Pulmonary rehabilitation for interstitial lung disease.

Pulmonary rehabilitation for interstitial lung disease (Review) Dowman L, Hill CJ, Holland AE

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2014, Issue 10 http://www.thecochranelibrary.com

Pulmonary rehabilitation for interstitial lung disease (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 1 Change in 6-minute walk distance immediately following pulmonary rehabilitation. Mean change from baseline, metres. . . . . Analysis 1.2. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 2 Change in 6-minute walk test at long-term follow-up. Mean change from baseline, metres. . . . . . . . . . . . . . . Analysis 1.3. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 3 Change in VO2 peak immediately following pulmonary rehabilitation, mL/kg/min. . . . . . . . . . . . . . . . . . Analysis 1.4. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 4 Change in VEmax immediately following pulmonary rehabilitation, L/min. . . . . . . . . . . . . . . . . . . . Analysis 1.5. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 5 Change in maximum heart rate immediately following pulmonary rehabilitation, beats per minute. . . . . . . . . . . . . Analysis 1.6. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 6 6-Month survival. Analysis 1.7. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 7 Change in dyspnoea score at long-term follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.8. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 8 Change in quality of life immediately following pulmonary rehabilitation. . . . . . . . . . . . . . . . . . . . . . . Analysis 1.9. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 9 Change in quality of life at long-term follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.10. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 10 Change in dyspnoea score immediately following pulmonary rehabilitation. . . . . . . . . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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[Intervention Review]

Pulmonary rehabilitation for interstitial lung disease Leona Dowman1 ,2,3 , Catherine J Hill2,4 , Anne E Holland1,4,5 1 Department of Physiotherapy, La Trobe University, Melbourne, Australia. 2 Department of Physiotherapy, Austin Hospital, Melbourne, Australia. 3 Institute for Breathing and Sleep, Austin Hospital, Heidelberg, Australia. 4 Institute for Breathing and Sleep, Melbourne, Australia. 5 Department of Physiotherapy, Alfred Health, Melbourne, Australia

Contact address: Anne E Holland, Department of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia. [email protected]. Editorial group: Cochrane Airways Group. Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 10, 2014. Review content assessed as up-to-date: 27 June 2014. Citation: Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD006322. DOI: 10.1002/14651858.CD006322.pub3. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise-induced hypoxia. Pulmonary rehabilitation, an intervention that includes exercise training, is beneficial for people with other chronic lung conditions; however its effects in ILD have not been well characterised. Objectives • To determine whether pulmonary rehabilitation in patients with ILD has beneficial effects on exercise capacity, symptoms, quality of life and survival compared with no pulmonary rehabilitation in patients with ILD. • To assess the safety of pulmonary rehabilitation in patients with ILD. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 6), MEDLINE (Ovid), EMBASE (Ovid), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO) and the Physiotherapy Evidence Database (PEDro) (all searched from inception to June 2014). We also searched the reference lists of relevant studies, international clinical trial registries and respiratory conference abstracts to look for qualifying studies. Selection criteria Randomised and quasi-randomised controlled trials in which pulmonary rehabilitation was compared with no pulmonary rehabilitation or with other therapy in people with ILD of any origin were included. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. Study authors were contacted to provide missing data and information regarding adverse effects. A priori subgroup analyses were specified for participants with idiopathic pulmonary fibrosis (IPF) and participants with severe lung disease (low diffusing capacity or desaturation during exercise). We planned to subgroup according to training modality applied, but there were insufficient data. Pulmonary rehabilitation for interstitial lung disease (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Main results Nine studies were included, six of which were published as abstracts. Five studies were included in the meta-analysis (86 participants who undertook pulmonary rehabilitation and 82 control participants). One study used a blinded assessor and intention-to-treat analysis. No adverse effects of pulmonary rehabilitation were reported. Pulmonary rehabilitation improved the six-minute walk distance with weighted mean difference (WMD) of 44.34 metres (95% confidence interval (CI) 26.04 to 62.64 metres) and improved oxygen consumption (VO2 ) peak with WMD of 1.24 mL/kg/min−1 (95% CI 0.46 to 2.03 mL/kg/min−1 ). Improvements in six-minute walk distance and VO2 peak were also seen in the subgroup of participants with idiopathic pulmonary fibrosis (IPF) (WMD 35.63 metres, 95% CI 16.02 to 55.23 metres; WMD 1.46 mL/kg/min−1 , 95% CI 0.54 to 2.39 mL/kg/min−1 , respectively). Reduced dyspnoea (standardised mean difference (SMD) -0.66, 95% CI -1.05 to -0.28) following pulmonary rehabilitation was also seen in the IPF subgroup (SMD -0.68, 95% CI -1.12 to -0.25). Quality of life improved following pulmonary rehabilitation for all participants on a variety of measures (SMD 0.59, 95% CI 0.20 to 0.98) and for the subgroup of people with IPF (SMD 0.59, 95% CI 0.14 to 1.03). Two studies reported longer-term outcomes, with no significant effects of pulmonary rehabilitation on clinical variables or survival at three or six months. Available data were insufficient to allow examination of the impact of disease severity or exercise training modality. Authors’ conclusions Pulmonary rehabilitation seems to be safe for people with ILD. Improvements in functional exercise capacity, dyspnoea and quality of life are seen immediately following pulmonary rehabilitation, with benefits also evident in IPF. Because of inadequate reporting of methods and small numbers of included participants, the quality of evidence was low to moderate. Little evidence was available regarding longer-term effects of pulmonary rehabilitation.

PLAIN LANGUAGE SUMMARY Pulmonary rehabilitation for interstitial lung disease (ILD) Review question: We reviewed available evidence on the effects of pulmonary rehabilitation on exercise capacity, shortness of breath and quality of life in people with interstitial lung disease (ILD). Background: People with ILD often have reduced exercise capacity and shortness of breath during exercise. Pulmonary rehabilitation can improve well-being in people with other chronic lung disease, but little is known regarding pulmonary rehabilitation in ILD. We wanted to discover whether pulmonary rehabilitation was safe for people with ILD, and whether it provided advantages over usual care. We also looked at whether people with idiopathic pulmonary fibrosis (IPF), a type of ILD that can progress rapidly, could benefit from pulmonary rehabilitation. Study characteristics: Nine studies were included; however only five studies provided sufficient information for the analysis (86 participants receiving pulmonary rehabilitation and 82 participants not receiving pulmonary rehabilitation). Three studies included only people with IPF, and the other six studies included people with a variety of ILDs. The average age of participants ranged from 36 to 71 years. Key results: No reports described unwelcome effects of pulmonary rehabilitation. Immediately following pulmonary rehabilitation, participants could walk farther than those who had not undertaken pulmonary rehabilitation (on average, 44 metres farther in six minutes). Participants also improved their maximum exercise capacity and reported less shortness of breath and improved quality of life. People with IPF also experienced improvements in exercise capacity, dyspnoea and quality of life following pulmonary rehabilitation. Information was insufficient to establish whether ongoing effects were noted once pulmonary rehabilitation had stopped. Quality of the evidence: Because of inadequate reporting of methods and small numbers of participants, the quality of evidence was low to moderate. This Cochrane plain language summary is current to June 2014.


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S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Pulmonary rehabilitation compared with no pulmonary rehabilitation for interstitial lung disease Patient or population: people with interstitial lung disease Settings: rehabilitation centres, hospital outpatient departments, home-based exercise Intervention: pulmonary rehabilitation Comparison: no pulmonary rehabilitation Outcomes

Illustrative comparative risks* (95% CI)

Assumed risk

Relative effect (95% CI)

Number of participants (studies)

Quality of the evidence (GRADE)

Corresponding risk

No pulmonary rehabili- Pulmonary tation tion

rehabilita-

Change in 6-minute walk distance 6-Minute walk test Follow-up: end of rehabilitation (8-12 weeks)

Mean change in 6-minute walk distance ranged across control groups from -4 to 17 metres

Mean change in 6-minute MD 44.34 (26.04 to 62. 168 walk distance in the inter- 64) (5 studies) vention groups was 44 higher (26 to 63 higher)

⊕⊕⊕ moderatea

Change in peak oxygen uptake Cardiopulmonary exercise test Follow-up: end of rehabilitation (8-12 weeks)

Mean change in peak oxygen uptake ranged across control groups from -0.02 to 0.4 mL/kg/min

Mean change in peak oxy- MD 1.24 (0.46 to 2.13) gen uptake in the intervention groups was 1.24 higher (0.46 to 2.03 higher)

80 (2 studies)

⊕⊕

lowb,c

Change in maximum ventilation Cardiopulmonary exercise test Follow-up: end of rehabilitation (8 weeks)

Mean change in maximum ventilation in control groups was -1.04 L/min

Mean change in maxi- MD 4.71 (0.10 to 9.32) mum ventilation in the intervention groups was 4.71 higher (0.1 to 9.32 higher)

52 (1 study)

⊕⊕

lowd

Comments

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Change in dyspnoea score Modified Medical Research Council Dyspnoea Scale Follow-up: end of rehabilitation (8-12 weeks)

Mean change in dyspnoea score ranged across control groups from 0.11 to 0.3 points

Mean change in dysp- SMD -0.66 (-1.05 to -0. 113 noea score in the inter- 28) (3 studies) vention groups was 0.60 lower (0.96 to 0.26 lower)

⊕⊕

lowa,e

Scores estimated using SMD -0.66 (-1.05 to -0. 28) Lower value post intervention is favourable, indicating improvement in dyspnoea

Change in quality of life Mean change in quality of Chronic Respiratory Dis- life in control groups was ease Questionnaire (total 3.29 points score) Follow-up: end of rehabilitation (8-12 weeks)

Mean change in quality SMD 0.59 (0.2 to 0.98) of life in the intervention groups was 8.9 higher (3 to 14.8 higher)

106 (3 studies)

⊕⊕

lowa,e

Scores estimated using SMD 0.59 (0.2 to 0.98) Higher value post intervention is favourable, indicating improvement in quality of life

6-Month survival

74 per 1000

67 per 1000 (10 to 353)

RR 0.9 (0.13 to 4.77)

57 (1 study)

⊕⊕

lowf

Adverse events Follow-up: 6 months

See comment

See comment

Not estimable

85 (2 studies)

See comment

No adverse events were reported during the study period

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio. GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. a Methods

of randomisation were not described for most studies, and only 1 study reported blinding of the assessor (risk of bias -1). study showed limitations in design: unblinded study and reporting bias (risk of bias -1). c Meta-analysis was limited to 2 studies with small numbers of participants (imprecision -1). d Two studies assessed this outcome; only 1 study provided sufficient data to pool (imprecision -2). e Meta-analysis was limited to 3 studies with small numbers of participants (imprecision -1).

b One

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f Only

1 study provided data on 6-month survival (imprecision -2).

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BACKGROUND

Description of the condition Interstitial lung disease (ILD) is a highly disabling group of conditions including idiopathic pulmonary fibrosis (IPF), acute and chronic interstitial pneumonias, connective tissue diseases and sarcoidosis. People with ILD frequently experience breathlessness on exertion, which limits their ability to undertake daily activities. Patients report low levels of physical functioning and vitality and high levels of dyspnoea and fatigue. Those with the greatest exercise limitations have the worst quality of life (Chang 1999). Available treatments for patients with ILD have proved largely ineffective, offering no improvement in survival and demonstrating only limited impact on quality of life. The mechanisms of reduced exercise capacity in ILD are multifactorial. Impaired gas exchange occurs as a result of destruction of the pulmonary capillary bed, resulting in ventilation-perfusion mismatch and oxygen diffusion limitations (Agusti 1991). Circulatory limitation results from pulmonary capillary destruction and pulmonary vasoconstriction and leads to pulmonary hypertension and cardiac dysfunction in some patients (Hansen 1996). Ventilatory limitations to exercise may also occur, although these are not thought to be a major contributor in most patients (Harris-Eze 1996). Peripheral muscle dysfunction may play a significant role in limiting exercise capacity (Markovitz 1998) as a result of physical deconditioning. Patients who experience dyspnoea and fatigue with functional activity commonly reduce their activity levels, leading to a vicious cycle of worsening exercise capacity and increasing symptoms. In addition, treatments for ILD such as corticosteroids and immunosuppressive therapy may lead to druginduced myopathy.

Description of the intervention Pulmonary rehabilitation includes patient assessment, regular participation in an exercise training programme, education and behavioural change (Spruit 2013). The role of pulmonary rehabilitation is well established in people with other chronic lung diseases such as chronic obstructive pulmonary disease (COPD), for whom it improves exercise performance and reduces symptoms (Spruit 2013). Several authors have postulated that similar effects of pulmonary rehabilitation may be seen in patients with ILD.

unclear. Despite this, recently published guidelines for pulmonary rehabilitation have advocated its use in ’individuals with chronic respiratory disorders other than COPD’ as ’there is now more robust evidence to support inclusion of some of these patient groups in pulmonary rehabilitation programs’ (Spruit 2013). However, it has been suggested that the benefits of pulmonary rehabilitation in ILD are smaller than those generally seen in COPD, and its ongoing effects are not sustained beyond six months (Spruit 2013). Guidelines for clinical management of both ILD (Wells 2008) and IPF (ATS 2011) indicate that more information is needed on the benefits of pulmonary rehabilitation for these patients. The greater prevalence of exercise-induced hypoxia, pulmonary hypertension and arrhythmia compared with other chronic lung diseases in this patient population raises the possibility that response to exercise rehabilitation may also differ (ATS 2011).

Why it is important to do this review This review was conducted to summarise results reported in the literature of studies evaluating the safety and efficacy of pulmonary rehabilitation in adult patients with ILD, and to determine the effects of pulmonary rehabilitation on exercise capacity, symptoms, quality of life and survival in this patient group. This is an update of a review originally published in 2008.

OBJECTIVES • To determine whether pulmonary rehabilitation in patients with ILD has beneficial effects on exercise capacity, symptoms, quality of life and survival compared with no pulmonary rehabilitation in patients with ILD. • To assess the safety of pulmonary rehabilitation in patients with ILD.

METHODS

Criteria for considering studies for this review

How the intervention might work

Types of studies

The mechanism by which pulmonary rehabilitation might improve outcomes in people with ILD has not been established. In people with other respiratory diseases, pulmonary rehabilitation may improve aerobic capacity and improves peripheral muscle performance (Spruit 2013). Effects on these outcomes in ILD are

Only randomised and quasi-randomised controlled trials in which a prescribed regimen of pulmonary rehabilitation was compared with no pulmonary rehabilitation or with other therapy in study participants with ILD were considered for this review. Single-blind and open studies were considered for inclusion.


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Types of participants People with ILD of any origin, diagnosed according to investigator definitions, were included. No exclusions were based on age, gender or physiological status. Types of interventions We considered any type of prescribed exercise training, supervised or unsupervised, provided with or without education. We recorded, when possible, the precise nature of the training (intensity, frequency, duration and whether supplemental oxygen was applied). Trials in which pulmonary rehabilitation was combined with another intervention (e.g. pharmacological therapy) were eligible for inclusion. Comparisons to be examined included the following. • Pulmonary rehabilitation versus no pulmonary rehabilitation. • Pulmonary rehabilitation versus another intervention. • Pulmonary rehabilitation combined with another intervention versus no pulmonary rehabilitation.

Database (PEDro). All databases were searched from the period of their inception to June 2014. No language restriction was applied. The full database search strategies are listed in the appendices (Appendix 1, Appendix 2, Appendix 3, Appendix 4 and Appendix 5). Searching other resources The reference lists of relevant studies and related review papers were handsearched for qualifying studies. Clinical trial registries were reviewed to search for relevant planned, ongoing and unpublished trials. Annual conference abstracts for the American Thoracic Society (ATS), the European Respiratory Society (ERS), the Asian Pacific Society of Respirology (APSR) and the Thoracic Society of Australia and New Zealand (TSANZ) were reviewed for relevant studies. In addition, we contacted the authors of randomised controlled trials to ask for information on other published and unpublished studies.

Data collection and analysis

Types of outcome measures Selection of studies Primary outcomes

Functional or maximal exercise capacity, measured during formal exercise tests (maximal oxygen uptake (VO2 max), peak oxygen uptake (VO2 peak), maximal ventilation (Ve max), maximum heart rate (HR max)) or field exercise tests (increase in distance walked). Secondary outcomes

• Dyspnoea: All measures of dyspnoea used were considered. • Quality of life: This was measured by generic or diseasespecific quality of life instruments. All quality of life instruments used were considered. • Adverse effects: Adverse cardiovascular events during exercise training were recorded, as were fractures, skeletal muscle injuries and deaths. • Survival

Search methods for identification of studies

Electronic searches We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 6), MEDLINE (Ovid), EMBASE (Ovid), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO) and the Physiotherapy Evidence

Two review authors (LD and AH) independently coded for relevance studies identified in the literature searches by examining titles, abstracts and keyword fields as follows. 1. Include: Study categorically meets all review criteria. 2. Unclear: Study appears to meet some review criteria, but available information is insufficient for review authors to categorically determine relevance. 3. Exclude: Study does not categorically meet all review criteria. Two review authors (LD and AH) used a full-text copy of studies in categories 1 and 2 to decide on study inclusion. Disagreements were resolved by consensus. A full record of decisions was kept, and simple agreement and kappa statistics were calculated. Data extraction and management Data were extracted independently by two review authors (LD and AH) who used a prepared checklist; they were then entered into Review Manager by the primary review author with random checks on accuracy. Disagreements were resolved by consensus. Data included characteristics of included studies (methods, participants, interventions, outcomes) and results of included studies. Authors of included studies were asked to provide details of missing data where applicable. Assessment of risk of bias in included studies Two review authors (LD and AH) assessed the internal validity of included studies using a component approach (including sequence


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generation for randomisation, allocation concealment, blinding of participants and assessors, loss to follow-up, completeness of outcome assessment and other possible bias prevention). Disagreements were resolved by consensus. We wrote to study authors to seek clarification when information was inadequate for review authors to judge the risk of bias. Measures of treatment effect For continuous variables, we recorded mean change from baseline or mean postintervention values and standard deviation (SD) for each group. When measures of improvement had opposite directions of effect on different scales (e.g. quality of life scales), all improvements were recorded as positive values, and all deteriorations were recorded as negative values. Mean differences (MDs) for outcomes measured with the same metrics or standardised mean differences (SMDs) for outcomes measured with different metrics with 95% confidence intervals (95% CIs) were calculated using RevMan 5.2. For binary outcome measures, we recorded the number of participants with each outcome event, by allocated treated group, to allow intention-to-treat analysis. Odds ratios (ORs) with 95% CIs were calculated for each study.

IPF, pulmonary rehabilitation could be less effective in this form of ILD. • Severity of lung disease: Patients with more advanced disease may be less able to participate in pulmonary rehabilitation. Participants were considered to have severe disease if diffusing capacity for carbon monoxide (TLCO) was less than 45% predicted (Flaherty 2001). In addition, participants who desaturated during exercise testing (SpO2 less than or equal to 88%) were compared with those who did not desaturate. • Type of exercise: Aerobic exercise training programmes may be more effective in improving symptoms and functional exercise tolerance than resistance training programmes. However, data were insufficient to allow review authors to perform this subgroup analysis. Sensitivity analysis The small number of studies precluded performance of sensitivity analyses and the creation of funnel plots to test for publication bias. If in future updates, more studies are included, sensitivity analysis will be performed to analyse the effects of allocation concealment, and intention-to-treat analysis will be performed on study results.

Data synthesis We performed a pooled quantitative analysis when trials were clinically homogeneous. A fixed-effect model or a random-effects model was used, depending on assessment of heterogeneity.

RESULTS

Subgroup analysis and investigation of heterogeneity

Description of studies

Subgroup analyses were conducted to explore possible sources of heterogeneity. Three subgroup analyses were specified a priori. • Type of interstitial lung disease: idiopathic pulmonary fibrosis (IPF) versus other: As a result of the progressive nature of

Results of the search See Figure 1 for the study flow diagram.


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Figure 1. Study flow diagram for 2009-2013 literature searches.


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In the original version, 4783 records were identified from the initial search of databases. From the studies on this list, 15 full-text articles were retrieved for closer inspection. No additional studies were identified upon handsearching of reference lists or contact with study authors. Review authors achieved agreement on 13 of the 15 full-text articles (87%) with kappa = 0.74, indicating substantial agreement. Disagreement was resolved by consensus. Five articles were deemed to meet the inclusion criteria for the original review. An update search conducted in December 2009 identified no relevant studies for inclusion in the review. The 2014 updated search of databases returned 1901 potential studies. Eight full-text articles from this list were retrieved for closer inspection. Six additional studies were identified upon handsearching of reference lists and review of international clinical trial registries and annual international respiratory conference abstracts. Correspondence with Jackson 2014 indicated that the final results of the study had been submitted and accepted for publication. Data from the accepted manuscript were used in the analysis. Agreement between review authors was achieved on 13 of the 14 full-text articles (92%) with kappa = 0.81, indicating substantial agreement. Disagreement was resolved by consensus. Four studies from the updated search were deemed to meet the inclusion criteria; one article is awaiting classification and therefore was not included in the analysis. Nine articles in total from the original and updated searches were included in this review. Common reasons for exclusion were that studies were not randomised controlled trials (n = 5), studies included participants without lung disease (n = 3), studies included mixed disease groups (n = 3) and studies did not include pulmonary rehabilitation (n = 2). Full details of excluded studies and of studies awaiting classification can be found in the Characteristics of excluded studies and Characteristics of studies awaiting classification tables.

participants were adults with mean age ranging from 36 to 71 years. One study did not report mean age (Menon 2011).

Interventions All studies compared pulmonary rehabilitation versus no pulmonary rehabilitation or a sham training control group. Eight studies examined pulmonary rehabilitation programmes conducted in the outpatient setting (Baradzina 2005; Holland 2008; Jackson 2014; Mejia 2000; Menon 2011; Nishiyama 2008; Perez Bogerd 2011; Vainshelboim 2013), whilst one study evaluated a home-based pulmonary rehabilitation programme (Wewel 2005). The length of pulmonary rehabilitation programmes varied from five to 12 weeks for outpatient rehabilitation and six months for home-based rehabilitation. Three studies examined the effects of aerobic training (Baradzina 2005; Mejia 2000; Wewel 2005), four studies used a combination of aerobic and resistance training (Holland 2008; Jackson 2014; Nishiyama 2008; Vainshelboim 2013) and the remaining studies did not specify the exercise modality used (Menon 2011; Perez Bogerd 2011). No study evaluated resistance training alone; therefore no subgroup analyses for type of exercise were possible. Four studies comprised exercise training alone (Holland 2008; Mejia 2000; Vainshelboim 2013; Wewel 2005), whereas four studies added interventions to exercise training that were not offered to the control group; these included educational lectures (Baradzina 2005; Jackson 2014; Nishiyama 2008; Perez Bogerd 2011), nutritional advice (Baradzina 2005; Perez Bogerd 2011), stress management (Baradzina 2005), physiotherapy (Baradzina 2005) and psychosocial support (Perez Bogerd 2011). Inclusion of additional interventions with exercise training was unclear in one study (Menon 2011).

Included studies Nine studies met the inclusion criteria for this review; all were parallel randomised controlled trials. Full details can be found in the Characteristics of included studies table. Six studies had been published in abstract form only (Baradzina 2005; Mejia 2000; Menon 2011; Perez Bogerd 2011; Vainshelboim 2013; Wewel 2005). Sample sizes ranged from 21 to 99 participants.

Participants Most studies included participants with a variety of ILDs (Holland 2008; Mejia 2000; Menon 2011; Perez Bogerd 2011; Wewel 2005), one of which was stratified for IPF (Holland 2008). Three studies included only participants with IPF (Jackson 2014; Nishiyama 2008; Vainshelboim 2013), whilst another study included only participants with sarcoidosis (Baradzina 2005). All

Outcomes All studies used a measure of functional exercise tolerance, most commonly the six-minute walk test (Holland 2008; Jackson 2014; Menon 2011; Nishiyama 2008; Perez Bogerd 2011; Vainshelboim 2013; Wewel 2005). Three studies also performed a cardiopulmonary exercise test (Holland 2008; Vainshelboim 2013; Wewel 2005). Quality of life was assessed in eight studies, using the Chronic Respiratory Disease Questionnaire (Holland 2008; Mejia 2000; Perez Bogerd 2011), the St George’s Respiratory Questionnaire (Nishiyama 2008; Perez Bogerd 2011; Vainshelboim 2013; Wewel 2005), the St George’s Respiratory Questionnaire (idiopathic pulmonary fibrosis version) (Jackson 2014) or the World Health Organization (WHO) questionnaire (Baradzina 2005). Dyspnoea was assessed in five studies using the modified Medical Research Council Scale (Holland 2008; Vainshelboim 2013), the


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Baseline Dyspnoea Index (Nishiyama 2008) and an unspecified measure (Baradzina 2005; Wewel 2005).

Risk of bias in included studies An overview of the risk of bias for the domains listed below is provided in Figure 2.


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Figure 2. Methodological quality summary: review authors’ judgements about each methodological quality item for each included study.


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Allocation All studies reported random allocation to groups; no study specified the method by which the sequence was generated. Four studies reported that the allocation sequence was concealed (Holland 2008; Jackson 2014; Nishiyama 2008; Vainshelboim 2013), three studies used sealed envelopes (Holland 2008; Nishiyama 2008; Vainshelboim 2013) and in the other study, group allocation was provided by an independent researcher (Jackson 2014). The remaining studies, all of which were available only in abstract form, did not provide sufficient information to permit assessment of whether the allocation sequence was concealed (Baradzina 2005; Mejia 2000; Menon 2011; Perez Bogerd 2011; Vainshelboim 2013; Wewel 2005). Blinding One study (Holland 2008) reported use of a blinded assessor for all outcome measures, and three studies indicated that the assessors were unblinded (Jackson 2014; Perez Bogerd 2011; Vainshelboim 2013). Insufficient data were available to show whether assessors were blinded in the other studies (Baradzina 2005; Mejia 2000; Menon 2011; Nishiyama 2008; Wewel 2005). Blinding of participants was not possible for any study because of the physical nature of the intervention. No studies reported whether data analysts were blinded to treatment allocation.

provided only in abstract form, and it is likely that not all data are currently available. It was not possible for review authors to determine whether all data were available for the other studies, all of which were provided only in abstract form (Baradzina 2005; Mejia 2000; Menon 2011; Wewel 2005); therefore it is likely that not all data from these studies are currently available.

Effects of interventions See: Summary of findings for the main comparison Pulmonary rehabilitation compared with no pulmonary rehabilitation for interstitial lung disease; Summary of findings 2 Pulmonary rehabilitation compared with no pulmonary rehabilitation for idiopathic pulmonary fibrosis Data and analyses tables summarise results of the meta-analysis for comparison of pulmonary rehabilitation versus no pulmonary rehabilitation. Sufficient data were available from five studies for pooling in a meta-analysis (Holland 2008; Jackson 2014; Nishiyama 2008; Perez Bogerd 2011; Vainshelboim 2013). Summary of findings for the main comparison and Summary of findings 2 summarise the quality of the evidence. For functional exercise capacity, maximal exercise capacity and quality of life, positive values reflect improvement. For measures of dyspnoea, negative values reflect improvement. Functional exercise capacity

Incomplete outcome data Three studies reported dropouts and loss to follow-up (Holland 2008; Jackson 2014; Nishiyama 2008). One of these reported that two participants in the exercise group withdrew before baseline data had been collected (Nishiyama 2008), and another study reported that three participants in the exercise group and one in the control group did not complete the intervention period (Jackson 2014). Data from these participants were not included in the analysis in either study (Jackson 2014; Nishiyama 2008). The other study reported a significant number of dropouts, with data analysis performed according to the intention-to-treat principle; the last observation carried forward method was used when data were not available (Holland 2008). The other studies did not report whether dropouts or losses to follow-up occurred. Selective reporting Four studies were listed on a clinical trial registry (Holland 2008; Jackson 2014; Perez Bogerd 2011; Vainshelboim 2013). Results were reported for all outcomes at all time points for two studies (Holland 2008; Jackson 2014), whereas the other two studies did not report all outcome measures mentioned in the clinical registry (Perez Bogerd 2011; Vainshelboim 2013). These studies were

Eight trials including 365 participants reported that pulmonary rehabilitation resulted in significant improvement in functional exercise capacity immediately following the programme, whilst no significant change was seen in six-minute walk distance following pulmonary rehabilitation in the remaining study (Jackson 2014). Five trials provided sufficient data on the six-minute walk test for meta-analysis, with a total of 86 participants in the pulmonary rehabilitation group and 82 participants in the control group (Holland 2008; Jackson 2014; Nishiyama 2008; Perez Bogerd 2011; Vainshelboim 2013). Results of the meta-analysis are shown in Figure 3. The common effect (mean difference, MD) for change in distance walked was 44.34 metres in favour of the pulmonary rehabilitation group (95% CI 26.04 to 66.64 metres). A significant effect of pulmonary rehabilitation was also seen in the subgroup of participants with IPF (four trials, n = 59 pulmonary rehabilitation, n = 52 control) with a common effect of 35.63 metres (95% CI 16.02 to 55.23 metres). Only one study provided sufficient data to show the effects of pulmonary rehabilitation among participants with severe lung disease (n = 23) or in participants who desaturated (n = 30), and no significant effects of pulmonary rehabilitation were evident in these groups (Holland 2008). One study (Holland 2008) reported results of the six-minute walk test at sixmonth follow-up (Analysis 1.2), and another study evaluated the


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six-minute walk test after a subsequent three-month observation period (Jackson 2014). No significant effect of pulmonary rehabilitation was evident at either time point. Tests of heterogeneity for all analyses of functional exercise capacity were not significant. Figure 3. Forest plot of comparison: 1 Pulmonary rehabilitation versus no pulmonary rehabilitation, outcome: 1.1 Change in 6-minute walk test immediately following pulmonary rehabilitation.

Maximal exercise capacity Three studies reported that cardiopulmonary exercise testing was performed following pulmonary rehabilitation; however data were available from only two studies with 42 participants in the pulmonary rehabilitation group and 38 participants in the control group (Holland 2008; Vainshelboim 2013). A significant increase in VO2 peak was noted between baseline and follow-up with an MD of 1.24 mL/kg/min (95% CI 0.46 to 2.03 mL/kg/min−1 ) in favour of the pulmonary rehabilitation group (Figure 4). A similar effect was seen in the subgroup of participants with IPF (two trials, n = 32 pulmonary rehabilitation, n = 26 control) with a common effect of 1.46 mL/kg/min−1 (95% CI 0.54 to 2.39 mL/ kg/min−1 ). No significant differences in VO2 peak were observed

among participants with severe lung disease or in participants who desaturated. Both studies reported that pulmonary rehabilitation resulted in a significant increase in maximum ventilation; however only one study with 57 participants (Holland 2008) provided sufficient data for meta-analysis (Analysis 1.4). The MD between groups was 4.71 L/min−1 (95% CI 0.10 to 9.32) in favour of the pulmonary rehabilitation group. The effect was more pronounced in the subgroup of participants with IPF (one study, 30 participants, MD 6.97 L/min−1 , 95% CI 0.87 to 13.07). No significant effects of pulmonary rehabilitation on maximum exercise parameters were seen in the subgroups of severe disease or in desaturators. No significant effect of pulmonary rehabilitation on maximum heart rate was evident (Analysis 1.5).


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Figure 4. Forest plot of comparison: 1 Pulmonary rehabilitation versus no pulmonary rehabilitation, outcome: 1.3 VO2 peak immediately following pulmonary rehabilitation, mL/kg/min.

Dyspnoea Dyspnoea was measured in five studies including 281 participants, with three reporting reduced dyspnoea immediately following pulmonary rehabilitation (Baradzina 2005; Holland 2008; Vainshelboim 2013) and two studies reporting no change (Nishiyama 2008; Wewel 2005). Data from three studies were pooled for meta-analysis with a total of 58 participants in the pulmonary rehabilitation group and 55 participants in the control group (Figure 5). Two studies utilised the modified Medical Research Council Scale (Holland 2008; Vainshelboim 2013), and the other used the Baseline Dyspnoea Index (Nishiyama 2008). The common effect (standardised mean difference, SMD) for change

in dyspnoea was -0.66 in favour of the pulmonary rehabilitation group (95% CI -1.05 to -0.28). A similar reduction in dyspnoea was seen among participants with IPF (48 participants in the pulmonary rehabilitation group and 42 participants in the control group), with an MD of -0.68 (95% CI -1.12 to -0.25, three studies, 90 participants). An effect in favour of pulmonary rehabilitation was seen in participants with severe disease and in those who desaturated; however this finding reached significance only for the desaturators (Figure 5). One study reported dyspnoea at six-month follow-up (Analysis 1.7). No significant effect of pulmonary rehabilitation on dyspnoea was evident at this time. Tests of heterogeneity for all analyses of dyspnoea were not significant.


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Figure 5. Forest plot of comparison: 1 Pulmonary rehabilitation versus no pulmonary rehabilitation, outcome: 1.6 Dyspnoea score immediately following pulmonary rehabilitation.

Quality of life Health-related quality of life was measured in eight studies, with significant differences between groups reported immediately following pulmonary rehabilitation in three studies (Holland 2008; Nishiyama 2008; Vainshelboim 2013). Two studies reported improvement in heath-related quality of life following pulmonary rehabilitation; however this finding did not reach statistical significance (Jackson 2014; Perez Bogerd 2011); in the remaining studies it was unclear whether differences were noted between groups. Data were available for pooling from three studies with a total of 54 participants in the pulmonary rehabilitation group and 52 participants in the control group (Figure 6). Two studies utilised the Chronic Respiratory Disease Questionnaire (Holland 2008), one used the St George’s Respiratory Questionnaire (Nishiyama 2008) and the other used the St George’s Respiratory Questionnaire (idiopathic pulmonary fibrosis version) (Jackson 2014). A common effect indicated improvement in quality of life associ-

ated with pulmonary rehabilitation (SMD 0.59, 95% CI 0.20 to 0.98). A similar effect in favour of pulmonary rehabilitation was seen in participants with IPF (SMD 0.59, 95% CI 0.14 to 103, three studies, 83 participants). Data regarding effects on quality of life in participants with severe disease and in those who desaturated were available from one study (Holland 2008), in which trends favouring pulmonary rehabilitation did not reach statistical significance. Data regarding longer-term effects on quality of life were available from two studies (Holland 2008; Jackson 2014) with one study reporting results at six-month follow-up (Analysis 1.9), and the other evaluating quality of life after a subsequent three-month observation period (Jackson 2014). No effects of pulmonary rehabilitation were noted at three months or six months, except in the subgroup of participants with severe disease, who had significantly improved quality of life compared with controls at six-month follow-up (SMD 14.93, 95% CI 0.54 to 29.32, one study, 23 participants).


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Figure 6. Forest plot of comparison: 1 Pulmonary rehabilitation versus no pulmonary rehabilitation, outcome: 1.8 Change in quality of life immediately following pulmonary rehabilitation.

Adverse events Information regarding adverse events was available from two studies (Holland 2008; Nishiyama 2008), neither of which reported adverse events during the study period. One study reported the death of one pulmonary rehabilitation participant during the intervention period; however this was believed to be unrelated to the intervention received, and the data were not included in the analysis (Jackson 2014). Survival Six-month survival was reported in one study including 57 participants (Holland 2008) in which two deaths were reported in each group (Analysis 1.6).


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A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Pulmonary rehabilitation compared with no pulmonary rehabilitation for idiopathic pulmonary fibrosis Patient or population: people with idiopathic pulmonary fibrosis Settings: rehabilitation centres, hospital outpatient departments, home-based exercise Intervention: pulmonary rehabilitation Comparison: no pulmonary rehabilitation Outcomes

Illustrative comparative risks* (95% CI)

Assumed risk

Relative effect (95% CI)

Number of participants (studies)

Quality of the evidence (GRADE)

Corresponding risk

No pulmonary rehabili- Pulmonary tation tion

rehabilita-

Change in 6-minute walk distance 6-Minute walk test Follow-up: end of rehabilitation (8-12 weeks)

Mean change in 6-minute walk distance ranged across control groups from -4 to 9 metres

Mean change in 6-minute MD 35.63 (16.02 to 55. 111 walk distance in the inter- 23) (4 studies) vention groups was 36 higher (16 to 55 higher)

⊕⊕⊕ moderatea

Change in peak oxygen uptake Cardiopulmonary exercise test Follow-up: end of rehabilitation (8-12 weeks)

Mean change in peak oxygen uptake ranged across control groups from -0.4 to 0.04 mL/kg/min

Mean change in peak oxy- MD 1.46 (0.54 to 2.39) gen uptake in the intervention groups was 1.46 higher (0.54 to 2.39 higher)

⊕⊕

lowb,c

Change in maximum ventilation Cardiopulmonary exercise test Follow-up: end of rehabilitation (8 weeks)

Mean change in maximum ventilation in the control groups was -1.15 L/min

Mean change in maxi- MD 6.97 (0.87 to 13.07) 30 mum ventilation in the in(1 study) tervention groups was 6.97 higher (0.87 to 13.07 higher)

58 (2 studies)

⊕⊕

lowd

Comments

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Change in dyspnoea Modified Medical Research Council Dyspnoea Scale Follow-up: end of rehabilitation (8-12 weeks)

Mean change in dyspnoea ranged across control groups from 0.23 to 0.3 points

Mean change in dysp- SMD -0.68 (-1.12 to -0. 90 noea in the intervention 25) (3 studies) groups was 0.80 lower (1.3 to 0.3 lower)

⊕⊕

lowa,e

Scores estimated using SMD -0.68 (-1.12 to -0. 25) Lower value post intervention is favourable, indicating improvement in dyspnoea

Change in quality of life Chronic Respiratory Disease Questionnaire (total score) Follow-up: end of rehabilitation (8-12 weeks)

Mean change in quality of life in the control groups was 8.53 points

Mean change in quality SMD 0.59 (0.14 to 1.03) 83 of life in the intervention (3 studies) groups was 9.9 higher (2.4 to 17.3 higher)

⊕⊕

lowa,e

Scores estimated using SMD 0.59 (0.14 to 1.03) Higher value post intervention is favourable, indicating improvement in quality of life

6-Month survival

143 per 1000

100 per 1000 (13 to 474)

OR 0.67 (0.08 to 5.4)

34 (1 study)

⊕⊕

lowf

Adverse events Follow-up: 6 months

See comment

See comment

Not estimable

62 (2 studies)

See comment

No adverse events were reported during the study period

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio. GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. a Methods

of randomisation were not described for most studies, and only 1 study reported blinding of the assessor (risk of bias -1). study showed limitations in design: unblinded study and reporting bias (risk of bias -1). c Meta-analysis was limited to 2 studies with small numbers of participants (imprecision -1). d Two studies assessed this outcome; only 1 study provided sufficient data for pooling (imprecision -2). e Meta-analysis was limited to 3 studies with small numbers of participants (imprecision -1).

b One

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f Only

1 study provided data on 6-month survival (imprecision -2).

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DISCUSSION Summary of main results This review identified nine studies comparing pulmonary rehabilitation versus no pulmonary rehabilitation or sham control among people with ILD. No adverse effects of this treatment were identified. Pulmonary rehabilitation resulted in a clear improvement in functional exercise capacity, as measured by the six-minute walk test, and a small increase in maximum exercise capacity. Significant reduction in dyspnoea and improvement in quality of life were seen immediately following pulmonary rehabilitation. Effects were similar in the subgroup of participants with IPF. Insufficient data were available to allow conclusions regarding the effects of pulmonary rehabilitation among those with severe disease and those who desaturated. To date, data are insufficient to allow conclusions regarding the long-term effects of pulmonary rehabilitation in ILD. Mean improvement in the six-minute walk test following pulmonary rehabilitation was 44.34 metres, which is similar to the mean improvement of 48 metres seen in people with COPD who have undergone pulmonary rehabilitation (Lacasse 2006). This suggests that people with ILD receive comparable benefit from pulmonary rehabilitation. This improvement exceeds the minimal important difference for six-minute walk distance among people with ILD, which ranges from 30 to 33 metres (Holland 2009). This indicates that providing a pulmonary rehabilitation programme that is well aligned with current guidelines for pulmonary rehabilitation (Spruit 2013) results in clinically important changes in functional capacity. Significant improvements were also seen in dyspnoea and in health-related quality of life following pulmonary rehabilitation, supporting the view that the observed improvement may be meaningful for patients.

difference for the six-minute walk distance in people with IPF, which is in the range of 29to 34 m (Holland 2009). Changes in quality of life, dyspnoea and maximum exercise capacity were also comparable in the subgroup of participants with IPF. Although patients with IPF appear to have smaller gains in functional capacity than those with other ILDs, they are equally important and meaningful for patients. Differences in functional outcomes do indicate that response to exercise may vary across the disease spectrum, which is not unexpected given the marked heterogeneity in clinical presentation and course. It should be noted however that of the five studies contributing to the meta-analysis, three included only participants with IPF (Jackson 2014; Nishiyama 2008; Vainshelboim 2013), whilst another included a majority of participants with IPF (Holland 2008); thus overall results of the meta-analysis are heavily influenced by the response of participants with IPF. All studies in this review utilised aerobic exercise training or a combination of aerobic and resisted exercise training. These strategies are well aligned with current guidelines for pulmonary rehabilitation (Spruit 2013), and the results therefore are readily applicable to clinical practice in pulmonary rehabilitation programmes. However, we were unable to draw inferences regarding the most effective exercise training strategy for people with ILD. Given the relatively modest improvements in exercise capacity documented here, this may be an important area for future research. The included studies used a range of programme durations (five weeks to six months) and training frequencies (two to five sessions per week). Longer programmes and more frequent sessions appear to yield greater benefit for people with other chronic lung diseases (Spruit 2013). To date the most effective dose of pulmonary rehabilitation for people with ILD has not been established.

Quality of the evidence Overall completeness and applicability of evidence Included studies involved participants with a range of ILDs, and studies often included samples of participants with mixed diagnoses (Holland 2008; Mejia 2000; Menon 2011; Perez Bogerd 2011; Wewel 2005). This recruitment strategy probably reflects the relatively uncommon nature and the shared pathophysiological features of many ILDs. Participants with IPF often have more severe physiological derangement and a more rapid disease course compared with those with other ILDs (Lama 2004), and we hypothesised that pulmonary rehabilitation might be less effective in people with IPF. However, this review indicates that participants with IPF did achieve significant improvement in six-minute walk test results, maximum exercise capacity, dyspnoea and health-related quality of life. Improvement in the six-minute walk test was smaller among participants with IPF (35.63 m vs 44.34 m); however this mean improvement still exceeded the minimal important

Several potential sources of bias were identified in this review. Of the nine studies identified, six were available only in abstract form (Baradzina 2005; Mejia 2000; Menon 2011: Perez Bogerd 2011; Vainshelboim 2013; Wewel 2005). These publications provided limited data on the outcomes of interest, and it was not possible for review authors to obtain additional data from study authors. Data that could be pooled for meta-analysis were usually limited to two or three studies. Despite this limitation, consistency was seen in most reported outcomes, with all but one study (Jackson 2014) reporting improved functional exercise capacity following pulmonary rehabilitation. Reasons for lack of improvement in functional exercise capacity in the remaining study (Jackson 2014) are unclear but may have been related to the method by which the six-minute walk test was conducted or may have involved the small numbers of included participants. Assessment of study quality was also difficult because available data were limited. As pulmonary rehabilitation is a physical intervention, it can be assumed that no participants were blinded; however only one study reported


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blinding of the assessor (Holland 2008). Only one study reported use of an intention-to-treat analysis (Holland 2008). Given the progressive nature of many ILDs, a significant dropout rate is likely and may impact both the size of the reported treatment effect and the feasibility of the intervention. Review outcomes were rated as of moderate quality (six-minute walk distance) or low quality (all other outcomes) using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system. Risk of bias was increased by poor reporting of methods and lack of assessor blinding. Imprecision was increased by the small numbers of included studies and participants, with one to five studies and 52 to 168 participants contributing to each outcome.

Potential biases in the review process All data were extracted independently by two review authors, and discrepancies were resolved through discussion. Risk of bias ratings were also completed independently by two review authors. We conducted a broad search, which included handsearching of conference abstracts and trial registries. We included studies that were published only in abstract form, to ensure that all available trials were included. However, despite attempts to contact the authors of abstracts, in many cases additional data were not available. This may have influenced assessment of trial quality and some estimates of effect.

tation tended to be smaller in people with IPF than in those with other types of ILD, this update has found similar, clinically important effects of rehabilitation in both groups, likely due to the larger number of trials including people with IPF that were included in this update.

AUTHORS’ CONCLUSIONS Implications for practice This review indicates that pulmonary rehabilitation seems to be safe for people with ILD and results in significantly improved functional exercise capacity, maximum exercise capacity, dyspnoea and health-related quality of life immediately following pulmonary rehabilitation. It is appropriate to include people with ILD in a standard pulmonary rehabilitation programme. To date, little evidence has suggested a long-term benefit of pulmonary rehabilitation in ILD.

Implications for research The optimum exercise training method for participants with ILD has not been established. Large studies are required to determine whether the benefits of pulmonary rehabilitation vary according to disease severity and whether any longer-term effects are associated with pulmonary rehabilitation in ILD. Future trials should ensure that assessors are blinded to the intervention and that appropriate methods are used to account for dropouts.

Agreements and disagreements with other studies or reviews This is an update of a Cochrane review published in 2008. Data included in the previous review suggested that improvement in functional exercise capacity following pulmonary rehabilitation in ILD was smaller than that seen in people with COPD (Lacasse 2006); however this update has found comparable improvements. This is a significant finding that supports the recent international statement suggesting that people with ILD should be included in pulmonary rehabilitation programmes (Spruit 2013). Although the previous review found that the effect of pulmonary rehabili-

ACKNOWLEDGEMENTS We would like to thank The Cochrane Airways Group for support and guidance. John White was the Editor for this review and commented critically on the review. The background and methods section of this review is based on a standard template used by Cochrane Airways Group.


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REFERENCES

References to studies included in this review Baradzina 2005 {published data only} Baradzina H. Short and long-term effects of pulmonary rehabilitation program in sarcoidosis. European Respiratory Journal 2013;42(Suppl 57):789S. Baradzina HL, Ponachevnaya NV. Pulmonary rehabilitation programme in sarcoidosis (abstract). European Respiratory Journal 2005;26(Suppl 49):333S. Holland 2008 {published and unpublished data} Holland AE, Hill CJ, Conron M, Munro P, McDonald CF. Short-term improvement in exercise capacity and symptoms following exercise training in interstitial lung disease. Thorax 2008;63:549–5. Jackson 2014 {published and unpublished data} Cohen MI, Cahalin LP, Gaunaurd IA, Ramos C, Cardonas D, Gomez-Marin O, Jackson R. Respiratory muscle performance before and after pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis. Cardiopulmonary Physical Therapy Journal 2013;24(4):44. Gaunaurd I, Eustis N, Cohen M, Tamos C, Sol C, Cardenas D, et al.Rehabilitation of patients with idiopathic pulmonary fibrosis: changes in quality of life, functional mobility, and oxygen metabolism. Cardiopulmonary Physical Therapy Journal 2011;22(4):30–1. Gaunaurd IA, Gomez-Marin O, Ramos D, Cardenas D, Cahalin L, Cohen M, et al.Effects of a pulmonary rehabilitation on exercise capacity and functional mobility for patient with IPF. American Journal of Respiratory and Critical Care Medicine 2013;187:A1800. Gomez O, Gaunaurd IA, Cohen M, Cardenas D, Cahalin L, Ramos C. Health related quality of life in IPF patients on a pulmonary rehabilitation program. American Journal of Respiratory and Critical Care Medicine 2013;187:A1814. Jackson R, Ramos C, Cardenas D, Sol C, Cohen M, Gaunaurd I, et al.Effects of aerobic and strength training on symptoms and exercise capacity of IPF patients [Abstract]. European Respiratory Society 22nd Annual Congress; Sep 1-5; Vienna. 2012; Vol. 40 Suppl 56:672s [P3686]. ∗ Jackson RM, Gómez-Marín OW, Ramos CF, Sol CM, Cohen MI, Gaunaurd IA, et al.Exercise limitation in IPF patients: a randomized trial of pulmonary rehabilitation. Lung 2014; Vol. 192, issue 3:367–76. Jackson RM, Ramos CF, Cardenas D, Gaunaurd I, Eustis N, Cohen M, et al.Effects of aerobic and strength training on symptoms and exercise capacity of IPF patients. American Journal of Respiratory and Critical Care Medicine 2012;185: A2398. Mejia 2000 {published data only} Mejia RA, Sansores RH, Perez-Padilla R, Mahler DA. Effects of exercise training on ’quality of life’ in patients with interstitial lung diseases (abstract). European Respiratory Journal 2000;16(Suppl 31):330s.

Menon 2011 {published data only (unpublished sought but not used)} ∗ Menon B, Vijayan VK, Bansal V, Prajapat B. Effect of pulmonary rehabilitation on gas exchange, muscle cross section area and functional parameters in interstitial lung disease [Abstract]. European Respiratory Society 21st Annual Congress; Sep 24-28; Amsterdam. Amsterdam, 2011; Vol. 38:878s. Prajapat B, Menon B, Bansal V, Vijayan V. Effect of mid thigh cross sectional area on CT as a marker of muscle mass in interstitial lung diseases after pulmonary rehabilitation. 16th Congress of the Asian Pacific Society of Respirology; 3-6 Nov; Shanghai. 2011. Nishiyama 2008 {published and unpublished data} ∗ Nishiyama O, Kondoh Y, Kimura T, Kato K, Kataoka A, Ogawa T, et al.Effects of pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis. Respirology 2008;13:394–9. Nishiyama O, Taniguchi H, Kondoh Y, Kimura T, Ogawa T, Watanabe F, et al.Pulmonary rehabilitation in idiopathic pulmonary fibrosis. American Thoracic Society 100th International Conference; May 21-26; Orlando. 2004:D96 Poster 110. Perez Bogerd 2011 {published data only} Perez Bogerd S, Wuyts W, Barbier V, Langer D, Burtin C, Van Remoortel H, et al.Preliminary results of pulmonary rehabilitation in interstitial lung diseases: a randomised controlled trial B32220095560 [Abstract]. European Respiratory Society Annual Congress; Sep 24-28; Amsterdam. 2011; Vol. 38, issue 55:259s [1451]. Vainshelboim 2013 {published and unpublished data} Kramer M, Vainshelboim B, Oliveira J, Yohoshua L, Wais I, Rusanov V, et al.Pulmonary rehabilitation improves exercise capacity and function in patients with idiopathic pulmonary fibrosis. American Journal of Respiratory and Critical Care Medicine 2013;187(Meeting Abstracts):A1832. ∗ Vainshelboim B, Oliveira L, Yohoshua L, Weis I, Fox B, Kramer M. The effect of pulmonary rehabilitation on exercise tolerance, pulmonary function, dyspnea and quality of life in patients with idiopathic pulmonary fibrosis. European Respiratory Society 23rd Annual Congress; Sep 7-11; Barcelona. 2013; Vol. 187, issue Meeting Abstracts: A1832. Wewel 2005 {published data only} Behnke M, Schwertfeger I, Zimmerman I, Kirsten D, Joerres RAJ, Magnussen H. Home-based exercise training in patients with interstitial lung disease (abstract). European Respiratory Journal 2003;22(Suppl 45):Abstract No: [1081]. ∗ Wewel AR, Behnke M, Schwertfeger I, Eberhardt F, Kroidl RF, Jorres RA, et al.Home-based walking training in patients with interstitial lung diseases (abstract). European Respiratory Journal 2005;26(Suppl 49):528S.

References to studies excluded from this review


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Arizono 2012 {published data only} Arizono S, Taniguchi H, Sakamoto K, Kondoh Y, Kimura T, Kataoka K, et al.Endurance time is the most responsive exercise measurement in idiopathic pulmonary fibrosis. Respiratory Care 2013 Dec 10 [Epub ahead of print].

Senstrom 1997 {published data only} Senstrom CH, Arge B, Sundbom A. Home exercise and compliance in inflammatory rheumatic diseases - a prospective clinical trial. Journal of Rheumatology 1997;24: 470–6.

Cockcroft 1981 {published data only} Cockcroft AE, Saunders MJ, Berry G. Randomised controlled trial of rehabilitation in chronic respiratory disability. Thorax 198;36:200–3.

Tryfon 2003 {published data only} Tryfon SM, Mavrofridis E, Ilonidis G, Patakas D. Cardiopulmonary effects of exercise, before and after oxygen delivery, in patients with usual interstitial pneumonia. European Respiratory Journal 2003;22(Suppl 45):Abstract No: [P639].

Cockcroft 1982 {published data only} Cockcroft AE, Berry G, Brown EB, Exall C. Psychological changes during a controlled trial of rehabilitation in chronic respiratory disability. Thorax 1982;37:413–6. Daltroy 1995 {published data only} Daltroy LH, Robb-Nicholson C, Iverson MD, Wright EA, Liang MH. Effectiveness of minimally supervised home aerobic training in patients with systemic rheumatic disease. British Journal of Rheumatology 1995;34:1064–9. Jastrzebski 2006 {published data only} Jastrzebski D, Gumola A, Gawlik R, Kozielski J. Dyspnoea and quality of life in patients with pulmonary fibrosis after six weeks of respiratory rehabilitation. Journal of Physiology and Pharmacology 2006;57(Suppl 4):139–48. Maddali Bongi 2011 {published and unpublished data} Maddali Bongi S, Del Rosso A, Galluccio F, Tai G, Sigismondi F, Passalacqua M, et al.Efficacy of a tailored rehabilitation program for systemic sclerosis. Clinical and Experimental Rheumatology 2009;27(Suppl 54):S44–S50. Naji 2006 {published data only} Naji NA, Connor MC, Donnelly SC, McDonnell TJ. Effectiveness of pulmonary rehabilitation in restrictive lung disease. Journal of Cardiopulmonary Rehabilitation 2006;26: 237–43. Nakazawa 2012 {published data only} Nakazawa A, Hagiwara E, Yamaguchi O, Ogata R, Shinohara T, Matsumoto Y, et al.Efficacy of pulmonary rehabilitation in patients with interstitial lung disease. European Respiratory Society Annual Congress. Vienna, Sep 1–5 2012:1896. Oh 2003 {published and unpublished data} Oh E. The effects of home-based pulmonary rehabilitation in patients with chronic lung disease. International Journal of Nursing Studies 2003;40:873–9. Ong 2001 {published data only} Ong KC, Wong WP, Jailani AR, Sew S, Ong YY. Effects of a pulmonary rehabilitation programme on physiologic and psychosocial outcomes in patients wtih chronic respiratory disorders. Annals of the Academy of Medicine, Singapore 2001;30:15–21. Senstrom 1996 {published data only} Senstrom CH, Arge B, Sundbom A. Dynamic training vs relaxation training as home exercise for patients wtih inflammatory rheumatic diseases. Scandinavian Journal of Rheumatology 1996;25:28–33.

References to studies awaiting assessment Dale 2011 {published data only} Dale M, McKeough Z, Munoz P, Corte P, Bye P, Alison J. Exercise training improves exercise capacity and quality of life in people with dust-related pleural and interstitial respiratory diseases: a randomised controlled trial [Abstract]. European Respiratory Society Annual Congress; Sep 24-28; Amsterdam. Amsterdam, 2011; Vol. 38:261s [1457].

Additional references Agusti 1991 Agusti AG, Roca J, Gea J, Wagner PD, Xaubet A, RodriguezRoisin R. Mechanisms of gas-exchange impairment in idiopathic pulmonary fibrosis. American Review of Respiratory Disease 1991;143(2):219–25. ATS 2011 Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK, et al.An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. American Journal of Respiratory and Critical Care Medicine 2011;183(6):788–852. Chang 1999 Chang JA, Curtis JR, Patrick DL, Raghu G. Assessment of health-related quality of life in patients with interstitial lung disease. Chest 1999;116(5):1175–82. Flaherty 2001 Flaherty KR, White ES, Gay SE, Martinez FJ, Lynch JP. Timing of lung transplantation for patients with fibrotic lung diseases. Seminars in Respiratory Critical Care Medicine 2001;22:517–32. Hansen 1996 Hansen JE, Wasserman K. Pathophysiology of activity limitation in patients with interstitial lung disease. Chest 1996;109(6):1566–76. Harris-Eze 1996 Harris-Eze AO, Sridhar G, Clemens RE, Zintel TA, Gallagher CG, Marciniuk DD. Role of hypoxemia and pulmonary mechanics in exercise limitation in interstitial lung disease. American Journal of Respiratory and Critical Care Medicine 1996;154(4 Pt 1):994–1001. Holland 2009 Holland AE, Hill CJ, Conron M, Munro P, McDonald CF. Small changes in six-minute walk distance are important


24

in diffuse parenchymal lung disease. Respiratory Medicine 2009;103:1430–5. Lacasse 2006 Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006, Issue 4. [DOI: 10.1002/14651858.CD003793.pub2] Lama 2004 Lama VN, Martinez FJ. Resting and exercise physiology in interstitial lung diseases. Clinical Chest Medicine 2004;25: 435–53. Markovitz 1998 Markovitz GH, Cooper CB. Exercise and interstitial lung disease. Current Opinion in Pulmonary Medicine 1998;4(5): 272–80. Spruit 2013 Spruit MA, Singh SJ, Garvey C, Zuwallack R, Nici L, Rochester C, et al.An official American Thoracic Society/

European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine 2013;188(8): e13–e62. Wells 2008 Bradley B, Branley HM, Egan JJ, Greaves MS, Hansell DM, Harrison NK. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax 2008;63(Suppl 5):v1–v58.

References to other published versions of this review Holland 2008 Holland AE, Hill C. Physical training for interstitial lung disease. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD006322.pub2] ∗ Indicates the major publication for the study


25

CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID] Baradzina 2005 Methods

Randomised controlled trial

Participants

Sarcoidosis: n = 65 Pulmonary rehabilitation group: n = 30, 12 male, mean age 38 years Control group: n = 35, 14 male, mean age 36 years

Interventions

Pulmonary rehabilitation group: 5-week multi-disciplinary exercise programme. Included exercise training (5 times weekly for 40 minutes), physiotherapeutic procedures, education, nutritional advice and stress management Control group: not specified

Outcomes

Walking test: type unspecified Health-related quality of life: WHO questionnaire All measures were obtained before and after the intervention period

Notes

Abstract

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Not specified

Allocation concealment (selection bias)

Unclear risk

Not specified

Blinding (performance bias and detection Unclear risk bias) All outcomes

Not specified

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

Not specified

Selective reporting (reporting bias)

Unclear risk

Not specified

Holland 2008 Methods

Randomised controlled trial Stratified for IPF

Participants

ILD: n = 57, including IPF: n = 34 n = 31 male Pulmonary rehabilitation group: n = 30, age mean (SD) 70 (8) years, TLCO mean (SD)


26

Holland 2008

(Continued)

50 (19) % predicted Control group: n = 27, age mean (SD) 67 (13) years, TLCO mean (SD) 49 (18) % predicted Interventions

Pulmonary rehabilitation group: 8-week outpatient exercise programme, twice-weekly supervised sessions consisting of 30 minutes of endurance exercise (cycling and walking) with initial intensity at 80% of walking speed on initial 6-minute walk test and progressed according to protocol. Upper limb endurance and functional strength training for lower limbs also performed Supplemental oxygen provided for SpO2 > 85%. Unsupervised home exercise programme prescribed 3 times per week Control group: weekly telephone calls for general health advice and support

Outcomes

6-Minute walk test Cardiopulmonary exercise test Chronic Respiratory Disease Questionnaire Modified Medical Research Council Scale Measured before and after intervention period. 6-Minute walk test and questionnaires repeated at 6-month follow-up

Notes

Supported by the Victorian Tuberculosis and Lung Association

Risk of bias Bias



Random sequence generation (selection Low risk bias)

Computer-generated random number sequence


Central location, sealed opaque envelope

Low risk

Blinding (performance bias and detection Low risk bias) All outcomes

Data collector blinded to treatment allocation.


Low risk

Intention-to-treat analysis, last observation carried forward


Low risk

All data available at all time points

Jackson 2014 Methods


Participants

IPF: n = 21 Pulmonary rehabilitation group: n = 11, age mean (SD) 71 (6), FVC mean (SD) 60 (11) % predicted, TLCO mean (SD) 44 (11) % predicted Control group: n = 10, age mean (SD) 66 (7), FVC mean (SD) 61 (14) % predicted, TLCO mean (SD) 43 (11) % predicted


27

Jackson 2014

(Continued)

Interventions

Pulmonary rehabilitation group: 12-week outpatient exercise programme, twice-weekly supervised sessions consisting of 30 minutes of endurance training (20 minutes of treadmill walking and 10 minutes of semi-recumbent cycling) with an initial intensity of 80% HRmax. Strength training for upper and lower limbs using therabands for 15-30 minutes, and flexibility exercise for upper and lower body performed for 15 minutes. Supplemental oxygen was provided to maintain SpO2 > 88%. Education component included PowerPoint presentations and handouts for 15 minutes a session (bi-weekly) Control group: no structured exercise

Outcomes

6-Minute walk test Constant work rate cycle test Treadmill exercise (METs) Maximum Inspiratory pressure Dyspnoea (Borg Index) Quality of life (SGRQ-I) Measured before and after intervention period

Notes

Ahead of print

Risk of bias Bias




Not specified


Independant researcher provided group allocation

Low risk

Blinding (performance bias and detection High risk bias) All outcomes

Study was a non-blinded pilot study


High risk

Three participants in the exercise group and one in the control group did not complete the intervention period; data were not included in the analysis


Low risk

All data available at all time points

Mejia 2000 Methods


Participants

ILD: n = 22 FVC: mean (SD) 61 (19) % predicted; age mean (SD) 52 (14) years

Interventions

12-Week exercise programme, 3 times weekly, supervised sessions of 30-35 minutes each, interval training


28

Mejia 2000

(Continued)

Pulmonary rehabilitation group: exercised at 60% of maximal power output on cycle ergometer Control group: sham exercise training at minimum workload achievable on cycle ergometer (no resistance) Outcomes

Chronic Respiratory Disease Questionnaire 12-Minute walk test Measured at baseline and at 12 weeks

Notes

Abstract

Risk of bias Bias




Not specified


Unclear risk

Not specified


Not specified


Unclear risk

Not specified


Unclear risk

Not specified

Menon 2011 Methods


Participants

ILD: n = 28

Interventions

Pulmonary rehabilitation group: 8 weeks of supervised pulmonary rehabilitation Control group: standard medical care

Outcomes

6-Minute walk test Mid-thigh cross-sectional area on CT (MTCSACT ) Carbon monoxide transfer factor (TLCO)

Notes

Abstract

Risk of bias Bias




29

Menon 2011

(Continued)


Not specified


Unclear risk

Not specified


Not specified


Low risk

All data on all 28 participants were reported


Unclear risk

Not specified

Nishiyama 2008 Methods


Participants

Idiopathic pulmonary fibrosis: n = 28 Pulmonary rehabilitation group: n = 13, male n = 12, age mean (SD) 68 (9) years, TLCO mean (SD) 59.4 (16.7) % predicted Control group: n = 15, male n = 9, age mean (SD) 65 (9) years, TLCO mean (SD) 48. 6 (16.7) % predicted

Interventions

Pulmonary rehabilitation group: 9-week outpatient exercise programme, twice-weekly supervised sessions. Exercise on treadmill at 80% of walking speed on initial 6-minute walk test, or on cycle ergometer at 80% of initial maximum workload. Strength training for limbs using elastic bands for approximately 20 minutes. Supplemental oxygen administered to achieve SpO2 > 90%. Some educational lectures were included (content unspecified) Control group: not specified

Outcomes

6-Minute walk test Baseline Dyspnoea Index St George’s Respiratory Questionnaire All measured at baseline and at 10 weeks

Notes

Supported by the Japanese Ministry of Health, Labor and Welfare

Risk of bias Bias




Not specified


Allocation concealed using sealed envelopes that had been prepared prior to the study

Low risk


30

Nishiyama 2008

(Continued)


Not specified


Low risk

Two patients randomised to exercise training but withdrew before baseline data collected


Unclear risk

Not specified

Perez Bogerd 2011 Methods


Participants

ILD: n = 34 Pulmonary rehabilitation group: n = 17, age mean (SD) 63 (12), male n = 12, TLCO mean (SD) 43 (15) % predicted Control group: n = 17, age mean (SD) 65 (9), male n = 7, TLCO mean (SD) 41 (11) % predicted

Interventions

Pulmonary rehabilitation group: 12 weeks of pulmonary rehabilitation consisting of exercise training, patient education, nutrition counselling and psychosocial support Control group: usual medical care

Outcomes

6-Minute walk test Peak work rate (W) on cardiopulmonary exercise test St George’s Respiratory Questionnaire Chronic Respiratory Disease Questionnaire Peripheral muscle force (quadriceps)

Notes

Abstract

Risk of bias Bias




Not specified


Not specified

Unclear risk


Non-blinded; study design in trial registry categorises masking as open label


Available data on all 34 participants were reported. Although 50 participants were included in the study, as stated in the study aims, data for only 3 months on 34 participants were available, indicating that 16 participants

Unclear risk


31

Perez Bogerd 2011

(Continued)

had not completed the allocated time frame at the time of reporting Selective reporting (reporting bias)

High risk

Not all domains for the Chronic Respiratory Disease Questionnaire and the St George’s Respiratory Questionnaire were reported in the results. Not all outcome measures from the clinical trial registry were reported in the abstract

Vainshelboim 2013 Methods


Participants

IPF: n = 32, age 67 (8) Pulmonary rehabilitation group: n = 15, FVC mean (SD) 66 (15.3) % predicted, TLCO mean (SD) 48.6 (17.2) % predicted Control group: n = 17, FVC mean (SD) 71 (19) % predicted, TLCO mean (SD) 51.9 (13.7) % predicted

Interventions

Pulmonary rehabilitation group: 12-week outpatient exercise programme, two 6-week blocks of twice-weekly 60-minute supervised sessions. First block consisted of aerobic interval training with treadmill walking, cycling and step climbing; second block consisted longer periods of continuous aerobic exercise with resistance training Control group: standard medical care

Outcomes

Cardiopulmonary exercise test 6-Minute walk test Modified Medical Research Council Dyspnoea score St George’s Respiratory Questionnaire Pulmonary function

Notes

Abstract

Risk of bias Bias




Not specified


Sealed opaque envelope

Low risk


Data collector not blinded to treatment allocation


Outcomes measures for all 32 participants were reported in the results

Low risk


32

Vainshelboim 2013

(Continued)


High risk

Not all domains for SGRQ were reported in the results

Wewel 2005 Methods


Participants

Interstitial lung disease: n = 99 Usual interstitial pneumonia: n = 38; extrinsic allergic alveolitis: n = 8; non-specific interstitial pneumonia: n = 30; sarcoidosis: n = 23 Pulmonary rehabilitation group: n = 49, age mean 59 years, TLCO mean 49% predicted Control group: n = 50, age mean 62 years, TLCO mean 44% predicted

Interventions

Pulmonary rehabilitation group: 6-month home-based walking training, twice-daily walking for 15 minutes Control group: no scheduled walking

Outcomes

6-Minute walk test Cardiopulmonary exercise test Walking distance at home (pedometer) St George’s Respiratory Questionnaire Dyspnoea: measure unspecified Measured at baseline and at 6 months

Notes

Abstract

Risk of bias Bias




Not specified


Unclear risk

Not specified


Not specified


Unclear risk

Not specified


Unclear risk

Not specified


33

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Arizono 2012

Not a randomised controlled trial

Cockcroft 1981

Mixed disease group: participants had chronic obstructive pulmonary disease and coal worker’s pneumoconiosis

Cockcroft 1982

Mixed disease group: participants had chronic obstructive pulmonary disease and coal worker’s pneumoconiosis

Daltroy 1995

Participants did not have ILD

Jastrzebski 2006


Maddali Bongi 2011

Rehabilitation programme did not qualify as pulmonary rehabilitation

Naji 2006


Nakazawa 2012


Oh 2003

Mixed disease group: diagnoses not reported

Ong 2001


Senstrom 1996


Senstrom 1997


Tryfon 2003

Participants did not undergo pulmonary rehabilitation

Characteristics of studies awaiting assessment [ordered by study ID] Dale 2011 Methods


Participants

Patients with dust-related respiratory disease including asbestosis, silicosis and asbestosis-related diffuse pleural thickening (n = 36) Mean age 71 (7), FVC 86 (20), TLCO 56 (14)

Interventions

Pulmonary rehabilitation group: 8-week exercise training programme, 3 times a week supervised sessions consisting of 30 minutes of endurance training (15 minutes each of cycling and walking) with an initial intensity of 60% peak work rate achieved on the incremental cycle test for cycling and 80% of walking speed achieved on the initial 6minute walk test. Training duration was increased to 20 minutes of cycling and 20 minutes of walking by the 12th training session Control group: usual medical care with no exercise training or advice on exercise training for 8 weeks


34

Dale 2011

(Continued)

Outcomes

6-Minute walk distance Endurance cycle test St George’s Respiratory Questionnaire

Notes

Participant cohort includes pleural disease, which is not an ILD. Data were reported for the population group as a whole; dust-related ILD data were not reported separately. Final manuscript is under preparation


35

DATA AND ANALYSES

Comparison 1. Pulmonary rehabilitation vs no pulmonary rehabilitation

Outcome or subgroup title

No. of studies

1 Change in 6-minute walk distance immediately following pulmonary rehabilitation. Mean change from baseline, metres 1.1 All participants 1.2 Idiopathic pulmonary fibrosis only 1.3 Severe lung disease 1.4 Desaturators

5

2 Change in 6-minute walk test at long-term follow-up. Mean change from baseline, metres 2.1 All participants 2.2 Idiopathic pulmonary fibrosis only 2.3 Severe lung disease

1

2.4 Desaturators 3 Change in VO2 peak immediately following pulmonary rehabilitation, mL/kg/min 3.1 All participants 3.2 Idiopathic pulmonary fibrosis only 3.3 Severe lung disease 3.4 Desaturators 4 Change in VEmax immediately following pulmonary rehabilitation, L/min 4.1 All participants 4.2 Idiopathic pulmonary fibrosis only 4.3 Severe lung disease 4.4 Desaturators 5 Change in maximum heart rate immediately following pulmonary rehabilitation, beats per minute 5.1 All participants

No. of participants

Statistical method

Effect size

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5 4

168 111

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

44.34 [26.04, 62.64] 35.63 [16.02, 55.23]

1 1

23 30


9.61 [-29.43, 48.65] 15.62 [-15.93, 47. 17] Subtotals only


1 1

57 34


1

23


1

30


2


7.40 [-36.42, 51.22] -23.08 [-70.59, 24. 43] 13.49 [-62.30, 89. 28] -22.24 [-89.85, 45. 37] Subtotals only

2 2

80 58


1.24 [0.46, 2.03] 1.46 [0.54, 2.39]

1 1 1

18 27

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-0.03 [-1.36, 1.30] 0.84 [-0.31, 1.99] Subtotals only

1 1

52 30


4.71 [0.10, 9.32] 6.97 [0.87, 13.07]

1 1 1

20 27

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

4.16 [-3.34, 11.66] 6.95 [0.03, 13.87] Subtotals only

1

52


-1.84 [-6.26, 2.58]


36

5.2 Idiopathic pulmonary fibrosis only 5.3 Severe lung disease 5.4 Desaturators 6 6-Month survival 6.1 All participants 6.2 Idiopathic pulmonary fibrosis only 6.3 Severe lung disease 6.4 Desaturators 7 Change in dyspnoea score at long-term follow-up 7.1 All participants 7.2 Idiopathic pulmonary fibrosis only 7.3 Severe lung disease 7.4 Desaturators 8 Change in quality of life immediately following pulmonary rehabilitation 8.1 All participants 8.2 Idiopathic pulmonary fibrosis only 8.3 Severe lung disease 8.4 Desaturators 9 Change in quality of life at long-term follow-up 9.1 All participants 9.2 Idiopathic pulmonary fibrosis only 9.3 Severe lung disease 9.4 Desaturators 10 Change in dyspnoea score immediately following pulmonary rehabilitation 10.1 All participants 10.2 Idiopathic pulmonary fibrosis only 10.3 Severe lung disease 10.4 Desaturators

1

30


-1.91 [-5.92, 2.10]

1 1 1 1 1

20 27

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI)

-5.38 [-11.46, 0.70] -0.45 [-6.07, 5.17] Subtotals only 0.89 [0.12, 6.82] 0.67 [0.08, 5.40]

1 1 1

23 30

Odds Ratio (M-H, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

1.64 [0.13, 21.10] 1.6 [0.13, 19.84] Subtotals only

1 1

57 34


-0.13 [-0.81, 0.55] 0.01 [-0.79, 0.81]

1 1 3

23 30

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI)

-0.12 [-1.23, 0.99] 0.20 [-0.84, 1.24] Subtotals only

3 3

106 83

Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI)

0.59 [0.20, 0.98] 0.59 [0.14, 1.03]

1 1 1

23 30

Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.86 [-0.00, 1.73] 0.42 [-0.31, 1.15] Subtotals only

1 1

57 34


8.78 [-2.18, 19.74] 7.05 [-8.29, 22.39]

1 1 3

23 30

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI)

14.93 [0.54, 29.32] 3.66 [-13.35, 20.67] Subtotals only

3 3

113 90


-0.66 [-1.05, -0.28] -0.68 [-1.12, -0.25]

1 1

23 30


-0.70 [-1.56, 0.15] -0.85 [-1.61, -0.09]

57 34


37

Analysis 1.1. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 1 Change in 6-minute walk distance immediately following pulmonary rehabilitation. Mean change from baseline, metres. Review:

Pulmonary rehabilitation for interstitial lung disease

Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 1 Change in 6-minute walk distance immediately following pulmonary rehabilitation. Mean change from baseline, metres

Study or subgroup

Pulmonary rehabilitation

Mean Difference

Control

Weight

IV,Fixed,95% CI

Mean Difference

N

Mean(SD)

N

Mean(SD)

IV,Fixed,95% CI

Holland 2008

30

31.2 (48.6)

27

-3.7 (59.8)

41.3 %

34.90 [ 6.42, 63.38 ]

Jackson 2014

11

-6.2 (86.91)

10

-15.3 (42.89)

10.0 %

9.10 [ -48.73, 66.93 ]

Nishiyama 2008

13

42 (50.8)

15

-4 (57.7)

20.7 %

46.00 [ 5.81, 86.19 ]

Perez Bogerd 2011

17

67 (62)

17

17 (103)

10.3 %

50.00 [ -7.15, 107.15 ]

Vainshelboim 2013

15

70 (67)

13

-11 (50)

17.7 %

81.00 [ 37.54, 124.46 ]

Subtotal (95% CI)

86

100.0 %

44.34 [ 26.04, 62.64 ]

1 All participants

82

Heterogeneity: Chi2 = 4.63, df = 4 (P = 0.33); I2 =14% Test for overall effect: Z = 4.75 (P < 0.00001) 2 Idiopathic pulmonary fibrosis only Holland 2008

20

25.05 (54.1)

14

8.93 (33.3)

44.4 %

16.12 [ -13.32, 45.56 ]

Jackson 2014

11

-6.2 (86.91)

10

-15.3 (42.89)

11.5 %

9.10 [ -48.73, 66.93 ]

Nishiyama 2008

13

42 (50.8)

15

-4 (57.7)

23.8 %

46.00 [ 5.81, 86.19 ]

Vainshelboim 2013

15

70 (67)

13

-11 (50)

20.4 %

81.00 [ 37.54, 124.46 ]

Subtotal (95% CI)

59

100.0 %

35.63 [ 16.02, 55.23 ]

100.0 %

9.61 [ -29.43, 48.65 ]

100.0 %

9.61 [ -29.43, 48.65 ]

100.0 %

15.62 [ -15.93, 47.17 ]

52

Heterogeneity: Chi2 = 6.94, df = 3 (P = 0.07); I2 =57% Test for overall effect: Z = 3.56 (P = 0.00037) 3 Severe lung disease Holland 2008

Subtotal (95% CI)

13

27.31 (63.84)

13

10

17.7 (28.87)

10

Heterogeneity: not applicable Test for overall effect: Z = 0.48 (P = 0.63) 4 Desaturators Holland 2008

Subtotal (95% CI)

17

17

25.23 (55.67)

13

9.61 (31.61)

13

100.0 % 15.62 [ -15.93, 47.17 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.97 (P = 0.33) Test for subgroup differences: Chi2 = 4.06, df = 3 (P = 0.26), I2 =26%

-100

-50

Favours control


0

50

100

Favours pulmonary rehab

38

Analysis 1.2. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 2 Change in 6-minute walk test at long-term follow-up. Mean change from baseline, metres. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 2 Change in 6-minute walk test at long-term follow-up. Mean change from baseline, metres

Study or subgroup


Mean Difference

Control

N

Mean(SD)

N

Mean(SD)

30

-5.2 (89.8)

27

-12.6 (79)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 All participants Holland 2008

Subtotal (95% CI)

30

27

100.0 %

7.40 [ -36.42, 51.22 ]

100.0 %

7.40 [ -36.42, 51.22 ]

100.0 %

-23.08 [ -70.59, 24.43 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.33 (P = 0.74) 2 Idiopathic pulmonary fibrosis only Holland 2008

Subtotal (95% CI)

20

-19.15 (101.25)

20

14

3.93 (32.41)

14

100.0 % -23.08 [ -70.59, 24.43 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.95 (P = 0.34) 3 Severe lung disease Holland 2008

Subtotal (95% CI)

13

-5.31 (95.6)

13

10

-18.8 (89)

10

100.0 %

13.49 [ -62.30, 89.28 ]

100.0 %

13.49 [ -62.30, 89.28 ]

100.0 %

-22.24 [ -89.85, 45.37 ]


Subtotal (95% CI)

17

17

-32 (105.8)

13

-9.76 (83.12)

100.0 % -22.24 [ -89.85, 45.37 ]

13

Heterogeneity: not applicable Test for overall effect: Z = 0.64 (P = 0.52) Test for subgroup differences: Chi2 = 1.33, df = 3 (P = 0.72), I2 =0.0%

-200

-100

Favours control


0

100

200


39

Analysis 1.3. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 3 Change in VO2 peak immediately following pulmonary rehabilitation, mL/kg/min. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 3 Change in VO2 peak immediately following pulmonary rehabilitation, mL/kg/min

Study or subgroup


Mean Difference

Control

Weight

IV,Fixed,95% CI

Mean Difference

N

Mean(SD)

N

Mean(SD)

IV,Fixed,95% CI

Holland 2008

27

0.67 (2.2)

25

-0.02 (1.14)

69.5 %

0.69 [ -0.25, 1.63 ]

Vainshelboim 2013

15

2.1 (2.3)

13

-0.4 (1.5)

30.5 %

2.50 [ 1.08, 3.92 ]

Subtotal (95% CI)

42

100.0 %

1.24 [ 0.46, 2.03 ]

1 All participants

38

Heterogeneity: Chi2 = 4.33, df = 1 (P = 0.04); I2 =77% Test for overall effect: Z = 3.10 (P = 0.0019) 2 Idiopathic pulmonary fibrosis only Holland 2008

17

0.74 (2.32)

13

0.04 (0.95)

57.7 %

0.70 [ -0.52, 1.92 ]

Vainshelboim 2013

15

2.1 (2.3)

13

-0.4 (1.5)

42.3 %

2.50 [ 1.08, 3.92 ]

Subtotal (95% CI)

32

100.0 %

1.46 [ 0.54, 2.39 ]

100.0 %

-0.03 [ -1.36, 1.30 ]

100.0 %

-0.03 [ -1.36, 1.30 ]

100.0 %

0.84 [ -0.31, 1.99 ]

100.0 %

0.84 [ -0.31, 1.99 ]

26


Subtotal (95% CI)

11

0.04 (1.52)

11

7

0.07 (1.33)

7


Subtotal (95% CI)

15

15

0.55 (1.81)

12

-0.29 (1.22)

12

Heterogeneity: not applicable Test for overall effect: Z = 1.44 (P = 0.15) Test for subgroup differences: Chi2 = 3.64, df = 3 (P = 0.30), I2 =18%

-4

-2

Favours control


0

2

4


40

Analysis 1.4. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 4 Change in VEmax immediately following pulmonary rehabilitation, L/min. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 4 Change in VEmax immediately following pulmonary rehabilitation, L/min

Study or subgroup


Mean Difference

Control

N

Mean(SD)

N

Mean(SD)

27

3.67 (10.41)

25

-1.04 (6.17)

Weight

IV,Fixed,95% CI



Subtotal (95% CI)

27

25

100.0 %

4.71 [ 0.10, 9.32 ]

100.0 %

4.71 [ 0.10, 9.32 ]

100.0 %

6.97 [ 0.87, 13.07 ]

100.0 %

6.97 [ 0.87, 13.07 ]

100.0 %

4.16 [ -3.34, 11.66 ]

100.0 %

4.16 [ -3.34, 11.66 ]

100.0 %

6.95 [ 0.03, 13.87 ]

100.0 %

6.95 [ 0.03, 13.87 ]


Subtotal (95% CI)

17

5.82 (12)

17

13

-1.15 (3.95)

13


Subtotal (95% CI)

11

3.72 (11.13)

11

9

-0.44 (5.52)

9


Subtotal (95% CI)

15

15

6.2 (10.34)

12

-0.75 (8.01)

12


-10

-5

Favours control


0

5

10


41

Analysis 1.5. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 5 Change in maximum heart rate immediately following pulmonary rehabilitation, beats per minute. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 5 Change in maximum heart rate immediately following pulmonary rehabilitation, beats per minute

Study or subgroup


Mean Difference

Control

N

Mean(SD)

N

Mean(SD)

27

-2.8 (10)

25

-0.96 (5.9)

Weight

IV,Fixed,95% CI



Subtotal (95% CI)

27

25

100.0 %

-1.84 [ -6.26, 2.58 ]

100.0 %

-1.84 [ -6.26, 2.58 ]

100.0 %

-1.91 [ -5.92, 2.10 ]

100.0 %

-1.91 [ -5.92, 2.10 ]

100.0 %

-5.38 [ -11.46, 0.70 ]

100.0 %

-5.38 [ -11.46, 0.70 ]

100.0 %

-0.45 [ -6.07, 5.17 ]

100.0 %

-0.45 [ -6.07, 5.17 ]


Subtotal (95% CI)

17

-3.06 (7.12)

17

13

-1.15 (3.95)

13


Subtotal (95% CI)

11

-5.27 (8.47)

11

9

0.11 (5.28)

9


Subtotal (95% CI)

15

15

-1.87 (8.58)

12

-1.42 (6.32)

12


-20

-10



0

10

20

Favours control

42

Analysis 1.6. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 6 6-Month survival. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 6 6-Month survival

Study or subgroup


Control

n/N

n/N

2/30

2/27

100.0 %

0.89 [ 0.12, 6.82 ]

30

27

100.0 %

0.89 [ 0.12, 6.82 ]

2/20

2/14

100.0 %

0.67 [ 0.08, 5.40 ]

20

14

100.0 %

0.67 [ 0.08, 5.40 ]

2/13

1/10

100.0 %

1.64 [ 0.13, 21.10 ]

13

10

100.0 %

1.64 [ 0.13, 21.10 ]

2/17

1/13

100.0 %

1.60 [ 0.13, 19.84 ]

17

13

100.0 %

1.60 [ 0.13, 19.84 ]

Odds Ratio

Weight

M-H,Fixed,95% CI

Odds Ratio M-H,Fixed,95% CI


Subtotal (95% CI)

Total events: 2 (Pulmonary rehabilitation), 2 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.11 (P = 0.91) 2 Idiopathic pulmonary fibrosis only Holland 2008

Subtotal (95% CI)

Total events: 2 (Pulmonary rehabilitation), 2 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.38 (P = 0.70) 3 Severe lung disease Holland 2008

Subtotal (95% CI)

Total events: 2 (Pulmonary rehabilitation), 1 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.38 (P = 0.71) 4 Desaturators Holland 2008

Subtotal (95% CI)

Total events: 2 (Pulmonary rehabilitation), 1 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.37 (P = 0.71)

0.005

0.1


1

10

200

Favours control


43

Analysis 1.7. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 7 Change in dyspnoea score at long-term follow-up. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 7 Change in dyspnoea score at long-term follow-up

Study or subgroup


Mean Difference

Control

N

Mean(SD)

N

Mean(SD)

30

-0.13 (1.43)

27

0 (1.18)

Weight

IV,Fixed,95% CI



Subtotal (95% CI)

30

27

100.0 %

-0.13 [ -0.81, 0.55 ]

100.0 %

-0.13 [ -0.81, 0.55 ]

100.0 %

0.01 [ -0.79, 0.81 ]

100.0 %

0.01 [ -0.79, 0.81 ]

100.0 %

-0.12 [ -1.23, 0.99 ]

100.0 %

-0.12 [ -1.23, 0.99 ]

100.0 %

0.20 [ -0.84, 1.24 ]

100.0 %

0.20 [ -0.84, 1.24 ]


Subtotal (95% CI)

20

-0.2 (1.4)

20

14

-0.21 (0.97)

14


Subtotal (95% CI)

13

0.38 (1.45)

13

10

0.5 (1.27)

10


Subtotal (95% CI)

17

17

0.35 (1.32)

13

0.15 (1.52)

13


-4

-2

favours pulmonary rehab


0

2

4

Favours control

44

Analysis 1.8. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 8 Change in quality of life immediately following pulmonary rehabilitation. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 8 Change in quality of life immediately following pulmonary rehabilitation

Study or subgroup


Std. Mean Difference

Control

Weight

IV,Fixed,95% CI


N

Mean(SD)

N

Mean(SD)

IV,Fixed,95% CI

Holland 2008

30

8.22 (17.18)

27

-3.29 (15.09)

53.1 %

0.70 [ 0.16, 1.24 ]

Jackson 2014

11

4 (14)

10

-4.6 (12)

19.7 %

0.63 [ -0.25, 1.51 ]

Nishiyama 2008

13

2.9 (14.13)

15

-3.1 (18.25)

27.2 %

0.35 [ -0.40, 1.10 ]

100.0 %

0.59 [ 0.20, 0.98 ]

1 All participants

Subtotal (95% CI)

54

52

Heterogeneity: Chi2 = 0.55, df = 2 (P = 0.76); I2 =0.0% Test for overall effect: Z = 2.97 (P = 0.0030) 2 Idiopathic pulmonary fibrosis only Holland 2008

20

5.53 (18.51)

14

-8.53 (16.82)

39.3 %

0.77 [ 0.06, 1.48 ]

Jackson 2014

11

4 (14)

10

-4.6 (12)

25.5 %

0.63 [ -0.25, 1.51 ]

Nishiyama 2008

13

2.9 (14.13)

15

-3.1 (18.25)

35.3 %

0.35 [ -0.40, 1.10 ]

100.0 %

0.59 [ 0.14, 1.03 ]

100.0 %

0.86 [ 0.00, 1.73 ]

100.0 %

0.86 [ 0.00, 1.73 ]

100.0 %

0.42 [ -0.31, 1.15 ]

100.0 %

0.42 [ -0.31, 1.15 ]

Subtotal (95% CI)

44

39

Heterogeneity: Chi2 = 0.64, df = 2 (P = 0.73); I2 =0.0% Test for overall effect: Z = 2.59 (P = 0.0097) 3 Severe lung disease Holland 2008

Subtotal (95% CI)

13

12.55 (16.56)

13

10

-2.15 (16.15)

10


Subtotal (95% CI)

17

17

5.73 (18.45)

13

-1.56 (14.93)

13

Heterogeneity: not applicable Test for overall effect: Z = 1.12 (P = 0.26)

-4

-2

Favours control


0

2

4


45

Analysis 1.9. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 9 Change in quality of life at long-term follow-up. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 9 Change in quality of life at long-term follow-up

Study or subgroup


Mean Difference

Control

N

Mean(SD)

N

Mean(SD)

30

2.58 (26.9)

27

-6.2 (13.88)

Weight

IV,Fixed,95% CI



Subtotal (95% CI)

30

27

100.0 %

8.78 [ -2.18, 19.74 ]

100.0 %

8.78 [ -2.18, 19.74 ]

100.0 %

7.05 [ -8.29, 22.39 ]

100.0 %

7.05 [ -8.29, 22.39 ]

100.0 %

14.93 [ 0.54, 29.32 ]

100.0 %

14.93 [ 0.54, 29.32 ]

100.0 %

3.66 [ -13.35, 20.67 ]


Subtotal (95% CI)

20

-3.06 (29.49)

20

14

-10.11 (15.79)

14


Subtotal (95% CI)

13

8.73 (20.15)

13

10

-6.2 (15.06)

10


Subtotal (95% CI)

17

17

-3.2 (31.95)

13

-6.86 (14.1)

100.0 % 3.66 [ -13.35, 20.67 ]

13


-50

-25

Favours control


0

25

50


46

Analysis 1.10. Comparison 1 Pulmonary rehabilitation vs no pulmonary rehabilitation, Outcome 10 Change in dyspnoea score immediately following pulmonary rehabilitation. Review:


Comparison: 1 Pulmonary rehabilitation vs no pulmonary rehabilitation Outcome: 10 Change in dyspnoea score immediately following pulmonary rehabilitation

Study or subgroup



Control

Weight

IV,Fixed,95% CI


N

Mean(SD)

N

Mean(SD)

IV,Fixed,95% CI

Holland 2008

30

-0.57 (1.36)

27

0.11 (0.91)

52.4 %

-0.57 [ -1.10, -0.04 ]

Nishiyama 2008

13

0 (1.3)

15

0.4 (1.5)

26.5 %

-0.28 [ -1.02, 0.47 ]

Vainshelboim 2013

15

-0.8 (0.9)

13

0.3 (0.6)

21.1 %

-1.38 [ -2.21, -0.54 ]

Subtotal (95% CI)

58

100.0 %

-0.66 [ -1.05, -0.28 ]

1 All participants

55

Heterogeneity: Chi2 = 3.92, df = 2 (P = 0.14); I2 =49% Test for overall effect: Z = 3.38 (P = 0.00072) 2 Idiopathic pulmonary fibrosis only Holland 2008

20

-0.55 (1.47)

14

0.23 (1.17)

39.0 %

-0.56 [ -1.26, 0.14 ]

Nishiyama 2008

13

0 (1.3)

15

0.4 (1.5)

34.0 %

-0.28 [ -1.02, 0.47 ]

Vainshelboim 2013

15

-0.8 (0.9)

13

0.3 (0.6)

27.0 %

-1.38 [ -2.21, -0.54 ]

Subtotal (95% CI)

48

100.0 %

-0.68 [ -1.12, -0.25 ]

100.0 %

-0.70 [ -1.56, 0.15 ]

100.0 %

-0.70 [ -1.56, 0.15 ]

100.0 %

-0.85 [ -1.61, -0.09 ]

100.0 %

-0.85 [ -1.61, -0.09 ]

42


Subtotal (95% CI)

13

-0.76 (1.48)

13

10

0.1 (0.57)

10


Subtotal (95% CI)

17

17

-0.71 (1.21)

13

0.15 (0.55)

13


-2

-1



0

1

2

Favours control

47

APPENDICES Appendix 1. CENTRAL search strategy #1 MeSH descriptor Lung Diseases, Interstitial explode all trees #2 interstitial* near lung* near disease* #3 (interstitial*) near (fibros* or pneumonitis or pneumonia or pneumopathy) #4 alveolitis* #5 bronchiolitis near obliterans #6 goodpasture* near syndrome* #7 granulomatosis #8 histiocytosis* #9 pneumoconiosis or pneumokoniosis or pneumonoconiosis or pneumonokoniosis #10 bagassosis #11 pulmonary* near sarcoid* #12 pulmonary* near fibros* #13 wegener* near granuloma* #14 lung* near purpura #15 (bird* near lung*) or (bird* near disease*) #16 (farmer* near lung*) or (farmer* near disease*) #17 (pigeon* near lung*) or (pigeon* near disease*) #18 (avian* near lung*) or (avian* near disease*) #19 (budgerigar* near lung*) or (budgerigar near disease*) #20 asbestosis or byssinosis or siderosis or silicosis or berylliosis or anthracosilicosis or silicotuberculosis #21 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20) #22 MeSH descriptor Scleroderma, Systemic explode all trees #23 scleroderma #24 MeSH descriptor Rheumatic Diseases explode all trees #25 rheumatic* #26 (#22 OR #23 OR #24 OR #25) #27 (#26 AND ( lung* OR pulmonary* OR respiratory* )) #28 (#21 OR #27) #29 MeSH descriptor Exercise Therapy explode all trees #30 MeSH descriptor Exercise explode all trees #31 MeSH descriptor Physical Fitness explode all trees #32 MeSH descriptor Rehabilitation, this term only #33 MeSH descriptor Physical Therapy Modalities explode all trees #34 MeSH descriptor Physical Exertion explode all trees #35 rehabilitat* or fitness* or exercis* or physical* or train* or activ* or physiotherap* or kinesiotherap* or exert* #36 (#29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35) #37 (#36 AND #28)


48

Appendix 2. MEDLINE (Ovid) search strategy (combined with RCT filter) 1 exp Lung Diseases, Interstitial/ 2 (interstitial$ adj lung$ adj disease$).mp. 3 (interstitial$ adj (fibros$ or pneumonitis or pneumonia or pneumopathy)).mp. 4 alveolitis.mp. 5 exp Bronchiolitis Obliterans/ or (bronchiolitis adj obliterans).mp. 6 (goodpasture$ adj syndrome$).mp. 7 granulomatosis.mp. 8 exp Histiocytosis/ or histiocytosis$.mp. 9 exp Pneumoconiosis/ or pneumoconiosis.mp. or pneumokoniosis.mp. or pneumonoconiosis.mp. 10 bagassosis.mp. 11 (pulmonary$ adj sarcoid$).mp. 12 (pulmonary$ adj fibros$).mp. 13 (wegener$ adj granuloma$).mp. 14 (lung$ adj purpura).mp. (6) 15 ((bird$ or farmer$ or pigeon$ or avian$ or budgerigar$) adj (lung$ or disease$)).mp. 16 (asbestosis or byssinosis or siderosis or silicosis or berylliosis or anthracosilicosis or silicotuberculosis).mp. 17 or/1-16 18 exp Scleroderma, Systemic/ 19 scleroderma.mp. 20 exp Rheumatic Diseases/ 21 rheumatic$.mp. 22 or/18-21 23 22 and (lung$ or pulmonary$ or respiratory$).mp. 24 17 or 23 25 exp Exercise Therapy/ 26 exp exercise/ 27 exp Physical Fitness/ 28 rehabilitation/ 29 exp Physical Therapy Modalities/ 30 exp Physical exertion/ 31 (rehabilitat$ or fitness$ or exercis$ or physical$ or train$ or active$ or activit$ or physiotherap$ or kinesiotherap$ or exert$).mp. 32 or/25-31 33 32 and 24

Appendix 3. CINAHL (EBSCO) search strategy S1 (MH “Lung Diseases, Interstitial+”) S2 interstitial* N3 lung* N3 disease* S3 interstitial* N3 (fibros* or pneumonitis or pneumonia or pneumopathy) S4 alveolitis S5 (MH “Bronchiolitis Obliterans+”) S6 bronchiolitis N3 obliterans S7 goodpasture* N3 syndrome* S8 granulomatosis S9 (MH “Histiocytosis+”) S10 histiocytosis S11 (MH “Pneumoconiosis+”) S12 pneumoconiosis or pneumokoniosis or pneumonoconiosis S13 bagassosis S14 pulmonary* N3 (sarcoid* or fibros*) Pulmonary rehabilitation for interstitial lung disease (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

49

S15 wegener* N3 granuloma* S16 lung* N3 purpura S17 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 S18 (MH “Scleroderma, Systemic+”) S19 scleroderma S20 (MH “Rheumatic Diseases+”) S21 rheumatic* S22 S18 OR S19 OR S20 OR S21 S23 lung* or pulmonary* or respiratory* S24 S22 AND S23 S25 S17 OR S24 S26 (MH “Physical Therapy+”) S27 (MH “Exercise”) S28 (MH “Physical Fitness”) S29 (MH “Rehabilitation”) S30 (MH “Rehabilitation, Pulmonary+”) S31 (MH “Exertion”) S32 rehabilitat* or fitness* or exercis* or physical* or train* or active* or activit* or physiotherap* or kinesiotherap* or exert* S33 S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 S34 S25 AND S33 S35 (MH “Randomized Controlled Trials”) S36 (MH “Double-Blind Studies”) S37 (MH “Random Assignment”) S38 (MH “Placebos”) S39 placebo* S40 random* S41 crossover* or cross-over* S42 clinical* N3 (trial* or study or studies) S43 (single* or double* or triple*) N3 blind* S44 S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 S45 S34 AND S44

Appendix 4. EMBASE (Ovid) search strategy (combined with RCT filter) 1 exp Interstitial Lung Disease/ 2 (interstitial$ adj lung$ adj disease$).mp. 3 Interstitial Pneumonia/ or exp lung fibrosis/ or (interstitial$ adj (fibros$ or pneumonitis or pneumonia or pneumopathy)).mp. 4 alveolitis.mp. 5 exp Bronchiolitis Obliterans/ or (bronchiolitis adj obliterans).mp. 6 (goodpasture$ adj syndrome$).mp. 7 granulomatosis.mp 8 exp Histiocytosis/ or histiocytosis$.mp. 9 exp Pneumoconiosis/ or pneumoconiosis.mp. or pneumokoniosis.mp. or pneumonoconiosis.mp. 10 bagassosis.mp. 11 (pulmonary$ adj sarcoid$).mp. 12 (pulmonary$ adj fibros$).mp. 13 (wegener$ adj granuloma$).mp. 14 (lung$ adj purpura).mp. 15 ((bird$ or farmer$ or pigeon$ or avian$ or budgerigar$) adj (lung$ or disease$)).mp. 16 (asbestosis or byssinosis or siderosis or silicosis or berylliosis or anthracosilicosis or silicotuberculosis).mp. 17 or/1-16 Pulmonary rehabilitation for interstitial lung disease (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

50

18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

exp systemic sclerosis/ scleroderma.mp. exp Rheumatic Disease/ rheumatic$.mp. or/18-21 22 and (lung$ or pulmonary$ or respiratory$).mp. 17 or 23 exp kinesiotherapy/ exp exercise/ exp fitness/ rehabilitation/ exp physiotherapy/ exertion.mp. (rehabilitat$ or fitness$ or exercis$ or physical$ or train$ or active$ or activit$ or physiotherap$ or kinesiotherap$ or exert$).mp. or/25-31

Appendix 5. PEDro search strategy interstitial scleroderma rheumatic disease* lung disease* (all limited to clinical trial) ILD (not limited to trial)

WHAT’S NEW Last assessed as up-to-date: 27 June 2014.

Date

Event

Description

27 June 2014

New citation required but conclusions have not changed Four new studies were identified Background was modified to describe pulmonary rehabilitation Summary of findings table was added

27 June 2014

Amended

Title changed from ’physical training’ to ’pulmonary rehabilitation’ to reflect current practice and terminology

27 June 2014

New search has been performed

New literature search run


51

HISTORY Protocol first published: Issue 1, 2007 Review first published: Issue 4, 2008

Date

Event

Description

2 February 2010

New search has been performed

Updated search re-run; no new studies were identified.

28 January 2009

Amended

Contact details changed

10 April 2008

Amended

Converted to new review format.

11 October 2006

New citation required and major changes

Substantive amendment

CONTRIBUTIONS OF AUTHORS Initiated the protocol: AH. Developed the protocol: AH and CH. Undertook literature search for the original version: AH and CH; for the updated version: AH and LD. Retrieved papers for the original version: AH; for the updated version: LD. Screened retrieved papers against eligibility criteria for the original version: AH and CH; for the updated version: AH and LD. Appraised quality for the original version: AH and CH; for the updated version: AH and LD. Extracted data for the original version: AH and CH; for the updated version: AH and LD. Wrote to study authors for additional information for the original version: AH; for the updated version: LD. Entered data into RevMan for the original version: AH; for the updated version: LD. Performed analysis for the original version: AH and CH; for the updated version: LD. Wrote review for the original version: AH and CH; amended manuscript for the updated version: LD; reviewed the updated version of the manuscript: AH and CH. Served as guarantor of the review: AH.

DECLARATIONS OF INTEREST AH and CH conducted one of the studies included in this review.


52

SOURCES OF SUPPORT Internal sources • No sources of support supplied

External sources • Victorian Tuberculosis and Lung Association, Australia. • National Health and Medical Research Council, Australia, Other. PhD stipend for Ms Dowman

DIFFERENCES BETWEEN PROTOCOL AND REVIEW We specified two subgroup analyses for this update. Subgroup analysis for exercise type could not be conducted, as we identified no trials on resistance training. Sensitivity analysis was not performed and funnel plots were not constructed because of the small number of included studies. If in future updates more studies are included, these analyses will be performed.

INDEX TERMS Medical Subject Headings (MeSH) ∗ Exercise; Exercise Therapy; Exercise Tolerance; Lung

Diseases, Interstitial [physiopathology; ∗ rehabilitation]; Randomized Controlled

Trials as Topic

MeSH check words Humans


53

Specific Needs of Patients Attending Pulmonary Rehabilitation with an Interstitial Lung Disease Associated with Rheumatological Disease.

Do we need a practice incremental shuttle walk test for patients with interstitial lung disease referred for pulmonary rehabilitation?

Meaningful patient education: How can pulmonary rehabilitation help to bridge the gap for those with interstitial lung disease?

Pulmonary rehabilitation in lung cancer.

Pulmonary rehabilitation in lung disease other than chronic obstructive pulmonary disease.

Interstitial lung disease.

New guidelines for childhood interstitial lung disease.

Arterial Carboxyhemoglobin Measurement Is Useful for Evaluating Pulmonary Inflammation in Subjects with Interstitial Lung Disease.

Combined BNP and Echocardiographic assessment in interstitial lung disease for pulmonary hypertension detection.

Respiratory bronchiolitis-interstitial lung disease.

Pharmacogenetics and interstitial lung disease.

Nitrofurantoin induced interstitial lung disease.

About the effect of pulmonary rehabilitation on lung function in patients with chronic obstructive pulmonary disease.

Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease.

Pulmonary Rehabilitation and Palliative Care for the Lung Cancer Patient.

Diffuse smoking-related lung disease: emphysema and interstitial lung disease.

Respiratory bronchiolitis with fibrosis-interstitial lung disease: a new form of smoking-induced interstitial lung disease.

Be honest and help me prepare for the future: What people with interstitial lung disease want from education in pulmonary rehabilitation.

Influence of Pulmonary Rehabilitation on Lung Function Changes After the Lung Resection for Primary Lung Cancer in Patients with Chronic Obstructive Pulmonary Disease.

Diffuse pulmonary interstitial disease; an immunohistologic study.

[Interstitial pulmonary fibrosis in Recklinghausen's disease].

Correlated studies of interstitial pulmonary disease.

Impact and predictors of acute exacerbation of interstitial lung diseases after pulmonary resection for lung cancer.

Prognostic factors for myositis-associated interstitial lung disease.