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Revalidatie bij patienten met COPD: een systematische literatuurstudie |
Bekkering G E, Cambach W, Hendriks H J, Chadwick-Straver R V, Gosselink R, Jongmans M, Paterson W J, van der Schans C P, Verhoef-de Wijk M C, Decramer M |
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Authors' objectives To assess the efficacy of rehabilitation programmes for patients with chronic obstructive pulmonary disease (COPD).
Searching MEDLINE (from 1982 to current) and the literature files of the Dutch Paramedical Institute (Npi; Physiotherapy Index, Rehabilitation Index and Occupational Index). The following keywords were used (both in English and Dutch): 'CARA', 'COPD', 'chronic bronchitis', 'emphysema', 'RCT', 'clinical trial', 'effect study', 'effectiveness', 'evaluation', 'endurance therapy', 'training', 'movement therapy', 'rehabilitation' and 'physiotherapy'. Bibliographies from retrieved studies were searched for additional references. Studies published in English, Dutch and German were eligible for inclusion. Abstracts and unpublished studies were excluded.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials (RCTs) which compared the intervention to a control (no intervention or an intervention that has no effect on the outcomes investigated).
Specific interventions included in the reviewMultifaceted rehabilitation. Components of rehabilitation programmes used in studies included in the review included training at the upper and lower extremities, breathing exercises, relaxation exercises, education, psychosocial counselling, training of the breathing muscles, bronchial lavage.
Participants included in the reviewPatients with COPD.
Outcomes assessed in the reviewOutcomes investigated had to relate to functional exercise capacity and quality of life. Specific outcomes reported in the included studies included walking distance in 6 and 12 minutes, maximum exercise capacity, sub-maximum exercise capacity, improvement in dyspnoea, emotions and control, tiredness, mastery, endurance and the Chronic Respiratory Disease Questionnaire (CRDQ) questionnaire.
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for the review, or how many of the reviewers performed the validity assessment.
Assessment of study quality Studies were assessed for the following methodological features: description of inclusion criteria, number of patients per group, pre-stratification on prognostic variables, description of randomisation, presentation of relevant baseline data, blinding, description of intervention, use of appropriate outcome measures, number of drop-outs, appropriate analysis and presentation of results.Studies were assessed for validity independently by two reviewers, disagreements were resolved through consensus or by referral to a third reviewer. Studies were given a score of 1, a or 0 for each of the 10 criteria. Study quality was described as "adequate" if a score of more than 5 was achieved.
Data extraction The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction. Data were extracted on number of participants, age, baseline forced expiratory volume in one second, contents and duration of the rehabilitation programme and results.
Methods of synthesis How were the studies combined?A narrative synthesis was presented. Study results were classified as "+" if the experimental intervention led to a statistically significant improvement (p<0.05) in the outcomes measured compared to the control group. A study was classified as "-" if no statistically significant differences were found or if the control appeared to be more effective than the intervention.
How were differences between studies investigated?Differences between the studies were discussed narratively.
Results of the review Nineteen studies met inclusion criteria. Of these, 11 RCTs were of sufficient methodological quality to be included in the analysis (n=454).
Study validity scores ranged from 5.5 to 7.5. The main methodological limitations of the studies were study size and blinding.
Functional exercise capacity (n=7).
Seven studies looked at walking distance and maximum exercise capacity. Five studies reported significant improvements in walking distance and four reported significant improvements in maximum exercise capacity in the intervention compared to the control group. Six of the seven studies showed a positive result of exercise training.
Quality of life (n=5).
The CRDQ was used to measure quality of life. Four out five studies reported a decrease in dyspnoea and in improvement in quality of life as measured by this scale. Two of the four studies showed improved scores on the fatigue scale and two other studies showed improved scores on the emotional function scale.
Authors' conclusions The most important findings of this systematic review are that rehabilitation programmes can improve functional exercise capacity (walking distance and endurance time on a bicycle ergometer) and quality of life (dyspnoea and mastery dimension of the CRDQ) of patients with COPD The effects on maximum exercise capacity are more equivocal.
CRD commentary A good review of the area. A reasonable literature search was conducted, although this could have been improved by searching additional databases. Unpublished studies were excluded and language limitations were imposed and so the results may be subject to publication bias. The authors do not report how many reviewers were involved in assessing study inclusion or data extraction. Methodological quality was appropriately investigated and discussed, study results were clearly presented in tables and a narrative synthesis was presented. The authors' conclusions follow from the results presented but should be interpreted with some degree of caution due to the possibility of publication bias.
Implications of the review for practice and research Research: The authors state that 'future studies should address the lack of methodological quality of individual studies, the relative efficacy of the various components of rehabilitation, and the long-term effects of rehabilitation programmes'.
Bibliographic details Bekkering G E, Cambach W, Hendriks H J, Chadwick-Straver R V, Gosselink R, Jongmans M, Paterson W J, van der Schans C P, Verhoef-de Wijk M C, Decramer M. Revalidatie bij patienten met COPD: een systematische literatuurstudie. Nederlands Tijdschrift voor Fysiotherapie 1998; 108(5): 120-127 Indexing Status Subject indexing assigned by CRD MeSH Lung Diseases, Obstructive /rehabilitation; Rehabilitation AccessionNumber 11999009418 Date bibliographic record published 31/08/2001 Date abstract record published 31/08/2001 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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