Can we make it last? Maintaining benefits achieved with pulmonary rehabilitation.

Chronic obstructive pulmonary disease (COPD), the only major chronic disease with increasing mortality, creates significant burdens on health care systems and resources. Pulmonary rehabilitation (PR) is now considered an essential component of the integrated care of patients with chronic respiratory diseases such as COPD [1]. This comprehensive intervention reduces dyspnea, increases exercise performance, and improves health-related quality of life (HRQOL). Furthermore, recent studies suggest that it can reduce health care costs [2]. While immediate goals of PR are indisputable, maintaining these benefits and seeing them translate into health advantages remains elusive. The article by Karapolat and colleagues [3] reinforces our concerns that the benefits achieved during this process deteriorate in the first months after program completion. Articles such as these must stimulate us to develop strategies designed to keep patients motivated and committed to their long-term health. Unfortunately, observations such as these are not limited to COPD patients, but can be seen with many interventions designed to elicit health behavior change such as regular exercise, weight loss, and smoking cessation. There are few studies of the long-term effects of PR. Exercise performance appears to decline toward baseline 6–12 months following the formal program, but remains improved compared to control subjects after one year. HRQOL benefits may still be identified up to two years after intervention [4]. Various strategies to maintain the benefits of PR have been studied. These include continuous PR, maintenance programs, and repeated courses of PR. Continuing PR for a prolonged period seems to provide only a small additional benefit [5]. Monthly sessions and/or telephone calls maintain benefit while applied, but these wear off rapidly when the intervention is discontinued [6]. Repeating a course of PR seems to reproduce the short-term gains but does appear to result in long-term benefits [7]. These studies underscore the need to promote health behavior change during the program. For PR to have an impact on the progressive and deteriorating nature of COPD, patients must be taught the skills they need to manage their condition and, more importantly, they must be instilled with the belief that these skills can make a difference in the course of their illness. Most of our knowledge in health behavior change comes from research in chronic disease populations, not specifically in patients with COPD. Long-term studies in the elderly [8] show that self-efficacy and belief in the benefits from regular exercise were predictors of exercise adherence. Confusion and depression were predictors of poor adherence. In a metaanalysis of 27 cross-sectional and 14 longitudinal studies of individuals 65 years or older, educational level and past exercise behavior were predictors of regular exercise performance, and perceived frailty and poor health were the greatest barriers to maintaining an exercise program [9]. A recent study of COPD patients compared enhanced to conventional follow-up after PR [10]. Adherence to regular exercise was highest immediately after program completion but fell in both groups over six months. The most common reasons for nonadherence were disease exacerbations and lung infections. Studies such as these provide important insight into the patterns and predictors of L. Nici (&) Pulmonary and Critical Care Section, Providence Veterans Administration Medical Center, 830 Chalkstone Avenue, Providence, Rhode Island 02908, USA e-mail: Linda_Nici@brown.edu