**5. Indications of pulmonary rehabilitation**

Patients with chronic lung condition who have symptomatic shortness of breath limiting their physical activity despite optimal medical management should be considered for pulmonary rehabilitation [44]. Patients with chronic diseases other than lung such as heart failure, musculoskeletal disease have the same benefit form pulmonary rehabilitation as patients with disabling lung conditions like chronic obstructive pulmonary disease, restrictive lung disease, and pulmonary hypertension. Pulmonary rehabilitation can markedly change the course of the disease if provided at an earlier stage of disease. This is due to improved exercise tolerance and physical activity, reduced exacerbations and improved self-efficacy and behavior change after pulmonary rehabilitation. [45]

One of the most important indicator for referral to pulmonary rehabilitation is based on the modified Medical Research Council Breathlessness (mMRC) score (see **Table 1**) [46]. The mMRC scale is a 0–4 grade scale used to establish levels of perceived respiratory disability. It allows patients to indicate the extent to which their breathlessness affects their mobility [45, 46].

It has been strongly recommended that patients with an mMRC dyspnea score of 2–4 who are functionally limited by breathlessness should be referred for pulmonary rehabilitation. However, benefits of pulmonary rehabilitation have also been seen in patients with an mMRC dyspnea score of 1 who are functionally limited by breathlessness. Patients with COPD who have an mMRC score of 4 achieve similar benefits from the pulmonary rehabilitation as those with a lower breathlessness score [47].

**5**

*Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease*

due to breathlessness when walking up at own pace

3 Stops for breath when walking 100 m or after a few minutes on level ground

4 Too short of breath to leave the house, or short of breath when dressing and undressing

Other frequent indications for referral to a pulmonary rehabilitation program include poor functional status, physical deconditioning, chronic fatigue, poor health-related quality of life and difficulty performing activities of daily living. Patients who are requiring increased use of medical resources due to frequent exacerbations, hospitalizations and emergency room visits also benefit from pulmonary

2 Walks slower than contemporaries on a level ground because of shortness of breath or has to stop

Candidates for lung volume reduction surgery for severe emphysema or for lung

Level of functional impairment [47, 52, 53] or disease severity does not affect the benefits seen in COPD patients with pulmonary rehabilitation program [54, 55]. A program of PR may be proposed in stable COPD as well as immediately after COPD

There are very few exclusion criteria for a referral to pulmonary rehabilitation,

• Unstable cardiovascular disease, uncontrolled diabetes and an ongoing ortho-

• Inability to do exercise safely because of any other medical illness like severe

• Untreated psychiatric illness and cognitive impairment which makes it hard for patients to follow directions are other reasons for not referring a patient to

• Lack of motivation is another exclusion criterion for pulmonary rehabilitation.

Adherence to pulmonary rehabilitation program is critical to see the ongoing benefits from the program. However, non- adherence and high dropout rate of 20–30% is reported in the studies listing predictive factors of non-adherence to

transplantation are also good candidates for PR [48]. Patients with COPD have shown improvements following a pulmonary rehabilitation program irrespective of

**6. Contraindications of pulmonary rehabilitation**

which includes patients with the following conditions [45, 46]:

pedic illness that will refrain patient from exercising.

arthritis, severe peripheral vascular disease.

**7. Nonadherence to pulmonary rehabilitation**

pulmonary rehabilitation. These factors include [52, 53, 57, 58]:

pulmonary rehabilitation.

*DOI: http://dx.doi.org/10.5772/intechopen.81742*

**Grade Level of breathlessness with the activities** 0 No shortness of breath except on strenuous exercise

1 Short of breath when walking on an incline

*The modified Medical Research Council Breathlessness (mMRC) score.*

rehabilitation.

**Table 1.**

exacerbation [56].

their age or gender [49–51].

*Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.81742*


### **Table 1.**

*Cardiorespiratory Fitness*

**4.4 Psychosocial**

the intervention group [41].

**4.5 Survival**

patients [35]. In fact, there is some literature to suggest reduced hospitalization in patients participating in PR programs immediately after acute exacerbation of

Anxiety and depression affect significantly in COPD patients leading to worse

COPD patients have been known to have improved mortality with cessation of smoking. There is some signal that an association exists between completion of PR and survival based on a retrospective analysis involving 1515 patients [42]. But a systematic review conducted of two randomized control trials showed significant survival benefit at 1 year in one trial but no significant benefit with another study at end of 3 years.

Patients with chronic lung condition who have symptomatic shortness of breath

limiting their physical activity despite optimal medical management should be considered for pulmonary rehabilitation [44]. Patients with chronic diseases other than lung such as heart failure, musculoskeletal disease have the same benefit form pulmonary rehabilitation as patients with disabling lung conditions like chronic obstructive pulmonary disease, restrictive lung disease, and pulmonary hypertension. Pulmonary rehabilitation can markedly change the course of the disease if provided at an earlier stage of disease. This is due to improved exercise tolerance and physical activity, reduced exacerbations and improved self-efficacy and behav-

One of the most important indicator for referral to pulmonary rehabilitation is based on the modified Medical Research Council Breathlessness (mMRC) score (see **Table 1**) [46]. The mMRC scale is a 0–4 grade scale used to establish levels of perceived respiratory disability. It allows patients to indicate the extent to which

It has been strongly recommended that patients with an mMRC dyspnea score of 2–4 who are functionally limited by breathlessness should be referred for pulmonary rehabilitation. However, benefits of pulmonary rehabilitation have also been seen in patients with an mMRC dyspnea score of 1 who are functionally limited by breathlessness. Patients with COPD who have an mMRC score of 4 achieve similar benefits from the pulmonary rehabilitation as those with a lower breathlessness score [47].

Neither of the study was powered to really derive the desired outcome [43].

**5. Indications of pulmonary rehabilitation**

ior change after pulmonary rehabilitation. [45]

their breathlessness affects their mobility [45, 46].

patient centered outcomes. Tselebis et al. conducted study in 101 consecutive patients and noted that psychological morbidity was improved with participation in PR program irrespective of severity of the disease (COPD) [37]. This was confirmed in a meta-analysis of six RCTs which indicated that pulmonary rehabilitation was more effective than standard care for the reduction of anxiety and depression [38]. HRQoL was noted to be significantly improved in patients with COPD participating in PR as well [34, 39]. The St. Georges Respiratory Questionnaire Scores were used in a meta-analysis, which showed significant improvement in HRQoL following pulmonary rehabilitation [40]. An early RCT compared pulmonary rehabilitation with education alone and demonstrated that self-efficacy improved in

COPD (AECOPD) beginning within 1 week of discharge [36].

**4**

*The modified Medical Research Council Breathlessness (mMRC) score.*

Other frequent indications for referral to a pulmonary rehabilitation program include poor functional status, physical deconditioning, chronic fatigue, poor health-related quality of life and difficulty performing activities of daily living. Patients who are requiring increased use of medical resources due to frequent exacerbations, hospitalizations and emergency room visits also benefit from pulmonary rehabilitation.

Candidates for lung volume reduction surgery for severe emphysema or for lung transplantation are also good candidates for PR [48]. Patients with COPD have shown improvements following a pulmonary rehabilitation program irrespective of their age or gender [49–51].

Level of functional impairment [47, 52, 53] or disease severity does not affect the benefits seen in COPD patients with pulmonary rehabilitation program [54, 55]. A program of PR may be proposed in stable COPD as well as immediately after COPD exacerbation [56].
