Pulmonary rehabilitation (PR) is an essential intervention in the management of patients with chronic obstructive pulmonary disease. To guide health care professionals in the implementation and evaluation of a PR program, this article discusses the current key concepts regarding exercise testing, prescription, and training, as well as self-management intervention as essential parts of PR and post-rehabilitation maintenance. Moreover, new approaches (alternative forms of organization and delivery, tele-rehabilitation, exercise adjuncts) and unique and challenging situations (patients experiencing acute exacerbations, advanced disease) are thoroughly reviewed. Finally, validated point-of-care resources and online tools are provided.
Key points
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Pulmonary rehabilitation is an effective multidisciplinary nonpharmacological intervention that represents the standard of care in chronic obstructive pulmonary disease (COPD) management.
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Exercise training, education, and self-management behavior-modification are fundamental elements of a pulmonary rehabilitation program.
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Challenges encountered in program delivery (including exacerbations, advanced COPD, resource constraints, geographic constraints, and reductions in gains) can be effectively addressed (through exercise adjuncts, tailored prescriptions, community-based/tele-based/home-based delivery, and self-management intervention, respectively).
Introduction
With an aging population, the burden of chronic obstructive pulmonary disease (COPD) continues to rise, impacting patients, their families, the health care system, and the society. The clinical course of COPD follows a well-known vicious circle of dyspnea-inactivity often punctuated with acute exacerbations, resulting in a poor quality of life in affected patients. This disease trajectory can be impacted by pulmonary rehabilitation (PR), considered now as an essential parts of COPD therapy.
There is robust evidence in the literature that PR leads to improvements in dyspnea, exercise capacity, health-related quality of life, and health care utilization in patients with COPD. , PR programs also emphasize self-management (SM) interventions to increase patient self-efficacy and healthy behaviors. However, despite the documented benefits and strong recommendations for their use, , PR remains underprescribed and underused. In 2018, the reported rates of PR use in the United States were only 2.7% within 12 months of hospitalization in Medicare beneficiaries, even though their hospitalization was within the 2 years since Medicare began reimbursement for PR. Older age (≥75 years) and lower socioeconomic status were factors associated with nonusage. In Canada, the access remained limited to fewer than 1% of patients with COPD. Increased awareness by health care providers, along with the development of strategies to facilitate access to PR, are needed.
This article provides a practical review of the elements of a PR program in addition to tackling relevant emerging topics, including alternate forms of organization and delivery, the role and training of the case manager, and specific challenges, such as patients with acute exacerbations of COPD (AECOPD) and those with advanced disease. Resources and online tools for health care professionals and patients are provided throughout the article.
Definition, concept and source documentations
Definition and Concept
PR is a comprehensive and multidisciplinary approach to the management of COPD. Given the robust evidence for benefit, , PR is an important component of the current standard of care in managing COPD, in addition to playing an ever-increasing role in the management of all chronic lung diseases. Society guidelines define PR as “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.”
Although the setting and delivery of PR varies widely based on the fiscal, geographic, and personnel availabilities, there is a general consensus on what constitutes the core components of a PR program. These include pre-rehabilitation assessment to individualize/optimize each individual’s PR program experience; exercise training; body composition interventions; SM education; and psychological and social interventions. , Additional indicators of quality in a PR program include its duration, the frequency of supervised exercise, and the measurement of health outcomes before and after the program. The multimodal approach also includes education on inhaler technique and adherence, energy utilization and conservation strategies, and how to recognize an exacerbation and the appropriate use of an Action Plan.
In addition, the patients themselves must also actively engage and be equipped with the tools to manage their own disease. Education targeting self-management is an important component of PR promoting behavior change and allowing for the benefits of PR to persist after program completion. SM reduces dyspnea, improves health-related quality of life, and reduces hospital admissions. Its relative novelty and heterogeneity in delivery prompted a standardized definition of SM in COPD management: “structured but personalized and often multi-component, with the goals of motivating, engaging and supporting the patients to positively adapt their health behavior skills and develop skills to better manage their disease.” The current SM model in modern PR programs emphasizes a collaborative approach; beyond didactic, passive instruction, the patient must also be motivated and confident to apply the knowledge they have learned following serial iterative interactions. It is through this critical step that patients may become active agents in their own health and change their health and lifestyle behaviors in a sustainable manner, thereby promoting more enduring benefits following PR participation.
Source Documentations
A comprehensive reference for PR is the “Rehabilitation” section of the Web site www.livingwellwithcopd.com , which includes resources for all of the elements of PR. In addition to many studies and clinical trials published to demonstrate its effectiveness, Living Well with COPD (LWWCOPD) is a high-quality resource referenced throughout this article, available to any health care provider following a simple account sign-up ( https://www.livingwellwithcopd.com/en/become-member.html ). Additional noteworthy resources include https://pulmonaryrehab.com.au , a Lung Foundation Australia open-access resource for high-yield PR materials, and http://www.livebetter.org , an American Thoracic Society/Gawlicki Family Foundation PR navigation tool geared toward patients with chronic lung disease.
Exercise training, testing and prescription in pulmonary rehabilitation
An important aim of PR is to stabilize or reverse the pathophysiological manifestations of the disease and to attempt to bring the patient to the highest possible functional capacity, achieved through SM intervention and exercise training.
Exercise Training in Pulmonary Rehabilitation
Exercise training is the cornerstone of effective PR because it increases exercise capacity, and improves activities of daily living (ADLs) and independent ADLs (IADLs). Physical conditioning through exercise training is also an important way to achieve the personal goals identified by the patient at the outset of the program (participate in a sport or hobby that they were once able to do), which can provide the means to reconnect to social networks and enhance quality of life.
Exercise imparts a certain load onto the peripheral muscles, and this increases the oxygen needs of the body. The patient’s respiratory system must exchange fuel (oxygen) for by-products (carbon dioxide) of metabolism, and transfer oxygen to the circulatory system; the heart and circulatory system must transport the oxygenated blood to the skeletal muscles used during exercise; and the mitochondria of these peripheral muscles must use oxygen efficiently in aerobic cellular respiration. Any abnormality or breakdown along any of these organ systems can lead to a reduced exercise capacity. Depending on the underlying cause, symptoms in daily life are manifested as dyspnea and/or leg fatigue, the 2 principal components evaluated when using the Borg scale. Adding to the complexity of exercise pathophysiology are layers of motivational and psychological aspects related to exercise, for example, the influence of previous traumatizing attacks of dyspnea, on one’s willingness to maximally exert one’s self during exercise sessions.
Exercise Capacity Testing
The ability to determine the baseline exercise capacity, and the principal cause for exercise limitation, are pivotal in the ability to prescribe a tailored exercise plan for the patient with COPD. The gold standard remains the cardiopulmonary exercise test (CPET). In a CPET, valuable information is gained by the determination of peak workload and the collection of expired gases, pulse oximetry, electrocardiography, blood pressure, Borg scores, and in many cases serial spirometric maneuvers and dynamic operational lung volumes. Through such data collection, not only can conventional measurements in performance athletics such as the ventilatory threshold and maximal (or peak) oxygen consumption be obtained, but additional critical respiratory limitations to exercise characteristics of COPD can be identified and quantified. In patients with COPD there are unique limitations, including ventilatory inefficiency and ventilation-perfusion mismatch, expiratory flow limitation and dynamic hyperinflation, a disproportionate work of breathing due to airway resistive and elastic abnormalities, and oxygen desaturation and hypercapnea. , Through incremental testing, the timing of these events in relation to peak workload, oxygen consumption, and Borg scores can help individualize the aerobic goals and limits for the exercise prescription.
The accessibility to CPET varies greatly depending on the resources (expertise, personnel, equipment) and practice patterns within the milieu where the PR program operates. Alternative means of testing include the 6-minute walking test (6MWT) or the incremental shuttle walking tests (ISWT). Although the 6MWT encourages the patient to walk as far as possible at their own pace in 6 minutes, the ISWT progressively increases walking speed and is therefore felt to be more akin to an incremental CPET study. Although less comprehensive from a physiologic and mechanistic perspective, useful information on exercise capacity can be collected from these alternative tests.
Exercise Prescription, Type, and Intensity
A helpful framework for developing an exercise prescription is the “ FITT’ ” paradigm: Frequency , Intensity , Time, and Type . Resources for upper and lower extremity aerobic and resistance prescriptions are available on the LWWCOPD Web site ( https://www.livingwellwithcopd.com/286-exercisepr-program-overview-and-principles.html ) as well as on the Lung Foundation Australia Web site ( https://pulmonaryrehab.com.au/importance-of-exercise/exercise-prescription-table ). Although endurance (aerobic) training has traditionally been the principal form of exercise in PR programs, many societies recommend that a combination of endurance and resistance types of training should be used. , Programs should initially allot time to introduce patients to the exercise equipment (treadmill, cycle ergometer, weights and resistance machines) such that they are familiarized with its safe use, particularly due to the known increased falls risk in patients with COPD. Although the ideal exercise program duration in COPD remains controversial, in general longer is better and at least 6 to 8 weeks is recommended. , Regarding aerobic exercise frequency, 3 to 5 sessions of 20 to 60 minutes each per week is recommended. ,
Aerobic training is preferentially achieved through lower limb exercise : in higher-resource settings this can be performed on a cycle ergometer or on a treadmill and in lower-resource settings by ground walking or by stair climbing. Aerobic training of the upper limbs is also possible, although less conventional. , Table 1 provides an approach to setting the initial intensity for each modality of aerobic exercise. Regarding the resistance-type exercise prescription, the recommended frequency and timing is 1 (if higher repetitions) to 4 (if lower repetitions) sets of 8 to 12 repetitions on 2 to 3 days per week, and the recommended intensity is 60% to 70% of the patient’s baseline 1-repetition maximum weight. , Resistance/weight machines, free weights, or elastic bands are commonly used, or even one’s own body weight, a form of exercise referred to as calisthenics.
| Aerobic Modality | Initial Intensity |
|---|---|
| Cycle ergometer | 60% of peak workload on CPET |
| Treadmill | 60%–80% of peak workload on CPET 80% of 6MWT speed a 75% of ISWT speed |
| Ground walking | 80% of 6MWT speed a |
| Stair climbing | Borg 4–6 |
| Upper extremity ergometer | 75% of peak oxygen consumption (incremental upper extremity CPET) |
In both aerobic and resistance components of the training program, gradual increases in duration/repetitions and workload/resistance can be applied under the close supervision of trained PR personnel in a stepwise fashion. A printable exercise tracking sheet intended for point-of-care use is available on the LWWCOPD Web site ( https://www.livingwellwithcopd.com/DATA/LIBRAIRIE/229_en∼v∼exercise-sheet.pdf ). To continue to benefit from the program, it is important to iteratively titrate the exercise prescription in collaboration with the patient. Typically a “moving titration,” targeting a Borg of 4 to 6, can allow for progressively more demanding sessions as the program continues. ,
Pulmonary rehabilitation patient selection, setting, and delivery
Patient Selection
PR can benefit almost every patient with COPD irrespective of disease severity, sex, ethnicity, or age ; however, guidelines recognize that patients with a significant symptom burden despite optimal treatment or with an elevated risk of AECOPD would benefit the most from PR participation. , , Comorbidities are not a contraindication to participation as long as they are not acute and uncontrolled and/or they do not interfere with the safe operation of the program; patients with comorbidities may in fact benefit the most from PR participation. , Initial selection and prioritization should not only focus on airflow obstruction severity but should additionally consider the patient’s symptom burden and health status.
Pulmonary Rehabilitation Referral and Participation
Despite the robust evidence supporting PR efficacy, poor referral rates continue to contribute to limited participation. Although PR referral should be considered by the physicians at any point in the chronic management of COPD, particular emphasis on referral should be placed during 3 key events: at diagnosis, before discharge following an AECOPD, and following progressive symptom deterioration. The most common patient barriers prohibiting PR participation are significant travel distance, lack of perceived benefit, and being an active smoker. To encourage participation in PR, the referring physician should first have a comprehensive discussion with the patient regarding the process and expected benefits of PR. Concerning the travel distance barrier, it has been proposed that PR delivery at peripheral community centers would increase both access and adherence. In support of this hypothesis, recent implementation studies have demonstrated that tele-health PR delivery to peripheral sites is feasible, safe, and effective. , Further studies are needed to better establish tele-rehabilitation strategies.
Setting and Delivery
PR can be conducted in a number of settings, from inpatient hospital-based, outpatient-based, and even home-based programs. The optimal setting for a specific program will vary according to community needs, available resources, and patient characteristics. Of note, patients with severe and advanced disease and those with multiple comorbidities often require hospital-based programs because of a greater need for supervision and multidisciplinary care. Despite being the “gold standard,” outpatient programs are limited by cost and availability constraints. , To overcome these limitations, home-based programs are under ongoing evaluation. Two studies demonstrated noninferiority of home-based versus hospital-based PR. , Short-term benefits on exercise capacity, breathlessness, and quality of life were observed, whereas adherence and completion rates were actually higher in home-based participants. Conflicting results in the literature may be secondary to heterogeneity in design, intervention, and support structures. To be recognized as PR, a home-based program must be capable of preserving all core components that define PR, including exercise program supervision, a multidimensional approach, and education with SM interventions. Tele-health is a novel PR delivery method that incorporates rapidly growing technological advances in remote management. Tele-health applications are numerous and can be incorporated in several clinical tasks including consultation, monitoring, and education. Tele-rehabilitation sessions can be delivered either within a health care institution or within the patient’s home. When comparing an 8-week in-center tele-rehabilitation program with standard in-center PR, Stickland and colleagues demonstrated that locally supervised group exercise sessions in combination with remote tele-casted education sessions resulted in similar benefits on quality of life and exercise capacity. At-home tele-rehabilitation is a further extension of remote PR. Although this has also demonstrated interesting results, larger studies are still needed.
Program Duration, Structure, and Staffing
Although the duration and number of PR sessions can vary by setting, minimal PR standards must still be met. Outpatient participants typically attend 2 to 3 sessions per week, whereas inpatient participants may attend up to 5 days per week. In the interest of program effectiveness, programs should contain at least 24 sessions. Although longer programs may produce greater gains, , physical capacity improvement tends to plateau after 12 weeks. Therefore, in the interest of optimizing attendance, cost, and intervention efficacy, most programs last 8 to 12 weeks. Typically, a PR team is interdisciplinary and the program is led by a medical director. ,
A physiotherapist and/or kinesiologist with experience in clinical exercise training are essential for exercise prescription and supervision. Designation within the PR team of the patient’s acting case manager (CM) should be considered; the CM can review the patient needs, coordinate individual and group education, and help the patient navigate the system. All the health care professionals who are part of the PR team should be involved in an interdisciplinary approach. Based on resource availability, the team should be complemented by a social worker, nutritionist, occupational therapist, and psychologist.
Importance of the Case Manager
The CM stands to play an important role in SM intervention as the patient’s principal health care system and chronic disease “navigator.” Table 2 presents the many central roles of the CM in comprehensive patient care, in addition to CM training recommendations. In those patients with recurrent AECOPD, the CM instructs and supports the patient on the timely completion of the written Action Plan. Recognition of symptom worsening (“problem learning”), deciding to adjust, change, or add medication (“decision making”), and contacting for assistance when needed are important tools acquired through the patient-CM relationship. Importantly, there is currently no evidence that an Action Plan without CM assistance is effective. A 2016 Cochrane review on Action plan efficacy showed a reduction in hospital admission; however, the results were mainly driven by the trial of Rice and colleagues that did include CM support. Training of the CM has not yet been studied and/or validated. In the absence of official guidelines, training in communication skills and in COPD care are recommended. To optimize their effectiveness, the CM should also ideally be trained in the basic principles of behavior change and in motivational interviewing.
| Role of the case manager |
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| Training a of the case manager |
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a This training should be delivered to the other members of the pulmonary rehabilitation team as well.
Behavior modification, exercise maintenance, and increased physical activity
The affected patient’s adaptation, their associated comorbidities, and the social impact of the illness are important determinants that influence COPD morbidity. Adaptive behavior change using patient-centered communication strategies and SM training can help address these determinants and can ultimately stimulate intrinsically motivated actions.
Self-Management Behavior Modification Intervention
Although education has always been an important part of the PR program, the paradigm shift from didactic to SM education was an important advancement that took place in the early 2000s. In 2003, Bourbeau and colleagues demonstrated a reduction in admission for AECOPD by 39.8% following the combined interventions of exercise training with weekly home education sessions for 8 weeks as well as Action Plan teaching. Following this landmark study, multiple subsequent SM clinical trials duplicated these positive results A Cochrane meta-analysis comprising 22 studies and 3854 participants demonstrated that SM resulted in an overall improvement in health-related quality of life and a reduction in respiratory-related hospital admissions. Although the heterogeneity of each SM intervention studied makes it difficult to determine the optimal form and content of an effective SM intervention, it is prudent and important to continue to apply the benefits of SM intervention toward PR program design.
Educational Components
The American Thoracic Society and European Respiratory Society emphasize the need to promote adaptive behavior change and SM in particular. The precise content of an SM educational intervention will depend on individual needs, the comorbidity profile, and the patient’s own capacity to manage his or her disease (self-efficacy, literacy, numeracy). Table 3 presents the common skills that require mastery and the healthy behaviors to be adopted and maintained through PR education. Content tailoring and small-group educational delivery (4–8 patients) are effective PR program approaches that encourage mutual enrichment through peer learning.
| Healthy Behavior | Self-Management Skill (Strategy) |
|---|---|
| Live in a smoke-free environment Comply with your medication | Quit smoking, remain nonsmoker, and avoid second-hand smoke Take medication as prescribed on a regular basis and use proper inhalation techniques |
| Manage to maintain comfortable breathing |
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| Conserve your energy Manage your stress and anxiety | Prioritize your activities, plan your schedule, and pace yourself Use your relaxation and breathing techniques, try to solve one problem at a time, talk about your problems and do not hesitate to ask for help, and maintain a positive attitude |
| Prevent and seek early treatment of COPD exacerbations | Get your flu shot every year and your vaccine for pneumonia Identify and avoid factors that can make your symptoms worse Use your plan of action according to the directives (recognition of symptom deterioration and actions to perform) Contact your resource person when needed |
| Maintain an active lifestyle | Maintain physical activities (eg, activities of daily living, walking, climbing stairs) Exercise regularly (according to a prescribed home exercise program) |
| Keep a healthy diet | Maintain a healthy weight, eat food high in protein and eat smaller meals more often (5–6 meals per day) |
| Have good sleep habits | Maintain a routine, avoid heavy meals and stimulants, and relax before bedtime |
| Maintain a satisfying sex life | Use positions that require less energy Share your feelings with your partner Do not limit yourself to intercourse, create a romantic atmosphere Use your breathing, relaxation, and coughing techniques |
| Get involved in leisure activities | Choose leisure activities that you enjoy Choose environments in which your symptoms will not be aggravated Pace yourself through the activities while using your breathing techniques Respect your strengths and limitations |
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