Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionContact Us   |  Subscribe   |  Advertise   |  Login  Page layout
Wide layoutNarrow layoutFull screen layout
Lung India Official publication of Indian Chest Society  
  Users Online: 1778   Home Print this page  Email this page Small font size Default font size Increase font size

  Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 38  |  Issue : 3  |  Page : 211-215  

Effect of home-based pulmonary rehabilitation on health-related quality of life, lung function, exercise tolerance, and dyspnea in chronic obstructive pulmonary disorder patients in a tertiary care center in South India


Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission21-Nov-2020
Date of Decision06-Jan-2021
Date of Acceptance03-Feb-2021
Date of Web Publication30-Apr-2021

Correspondence Address:
Dr. N Priya
Department of Pulmonary Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_895_20

Rights and Permissions
   Abstract 


Context: Home-based pulmonary rehabilitation (PR) can increase compliance in chronic obstructive pulmonary disorder (COPD). There is paucity of data on this in India. Aims: To study the effectiveness of home-based PR on lung function, health-related quality of life, exercise tolerance and dyspnea among patients with COPD. Setting: The Department of Pulmonary Medicine, Christian Medical College, Vellore. Subjects and Methods: This was a quasi-experimental study which included COPD patients who found hospital-based PR impractical. Those willing for home-based PR constituted the intervention group and those unwilling, constituted the control group. Both groups received standard of care otherwise. At 6 weeks, forced expiratory volume in 1 sec (FEV1), St. George Respiratory Questionnaire (SGRQ), six-minute walk test distance (6MWD), COPD assessment test (CAT) score and modified Borg dyspnea scale were compared with their baseline values. Statistical Analysis: Student paired t-test. Results: A total of 42 patients completed the study, 21 in each arm. The baseline characteristics were comparable. The improvement in FEV1 was 90 ml in the intervention group and 4 ml in the control group (P = 0.01). There was no significant difference in 6MWD change. SGRQ score, Borg scale and CAT score improved significantly by 10.4, 2.4, and 3.4, respectively, in the intervention group when compared to the control group (P = 0.01). Conclusions: Home-based PR effectively provides tangible benefits in FEV1, QOL, exercise tolerance and dyspnea. It should be offered to those who are unable to avail institution-based PR, especially in this era of COVID pandemic.

Keywords: Chronic obstructive pulmonary disorder, home-based pulmonary rehabilitation, quality of life


How to cite this article:
Priya N, Isaac BT, Thangakunam B, Christopher DJ. Effect of home-based pulmonary rehabilitation on health-related quality of life, lung function, exercise tolerance, and dyspnea in chronic obstructive pulmonary disorder patients in a tertiary care center in South India. Lung India 2021;38:211-5

How to cite this URL:
Priya N, Isaac BT, Thangakunam B, Christopher DJ. Effect of home-based pulmonary rehabilitation on health-related quality of life, lung function, exercise tolerance, and dyspnea in chronic obstructive pulmonary disorder patients in a tertiary care center in South India. Lung India [serial online] 2021 [cited 2021 Jun 17];38:211-5. Available from: https://www.lungindia.com/text.asp?2021/38/3/211/315311




   Introduction Top


Globally, chronic obstructive pulmonary disorder (COPD) has emerged as a major cause of morbidity and mortality, expected to become the 3rd most leading cause of death and the 5th leading cause of loss of “Disability Adjusted Life Years” (DALYs) as per the projection of the Global Burden of Disease Study. The region-wise projections for the developing countries including India were even worse.[1] Of the total global DALYs due to chronic respiratory diseases in 2016, 32% occurred in India. In 2016, COPD and asthma were responsible for 75.6% and 20% of the chronic respiratory disease DALYs in India.[2]

Considering the above data, the economic burden of COPD is enormous. The 2001 global Initiative for chronic obstructive lung diseases (GOLD) listed pulmonary rehabilitation (PR) as an established treatment for COPD. This was a huge step in the acceptance of PR as a standard treatment for the care of COPD patients. Since then and till now, the evidence and recommendation for rehabilitation have gained in leaps and bounds.[3] PR is supported by compelling evidence that such programs deliver improvement in exercise capacity, reduction in breathlessness and improvement in health-related quality of life, irrespective of disease severity[4] and also reduces the number of exacerbations and hospitalization.[5]

Of the patients with COPD who are referred to PR, 8% to 50% never attend the same,[6],[7] while noncompletion rates range from 10% to 32%.[8],[9] This is due to either lack of access or patient-related factors. The practical reasons for this lack of access include shortage of programs, particularly in rural and regional centers, and an insufficient number of qualified health care professionals. Patient-related barriers to attendance have also been identified, with travel and transport to center-based programs being the most common obstacles to attendance in this disabled group.[10],[11]

Considering all the above drawbacks, alternative models were thought to overcome all these barriers and hence home based PR was proposed as a new model to enhance access and remove patient barriers, while containing the rising costs of healthcare associated with COPD.[12],[13],[14],[15] Direct comparison of home- and hospital-based PR has been made in a few studies.[12],[13],[14],[15] There are systematic reviews and meta-analysis available on the effect of PR in patients with COPD. Although there are few studies on PR for COPD in India, there is lack of data on the feasibility and effectiveness of such programs in the developing world. Hence, we decided to study the effectiveness of a home-based PR in COPD patients in a tertiary care hospital in South India, among the local urban population.


   Subjects and Methods Top


This is a quasi-experimental study carried out in the outpatient clinics of the Department of Pulmonary Medicine, Christian Medical College, Vellore, from 2018 to September 2019. Approval of the Institutional Review Board was obtained. The objectives of this study were to study the effect of home based PR in COPD. The outcomes of interest were; exercise tolerance, perceived dyspnea as assessed by Modified Borg dyspnea scale, St. George Respiratory Questionnaire (SGRQ), six-minute walk test distance (6MWD), Spirometry (forced expiratory volume in 1 s [FEV1]) and COPD assessment test (CAT) score.

The patients who fulfilled the diagnostic criteria of COPD based on GOLD 2018 guidelines and categorized into Groups B, C, or D were recruited. All of them were on optimal COPD treatment as per their category. Based on a previous study done by Finnert et al.,[16] the sample size was calculated to be 21 in each arm, which have provided 80% power and 5% error to determine the statistically significant difference in total SGRQ and each domain of SGRQ scores between the two groups. Accounting for drop outs, 25 patients were planned for recruitment to each arm.

All the subjects were instructed on the benefits of performing regular physical activity for the rest of their lives and its impact on their quality of life. All eligible patients were advised hospital-based PR. Those who found it inconvenient or impractical to come to the hospital were offered home-based PR and recruited in to the study. Those patients who were willing for home-based PR constituted the study group and those unwilling for home-based rehabilitation constituted the control group. Those in the study group underwent 30 min sessions of supervised PR which included breathing exercises, pursed lip and diaphragmatic exercises, upper and lower limb training, slow walking, with a session for 30 min. An additional session was scheduled as required. They were then advised to follow the same at home for 6 weeks. Telephonic calls were made every two weekly to ensure that they are continuing to perform the exercises at home and any clarifications sought were addressed. Both groups were assessed after 6 weeks. Pre- and post-rehabilitation assessment included symptom assessment, modified Borg's dyspnea scale, SGRQ, 6MWD, CAT score and FEV1. These were analyzed using Student paired t-test.


   Results Top


A total of 42 patients completed the study and were analyzed. Half of them (21) who were willing to undergo home-based PR constituted the study group. The other half (21) who did not undergo PR constituted the control group [Figure 1].
Figure 1: Consort diagram

Click here to view


The baseline characteristics of clinical significance in both these groups have been tabulated below as the mean ± (standard deviation) [Table 1]. The baseline characteristics of the two groups were similar. The mean age of the patients in the study group was 63.1 ± 8.01 years and that among the controls was 65 ± 10.7 years. The subjects were predominantly men and that could be largely explained by the fact that smokers are almost exclusively men in Southern India. Among the study group, 6 patients were in GOLD group B, 9 in group C and 6 in group D. Among the control group, 4 patients were in group B, 8 in group C and 9 group D. Hence, the distribution of the subjects among the different GOLD groups was similar. The mean baseline FEV1 was 150 ml more among those who underwent PR compared to those who did not, though the difference was not statistically significant.
Table 1: Baseline characteristics of cases and controls expressed as mean±standard deviation

Click here to view


The changes in dyspnea score, spirometry, six min walk test, and SGRQ are tabulated in [Table 2]. Compared to the baseline FEV1, there was a mean improvement of 90 ml in the FEV1 of those who underwent PR. This when compared to the drop in FEV1 of 4 ml among those who did not undergo PR was statistically significant (P = 0.01) [Table 2].
Table 2: Change in variables from baseline to 6 weeks

Click here to view


At baseline visit, the mean 6MWD for the intervention group was 386.25 ± 88.2 (95% Confidence interval [CI] 350–422) meters whereas the controls walked 376.4 ± 96.2 (95% CI-334–408) meters. The intervention group who underwent PR had a mean improvement of 20 meters after 6 weeks compared to the controls who had a mean increase of 7 meters. However, there was no statistically significant difference between the groups [Table 2].

At the baseline visit, the mean total SGRQ was slightly better in the intervention group compared to controls. However, the difference was not statistically significant (P = 0.11). At the follow-up visit after 6 weeks, the mean total SGRQ score in the intervention group improved from a baseline of 78.42 ± 14.5 to 68.16 ± 6.5 which was statistically significant (P = 0.01). However, in the control group, who did not undergo rehabilitation, there was worsening of the SGRQ score from 80 ± 5.0 to 82 ± 4.56, which was also statistically significant (P = 0.01). The mean difference in the change in SGRQ scores between the intervention group and controls was also statistically significant (P = 0.01) as mentioned in [Table 2].

Compared to the baseline mean Borg scale3.64 ± 1.18 (95% CI 3.32–3.97), there was statistically significant improvement by 2.5 points in the intervention group after 6 weeks. The mean difference between change in Borg's score between the intervention group and the controls was also statistically significant (P = 0.01). At the end of the study after 6 weeks, the mean CAT score was reduced by 3.5, indicating improvement in the quality of life among the intervention group, whereas it slightly worsened in the control group. The mean CAT score improvement between both the groups was also statistically significant in cases (P = 0.01), at the end of the study as mentioned in [Table 2].


   Discussion Top


At the end of our home-based PR program, the subjects in the study group had a mean increase in the FEV1 by 90 ml (P-0.01). In a prospective study, comparing a group of 190 COPD patients undergoing PR with 67 patients receiving standard pharmacotherapy, a mean improvement of FEV1 from 1240 mL to 1252.4 mL was found in the former, while the values changed from 1367 mL to 1150 mL in the latter (P < 0.001).[17] These observations suggest that the improvement of lung function in COPD patients undergoing PR should be also included among the expected outcomes and routinely assessed as an index of clinical success during the treatment. A minimal clinically important difference (MCID) provides a guide as to whether intervention offers a minimum level of perceived benefit and moves beyond the concept of statistical differences. Studies have shown that in COPD, MCID of 100 ml for trough FEV1 has been proposed based on clinical anchoring to endpoints.[18] The improvement in the intervention group of our study just falls short of this.

Interestingly, other studies[19] did not show significant modification of pulmonary function after a home-based training program. PR causes a change in peripheral myopathy but not ventilatory limitation. The airflow limitation in most cases is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.[20]

Postrehabilitation, in our study, the patients walked farther than the controls (20 m vs. 7 m). Previous studies have concluded that 25 m to 30 m are the minimum clinically important difference in 6 MWD.[18] This is also comparable with other studies. In a well-designed study, Maltais et al.[21] demonstrated that a home-based PR program is as effective as conventional PR in patients with moderate-to-severe COPD. After 6 weeks of training, subjects achieved better performance with their 6MWD increased by an average of 42.8 m after rehabilitation and also had reduction in shortness of breath. The simple, low-cost, and easy-to-execute protocol described in this study seems to be adequate for the majority of patients with COPD. An attempt was made to encourage adherence through weekly telephone contact to encourage the subjects to perform the rehabilitation exercises. The MCID found for severe COPD patients was 26 m.[19] Our sample size was perhaps inadequate to show a significant difference in the walk distance.

In our study, the effect of PR was well seen in the patient's quality of life, the effort tolerance and the perceived dyspnea as assessed by improvement in the respiratory questionnaire, CAT and Borg scale. Dyspnea is a significant limiting factor for exertion in patients with COPD. Thus, it is to be expected that any intervention that helps to diminish dyspnea should be associated with improved functional capacity and quality of life in patients with COPD. In our study, only the subjects in the home-based rehabilitation group exhibited improvement in the symptom, activity, impact domains of the SGRQ, which is related to dyspnea. As shortness of breath limits physical activities, the clinically significant reduction in the activity domain score may also be considered as an indirect measure of improvement in dyspnea. Despite using different protocols, other studies on home-based rehabilitation have also demonstrated that dyspnea may be reduced in patients with COPD.[17] Different factors might have influenced improvements in quality of life. The subjects additionally benefited from supervision on their technique of use of inhaled medication, which may also have contributed to improved respiratory function and a possible reduction in pulmonary hyperinflation, resulting in improved physical capacity.[17] Thus, the improvement in the quality of life likely occurred from a combination of these factors, rather than merely the training itself.

In a randomized controlled trial of a home-based 12-week training program involving 58 severe or very severe COPD patients, a significant improvement in quality of life, dyspnea and exercise tolerance (P < 0.008),[21] but not with pulmonary function could be demonstrated. In another nonrandomized observational study of 102 COPD patients, who followed a 7-week program of PR, the authors concluded that patients with worse disease status (combination of lower FEV1, more hyperinflation, lower exercise capacity, and worse quadriceps force) improved most in endurance exercise capacity.[22]

We also, found statistically significant improvement of the quality of life as assessed by the SGRQ. Studies have shown that in COPD, the minimal clinically significant difference seen in SGRQ scoring is a reduction by at least 4 points. Our study has shown both clinically and statistically significant improvement in SGRQ scores post rehabilitation by a score of 10 points, which implies high clinical significance.[23]

The CAT is a simple to use patient-completed quality of life instrument that contains eight questions covering the impact of symptoms in COPD. It is not known how the CAT score performs in the context of clinical PR programs or what the minimum clinically significant difference is.[24] CAT score is simple to implement as an outcome measure. In our study also, CAT score showed significant improvement by a reduction in score by 3 points among cases. In studies in COPD, the minimally clinical difference in Borg's scale is an improvement by 1 point. In our study, there is an improvement in Borg's scale by 3 points post rehabilitation which is both clinically and statistically significant.

In this era of COVID-19 pandemic, where there is hesitancy and hindrance to provide face-to-face institutional PR, home-based PR would be a better and safer alternative for COPD patients. Supervised tele-PR is now gaining popularity, as it has been found to be comparable to institutional rehabilitation.[25]

This study has a few limitations. First, there was no long-term follow-up of the subjects in the home-based rehabilitation group, and we do not know how much these subjects adhered to the exercises on their own. The nonrandomized nature of the study was also a significant factor. The factors such as socio-economic status, educational status were not matched here as those factors also may influence their nature of learning and the performance of PR. The sample size was calculated based on the domains in the SGRQ. Hence, the sample size may not have been adequate for the other parameters such as FEV1 and 6MWD.


   Conclusions Top


From our study we conclude that a low-cost, home-based PR program is effective intervention in COPD with improvement in lung functions (improvement in FEV1), improvement in the quality of life as measured by an increase in SGRQ, Borg, and CAT score. The study also supports the hypothesis that home-based PR can enhance the physical capacity of patients with COPD and improvement of the quality of life. Whether in a resource limited setting, home-based PR program can replace the hospital-based PR program, requires further randomized trials. In this era of COVID-19 pandemic, home-based PR could indeed be a better option for COPD patients.

Acknowledgement

Respiratory physiotherapists who supervised the pulmonary rehabilitation programme of the institution.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lopez AD, Shibuya K, Rao C, Mathers CD, Hansell AL, Held LS, et al. Chronic obstructive pulmonary disease: Current burden and future projections. Eur Respir J 2006;27:397-412.  Back to cited text no. 1
    
2.
India State-Level Disease Burden Initiative CRD Collaborators. The burden of chronic respiratory diseases and their heterogeneity across the states of India: The Global Burden of Disease Study 1990-2016. Lancet Glob Health 2018;6:e1363-74.  Back to cited text no. 2
    
3.
Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. Am J Respir Crit Care Med 2017;195:557-82.  Back to cited text no. 3
    
4.
Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006;(4):CD003793.  Back to cited text no. 4
    
5.
Rubí M, Renom F, Ramis F, Medinas M, Centeno MJ, Górriz M, et al. Effectiveness of pulmonary rehabilitation in reducing health resources use in chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2010;91:364-8.  Back to cited text no. 5
    
6.
Brooks D, Sottana R, Bell B, Hanna M, Laframboise L, Selvanayagarajah S, et al. Characterization of pulmonary rehabilitation programs in Canada in 2005. Can Respir J 2007;14:87-92.  Back to cited text no. 6
    
7.
Yohannes AM, Connolly MJ. Pulmonary rehabilitation programmes in the UK: A national representative survey. Clin Rehabil 2004;18:444-9.  Back to cited text no. 7
    
8.
Arnold E, Bruton A, Ellis-Hill C. Adherence to pulmonary rehabilitation: A qualitative study. Respir Med 2006;100:1716-23.  Back to cited text no. 8
    
9.
Taylor R, Dawson S, Roberts N, Sridhar M, Partridge MR. Why do patients decline to take part in a research project involving pulmonary rehabilitation? Respir Med 2007;101:1942-6.  Back to cited text no. 9
    
10.
O'Shea SD, Taylor NF, Paratz JD. But watch out for the weather: Factors affecting adherence to progressive resistance exercise for persons with COPD. J Cardiopulm Rehabil Prev 2007;27:166-74.  Back to cited text no. 10
    
11.
Holland AE, Mahal A, Hill CJ, Lee AL, Burge AT, Moore R, et al. Benefits and costs of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease – A multi-centre randomised controlled equivalence trial. BMC Pulm Med 2013;13:57.  Back to cited text no. 11
    
12.
Güell MR, de Lucas P, Gáldiz JB, Montemayor T, Rodríguez González-Moro JM, Gorostiza A, et al. Home vs. hospital-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: A Spanish multicenter trial. Arch Bronconeumol 2008;44:512-8.  Back to cited text no. 12
    
13.
Maltais F, Bourbeau J, Shapiro S, Lacasse Y, Perrault H, Baltzan M, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: A randomized trial. Ann Intern Med 2008;149:869-78.  Back to cited text no. 13
    
14.
Puente-Maestu L, Sánz ML, Sánz P, Cubillo JM, Mayol J, Casaburi R. Comparison of effects of supervised versus self-monitored training programmes in patients with chronic obstructive pulmonary disease. Eur Respir J 2000;15:517-25.  Back to cited text no. 14
    
15.
Strijbos JH, Postma DS, van Altena R, Gimeno F, Koëter GH. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. A follow-up of 18 months. Chest 1996;109:366-72.  Back to cited text no. 15
    
16.
Finnerty JP, Keeping I, Bullough I, Jones J. The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease: A randomized controlled trial. Chest 2001;119:1705-10.  Back to cited text no. 16
    
17.
Incorvaia C, Russo A, Foresi A, Berra D, Elia R, Passalacqua G, et al. Effects of pulmonary rehabilitation on lung function in chronic obstructive pulmonary disease: The FIRST study. Eur J Phys Rehabil Med 2014;50:419-26.  Back to cited text no. 17
    
18.
Ries AL. Minimally clinically important difference for the UCSD Shortness of Breath Questionnaire, Borg Scale, and Visual Analog Scale. COPD 2005;2:105-10.  Back to cited text no. 18
    
19.
Rejbi IB, Trabelsi Y, Chouchene A, Ben Turkia W, Ben Saad H, Zbidi A, et al. Changes in six-minute walking distance during pulmonary rehabilitation in patients with COPD and in healthy subjects. Int J Chron Obstruct Pulmon Dis 2010;5:209-15.  Back to cited text no. 19
    
20.
Berton DC, Silveira L, Da Costa CC, De Souza RM, Winter CD, Zimermann Teixeira PJ. Effectiveness of pulmonary rehabilitation in exercise capacity and quality of life in chronic obstructive pulmonary disease patients with and without global fat-free mass depletion. Arch Phys Med Rehabil 2013;94:1607-14.  Back to cited text no. 20
    
21.
Xu J, He S, Han Y, Pan J, Cao L. Effects of modified pulmonary rehabilitation on patients with moderate to severe chronic obstructive pulmonary disease: A randomized controlled trail. Int J Nurs Sci 2017;4:219-24.  Back to cited text no. 21
    
22.
Altenburg WA, de Greef MH, ten Hacken NH, Wempe JB. A better response in exercise capacity after pulmonary rehabilitation in more severe COPD patients. Respir Med 2012;106:694-700.  Back to cited text no. 22
    
23.
Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: The Six Minute Walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997;155:1278-82.  Back to cited text no. 23
    
24.
Dodd JW, Hogg L, Nolan J, Jefford H, Grant A, Lord VM, et al. The COPD assessment test (CAT): Response to pulmonary rehabilitation. A multicentre, prospective study. Thorax 2011;66:425-9..  Back to cited text no. 24
    
25.
Hansen H, Bieler T, Beyer N, Kallemose T, Wilcke JT, Østergaard LM, et al. Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: A randomised multicentre trial. Thorax 2020;75:413-21.  Back to cited text no. 25
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Subjects and Methods
   Results
   Discussion
   Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed910    
    Printed14    
    Emailed0    
    PDF Downloaded187    
    Comments [Add]    

Recommend this journal