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

Disclosures

CHEST. 2007;131(5):4S-42S. 

In This Article

Postrehabilitation Maintenance Strategies

Although the benefits of pulmonary rehabilitation have been demonstrated up to 2 years following a short-term intervention,[41] most studies suggest that the clinical benefits of pulmonary rehabilitation tend to wane gradually over time. This is underscored in 12-month follow-up data from a cohort of patients with COPD who had completed a 10-week comprehensive pulmonary rehabilitation program.[68] At the end of the 10-week program, participants were given a structured home exercise program to follow. At the follow-up evaluation 1 year later, participants who had continued with the "prescribed" exercise routine maintained the gains that had been achieved in physical endurance, psychological functioning, and cognitive functioning during the initial intervention. However, participants who did not maintain the exercise routine exhibited significant declines in all areas of functioning, including exercise endurance, psychological functioning, and cognitive functioning.

Interest has thus arisen in strategies to maintain the benefits of pulmonary rehabilitation over time, such as repeated courses of rehabilitation treatment or maintenance interventions. In the study by Foglio and colleagues,[36] although repeated pulmonary rehabilitation interventions spaced 1 year apart led to significant short-term gains similar to those seen following an initial 8-week outpatient program, no additive, long-term physiologic benefits were noted. A study by Ries and colleagues[40] demonstrated that a 12-month maintenance intervention (consisting of monthly supervised exercise and educational reinforcement sessions and weekly telephone contacts) following an initial 8-week outpatient pulmonary rehabilitation program led to modest improvements in the maintenance of walking endurance, health status, and health-care utilization compared with usual care following pulmonary rehabilitation over a 1-year follow-up period. However, a gradual decline in these outcomes was noted over time in both patient groups, and the initial benefits of the maintenance intervention were no longer evident at 24 months of follow-up. In a separate study by Puente-Maestu and colleagues,[69] a 13-month maintenance program (consisting of patient self-governed walking 4 km per day at least 4 days per week with supervised sessions every 3 months) led to small gains in tolerance of high-intensity constant-work-rate exercise and quality of life after an initial 8 weeks of lower extremity training (two different regimens), but the effects of the maintenance program on the ability to perform lower intensity exercise or ADLs were not tested. Grosbois and colleagues[70] showed that 18 months of both self-managed, home-based, and center-based supervised exercise maintenance were beneficial in maintaining the benefits in maximal exercise tolerance following a 7-week outpatient pulmonary rehabilitation program. In this study, center-based exercise maintenance afforded no benefits over the patient self-managed, home-based approach. Other studies[71] have failed to demonstrate any benefit of maintenance programs following the short-term rehabilitation intervention. Although most studies have not yet assessed how maintenance programs truly impact patients' ability to perform daily activities outside of the program setting, participation after pulmonary rehabilitation in regular exercise such as walking has been associated with a slower decline in HRQOL and dyspnea during ADLs.[72]

Thus, the role of maintenance pulmonary rehabilitation interventions following initial structured programs remains uncertain at this time, and the benefits of such interventions studied to date are modest, at best. Additional research is needed to clarify the relative impact of the many factors that can impact duration benefits from short-term pulmonary rehabilitation, such as the maintenance program structure, content, and location; exacerbations of respiratory disease; complications of other medical comorbidities; and the absence of reimbursement for continued patient participation. An additional important topic that must be addressed in the future is that of long-term patient participation. A relatively small number of patients who are offered a community-based exercise maintenance program will accept it and adhere to it.[73] Moreover, among those persons who do enroll in maintenance programs, attrition is problematic, resulting from factors such as disease exacerbations, loss of interest and/or motivation, transportation barriers, depression, program costs, and other personal issues affecting patients' lives. Additional work is needed to evaluate the optimal methods to incorporate short-term rehabilitation strategies into long-term disease management programs for patients with chronic lung disease.

10. Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Grade of recommendation, 2C

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....