Functional status following pulmonary rehabilitation in people with AECOPD: a systematic review and meta-analysis

Introduction: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) lead to a decline not only in the patient’s lung function but also in other important health domains, such as functional status. Functional status includes functional capacity and functional performance. Functional capacity refers to one’s maximal potential to realize a functional activity in a standardized environment. Functional performance refers to the activities people actually do during their daily life. Pulmonary rehabilitation (PR) is fundamental for COPD management, however, its effectiveness in improving the functional status (capacity and performance) during and after AECOPD is less known. Objectives: To systematize the effects of PR in the functional status (capacity and performance) during or immediately after an AECOPD. Methods: This systematic review was registered (no. CRD42022298593). Systematic searches for randomised controlled trials (RCTs) comparing PR (with, at least, exercise training and education and/or psychosocial support) with usual care in people during and/or after AECOPD were conducted in PubMed/MEDLINE, Scopus, and Web of Science Core Collection. Two independent reviewers assessed the titles, abstracts and full text of studies, extracted data and assessed the risk of bias with the Risk of Bias 2 tool. Mean and standardized differences (MD/SMD) were calculated to synthesize results. A statistical random effects model was applied in the meta-analysis. Results: Eight studies were included. The total number of participants was 533, with an age range of 58-74 years and an FEV1%predicted of 35-56%pred. PR was conducted in inpatient (n = 3), outpatient (n = 4) and inpatient/outpatient (n = 1) settings with varying durations and frequencies. Functional capacity was assessed with six measures, the six-minute walk test (6MWT) (n = 3), incremental shuttle walk test (ISWT) (n = 2), the 2-minute walk test (2MWT) (n = 1), 5-repetition sit-to-stand test (5 STS) (n = 1), 30-second sit-to-stand test (30sec STS) (n = 1), and timed up and go (TUG) (n = 1). Functional performance was assessed with four measures, the functional independence measure (FIM) (n = 1), london chest activity of daily living (LCADL) (n = 1), activity of daily living dyspnoea (ADL-D) (n = 1) and stepwatch activity monitor (steps/day) (n = 1). Significant improvements were observed in functional capacity, measured with the 6MWT (n = 159, MD 91.5, 95%CI [23.5; 159.5], p = 0.008) after outpatient and in TUG (n = 32, MD -2.2, 95%CI [-3.9; -0.5], p = 0.009) after inpatient PR in the EG compared to CG. Functional performance, measured with the ADL-D and the LCADL (n = 160, SMD 1.0, 95%CI [0.8; 1.2], p < 0.0001), as well as with the FIM (n = 44, MD 7.5, 95%CI [2.1; 12.8], p = 0.006), improved significantly after inpatient PR in comparison to usual care. No other significant between-group differences were observed for functional capacity or performance. Conclusions: Pulmonary rehabilitation improves functional status during or immediately after an AECOPD. Nevertheless, few studies with small samples and high heterogeneity of outcome measures and interventions exist, which hinders conclusions. Functional performance is less assessed than functional capacity. Inclusion of both is fundamental to tailor PR in AECOPD and ensure benefits translate not just to what people can, but also do in their daily life.

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