21^st Century Therapies for COPD
Richard Casaburi, Ph.D.,M.D. 
President, PERF

III. Perfecting Pulmonary Rehabilitation

       When it comes to progress in pulmonary rehabilitation, I would be very happy if the next ten years are as good as the last ten.  As the decade of the 1990s began, pulmonary rehabilitation was fairly widely practiced, but was discounted as mainline therapy by many because the scientific basis for rehabilitation was weak.  To a large extent, the components of pulmonary rehabilitation programs had not been studied to see whether a distinct benefit could be demonstrated.  Beneficial outcomes of a comprehensive program of pulmonary rehabilitation were claimed, but not scientifically demonstrated.  Few controlled trials had been conducted, making it exceedingly difficult for rehabilitation advocates to prove their case.

      Today, it is reasonable to state that pulmonary rehabilitation is the standard of care for patients debilitated by chronic obstructive lung disease.  Though more needs to be done, we have a critical mass of scientific data supporting the value of rehabilitative therapy.  Included are a number of well-done randomized trials.  Moreover, we have two comprehensive documents, written by panels of rehabilitation experts, that summarize this progress. These documents have the weight of the medical science establishment behind them.  Reading them tells a lot about the progress that’s been made.  In 1997, Evidence-Based Guidelines for Pulmonary Rehabilitation were published in the journal Chest (112:1363-1396).  Just this year, Pulmonary Rehabilitation-1999 was published in the American Journal of Respiratory and Critical Care Medicine (159:1666-1682).  These papers are required reading for all rehabilitation professionals.

     Since we have few therapies that improve the function of the COPD lung (and those that we have are of limited effectiveness), rehabilitation is emerging as the technique of choice to improve the function of everything except the lung.  It has been discovered that it is not only the lung that functions poorly in the COPD patient!  For example, psychological dysfunction (e.g., depression) often keeps the patient homebound and isolated.  Psychosocial interventions that are part of pulmonary rehabilitation make the patient more functional and improve quality of life.  Muscle dysfunction, most prominent in the muscles of ambulation, has been detected and therapies for that improve muscle function have been shown to improve exercise tolerance.  This is of tremendous importance, since exercise intolerance is often the thing that bothers COPD patients most.

       In fact, exercise training has been established as the most important component of pulmonary rehabilitation.  It has been argued that exercise training is more effective than either bronchodilators or oxygen therapy in decreasing the shortness of breath that occurs during everyday activities.  Key lessons have been learned.  It has been shown that vigorous, high intensity programs are necessary to optimize the benefits of training.  Supervised programs in which patients exercise in groups are usually superior to home-based exercise.  Other benefits of pulmonary rehabilitation besides reduction of shortness of breath have been demonstrated.  Because we now have scientifically designed questionnaires, we know that a program of pulmonary rehabilitation often improves the patient’s quality of life.  There is reasonably good data that indicates that this therapy decreases the patient’s use of health care resources and reduces hospitalization.  Whether pulmonary rehabilitation prolongs life is an open question.  A large enough randomized trail has yet to be conducted to determine whether there is a modest benefit.  (It seems likely that a study consisting of several thousand patients randomized to receive rehabilitation or not to receive rehabilitation who are then followed for at least 5 years would be necessary to answer this question.  Such a study may never be performed!)

     Pulmonary rehabilitation has received support from an unexpected source.  The brouhaha over the value of volume reduction surgery (which I will address in a few months) resulted in the designing of a complex clinical trial.  The designers of the trial decided to contrast volume reduction surgery with the best available care currently available for COPD.  Importantly, a rigorous and comprehensive program of pulmonary rehabilitation was chosen as a key component of the best available care.  This has given a psychological boost to those of us who have sought to expand the availability of rehabilitative therapies.  And progress is being made.  For the first time, direct funding of a program of pulmonary rehabilitation by Medicare is in the pipeline.  Importantly, rehabilitation professionals are being consulted about the details of this funding and their suggestions are receiving a good hearing.      

Let me give you my thoughts about what is on the drawing board for improvements in the practice of pulmonary rehabilitation

1. Exercise programs will continue to be improved.  In particular, the value of strength training will become appreciated.  Strength is important to perform many activities of daily living.  People who are weak fall – and broken bones result.  Work is underway to design training programs that are suitable for COPD patients.
   

2. Patients entering rehabilitation often have muscle weakness so profound that starting an exercise program is difficult.  Techniques for “jump starting” the exercise program are being sought.  Nutritional therapy, anabolic hormones and other ergogenic aids are being investigated.  There is a lot of experience in the sports world with these strategies.  What may be unethical in competitive athletics may be a great idea when considering debilitated patients!
   

3. We must do a better job in individualizing therapy for the patient.  This requires that we do a better job of evaluating the patient’s capabilities at the beginning of the program and using this information to guide program design.  
   

4. There is a reasonably good database regarding how patients with COPD respond to rehabilitation.  Much less is know about how patients with other lung disease respond.  Studies of patients with, for example, restrictive lung disease, cystic fibrosis, asthma and ventilator dependence are needed.  Until then, we can only guess that strategies that work for COPD patients are satisfactory for these other patient groups.
   

5. It is, frankly, scandalous that pulmonary rehabilitation is a therapy offered only to middle class and upper class patients.  Poor and minority patients seldom have access to rehabilitative services.  Yet, for a given level of lung disease, the impact of COPD on quality of life is often more severe for this patient group.  There are two priorities.  First, rehabilitation programs must be redesigned to be culturally and socioeconomically appropriate to poor and minority patients.  Second, health care policy makers must be convinced that rehabilitation is high priority therapy for all patients.

In the next article I will report on the results of the 5^th Oxygen Consensus Conference and its implications for improvements in ambulatory oxygen therapy for COPD patients.

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