An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial

Abstract

Objective: To investigate whether an early rehabilitation intervention initiated during acute admission for exacerbations of chronic respiratory disease reduces the risk of readmission over 12 months and ameliorates the negative effects of the episode on physical performance and health status.

Design: Prospective, randomised controlled trial.

Setting: An acute cardiorespiratory unit in a teaching hospital and an acute medical unit in an affiliated teaching district general hospital, United Kingdom.

Participants: 389 patients aged between 45 and 93 who within 48 hours of admission to hospital with an exacerbation of chronic respiratory disease were randomised to an early rehabilitation intervention (n=196) or to usual care (n=193).

Main outcome measures: The primary outcome was readmission rate at 12 months. Secondary outcomes included number of hospital days, mortality, physical performance, and health status. The primary analysis was by intention to treat, with prespecified per protocol analysis as a secondary outcome.

Interventions: Participants in the early rehabilitation group received a six week intervention, started within 48 hours of admission. The intervention comprised prescribed, progressive aerobic, resistance, and neuromuscular electrical stimulation training. Patients also received a self management and education package.

Results: Of the 389 participants, 320 (82%) had a primary diagnosis of chronic obstructive pulmonary disease. 233 (60%) were readmitted at least once in the following year (62% in the intervention group and 58% in the control group). No significant difference between groups was found (hazard ratio 1.1, 95% confidence interval 0.86 to 1.43, P=0.4). An increase in mortality was seen in the intervention group at one year (odds ratio 1.74, 95% confidence interval 1.05 to 2.88, P=0.03). Significant recovery in physical performance and health status was seen after discharge in both groups, with no significant difference between groups at one year.

Conclusion: Early rehabilitation during hospital admission for chronic respiratory disease did not reduce the risk of subsequent readmission or enhance recovery of physical function following the event over 12 months. Mortality at 12 months was higher in the intervention group. The results suggest that beyond current standard physiotherapy practice, progressive exercise rehabilitation should not be started during the early stages of the acute illness.Trial registration Current Controlled Trials ISRCTN05557928.

Fig 1 Training intervention algorithm. Prescription protocol for progressive aerobic, resistance, and non-volitional training

Fig 2 Flow of participants through study

Fig 3 Cumulative incidence of hospital readmission, using competing risks regression analysis, in usual care and early rehabilitation groups. The groups did not differ (P=0.4)

Fig 4 Kaplan-Meier plots showing survival in follow-up period

Fig 5 Intention to treat analysis: change in functional measures (from first measure) in year after admission in all participants. Initial measures were taken at discharge for incremental and endurance shuttle walk tests and at baseline for quadriceps maximal voluntary contraction and St George’s respiratory questionnaire. *P<0.05

Fig 6 Change in functional measures (from first measure) in year after admission in participants who were not readmitted in subsequent year (n=156) Initial measures were taken at discharge for incremental and endurance shuttle walk tests and at baseline for maximal voluntary contraction and St George’s respiratory questionnaire. *P<0.05