Rehabilitation for Patients With Pulmonary Hypertension

Study Overview
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Brief Summary
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The purpose of this study is to test the impact of a personalized, partly supervised rehabilitation program on the exercise capacity in patients with pulmonary hypertension. The rehabilitation program consists of 2 weeks inpatient, 2 weeks ambulatory and 11 weeks home based rehabilitation.

Detailed Description
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The present study is a 15 weeks, randomized (1:1) controlled trial. Patients in both groups will not change their usual medical treatment. After 2 clinical visits (screening and randomization visit), patients in the intervention group will follow a 15 week rehabilitation program consisting of 2 weeks inpatient, 2 weeks outpatient and 11 weeks home based rehabilitation. At the end of the outpatient rehabilitation phase (week 4) and the home-based program (week 15), clinical outcomes will be reassessed.

Official Title
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A Randomized Controlled Trial to Evaluate the Effect of a Rehabilitation Program on the Exercise Capacity of Patients With Pulmonary Hypertension

Conditions
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Pulmonary Hypertension

Intervention / Treatment
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* Other: Pulmonary rehabilitation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female and male patients ≥ 18 years Pulmonary arterial hypertension (PAH, Group 1 of Nice classification) and chronic thromboembolic pulmonary hypertension (CTEPH, group 4) WHO functional class II-III PH diagnosed by right heart catheter showing: Baseline mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg Baseline pulmonary vascular resistance (PVR) ≥ 240dyn x s x cm-5 Baseline pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHgg Patients receiving optimized conventional PH therapy including intensified treatment with diuretics and who have been stable for 2 months before entering the study. Except for diuretics, medical treatment should not be expected to change during the entire 15-week study period. Negative pregnancy test (β-HCG) at the start of the trial and appropriate contraception throughout the study for women with child- bearing potential Able to understand and willing to sign the Informed Consent Form Exclusion Criteria: PH of any cause other than permitted in the entry criteria, e.g. concomitantly to portal hypertension, complex congenital heart disease, reversed shunt, HIV infection, suspected pulmonary veno-occlusive disease based on pulmonary edema during a previous vasoreactivity test or on abnormal findings compatible with this diagnosis (septal lines or pulmonary edema at high resolution computer tomography), congenital or acquired valvular defects with clinically relevant myocardial function disorders not related to pulmonary hypertension or unclear diagnosis Patients with signs of right heart decompensation Walking disability Acute infection, pyrexia Any change in disease-targeted therapy within the last 2 months Any subject who is scheduled to receive an investigational drug during the course of this study Severe lung disease: FEV1/FVC <0.5 and total lung capacity <70% of the normal value Active myocarditis, instable angina pectoris, exercise induced ventricular arrhythmias, decompensated heart failure, active liver disease, porphyria or elevations of serum transaminases >3 x ULN (upper limit of normal) or bilirubin >1.5 x ULN Hemoglobin concentration of less than 75% of the lower limit of normal Systolic blood pressure <85 mmHg History or suspicion of inability to cooperate adequately

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized controlled trial
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Rehabilitation group<br>15 weeks pulmonary rehabilitation program consisting of 2 weeks inpatient, 2 weeks outpatient and 11 weeks home-based rehabilitation. | Other: Pulmonary rehabilitation<br>* Rehabilitation program consisting of 2 weeks inpatient (supervised training 5 times per week), 2 weeks outpatient (supervised sessions 3 times per week) and 11 weeks home-based exercise training (weekly phone call). During the inpatient phase, patients will receive on top of the supervised training sessions a consultation of the dietitian, PH psychologist, social worker and specialized nurse. During the ambulatory rehabilitation phase patients will have 2 session with the occupational therapist. Every supervised training session contains: Interval training on a cyclo-ergometer Strength training of the upper and lower extremities Guided walks<br>|
| No Intervention: Control group<br>Usual care | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in functional exercise capacity | Change in six minutes-walk distance measured at baseline, after 4 weeks and at the end of the study (15 weeks after randomization). | Baseline, 4 weeks, 15 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Difference in change over time between the rehabilitation and the control group in SF-36 | Health related quality of life (HRQoL) will be measured by the extensively validated generic HRQoL questionnaire, the 36-Item Short Form Survey Instrument (SF-36). This questionnaire includes two main scores with a physical component and an emotional component scale and eight subscales. The score ranges between 0 and 100, higher scores indicate a better quality of life. The questionnaire is self-administered and will be completed on paper | Baseline, 4 weeks, 15 weeks | 
| Difference in change over time between the rehabilitation and the control group in EmPHasis-10. | Health related quality of life (HRQoL) will be measured the EmPHasis-10 questionnaire, measuring the impact of PH on health related quality of life. The score ranges between 0 and 50, higher scores indicate worse quality of life. | Baseline, 4 weeks, 15 weeks | 
| Change from baseline to 15 weeks between the rehabilitation and the control group in WHO functional class | The WHO functional classification ranges from class I (patients with PH but without resting limitation of physical activity) to class IV (patients with PH with inability to carry out any physical activity without symptoms). The WHO functional class is a powerful predictor of survival in patients with PH. | Baseline, 15 weeks | 
| Difference in change over time between the rehabilitation and the control group in Borgscale at the end of the 6MWD test | Borg (0-10) scale reporting on dyspnea and fatigue will be administered at the end of the six-minutes walk test. The score ranges between 0 and 10, a higher score means more symptoms of dyspnea / fatigue. | Baseline, 4 weeks, 15 weeks | 
| Change from baseline to 15 weeks between the rehabilitation and the control group in maximal exercise capacity | Maximal exercise capacity will be assessed by a maximal incremental cycling test. After a 2-min resting period and 3 minutes of unloaded cycling, the patients will start at 20 W and cycle until symptom limitation at an incremental workload of 10 W/min. Oxygen consumption, carbon dioxide output and ventilation will be measured breath by breath (Vmax series, SensorMedics, Anaheim, CA). Heart rate and oxygen saturation will be registered continuously. Peak workload, oxygen consumption (VO2 max), heart rate, blood pressure, oxygen saturation, ventilation and VE/VCO2 slope will be retrieved. | Baseline, 15 weeks | 
| Difference in change over time between the rehabilitation and the control group in Objectively measured physical activity | At every time point, physical activity will be measured for 1 week, using a physical activity monitor validated to be used in patients with respiratory disease. Patients will be asked to wear the monitor during waking hours. The mean number of steps per day and time spent in activities of at least moderate intensity will be retrieved as outcomes. | Baseline, 4 weeks, 15 weeks | 
| Difference in change over time between the rehabilitation and the control group in symptoms of anxiety and depression (HADs questionnaire) | Symptoms of anxiety and depression will be assessed by the Depression, Anxiety, and Stress Scale. This questionnaires is self-administered and will be completed on paper. Higher scores indicate more symptoms of anxiety / depression. | Baseline, 4 weeks, 15 weeks | 
| Difference in change over time between the rehabilitation and the control group in Isometric quadriceps force | An isometric maximal volitional contraction of the right quadriceps muscle be performed using the Biodex dynamometer with the patient seated with a 90° hip and 60° knee flexion. The best of 3 reproducible measurements will be retrieved as a measure of quadriceps force. | Baseline, 4 wekes, 15 weeks | 
| Change from baseline to 15 weeks between the rehabilitation and the control group in hemodynamics measured by echocardiography | Hemodynamics measured by echocardiography at rest and during a symptom limiting exercise test. The following outcomes will be investigated: Change in tricuspid annular plane systolic excursion, Change in tissue Doppler imaging, Change in left ventricular pump function, Change in right ventricular pump function , Change in thickness of interventricular septum, Change insize of inferior vena cava, Change in systolic pulmonary arterial pressure, Change in left ventricular eccentricity index, Change in Tei index , Change in right ventricular area, Change in right atrial area | Baseline, 15 weeks | 
| Change from baseline to 15 weeks between the rehabilitation and the control group in proportion of patients who exceeded the MID in 6MWD | MID will be defined as an increase of at least 30m | Baseline, 15 weeks | 
| Change from baseline to 15 weeks between the rehabilitation and the control group in heart function as measured by MRI (optional) | MRI scan at rest and during exercise combined with right heart catherization and blood sampling before and after the exercise protocol. | Baseline, 15 weeks | 
| adverse events | Patients will be asked about visits to general practitioner and hospitalizations due to any medical reasons in order to control the occurrence of adverse events. In a semi-structured way,, occurrence of exercise related and non-exercise related adverse events will be collected. | 15 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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pulmonary rehabilitation, physical activity