Table 1.
Effects of rehabilitation on frailty in people with chronic respiratory disease
| Study (Country) | Design | Participants | Intervention | Impacts on Frailty | Other Relevant Findings |
|---|---|---|---|---|---|
| Community | |||||
| Gephine et al. (24) 2021 (France) | Prospective cohort study | 47 people with COPD and chronic respiratory failure referred for home-based pulmonary rehabilitation | Eight-week home-based pulmonary rehabilitation comprising one supervised 90-min session and at least four unsupervised exercise sessions per week, plus educational, motivational, and self-management plans. | Shift from physical frailty (measured using the physical frailty phenotype) toward more robust state: of 18 completers initially frail, 4 (22%) remained frail, 11 (61%) became prefrail, and 3 (17%) became robust. | Health-related quality of life, fatigue, and anxiety and depressive symptoms of individuals who were physically frail before the program were improved by pulmonary rehabilitation, whereas these significant benefits were not seen in their nonfrail counterparts. |
| Maddocks et al. (15) 2016 (United Kingdom) | Prospective cohort study | 816 people with COPD referred for pulmonary rehabilitation | Eight-week outpatient pulmonary rehabilitation comprising two supervised sessions (2 h exercise, 45 min multidisciplinary education) plus at least one additional unsupervised home-based exercise session per week. | Shift from physical frailty (measured using the physical frailty phenotype) toward more robust state: of 115 completers initially frail, 44 (38%) remained frail, 64 (56%) became prefrail, and 7 (6%) became robust. A small number of completers (13 of 390 [3.3%]) moved from prefrail to frail. | Adjusting for age and sex, a gradient of treatment response in favor of participants who were frail was evident for MRC score, handgrip strength, ISWT, CRQ fatigue, emotional and mastery domains, CAT score, and HADS scores. However, being frail was associated with double the odds of noncompletion (adjusted OR, 2.20 [95% CI, 1.39% to 3.46]). |
| Mesquita et al. (83) 2016 (the Netherlands) | Prospective cohort study | 378 people with stable COPD completing pulmonary rehabilitation | Eight-week inpatient or 14-week outpatient pulmonary rehabilitation comprising 40 sessions. Participants were supervised by an interdisciplinary team and undertook exercise training and (if indicated) nutritional support, occupational therapy, psychological counseling, and education. | Mean Timed Up and Go time improved significantly from 10.2 ± 2.7 to 9.7 ± 2.3 s after pulmonary rehabilitation (mean change, −0.5 s [95% CI, −0.6 to −0.3 s]; P < 0.0001). | After stratifying for normal vs. abnormal (>11 s) baseline Timed Up and Go time, only the latter group showed significant improvements after rehabilitation: −1.5 (95% CI, −1.9 to −1.0) vs. 0.01 (95% CI, −0.2 to 0.2) seconds (P < 0.001). |
| Mittal et al. (25) 2015 (United States) | Prospective cohort study | 41 people with chronic lung disease (77% with COPD) referred for pulmonary rehabilitation | Six- to 12-wk outpatient pulmonary rehabilitation comprising supervised exercise (40 to 50 min machine time plus light upper body exercise with weights) and education, two or three times per week. Each session ran 60 to 90 min. | The number of people with frailty (physical frailty phenotype) decreased in those completing 6 wk (from five to two) and in those completing 12 wk (from three to one) of rehabilitation. Five people had deterioration in their frailty status (four from robust to prefrail, one from prefrail to frail). | At Week 6, mean (SD) gait speed increased from 52.9 (15.4) to 61 (12.9) m/min after rehabilitation (n = 37); no additional increase was seen at 12 wk (n = 22). |
| Stoffels et al. (46) 2021 (the Netherlands) | Retrospective cohort study | 632 people with COPD completing pulmonary rehabilitation | Eight-week inpatient or 14-wk outpatient pulmonary rehabilitation comprising 40 sessions. Participants were supervised by an interdisciplinary team and undertook exercise training and (if indicated) nutritional support, occupational therapy, psychological counseling, and education. | SPPB scores significantly improved from median 9 (IQR 8 to 10) to 10 (9 to 11) points after rehabilitation. When performance was categorized as low (0 to 6 points), medium (7 to 9 points), and high (10 to 12 points), proportions in each group were significantly different after rehabilitation (low, 11% to 8%; medium, 47% to 35%; high, 42% to 57%). | Participants with low baseline performance on the SPPB (0 to 6 points) showed significant improvements in balance, gait speed, and sit-to-stand, participants with medium baseline SPPB scores (7 to 9 points) showed significant improvements in gait speed and sit-to-stand, and participants with high baseline SPPB scores (10 to 12 points) showed significant improvements only in sit-to-stand. |
| McClellan et al. (28) 2014 (United States) | Retrospective cohort study | 119 people who completed pulmonary rehabilitation (80% COPD/asthma) | Pulmonary rehabilitation comprising supervised exercise and education sessions; mean duration was 19.3 (SD, 7.4) weeks (setting and frequency not specified). | Improvements in gait speed (>60 m/min in n = 10 at baseline vs. n = 29 after rehabilitation; P < 0.001) suggest that participants were less likely to be classified as frail after rehabilitation. | Participants with the lowest initial gait speeds had the largest increases after rehabilitation. Although most participants had gait speeds <60 m/min after rehabilitation, 62% had increases in walk distance of 30 m or more (considered a minimal clinically important distance in relation to survival in COPD [84]). |
| Transplantation | |||||
| Diamond et al. (23) 2021 (United States) | Prospective cohort study (pilot) | 17 lung transplant recipients deemed frail/prefrail at discharge (SPPB score ⩽ 9) | Digital app to deliver home-based rehabilitation over 8 wk alongside standard rehabilitation. Incorporates daily exercise prescriptions, exercise videos with descriptions, exercise completion documentation, and healthcare provider messaging. The provider can view real-time feedback and adjust prescriptions accordingly. | Participants showed improvements in physical frailty phenotype scores (median change, −1 [IQR −3 to 0]) and SPPB scores (median change, 5 [IQR 4 to 7]) after intervention. By SPPB definitions, nine were no longer frail and four were prefrail after the intervention. | Participants also showed improvements on the Duke Activity Status Index (median change, 17.58 [IQR, 8.60 to 21.88]) and the Lung Transplant Valued Life Activities scale (median change, −1.09 [IQR, −1.71 to −0.40]). Participants reported positive experiences of the app. |
| Courtwright et al. (22) 2019 (United States) | Prospective cohort study | 83 lung transplant recipients who completed postdischarge outpatient pulmonary rehabilitation | Outpatient pulmonary rehabilitation starting within 3 d of discharge, attending three sessions per week for 4 to 6 wk. Tailored supervised sessions of 60 to 75 min incorporate progressive programs of aerobic exercise, muscle strengthening, balance, postural retraining, education, and chest expansion exercises. | Among 35 participants who were frail at discharge (median SPPB score, 6 [IQR, 4 to 6] points), 85.7% were not frail at completion. Median improvement in SPPB score was 6 points (IQR, 5 to 7), resulting in a postrehabilitation median SPPB score of 12 points (IQR, 11 to 12 points). | Median 6‐minute walk distance at the start of the program was 808 ft (IQR, 577 to 1,015 ft) compared with 1,429 ft (IQR, 1,179 to 1,600 ft) at completion (P < 0.001). |
| Singer et al. (26) 2018 (United States) | Prospective cohort study | 15 lung transplantation candidates with frailty (SPPB score ⩽ 11) | Digital app to deliver home-based rehabilitation over 8 wk comprising daily exercise prescriptions, exercise videos with descriptions, exercise completion documentation and healthcare provider messaging. The provider could view real-time feedback and adjust prescriptions accordingly. Participants also received activity trackers, resistance bands, and a nutrition counseling session. | Among 13 participants completing rehabilitation, SPPB frailty improved in seven (54%) participants; mean change within participants was 1.0 (SD, 1.9). Physical frailty phenotype scores improved in eight (62%) participants; mean change across participants was −0.6 (SD, 1.0). Of six participants deemed frail by the physical frailty phenotype at baseline, four were no longer frail after the intervention. | Participants did not show significant improvements in 6MWD, grip strength, Lung Transplant Valued Life Activities scale score, or Duke Activity Status Index score, although the study was not powered for these outcomes. Participants reported that the app was engaging and easy to use. |
| Wickerson et al. (27) 2020 (Canada) | Retrospective cohort study | 62 lung transplantation candidates accepted for transplantation who underwent rehabilitation | Six-week pretransplantation rehabilitation (n = 62) comprising three 90-min sessions per week. Sessions include stretching, functional exercises, resistance training, and aerobic exercise. | At baseline, 13 were frail/prefrail (SPPB score ⩽ 9), with a median SPPB score of 9 (IQR, 7 to 9) points. Of these, three remained frail/prefrail after rehabilitation; median SPPB score increased to 11.5 (IQR, 10 to 12 points). Improvements most often occurred in the sit-to-stand domain. Of 49 not frail at baseline, 4 became frail/prefrail after rehabilitation, with no change in median SPPB score from 12 (IQR, 11 to 12) points. | There was no change in postrehabilitation mean (SD) 6MWD (362 ± 86 vs. 356 ± 101 m). |
Definition of abbreviations: 6MWD = 6-minute-walk distance; CAT = COPD Assessment Test; CI = confidence interval; COPD = chronic obstructive pulmonary disease; CRQ = Chronic Respiratory Questionnaire; HADS = Hospital Anxiety and Depression Scale; IQR = interquartile range; ISWT = Incremental Shuttle Walk Test; MRC = Medical Research Council; OR = odds ratio; SD = standard deviation; SPPB = Short Physical Performance Battery.