Pulmonary Rehabilitation* Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

Andrew L. Ries, MD, MPH, FCCP (Chair); Gerene S. Bauldoff, RN, PhD, FCCP; Brian W. Carlin, MD, FCCP; Richard Casaburi, PhD, MD, FCCP; Charles F. Emery, PhD; Donald A. Mahler, MD, FCCP; Barry Make, MD, FCCP; Carolyn L. Rochester, MD; Richard ZuWallack, MD, FCCP; Carla Herrerias, MPH


CHEST. 2007;131(5):4S-42S. 

In This Article

Psychological and Behavioral Components of Pulmonary Rehabilitation

Based on little published evidence, the 1997 guidelines panel concluded that "Evidence to date does not support the benefits of short-term psychosocial interventions as single therapeutic modalities, but longer term interventions may be beneficial" and that "expert opinion supports the inclusion of education and psychosocial interventions as components of comprehensive pulmonary rehabilitation programs for patients with COPD."

Some studies[146,147] have confirmed that there is a relatively high prevalence of psychological distress among patients with COPD. Depression and anxiety are the most commonly reported psychological concerns. However, due to the variety of methods utilized in measuring depression and anxiety, prevalence estimates for clinically significant depression vary from 7 to 57%,[148] and estimates for clinically significant anxiety vary from 10 to 96%.[149,150] Data indicate that clinical depression may not be associated with mortality among patients with COPD.[151] However, no studies have evaluated the influence of depressive symptoms on survival among patients with COPD, despite evidence among patients with cardiac disease that mortality is associated with depressive symptoms. Studies[54,152,153] also have documented changes in cognitive functioning among patients with COPD, including impairments in memory performance and higher cognitive skills (eg, attention and complex visual-motor processes, abstraction ability, and verbal tasks).

Overall, psychological distress is an important clinical feature of COPD because patients with COPD are more likely than age-matched peers to report symptoms of distress, especially depression and anxiety. In addition, psychological distress among patients with COPD predicts impaired quality of life and restricted ADLs.[154] Functional capacity is more strongly associated with emotional/psychosocial factors (eg, depression, anxiety, somatization, low self-esteem, attitudes toward treatment, and social support) than with traditional physiologic indicators.[155] Although psychological factors are associated with functional performance, the influence of psychological factors on disease progression and mortality is unknown.

During the past decade, there have been very few studies evaluating nonexercise psychosocial interventions among patients with COPD. Rose and colleagues[156] reviewed studies evaluating psychosocial interventions to treat anxiety and panic. They described only one study[55] published since 1995 with a randomized control group. Participants in this study were randomly assigned to one of the following three groups: exercise with ESM (designed to provide the standard of care in pulmonary rehabilitation); ESM (designed to provide participants with the psychosocial components of rehabilitation minus any exercise training); and a nonintervention waiting list. Outcomes from participants in the ESM group reflected the effects of a psychosocial intervention. The results indicated that ESM participants achieved significant increases in their knowledge about and treatment of COPD, but there were no effects of ESM on indicators of anxiety, depression, or quality of life. In addition, ESM participants did not exhibit changes in cognitive function. Thus, the data indicate that ESM alone in the absence of exercise had a minimal impact on psychosocial functioning. These data are consistent with the results of a 2005 study[157] indicating that patients with COPD who attended an educational lecture series in addition to undergoing exercise training did not experience any benefits beyond those experienced by participants in exercise training without education or those who underwent exercise training with activity training. Despite the absence of any apparent benefit from educational training in the latter study, it is noteworthy that the retention of participants assigned to the educational group was 100% at 12 weeks compared to 64% and 84%, respectively, in the other two groups. Thus, the educational intervention may have facilitated aspects of program adherence that the other regimens did not.

Behavioral factors are important in the preventive care and rehabilitation of patients with COPD. Specifically, smoking is well known to be the primary risk factor for the onset of COPD. Diagnosis with COPD is not always a sufficient health threat to motivate smokers to quit. Data regarding smoking cessation interventions among pulmonary rehabilitation patients are sparse. In a 2005 study[158] of patients with COPD who were smoking, participants were randomly assigned to either a smoking cessation educational intervention or to usual care. Participants were recruited at various primary care sites throughout the Netherlands. The results indicated that quit rates in the intervention group were approximately double those in the usual-care group (16% vs 9%, respectively). These data confirm that a diagnosis of COPD is not a sufficient stimulus to initiate the process of smoking cessation, but educational information may facilitate quitting in some patients.

The data suggest that depression and anxiety are more common among patients with COPD than in the public at large. Data indicate that psychosocial intervention may facilitate behavioral changes, such as smoking cessation, as well as the management of symptoms, including dyspnea. However, psychosocial interventions alone may not lead to reduced psychological distress.

18. There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. Grade of recommendation, 2C

19. Although no recommendation is provided, since scientific evidence is lacking, current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD.


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