Wijkstra, Peter Jan

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Proceedings - University of Groningen

   University of GroningenHome rehabilitation in patients with chronic obstructive pulmonary disease the short- term andlong-term effectsWijkstra, Peter JanIMPORTANT 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:1995Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Wijkstra, P. J. (1995). Home rehabilitation in patients with chronic obstructive pulmonary disease the short-term and long-term effects. s.n.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: 28-10-2022Home rehabilitationSUMMARYThe presented studies in this thesis show the benefits of rehabilitation athome in patients with Chronic Obstructive Pulmonary Disease (COPD). In thepast, rehabilitation programmes have been carried out by several investigatorsin different settings and have been designed to improve functional capacity andto alleviate symptoms. In contrast to inpatient programmes rehabilitation athome is more convenient for the patients, because they stay in touch with theirfamilies and apply their training in daily practice. Furthermore, a home careprogramme is possibly cheaper as compared to an inpatient programme. In thisrespect it is remarkable that most studies have investigated effects of inpatientrehabilitation only.In chapter I a review is given with respect to the effects of rehabilitationon impairment, disability and handicap as published up to the time this thesiswas prepared. It is clear that rehabilitation has a number of benefits, likeimproved exercise tolerance and reduction of symptoms. However, mostrehabilitation programmes have investigated short-term effects withoutincluding a control group. Therefore, the aim of our study was to assess bothshort-term and long-term effects of rehabilitation at home in a controlled studyon subjective and objective variables. In addition, we investigated the validityand reliability of the Chronic Respiratory Questionnaire to assess quality of life.Finally, we investigated the validity of peak inspiratory mouth pressure toassess inspiratory muscle strength, because the latter may give additionalinformation about the impairment in COPD.The patients and methods of the study are described in chapter 2. Allpatients showed severe airways obstruction (mean FEV r 44yo of predicted,mean FEV,/M 37%) and low reversibility ( mean increase in FEV, of 0.15 L,5% of predicted FEV'). After stratified randomization the patients v/ereallocated to one of the 3 groups, consisting of 15 patients each. Two groups (Aand B) started a rehabilitation programme for 1.5 year, while 1 group formedthe control group (C), which received no rehabilitation at all. Patients weresupervised by a multidisciplinary team during their rehabilitation progmmme athome, consisting of a pulmonologist, a local physiotherapist, a local nurse, and154rf rehabilitation atse (COPD). In therveral investigatorsional capacity ands rehabilitation atin touch with theirlore, a home care)rogramme. In this:ffects of inpatient.s of rehabilitationre time this thesisof benefits, like, However, mosteffects withoutvas to assess botha controlled studyigated the validityess quality of life.nouth pressure toy give additionaln chapter 2. All.4% of predicted,n  FEV,  o f  0 .15  L ,he patients wereh. Two groups (Ae 1 group formedall. Patients wereion programme ata local nurse, andChapter 10a general practitioner. During the first 12 weeks both rehabilitation groups(A+B) visited a local physiotherapist twice a week. Thereafter, group A visitedthe same physiotherapist once a week, while group B received a follow-up ofonce a month. Both groups visited the general practitioner once a month duringthe first 3 months, while the local nurse was visited by both groups once amonth during 18 months.we used peak inspiratory mouth pressure (P.plmax) to assess inspiratorymuscle strength. Because the validity of P.PImax is not known, we investigatedin chapter 3 whether P.PImax is a valid assessment of inspiratory musclestrength by comparing it with the maximal oesophageal pressure during a sniffmanoeuvre (sniff Poes) in patients with COPD. In addition we investigated thediscriminating capacity of P.PImax. P.PImax showed no learning effect, whilethe intra-individual coefficient of variation was acceptable. Measures ofagreement showed no significant discrepancies between the mean P.PImax andmean sniff Poes. Moreover, P.PImax was significantly lower in both male andfemale coPD patients compared with healthy males and healthy females ofcomparable age. our conclusion is that P.PImax is a valid assessment ofinspiratory muscle strength. In addition, it is a non-invasive method and itrequires little time to assess inspiratory muscle strength. Therefore, it can beeasily used in clinical practice.Quality of life is an important outcome variable in rehabilitation research. Inour study we assessed quality of life by the Chronic Respiratory Questionnaire(cRQ) which contains 4 dimensions: dyspnoea, fatigue, emotion, and mastery.In chapter 4 we investigated the reliability and validity of the cRe, becauseno research was done so far on the psychometric qualities of the cRQ. Theitems of the dimensions fatigue, emotion, and mastery showed a high internalconsistency reliability as well as a high test re-test reliability. In addition, thesethree dimensions correlated significantly with dimensions which cover the samedomains in the scl-90. The latter is a valid questionnaire containingdimensions, like anxiety, depression, sleeping disturbances, and somatization.The items of the dimension dyspnoea showed a low internal consistencyreliability and a moderate test re-test reliability. We concluded that thedimensions fatigue, emotion, and mastery of the CRQ are valid and reliable to1 5 5Home rehabilitationassess quality of life in patients with COPD. We suggest not to include thisdimension in the overall score of the CRQ in comparative research, because theitems of the dimension dyspnoea showed to be less reliable. Nevertheless, thisdimension can be used for intra-individual comnarison.Several studies have investigated the relationship between either objectivevariables or subjective variables on the one hand with exercise tolerance on theother hand. In chapter 5 we investigated the predictive value of both objective(lung function and inspiratory muscle strength) and subjective (quality of lifeand dyspnoea) variables on exercise tolerance. Regression analyses showed thatthe transfer factor for carbonmonoxide (Tr.o) and maximal oesophagealinspiratory pressure (Plmax Pes) were the best predictors of both Wmax and 6-minute walking distance (6MD); the explained variance was 690Á and 54Yo,respectively. We therefore concluded that objective variables are betterpredictors of exercise tolerance in patients with COPD than subjectivevariables.The short-term effects of rehabilitation at home are described in chapter 6and 7. In chapter 6 we assessed the effects of rehabilitation on quality of life.After l2 weeks the rehabilitation group had a significantly improved quality oflife compared to the control group. Although the rehabilitation group showedan improved Wmax as well, the extend of exercise tolerance improvement wasnot significantly correlated with the level of improvement in quality of life. Inchapter 7 we investigated the effects of rehabilitation on dyspnoea andphysiological variables, i.e VOrmax (symptom limited), maximal lactate leveland Tension Time lndex (TTI). The rehabilitation group showed a significantdecrease in dyspnoea, lactate, and TTI, next to a significantly higher Wmax,6MD, and VOrmax compared to the control group. We concluded thatrehabilitation at home provides short-term improvements in both objectivevariables (Wmax and 6MD) and subjective variables, like quality of life. Thefinding that after 12 weeks of rehabilitation lactate, dyspnoea and TTI at themaximal exercise effort were not significantly different between therehabilitation group and the control group is likely due to the fact that theseparameters were measured at a significantly higher Wmax in the rehabilitationgroup than in the control group.r56Chapter l0rot to include thisearch, because theNevertheless, thisrn either objective;e tolerance on the: of both objectiveve (quality of lifealyses showed that;.imal oesophagealboth Wmax and 6-as 690Á and 54%o,riables are better) than subjectiveribed in chapter 6on quality of life.mproved quality oftion group showed: improvement wasr quality of life. Inon dyspnoea andximal lactate levelrowed a significantntly higher Wmax,y'e concluded thatin both objectiveluality of life. Therea and TTI at the'ent between thethe fact that thesen the rehabilitationIn chapter 8 and 9 we investigated the long-term effects of rehabilitation athome. In chapter 8 we showed that quality of life improves in bothrehabilitation groups (A, weekly follow-up and B, monthly follow-up) over l8months of follow-up, being significant in group B when quality of life after 3,6, 12, an 18 months was compared to baseline level in quality of life.Moreover, group B showed a significantly higher quality of life compared tothe control group C at 3 and 12 months. Both rehabilitation groups did notimprove their Wmax and 6-minute walking distance during l8 months, whereascontrol group C showed a gradual decline in Wmax and 6MD, being significantat 12 and l8 months compared to their baseline value (chapter 9). In addition,group A improved their inspiratory muscle function and dyspnoea score atWmax at 18 months, both compared to baseline. The dyspnoea at Wmax ingroup A was also significantly improved compared to control group C.Therefore, we conclude that weekly follow-up of physiotherapy is necessary toimprove dyspnoea at Wmax, while monthly follow-up of physiotherapy issufficient to sustain an initially improved quality of life.CONCLUSIONSThe following conclusions can be drawn from our study, in which weincluded COPD patients with severe airways obstruction ( inclusion criteria :FEVI < 60% predicted, and 2) FEV'/IVC< 50yo, both after bronchodilation).1) Rehabilitation at home in patients with COPD provides both short- andlong-term improvements in quality of life.2) Rehabilitation at home in patients with COPD provides short-termimprovements in exercise tolerance, inspiratory muscle strength andendurance capacity of the inspiratory muscles. Furthermore, after 12 weeksof rehabilitation at home there is a trend in decreasing the workload of theinspiratory muscles (Tension Time Index) and a reduction of the maximallactate level at Wmax.3) Weekly follow-up of physiotherapy after an initial comprehensiverehabilitation programme at home in patients with COPD shows a trend inimproving inspiratory muscle function.157Home rehabilitation4) Weekly follow-up of physiotherapy after an initial comprehensiverehabilitation programme at home in patients with COPD decreasesdyspnoea during maximal exercise.5) Monthly follow-up of physiotherapy after an initial comprehensiverehabilitation programme at home in patients with COPD is sufficient tosustain an initially improved quality of life.6) Peak inspiratory mouth pressure is a valid assessment of inspiratory musclestrength.7) The items of the Chronic Respiratory Questionnaire relating to thedimensions fatigue, emotion, and mastery are reliable and valid and cangenerally be used to assess quality of life.8) Diffusion capacity and inspiratory muscle strength are the best predictors ofexercise tolerance in COPD patients with severe airways obstruction.DIRECTIONS FOR FUTURE RESEARCHRehabilitation programmes have shown to be beneficial in patients withCOPD. There remain, however, several questions.1) Our multidisciplinary rehabilitation programme showed to be beneficial inthe treatment of patients with COPD, which is in agreement with otherstudies. However, until now the effects of specific parts of thiscomprehensive programme on impairment, disability, and handicap are notknown. Therefore, further rehabilitation studies should focus on the questionhow specific treatment modalities can improve pafticular elements inpatients with COPD.2) The combination of an improved inspiratory muscle function at rest and animproved dyspnoea during exercise after rehabilitation suggests a relationbetween both variables. Further studies should be carried out to investigatethe effects of inspiratory muscle training on functional variables, likeexercise tolerance, dyspnoea, and ADL.3) Our study shows a decrease in the workload of the inspiratory muscles asassessed by the Tension Time Index (TTI) after rehabilitation. Therefore, weadvocate to incorporate the assessment of TTI in exercise tests in patients1 5 8Chapter 10nitial comprehensiveith COPD decreasesnitial comprehensiveIOPD is sufficient toof inspiratory muscleaire relating to thele and valid and canthe best predictors ofrs obstruction.icial in patients withed to be beneficial inagreement with otherrecific parts of thisand handicap are notfocus on the question'articular elements inunction at rest and anrn suggests a relationried out to investigate;tional variables, likeinspiratory muscles aslitation. Therefore, werrcise tests in patients4)s)6)with COPD in order to find possible specific training effects on theinspiratory muscles after rehabilitation. In addition, a decrease of the TTImay cause also a decrease of dyspnoea and in this way the TTI may behelpful in the understanding of dyspnoea during exercise.Our study is the first study to show a decline in exercise tolerance in thecontrol group in contrast to other previous studies in which no control groupwas included. Therefore, further long-term studies must include a controlgroup to investigate whether rehabilitation improves exercise tolerance orprevents a decline of it.An important question in rehabilitation studies is whether long-termrehabilitation programmes decrease the number of exacerbations andhospitalizations. To be able to answer this question it is important that thepatients are stratified for the number of exacerbations and hospitalizationsthey had before the study, because lung function or exercise tolerancecannot predict the exacerbation rate nor the hospitalization rate.Although it is clear that rehabilitation has a number of benefits, animportant point of further investigation should be a cost-benefit analysis. Inthis analysis one has to compare on the one hand the benefits ofrehabilitation, like a decrease in dyspnoea, improved quality of life, anincreased life span and on the other hand the costs of a rehabilitationprogramme.159

Home rehabilitation in patients with chronic obstructive pulmonary disease the short- term and long-term effects

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Home rehabilitation in patients with chronic obstructive pulmonary disease the short- term and long-term effects

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