Original Article
Effect of a Domiciliary Pulmonary Rehabilitation Programme on Disability in Patients with Interstitial Lung Diseases Krishan Gupta, Raj Kumar and S.N. Gaur Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
ABSTRACT
Objectives. To evaluate the effect of a domiciliary pulmonary rehabilitation programme (PRP) with supervision at regular intervals in the out-patient department, on pulmonary function (PFT) parameters, 6-minute walking distance (6-MWD), grade and severity of dyspnoea and quality of life (QoL) in patients with interstitial lung disease (ILD). Methods. It was a prospective study of 22 patients diagnosed to have ILD. These were divided into study and control group. All patients had a baseline evaluation, followed by an evaluation after six weeks of standard pharmacological treatment. The study group then undergone a pulmonary rehabilitation programme for the next six weeks, in addition to pharmacological treatment; whereas the control group continued with the pharmacological treatment. The PRP included patient education, and exercise training for 20 minutes everyday. Outcome of parameters including forced expiratory volume in one second (FEV1) forced vital capacity (FVC), FEV1/FVC%, inspiratory capacity (IC), residual volume (RV), total lung capacity (TLC), diffuse lung capacity (DLCO) and diffusion per unit volume (DL/VA), 6-MWD, severity and grade of dyspnoea and quality of life were measured in both the groups before and after completion of the treatment of six weeks. Results. No significant change was observed from the baseline values after six weeks of standard pharmacological treatment. The study group showed a significant improvement in dyspnoea grading by Medical Research Council (MRC) scale and visual analog scale (VAS) 6-MWD, QoL (as assessed by emotion, fatigue, dyspnoea and mastery components of CRDQ) following PRP. However, no significant change was observed in PFT parameters after PRP. Conclusions. A six weeks domiciliary pulmonary rehabilitative programme was effective in increasing exercise endurance, and reducing the severity of dyspnoea and improving the quality of life of patients with ILD. [Indian J Chest Dis Allied Sci 2007; 49: 213-217] Key words: Interstitial lung disease, Quality of life, Pulmonary rehabilitation programme, Pulmonary function, Dyspnoea.
INTRODUCTION Pulmonary rehabilitation programme (PRP) has been reported to be beneficial in interstitial lung diseases (ILD)1 and non obstructive diseases. 2 Interstitial lung diseases are a heterogeneous group of acute and chronic disorders of diverse aetiology, such as sarcoidosis, systemic lupus erythematosus (SLE), interstitial pulmonary fibrosis (IPF) etc., that primarily present with diffuse fibrosis of the interstitum, but not exclusively and may extend to alveolar spaces, and bronchioles. Pulmonary rehabilitation programme is a well-established and widely accepted therapeutic tool used with standard pharmacotherapy and alleviates symptoms, improves the quality of life and, functional capacity in patients with chronic lung diseases and, thus, optimise a patient’s physical and psychological
functioning.3 However, pulmonary rehabilitation does not result in improvement in lung function as assessed by FEV1, FVC, or FEV1/FVC ratio. Pulmonary rehabilitation programme is a multidisciplinary programme that is individually tailored and designed to optimise physical and social performance and autonomy. Despite substantial variability in programme structure setting,4 pulmonary rehabilitation performed in-patient, 5 out-patient 6 or domiciliary setting has documented clinical efficacy. Domiciliary pulmonary rehabilitation has been preferred over hospital in-patient or out-patient settings as it is convenient for the patient and family members. The objectives of PRP in chronic lung disease patients are to control and alleviate, as much as possible, the symptoms and patho-physiological complications and to teach the patient how to achieve optimal capability for carrying out activities of daily living.7 The goal of
[Received: July 28, 2005; accepted after revision: July 10, 2007]
Correspondence and reprint requests: Dr S.N. Gaur, Professor and Head, Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi-110 007, India; E-mail:
[email protected].
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Pulmonary Rehabilitation Programme in ILD Patients
PRP is achieved by general conditioning, upper body exercise, 8 lower body exercise and reduction in dyspnoea6 and meeting educational, psychological9 and medical needs. Major components of PRP include exercise training, education, psychological and behavioural interventions and outcome assessments.3 Patient education about the disease and its management is a central feature of PRP but is not effective alone.10 However, the patient can become more skilled at collaborative self-management and more adherent to the treatment plans. In ILD, repeated exercise at rather lower levels that the patient can tolerate, definitely improve the ability to exercise. Training can be set at a low intensity with long duration or high intensity with short duration per session.11 Nutritional supplements can improve fat free mass and muscle strength. The effect of nutrition on efficacy of physical training is, however, unknown. Anabolic agents are also being examined which may increase the muscle but not exercise capacity. 12 Nutritional supplement alone has no advantage in anthropometric measurements, lung function or functional exercise capacity.13 Psychological intervention may be useful in motivating the patient, since identification of readiness to change may improve compliance with physical training.14 While the beneficial effects of pulmonary rehabilitation programme are well-documented in COPD, there is little information about its role in ILDs. Therefore, the present study was carried out.
MATERIAL AND METHODS It was a prospective follow-up study of cohort of patients with stable, moderate-to-severe interstitial lung fibrosis due to any cause attending the out-patient department of Vallabhbhai Patel Chest Institute, Delhi, from April 2002 to April 2003. Interstitial lung disease was diagnosed on the basis of chest radiography, computed tomographic (CT) scan and lung function tests (restrictive lung defect with low diffusion capacity). Patients on conventional pharmacological treatment for at least three months, had moderate-tosevere dyspnoea on exertion persistent for more than six months, with TLC and DLCO of greater than 70% of predicted were included in the study. Patients with other co-morbid conditions of cardiovascular, respiratory or other systems (which may interfere with pulmonary functions), or those having significant disabling orthopaedic or musculo-skeletal disorders (which may interfere with exercise training) were excluded from the study. After an initial assessment of the patients, a six-week of standard treatment including steroids was given. The second assessment was made after six weeks. The cases were them divided into two groups (study group and control group) with matching for age, sex, TLC, DLCO
K. Gupta et al
and DL/VA (Table 1). The control group continued on standard treatment throughout the study period, whereas the study group was given additional pulmonary rehabilitation for six-weeks. The effect of pulmonary rehabilitation on defined parameters was fully evaluated and statistically analysed after six weeks in both the groups. All the patients received standard treatment in the form of oral steroids, inhaled steroids, bronchodilators, mucolytics and theophylline as decided by the treating physician on the primary lung pathology of ILD. The standard treatment was not changed during the study period. The evaluation of parameters during baseline second and third stage included a complete haemogram, chest radiography, lung function tests (including spirometry, lung volumes and diffusion capacity), evaluation of level of the dyspnoea using visual analog scale and MRC scale, six-minute walk distance, MRC and chronic respiratory diseases questionnaire (CRDQ). Table 1. Baseline characteristics of patients in the study and the control group Variable
Group
Mean ± SD (n=11)
Age (years)
Study Control
44.18 ± 3.222 50.73 ± 3.377
TLC (L)
Study Control
2.644 ± 0.223 2.662 ± 0.114
DLCO Study (mL/min/mmHg) Control
10.44 ± 1.039 9.332 ± 0.912
DL/VA
Study Control
4.303 ± 0.796 4.371 ± 0.369
TLC (% Predicted)
Study Control
55.36 ± 3.553 61.36 ± 2.55
DLCO (% Predicted)
Study Control
42.09 ± 3.765 43.36 ± 4.296
DL/VA (% Predicted)
Study Control
85.09 ± 17.95 90.00 ± 26.59
Differences were not significant for any comparison.
The PRP consisted of a regular exercise programme for the upper and lower limbs, and ventilatory muscles. These were advised for 20 minutes daily for at least five days a week, for six weeks. Upper limb exercises included lifting of weights (1-2 kg). Lower limb exercise included brisk walking and stationary bicycling. Ventilatory muscle exercise was done using an Incentive spirometer. The techniques of exercise were taught to the patients. Patient education was given in a classroom style informing them about their diseases and emphasising the importance of adherence to the prescribed treatment and the PRP. The patients were given proper nutritional advice according to their nutritional status and psychological interventions, counselling and advice were provided by the treating physician.
2007; Vol. 49
The Indian Journal of Chest Diseases & Allied Sciences
The various evaluation parameters of the second evaluation were compared with baseline (first) evaluation and those of third evaluation were compared with second evaluation in both the study and the control groups using statistical software Graphpad Prism 2.01. Repeated measurement of analysis of variance (ANOVA) tests and Bonferroni’s post hoc test were employed to assess the efficacy of the intervention (PRP) at different points of evaluation. The study and the control group were matched using unpaired ‘t’ test.
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sclerosis, and 16 IPF) 11 each in the study and the control group completed the study. Out of the remaining eight, two died and six did not turn up for follow up. The mean height, weight and body-mass index in the study group were 157.1 cm, 63.55 kg and 25.68 kg/m2, respectively and in the control group these were 152.2 cm, 60.18 kg, and 26.03 kg/m2, respectively. In the study group, the absolute value of the pulmonary function test parameters including FEV1, FVC, FEV 1/FVC%, RV, IC, TLC, DLCO and DL/VA showed no significant change after conventional treatment of six weeks and after PRP of further six weeks. In the control group too there was no significant change on the second and third evaluation, as shown in table 2.
RESULTS Thirty diagnosed cases of ILD were initially included in the study, but only 22 (5 sarcoidosis, one systemic
Table 2. Pulmonary function parameters at baseline and after interventions PFT Variable
Groups
Baseline Values (Mean ± SD) (N=11)
After 6 Weeks (Mean ± SD) (N=11)
After Intervention (Mean ± SD) (N=11)
F - ratio
FEV1 (L)
Study Control
1.33 ± 0.401 1.283 ± 0.266ns
1.431 ± 0.484 1.284 ± 0.245ns
1.432 ± 0.490 1.240 ± 0.219ns
1.536ns 0.886ns
FEC (L)
Study Control
1.838 ± 0.618 1.712 ± 0.377ns
1.896 ± 0.600 1.711 ± 0.274ns
1.935 ± 0.624 1.674 ± 0.327ns
3.839* 0.256ns
FEV1/FVC
Study Control
74.30 ± 14.67 76.09 ± 11.94ns
77.18 ± 15.5 75.64 ± 12.52ns
74.82 ± 15.63 75.36 ± 14.51ns
0.638ns 0.161ns
TLC (L)
Study Control
2.644 ± 0.740 2.662 ± 0.379ns
2.743 ± 0.864 2.780 ± 0.561ns
2.758 ± 0.905 2.730 ± 0.484ns
0.854ns 1.088ns
DLCO (mL/min/mmHg)
Study Control
10.44 ± 3.447 9.332 ± 3.026ns
11.96 ± 4.576 9.222 ± 2.731ns
11.51 ± 4.233 8.564 ± 4.729ns
1.148ns 0.300ns
DL/VA
Study Control
4.303 ± 0.796 4.371 ± 1.279ns
5.175 ± 2.085 4.133 ± 1.268ns
4.593 ± 1.198 3.915 ± 1.940ns
1.36ns 0.597ns
RV (L)
Study Control
0.759 ± 0.266 0.940 ± 0.209ns
0.842 ± 0.352 1.053 ± 0.313ns
0.823 ± 0.371 1.0 ± 0.247ns
0.331ns 0.965ns
IC (L)
Study Control
1.209 ± 0.514 1.187 ± 0.262ns
1.270 ± 0.500 1.215 ± 0.332ns
1.319 ± 0.490 1.201 ± 0.266ns
2.018ns 0.077ns
Variation in the superscript indicates significance of difference at different evaluations; p0.05), n=sample size Table 3. Dyspnoea, 6-MWD and QoL parameters at baseline and after interventions Parameters
Groups
Baseline Values (Mean ± SD) (N=11)
VAS (%)
Study Control
41.82 ± 9.558 45.45 ± 14.22ns
6 MWD (Meters)
Study Control
CRDQ (Emotion)
After 6 Weeks (Mean ± SD) (N=11)
After Intervention (Mean ± SD) (N=11)
F - ratio
52.55 ± 8.904 51.82 ± 10.79ns
34.09 ± 8.608 65.00 ± 9.747*
46.12* 17.30*
482.3 ± 75.01 337.1 ± 133.8**
435.6 ± 106.4 300.5 ± 125.2***
579.7 ± 111.9 259.6 ± 100.7*
26.71* 32.11*
Study Control
34.27 ± 9.540 31.55 ± 8.664ns
31.64 ± 8.213 29.09 ± 8.994ns
39.73 ± 8.568 24.91 ± 9.439**
23.70* 22.87*
CRDQ (Dyspnoea)
Study Control
14.73 ± 4.002 18.09 ± 4.460ns
13.82 ± 4.262 17.36 ± 3.443
20.18 ± 3.027 13.45 ± 4.435**
60.06* 23.10*
CRDQ (Fatigue)
Study Control
10.55 ± 4.204 11.18 ± 3.341ns
9.909 ± 3.015 10.73 ± 3.133ns
14.09 ± 3.506 8.364 ± 3.171*
34.58* 13.87*
CRDQ (Mastery)
Study Control
16.45 ± 6.362 13.00 ± 3.975ns
15.36 ± 6.005 11.55 ± 4.034ns
21.27 ± 4.819 8.909 ± 4.369*
27.03* 24.43*
N= sample size, *=p
