Background
Methods
Protocol and registration
Eligibility criteria
Information sources and search strategy
Study selection
Data analysis and risk of bias
Results
Study selection
Included studies
Reference | Country | Study design | Setting, duration and frequency | Participants | Intervention | Intervention after discharge | Usual care | Notes | Outcomes | Dropouts |
---|---|---|---|---|---|---|---|---|---|---|
Behnke 2000 [27] | Germany | RCT | Setting: in- and outpatient Duration: hospital-based 10 days, home-based 6 months Frequency: 7/week | 46 admitted patients with AECOPD (mean age: 64–68 years, FEV1: 36% predicted). Comorbidities: not specified. | PR consisted of conventional therapy including 30 min of daily breath exercises with respirologists and hospital-based training. Exercise training consisted of daily 6MWT and 5 self-controlled walking sessions at 75% of the treadmill walking distance of the respective day. | Supervised home-based training for 6 mo.: walking training 3/day at 125% of the best 6MWD, health check every 2 weeks (mo. 0–3) followed by phone calls from mo. 3–6. | Usual care: standard inpatient care and community care with respirologists (30 min of daily breathing exercises) but without exercise training | Both groups (intervention and usual care) were supervised by the physician. | Mortalityb Walking testb COPD related hospital readmissionsb Dropouta | 16 dropouts (8 in PR group and 8 in control group) |
Daabis 2017 [31] | Egypt | RCT | Setting: outpatient Duration: 8 weeks Frequency: 3/week | 30 admitted patients with AECOPD (mean age: 58–61 years, FEV1: 53–56% of predicted). Comorbidities: not specified. | PR consisted of patient assessment, exercise training (ET), patient education including self-management of the disease, nutrition and lifestyle issues. Exercise training consisted of ET with 30-min of walking at the intensity of 75% 6MWT including 30-min of low-intensity RT. | Outpatient PR | Medical treatment. | All patients received standard treatment with optimal medical treatment. | HRQoLa Walking distancea | No dropouts reported |
Deepak 2014 [32] | India | RCT | Setting outpatient Duration: 12 weeks | 60 admitted patients with AECOPD (mean age: 59 years, FEV1: 47–53% of predicted, 93% men). Comorbidities: not specified. | PR consisted of patient assessment, exercise testing, exercise training (mixture of limb strengthening and aerobic activities, tailored to individual baseline function), education, nutrition and psycho-social rehabilitation. | Outpatient PR | Conventional treatment without PR. | All patients received conventional management consisting of medical treatment. | HRQoLa Walking distancea | 4 dropouts |
Eaton 2009 [28] | New Zealand | RCT | Setting: in- and outpatient Duration: 8 weeks Frequency: 2/week | 97 admitted patients with AECOPD (mean age: 70 years, FEV1: 35–36% of predicted, 42–45% men). Comorbidities: Measured with Charlson index (PR group: 3.1; control: 3.2). | PR consisted of a daily 30-min structured, supervised exercise regimen that included walking and upper and lower limb strengthening exercises. | Hospital-based outpatient program consisting of 1-h sessions of supervised exercise training and educational sessions (e.g. coping with dyspnea, management of ADL, nutritional advises, airway clearance). | Usual care standardized in according with the ATS/ERS COPD guidelines and standardized advises on the benefits of exercise and maintaining daily activities. | All patients received usual care standardized in according with the ATS/ERS COPD guidelines. | Walking distancea COPD related hospital readmissionsb Dropouta | 13 dropouts (8 in PR group and 5 in control group) |
Kirsten 1998 [29] | Germany | RCT | Setting: inpatient Duration: 10 days Frequency: 7/week | 31 admitted patients with AECOPD (mean age: 62–66 years, FEV1: 34–38% of predicted, 90% men). Comorbidities: not specified. | PR consisted of 6MWT each day and additional 5 walking sessions per day at ≥75% of the respective walking distance. | Inpatient supervised walking sessions 5/day. | Usual care with optimal medical treatment. | All patients received standard medical treatment. | Walking testa | 2 dropouts (not reported in which group) |
Ko 2011 [34] | China | RCT | Setting: outpatient Duration: 8 weeks Frequency: 3/week | 60 admitted patients with AECOPD (mean age: 73–74 years, FEV1: 41–46% of predicted, 98% men). Comorbidities: coronary artery disease, cardiac arrhythmic, heart failure, hypertension, diabetes. | PR consisted of supervised exercise training including treadmill, arm cycling, arm and leg strength training at 60–70% of VO2max or HRmax and were advised to perform at least 20 min home exercises a day. Education on proper breathing techniques and how to cope with daily activities. | Supervised outpatient exercise training. | Usual care with instructions to perform regular exercise at home (walking and muscle stretching exercise). | Both groups were seen by the nurse specialist at the baseline assessment. | HRQoLb Mortalitya,b Walking testb Dropouta,b | 9 dropouts (5 in PR group and 4 in control group) at the end of treatment. 6 dropouts (2 in PR group and 4 in control group) at the longest follow-up. |
Ko 2017 [33] | China | RCT | Setting: outpatient Duration: 8 weeks (1 year follow up) Frequency: 3/week | 180 admitted patients with AECOPD (mean age: 75 years, FEV1: 42–47% of predicted, 94–97% men). Comorbidities: hypertension, type 2 diabetes, hyperlipidemia, ischemic heart disease, heart failure, old pulmonary tuberculosis. | PR consisted of education (smoking cessation, technique of using medications, nutrition, dyspnea management, self-management, psychological distress, exercise benefits and strategies, breathing and sputum-removal techniques) and individual physical training program to perform at home or a short course of outpatient PR. | Patients are offered supervised exercise training 3/week, if declining they are offered instructions for self-training, education, and telephone calls. | Usual care with medical treatment. | All patients received standard treatment with optimal medical therapy. | HRQoLb Mortalitya Walking testb Days in hospitala | 38 dropouts (17 in PR group and 21 in control group) |
Man 2004 [35] | England | RCT | Setting: outpatient Duration: 8 weeks Frequency: 2/week | 42 admitted patients with AECOPD (mean age: 70 years, FEV1: 37–42% of predicted, 40% men). Comorbidities: not specified. | Supervised multidisciplinary PR, 1-h of exercise (aerobic walking and cycling, strength training for the upper and lower limb) and 1-h of education (with an emphasis on self-management of the disease, nutrition and lifestyle issues). | Supervised multidisciplinary PR. | Usual care with optimal medical treatment. | All admitted patients received standard treatment and home diaries which included a disease specific information pack. | HRQoFb Mortalityb Walking testb COPD related hospital readmissionsb Dropouta | 8 dropouts (3 in PR group and 5 in control group) |
Murphy 2005 [39] | Ireland | RCT | Setting: outpatient home-based Duration: 6 weeks Frequency: 2/week | 31 admitted patients with AECOPD (mean age: 65–67 years, FEV1: 38–42% of predicted, 65% men). Comorbidities: not specified. | PR consisted of 30–40-min supervised home-based exercise program, aerobic exercises including stepping up and down a stair, sitting to stand from a chair, upper limb strength exercises with low-impact elastic band at 3–5 on the Borg breathlessness score. | Supervised home-based exercise program. | Standard medical treatment without any form of PR exercises or lifestyle changes advice. | All patients received standard medical treatment. | Walking testa COPD related hospital readmissionsb Dropouta | 5 dropouts (3 in PR group and 2 in control group) |
Puhan 2012 [30] | Switzerland | RCT | Setting: in- and outpatient Duration: 12 weeks Frequency: 24 sessions (range 18–36) | 36 admitted patients with AECOPD (mean age: 67 years, FEV1: 43–46% of predicted, 58% men). Comorbidities: cardiovascular, endocrine, musculoskeletal, other. | Early inpatient PR within 2 weeks after exacerbation, exercise training included endurance, strength and calisthenics training in addition with education (e.g. individual action plan, mediational use, exercise at home, coping with daily activities, smoking cessation). | Outpatient PR, exercise training included endurance, strength and calisthenics training in addition with education (as described under intervention). | Late PR starting 6 mo. after exacerbation, exercise training included endurance, strength and calisthenics training in addition with education. | Recommended number of exercise session 24 (ranged between 18 and 36). | Mortalitya Dropouta | 8 dropouts (4 in PR group and 4 in control group) |
Revitt 2018 [37] | United Kingdom | RCT | Setting: inpatient Duration: 6 weeks Frequency: 2/week | 28 admitted patients with AECOPD (mean age: 66 years; FEV1: 1.18 l). Comorbidities: not specified. | Early PR within 4 weeks of discharge. PR consisted of individualized aerobic and resistance exercises and education on chest clearance and energy conservation. | Hospital-based PR. | Late PR initiated 7 weeks after discharge including exercise and education. | All patients received the same PR program. | Dropouta | 11 dropouts (3 in control group prior to the program and 8 in PR group during the program) |
Seymour 2010 [36] | United Kingdom | RCT | Setting: outpatient (hospital-led) Duration: 8 weeks Frequency: 2/week | 60 admitted patients with AECOPD (mean age: 65-67 years, FEV1: 52% of predicted, 45% men). Comorbidities: hypertension, type 2 diabetes, ischemic heart disease. | PR consisted of supervised exercise training including a mixture of limb strengthening and aerobic activities tailored to individual baseline function and education session (lasting 2 h). | Hospital-led supervised exercise training. | Usual care with optimal medical treatment. | All patients were provided with general information about COPD and offered outpatient appointments with their general practitioner or respiratory team. | HRQoFb Walking testa COPD related hospital readmissionsb Dropoutb | 11 dropouts (7 in PR group and 4 in control group) |
Troosters 2000 [38] | Belgium | RCT | Setting: outpatient Duration: 6 mo (18 mo follow up) Frequency: 2–3/week | 100 patients with AECOPD referred to outpatient clinic (mean age: 60–63 years, FEV1: 41–43% of predicted, 87% men). Comorbidities: not specified. | PR consisted of 90-min supervised ET and RT. ET consisting of cycling, treadmill walking, and stair climbing at 60–80% of initial Wmax during cycle ergometer/maximal walking speed. RT consisting of strength exercises for 5 muscle groups, 10 reps at 60% 1RM. | Supervised outpatient exercise training. | Usual medical care consisting of standard community care with respirologist. | During exercise training supplemental oxygenwas given to maintain oxygen saturation above 90%. | Mortalitya walking testa dropouta,b | 30 dropouts (13 in PR group and 17 in control group) at the end of treatment. 21 dropouts (11 in PR group and 10 in control group) at the longest follow-up. |
Risk of bias within studies
Supervised early PR versus usual care for patients with acute exacerbation of COPD | |||||
---|---|---|---|---|---|
Outcome Timeframe | Study results and measurements | Absolute effect estimates | Certainty in the effects estimates (Quality of evidence) | Plain text summary | |
Usual care | Early PR | ||||
Mortality End of treatment Critical | Relative risk 0.58 (CI 95% 0.35–0.98) Based on data from 319 patients (4 studies) | 173 per 1.000 | 100 per 1.000 | Moderate Due to serious risk of biasa | Early pulmonary rehabilitation probably decreases mortality at the end of treatment |
Difference: 73 fewer per 1.000 (CI 95% 112 fewer - 3 fewer) | |||||
Mortality Longest follow-up Critical | Relative risk 0.55 (CI 95% 0.12–2.57) Based on data from 127 patients (3 studies) | 63 per 1.000 | 35 per 1.000 | Low Due to serious risk of biasand serious risk of imprecisiona,b | Early pulmonary rehabilitation may decrease mortality slightly at the longest follow-up |
Difference: 28 fewer per 1.000 (CI 95% 55 fewer - 99 more) | |||||
Days in hospital End of treatment Important | Measured by: Days Lower is better Based on data from 180 patients (1 study) | 0.86 (mean) | 4.59 (mean) | Moderate Due to serious imprecisionc | Early pulmonary rehabilitation probably decreases days in hospital at the end of treatment |
Difference: MD 4.27 lower (CI 95% 6.85 lower - 1.69 lower) | |||||
Days in hospital Longest follow-up Important | No studies were found that looked at number of days in hospital at the longest follow-up | ||||
Readmission due to exacerbation End of treatment Important | No studies were found that looked at readmission to hospital due to exacerbation at the end of treatment | ||||
Readmission due to exacerbation Longest follow-up Important | Rate ratio 0.47 (CI 95% 0.29–0.75) Based on data from 365 patients (6 studies) | Moderate Due to serious risk of biasa,d | Early pulmonary rehabilitation probably decreases readmission to hospital due to exacerbation at the longest follow-up | ||
Health-related quality of life End of treatment Important | Measured by: SGRQ Lower is better Based on data from 86 patients (2 studies) | Difference: MD 19.43 lower (CI 95% 29.09 lower - 9.77 lower) | Low Due to serious risk of bias and serious risk of imprecisiona,c | Early pulmonary rehabilitation may improve health-related quality of life at the end of treatment | |
Health-related quality of life Longest follow-up Important | Measured by: SGRQ Lower is better Based on data from 323 patients (4 studies) | Difference: MD 8.74 lower (CI 95% 12.02 lower - 5.45 lower) | Moderate Due to serious risk of biasa,d | Early pulmonary rehabilitation probably improves health-related quality of life at the longest follow-up | |
Exercise capacity End of treatment Important | Measured by: SWT (meters) Higher is better Based on data from 95 patients (3 studies) | Difference: MD 54.7 more (CI 95% 30.83 more - 78.57 more) | Moderate Due to serious risk of biasa,d | Early pulmonary rehabilitation probably increases exercise capacity at the end of treatment | |
Exercise capacity End of treatment Important | Measured by: 6MWT (meters) Higher is better Based on data from 274 patients (5 studies | Difference: MD 76.89 more (CI 95% 21.34 more - 132.45 more) | Low Due to serious risk of bias and serious inconsistencya,d,e | Early pulmonary rehabilitation probably increases exercise capacity at the end of treatment | |
Exercise capacity Longest follow-up Important | Measured by: SWT (meters) Higher is better Based on data from 2017 patients (3 studies) | Difference: MD 90.27 higher (CI 95% 69.53 lower - 250.08 higher) | Low Due to serious risk of bias and serious inconsistency leading to serious imprecisiona,b,d,e | Early pulmonary rehabilitation may increase exercise capacity at the longest follow-up | |
Dropout rate End of treatment Important | Relative risk 0.99 (CI 95% 0.71–1.39) Based on data from 440 patients (8 studies) | 217 per 1.000 | 215 per 1.000 | Moderate Due to serious risk of biasa,d | Early pulmonary rehabilitation probably has little impact on the dropout rate at the end of treatment |
Difference: 2 fewer per 1.000 (CI 95% 63 fewer - 85 more) | |||||
Dropout rate Longest follow-up Important | Relative risk 1.05 (CI 95% 0.6–1.85) Based on data from 181 patients (3 studies) | 202 per 1.000 | 212 per 1.000 | Moderate Due to serious risk of biasa,d | Early pulmonary rehabilitation probably has little impact on dropout at the longest follow-up |
Difference: 10 more per 1.000 (CI 95% 81 fewer - 172 more) | |||||
Falls Longest follow-up Important | No studies were found that looked at falls at the longest follow-up | ||||
Activities of daily living End of treatment Important | No studies were found that looked at activities of daily living at the end of treatment | ||||
Activities of daily living Longest-follow-up Important | No studies were found that looked at activities of daily living at the longest follow-up |