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Meta-Analysis
. 2016 Dec 8;12(12):CD005305.
doi: 10.1002/14651858.CD005305.pub4.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

Milo A Puhan  1 , Elena Gimeno-Santos  2 , Christopher J Cates  3 , Thierry Troosters  4
Affiliations
Meta-Analysis

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

Milo A Puhan et al. Cochrane Database Syst Rev. .

Abstract

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.

PubMed Disclaimer

Conflict of interest statement

MA Puhan, E Gimeno‐Santos, CJ Cates: no conflicts of interest to declare.

T Troosters conducts research in this field and recruits participants with acute exacerbations into rehabilitation programmes.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.1 Hospital readmission (to end of follow‐up).
4
4
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.37 Hospital readmission (to end of follow‐up) with separated new trial data.
5
5
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.2 Mortality.
6
6
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.38 Mortality with separated new trial data.
7
7
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.4 Health‐related quality of life: St George's Respiratory Questionnaire.
8
8
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.39 Health‐related quality of life: SGRQ total with separated new trial data.
9
9
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.5 Change from baseline in 6‐minute walking test.
10
10
Forest plot of comparison: 1 Rehabilitation versus control, outcome: 1.40 Change from baseline in 6‐minute walking test with separated new trial data.
1.1
1.1. Analysis
Comparison 1 Rehabilitation versus control, Outcome 1 Hospital readmission (to end of follow‐up).
1.2
1.2. Analysis
Comparison 1 Rehabilitation versus control, Outcome 2 Mortality.
1.3
1.3. Analysis
Comparison 1 Rehabilitation versus control, Outcome 3 Health‐related quality of life: Chronic Respiratory Disease Questionnaire (CRQ).
1.4
1.4. Analysis
Comparison 1 Rehabilitation versus control, Outcome 4 Health‐related quality of life: St George's Respiratory Questionnaire.
1.5
1.5. Analysis
Comparison 1 Rehabilitation versus control, Outcome 5 Change from baseline in 6‐minute walking test.
1.6
1.6. Analysis
Comparison 1 Rehabilitation versus control, Outcome 6 Change from baseline in shuttle walk test.
1.7
1.7. Analysis
Comparison 1 Rehabilitation versus control, Outcome 7 Subgroup analysis hospital readmission: extensiveness of rehabilitation programme.
1.8
1.8. Analysis
Comparison 1 Rehabilitation versus control, Outcome 8 Subgroup analysis hospital readmission: length of follow‐up.
1.9
1.9. Analysis
Comparison 1 Rehabilitation versus control, Outcome 9 Subgroup analysis hospital readmission: generation of random sequence.
1.10
1.10. Analysis
Comparison 1 Rehabilitation versus control, Outcome 10 Subgroup analysis hospital readmission: concealment of random allocation.
1.11
1.11. Analysis
Comparison 1 Rehabilitation versus control, Outcome 11 Subgroup analysis hospital readmission: blinding.
1.12
1.12. Analysis
Comparison 1 Rehabilitation versus control, Outcome 12 Subgroup analysis mortality: extensiveness of rehabilitation programme.
1.13
1.13. Analysis
Comparison 1 Rehabilitation versus control, Outcome 13 Subgroup analysis mortality: length of follow‐up.
1.14
1.14. Analysis
Comparison 1 Rehabilitation versus control, Outcome 14 Subgroup analysis mortality: generation of random sequence.
1.15
1.15. Analysis
Comparison 1 Rehabilitation versus control, Outcome 15 Subgroup analysis mortality: concealment of random allocation.
1.16
1.16. Analysis
Comparison 1 Rehabilitation versus control, Outcome 16 Subgroup analysis mortality: blinding.
1.17
1.17. Analysis
Comparison 1 Rehabilitation versus control, Outcome 17 Subgroup analysis CRQ dyspnoea domain: extensiveness of rehabilitation programme.
1.18
1.18. Analysis
Comparison 1 Rehabilitation versus control, Outcome 18 Subgroup analysis CRQ dyspnoea domain: length of follow‐up.
1.19
1.19. Analysis
Comparison 1 Rehabilitation versus control, Outcome 19 Subgroup analysis CRQ dyspnoea domain: generation of random sequence.
1.20
1.20. Analysis
Comparison 1 Rehabilitation versus control, Outcome 20 Subgroup analysis CRQ dyspnoea domain: concealment of random allocation.
1.21
1.21. Analysis
Comparison 1 Rehabilitation versus control, Outcome 21 Subgroup analysis CRQ dyspnoea domain: blinding.
1.22
1.22. Analysis
Comparison 1 Rehabilitation versus control, Outcome 22 Subgroup analysis SGRQ total score: extensiveness of rehabilitation programme.
1.23
1.23. Analysis
Comparison 1 Rehabilitation versus control, Outcome 23 Subgroup analysis SGRQ total score: length of follow‐up.
1.24
1.24. Analysis
Comparison 1 Rehabilitation versus control, Outcome 24 Subgroup analysis SGRQ total score: generation of random sequence.
1.25
1.25. Analysis
Comparison 1 Rehabilitation versus control, Outcome 25 Subgroup analysis SGRQ total score: concealment of random allocation.
1.26
1.26. Analysis
Comparison 1 Rehabilitation versus control, Outcome 26 Subgroup analysis SGRQ total score: blinding.
1.27
1.27. Analysis
Comparison 1 Rehabilitation versus control, Outcome 27 Subgroup analysis 6‐minute walking test: extensiveness of rehabilitation programme.
1.28
1.28. Analysis
Comparison 1 Rehabilitation versus control, Outcome 28 Subgroup analysis 6‐minute walk test: length of follow‐up.
1.29
1.29. Analysis
Comparison 1 Rehabilitation versus control, Outcome 29 Subgroup analysis 6‐minute walk test: generation of random sequence.
1.30
1.30. Analysis
Comparison 1 Rehabilitation versus control, Outcome 30 Subgroup analysis 6‐minute walk test: concealment of random allocation.
1.31
1.31. Analysis
Comparison 1 Rehabilitation versus control, Outcome 31 Subgroup analysis 6‐minute walk test: blinding.
1.32
1.32. Analysis
Comparison 1 Rehabilitation versus control, Outcome 32 Subgroup analysis shuttle walk test: extensiveness of rehabilitation programme.
1.33
1.33. Analysis
Comparison 1 Rehabilitation versus control, Outcome 33 Subgroup analysis shuttle walk test: length of follow‐up.
1.34
1.34. Analysis
Comparison 1 Rehabilitation versus control, Outcome 34 Subgroup analysis shuttle walk test: generation of random sequence.
1.35
1.35. Analysis
Comparison 1 Rehabilitation versus control, Outcome 35 Subgroup analysis shuttle walk test: concealment of random allocation.
1.36
1.36. Analysis
Comparison 1 Rehabilitation versus control, Outcome 36 Subgroup analysis shuttle walk test: blinding.
1.37
1.37. Analysis
Comparison 1 Rehabilitation versus control, Outcome 37 Hospital readmission (to end of follow‐up) with separated new trial data.
1.38
1.38. Analysis
Comparison 1 Rehabilitation versus control, Outcome 38 Mortality with separated new trial data.
1.39
1.39. Analysis
Comparison 1 Rehabilitation versus control, Outcome 39 Health‐related quality of life: SGRQ total with separated new trial data.
1.40
1.40. Analysis
Comparison 1 Rehabilitation versus control, Outcome 40 Change from baseline in 6 minute walking test with separated new trial data.
See this image and copyright information in PMC

Update of

Comment in

  • COPD: Reha nach Exazerbation sinnvoll.
    Glöckl R. Glöckl R. MMW Fortschr Med. 2017 May;159(9):43. doi: 10.1007/s15006-017-9645-y. MMW Fortschr Med. 2017. PMID: 28509021 German. No abstract available.

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References to other published versions of this review

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