Scolaris Content Display Scolaris Content Display

Rehabilitación pulmonar para la enfermedad pulmonar obstructiva crónica

Appendices

Appendix 1. Archive of previous search methods and results

Search strategy used for review versions published up to 2004

We searched all records in the Cochrane Airways Group Register coded as 'COPD' for original articles published in any language using the following strategy: rehabilitat* or fitness* or exercis* or physical* or train*

In the first version of this review (Lacasse 1996), 522 publications were retrieved from the computerised search. The review authors reduced this list to 68 potentially eligible papers (quadratic weighted Kappa 0.53, 95% CI 0.45 to 0.61) that were assessed in detail. From this study list, 47 were excluded as the result of wrong population studies (n = 4), intervention not meeting the definition of rehabilitation (n = 7), control group not receiving conventional community care (n = 29), trials not randomised (n = 7). Both primary review authors agreed to include 17 papers in the meta‐analysis (quadratic Kappa 0.89, 95% CI 0.65 to 1.00). Six of the 14 RCTs included in the original meta‐analysis (Lacasse 1996) were not uncovered by this literature search. Therefore, a total of 23 randomised controlled trials were included. This represents an addition of nine RCTs to the meta‐analysis published in 1996 (Lacasse 1996). We contacted the authors of these trials for any additional information required; response rate was 91% (21/23).

An updated search for the review was undertaken in October 2004, which identified an additional 998 references. These were filtered to a list of 139 references, which were considered in the update of the review. Of these, 93 studies failed to meet the inclusion criteria. The original version of the review as previously indicated had included 23 trials. From the updated search (2004), eight additional RCTs (represented by 17 references) met the inclusion criteria of the review (Behnke 2000a; Boxall 2005; Casaburi 2004; Chlumsky 2001; Finnerty 2001; Güell 1998; Singh 2003; Xie 2003). Six papers were awaiting assessment (Corrado 1995: published as conference abstract; Fernández 1998: paper not available; Shu 1998: published as conference abstract; Tregonning 2000: published as conference abstract; Ward 1999: published as conference abstract; Wright 2002: unclear study methods). One trial was ongoing (Whiteford 2004). As an outcome of the update in 2004, a total of 31 RCTs (represented by 65 references) contributed to the meta‐analysis.

Appendix 2. Sources and search methods for the Cochrane Airways Group Specialised Register (CAGR)

Electronic searches: core databases

Database

Frequency of search

CENTRAL

Monthly

MEDLINE (Ovid)

Weekly

EMBASE (Ovid)

Weekly

PsycINFO (Ovid)

Monthly

CINAHL (EBSCO)

Monthly

AMED (EBSCO)

Monthly

 

Handsearches: core respiratory conference abstracts

Conference

Years searched

American Academy of Allergy, Asthma and Immunology (AAAAI)

2001 onwards

American Thoracic Society (ATS)

2001 onwards

Asia Pacific Society of Respirology (APSR)

2004 onwards

British Thoracic Society Winter Meeting (BTS)

2000 onwards

Chest Meeting

2003 onwards

European Respiratory Society (ERS)

1992, 1994, 2000 onwards

International Primary Care Respiratory Group Congress (IPCRG)

2002 onwards

Thoracic Society of Australia and New Zealand (TSANZ)

1999 onwards

 

MEDLINE search strategy used to identify trials for the CAGR

COPD search

1. Lung Diseases, Obstructive/

2. exp Pulmonary Disease, Chronic Obstructive/

3. emphysema$.mp.

4. (chronic$ adj3 bronchiti$).mp.

5. (obstruct$ adj3 (pulmonary or lung$ or airway$ or airflow$ or bronch$ or respirat$)).mp.

6. COPD.mp.

7. COAD.mp.

8. COBD.mp.

9. AECB.mp.

10. or/1‐9

Filter to identify RCTs

1. exp "clinical trial [publication type]"/

2. (randomised or randomised).ab,ti.

3. placebo.ab,ti.

4. dt.fs.

5. randomly.ab,ti.

6. trial.ab,ti.

7. groups.ab,ti.

8. or/1‐7

9. Animals/

10. Humans/

11. 9 not (9 and 10)

12. 8 not 11

The MEDLINE strategy and RCT filter are adapted to identify trials in other electronic databases

Appendix 3. Search strategy to identify relevant trials from the CAGR

#1 MeSH DESCRIPTOR Pulmonary Disease, Chronic Obstructive Explode All

#2 MeSH DESCRIPTOR Bronchitis, Chronic

#3 (obstruct*) near3 (pulmonary or lung* or airway* or airflow* or bronch* or respirat*)

#4 COPD:MISC1

#5 (COPD OR COAD OR COBD):TI,AB,KW

#6 #1 OR #2 OR #3 OR #4 OR #5

#7 MeSH DESCRIPTOR Rehabilitation

#8 MeSH DESCRIPTOR Respiratory Therapy

#9 rehabilitat*

#10 fitness*

#11 exercis*

#12 train*

#13 #7 or #8 or #9 or #10 or #11 or #12

#14 #6 and #13

[Note: in search line #4, MISC1 denotes the field in which the reference has been coded for condition, in this case, COPD]

Appendix 4. Exclusion criteria used to sort and categorise references

Exclusion criteria

Less than 90% of participants have a diagnosis of COPD

Not a programme, or programme does NOT contain any exercise component

Has an exercise component but is NOT aerobically demanding

Programme of less than 4 weeks' duration

Control received more than conventional care

Includes ventilated patients (hospital ventilated)

Within 4 weeks post exacerbation

This citation linked to main study paper already being screened

Duplicate citation (identical to a citation previously included)

The intervention is a medication

Appendix 5. Eligibility classification allocated to studies

Classification

Action

Excluded

Study excluded

Important article but not to be included in review

Study excluded

Included but needs translation

Study included and proceeds to next stage

Included

Study included and proceeds to next stage

More information needed before inclusion decision

Awaiting additional information before study proceeds

Appendix 6. Risk of bias domains and judgements

Sequence generation (possible selection bias)

A detailed description of the methods used to generate the allocation sequence was developed for each study to facilitate an assessment of whether it should produce comparable groups.

Risk of bias for sequence generation was graded based on the following:

  • low risk (any truly random process, e.g. random number table; computer random number generator);

  • high risk (any non‐random process, e.g. odd or even date of birth; hospital or clinic record number); or

  • unclear risk.

Allocation concealment (possible selection bias)

A description of the methods used to conceal the allocation sequence for each study was presented, and this determined whether the intervention allocation might have been anticipated in advance of, or during, recruitment, or changed after assignment.

Risk of bias associated with allocation concealment was graded as follows:

  • low risk (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);

  • high risk (open random allocation; unsealed or non‐opaque envelopes, alternation; date of birth); or

  • unclear risk.

Blinding of participants and personnel (possible performance bias)

The nature of the interventions involved in pulmonary rehabilitation would make it highly unlikely or impossible to blind participants or personnel delivering the interventions.

However, it would be possible to blind outcome assessors. Therefore, we assessed the risk of bias for blinding of outcome assessors as:

  • high risk;

  • low risk; or

  • unclear risk.

Blinding of outcome assessment (checking for possible detection bias)

We will describe for each included study the methods used, if any, to blind outcome assessors from knowledge

of which intervention participants received. We will assess the risk of bias for blinding of outcome assessment as:

  • low risk;

  • high risk; or

  • unclear risk.

Incomplete outcome data (possible attrition bias associated with withdrawals, drop‐outs, deviations from original protocol)

A description of completeness of data for each outcome at all stages of the study was presented. This included examining attrition and exclusions from the analysis. Each study was examined to identify whether attrition and exclusions were reported (comparing the numbers presented at each stage with the total number of randomised participants). The studies were also examined for rationale and justifications explaining any attrition or exclusions. In instances where enough information could be identified or was obtained from the trial authors, we re‐included missing data in the analyses. We assessed the risk of bias for completeness of data as follows:

  • low risk (20% or less missing data);

  • high risk (more than 20% missing data); or

  • unclear risk.

Selective reporting bias

Studies were examined for selective outcome reporting bias by cross‐checking that all outcomes identified in the methods section of the results publication were reported in the results section of the trial publication(s).

The risk of bias for selective reporting was graded as follows:

  • high risk (where not all of the study’s prespecified outcomes had been reported; one or more reported primary outcomes were not prespecified; outcomes of interest were reported incompletely and so cannot be used; study failed to include results of a key outcome that would have been expected to have been reported);

  • low risk (where it was clear that all of the study’s prespecified outcomes and all expected outcomes of interest to the review have been reported); or

  • unclear risk.

Other sources of bias (bias due to problems not covered by the items above)

If the review authors believed that any other possible sources of bias were matters of concern, these were recorded.

The level at which studies were seen to be free of other problems that could put them at risk of bias was graded as:

  • low risk;

  • high risk; or

  • unclear risk.

Overall risk of bias

An overall judgement was made in relation to whether studies were at high risk of bias, according to the criteria given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and identified above. The magnitude of the overall bias, along with the degree to which the bias was likely to have impacted the findings, was assessed for each study using the following grades:

  • low risk;

  • high risk; or

  • unclear risk.

Funnel plot of comparison: 1 Rehabilitation versus usual care, outcome: 1.4 QoL ‐ Change in CRQ (Dyspnoea) (see for Egger and Begg‐Mazumdar: Kendall's test results).
Figures and Tables -
Figure 1

Funnel plot of comparison: 1 Rehabilitation versus usual care, outcome: 1.4 QoL ‐ Change in CRQ (Dyspnoea) (see Table 1 for Egger and Begg‐Mazumdar: Kendall's test results).

Funnel plot of comparison: 1 Rehabilitation versus usual care, outcome: 1.5 QoL ‐ Change in SGRQ (Total) (see for Egger and Begg‐Mazumdar: Kendall's test results).
Figures and Tables -
Figure 2

Funnel plot of comparison: 1 Rehabilitation versus usual care, outcome: 1.5 QoL ‐ Change in SGRQ (Total) (see Table 1 for Egger and Begg‐Mazumdar: Kendall's test results).

Study flow diagram.
Figures and Tables -
Figure 3

Study flow diagram.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 5

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Comparison 1 Rehabilitation versus usual care, Outcome 1 QoL ‐ Change in CRQ (Fatigue).
Figures and Tables -
Analysis 1.1

Comparison 1 Rehabilitation versus usual care, Outcome 1 QoL ‐ Change in CRQ (Fatigue).

Comparison 1 Rehabilitation versus usual care, Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
Figures and Tables -
Analysis 1.2

Comparison 1 Rehabilitation versus usual care, Outcome 2 QoL ‐ Change in CRQ (Emotional Function).

Comparison 1 Rehabilitation versus usual care, Outcome 3 QoL ‐ Change in CRQ (Mastery).
Figures and Tables -
Analysis 1.3

Comparison 1 Rehabilitation versus usual care, Outcome 3 QoL ‐ Change in CRQ (Mastery).

Comparison 1 Rehabilitation versus usual care, Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).
Figures and Tables -
Analysis 1.4

Comparison 1 Rehabilitation versus usual care, Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).

Comparison 1 Rehabilitation versus usual care, Outcome 5 QoL ‐ Change in SGRQ (Total).
Figures and Tables -
Analysis 1.5

Comparison 1 Rehabilitation versus usual care, Outcome 5 QoL ‐ Change in SGRQ (Total).

Comparison 1 Rehabilitation versus usual care, Outcome 6 QoL ‐ Change in SGRQ (Symptoms).
Figures and Tables -
Analysis 1.6

Comparison 1 Rehabilitation versus usual care, Outcome 6 QoL ‐ Change in SGRQ (Symptoms).

Comparison 1 Rehabilitation versus usual care, Outcome 7 QoL ‐ Change in SGRQ (Impacts).
Figures and Tables -
Analysis 1.7

Comparison 1 Rehabilitation versus usual care, Outcome 7 QoL ‐ Change in SGRQ (Impacts).

Comparison 1 Rehabilitation versus usual care, Outcome 8 QoL ‐ Change in SGRQ (Activity).
Figures and Tables -
Analysis 1.8

Comparison 1 Rehabilitation versus usual care, Outcome 8 QoL ‐ Change in SGRQ (Activity).

Comparison 1 Rehabilitation versus usual care, Outcome 9 Maximal Exercise (Incremental shuttle walk test).
Figures and Tables -
Analysis 1.9

Comparison 1 Rehabilitation versus usual care, Outcome 9 Maximal Exercise (Incremental shuttle walk test).

Comparison 1 Rehabilitation versus usual care, Outcome 10 Maximal Exercise Capacity (cycle ergometer).
Figures and Tables -
Analysis 1.10

Comparison 1 Rehabilitation versus usual care, Outcome 10 Maximal Exercise Capacity (cycle ergometer).

Comparison 1 Rehabilitation versus usual care, Outcome 11 Functional Exercise Capacity (6MWT)).
Figures and Tables -
Analysis 1.11

Comparison 1 Rehabilitation versus usual care, Outcome 11 Functional Exercise Capacity (6MWT)).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 1 QoL ‐ Change in CRQ (Fatigue).
Figures and Tables -
Analysis 2.1

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 1 QoL ‐ Change in CRQ (Fatigue).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
Figures and Tables -
Analysis 2.2

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 3 QoL ‐ Change in CRQ (Mastery).
Figures and Tables -
Analysis 2.3

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 3 QoL ‐ Change in CRQ (Mastery).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).
Figures and Tables -
Analysis 2.4

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 5 QoL ‐ Change in SGRQ (Total).
Figures and Tables -
Analysis 2.5

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 5 QoL ‐ Change in SGRQ (Total).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 6 QoL ‐ Change in SGRQ (Symptoms).
Figures and Tables -
Analysis 2.6

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 6 QoL ‐ Change in SGRQ (Symptoms).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 7 QoL ‐ Change in SGRQ (Impacts).
Figures and Tables -
Analysis 2.7

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 7 QoL ‐ Change in SGRQ (Impacts).

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 8 QoL ‐ Change in SGRQ (Activity).
Figures and Tables -
Analysis 2.8

Comparison 2 Rehabilitation versus usual care (subgroup analysis hospital vs community), Outcome 8 QoL ‐ Change in SGRQ (Activity).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 1 QoL ‐ Change in CRQ (Fatigue).
Figures and Tables -
Analysis 3.1

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 1 QoL ‐ Change in CRQ (Fatigue).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
Figures and Tables -
Analysis 3.2

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 3 QoL ‐ Change in CRQ (Mastery).
Figures and Tables -
Analysis 3.3

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 3 QoL ‐ Change in CRQ (Mastery).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).
Figures and Tables -
Analysis 3.4

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 4 QoL ‐ Change in CRQ (Dyspnoea).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 5 QoL ‐ Change in SGRQ (Total).
Figures and Tables -
Analysis 3.5

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 5 QoL ‐ Change in SGRQ (Total).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 6 QoL ‐ Change in SGRQ (Symptoms).
Figures and Tables -
Analysis 3.6

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 6 QoL ‐ Change in SGRQ (Symptoms).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 7 QoL ‐ Change in SGRQ (Impacts).
Figures and Tables -
Analysis 3.7

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 7 QoL ‐ Change in SGRQ (Impacts).

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 8 QoL ‐ Change in SGRQ (Activity).
Figures and Tables -
Analysis 3.8

Comparison 3 Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other), Outcome 8 QoL ‐ Change in SGRQ (Activity).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 1 QoL ‐ Change in CRQ (Dyspnoea).
Figures and Tables -
Analysis 4.1

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 1 QoL ‐ Change in CRQ (Dyspnoea).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).
Figures and Tables -
Analysis 4.2

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 2 QoL ‐ Change in CRQ (Emotional Function).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 3 QoL ‐ Low Risk CRQ (Fatigue).
Figures and Tables -
Analysis 4.3

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 3 QoL ‐ Low Risk CRQ (Fatigue).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 4 QoL ‐ Low Risk CRQ (Mastery).
Figures and Tables -
Analysis 4.4

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 4 QoL ‐ Low Risk CRQ (Mastery).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 5 QoL ‐ Low Risk SGRQ (Total).
Figures and Tables -
Analysis 4.5

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 5 QoL ‐ Low Risk SGRQ (Total).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 6 QoL ‐ Low Risk SGRQ (Symptoms).
Figures and Tables -
Analysis 4.6

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 6 QoL ‐ Low Risk SGRQ (Symptoms).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 7 QoL ‐ Low Risk SGRQ (Impacts).
Figures and Tables -
Analysis 4.7

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 7 QoL ‐ Low Risk SGRQ (Impacts).

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 8 QoL ‐ Low Risk SGRQ (Activity).
Figures and Tables -
Analysis 4.8

Comparison 4 Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome), Outcome 8 QoL ‐ Low Risk SGRQ (Activity).

Summary of findings for the main comparison. Rehabilitation versus usual care for chronic obstructive pulmonary disease

Rehabilitation versus usual care for chronic obstructive pulmonary disease

Patient or population: patients with chronic obstructive pulmonary disease
Settings: hospital and community
Intervention: rehabilitation versus usual care

Outcomes

Illustrative comparative effects* (95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Response on control

Treatment effect

Usual care

Rehabilitation versus usual care

QoL ‐ Change in CRQ (dyspnoea)
CRQ Questionnaire. Scale from 1 to 7

(Higher is better and 0.5 unit is an important difference)
Follow‐up: median 12 weeks

Median change = 0 units

Mean QoL ‐ change in CRQ (Dyspnoea) in the intervention groups was
0.79 units higher
(0.56 to 1.03 higher)

1283
(19 studies)

⊕⊕⊕⊝
Moderate1,2,3

Sensitivity analysis from studies at lower risk of bias was similar (MD 0.99, 95% CI 0.64 to 1.34; participants = 384; studies = 5; I2 = 34%)

QoL ‐ Change in SGRQ (total)
Scale from 0 to 100

(Lower is better and 4 units is an important difference)
Follow‐up: median 12 weeks

Median change = 0.42 units

Mean QOL ‐ change in SGRQ (total) in the intervention groups was
6.89 units lower
(9.26 to 4.52 lower)

1146
(19 studies)

⊕⊕⊕⊝
Moderate2,3,4

Sensitivity analysis from studies at lower risk of bias was similar (MD ‐5.15, 95% CI ‐7.95 to ‐2.36; participants = 572; studies = 7; I2 = 51%)

Change in maximal exercise (Incremental Shuttle walk test (ISWT))
Distance metres
Follow‐up: median 12 weeks

Median change = 1 metre

Mean maximal exercise (incremental shuttle walk test) in the intervention groups was
39.77 metres higher
(22.38 to 57.15 higher)

694
(8 studies)

⊕⊕⊕⊝
Moderate2,3,5

Change in functional exercise capacity (6MWT))
Distance metres
Follow‐up: median 12 weeks

Median change = 3.4 metres

Mean functional exercise capacity (6MWT)) in the intervention groups was
43.93 metres higher
(32.64 to 55.21 higher)

1879
(38 studies)

⊕⊝⊝⊝
Very low2,3,6,7

Change in maximal exercise capacity (cycle ergometer)
Workmax (watt)
Follow‐up: median 12 weeks

Median change = ‐0.05 watts

Mean maximal exercise capacity (cycle ergometer) in the intervention groups was
6.77 watts higher
(1.89 to 11.65 higher)

779
(16 studies)

⊕⊕⊝⊝
Low2,3,8,9

*The basis for the response on control is the median control group response across studies.
CI: confidence interval; MD: mean difference.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

117 studies reported random sequence generation (1 unclear), 12 reported allocation concealment 2 did not have allocation concealment and it is unclear in 5 studies. 4 studies did not blind assessors, 11 blinded assessors and 4 were unclear as to assessor blinding. 6 studies had attrition bias greater than 20%.
2Downgraded as there is a high level of heterogeneity within the results. Several factors may impact heterogeneity, including content of the intervention programme, setting of the programme and severity of COPD.
3Greater than optimal Information size (OIS). 95% confidence interval does not includes "no effect," nor does the confidence limit cross the MID, so no need to downgrade.
418 studies reported random sequence generation (2 unclear), 10 reported allocation concealment, 2 did not have allocation concealment and it is unclear in 7 studies. 3 studies did not blind assessors, 9 blinded assessors and 7 were unclear as to assessor blinding. 7 studies had attrition bias greater than 20%.
5All 8 studies reported random sequence generation, 5 reported allocation concealment and it is unclear in 3 studies. 5 studies had blind assessors with 1 not blinded, and 2 were unclear as to assessor blinding. 4 studies had attrition bias greater than 20%.
634 studies reported random sequence generation, 4 were unclear, 20 reported allocation concealment, 3 did not have allocation concealment and it is unclear in 15 studies. 5 studies did not blind assessors, 19 blinded assessors and 13 were unclear as to assessor blinding. 13 studies had attrition bias greater than 20% and 2 were unclear.
7Downgraded as bias indicated for 6‐minute walk test: Egger: bias = 1.24304 (95% CI = 0.183967 to 2.302131; P value 0.0227). Begg‐Mazumdar: Kendall's tau = 0.16074 (P value 0.1601).
8All 16 studies reported random sequence generation, 6 reported allocation concealment, 3 did not have allocation concealment and it is unclear in 7 studies. 2 studies did not blind assessors, 10 blinded assessors and 4 were unclear as to assessor blinding. 4 studies had attrition bias greater than 20%.
9Downgraded as bias indicated for cycle ergometer test: Egger: bias = 1.57164 (95% CI = 0.6053 to 2.337984; P value 0.0036). Begg‐Mazumdar: Kendall's tau = ‐0.2666667 (P value 0.139).

Figures and Tables -
Summary of findings for the main comparison. Rehabilitation versus usual care for chronic obstructive pulmonary disease
Table 1. Publication bias: results of Egger and Begg‐Mazumdar Kendall's tests

CRQ Fatigue

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.22807; P value 0.1863

Egger: bias = 1.61189 (95% CI = ‐0.194745 to 3.418525); P value 0.077

CRQ Emotional

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.204678; P value 0.2378

Egger: bias = 0.997332 (95% CI = ‐0.618039 to 2.612702); P value 0.2101

CRQ Mastery

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.146199; P value 0.4063

Egger: bias = 1.531134 (95% CI = ‐0.268167 to 3.330434); P value 0.0904

CRQ Dyspnoea

(see Figure 1 for funnel plot)

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.274854; P value 0.1082

Egger: bias = 1.275427 (95% CI = ‐0.761574 to 3.312427); P value 0.204

SGRQ Total

(see Figure 2 for funnel plot)

Bias indicators

Begg‐Mazumdar: Kendall's tau = ‐0.052632; P value 0.73

Egger: bias = ‐0.459813 (95% CI = ‐2.086751 to 1.167125); P value 0.5588

SGRQ Symptoms

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.017544; P value 0.945

Egger: bias = 0.076734 (95% CI = ‐1.241745 to 1.395213); P value 0.9037

SQRQ Activity

Bias indicators

Begg‐Mazumdar: Kendall's tau = ‐0.052632; P value 0.73

Egger: bias = ‐0.336937 (95% CI = ‐2.10096 to 1.427086); P value 0.692

6MWT

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.16074; P value 0.1601

Egger: bias = 1.24304 (95% CI = 0.183967 to 2.302131); P value 0.0227

Incremental Shuttle Walk Test

Bias indicators

Begg‐Mazumdar: Kendall's tau = 0.0776906; P value 0.846

Egger: bias = ‐0.21 2523 (95% CI = ‐2.7776 to 2.351859); P value 0.846

Cycle Ergometer

Bias indicators

Begg‐Mazumdar: Kendall's tau = ‐0.2666667; P value 0.139
Egger: bias = 1.57164 (95% CI = 0.6053 to 2.337984); P value 0.0036

Figures and Tables -
Table 1. Publication bias: results of Egger and Begg‐Mazumdar Kendall's tests
Table 2. Baseline characteristics

Study

Rehab sample size

Male

Female

Mean age (SD)

FEV1 (SD)

Control sample size

Male

Female

Mean age (SD)

FEV1 (SD)

Barakat 2008

35

na

na

63.7

41.9

36

na

na

65.9

43.3

Baumann 2012

37

na

na

65

45

44

na

na

63

47

Behnke 2000a

23

12

3

64.0 (1)

34.1 (7.4)

23

11

4

68.0 (2.2)

37.5 (6.6)

Bendstrup 1997

27

7

9

64 (3)

1.02 L/min (0.06)

20

7

9

65 (2)

1.04 L/min (0.07)

Booker 1984

32

na

na

66 (8)

0.85 L (0.29)

37

na

na

65 (7)

0.97 L (0.37)

Borghi‐Silva 2009

20

13

7

67 (10)

33 (9)

14

12

8

67(10)

35 (11)

Boxall 2005

23

11

12

77.6 (7.6)

40.5 (15.9)

23

15

8

75.8 (8.1)

37.7 (15.0)

Busch 1988

7

5

2

65 (16)

26% (9)

7

6

1

66 (16)

27% (11)

Cambach 1997

15

7

8

62 (5)

59% (16)

8

6

2

62 (9)

60% (23)

Casaburi 2004

12

12

0

69 (10)

36% (9)

12

12

0

68 (9)

39% (12)

Casey 2013

178

117

61

68.8 (10.2)

57.6 (14.3)

172

106

66

68.4 (10.3)

59.7 (13.8)

Cebollero 2012

28

28

0

68 (7)

47.8 (5)

8

8

0

69(5)

38.7 (5)

Chan 2011

69

61

8

73.6 (7.5)

91 (0.39)

67

58

9

73.6 (7.4)

89 (0.39)

Chlumsky 2001

13

12

1

63 (11)

43% (21)

6

5

1

65 (13)

51% (17)

Clark 1996

32

na

na

58 (8)

1.72 L (0.83)

16

na

na

55 (8)

1.44 L (0.59)

Cochrane 2006

74

32

42

na

na

50

18

32

na

na

Cockcroft 1981

18

18

0

61 (5)

1.53 L (0.70)

16

16

0

60 (5)

1.32 L (0.44)

De Souto Araujo 2012

21

12

9

59

39.2 (11.4)

/43.9 (10.3)

11

8

3

71.1

45.1 (12.6)

Deering 2011

25

11

14

67.7 (5.3)

77.0 (19)

19

8

8

68.6 (5.5)

45.8 (18.3)

Elci 2008

39

33

6

59.67 (8.6)

47.7

39

33

6

58.08 (11.45)

46.28

Emery 1998

25

15

14

65 (6)

1.29 L (0.63)

25

12

13

67 (7)

1.02 L (0.37)

Engström 1999

26

14

12

66 (5)

31% (11)

24

12

12

67 (5)

34% (10)

Faager 2004

10

3

7

72 (9)

26 (7)

10

3

7

70 (8)

28 (6)

Faulkner 2010

10

na

na

na

na

10

na

na

na

na

Fernandez 2009

30

29

1

66 (8)

33 (10)

20

20

0

70 (5)

38 (12)

Finnerty 2001

36

25

11

70 (8)

41% (19)

29

19

10

68 (10)

41% (16)

Gohl 2006

17

6

4

62.5 (7)

53.4 (10.7)

17

7

2

53.7 (5.8)

63.2 (8.5)

Goldstein 1994

38

21

17

66 (7)

35% (15)

40

17

23

65 (8)

35% (12)

Gosselink 2000

37

31

6

60 (9)

41% (16)

33

30

3

63 (7)

43% (12)

Gottlieb 2011

35

7

15

74.1 (66–82)

64.27 (7.9)

26

7

13

73.2 (67–88)

67.05 (8.8)

Griffiths 2000

93

57

37

68 (8)

40% (16)

91

54

37

68 (8)

39% (16)

Gurgun 2013

30

28

28

64.0 (10.8)

41.9 (10.8)

16

15

1

67.8 (6.6)

39.3 (9.3)

Güell 1995

30

30

30

64 (7)

31% (12)

30

30

0

66 (6)

39% (14)

Güell 1998

18

16

2

68 (8)

32% (11)

17

17

0

66 (8)

38% (15)

Hernandez 2000

20

20

0

64 (8)

71.1 (18.9)

17

17

0

63 (7)

74.7 (14.7)

Hoff 2007

6

4

2

62.8 (1.4)

49.9 (4.6)

6

4

2

60.6 (3.0)

45.2 (6.0)

Jones 1985

8

6

2

64 (6)

0.78 L (0.27)

6

1

5

63 (8)

0.68 L (0.12)

Karapolat 2007

26

21

5

64.81 (9.4)

55.50%

19

18

1

67.21 (6.72)

58%

Lake 1990

7

6

1

66.3 (6.8)

0.83 L (0.25)

7

4

3

65.7 (3.5)

0.97 L (0.29)

Lindsay 2005

25

20

5

69.5 (9.3)

0.9 L (0.3)

25

18

7

69.8 (10.3)

0.8 L (0.4)

Liu 2012

36

26

10

61.34 (8.3)

61.27 (5.86)

36

29

7

62.2 (6.34)

61.43 (6.17)

McGavin 1977

12

12

0

61 (6)

0.97 L (0.33)

12

12

0

57 (8)

1.15 L (0.72)

McNamara 2013

38

18

15

72 (10)

60 (10)

15

8

7

70 (9)

55 (20)

Mehri 2007

20

11

9

52.1 (10.7)

na

18

7

11

52.17 (11.6)

na

Mendes De Oliveira 2010

56

46

10

66.4/71.3

47.5/ 51.5

29

19

10

70.8

41.4

Nalbant 2011

14

11

3

73.5

58.5 (48‐65)

15

13

2

68

57 (44‐66)

O'Shea 2007

27

na

na

66.9 (7)

49

27

na

na

68.4 (9.9)

52

Ozdemir 2010

25

25

0

60.9 (8.8)

54.5 (15.6)

25

25

0

64.1 (8.9)

54.1 (20.2)

Paz‐Diaz 2007

10

6

4

67 (5)

34 (11)

14

12

2

62 (7)

30 (9)

Petty 2006

149

80

69

68.8 (9.2)

na

73

40

33

66.8 (9.9)

na

Reardon 1994

10

5

5

66 (8)

35% (10)

10

5

5

66 (7)

33% (15)

Ringbaek 2000

24

1

23

62 (7)

50% (17)

21

6

15

65 (8)

44% (14)

Gomez 2006

64

39

9

64.1/64.9

74 (66.5‐81.5)

33

19

4

63.4

60.1 (55.6‐64.4)

Simpson 1992

14

5

9

73 (5)

40% (19)

14

10

4

70 (6)

39% (21)

Singh 2003

20

na

na

na

28 (7.5)

20

na

na

na

26 (7.1)

Sridhar 2008

61

30

31

69.9 (9.6)

42.9 (15.5)

61

30

31

69.68 (10.4)

48.9 (18.69)

Strijbos 1996

15

14

1

61 (6)

40% (20)

15

12

3

63 (5)

43% (9)

Theander 2009

15

3

9

66

35.1 (7.6)

15

10

4

64

32.3 (9.5)

Vallet 1994

10

7

3

60 (9)

57.2

10

8

2

58 (6)

55.7

Van Wetering 2010

102

72

30

65.9 (8.8)

58 (17)

97

69

28

67.2 (8.9)

60 (15)

Vijayan 2010

16

na

na

na

na

15

na

na

na

na

Weiner 1992

12

6

6

67 (9)

32.8 (3)

12

5

7

61 (9)

39.2 (2.8)

Wen 2008

32

31

1

67 (7)/68 (7)

46 (10)/50 (14)

9

9

0

66(10)

52 (14)

Wijkstra 1994

28

23

5

64 (5)

44% (11)

15

14

1

62 (5)

45% (9)

Xie 2003

25

22

3

54 (6)

42% (16)

25

21

4

54 (6)

40% (17)

na: not available.

Figures and Tables -
Table 2. Baseline characteristics
Table 3. Study design

Study

Follow‐up

Duration

(weeks)

Setting

Programme

type

Barakat 2008

14 weeks

14

Outpatient

Exercise + other

Baumann 2012

6 months

8

Community

Exercise + other

Behnke 2000a

3, 6 months

24

Inpatient

Exercise + other

Bendstrup 1997

12, 24 weeks

12

Outpatient

Exercise

Booker 1984

3, 6, 12 months

9

Home

Exercise + other

Borghi‐Silva 2009

6 weeks

6

Outpatient

Exercise

Boxall 2005

12 weeks

12

Home

Exercise + other

Busch 1988

18 weeks

18

Home

Exercise

Cambach 1997

3 months

12

Community

Exercise + other

Casaburi 2004

10 weeks

10

Outpatient

Exercise + other

Casey 2013

12 weeks

8

Community

Exercise + other

Cebollero 2012

12 weeks

12

Outpatient

Exercise

Chan 2011

3 months

12

Community

Exercise

Chlumsky 2001

8 weeks

8

Outpatient

Exercise

Clark 1996

12 weeks

12

Home

Exercise

Cochrane 2006

6 weeks, 6 months, 12 months

6

Outpatient

Exercise + other

Cockcroft 1981

2, 6 months

6

Outpatient

Exercise

De Souto Araujo 2012

8 weeks

8

Community

Exercise

Deering 2011

8 weeks

7

Outpatient

Exercise + other

Elci 2008

1, 3 months

12

Community

/Home

Exercise + other

Emery 1998

10 weeks

10

Outpatient

Exercise + other

Engström 1999

12 months

52

Outpatient

/Home

Exercise + other

Faager 2004

8 weeks, 6 months

8

Inpatient

/Home

Exercise + other

Faulkner 2010

week 9

8

Community

Exercise + other

Fernandez 2009

1 year

52

Home

Exercise + other

Finnerty 2001

12, 24 weeks

6

Outpatient

Exercise + other

Gohl 2006

12 months

52

Community

Exercise

Goldstein 1994

24 weeks

8

Inpatient

Exercise + other

Gosselink 2000

6, 18 months

24

Outpatient

Exercise

Gottlieb 2011

6 months

7

Community

Exercise + other

Griffiths 2000

1 year

6

Outpatients

/Home

Exercise + other

Gomez 2006

3, 6 months

12

Community

Exercise + other

Güell 1995

3, 6, 9, 12, 18, 24 months

12

Outpatient

/Home

Exercise

Güell 1998

8 weeks

8

Outpatient

Exercise

Gurgun 2013

8 weeks, 6 months

8

Outpatient

Exercise + other

Hernandez 2000

12 weeks

12

Home

Exercise

Hoff 2007

8 weeks

8

Outpatient

Exercise

Jones 1985

10 weeks

10

Home

Exercise

Karapolat 2007

8, 12 weeks

8

Outpatient

Exercise + other

Lake 1990

8 weeks

8

Outpatient

Exercise

Lindsay 2005

6 weeks, 3 months

6

Community

Exercise + other

Liu 2012

6 months

24

Inpatient

/Home

Exercise

McGavin 1977

14 weeks

?12

Home

Exercise

McNamara 2013

8 weeks

8

Outpatient

Exercise

Mehri 2007

4 weeks

4

Outpatient

Exercise

Mendes De Oliveira 2010

12 weeks

12

Outpatient

/Home

Exercise + other

Nalbant 2011

3, 6 months

24

Nursing home

Exercise + other

O'Shea 2007

3, 6 months

12

Outpatient

/Home

Exercise

Ozdemir 2010

1 month

4

Outpatient

Exercise

Paz‐Diaz 2007

8 weeks

8

Outpatient

Exercise

Petty 2006

8 weeks

8

Home

Exercise + other

Reardon 1994

6 weeks

6

Outpatient

Exercise + other

Ringbaek 2000

8 weeks

8

Outpatient

Exercise + other

Simpson 1992

8 weeks

8

Outpatient

Exercise

Singh 2003

4 weeks

4

Home

Exercise

Sridhar 2008

6 months

6

Outpatients

/Home

Exercise + other

Strijbos 1996

3, 6, 12, 18 months

12

Outpatient

Exercise + other

Theander 2009

12 weeks

12

Outpatient

/Home

Exercise + other

Vallet 1994

8 weeks

8

Inpatient

Exercise

Van Wetering 2010

4 months

12

Community

Exercise + other

Vijayan 2010

Unclear

6

Unclear

Exercise

Weiner 1992

6 months

24

Outpatient

Exercise

Wen 2008

12 weeks

12

Outpatient

Exercise

Wijkstra 1994

12 weeks

12

Outpatient

/Home

Exercise + other

Xie 2003

12 weeks

12

Home

Exercise

Figures and Tables -
Table 3. Study design
Table 4. Summary of subgroup analysis

Pulmonary rehabilitation versus usual care. Subgroup: community versus hospital‐delivered programme

Outcome

Subscale

Subgroups

Heterogeneity

MD [95% CI]

Test for subgroup differences

CRQ

Fatigue

Community

Tau² = 0.10; I² = 52%

0.44 [0.14, 0.75]

Chi² = 3.98, df = 1 (P value 0.05), I² = 74.9%

Hospital

Tau² = 0.09; I² = 51%

0.86 [0.58, 1.14]

CRQ

Emotional Function

Community

Tau² = 0.00; I² = 0%

0.21 [0.04, 0.39]

Chi² = 12.24, df = 1 (P value 0.0005), I² = 91.8%

Hospital

Tau² = 0.06; I² = 39%

0.77 [0.51, 1.03]

CRQ

Mastery

Community

Tau² = 0.07; I² = 45%

0.40 [0.12, 0.67]

Chi² = 8.58, df = 1 (P value 0.003), I² = 88.3%

Hospital

Tau² = 0.05; I² = 31%

0.95 [0.70, 1.20]

CRQ

Dyspnoea

Community

Tau² = 0.03; I² = 26%

0.58 [0.34, 0.81]

Chi² = 4.05, df = 1 (P value 0.04), I² = 75.3%

Hospital

Tau² = 0.17; I² = 60%

0.99 [0.66, 1.32]

SGRQ

Total

Community

Tau² = 24.00; I² = 73%

‐8.15 [‐12.16, ‐4.13]

Chi² = 0.69, df = 1 (P value 0.41), I² = 0%

Hospital

Tau² = 6.41; I² = 35%

‐6.05 [‐8.91, ‐3.20]

SGRQ

Symptoms

Community

Tau² = 6.28; I² = 24%

‐3.66 [‐7.07, ‐0.24]

Chi² = 1.65, df = 1 (P value 0.20), I² = 39.2%

Hospital

Tau² = 4.96; I² = 15%

‐6.91 [‐10.51, ‐3.30]

SGRQ

Impact

Community

Tau² = 19.91; I² = 63%

‐8.17 [‐12.00, ‐4.34]

Chi² = 0.46, df = 1 (P value 0.50), I² = 0%

Hospital

Tau² = 22.39; I² = 58%

‐6.21 [‐10.33, ‐2.09]

SGRQ

Activity

Community

Tau² = 48.91; I² = 78%

‐7.82 [‐13.37, ‐2.28]

Chi² = 0.93, df = 1 (P value 0.33), I² = 0%

Hospital

Tau² = 10.45; I² = 36%

‐4.58 [‐8.16, ‐1.00]

Pulmonary rehabilitation versus usual care. Subgroup: exercise only programme versus exercise plus additional elements in programme

Outcome

Subscale

Subgroups

Heterogeneity

MD [95% CI]

Test for subgroup differences

CRQ

Fatigue

Exercise only

Tau² = 0.00; I² = 0%

0.73 [0.54, 0.92]

Chi² = 0.26, df = 1 (P value 0.61), I² = 0%

Exercise + other

Tau² = 0.29; I² = 79%

0.61 [0.18, 1.03]

CRQ

Emotional Function

Exercise only

Tau² = 0.00; I² = 0%

0.51 [0.31, 0.71]

Chi² = 0.09, df = 1 (P value 0.77), I² = 0%

Exercise + other

Tau² = 0.28; I² = 79%

0.58 [0.16, 1.00]

CRQ

Mastery

Exercise only

Tau² = 0.01; I² = 11%

0.66 [0.44, 0.88]

Chi² = 0.12, df = 1 (P value 0.73), I² = 0%

Exercise + other

Tau² = 0.31; I² = 79%

0.74 [0.31, 1.18]

CRQ

Dyspnoea

Exercise only

Tau² = 0.06; I² = 31%

0.83 [0.56, 1.10]

Chi² = 0.13, df = 1 (P value 0.72), I² = 0%

Exercise + other

Tau² = 0.25; I² = 77%

0.74 [0.35, 1.13]

SGRQ

Total

Exercise only

Tau² = 62.83; I² = 70%

‐7.87 [‐16.72, 0.98]

Exercise + other

Tau² = 10.17; I² = 56%

‐6.76 [‐9.19, ‐4.34]

Chi² = 0.06, df = 1 (P value 0.81), I² = 0%

SGRQ

Symptoms

Exercise only

Tau² = 0.00; I² = 0%

‐7.38 [‐12.33, ‐2.44]

Exercise + other

Tau² = 13.88; I² = 41%

‐4.38 [‐7.62, ‐1.15]

Chi² = 0.99, df = 1 (P value 0.32), I² = 0%

SGRQ

Impact

Exercise only

Tau² = 33.34; I² = 63%

‐6.11 [‐12.60, 0.38]

Exercise + other

Tau² = 17.12; I² = 59%

‐7.61 [‐10.64, ‐4.57]

Chi² = 0.17, df = 1 (P value 0.68), I² = 0%

SGRQ

Activity

Exercise only

Tau² = 139.67; I² = 78%

‐9.33 [‐21.66, 2.99]

Chi² = 0.30, df = 1 (P value 0.59), I² = 0%

Exercise + other

Tau² = 18.51; I² = 60%

‐5.79 [‐8.95, ‐2.64]

CRQ: Chronic Respiratory Disease Questionnaire; MD: mean difference; SGRQ: St. George's Respiratory Questionnaire.

Figures and Tables -
Table 4. Summary of subgroup analysis
Comparison 1. Rehabilitation versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 QoL ‐ Change in CRQ (Fatigue) Show forest plot

19

1291

Mean Difference (IV, Random, 95% CI)

0.68 [0.45, 0.92]

2 QoL ‐ Change in CRQ (Emotional Function) Show forest plot

19

1291

Mean Difference (IV, Random, 95% CI)

0.56 [0.34, 0.78]

3 QoL ‐ Change in CRQ (Mastery) Show forest plot

19

1212

Mean Difference (IV, Random, 95% CI)

0.71 [0.47, 0.95]

4 QoL ‐ Change in CRQ (Dyspnoea) Show forest plot

19

1283

Mean Difference (IV, Random, 95% CI)

0.79 [0.56, 1.03]

5 QoL ‐ Change in SGRQ (Total) Show forest plot

19

1146

Mean Difference (IV, Random, 95% CI)

‐6.89 [‐9.26, ‐4.52]

6 QoL ‐ Change in SGRQ (Symptoms) Show forest plot

19

1153

Mean Difference (IV, Random, 95% CI)

‐5.09 [‐7.69, ‐2.49]

7 QoL ‐ Change in SGRQ (Impacts) Show forest plot

19

1149

Mean Difference (IV, Random, 95% CI)

‐7.23 [‐9.91, ‐4.55]

8 QoL ‐ Change in SGRQ (Activity) Show forest plot

19

1148

Mean Difference (IV, Random, 95% CI)

‐6.08 [‐9.28, ‐2.88]

9 Maximal Exercise (Incremental shuttle walk test) Show forest plot

8

694

Mean Difference (IV, Random, 95% CI)

39.77 [22.38, 57.15]

10 Maximal Exercise Capacity (cycle ergometer) Show forest plot

16

779

Mean Difference (IV, Random, 95% CI)

6.77 [1.89, 11.65]

11 Functional Exercise Capacity (6MWT)) Show forest plot

38

1879

Mean Difference (IV, Random, 95% CI)

43.93 [32.64, 55.21]

Figures and Tables -
Comparison 1. Rehabilitation versus usual care
Comparison 2. Rehabilitation versus usual care (subgroup analysis hospital vs community)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 QoL ‐ Change in CRQ (Fatigue) Show forest plot

19

1291

Mean Difference (IV, Random, 95% CI)

0.68 [0.45, 0.92]

1.1 QoL ‐ Community CRQ (Fatigue)

9

648

Mean Difference (IV, Random, 95% CI)

0.44 [0.14, 0.75]

1.2 QoL ‐ Hospital CRQ (Fatigue)

10

643

Mean Difference (IV, Random, 95% CI)

0.86 [0.58, 1.14]

2 QoL ‐ Change in CRQ (Emotional Function) Show forest plot

19

1291

Mean Difference (IV, Random, 95% CI)

0.56 [0.34, 0.78]

2.1 QoL ‐ Community (Emotional Function)

9

648

Mean Difference (IV, Random, 95% CI)

0.21 [0.04, 0.39]

2.2 QoL ‐ Hospital CRQ (Emotional Function)

10

643

Mean Difference (IV, Random, 95% CI)

0.77 [0.51, 1.03]

3 QoL ‐ Change in CRQ (Mastery) Show forest plot

19

1212

Mean Difference (IV, Random, 95% CI)

0.71 [0.47, 0.95]

3.1 QoL ‐ Community CRQ (Mastery)

9

569

Mean Difference (IV, Random, 95% CI)

0.40 [0.12, 0.67]

3.2 QoL ‐ Hospital CRQ (Mastery)

10

643

Mean Difference (IV, Random, 95% CI)

0.95 [0.70, 1.20]

4 QoL ‐ Change in CRQ (Dyspnoea) Show forest plot

19

1283

Mean Difference (IV, Random, 95% CI)

0.82 [0.59, 1.05]

4.1 QoL ‐ Community Based CRQ (Dyspnoea)

8

633

Mean Difference (IV, Random, 95% CI)

0.58 [0.34, 0.81]

4.2 QoL ‐ Hospital Based CRQ (Dyspnoea)

11

650

Mean Difference (IV, Random, 95% CI)

0.99 [0.66, 1.32]

5 QoL ‐ Change in SGRQ (Total) Show forest plot

19

1146

Mean Difference (IV, Random, 95% CI)

‐6.89 [‐9.26, ‐4.52]

5.1 QoL ‐ Community in SGRQ (Total)

9

643

Mean Difference (IV, Random, 95% CI)

‐8.15 [‐12.16, ‐4.13]

5.2 QoL ‐ Hospital SGRQ (Total)

10

503

Mean Difference (IV, Random, 95% CI)

‐6.05 [‐8.91, ‐3.20]

6 QoL ‐ Change in SGRQ (Symptoms) Show forest plot

19

1153

Mean Difference (IV, Random, 95% CI)

‐5.09 [‐7.69, ‐2.49]

6.1 QoL ‐ Community SGRQ (Symptoms)

9

649

Mean Difference (IV, Random, 95% CI)

‐3.66 [‐7.07, ‐0.24]

6.2 QoL ‐ Hospital SGRQ (Symptoms)

10

504

Mean Difference (IV, Random, 95% CI)

‐6.91 [‐10.51, ‐3.30]

7 QoL ‐ Change in SGRQ (Impacts) Show forest plot

19

1149

Mean Difference (IV, Random, 95% CI)

‐7.23 [‐9.91, ‐4.55]

7.1 QoL ‐ Community SGRQ (Impacts)

9

646

Mean Difference (IV, Random, 95% CI)

‐8.17 [‐10.00, ‐4.34]

7.2 QoL ‐ Hospital SGRQ (Impacts)

10

503

Mean Difference (IV, Random, 95% CI)

‐6.21 [‐10.33, ‐2.09]

8 QoL ‐ Change in SGRQ (Activity) Show forest plot

19

1148

Mean Difference (IV, Random, 95% CI)

‐6.08 [‐9.28, ‐2.88]

8.1 QoL ‐ Community SGRQ (Activity)

9

645

Mean Difference (IV, Random, 95% CI)

‐7.82 [‐13.37, ‐2.28]

8.2 QoL ‐ Hospital SGRQ (Activity)

10

503

Mean Difference (IV, Random, 95% CI)

‐4.58 [‐8.16, 1.00]

Figures and Tables -
Comparison 2. Rehabilitation versus usual care (subgroup analysis hospital vs community)
Comparison 3. Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 QoL ‐ Change in CRQ (Fatigue) Show forest plot

19

1291

Mean Difference (IV, Random, 95% CI)

0.68 [0.45, 0.92]

1.1 QoL ‐ Exercise Only CRQ (Fatigue)

10

480

Mean Difference (IV, Random, 95% CI)

0.73 [0.54, 0.92]

1.2 QoL ‐ Exercise + Other CRQ (Fatigue)

9

811

Mean Difference (IV, Random, 95% CI)

0.61 [0.18, 1.03]

2 QoL ‐ Change in CRQ (Emotional Function) Show forest plot

19

1291

Mean Difference (IV, Random, 95% CI)

0.56 [0.34, 0.78]

2.1 QoL ‐ Exercise Only CRQ (Emotional Function)

10

480

Mean Difference (IV, Random, 95% CI)

0.51 [0.31, 0.71]

2.2 QoL ‐ Exercise + Other CRQ (Emotional Function)

9

811

Mean Difference (IV, Random, 95% CI)

0.58 [0.16, 1.00]

3 QoL ‐ Change in CRQ (Mastery) Show forest plot

19

1212

Mean Difference (IV, Random, 95% CI)

0.71 [0.47, 0.95]

3.1 QoL ‐ Exercise Only CRQ (Mastery)

10

480

Mean Difference (IV, Random, 95% CI)

0.66 [0.44, 0.88]

3.2 QoL ‐ Exercise + Other CRQ (Mastery)

9

732

Mean Difference (IV, Random, 95% CI)

0.74 [0.31, 1.18]

4 QoL ‐ Change in CRQ (Dyspnoea) Show forest plot

19

1283

Mean Difference (IV, Random, 95% CI)

0.79 [0.56, 1.03]

4.1 QoL ‐ Exercise Only CRQ (Dyspnoea)

10

474

Mean Difference (IV, Random, 95% CI)

0.83 [0.56, 1.09]

4.2 QoL ‐ Exercise + Other CRQ (Dyspnoea)

9

809

Mean Difference (IV, Random, 95% CI)

0.74 [0.35, 1.13]

5 QoL ‐ Change in SGRQ (Total) Show forest plot

19

1146

Mean Difference (IV, Random, 95% CI)

‐6.89 [‐9.26, ‐4.52]

5.1 QoL Exercise Only SGRQ (Total)

5

230

Mean Difference (IV, Random, 95% CI)

‐7.87 [‐16.72, 0.98]

5.2 QoL Exercise + Other SGRQ (Total)

14

916

Mean Difference (IV, Random, 95% CI)

‐6.76 [‐9.19, ‐4.34]

6 QoL ‐ Change in SGRQ (Symptoms) Show forest plot

19

1153

Mean Difference (IV, Random, 95% CI)

‐5.09 [‐7.69, ‐2.49]

6.1 QoL ‐ Exercise Only SGRQ (Symptoms)

5

230

Mean Difference (IV, Random, 95% CI)

‐7.38 [‐12.33, ‐2.44]

6.2 QoL ‐ Exercise + Other SGRQ (Symptoms)

14

923

Mean Difference (IV, Random, 95% CI)

‐4.38 [‐7.62, ‐1.15]

7 QoL ‐ Change in SGRQ (Impacts) Show forest plot

19

1149

Mean Difference (IV, Random, 95% CI)

‐7.23 [‐9.91, ‐4.55]

7.1 QoL ‐ Exercise Only SGRQ (Impacts)

5

230

Mean Difference (IV, Random, 95% CI)

‐6.11 [‐12.60, 0.38]

7.2 QoL ‐ Exercise + Other SGRQ (Impacts)

14

919

Mean Difference (IV, Random, 95% CI)

‐7.61 [‐10.64, ‐4.57]

8 QoL ‐ Change in SGRQ (Activity) Show forest plot

19

1148

Mean Difference (IV, Random, 95% CI)

‐6.08 [‐9.28, ‐2.88]

8.1 QoL ‐ Exercise Only SGRQ (Activity)

5

230

Mean Difference (IV, Random, 95% CI)

‐9.33 [‐21.66, 2.99]

8.2 QoL ‐ Exercise + Other SGRQ (Activity)

14

918

Mean Difference (IV, Random, 95% CI)

‐5.79 [‐8.95, ‐2.64]

Figures and Tables -
Comparison 3. Rehabilitation versus usual care (subgroup analysis exercise only vs exercise and other)
Comparison 4. Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 QoL ‐ Change in CRQ (Dyspnoea) Show forest plot

5

384

Mean Difference (IV, Random, 95% CI)

0.99 [0.64, 1.34]

1.1 QoL ‐ Low Risk CRQ (Dyspnoea)

5

384

Mean Difference (IV, Random, 95% CI)

0.99 [0.64, 1.34]

2 QoL ‐ Change in CRQ (Emotional Function) Show forest plot

5

386

Mean Difference (IV, Random, 95% CI)

0.60 [0.09, 1.11]

2.1 QoL ‐ Low Risk (Emotional Function)

5

386

Mean Difference (IV, Random, 95% CI)

0.60 [0.09, 1.11]

3 QoL ‐ Low Risk CRQ (Fatigue) Show forest plot

5

386

Mean Difference (IV, Random, 95% CI)

0.90 [0.41, 1.39]

4 QoL ‐ Low Risk CRQ (Mastery) Show forest plot

5

386

Mean Difference (IV, Random, 95% CI)

0.77 [0.28, 1.26]

5 QoL ‐ Low Risk SGRQ (Total) Show forest plot

7

572

Mean Difference (IV, Random, 95% CI)

‐5.15 [‐7.95, ‐2.36]

6 QoL ‐ Low Risk SGRQ (Symptoms) Show forest plot

7

572

Mean Difference (IV, Random, 95% CI)

‐4.12 [‐8.45, 0.21]

7 QoL ‐ Low Risk SGRQ (Impacts) Show forest plot

7

572

Mean Difference (IV, Random, 95% CI)

‐5.92 [‐10.01, ‐1.82]

8 QoL ‐ Low Risk SGRQ (Activity) Show forest plot

7

572

Mean Difference (IV, Random, 95% CI)

‐5.33 [‐8.10, ‐2.57]

Figures and Tables -
Comparison 4. Rehabilitation versus usual care (sensitivity analysis by allocation concealment and incomplete outcome)