Pulmonary Rehabilitation After Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Patients Who Previously Completed a Pulmonary Rehabilitation Program 
Long-Term Effects of a Maintenance Program After Supervised or Self-Monitored Training Programs in Patients with COPD
 Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme Exercise adherence or maintenance among older adults: 1-year follow-up study. Pilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease. Impact of COPD in North America and Europe in 2000: subjects' perspective of Confronting COPD International Survey Exercise maintenance following pulmonary rehabilitation: effect of distractive stimuli. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease. Short- and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction. Maintaining benefits following pulmonary rehabilitation: a randomised controlled trial The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease. Maintaining exercise capacity and quality of life following pulmonary rehabilitation. Long-term benefits of exercise maintenance after outpatient rehabilitation program in patients with chronic obstructive pulmonary disease. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial Home-Based Exercise Training as Maintenance after Outpatient Pulmonary Rehabilitation An integrated programme after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: effect on emotional and functional dimensions of quality of life Long-term follow-up of physical activity behavior in older adults. A randomised 2 x 2 trial of community versus hospital pulmonary rehabilitation, followed by telephone or conventional follow-up.
PURPOSE Acute exacerbations of chronic obstructive pulmonary disease ( AE COPD ) impair health-related quality of life ( HRQL ) . We evaluated the effect of an abbreviated repeat pulmonary rehabilitation ( PR ) program on HRQL after an AE COPD . METHODS Patients who had completed PR were followed for up to 12 months to identify an AE COPD and then placed in r and omized groups to receive a 3-week repeat-PR intervention or usual care .  Measures of HRQL ( Chronic Respiratory Disease Question naire , CRQ ) and functional exercise capacity ( 6-minute walk distance , 6MWD ) were collected at 2 ( T1 ) , 5 ( T2 ) , and 12 weeks ( T3 ) post-AE COPD . The repeat-PR program was undertaken between T1 and T2 . Between-group differences were examined using repeated- measures analysis of variance or covariance . RESULTS Of the 60 patients ( 30 men , age 69±8 years , forced expiratory volume in 1 second 0.86±0.40 L , 6MWD 367±99 m ) followed , 41 experienced an AE COPD 14 ± 11 weeks after completion of the initial PR program and 33 completed the study . Of these , 16 and 17 were r and omized to the intervention and control groups , respectively . No between-group differences were demonstrated at T2 or T3 . With the exclusion of 5 subjects who experienced a second AE COPD between T1 and T3 , the participants in the intervention group demonstrated greater reduction in dyspnea when compared to those in the control group at T3 ( 0.8±1.6 vs −0.4±1.3 points per item , P = .04 ) . CONCLUSIONS The reduction in dyspnea in those who did not experience a second AE COPD provides preliminary evidence for the role of repeat programs . The application of repeat PR should be refined in larger trials Abstract The evaluation of a 13-month maintenance program ( MP ) for 39 severe COPD patients with FEV1%pred 44(7)% who , as result of two different 8-week leg exercise training ( LET ) programs , one supervised at the hospital ( group S ; n = 20 ) and the other self-monitored ( SM ; n = 19 ) , had achieved different levels of exercise tolerance . After LET , patients in group S had a higher maximal oxygen uptake and endurance time than patients in the SM group [ O2max 1.43(0.30 ) l · min−1 ] vs l.25(0.27 ) l · min−1 and endurance-time 16(4 ) min vs 12 ( 5 ) min , respectively ) . During the MP patients were advised to walk vigorously at least 4 km/day , 4 times/wk . After the MP , while endurance time remained higher than at baseline , it had decreased ( p < 0.01 ) immediately after LET in both groups and no differences were evident between groups ( 11(4 ) min and 10(4 ) , respectively ) . In contrast , Chronic Respiratory Diseases Question naire scores , which had improved significantly after LET in both groups , remained high . Long-term effects of MP were independent of the training strategy or whether physiological improvements had been obtained with the initial LET . SM exercise programs do not seem capable of maintaining physiological improvements in exercise tolerance , though “ quality of life ” can be maintained BACKGROUND Pulmonary rehabilitation programmes improve the health of patients disabled by lung disease but their cost effectiveness is unproved . We undertook a cost/utility analysis in conjunction with a r and omised controlled clinical trial of pulmonary rehabilitation versus st and ard care . METHODS Two hundred patients , mainly with chronic obstructive pulmonary disease , were r and omly assigned to either an 18 visit , 6 week rehabilitation programme or st and ard medical management . The difference between the mean cost of 12 months of care for patients in the rehabilitation and control groups ( incremental cost ) and the difference between the two groups in quality adjusted life years ( QALYs ) gained ( incremental utility ) were determined . The ratio between incremental cost and utility ( incremental cost/utility ratio ) was calculated . RESULTS Each rehabilitation programme for up to 20 patients cost £ 12 120 . The mean incremental cost of adding rehabilitation to st and ard care was £ –152 ( 95 % CI –881 to 577 ) per patient , p = NS . The incremental utility of adding rehabilitation was 0.030 ( 95 % CI 0.002 to 0.058 ) QALYs per patient , p=0.03 . The point estimate of the incremental cost/utility ratio was therefore negative . The bootstrapping technique was used to model the distribution of cost/utility estimates possible from the data . A high likelihood of generating QALYs at negative or relatively low cost was indicated . The probability of the cost per QALY generated being below £ 0 was 0.64 . CONCLUSIONS This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service Follow-up evaluation was conducted of 101 older men and women ( mean age = 67 + /- 5 years ) who had participated in a r and omized study of physiological and psychological effects of aerobic exercise . Eighty-five subjects completed the follow-up evaluation , and almost all of them ( 94 % ) reported continuing with physical activity , as assessed by a self-report measure . Total energy expenditure was calculated as an indicator of exercise maintenance , and energy expenditure at follow-up was predicted from measures of physiological functioning , psychological well-being , and cognitive functioning obtained at the conclusion of the structured exercise program . Greater cardiorespiratory endurance , faster psychomotor speed , and lower anxiety predicted exercise behavior at follow-up , accounting for 13 % of the variance in exercise behavior . Gender was not a significant predictor of exercise behavior Objective To determine the feasibility and efficacy of a six-month , cell phone-based exercise persistence intervention for patients with chronic obstructive pulmonary disease ( COPD ) following pulmonary rehabilitation . Methods Participants who completed a two-week run-in were r and omly assigned to either MOBILE-Coached  ( n = 9 ) or MOBILE-Self-Monitored  ( n = 8) . All participants met with a nurse to develop an individualized exercise plan , were issued a pedometer and exercise booklet , and instructed to continue to log their daily exercise and symptoms . MOBILE-Coached also received weekly reinforcement text messages on their cell phones ; reports of worsening symptoms were automatically flagged for follow-up . Usability and satisfaction were assessed . Participants completed incremental cycle and six minute walk ( 6MW ) tests , wore an activity monitor for 14 days , and reported their health-related quality of life ( HRQL ) at baseline , three , and six months . Results The sample had a mean age of 68 ±11 and forced expiratory volume in one second 18 % predicted . Participants reported that logging their exercise and symptoms ( FEV1 ) of 40 ± was easy and that keeping track of their exercise helped them remain active . There were no differences between groups over time in maximal workload , 6MW distance , or HRQL ( p > 0.05 ) ; however , MOBILE-Self-Monitored increased total steps/day whereas MOBILE-Coached logged fewer steps over six months ( p = 0.04 ) . Conclusions We showed that it is feasible to deliver a cell phone-based exercise persistence intervention to patients with COPD post-rehabilitation and that the addition of coaching appeared to be no better than self-monitoring . The latter finding needs to be interpreted with caution since this was a purely exploratory study . Trial registration Clinical Trials.gov ( NCT00373932 ) We examined the feasibility of home-based walking training to maintain the benefits of a short-term exercise training in patients with severe chronic obstructive pulmonary disease ( COPD ) . After initial recovery from an exacerbation , 46 patients were r and omized into a training and a control group , and 30 patients completed the programme ( mean + /- SD FEV1 , 36 + /- 7 % predicted ) . The training group performed a 10-day walking training programme in the hospital , followed by a 6-month programme of supervised walking training at home , integrated into daily activities . The control group did not have exercise training in the hospital or at home . Until 6 months after discharge , lung function , exercise performance and symptom scores were assessed . Six-minute walking distance in the training group improved from day 1 to day 10 ( P<0.001 ) and this effect was maintained over 6 months ( P<0.001 ) . On average , daily walking distance at home was 2308 m and walking was reported on 157 days . Quality of life ( QoL ) scores changed significantly over 6 months ( P<0.001 ) . The control group showed no significant changes in exercise performance or QoL scores throughout the whole study period . Therefore , ( i ) significant improvements in exercise performance and Chronic Respiratory Disease Question naire ( CRQ ) scores could be achieved after recovery from an exacerbation and ( ii ) these improvements were maintained after discharge , when supported by a home-based walking training To date , no international surveys estimating the burden of chronic obstructive pulmonary disease ( COPD ) in the general population have been published . The Confronting COPD International Survey aim ed to quantify morbidity and burden in COPD subjects in 2000 . From a total of 201,921 households screened by r and om-digit dialling in the USA , Canada , France , Italy , Germany , the Netherl and s , Spain and the UK , 3,265 subjects with a diagnosis of COPD , chronic bronchitis or emphysema , or with symptoms of chronic bronchitis , were identified . The mean age of the subjects was 63.3 yrs and 44.2 % were female . Subjects with COPD in North America and Europe appear to underestimate their morbidity , as shown by the high proportion of subjects with limitations to their basic daily life activities , frequent work loss ( 45.3 % of COPD subjects of < 65 yrs reported work loss in the past year ) and frequent use of health services ( 13.8 % of subjects required emergency care in the last year ) , and may be undertreated . There was a significant disparity between subjects ' perception of disease severity and the degree of severity indicated by an objective breathlessness scale . Of those with the most severe breathlessness ( too breathless to leave the house ) , 35.8 % described their condition as mild or moderate , as did 60.3 % of those with the next most severe degree of breathlessness ( breathless after walking a few minutes on level ground ) . This international survey confirmed the great burden to society and high individual morbidity associated with chronic obstructive pulmonary disease in subjects in North America and Europe STUDY OBJECTIVE To determine if distractive auditory stimuli ( DAS ) in the form of music would promote adherence to a walking regimen following completion of a pulmonary rehabilitation program ( PRP ) and , thereby , maintenance of gains achieved during the program . DESIGN Experimental , r and omized , two-group design with testing at baseline , 4 weeks , and 8 weeks . SETTING Outpatient . PATIENTS Twenty-four patients ( 4 men and 20 women ) with moderate-to-severe COPD ( FEV(1 ) 41.3 + /- 13 % predicted [ mean + /- SD ] ) . INTERVENTION Experimental group subjects ( n = 12 ) were instructed to walk at their own pace for 20 to 45 min , two to five times a week , using DAS with a portable audiocassette player . The control group ( n = 12 ) received the same instructions , but no DAS . MEASUREMENTS AND RESULTS Primary outcome measures were perceived dyspnea during activities of daily living ( ADL ) and 6-min walk ( 6MW ) distance . Secondary outcome measures were anxiety , depressive symptoms , health-related quality of life ( QoL ) , global QoL , and breathlessness and fatigue at completion of the 6MW . In addition , all subjects recorded the distance and time walked using self-report ( pedometers and daily logs ) . There was a significant decrease in perceived dyspnea during ADL ( p = 0.0004 ) and a significant increase in 6MW distance ( p = 0.0004 ) over time in the DAS group compared to the control group . DAS subjects increased 6MW distance 445 + /- 264 feet ( mean + /- SD ) from baseline to 8 weeks , whereas control subjects decreased 6MW distance to 169 + /- 154 feet . No significant differences were noted for the remaining variables . The cumulative distance walked by the DAS group was 19.1 + /- 16.7 miles compared to 15.4 + /- 8.0 miles for the control group , a 24 % difference ( p = 0.49 ) . Despite this difference , self-report exercise log data were similar for the two groups . CONCLUSION Subjects who used DAS while walking had improved functional performance and decreased perceptions of dyspnea , whereas control subjects could not maintain post-PRP gains . DAS is a simple , cost-effective strategy that may have the potential to augment the effectiveness of post-PRP maintenance training OBJECTIVES To evaluate the effectiveness of an exercise adherence intervention to maintain daily activity , adherence to exercise , and exercise capacity over 1 year after completion of an outpatient pulmonary rehabilitation program . DESIGN A 2-group , experimental design was used with r and omization into intervention and usual care groups . SETTING Outpatient pulmonary rehabilitation program in a university-affiliated medical center . PARTICIPANTS One hundred six subjects ( 98 men ; 98 with chronic obstructive pulmonary disease ) with a mean age of 67 years and chronic lung disease . INTERVENTION Twelve-week adherence intervention ( weekly phone calls and home visit ) including counseling on establishing , monitoring , and problem-solving in maintaining a home exercise program . MAIN OUTCOME MEASURES Primary outcomes included daily activity ( accelerometer ) , exercise adherence ( exercise diary ) , and exercise capacity ( six-minute walk test ) . All measures were performed at baseline , after the pulmonary rehabilitation program ( 8 wk ) , after the adherence intervention ( 20 wk ) , and at 1 year . RESULTS A rank-based analysis of covariance showed less decline at 20 weeks in exercise adherence ( intervention mean , + 3 min ; control mean , -13 min ; P=.015 ) and exercise capacity ( intervention mean , -10.7 m ; control mean , -35.4 m ; P=.023 ) . There were no differences in daily activity at 20 weeks or any differences in any primary variable at 1 year . CONCLUSIONS The intervention enhanced exercise adherence and exercise capacity in the short term but produced no long-term benefit . These findings are in part attributed to the disappointing measurement characteristics of the accelerometer used to measure daily activity . The intervention was acceptable to participants . Further study is needed to fashion interventions that have more persistent benefit PURPOSE Pulmonary rehabilitation programs are effective in patients with severe chronic obstructive pulmonary disease ( COPD ) in the short term , but their long-term effects are not known . We investigated the short- and long-term effects of a 6-month outpatient rehabilitation program in patients with severe COPD . SUBJECTS AND METHODS One hundred patients were r and omly assigned to receive either an exercise training program that included cycling , walking , and strength training ( n = 50 ) or usual medical care ( n = 50 ) . Thirty-four patients in the training group were evaluated after 6 months ( end of training ) , and 26 were evaluated after 18 months of follow-up . In the control group , 28 patients were evaluated at 6 months and 23 after 18 months . We measured pulmonary function , 6-minute walking distance , maximal exercise capacity , peripheral and respiratory muscle strength , and quality of life ( on a 20 to 140-point scale ) , and estimated the cost-effectiveness of the program . RESULTS At 6 months , the training group showed improvement in 6-minute walking distance [ mean difference ( training - control ) of 52 m ; 95 % confidence interval ( CI ) , 15 to 89 m ] , maximal work load ( 12 W ; 95 % CI , 6 to 19 W ) , maximal oxygen uptake ( 0.26 liters/min ; 95 % CI , 0.07 to 0.45 liters/min ) , quadriceps force ( 18 Nm ; 95 % CI , 7 to 29 Nm ) , inspiratory muscle force ( 11 cm H(2)O ; 95 % CI , 3 to 20 cm H(2)O ) , and quality of life ( 14 points ; 95 % CI , 6 to 21 points ; all P < 0.05 ) . At 18 months all these differences persisted ( P < 0.05 ) , except for inspiratory muscle strength . For 6-minute walking distance and quality of life , the differences between the training group and controls at 18 months exceeded the minimal clinical ly-important difference . CONCLUSION Among patients who completed the 6-month program , outpatient training result ed in significant and clinical ly relevant changes in 6-minute walking distance , maximal exercise performance , peripheral and respiratory muscle strength , and quality of life . Most of these effects persisted 18 months after starting the program The aim of this study was to evaluate the long-term outcome of an outpatient pulmonary rehabilitation programme ( PRP ) in patients with chronic airway obstruction ( CAO ) . In 61 CAO patients ( 35 asthmatics and 26 chronic obstructive pulmonary disease ( COPD ) ) lung and respiratory muscle function , exercise tolerance ( by symptom limited cycloergometer and walking tests ) , dyspnoea ( Borg scale , visual analogue scale ( VAS ) , baseline and transitional dyspnoea index ( BDI and TDI , respectively ) ) and quality of life ( St George 's Respiratory Question naire ( SGRQ ) ) were assessed at baseline ( to ) , at discharge ( t1 ) and 12 months postdischarge ( t2 ) . Preprogramme and post-programme hospital admissions and exacerbations of disease were also recorded . In comparison with baseline , no significant change was observed in lung function tests in either diagnostic group , either at t1 or at t2 . In both groups improvements in respiratory muscle strength , exercise tolerance , Borg scale and VAS reported at t1 were partially reduced at t2 . Analysis of variance showed that these changes over time were similar in the two groups . Mean values of SGRQ and BDI/TDI improved at t1 , and , unlike exercise tolerance , did not worsen at t2 . However , a clinical ly relevant difference in SGRQ between t2 and to was reported only in 56 % of asthmatics and 52 % of COPD patients . Compared with the preceding 2 yrs , in the year following PRP , hospital admissions and disease exacerbations decreased significantly in both diagnostic groups . Regardless of diagnosis , patients with chronic airway obstruction who underwent an outpatient pulmonary rehabilitation programme maintained an improved quality of life 12 months postdischarge despite a partial loss of the improvement in exercise tolerance The aim of this study was to determine if weekly , supervised , outpatient-based exercise plus unsupervised home exercise following an 8-week pulmonary rehabilitation programme would maintain functional exercise capacity and quality of life at 12 months better than st and ard care of unsupervised home exercise training . Chronic obstructive pulmonary disease ( COPD ) subjects completed an 8-week pulmonary rehabilitation programme  , were r and omised to an intervention group ( IG ) of weekly , supervised , exercise plus home exercise or to a control group ( CG ) of unsupervised home exercise and followed for 12 months . Outcome measurements at baseline ( after pulmonary rehabilitation ) , and 3 , 6 and 12 months included the 6-min walk test and St George 's Respiratory Question naire ( SGRQ ) .  59 subjects with moderate COPD ( Global Initiative for Chronic Obstructive Lung Disease stage II ) were recruited and 48 subjects completed the study . 12-month mean difference showed no significant change from baseline in 6-min walk distance ( IG -11 m , 95 % CI -21–10 m ; CG -6 m , 95 % CI -34–11 m ) or total SGRQ score ( IG 3 , 95 % CI -0.8–7 ; CG -3 , 95 % CI -7–3 ) . 12 months following pulmonary rehabilitation both weekly , supervised , outpatient-based exercise plus unsupervised home exercise and st and ard care of unsupervised home exercise successfully maintained 6-min walk distance and quality of life in subjects with moderate COPD The purpose of this study was to examine the effects of two postrehabilitation programmes on functional exercise tolerance and health-related quality of life in patients with chronic obstructive pulmonary disease ( COPD ) . Subjects with COPD ( n=109 ) were r and omised to receive either enhanced follow-up ( EF ) or conventional follow-up ( CF ) . Subjects in the EF group attended a monthly support group and received a telephone call from a staff member at the midpoint ( 2 weeks ) between their visits . Both groups had scheduled appointments with a physical therapist and physician at 3‐monthly intervals after discharge . Longitudinal data were recorded in 85 subjects ( 37 EF and 48 CF ) . Over the course of the study , there was no difference in distance walked in 6 min between the two groups but a significant difference for time and a group-time interaction . There was no difference in total chronic respiratory disease question naire score between groups at baseline or at any time interval despite a significant difference with time . There was a clear deterioration in functional exercise capacity and health-related quality of life after completion of respiratory rehabilitation but no difference between the groups PURPOSE To compare the effects of short-term ( 3 months ) and long-term ( 18 months ) involvement in an exercise program on self-reported disability and physical function in patients with chronic obstructive pulmonary disease ( COPD ) . METHODS A total of 140 patients with COPD were studied in a r and omized , single-blinded clinical trial . Self-reported disability and physical function were assessed using a  21-item question naire , a 6-minute walk , timed stair climb , and an overhead task .  RESULTS At the completion of the trial , participants in the long-term intervention reported 12 % less disability than those in the short-term intervention ( adjusted mean with 95 % confidence interval , 1.53 ( 1.43 - 1.63 ) versus 1.71 ( 1.61 to 1.81 ) units , respectively ; P=.016 ) , walked 6 % farther during 6-minutes ( 1,815.0 [ 1,750.4 - 1,879.6 ] vs 1,711.5 [ 1,640.7 - 1,782.3 ] feet , respectively ) , climbed steps 11 % faster ( 11.6 [ 11.0 - 12.2 ] vs 12.9 [ 12.3 - 13.5 ] seconds , respectively ) , and completed an overhead task 8 % faster ( 46.8 [ 44.4 - 49.2 ] vs 50.4 [ 47.8 - 53.0 ] seconds , respectively ) than those in the short-term intervention . CONCLUSION An 18 month exercise program results in greater improvements in self-reported disability and physical function in patients with COPD when compared with a 3-month exercise program . As such , long-term exercise should be recommended for all patients with COPD OBJECTIVE The optimum method for sustaining the benefits gained from  pulmonary rehabilitation ( PR )  has not been determined . In this report the authors describe the 4-year referral and uptake patterns to a hospital-based outpatient PR programme , and the sustained benefits of PR in patients with COPD attending a community-based maintenance exercise programme .  METHODS Entry and exit data were mapped for all patients referred to the PR service over the review period . All eligible patients were offered a community-based maintenance exercise programme upon completion of PR . A total of 21 patients underwent follow-up assessment of functional exercise capacity , quality of life ( QOL ) and health-care utilization . RESULTS Over a 4-year period , 467 patients ( 80 % with COPD ) were referred to the programme , of whom 230 entered PR . In total , 172 patients completed PR , with attrition ( 25 % ) being mostly due to medical problems . Of the 84 patients who elected for the community-based programme , 46 were still attending at follow up and 21 patients with moderate-to-severe COPD ( 44.9 + /- 12.6 ( mean + /- SD ) FEV(1)% predicted ) were reassessed at 18.4 + /- 11.9 months post PR . Significant improvements ( mean change ( 95 % confidence interval ) ) persisted in 6-min walk distance ( 41.1 m ( 15.7 - 66.5 ) ) , distance walked in 20 min ( 195.1 m ( 82.3 - 308 ) ) and in QOL ( Chronic Respiratory Disease Question naire ) ( 11.0 points ( 4.4 - 17.6 ) ) ( P < 0.01 ) . The QOL improvements exceeded the minimum clinical ly important difference . A trend towards a reduction in COPD -related hospital admissions , bed-days and emergency department presentations was observed in the 12 months following PR . Self-reported adherence with the home exercise programme indicated that 67 % of patients were exercising at least 3 - 5 days each week in addition to attending a class . CONCLUSION For patients with moderate-to-severe COPD , a weekly community-based maintenance exercise class , supervised by a physiotherapist , combined with a home exercise programme is an effective intervention for maintaining improvements following PR BACKGROUND Optimal strategies to maintain short-term benefits of an initial rehabilitation program ( RP ) are not known . To assess the long-term effects of exercise maintenance ( EM ) after an initial outpatient RP , the authors conducted a prospect i ve study . PATIENTS AND METHODS Fifty-eight patients with moderate to moderately severe chronic obstructive pulmonary disease who completed an initial 7-week outpatient RP were included . They were allocated into four groups according to the conditions of EM they self-selected : 15 patients received a structured EM session supervised by a physiotherapist twice a week ( group A ) ; 14 patients received a structured EM session supervised by a physiotherapist once a week ( group B ) ; 15 patients continued self EM daily at home ( group C ) ; and 14 patients did not continue EM ( group D ) . Patients were evaluated before , immediately after , and 18 months after the initial outpatient RP . Measurements included exercise testing on a cycle ergometer and a visual analog scale to evaluate chronic dyspnea . RESULTS After RP , all patients exhibited improvements in maximal workload ( P < 0.05 ) and in dyspnea ( P < 0.05 ) . Improvements in maximal workload were maintained at 18 months in patients in groups A , B , and C but these only reached significance in groups B and C ( P < 0.05 ) . On the other h and , maximal workload returned to baseline values in group D ( P = 0.01 ) at 18 months . CONCLUSION Our results indicate definite benefits of EM after an initial outpatient RP compared with no EM . Daily EM at home appears to be as efficient as structured EM sessions supervised by a physiotherapist , once or twice a week , in moderate to moderately severe chronic obstructive pulmonary disease BACKGROUND Pulmonary rehabilitation seems to be an effective intervention in patients with chronic obstructive pulmonary disease . We undertook a r and omised controlled trial to assess the effect of outpatient pulmonary rehabilitation on use of health care and patients ' wellbeing over 1 year . METHODS 200 patients with disabling chronic lung disease ( the majority with chronic obstructive pulmonary disease ) were r and omly assigned a 6-week multidisciplinary rehabilitation programme ( 18 visits ) or st and ard medical management . Use of health services was assessed from hospital and general- practice records . Analysis was by intention to treat . FINDINGS There was no difference between the rehabilitation ( n=99 ) and control ( n=101 ) groups in the number of patients admitted to hospital ( 40 vs 41 ) but the number of days these patients spent in hospital differed significantly ( mean 10.4 [ SD 9.7 ] vs 21.0 [ 20.7 ] , p=0.022 ) . The rehabilitation group had more primary -care consultations at the general-practitioner 's premises than did the control group ( 8.6 [ 6.8 ] vs 7.3 [ 8.3 ] , p=0.033 ) but fewer primary -care home visits ( 1.5 [ 2.8 ] vs 2.8 [ 4.6 ] , p=0.037 ) . Compared with control , the rehabilitation group also showed greater improvements in walking ability and in general and disease-specific health status . INTERPRETATION For patients chronically disabled by obstructive pulmonary disease , an intensive , multidisciplinary , outpatient programme of rehabilitation is an effective intervention , in the short term and the long term , that decreases use of health services Background : Pulmonary rehabilitation is successful in improving exercise capacity and quality of life in patients with chronic obstructive pulmonary disease ( COPD ) . However , training effects diminish over time . Objectives : We evaluated the effects of simple , daily , structured , self-monitored , home-based exercise training for patients with moderate COPD after a 3-week outpatient rehabilitation . Methods : We conducted a r and omized , controlled , observer-blind trial . Twenty patients were recruited . Ten patients performed home-based exercise training ( mean age 67 years , 95 % confidence interval [ CI ] 63–72 ; FEV1 58.6 % , 95 % CI 53.8–63.4 ) , and 10 patients served as controls ( mean age 72 years , 95 % CI 69–77 ; FEV1 62.5 % , 95 % CI 57.7–67.3 ) . At baseline , and after 3 and 6 months , we assessed exercise capacity ( 6-min walk test , 6MWT , primary endpoint ) , health-related quality of life ( Chronic Respiratory Question naire , CRQ ) and lung function . An intention-to-treat analysis was performed using two-way ANOVA models for comparison of time trends between r and om groups . Results : The training group had better results than the control group in 6MWT ( p = 0.033 ) , in CRQ total ( p = 0.027 ) , CRQ dyspnea ( p = 0.014 ) and CRQ fatigue ( p = 0.016 ) . Improvement in FEV1 was also better in the intervention group than in the control group ( p = 0.007 ) . Conclusions : We demonstrated that training effects obtained from an outpatient rehabilitation program can be maintained by home-based exercise training in patients with moderate COPD Objective : To assess whether a maintenance integrated health care programme is effective in improving functional and emotional dimensions of quality of life in patients with chronic obstructive pulmonary disease ( COPD ) after a first pulmonary rehabilitation . Design : Prospect i ve controlled trial . Setting : Three rehabilitation centres and three patient self-help associations within a health care network in France . Subjects : Forty patients with moderate to severe COPD . Interventions : After a first four-week inpatient pulmonary rehabilitation programme , patients took part in a maintenance integrated health care programme or usual care for 12 months . Main measures : The primary outcomes were the change in functional and emotional dimensions of quality of life measured by the St George ’s Respiratory Question naire ( SGRQ ) , the brief World Health Organization Quality of Life question naire ( Brief-WHOQOL ) and six specific questions using a 10-cm visual analogue scale . Secondary outcomes were change in exercise tolerance measured by six-minute walking test and cycle exercise . Results : At one year , the maintenance intervention ( n = 11 ) produced improvements in functional and emotional dimensions scores of quality of life and exercise tolerance . Patients in the usual aftercare group ( n = 16 ) exhibited maintenance of functional dimension scores of quality of life , but a clinical ly relevant decline in emotional scores of quality of life and in six-minute walking distance one year after the pulmonary rehabilitation . Conclusion : Patient self-help association seems to be an innovative and efficient organizational structure to support patients with COPD after pulmonary rehabilitation in real-life setting s. A distinction between emotional and functional dimensions of quality of life may improve the design and evaluation of integrated health care programmes in patients with COPD OBJECTIVE To examine the contribution of social-cognitive factors ( self-efficacy and affect ) in predicting long-term physical activity in a sample of older adults ( N=174 ) . DESIGN A prospect i ve design assessed physical activity and psychosocial variables at 2 and 5 years following a 6-month r and omized , controlled exercise trial . MAIN OUTCOME MEASURES The primary outcome variable was self-reported physical activity , with previous behavior , self-efficacy , and affect assessed as determinants of physical activity . RESULTS Covariance modeling analyses indicated that physical activity at Year 2 was the strongest predictor of physical activity at 5-year follow-up . Both self-efficacy and affect at Year 2 were also associated with physical activity at Year 5 , as was original treatment condition . Variables accounted for 35 % of the variance in Year 5 activity . CONCLUSION Older adults with higher levels of physical activity , more positive affect , and higher self-efficacy at Year 2 were more likely to continue to be active at Year 5 . This study is one of the longest follow-ups of exercise behavior in older adults and has implication s for structuring environments to maximize the maintenance of physical activity OBJECTIVES To determine whether pulmonary rehabilitation carried out in a community setting is more effective than that carried out in a st and ard hospital setting and which is more cost-effective ; also whether telephone follow-up is both cost-effective and useful in prolonging the beneficial effects of a pulmonary rehabilitation programme . DESIGN A r and omised trial . Participants were r and omised in 2 x 2 factorial fashion to hospital or community rehabilitation and telephone or st and ard follow-up with review . SETTING Hospitals or community sites in Sheffield . The community venues were selected to be close to public transport routes and have good parking and level access . The two hospital venues were the physiotherapy gym and a staff gym within the grounds of the hospital . PARTICIPANTS Patients with chronic obstructive pulmonary disease diagnosed by respiratory physicians according to Global Initiative for Chronic Obstructive Lung Disease guidelines . INTERVENTIONS Participants were r and omised to one of four groups : hospital rehabilitation with no telephone follow-up ; hospital rehabilitation with telephone follow-up ; community rehabilitation with no telephone follow-up ; or community rehabilitation with telephone follow-up . All were blinded to the telephone intervention arm until 1 month post rehabilitation , when only the assessment team and research participants were unblinded . MAIN OUTCOME MEASURES The primary outcome measure was the difference in improvement in endurance shuttle walking test ( ESWT ) between hospital and community pulmonary rehabilitation groups post rehabilitation , and the difference in ESWT during 18 months ' follow-up between those receiving telephone encouragement and those receiving st and ard care . A secondary measure was health-related quality of life . RESULTS A total of 240 participants had evaluable data . Of these , 129 were r and omised to hospital rehabilitation ( 64 with telephone follow-up and 65 with no telephone follow-up ) and 111 to community rehabilitation ( 55 with telephone follow-up and 56 with no telephone follow-up ) . For the primary outcome measure , there were 162 patients with data for analysis : hospital rehabilitation with no telephone follow-up ( n = 38 ) ; hospital rehabilitation with telephone follow-up ( n = 48 ) ; community rehabilitation with no telephone follow-up ( n = 43 ) ; and community rehabilitation with telephone follow-up ( n = 33 ) . For the acute phase post-rehabilitation outcomes , before patients had the opportunity for telephone follow-up , we compared outcomes between the 76 patients in the community rehabilitation group and the 86 patients in the hospital rehabilitation group . Patients in the hospital rehabilitation group increased the distance they could walk at the post-rehabilitation follow-up by 283 m ( SD 360 m ) , an increase relative to baseline of 109 % ( SD 137 % ) . Patients in the community rehabilitation group increased the distance they could walk at the post-rehabilitation follow-up by 216 m ( SD 340 m ) , an increase relative to baseline of 91 % ( SD 133 % ) . There was no statistically significant difference between the groups [ 17.8 % ( 95 % CI -24.3 to 59.9 , p = 0.405 ) ] . For longer term outcomes at 6 , 12 and 18 months post rehabilitation there was no evidence of a rehabilitation group effect . After allowing for the initial post-rehabilitation baseline distance walked , time ( follow-up visit ) and the factorial design ( telephone follow-up group ) , the average difference in the post-rehabilitation follow-up distance walked on the ESWT between the hospital and community rehabilitation groups was 1.5 m ( 95 % CI -82.1 to 97.2 , p = 0.971 ) , and between the telephone and no-telephone groups it was 56.9 m ( 95 % CI -25.2 to 139 , p = 0.174 ) . There was no difference between hospital or community groups in terms of acute effect or persistence of effect . Health economic analysis favoured neither hospital nor community setting s , nor did it clearly favour telephone follow-up or routine care . CONCLUSIONS Pulmonary rehabilitation delivered in a community setting has similar efficacy to that produced in a more traditional hospital-based setting , both setting s producing significant improvements in terms of exercise capacity and quality of life acutely and after long-term follow-up . Health economic analysis showed that neither hospital nor community programmes were greatly favoured . The choice of model will depend on local factors of convenience , existing availability of re sources and incremental costs . Staff characteristics may be important in gaining optimal outcome , and care should be taken in staff recruitment and training . TRIAL REGISTRATION Current Controlled Trials IS RCT N86821773
OBJECTIVE To examine existing research on  pulmonary exercise rehabilitation ( PR ) maintenance interventions .