# Exercise as it relates to Disease/The effects of outpatient rehabilitation on quality of life and exercise tolerance in COPD

This Wiki Facts Sheet critiques the article Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease, published in the European Respiratory Journal in 1997.

## What is the background to the research?

Chronic Obstructive Pulmonary Disease (COPD) is a disease that causes an obstruction in the bronchial tubes. In most cases of COPD there are two related diseases, emphysema and chronic bronchitis.
The management of COPD can be difficult, but exercise programs have been implemented which can benefit patients whether it be to maintain exercise tolerance or dyspnea. The maintenance of lung function and exercise capacity for a COPD patient is an important factor for daily living as deterioration of these will lead to a rapid mortality rate.
Pulmonary rehabilitation is a program that has been found to be effective in educating and physically training COPD patients on how to rehabilitate breathlessness, exercise capacity and infer strategies to maintain dyspnea to improve the quality of living.

## Where is the research from?

The research was corresponded by Bendstrup, K.E, supported by the allowances from The Foundation for Medical Research of Ribe, Ringøbing, and Southern Jutland countries and The National Association Against Lung Disease at the department of Medicine, in a hospital setting located in Esbjerg, Denmark. The article was published in 1997. Bendstrup, K.E, has completed and has been a part of further research on articles relating to respiratory function and diseases,. Despite the date and location of the research it shows relevant data in regard to recent outpatient COPD rehabilitation worldwide.

## What kind of research was this?

The research was a randomised and controlled trial consisting of 2 groups a controlled group and an intervention group.
The research measured the outcome of the activates of daily living (ADL), quality of life and the exercise tolerance for patients with moderate to severe chronic obstructive pulmonary disease. In this study there were forty-seven patients who were eligible to participate from 140 patients diagnosed with COPD. The specific criteria for the research involved the forced vital capacity in one second/forced vital capacity (FEV1/FVC) ratio to be less than 70%, an FEV1 between 25%-50 and no changes in medication and exercise status for at least 4 weeks.
An approximate decrease of thirty-two percent in the participation rate was due to factors such as an unrelated death to the study, incompletion of the programme, dropping out of the programme and unrelated medical procedures.

## What the research involve?

The treatment group and controlled group consisted of 16 patients each. Lung function/spirometry, activities of daily living and exercise tolerance related assessments were conducted at the start of the trial to measure the baseline of the patients.
These assessments were:
* Activates of daily living (ADL) score (specified for the COPD patients)
* York Quality of Life Questionnaire (YQLQ)
* 6-minute walking distance (6MWD) score
* Chronic Respiratory Disease Questionnaire (CRDQ) Forced expiratory volume in one second (FEV1)
* Forced vital capacity (FVC)
The trial lasted for 12 weeks, with an assessment at the start middle (week 6) and end (week 12) of the trial, followed by a follow up appointment 12 weeks post finishing the trial on the 24th week.
The intervention group attended the pulmonary rehabilitation sessions, these sessions were held for 1 hour, three times per week for the period of the 12 weeks run by a physiotherapist and an auxiliary nurse. Exercise thought out the programme consisted of upper limb and lower limb, strength and endurance training as well as coordination, and balance.
An education session was also held once a week for 12 sessions. The patients were educated on the lungs, pathophysiology, complications with COPD and management and coping with dyspnea.
An additional smoking sensation therapy class held by an occupational therapist was held for those who wished to quit smoking.

## What were the basic results?

The improvements of the activities of daily living in the COPD patients who attended the intervention pulmonary rehabilitation sessions showed significant improvements in comparison to the control group. This improvement could have been due to the fact that the exercise tolerance had increased. This increase was shown in the ADL questionnaire where strenuous activities such as shopping, and cleaning were presented to have improvement. There were positive results to the Chronic Respiratory Disease Questionnaire which included questions related to breathlessness, emotional function, and fatigue. After the 24-week assessment, there was no significant change in comparison to the control group in the FEV1 and FVC meaning that lung function did not significantly improve when comparing the two groups.
Smoking sensation therapy was provided for the patients who wished to discontinue smoking. The therapy including free nicotine patches, education sessions of the benefits and problems of smoking sensations as well advice which was provided by an occupational therapist. None of the patients who wished to partake in the smoking sensation therapy succeeded, tobacco consumption stayed the same.

## What conclusions can we make?

This study shows that a well thought out rehabilitation programme can improve the activities of daily living and exercise tolerance in patients with COPD. Incorporating fitness, lung function and ADL type-based rehabilitation will help in increasing the exercise tolerance in moderate to severe COPD patients.

## Practical advice

To have a greater understanding of COPD and the effects of pulmonary rehabilitation, further research is required with larger sample sizes, as well as a range of economical statuses should be considered for further studies. For a more accurate measure of the results, extra physiotherapists and auxiliary nurses should be present to assist in the data collection.
Additional follow up appointments every 6 months for a further understanding of the effectiveness of the programme would also be beneficial. Having follow up appointments will provide evidence on how the patient is maintaining their ADL with COPD. Offering a long-term rehabilitation by referring an exercise physiologist may be useful COPD patients ADL and exercise tolerance for maintaining.

## Further information and resources

For further understanding of pulmonary rehabilitation presents information on guidelines and assessments for pulmonary rehabilitation. The European Repository Journals provides studies on a range of topics regarding respiratory and lung function. To look into resent research, is a recent study showing research on the relationship between pulmonary rehabilitation and the dependency in COPD.

## References

* ↑ William C. Shiel Jr., F. (2019). Definition of Chronic obstructive pulmonary disease. [online] MedicineNet. Available at: https://www.medicinenet.com/script/main/art.asp?articlekey=7784
* 1 2 COPD Guidelines For Exercise & Pulmonary Rehab | Cleveland Clinic. (2019). Retrieved from https://my.clevelandclinic.org/health/articles/9450-copd-exercise--activity-guidelines
* 1 2 3 4 Bendstrup, K., Jensen, J., Holm, S., & Bengtsson, B. (1997). Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease. European Respiratory Journal, 10(12), 2801-2806. doi: 10.1183/09031936.97.10122801
* ↑ (2019). from https://www.resmedjournal.com/article/S0954-6111(98)90017-8/pdf
* ↑ Bendstrup, K., Gram, J., & Jensen, J. (2002). Effect of inhaled heparin on lung function and coagulation in healthy volunteers. European Respiratory Journal, 19(4), 606-610. doi: 10.1183/09031936.02.00105202
* ↑ Rochester, C. (2019). Patient assessment and selection for pulmonary rehabilitation. Respirology, 24(9), 844-853. doi: 10.1111/resp.13616
* ↑ Home | European Respiratory Society. (2019). Retrieved from https://erj.ersjournals.com/
* ↑ Janssen, D., Wilke, S., Smid, D., Franssen, F., Augustin, I., Wouters, E., & Spruit, M. (2016). Relationship between pulmonary rehabilitation and care dependency in COPD. Thorax, 71(11), 1054-1056. doi: 10.1136/thoraxjnl-2016-208836