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Pulmonary Rehabilitation Nicholas S Hill Division of Pulmonary Critical Care and Sleep Medicine Tufts–New England Medical Center Boston Massachusetts Pulmonary rehabilitation programs use

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Pulmonary Rehabilitation Nicholas S Hill Division of Pulmonary Critical Care and Sleep Medicine Tufts–New England Medical Center Boston Massachusetts Pulmonary rehabilitation programs use Powered By Docstoc
					Pulmonary Rehabilitation
Nicholas S. Hill
Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts–New England Medical Center, Boston, Massachusetts


Pulmonary rehabilitation programs use multidisciplinary teams to                         logic defect that gives rise to a disability (i.e., some loss of
optimize physical and social functioning of patients with chronic                        function). This begets a handicap, which is the disadvantage
respiratory impairment. These programs provide rehabilitation in                         caused by the disability, leading to a lower than desired level
inpatient, outpatient, or home settings, using at least three sessions                   of functioning within the societal context. Thus, the goals of
weekly (one may be unsupervised) for at least 6 wk. The programs                         pulmonary rehabilitation are to (1 ) alleviate symptoms, (2 ) re-
usually consist of exercise training, education, and psychosocial/                       store functional capabilities as much as possible, and (3 ) reduce
behavioral components. Upper extremity exercises and instruction
                                                                                         handicap, thus enhancing overall quality of life.
on breathing technique are included in most rehabilitation pro-
grams and reduce dyspnea, but the contribution of these to im-
                                                                                             These beg the question: Shouldn’t all medical care for patients
proved functional capacity remains unproven. Decreases in the sen-                       with chronic illnesses share these goals of a rehabilitation program?
sation of dyspnea, increased functional exercise capacity, and                           If so, then how does rehabilitation differ from optimal compre-
enhanced quality of life of patients with chronic obstructive pulmo-                     hensive care administered by any physician? The answer is that
nary disease (COPD) are established benefits of pulmonary rehabili-                      although all medical care of chronic illnesses should aim to
tation. Evidence is lacking for the efficacy of rehabilitation for pa-                   optimize overall patient function and quality of life, pulmonary
tients with non-COPD causes of pulmonary impairment, but many                            rehabilitation programs are structured to bring about specific
of these patients probably benefit. Despite the availability of strong                   enhancements by applying a multidisciplinary approach within
evidence to support the efficacy of pulmonary rehabilitation pro-                        the context of a focused program. The essential components
grams in patients with severe COPD, third-party reimbursement                            include exercise training, education, other possible interventions,
policies have been inconsistent. Nonetheless, enrollment in a pul-                       and outcomes assessment. To achieve the above goals, profes-
monary rehabilitation program is encouraged for all appropriate                          sionals from a variety of disciplines, as shown in Table 1, directly
candidates with chronic respiratory impairment, particularly for                         participate in pulmonary rehabilitation programs, or at least are
those with severe COPD.
                                                                                         readily available for consultation.
Keywords: chronic obstructive pulmonary disease; rehabilitation
exercise training                                                                        STRUCTURE OF A PULMONARY
                                                                                         REHABILITATION PROGRAM
Pulmonary rehabilitation has been advocated for several decades
as a way to provide comprehensive care and improve the func-                             A physician, usually a pulmonologist, serves as medical director.
tional status of patients with chronic respiratory diseases. How-                        This individual is responsible for overall medical direction of
ever, convincing evidence in the form of randomized controlled                           the program and should perform an initial assessment on all
trials to support the efficacy of this intervention has been avail-                       prospective patients to ascertain their appropriateness for the
able only for the past decade (1). In addition, many questions                           program, as well as to ensure that the medical regimen has been
remain about pulmonary rehabilitation, including its effect on                           optimized. The physician can also identify comorbidities that
important outcomes like resource utilization or survival, responses                      might necessitate modifications in the patient’s individualized
of non–chronic obstructive pulmonary disease (non-COPD), opti-                           program. A physician should be readily available to help with
mal structure and essential components of a rehabilitation pro-                          medical emergencies, or a plan should be in place for prompt
gram, the best ways to assess outcomes, and reimbursement issues.                        action (i.e., calling 911) should a medical emergency arise. A
According to the official statement of the American Thoracic                              physiatrist may also participate in the program, to assist with
Society, “pulmonary rehabilitation is a multidisciplinary pro-                           management of nonpulmonary handicaps.
gram of care for patients with chronic respiratory impairment                               Physical, educational, and respiratory therapists are also es-
that is individually tailored and designed to optimize physical                          sential to the program. The physical therapist prescribes a spe-
and social performance and autonomy” (2). This article describes                         cific exercise regimen tailored to the individual patient’s handi-
the structure and essential components of a typical rehabilitation                       caps and goals, whereas the occupational therapist teaches
program, examines evidence supporting efficacy and probable                               conservation measures and assesses needs for prosthetic devices
mechanisms of action, and discusses reimbursement issues and                             or wheelchairs. The respiratory therapist also helps to oversee
questions for the future.                                                                the exercise program, and teaches breathing exercises, as well
                                                                                         as proper use of aerosolized medications and oxygen. In some
GOALS OF PULMONARY REHABILITATION                                                        programs, nurses with special expertise in respiratory disorders
Patients who are candidates for pulmonary rehabilitation have                            help to oversee the exercise and educational components, partic-
respiratory impairment, defined as an underlying pathophysio-                             ularly for inpatient programs. In others, an exercise physiologist
                                                                                         prescribes and monitors the exercise program. A nutritionist
                                                                                         should help patients formulate nutritional goals and educate on
                                                                                         proper diet. A social worker assesses needs for home services,
(Received in original form November 23, 2005; accepted in final form December 5, 2005)   works with third-party payers to help patients obtain needed
Correspondence and requests for reprints should be addressed to Nicholas                 benefits, and may provide counseling. A psychologist may also
S. Hill, M.D., Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts–New       be available to provide counseling as well as instruction in coping
England Medical Center, 750 Washington Street #257, Boston, MA 02111. E-mail:
                                                                                         strategies and relaxation exercises. Professionals helping to run
nhill@tufts-nemc.org
                                                                                         the rehabilitation program should meet on a regular basis to go
Proc Am Thorac Soc Vol 3. pp 66–74, 2006
DOI: 10.1513/pats.200511-121JH                                                           over individual patient progress and discuss program modifica-
Internet address: www.atsjournals.org                                                    tions to help patients meet their goals. The specific professionals
Hill: Pulmonary Rehabilitation                                                                                                                              67

TABLE 1. MULTIDISCIPLINARY TEAM PARTICIPATING ON A                             TABLE 3. INDICATIONS AND CONTRAINDICATIONS TO
PULMONARY REHABILITATION TEAM                                                  PULMONARY REHABILITATION
Physicians                                                                     Indications
  Pulmonologist                                                                  Symptomatic impairment attributable to pulmonary disability
  Physiatrist                                                                    Failure of standard medical regimen to achieve adequate symptomatic relief
Therapists                                                                       Motivated, adherent patient
  Physical                                                                     Contraindications
  Occupational                                                                   Lack of motivation
  Respiratory                                                                    Nonadherence
Nurse or exercise physiologist                                                   Inadequate financial resources
Nutritionist                                                                     Severe cognitive dysfunction or psychiatric illness
Social worker                                                                    Unstable comorbidity (unstable angina, uncompensated congestive heart failure)
Psychologist                                                                     Severe exercise-induced hypoxemia, not correctable with O2 supplementation
                                                                                 Inability to exercise due to severe lung or other disease (arthritis, stroke)
                                                                                 Cigarette smoking*

                                                                                 * Only as per some insurers; Medicare requires smoking abstinence for at least
involved vary from program to program and no one blueprint                     3 mo before it will cover pulmonary rehabilitation.
applies to all. Programs can run successfully with a physician
and one or two therapists (2), but individuals representing other
disciplines should be available at least on a consultative basis.
                                                                               pulmonary function impairment or the need for chronic oxygen
SETTING FOR PULMONARY REHABILITATION                                           therapy will be reimbursed. Contraindications to participation
                                                                               include the lack of motivation, significant cognitive impairment,
Pulmonary rehabilitation is administered in inpatient, outpa-                  inability to attend the program consistently, unstable medical
tient, or home settings, or some combination of these. In the                  conditions that may pose risks, or the inability to participate in
United States (but not in Europe), inpatient rehabilitation is                 an exercise program because of a severe arthritic or other limiting
usually reserved for patients who are too disabled to travel to                condition. Although cigarette smoking is sometimes considered
and from an outpatient program and the focus of these programs                 a contraindication, smokers and nonsmokers have similar re-
is more often on optimizing medical or ventilator regimens than                sponses to rehabilitation. Active smokers should be encouraged
on the exercise components. In Europe, ambulatory patients                     to quit, and participation in a smoking cessation program can
may be admitted to an inpatient program to undergo intensive                   be made a condition of their participation. A number of studies
therapy and to avoid the inconvenience of daily travel. Possible               have examined predictors of a favorable response to rehabilita-
indications for inpatient pulmonary rehabilitation in the United               tion. Zuwallach and coworkers (11) found that those with the
States are listed in Table 2.                                                  lowest maximal oxygen uptakes at baseline had the largest pro-
   Most studies on pulmonary rehabilitation have focused on                    portionate improvements, whereas baseline pulmonary function
the outpatient setting, sometimes with the expectation that pa-                was not predictive. Troosters and colleagues (12) found that
tients will perform some of their exercises at home, and encour-               patients with no ventilatory reserve and normal skeletal muscle
aging patients to continue exercise regimens at home after com-                strength (inspiratory muscles, handgrip, and quadriceps) were
pletion of the program. A number of studies have demonstrated                  least likely to improve. Thus, the candidate most likely to benefit
improved endurance and/or quality of life after completion of                  is a previously sedentary (and presumably deconditioned) pa-
home-based rehabilitation programs (4–8). A multicenter ran-                   tient with no more than moderately severe disease.
domized controlled trial of home-based pulmonary rehabilita-
tion is currently underway in Canada (9). One study found that
                                                                               INITIAL ASSESSMENT
a home-based program achieved more durable benefits than a
hospital-based program (10), but direct comparisons between                    The physician director performs a screening assessment to deter-
home-based and outpatient programs are lacking.                                mine the suitability of prospective rehabilitation candidates. The
                                                                               physician takes a medical history and examines the patient, seek-
CANDIDATES FOR PULMONARY REHABILITATION                                        ing underlying conditions that might alter or even preclude par-
                                                                               ticipation in a rehabilitation program. For example, patients at
Candidates for pulmonary rehabilitation are patients with symp-
                                                                               risk for coronary artery disease who have not yet undergone an
tomatic impairment attributable to their respiratory condition
                                                                               adequate evaluation may be asked to complete an exercise stress
(Table 3). Patients should be motivated, not have significant
                                                                               test before being enrolled into the program. The physician should
transportation problems, and be capable of understanding the
                                                                               also ascertain that the patient is on an optimal medical regimen,
purpose and educational content of the program. Though some
                                                                               including bronchodilators, antiinflammatory drugs, and oxygen
randomized controlled trials suggest that even patients with mild
                                                                               supplementation as indicated.
impairment may benefit from rehabilitation, Medicare guidelines
(see below) specify that only those with moderate to severe
                                                                               ESSENTIAL COMPONENTS OF A PULMONARY
                                                                               REHABILITATION PROGRAM
                                                                               Exercise Training
TABLE 2. INDICATIONS FOR INPATIENT AS OPPOSED TO
OUTPATIENT PULMONARY REHABILITATION                                            Virtually every pulmonary rehabilitation program includes exercise
Severe impairment
                                                                               training as a centerpiece. In general, improvements in exercise
Multiple comorbidities                                                         performance can occur only if patients exercise on a regular basis.
Chronic invasive mechanical ventilation                                        This is usually accomplished in a group setting using individually
Slow convalescence from an acute respiratory illness                           tailored exercise prescriptions supervised by therapists. Some
Preparing a debilitated or chronically ventilated patient for discharge home   programs offer one-to-one exercise supervision by a therapist,
Transportation problems, too distant from program
                                                                               but the cost-effectiveness of this approach is dubious. Most
68                                                                           PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY             VOL 3 2006

programs offer a variety of exercise regimens aimed at improving
strength and endurance. The frequency, intensity, and specificity                                                    Figure 2. Effect of individual-
of exercise sessions are considered the main determinants of the                                                    ized training (open circles) and
training effect.                                                                                                    standard training (closed squares)
    Frequency. For pragmatic reasons, most pulmonary rehabili-                                                      regimens on lactate accumula-
tation programs hold sessions only two or three times weekly.                                                       tion in seven patients with severe
Some evidence indicates that two sessions per week may be                                                           chronic obstructive pulmonary
inadequate for a training effect (13), but most programs meeting                                                    disease. Horizontal axis is per-
                                                                                                                    centage of pretraining maximal
only twice weekly instruct patients to exercise at home in be-
                                                                                                                    oxygen uptake. Individualized
tween sessions. The frequency of exercise sessions to obtain an
                                                                                                                    training decreases lactate accu-
optimal training effect has not been established, but the regimen                                                   mulation at higher intensity exer-
of twice-weekly supervised sessions with additional unsupervised                                                    cise levels. *p 0.05, **p 0.01,
sessions at home has been advocated by at least one consensus                                                       ***p      0.001 between groups.
group (14).                                                                                                         Reproduced by permission from
    Intensity. Most studies indicate that there is a threshold for                                                  Reference 17.
the training effect. If a level of intensity corresponding to 60 to
75% of the maximum oxygen uptake can be sustained for at
least 20 to 30 min for a few days per week, an improvement in
endurance is a virtual certainty (2), although concerns have been                  Specificity. Training regimens are specific in that the type of
raised about patients’ ability to adhere to a high-intensity regi-             exercise determines the nature of the gain. For example, walking
men. Clark and colleagues (15) examined the efficacy of low-                    endurance increases after training of the lower extremities but
intensity isotonic exercises of the upper and lower extremities                not upper extremities (19). Furthermore, endurance exercises
performed at home in a group of 40 patients with COPD. These                   improve endurance capabilities more than strength, whereas
authors demonstrated a dramatic improvement in treadmill                       strength training (i.e., weightlifting) increases strength but not
walking time (Figure 1) and suggested that their program would                 necessarily endurance (20) or other outcomes such as exercise
be applicable in patients with COPD with a wide range of func-                 capacity or health status (21). Therefore, most programs incorpo-
tional defects. Punzal and coworkers (16) used a high-intensity                rate a variety of training regimens. Gradually increasing the
exercise program, exercising patients at approximately 85% of                  duration and intensity of workouts on a track, treadmill, or cycle
their maximal baseline treadmill walking speed, and also demon-                ergometer increases lower extremity endurance.
strated significant endurance benefits. Vallet and coworkers (17)                    Some patients with COPD become uncomfortably dyspneic
compared an individually tailored exercise regimen that targeted               while using the upper extremities for reaching or personal hy-
the heart rate at anaerobic threshold to a standard lower intensity            giene because this diverts shoulder girdle muscles that the patient
regimen that targeted 50% of the maximal heart rate. The indi-                 is using to assist breathing. Upper extremity muscle training
vidually tailored regimen increased O2 pulse and reduced lactate               using unsupported weightlifting techniques (22), stretching of
accumulation compared with the standard regimen (Figure 2).                    elastic bands (Ther-a-bands; Hygenic Corp., Akron, OH) or hand
However, many programs lack the facilities to monitor oxygen                   cranks (for endurance) can alleviate symptoms related to the use
uptake and use symptom guidance instead (18). Patients exercise                of the upper extremities. An arm-training program decreases the
at a level that gives them moderate dyspnea (Borg 3) but at                    work effort, level of dyspnea, and dynamic hyperinflation associ-
sustainable levels of exercise. Training at such levels has been               ated with a given level of arm exercise (23).
shown to increase endurance at the end of a program (18).                          Some programs also incorporate specific exercises aimed at
                                                                               improving respiratory muscle strength, such as inspiratory
                                                                               threshold training, a largely isometric exercise in which a device
                                                                               permits inspiratory flow only if a threshold negative pressure is
                                                                               reached, or inspiratory resistive training, in which patients in-
                                                                               spire through a resistor. It is unclear whether one technique is
                                                                               superior to the other (24), perhaps partly because adherence to
                                                                               inspiratory threshold training has been a problem. In a meta-
                                                                               analysis, Lotters and colleagues (25) found a nonsignificant trend
                                                                               for improved exercise capacity after inspiratory muscle training
                                                                               (IMT) alone or as an adjunct to general exercise training. A
                                                                               subgroup analysis showed that patients with greater inspiratory
                                                                               muscle weakness at baseline had significantly more benefit than
                                                                               those with normal inspiratory muscle strength. They concluded
                                                                               that IMT is an important component of rehabilitation in patients
                                                                               with COPD with inspiratory muscle weakness, but failed to con-
                                                                               sider that this result could also be attributed to regression toward
                                                                               the mean.
                                                                                   More recently, Weiner and colleagues (26) demonstrated that
                                                                               resistance training of expiratory muscles might be useful as an
                                                                               adjunct to rehabilitation. Not only did patients with trained
Figure 1. Total work performed on a treadmill (endurance walk test) is         expiratory muscles have greater expiratory muscle strength and
shown before and after exercise program in the training group (open            endurance than control subjects but they also had significantly
circles) and in the control group (closed circles). The mean difference in     greater 6-min walk distances. Another recent study found that
the training group (before–after) was 6,372 J versus 430 J in the control      hyperpnea training improved respiratory muscle endurance but
group (p 0.001 by Student’s t test). Reproduced by permission from             did not translate into improved overall function (27). Given the
Reference 15.                                                                  lack of evidence for improvement in overall function attributable
Hill: Pulmonary Rehabilitation                                                                                                                     69

to strength or endurance training of the respiratory muscles, the    fat-free muscle mass, strength, and quality of life score in patients
place of respiratory muscle training in rehabilitation programs      whose diets were supplemented with creatine (35).
remains controversial (28).
                                                                     Outcome Assessment
Education                                                            Pulmonary rehabilitation programs monitor outcomes partly as
Pulmonary rehabilitation programs include an educational com-        indicators of performance and to ensure quality, but also because
ponent usually provided during group teaching and discussion         many third-party payers now require such assessments to qualify
sessions, but sometimes to individuals (29). These group sessions    for reimbursement. Outcome measures usually include a func-
are typically scheduled immediately before or after exercise ses-    tional assessment. Many programs use the 6-min walk test or
sions. Different topics are addressed, often on a weekly basis       the 10-m shuttle test (36, 37). Both are widely applied tests of
(Table 4). The effectiveness of the educational component has        functional endurance that are of prognostic value. The shuttle
not been tested in controlled studies, and the importance of         walk test is an incremental test, but both it and the 6-min walk
education as a component of a pulmonary rehabilitation program       test are effort-dependent and subject to nonrespiratory limita-
has not been established.                                            tions such as weakness, pain, or arthritis. Some programs per-
                                                                     form maximal cardiopulmonary exercise tests that test maximal
Psychosocial and Behavioral Component                                capacity rather than endurance. These tests are usually combined
Because of the psychologic and emotional stress patients experi-     with a dyspnea assessment as a rough gauge of effort, such as
ence as part of their chronic illness as well as the high rate of    the Borg score or rating on a visual analog scale.
depression, most pulmonary rehabilitation programs incorporate          Many programs also use dyspnea scales such as the Baseline
psychosocial and behavioral interventions (30). Psychologists or     and Transitional Dyspnea indices that assess dyspnea as related
social workers may administer these during educational sessions,     to function, effort, and task (38). In addition, most programs
teaching coping and stress reduction strategies as well as relax-    use questionnaires to assess overall quality of life (or health
ation techniques (31). In a recent controlled trial, an occupa-      status). The Short Form-36 is a commonly used proprietary in-
tional therapist taught controlled breathing and energy conserva-    strument that tests overall health status. Disease-specific ques-
tion techniques during specific activities such as bed making or      tionnaires such as the St. George’s Respiratory Questionnaire
table setting, and was able to show improved dyspnea and overall     (SGRQ) (39) or the Chronic Respiratory Disease Questionnaire
functional scores compared with didactic lectures (32). Sexual       (CRQ) (40) are also commonly used. Both are validated ques-
dysfunction may be addressed and sexual counseling offered.          tionnaires in patients with COPD, and some evidence suggests
Patients with incapacitating stress, anxiety, or depression may      that the CRQ is a bit more sensitive than the SGRQ in detecting
warrant individual counseling or referral to a psychiatrist for      improvements (41). A composite index has recently been de-
medical therapy.                                                     scribed that combines body mass index (B), severity of airway
                                                                     obstruction (O), dyspnea index (D), and exercise capacity (E)
Other Interventions                                                  (BODE index) and correlates with prognosis of patients with
Breathing techniques have traditionally been taught as part of       COPD (34). This has registered improvement after completion
pulmonary rehabilitation programs including pursed lip breath-       of a pulmonary rehabilitation program and was associated with
ing and diaphragmatic breathing (33). Pursed lip breathing can       improved outcomes (42). Whether this composite index adds to
improve oxygenation and relieve the sensation of dyspnea, al-        the value of traditional single-outcome indices remains to be
though studies demonstrating that these gains translate into im-     determined.
proved functional status or state of well-being are lacking. Bene-
ficial effects of diaphragmatic breathing exercises have not been     EVIDENCE FOR THE EFFICACY OF
demonstrated (33).                                                   PULMONARY REHABILITATION
   Nutritional intervention is another important aspect of pul-      Patients with COPD
monary rehabilitation, although most programs use nutritional
consultants rather than include nutritionists as full-time mem-      Numerous randomized controlled trials have established the
bers of the rehabilitation team. Patients with chronic respiratory   efficacy of pulmonary rehabilitation for COPD (3, 4, 43–48) (see
conditions are frequently either over- or underweight, and a low     Table 5). One of the most comprehensive is that by Ries and
body mass index correlates with a worse prognosis (34). Few          coworkers (49) on 119 patients randomized to receive education
studies have demonstrated that nutritional interventions im-         plus exercise training or education alone. In this study, tests of
prove outcomes, but one recently showed improvements in              both maximal and endurance exercise showed significant benefits
                                                                     that persisted for 1 yr. Dyspnea and self-efficacy were also im-
                                                                     proved, but lung function and quality of well-being did not
                                                                     change. There were trends for improved survival (67 vs. 56%
TABLE 4. TOPICS OFTEN COVERED DURING GROUP
EDUCATION SESSIONS

What’s wrong in common lung diseases                                 TABLE 5. SIGNIFICANT BENEFITS OF PULMONARY
Breathing medications                                                REHABILITATION
Oxygen therapy
Energy conservation techniques                                       Established by multiple randomized controlled trials (Level A evidence)
Relaxation techniques                                                  1. Improved functional capacity (6-min walk or Shuttle Walk Test)
Breathing techniques                                                   2. Reduced dyspnea*
  Pursed lip breathing                                                 3. Improved health-specific quality of life*
  Diaphragmatic breathing
Nutrition                                                            Observed in some randomized controlled trials (Level B evidence)
What to do in emergencies                                             1. Reduced need for hospitalization*
Traveling with lung disease
                                                                       * Only in patients with chronic obstructive pulmonary disease with severe airway
End-of-life issues
                                                                     obstruction.
70                                                                     PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY                  VOL 3 2006

after up to 6 yr of follow-up) and reduced hospital days per             Non-COPD Disorders
patient per year ( 2.3 vs. 1.3 d/patient/yr), but these did not          Most evidence and all of the randomized controlled trials pertain
reach statistical significance.                                           to the efficacy of pulmonary rehabilitation for patients with
    More recently, a Cochrane meta-analysis assessed the efficacy         COPD. However, rehabilitation is still of potential benefit for
of pulmonary rehabilitation for COPD (50), but the Ries study            patients with many non-COPD disorders (Table 6). As long as
was excluded because it had an educational intervention in its           patients have enough reserve to perform some exercise, it is
control group, not just conventional therapy. The Cochrane anal-         likely that they can obtain a training effect. Furthermore, educa-
ysis examined results of 23 randomized controlled trials, con-           tion about their disease may enhance coping abilities as well as
cluding that rehabilitation of patients with COPD significantly           adherence to their medical regimen.
(both statistically and clinically) improves dyspnea and disease-           Because patients with non-COPD disorders may have unique
specific quality of life, including scales of fatigue and mastery.        requirements, the pulmonary rehabilitation program needs to
Functional exercise capacity as assessed by the 6-min walk dis-          be individually tailored for them. For example, patients with
tance also increased significantly, an average of 49 m, which             asthma may not have as much exercise impairment as most
is at the margin of the estimated minimal clinically significant          patients with COPD, but for them, education about the proper
difference of 54 m (51). The greatest benefit was apparent in             use of medication, especially during emergencies, as well as
patients with severe as opposed to mild to moderate COPD;                environmental controls deserves more emphasis. Patients with
benefit was maintained for at least 6 mo; and supervised pro-             asthma enrolled in a swim training program increased their
grams tended to offer greater benefit than unsupervised pro-              12-min walk distance after 10 wk of training, with a decrease in
grams. Although the Cochrane analysis found no overall reduc-            the occurrence of exercise-induced bronchospasm (59). Patients
tion in the need for hospitalization after rehabilitation, some          with certain neuromuscular diseases, such as post-polio syn-
individual studies have found significant reductions in hospital          drome, may benefit from comprehensive rehabilitation (60),
days per year (52) as well as annual health care use and direct          demonstrating increased strength and endurance of affected
costs (53). A recent study also found reductions in patients with        muscles (61). However, muscle strengthening or conditioning
COPD with anxiety and depression after pulmonary rehabilita-             exercises are unlikely to be helpful in patients with advanced
tion compared with matched control subjects (54). A follow-              progressive neuromuscular diseases, such as muscular dystro-
up meta-analysis focusing just on patients with mild–moderate            phies (62). Such patients may still benefit from flexibility exer-
COPD concluded that exercise can improve conditioning in                 cises to minimize contractures or programs to optimize their
these patients, but that studies are lacking to support the idea         use of ventilator assistance regimens. Patients with lung cancer
that rehabilitation favorably influences dyspnea, quality of life,        require different kinds of education and may be recovering from
or disease progression in the mild–moderate subgroup (55).               the effects of radiation or chemotherapy (63). They may also
    An important limitation inherent to all of the controlled stud-      have pain management problems that demand special attention.
ies is the inability to blind patients or investigators to treatment     Those with interstitial fibrosis may experience profound exer-
group, leaving the results open to bias. Nonetheless, the authors        cise-induced oxygen desaturations that pose challenges for the
of the Cochrane review concluded that no additional trials are           delivery of high-flow oxygen during exercise, and patients with
needed comparing pulmonary rehabilitation with conventional              cystic fibrosis may need coaching on secretion removal or special
therapy in patients with COPD. However, they opined that addi-           precautions if they are harboring highly resistant organisms, such
tional study is needed to determine what components of a reha-           as Burkholderia cepacia. Small, uncontrolled series of patients
bilitation program are essential, the ideal program length, the          with cystic fibrosis indicate that they respond favorably to exer-
best combination of intensity, frequency and specific exercises           cise programs (64, 65). Patients with bronchiectasis also respond
for the training program, the value of breathing exercises, and          to exercise training, but without added benefit from IMT (66).
how best to maintain benefits.                                            With the advent of new and more effective therapies for pulmo-
    Several recent studies have shed light on some of these ques-        nary arterial hypertension, the initiation of an exercise program
tions. A study in the United Kingdom found that early rehabilita-        to coincide with the initiation of new medical therapy may
tion (within 10 d) after a hospitalization for a COPD exacerbation       enhance functional improvement in such patients. Pulmonary
improved exercise capacity and health status at the 3-mo time            rehabilitation has also been used pre- and postoperatively for
point compared with standard care (56). A Danish group using             lung resection, lung transplantation (67), and lung volume reduc-
hour-long exercise sessions twice weekly for 8 wk found no               tion surgeries, and was included as standard therapy in both the
significant improvement in 6-min walk distance or health-related
quality of life, and speculated that two sessions weekly might
be too few to produce a training effect (13). However, there was         TABLE 6. NON–CHRONIC OBSTRUCTIVE PULMONARY
a high dropout rate and adherence with the exercise program              DISEASE CHRONIC RESPIRATORY CONDITIONS THAT MAY
was not specified. Clearly, there must be a minimum threshold             BENEFIT FROM A PULMONARY REHABILITATION PROGRAM
of exercise frequency if a training effect is to be achieved, and
                                                                         Asthma
two sessions/wk may be close to that threshold, but exercise             Chest wall disease
duration (each session as well as the duration of the program)           Cystic fibrosis
as well as exercise intensity must also be factored in. With regard      Interstitial lung disease; post-ARDS pulmonary fibrosis
to the optimal duration of a pulmonary rehabilitation program,           Lung cancer
Green and colleagues (57) found that 7 wk of rehabilitation was          Neuromuscular diseases such as post–polio syndrome
                                                                           Exercise program may not be appropriate for advanced disease
better than 4 wk. Another recent study found that 6-min walk               Flexibility training
distance of patients with severe COPD increased between 12                 Optimization of ventilator assistance re:
and 24 wk of pulmonary rehabilitation and recommended that                    Perioperative states (e.g., thoracic, abominal surgery)
supervised programs extend for at least 24 wk to optimize bene-               Pre- and post–lung transplantation, LVRS
fits, but this study was uncontrolled (58). For pragmatic reasons,        Pulmonary vascular disease
including the reimbursement policies of insurers, however, most            Definition of abbreviations: ARDS adult respiratory distress syndrome;
programs last between 6 and 12 wk.                                       LVRS lung volume reduction surgery.
Hill: Pulmonary Rehabilitation                                                                                                       71

surgery and control arms in the National Emphysema Therapy            gram. Optimization of and improved adherence to the medical
Trial, which evaluated the efficacy of lung volume reduction           regimen, weight loss, and smoking cessation, and better treatment
surgery (68).                                                         of comorbidities, such as cardiovascular disease or obstructive
                                                                      sleep apnea, are other possible but unsubstantiated mechanisms
MAINTENANCE OF BENEFIT                                                of benefit. The increased attention from professionals as well as
Some studies have monitored patients for up to 2 yr (47, 49).         the educational component in rehabilitation programs may also
Ries and colleagues (49) found that improvements in functional        be important in improving overall health status, but this has not
exercise capacity are sustained for at least 12 mo. Troosters and     been established. Thus, although conditioning of peripheral (i.e.,
coworkers (69) later demonstrated that improvements in the            quadriceps) muscle appears to be an important mechanism of
6-min walk test and quality of life exceeded minimal clinically       rehabilitation benefit in many patients with COPD, identification
significant differences for 18 mo. Ideally, patients are to apply      of a single mechanism that applies to all patients seems unlikely;
what they have learned in the rehabilitation phase of the pro-        rather, multiple factors appear to play a role in limiting patient
gram, undergoing a lifestyle change that includes regular exer-       function and a multipronged approach is most likely to be suc-
cise. Unfortunately, many if not most patients fail to adhere to      cessful in effecting improvement, with specific reversible factors
this ideal, and programmatic benefits are eventually lost. Some        varying from one individual patient to another.
programs encourage patients to return to the rehabilitation cen-
ter two or three times weekly after completion of the formal
program so that the exercise program can be maintained. They          USE OF OXYGEN SUPPLEMENTATION IN
offer continued but less intense supervision and usually charge       PULMONARY REHABILITATION
a small fee because such maintenance programs are not covered         Oxygen supplementation has long been considered routine in
by insurance.                                                         pulmonary rehabilitation to maintain O2 saturation of more than
   Whether formal maintenance programs after completion of            88%, on the basis of studies showing that O2 supplementation
the rehabilitation program extend or enhance initial benefits has
                                                                      used in this fashion improves exercise performance. Recently,
not been established. Ries and colleagues (70) tested a mainte-
                                                                      Emtner and colleagues (78) demonstrated that even patients
nance program consisting of weekly phone calls and monthly
reinforcement sessions. Functional exercise capacity and overall      with COPD who do not desaturate during exercise still have
health status were better sustained by maintenance than conven-       significant gains with O2 supplementation, including greater exer-
tional management for 12 mo, but the advantage disappeared            cise endurance (30% prolongation) and improved health quality.
by 24 mo. In another study, once-weekly training sessions after a     The mechanism of this benefit is unclear, and this finding must
3-mo intensive rehabilitation period failed to sustain the benefits    be confirmed before routine adoption can be recommended.
achieved, but 2 to 3 h of exercise weekly during the maintenance      Heliox, the mixture of oxygen (up to 40%) and helium, reduces
period prevented some of the deterioration (71). Distractive          gas density compared with air and lowers resistance to airflow
stimuli during exercise sessions (music via earphones) have been      in regions of turbulence. It can reduce air trapping and enhance
found to improve maintenance of the beneficial effects of a            exercise tolerance in patients with COPD and could serve as an
rehabilitation program (72).                                          additional way to augment the training effect (79).

MECHANISM OF BENEFIT
                                                                      NONINVASIVE VENTILATION AS AN ADJUNCT
For years, physiologists have pointed to the mechanical dis-          TO REHABILITATION
advantages and propensity to fatigue of the respiratory muscles
in patients with COPD and have speculated that therapies aimed        The use of long-term use of noninvasive positive-pressure venti-
at increasing the strength and endurance of inspiratory muscles       lation to improve functional and health status of patients with
would improve overall function (73). Numerous studies demon-          severe, stable COPD has long been controversial. A recent ran-
strate that specific muscle training can enhance strength and/or       domized study from Italy (80) has demonstrated that noninvasive
endurance of the inspiratory muscles in patients with COPD,           ventilation used for 2 yr in patients with severe COPD and
but these specific improvements have not been shown to contrib-        chronic CO2 retention prevented the deterioration in daytime
ute to enhancements in overall functional or health status. More-     gas exchange and health status that was observed among control
over, the improvements in dyspnea scores, functional exercise         subjects, and tended to reduce hospital days per patient per
capacity, and health status that accrue from participation in a       year. Noninvasive positive-pressure techniques can also be used
pulmonary rehabilitation program do not correlate with im-            during exercise training to permit the attainment of a higher
provements in pulmonary function.                                     level of intensity during training, potentially augmenting the
    Alternative possible mechanisms for the benefits of rehabili-      training effect (81, 82). Continuous positive airway pressure,
tation include improved cardiovascular conditioning and effi-          pressure support (83), and proportional assist ventilation (84)
                                         ˙
ciency as demonstrated by increased Vo2max, lower heart rate
             ˙                ˙                                       all augment the level of exercise intensity attainable, with the
for a given Vo2 and lower Vo2 for a given work load (74), and
                                                                      greatest effect attributable to proportional assist ventilation.
strengthening and conditioning of weakened peripheral muscles
                                                                      However, no study has yet demonstrated that this greater exer-
(75). Saey and colleagues (76) recently demonstrated that mech-
anisms of exercise limitation differ between patients with COPD:      cise intensity actually translates into improved functional exer-
some (fatiguers) had evidence of quadriceps muscle fatigue and        cise capacity, and one study suggests otherwise (85).
had no improvement after inhalation of ipratropium, whereas               Another way to use noninvasive ventilation as an adjunct to
others (nonfatiguers) had no evidence of quadriceps fatigue but       rehabilitation is to rest respiratory muscles between exercise
rather had ventilatory limitation and responded to ipratropium        periods. Garrod and coworkers (86) used this approach in a
by increasing exercise endurance. Mador and coworkers (77)            controlled trial of patients with severe, stable COPD undergoing
have shown that quadriceps muscles of patients with COPD are          rehabilitation. They found that the noninvasive positive-pressure
more resistant to fatigue after completion of a rehabilitation pro-   ventilation–treated group improved its performance on the
72                                                                        PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY                        VOL 3 2006

shuttle walk test (Figure 3) and had an improved quality of                 of life of patients with severe COPD and probably in those
life (CRQ), even though the average patient used noninvasive                with other chronic non-COPD causes of pulmonary impairment.
positive-pressure ventilation for only 2 h daily. However, because          Multidisciplinary programs provide rehabilitation in inpatient,
this study was not blinded, the possibility of bias could not be            outpatient, or home settings using at least three sessions weekly
entirely excluded.                                                          (one may be unsupervised) over at least 6 wk. The programs
    Although some of the above studies are promising, noninva-              usually consist of exercise training, education, and psychosocial/
sive ventilation is not yet a standard component of pulmonary               behavioral components, but lower extremity conditioning is the
rehabilitation and should remain an investigational technique               only component with established benefit. Upper extremity exer-
pending further study.                                                      cises and instruction on breathing technique are included in
                                                                            most rehabilitation programs, but the contribution of these to
REIMBURSEMENT ISSUES                                                        improved functional exercise capacity remains unproven. The
                                                                            value of IMT is likewise unclear and such training is not consid-
Third-party payers have long been ambivalent about reimburs-
                                                                            ered a routine component of rehabilitation.
ing for pulmonary rehabilitation. Reimbursement policies have
                                                                                Despite the availability of strong evidence to support the
varied from time to time, payer to payer, and region to region.
                                                                            efficacy of pulmonary rehabilitation programs in patients with
Although the Center for Medicaid and Medicare Services has
created codes for pulmonary rehabilitation, there is no national            severe COPD, third-party reimbursement policies have been
policy on reimbursement, and regional Medicare providers often              inconsistent, and there is currently no national policy. Despite
deny payment.                                                               this impediment, enrollment in a pulmonary rehabilitation pro-
    Pending a national policy, most providers of pulmonary reha-            gram is encouraged for all appropriate candidates with chronic
bilitation rely on collections for physical therapy and billable            respiratory impairment, particularly for those with severe COPD.
tests. Several physical therapy codes can be used and are often             Investigators are encouraged to accumulate evidence to fill current
reimbursed as long as patients meet certain criteria. These in-             knowledge gaps, including the establishment of what mecha-
clude an International Classification of Diseases–9 diagnosis of             nisms and components of pulmonary rehabilitation are essential
emphysema, COPD, or chronic bronchitis, and having a reduced                to success, what specific exercise prescriptions bring about the
FEV1 (ranging from 50 to 65% of predicted depending on the                  largest benefit, how best to sustain benefits over the long-term,
state) or meeting the criteria for oxygen therapy. In addition,             and what non-COPD causes of respiratory impairment respond
patients must have ceased smoking for at least 3 mo.                        favorably to rehabilitation.
    These guidelines are not based on scientific evidence but must           Conflict of Interest Statement : N.S.H. does not have a financial relationship with
be met nonetheless. Many managed-care plans pattern their                   a commercial entity that has an interest in the subject of this manuscript.
reimbursement policies after Medicare guidelines, but others
may be willing to pay global rates. Plans that use case managers            References
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