The presented studies in this thesis show the benefits of rehabilitation at home in patients with Chronic Obstructive Pulmonary Disease (COPD). In the past, rehabilitation programmes have been carried out by several investigators
in different settings and have been designed to improve functional capacity and to alleviate symptoms. In contrast to inpatient programmes rehabilitation at home is more convenient for the patients, because they stay in touch with their families and apply their training in daily practice.

Zie: Summary

Wijkstra, Peter Jan,

Wijkstra, Peter Jan

University of Groningen Research Database

  
 University of Groningen
Home rehabilitation in patients with chronic obstructive pulmonary disease the short- term and
long-term effects
Wijkstra, Peter J.
IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from
it. Please check the document version below.
Document Version
Publisher's PDF, also known as Version of record
Publication date:
1995
Link to publication in University of Groningen/UMCG research database
Citation 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.
Copyright
Other 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 the
author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).
Take-down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately
and investigate your claim.
Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the
number of authors shown on this cover page is limited to 10 maximum.
Download date: 10-02-2018
Home rehabilitation
SUMMARY
The presented studies in this thesis show the benefits of rehabilitation at
home in patients with Chronic Obstructive Pulmonary Disease (COPD). In the
past, rehabilitation programmes have been carried out by several investigators
in different settings and have been designed to improve functional capacity and
to alleviate symptoms. In contrast to inpatient programmes rehabilitation at
home is more convenient for the patients, because they stay in touch with their
families and apply their training in daily practice. Furthermore, a home care
programme is possibly cheaper as compared to an inpatient programme. In this
respect it is remarkable that most studies have investigated effects of inpatient
rehabilitation only.
In chapter I a review is given with respect to the effects of rehabilitation
on impairment, disability and handicap as published up to the time this thesis
was prepared. It is clear that rehabilitation has a number of benefits, like
improved exercise tolerance and reduction of symptoms. However, most
rehabilitation programmes have investigated short-term effects without
including a control group. Therefore, the aim of our study was to assess both
short-term and long-term effects of rehabilitation at home in a controlled study
on subjective and objective variables. In addition, we investigated the validity
and reliability of the Chronic Respiratory Questionnaire to assess quality of life.
Finally, we investigated the validity of peak inspiratory mouth pressure to
assess inspiratory muscle strength, because the latter may give additional
information about the impairment in COPD.
The patients and methods of the study are described in chapter 2. All
patients 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/ere
allocated to one of the 3 groups, consisting of 15 patients each. Two groups (A
and B) started a rehabilitation programme for 1.5 year, while 1 group formed
the control group (C), which received no rehabilitation at all. Patients were
supervised by a multidisciplinary team during their rehabilitation progmmme at
home, consisting of a pulmonologist, a local physiotherapist, a local nurse, and
154
rf rehabilitation at
se (COPD). In the
rveral investigators
ional capacity and
s rehabilitation at
in touch with their
lore, a home care
)rogramme. In this
:ffects of inpatient
.s of rehabilitation
re time this thesis
of benefits, like
, However, most
effects without
vas to assess both
a controlled study
igated the validity
ess quality of life.
nouth pressure to
y give additional
n chapter 2. All
.4% of predicted,
n  FEV,  o f  0 .15  L ,
he patients were
h. Two groups (A
e 1 group formed
all. Patients were
ion programme at
a local nurse, and
Chapter 10
a general practitioner. During the first 12 weeks both rehabilitation groups
(A+B) visited a local physiotherapist twice a week. Thereafter, group A visited
the same physiotherapist once a week, while group B received a follow-up of
once a month. Both groups visited the general practitioner once a month during
the first 3 months, while the local nurse was visited by both groups once a
month during 18 months.
we used peak inspiratory mouth pressure (P.plmax) to assess inspiratory
muscle strength. Because the validity of P.PImax is not known, we investigated
in chapter 3 whether P.PImax is a valid assessment of inspiratory muscle
strength by comparing it with the maximal oesophageal pressure during a sniff
manoeuvre (sniff Poes) in patients with COPD. In addition we investigated the
discriminating capacity of P.PImax. P.PImax showed no learning effect, while
the intra-individual coefficient of variation was acceptable. Measures of
agreement showed no significant discrepancies between the mean P.PImax and
mean sniff Poes. Moreover, P.PImax was significantly lower in both male and
female coPD patients compared with healthy males and healthy females of
comparable age. our conclusion is that P.PImax is a valid assessment of
inspiratory muscle strength. In addition, it is a non-invasive method and it
requires little time to assess inspiratory muscle strength. Therefore, it can be
easily used in clinical practice.
Quality of life is an important outcome variable in rehabilitation research. In
our 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, because
no research was done so far on the psychometric qualities of the cRQ. The
items of the dimensions fatigue, emotion, and mastery showed a high internal
consistency reliability as well as a high test re-test reliability. In addition, these
three dimensions correlated significantly with dimensions which cover the same
domains in the scl-90. The latter is a valid questionnaire containing
dimensions, like anxiety, depression, sleeping disturbances, and somatization.
The items of the dimension dyspnoea showed a low internal consistency
reliability and a moderate test re-test reliability. We concluded that the
dimensions fatigue, emotion, and mastery of the CRQ are valid and reliable to
1 5 5
Home rehabilitation
assess quality of life in patients with COPD. We suggest not to include this
dimension in the overall score of the CRQ in comparative research, because the
items of the dimension dyspnoea showed to be less reliable. Nevertheless, this
dimension can be used for intra-individual comnarison.
Several studies have investigated the relationship between either objective
variables or subjective variables on the one hand with exercise tolerance on the
other hand. In chapter 5 we investigated the predictive value of both objective
(lung function and inspiratory muscle strength) and subjective (quality of life
and dyspnoea) variables on exercise tolerance. Regression analyses showed that
the transfer factor for carbonmonoxide (Tr.o) and maximal oesophageal
inspiratory 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 better
predictors of exercise tolerance in patients with COPD than subjective
variables.
The short-term effects of rehabilitation at home are described in chapter 6
and 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 of
life compared to the control group. Although the rehabilitation group showed
an improved Wmax as well, the extend of exercise tolerance improvement was
not significantly correlated with the level of improvement in quality of life. In
chapter 7 we investigated the effects of rehabilitation on dyspnoea and
physiological variables, i.e VOrmax (symptom limited), maximal lactate level
and Tension Time lndex (TTI). The rehabilitation group showed a significant
decrease in dyspnoea, lactate, and TTI, next to a significantly higher Wmax,
6MD, and VOrmax compared to the control group. We concluded that
rehabilitation at home provides short-term improvements in both objective
variables (Wmax and 6MD) and subjective variables, like quality of life. The
finding that after 12 weeks of rehabilitation lactate, dyspnoea and TTI at the
maximal exercise effort were not significantly different between the
rehabilitation group and the control group is likely due to the fact that these
parameters were measured at a significantly higher Wmax in the rehabilitation
group than in the control group.
r56
Chapter l0
rot to include this
earch, because the
Nevertheless, this
rn either objective
;e tolerance on the
: of both objective
ve (quality of life
alyses showed that
;.imal oesophageal
both Wmax and 6-
as 690Á and 54%o,
riables are better
) than subjective
ribed in chapter 6
on quality of life.
mproved quality of
tion group showed
: improvement was
r quality of life. In
on dyspnoea and
ximal lactate level
rowed a significant
ntly higher Wmax,
y'e concluded that
in both objective
luality of life. The
rea and TTI at the
'ent between the
the fact that these
n the rehabilitation
In chapter 8 and 9 we investigated the long-term effects of rehabilitation at
home. In chapter 8 we showed that quality of life improves in both
rehabilitation groups (A, weekly follow-up and B, monthly follow-up) over l8
months 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 to
the control group C at 3 and 12 months. Both rehabilitation groups did not
improve their Wmax and 6-minute walking distance during l8 months, whereas
control group C showed a gradual decline in Wmax and 6MD, being significant
at 12 and l8 months compared to their baseline value (chapter 9). In addition,
group A improved their inspiratory muscle function and dyspnoea score at
Wmax at 18 months, both compared to baseline. The dyspnoea at Wmax in
group A was also significantly improved compared to control group C.
Therefore, we conclude that weekly follow-up of physiotherapy is necessary to
improve dyspnoea at Wmax, while monthly follow-up of physiotherapy is
sufficient to sustain an initially improved quality of life.
CONCLUSIONS
The following conclusions can be drawn from our study, in which we
included 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- and
long-term improvements in quality of life.
2) Rehabilitation at home in patients with COPD provides short-term
improvements in exercise tolerance, inspiratory muscle strength and
endurance capacity of the inspiratory muscles. Furthermore, after 12 weeks
of rehabilitation at home there is a trend in decreasing the workload of the
inspiratory muscles (Tension Time Index) and a reduction of the maximal
lactate level at Wmax.
3) Weekly follow-up of physiotherapy after an initial comprehensive
rehabilitation programme at home in patients with COPD shows a trend in
improving inspiratory muscle function.
157
Home rehabilitation
4) Weekly follow-up of physiotherapy after an initial comprehensive
rehabilitation programme at home in patients with COPD decreases
dyspnoea during maximal exercise.
5) Monthly follow-up of physiotherapy after an initial comprehensive
rehabilitation programme at home in patients with COPD is sufficient to
sustain an initially improved quality of life.
6) Peak inspiratory mouth pressure is a valid assessment of inspiratory muscle
strength.
7) The items of the Chronic Respiratory Questionnaire relating to the
dimensions fatigue, emotion, and mastery are reliable and valid and can
generally be used to assess quality of life.
8) Diffusion capacity and inspiratory muscle strength are the best predictors of
exercise tolerance in COPD patients with severe airways obstruction.
DIRECTIONS FOR FUTURE RESEARCH
Rehabilitation programmes have shown to be beneficial in patients with
COPD. There remain, however, several questions.
1) Our multidisciplinary rehabilitation programme showed to be beneficial in
the treatment of patients with COPD, which is in agreement with other
studies. However, until now the effects of specific parts of this
comprehensive programme on impairment, disability, and handicap are not
known. Therefore, further rehabilitation studies should focus on the question
how specific treatment modalities can improve pafticular elements in
patients with COPD.
2) The combination of an improved inspiratory muscle function at rest and an
improved dyspnoea during exercise after rehabilitation suggests a relation
between both variables. Further studies should be carried out to investigate
the effects of inspiratory muscle training on functional variables, like
exercise tolerance, dyspnoea, and ADL.
3) Our study shows a decrease in the workload of the inspiratory muscles as
assessed by the Tension Time Index (TTI) after rehabilitation. Therefore, we
advocate to incorporate the assessment of TTI in exercise tests in patients
1 5 8
Chapter 10
nitial comprehensive
ith COPD decreases
nitial comprehensive
IOPD is sufficient to
of inspiratory muscle
aire relating to the
le and valid and can
the best predictors of
rs obstruction.
icial in patients with
ed to be beneficial in
agreement with other
recific parts of this
and handicap are not
focus on the question
'articular elements in
unction at rest and an
rn suggests a relation
ried out to investigate
;tional variables, like
inspiratory muscles as
litation. Therefore, we
rrcise tests in patients
4)
s)
6)
with COPD in order to find possible specific training effects on the
inspiratory muscles after rehabilitation. In addition, a decrease of the TTI
may cause also a decrease of dyspnoea and in this way the TTI may be
helpful in the understanding of dyspnoea during exercise.
Our study is the first study to show a decline in exercise tolerance in the
control group in contrast to other previous studies in which no control group
was included. Therefore, further long-term studies must include a control
group to investigate whether rehabilitation improves exercise tolerance or
prevents a decline of it.
An important question in rehabilitation studies is whether long-term
rehabilitation programmes decrease the number of exacerbations and
hospitalizations. To be able to answer this question it is important that the
patients are stratified for the number of exacerbations and hospitalizations
they had before the study, because lung function or exercise tolerance
cannot predict the exacerbation rate nor the hospitalization rate.
Although it is clear that rehabilitation has a number of benefits, an
important point of further investigation should be a cost-benefit analysis. In
this analysis one has to compare on the one hand the benefits of
rehabilitation, like a decrease in dyspnoea, improved quality of life, an
increased life span and on the other hand the costs of a rehabilitation
programme.
159


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

NARCIS 

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

English

ARTS repository - 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: 06-06-2022Home 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

   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: 30-10-2023Home 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

Dissertations of the 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: 28-12-2022Home 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

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   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).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: 12-11-2019Home 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

   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: 09-09-2023Home 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

   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: 16-07-2023Home 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

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

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