Evaluation of the intervention of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Search for literature on home-based PR. The keywords used are “COPD,” “COAD,” or “chronic obstructive pulmonary disease” and “home-based pulmonary rehabilitation.” It includes four relevant databases (PubMed, Web of Science, Medline, and China National Knowledge Infrastructure) established from January 2008 to January 2018. According to the predetermined selection and exclusion criteria, the qualification and selection of the article are evaluated by screening and obtaining the complete text. The selection procedures of studies are presented in a PRISMA flowchart (Figure 1).

The research included in this review must meet the following criteria: articles published in English or Chinese (the language used by the author) were searched in four databases from June 2008 to June 2018. The study focused on home-based lung-rehabilitation interventions and measured results in patients with COPD. Reviews, editorial, literary reviews, and conference papers are not included in this review.

The criteria for inclusion in this review were:

Focuses: (1) patients with COPD, (2) home-based PR, and (3) articles published from 2008 to 2018.

Type of studies: RCT

The criteria for exclusion were (1) editorial, (2) literature review, (3) PR not at home but in community or hospital, (4) focus on self-management, and (5) patients without COPD.

The selection procedures of studies are presented in a PRISMA flowchart (Figure 1).

Figure 1

The “bias risk” of Cochrane collaboration was used to appraise the quality and bias risk of each article included in RCT. The tool assessed seven specific domains: generation of the random sequence, assignment of concealment, blindness for the subject and the intervention provider, blind method of the results assessment, incomplete data, and selectivity of the result report, which can be assessed as “low-bias risk,” “high-bias risk,” or “not clear bias risk.

According to the judgment standard criteria (Cochrane Handbook for Systematic Reviews of Intervention. Part 2:8.5), in the case of a systematic review of the intervention, if there is no data in the test, further information can be collected by contacting the original author.

The meta-analysis was performed using ReviewManager5.3 software provided by the Cochrane Collaboration. If data cannot be converted or merged, a descriptive analysis is used.

In the initial extensive search, the two reviewers separately evaluated the titles and abstracts of all potentially germane articles by strictly complying with the inclusion/exclusion criteria and the differences in research options. The two researchers independently extracted the following data from all included studies: health-related quality of life (HRQOL) score, dyspnea, exercise ability, exercise tolerance, pulmonary function, anxiety and depression, adverse events, etc. They resolved the differences through discussions until a consensus was reached.

All 21 studies focused on home-based PR interventions in 14 countries and regions, namely, the USA (n = 3, 14.3%), China (n = 2, 9.5%), Taiwan (n = 2, 9.5%), Spain (n = 2, 9.5%), Brazil (n = 2, 9.5%), The Netherlands (n = 2, 9.6%), Australia (n = 1, 4.8%), Germany (n = 1, 4.8%), Iran (n = 1, 4.8%), Italy (n = 1, 4.8%), France (n =1, 4.8%), UK (n = 1, 4.8%), Britain (n = 1, 4.8%), and Japan (n = 1, 4.8%). The 21 studies were randomized controlled trials (Table 1).

In these studies, the size of the sample ranged from 20 to 287 patients, with a total of 1694 patients. The wear rate is 0–49.5%, with an average of 23.6% (400/1694). The reasons why patients refuse to participate in or withdraw from home-based PR are (1) the causes of illness, such as acute exacerbation of COPD or deterioration or complications, or suffering from another illness or death, which affects PR training,^{13,14,15,16,17,18,19,20,21,22,23,24,25,26,27} (2) loss of visit,^{15,18,21,22,23,28} and (3) lack of cooperation.^{15,16,17,21,22,24,27,28} There are also other factors, such as time conflict,¹⁴ difficulty in operating instruments,¹³ and entering into another maintenance procedure.¹⁷ There are also traffic problems in central PR.¹³ Some articles only mention the number of dropouts without explaining the reasons for dropping out.^29,30,31,32 One article mentions that one dropout is due to death, whereas others do not explain the reasons for drop out.²⁷ Another article³³ does not explain dropouts. Most of the home-based PR patients in these intervention studies were middle-aged and elderly, ranging in age from 40 to 80 years. Two other articles dealt with young and middle-aged people whose age requirements were >18 years (Table 1).

Most of these theoretical frameworks focused on the comparison of two PRs, including the home-based pulmonary and the central-based PR,^{15,16,21,22,28} and the home-based PR^{13,14,17,18,19,20,23,24,25,26,27,29,30,31,32,33} Moreover, there is an article that compares home-based PR with central-based PR and family routine rehabilitation.³² In these articles, the control group’s family routine rehabilitation usually refers to conventional treatment care with or without respiratory training. Routine treatment care refers to drug therapy and health education. Drug therapy refers to the use of bronchodilators, anticholinergic drugs, cough relieving expectorant drugs, and so on. Health education refers to COPD’s disease knowledge, smoking ban, diet, medication, prevention and treatment of acute attack, rest, and so on. Breathing training usually refers to lip breathing and abdominal breathing. The control group family/central PR involved in these articles refers to the addition of some rehabilitation exercises on the basis of conventional rehabilitation, such as aerobic exercise, endurance training, upper limb exercise (ULE), lower limb exercise (LLE), and relaxation training (Table 1).

The mode of intervention can be divided into two major categories, namely regulatory^{15,18,19,20,21,22,24,25,26,27,28,29,30,31,32,33} and unsupervised,^{13,14,16,17,23} with supervision including: telephone supervision—checking and urging patients’ to exercise through regular telephone conversations; follow up regularly—physical therapists visit home regularly to check the condition of patients’ exercise and give further guidance to them.^{19,26,27,29,31} Time supervision meeting—patients do diary records at home, and regularly return to the center to meet with physiotherapists.^18,20 Unsupervised—usually refers to the unified guidance to the patient before the intervention and giving out the pamphlets; the patient exercises according to these instructions at home, during the no-appointment period. What form of supervision is followed? The means of interventions are divided into instrumental^{13,14,15,17,18,26,27,28,30} and noninstrumental.^{16,19,20,21,22,23,24,25,29,31,32,33} Instrumental assistance generally includes the following elements: walking with endurance to the music on a cell phone or other instruments for maximum endurance walking^13,14; walking through a pedometer which^17,26 provides guidance, this instrument is also used to detect heart rate²⁸; combining with home ventilator to carry out PR^18,27; inhalation and atomization inhalation³⁰; and lending portable ergo cycles that could adjust the resistance manually.¹⁵ No instrumental assistance usually refers to PR exercises without any instrumental assistance (Table 1).

In some articles, the duration of intervention is about 28.6 min (ranges from 15 to 70 min) with an average frequency of 4.7/week (range 2/week 7)^{14,15,16,17,18,19,21,22,23,24,25,27,32,33}; some articles determine the duration of each exercise based on the intensity of the set of exercise targets;^13,26,28,31 and in some articles, the intervention changes and adjusts according to the tolerability of subjects.^20,29,30

Different follow-up period also showed in the Table 1: 12 months (n = 5, 23.8%), 6 months (n = 4, 19%), 4 months (n = 1, 4.8%), 3 months (n = 5, 23.8%), 2 months (n = 3, 14.3%), 10 weeks (n = 1, 4.8%), and 7 weeks (n = 2, 9.5%).

The intervention in these articles with or without supervision is trained by a physiotherapist or professional medical staff, and all these studies have formulated and followed a special intervention program and included regular checks in the entire intervention program to maintain the standard of treatment.

The intervention of the nearly 1/3rd of the articles was delivered to the combination of the intervener and the patient’s face-to-face and telephone conversation, and nearly 1/5 (n = 4, 19%) was delivered with a combination of face-to-face and diary contacts between the intervener and the patient; and the intervention of the nearly 1/5^th of the articles was delivered to the intervention group with three groups of face-to-face, telephone, and diary contacts with the patient. Combined to deliver (n = 4, 19%), there are other interventions that are delivered by the intervener to the patient’s face-to-face (n = 3, 14.3%) and the diary to contact (n = 2, 9.5%), respectively; in addition, the intervention of an article²⁶ is delivered to the log of the pedometer (n = 1, 4.5%) (Table 1).