Chronic obstructive pulmonary disease (COPD) is a chronic, progressive respiratory disease. Patient can become quite frail during its long, protracted duration. A new study suggests that exercise rehabilitation can help to reverse the frailty associated with long term COPD. It also has significant implications for the 1 in 10 seniors, over age 65, who develop frailty for other reasons.
The study done at Kings College in London found that one in four patients with COPD routinely referred for exercise (pulmonary) rehabilitation programs that involve regular exercise is frail. (That frailty was suspected to be a limiting factor for continuing exercise rehabilitation, or for benefitting from it.)
However, the research showed that pulmonary rehabilitation can improve or reverse frailty. The frail patients who did finish the eight week program (about 55 percent of 209 subjects) had improvements in the measures of breathlessness, exercise performance, health status and physical activity compared to the non-frail participants. After the eight week rehabilitation, more than 60 percent of the subjects no longer qualified for the criteria that identify frailty.** Understanding frailty**
There are physical and psychological factors that perpetuate and augment frailty. The frail person is typically afraid to engage in activities that involve physical effort. They perceive the demands as impossible.
Chronic obstructive pulmonary diseasehas the added factor of breathlessness, a very unpleasant feeling that people go to every length to avoid. As a result, their inactivity further decreases muscle tone and readiness for exertion. This makes it even harder to engage in physical activity, perpetuating a vicious cycle.
What is the benefit of a ** pulmonary rehabilitation**** program?**
When patients have this fear of activities perceived as being beyond their physical ability, there may be a benefit to exercising in a supervised setting. This approach to exercise decreases the fear of being helpless and alone during the effort. The standard rehabilitation program focuses on fall prevention, and works on improving balance. Patients also learn ways to avoid breathlessness, using techniques that help with energy conservation. Patients learn to be smarter when performing certain physical tasks, so they conserve energy.
The Kings College study assessed the impact of respiratory limitation in frailty, but the findings could be applied to all frailty. This research showed how exercise rehabilitation increased self-confidence in frail patients, which is especially important.
The findings also stress the importance of a holistic approach to exercise training. The National Institute of Health emphasizes the benefits of rehabilitation when tailored to one's abilities and needs.
Who benefits from a pulmonary rehabilitation program?
Pulmonary rehabilitation programs require a multidisciplinary approach involving different health professionals, so cost is a consideration. For this reason there are certain requirements for Centers for Medicare & Medicaid Services or CMS (the federal agency that manages the Medicare program) to qualify an individual for this program. The criteria are based on the classification of severity of COPD in the individual.
There are strong rehabilitation recommendations for those COPD patients who are classified as severe COPD with an FEV1 (the volume of air that is expired after the first second) of less than 50 percent of that predicted for a healthy individual. There are weaker rehabilitation recommendations for those who have a FEV1 of greater than 50 percent, but who have excessive symptoms.
Poor candidates for pulmonary rehabilitationOne of the criteria to enter the pulmonary rehabilitation program is willingness to participate fully. Lack of motivation is a reason to be eliminated from the program given the high intensity and effort made by the professionals involved.
Other issues to be taken into consideration in the initial evaluation are presence of dementia, psychiatric illness, unstable cardiac disease, and inability to do exercises because of orthopedic conditions.
According to CMS regulations, those who are actively smoking are considered to have a relative (not absolute) contraindication to participate. They have to be willing (and committed) to enter a smoking cessation program in order to participate in the rehabilitation program.
Outcomes of patients who finish rehabilitation programs
Many studies show improvements in the sense of well-being as measured by quality of life questionnaires.
In some of the studies there is an improvement in objective performance of exercises as measured by the six-minute walk test.
Research still needs to assess whether pulmonary rehabilitation shows an actual decrease in the progression of COPD. Usually there is persistent deterioration once disease initiates. The best that can be hoped for with treatment is to decrease the progression of disease, since there is no cure. There are conflicting reports with regard to impact on complications and exacerbations. Some small studies have suggested improvement in mortality rates associated with COPD but experts suggest that the studies need further validation.
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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, Qualified Medical Examiner for the State of California Department of Industrial Relations, and Director of Intensive Care Services at Glendale Memorial Hospital.His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.