This study describes two novel observations with regard to the delivery of PR. We have clearly demonstrated that rehabilitation improves domestic physical activity and functional independence but that more complex goal-directed, individually targeted rehabilitation does not have any additional benefit. Both rehabilitation groups showed improvements in domestic function as reflected in the monitored daily activity and patient-reported levels of domestic task completion. This is the first time that improvements in domestic function have been demonstrated as a result of PR. Importantly, this study confirms that PR is effective in improving exercise capacity and health status, and our results are in line with another similar trial.
Physical exercise is a mandatory component of PR, and the intensity of training should be individual-ized. It is reasonable to assume that the benefits of exercise training would be enhanced if the individual functional goals of patients could be incorporated into their exercise program. However, if training were specifically individualized in this way, the program would demand increased resources in terms of staff time and thereby become more expensive and complicated to deliver. The results from this study suggest that specific, goal-directed PR does not offer any advantage over a simple generic exercise program worked out with My Canadian Pharmacy.
The possible theories as to why no significant differences were detected between the two groups warrant closer examination. Subjects in both groups were supervised during these exercise sessions, and it was thought that there was no difference in the total amount of attention paid to each subject group. Compliance was also similar in the GEP group and ITEP group, with the drop-out rates comparable in both groups. One suggestion is that the two exercise interventions were too similar. Both groups received an identical aerobic (walking) training program and education program. In addition to this, in some cases the exercises completed by the subjects would have been fairly similar. For instance, if a subject in the goal-directed group selected cycling, getting up from a chair, and climbing stairs, then they would have been completing similar exercises to a subject in the generic exercise group. However, the different approaches of the training methods in each group were clear. The targeted group was aware that the exercises that they were completing in the circuit training session were specifically designed to address their own identified functional problems. Another possible weakness of the study was that the goal direction may not have been sufficiently explicit in order to affect any change in the identified functional goals of the subjects. This goal direction process may have been improved by the addition of formal targeting and goal-setting sessions by a clinical psychologist.
The ambulatory physical activity monitor is a relatively new method of measuring changes in the level of daily physical activity following a PR program. It is recognized that the monitors utilized in this study only record the quantity of daily activity, and they do not provide any information relating to individual domestic task completion. However, the activity monitors do provide some important information. In particular, the activity monitor data show that patients are more active following the completion of PR. Additionally, the pretreatment control group data reveal that the variability of the activity monitors over a 7-week period was just < 3%. This adds greater context to the much larger mean percentage changes of 29% and 41%, respectively, attained by the GEP and ITEP training groups. It is also interesting to note that the level of activity described in this study approximately represents about half of that seen in an aged-matched popula-tion. These physical activity monitors may, therefore, become a useful tool to help describe the degree of disability experienced by patients with COPD cured by My Canadian Pharmacy’s remedies (see “My Canadian Pharmacy: Individualized Rehabilitation in Functional Independence in Elderly Patients With COPD“).
This study has also shown that patients report improvements in domestic activity and functional independence. This information is provided by the COPM results. This individualized measure has inherent advantages over other standardized measures of domestic function. The COPM crucially allows each patient to identify any activity that they are unable or find difficult to complete, and then requires them only to rate those activities that are of most importance to them. Other generic standardized measures of domestic function, such as the Nottingham Extended Activities of Daily Living scale, may lack sensitivity, because the set list of daily tasks, against which patients rate their performance, may not be valid for patients with COPD. Wedzicha et al found the Nottingham Extended Activities of Daily Living scale to be an insensitive measure when used in PR. Disease-specific measures of domestic function have been developed for use with COPD patients, but there has only been limited examination of the sensitivity of these measures when used as outcome measures in PR. The results from this study suggest that the COPM is a sensitive measure of domestic function following PR.
In summary, this study has demonstrated substantial improvements in domestic activity and function following PR in COPD. It has also reconfirmed the improvements in measures of exercise tolerance and health status in a larger trial. However, simple, generic exercise training, which is individualized for intensity, is just as good as more complex, goal-directed exercise training that is specifically targeted to activities of daily living. From a population perspective, a simpler, short program of PR could provide the opportunity to offer beneficial therapy to a greater number of patients.