COPD is the most common chronic pulmonary disorder, and is one of the biggest causes of unnatural death in India. It is a systemic disorder which involves not only lungs but also musculoskeletal system, heart and psychological aspects of a patient. Pulmonary rehabilitation is a holistic multidisciplinary therapy which involves education, nutrition, physiotherapy and psychological support. In this paper, we are comparing quality of life and overall health status of patients receiving rehabilitation along with SOC treatment with patients only on pharmacotherapy.

Inclusion Criteria 

• Stable COPD who were willing to participate in the study

• Patients who were never involved in a pulmonary rehabilitation program. 

• Patients who had given up smoking for at least two month before the study

Exclusion Criteria 

• Unstable COPD

• Critically ill patients of COPD 

• Pregnant females

• Attack of  Acute exacerbation of COPD within last 2 months

• Patients with history of chest surgery. 

• Associated severe co morbid conditions 

• Patients unable to perform physiotherapy due any physical or mental problem

Procedure for Pulmonary Rehabilitation

All the subjects were informed about the entire procedure and were explained in detail about the treatment and aim of the study. They were included in the study after a written consent was obtained from them. Initial physiotherapy session includes assessment, identification of participant’s needs, goal setting, breathing re-education and a suggested home program.   

Exercise training consisted of starting with warm up exercises like knee – tensing, bicep curl, heel toe raise, ball throwing and catching, step-ups, sit to stand, walking sideways, calf exercises, Arm raises, Bend down, etc. for a period of 5 minutes followed by aerobic training like treadmill walking, jogging, cycling etc for about 25-30 minutes and finally terminating session with cool down exercises for 5 minutes in a circuit training method. 

Participants progress by increasing duration or frequency, usually in weekly increments. If training is interrupted by illness or holiday, the programme is restarted at a lower level.

Adjuncts for bronchial hygiene like postural drainage, coughing, huffing, steam inhalation etc. taught and advised to the participants simultaneously. 

Education program which provide a rationale and reinforcement of the physical training program were included. This includes. 

• What is COPD

• Medical intervention and management of exacerbation 

• Breathing re-training and energy conservation

• Why exercise is so important

• Relaxation skills

• Nutrition in lung disease 

• Management of anxiety and depression 

• Advice for good nutrition and well balanced diet for optimal weight gain was also delivered

• Patients were asked to improve hydration which can help to mobilize secretions

Vitals, mMRC dyspnea scale, 6 minute walk distance, quality of life (SGRQ) and spirometric findings were recorded at baseline, 2 week, 4 week, 6 week and at the end of the program i.e. 8 week. Statistical analysis were performed using student’s‘t’ test and p values observed.

Observations

In present study 50 patients (48 males, 2 female) suffering from COPD were included in the study and various parameters were recorded before and after pulmonary rehabilitation program. 

Mean values of difference in values before and after rehabilitation program were compared and student’s‘t’ test was applied for evaluating the significance of difference in both the groups with ‘p’ value <0.05. 

The study showed that average age was 57.48±10, ranges from 40 to 80. Smoking was seen all patients of this study. Mean smoking index was 567.1 (max- 900, min- 300) and mean pack year was 23.0.

In present study BMI was found be lower side. Mean BMI was 17.88, suggest severe muscle wasting was seen due to chronicity of disease.

• Chest expansion at axillary level (2.09 ± 0.39) improved significantly after, program (2.54 ± 0.46, p value <0.0001)

• dyspnoea score which was graded according to Modified Medical Research Council Dyspnoea scale (MMRC) was 3.0 ± 0.66 before starting program of pulmonary rehabilitation. At the end of 8 week program dyspnoea score was 1.89 ± 0.83 which was markedly improved. (1.89 ± 0.83, p value <0.0001) which is statistically very significant

•  Before starting program in study group the Health Related Quality of Life score which was calculated by SGRQ (St. George Respiratory questionnaire) were 49.74 ± 5.17 and at end of 8 week program 40.92 ± 4.87 Application of T test showed ‘P’ value is <0.0001 which is statistically significant

• 6 minute walk distance (280.9 ± 18.04) improved significantly after program (303 ± 17.34) (‘p’ value <0.0001) 

• Forced Vital Capacity before pulmonary rehabilitation program 46.06 ± 16.62 and after pulmonary rehabilitation program 46.44 ± 16.41

• Baseline FEV1 on starting of pulmonary rehabilitation 31.26 ± 12.83 and after program 31.60 ± 12.68

• FEV1 / FVC ratio before pulmonary rehabilitation program 0.69 ± 0.19 and after program 0.70 ± 0.19

• Spirometric parameters like FVC (p value 0.02), FEV1 (p value 0.17) and FEV1 / FVC ratio (p value 0.76) do not show any statistically significant changes after program

• So results were found to be statistically significant for all parameters except the pulmonary function test which led to the acceptance of alternate hypothesis

The NICE guidelines [1] and Cochrane review [2] of pulmonary rehabilitation strongly support the inclusion of pulmonary rehabilitation for patients with COPD. Their trials showed evidence supporting the benefit of pulmonary rehabilitation for patients with COPD is robust. Large bodies of evidence now support the use of pulmonary rehabilitation in the management of patients with COPD, with many randomized controlled trials describing its potential benefits including improved exercise capacity, increased quality of life, enhanced patients sense of control over their condition, improved emotional function, improved dyspnoea and fatigue, increased functional outcomes, reduced length of hospital stays and number of hospitalizations, reduction  in primary care consultations and survival benefit [2,3]. Although evidence suggests that no change in FEV₁ occurs as a result of pulmonary rehabilitation [4], important changes in self – efficacy (for example in functional capacity and confidence in coping with the disease) have been demonstrated on completion of a program. 

Recent study shows that one year of outpatient pulmonary rehabilitation is an effective intervention and leads to a significant improvement in exercise tolerance and QOL in COPD patients, also reducing COPD exacerbation rates and hospitalizations [5].

6 MWTD found to be an important, simple, and repeatable parameter for evaluation of the functional improvement obtained after pulmonary rehabilitation program, independent of the severity of the disease

Ergün et al. [6] and Chang et al. [7] found no significant changes in FEV₁ after 8 weeks of pulmonary rehabilitation which finding is consistent with present study.

Table 1: Shows Comparison of Common Variables in Different Trials

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3. Trikalinos, T.A. et al. “Pulmonary rehabilitation for COPD and other lung disease.” Technology Assessment Programme, Tufts University, 2006.

4. Chartered Society of Physiotherapy. “The effectiveness of pulmonary rehabilitation: evidence and implications for physiotherapists.” 2003.

5. Zwick, R.H. et al. “The effect of one year outpatient pulmonary rehabilitation on patients with COPD.” Wiener Klinische Wochenschrift, vol. 121, no. 5–6, 2009, pp. 189–195.

6. Ergün, P. et al. “Comprehensive out-patient pulmonary rehabilitation: treatment outcomes in early and late stages of chronic obstructive pulmonary disease.” Annals of Thoracic Medicine, vol. 6, no. 2, 2011, pp. 70–76.

7. Chang, A.T. et al. “Rationale and design of the PRSM study: pulmonary rehabilitation or self management for chronic obstructive pulmonary disease (COPD), what is the best approach?” Contemporary Clinical Trials, vol. 29, no. 5, 2008, pp. 796–800.

8. Murphy, K. et al. “A cluster randomised controlled trial evaluating the effectiveness of a structured pulmonary rehabilitation education programme for improving the health status of people with chronic obstructive pulmonary disease (COPD): the PRINCE study protocol.” BMC Pulmonary Medicine, vol. 11, 2011, pp. 4.

9. Hajiro, T. and Nishimura, K. “A comparison of the level of dyspnoea versus disease severity indicating the health related quality of life of patients with COPD.” Chest.

10. Rossi, G. et al. “Length and clinical effectiveness of pulmonary rehabilitation in outpatients with chronic airway obstruction.” Chest, vol. 127, 2005, pp. 105–109.

11. Zwick, R.H. et al. “The effect of one year outpatient pulmonary rehabilitation on patients with COPD.” Wiener Klinische Wochenschrift, vol. 121, no. 5–6, 2009, pp. 189–195.