Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials

Figures & data

Figure 1. Flow diagram for the identification of the studies.

Figure 2. Risk of bias assessment for the randomized trials included in the meta-analysis. (A) Risk of bias summary; (B) Risk of bias graph. Symbols. (+): low risk of bias; (?): unclear risk of bias; (–): high risk of bias.

Table 1. Characteristics of the studies included in this meta-analysis.

Authors/year of publication	Country	Mean age (years)	Male (%) PR/Con	Mean FEV1 (% or L) PR/Con	Type of study	Intervention		Follow-up
						PR	Con
Engstrom/1999 [37]	Sweden	PR: 66 ± 5.4	53.8/50	30.7/34.1	RCT	26	24	12M
		Con: 66.8 ± 5.4
Griffiths/2000 [14]	UK	PR: 68.2 ± 8.2	61.6/58.4	39.7/39.4	RCT	99	101	12M
		Con: 68.3 ± 8.1
Ringbaek/2000 [38]	Denmark	PR:61.8 ± 6.8	4.17/28.6	49.5/44.3	RCT	24	21	2M
		Con: 64.6 ± 7.7
Finnerty/2001 [39]	UK	PR:70.4 ± 8.0	69.4/65.5	41.2/41.2	RCT	36	29	6M
		Con: 68.4 ± 10.4
Boxall/2005 [15]	Australia	PR:77.6 ± 7.6	47.8/65.2	40.5/37.7	RCT	23	23	3M
		Con: 75.8 ± 8.1
Karapolat/2007 [40]	Turkey	PR: 65.1 ± 9.4	81.5/95.5	54.8/55	RCT	27	22	3M
		Con: 66.6 ± 8.4
Paz-Diaz/2007 [41]	USA	PR: 67 ± 5	60/85.7	34/30	RCT	10	14	2M
		Con: 62 ± 7
Eli/2008 [42]	Turkey	PR: 59.67 ± 8.6	15.4/15.4	47.77/46.28	RCT	39	39	3M
		Con: 58.08 ± 11.45
Donesky-cuenco/2009 [25]	USA	PR: 72.2 ± 6.5	28.6/26.7	51.2/44.4	RCT	14	15	3M
		Con: 67.7 ± 11.5
Fernandez/2009 [43]	Spain	PR: 66 ± 8	NA	33/38	RCT	27	14	12M
		Con: 70 ± 5
Theander/2009 [44]	Sweden	PR: 66 ± 2	25/71.4	35.1/32.3	RCT	12	14	3M
		Con: 64 ± 2
Vanwetering/2010 [45]	Netherlands	64 ± 8.7	61.5	54.7	RCT	16	14	4M
Yeh/2010 [23]	USA	PR: 65 ± 2	60/60	53/47	RCT	5	5	3M
		Con: 66 ± 6
Chan/2011 [46]	China	PR: 73.6 ± 7.5	88/87	0.91/0.89	RCT	69	67	3M
		Con: 73.6 ± 7.4
Deering/2011 [47]	Ireland	PR: 67.7 ± 5.3	NA	48.5/45.8	RCT	25	19	3M
		Con: 68.6 ± 5.5
Gottlieb/2011 [16]	Denmark	PR: 74.1	31.8/35	64.27/67.05	RCT	22	20	18M
		Con: 73.2
Baumann/2012 [48]	Germany	PR: 63 ± 11	62.2/54.5	47/45	RCT	37	44	6M
		Con: 65 ± 8
De Souto Araujo/2012 [49]	Brazil	PR: 56.9 ± 7.9	61.5/72.7	39.2/45.1	RCT	13	11	2M
		Con: 71.1 ± 10.1
Chan/2013 [18]	China	PR: 71.7 ± 8.2	99/87	0.89/0.89	RCT	70	67	6M
		Con: 73.6 ± 7.4
Gurgun/2013 [17]	Turkey	PR: 66.8 ± 9.6	100/100	41.9/39.3	RCT	15	16	2M
		Con: 67.8 ± 6.6
Amin/2014 [50]	USA	PR: 66.8 ± 8.1	33/60	63.6/60.8	RCT	9	10	3M
		Con: 72 ± 10.1
Cameron-Tucker/2014 [52]	Australia	PR: 64.5 ± 9.13	53/54	NA	RCT	43	41	1.5M
		Con: 67.1 ± 9.41
De Sousa Pinto/2014 [54]	Brazil	PR: 68.9 ± 9.2	95.7/94.4	33.5/34.5	RCT	23	18	3M
		Con: 71.9 ± 7.6
Gupta/2014 [27]	India	PR: 52.5 ± 3.9	96/96	51.1/49.6	RCT	25	25	3M
		Con: 52 ± 4.1
Ng/2014 [20]	China	PR: 74.16 ± 6.46	93.6/88.8	1.1/1.23	RCT	94	98	6M
		Con: 74.13 ± 6.81
Niu/2014 [21]	China	PR: 59.7 ± 2.76	95/90	41.9/43.7	RCT	20	20	6M
		Con: 61.3 ± 2.89
Wootton/2014 [57]	Australia	PR: 69 ± 8	58.9/58.3	43/43	RCT	95	48	2M
		Con: 68 ± 9
Fukuoka/2016 [26]	Japan	PR: 74.6 ± 6.7	100/66.7	0.93/1.2	RCT	5	3	0.5M
		Con: 77 ± 7
Ranjita/2016 [29]	India	PR: 53.69 ± 5.66	NA	NA	RCT	36	36	3M
		Con: 54.41 ± 5.4
De Roos/2017 [53]	Netherlands	PR: 69.4 ± 9.7	31/38	68/65	RCT	26	26	2.5M
		Con: 71 ± 9.4
Kaminsky/2017 [28]	USA	PR: 68 ± 7	33/45	43/42	RCT	21	22	3M
		Con: 68 ± 9
Thokchom/2018 [30]	India	PR: 57.8 ± 2.68	76.2/80	1.24/1.22	RCT	21	20	3M
		Con: 60.65 ± 1.84
Varas/2018 [56]	Spain	PR: 69.5 ± 7.4	85.7/68.4	45.8/52.3	RCT	21	19	12M
		Con: 64.8 ± 9.1
Zhu/2018 [24]	China	PR: 67.87 ± 5.22	93/97	35.11/40.77	RCT	30	30	9M
		Con: 68.1 ± 6.57
Lahham/2019 [51]	Australia	PR: 68 ± 9	58.6/58.6	0.9/0.92	RCT	29	29	6M
		Con: 67 ± 10
Wang/2019 [22]	China	PR: 67.83 ± 5.32	88.5/87.5	55.46/62.55	RCT	26	24	3M
		Con: 67.86 ± 5.98
Yudhawati/2019 [31]	Indonesia	PR: 64.4 ± 10.4	NA	43.53/40.87	RCT	15	15	3M
		Con: 65.33 ± 8.1
Kantatong/2020 [19]	Thailand	PR: 69.68 ± 7.67	60/76	68.21/68.37	RCT	25	25	3M
		Con: 67.48 ± 10.17
Ko/2020 [55]	China	PR:76 ± 8	99/96	49/46	RCT	68	68	12M
		Con: 74 ± 7

PR: pulmonary rehabilitation; Con: control; RCT: randomized controlled trials; FEV1: forced expiratory volume in one second; L: litre; Y: years; M: months; NA: not available.

Figure 3. Effect of pulmonary rehabilitation in individuals with COPD. (A) 6MWT; (B) SGRQ score; (C) MRC; (D) Borg score.

Figure 4. Effect of pulmonary rehabilitation on lung function in individuals with COPD. (A) FEV1%; (B) FVC%; (C) FEV1/FVC%.

Figure 5. Subgroup analysis of the effect of pulmonary rehabilitation in individuals with COPD. (A) 6MWT; (B) SGRQ score; (C) FEV1.

Figure 6. Funnel plot for publication bias test. Each point represents a separate study for the indicated association. (A) 6MWT; (B) SGRQ score; (C) FEV1.

Engstrom C, Persson LO, Larsson S, et al. Long-term effects of a pulmonary rehabilitation programme in outpatients with chronic obstructive pulmonary disease: a randomized controlled study. Scand J Rehabil Med. 1999;31(4):207–213.

 PubMedGoogle Scholar

Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355(9201):362–368.

 PubMed Web of Science ®Google Scholar

Ringbaek TJ, Broendum E, Hemmingsen L, et al. Rehabilitation of patients with chronic obstructive pulmonary disease. Exercise twice a week is not sufficient!. Respir Med. 2000;94(2):150–154.

 PubMed Web of Science ®Google Scholar

Finnerty JP, Keeping I, Bullough I, et al. The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease* a randomized controlled trial. Chest. 2001;119(6):1705–1710.

 PubMed Web of Science ®Google Scholar

Boxall AM, Barclay L, Sayers A, et al. Managing chronic obstructive pulmonary disease in the community. A randomized controlled trial of home-based pulmonary rehabilitation for elderly housebound patients. J Cardiopulm Rehabil. 2005;25(6):378–385.

 PubMedGoogle Scholar

Karapolat H, Atasever A, Atamaz F, et al. Do the benefits gained using a Short-Term pulmonary rehabilitation program remain in COPD patients after participation? Lung. 2007;185(4):221–225.

 PubMed Web of Science ®Google Scholar

Paz-Díaz H, Montes de Oca M, López JM, et al. Pulmonary rehabilitation improves depression, anxiety, dyspnea and health status in patients with COPD. Am J Phys Med Rehabil. 2007;86(1):30–36.

 PubMed Web of Science ®Google Scholar

Eli A, Breki e, Ovayolu N, et al. The efficacy and applicability of a pulmonary rehabilitation programme for patients with COPD in a secondary-care community hospital. Respirology. 2008;13(5):703–707.

 PubMed Web of Science ®Google Scholar

Donesky-Cuenco D, Nguyen HQ, Paul S, et al. Yoga therapy decreases dyspnea-related distress and improves functional performance in people with chronic obstructive pulmonary disease: a pilot study. J Altern Complement Med. 2009;15(3):225–234.

 PubMed Web of Science ®Google Scholar

Fernandez AM, Pascual J, Ferrando C, et al. Home-based pulmonary rehabilitation in very severe COPD: is it safe and useful? J Cardiopulm Rehabil Prev. 2009;29(5):325–331.

 PubMed Web of Science ®Google Scholar

Theander K, Jakobsson P, Jorgensen N, et al. Effects of pulmonary rehabilitation on fatigue, functional status and health perceptions in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Clin Rehabil. 2009;23(2):125–136.

 PubMed Web of Science ®Google Scholar

van Wetering CR, Hoogendoorn M, Broekhuizen R, et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: a prespecified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc. 2010;11(3):179–187.

 PubMed Web of Science ®Google Scholar

Yeh GY, Roberts DH, Wayne PM, et al. Tai chi exercise for patients with chronic obstructive pulmonary disease: a pilot study. Respir Care. 2010;55(11):1475–1482.

 PubMed Web of Science ®Google Scholar

Chan AW, Lee A, Suen LK, et al. Tai chi Qigong improves lung functions and activity tolerance in COPD clients: a single blind, randomized controlled trial. Complement Ther Med. 2011;19(1):3–11.

 PubMed Web of Science ®Google Scholar

Deering BM, Fullen B, Egan C, et al. Acupuncture as an adjunct to pulmonary rehabilitation. J Cardiopulm Rehabil Prev. 2011;31(6):392–399.

 PubMed Web of Science ®Google Scholar

Gottlieb V, Lyngsø AM, Nybo B, et al. Pulmonary rehabilitation for moderate COPD (GOLD 2)-does it have an effect? Copd. 2011;8(5):380–386.

 PubMedGoogle Scholar

Baumann HJ, Kluge S, Rummel K, Klose H, et al. Low intensity, long-term outpatient rehabilitation in COPD: a randomised controlled trial. Respir Res. 2012;13(1):86.

 PubMed Web of Science ®Google Scholar

de Souto Araujo ZT, de Miranda Silva Nogueira PA, Cabral EE, et al. Effectiveness of low-intensity aquatic exercise on COPD: a randomized clinical trial. Respir Med. 2012;106(11):1535–1543.

 PubMed Web of Science ®Google Scholar

Chan AW, Lee A, Lee DT, et al. The sustaining effects of Tai chi Qigong on physiological health for COPD patients: a randomized controlled trial. Complement Ther Med. 2013;21(6):585–594.

 PubMed Web of Science ®Google Scholar

Gurgun A, Deniz S, Argın M, et al. Effects of nutritional supplementation combined with conventional pulmonary rehabilitation in muscle-wasted chronic obstructive pulmonary disease: a prospective, randomized and controlled study. Respirology. 2013;18(3):495–500.

 PubMed Web of Science ®Google Scholar

Amin S, Abrazado M, Quinn M, et al. A controlled study of community-based exercise training in patients with moderate COPD. BMC Pulm Med. 2014;14(1):125.

 PubMed Web of Science ®Google Scholar

Cameron-Tucker HL, Wood-Baker R, Owen C, et al. Chronic disease self-management and exercise in COPD as pulmonary rehabilitation: a randomized controlled trial. Int J Chron Obstruct Pulmon Dis. 2014;9:513–523.

 PubMed Web of Science ®Google Scholar

de Sousa Pinto JM, Martín-Nogueras AM, Calvo-Arenillas JI, et al. Clinical benefits of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 2014;34(5):355–359.

 PubMed Web of Science ®Google Scholar

Gupta A, Gupta R, Sood S, et al. Pranayam for treatment of chronic obstructive pulmonary disease: results from a randomized, controlled trial. Integr Med A Clin J. 2014;13(1):26.

 Google Scholar

Ng L, Chiang LK, Tang R, et al. Effectiveness of incorporating Tai Chi in a pulmonary rehabilitation program for Chronic Obstructive Pulmonary Disease (COPD) in primary care – a pilot randomized controlled trial. Eur J Integr Med. 2014;6(3):248–258.

 Web of Science ®Google Scholar

Niu R, He R, Luo B-L, et al. The effect of tai chi on chronic obstructive pulmonary disease: a pilot randomised study of lung function, exercise capacity and diaphragm strength. Heart, Lung and Circulation. 2014;23(4):347–352.

 PubMed Web of Science ®Google Scholar

Wootton SL, Ng LW, McKeough ZJ, et al. Ground-based walking training improves quality of life and exercise capacity in COPD. Eur Respir J. 2014;44(4):885–894.

 PubMed Web of Science ®Google Scholar

Fukuoka A, Ueda M, Ariyama Y, et al. Effect of laughter yoga on pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. 2016.

 Google Scholar

Ranjita R, Hankey A, Nagendra H, et al. Yoga-based pulmonary rehabilitation for the management of dyspnea in coal miners with chronic obstructive pulmonary disease: a randomized controlled trial. J Ayurveda Integr Med. 2016;7(3):158–166.

 PubMedGoogle Scholar

de Roos P, Lucas C, Strijbos JH, et al. Effectiveness of a combined exercise training and home-based walking programme on physical activity compared with standard medical care in moderate COPD: a randomised controlled trial. Physiotherapy. 2018;104(1):116–121.

 PubMed Web of Science ®Google Scholar

Kaminsky DA, Guntupalli KK, Lippmann J, et al. Effect of yoga breathing (pranayama) on exercise tolerance in patients with chronic obstructive pulmonary disease: a randomized, controlled trial. J Altern Complement Med. 2017;23(9):696–704.

 PubMed Web of Science ®Google Scholar

Thokchom SK, Gulati K, Ray A, et al. Effects of yogic intervention on pulmonary functions and health status in patients of COPD and the possible mechanisms. Complement Ther Clin Pract. 2018;33:20–26.

 PubMed Web of Science ®Google Scholar

Varas AB, Córdoba S, Rodríguez-Andonaegui I, et al. Effectiveness of a community-based exercise training programme to increase physical activity level in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Physiother Res Int. 2018;23(4):e1740.

 PubMed Web of Science ®Google Scholar

Zhu S, Shi K, Yan J, et al. A modified 6-form Tai Chi for patients with COPD. Complement Ther Med. 2018;39:36–42.

 PubMed Web of Science ®Google Scholar

Lahham A, McDonald CF, Moore R, et al. The impact of home-based pulmonary rehabilitation on people with mild chronic obstructive pulmonary disease: a randomised controlled trial. Clin Respir J. 2020;14(4):335–344.

 PubMed Web of Science ®Google Scholar

Wang L, Wu K, Chen X, et al. The effects of tai chi on lung function, exercise capacity and health related quality of life for patients with chronic obstructive pulmonary disease: a pilot study. Heart Lung Circ. 2019;28(8):1206–1212.

 PubMed Web of Science ®Google Scholar

Yudhawati R, Hs MR. Effect of yoga on FEV1, 6-minute walk distance (6-MWD) and quality of life in patients with COPD group B. Adv Respir Med. 2019;87(5):261–268.

 PubMed Web of Science ®Google Scholar

Kantatong T, Panpanich R, Deesomchok A, et al. Effects of the tai chi qigong programme on functional capacity, and lung function in chronic obstructive pulmonary disease patients: a ramdomised controlled trial. J Tradit Complement Med. 2020;10(4):354–359.

 PubMedGoogle Scholar

Ko FW, Tam W, Siu EHS, et al. Effect of short-course exercise training on the frequency of exacerbations and physical activity in patients with COPD: a randomized controlled trial. Respirology. 2021;26(1):72–79.

 PubMed Web of Science ®Google Scholar

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.