Pulmonary Rehabilitation Programmes Within Three Days of Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Figures & data

Figure 1 Study selection process for this review.

Figure 2 Continue.

Figure 2 (A) Risk of bias graph. (B) Risk of bias summary.

Table 1 Basic Characteristics of Included Studies

First Author Year	Country	Design	Patients N(EG/CG)	Gender (M/F)	Age	Duration of PR	Follow Up	Frequency	Program of EG	CG Group	Outcomes
Vermeeren 2004^Citation41	Netherlands	RCTs 2 arms	47(23/24)	EG 14/9 CG 18/6	EG 66.0±8.0 CG 65.0±10	From the second day of admission to discharge	No	Three times a day, 125mL each time	Nutritional support (Nutricia)	Placebo	QMS
Tang 2012^Citation42	Australia	RCTs 2 arms	32(21/11)	EG 7/14 CG 6/5	EG 70.7±10.2 CG 78.0±8.8	From the second day of admission to discharge	No	Twice a day, 15 minutes each time	Aerobic and resistance exercise	Sputum clearance, mobility assessments, functional training	Adverse events
Greulich 2014^Citation43	Germany	RCTs 2 arms	49(23/26)	EG 14/6 CG 12/8	EG 66.4±9.9 CG70.4±10.1	From the second day of admission to discharge	No	Once a day, 26 minutes each time	Whole body vibration training, mobilisation to bedside and stand, respiratory therapy, passive muscle movements	Mobilisation to bedside and stand, respiratory therapy, passive muscle movements	6MWD, SGRQ, DoHS, 5 STS, adverse events
Osadnik 2014^Citation44	Australia	RCTs 2 arms	90 (45/45)	EG28/17 CG30/15	EG 69.5±9.8 CG67.8±11.6	From the second day of admission to discharge	6 months	Once a day, 20 minutes each time	PEP therapy	Usual care	DoHS, adverse events
Borges 2014^Citation45	Brazil	RCTs 2 arms	29 (15/14)	EG8/7 CG10/4	EG 64.1±12.5 CG67.8±9.0	From the third day of admission to discharge	1 month	Once a day, 2 sets of 8 repetitions each time	Whole-body resistance training	Usual care	DoHS, 6MWD, SGRQ
He 2015^Citation46	China	RCTs 2 arms	94 (66/28)	EG60/6 CG23/5	EG 69.2±1.5 CG73.9±1.8	From the second day of admission to discharge	No	Once a day, 20 minutes each time	Exercise training, relaxation, education, breathing retraining	Usual care	6MWD, adverse events,
Torres-Sánchez2017^Citation47	Spain	RCTs 2 arms	58(29/29)	EG22/7 CG20/9	EG75.7±6.3 CG72.1±8.2	From the second day of admission to discharge	No	Once a day	Cycling exercise	Usual care	QMS, adverse events
Öncü 2017^Citation48	Turkey	RCTs 2 arms	70(35/35)	EG28/7 CG26/9	-	From the second day of admission to discharge	No	Once a day, 45 minutes each time	Transcutaneous Electrical Nerve Stimulation	False stimulation	6MWD
Torres-Sánchez2018^Citation49	Spain	RCTs 2 arms	90 (60/30)	EG54/6 CG24/6	EG 72.6±9.9 CG71.1±9.4	From the second day of admission to discharge	No	Once a day, 30 to 40 minutes each time	Controlled breathing, range of motion exercises, Resistance exercises	Usual care	DoHS
Lopez Lopez 2018^Citation50	Spain	RCTs 2 arms	39(27/12)	EG21/6 CG10/2	EG63.4±11.3 CG64.3±8.5	From the first day of admission to discharge	No	Once a day, 45 minutes each time	Functional electrostimulation, calisthenic exercises	Usual care	DoHS, 5 STS
Lopez Lopez 2019^Citation51	Spain	RCTs 2 arms	48(32/16)	-	EG70.0±7.3 CG68.5±8.9	From the second day of admission to discharge	No	Once to two a day, 30 minutes each time	Functional electrostimulation, cycling exercise	Usual care	5 STS, QMS, adverse events
Lopez Lopez 2020^Citation52	Spain	RCTs 2 arms	66(44/22)	-	EG71.9±9.6 CG68.5±8.9	From the second day of admission to discharge	No	Once a day	Neuromuscular stimulation, lower limb exercises, self-management	Usual care	DoHS,5 STS, adverse events
Knaut 2020^Citation53	Brazil	RCTs 2 arms	26(13/13)	EG9/4 CG8/5	EG66.8±9.5 CG69.3±13.5	From the third day of admission to discharge	No	Twice a day, 15 minutes each time	Aerobic exercise	Usual care	SGRQ, 6MWD, DoHS
Lu 2020^Citation54	China	RCTs 2 arms	72(36/36)	-	EG67.4±7.1 CG68.3±6.8	From the second day of admission to 9 weeks	No	Three times a day, repeat each action 15 to 20 times each time	Zheng’s Supine Rehabilitation Exercise	Usual care	DoHS, 6MWD

Abbreviations: F, female; M, male; EG, experimental group; CG, control group; RCTs, randomized controlled trials; 6MWD, 6-minute walk distance; SGRQ, the Saint George’s Respiratory Questionnaire; 5 STS, five times sit to stand test; DoHS, duration of hospital stay.

Figure 3 Experimental group versus control group, 6MWD.

Figure 4 Experimental group versus control group, SGRQ.

Figure 5 Experimental group versus control group, DoHS.

Figure 6 Experimental group versus control group, QMS.

Figure 7 Experimental group versus control group, 5 STS.

Table 2 Quality of Evidence

Certainty Assessment							№ of Patients		Effect		Certainty	Importance
№ of Studies	Study Design	Risk of Bias	Inconsistency	Indirectness	Imprecision	Other Considerations	EG	CG	Relative (95% CI)	Absolute (95% CI)
6MWT
6	Randomized trials	Serious ^a	Serious ^b	Not serious	Not serious	None	180	139	-	MD 69.64 higher (40.26 higher to 99.01 higher)	⨁⨁◯◯ LOW	IMPORTANT
SGRQ
3	Randomized trials	Serious ^a	Not serious	Not serious	Not serious	None	144	103	-	MD 12.77 lower (16.03 lower to 9.5 lower)	⨁⨁⨁◯ MODERATE	CRITICAL

Notes: ^alack of blinding and concealment of allocation are not clear. ^bHigh heterogeneity (I² >50%).

Abbreviations: CI, Confidence interval; MD, Mean difference.

Table 3 Results of Sensitivity Analysis

Outcomes	Deletion	Result
6MWD	Öncü E 2017	χ2=44.06, P<0.0001;I^2=91%	MD76.96; 95% CI [41.13, 112.79]
	Knaut C 2020	χ2=34.12, P<0.0001;I^2=88%	MD86.50; 95% CI [45.38, 127.61]
	He M 2015	χ2=43.98, P<0.0001;I^2=91%	MD83.66; 95% CI [33.47, 133.86]
	Greulich T 2014	χ2=41.63, P<0.0001;I^2=90%	MD66.34; 95% CI [35.68, 97.01]
	Borges RC 2014	χ2=28.05, P<0.0001;I^2=86%	MD55.45; 95% CI [29.10, 81.80]
	Lu H 2020	χ2=26.21, P<0.0001;I^2=85%	MD55.44; 95% CI [28.91, 81.97]
SGRQ	Borges RC 2014	χ2=0.90, P=0.34;I^2=0%	MD-13.13; 95% CI [−16.52, −9.74]
	Greulich T 2014	χ2=0, P=0.99;I^2=0%	MD-8.35; 95% CI [−16.16, −0.53]
	Knaut C 2020	χ2=0.73, P=0.39;I^2=0%	MD-13.25; 95% CI [−16.69, −9.81]
DoHS	Borges RC 2014	χ2=3.55, P=0.74;I^2=0%	MD0.32; 95% CI [−0.03, 0.68]
	Greulich T 2014	χ2=6.92, P=0.33;I^2=13%	MD0.27; 95% CI [−0.08, 0.62]
	Osadnik CR 2014	χ2=6.91, P=0.33;I^2=13%	MD0.26; 95% CI [−0.09, 0.61]
	Lu H 2020	χ2=4.86, P=0.56;I^2=0%	MD-0.22; 95% CI [−0.97, 0.52]
	Lopez Lopez L 2018	χ2=6.90, P=0.33; I^2I^2=13%	MD0.26; 95% CI [−0.09, 0.61]
	Torres-Sánchez I 2018	χ2=6.80, P=0.34;I^2=12%	MD0.25; 95% CI [−0.11, 0.61]
	Lopez Lopez L2020	χ2=5.89, P=0.44;I^2=0%	MD0.31; 95% CI [−0.05,0.68]
	Knaut C 2020	χ2=5.00, P=0.54;I^2=0%	MD0.29; 95% CI [−0.06, 0.64]
QMS	Vermeeren MA 2004	χ2=0.22, P=0.64;I^2=0%	MD28; 95% CI [13.30,42.69]
	Torres-Sánchez I 2018	χ2=5.49, P=0.02;I^2=82%	MD14.43; 95% CI [−16.80,45.67]
	Lopez Lopez L 2019	χ2=6.92, P=0.009;I^2=86%	MD11.81; 95% CI [−12.15,35.78]
5 STS	Greulich T 2014	χ2=0.66, P=0.72;I^2=0%	MD-2.45; 95% CI [−7.79, 2.89]
	Lopez Lopez L 2018	χ2=2.17, P=0.34;I^2=8%	MD-3.36; 95% CI [−8.59, 1.86]
	Lopez Lopez L 2019	χ2=1.33, P=0.52;I^2=0%	MD-6.30; 95% CI [−13.01, 0.42]
	Lopez Lopez L 2020	χ2=2.41, P=0.30;I^2=17%	MD-4.20; 95% CI [−10.10,1.71]

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