklet and, if required, received smoking cessation counselling (minimal intervention strategy) and 4 visits from a dietitian for counselling and supplements. This was followed by a 20-month maintenance program, involving monthly visits to the physiotherapist for monitoring and encouragement. After an exacerbation, participants were allowed 6 extra training sessions over 3 weeks. Extra dietitian and nursing appointments were made if indicated. The control group participants received brief smoking cessation advice and advice to eat more if malnourished, from their respiratory physician.

Outcome measures

The primary outcomes were the St George's Respiratory Questionnaire (SGRQ) total score and the number of exacerbations. Secondary outcomes were SGRQ domain scores, the modified Medical Research Council (MRC) dyspnoea scale, a cycle endurance test, the sixminute walk test distance (6MWD), strength of respiratory and limb muscles, fat-free mass, and lung function. At 24 months, perceived effectiveness of care was rated on a 5-point Likert scale.

Results

Follow-up was 93% at 4 months and 79% at 24 months. At 4 months, improvement in SGRQ score was significantly better in the intervention group by 4.2 points (95% CI 3.9 to 4.5), but exacerbations did not significantly differ, RR 1.01 (95% CI 0.57 to 1.79). Other outcomes that were significantly better in the intervention group were SGRQ activity and impact scores, MRC score, cycle endurance time, peak work, 6MWD, handgrip force, and fat-free mass. At 24 months, SGRQ, cycle endurance time, and 6WMD remained significantly better in the intervention group and exacerbations remained not significantly different. The intervention was perceived as significantly more effective.

Conclusion

Communitybased pulmonary rehabilitation is effective for people with COPD.