Introduction
There is considerable evidence of the beneficial effects of pulmonary rehabilitation on exercise capabilities and health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD) [
1]. Clinically relevant effects may be achieved by rehabilitation programmes of differing designs in terms of setting (inpatient vs. outpatient vs. home-based), duration (short-term vs. long-term), and intensity (high vs. low intensity) [
1]. As it is well known that achieved improvements decline following short-term programmes, efforts have been made to improve long-term maintenance [
1].
Although the evidence for the efficacy of pulmonary rehabilitation is strong and it is highly recommended by current guidelines, only a minority of eligible COPD patients is included in rehabilitation programmes [
2]. Reasons for this discrepancy may be lack of belief in the efficacy of such programmes, lack of local access, and concerns about the cost. While the first aspect should be addressed by intensified promotion on the beneficial effects of pulmonary rehabilitation in the medical community, the other two may be answered by the design of simple and locally available programmes using a minimum amount of resources that still produce clinically relevant effects.
Current guidelines on pulmonary rehabilitation recommend interventions with a frequency of at least 2–3 supervised sessions of high-intensity training per week [
1]. This facilitates optimal short-term results, but may lead to lower adherence rates and higher costs in the long-term.
Ambulatory ‘lung sport’ groups with 15–20 participants and weekly sessions, which are fairly common in Germany, have shown long-term effects on cardiopulmonary fitness in mild to moderate obstructive airways diseases [
3,
4]. However, patients with more severe limitations may find it difficult to exercise with those with less severe disease. Therefore, we developed the concept of physiotherapist-lead training groups of 6–10 members where it is possible to tailor training intensity to the different, and often very limited, physical capabilities of the participants.
The purpose of the present study was to evaluate whether a continuous, low-intensity, long-term, physiotherapist-lead outpatient pulmonary rehabilitation programme can induce significant improvements in the exercise capabilities and HRQoL in patients with moderate to severe COPD using less resources than previously published programmes.
Discussion
Our study in patients with moderate to severe COPD shows that a physiotherapist-lead, long-term pulmonary rehabilitation programme of lower training intensity and frequency than currently recommended achieved clinically significant improvements in terms of physical capabilities and HRQoL. The observed results fell above previously published thresholds for minimal clinically important differences regarding 6MWT (54 m), maximum work load (4 ± 1 Watt) and SGRQ total score (4 points) [
19][
20][
21]. The effect sizes were comparable to results of previously published programmes using higher intensity and costs [
16‐
18,
22,
23].
However, the intervention used in our study differs from previous studies. Most long-term studies evaluated maintenance programmes following an initial intense rehabilitation programme [
22‐
24]. In contrast, our programme consisted of low intensity weekly training over the whole study interval, which is deemed insufficient by the ATS/ERS guidelines [
1].
Troosters et al. in their pioneer study evaluated a long-term outpatient rehabilitation programme and found similar effects in a population comparable to ours [
16]. However, their programme required a significantly greater amount of resources, namely personell and equipment. In addition, training was performed two to three times a week in a single specialized center.
Guell et al. addressed long-term effects of outpatient rehabilitation in COPD [
17]. The impressive improvements in 6MWT are difficult to interpret, as the investigators did not report practice tests and whether assessors were blinded. Furthermore, improvements were obtained during the first 3 months while only breathing retraining and no exercise training was performed.
Recently, a physiotherapist-lead programme similar to ours was reported to induce favourable effects regarding exercise capabilities and subdomains of HRQoL questionaires [
25]. Again, the frequency was higher (2–3 sessions per week) and the group size smaller than in our study (2–3 participants).
The question arises why our programme achieved the presented results despite using a training intensity, frequency and total time that was lower than that recommended by current guidelines [
1] on which most current rehabiliation programmes were based. It is well known, that in the short-term, programmes of higher intensity and frequency produce better results in terms of exercise capabilities [
1]. However, in long-term programmes factors other than these appear to be crucial for success.
First, it appears obvious that the overall amount of home training rather than supervised training time determines the efficacy of long-term pulmonary rehabilitation. As yet, studies measuring the amount of home training with sufficient precision are lacking. A certain frequency of supervised training sessions appears to be necessary as a reminder to maintain increased physical activity at home. Repeated courses, telephone interventions, and regularly scheduled visits of medical personell have been shown to have only modest impact on long-term outcomes [
1]. Our study shows that weekly sessions may represent a sufficient stimulus for unsupervised exercise to induce significant effects. In line with our observation, Spencer et al. reported successful maintenance for 12 months of initially achieved improvements by either once weekly supervised or even unsupervised home training [
23]. Interestingly, the American College of Sports Medicine published guidelines for older adults and people with chronic diseases, which reduced the minimum recommended level of effective physical exercise [
26].
Second, reaching the highest intensity of supervised training is of lesser importance in the long-term setting. If severely impaired patients cannot follow the training protocol due to excessive demands its effects and consequently patient adherence will be significantly reduced [
27]. These findings stress the point that in terms of long-term efficacy it appears to be more important to find an adequate, i.e. tolerable, level of training intensity rather than aiming at the highest possible intensity. In line with these results, the ATS/ERS guidelines state that while high-intensity targets may be beneficial for inducing physiological changes in patients who can reach these levels, low intensity targets may be more appropriate to achieve long-term adherence and health benefits for a wider population [
1].
Third, adherence is of significant importance. A recent study found that with adherence rates below 70% no improvement can be expected from rehabilitation programmes [
22]. In our programme adherence was 75%. We speculate that offering training sites in the patients’ neighbourhood was of critical importance for the success of our programme as travel time is a well known reason for non-adherence [
28]. Patient-perceived barriers such as excessive intensity, costs or distance to training site were recently found to be predictive of a failure to maintain initially achieved rehabilitation effects [
29].
The practicability of any rehabilitation programme depends on the average cost and local access for a wide patient population. In a recent review, the affordability of the average costs of $2615 per patient per 6 months reported in the pilot study of Troosters was questioned in current health care systems [
30]. Poor access to pulmonary rehabilitation programmes impedes widespread use of this effective intervention [
2]. To increase accessability, we designed our programme using the locally available infrastructure, i.e. supervised training was performed in physiotherapy practices. This design and the fact that only once weekly supervised sessions were held resulted in reduced costs per patient, which appeared to be lower than in previously published programmes. Obviously, the presented cost calculation needs to be interpreted with caution as it is difficult to transfer into other health care settings.
The observed dropout rate of 26% is in the previously reported range from 19 to 31% [
16,
23,
24]. This documents that our programme was feasible under conditions close to real life. Therefore, we expect that the effects of our programme may be repeated on a broader scale.
The present study has some limitiations. As we did not incorporate an intervention group using higher training intensity and frequency, we cannot rule out that an intervention conforming more closely to the guidelines might have induced greater effects. However, as the effects detected in our study fall in the upper range of published results, we doubt that an increase in intensity and/or frequency would have produced a significant additional effect.
We only performed outcome measurements after baseline assessments. Thereby, we do not know whether there was an initial improvement that vanished subsequently as has been reported from effects achieved by short-term programmes. However, it has been consistently reported that rehabilitation effects might be sustained as long as the intervention is continued [
16,
17,
22‐
24].
We did not measure the actual extent of overall physical activity. Hence, we can only speculate that life style changes, i.e. increased physical activity in daily life, induced the observed effects, as Effing et al. detected using pedometers in a study similar to our programme [
25]. However, as long as we do not have data regarding physical activity at home, further studies extending the findings of our pilot study are needed before it can be stated that a programme of lower intensity is equally effective as currently recommended programmes.
6MWT assessors were not blinded to allocation status, possibly causing a bias. We do not believe that this factor influenced our results, as changes in 6MWT compare well to those seen during cycle ergometry, which was performed in a blinded manner.
We did not use the results of cardiopulmonary exercise testing to adjust training intensity as it usually done. Instead, training intensity was guided by dyspnea ratings using the Borg scale. It has been shown before that dyspnea ratings and/or heart rate measurements can be used as a target for patients with COPD to regulate/monitor the intensity of exercise training [
31,
32].
In contrast to SGRQ activity, impact and total scores, which significantly improved in the training group compared to the control group, SGRQ symptom scores showed a reverse pattern with greater improvements seen in the control group. This observation may be purely by chance, but may also point to the aspect that exercise training does not alter the disease itself with its symptoms of cough and sputum production.
In summary, this study shows that a long-term, physiotherapist-lead pulmonary rehabilitation programme using a lower training intensity and frequency than currently recommended may achieve clinically relevant improvements in exercise capabilities and health-related quality of life in patients with moderate to severe COPD. However, before low-intensity programmes as ours may be rated as comparably effective as currently recommended programmes, further studies corroborating our findings are needed. The simple design and small amount of necessary resources may help to offer effective pulmonary rehabilitation to a greater proportion of eligible patients. Results may only be reproducible in a similar setting with adequately motivated patients.
Acknowledgements
This work forms part of the doctoral thesis of K. Rummel. The authors acknowledge S. Baumgart, I. Böttge, G. Breiholdt, W. Dossmann, B. von Eisenhart, A. Gericke, S. Georgi, V. Molkenthin for performing the physiotherapy and supervising the training sessions during the study. The authors thank Dr. Aries, Dr. Hißnauer, Dr. Koppermann and Dr. Timmermann for performing the cardiopulmonary exercise testing. The authors wish to gratefully acknowledge the editorial support from Liz Wager.
Funding
This study was supported by an unrestricted educational grant from GlaxoSmithKline, Germany. The funding source had no role in the design, conduct or reporting of the study or the decision to submit the manuscript for publication.
Competing interests
All authors declare that they have no competing interests.
Authors’ contributions
HJB, TS, and AM participated in developing the study design, KR collected the data, KR and HJB performed the statistical analyses, HJB and AM drafted the manuscript. All authors revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.