Textbooks of Pulmonary Rehabilitation [PDF]

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Textbook of Pulmonary Rehabilitation Enrico Clini Anne E. Holland Fabio Pitta Thierry Troosters Editors



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Textbook of Pulmonary Rehabilitation



Enrico Clini  •  Anne E. Holland Fabio Pitta  •  Thierry Troosters Editors



Textbook of Pulmonary Rehabilitation



Editors Enrico Clini Department of Medical and Surgical Sciences University of Modena Azienda Ospedaliero Universitaria di Modena Policlinico Modena, Italy Fabio Pitta State University of Londrina Londrina, Paraná, Brazil



Anne E. Holland Alfred Health and Institute for Breathing and Sleep, La Trobe University Melbourne, Australia Thierry Troosters Department of Rehabilitation Sciences KU Leuven, Respiratory Division and Rehabilitation University Hospital Leuven Leuven, Belgium



ISBN 978-3-319-65887-2    ISBN 978-3-319-65888-9 (eBook) https://doi.org/10.1007/978-3-319-65888-9 Library of Congress Control Number: 2017962903 © Springer International Publishing AG 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland



Foreword



To borrow a phrase from Charles Dickens, for pulmonary rehabilitation this is the best of times and the worst of times. A strong scientific basis has been gathered which makes pulmonary rehabilitation arguably the most effective therapy we have to offer patients with pulmonary disease. Yet the lack of availability to the vast majority of patients lessens its impact. This is manifestly true for patients with chronic obstructive pulmonary disease (COPD), and even more so for patients with other chronic pulmonary conditions. This volume helps to clarify these issues and, hopefully, will provide a path forward. Pulmonary rehabilitation is no longer a young discipline. Founded in the concepts of Alvan Barach, who more than 60 years ago posited that exercise was effective therapy for his emphysema patients. Made tangible by Tom Petty, who organized the first multidisciplinary team to deliver pulmonary rehabilitation almost 50 years ago. Nurtured by practitioners who understood the benefits, established programs and spread the word. Recognized by exercise scientists who established the scientific basis of the exercise programs that are the core of pulmonary rehabilitation, introducing concepts such as limb muscle dysfunction and dynamic hyperinflation, which have helped to rationalize new adjuncts to exercise programs. And then promoted as standard of care by every relevant professional organization in authoritative documents. The 2016 GOLD Guidelines concludes “…all COPD patients appear to benefit from rehabilitation and maintenance of physical activity, improving their exercise tolerance and experiencing decreased dyspnea and fatigue.” It is worth trying to discern why pulmonary rehabilitation is so little used despite its unequivocal benefits. Consider that there are three major therapies widely recognized as effective for COPD: bronchodilators, supplemental oxygen, and pulmonary rehabilitation. Although we have little in the way of head to head trials, it may be concluded that rehabilitation, in comparison to the other two, yields superior benefits in terms of enhancement of exercise tolerance, reduction of dyspnea, and improvement of health-related quality of life, all highly relevant patient-centered benefits. Yet uptake of these three therapies by COPD patients is quite the opposite. Bronchodilators, especially the long-acting variety, are almost universally used. Supplemental oxygen is widely available to those patients demonstrating clinically significant hypoxemia. In contrast, a 2013 survey (Desveaux et al., J. COPD) concludes: “the annual national capacity for pulmonary rehabilitation…consistently translated to ≤1.2% of the estimated COPD population” for the countries surv



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veyed. In the United States, a recent Medicare database examination (Nishi et al. J Cardiopulm Rehabil, 2016) revealed that, among Medicare beneficiaries, pulmonary rehabilitation participation rate increased from 2.6% in 2003 to (only) 3.7% in 2012. As many COPD patients lack Medicare coverage, these percentages likely overestimate the participation in the overall COPD population in the United States. A 2015 American Thoracic Society/European Respiratory Society (ATS/ERS) Policy Statement (Rochester et al., Am J Respir Crit Care Med), dealing with strategies to enhance the implementation of pulmonary rehabilitation, concludes that “the ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.” But this call seems to be going largely unanswered. This situation persists despite the fact that all three therapies have essentially universal support as standard of care for symptomatic COPD. Is this because of cost differentials? No, it can be seen that the annual cost of standard bronchodilator therapy, long-term oxygen therapy, and a program of pulmonary rehabilitation is roughly in the same range. In fact, analyses such as the one conducted by the British Thoracic Society (BTS Reports, 2012) conclude that pulmonary rehabilitation has a substantially lower cost per quality-adjusted life-year (QALY) than does bronchodilator therapy. It might be asked what pulmonary rehabilitation lacks that bronchodilator therapy and supplemental oxygen possess that explains the differential in uptake of these therapies. On reflection, bronchodilator therapy uptake is supported by an extensive marketing effort, both directly to patients and to medical providers. Oxygen therapy, on the other hand, is not marketed, but its provision is near mandatory because it is widely accepted that failure to provide long-term oxygen therapy to hypoxemic COPD patients is associated with substantially increased mortality. This conclusion is founded on two, relatively small, randomized clinical trials (total of about 300 patients) performed more than 35 years ago. Nevertheless, the perception that survival is enhanced by longterm oxygen therapy has made its provision (and funding) more or less mandatory for those meeting the criteria established in these clinical trials. Indeed, it may be asserted that all therapies that prolong survival have high priority. It seems unlikely that pulmonary rehabilitation will ever be supported by an extensive marketing effort, but it might be asked whether rehabilitation reduces COPD mortality. It seems understandable that this information is not available. Large-scale multicenter investigations of pulmonary rehabilitation are almost nonexistent. Even if a substantial survival benefit is postulated, because, in stable COPD, the likelihood of dying in the short term is rather low, it would take a very large randomized clinical trial (many thousands of participants) to provide adequate resolution. A design that might be more feasible would be to study rehabilitation of patients shortly after a COPD hospitalization. Because post-hospitalization patients have a relatively high mortality, the number of participants to adequately investigate a given postulated reduction in mortality would be appreciably reduced. As we look forward, it seems important to incorporate “next generation” features into our model of pulmonary rehabilitation. Formal behavior modifi-



Foreword



Foreword



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cation techniques can improve adherence and, especially, promote increases in physical activity in everyday life. Maintenance programs, perhaps incorporating telemedicine approaches, can help prolong benefit. Addition of these components might well increase the likelihood of the survival advantage whose establishment can be predicted to change the attitude of patients, providers, and payers alike, resulting in increased demand and better provision of pulmonary rehabilitation services. Richard Casaburi, Ph.D., M.D. UCLA School of Medicine, Rehabilitation Clinical Trials Center Los Angeles Biomedical Research Institute, Torrance, CA, USA



Contents



Part I  Introductory Aspects 1 A Historical Perspective of Pulmonary Rehabilitation����������������   3 Bartolome R. Celli and Roger S. Goldstein 2 Current Concepts and Definitions��������������������������������������������������   19 Martijn Spruit and Linda Nici Part II  Participants 3 Identifying Candidates for Pulmonary Rehabilitation����������������   25 Thierry Troosters 4 The Complexity of a Respiratory Patient��������������������������������������   37 Lowie E.G.W. Vanfleteren Part III  Assessment 5 Assessment of Exercise Capacity����������������������������������������������������   47 Ioannis Vogiatzis, Paolo Palange, and Pierantonio Laveneziana 6 Assessment of Limb Muscle Function��������������������������������������������   73 Roberto A. Rabinovich, Kim-Ly Bui, André Nyberg, Didier Saey, and François Maltais 7 Assessment of Patient-Reported Outcomes ����������������������������������   93 Anja Frei and Milo Puhan 8 Assessment of Physical Activity������������������������������������������������������ 109 Heleen Demeyer and Henrik Watz 9 Global Assessment���������������������������������������������������������������������������� 121 Sally Singh Part IV  Program Components 10 Exercise Training in Pulmonary Rehabilitation���������������������������� 133 Chris Burtin and Richard ZuWallack



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11 Nutrition in Pulmonary Rehabilitation������������������������������������������ 145 Annemie Schols 12 Occupational Therapy and Pulmonary Rehabilitation���������������� 159 Louise Sewell 13 Psychological Considerations in Pulmonary Rehabilitation ���������������������������������������������������������������������������������� 171 Samantha Louise Harrison and Noelle Robertson 14 The Respiratory Nurse in Pulmonary Rehabilitation������������������ 183 Vanessa M. McDonald, Mary Roberts, and Kerry Inder 15 The Physical Activity Coach in Pulmonary Rehabilitation ���������������������������������������������������������������������������������� 195 Chris Burtin 16 Breathing Exercises and Mucus Clearance Techniques in Pulmonary Rehabilitation���������������������������������������������������������� 205 Catherine J. Hill, Marta Lazzeri, and Francesco D’Abrosca 17 Self-Management in Pulmonary Rehabilitation �������������������������� 217 Jean Bourbeau, Waleed Alsowayan, and Joshua Wald 18 Inspiratory Muscle Training ���������������������������������������������������������� 233 Daniel Langer Part V  Outcomes and Expected Results 19 Patient-Centered Outcomes������������������������������������������������������������ 253 Karina C. Furlanetto, Nidia A. Hernandes, and Fabio Pitta 20 COPD: Economical and Surrogate Outcomes—The Case of COPD������������������������������������������������������ 273 Roberto W. Dal Negro and Claudio F. Donner Part VI  Organization 21 Conventional Programs: Settings, Cost, Staffing, and Maintenance������������������������������������������������������������������������������ 285 Carolyn L. Rochester and Enrico Clini 22 Contemporary Alternative Settings������������������������������������������������ 297 Anne E. Holland 23 Telehealth in Pulmonary Rehabilitation���������������������������������������� 307 Michele Vitacca and Anne Holland



Contents



Contents



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Part VII  Specific Scenarios 24 Thoracic Oncology and Surgery���������������������������������������������������� 325 Catherine L. Granger and Gill Arbane 25 Transplantation�������������������������������������������������������������������������������� 337 Rainer Gloeckl, Tessa Schneeberger, Inga Jarosch, and Klaus Kenn 26 Rehabilitation in Intensive Care���������������������������������������������������� 349 Rik Gosselink and Enrico Clini 27 Cystic Fibrosis���������������������������������������������������������������������������������� 367 Thomas Radtke, Susi Kriemler, and Helge Hebestreit 28 Pulmonary Rehabilitation in Restrictive Thoracic Disorders�������������������������������������������������������������������������� 379 Anne Holland and Nicolino Ambrosino 29 Conclusions: Perspectives in Pulmonary Rehabilitation�������������� 391 Enrico Clini, Anne E. Holland, Fabio Pitta, and Thierry Troosters



Part I Introductory Aspects



1



A Historical Perspective of Pulmonary Rehabilitation Bartolome R. Celli and Roger S. Goldstein



1.1



Introduction



The association between a healthy body and a better functioning mind has been understood for a very long time. In his satires, the Roman poet Juvenal (English translation by Niall Rudd: http://books.google.ca/books?id=ngJemlYfB4M C&pg=PA86) condensed the concept into one of the most famous phrases in Western civilization “Mens sana in corpore sano,” best translated as “A healthy mind lives within a healthy body.” Indeed, all through antiquity and certainly in the Greco-Roman culture, a fit body was a sign of health and exercise became an integral part of their lives.



B.R. Celli, M.D., F.C.C.P., F.E.R.S. (*) Pulmonary and Critical Care Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA e-mail: [email protected] R.S. Goldstein, MB, ChB, FRCP(C), FCCP National Sanitarium Chair in Respiratory Rehabilitation Research, Program in Respiratory Rehabilitation, West Park Healthcare Centre, Medicine and Physical Therapy, University of Toronto, Toronto, ON, Canada e-mail: [email protected] © Springer International Publishing AG 2018 E. Clini et al. (eds.), Textbook of Pulmonary Rehabilitation, https://doi.org/10.1007/978-3-319-65888-9_1



1.2



Early Times



Unfortunately, loss of health was thought to be best treated with rest, which perhaps was beneficial for infectious diseases and trauma, which were the most frequent cause of death until our very recent past. Indeed, the development of “resting institutes” to care for the sick was first developed in the East, with the “Ayurvedic hospitals” of Sri Lanka representing the earliest example of actual physical places devoted to harboring the sick and helping them recover. Although the Greek culture also had its healing temples dedicated to their healer god Asclepius, it was the Romans who in the Western civilization first developed physical institutions called “Valetudinaria” to harbor and help the sick, primarily caring for sick slaves, gladiators, and soldiers (Medicine. An Illustrated History. Lyons A.S. and Petrucelli R.J. Aberdale Press, NY, 1987. pp. 175 and 205). This was needed to keep the empire functional and the health of the legions was central to this purpose. Bed rest as a therapy reached its highest acceptance in the nineteenth century when patients with many different illnesses were placed in absolute bed rest and were passively cared for by health assistants and nurses. This became particularly true for patients suffering from tuberculosis (Fig. 1.1), and the “sanatoriums” were built with the specific purpose of providing rest, good air, and nutrition for these patients [1]. Of note, what is known today 3



B.R. Celli and R.S. Goldstein



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a



b



c



Fig. 1.1 (a) Patients with tuberculosis treated with bed rest, nutrition, and fresh air [1]. (b) Patients with tuberculosis taking the cure, midwinter 1905 [2]. (c) Patients with tuberculosis taking the cure under the oak tree, summer 1906 [2]



as “The American Thoracic Society (ATS),” an organization focused on improving care for pulmonary diseases, critical illnesses, and sleep-­ related breathing disorders, was established in 1905 as the American Sanatorium Association to assist with the care of patients with tuberculosis.



1.3



 ulmonary Rehabilitation Is P Born



The belief was that a regimen of rest and good nutrition offered the best therapy to help individuals affected by tuberculosis to boost their own immune system to control the infection. In 1863, the first sanatorium opened in Europe (now Poland) for the treatment of tuberculosis. The accepted thought was that rest at high altitude, fresh air, and good nutrition could lead to resolution and control of the disease. Sanatoriums became quite popular and spread throughout the world, with the first one in the United States opening in 1885 in the Adirondack Region in Saranac Lake, New York, and the first one in Canada opening in Muskoka, Ontario, in 1897



(Fig. 1.1) [2]. The mountainous characteristics of these locations represented the perfect geography to develop these health resorts for patients with tuberculosis and many were built in these regions. It was the one in Denver, Colorado, that drew the attention of Dr. Charles Denison (1849–1909), a Vermont-born pulmonologist who was also a ­climatologist (Fig.  1.2). Having developed tuberculosis in Hartford, Connecticut, he moved to Texas for a short period and finally to Denver, where, after his recovery, he had a very successful career as a professor of medicine until his death. Dr. Denison had an inquisitive mind and noticed that he felt better after exercising rather than plain resting. Prompted by this observation, he wrote a book entitled Exercise and Food for Pulmonary Invalids, which constitutes the first written scientific testimony in the field of pulmonary rehabilitation (Fig. 1.2). In his book, Dr. Denison wrote “Let it be understood that in recommending exercise for respiratory invalids, acute and inflammatory conditions of the lungs are excluded.” Indeed, he recommended that the exercise become part of the “recuperative” period and that bed rest be limited



1  A Historical Perspective of Pulmonary Rehabilitation



a



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Fig. 1.2 (a) Photograph of Dr. Charles Denison, author of the first book on the use of exercise in respiratory invalids. (b) Exercise and food for pulmonary invalids. Charles Denison. The Chain and Hardy Co., Denver, Colorado, 1895



to the acute phases of the disease. Throughout the book, he expanded with excellent figures on breathing exercises, with particular emphasis of exercises of the upper extremities and expansion of the thorax. He also added that “walking, hill climbing, bicycling and rowing were excellent exercises that could help the patients.” He went on to state “these forms of exercise are purposely graduated to enable the attending physician to know how far a given person should proceed a given time.” In other words, he felt it would be wise to have some degree of supervision by a healthcare professional to determine the best program tailored to the individual patient. This was the insight that prompted the birth of pulmonary rehabilitation as we know it today. It was soon afterward, when at the early twentieth century, Dr. Alvan Barach in New York began to make observations and complete studies that constituted a first effort to consolidate the body of knowledge of pulmonary rehabilitation as a science. Barach was very interested in dyspnea as a cardinal symptom of respiratory disease. Indeed,



he was the first to observe that the leaning forward position improved the sensation in patients with emphysema and wrote about a series of breathing exercise to improve this symptom in those patients [3, 4]. By expressing and writing his views on the topic, he raised some interest among certain groups, while his detractors discarded his ideas as being esoteric. However, the end result of his observations was an increase in the interest of the potential benefit of breathing exercises, and several clinical studies began to expand those observations to include whole-body exercise. His treatment manual for patients with emphysema published in 1969 (Fig. 1.3) highlighted the importance of exercise as part of comprehensive COPD management. At about this time, Dr. Albert Haas, also working in New York, expanded on the concepts of rehabilitation for patients with respiratory diseases. A native of Hungary, he received his MD from the University of Budapest in 1940. Of interest, like Denison, he also developed tuberculosis as a youngster, from which he recovered completely. He moved to



B.R. Celli and R.S. Goldstein



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a



b



Fig. 1.3 (a) Photograph of Dr. Alvan L. Barach. (b) A treatment manual for patients with pulmonary emphysema. Alvan L. Barach, Grune & Stratton, New York, NY, 1969



France after the invasion of Hungary by the Nazis, and there, he joined the resistance. He was captured, made prisoner, and sent to the concentration camp in Dachau. Because of his medical training, but without being a surgeon, he was made to operate on sick individuals, which allowed him to acquire sufficient expertise in surgery to be of use in his career. He finally made his way to New York where he completed training in Bellevue and during his very academic and clinical career published a series of studies based on his own experience of exercise during his time with tuberculosis. Given this background, it came natural to him to study the value of breathing and whole-body exercise in patients with thoracoplasty and other thoracic surgical procedures [5–7]. The observational foundations laid by these pioneering scientists were followed by several important contributions by researchers who applied more modern methods to the explorations of questions related to the application of knowledge acquired from many different fields of medicine, primarily the new knowledge about mechanics of breathing, gas exchange, and cardiac as well as respiratory response to exercise [8, 9]. A second important event in this early period field of pulmonary rehabilitation was the novel idea that supplemental oxygen could be administered as a therapeutic agent to patients with respi-



ratory ailments. Joseph Priestley in England, Carl Scheele in Sweden, and Antoine Lavoisier in France are all credited with the discovery of oxygen in the last quarter of the eighteenth century, but it took almost two centuries before Alvan Barach in the United States [10–12] and J. E. Cotes in England [13, 14] at almost the same time first reported the benefits of supplemental oxygen to patients with emphysema or respiratory insufficiency. These advances included the first ­references to portable oxygen in an attempt to improve the functional capacity of these patients [15].



1.4



Juvenile Years of the Field



By the midportion of the twentieth century, a group of pulmonary physicians attempted to integrate the experiences in the field into a comprehensive body of information. Of these attempts, the one that best relates to this historical review was the Eight Aspen Emphysema Conference that took place in Denver, Colorado. Instrumental in its organization and running was the then young Denver-born, attending Dr. Thomas Petty (Fig. 1.4), whose interest was centered in the clinical application of many of the concepts developed by the abovementioned pioneers with integration of pharmacotherapy and even potential surgical therapies, this being the conference where Otto C. Brantigan presented his



1  A Historical Perspective of Pulmonary Rehabilitation



a



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b



Fig. 1.4 (a) Photograph of Dr. Thomas Petty in his office at the University of Colorado. Dr. Petty coordinatored the Eighth Aspen Lung Conference, the first meeting where the concept of multidisciplinary treatment of patients with COPD was discussed. (b) One of the original rehabilita-



tion studies “A comprehensive care program for chronic airway obstruction. Methods and preliminary evaluation of symptomatic and functional improvement.” Thomas L. Petty [17]



results of operative techniques for advanced emphysema, with the attendance of Drs. William F. Miller from Dallas, who had already begun to publish results of trials of exercise in patients with emphysema [16], Ben V. Branscomb, Gordon L. Snider, and Reuben Cherniack. Most attendees discussed the interesting observation that the patients studied until then and reported significant improvement in their symptoms, but no objective evidence of lung function improvement, a problem that would puzzle many investigators in the field for decades. Indeed, the summary of that conference provided by Dr. Theodore Noehren centered on that difficult paradox that needed more research, and he even labeled that unknown factor as the Factor “R.” As a consequence, Dr. Petty and coworkers applied and were granted a contract to develop and explore the scientific basis and benefits of a comprehensive pulmonary rehabilitation program funded by the Chronic Respiratory Disease Control Program of the Public Health Service. Actually two such demonstration projects were funded, the one in Denver and the other in Minneapolis. The description provided by Dr. Petty fully resembles the current components of modernday pulmonary rehabilitation as it included patient and family education, pharmacological strategies, breathing retraining, physical reconditioning, and optimization of oxygen therapy. This program



started in 1966 and had already collected over 180 patients by 1968, the findings of which were presented in the high-­impact general medical journal the Annals of Internal Medicine in 1969 (Fig. 1.4) [17]. This breakthrough brought the field to a new level, as it began to be recognized as an important tool in the therapy of patients with chronic obstructive pulmonary diseases. Another important push was added, when a specifically planned meeting took place in California, at the Human Interaction Research Institute, organized by Dr. Edward Glaser. The proceedings of this conference were published in the same year, and they may represent the first well-organized body of scientific information on pulmonary rehabilitation. Among other participants, there was another rising star, Dr. John Hodgkin from Loma Linda, California, who was tasked with the charge of organizing the proceeds and discussions into a coherent body of information. After receiving multiple versions, input, and thoughts from 29 authors, the summary was published in the Journal of the American Medical Association [18] and became the best source of comprehensive information in the field. Pulmonary rehabilitation had moved from an obscure form of therapy that had been considered the realm of charlatans to a concept that had enough evidence to have its principles published in the most prestigious journals in



B.R. Celli and R.S. Goldstein



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medicine. In the decade of the 1970s, the content of this workshop was expanded, and the American College of Chest Physicians published a book with a more comprehensive version of the topics. The growth and interest were not exclusive of the United States and pulmonary rehabilitation began to expand worldwide. The group in Nancy, France, and Spain led by Manuel Gimenez published studies on the beneficial use of breathing retraining in patients with chronic bronchitis [19, 20]. Simultaneously, an active interest in testing the potential benefit of oxygen therapy took the field to a new level. The results of two randomized clinical trials testing the effect of 12-h, 24-h, or no oxygen supplementation to hypoxemic patients with COPD, with mortality as the outcome, were undertaken in North America and in the United Kingdom [21, 22]. The results of these trials were revolutionary as both provided for the first time an agent capable of improving survival to patients with a chronic disease, for which there was consensus and there were no lifesaving options. Of interest, both trials were conducted on a background of comprehensive therapy, very similar to what would be considered pulmonary rehabilitation. These results elevated the field even more, by bringing into it the design of randomized trials to test the benefits and



risks of any new intervention. The ground had been cleared for pulmonary rehabilitation to mature.



1.5



Pulmonary Rehabilitation Matures



The growth of pulmonary rehabilitation from anecdotal benefits of enthusiastic pioneers to it being accepted as the standard of care for chronic respiratory disease parallels a requirement for the establishment of many aspects of medical care, namely, scientific evidence. The four decades that span the period from the early 1980s until now have seen an explosion in the number and importance of studies related to pulmonary rehabilitation. This dramatic increase has been heralded by the development of valid, reproducible, interpretable, evaluative, outcome measures which enabled the transformation of clinical observations into science, thus setting the stage for randomized controlled trials. Key among these advances has been the introduction by Gordon Guyatt and colleagues of a disease-­ specific COPD questionnaire looking at domains of dyspnea, fatigue, emotional function, and mastery (Fig. 1.5) [23]. Other questionnaires such as



10 9 8



Questionnaire Score



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Fig. 1.5  A measure of quality of life for COPD. The Chronic Respiratory Disease Questionnaire (CRDQ) developed by Guyatt and colleagues [23]



6 5 4 3 2 1 0



Dyspnoea



Fatigue



Emotional Function



Mean (SEM) values before and after respiratory rehabilitation



Mastery



1  A Historical Perspective of Pulmonary Rehabilitation



the St. George’s Respiratory Questionnaire (SGRQ) looking at symptom activity and impacts followed a few years later [24]. Today, there are at least 20 COPD disease-specific questionnaires, and the key is to know their psychometric properties and match the outcome selected to the clinical design for the question asked [25]. The other major outcome development was that of field exercise tests, recognizing that most PR patients could not be evaluated by a formal cardiopulmonary exercise test. The 6-min walk test came from the 12-min run (Fig. 1.6) [26–28] used to assess fitness in US military recruits and found to have similar results for maximum oxygen uptake to laboratory measures of incremental exercise. A few years later, the incremental and shuttle



9



walk tests, originally used to test fitness among UK police applicants, were adapted for use in patients with COPD (Fig. 1.6) [29–31]. The concept of the minimum clinically important difference [32] enabled test interpretability to reach beyond statistical significance to clinical importance. Whereas 172 manuscripts were published in 1980, there were 1190 in the year 2016, a substantial increase not only in the number but in the quality of published papers. It is impossible to cite all of the important manuscripts and studies that have expanded the field. However, we shall make an attempt to reflect the most important developments. In 1980, Sahn and coworkers published the 10-year experience of the Denver cohort of patients [33]. In that study, a survival



a 2.4 115 normal males



R=0.89



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12 Min Run Test in Miles



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Fig. 1.6 (a) The 12-min run and maximal oxygen consumption. Taken from healthy males. Note the close association [26–28]. (b) The shuttle run and maximal oxygen consumption. Note the close association [29–31]



B.R. Celli and R.S. Goldstein



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b 70 91 Adult subjects



R=0.84



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VO2 max, ml kg-1 min-1



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Maximal Speed, km h-1



Fig. 1.6 (continued)



benefit was observed when compared to patients with the same degree of emphysema drawn from the Denver area. This provided even more impetus to scientists in the field to investigate the potential mechanism responsible for the reported and observed benefits of pulmonary rehabilitation. For the first time, the evidence, at least for patients with COPD, was acknowledged objectively by the American Thoracic Society [34], but the components, methods, and outcome measurements remained somewhat nebulous. The content of comprehensive programs was placed in perspective by the publication of sev-



eral books that have made an imprint on rehabilitation and have continued to do so. These books were edited by authorities who had helped develop the field and included Pulmonary Rehabilitation: Guidelines to Success. Under the leadership of Dr. John Hodgkin, this book was first edited in Boston by Butterworth in 1984, with the 4th edition published by Elsevier in 2009. Richard Casaburi and Thomas Petty edited the book entitled Principles and Practice of Pulmonary Rehabilitation in the United States, while several other books in different countries have followed, as the word on the benefit of



1  A Historical Perspective of Pulmonary Rehabilitation



these programs has expanded across the globe. In parallel to these developments, interest has grown in the review of evidence to grade recommendations. This concept has led to the development of guidelines aimed at providing help to healthcare deliverers and to improve overall health of afflicted patients. This also occurred in pulmonary rehabilitation. Independent international societies either on their own or in joint statements have published a flurry of guidelines addressing the large body of data that has accumulated on pulmonary rehabilitation. At an international level, collaborative consensus statements by international organizations such as the American Thoracic Society and European Respiratory Society have provided very detailed summaries of the evidence in support of pulmonary rehabilitation as well as the many unanswered questions [35–38]. The most important historical element is the high grade of evidence that supports many of the components that are recommended. The evidence is so strong that the Global Initiative for Obstructive Lung Disease (GOLD), in its most recent revision by Vogelmeier [39], includes pulmonary rehabilitation as one of the key therapeutic elements. They state “Pulmonary rehabilitation improves dyspnea, health status and exercise tolerance in stable patients (Evidence A). Pulmonary rehabilitation reduces hospitalizations in patients with recent exacerbation (≤4 weeks from prior hospitalization) (Evidence B).” Added to the statement on the benefits of oxygen therapy in hypoxemic patients (Evidence A), no other ­therapeutic package carries the same weight of evidence.



1.6



Major Recent Advances



Most medical advances occur by small increments, especially as the complexities of biology are deciphered at the molecular level and the gains are measured in microns. This is also true in the field of pulmonary rehabilitation. However, the last three decades have seen major developments. Let us review some of them.



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Early randomized controlled trials of pulmonary rehabilitation [40–42] consistently reflected the improvements in dyspnea and quality of life associated with PR (Fig. 1.7) [43]. Whereas sensitization to dyspnea was thought to play a major role in the improved sensation of well-being after pulmonary rehabilitation in patients with COPD [44], studies documenting the increase in the oxidative enzyme content of the vastus lateralis muscle of COPD patients undergoing exercise training provided new insight into biological reasons for the increase in exercise endurance after rehabilitation [45]. These well-conducted physiological studies proved that patients with COPD could undergo intense training and derive important benefits in terms of improvements in lactic acid production, ventilatory requirements, and pattern of breathing that helped explained some of the increased tolerance to exercise and lower scores of dyspnea for the same work intensity (Fig. 1.8) [46]. The scales that allowed measurement of the sensation of dyspnea were further validated [47, 48], and with the advantage that extended to other domains [49, 50], the benefits on health status now became possible [23–25, 51–53]. Indices that reflect the multidimensional nature of COPD that respond to rehabilitation were also developed and tested [54, 55]. In the management of COPD, no therapy has matched the benefits seen in all of these scales after pulmonary rehabilitation. Together with the improvements in understanding the mechanisms responsible for the benefits of the programs, our knowledge about the type and duration of exercise to be recommended also improved [56–59]. Along with the improvement seen with leg exercise, evidence arose about the adverse effect of upper extremity exercise on breathing [60, 61] and the improvements seen when upper extremities are included in the training [62, 63]. When the norm was that patients were to be trained in well-supervised areas in hospital, several well-­controlled studies have shown that benefits can be achieved in good home programs [64–66]. More recently evidence is accumulating that distance rehabilitation using tele-technology results in changes to quality of life and exercise similar to that reported from institutionally based outpatient programs [67].



B.R. Celli and R.S. Goldstein



12 Fig. 1.7  Change in the dyspnea domain of chronic respiratory questionnaire following pulmonary rehabilitation [43]



Mean Difference 95% CI



Study Behnke 2000 Cambach 1997 Goldstein 1994 Gosselink 2000 Griffiths 2000 Guell 1995 Guell 1998 Hernandez 2000 Simpson 1992 Singh 2003 Wijkstra 1994 Overall effect z=10.13



p