Systematic review of clinical effectiveness, components, and delivery of pulmonary rehabilitation in low-resource settings

Abstract

Pulmonary rehabilitation (PR) is a guideline-recommended multifaceted intervention that improves the physical and psychological well-being of people with chronic respiratory diseases (CRDs), though most of the evidence derives from trials in high-resource settings. In low- and middle-income countries, PR services are under-provided. We aimed to review the effectiveness, components and mode of delivery of PR in low-resource settings. Following Cochrane methodology, we systematically searched (1990 to October 2018; pre-publication update March 2020) MEDLINE, EMBASE, CABI, AMED, PUBMED, and CENTRAL for controlled clinical trials of adults with CRD (including but not restricted to chronic obstructive pulmonary disease) comparing PR with usual care in low-resource settings. After duplicate selection, we extracted data on exercise tolerance, health-related quality of life (HRQoL), breathlessness, included components, and mode of delivery. We used Cochrane risk of bias (RoB) to assess study quality and synthesised data narratively. From 8912 hits, we included 13 studies: 11 were at high RoB; 2 at moderate RoB. PR improved functional exercise capacity in 10 studies, HRQoL in 12, and breathlessness in 9 studies. One of the two studies at moderate RoB showed no benefit. All programmes included exercise training; most provided education, chest physiotherapy, and breathing exercises. Low cost services, adapted to the setting, used limited equipment and typically combined outpatient/centre delivery with a home/community-based service. Multicomponent PR programmes can be delivered in low-resource settings, employing a range of modes of delivery. There is a need for a high-quality trial to confirm the positive findings of these high/moderate RoB studies.

Challenges in the Implementation of Chronic Obstructive Pulmonary Disease Guidelines in Low- and Middle-Income Countries: An Official American Thoracic Society Workshop Report

“…Availability and access to rehabilitation is recognized as AMERICAN THORACIC SOCIETY DOCUMENTS fundamental to achieving WHO Sustainable Development Goal 3. Data are emerging that culturally adapted PR can be successfully implemented for COPD in LMICs (54)(55)(56)(57)(58), but cost-effectiveness data are missing and are necessary to help address major challenges around staff training, space, the provision of equipment, the retention rate in programs, and the awareness and support needed to refer people to such programs. Alternative approaches, including digital options, may improve access to PR, but there has been little study of the use of "remote PR" in LMICs.…”

Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study

“…In low- and middle-income countries, where pulmonary rehabilitation centers are limited and difficult accessed, some of these interventions can be done at home. Home weights such as water bottles can also be used for resistance training at home [ 47 ]. Traditional rituals such as local and indigenous dances in physical exercise are another Solution for pulmonary rehabilitation programs that will increase patient acceptance, access, and participation in low income countries.…”

Strategies for the prevention, diagnosis and treatment of COPD in low- and middle- income countries: the importance of primary care

“…Pulmonary rehabilitation is one of the key nonpharmacologic treatments, consisting of graded exercise and patient education. It is a very effective method that has shown symptom alleviation, quality of life improvement and costeffectiveness [97]. The main barriers to wide use of pulmonary rehabilitation are the lack of awareness, shortage of trained health-care workers on pulmonary rehabilitation techniques and the lack of funds [98].…”