Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease
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Pulmonary rehabilitation for chronic obstructive pulmonary
disease (Review)
McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2015, Issue 2
http://www.thecochranelibrary.com
Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
disease (Review)
McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2015, Issue 2
http://www.thecochranelibrary.com
Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
7BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
20DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
144DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Rehabilitation versus usual care, Outcome 1 QoL - Change in CRQ (Fatigue). . . . . 147
Analysis 1.2. Comparison 1 Rehabilitation versus usual care, Outcome 2 QoL - Change in CRQ (Emotional Function). 149
Analysis 1.3. Comparison 1 Rehabilitation versus usual care, Outcome 3 QoL - Change in CRQ (Mastery). . . . 150
Analysis 1.4. Comparison 1 Rehabilitation versus usual care, Outcome 4 QoL - Change in CRQ (Dyspnoea). . . . 151
Analysis 1.5. Comparison 1 Rehabilitation versus usual care, Outcome 5 QoL - Change in SGRQ (Total). . . . . 152
Analysis 1.6. Comparison 1 Rehabilitation versus usual care, Outcome 6 QoL - Change in SGRQ (Symptoms). . . 153
Analysis 1.7. Comparison 1 Rehabilitation versus usual care, Outcome 7 QoL - Change in SGRQ (Impacts). . . . 154
Analysis 1.8. Comparison 1 Rehabilitation versus usual care, Outcome 8 QoL - Change in SGRQ (Activity). . . . 155
Analysis 1.9. Comparison 1 Rehabilitation versus usual care, Outcome 9 Maximal Exercise (Incremental shuttle walk
test). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Analysis 1.10. Comparison 1 Rehabilitation versus usual care, Outcome 10 Maximal Exercise Capacity (cycle ergometer). 157
Analysis 1.11. Comparison 1 Rehabilitation versus usual care, Outcome 11 Functional Exercise Capacity (6MWT)). 158
Analysis 2.1. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 1 QoL -
Change in CRQ (Fatigue). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Analysis 2.2. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 2 QoL -
Change in CRQ (Emotional Function). . . . . . . . . . . . . . . . . . . . . . . . . . 161
Analysis 2.3. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 3 QoL -
Change in CRQ (Mastery). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Analysis 2.4. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 4 QoL -
Change in CRQ (Dyspnoea). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Analysis 2.5. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 5 QoL -
Change in SGRQ (Total). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Analysis 2.6. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 6 QoL -
Change in SGRQ (Symptoms). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Analysis 2.7. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 7 QoL -
Change in SGRQ (Impacts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Analysis 2.8. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 8 QoL -
Change in SGRQ (Activity). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Analysis 3.1. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 1 QoL - Change in CRQ (Fatigue). . . . . . . . . . . . . . . . . . . . . . . . 172
Analysis 3.2. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 2 QoL - Change in CRQ (Emotional Function). . . . . . . . . . . . . . . . . . . 173
iPulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
7BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
20DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
144DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Rehabilitation versus usual care, Outcome 1 QoL - Change in CRQ (Fatigue). . . . . 147
Analysis 1.2. Comparison 1 Rehabilitation versus usual care, Outcome 2 QoL - Change in CRQ (Emotional Function). 149
Analysis 1.3. Comparison 1 Rehabilitation versus usual care, Outcome 3 QoL - Change in CRQ (Mastery). . . . 150
Analysis 1.4. Comparison 1 Rehabilitation versus usual care, Outcome 4 QoL - Change in CRQ (Dyspnoea). . . . 151
Analysis 1.5. Comparison 1 Rehabilitation versus usual care, Outcome 5 QoL - Change in SGRQ (Total). . . . . 152
Analysis 1.6. Comparison 1 Rehabilitation versus usual care, Outcome 6 QoL - Change in SGRQ (Symptoms). . . 153
Analysis 1.7. Comparison 1 Rehabilitation versus usual care, Outcome 7 QoL - Change in SGRQ (Impacts). . . . 154
Analysis 1.8. Comparison 1 Rehabilitation versus usual care, Outcome 8 QoL - Change in SGRQ (Activity). . . . 155
Analysis 1.9. Comparison 1 Rehabilitation versus usual care, Outcome 9 Maximal Exercise (Incremental shuttle walk
test). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Analysis 1.10. Comparison 1 Rehabilitation versus usual care, Outcome 10 Maximal Exercise Capacity (cycle ergometer). 157
Analysis 1.11. Comparison 1 Rehabilitation versus usual care, Outcome 11 Functional Exercise Capacity (6MWT)). 158
Analysis 2.1. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 1 QoL -
Change in CRQ (Fatigue). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Analysis 2.2. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 2 QoL -
Change in CRQ (Emotional Function). . . . . . . . . . . . . . . . . . . . . . . . . . 161
Analysis 2.3. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 3 QoL -
Change in CRQ (Mastery). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Analysis 2.4. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 4 QoL -
Change in CRQ (Dyspnoea). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Analysis 2.5. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 5 QoL -
Change in SGRQ (Total). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Analysis 2.6. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 6 QoL -
Change in SGRQ (Symptoms). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Analysis 2.7. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 7 QoL -
Change in SGRQ (Impacts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Analysis 2.8. Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 8 QoL -
Change in SGRQ (Activity). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Analysis 3.1. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 1 QoL - Change in CRQ (Fatigue). . . . . . . . . . . . . . . . . . . . . . . . 172
Analysis 3.2. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 2 QoL - Change in CRQ (Emotional Function). . . . . . . . . . . . . . . . . . . 173
iPulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.3. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 3 QoL - Change in CRQ (Mastery). . . . . . . . . . . . . . . . . . . . . . . 175
Analysis 3.4. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 4 QoL - Change in CRQ (Dyspnoea). . . . . . . . . . . . . . . . . . . . . . . 176
Analysis 3.5. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 5 QoL - Change in SGRQ (Total). . . . . . . . . . . . . . . . . . . . . . . . 178
Analysis 3.6. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 6 QoL - Change in SGRQ (Symptoms). . . . . . . . . . . . . . . . . . . . . . 179
Analysis 3.7. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 7 QoL - Change in SGRQ (Impacts). . . . . . . . . . . . . . . . . . . . . . . 181
Analysis 3.8. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 8 QoL - Change in SGRQ (Activity). . . . . . . . . . . . . . . . . . . . . . . 182
Analysis 4.1. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 1 QoL - Change in CRQ (Dyspnoea). . . . . . . . . . . . . . . . . . . 184
Analysis 4.2. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 2 QoL - Change in CRQ (Emotional Function). . . . . . . . . . . . . . . 185
Analysis 4.3. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 3 QoL - Low Risk CRQ (Fatigue). . . . . . . . . . . . . . . . . . . . 186
Analysis 4.4. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 4 QoL - Low Risk CRQ (Mastery). . . . . . . . . . . . . . . . . . . . 187
Analysis 4.5. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 5 QoL - Low Risk SGRQ (Total). . . . . . . . . . . . . . . . . . . . 188
Analysis 4.6. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 6 QoL - Low Risk SGRQ (Symptoms). . . . . . . . . . . . . . . . . . . 189
Analysis 4.7. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 7 QoL - Low Risk SGRQ (Impacts). . . . . . . . . . . . . . . . . . . 190
Analysis 4.8. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 8 QoL - Low Risk SGRQ (Activity). . . . . . . . . . . . . . . . . . . . 191
191ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
201APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
206WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
207HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
207CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
208DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
208DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
208INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiPulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Outcome 3 QoL - Change in CRQ (Mastery). . . . . . . . . . . . . . . . . . . . . . . 175
Analysis 3.4. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 4 QoL - Change in CRQ (Dyspnoea). . . . . . . . . . . . . . . . . . . . . . . 176
Analysis 3.5. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 5 QoL - Change in SGRQ (Total). . . . . . . . . . . . . . . . . . . . . . . . 178
Analysis 3.6. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 6 QoL - Change in SGRQ (Symptoms). . . . . . . . . . . . . . . . . . . . . . 179
Analysis 3.7. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 7 QoL - Change in SGRQ (Impacts). . . . . . . . . . . . . . . . . . . . . . . 181
Analysis 3.8. Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other),
Outcome 8 QoL - Change in SGRQ (Activity). . . . . . . . . . . . . . . . . . . . . . . 182
Analysis 4.1. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 1 QoL - Change in CRQ (Dyspnoea). . . . . . . . . . . . . . . . . . . 184
Analysis 4.2. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 2 QoL - Change in CRQ (Emotional Function). . . . . . . . . . . . . . . 185
Analysis 4.3. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 3 QoL - Low Risk CRQ (Fatigue). . . . . . . . . . . . . . . . . . . . 186
Analysis 4.4. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 4 QoL - Low Risk CRQ (Mastery). . . . . . . . . . . . . . . . . . . . 187
Analysis 4.5. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 5 QoL - Low Risk SGRQ (Total). . . . . . . . . . . . . . . . . . . . 188
Analysis 4.6. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 6 QoL - Low Risk SGRQ (Symptoms). . . . . . . . . . . . . . . . . . . 189
Analysis 4.7. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 7 QoL - Low Risk SGRQ (Impacts). . . . . . . . . . . . . . . . . . . 190
Analysis 4.8. Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete
outcome), Outcome 8 QoL - Low Risk SGRQ (Activity). . . . . . . . . . . . . . . . . . . . 191
191ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
201APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
206WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
207HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
207CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
208DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
208DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
208INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiPulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Pulmonary rehabilitation for chronic obstructive pulmonary
disease
Bernard McCarthy1, Dympna Casey1, Declan Devane1, Kathy Murphy1, Edel Murphy1, Yves Lacasse2
1School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland. 2Institut Universitaire de Cardiologie et
de Pneumologie de Québec, Université Laval, Québec, Canada
Contact address: Bernard McCarthy, School of Nursing and Midwifery, National University of Ireland Galway, Aras Moyola, Galway,
Co. Galway, Ireland. Bernard.mccarthy@nuigalway.ie.
Editorial group: Cochrane Airways Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 2, 2015.
Review content assessed as up-to-date: 26 March 2014.
Citation: McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic
obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. DOI:
10.1002/14651858.CD003793.pub3.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease
(COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise
capacity) attributable to the programmes. This review updates the review reported in 2006.
Objectives
To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal
exercise capacity in persons with COPD.
Search methods
We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were
current as of March 2014.
Selection criteria
We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional
(FEC) or maximal (MEC) exercise capacity were measured. We defined ’pulmonary rehabilitation’ as exercise training for at least four
weeks with or without education and/or psychological support. We defined ’usual care’ as conventional care in which the control group
was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of
usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered
best practice at the start of the trial for all participants.
Data collection and analysis
We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary
study. We used standard methods as recommended by The Cochrane Collaboration.
1Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pulmonary rehabilitation for chronic obstructive pulmonary
disease
Bernard McCarthy1, Dympna Casey1, Declan Devane1, Kathy Murphy1, Edel Murphy1, Yves Lacasse2
1School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland. 2Institut Universitaire de Cardiologie et
de Pneumologie de Québec, Université Laval, Québec, Canada
Contact address: Bernard McCarthy, School of Nursing and Midwifery, National University of Ireland Galway, Aras Moyola, Galway,
Co. Galway, Ireland. Bernard.mccarthy@nuigalway.ie.
Editorial group: Cochrane Airways Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 2, 2015.
Review content assessed as up-to-date: 26 March 2014.
Citation: McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic
obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. DOI:
10.1002/14651858.CD003793.pub3.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease
(COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise
capacity) attributable to the programmes. This review updates the review reported in 2006.
Objectives
To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal
exercise capacity in persons with COPD.
Search methods
We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were
current as of March 2014.
Selection criteria
We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional
(FEC) or maximal (MEC) exercise capacity were measured. We defined ’pulmonary rehabilitation’ as exercise training for at least four
weeks with or without education and/or psychological support. We defined ’usual care’ as conventional care in which the control group
was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of
usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered
best practice at the start of the trial for all participants.
Data collection and analysis
We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary
study. We used standard methods as recommended by The Cochrane Collaboration.
1Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total
of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.
We noted no significant demographic differences at baseline between members of the intervention group and those who received usual
care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for
the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two
males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were
community based (at community centres or in individual homes) and one study had both a hospital component and a community
component. Most programmes were of 12 weeks’ or eight weeks’ duration with an overall range of four weeks to 52 weeks.
The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition,
it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by
several studies, this impacted the overall risk of bias.
We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic
Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal
clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies
= 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional
function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19;
low-quality evidence). Statistically significant improvements were noted in all domains of the St. George’s Respiratory Questionnaire
(SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-
quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15,
95% CI -7.95 to -2.36; N = 572; studies = 7).
Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal
exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95%
CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In
relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical
significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).
The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a
significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in
the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference.
Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant
difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more
complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution.
Authors’ conclusions
Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals
have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important
component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our
opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research
studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree
of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of
the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based
programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.
P L A I N L A N G U A G E S U M M A R Y
Pulmonary rehabilitation for chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) describes a chronic lung condition that prevents the air supply from getting to the
lungs. Symptoms include breathlessness, coughing, tiredness and frequent chest infection. Worldwide, COPD is a major cause of ill
health.
2Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total
of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.
We noted no significant demographic differences at baseline between members of the intervention group and those who received usual
care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for
the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two
males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were
community based (at community centres or in individual homes) and one study had both a hospital component and a community
component. Most programmes were of 12 weeks’ or eight weeks’ duration with an overall range of four weeks to 52 weeks.
The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition,
it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by
several studies, this impacted the overall risk of bias.
We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic
Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal
clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies
= 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional
function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19;
low-quality evidence). Statistically significant improvements were noted in all domains of the St. George’s Respiratory Questionnaire
(SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-
quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15,
95% CI -7.95 to -2.36; N = 572; studies = 7).
Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal
exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95%
CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In
relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical
significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).
The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a
significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in
the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference.
Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant
difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more
complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution.
Authors’ conclusions
Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals
have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important
component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our
opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research
studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree
of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of
the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based
programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.
P L A I N L A N G U A G E S U M M A R Y
Pulmonary rehabilitation for chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) describes a chronic lung condition that prevents the air supply from getting to the
lungs. Symptoms include breathlessness, coughing, tiredness and frequent chest infection. Worldwide, COPD is a major cause of ill
health.
2Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pulmonary rehabilitation programmes include exercise as a key component; some programmes contain other interventions such as
assessment, education, psychological support and dietary advice. Pulmonary rehabilitation is one of the key recommended approaches
in the treatment of COPD. This review compared the impact of pulmonary rehabilitation versus usual care on the health-related quality
of life of people with COPD. We included 65 studies involving 3822 participants. Participants were randomly assigned to receive
pulmonary rehabilitation or usual care. The quality of the studies was generally good.
This review highlights that pulmonary rehabilitation improves the health-related quality of life of people with COPD. Results
strongly support inclusion of pulmonary rehabilitation as part of the management and treatment of patients with COPD.
Future studies should concentrate on identifying the most important components of pulmonary rehabilitation, the ideal length of a
programme, the intensity of training required and how long the benefits of the programme last.
3Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
assessment, education, psychological support and dietary advice. Pulmonary rehabilitation is one of the key recommended approaches
in the treatment of COPD. This review compared the impact of pulmonary rehabilitation versus usual care on the health-related quality
of life of people with COPD. We included 65 studies involving 3822 participants. Participants were randomly assigned to receive
pulmonary rehabilitation or usual care. The quality of the studies was generally good.
This review highlights that pulmonary rehabilitation improves the health-related quality of life of people with COPD. Results
strongly support inclusion of pulmonary rehabilitation as part of the management and treatment of patients with COPD.
Future studies should concentrate on identifying the most important components of pulmonary rehabilitation, the ideal length of a
programme, the intensity of training required and how long the benefits of the programme last.
3Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Rehabilitation versus usual care for chronic obstructive pulmonary disease
Patient or population: patients with chronic obstructive pulmonary disease
Settings: hospital and community
Intervention: rehabilitation versus usual care
Outcomes Illustrative comparative effects* (95% CI) Number of participants
(studies)
Quality of the evidence
(GRADE)
Comments
Response on control Treatment effect
Usual care Rehabilitation versus usual
care
QoL - Change in CRQ (dysp-
noea)
CRQ Questionnaire. Scale
from 1 to 7
(Higher is better and 0.5 unit
is an important difference)
Follow-up: median 12 weeks
Median change = 0 units Mean QoL - change in CRQ
(Dyspnoea) in the intervention
groups was
0.79 units higher
(0.56 to 1.03 higher)
1283
(19 studies)
⊕⊕⊕©
Moderate1,2,3
Sensitivity analysis from stud-
ies at lower risk of bias was
similar (MD 0.99, 95% CI 0.64
to 1.34; participants = 384;
studies = 5; I2 = 34%)
QoL - Change in SGRQ (total)
Scale from 0 to 100
(Lower is better and 4 units is
an important difference)
Follow-up: median 12 weeks
Median change = 0.42 units Mean QOL - change in SGRQ
(total) in the intervention
groups was
6.89 units lower
(9.26 to 4.52 lower)
1146
(19 studies)
⊕⊕⊕©
Moderate2,3,4
Sensitivity analysis from stud-
ies at lower risk of bias was
similar (MD -5.15, 95% CI -
7.95 to -2.36; participants =
572; studies = 7; I2 = 51%)
Change in maximal exercise
(Incremental Shuttle walk
test (ISWT))
Distance metres
Follow-up: median 12 weeks
Median change = 1 metre Mean maximal exercise (in-
cremental shuttle walk test) in
the intervention groups was
39.77 metres higher
(22.38 to 57.15 higher)
694
(8 studies)
⊕⊕⊕©
Moderate2,3,5
4Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Rehabilitation versus usual care for chronic obstructive pulmonary disease
Patient or population: patients with chronic obstructive pulmonary disease
Settings: hospital and community
Intervention: rehabilitation versus usual care
Outcomes Illustrative comparative effects* (95% CI) Number of participants
(studies)
Quality of the evidence
(GRADE)
Comments
Response on control Treatment effect
Usual care Rehabilitation versus usual
care
QoL - Change in CRQ (dysp-
noea)
CRQ Questionnaire. Scale
from 1 to 7
(Higher is better and 0.5 unit
is an important difference)
Follow-up: median 12 weeks
Median change = 0 units Mean QoL - change in CRQ
(Dyspnoea) in the intervention
groups was
0.79 units higher
(0.56 to 1.03 higher)
1283
(19 studies)
⊕⊕⊕©
Moderate1,2,3
Sensitivity analysis from stud-
ies at lower risk of bias was
similar (MD 0.99, 95% CI 0.64
to 1.34; participants = 384;
studies = 5; I2 = 34%)
QoL - Change in SGRQ (total)
Scale from 0 to 100
(Lower is better and 4 units is
an important difference)
Follow-up: median 12 weeks
Median change = 0.42 units Mean QOL - change in SGRQ
(total) in the intervention
groups was
6.89 units lower
(9.26 to 4.52 lower)
1146
(19 studies)
⊕⊕⊕©
Moderate2,3,4
Sensitivity analysis from stud-
ies at lower risk of bias was
similar (MD -5.15, 95% CI -
7.95 to -2.36; participants =
572; studies = 7; I2 = 51%)
Change in maximal exercise
(Incremental Shuttle walk
test (ISWT))
Distance metres
Follow-up: median 12 weeks
Median change = 1 metre Mean maximal exercise (in-
cremental shuttle walk test) in
the intervention groups was
39.77 metres higher
(22.38 to 57.15 higher)
694
(8 studies)
⊕⊕⊕©
Moderate2,3,5
4Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Change in functional exer-
cise capacity (6MWT))
Distance metres
Follow-up: median 12 weeks
Median change = 3.4 metres Mean functional exercise ca-
pacity (6MWT)) in the inter-
vention groups was
43.93 metres higher
(32.64 to 55.21 higher)
1879
(38 studies)
⊕©©©
Very low2,3,6,7
Change in maximal exercise
capacity (cycle ergometer)
Workmax (watt)
Follow-up: median 12 weeks
Median change = -0.05 watts Mean maximal exercise ca-
pacity (cycle ergometer) in the
intervention groups was
6.77 watts higher
(1.89 to 11.65 higher)
779
(16 studies)
⊕⊕©©
Low2,3,8,9
*The basis for the response on control is the median control group response across studies.
CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
117 studies reported random sequence generation (1 unclear), 12 reported allocation concealment 2 did not have allocation concealment
and it is unclear in 5 studies. 4 studies did not blind assessors, 11 blinded assessors and 4 were unclear as to assessor blinding. 6
studies had attrition bias greater than 20%.
2Downgraded as there is a high level of heterogeneity within the results. Several factors may impact heterogeneity, including content of
the intervention programme, setting of the programme and severity of COPD.
3Greater than optimal Information size (OIS). 95% confidence interval does not includes ‘ ‘ no effect,’’ nor does the confidence limit cross
the MID, so no need to downgrade.
418 studies reported random sequence generation (2 unclear), 10 reported allocation concealment, 2 did not have allocation concealment
and it is unclear in 7 studies. 3 studies did not blind assessors, 9 blinded assessors and 7 were unclear as to assessor blinding. 7
studies had attrition bias greater than 20%.
5All 8 studies reported random sequence generation, 5 reported allocation concealment and it is unclear in 3 studies. 5 studies had blind
assessors with 1 not blinded, and 2 were unclear as to assessor blinding. 4 studies had attrition bias greater than 20%.
634 studies reported random sequence generation, 4 were unclear, 20 reported allocation concealment, 3 did not have allocation
concealment and it is unclear in 15 studies. 5 studies did not blind assessors, 19 blinded assessors and 13 were unclear as to assessor
blinding. 13 studies had attrition bias greater than 20% and 2 were unclear.
5Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
cise capacity (6MWT))
Distance metres
Follow-up: median 12 weeks
Median change = 3.4 metres Mean functional exercise ca-
pacity (6MWT)) in the inter-
vention groups was
43.93 metres higher
(32.64 to 55.21 higher)
1879
(38 studies)
⊕©©©
Very low2,3,6,7
Change in maximal exercise
capacity (cycle ergometer)
Workmax (watt)
Follow-up: median 12 weeks
Median change = -0.05 watts Mean maximal exercise ca-
pacity (cycle ergometer) in the
intervention groups was
6.77 watts higher
(1.89 to 11.65 higher)
779
(16 studies)
⊕⊕©©
Low2,3,8,9
*The basis for the response on control is the median control group response across studies.
CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
117 studies reported random sequence generation (1 unclear), 12 reported allocation concealment 2 did not have allocation concealment
and it is unclear in 5 studies. 4 studies did not blind assessors, 11 blinded assessors and 4 were unclear as to assessor blinding. 6
studies had attrition bias greater than 20%.
2Downgraded as there is a high level of heterogeneity within the results. Several factors may impact heterogeneity, including content of
the intervention programme, setting of the programme and severity of COPD.
3Greater than optimal Information size (OIS). 95% confidence interval does not includes ‘ ‘ no effect,’’ nor does the confidence limit cross
the MID, so no need to downgrade.
418 studies reported random sequence generation (2 unclear), 10 reported allocation concealment, 2 did not have allocation concealment
and it is unclear in 7 studies. 3 studies did not blind assessors, 9 blinded assessors and 7 were unclear as to assessor blinding. 7
studies had attrition bias greater than 20%.
5All 8 studies reported random sequence generation, 5 reported allocation concealment and it is unclear in 3 studies. 5 studies had blind
assessors with 1 not blinded, and 2 were unclear as to assessor blinding. 4 studies had attrition bias greater than 20%.
634 studies reported random sequence generation, 4 were unclear, 20 reported allocation concealment, 3 did not have allocation
concealment and it is unclear in 15 studies. 5 studies did not blind assessors, 19 blinded assessors and 13 were unclear as to assessor
blinding. 13 studies had attrition bias greater than 20% and 2 were unclear.
5Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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