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. 2023 Mar 22;3(3):CD011285.
doi: 10.1002/14651858.CD011285.pub3.

Exercise-based rehabilitation programmes for pulmonary hypertension

Norman R Morris  1   2 , Fiona D Kermeen  3 , Arwel W Jones  4 , Joanna Yt Lee  4 , Anne E Holland  4   5   6
Affiliations

Exercise-based rehabilitation programmes for pulmonary hypertension

Norman R Morris et al. Cochrane Database Syst Rev. .

Abstract

Background: Individuals with pulmonary hypertension (PH) have reduced exercise capacity and quality of life. Despite initial concerns that exercise training may worsen symptoms in this group, several studies have reported improvements in functional capacity and well-being following exercise-based rehabilitation.

Objectives: To evaluate the benefits and harms of exercise-based rehabilitation for people with PH compared with usual care or no exercise-based rehabilitation.

Search methods: We used standard, extensive Cochrane search methods. The latest search date was 28 June 2022.

Selection criteria: We included randomised controlled trials (RCTs) in people with PH comparing supervised exercise-based rehabilitation programmes with usual care or no exercise-based rehabilitation.

Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were 1. exercise capacity, 2. serious adverse events during the intervention period and 3. health-related quality of life (HRQoL). Our secondary outcomes were 4. cardiopulmonary haemodynamics, 5. Functional Class, 6. clinical worsening during follow-up, 7. mortality and 8. changes in B-type natriuretic peptide. We used GRADE to assess certainty of evidence.

Main results: We included eight new studies in the current review, which now includes 14 RCTs. We extracted data from 11 studies. The studies had low- to moderate-certainty evidence with evidence downgraded due to inconsistencies in the data and performance bias. The total number of participants in meta-analyses comparing exercise-based rehabilitation to control groups was 462. The mean age of the participants in the 14 RCTs ranged from 35 to 68 years. Most participants were women and classified as Group I pulmonary arterial hypertension (PAH). Study durations ranged from 3 to 25 weeks. Exercise-based programmes included both inpatient- and outpatient-based rehabilitation that incorporated both upper and lower limb exercise. The mean six-minute walk distance following exercise-based rehabilitation was 48.52 metres higher than control (95% confidence interval (CI) 33.42 to 63.62; I² = 72%; 11 studies, 418 participants; low-certainty evidence), the mean peak oxygen uptake was 2.07 mL/kg/min higher than control (95% CI 1.57 to 2.57; I² = 67%; 7 studies, 314 participants; low-certainty evidence) and the mean peak power was 9.69 W higher than control (95% CI 5.52 to 13.85; I² = 71%; 5 studies, 226 participants; low-certainty evidence). Three studies reported five serious adverse events; however, exercise-based rehabilitation was not associated with an increased risk of serious adverse event (risk difference 0, 95% CI -0.03 to 0.03; I² = 0%; 11 studies, 439 participants; moderate-certainty evidence). The mean change in HRQoL for the 36-item Short Form (SF-36) Physical Component Score was 3.98 points higher (95% CI 1.89 to 6.07; I² = 38%; 5 studies, 187 participants; moderate-certainty evidence) and for the SF-36 Mental Component Score was 3.60 points higher (95% CI 1.21 to 5.98 points; I² = 0%; 5 RCTs, 186 participants; moderate-certainty evidence). There were similar effects in the subgroup analyses for participants with Group 1 PH versus studies of groups with mixed PH. Two studies reported mean reduction in mean pulmonary arterial pressure following exercise-based rehabilitation (mean reduction: 9.29 mmHg, 95% CI -12.96 to -5.61; I² = 0%; 2 studies, 133 participants; low-certainty evidence).

Authors' conclusions: In people with PH, supervised exercise-based rehabilitation may result in a large increase in exercise capacity. Changes in exercise capacity remain heterogeneous and cannot be explained by subgroup analysis. It is likely that exercise-based rehabilitation increases HRQoL and is probably not associated with an increased risk of a serious adverse events. Exercise training may result in a large reduction in mean pulmonary arterial pressure. Overall, we assessed the certainty of the evidence to be low for exercise capacity and mean pulmonary arterial pressure, and moderate for HRQoL and adverse events. Future RCTs are needed to inform the application of exercise-based rehabilitation across the spectrum of people with PH, including those with chronic thromboembolic PH, PH with left-sided heart disease and those with more severe disease.

Trial registration: ClinicalTrials.gov clinicaltrials.gov/ct2/show/NCT04254289 clinicaltrials.gov/ct2/show/NCT04559516 clinicaltrials.gov/ct2/show/NCT04683822 clinicaltrials.gov/ct2/show/NCT02371733.

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Conflict of interest statement

NM: none.

FK: none.

AJ: none.

JL: none.

AH: declared membership of the Cochrane Airways Editorial Board. AH was not involved in the editorial process for this review.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Figure 4. Funnel plot comparison: exercise intervention versus usual care for change in six‐minute walk distance following exercise‐based rehabilitation.
1.1
1.1. Analysis
Comparison 1: Exercise versus control, Outcome 1: Exercise capacity: 6‐minute walk distance (6MWD)
1.2
1.2. Analysis
Comparison 1: Exercise versus control, Outcome 2: Exercise capacity: 6MWD inpatient vs outpatient studies
1.3
1.3. Analysis
Comparison 1: Exercise versus control, Outcome 3: Exercise capacity: peak exercise capacity (VO 2peak)
1.4
1.4. Analysis
Comparison 1: Exercise versus control, Outcome 4: Exercise capacity: VO 2peak, inpatient vs outpatient studies
1.5
1.5. Analysis
Comparison 1: Exercise versus control, Outcome 5: Exercise capacity: peak power
1.6
1.6. Analysis
Comparison 1: Exercise versus control, Outcome 6: Exercise capacity: peak power, inpatient vs outpatient studies
1.7
1.7. Analysis
Comparison 1: Exercise versus control, Outcome 7: Exercise capacity: anaerobic threshold
1.8
1.8. Analysis
Comparison 1: Exercise versus control, Outcome 8: Serious adverse events
1.9
1.9. Analysis
Comparison 1: Exercise versus control, Outcome 9: Health‐related quality of life (HRQoL) 36‐item Short Form (SF‐36): Physical Component Summary
1.10
1.10. Analysis
Comparison 1: Exercise versus control, Outcome 10: HRQoL SF‐36: Mental Component Summary
1.11
1.11. Analysis
Comparison 1: Exercise versus control, Outcome 11: HRQoL SF‐36: Physical Function
1.12
1.12. Analysis
Comparison 1: Exercise versus control, Outcome 12: HRQoL SF‐36: Role Physical
1.13
1.13. Analysis
Comparison 1: Exercise versus control, Outcome 13: HRQoL SF‐36: Bodily Pain
1.14
1.14. Analysis
Comparison 1: Exercise versus control, Outcome 14: HRQoL SF‐36: General Health
1.15
1.15. Analysis
Comparison 1: Exercise versus control, Outcome 15: HRQoL SF‐36: Mental Health
1.16
1.16. Analysis
Comparison 1: Exercise versus control, Outcome 16: HRQoL SF‐36: Role Emotional
1.17
1.17. Analysis
Comparison 1: Exercise versus control, Outcome 17: HRQoL SF‐36: Vitality
1.18
1.18. Analysis
Comparison 1: Exercise versus control, Outcome 18: HRQoL SF‐36: Social Function
1.19
1.19. Analysis
Comparison 1: Exercise versus control, Outcome 19: HRQoL: CAMPHOR Activities
1.20
1.20. Analysis
Comparison 1: Exercise versus control, Outcome 20: HRQoL: CAMPHOR Symptoms
1.21
1.21. Analysis
Comparison 1: Exercise versus control, Outcome 21: HRQoL: CAMPHOR Quality of Life
1.22
1.22. Analysis
Comparison 1: Exercise versus control, Outcome 22: Cardiopulmonary haemodynamics
1.23
1.23. Analysis
Comparison 1: Exercise versus control, Outcome 23: Functional Class
1.24
1.24. Analysis
Comparison 1: Exercise versus control, Outcome 24: B‐type natriuretic peptide
1.25
1.25. Analysis
Comparison 1: Exercise versus control, Outcome 25: Exercise capacity: 6MWD, sensitivity analysis
1.26
1.26. Analysis
Comparison 1: Exercise versus control, Outcome 26: Exercise capacity: VO 2peak, sensitivity analysis
1.27
1.27. Analysis
Comparison 1: Exercise versus control, Outcome 27: Exercise capacity: peak power, sensitivity analysis
1.28
1.28. Analysis
Comparison 1: Exercise versus control, Outcome 28: HRQoL SF‐36: Physical Component Score sensitivity analysis
1.29
1.29. Analysis
Comparison 1: Exercise versus control, Outcome 29: HRQoL SF‐36: Mental Component Score sensitivity analysis
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Babu 2013 {published data only}
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Nagel 2012 {published data only}
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NCT03186092 {unpublished data only}
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NCT03476629 {published data only}
    1. NCT03476629. Effects of different types of physical training in patients with pulmonary arterial hypertension (PAH) [Effects of combined training versus aerobic training versus respiratory muscle training in patients with pulmonary hypertension: a randomized, controlled clinical trial]. clinicaltrials.gov/ct2/show/NCT03476629 (first received 26 March 2018).
NCT04254289 {published data only}
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NCT04559516 {published data only}
    1. NCT04559516. Remote exercise program delivery using a mobile application for pulmonary arterial hypertension (REVAMP). www.clinicaltrials.gov/ct2/show/NCT04559516 (first received 23 September 2020).
NCT04683822 {published data only}
    1. NCT04683822. Telerehabilitation in patients with pulmonary hypertension [Investigation of the effectiveness of a home exercise program combined with telerehabilitation in pulmonary hypertension patients]. clinicaltrials.gov/ct2/show/NCT04683822 (first received 24 December 2020).
Ontiyuelo 2019 {published data only}
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Robalo Cordeiro 2011 {published data only}
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Rokach 2019 {published data only}
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Skibarkienė 2019 {published data only}
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Tran 2020 {published data only}
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    1. Yılmaz BC, Güçlü MB, Keleş MN, Taçoy GA, Çengel A. Effects of upper extremity aerobic exercise training on oxygen consumption, exercise capacity, dyspnea and quality of life in patients with pulmonary arterial hypertension. Heart and Lung 2020;49(5):564-71. - PubMed

References to studies awaiting assessment

NCT00477724 {published data only}
    1. NCT00477724. Incidence of latent pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension after endarterectomy and influence of exercise and respiratory therapy. clinicaltrials.gov/show/NCT00477724 (first received 24 May 2007).
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    1. NCT00491309. Exercise and respiratory therapy in patients with rheumatoid arthritis / collagenosis and pulmonary hypertension. clinicaltrials.gov/ct2/show/NCT00491309 (first received 26 June 2007).
NCT02558582 {published data only}
    1. NCT02558582. Effect of exercise training in patients with pulmonary hypertension [Effect of exercise training in arterial and chronic thromboembolic pulmonary hypertension in Switzerland and standardization with European countries]. clinicaltrials.gov/ct2/show/nct02558582 (first received 24 September 2015).
NCT02579954 {published data only}
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NCT03045666 {published data only}
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NCT04188756 {published data only}
    1. NCT4188756. RV systolic and diastolic function and contractile reserve under acute exercise and in response to chronic exercise-based rehabilitation (Reserve). clinicaltrials.gov/show/NCT04188756 (first received 6 December 2019).
NCT04224012 {published data only}
    1. NCT04224012. Effect of exercise and respiratory therapy on right ventricular function in severe pulmonary hypertension. clinicaltrials.gov/show/NCT04224012 (first received 13 January 2020.
NCT04909008 {published data only}
    1. NCT04909008. Exercise training to improve cardiopulmonary hemodynamics in heart failure patients [Exercise training to improve pulmonary haemodynamic and right ventricular function in heart failure patients with pulmonary hypertension]. clinicaltrials.gov/show/NCT04909008 (first received 1 June 2021).
NCT05242380 {published data only}
    1. NCT05242380. Exercise training in patients with pulmonary arterial hypertension [The effects of kettlebell exercise training in patients with pulmonary arterial hypertension]. ClinicalTrials.gov/show/NCT05242380 (first received 16 February 2022).

References to ongoing studies

McGregor 2020 {published data only}
    1. ISRCTN10608766. Supervised pulmonary hypertension exercise rehabilitation (sphere) trial [Supervised pulmonary hypertension exercise rehabilitation (SPHERe): a multi-centre randomized controlled trial]. www.isrctn.com/ISRCTNISRCTN10608766 (first received 13 March 2019).
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Morris 2018 {unpublished data only}
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References to other published versions of this review

Morris 2014
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