Introduction
Materials and methods
Literature search strategy
Electronic database | Searching strategy |
---|---|
PubMed | (rehabilitation [Title/Abstract] OR rehabilitation [Text Word] OR readaptation [Title/Abstract] OR readaptation [Text Word]) AND (pulmonary [Title/Abstract] OR pulmonary [Text Word] OR respiratory [Title/Abstract] OR respiratory [Text Word]) AND (inpatient [Title/Abstract] OR in-patient [Title/Abstract] OR inpatient [Text Word] OR in-patient [Text Word]) AND (outpatient [Text Word] OR out-patient [Title/Abstract] OR outpatient [Title/Abstract] OR out-patient [Text Word]) |
Web of Science | (TS = readaptation OR TS = rehabilitation) AND (TS = pulmonary OR TS = respiratory) AND (TS = inpatient OR TS = in-patient) AND (TS = outpatient OR TS = out-patient) |
COCHRANE | (rehabilitation OR readaptation) AND (pulmonary OR respiratory) AND (inpatient OR in-patient) AND (outpatient OR out-patient) |
Study selection
Data extraction
Risk of bias assessment
Best-evidence synthesis
-
One low risk of bias study and two or more moderate/high risk of bias studies.
-
Or two or more moderate/ high risk of bias studies and consistent findings in all studies (≥ 75%);
-
One or more moderate/high risk of bias studies or one low risk of bias study and consistent findings in all studies (≥ 75%);
Results
Selection and search results
General description of the included studies
Author, Year, Country | Type of study | Total Sample size and per group | Group assignment criteria | Anthropometric characteristics | Respiratory disease diagnosis | Disease severity | PR Program content: | Duration (weeks), number of sessions, and Intensity of exercise training | Risk of bias | Outcome measure | Main results with mean average and [confidence interval] or (± standard deviation) |
---|---|---|---|---|---|---|---|---|---|---|---|
Bowen 2000 USA [24] | Retrospective study | n = 149 inPR vs. outPR: n = 36 vs. n = 113 | n.a. | inPR vs. outPR: • age (years): 70 ± 6 vs. 69 ± 9 • BMI: 22.7 ± 6.3 vs. 25.5 ± 5.4 • Male patients: 33% vs. 49% | inPR vs. outPR: • n.a. vs. n.a. (total:COPD (n = 133), chronic asthma (n = 12), chest-wall disease (n = 3), pulmonary fibrosis (n = 1)) | inPR vs. outPR: • FEV1 (% predicted): 30 ± 13 vs. 39 ± 19 • Dyspnea: n.a. • Number and type of comorbidities: n.a. • Exercise tolerance in baseline (6MWD in m): 422 ± 189 vs. 1123 ± 457 | n.a. | • n.a. • n.a. • n.a. | High | Survival status | No significant differences between inPR and outPR for survival status |
Braeken 2017 Netherlands [25] | Retrospective study | n = 419 inPR vs. outPR: n = 261 vs. n = 158 | Severity of the disease, co-morbid conditions, and access to nearby facilities (details not provided) | inPR vs. outPR: • age (years): n.a. vs. n.a. • BMI: n.a. vs. n.a. • Male patients: n.a. vs. n.a. | inPR vs. outPR: • COPD: n = 261 vs. n = 158 | inPR vs. outPR: • FEV1 (% predicted): n.a. • Dyspnea: n.a. • Number and type of comorbidities: n.a. • Exercise tolerance in baseline (6MWD in m): 388 ± 120 vs. 502 ± 93 | n.a. | • inPR vs. outPR: 8 vs. 16 • inPR vs. outPR: 40 vs. 40 • n.a. | High | HRQoL | HRQoL improvement is significantly higher for inPR than for outPR for CAT, SGRQ-C, and CCQ (inPR: −3.8 [− 4.7–-2.9]/outPR: − 1.7 [− 2.7–-0.9] (p = 0.002); inPR: − 11.0 [− 12.7–-9.3]/outPR: − 6.1 [− 8.5–-3.7] (p = 0.001); inPR: − 0.8 [− 1.0–-0.7]/ outPR: − 0.2 [− 0.35–-0.1], (p < 0.001), respectively) |
Exercise tolerance | Exercise tolerance improvement is significantly higher for inPR than for outPR for 6MWD and no significant difference between inPR and outPR for CWRT (inPR: + 36.5 [27.5–45.5] m/outPR: + 0.7 [−7.3–8.7] m, (p < 0.001); inPR: + 196.4 s [158.6–234.1]/outPR: + 221.8 s [168.5–275.0] (ns), respectively) | ||||||||||
Psychological status | Psychological status improvement is significantly higher for inPR than for outPR for HADS anxiety and for HADS depression (inPR: −2.1 [− 2.6–-1.6] points/outPR: −1.1 [− 1.6–-0.6] points (p = 0.005); inPR: − 2.6 [− 3.1–-2.1] points/outPR: − 1.3 [− 1.9–-0.8] points (p < 0.001), respectively) | ||||||||||
Dropouts/adherence | No significant differences between inPR and outPR for dropouts/adherence | ||||||||||
Clini 2001 Italy [26] | Retrospective study | n = 86 inPR vs. outPR: n = 43 vs. n = 43 | Travel time from home (if > 1 h then inPR) | inPR vs. outPR: • age (years): 64 ± 8 vs. 64 ± 7 • BMI: 22 ± 4 vs. 24 ± 3 • Male patients: 67.4% vs. 67.4% | inPR vs. outPR: • COPD: n = 34 vs. n = 34 • Asthma n = 9 vs. n = 9 | inPR vs. outPR: • FEV1 (% predicted): 57 ± 28 vs. 53 ± 21 • Dyspnea (Borg scale): 6.4 ± 1.6 vs. 8.5 ± 1.9 • Number and type of comorbidities: n.a. • Exercise tolerance in baseline (VO2 peak in mL kg min− 1): 15 ± 4 vs. 10 ± 8 | •exercise training (supervised incremental exercise until the patient achieved 30 min of continuous cycling at 70 to 80% of the maximal load achieved on an incremental cycle ergometer exercise test carried out at hospital admission) •resistance training (abdominal muscle activities, upper and lower limb muscle activities lifting weights progressively (from 300 to 500 g), and shoulder and full arm circling) •education (diagnosis-specific education sessions and nutritional programs and psychosocial counseling) | • inPR vs. outPR: 3 vs. 8 • inPR vs. outPR: 12 vs. 24 • 70 to 80% of the maximal load | High | Exercise tolerance | No significant differences between inPR and outPR for exercise tolerance in peak workload (inPR: + 20%/outPR: + 16%, ns) |
Dyspnea | No significant differences between inPR and outPR dyspnea in Borg scale (inPR: −34%/outPR-26%, ns) | ||||||||||
Economic costs | The total per session was higher in inPR than outPR (246.9 euro vs. 171 euro, respectively) The total per program was lower in inPR than outPR (2715.9 euro vs. 3591 euro, respectively) The Grand total (including transports costs) was lower in inPR than outPR (2720 euro vs. 3677.7 euro, respectively) | ||||||||||
Guler 2021 Canada, USA, Australia, Germany, and Switzerland [27] | Retrospective study | n = 701 inPR vs. outPR: n = 196 vs. n = 505 | n.a. | inPR vs. outPR: • age (years): 70 ± 11 vs. 69 ± 12 • BMI: 26.8 ± 6.2 vs. 29.9 ± 6.2 | inPR vs. outPR: fibrotic ILD: n = 196 vs. n = 505 | inPR vs. outPR: • FEV1 (% predicted): 66 ± 20 vs. 72 ± 22 • Dyspnea: n.a. • Number and type of comorbidities: n.a. • Exercise tolerance in baseline (6MWD in m) 262 ± 128 vs. 358 ± 125 | •exercise training (aerobic training and/or interval training with a gradual symptom-limited increase in workload) •resistance training: (resistance training covered all large muscle groups and typically consisted of three sets with 8–12 repetitions) •education (educational sessions typically covered information on the pathophysiology of lung diseases, oxygen and medication use, symptom control, coping mechanisms, and self-management, with additional counseling on smoking cessation, nutrition and psychological support if needed) | • inPR vs. outPR: 2–4 vs. 6–12 • inPR vs. outPR: 20–80 vs. 12–36 • gradual symptom-limited increase in workload. | High | Exercise tolerance | Exercise tolerance improvement is higher for inPR than for outPR for 6 MWD ((inPR: + 55 (±83) m/outPR: + 34 (±65) m |
Dropouts/adherence | No statistics were performed for this outcome | ||||||||||
Survival status | No statistics were performed for this outcome | ||||||||||
Hjalmarsen 2014 Norway [28] | Retrospective study | n = 144 inPR vs. outPR: n = 72 vs. n = 72 | n.a. | inPR vs. outPR: • age (years): 67.5 ± 8.2 vs. 70.4 ± 9.1 • BMI: 25.4 ± 5.6 vs.25.4 ± 5.6 • Male patients: 56.9% vs. 44.4% | inPR vs. outPR: • COPD: n = 72 vs. n = 72 | inPR vs. outPR: • FEV1 (% predicted): 54.5 ± 21.8 vs. 52.2 ± 17.7 • Dyspnea: n.a. • Number and type of comorbidities: n.a. • Exercise tolerance in baseline (6MWD in m) 379.9 ± 128.8 vs. 367 ± 158 | •exercise training and resistance training (2 hours of exercise training daily, including endurance and strength training. Ventilatory muscle training was part of the exercise program. The endurance and strength training programs involved both upper- and lower extremity training on fitness center equipment including arm ergometer, cycle ergometer, and treadmill •education (12 lectures on patient education) | • inPR vs. outPR: 4 vs. 8 • inPR vs. outPR: 20 vs. 16 • Mild and moderate COPD patients: High-intensity endurance training. Severe hypoxemic patients: low-intensity exercise keeping the SpO2 above 85% and the pulse below 130 per minute during activity | High | Survival status | No significant differences between inPR and outPR for survival status |
Stoffels 2021 Netherlands [29] | Retrospective study | n = 625 inPR vs. outPR: n = 387 vs. n = 238 | n.a. | inPR vs. outPR: • age (years): 66 ± 8 vs. 65 ± 8 • BMI: 25 [21–31] vs. 25 [22–30] Male patients: 45% vs. 59% | inPR vs. outPR: COPD: n = 387 vs. n = 238 | inPR vs. outPR: • FEV1 (% predicted): 38 [28–54] vs. 51 [38–70] • Dyspnea (mMRC score): 3 [2–4] vs. 2 [2–3] • Number and type of comorbidities: n.a. • Exercise tolerance in baseline (6MWD in m): 332 ± 102 vs. 432 ± 88 | •exercise training and resistance training: (exercises to strengthen muscles of the upper and lower extremities, treadmill walking, stationary cycling, flexibility exercises, and daily supervised outdoor walks) •education (nutritional support, psychological counseling, and educational sessions | • inPR vs. outPR: 8 vs. 14 • inPR vs. outPR: 40 vs. 40 • n.a. | High | HRQoL | HRQoL improvement is significantly higher for inPR than for outPR for CAT (inPR (n = 347): −3 (±6)/ outPR (n = 208): −1 (±6) (p < 0.001) |
Exercise tolerance | Exercise tolerance improvement is significantly higher for inPR than for outPR for 6MWD, CWRT TTE and 4MGS (inPR (n = 377): + 26 m (±59)/ outPR (n = 234): + 13 m (±47), (p = 0.002), inPR (n = 312): + 126 s [34–398] outPR (n = 227): + 77 s [−24–272] (p = 0.001), inPR (n = 387): + 0.1 m.s-1 [− 0.2–0.4]/outPR (n = 238): − 0.2 m.s− 1 [0.4–0], (p < 0.001), respectively) No significant difference between inPR and outPR for 5STS (inPR (n = 387) -1 s [− 4–1]/outPR (n = 238): − 1 s [− 4–0] (ns)) | ||||||||||
Muscle strength | No significant difference between inPR and outPR for isokinetic quadriceps peak (inPR (n = 268): + 9 Nm [3–18]/outPR (n = 183): + 6 Nm [1–12] (ns)) | ||||||||||
Dyspnea | Dyspnea improvement is significantly higher for inPR than for outPR for mMRC (inPR (n = 363): − 1 [− 2–0] points/outPR (n = 222): 0 [− 1–0] points (p < 0.001)) | ||||||||||
Psychological status | Psychological status improvement is significantly higher for inPR than for outPR for HADS anxiety and for HADS depression (inPR (n = 345): −1 [−3–1] points/outPR (n = 208): − 1 [−2–1] points (p = 0.001), inPR (n = 345):-2 [−4–0] points/outPR (n = 208): − 1 [− 2–1] points (p < 0.001), respectively) | ||||||||||
Dropouts/ Adherence | No significant differences between inPR and outPR for dropouts/ adherence |
Study design
Population characteristics
Group assignment criteria
Pulmonary rehabilitation characteristics
Comparison of outpatient and inpatient pulmonary rehabilitation programs and best-evidence synthesis assessment
-
moderate evidence in favor of inPR for health-related quality of life and psychological status
-
moderate evidence in favor of no difference between the two modalities for dropouts/adherence and survival status
-
limited evidence in favor of no difference between the two modalities for muscle strength
-
conflicting evidence in favor of inPR or in favor of no difference between the two modalities for exercise tolerance and dyspnea,
-
conflicting evidence in favor of inPR or in favor of outPR for economic costs
-
no evidence for healthcare burden and refusals
Outcomes | Significant differences in favor of inPR: Study (Outcome) [Risk of Bias] | Significant differences in favor of outPR Study (Outcome) [Risk of Bias] | No difference between inPR and outPR Study (Outcome) [Risk of Bias] | Best-evidence synthesis |
---|---|---|---|---|
Health-related quality of life | Braeken et al. (CAT) [HR] Braeken et al. (SGRQ-C) [HR] Braeken et al. (CCQ) [HR] Stoffels et al. (CAT) [HR] | none | none | MODERATE EVIDENCE with four outcomes (100%) in favor of inPR |
Exercise tolerance | Braeken et al. (6MWD) [HR] Guler et al. (6MWD) [HR] Stoffels et al. (6MWD) [HR] Stoffels et al. (CWRT TTE) [HR] Stoffels et al. (4MGS) [HR] | none | Braeken et al. (CWRT) [HR] Clini et al. (peak workload) [HR] Stoffels et al. (5STS) [HR] | CONFLICTING EVIDENCE with five outcomes (63%) in favor of inPR and three outcomes (37%) in favor of no difference between the two modalities |
Muscle Strength | none | none | Stoffels et al. (isokinetic quadriceps peak) [HR] | LIMITED EVIDENCE with one outcome (100%) in favor of no difference between the two modalities |
Dyspnea | Stoffels et al. (mMRC) [HR] | none | Clini et al. (Borg scale) [HR] | CONFLICTING EVIDENCE with one outcome (50%) in favor of inPR and one outcome (50%) in favor of no difference between the two modalities |
Psychological status | Braeken et al. (HADS-anxiety) [HR] Braeken et al. (HADS-depression) [HR] Stoffels et al. (HADS-anxiety) [HR] Stoffels et al. (HADS-depression) [HR] | none | none | MODERATE EVIDENCE with four outcomes (100%) in favor of inPR |
Healthcare burden | none | none | none | NO EVIDENCE |
Refusals | none | none | none | NO EVIDENCE |
Dropouts/Adherence | none | none | Braeken et al. [HR] Stoffels et al. [HR] | MODERATE EVIDENCE with two outcomes in favor of no difference between the two modalities |
Economic costs | Clini et al. (total per program) [HR] Clini et al. (grand total) [HR] | Clini et al. (total per session) [HR] | none | CONFLICTING EVIDENCE with two outcomes (67%) in favor of inPR and one outcome (33%) in favor of outPR |
Survival status | none | none | Bowen et al. [HR] Hjalmarsern et al. [HR] | MODERATE EVIDENCE with two outcomes (100%) in favor of no difference between the two modalities |