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      International Journal of COPD (submit here)

      This international, peer-reviewed Open Access journal by Dove Medical Press focuses on pathophysiological processes underlying Chronic Obstructive Pulmonary Disease (COPD) interventions, patient focused education, and self-management protocols. Sign up for email alerts here.

      39,063 Monthly downloads/views I 2.893 Impact Factor I 5.2 CiteScore I 1.16 Source Normalized Impact per Paper (SNIP) I 0.804 Scimago Journal & Country Rank (SJR)

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      Increased mortality in patients with severe COPD associated with high-intensity exercise: a preliminary cohort study

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          Abstract

          Introduction

          Intensity of exercise is believed to be a key determinant of response to chronic obstructive pulmonary disease (COPD) rehabilitation. We hypothesized that a higher intensity of exercise, in combination with physiotherapist-led instructions and education in management of breathlessness, would lead to better self-management, possibly delaying calls to the emergency service and preventing hospitalization.

          Objective

          We aimed to test this hypothesis in a subsequent randomized trial, and in order to test study processes and estimate hospitalization rates, we did a small preliminary prospective cohort study on severe COPD patients referred to outpatient rehabilitation.

          Methods

          In 2013, four rehabilitation courses were scheduled (spring, summer, autumn, and winter) each lasting 8 weeks and including eight to ten patients. This preliminary study was designed as a controlled cohort study. The bi-weekly exercise sessions in the spring and autumn courses included a high-intensity walking exercise at 95% of estimated VO 2 max for as long as possible. The other two rehabilitation courses included the usual walking exercise intensity (85% of estimated VO 2 max). Hospitalization rates were assessed from the participants’ medical records in an 18-month period.

          Results

          We were able to enroll 31 patients in total (15 in the high-intensity exercise group and 16 in regular intensity). There were no group differences in the hospitalization rates. However, during review of the medical records, we observed a striking mortality rate among participants who had attended the high-intensity rehabilitation courses (five deaths) compared to the standard rehabilitation (zero deaths). Four of the five deaths were COPD exacerbations. Fisher’s exact test was statistically significant ( P=0.046), as was a log-rank test ( P=0.019) of the Kaplan–Meier estimated survival rates.

          Conclusion

          These results from this small preliminary cohort study are alarming and raise concerns about the possible serious risks associated with high-intensity exercise rehabilitation of severe COPD patients.

          Most cited references6

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          Development of a shuttle walking test of disability in patients with chronic airways obstruction.

          S J Singh, M. Morgan, S. Scott … (1992)
          The aim was to develop a standardised and externally paced field walking test, incorporating an incremental and progressive structure, to assess functional capacity in patients with chronic airways obstruction. The usefulness of two different shuttle walking test protocols was examined in two separate groups of patients. The initial 10 level protocol (group A, n = 10) and a subsequent, modified, 12 level protocol (group B, n = 10) differed in the number of increments and in the speeds of walking. Patients performed three shuttle walking tests one week apart. Then the performance of patients (group C, n = 15) in the six minute walking test was compared with that in the second (modified) shuttle walking test protocol. Heart rate was recorded during all the exercise tests with a short range telemetry device. The 12 level modified protocol provided a measure of functional capacity in patients with a wide range of disability and was reproducible after just one practice walk; the mean difference between trial 2 v 3 was -2.0 (95% CI -21.9 to 17.9) m. There was a significant relation between the distance walked in the six minute walking test and the shuttle walking test (rho = 0.68) but the six minute walking test appeared to overestimate the extent of disability in some patients. The shuttle test provoked a graded cardiovascular response not evident in the six minute test. Moreover, the maximal heart rates attained were significantly higher for the shuttle walking test than for the six minute test. The shuttle walking test constitutes a standardised incremental field walking test that provokes a symptom limited maximal performance. It provides an objective measurement of disability and allows direct comparison of patients' performance.
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            Pulmonary rehabilitation for chronic obstructive pulmonary disease.

            Y Lacasse, Thalia R. Goldstein, T Lasserson … (2005)
            The widespread application of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function attributable to the programs. This review updates that reported in 2001. To determine the impact of rehabilitation on health-related quality of life (QoL) and exercise capacity in patients with COPD. We identified additional RCTs from the Cochrane Airways Group Specialised Register. Searches were current as of July 2004. We selected RCTs of rehabilitation in patients with COPD in which quality of life (QoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. Rehabilitation was defined as exercise training for at least four weeks with or without education and/or psychological support. Control groups received conventional community care without rehabilitation. We calculated weighted mean differences (WMD) using a random-effects model. We requested missing data from the authors of the primary study. We included the 23 randomized controlled trials (RCTs) in the 2001 Cochrane review. Eight additional RCTs (for a total of 31) met the inclusion criteria. We found statistically significant improvements for all the outcomes. In four important domains of QoL (Chronic Respiratory Questionnaire scores for Dyspnea, Fatigue, Emotional function and Mastery), the effect was larger than the minimal clinically important difference of 0.5 units (for example: Dyspnoea score: WMD 1.0 units; 95% confidence interval: 0.8 to 1.3 units; n = 12 trials). Statistically significant improvements were noted in two of the three domains of the St. Georges Respiratory Questionnaire. For FEC and MEC, the effect was small and slightly below the threshold of clinical significance for the six-minute walking distance (WMD: 48 meters; 95% CI: 32 to 65; n = 16 trials). Rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances patients' sense of control over their condition. These improvements are moderately large and clinically significant. Rehabilitation forms an important component of the management of COPD.
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              Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.

              Milo A. Puhan, Elena Gimeno-Santos, Madlaina Scharplatz … (2011)
              Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established. To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity). Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010. Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation. We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies. We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies. Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Chron Obstruct Pulmon Dis
                Journal ID (iso-abbrev): Int J Chron Obstruct Pulmon Dis
                Journal ID (publisher-id): International Journal of COPD
                Title: International Journal of Chronic Obstructive Pulmonary Disease
                Publisher: Dove Medical Press
                ISSN (Print): 1176-9106
                ISSN (Electronic): 1178-2005
                Publication date Collection: 2016
                Publication date (Electronic): 26 September 2016
                Volume: 11
                Pages: 2329-2334
                Affiliations
                [1 ]Department of Physio- and Occupational Therapy
                [2 ]The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
                Author notes
                Correspondence: Marius Henriksen, The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr Fasanvej 57, DK 2000, Copenhagen, Denmark, Tel +45 3816 4160, Email marius.henriksen@ 123456regionh.dk
                Article
                Publisher ID: copd-11-2329
                DOI: 10.2147/COPD.S114911
                PMC ID: 5044988
                PubMed ID: 27713626
                SO-VID: d9f2cb89-3c50-4f5d-95b5-0cb91b4e8349
                Copyright © © 2016 Schaadt et al. This work is published and licensed by Dove Medical Press Limited
                License:

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                History
                Categories
                Subject: Original Research

                ScienceOpen disciplines: Respiratory medicine
                Keywords: chronic obstructive pulmonary disease,exercise,rehabilitation,mortality
                Data availability:
                ScienceOpen disciplines: Respiratory medicine
                Keywords: chronic obstructive pulmonary disease, exercise, rehabilitation, mortality

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