The role and effectiveness of pulmonary rehabilitation in COPD This study examined the medium-term effect of a maintenance programme after initial pulmonary rehabilitation. The results of the study an their implications are discussed in the commentary. Abstract of Original Article Although the benefits of pulmonary rehabilitation (PR) have been demonstrated in patients with COPD, most studies suggest that short-term programs are insufficient to maintain the benefits beyond a post-discharge period of 6 months to 1 year. We were interested to evaluate the effects of an innovative maintenance intervention compared with a usual after-care. Forty moderate to severe COPD patients, who had just completed their first inpatient PR, were consecutively included in either a maintenance group (MG) or a standard after-care group. The maintenance program was coordinated within a health-care network including self-help associa- tions, and offered weekly activities. We measured the 6-min walk distance (6MWD), the quality of life using the St George Respiratory Questionnaire (SGRQ), the dyspnea, the maximal workload and the health-care utilization. Data were collected at respiratory clinic admission and discharge, and at 6- and 12-month visits after the PR. After 12 months, we found statistically and clinically significant differences in favor of the MG in 6MWD (74 m; pp0.01) and in the three domains of SGRQ: symptom (19%; pp0.01), activity (27%; pp0.01) and impact (32%; pp0.01). The results showed no difference between groups in dyspnea and maximal workload. We also found that the number of days spent in hospital for respiratory disorders was significantly lower in the MG after 12 months (pp0.03). The multidisciplinary management of COPD patients in the post-rehabilitation period within a health-care network including self-help associations seems to be an effective strategy for maintaining, and even improving, the benefits of a first initial structured program. ARTICLE IN PRESS Commentary by Patrick White Department of General Practice and Primary Care, King’s College, London, UK Pulmonary rehabilitation (PR) should be a routine now for all patients with symptomatic COPD, although funding for PR is extremely variable and many patients in primary care do not have access unless they are referred to a specialist service. In the UK, the Healthcare Commission reported that only 5% of people with COPD were receiving PR in 2006. 1 Moullec et al’s study takes the debate about the role and effectiveness of PR in COPD a step further by examining the medium term (1 year) effect of a maintenance programme after initial PR. The effects in the patients that they studied are without doubt impressive. There are a number of challenging questions that arise from this study which still need to be addressed and draw attention also to the limitations of previous trials of COPD. It is not easy to work out from this study why only 50 of 650 possible subjects were recruited. Patients had inpatient pulmonary rehabilitation for 4 weeks, which is in itself highly unusual, and must have been extremely costly. This is certainly not recommended in international guidelines and there is no evidence that the outcome of rehabilitation is better in patients who receive the treatment in hospital compared to those who are treated as outpatients. The main concern with this paper however is that the intervention group subjectswere chosen because they lived in an area in which there was already a self-help association, whereas subjects in the comparative group lived in towns without existing self-help associations. There are a number of possible explanations for the poor outcome in those living in areas without existing self-help. These include the quality of the basic COPD care, as well as the responsiveness of services during an exacerbation. The other major concern is the relatively low age-range of patients recruited to the study. At just under 60 years of age on average, this is probably at least 10 years younger than the average COPD patient seen in primary care. While more definitive work is required to explore the effectiveness of long-term maintenance pulmonary rehabilitation, this study does give encouragement to its pursuit. 1. Healthcare Commission. Clearing the air: a national study of chronic obstructive pulmonary disease. London: Comission for Healthcare Audit and Inspection; 2006. Original article reference: Moullec G, Ninot G, Varray A, Desplan J, Hayot M, Prefaut C. An innovative maintenance follow-up program after a first inpatient pulmonary rehabilitation. Respiratory Medicine 2008;102:556–566. 10.1016/j.rmedu.2008.06.018 RESPIRATORY MEDICINE : COPD UPDATE 4 (2008) 101– 104 104
The role and effectiveness of pulmonary rehabilitation in
COPDThis study examined the medium-term effect of a maintenance
programme after initial pulmonary rehabilitation. The results of
the study antheir implications are discussed in the
commentary.Abstract of Original
ArticleAlthoughthebenetsofpulmonaryrehabilitation(PR)havebeen
demonstrated in patients with COPD, most studiessuggest that
short-term programs are insufcient to maintainthe benets beyond a
post-discharge period of 6 months to 1year. We were interested to
evaluate the effects of aninnovative maintenance intervention
compared with a usualafter-care. Forty moderate to severe COPD
patients, who hadjust completedtheir rst inpatient PR,
wereconsecutivelyincludedineitheramaintenancegroup(MG)
orastandardafter-care group. The maintenance program was
coordinatedwithina health-care network including self-help
associa-tions,andoffered weeklyactivities.Wemeasuredthe6-minwalk
distance (6MWD), the quality of life using the St GeorgeRespiratory
Questionnaire (SGRQ), the dyspnea, the maximalworkload and the
health-care utilization. Data were
collectedatrespiratoryclinicadmissionanddischarge,
andat6-and12-monthvisits after the PR. After 12 months, we
foundstatisticallyandclinicallysignicant
differencesinfavoroftheMGin6MWD(74m; pp0.01)
andinthethreedomainsofSGRQ:symptom(19%;pp0.01),activity(27%;pp0.01)andimpact
(32%; pp0.01). The results showed no
differencebetweengroupsindyspneaandmaximal workload.Wealsofound
that the number of days spent in hospital
forrespiratorydisorderswassignicantlylowerintheMGafter12months(pp0.03).
Themultidisciplinarymanagement ofCOPDpatients in the
post-rehabilitation period within
ahealth-carenetworkincludingself-helpassociationsseemsto be an
effective strategy for maintaining, and evenimproving, the benets
of a rst initial structured program.ARTICLEINPRESSCommentary by
Patrick WhiteDepartment of General Practice and Primary Care, Kings
College, London, UKPulmonary rehabilitation (PR) should be a
routine now for all patients with symptomatic COPD, although
funding for PR isextremely variable and many patients in primary
care do not have access unless they are referred to a specialist
service. Inthe UK, the Healthcare Commission reported that only 5%
of people with COPD were receiving PR in
2006.1MoullecetalsstudytakesthedebateabouttheroleandeffectivenessofPRinCOPDastepfurtherbyexaminingthemedium
term (1 year) effect of a maintenance programme after initial PR.
The effects in the patients that they studied arewithout doubt
impressive. There are anumber of challenging questionsthat arise
from this study whichstill need tobeaddressed and draw attention
also to the limitations of previous trials of
COPD.Itisnoteasytoworkoutfromthisstudywhyonly50of650possiblesubjectswererecruited.
Patientshadinpatientpulmonaryrehabilitationfor4weeks,
whichisinitselfhighlyunusual, andmusthavebeenextremelycostly.
Thisiscertainly not recommended in international guidelines and
there is no evidence that the outcome of rehabilitation is
betterinpatientswhoreceivethetreatmentinhospitalcomparedtothosewhoaretreatedasoutpatients.Themainconcernwith
this paper however is that the intervention group subjects were
chosen because they lived in an area in which therewasalready
aself-help association,whereassubjects inthecomparative grouplived
intowns without existing self-helpassociations. There are a number
of possible explanations for the poor outcome in those livingin
areas without existingself-help. These include the quality of the
basic COPDcare, as well as the responsiveness of services during
anexacerbation. The other major concern is the relatively low
age-rangeof patients recruited to the study. At just under
60yearsofageonaverage,thisisprobablyatleast10yearsyoungerthantheaverageCOPDpatientseeninprimarycare.Whilemoredenitive
workisrequiredtoexploretheeffectivenessoflong-termmaintenance
pulmonaryrehabilitation,this study does give encouragement to its
pursuit.1. HealthcareCommission. Clearing the air: anational
studyof chronic obstructive pulmonarydisease. London:
ComissionforHealthcare Audit and Inspection; 2006.Original article
reference: Moullec G, Ninot G, Varray A, Desplan J, Hayot M,
Prefaut C. An innovative maintenance follow-upprogram after a rst
inpatient pulmonary rehabilitation. Respiratory Medicine
2008;102:556566.10.1016/j.rmedu.2008.06.018R E S P I R ATORY ME DI
C I NE : C OP D UP DAT E 4( 2008) 101 104 104
