Efficacy of supervised maintenance exercise following pulmonary rehabilitation on health care use: a systematic review and meta-analysis

Figures & data

Table 1 Characteristics of included studies

Study (country)	Sample size, gender, age	FEV1% predicted (spirometry), smoking history	Inclusion/exclusion criteria	Study aim, design, unit of allocation	Pulmonary rehabilitation program (setting, components, duration, frequency)	Maintenance program (setting, components, duration, frequency)	Primary outcome (1) and other outcomes and follow-up (2)
Ries et al (2003)^Citation16 (USA)	164 participants Int: n=83 Con: n=81 Males: n=89 Females: n=75 Age, mean ± SD All: 67±8	FEV1%pred, mean All: 45% No data available for smoking status	Inclusion: clinical diagnosis of chronic lung disease; chronic symptoms and perceived disability from disease; stable state; no other significant medical or psychiatric conditions that would interfere with program participation; commitment to abstain from smoking	Assess a telephone-based maintenance intervention for retaining benefits following pulmonary rehabilitation RCT, cluster	Exercise and education combined with psychosocial support Twelve 2 h sessions over 8 weeks	Weekly semistructured phone calls and monthly supervised reinforcement sessions (1.5 h supervised exercise, 1.0 h topic review, 0.5 h social time) for 12 months	(1) Pulmonary function, exercise tolerance, dyspnea, depression (2) QoL, health status, health care use
Brooks et al (2002)^Citation17 (Canada)	85 participants Int: n=37 Con: n=48 Males: n=50 Females: n=35 Age, mean ± SD Int: 68±1 Con: 68±1	FEV1%pred, mean ± SD Int: 32±2% Con: 32±2% All nonsmokers for at least 6 months	Inclusion: severe stable COPD (FEV1<40% predicted, FEV1/FVC <0.70); completion of inpatient or outpatient rehabilitation; nonsmoker for a minimum of 6 months; aged 49–85 years Exclusion: coexisting conditions that might limit exercise tolerance or cognitive functioning; noncompliance with respiratory rehabilitation; mechanical ventilatory support for any part of the day; inability to communicate in English; living too far away to participate	Compare the effects of two postrehabilitation programs on functional exercise capacity and health-related QoL in patients with COPD RCT, individual	Exercises – breathing, treadmill or cycle exercises, interval and upper extremity training, leisure walking Patient education and psychosocial support included (relaxation and occupational therapies) Inpatient – five times a week for 6 weeks Outpatient – three times a week at the center and at home for 8 weeks	Monthly 2 h group sessions supervised by a physical therapist for 12 months. First hour for discussion around home exercise program, second hour for performing components of the home exercise program under supervision. Phone calls made between visits with standardized questions regarding adherence to home exercises	(1) 6MWT, CRQ (2) Medical outcomes survey: short-form 36, SGRQ, subject compliance, pulmonary function
Spencer et al (2010)^Citation18 (Australia)	48 participants Int: n=24 Con: n=24 Males: n=22 Females: n=26 Age, mean ± SD Int: 65±8 Con: 67±7	FEV1%pred, mean ± SD Int: 57±21% Con: 60±16% Current smokers Int: n=6 Con: n=5	Inclusion: COPD diagnosis; completed an 8 week pulmonary rehabilitation program; FEV1/FVC <70% and FEV1<80% predicted Exclusion: exacerbation in previous month; supplemental oxygen; comorbidities that would prevent performing exercises; clinic patients (pulmonary rehabilitation)	Determine if weekly supervised exercise following pulmonary rehabilitation would maintain functional exercise capacity and QoL RCT, individual	Exercises – 20 min walking, 20 min cycling, 10 min arm cycling, upper and lower limb strength training 8 weeks in a pulmonary rehabilitation gym	Pulmonary rehabilitation gym for 12 months. Supervised exercise 1 day/week with unsupervised exercise 4 days/week. Exercises prescribed in line with exercise undertaken during pulmonary rehabilitation	(1) 6MWT, SGRQ (2) Lung function tests, ISWT, ESWT, HADS, hospital admissions, length of stay and exacerbations
Ringbaek et al (2010)^Citation19 (Denmark)	96 participants Int: n=55 Con: n=41 Males: n=31 Females: n=63 Age, mean ± SD Int: 67±1 Con: 69±9	FEV1%pred, mean ± SD Int: 36±14% Con: 37±16% Current smokers Int: n=13 Con: n=7	Inclusion: stable COPD (FEV1 <80%, FEV1/FVC <70%); motivation for pulmonary rehabilitation; completion of 7 weeks of pulmonary rehabilitation Exclusion: musculoskeletal, cardiac or cognitive problems	Examine whether maintenance training improved long-term effect of pulmonary rehabilitation RCT, individual	Supervised walking and cycling both at 85% of predicted VO2 peak and unsupervised exercise at home Twice a week for 7 weeks with supplementary education once a week	Weekly supervised exercise for the first 6 months, every second week for the next 6 months, and no supervised exercise for the last 6 months. Unsupervised exercise at home encouraged	(1) ESWT, SGRQ (2) Hospitalization (time to first admission, admission rates, days in hospital), exercise adherence, attendance at evaluation visits
Wilson et al (2015)^Citation20 and Burns et al (2016)^Citation21 (UK)	148 participants Int: n=73 Con: n=75 Males: n=91 Females: n=57 Age, mean ± SD Int: 67±15 Con: 69±9	FEV1%pred, mean ± SD All: 41±16% >20 pack-year smoking history No data available on current smoking status	Inclusion: >35 years of age; COPD diagnosis (FEV1<80%); >20 pack-year smoking history; completed at least 60% of pulmonary rehabilitation sessions Exclusion: cardiac or pulmonary disease (other than COPD); myocardial infarction within 6 months or unstable angina; respiratory infection within last 4 weeks; uncontrolled or severe comorbidities; cognitive complications	Evaluate long-term effect of maintenance exercise on health-related QoL Assess the cost-effectiveness of maintenance exercise following pulmonary rehabilitation on health-related QoL RCT, individual	Exercises – walking, cycling, sit to stand, step-ups, arm exercises with dumbbells. High intensity (85% of maximum capacity) Once a week for 8 weeks (1 h for exercise and 1 h for education). Endurance exercise everyday and strength exercise two more times a week at home	Individually tailored strength and endurance exercises including walking, cycling, sit-to-stand, step-ups, and arm exercises with dumbbells One 2 h (1 h exercise and 1 h education) session every 3 months for 12 months. Same group of patients from original pulmonary rehabilitation. Home exercise program review	(1) CRQ (dyspnea) (2) CRQ (other domains), ESWT, BMI, body fat, HADS, EQ5D
Roman et al (2013)^Citation22 (Spain)	71 participants Con: n=23 RHB: n=22 RHBM: n=26 Males: n=58 Females: n=13 Age, mean (95% CI) RHBM: 65 (62–68) RHB: 64 (60–68) Con: 63 (60–66)	FEV1%pred, mean (95% CI) Con: 60% (56–64) RHB: 60% (55–65) RHBM: 61% (56–66) Current smokers Con: n=8 RHB: n=7 RHBM: n=9	Inclusion: 35–74 years old; moderate COPD diagnosis; smokers or nonsmokers Exclusion: musculoskeletal conditions affecting ability to exercise; terminal illness/other severe disease	Use maintenance postpulmonary rehabilitation to improve QoL in COPD RCT, individual	Exercises – low intensity peripheral muscle training. Abdominal, upper and lower limb exercises, shoulder and full arm circling, weight-lifting, and other exercises. Each exercise repeated 8–10 times over 45 min Three 1 h sessions a week for 12 weeks with 15 min of respiratory physiotherapy every session and 45 min of education during weeks 1, 6+12	Low intensity peripheral muscle training. One session a week for 9 months	(1) CRQ (2) Pulmonary function, 6MWT, hospital admissions, GP visits, exacerbations
Moullec et al (2008)^Citation23 and Moullec and Ninot (2010)^Citation24 (France)	40 participants Int: n=14 Con: n=26 Males: n=31 Females: n=9 Age, mean ± SD Int: 63±7 Con: 60±10	FEV1%pred, mean ± SD Int: 53±16% Con: 47±19% No data available on smoking status	Inclusion: FEV1/FVC <0.7, FEV1 30%–79% predicted; no indication for home oxygen therapy; stable state for the previous 2 months; no change in medication and symptoms for the previous 4 weeks; >40 years of age; no previous pulmonary rehabilitation experience Exclusion: medical or psychiatric disturbances that would hinder program participation; diagnosis of asthma; congestive left heart failure; terminal disease	Determine changes in the emotional and functional dimensions of QoL in COPD 1 year after a pulmonary rehabilitation program with or without a follow-up intervention Quasi-RCT, individual	Twenty inpatient sessions over 4 weeks	Community gymnasium Individualized strength, interval, breathing, and endurance training with nature walking at ventilatory threshold 96 sessions across 12 months. Exercise training (3.5 h/week; 72 sessions); health education (2 h/month; 12 sessions); psychosocial support (with discussion group 1 h/month; 12 sessions)	(1) 6MWT, QoL (SGRQ and WHOQoL-Brief) (2) Six-item questionnaire with a VAS, maximal exercise capacity, physical activity, health care utilization, attendance, pulmonary function
Guell et al (2017)25 (Spain)	138 participants Int: n=68 Con: n=70 Males: n=123 Females: n=15 Age, mean ± SD Int: 64±9 Con: 64±8	FEV1%pred, mean ± SD Int: 34±11% Con: 34±9% No data available on smoking status	Inclusion: COPD diagnosis (grade II–IV severity); clinically stable during previous 4 weeks; 18–75 years old; exsmokers or with intention to quit; BODE index value between 3 and 10 Exclusion: bronchodilator response (FEV1 increment >15% of the baseline value after 200 μg of inhaled bronchodilator); other respiratory diagnoses; severe coronary artery disease; orthopedic diseases limiting mobility; life expectancy <2 years; inability to cooperate	Assess the efficacy of a supervised maintenance program after pulmonary rehabilitation on improving symptoms, exercise capacity, and health-related QoL compared to just pulmonary rehabilitation on its own RCT, individual	Three hospital-based 2 h sessions a week for 8 weeks. Supplemented with four education sessions and chest physiotherapy 30 min weight-lifting (0.5 kg in each hand, increased by 1 kg a week until peak tolerance), 30 min leg cycling (start at 50% maximum load achieved during initial exercise test, load increased by 10 W if heart rate and oxygen saturation are stable and exercise is tolerated)	Supervised exercise on alternate weeks at hospital for 36 months. Unsupervised home exercise program (3 days a week) similar to hospital program (15 min chest physiotherapy, 30 min arm training, 30 min leg training). Supplemented by structured phone calls from physiotherapists every 15 days Exercise similar to pulmonary rehabilitation. Exercises, if well tolerated, were progressed at hospital visits	1) BODE index (2) 6MWT, health-related QoL, and CRQ

Abbreviations: BMI, body mass index; BODE, body mass index, airflow obstruction, dyspnea, and exercise index; Con, control group; Int, intervention group; CRQ, chronic respiratory questionnaire; ESWT, endurance shuttle walk test; EQ5D, Euro Quality of Life Five Dimensions questionnaire; FEV₁%pred, forced expiratory volume in 1 s % of predicted; FVC, forced vital capacity; GP, general practitioner; HADS, hospital anxiety and depression scale; ISWT, incremental shuttle walk test; 6MWT, 6 min walk test; QoL, quality of life; RCT, randomized controlled trial; RHB, pulmonary rehabilitation with no maintenance; RHBM, pulmonary rehabilitation with maintenance; SD, standard deviation; SGRQ, St George’s Respiratory Questionnaire; VAS, visual analog scale; WHOQoL-Brief, World Health Organization Quality of Life Brief questionnaire.

Figure 1 Flow diagram of study selection.

Note: ^aSome studies excluded for multiple reasons.

Table 2 Risk of bias assessment

Study	Random sequence generation	Allocation concealment	Blind outcome assessment	Incomplete outcome data	Selective reporting (reporting bias)	Other bias	Overall risk
Ries et al (2003)^Citation16	Low	Low	Low	Low	Low	Low	Low
Brooks et al (2002)^Citation17	Low	Low	Unclear	High	Low	Low	Medium
Spencer et al (2010)^Citation18	Low	Low	High	Low	Low	Low	Medium
Ringbaek et al (2010)^Citation19	Unclear	Unclear	Unclear	Low	Low	Low	High
Wilson et al (2015)^Citation20 and Burns et al (2016)^Citation21	Low	Low	Low	High	Low	Low	Medium
Roman et al (2013)^Citation22	Low	Unclear	Unclear	High	Low	Low	High
Moullec et al (2008)^Citation23 and Moullec and Ninot (2010)^Citation24	High	High	Unclear	High	Low	Low	High
Guell et al (2017)^Citation25	Low	Low	Unclear	High	High	Low	High

Figure 2 Trial-level data, effect estimates, and forest plot of comparison for the overall risk (of experiencing at least one event) (A) and incidence rates (B) of respiratory-cause hospitalization.

Abbreviations: CI, confidence interval; IV, inverse variance; SE, standard error.

Figure 3 Trial-level data, effect estimates, and forest plot of comparison for the overall risk (of experiencing at least one event) (A) and incidence rates (B) of exacerbation requiring treatment with medication.

Abbreviations: CI, confidence interval; IV, inverse variance; SE, standard error.

Figure 4 Trial-level data, effect estimates, and forest plot of comparison for the risk of mortality.

Abbreviations: CI, confidence interval; IV, inverse variance.

Figure 5 Sensitivity analyses on trial-level data, effect estimates, and forest plot of comparison for the risk of hospital admission for a respiratory cause excluding Guell et al.²⁵

Abbreviations: CI, confidence interval; IV, inverse variance.

Figure 6 Sensitivity analyses on trial-level data, effect estimates, and forest plot of comparison for the risk of hospital admission for a respiratory cause including 0–12 months follow-up of Guell et al.²⁵

Abbreviations: CI, confidence interval; IV, inverse variance.

Figure S1 Trial-level data, effect estimates, and forest plot of comparison for the risk of all-cause hospital admission.

Abbreviations: CI, confidence interval; IV, inverse variance.

Figure S2 Trial-level data, effect estimates, and forest plot of comparison for the risk of GP visits.

Abbreviations: CI, confidence interval; GP, general practitioner; IV, inverse variance.

Table S1 Example search strategy of a bibliographic database (CINAHL)

Number	Search term	Field
1	Lung diseases, obstructive	MH (explode)
2	Lung diseases, interstitial	MH (explode)
3	Pulmonary fibrosis	MH (explode)
4	COPD	TX
5	Chronic obstructive pulmonary disease	TX
6	COAD	TX
7	COBD	TX
8	Emphysem*	TX
9	Chronic bronchitis	TX
10	Cystic fibrosis	TX
11	Pneumoconiosis	TX
12	Sarcoidosis	TX
13	Asthma	TX
14	Bronchiectasis	TX
15	Alveolitis	TX
16	Histiocytosis	TX
17	Granulomatosis	TX
18	Bagassosis	TX
19	Asbestosis OR byssinosis OR siderosis OR silicosis OR berylliosis OR anthracosilicosis	TX
20	Scleroderma	TX
21	1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20
22	Exercise therapy	MH (explode)
23	Activities of daily living	MH (explode)
24	Rehabilitation research	MH
25	Physical and rehabilitation medicine	MH (explode)
26	Physical fitness	MH
27	Exercise movement techniques	MH (explode)
28	Telerehabilitation	MH
29	Rehabilitation N2 pulmonary OR respiratory OR physical OR early	TI, AB
30	Exercis* N3 supervi* OR training OR maintenance OR program*	TI, AB
31	Physical activit*	TI, AB
32	Maintenance N2 intervention OR group OR exercise OR program* OR training	TI, AB
33	22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32
34	Randomised	TI, AB
35	Randomized	TI, AB
36	Randomly	TI, AB
37	Trial	TI, AB
38	Controlled	TI, AB
39	34 OR 35 OR 36 OR 37 OR 38
40	21 AND 33 AND 39

Notes: Searches encompassed other chronic lung conditions as part of a wider review.

* Truncation operator.

Table S2 Characteristics of excluded studies

Study	Reason(s) for exclusion
Andrews et al (2015)^Citation1	Not a randomized trial
Bernocchi et al (2016)^Citation2	Intervention not relevant (unsupervised)
Berry et al (2003)^Citation3	Outcomes not applicable
Bertolini et al (2016)^Citation4	Not randomized; outcomes not applicable; intervention not relevant (unsupervised)
Brooks et al (2002)^Citation5	Outcomes not applicable
Browne et al (2013)^Citation6	Conference abstract – full text included
Carrieri-Kohlman et al (2005)^Citation7	Intervention not relevant (did not include pulmonary rehabilitation)
Cejudo et al (2014)^Citation8	Conference abstract – full text included; outcomes not applicable
Cejudo et al (2014)^Citation9	Conference abstract – full text included; outcomes not applicable
Cruz et al (2016)^Citation10	Intervention not relevant (behavioral feedback intervention-unsupervised)
Desveaux et al (2016)^Citation11	Ongoing trial – data not available
du Moulin et al (2009)^Citation12	Intervention not relevant (unsupervised); outcomes not applicable
Eisner and van Straten (2003)^Citation13,a	Conference title only
Elliott et al (2004)^Citation14	Outcomes not applicable
Fu et al (2016)^Citation15	Intervention not relevant (no exercise intervention post-pulmonary rehabilitation)
Gomez et al (2006)^Citation16	Conference abstract – full text included
Guell et al (2000)^Citation17	Intervention not relevant (control group did not receive pulmonary rehabilitation)
Heppner et al (2006)^Citation18	Not a randomized trial
Hill and McDonald (2004)^Citation19	Outcomes not applicable
Kotrach et al (2016)^Citation20	Intervention not relevant (unsupervised)
Linneberg et al (2012)^Citation21	Outcomes not applicable
Martinez et al (2008)^Citation22	Conference abstract – full text included
Moy et al (2015)^Citation23	Ongoing trial – data not available
Perumal et al (2010)^Citation24	Not a randomized trial
Pleguezuelos et al (2013)^Citation25	Intervention not relevant (unsupervised); outcomes not applicable
Ries et al (2008)^Citation26	Intervention not relevant (unsupervised and control group received additional care); outcomes not applicable
Ringbaek et al (2009)^Citation27	Conference abstract – full text included
Rodriguez-Trigo et al (2011)^Citation28	Conference abstract – full text included
Scalvini et al (2016)^Citation29	Intervention not relevant (unsupervised)
Spencer et al (2007)^Citation30	Conference abstract – full text included
Spencer et al (2009)^Citation31	Conference abstract – full text included
Swerts et al (1990)^Citation32	Outcomes not applicable
van Wetering et al (2010)^Citation33	Intervention not relevant (control group did not receive pulmonary rehabilitation); outcomes not applicable
Vasilopoulou et al (2017)^Citation34	Intervention not relevant (control group did not receive pulmonary rehabilitation)

Notes: Abstract and full text were nonretrievable.

a Study excluded due to presentation as a conference title only in search results.

Table S3 Ongoing studies

Study name or title	Study period (start and end dates) (country)	Study design	Participants	Intervention and comparison	Relevant outcomes
LEAP: design and rationale of a randomized controlled trial of Tai Chi^Citation23	August 2012 to September 2017 (USA)	Randomized controlled trial (2:2:1 ratio)	90 COPD patients who have just been discharged from pulmonary rehabilitation	1. Tai Chi (1 h, twice a week for 3 months, then once a week for 3 months. A total of 36 classes) 2. Usual care (general recommendations for exercise) 3. Walking group (same frequency and duration as Tai Chi)	Hospital admissions (respiratory) and acute exacerbations (use of corticosteroids and/or antibiotics verified by medical records)
Effects of a community-based, postrehabilitation exercise program in COPD: protocol for a randomized controlled trial with embedded process evaluation^Citation11	November 2012 to August 2018 (Canada)	Randomized controlled trial	100 COPD patients who have completed pulmonary rehabilitation within the last 2 weeks	1. Usual care (standard home exercise instructions postpulmonary rehabilitation) 2. Community-based exercise program (1 h, minimum of two sessions per week (option to do more) for 1 year)	Exacerbations (self-reported)

Abbreviation: LEAP, long-term exercise after pulmonary rehabilitation.

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