Outcomes of pulmonary rehabilitation in chronic obstructive pulmonary disease
AuthorLuk, Edwin Kai Man
Document TypePhD thesis
Access StatusOpen Access
© 2017 Dr. Edwin Kai Man Luk
Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease causing significant impairment and activity limitation. One in 20 Australians over 45 have COPD and in 2004 COPD related diseases were the fifth leading cause of death in Australia (1). COPD remains the second leading cause of avoidable hospital admissions (2). Significant costs are involved to manage persons with COPD including acute hospitalisation, rehabilitation and supportive care (3). COPD affects not only the lungs but has widespread systemic involvement, therefore symptoms extend beyond a productive cough and dyspnoea (4). Up until recently, it was thought that exercise was detrimental for patients with COPD and bedrest was the only appropriate activity (5). Evidence since then has proven that even though physical exercise does not change lung function, it can improve clinically meaningful physical and Quality of Life (QOL) outcomes (6, 7). Despite this, beyond physical exercise, it is unclear which are the best components and intensity in a Pulmonary Rehabilitation (PR) program (8, 9). The main hypothesis of this thesis is that PR is effective in the management of COPD in relation to improving general wellbeing and QOL as well as reducing healthcare utilisation. The International Classification of Function, Disability and Health (ICF) was utilised to identify impairments, limitations and participation restrictions in persons with COPD. Four linked studies were developed in this thesis to address current gaps in evidence based practice in the management of stable COPD. A standardised framework was utilised to develop protocols for these studies. Firstly, a systematic review was developed to look into existing research into non-pharmacological and non-surgical interventions in the management of COPD and identify areas requiring further research. Two studies were then designed to investigate the performance of PR. One study investigated the acute healthcare utilisation of patients who participate in an Integrated Disease Management (IDM) and a PR program. Another study investigated whether physical and QOL gains following PR were maintained into the longer term. Lastly, a new intervention was added to a pre-existing community PR program to further improve its effectiveness. Gaps in evidence in relation to the optimal type of interventions and performance of PR were identified and recommendations were made to enhance current COPD management guidelines and guide future research. Study 1 presented a systematic review on commonly used non-pharmacological, non-surgical interventions in PR. High quality evidence was available for physical exercise. Interventions such as inspiratory muscle training, self-management and integrated disease management have systematic reviews confirming their effectiveness. Techniques such as breathing exercises and psychological interventions have yet to show consistent improvements between trials. The study highlighted further large trials are required for some of these interventions. The optimal intensity, combination or components of PR remain unknown. Study 2 was designed to see whether further improvements in patient participation and clinical outcomes could be made to a pre-existing community PR program. A cohort of patients was given additional group based Cognitive Behavioural Therapy (CBT) with themes designed to complement the physical and education components. The CBT group had significant improvements in exercise capacity, fatigue, stress and depression. No significant changes were seen in the control group. This showed CBT should be considered as an add on to current conventional PR programs to enhance its performance. Studies 3 and 4 looked at the structure and effectiveness of the PR program. Study 3 reassessed patients more than one year after completion of a PR program. The repeat assessment consisted of recording patients’ physical exercise capacity, QOL, anxiety and depression measures. Following PR, many of gains made immediately post PR were lost in the long term. This highlights the need for regular surveillance or monitoring of these patients post-PR to identify those requiring further intervention. Study 4 investigated changes in acute healthcare utilisation following enrolment in IDM and PR programs. Using 12 years of consecutive patient data, a comparison was made between hospitalisation and ED presentations before and after participation in IDM. This showed IDM alone was effective in the reduction of healthcare utilisation, however the addition of PR did not reduce healthcare usage further. A survival benefit was seen in those who were PR completers compared to patients who received IDM only. This was the first such study that allowed a comparison of whether the combination of both IDM and PR produced any additional benefit. In conclusion PR programs are highly effective in improving the QOL and wellbeing of persons with COPD. A multifaceted approach is required for the management of COPD. Rehabilitation strategies act to complement but not replace optimal pharmacological and surgical therapy. The ICF model in which the thesis is based upon allows the accurate documentation and mapping of the disability associated with the disease.
Keywordschronic obstructive pulmonary disease; pulmonary rehabilitation; exercise; cognitive therapy
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