Patients with COVID-19 or post-COVID-19 will most probably have a need for rehabilitation during and directly after the hospitalisation. Data on safety and efficacy are lacking. Healthcare ...professionals cannot wait for published randomised controlled trials before they can start these rehabilitative interventions in daily clinical practice, as the number of post-COVID-19 patients increases rapidly. The Convergence of Opinion on Recommendations and Evidence process was used to make interim recommendation for the rehabilitation in the hospital and post-hospital phase in COVID-19 and post-COVID-19 patients, respectively.
93 experts were asked to fill out 13 multiple choice questions. Agreement of directionality was tabulated for each question. At least 70% agreement on directionality was necessary to make consensus suggestions.
76 experts (82%) reached consensus on all questions based upon indirect evidence and clinical experience on the need for early rehabilitation during the hospital admission, the screening for treatable traits with rehabilitation in all patients at discharge and 6-8 weeks after discharge, and around the content of rehabilitation for these patients. It advocates for assessment of oxygen needs at discharge and more comprehensive assessment of rehabilitation needs including physical as well as mental aspects 6-8 weeks after discharge. Based on the deficits identified multidisciplinary rehabilitation should be offered with attention for skeletal muscle and functional as well as mental restoration.
This multinational task force recommends early, bedside rehabilitation for patients affected by severe COVID-19. The model of pulmonary rehabilitation may suit as a framework, particularly in a subset of patients with long term respiratory consequences.
Background
Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise‐induced hypoxia. Pulmonary rehabilitation, an intervention that includes exercise ...training, is beneficial for people with other chronic lung conditions; however its effects in ILD have not been well characterised.
Objectives
• To determine whether pulmonary rehabilitation in patients with ILD has beneficial effects on exercise capacity, symptoms, quality of life and survival compared with no pulmonary rehabilitation in patients with ILD.
• To assess the safety of pulmonary rehabilitation in patients with ILD.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 6), MEDLINE (Ovid), EMBASE (Ovid), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO) and the Physiotherapy Evidence Database (PEDro) (all searched from inception to June 2014). We also searched the reference lists of relevant studies, international clinical trial registries and respiratory conference s to look for qualifying studies.
Selection criteria
Randomised and quasi‐randomised controlled trials in which pulmonary rehabilitation was compared with no pulmonary rehabilitation or with other therapy in people with ILD of any origin were included.
Data collection and analysis
Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. Study authors were contacted to provide missing data and information regarding adverse effects. A priori subgroup analyses were specified for participants with idiopathic pulmonary fibrosis (IPF) and participants with severe lung disease (low diffusing capacity or desaturation during exercise). We planned to subgroup according to training modality applied, but there were insufficient data.
Main results
Nine studies were included, six of which were published as s. Five studies were included in the meta‐analysis (86 participants who undertook pulmonary rehabilitation and 82 control participants). One study used a blinded assessor and intention‐to‐treat analysis. No adverse effects of pulmonary rehabilitation were reported. Pulmonary rehabilitation improved the six‐minute walk distance with weighted mean difference (WMD) of 44.34 metres (95% confidence interval (CI) 26.04 to 62.64 metres) and improved oxygen consumption (VO2) peak with WMD of 1.24 mL/kg/min‐1 (95% CI 0.46 to 2.03 mL/kg/min‐1). Improvements in six‐minute walk distance and VO2 peak were also seen in the subgroup of participants with idiopathic pulmonary fibrosis (IPF) (WMD 35.63 metres, 95% CI 16.02 to 55.23 metres; WMD 1.46 mL/kg/min‐1, 95% CI 0.54 to 2.39 mL/kg/min‐1, respectively). Reduced dyspnoea (standardised mean difference (SMD) ‐0.66, 95% CI ‐1.05 to ‐0.28) following pulmonary rehabilitation was also seen in the IPF subgroup (SMD ‐0.68, 95% CI ‐1.12 to ‐0.25). Quality of life improved following pulmonary rehabilitation for all participants on a variety of measures (SMD 0.59, 95% CI 0.20 to 0.98) and for the subgroup of people with IPF (SMD 0.59, 95% CI 0.14 to 1.03). Two studies reported longer‐term outcomes, with no significant effects of pulmonary rehabilitation on clinical variables or survival at three or six months. Available data were insufficient to allow examination of the impact of disease severity or exercise training modality.
Authors' conclusions
Pulmonary rehabilitation seems to be safe for people with ILD. Improvements in functional exercise capacity, dyspnoea and quality of life are seen immediately following pulmonary rehabilitation, with benefits also evident in IPF. Because of inadequate reporting of methods and small numbers of included participants, the quality of evidence was low to moderate. Little evidence was available regarding longer‐term effects of pulmonary rehabilitation.
Abstract
Background. Mobility limitations are common following stroke and frequently lead to poor participation in physical activity (PA).
Purpose. The purpose of this study was to describe PA across ...the various stages following stroke (acute, subacute, and chronic).
Data Sources. Searches were conducted in 5 databases.
Study Selection. Eligible studies included participants with stroke whose PA was quantitatively measured for at least 4 hours in a single session. Two reviewers independently reviewed titles and abstracts.
Data Extraction. One reviewer extracted data and assessed quality using the Downs and Black checklist. Weighted means were calculated for PA outcomes.
Data Synthesis. Searches yielded 103 eligible papers including 5306 participants aged 21 to 96 years. Devices (eg, activity monitors) were used in 73 papers, and behavioral mapping (observational monitoring) in 30. Devices show that people with stroke took on average 5535 steps per day (n = 406, 10 studies) in the subacute phase and 4078 steps (n = 1280, 32 studies) in the chronic phase. Average daily walking duration (% measured time) was higher in the chronic phase (9.0%, n = 100) than subacute (1.8%, n = 172), and sedentary time was >78% regardless of time post stroke. Acute data were lacking for these variables. Matched healthy individuals took an average of 8338 steps per day (n = 129). Behavioral mapping showed time in bed was higher in the acute than subacute phase (mean 45.1% versus 23.8%), with similar time spent sitting (mean 37.6% versus 32.6%).
Limitations. Limitations of this review include not pooling data reported as medians.
Conclusions. Physical activity levels do not meet guidelines following stroke. Time spent inactive and sedentary is high at all times. Increasing PA and developing standardized activity targets may be important across all stages of stroke recovery.
Background
Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise‐induced hypoxia. Pulmonary rehabilitation is often used to improve symptoms, ...health‐related quality of life and functional status in other chronic lung conditions. There is accumulating evidence for comparable effects of pulmonary rehabilitation in people with ILD. However, further information is needed to clarify the long‐term benefit and to strengthen the rationale for pulmonary rehabilitation to be incorporated into standard clinical management of people with ILD. This review updates the results reported in 2014.
Objectives
To determine whether pulmonary rehabilitation in people with ILD has beneficial effects on exercise capacity, symptoms, quality of life and survival compared with no pulmonary rehabilitation in people with ILD.
To assess the safety of pulmonary rehabilitation in people with ILD.
Search methods
We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO) and PEDro from inception to April 2020. We searched the reference lists of relevant studies, international clinical trial registries and respiratory conference s to look for qualifying studies.
Selection criteria
We included randomised controlled trials and quasi‐randomised controlled trials in which pulmonary rehabilitation was compared with no pulmonary rehabilitation or with other therapy in people with ILD of any origin.
Data collection and analysis
Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We contacted study authors to request missing data and information regarding adverse effects. We specified a priori subgroup analyses for participants with idiopathic pulmonary fibrosis (IPF) and participants with severe lung disease (low diffusing capacity or desaturation during exercise). There were insufficient data to perform the prespecified subgroup analysis for type of exercise training modality.
Main results
For this update, we included an additional 12 studies resulting in a total of 21 studies. We included 16 studies in the meta‐analysis (356 participants undertook pulmonary rehabilitation and 319 were control participants). The mean age of participants ranged from 36 to 72 years and included people with ILD of varying aetiology, sarcoidosis or IPF (with mean transfer factor of carbon dioxide (TLCO) % predicted ranging from 37% to 63%). Most pulmonary rehabilitation programmes were conducted in an outpatient setting, with a small number conducted in home‐based, inpatient or tele‐rehabilitation settings. The duration of pulmonary rehabilitation ranged from three to 48 weeks. There was a moderate risk of bias due to the absence of outcome assessor blinding and intention‐to‐treat analyses and the inadequate reporting of randomisation and allocation procedures in 60% of the studies.
Pulmonary rehabilitation probably improves the six‐minute walk distance (6MWD) with mean difference (MD) of 40.07 metres, 95% confidence interval (CI) 32.70 to 47.44; 585 participants; moderate‐certainty evidence). There may be improvements in peak workload (MD 9.04 watts, 95% CI 6.07 to 12.0; 159 participants; low‐certainty evidence), peak oxygen consumption (MD 1.28 mL/kg/minute, 95% CI 0.51 to 2.05; 94 participants; low‐certainty evidence) and maximum ventilation (MD 7.21 L/minute, 95% CI 4.10 to 10.32; 94 participants; low‐certainty evidence). In the subgroup of participants with IPF, there were comparable improvements in 6MWD (MD 37.25 metres, 95% CI 26.16 to 48.33; 278 participants; moderate‐certainty evidence), peak workload (MD 9.94 watts, 95% CI 6.39 to 13.49; low‐certainty evidence), VO2 (oxygen uptake) peak (MD 1.45 mL/kg/minute, 95% CI 0.51 to 2.40; low‐certainty evidence) and maximum ventilation (MD 9.80 L/minute, 95% CI 6.06 to 13.53; 62 participants; low‐certainty evidence). The effect of pulmonary rehabilitation on maximum heart rate was uncertain.
Pulmonary rehabilitation may reduce dyspnoea in participants with ILD (standardised mean difference (SMD) –0.36, 95% CI –0.58 to –0.14; 348 participants; low‐certainty evidence) and in the IPF subgroup (SMD –0.41, 95% CI –0.74 to –0.09; 155 participants; low‐certainty evidence). Pulmonary rehabilitation probably improves health‐related quality of life: there were improvements in all four domains of the Chronic Respiratory Disease Questionnaire (CRQ) and the St George's Respiratory Questionnaire (SGRQ) for participants with ILD and for the subgroup of people with IPF. The improvement in SGRQ Total score was –9.29 for participants with ILD (95% CI –11.06 to –7.52; 478 participants; moderate‐certainty evidence) and –7.91 for participants with IPF (95% CI –10.55 to –5.26; 194 participants; moderate‐certainty evidence). Five studies reported longer‐term outcomes, with improvements in exercise capacity, dyspnoea and health‐related quality of life still evident six to 12 months following the intervention period (6MWD: MD 32.43, 95% CI 15.58 to 49.28; 297 participants; moderate‐certainty evidence; dyspnoea: MD –0.29, 95% CI –0.49 to –0.10; 335 participants; SGRQ Total score: MD –4.93, 95% CI –7.81 to –2.06; 240 participants; low‐certainty evidence). In the subgroup of participants with IPF, there were improvements at six to 12 months following the intervention for dyspnoea and SGRQ Impact score. The effect of pulmonary rehabilitation on survival at long‐term follow‐up is uncertain. There were insufficient data to allow examination of the impact of disease severity or exercise training modality.
Ten studies provided information on adverse events; however, there were no adverse events reported during rehabilitation. Four studies reported the death of one pulmonary rehabilitation participant; however, all four studies indicated this death was unrelated to the intervention received.
Authors' conclusions
Pulmonary rehabilitation can be performed safely in people with ILD. Pulmonary rehabilitation probably improves functional exercise capacity, dyspnoea and quality of life in the short term, with benefits also probable in IPF. Improvements in functional exercise capacity, dyspnoea and quality of life were sustained longer term. Dyspnoea and quality of life may be sustained in people with IPF. The certainty of evidence was low to moderate, due to inadequate reporting of methods, the lack of outcome assessment blinding and heterogeneity in some results. Further well‐designed randomised trials are needed to determine the optimal exercise prescription, and to investigate ways to promote longer‐lasting improvements, particularly for people with IPF.
Background
People with osteoarthritis (OA) often are physically inactive. Surgical treatment including total hip arthroplasty or total knee arthroplasty can substantially improve pain, physical ...function, and quality of life. However, their impact on physical activity levels is less clear.
Questions/purposes
We used accelerometers to measure levels of physical activity pre- and (6 months) postarthroplasty and to examine the proportion of people meeting the American Physical Activity Guidelines.
Methods
Sixty-three people with hip or knee OA awaiting arthroplasty were recruited from a major metropolitan hospital. Physical activity was measured using accelerometry before, and 6 months after, surgery. The ActiGraph GT1M (ActiGraph LLC, Fort Walton Beach, FL, USA) was used in this study and is a uniaxial accelerometer contained within a small activity monitor designed to measure human movement through changes in acceleration, which can then be used to estimate physical activity over time. Questionnaires were used to assess patient-reported changes in pain, function, quality of life, and physical activity. Complete data sets (including valid physical activity data) for both time points were obtained for 44 participants (70%). At baseline before arthroplasty, the activity level of patients was, on average, sedentary for 82% of the time over a 24-hour period (based on accelerometry) and self-rated as “sometimes participates in mild activities such as walking, limited shopping, and housework” according to the UCLA activity scale.
Results
There was no change in objectively measured physical activity after arthroplasty. The majority of participants were sedentary, both before and after arthroplasty, and did not meet the American Physical Activity Guidelines recommended to promote health. This was despite significant improvements in self-reported measures of pain, function, quality of life, and physical activity after arthroplasty.
Conclusions
Despite patient-reported improvements in pain, function, and physical activity after arthroplasty, objectively measured improvements in physical activity may not occur. Clinicians should incorporate strategies for improving physical activity into their management of patients after hip and knee arthroplasty to maximize health status. Future research is needed to explore the factors that impact physical activity levels in people after arthroplasty.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Field walking tests are commonly employed to evaluate exercise capacity, assess prognosis and evaluate treatment response in chronic respiratory diseases. In recent years, there has been a wealth of ...new literature pertinent to the conduct of the 6-min walk test (6MWT), and a growing evidence base describing the incremental and endurance shuttle walk tests (ISWT and ESWT, respectively). The aim of this document is to describe the standard operating procedures for the 6MWT, ISWT and ESWT, which can be consistently employed by clinicians and researchers. The Technical Standard was developed by a multidisciplinary and international group of clinicians and researchers with expertise in the application of field walking tests. The procedures are underpinned by a concurrent systematic review of literature relevant to measurement properties and test conduct in adults with chronic respiratory disease. Current data confirm that the 6MWT, ISWT and ESWT are valid, reliable and responsive to change with some interventions. However, results are sensitive to small changes in methodology. It is important that two tests are conducted for the 6MWT and ISWT. This Technical Standard for field walking tests reflects current evidence regarding procedures that should be used to achieve robust results.
Pulmonary rehabilitation is an essential component of care for people with chronic obstructive pulmonary disease (COPD) and is supported by strong scientific evidence. Despite this, many people with ...COPD do not complete their program or choose not to attend at all. The aim of this study was to determine the factors associated with uptake and completion of pulmonary rehabilitation for people with COPD. Seven electronic databases were searched for qualitative or quantitative studies that documented factors associated with uptake and completion of pulmonary rehabilitation in people with COPD. Two reviewers independently extracted data, which was synthesized to provide overall themes. Travel and transport were consistently identified as barriers to both uptake and completion. A lack of perceived benefit of pulmonary rehabilitation also influenced both uptake and completion. The only demographic features that consistently predicted non-completion were being a current smoker (pooled odds ratio 0.17, 95% confidence interval 0.10 to 0.32) and depression. The limited data available regarding barriers to uptake indicated that disruption to usual routine, influence of the referring doctor and program timing were important. In conclusion poor access to transport and lack of perceived benefit affect uptake of pulmonary rehabilitation. Current smokers and patients who are depressed are at increased risk of non-completion. Enhancing attendance in pulmonary rehabilitation will require more attention to transportation, support for those at risk of non-completion and greater involvement of patients in informed decisions about their care.
Background
Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined ...as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home‐based) are emerging.
Objectives
To determine whether supervised pulmonary rehabilitation maintenance programmes improve health‐related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in‐person) during the supervised maintenance programme.
Search methods
We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand‐searched conference s and grey literature through the Cochrane Airways Trials Register and CENTRAL.
Selection criteria
We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events.
Data collection and analysis
Two review authors independently screened titles and s, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta‐analysed using a random‐effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face‐to‐face supervision). We used the GRADE approach to assess the certainty of evidence.
Main results
We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In‐person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in‐person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias.
Low‐ to moderate‐certainty evidence showed that supervised maintenance programmes may improve health‐related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six‐minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI ‐1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all‐cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in‐person supervision. No adverse events were reported.
Authors' conclusions
This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health‐related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear.
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