Managing COPD With Pulmonary Rehab Through Exercise and Behavioral, Web-Based Interventions

Combining pharmacological treatment, pulmonary rehabilitation, and behavioral and web-based interventions may benefit patients after a COPD exacerbation.

Higher exercise capacity and physical activity are critical in managing chronic obstructive pulmonary disease (COPD), as they contribute to better health status, reduced healthcare utilization, and increased survival.

Authors of an article published in breathe outlined general approaches to increasing exercise capacity and physical activity among patients with COPD, including pulmonary rehabilitation and behavioral interventions.

“These are by no means the only approaches, nor are they mutually exclusive,” noted lead author Antarpreet Kaur, MD, and colleagues. “Indeed, combining them, as necessary, to meet the needs of the individual respiratory patient may promote optimal outcomes.”

Beginning With Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is a globally recognized standard of care for COPD. Despite its benefits, PR is significantly underutilized, with less than 2% of US patients with Medicare receiving it within 90 days post-hospitalization for a COPD exacerbation. The COVID-19 pandemic also disrupted PR services, prompting the development of remote PR sessions and telemedicine, which may now help expand PR access and delivery.

Exercise training, a key component of PR for COPD, significantly improves both functional and maximal exercise capacity. A 2015 Cochrane review found that PR exercise training led to greater increases in exercise capacity compared with usual care, with significant improvements in maximal exercise capacity and functional exercise capacity.

Other research indicates that high-intensity exercise training reduces dynamic hyperinflation, leading to greater exercise tolerance in patients with COPD. However, the long-term effectiveness of exercise training is less established, with short-term gains often diminishing over time, and maintenance exercise programs have not consistently preserved these benefits. Additional components of PR, such as education and self-management training, have not shown added benefits over exercise training alone for improving exercise capacity and QOL.

“Increasing physical activity in individuals with COPD participating in PR will require behavior change resulting from collaborative self-management interventions,” Dr. Kaur and colleagues wrote.

Implementing Behavioral Interventions

Behavioral interventions aim to enhance exercise capacity and physical activity among patients with COPD by addressing capability, opportunity, and motivation.

Common interventions include facilitated opportunities for exercise, feedback from wearable activity monitors, and coaching or counseling to promote regular physical activity. Each type involves multiple behavior change techniques, focusing on different aspects of behavioral influence.

While PR is effective in increasing exercise capacity, it often lacks long-term effects on physical activity. Feedback from wearable devices, such as pedometers, has been shown to significantly improve daily step counts, making it a useful standalone or PR-complementary intervention.

Coaching and counseling, including motivational interviewing, enhance self-efficacy and QOL but may have mixed impacts on physical activity and exercise capacity.

Combined interventions that incorporate activity feedback and coaching demonstrate the most consistent benefits but face challenges in sustained engagement and behavior change.

“As work in this area progresses, streamlining interventions to include the most effective components and/or personalizing content to match individuals’ key barriers to behavior change may be beneficial. Engagement with frameworks such as the behavior change wheel to specify target behaviors and select appropriate intervention functions and behavior change techniques may also strengthen this work,” Dr. Kaur and colleagues wrote.

Rise of Web-based Interventions

The latest data surrounding web-based interventions shows promise in increasing exercise capacity and physical activity among patients with COPD, either alone or combined with other methods, according to the review authors.

Technological tools and web-based interventions outside PR, such as remote monitoring devices, have shown potential in improving exercise capacity and physical activity among patients with COPD. Initial findings from small studies suggest benefits such as increased 6-minute walk distances and daily exercise time. However, the quality of evidence remains low, necessitating larger, high-quality trials to confirm these results.

“These technologies have the potential to help control rising healthcare costs, improve efficiency of care, and address staffing challenges that may be present in PR,” Dr. Kaur and colleagues said.

The American Thoracic Society’s guideline recommends offering both center-based and telerehabilitation PR to adults with stable chronic respiratory disease, though challenges in recruitment and variability in study designs limit widespread implementation and conclusive comparisons. As digital awareness increases, incorporating technological advances into healthcare could enhance access and reduce health inequalities.

The authors concluded that “achieving optimal outcomes in the COPD patient may require several of these approaches. Data supporting combining these treatment areas are still a work in progress, but, as discussed, there is some support that combining behavioral or web-based interventions with PR may add further benefit, especially in physical activity promotion.”