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Meta-Analysis
. 2015 Feb 23;2015(2):CD003793.
doi: 10.1002/14651858.CD003793.pub3.

Pulmonary rehabilitation for chronic obstructive pulmonary disease

Bernard McCarthy  1 , Dympna Casey, Declan Devane, Kathy Murphy, Edel Murphy, Yves Lacasse
Affiliations
Meta-Analysis

Pulmonary rehabilitation for chronic obstructive pulmonary disease

Bernard McCarthy et al. Cochrane Database Syst Rev. .

Abstract

Background: Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise capacity) attributable to the programmes. This review updates the review reported in 2006.

Objectives: To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal exercise capacity in persons with COPD.

Search methods: We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were current as of March 2014.

Selection criteria: We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. We defined 'pulmonary rehabilitation' as exercise training for at least four weeks with or without education and/or psychological support. We defined 'usual care' as conventional care in which the control group was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered best practice at the start of the trial for all participants.

Data collection and analysis: We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary study. We used standard methods as recommended by The Cochrane Collaboration.

Main results: Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.We noted no significant demographic differences at baseline between members of the intervention group and those who received usual care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were community based (at community centres or in individual homes) and one study had both a hospital component and a community component. Most programmes were of 12 weeks' or eight weeks' duration with an overall range of four weeks to 52 weeks.The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition, it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by several studies, this impacted the overall risk of bias.We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies = 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19; low-quality evidence). Statistically significant improvements were noted in all domains of the St. George's Respiratory Questionnaire (SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15, 95% CI -7.95 to -2.36; N = 572; studies = 7).Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95% CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference. Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution.

Authors' conclusions: Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.

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Conflict of interest statement

The review authors DC, BMC, KM and DD were involved in the PRINCE study conducted by Casey 2013, a cluster‐randomised trial that was included in this review. The risk of bias table for this study was therefore completed by two independent review authors, who were not involved in this trial but were experienced in conducting Cochrane systematic reviews. These were the review authors EM and Miriam Brennan, Lecturer at the School of Nursing & Midwifery, NUI Galway.

Figures

1
1
Funnel plot of comparison: 1 Rehabilitation versus usual care, outcome: 1.4 QoL ‐ Change in CRQ (Dyspnoea) (see Table 2 for Egger and Begg‐Mazumdar: Kendall's test results).
2
2
Funnel plot of comparison: 1 Rehabilitation versus usual care, outcome: 1.5 QoL ‐ Change in SGRQ (Total) (see Table 2 for Egger and Begg‐Mazumdar: Kendall's test results).
3
3
Study flow diagram.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
5
5
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 1 QoL ‐ Change in CRQ (Fatigue).
1.2
1.2. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
1.3
1.3. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 3 QoL ‐ Change in CRQ (Mastery).
1.4
1.4. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).
1.5
1.5. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 5 QoL ‐ Change in SGRQ (Total).
1.6
1.6. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 6 QoL ‐ Change in SGRQ (Symptoms).
1.7
1.7. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 7 QoL ‐ Change in SGRQ (Impacts).
1.8
1.8. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 8 QoL ‐ Change in SGRQ (Activity).
1.9
1.9. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 9 Maximal Exercise (Incremental shuttle walk test).
1.10
1.10. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 10 Maximal Exercise Capacity (cycle ergometer).
1.11
1.11. Analysis
Comparison 1 Rehabilitation versus usual care, Outcome 11 Functional Exercise Capacity (6MWT)).
2.1
2.1. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 1 QoL ‐ Change in CRQ (Fatigue).
2.2
2.2. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
2.3
2.3. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 3 QoL ‐ Change in CRQ (Mastery).
2.4
2.4. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).
2.5
2.5. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 5 QoL ‐ Change in SGRQ (Total).
2.6
2.6. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 6 QoL ‐ Change in SGRQ (Symptoms).
2.7
2.7. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 7 QoL ‐ Change in SGRQ (Impacts).
2.8
2.8. Analysis
Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 8 QoL ‐ Change in SGRQ (Activity).
3.1
3.1. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 1 QoL ‐ Change in CRQ (Fatigue).
3.2
3.2. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
3.3
3.3. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 3 QoL ‐ Change in CRQ (Mastery).
3.4
3.4. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).
3.5
3.5. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 5 QoL ‐ Change in SGRQ (Total).
3.6
3.6. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 6 QoL ‐ Change in SGRQ (Symptoms).
3.7
3.7. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 7 QoL ‐ Change in SGRQ (Impacts).
3.8
3.8. Analysis
Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 8 QoL ‐ Change in SGRQ (Activity).
4.1
4.1. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 1 QoL ‐ Change in CRQ (Dyspnoea).
4.2
4.2. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
4.3
4.3. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 3 QoL ‐ Low Risk CRQ (Fatigue).
4.4
4.4. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 4 QoL ‐ Low Risk CRQ (Mastery).
4.5
4.5. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 5 QoL ‐ Low Risk SGRQ (Total).
4.6
4.6. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 6 QoL ‐ Low Risk SGRQ (Symptoms).
4.7
4.7. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 7 QoL ‐ Low Risk SGRQ (Impacts).
4.8
4.8. Analysis
Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 8 QoL ‐ Low Risk SGRQ (Activity).
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    1. Elias MT, Ortega F, Toral J, Sanchez H, Cejudo P, Montemayor T. Results from a home‐based exercise training program in patients with COPD [Resultados de un programa domiciliario de entrenamiento al ejercicio en pacientes con EPOC]. Neumosur 1998;10(1):16‐7.
    1. Elías MT, Ortega F, Toral J, Sánchez H, Cejudo P, Montemayor T. Improvement in exercise tolerance and quality of life in COPD patients following a home training programme [Mejoria en la tolerancia al ejercico y en la calidad de vida en pacientes EPOC tras un programa de entrenamiento domiciliario]. Archivos de Bronconeumologìa 1998;34(Suppl 1):34.
Hoff 2007 {published data only}
    1. Hoff J, Tjonna AE, Steinshamn S, Hoydal M, Richardson RS, Helgerud J. Maximal strength training of the legs in COPD: a therapy for mechanical inefficiency. Medicine and Science in Sports and Exercise 2007;39(2):220‐6. - PubMed
Jones 1985 {published data only}
    1. Jones DT, Thomson RJ, Sears MR. Physical exercise and resistive breathing in severe chronic airways obstruction ‐ are they effective?. European Journal of Respiratory Diseases 1985;67:159‐66. - PubMed
Karapolat 2007 {published data only}
    1. Karapolat H, Atasever A, Atamaz F, Kirazli J, Elmas F, Erdinc E. Do the benefits gained using a short‐term pulmonary rehabilitation program remain in COPD patients after participation?. Lung 2007;185:221‐5. - PubMed
Lake 1990 {published data only}
    1. Lake FR, Henderson K, Briffa T, Openshaw J, Musk AW. Upper‐limb and lower‐limb exercise training in patients with chronic airflow obstruction. Chest 1990;97:1077‐82. - PubMed
Lindsay 2005 {published data only (unpublished sought but not used)}
    1. Lindsay M, Lee A, Chan K, Poon P, Han LK, Wong WC, et al. Does pulmonary rehabilitation give additional benefit over tiotropium therapy in primary care management of chronic obstructive pulmonary disease? Randomized controlled clinical trial in Hong Kong Chinese. Journal of Clinical Pharmacy and Therapeutics 2005;30(6):567‐73. - PubMed
    1. Lindsay M, Lee A, Poon P, Han LK, Wong WC, Wong W, et al. Does pulmonary rehabilitation give additional benefits to primary care patients with chronic obstructive pulmonary disease? Results from randomized controlled clinical trial in Hong Kong [Abstract]. Respirology 2004;9(Suppl):A100.
Liu 2012 {published data only}
    1. Liu XD, Jin HZ, Ng Bh‐ P, Gu YH, Wu Y‐C, Lu G. Therapeutic effects of qigong in patients with COPD: a randomized controlled trial. Hong Kong Journal of Occupational Therapy 2012;22(1):38‐46.
McGavin 1977 {published data only}
    1. McGavin CR, Gupta SP, Lloyd EL, McHardy GJR. A controlled trial of self‐regulated physical training in chronic bronchitis. British Journal of Diseases of the Chest 1976;70(4):278.
    1. McGavin CR, Gupta SP, Lloyd EL, McHardy GJR. Physical rehabilitation for the chronic bronchitis: results of a controlled trial of exercises in the home. Thorax 1977;32:307‐11. - PMC - PubMed
McNamara 2013 {published and unpublished data}
    1. McNamara RJ, Alison JA, McKenzie DK, McKeough ZJ. Water‐based exercise improves exercise capacity in people with COPD with physical co‐morbid conditions [Abstract]. Respirology 1010;15(Suppl 1):A24 [TO 056].
    1. McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA. Water‐based exercise in COPD with physical comorbidities: a randomised controlled trial. European Respiratory Journal 2013;6:1284‐91. - PubMed
    1. McNamara, RJ, Alison JA, McKenzie DK, McKeough ZJ. Water‐based exercise in people with COPD and physical co‐morbid conditions: a randomised controlled trial [Abstract]. European Respiratory Society 20th Annual Congress; 2010 Sep 18‐22; Barcelona. 2010:181.
Mehri 2007 {published data only}
    1. Mehri SN, Khoshnevis MA, Zarrehbinan F, Hafezi S, Ghasemi A, Ebadi A. Effect of treadmill exercise training on VO2 peak in chronic obstructive pulmonary disease. Tanaffos 2007;6(4):18‐24.
Mendes De Oliveira 2010 {published and unpublished data}
    1. Mendes De Oliveira JC, Studart Leitao Filho FS, Malosa Sampaio LM, Negrinho De Oliveira AC, Hirata RP, Costa D, et al. Outpatient vs. home‐based pulmonary rehabilitation in COPD: a randomized controlled trial. Multidisciplinary Respiratory Medicine 2010;5(6):401‐8. - PMC - PubMed
    1. Oliveira JCM, Filho FSL, Sampaio L, Oliveira AC, Hirata R, Costa D. Outpatient vs. home‐based pulmonary rehabilitation in COPD: A randomized controlled trial [Abstract]. European Respiratory Society 21st Annual Congress; 2011 Sep 24‐28; Amsterdam 2011;38(55):879s [P4805].
Nalbant 2011 {published data only (unpublished sought but not used)}
    1. Nalbant O, Nur H, Ogus C, Toraman NF. Effects of long‐term aerobic exercise program in chronic obstructive pulmonary disease. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi 2011;57(1):8‐13.
O'Shea 2007 {published data only}
    1. O' Shea SD, Taylor NF, Paratz J. Peripheral strength training for people with chronic obstructive pulmonary disease [Abstract]. Respirology 2005;10(suppl):A58.
    1. O'Shea SD, Taylor NF, Paratz JD. A predominantly home‐based progressive resistance exercise program increases knee extensor strength in the short‐term in people with chronic obstructive pulmonary disease: a randomised controlled trial. Australian Journal of Physiotherapy 2007;53(4):229‐37. - PubMed
    1. O'Shea SD, Taylor NF, Paratz JD. Peripheral strength training for people with chronic obstructive pulmonary disease: a randomised controlled trial. [abstract]. Australian Journal of Physiotherapy 2006;52(2):s22. - PubMed
    1. O'Shea SD, Taylor NF, Paratz JD. Qualitative outcomes of progressive resistance exercise for people with COPD. Chronic Respiratory Disease 2007;4(3):135‐42. - PubMed
Ozdemir 2010 {published data only}
    1. Ozdemir EP, Solak O, Fidan F, Demirdal US, Evcik, D, Unlu M, et al. The effect of water‐based pulmonary rehabilitation on anxiety and quality of life in chronic pulmonary obstructive disease patients. Turkiye Klinikleri Journal of Medical Sciences 2010;30(1):880‐7.
Paz‐Diaz 2007 {published data only}
    1. Paz‐Diaz H, Montes de Oca M, Lopez JM, Celli BR. Pulmonary rehabilitation improves depression, anxiety, dyspnea and health status in patients with COPD. American Journal of Physical Medicine and Rehabilitation 2007;86(1):30‐6. - PubMed
Petty 2006 {published data only}
    1. Petty TL, Dempsey EC, Collins T, Pluss W, Lipkus I, Cutter GR, et al. Impact of customized videotape education on quality of life in patients with chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation 2006;26(2):112‐7. - PubMed
Reardon 1994 {published data only}
    1. Reardon J, Awad E, Normandin E, Vale F, Clark B, ZuWallack RL. The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea. Chest 1994;105:1046‐52. - PubMed
Ringbaek 2000 {published data only}
    1. Broendum E, Lybeck K, Andersen C, Hemmingsen L, Nielsen D, Lange P, et al. Rehabilitation in patients with COPD ‐ the effect of a "twice‐a‐week‐programme". European Respiratory Society 9th Annual Congress; 1999 Oct 9‐13; Madrid. 1999:208.
    1. Ringbaek TJ, Broendum E, Hemmingsen L, Lybeck K, Nielsen D, Andersen C, et al. Rehabilitation of patients with chronic obstructive pulmonary disease. Exercise twice a week is not sufficient!. Respiratory Medicine 2000;94(2):150‐4. - PubMed
Simpson 1992 {published data only}
    1. Simpson K, Killian K, McCartney N, Jones NL. Randomised controlled trial of weightlifting exercise in patients with chronic airflow limitation. Thorax 1992;47:70‐5. - PMC - PubMed
Singh 2003 {published data only}
    1. Singh V, Khandelwal DC, Khandelwal R, Abusaria S. Pulmonary rehabilitation in patients with chronic obstructive pulmonary diseases. Indian Journal of Chest Diseases and Allied Sciences 2003;45(1):13‐7. - PubMed
Sridhar 2008 {published data only}
    1. Sridhar M, Taylor R, Dawson S, Roberts NJ, Partridge MR. A nurse led intermediate care package in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease. Thorax 2008;63(3):194‐200. - PubMed
Strijbos 1996 {published data only}
    1. Strijbos JH, Koëter GH, Meinesz AF. Home care rehabilitation and perception of dyspnea in chronic obstructive pulmonary disease. Chest 1990;97(Suppl):109‐10. - PubMed
    1. Strijbos JH, Postma DS, Altena R, et al. A comparison between an outpatient hospital‐based pulmonary rehabilitation program and a home‐care pulmonary rehabilitation program in patients with COPD. A follow‐up of 18 months. Chest 1996;109(2):366‐72. - PubMed
    1. Strijbos JH, Postma DS, Altena R, Gimeno F, Koeter GH. Feasibility and effects of a home‐care rehabilitation program in patients with chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation 1996;16(6):386‐93. - PubMed
    1. Strijbos JH, Wijkstra PJ, Postma DS, Koeter GH. Five year effects of rehabilitation at different settings in patients with chronic obstructive pulmonary disease. European Respiratory Society 9th Annual Conference; 1999; Oct 9‐13; Madrid. 1999:209.
Theander 2009 {published data only}
    1. Theander K, Jakobsson P, Jorgensen N, Unosson M. Effects of pulmonary rehabilitation on fatigue, functional status and health perceptions in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Clinical Rehabilitation 2009;23(2):125‐36. - PubMed
Vallet 1994 {published data only}
    1. Vallet G, Varray A, Fontaine JL, Prefaut C. Interest of individualized training program at the ventilatory threshold in mild to moderate COPD patients [Intérêt du réentraînement à l'effort individualisé, au niveau du seuil ventilatoire, au cours de la bronchopneumopathie chronique obstructive de sévérité modérée]. Revue des Maladies Respiratoires 1994;11(5):493‐501. - PubMed
Van Wetering 2010 {published data only}
    1. Hoogendoorn M, Wetering CR, Schols AM, Rutten‐van Molken MP. Is INTERdisciplinary Community‐based COPD management (INTERCOM) cost effective?. European Respiratory Journal 2010;35:79‐87. - PubMed
    1. Wetering CR, Hoogendoorn M, Munck DR, Rutten‐van Molken MP, Schols AM. Cost‐effectiveness of a 24 month INTERdisciplinary COMmunity ‐based COPD management program (INTERCOM) in patients with less advanced airflow obstruction [Abstract]. American Thoracic Society International Conference, May 15‐20, 2009, San Diego. 2009:A5373.
    1. Wetering CR, Hoogendoorn M, Mol SJ, Rutten‐Van Molken M, Schols AM. Short‐ and long‐term efficacy of a community‐based COPD management programme in less advanced COPD: a randomised controlled trial. Thorax 65;1:7‐13. - PubMed
    1. Wetering CR, Hoogendoorn M, Broekhuizen R, Geraerts‐Keeris GJ, Munck DR, Rutten‐van Mölken MP. Efficacy and costs of nutritional rehabilitation in muscle‐wasted patients with chronic obstructive pulmonary disease in a community‐based setting: a prespecified subgroup analysis of the INTERCOM trial. Journal of the American Medical Directors Association 2010;11(3):179‐87. - PubMed
    1. Wetering CR, Nooten FE, Mol, SJ, Hoogendoorn M, Rutten‐Van Molken MP, Schols AM. Systemic impairment in relation to disease burden in patients with moderate COPD eligible for a lifestyle program. Findings from the INTERCOM trial. International Journal of COPD 2008;3(3):443‐51. - PMC - PubMed
Vijayan 2010 {published data only (unpublished sought but not used)}
    1. Vijayan VK, Senthil K, Menon B, Bansal V. Effect of pulmonary rehabilitation on markers of inflammation, muscle mass and exercise capacity in patients with chronic obstructive pulmonary disease (COPD) [Abstract]. 15th Congress of the Asian Pacific Society of Respirology; 2010 Nov 22‐25; Manila. 2010.
Weiner 1992 {published data only}
    1. Weiner P, Azgad Y, Ganam R. Inspiratory muscle training combined with general exercise reconditioning in patients with COPD. Chest 1992;102:1351‐6. - PubMed
Wen 2008 {published data only}
    1. Wen H, Gao Y, An JY. Comparison of high‐intensity and anaerobic threshold programs in rehabilitation for patients with moderate to severe chronic obstructive pulmonary disease. [Chinese]. Chung‐Hua Chieh Ho Ho Hu Hsi Tsa Chih Chinese Journal of Tuberculosis & Respiratory Diseases 2008;31(8):571‐6. - PubMed
Wijkstra 1994 {published data only}
    1. Wijkstra PJ, Kraan J, Mark THW, Altena R, Postama DS, Koeter GH. Long‐term benefits of rehabilitation at home on inspiratory muscle function and dyspnoea in patients with chronic obstructive pulmonary disease (COPD). European Respiratory Journal 1994;7(Suppl 18):296S.
    1. Wijkstra PJ, Altena R, Kraan J, Otten V, Postma DS, Koëter GH. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. European Respiratory Journal 1994;7:269‐73. - PubMed
    1. Wijkstra PJ, Mark TW, Kraan J, Altena R, Koeter GH, Postma DS. Long‐term effects of home rehabilitation on physical performance in chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine 1996;153(4 (pt 1)):1234‐41. - PubMed
Xie 2003 {published data only}
    1. Xie SL, Zhu MG, Cui HB, Liu HY. Influence of home‐based training program on patients with COPD. Zhonghua Linchuang Kangfu Zazhi 2003;7(18):2554‐5.

References to studies excluded from this review

Akinci 2011 {published and unpublished data}
    1. Akinci AC, Olgun N. The effectiveness of nurse‐led, home‐based pulmonary rehabilitation in patients with COPD in Turkey. Rehabilitation Nursing 2011;36(4):159‐65. - PubMed
Ambrosino 1981 {published data only}
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Ambrosino 2006 {published data only}
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Amin 2011 {published and unpublished data}
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Arnadottir 2001 {published data only}
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Backer 2003 {published data only}
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Bauldoff 1996 {published data only}
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Bauldoff 2002 {published data only}
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Behnke 2002 {published data only}
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Behnke 2002a {published data only}
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Behnke 2003 {published data only}
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Bernard 1999 {published data only}
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Berry 1996 {published data only}
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Bjerre‐Jepsen 1981 {published data only}
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Böhning 1990 {published data only}
    1. Bohning W, Wettengel R. Physical exercise training in COPD during a 4‐week rehabilitation programme. European Respiratory Journal 1990;3(Suppl 10):212S.
Bourbeau 2000 {published data only}
    1. Bourbeau J, Collet JP, Schwartzman K, Beaupre A, Begin R, Maltais F, et al. Integrating rehabilitative elements into a COPD self‐management program reduces exacerbations and health service utilization: a randomized clinical trial. American Journal of Respiratory and Critical Care Medicine 2000;161(Suppl 3):A254.
    1. Bourbeau J, Julien M, Rouleau M, Maltais F, Beaupré A, Bégin R. Impact of an integrated rehabilitative self‐management program on health status of COPD patients: a multicentre randomised clinical trial. European Respiratory Journal 2000;16(Suppl 31):159S.
Bourjeily‐Habr 2002 {published data only}
    1. Bourjeily‐Habr G, Rochester CL, Palermo F, Snyder P, Mohsenin V. Randomised controlled trial of transcutaneous electrical muscle stimulation of the lower extremities in patients with chronic obstructive pulmonary disease. Thorax 2002;57(12):1045‐9. - PMC - PubMed
Breyer 2010 {published data only}
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Brooks 2000 {unpublished data only}
    1. Brooks D, Krip B, Mangovski Alzamora S, Avendano M, Goldstein R. The influence of post‐rehabilitation program on health related quality of life (HRQL) and functional exercise capacity in patients with chronic obstructive pulmonary disease (COPD). American Journal of Respiratory and Critical Care Medicine 2000;161(Suppl 3):A504.
Cai 2003 {published data only}
    1. Cai H. Rehabilitation effect of combination of respiration exercise, Jinshuibao capsule and external application in stable stage of chronic obstructive pulmonary diseases. Zhonghua Linchuang Kangfu Zazhi 2003;7(5):877.
Carrieri‐Kohlman 96 {published data only}
    1. Carrieri‐Kohlman V, Gormley JM, Douglas MK, Paul SM, Stulbarg MS. Exercise training decreases dyspnea and the distress and anxiety associated with it. Monitoring alone may be as effective as coaching. Chest 1996;110(6):1526‐35. - PubMed
Cegla 2002 {published data only}
    1. Cegla UH, Jost HJ, Harten A, Weber T, Wissmann S. Course of severe COPD with and without physiotherapy with the RC‐Cornet®: a randomized 2 years long‐term study. Pneumologie 2002;56(7):418‐24. - PubMed
Chen 2011 {published data only}
    1. Chen G, Zhou X, Hu X, Liu Y, Li Q. Effect of exercise on the quality of life and pulmonary function in patients with chronic obstructive pulmonary disease. Zhong Nan da Xue Xue Bao. Yi Xue Ban [Journal of Central South University. Medical Sciences] 2011;36(7):682‐6. - PubMed
Ciric 2008 {published data only}
    1. Ciric Z, Stankovic I, Rancic M, Pejcic T, Radovic M. Pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Vojnosanitetski Pregled 2008;65(7):533‐8. - PubMed
Clark 2000 {published data only}
    1. Clark CJ, Cochrane LM, Mackay E, Paton B. Skeletal muscle strength and endurance in patients with mild COPD and the effects of weight training. European Respiratory Journal 2000;15(1):92‐7. - PubMed
    1. Mackay EM, Clark CJ, Cochran LM, Bell F. The effect of a 12 week weight training programme in improving muscle endurance in patients with chronic obstructive pulmonary disease. 12th International Congress of the World Confederation of Physical Therapy; 1995; Washington DC. 1995; Vol. 30:430.
Cockcroft 1985 {published data only}
    1. Cockcroft A, Beaumont A, Guz A. Effect of exercise training on walking distance, exercise ventilation and breathlessness in patients with COAD. Clinical Science 1985;69(Suppl 12):7.
Coppoolse 1999 {published data only}
    1. Coppoolse R, Schols A, Baarends EM, Mostert R, Akkermans MA, Janssen PP, et al. Interval versus continuous training in patients with severe COPD: a randomized clinical trial. European Respiratory Journal 1999;14(2):258‐63. - PubMed
Covey 2004 {published data only}
    1. Covey MK, Larson JL. Exercise and COPD. American Journal of Nursing 2004;104(5):40‐3. - PubMed
Cox 1993 {published data only}
    1. Cox NJ, Hendricks JC, Binkhorst RA, Herwaarden CL. A pulmonary rehabilitation program for patients with asthma and mild chronic obstructive pulmonary diseases (COPD). Lung 1993;171(4):235‐44. - PubMed
de Blasio 2000 {published data only}
    1. Blasio F. A doubting Thomas dealing with pulmonary rehabilitation. Chest 2000;117(4):929‐31. - PubMed
Dekhuijzen 1990 {published data only}
    1. Dekhuijzen PNR, Beek MML, Folgering HTM, Herwaarden CLA. Psychological changes during pulmonary rehabilitation and target‐flow inspiratory muscle training in COPD patients with a ventilatory limitation during exercise. International Journal of Rehabilitation Research 1990;13:109‐17. - PubMed
Dekhuijzen 1991 {published data only}
    1. Dekhuijzen PN, Folgering HT, Herwaarden CL. Target‐flow inspiratory muscle training during pulmonary rehabilitation in patients with COPD. Chest 1991;99(1):128‐33. - PubMed
    1. Dekhuijzen PNR, Herwaarden van CLA, Folgering HThM. Target‐flow inspiratory muscle training (IMT) increases inspiratory muscle strength and endurance [Abstract]. European Respiratory Journal 1989;2(Suppl):389S.
de Lucas Ramos 1998 {published data only}
    1. Lucas Ramos P, Rodriguez Gonzalez‐Moro JM, Garcia de Pedro J, Santacruz Siminiani A, Tatay Marti E, Cubillo Marcos JM. Training of inspiratory muscles in chronic obstructive lung disease. Its impact on functional changes and exercise tolerance. Archivos de Bronconeumologia 1998;34(2):64‐70. - PubMed
Demir‐Deriven 2001 {published data only}
    1. Demir‐Deviren S, Carrieri‐Kohlman V, Nguyen H, Neuhaus J, Eiser S, Stulbarg MS. Long term effect of exercise on dyspnea and exercise performance in COPD: how much training is enough?. American Journal of Respiratory and Critical Care Medicine 2001;163(Suppl 5):A13.
Demir‐Deriven 2002 {published data only}
    1. Demir‐Deviren S, Carrieri‐Kohlman V, Nguyen H, Paul SM, Stulbarg MS. Effects of gender on dyspnea with activities of daily living and health‐related quality of life after long term exercise training in patients with COPD. American Journal of Respiratory and Critical Care Medicine 2002;165(Suppl 8):A734.
Dewse 1998 {published data only}
    1. Dewse M. Improving pulmonary disease outcomes. Nursing New Zealand 1998;4(9):20‐2. - PubMed
Di Marzo 2000 {published data only}
    1. Marzo A, Torrice M, Ciappi G. Inspiratory muscle training and relaxation therapy in advanced COPD patients. European Respiratory Journal 2000;16(Suppl 31):46S.
    1. Marzo A, Torrice M, Ciappi G. Inspiratory muscles training and relaxation in COPD patients. American Journal of Respiratory and Critical Care Medicine 2000;161(Suppl 3):A752.
Downes Vogel 2002 {published data only}
    1. Downes Vogel PJ. Effect of adding inspiratory muscle training to a pulmonary rehabilitation program for patients with COPD which includes upper extremity exercises. American Journal of Respiratory and Critical Care Medicine 2002;165(Suppl 8):A737.
Dushianthan 2009 {published data only}
    1. Dushianthan A. Safety and effectiveness of home‐based pulmonary rehabilitation in COPD. Thorax 2009;64(7):619.
Egan 2012 {published and unpublished data}
    1. Egan C, Costello R, Deering B, McCormack N, Blake C. Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respiratory Medicine 2012;106:1671‐9. - PubMed
Ellum 2002 {published data only}
    1. Ellum SG, Rafferty GF, Nikoletou D, Moxham J. Effect of forward lean sitting on work of breathing and breathless scores in stable, severe COPD patients following exercise induced breathlessness. American Journal of Respiratory and Critical Care Medicine 2002;165(Suppl 8):A267.
Emtner 1998 {published data only}
    1. Emtner M, Finne M, Stalenheim G. High‐intensity physical training in adults with asthma. A comparison between training on land and in water. Scandinavian Journal of Rehabilitation Medicine 1998;30(4):201‐9. - PubMed
Epstein 1997 {published data only}
    1. Epstein SK, Celli BR, Martinez FJ, Couser JI, Roa J, Pollock M, et al. Arm training reduces the VO2 and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation 1997;17(3):171‐7. - PubMed
Esteve 1996 {published data only}
    1. Esteve F, Blanc‐Gras N, Gallego J, Benchetrit G. The effects of breathing pattern training on ventilatory function in patients with COPD. Biofeedback and Self Regulation 1996;21(4):311‐21. - PubMed
Fan 2008 {published data only}
    1. Fan VS, Giardino ND, Blough DK, Kaplan RM, Ramsey SD, Fishman AP, et al. Costs of pulmonary rehabilitation and predictors of adherence in the National Emphysema Treatment Trial. COPD 2008;5(2):105‐16. - PubMed
    1. Fan VS, Ramsey SD, Blough DK. Costs of pulmonary rehabilitation and predictors of adherence [Abstract]. Poster #608. American Thoracic Society International Conference; 2007 May 18‐23; San Francisco. 2007; Vol. Poster #608.
Foglio 2001 {published data only}
    1. Foglio K, Bianchi L, Ambrosino N. Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2‐year controlled study. Chest 2001;119(6):1696‐704. - PubMed
Gadoury 2005 {published data only}
    1. Gadoury MA, Schwartzman K, Rouleau M, Maltais F, Julien M, Beaupre A, et al. Self‐management reduces both short‐ and long‐term hospitalisation in COPD. European Respiratory Journal 2005;26(5):853‐7. - PubMed
Gale 2009 {published data only}
    1. Gale NS, Duckers JM, Proud D, Lines T, Enright S, Cockcroft JR, et al. Pulmonary rehabilitation improves cardiovascular risk factors in patients with COPD. Thorax 2009;64(Suppl IV):A40 [S75]. - PMC - PubMed
Garuti 2010 {published data only}
    1. Garuti G. Home rehabilitation and therapy. Rassegna di Patologia dell'Apparato Respiratorio 2010;25(2):76‐7.
Gautier 1998 {unpublished data only}
    1. Gautier V, Godard P, Serres I, Hayot M, Prefaut C. Respiratory rehabilitation in chronic obstructive pulmonary disease (COPD) outpatients under long term oxygen therapy. American Journal of Respiratory and Critical Care Medicine 1998;157(Suppl 3):A119.
Gautier 2002 {unpublished data only}
    1. Gautier V, Pison C, Fournial F, Benichou M, Tardif C, Veale D, et al. Home rehabilitation in COPD patients on long term oxygen therapy (LTOT): a multi‐centre randomized controlled study [abstract]. European Respiratory Society Annual Congress; 2002; September 14‐18; Stockholm. 2002:Abstract nr: P1520.
Ghanem 2010 {published data only}
    1. Ghanem ME, Laal EA, Mehany M, Tolba K. Home‐based pulmonary rehabilitation program: Effect on exercise tolerance and quality of life in chronic obstructive pulmonary disease patients. Annals of Thoracic Medicine 2010;5(1):18‐25. - PMC - PubMed
Gimenez 2000 {published data only}
    1. Gimenez M, Servera E, Vergara P, Bach JR, Polu JM. Endurance training in patients with chronic obstructive pulmonary disease: A comparison of high versus moderate intensity. Archives of Physical Medicine and Rehabilitation 2000;81(1):102‐9. - PubMed
Girodo 1992 {published data only}
    1. Girodo M, Ekstrand KA, Metivier GJ. Deep diaphragmatic breathing: rehabilitation exercises for the asthmatic patient. Archives of Physical Medicine and Rehabilitation 1992;73(8):717‐20. - PubMed
Goldman 1997 {unpublished data only}
    1. Goldman J, Carr V, Dobson L, Jones S, Rowles R, Wallace L. A randomised controlled trial of pulmonary rehabilitation (PR) in a district general hospital. Thorax 1997;52(Suppl 6):A10.
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Green 1999 {published data only}
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Grosbois 1999 {published data only}
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References to studies awaiting assessment

Aksu 2006 {published data only}
    1. Aksu B, Inanir M, Basyigit I, Dursun N, Yildiz F. Comparison of two different exercise programs in chronic obstructive pulmonary disease [Abstract]. European Respiratory Journal 2006;28(Suppl 50)(5555c):3198.
D'Amico 2010 {published data only}
    1. D'Amico F, Grasso R, Chirafisi F. Adapted physical activity in elderly people with chronic obstructive bronchopneumopathy and hypertension.. High Blood Pressure and Cardiovascular Prevention 2010;17(3):131‐90.
Meshcheryakova 2010 {published data only}
    1. Meshcheryakova N, Belevskiy A, Cherniak A, Semashko O. The role of exercise and respiratory training on the depression level in COPD patients [Abstract]. European Respiratory Society 20th Annual Congress; 2010 Sep 18‐22; Barcelona 2010;18(22):632.
Meshcheryakova 2012 {published and unpublished data}
    1. Meshcheryakova N, Belevskiy A, Cherniak A. Physical training is a universal method of pulmonary rehabilitation of patients with chronic obstructive pulmonary disease]. [Russian]. Terapevticheskii Arkhiv 2012;3:17‐21. - PubMed
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References to ongoing studies

Chang 2008 {published data only}
    1. Chang AT, Haines T, Jackson C, Yang I, Nitz J. Rationale and design of the PRSM study: pulmonary rehabilitation or self management for chronic obstructive pulmonary disease (COPD), what is the best approach?. Contemporary Clinical Trials 2008;29(2):796‐800. - PubMed
Gurgun 2011 {published data only}
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Sathyapala 2008 {published data only}
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