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ORIGINAL ARTICLE
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 362-368
Comparing the effects of self-management and hospital-based pulmonary rehabilitation programs in COPD patients
B Kilic1, HS Cicek2, MZ Avci3, 4
1 Department of Medical Nursing, University of Health Sciences, Gulhane Nursing Faculty, Ankara, Turkey
2 Cyprus International University, Health Sciences Faculty, Nursing School, Lefkosa, Cyprus, TRNC, Cyprus
3 Cyprus Science University, Health Sciences Faculty, Girne, Cyprus, TRNC, Cyprus
Correspondence Address:
Prof. H S Cicek
Cyprus International University, Health Sciences Faculty, Lefkosa
Cyprus
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_165_20
Abstract
Background: Pulmonary rehabilitation (PR) is a core component of the management of patients with chronic obstructive pulmonary disease (COPD). Although several types of PR programs are implemented for patients with COPD on the basis of patient preferences or clinical protocols, the clinical efficiencies of these programs may vary, with each program having its own unique purpose, procedures, benefits, challenges, and effectiveness. Aim: The aim of this study was to compare the effects of self-management and hospital-based PR programs in COPD patients. Materials and Methods: This study was prospective intervention research. Fifty-eight patients with stable COPD were randomly allocated to a hospital-based outpatient group and a self-management group before commencement of a 12-week PR program. Before and after the PR program, all patients were evaluated using the 6-min walk test, Modified Borg Scale, St. George's Respiratory Questionnaire, State–Trait Anxiety Inventory, and Standardized Mini-Mental Test. Results: Pulmonary functions, dyspnea, quality of life, and 6MWT distance were significantly improvement the hospital-based PR than self-management PR (P < 0.05). Moreover, cognitive function significantly improved after the PR program in both groups with no significant intergroup difference (P > 0.05). Conclusions: Our findings suggest that PR is useful for to improvement functional capacity, quality of life, cognitive function and anxiety, in patients with COPD. A hospital-based PR is more effective than a self-management PR program.
Keywords: Anxiety, cognitive function, dyspnea, quality of life, rehabilitation
Introduction 
Chronic obstructive pulmonary disease (COPD) is a complex multicomponent disorder characterized by progressive irreversible respiratory symptoms and extrapulmonary comorbidities, including anxiety, depression, and mild cognitive impairment.[1] The prevalence of COPD is estimated to be 11.7% worldwide.[2] In the later stages of the disease, clinical deterioration and added complications compromise the quality of the life of the patient and result in increased treatment expenses. Patients also exhibit a decrease in their exercise capacity and daily activities.[3] Furthermore, with disease progression and worsening of dyspnoea, patients become dependent on others and exhibit social isolation, depression, and anxiety.[4]
Cognitive deterioration in patients with COPD is a multifactorial process associated with decreased physical activity and cerebral blood flow, tissue hypoxia, systemic inflammation, and oxidative stress.[5] Studies have shown that patients with moderate and severe COPD exhibit neurophysiological disorder. In fact, even patients with mild hypoxia can exhibit cognitive disorders.[6] Because COPD is a multifactorial disease, identification of coexisting depression, anxiety, and cognitive disorders as well as comorbidities associated with the prognosis is very important.[1] Pulmonary rehabilitation (PR) is a symptomatic, evidence-based, multidisciplinary, comprehensive treatment approach for patients with chronic respiratory diseases who exhibit restricted daily life activities. PR programs can be conducted in different settings, including inpatient, outpatient, community, home settings, and they can reverse the progressive disabilities caused by COPD.[7],[8] A variety of PR programs are implemented depending on patient preferences or clinical protocols; however, not much is known about the efficacy of these different programs. In the present study, we compared the effects of self-management and hospital-based PR programs in COPD patients.
Methods Ethical considerations: This study obtained ethical approval from the Institutional Ethical Board Gulhane University (Approval no. 50687469-1491-149-15/1648.4-274).
Design: This study was designed as a prospective intervention study.
Sample and Settings: Individuals diagnosed with COPD according to the GOLD guidelines[1] at Respiratory Disease Clinic, Gulhane Training and Research Hospital Ankara, Turkey, between 1st January 2016 and 31st May 2016 were considered for this study. Other inclusion criteria were as follows: stable disease, ex-smokers, and no history of participation in a PR program. The sample size was calculated using G* Power 3.1.,[9] which showed that each group should include 27 patients for a 95% confidence interval and 80% power under the assumption that the Standardized Mini-Mental Test (SMMT) final scores were 23.8 ± 4.39 and 26.7 ± 2.88 for groups, respectively. Eventually, a total of 58 patients, including 27 in the hospital-based pulmoner rehabilitation group (HBPR) and 31 in the self-management pulmoner rehabilitation group (SMPR) completed the study.
Data Collection: Outpatients who fulfilled the inclusion criteria were randomly divided into a hospital-based pulmonary rehabilitation group (HBPR) and a self-management pulmonary rehabilitation group (SMPR). Researchers were blinded. The first patient was included in the HBPR, and subsequent allocation was performed using double block randomization.
Pulmonary rehabilitation program
The PR programs used in this study included patient training and exercise. Both groups were trained by a specialized nurse. Before exercise training initiation, the patients received a presentation about the disease (definition, etiology, symptoms, risk factors, exacerbation, oxygen use, nutrition, travel conditions, daily life activity, and drugs, etc.). All patients received one-on-one training in the presence of a relative/guardian and also received an education booklet. Subsequently, controlled respiratory and relaxation techniques and coughing exercises were shown, and the patients were taught how to use these respiratory techniques in daily life activity (climbing stairs, walking, exercising, etc.). The overall training process required 2–3 h.
The total duration of the PR programs was 12 weeks. In the HBPR, patients participated in three hourly sessions a week, with 45 min of exercise and 15 min of rest in each session. The patients were received in groups of 3–6. A 10-min warm-up was followed by exercises for strengthening the upper and lower extremities. Each exercise was repeated 10 times, and the total duration was 20 min. This was followed by 5-min diaphragm exercises, with each exercise repeated 10 times. Finally, the patients performed stretches (10 s for each stretch) for 10 min to cool down. To ensure exercise continuity, we provided each patient with an exercises training booklet and CD.
In the SMPR, all patients exercised under the supervision of the nurse for 3 days in the first week. They were taught how to perform the extremity strengthening and respiratory exercises together and provided with a CD and training booklet for learning reinforcement. After the first week, they were asked to perform the exercises at home for 45 min 3 days a week, and their exercises were checked by the researcher via phone on the determined exercise day. SMPR exercised without supervision.
Measurements
Patient Information Form: The first part of the data collection process involved the completion of a data collection form pertaining to the following parameters: age, sex, disease stage, body mass index, pulmonary function test results, cumulative smoking history (pack-years), dyspnea severity, number of acute exacerbations of COPD within the last year, and presence of comorbidities.
Pulmonary Function Tests (PFTs): Pulmonary function parameters, namely the forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and diffusing capacity of the lungs for carbon monoxide (DLCO), were measured before and the PR program. Moreover, the forced expiratory flow at 25–75% (FEF 25–75%), which is a parameter for assessing small airway disease, was measured. All pulmonary function tests were performed before and after bronchodilator inhalation.[10]
6-min walk test (6MWT): The distance covered in 6MWT was measured in the corridor of our department before and after the PR program. The patients were instructed to walk as fast as possible.[11] The oxygen saturation and heart rate were measured before, during, and after the test and the modified Borg scale was used to evaluate dyspnea.[12]
Health-related quality of life assessment: St. George's Respiratory Questionnaire (SGRQ) was used to assess the health-related quality of life before and after the PR program. This questionnaire comprises two parts (three components), with part I generating the Symptoms score and part 2 generating the Activity and Impacts scores. A total score that summarizes the impact of the disease on the overall health status is also derived. The score ranges from 0 (excellent health) to 100 (most severe disease). A minimum change of 4 units in the score has been established as clinically relevant after patient and clinician testing. The total score is derived by dividing the total score for the three components by the maximum possible score.[13]
State–Trait Anxiety Inventory (STAI-II): The State–Trait Anxiety Inventory, developed by Spielberger et al., was used to evaluate anxiety before and after the PR program. It measures two types of anxiety: state anxiety and trait anxiety. State anxiety represents the feelings (fear, nervousness, discomfort, etc.) experienced during events over the past 2 weeks, whereas trait anxiety represents the feelings (stress, worry, discomfort, etc.) experienced during typical situations encountered on a daily basis. The two forms of anxiety are separately assessed via 20 questions (total 40 questions) that are answered by the patients using a 4-point Likert Scale. Scores range from 20 to 80, with higher scores indicating greater anxiety.[14]
Standardized Mini-Mental Test (SMMT): SMMT, which can be easily used for measuring the cognitive function of patients, was used to assess orientation, attention, memory, motor skills, and linguistic performance before and after the PR program. Individuals who score 25 out of 30 in this test are suspected to have a cognitive disorder, while those who score lower than 20 are confirmed to have a cognitive disorder.[15] The Turkish version of the test was developed by Gungen et al., whose team also developed a modified version for illiterate individuals.[16]
Statistical analysis
The data were analyzed using the SPSS software, version 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Numerical data are expressed as mean ± standard deviation or median (min–max). The Chi-square test or Fisher's exact test was used to investigate the presence of differences between independent groups. Before comparison of the numerical data, we checked whether the parametric test assumptions were met, and the Mann–Whitney U Test was used for data did not show normal distribution. A P value of <0.05 was considered statistically significant.
Results The demographic and medical characteristics of the patients in both groups are shown in [Table 1]. There were no significant differences in any parameter between the two groups (age, P: 0.64; sex, P: 0.493; BMI, P: 0.524; GOLD Stage, P: 0.171; medical problems, P: 0.358; smoking, P: 0.558).
The patients' symptoms and symptom-related measures before and after the PR program are shown in [Table 2]. Coughing, wheezing, sputum, dyspnea, and sleeping problems (P: 0.009) were significantly alleviated after the HBPR program (P ≤ 0.001). In the SMPR, only dyspnea showed a significant change after the PR program (P: 0.017).
With regard to pulmonary function, FVC and FEV1 showed significant improvements after the HBPR program (P: 0.006, P: 0.002). No significant improvements in pulmonary function were observed after the SMPR program (P > 0.05). FVC (P ≤ 0.001), FEV1 (P: 0.004), and FEF25%–75% (P: 0.005) after the PR program were significantly better in the HBPR than in the SMPR. The results of PFTs for both groups are shown in [Table 3].
The quality of life and 6MWT distance exhibited significant improvements after the PR program in both groups (P ≤ 0.001, P: 0.005), with the improvements being significantly better in the HBPR than in the SMPR [P ≤ 0.001; [Table 4]].
Table 4: Quality of Life and 6-min Walk Test Results Before and After PRThe HBPR program significantly improved the state (P: 0.004) and trait (P: 0.006) anxiety scores, while no cognitive dysfunction was observed before the PR program. After the PR program, anxiety levels were significantly lower in the HBPR than in the SMPR (P: 0.001, P ≤ 0.001), whereas cognitive function was comparable between both groups [P: 0.553; [Table 5]].
Table 5: Comparison of STAI I-II and SMMT Results of the Groups Before and After PR Discussion Although several types of PR programs are implemented for patients with COPD on the basis of patient preferences or clinical protocols, the clinical efficiencies of these programs may vary, with each program having its own unique purpose, procedures, benefits, challenges, and effectiveness.[17] In the present study, we compare the effects of self-management and hospital-based PR programs in COPD patients.
PFTs play an important role in the definitive diagnosis of COPD, monitoring of the disease course, evaluation of treatment effects, and assessment of airflow restrictions and their intensity.[1] While some studies have shown that PR is ineffective in improving pulmonary function parameters, others have shown positive effects of these programs, reporting statistically significant increases in FEV1 values and alleviation of dyspnea.[18],[19],[20] Incorvaia et al. (2014) reported improvements in FVC and FEV1 values in their study on the efficiency of PR for COPD.[21] The authors found that the PR program slowed down, or even arrested, the decline in FEV1. Sahin et al. (2016) found an improvement in DLCO and increase in FEV1 after an 8-week outpatient PR program for 68 patients with COPD and severe diffusion defects.[20] In the present study, we observed an increase in FVC, FEV1, and DLCO after the 12-week HBPR program, whereas no significant change in PFTs results were observed after the 12-week SMPR program. This difference between groups was probably due to continuous monitoring of patient compliance with the exercise techniques, the use of motivation-enhancing techniques, and strict control of the exercise duration.
Chronic and progressive dyspnea, fatigue, coughing, and sputum are the most frequent symptoms of COPD, whereas wheezing and sleeping problems are not specific to COPD and can vary day after day and even during the same day.[1] Several studies have shown that PR alleviates dyspnea and fatigue and improves the sleep quality.[22],[23] In the present study, coughing, wheezing, sputum, dyspnea, and sleeping problems were significantly alleviated after the PR program in the HBPR, whereas no significant differences were observed in the SMPR. This result can be attributed to the significant improvement in pulmonary function and the consequent increase in oxygen supply to the muscles in the HBPR.[24]
The decreased pulmonary function and limited exercise capacity in patients with COPD lower the quality of life of these patients.[19] In a previous study evaluating model PR programs and strategies, PR was found to strengthen the peripheral muscles, increase the oxygen consumption and exercise capacity of muscles, and alleviate dyspnea.[24] Other studies showed that PR improves the quality of life and functional capacity of patients.[25] Similarly, our study also found a significant improvement in the quality of life after both the HBPR and SMPR programs. Some studies have also shown an increase in the 6MWT distance along with an improvement in the quality of life after PR for patients with COPD.[19],[26] We found a greater improvement in the quality of life in the HBPR than in the SMPR. Moreover, the 6MWT distance after PR had improved by 68.22 and 14.48 m in the HBPR and SMPR, respectively. This difference in the 6MWT distance and quality of life between the two groups can be attributed to the greater improvement PFTs in HBPR were also elevation of improvement in muscle strength also supported the alleviation of COPD symptoms.
Although anxiety is commonly observed in patients with COPD, prevalence studies have shown variable effects, and there is no standard approach for diagnosing anxiety in these patients.[27] In the present study, anxiety levels before the PR program were high in both patient groups. It has been reported that there is a significant relationship between the dyspnea level and anxiety in patients with COPD, and that PR reduces anxiety in these patients.[28] In our HBPR, there was an apparent decrease in both state and trait anxiety levels along with the decrease in the dyspnea level after the PR program. On the other hand, the SMPR showed a slight improvement in the trait anxiety score along with the decrease in the dyspnea level, while there was no change in the state anxiety score. These differences between groups can be attributed to the fact that dyspnea improved to a greater extent in the HBPR. Moreover, in the HBPR, exercises were performed under supervision, group interactions were better because of an appropriate communication environment, and improvements in life quality and disease-related parameters were greater than those in the SMPR.
Cognitive impairment is common in patients with COPD. PR has been shown to improve cognitive function.[29] In the present study, no cognitive function disorder was found in the patients with COPD, with SMMT scores of 27.74 ± 1.63 and 27.45 ± 2.2 before the PR program in the both groups, respectively. Nevertheless, both groups exhibited a significant improvement in these scores after PR. The SMMT score after PR was also similar in both groups. This was probably because we included quit smokers with stable COPD in our study. A meta-analysis of previous studies revealed that smoking deteriorates cognitive function, that the amount of smoking is associated with the development of cognitive function disorders, and that cognitive function improves after the patient quits smoking.[30] Because cognitive dysfunction in patients with COPD is largely determined by SMMT, the prevalence rate considerably varies.[31] Although we used SMMT to evaluate cognitive dysfunction in our study, we recommend that future studies should use more extensive scales.
This study has some limitations. First, the patients, and consequently their results, could have been affected by seasonal changes throughout the study period. Second, STAI was filled in by the researcher in case of illiterate patients. Third, drug use and nutrition at home could not be supervised by the nurses.
In conclusion, our findings suggest that PR is useful for controlling symptoms; alleviating anxiety; and improving pulmonary function, functional capacity, life quality, and cognitive function in patients with COPD. Because of strict nurse supervision, HBPR programs are preferred. Further studies should evaluate various types of PR programs in larger patient samples.
Declaration of patient consent
All participants provided written informed consent prior to participation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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