Innovating rehabilitation modalities for individuals with COPD

This PhD thesis aimed to develop and test innovative exercise training modalities in an attempt to tackle the current challenges of uptake and adherence to pulmonary rehabilitation (PR) programs in individuals with COPD, with a particular focus on improving accessibility through or in collaboration with primary care physiotherapy.  Two new exercise programs were rolled out successfully and showed promising results.

Pulmonary rehabilitation is a multidisciplinary approach typically involving exercise training and educational, social, psychological, nutritional and occupational support. PR is widely recognised as an effective intervention, however, alternatives have been advocated for and have been explored in the last years to address the current challenges of uptake and adherence. Chapter 1 introduces a new implementation of PR for individuals with COPD: a hybrid model integrating PR across two settings/providers: the outpatient centre and primary care physiotherapy. The effects of a three-month PR program on physical measures and health-related quality of life were comparable between the conventional and hybrid PR group, aligning with expected results from PR. Both programs showed clinically relevant improvements in functional exercise capacity. The weekly travel time for the patient was substantially reduced with hybrid PR and the number of patients dropping out of the program was lower compared to conventional PR.

Chapters 2, 3 and 4 focused on exercise training after an AECOPD. Exercise training is a component of PR, and relates to the planned, structured, and repetitive physical movement performed to maintain or enhance physical fitness. To fully capture the available literature on exercise interventions for individuals with COPD after an AECOPD, the scoping review in Chapter 2 mapped the content, uptake and adherence of exercise interventions. Fifty-nine different interventions were identified varying in training components. We showed that high heterogeneity and inconsistent reporting arise with current literature and highlighted the importance of adequate reporting and including fidelity assessments in future research. Additionally, considering the similar impact of an AECOPD for moderate and severe AECOPDs, future research should aim to evaluate exercise interventions for individuals recovering from a moderate AECOPD.

In Chapter 3, we designed a novel exercise training program, provided in primary care, for individuals after an AECOPD. Based on a literature review, a qualitative study with relevant stakeholders, and a feasibility study that included eight patients after a moderate or severe AECOPD, the developed program was adapted stepwise to make it feasible and acceptable. The efficacy of the designed program was subsequently assessed in Chapter 4. Compared to the control group, the exercise training program effectively improved quadriceps muscle force after an AECOPD, if individuals adhered to the study protocol. The intervention was offered to individuals declining centre-based PR and could start quickly when the treatment for the AECOPD was stopped (14 ± 9 days between the stop of medication and the start of physiotherapy). However, as our results suggest, this program may not be suited for patients experiencing a moderate AECOPD as no effects were observed on quadriceps muscle force in this population. 

In general, two novel exercise training programs were introduced which provided new insights into the care of individuals with COPD. The barriers to clinical implementation for both of these programs appear to be low as they were both executed in a real-world setting.