Pulmonary rehabilitation (PR) has emerged from the dark depths of despair to a successful system of care, with documented improvements in quality of life and daily function. PR isn’t just successful—it is magical, according to Roger S. Goldstein, MBChB, FCCP, during the 2020 Canadian Thoracic Society Honorary Lecture,“The Magic of Rehabilitation” on Monday, October 19.
“In magic, there are dramatic and unforeseen changes,” said Dr. Goldstein, professor of medicine and physical therapy and founding chair of Respiratory Rehabilitation Research, University of Toronto and head of respiratory medicine at West Park Healthcare Centre. The session recordings are available for viewing on the virtual CHEST 2020 meeting platform through January 18, 2021, for registered attendees.
“And who would have known, 25 years ago, that pulmonary rehabilitation would have created such dramatic change in the quality of life in patients with lung disease? And who knew, 25 years ago, that pulmonary rehabilitation would take patients from that dark place of hopelessness and helplessness to a life of improved exercise and activity, reintegration into the community, and enhanced autonomy? The results of pulmonary rehabilitation are so altogether different from whence they came that I call it magic.”
The magic began with two papers in 1969 reporting the successful use of exercise therapy to performance in patients with what would now be called COPD.
But there were no outcome measures until the 1970s, Dr. Goldstein noted, and the standard 6-minute walk test did not appear until 1982.
“No outcome measures, no trials,” he said. “Once we had disease-specific measures such as dyspnea, fatigue, emotional functioning, and mastery, we could conduct trials and begin to discover what works to improve patients’ ability to function and their quality of life.”
Dyspnea may be the most obvious symptom of severe lung disease, he continued, but fatigue can be just as troubling for patients. So can anxiety, depression, loneliness, and pain.
A growing number of trials showed PR can produce statistically and clinically significant improvements in all of these outcomes, along with fewer acute exacerbations, fewer emergency department visits, fewer and shorter hospitalizations, fewer unscheduled primary care visits, and increased survival.
A 2020 retrospective analysis of nearly 200,000 Medicare patients across 4,500 hospitals showed a dramatic increase in survival for COPD patients hospitalized with acute exacerbations who went on to PR.
Each additional week of PR is associated with increased survival, Dr. Goldstein noted. But only 1.5% of AECOPD patients actually went on to PR.
Patients who failed to appear or failed to continue PR gave multiple reasons. They couldn’t get to the sessions, they couldn’t do the exercises, they didn’t believe they would benefit.
Multivariate analysis found the primary risk factors for nonattendance were living alone and being on long-term oxygen therapy. Risk factors for nonadherence included smoking, poor exercise capacity, and hospitalization. Lack of insurance coverage is another problem in some areas, including the US.
Dr. Goldstein said the first step is to offer reassurance that providers are there to help. Studies in Australia and elsewhere have found that at-home exercise programs, climbing stairs or porch steps, walking, resistance exercises using bottles of water or canned goods, can be just as effective as monitored and supervised in-person or telehealth PR programs.
“We need to meet the preferences of patients in regard to the timing of PR and the type of exercise,” Dr. Goldstein said. “Most importantly, psychosocial care and psychological care have to come first, then exercise. The problem with adherence is understanding what makes people tick. We first have to address patients’ realities like pain, loneliness, and isolation, then we can work on pulmonary rehabilitation.”