Home-based Physiotherapy for Severe Chronic Obstructive Pulmonary Disease (COPD)
Posted on 8th May 2017 by Kristen Dufresne
COPD, or Chronic Obstructive Pulmonary Disease, is an obstructive lung disease that impacts a persons’ ability to breath. Their airways become “floppy” and it’s difficult to exhale and replace the air in their lungs, leaving patients short of breath even with minor activity. Severity of COPD is measured via a pulmonary function test, and in this review “severe COPD” was defined as a forced expiratory volume in one second (FEV1) less than 50% expected.
Exercise is an important aspect of care for patients with COPD, as several disease-related factors lead to increased muscle-wasting (2). Often pulmonary rehabilitation programs are part of the treatment for COPD (3), but long wait-times can limit accessibility (4). Home programs may provide a low-cost way to help those living with COPD maintain their level of function.
Thomas and colleagues (1) conducted a systematic review and meta-analysis on the effectiveness of a home-based physiotherapy program on reducing breathlessness during activities of daily living (ADLs) in people with severe COPD (FEV1 less than 50% expected). Included studies investigated respiratory muscle training (inspiratory or expiratory muscles), or exercises (either walking or pulmonary rehabilitation). All results showed statistical significance for improving breathlessness during ADLs, except for expiratory muscle training.
The authors searched several databases and the bibliographies of potentially relevant studies, systematic reviews, and official statements (e.g., American Thoracic Society, European Respiratory Society). Included studies were randomized control trials, included individuals who were over 18 years old with severe COPD and no cardiovascular comorbidities, and utilized a valid and reliable outcome measure specific to breathlessness during ADLs.
Two reviewers assessed quality and extracted data from included studies. Often summary statistics were not directly reported; other relevant information was extracted and a predominantly qualitative summary of the articles and their findings was undertaken. One meta-analysis was possible based on data availability.
Of 1686 potentially relevant articles, 66 were reviewed in full and in the end seven studies met the inclusion criteria. Studies were homogeneous at baseline regarding age and COPD severity, although 80% of all subjects were male.
Five studies investigated inspiratory or expiratory muscle training, and two studies investigated exercises. All results except for expiratory muscle training showed statistical significance for improving breathlessness during ADLs. Five studies demonstrated clinical significance, four for inspiratory muscle training and one for exercise. One meta-analysis was done, which indicated that inspiratory muscle training improved patient breathlessness significantly compared with controls.
Respiratory Muscle Training involved progressively working up to a maximum of 60% of their peak inspiratory maximum or peak expiratory maximum over the treatment duration. Training programs varied from three to 12 months in duration. The two studies looking at exercise included: home-based pulmonary rehabilitation (30 minutes, 2 times/week; 1-month program) and walking (1-hour, four times per week; 2-month program).
The authors concluded that the current evidence indicates that home-based physiotherapy interventions (walking and inspiratory muscle training specifically) may have a beneficial impact on breathlessness during ADLs, among patients with severe COPD. However, further research is needed to provide additional information.
- Strong homogeneous similarity of all study participants against all principle baseline criteria.
- Excluding participants with cardiovascular comorbidities limits the external reliability as real-world populations will often have cardiovascular comorbidities.
- Overall study quality was moderate at best, and all studies had small sample sizes (ranging from 8 to 21).
- The home-based pulmonary rehabilitation program intervention included several components (breathing strategies, removal of secretions, walking, and work simplification of ADLs), making it impossible to determine the relative impact of each variable on study outcomes.
- Four of the seven studies did not report on intention-to-treat analyses.
- Thomas MJ, Simpson J, Riley R, & Grant E. The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD: A systematic review. Physiotherapy. 2010. 96;108-119
- Mathur S, Brooks D, Carvalho C. Structural alterations of skeletal muscle in COPD. Front. Physiol., 19 March 2014.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. DOI: 10.1002/14651858.CD003793.pub3.
- Bowen JM, Campbell K, Sutherland S, Bartlett A, Brooks D, Qureshi R, Goldstein R, Gershon AS, Prevost S, Samis L, Kaplan AG, Hopkins RB, Macdougald C, Nunes E, O’Reilly DJ, Goeree R. Pulmonary rehabilitation in Ontario: a cross-sectional survey. Ont Health Technol Assess Ser [Internet]. 2015 March;15(8):1–67. Available from: http://www.hqontario.ca/evidence/publications-and-ohtacrecommendations/ontario-health-technology-assessment-series/pulmonary-rehabilitation-ontario