Table 1.
Characteristics of included studies
| Study (country) | Sample size, gender, age | FEV1% predicted (spirometry), smoking history | Inclusion/exclusion criteria | Study aim, design, unit of allocation | Pulmonary rehabilitation program (setting, components, duration, frequency) | Maintenance program (setting, components, duration, frequency) | Primary outcome (1) and other outcomes and follow-up (2) |
|---|---|---|---|---|---|---|---|
| Ries et al (2003)16 (USA) | 164 participants Int: n=83 Con: n=81 Males: n=89 Females: n=75 Age, mean ± SD All: 67±8 |
FEV1%pred, mean All: 45% No data available for smoking status |
Inclusion: clinical diagnosis of chronic lung disease; chronic symptoms and perceived disability from disease; stable state; no other significant medical or psychiatric conditions that would interfere with program participation; commitment to abstain from smoking | Assess a telephone-based maintenance intervention for retaining benefits following pulmonary rehabilitation RCT, cluster | Exercise and education combined with psychosocial support Twelve 2 h sessions over 8 weeks | Weekly semistructured phone calls and monthly supervised reinforcement sessions (1.5 h supervised exercise, 1.0 h topic review, 0.5 h social time) for 12 months | (1) Pulmonary function, exercise tolerance, dyspnea, depression (2) QoL, health status, health care use |
| Brooks et al (2002)17 (Canada) | 85 participants Int: n=37 Con: n=48 Males: n=50 Females: n=35 Age, mean ± SD Int: 68±1 Con: 68±1 |
FEV1%pred, mean ± SD Int: 32±2% Con: 32±2% All nonsmokers for at least 6 months |
Inclusion: severe stable COPD (FEV1<40% predicted, FEV1/FVC <0.70); completion of inpatient or outpatient rehabilitation; nonsmoker for a minimum of 6 months; aged 49–85 years Exclusion: coexisting conditions that might limit exercise tolerance or cognitive functioning; noncompliance with respiratory rehabilitation; mechanical ventilatory support for any part of the day; inability to communicate in English; living too far away to participate | Compare the effects of two postrehabilitation programs on functional exercise capacity and health-related QoL in patients with COPD RCT, individual | Exercises – breathing, treadmill or cycle exercises, interval and upper extremity training, leisure walking Patient education and psychosocial support included (relaxation and occupational therapies) Inpatient – five times a week for 6 weeks Outpatient – three times a week at the center and at home for 8 weeks | Monthly 2 h group sessions supervised by a physical therapist for 12 months. First hour for discussion around home exercise program, second hour for performing components of the home exercise program under supervision. Phone calls made between visits with standardized questions regarding adherence to home exercises | (1) 6MWT, CRQ (2) Medical outcomes survey: short-form 36, SGRQ, subject compliance, pulmonary function |
| Spencer et al (2010)18 (Australia) | 48 participants Int: n=24 Con: n=24 Males: n=22 Females: n=26 Age, mean ± SD Int: 65±8 Con: 67±7 |
FEV1%pred, mean ± SD Int: 57±21% Con: 60±16% Current smokers Int: n=6 Con: n=5 |
Inclusion: COPD diagnosis; completed an 8 week pulmonary rehabilitation program; FEV1/FVC <70% and FEV1<80% predicted Exclusion: exacerbation in previous month; supplemental oxygen; comorbidities that would prevent performing exercises; clinic patients (pulmonary rehabilitation) | Determine if weekly supervised exercise following pulmonary rehabilitation would maintain functional exercise capacity and QoL RCT, individual | Exercises – 20 min walking, 20 min cycling, 10 min arm cycling, upper and lower limb strength training 8 weeks in a pulmonary rehabilitation gym | Pulmonary rehabilitation gym for 12 months. Supervised exercise 1 day/week with unsupervised exercise 4 days/week. Exercises prescribed in line with exercise undertaken during pulmonary rehabilitation | (1) 6MWT, SGRQ (2) Lung function tests, ISWT, ESWT, HADS, hospital admissions, length of stay and exacerbations |
| Ringbaek et al (2010)19 (Denmark) | 96 participants Int: n=55 Con: n=41 Males: n=31 Females: n=63 Age, mean ± SD Int: 67±1 Con: 69±9 |
FEV1%pred, mean ± SD Int: 36±14% Con: 37±16% Current smokers Int: n=13 Con: n=7 |
Inclusion: stable COPD (FEV1 <80%, FEV1/FVC <70%); motivation for pulmonary rehabilitation; completion of 7 weeks of pulmonary rehabilitation Exclusion: musculoskeletal, cardiac or cognitive problems | Examine whether maintenance training improved long-term effect of pulmonary rehabilitation RCT, individual | Supervised walking and cycling both at 85% of predicted VO2 peak and unsupervised exercise at home Twice a week for 7 weeks with supplementary education once a week | Weekly supervised exercise for the first 6 months, every second week for the next 6 months, and no supervised exercise for the last 6 months. Unsupervised exercise at home encouraged | (1) ESWT, SGRQ (2) Hospitalization (time to first admission, admission rates, days in hospital), exercise adherence, attendance at evaluation visits |
| Wilson et al (2015)20 and Burns et al (2016)21 (UK) | 148 participants Int: n=73 Con: n=75 Males: n=91 Females: n=57 Age, mean ± SD Int: 67±15 Con: 69±9 |
FEV1%pred, mean ± SD All: 41±16% >20 pack-year smoking history No data available on current smoking status | Inclusion: >35 years of age; COPD diagnosis (FEV1<80%); >20 pack-year smoking history; completed at least 60% of pulmonary rehabilitation sessions Exclusion: cardiac or pulmonary disease (other than COPD); myocardial infarction within 6 months or unstable angina; respiratory infection within last 4 weeks; uncontrolled or severe comorbidities; cognitive complications |
Evaluate long-term effect of maintenance exercise on health-related QoL Assess the cost-effectiveness of maintenance exercise following pulmonary rehabilitation on health-related QoL RCT, individual | Exercises – walking, cycling, sit to stand, step-ups, arm exercises with dumbbells. High intensity (85% of maximum capacity) Once a week for 8 weeks (1 h for exercise and 1 h for education). Endurance exercise everyday and strength exercise two more times a week at home | Individually tailored strength and endurance exercises including walking, cycling, sit-to-stand, step-ups, and arm exercises with dumbbells One 2 h (1 h exercise and 1 h education) session every 3 months for 12 months. Same group of patients from original pulmonary rehabilitation. Home exercise program review | (1) CRQ (dyspnea) (2) CRQ (other domains), ESWT, BMI, body fat, HADS, EQ5D |
| Roman et al (2013)22 (Spain) | 71 participants Con: n=23 RHB: n=22 RHBM: n=26 Males: n=58 Females: n=13 Age, mean (95% CI) RHBM: 65 (62–68) RHB: 64 (60–68) Con: 63 (60–66) |
FEV1%pred, mean (95% CI) Con: 60% (56–64) RHB: 60% (55–65) RHBM: 61% (56–66) Current smokers Con: n=8 RHB: n=7 RHBM: n=9 |
Inclusion: 35–74 years old; moderate COPD diagnosis; smokers or nonsmokers Exclusion: musculoskeletal conditions affecting ability to exercise; terminal illness/other severe disease |
Use maintenance postpulmonary rehabilitation to improve QoL in COPD RCT, individual | Exercises – low intensity peripheral muscle training. Abdominal, upper and lower limb exercises, shoulder and full arm circling, weight-lifting, and other exercises. Each exercise repeated 8–10 times over 45 min Three 1 h sessions a week for 12 weeks with 15 min of respiratory physiotherapy every session and 45 min of education during weeks 1, 6+12 | Low intensity peripheral muscle training. One session a week for 9 months | (1) CRQ (2) Pulmonary function, 6MWT, hospital admissions, GP visits, exacerbations |
| Moullec et al (2008)23 and Moullec and Ninot (2010)24 (France) | 40 participants Int: n=14 Con: n=26 Males: n=31 Females: n=9 Age, mean ± SD Int: 63±7 Con: 60±10 |
FEV1%pred, mean ± SD Int: 53±16% Con: 47±19% No data available on smoking status |
Inclusion: FEV1/FVC <0.7, FEV1 30%–79% predicted; no indication for home oxygen therapy; stable state for the previous 2 months; no change in medication and symptoms for the previous 4 weeks; >40 years of age; no previous pulmonary rehabilitation experience Exclusion: medical or psychiatric disturbances that would hinder program participation; diagnosis of asthma; congestive left heart failure; terminal disease | Determine changes in the emotional and functional dimensions of QoL in COPD 1 year after a pulmonary rehabilitation program with or without a follow-up intervention Quasi-RCT, individual | Twenty inpatient sessions over 4 weeks | Community gymnasium Individualized strength, interval, breathing, and endurance training with nature walking at ventilatory threshold 96 sessions across 12 months. Exercise training (3.5 h/week; 72 sessions); health education (2 h/month; 12 sessions); psychosocial support (with discussion group 1 h/month; 12 sessions) | (1) 6MWT, QoL (SGRQ and WHOQoL-Brief) (2) Six-item questionnaire with a VAS, maximal exercise capacity, physical activity, health care utilization, attendance, pulmonary function |
| Guell et al (2017)25 (Spain) | 138 participants Int: n=68 Con: n=70 Males: n=123 Females: n=15 Age, mean ± SD Int: 64±9 Con: 64±8 |
FEV1%pred, mean ± SD Int: 34±11% Con: 34±9% No data available on smoking status |
Inclusion: COPD diagnosis (grade II–IV severity); clinically stable during previous 4 weeks; 18–75 years old; exsmokers or with intention to quit; BODE index value between 3 and 10 Exclusion: bronchodilator response (FEV1 increment >15% of the baseline value after 200 μg of inhaled bronchodilator); other respiratory diagnoses; severe coronary artery disease; orthopedic diseases limiting mobility; life expectancy <2 years; inability to cooperate |
Assess the efficacy of a supervised maintenance program after pulmonary rehabilitation on improving symptoms, exercise capacity, and health-related QoL compared to just pulmonary rehabilitation on its own RCT, individual | Three hospital-based 2 h sessions a week for 8 weeks. Supplemented with four education sessions and chest physiotherapy 30 min weight-lifting (0.5 kg in each hand, increased by 1 kg a week until peak tolerance), 30 min leg cycling (start at 50% maximum load achieved during initial exercise test, load increased by 10 W if heart rate and oxygen saturation are stable and exercise is tolerated) | Supervised exercise on alternate weeks at hospital for 36 months. Unsupervised home exercise program (3 days a week) similar to hospital program (15 min chest physiotherapy, 30 min arm training, 30 min leg training). Supplemented by structured phone calls from physiotherapists every 15 days Exercise similar to pulmonary rehabilitation. Exercises, if well tolerated, were progressed at hospital visits | 1) BODE index (2) 6MWT, health-related QoL, and CRQ |
Abbreviations: BMI, body mass index; BODE, body mass index, airflow obstruction, dyspnea, and exercise index; Con, control group; Int, intervention group; CRQ, chronic respiratory questionnaire; ESWT, endurance shuttle walk test; EQ5D, Euro Quality of Life Five Dimensions questionnaire; FEV1%pred, forced expiratory volume in 1 s % of predicted; FVC, forced vital capacity; GP, general practitioner; HADS, hospital anxiety and depression scale; ISWT, incremental shuttle walk test; 6MWT, 6 min walk test; QoL, quality of life; RCT, randomized controlled trial; RHB, pulmonary rehabilitation with no maintenance; RHBM, pulmonary rehabilitation with maintenance; SD, standard deviation; SGRQ, St George’s Respiratory Questionnaire; VAS, visual analog scale; WHOQoL-Brief, World Health Organization Quality of Life Brief questionnaire.