Q Qu ua al li it ty y o of f l li if fe e i in n p pa at ti ie en nt ts s w wi it th h c ch hr ro on ni ic c o ob bs st tr ru uc ct ti iv ve e p pu ul lm mo on na ar ry y d di is se ea as se e i im mp pr ro ov ve es s a af ft te er r r re eh ha ab bi il li it ta at ti io on n a at t h ho om me e P.J. Wijkstra*, R. Van Altena*, J. Kraan* We studied 43 patients with severe airflow obstruction: forced expiratory volume in one second (FEV 1 ) 1.3±0.4 l (mean±SD), FEV 1 /inspiratory vital capacity (IVC) 37±7.9%. After stratification, 28 patients were randomly allocated in a home rehabilitation programme for 12 weeks. Fifteen patients in a control group received no rehabilitation. The rehabilitation group received physiotherapy by the local physiotherapist, and supervision by a nurse and a general practitioner. Quality of life was assessed by the four dimensions of the Chronic Respiratory Questionnaire (CRQ).We found a highly significant improvement in the rehabilitation group compared to the control group for the dimensions dyspnoea, emotion, and mastery. Lung function showed no changes in the rehabilitation group. The exercise tolerance improved significantly in the rehabilitation group compared to the control group. The improvement in quality of life was not correlated with the improvement in exercise tolerance.Rehabilitation of COPD patients at home may improve quality of life; this improvement is not correlated with an improvement in lung function and exercise tolerance.

Background -Several studies have shown that both objective and subjective measurements are related to exercise capacity in patients with chronic obstructive pulmonary disease (COPD) (Thorax 1994;49:468-472) Patients with chronic obstructive pulmonary disease (COPD) usually have a decreased exercise tolerance and a reduced quality of life. While spirometric measurements seem to be related to maximum ventilation in a bicycle ergometer performance,' in general they correlate weakly with less stressful tests such as the walking distance.2 5 Moreover, it has been shown that the transfer factor for carbon monoxide (TLCO) is positively correlated with the walking distance test.67Although dynamic and static lung volumes, compliance, and gas transfer (lung function) generally establish the level of impairment in COPD, Mahler and coworkers showed that maximal inspiratory pressure (MIP) provides additional information on impairment.8 Loiseau and coworkers9 also showed that exercise capacity in patients with COPD was related to the impairment of the inspiratory muscles. In addition, it has been shown in other studies that walking distance tests are related to psychosocial measurements, while no relation has been found between psychosocial measurements and bicycle ergometer tests.4 10 11Both objective and subjective measurements are related to exercise capacity in patients with COPD. However, we are not aware of any research on their relative effect on a walking distance test compared with a bicycle ergometer test. In this study we have therefore investigated the relative contribution of lung function, maximal inspiratory pressure, dyspnoea, and quality of life to the performance in a walking distance test as well as a bicycle ergometer test in patients with COPD. Methods PATIENTSForty patients with known COPD"2 (table 1) who started a rehabilitation programme were studied. Entry criteria were: (a) postbronchodilator FEV, (forced expiratory volume in one second) <60% predicted, and (2) postbronchodilator FEV,/IVC (inspiratory vital capacity) <50% (after two inhalations of 40,ug Rehabilitation Centre,

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Background -The Chronic Respiratory Questionnaire (CRQ) is frequently applied to assess quality of life in patients with chronic obstructive pulmonary disease (COPD). However, the reliability and validity of this questionnaire have not yet been determined. This study investigates the reliability and validity of the four separate dimensions of the CRQ.Methods -The CRQ was administered on two consecutive days to 40 patients with COPD (mean FEV1 44% predicted, FEVj/ IVC 37% predicted). Internal consistency reliability of each dimension was investigated by Cronbach's a reliability coefficient, test retest reliability by the Spearman-Brown reliability coefficient (p), and content validity by Pearson's correlation coefficient between the CRQ and the symptom checklist (SCL-90). Results -Items of the fatigue, emotion, and mastery dimensions showed a high internal consistency reliability (a = 0-71-0 88) as well as a high test retest reliability (p above 0 90). These three dimensions correlated with comparable dimensions of the SCL-90. Items of the dyspnoea dimension showed a low internal consistency reliability (ox=0-53) and a test retest reliability of p = 0 73. Conclusions -Items of the dimensions fatigue, emotion, and mastery of the CRQ are reliable and valid and can be used to assess quality of life in patients with severe airways obstruction. Items of the dyspnoea dimension are less reliable and should not be included in the overall score of the CRQ in comparative research. However, by scoring the items of dyspnoea separately they may be useful for the evaluation of the effects of intervention in a specific patient. (Thorax 1994;49:465-467) Impaired lung function may, in addition to limiting exercise, result in an impaired quality of life. 1-3 A study by Traver showed that health care use by patients with chronic obstructive pulmonary disease (COPD) was related more to impaired quality of life than to the severity of the disease itself.4 It is therefore important to measure quality of life in COPD as well as lung function and exercise tolerance.Two general health measurements -the Quality of Well Being scale5 and the Sickness Impact Profile6 -were developed for use in these patients. Because these instruments are not sensitive enough to detect small changes7 after treatment, Guyatt and coworkers developed the Chronic Respiratory Questionnaire (CRQ).8 They showed that the CRQ was precise, valid, and responsive,89 but did not investigate the internal consistency reliability of the separate dimensions. Furthermore, responsiveness to change is more an indication of the validity of a measuring instrument than a separate characteristic. '0 This means that reproducible and responsive measurement instruments may contain items which have nothing in common" -that is, the sets of items do not measure the dimensions they constitute. We have therefore investigated the internal consistency and the test retest reliability of the separate dimensions of the CRQ. The content validity of the CRQ was assessed by correlating ...

Background -Pulmonary rehabilitation has been shown to have short term subjective and objective benefits for patients with chronic obstructive pulmonary disease (COPD). However, appropriately controlled studies have not previously been performed, nor have the benefits of different types ofcontinuation programme for rehabilitation been investigated. Both these problems have been addressed in a single study of the long term effects of once monthly physiotherapy versus once weekly physiotherapy at home after a comprehensive home rehabilitation programme on quality of life and exercise tolerance in patients with COPD. Methods -Thirty six patients with severe airways obstruction (mean (SD) forced expiratory volume in one second (FEVy) 1.3(0.4) 1, FEV,/inspiratory vital capacity (IVC) 37.2(7.9)%) were studied. Twenty three patients followed a rehabilitation programme at home for 18 months consisting ofphysiotherapy and supervision by a nurse and general practitioner. During the first three months all 23 patients visited the physiotherapist twice a week for a 0 5 hour session. Thereafter, 11 patients (group A) received a session ofphysiotherapy once weekly while 12 patients (group B) received a session of physiotherapy once a month. The control group C (13 patients) received no rehabilitation at all. Quality of life was assessed by the Chronic Respiratory Questionnaire, exercise tolerance by the six minute walking distance, and lung function by FEV, and IVC. Outcome measures were assessed at baseline and at three, six, 12, and 18 months. Results -Long term improvements in quality of life were found in patients in groups A and B, but not in those in group C compared with baseline, but these only reached significance in group B at all time points. Patients in group B had a higher quality of life than those in group C only at three and 12 months. There was a decrease in both six minute walking distance (at 12 and 18 months) and IVC (at three, 12, and 18 months) in patients in group C compared with the baseline measurement. Between groups analysis showed no differences for six minute walking distance, FEV,, and IVC.Conclusions -This study is the first to show that rehabilitation at home for three months followed by once monthly physiotherapy sessions improves quality of life over 18 months. The change in quality of life was not associated with a change in exercise tolerance. (Thorax 1995;50:824-828) Keywords: home rehabilitation, quality of life, exercise tolerance, chronic obstructive pulmonary disease.Rehabilitation of patients with chronic obstructive pulmonary disease (COPD) improves both quality of life and exercise tolerance.1-8 Most studies have had a short follow up of up to six months""68 and were carried out in a clinical setting.3-68 Quality of life has not frequently been assessed by a valid questionnaire, and only one study3 showed both an improved exercise tolerance and an improved quality oflife after one year. This study assessed quality of life by the Chronic Respiratory Questionnaire, which was...