Wijkstra, P J

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Proceedings - University of Groningen

   University of GroningenHome based rehabilitation for patients with COPDWijkstra, P JPublished in:Monaldi Archives for Chest DiseaseIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2003Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Wijkstra, P. J. (2003). Home based rehabilitation for patients with COPD: Is it equally effective as comparedto outpatient rehabilitation? Monaldi Archives for Chest Disease, 59(4), 335-7.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 12-10-2022Monaldi Arch Chest Dis2003; 59: 4, 335-337 PROCEEDINGS OF “ADVANCES IN PULMONARY REHABILITATION”Home based rehabilitation for patientswith COPD. Is it equally effective as compared to outpatient rehabilitation?P.J. WijkstraIntroductionPulmonary rehabilitation programmes are nowwell established to provide a multidisciplinary ap-proach to control and alleviate symptoms and tooptimise functional capacity in patients withchronic obstructive pulmonary disease (COPD).The benefits of pulmonary rehabilitation havebeen shown in many randomised controlled stud-ies [1-4]. While, most of them were carried out inan inpatient or outpatient setting, the last decade asubstantial number of studies have investigated itseffects in the home setting. The latter option can bevery attractive to patients with severe COPD, as itis more convenient for them and their family, pa-tients can train in their own environment and itmight be easier for them to apply their training indaily life. This paper will focus on some aspects ofhome based rehabilitation and will also compareits effects with outpatient rehabilitation. The fol-lowing issues will be discussed:1) Which patient should be included?2) How is the organisation of the programme?3) What are the effects?4) Is it equally effective as compared to outpa-tient rehabilitation?Which patient should be included?In 1997 the rehabilitation and Chronic CareScientific Group of the European Respiratory So-ciety published a position paper on rehabilitationfor patients with COPD [5]. According to this pa-per typical candidates for home based rehabilita-tion would be: 1) newly diagnosed and first timehospitalised patients, 2) patients with recurrent ex-acerbations, 3) patients after formal inpatient oroutpatient rehabilitation, 4) anxious, confused andforgaetfull patients 5) end stage terminal patients.They concluded that home based rehabilitationwas more a sort of follow-up after inpatient or out-patient rehabilitation. In fact this is correct becauserehabilitation in the home setting can not providethe same multidisciplinary treatment as comparedto an in-or outpatient programme. However, thequestion is whether every patient needs this multi-disciplinary approach. Until now literature did notinvestigate which patient is a suitable candidate foreither inpatient rehabilitation or training in thehome setting. Most studies that showed positiveeffects of rehabilitation in the community includedpatients with a mean forced expiratory volume inone second (FEV1) between 40% and 60% pre-dicted [6-10]. The study of Wedzicha et al. includ-ed patients with a lower FEV1 (mean 37% pred.)and showed that home based rehabilitation in thesepatients was not effective [11]. However, there aresome concerns about the intensity of training inthis study. The well-known meta-analysis of respi-ratory rehabilitation showed that home rehabilita-tion could be equally effective in improving func-tional status and quality of life as compared to in-patient rehabilitation [1]. At present we can notconclude that rehabilitation at home for a specifictype of patient is less effective. The complexity ofmedical, psychological and social problems of apatient with COPD determines the staff needed fora rehabilitation programme and thus determinesthe setting. This means that if the situation is com-plex and therefore multidisplinary treatment isnecessary, rehabilitation in the home setting is notthe preferable setting. However, if a less intensiveintervention is needed, patients can be adequatelytrained both in an outpatient setting and at home.How is the organisation of the programme?In fact home based rehabilitation can be set upin two different ways. While initial instruction andsupervision takes place in the outpatient clinic ofthe hospital, the patients train in their own homes.Another possibility is that both training and super-vision takes place in the community, where pa-tients do their daily training at home and visit reg-ularly their physical therapist. Because in neitherset up the programme takes entirely place in thehouse of the patient some people prefer to talkabout community based rehabilitation instead ofDepartment of Pulmonary Diseases / Home Mechanical Ventilation, University Hospital of Groningen, The Netherlands.Correspondence: PJ Wijkstra, PhD, MD; Department of Pulmonary Diseases / Home Mechanical Ventilation; UniversityHospital Groningen, Post-box 30001, 9700 RB Groningen, The Netherlands; e-mail:p.j.wijkstra@int.azg.nlMonaldi Arch Chest Dis 2003; 59: 4, 335-337.336P.J. WIJKSTRAhome based rehabilitation. Nevertheless, in all sit-uations an initial evaluation of the patients has totake place in the hospital. This assessment shouldinclude lung function and exercise tests. Base up-on the outcomes the responsible pulmonary physi-cian should decide if the patient is a good candi-date for a programme in the community. The struc-ture of such a programme is not well described.Exercises can be carried out unsupervised [12] orthe patients can be supervised by a physical thera-pist [6, 8, 10, 11]. In some studies the patients werealso supervised by a general practitioner or a spe-cialised nurse [8, 10].What are the effects of home based rehabilitation?The first study showing benefits of training athome was the study of Mcgavin et al. [12]. Theyfound that 3 months of unsupervised stairclimbingbenefitted significantly general well-being and re-duced dyspnoea. In addition the 12 minute walk-ing distance (12-MWD) increased significantly inthe exercise group in contrast to the control group.In the nineties several other studies showed thathome based rehablitaton was effective in improv-ing exercise tolerance [6-8, 10] and Quality of life(QOL) [6, 7, 10], while it reduced dyspnoea [7,10]. In addition two dutch studies showed thatbenefits can even be maintained for up to 18months, both with [13] and without supervision[8]. In contrast Wedzicha et al. did not find bene-fits of rehabilitation at home in patients with amean FEV1 of around 0.9 L and a dyspnoea soreof 5 on the Medical Research Council scale(MRC) [11]. No significant changes were found inboth shuttle walking distance and quality of lifescore. However, there is some discussion whetherthe intensity of training in this group was highenough to achieve benefits. Still, this study raisesthe question whether patients with severe COPDcan be included for training in the home setting. Inthis respect, an interesting paper was published re-cently. In the study of Neder et al. 15 patients withadvanced COPD (mean FEV1 39% pred.) wererandomised to either a home based 6 week quadri-ceps femoris neuromuscular electrical stimulation(NMES) training programme (n=9) or to a 6 weekcontrol period before receiving NMES (n=6) [14].Knee extensor strength and endurance, wholebody exercise capacity, and health related qualityof life were assessed. All patients were able tocomplete the NMES training programme success-fully, even in the presence of exacerbations (n=4).This study showed significant improvements inmuscle function, maximal and endurance exercisetolerance, and the dyspnoea domain of the CRDQ(p<0.05) after NMES. They concluded that se-verely disabled COPD patients with incapacitat-ing dyspnoea, short term electrical stimulation ofselected muscles can improve muscle function,exercise tolerance, and breathlessness during ac-tivities of daily living. From this study we learnthat even for this group of patients a training pro-gramme in the community can be effective.Is home based rehabilitation equally effectiveas compared to outpatient rehabilitation?In contrast to the previous section there are on-ly limited studies available that have investigatedthis question. Currently, there are two studies com-paring rehabilitation in the home setting with out-patient setting [8, 15]. Strijbos et al. were the firstcomparing the effects of a 12-week hospital basedoutpatient rehabilitation programme (HRP) withthose of a 12 week home care rehabilitation pro-gramme (HCRP) in patients with COPD (meanFEV1 1.0 L, 42% pred.) [8]. A control group didnot receive rehabilitation. Patients in the HRPgroup came to the hospital twice a week during 12consecutive weeks. The sessions of physical thera-py (exercise training, breathing and relaxation ex-ercises, broncial hygiene and education) took 1hour each. The patients were instructed to practicedaily at home for 15 minutes. Patients in the HRCPgroup received the same programme at home,however, supervised by a local physical therapist.These programmes had a duration 1 hour and weregiven 24 times (in 12 weeks). The patients were al-so instructed to practice daily at home for 15 min-utes. Besides physical therapy the patients werevisited once monthly by a specialised nurse whochecked medication and motivated the patients tocontinue their exercises. After 3 and 6 months thesame improvements were detected for maximalexercise capacity (Wmax), 4 minute walking test,and dyspnoea levels at the same workload(Wmax). Still after HRCP a further ongoing im-provement in Wmax was observed while it tendedto decrease in the HRP group. The authors recom-mend initiation of home based rehabilitation in pa-tients with COPD as the improvements are main-tained longer in this setting.Puente Maestu recently published a studycomparing a high intensity supervised trainingprogramme with a selfmonitored trainings pro-gramme of low intensity during 8 weeks [15].Fourty one patients with COPD (FEV1 41 ± 6%pred.) were randomly assigned either to a super-vised training on a treadmill (S group) for 4 days aweek or walking exercises on 4 days a week (SMgroup). The S group trained on a treadmill startingat 3 km/h and a slope leading to an oxygen uptakeequivalent of 25% of the difference between max-imum oxygen uptake (VO2 max) and the oxygenuptake at which the lactic acidosis threshold wasdetected (VO2, lat). From that point they tried toincrease the treadmill distance for 2% for everyweek. Patients trained 4 days a week for 60 min-utes per day under supervision. The SM group wasapplied with a pedometer and was asked to walk 3or 4 km in 1 hour a day on level ground for 4 daysa week. Due to the design of the study, there was asignificant difference in total work performed be-tween both groups, 8001 Kilo-Joules (kJ) and4237 kJ respectively. After 8 weeks of training asignificantly higher VO2 max was shown in the in-cremental test in the S group. There was also a sig-nificant decrease in lacatate accumulation and res-piratory rate at the end of the constant exercise test337HOME BASED REHABILITATION FOR PATIENTS WITH COPD. IS IT EQUALLY EFFECTIVE AS COMPARED TO OUTPATIENT REHABILITATION?in the S group. However, no significant effects be-tween both groups were found for QOL, whichmight be more important for the patient. This sug-gests that high intensity training is necessary toachieve physiological improvements, while a lowintensity self administered programme can achievethis to a lesser degree. Larsson et al. [9] showedsome years ago that home based training could al-so lead to physiological training effects. Cycle er-gometer training for 4 months in patients with amean FEV1 of 50% pred., increased peak oxygenuptake on a graded exercise test and lead to a de-crease in heart rate and minute ventilation with nochange in oxygen uptake at identical work rates atsubmaximal levels. In addition, Wijkstra et al.showed earlier that home based rehabilitation leada significant increase in VO2 max, while there wasafter 12 weeks of training a significant decrease inlactate accumulation and decrease in the workloadof the inspiratory muscles at a significantly higherWmax [16]. This all means that the setting of re-habilitation setting does not determine whether ph-siological improvements can be achieved, but theintensity level. When the intensity of training ishigh enough physiological effects can be achievedin the home setting as well.In summary, home based rehabilitation is anatttractive approach for patients with severeCOPD. Low intensity programmes in the commu-nity can improve both exercise capacity and quali-ty of life. There is also some evidence that truephysiological improvements can be achieved aswell if the intensity of training is high enough. Forpatients with incapacitating dypsnoea neuro elec-trical muscle stimulation in the home setting seemsto be an attractive approach for the future. At thismoment there is no evidence that home based re-habilitation is less effective as compared to outpa-tient rehabilitation. Both settings are probablycomplementary and either one is preferable de-pending on the type of patient and available thera-py in the community.Reference1. Lacasse Y, Wong E, Guyatt GH, King D, Cook DJ,Goldstein RS. Meta-analysis of respiratory rehabilita-tion in chronic obstructive pulmonary disease. Lancet1996; 348 (9035): 1115-1119.2. Goldstein RS, Gort EH, Stubbing D, Avendano MA,Guyatt GH. Randomised controlled trial of respiratoryrehabilitation. The Lancet 1994; 344: 1394-1397.3. Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V,Mullins J, Shiels K et al. Results at 1 year of outpatientmultidisciplinary pulmonary rehabilitation: a ran-domised controlled trial. Lancet 2000; 355 (9201): 362-368.4. Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Ef-fects of pulmonary rehabilitation on physiologic andpsychosocial outcomes in patients with chronic ob-structive pulmonary disease. Ann Intern Med 1995; 122(11): 823-832.5. Donner CF, Muir JF. Selection criteria and programmesfor pulmonary rehabilitation in COPD patients. Reha-bilitation and Chronic Care Scientific Group of the Eu-ropean Respiratory Society. Eur Respir J 1997; 10 (3):744-757.6. Cambach W, Chadwick-Straver RV, Wagenaar RC,van Keimpema AR, Kemper HC. The effects of a com-munity-based pulmonary rehabilitation programme onexercise tolerance and quality of life: a randomizedcontrolled trial. Eur Respir J 1997; 10 (1): 104-113.7. Hernandez MT, Rubio TM, Ruiz FO, Riera HS, Gil RS,Gomez JC. Results of a home-based training programfor patients with COPD. Chest 2000; 118 (1): 106-114.8. Strijbos JH, Postma DS, van Altena R, Gimeno F,Koeter GH. A comparison between an outpatient hospi-tal-based pulmonary rehabilitation program and ahome-care pulmonary rehabilitation program in patientswith COPD. A follow-up of 18 months. Chest 1996;109 (2): 366-372.9. Larson JL, Covey MK, Wirtz SE, Berry JK, Alex CG,Langbein WE et al. Cycle ergometer and inspiratorymuscle training in chronic obstructive pulmonary dis-ease. Am J Respir Crit Care Med 1999; 160 (2): 500-507.10. Wijkstra PJ, van Altena R, Kraan J, Otten V, PostmaDS, Koeter GH. Quality of life in patients with chronicobstructive pulmonary disease improves after rehabili-tation at home. Eur Respir J 1994; 7 (2): 269-273.11. Wedzicha JA, Bestall JC, Garrod R, Garnham R, PaulEA, Jones PW. Randomized controlled trial of pul-monary rehabilitation in severe chronic obstructive pul-monary disease patients, stratified with the MRC dysp-noea scale. Eur Respir J 1998; 12 (2): 363-369.12. McGavin CR, Gupta SP, Lloyd EL, McHardy GJ. Phys-ical rehabilitation for the chronic bronchitic: results of acontrolled trial of exercises in the home. Thorax 1977;32 (3): 307-311.13. Wijkstra PJ, Ten Vergert EM, van Altena R, Otten V,Kraan J, Postma DS et al. Long term benefits of reha-bilitation at home on quality of life and exercise toler-ance in patients with chronic obstructive pulmonarydisease. Thorax 1995; 50 (8): 824-828.14. Neder JA, Sword D, Ward SA, Mackay E, CochraneLM, Clark CJ. Home based neuromuscular electricalstimulation as a new rehabilitative strategy for severelydisabled patients with chronic obstructive pulmonarydisease (COPD). Thorax 2002; 57 (4): 333-337.15. Puente-Maestu L, Sanz ML, Sanz P, Cubillo JM, May-ol J, Casaburi R. Comparison of effects of supervisedversus self-monitored training programmes in patientswith chronic obstructive pulmonary disease. Eur RespirJ 2000; 15 (3): 517-525.16. Wijkstra PJ, van der Mark TW, Kraan J, van Altena R,Koeter GH, Postma DS. Effects of home rehabilitationon physical performance in patients with chronic ob-structive pulmonary disease (COPD). Eur Respir J1996; 9 (1): 104-110.

Home based rehabilitation for patients with COPD:Is it equally effective as compared to outpatient rehabilitation?

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Home based rehabilitation for patients with COPD:Is it equally effective as compared to outpatient rehabilitation?

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