Background
Guidelines have provided positive recommendations for pulmonary rehabilitation after exacerbations of chronic obstructive pulmonary disease (COPD), but recent studies indicate that ...postexacerbation rehabilitation may not always be effective in patients with unstable COPD.
Objectives
To assess effects of pulmonary rehabilitation after COPD exacerbations on hospital admissions (primary outcome) and other patient‐important outcomes (mortality, health‐related quality of life (HRQL) and exercise capacity).
Search methods
We identified studies through searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PEDro (Physiotherapy Evidence Database) and the Cochrane Airways Review Group Register of Trials. Searches were current as of 20 October 2015, and handsearches were run up to 5 April 2016.
Selection criteria
Randomised controlled trials (RCTs) comparing pulmonary rehabilitation of any duration after exacerbation of COPD versus conventional care. Pulmonary rehabilitation programmes had to include at least physical exercise (endurance or strength exercise, or both). We did not apply a criterion for the minimum number of exercise sessions a rehabilitation programme had to offer to be included in the review. Control groups received conventional community care without rehabilitation.
Data collection and analysis
We expected substantial heterogeneity across trials in terms of how extensive rehabilitation programmes were (i.e. in terms of number of completed exercise sessions; type, intensity and supervision of exercise training; and patient education), duration of follow‐up (< 3 months vs ≥ 3 months) and risk of bias (generation of random sequence, concealment of random allocation and blinding); therefore, we performed subgroup analyses that were defined before we carried them out. We used standard methods expected by Cochrane in preparing this update, and we used GRADE for assessing the quality of evidence.
Main results
For this update, we added 11 studies and included a total of 20 studies (1477 participants). Rehabilitation programmes showed great diversity in terms of exercise training (number of completed exercise sessions; type, intensity and supervision), patient education (from none to extensive self‐management programmes) and how they were organised (within one setting, e.g. pulmonary rehabilitation, to across several settings, e.g. hospital, outpatient centre and home). In eight studies, participants completed extensive pulmonary rehabilitation, and in 12 studies, participants completed pulmonary rehabilitation ranging from not extensive to moderately extensive.
Eight studies involving 810 participants contributed data on hospital readmissions. Moderate‐quality evidence indicates that pulmonary rehabilitation reduced hospital readmissions (pooled odds ratio (OR) 0.44, 95% confidence interval (CI) 0.21 to 0.91), but results were heterogenous (I2 = 77%). Extensiveness of rehabilitation programmes and risk of bias may offer an explanation for the heterogeneity, but subgroup analyses were not statistically significant (P values for subgroup effects were between 0.07 and 0.11). Six studies including 670 participants contributed data on mortality. The quality of evidence was low, and the meta‐analysis did not show a statistically significant effect of rehabilitation on mortality (pooled OR 0.68, 95% CI 0.28 to 1.67). Again, results were heterogenous (I2 = 59%). Subgroup analyses showed statistically significant differences in subgroup effects between trials with more and less extensive rehabilitation programmes and between trials at low and high risk for bias, indicating possible explanations for the heterogeneity. Hospital readmissions and mortality studies newly included in this update showed, on average, significantly smaller effects of rehabilitation than were seen in earlier studies.
High‐quality evidence suggests that pulmonary rehabilitation after an exacerbation improves health‐related quality of life. The eight studies that used St George's Respiratory Questionnaire (SGRQ) reported a statistically significant effect on SGRQ total score, which was above the minimal important difference (MID) of four points (mean difference (MD) ‐7.80, 95% CI ‐12.12 to ‐3.47; I2 = 64%). Investigators also noted statistically significant and important effects (greater than MID) for the impact and activities domains of the SGRQ. Effects were not statistically significant for the SGRQ symptoms domain. Again, all of these analyses showed heterogeneity, but most studies showed positive effects of pulmonary rehabilitation, some studies showed large effects and others smaller but statistically significant effects. Trials at high risk of bias because of lack of concealment of random allocation showed statistically significantly larger effects on the SGRQ than trials at low risk of bias. High‐quality evidence shows that six‐minute walk distance (6MWD) improved, on average, by 62 meters (95% CI 38 to 86; I2 = 87%). Heterogeneity was driven particularly by differences between studies showing very large effects and studies showing smaller but statistically significant effects. For both health‐related quality of life and exercise capacity, studies newly included in this update showed, on average, smaller effects of rehabilitation than were seen in earlier studies, but the overall results of this review have not changed to an important extent compared with results reported in the earlier version of this review.
Five studies involving 278 participants explicitly recorded adverse events, four studies reported no adverse events during rehabilitation programmes and one study reported one serious event.
Authors' conclusions
Overall, evidence of high quality shows moderate to large effects of rehabilitation on health‐related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self‐management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.
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.
ABSTRACTIn this cross-sectional study, we evaluated skeletal muscle strength and physical performance (1min- STS and SPPB tests), dyspnea, fatigue and Single Breath Counting at discharge from a ...post-acute Covid Department, in patients recovering from COVID-19 pneumonia who had no locomotor disability prior to the infection.Quadriceps and biceps were weak in 86% and 73% of patients, respectively. Maximal Voluntary Contraction for quadriceps was 18.9 (6.8) Kg and for biceps 15.0 (5.5) Kg, i.e. 57 and 69% of the predicted normal value (%pred). The number of chair rises in the 1min-STS was 22.1 (7.3) (63% pred), while the SPPB score was 7.9 (3.3) (68% pred). At the end of the 1min-STS test, 24% of patients showed exercise-induced desaturation. The SBC count was 35.4 (12.3), i.e. 71.8% that of healthy controls. Mild-to-moderate dyspnea and fatigue were found after ADL Borg score 0.5 (0-2) and 1 (0-2) and after the 1min-STS Borg score 3 (2-5) and 1 (0-3). Significant correlations were observed between muscle strength and physical performance indices (R from 0.31 to 0.69).The high prevalence of impairment in skeletal muscle strength and physical performance in hospitalized patients recovering from COVID-19 pneumonia without prior locomotor disabilities suggests the need for rehabilitation programs after discharge.
ABSTRACT
Abundant evidence supports the use of pulmonary rehabilitation as a treatment for stable and exacerbated chronic obstructive pulmonary disease. Several questions around the science base of ...rehabilitation in other patient groups as well as the role of rehabilitation as a component in other comprehensive care trajectories remain to be addressed. The impact of a rehabilitation programme could also perhaps be enhanced if clear guidance would be available on how to individualize the components of a rehabilitation programme in individual patients. The rehabilitation community, in an attempt to increase access to programmes, has developed less rigorous interventions. These may serve specific patients (e.g. less severe patients or may be used as a maintenance programme), but in order to have conceptual clarity they should not be called substitutes for rehabilitation if they do not meet the definition of rehabilitation. Reaching clarity on the best format for maintenance programmes in order to achieve long‐lasting health benefits for patients is another challenge. Furthermore, as many patients as possible should be referred to adequate rehabilitation programmes within their reach with fair reimbursement. Programmes should take into account the burden of the disease of a patient, the required components to tackle the problems, adequate assessment to document the outcome and the patient's preference. In summary, pulmonary rehabilitation is one of the most potent evidence‐based therapies for patients with respiratory diseases. Researchers should continue to fine tune the interventions, get clarity on terminology as well as the ultimate outcomes for rehabilitation to ensure sustainable health effects.
Background Consumer-based activity trackers are used to measure and improve physical activity. However, the accuracy of these devices as clinical endpoint or coaching tool is unclear. We investigated ...the use of two activity trackers as measuring and coaching tool in patients with Chronic Obstructive Pulmonary Disease (COPD) and healthy age-matched controls. Methods Daily steps were measured by two consumer-based activity trackers (Fitbit Zip, worn at the hip and Fitbit Alta, worn at the wrist) and a validated activity monitor (Dynaport Movemonitor) in 28 patients with COPD and 14 healthy age-matched controls for 14 consecutive days. To investigate the accuracy of the activity trackers as a clinical endpoint, mean step count per patient were compared with the reference activity monitor and agreement was investigated by Bland-Altman plots. To evaluate the accuracy of activity trackers as coaching tool, day-by-day differences within patients were calculated for all three devices. Additionally, consistency of ranking daily steps between the activity trackers and accelerometer was investigated by Kendall correlation coefficient. Results As a measuring tool, the hip worn activity tracker significantly underestimates daily step count in patients with COPD as compared to DAM (mean#177;SD DELTA-1112#177;872 steps/day; p0.0001). This underestimation is less prominent in healthy subjects (p = 0.21). The wrist worn activity tracker showed a non-significant overestimation of step count (p = 0.13) in patients with COPD, and a significant overestimation of daily steps in healthy controls (mean#177;SD DELTA+1907#177;2147 steps/day; p = 0.006). As a coaching tool, both hip and wrist worn activity tracker were able to pick up the day-by-day variability as measured by Dynaport (consistency of ranking resp. r = 0.80; r = 0.68 in COPD). Conclusion Although the accuracy of hip worn consumer-based activity trackers in patients with COPD and wrist worn activity trackers in healthy subjects as clinical endpoints is unsatisfactory, these devices are valid to use as a coaching tool.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
This document reviews 1) the measurement properties of commonly used exercise tests in patients with chronic respiratory diseases and 2) published studies on their utilty and/or evaluation obtained ...from MEDLINE and Cochrane Library searches between 1990 and March 2015.Exercise tests are reliable and consistently responsive to rehabilitative and pharmacological interventions. Thresholds for clinically important changes in performance are available for several tests. In pulmonary arterial hypertension, the 6-min walk test (6MWT), peak oxygen uptake and ventilation/carbon dioxide output indices appear to be the variables most responsive to vasodilators. While bronchodilators do not always show clinically relevant effects in chronic obstructive pulmonary disease, high-intensity constant work-rate (endurance) tests (CWRET) are considerably more responsive than incremental exercise tests and 6MWTs. High-intensity CWRETs need to be standardised to reduce interindividual variability. Additional physiological information and responsiveness can be obtained from isotime measurements, particularly of inspiratory capacity and dyspnoea. Less evidence is available for the endurance shuttle walk test. Although the incremental shuttle walk test and 6MWT are reliable and less expensive than cardiopulmonary exercise testing, two repetitions are needed at baseline. All exercise tests are safe when recommended precautions are followed, with evidence suggesting that no test is safer than others.
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.
OBJECTIVES:To investigate whether a daily exercise session, using a bedside cycle ergometer, is a safe and effective intervention in preventing or attenuating the decrease in functional exercise ...capacity, functional status, and quadriceps force that is associated with prolonged intensive care unit stay. A prolonged stay in the intensive care unit is associated with muscle dysfunction, which may contribute to an impaired functional status up to 1 yr after hospital discharge. No evidence is available concerning the effectiveness of an early exercise training intervention to prevent these detrimental complications.
DESIGN:Randomized controlled trial.
SETTING:Medical and surgical intensive care unit at University Hospital Gasthuisberg.
PATIENTS:Ninety critically ill patients were included as soon as their cardiorespiratory condition allowed bedside cycling exercise (starting from day 5), given they still had an expected prolonged intensive care unit stay of at least 7 more days.
INTERVENTIONS:Both groups received respiratory physiotherapy and a daily standardized passive or active motion session of upper and lower limbs. In addition, the treatment group performed a passive or active exercise training session for 20 mins/day, using a bedside ergometer.
MEASUREMENTS AND MAIN RESULTS:All outcome data are reflective for survivors. Quadriceps force and functional status were assessed at intensive care unit discharge and hospital discharge. Six-minute walking distance was measured at hospital discharge. No adverse events were identified during and immediately after the exercise training. At intensive care unit discharge, quadriceps force and functional status were not different between groups. At hospital discharge, 6-min walking distance, isometric quadriceps force, and the subjective feeling of functional well-being (as measured with “Physical Functioning” item of the Short Form 36 Health Survey questionnaire) were significantly higher in the treatment group (p < .05).
CONCLUSIONS:Early exercise training in critically ill intensive care unit survivors enhanced recovery of functional exercise capacity, self-perceived functional status, and muscle force at hospital discharge.
Changes in physical activity (PA) are difficult to interpret because no framework of minimal important difference (MID) exists. We aimed to determine the minimal important difference (MID) in ...physical activity (PA) in patients with Chronic Obstructive Pulmonary Disease and to clinically validate this MID by evaluating its impact on time to first COPD-related hospitalization.
PA was objectively measured for one week in 74 patients before and after three months of rehabilitation (rehabilitation sample). In addition the intraclass correlation coefficient was measured in 30 patients (test-retest sample), by measuring PA for two consecutive weeks. Daily number of steps was chosen as outcome measurement. Different distribution and anchor based methods were chosen to calculate the MID. Time to first hospitalization due to an exacerbation was compared between patients exceeding the MID and those who did not.
Calculation of the MID resulted in 599 (Standard Error of Measurement), 1029 (empirical rule effect size), 1072 (Cohen's effect size) and 1131 (0.5SD) steps.day-1. An anchor based estimation could not be obtained because of the lack of a sufficiently related anchor. The time to the first hospital admission was significantly different between patients exceeding the MID and patients who did not, using the Standard Error of Measurement as cutoff.
The MID after pulmonary rehabilitation lies between 600 and 1100 steps.day-1. The clinical importance of this change is supported by a reduced risk for hospital admission in those patients with more than 600 steps improvement.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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