Norweg AM, Whiteson J, Malady R, Mola A, Rey M

Chest. 2005;128(2):663-672.

STUDY OBJECTIVES:

To study the short-term and long-term effects of combining activity training or lectures to exercise training on quality of life, functional status, and exercise tolerance.

DESIGN:

Randomized clinical trial.

SETTING:

Outpatient pulmonary rehabilitation center.

PARTICIPANTS:

Forty-three outpatients with COPD.

INTERVENTIONS:

Patients were randomized to 1 of 3 treatment groups: exercise training alone, exercise training plus activity training, and exercise training plus a lecture series. The mean treatment period was 10 weeks.

MEASUREMENT:

The Chronic Respiratory Disease Questionnaire, the modified version of the Pulmonary Functional Status and Dyspnea Questionnaire, and the COPD Self-Efficacy Scale were administered at baseline and 6, 12, 18, and 24 weeks from the beginning of the rehabilitation program. The 6-minute walk test was used to measure exercise tolerance.

RESULTS:

Benefits of activity training combined with exercise included less dyspnea (P <= .04) and fatigue (P<= .01) and increased activity involvement (P <= .02) and total functional status (P <= .02) in the short term compared with treatment groups for comparatively older participants. Compared with the lecture series adjunct, the activity training adjunct resulted in significantly higher gains in total quality of life (P = .04) maintained at 24 weeks. Significantly worse emotional function and functional status resulted from the lecture series adjunct in the oldest participants (P <= .03). Treatment groups did not differ significantly on exercise tolerance or self-efficacy.

CONCLUSIONS:

Evidence for additional benefits of activity-specific training combined with exercise was found. A behavioral method emphasizing structured controlled breathing and supervised physical activity was statistically significantly more effective than didactic instruction in facilitating additional gains and meeting participants' learning needs.

COMMENTARY:

It has been clearly established that pulmonary rehabilitation (PR) benefits patients with COPD and other chronic respiratory disorders. The exercise training component of PR has been demonstrated convincingly to lead to improvements in exercise tolerance and capacity. However, the degree to which various other individual components included in PR, such as training with pacing, breathing, and energy conservation techniques and the other educational components, contribute to the overall gains in exercise tolerance, reduction in dyspnea, and improvements in quality of life after PR is not fully defined, despite the widely held belief by experts in the filed that these components are essential. The purpose of the present trial was, therefore, to assess the short- and long-term effects of combining activity training or lectures with the exercise component of PR on outcomes of exercise tolerance, functional status, and quality of life among 43 medically stable patients with severe COPD. Patients were randomized to 1 of 3 treatment groups: exercise training alone (a total of 15 sessions, 1 hour each, treadmill walking, and upper extremity training with hand weights), exercise training plus activity training (a behavioral method emphasizing dyspnea management strategies and breathing pattern training, especially during activities reported by the patient to lead to particular dyspnea), or exercise training plus a didactic educational lecture series (weekly sessions, 45 minutes each). Study participants underwent a 6-minute walk test, the Chronic Respiratory Disease Questionnaire, the Modified Pulmonary Function Status and Dyspnea Questionnaire, and the COPD Self-Efficacy Questionnaire at baseline and at 6, 12, 18, and 24 weeks after the start of the PR program. There were no differences noted between study groups in exercise tolerance or self-efficacy. There were, however, greater short-term reductions in dyspnea and fatigue reported by patients who underwent a combination of exercise training and activity training among the older participants. As compared with the lecture series alone, the activity training component led to greater gains in patient-reported quality of life at 24 weeks.

This study provides evidence emphasizing the importance of including training of participants in dyspnea management techniques and breathing pattern during the exercise training component of PR. The inclusion of these methods within active exercise training, in particular during activities that the patient finds most troublesome, can lead to greater gains in quality of life as compared with exercise training and a didactic lecture series alone. However, the results of this study should not be used to conclude that didactic education is not important in PR programs because the duration, timing, and content of the lectures, as well as the patient population in the program, may all influence the relative gains resulting from education sessions, and didactic education may indeed be a useful and even optimal means of achieving other outcomes not evaluated in this study, such as patient knowledge regarding their disease and self-management strategies (such as early intervention for acute exacerbations) and partnering with healthcare providers, among others. Other studies designed to investigate outcomes relative to the topics included in most PR lecture series are needed to better assess the utility of the lecture component of PR programs.

CR