Additional Evidence for the Long-Term Benefits of Pulmonary Rehabilitation

Long-Term Exercise Adherence

Exercise is the component of pulmonary rehabilitation that consistently demonstrates the most improvement in patient health outcomes.² Providing guidelines for exercise and long-term self-management strategies to promote exercise so patients can continue to experience the benefits of exercise over the long term is a high priority for pulmonary rehabilitation clinicians.¹¹ Although a pulmonary rehabilitation program involves a group setting, the patients receive individualized attention, which is critical to managing dyspnea and reducing the anxiety often associated with dyspnea.¹²

During the course of a pulmonary rehabilitation program, patients are encouraged to increase both the endurance and intensity of exercise and create an exercise routine that will continue to support their health and quality of life after the pulmonary rehabilitation program concludes. The exercise program is promoted as a lifestyle change to continue indefinitely. As with pharmacologic studies in which the subject's perceived benefit of treatment is recognized to affect the subject's decision to continue or discontinue treatment,¹³ those who experience more immediate health benefits may be more likely to continue exercise after pulmonary rehabilitation.

Similar to our previously published findings,¹⁴ subjects who exercised regularly after pulmonary rehabilitation maintained a stable duration of 25–30 min/session, but the frequency (d/week) declined over time. This reinforces the importance of encouraging patients to maintain their commitment to a regular exercise schedule. Once they start the exercise session, they are likely to continue for the full duration. In addition, when maintenance exercise is available on multiple days/week, patients are able to come to the pulmonary rehabilitation facility for all of their exercise sessions and are not required to overcome the additional barrier of developing another exercise routine at a different location.

Given that our data support ongoing exercise regardless of venue, the first priority must be to reinforce the importance of long-term, ongoing exercise in this patient population. The decision about whether maintenance exercise at the pulmonary rehabilitation facility is the best option or whether another venue is preferable is a very personal decision based on many factors, such as disease severity, emotional status, occupational status, transportation, and living situation.

Pursed-Lip Breathing Techniques

Pursed-lip breathing has been shown to be effective in the short term by controlling panic and decreasing breathing frequency and anxiety. It is well accepted as a valuable therapy to counteract shortness of breath in patients with chronic lung disease.¹⁵ Our findings support the value of pursed-lip breathing with high adherence rates for up to 7 y after participation in pulmonary rehabilitation (88–96%). Pursed-lip breathing is readily available, does not require expensive equipment, and can be easily implemented during activity.¹⁶ Although there is no standard pursed-lip breathing training technique and the focus of those who teach pursed-lip breathing may be on back pressures, expiratory flow, oxygen saturation, or residual volume, patients still report significant benefit and continue to use pursed-lip breathing. Perhaps additional investigation and measurement of pressure, volume, timing, gas exchange, and activity could clarify the pulmonary mechanics related to benefits.¹⁷

Given the clinical benefits of pursed-lip breathing in both symptoms and gas exchange, especially in combination with oximetry-based biofeedback, research evidence supports recommendations that patients with chronic respiratory disease use these training techniques.^17,18 Focus on a counted breathing pattern during pursed-lip breathing may attain benefits similar to visualization and relaxation techniques. Pursed-lip breathing helps patients avoid and alleviate dyspnea and maintain control of breathing.

Energy Conservation Strategies

Although pacing and energy conservation are well accepted as part of clinical practice and have been tested in lung cancer,^19–21 very little research has been done to evaluate their effectiveness in other chronic lung diseases. Energy conservation is part of the larger discipline of occupational therapy and is often taught in conjunction with the use of gadgets that minimize bending, climbing, and straining, such as bath stools, hand-held showerheads, reaching tools, elastic shoestrings, sock pulls, and button hooks.^22,23 These techniques are also an integral component of pulmonary rehabilitation programs.²⁴ By using these techniques, patients are able to do more with less shortness of breath, allowing them to become more independent. They are also instructed on pacing activities and prioritizing chores because energy conservation is important with daily fluctuation in energy levels.

Although often counterintuitive to patients, training in pacing is not a contradiction to exercise training, as pacing enables greater participation and enjoyment of activities, whereas exercise training conditions patients, allowing them to use pacing throughout a more active and longer lifetime and reverse the cycle of decline. The vast majority of subjects reported continued practice of this intervention for years after pulmonary rehabilitation.

Contact With the Health-Care Provider's Office at the First Sign of an Exacerbation

COPD exacerbations are often under reported.^25,26 Exacerbations are associated with subsequent worsening depression and health status, as well as higher mortality after hospitalization.²⁷ When the health-care provider is notified at the first sign of an exacerbation, there is an opportunity to intervene early with out-patient medical management, such as prednisone, oral antibiotics, nebulizer treatments, and supplemental oxygen. These treatments can prevent an emergency department visit with its attendant costs, invasive therapies, and stress. Conferring with the health-care provider can also trigger a review of symptoms, discuss preventive measures, and generate an action plan for patients for future exacerbations. Participation in maintenance exercise at a pulmonary rehabilitation facility allows pulmonary rehabilitation clinicians to facilitate notification of the health-care provider at the first sign of an exacerbation.

Support Group Participation

Very few reports have been published on the topic of support groups for patients with chronic respiratory disease. One study in Better Breathers support group members with COPD reported that members demonstrated high levels of self-care that were positively associated with hope and optimism.²⁸ A disease-management program delivered in a support group format resulted in subjects with idiopathic pulmonary fibrosis feeling less isolated, more able to put their disease into perspective, and valued by participating in research and helping others.²⁹ Support groups have been found to be beneficial in many other patient populations, including diabetes,³⁰ cancer,^31–33 caregivers,³⁴ and online groups.³⁵ Support groups can take many formats, including peer or professional facilitation, hospital or nonprofit sponsorship, in-person or online formats, education, or skill-focused content. In our sample of subjects who attended pulmonary rehabilitation, subjects consistently reported distance, transportation, and scheduling conflicts as the primary barriers to participation in the follow-up monthly support meetings. Virtual meeting tools, such as internet-based support groups and chat rooms, may be more successful in retaining participation. Several internet-based support groups have been tested with positive results.³⁶

Modifiable barriers to support group participation in this sample included lack of awareness and lack of interest, suggesting that improved communication about programs and needs assessments to tailor programs to the specific needs of patients may improve participation. Frequent discussion of the benefits of ongoing participation in the support group after intensive pulmonary rehabilitation can be integrated into the pulmonary rehabilitation sessions.

Long-Term Exercise Adherence and Health-Care Utilization

It is well documented that pulmonary rehabilitation participation decreases health-care utilization for at least 1 y after completion.^3,37–40 We sought to extend those findings by analyzing the effect of ongoing exercise after pulmonary rehabilitation. Contrary to the findings of Heppner et al,⁴¹ who found that subjects who continued to walk regularly after a pulmonary rehabilitation program utilized health care as often as those who did not, our findings show that fewer subjects visited the emergency department or required hospitalization after pulmonary rehabilitation. In the subgroup of subjects who did require an emergency department visit or hospitalization, however, the average number of emergency department visits or hospital days was unchanged after pulmonary rehabilitation. Overall physical activity has been shown to reduce hospital admissions.⁴² Further comparison of our results with others is difficult because health-care utilization outcome measurement is not standardized.⁴³

Questionnaire Adherence

Baseline demographics were quite different between those who completed questionnaires and those who did not. In general, those who did not complete questionnaires suffered from more severe COPD with lower FEV₁, had shorter 6-min walk distances, and reported more depressive symptoms. These differences suggest that subjects who completed the surveys were healthier and raise questions about the generalizability of our findings. They also underscore the importance of personal follow-up with patients who are more severely ill and least likely to participate in mailed questionnaires.

There may be a bias between those who complete questionnaires and those who do not. Perhaps patients stop completing questionnaires because they feel worse,¹³ or conversely, they may want to continue to complete questionnaires to document their decline. If patients who are more severely ill discontinue survey completion more frequently or earlier than those who are less severely ill, that bias would lead to results indicating that pulmonary rehabilitation has more long-lasting benefits than in actuality.¹³

Limitations

The data for this study were self-reported with inconsistent follow-up, which limits the generalizability of our findings to those who complete pulmonary rehabilitation and participate in ongoing data collection. Based on our experience using these quality improvement data for research purposes, it is important for the researcher to be involved in the initial development of the questionnaires and to avoid changes in the questionnaires over time, unless they serve both the needs of the researcher and the clinician. The clinical nature of the data led to imprecise or missing measures of smoking status and non-COPD diagnoses. Systems to follow-up with subjects who do not respond to the surveys should be put in place from the beginning.