Table 4.
Comprehensive PR in COPD patients
| Source | Study design | Sample size (n) | Intervention | Measurement instruments | Results |
|---|---|---|---|---|---|
| Luk et al274 | Prospective cohort study | n=83 patients with COPD who had completed PR, FEV1 mean: 46% | Assessment after 22 months following an 8-week PRP | HADS, CRQ, ISWT | ISWT gain was lost at the long-term reassessment. In CRQ, only the domains of dyspnea and fatigue remained statistically significant, and improvements in HADS scores persisted at the long-term reassessment but were not statistically significant |
| Sciriha et al275 | Prospective observational study | n=60 COPD patients stage I–IV with MRC grade 2 or above | PRP for 12 weeks 2 hours sessions, twice-weekly | HADS, SGRQ, 6MWT, Borg scale, CAT | Anxiety scoring decreased significantly by 12 weeks, while the depression rating improved by 8 weeks. No significant changes on anxiety ratings for stage III–IV COPD participants as opposed to the milder group of patients who had significant changes after 3 weeks. Participants with an MRC 2–3 had significant changes in depression ratings after 12 weeks of PRP |
| Grosbois et al276 | Retrospective observational study | n=211 patients with COPD FEV1 mean: 41.5%±17.7% | Home-based PR individually managed once a week for 8 weeks unsupervised on the other days of the week | HADS, 6MST, VSRQ | 6MST was significantly improved after completion of the program, at 6 and 12 months. HADS and VSRQ scores improved after PR, and this improvement persisted at 6 and 12 months |
| Boutou et al196 | Prospective observational study | n=787 COPD outpatients stage I–IV from 8 PR centers | PRP over 8–12 weeks with two supervised sessions and one or more unsupervised home exercise sessions each week | HAD-A, HAD-D, CRDQ, CAT, 6MWT, ISWT | Significant improvements in 6MWT or ISWT distance. Anxiety and depression scores fell post PR. QoL also improved with significant fall in CAT scores while CRDQ scores increased. Patients who completed PR were significantly older with less severe airflow obstruction, lower anxiety and depression scores, less dyspnea and better HRQoL |
| da Costa et al277 | Prospective observational study | n=125 COPD patients FEV1 mean: 43.18%±18.79% | PRP of 3 weekly sessions of 60 minutes duration for 12 weeks, a total of 36 sessions | BAI, BDI, SGRQ | Significant decreases in anxiety and depression scores and improvements in QoL were observed. Weak correlations were observed when correlating the BAI to the SGRQ |
| Jácome and Marque224 | Quasiexperimental study | n=26 COPD patients FEV1 mean: 83.8%±6.4% | 12-week PR program 3 sessions/week, 60 minutes each, with exercise training and psychoeducation | DASS, SGRQ, 6MWT, MMRC, TUG | Significant improvements were observed on 6MWT, MMRC, TUG and SGRQ total scores. No significant improvement in the SGRQ impact score and DASS scores |
| Tselebis et al278 | Prospective observational study | n=101 stage I–IV COPD patients | PRP for a period of 3 months, with three sessions per week, each lasting 50 minutes | STAI, BDI | Significant decreases in anxiety and depression rates were observed. A statistically significant reduction in anxiety and depression was revealed at all stages of COPD |
| Bhandari et al279 | Retrospective observational study | n=366 COPD patients FEV1 mean: 47%±17% at program entry, 25% had abnormal anxiety scores and 17% had abnormal depression scores | Sixteen 3-hour sessions given twice weekly over an 8-week outpatient PR program | HADS, CRQ-SR, 6MST | Of the 366 patients, 257 completed the program and 235 completed final outcome evaluation. Among patients who completed PR, there were significant improvements on all dimensions (CRQ-SR, 6MST scores, and reduced HADS scores) |
| Hogg et al280 | Prospective observational study | n=812 stage I–IV COPD patients were assessed | 656 started PR twice or once weekly for 8 weeks | HADS, ISWT, CRQ, MRC | 441 completed. Significant improvements were seen in ISWT, CRQ-SR and HADS scores. Twice-weekly compared with once-weekly programs showed similar improvement |
| Bentsen et al281 | Prospective observational study | COPD patients assessed at baseline (T1: N=100), immediately before (T2: N=66), immediately after (T3: N=54) and 3 months after (T4: N=43) | 6-week outpatient PRP, including education, psychosocial support and training sessions | HADS, COPD self-efficacy scale, ISWT | A tendency of less anxiety and depression immediately after (T3) compared with immediately before (T2) the PR program, but the changes were not significant. Higher level of self-efficacy and better exercise capacity are suggested to relieve anxiety and depression |
| Harrison et al282 | Comparative effectiveness research | n=518 patients with COPD Patients were categorized into 3 groups based on HADS scores pre PR (“none” 0–7, “probable” 8–10 and “presence” 11–21) | PRP twice a week for 7 weeks. A “responder” was defined as achieving a change of ≥48 m on ISWT and a “completer” if attended discharge assessment for PR | HADS, ISWT, CRQ-SR | Anxiety and depression did not reduce following PR in patients with no symptoms. Patients with a “probable” or “presence” of symptoms had significant reductions. There was a difference between subgroups in change for anxiety and depression with patients scoring highest on the HADS having the greatest reductions. There was no correlation between anxiety or depression and completion of PR. Responders and nonresponders did not differ in their anxiety or depression levels |
| Bratås et al283 | Prospective cohort study | n=111 stage I–IV COPD patients measured at baseline, 4 weeks and 6-month follow up | Evaluate the short- and long-term effects of a 4-week inpatient PRP | HADS, SGRQ | SGRQ scores and depression improved between baseline and program completion. After 6 months follow up, all SGRQ and HADS scores deteriorated. No significant differences between baseline and the end of follow up were found, except for worsening HADS anxiety score |
| Von Leupoldt et al284 | Prospective observational study | n=238 COPD patients with mean FEV1% predicted =54 | 3-week outpatient PR program was performed 6 h/d for 5 d/wk | 6MWD, 6MWT, HADS, SF-36 | PR was significantly associated with improvements in 6MWD, dyspnea after the 6MWT and during activities, and increased physical and mental QoL, as well as reduced anxiety and depression |
| Pirraglia et al285 | Prospective observational study | n=81 COPD patients with mean FEV1 1.23±0.39 L | PRP twice weekly for 8 weeks | BDI, BAI, CRQ-SR | The CRQ-SR and BDI scores improved significantly. Improvement in depressive symptoms was associated with improvement in fatigue, emotion and mastery |
| Bratås et al286 | Prospective observational study | n=136 patients with mild-to- severe COPD | Inpatient PRP for 7.5 hours a day, 5 d/wk for 4 weeks | HADS, SGRQ, 6MWD, TDI | A PRP improves HRQL and exercise capacity and reduces depression in COPD patients. Patients with mild or moderate disease are more likely to achieve an improved HRQoL after rehabilitation than patients with severe or very severe disease |
| Spencer et al287 | RCT | n=59 patients with moderate COPD completed an 8-week PRP I=31, C=28 |
Supervised, outpatient- based exercise plus unsupervised home exercise vs standard care of unsupervised home exercise training following an 8-week PRP | HADS, 6MWD, SGRQ | 12 months following pulmonary rehabilitation both weekly, supervised, outpatient-based exercise plus unsupervised home exercise and standard care of unsupervised home exercise successfully maintained 6MWD, SGRQ scores in subjects with moderate COPD. No significant change from baseline to 12 months for HADS scores |
| Ozdemir et al288 | RCT | n=50 male patients with COPD stage II and III I=25, C=25 |
4-week water-based PRP for 35 minutes, three times a week (totally 12 sessions) vs only medical therapy | HADS, 6MWD, CRDQ | Water-based exercises are effective in improving QoL and anxiety level in COPD patients |
| Godoy et al289 | Prospective observational study | n=30 patients with severe and extremely severe COPD | 12-week PRP, which included 24 physical exercise sessions, 24 respiratory rehabilitation sessions, 12 psychotherapy sessions and 3 educational sessions | BAI, BDI, SGRQ, 6MWT | Pre-PRP and post-PRP values revealed a significant decrease in the levels of anxiety and depression, as well as significant improvements in the distance covered on the 6MWT and the QoL index. The benefits provided by the PRP persisted throughout the 24-month study period |
| Elçi et al290 | RTC | n=78 inpatients with severe COPD | PRP (24 sessions, 90 minutes duration) vs standard medical care | HADS, SF-36, SGRQ, 6MWD | Significant differences were observed in the 6MWD measurements at the third month, as well as in the SF-36 QoL scale, SGRQ and HADS measurements at the second and third months, irrespective of FEV1 |
| Paz-Díaz et al223 | RCT | n=24 patients with severe COPD I=10, C=14 |
8-week PR program, 3 times a week for 8 weeks | BDI, STAI, MMRC, SGRQ | After PR, there was a significant improvement in the severity of depression, a decrease in symptoms, an increase in daily living activities, and a decrease in the total score of the SGRQ. Dyspnea measured by the MRC scale was significantly better in the PR group |
| Güell et al226 | RCT | n=40 patients with severe COPD FEV1, 35%±13%, I=18, C=17 | 16 weeks of PR that included breathing retraining and exercise | MBHI, SCL-90-R, 6MWD, CRQ | PR may decrease psychosocial morbidity in COPD patients even when no specific psychological intervention is performed. Findings from this study also confirm the positive impact of PR on functional exercise capacity and HRQoL |
| Alexopoulos et al225 | Prospective observational study | n=63 patients with COPD and major depression recruited from a pulmonary rehabilitation unit | Brief inpatient PRP (median length of stay was 16 days) | Hamilton Depression Scale | Approximately 51% of subjects met criteria for response and 39% met criteria for remission. History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. Improvement of depression may be the result of behavioral interventions rather than the use of antidepressant drugs |
| Kayahan et al291 | RCT |
I=26 PR, C= 19 Stage I–III COPD patients |
2 months PR program, for 3 days and 2 1/2 hours weekly | HAM-A, HAM-D | There was a significant decrease in HAM-A scores in the rehabilitation group. On the contrary the HAM-A scores did not change in control group. The decrease in HAM-A scores in rehabilitation group was also statistically significant compared with the control group. There was no significant difference in HAM-D scores within the two groups and also there was no significant difference between the two groups in HAM-D scores. The health status, exercise tolerance and dyspnea intensity improved significantly in the rehabilitation group compared to the control group |
| Arnardóttir et al292 | RCT | n=60 patients with COPD stage II and III I=28, FEV1: 35%±13% C=32, FEV1: 32%±10% |
PR program twice weekly (90-minute duration) for 16 weeks after randomization to interval – 3-minute intervals (I) – or continuous training (C) | HADS, SF-36, CRDQ, 12 MWD | Interval training and continuous training were equally potent in improving peak exercise capacity, functional exercise capacity, dyspnea, mental health and HRQoL in patients with moderate or severe COPD |
| Goldberg et al293 | Prospective observational study | n=45 patients with COPD stage III | 3 weeks of inpatient PRP | BDI, Hamilton Anxiety Scale, Goldberg Scale, and Modified Borg Scale | The program significantly reduced anxiety and depression, and increased positive psychological outlook in severe pulmonary disease. Perceived breathlessness on the Borg Scale was significantly reduced |
| Trappenburg et al294 | Prospective observational study | n=81 patients with COPD stage II–IV, FEV1: 40%±16% | 3 months PR program (2 hours sessions, 3 times per week) | HADS, CRDQ, PFSDQ-M, 6MWT | The effects of rehabilitation are not affected by baseline psychosocial factors. Patients with less favorable psychologic or sociodemographic conditions can also benefit from pulmonary rehabilitation |
| Garuti et al195 | Prospective observational study | n=149 COPD patients, stage II–III, after an exacerbation | Inpatient PRP twelve 3-hours daily sessions | HADS, SGRQ, 6MWD | Inpatient pulmonary rehabilitation may improve levels of anxiety and depression as well as symptoms, exercise capacity and HRQoL in moderate-to-severe COPD patients after an acute exacerbation |
| Cilione et al295 | Prospective observational study | n=132 COPD patients stage II and III recovering from an acute exacerbation | Inpatient PR program: 12 sessions (6 d/wk), lasted for 3 hours daily | HADS, SGRQ, 6MWD | 6MWD increased by 34%, HAD-anxiety decreased by 16%, HAD-depression decreased by 13% and SGRQ decreased by 11% |
| White et al296 | RCT | n=103 COPD patients stage III, n1=44, n2=49 | n1: PRP twice a week for a 2-hour session for 6 weeks vs n2: brief advice | HADS, SF-36, CRQ, shuttle walking distance | At 3 months both groups reported reduced anxiety on the Hospital Anxiety and Depression Scale and dimensions of QoL, but differences between groups were not significant. Shuttle walking distance increased significantly in the intervention group compared to controls |
| Withers et al217 | Prospective observational study | n=99 COPD patients stage III (35 had significant anxiety at screening and 18 significant depression) | 3 months PR program | HADS, shuttle walk distance | PR produced statistically significant falls in mean HADS scores, which remained significantly lowered at 6-month follow up. Patients with high anxiety levels showed significantly greater improvements in shuttle walk distance than those with low HAD scores |
| Emery et al261 | RTC | n=79 COPD outpatients stage II–III, EXESM =29, ESM =25, WL =25 | EXESM: 10-week PR with exercise, education, and stress management ESM: education and stress management; and WL: wait list control | CES-D, SCL-90-R, STAI, SIP and Physiologic Measures | Intervention participants in the PRP group, compared to the other 2 groups, reported improved endurance, reduced anxiety, and improved cognitive performance |
| Ries et al219 | RTC | n=119 stable COPD outpatients stage I–III, n1=57, n2=62 | n1:8-week PR program (twelve 4-hour sessions) vs n2: an 8-week education program (four 2-hour sessions biweekly for 8 weeks) | CES-D, Quality of Well- Being Scale and Physiologic Measures | Measures of lung function, depression, and general QoL, did not differ between groups. Differences tended to diminish after 1 year of follow-up |
| Emery et al297 | Prospective observational study | 64 PR patients with COPD FEV1/FVC <0.7 | PRP for 4 hours a day, 5 d/wk for 30 days | SCL-90-R, PGWI, neuropsychological assessment | Enhanced cognitive functioning and psychological well-being |
| Dekhuijzen et al298 | RTC | n=60 COPD outpatients stage II–III, with anxiety, depression. 3 groups of 20 patients: PR 2, TF-IMT and PR + TF-IMT | PR and PR + TF-IMT: 10-week PR program (5 d/wk for 2 hours) vs TF-IMT | SCL-90, DPI, 12 MWD, ADL | PR with or without additional TF-IMT resulted in a decrease of anxiety and depression, but there were no significant differences between the two patient groups. In the PR group, these scores were still decreased after a 1-year follow-up period. TF-IMT alone had no effects on the psychological parameters |
| Coventry and Hind216 | Review and meta- analysis: 6 RCTs | n=269 clinically stable moderate-to-severe COPD patients | Comparing PRP ≥4 weeks with up to 3 sessions/wk vs standard care (with or without education) | Standardized measures of depression and/or anxiety and generic or disease-specific HRQoL measures | PRP was significantly more effective than standard care in reducing short-term anxiety and depression. Long-term follow up data showed that gains in both psychological health status and HRQoL were not sustained at 12 months |
| Coventry et al246 | Review and meta- analysis: 30 RCTs | n=2,063 COPD patients stage II–III | Multicomponent exercise training vs relaxation techniques vs CBT vs self-management education | Standardized measures of depression and/or anxiety | Multicomponent exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population |
| Wiles et al299 | Review: 12 RCTs | n=738 COPD patients stage II–III | Exercise and psychological components vs control conditions or active comparators | Standardized measures of depression and/or anxiety, QoL, dyspnea, functional exercise capacity | Results for depression, anxiety, QoL, dyspnea, functional exercise capacity favored interventions which included both exercise + psychological components compared with control conditions. Compared with active comparators results were inconsistent for depression and QoL |
Abbreviations: HADS, Hospital Anxiety and Depression Scale; ISWT, incremental shuttle walk test; HAM-D, Hamilton Depression Rating Scale; HAM-A, Hamilton Anxiety Rating Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; STAI, State Trait Anxiety Inventory; MMRC, Modified Medical Research Council Scale; CRQ-SR, Chronic Respiratory Questionnaire – Self reported; CRDQ, Chronic Obstructive Disease Questionnaire; SCL-90-R, Hopkins Symptoms Checklist Revised; DASS, Depression Anxiety and Stress Scales; CES-D, Center for Epidemiologic Studies Depression Scale; PGWI, Psychological General Well-being Index; QoL, quality of life; SF-36, 36-Item Short Form Health Survey; 6MWT, 6-minutes walking test; MBHI, Millon Behavior Health Inventory; 12 MWD, 12 minutes walking distance; SGRQ, St Georges Respiratory Questionnaire; SIP, Sickness Impact Profile; TDI, Transitional Dyspnea Index; MHLC, Multidimensional Health Locus of Control inventory; 6MST, 6-minute stepper test; TUG, Timed Up and Go; VSRQ, Visual Simplified Respiratory Questionnaire; MCID, minimal clinically important difference; PFSDQ-M, Modified Pulmonary Functional Status and Dyspnea Questionnaire; MRC, Medical Research Council; ADL, Activities-in-Daily-Life; DPI, Dutch Personality Inventory; PR, pulmonary rehabilitation; TF-IMT, target-flow inspiratory muscle training; I, intervention group; C, control group; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; HRQoL, health-related QoL; CAT, COPD assessment test; HAD-D, Hospital Anxiety and Depression Scale – Depression subscale; HAD-A, Hospital Anxiety and Depression Scale – Anxiety subscale.