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Cochrane Database of Systematic Reviews

Exercise‐based rehabilitation programmes for pulmonary hypertension

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Information

DOI:
https://doi.org/10.1002/14651858.CD011285.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 18 January 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Airways Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Norman R Morris

    Correspondence to: Allied Health Research Collaborative, The Prince Charles Hospital, Chermside, Australia

    [email protected]

    School of Allied Health Sciences and Menzies Health Institute, Griffith University, Nathan, Australia

  • Fiona D Kermeen

    Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia

  • Anne E Holland

    Discipline of Physiotherapy, La Trobe University, Melbourne, Australia

    Department of Physiotherapy, The Alfred Hospital, Melbourne, Australia

Contributions of authors

NM drafted the protocol with the assistance from AH and FK. NM and AH identified studies for the review, extracted data from the studies and drafted the review. All authors provided critical feedback on the review.

Sources of support

Internal sources

  • Griffith University, Australia.

    Salary support, Norman Morris

  • Queensland Health, Australia.

    Salary support, Fiona Kermeen

  • Alfred Health and La Trobe University, Australia.

    Salary support, Anne Holland

External sources

  • The authors declare that no such external funding was received for this systematic review, Other.

Declarations of interest

NM: none known

FK: none known

AH: none known

Acknowledgements

Rebecca Normansell was the Editor for this review and commented critically on the review.

The Background and Methods sections of this review are based on a standard template used by Cochrane Airways.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Airways Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS, or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2023 Mar 22

Exercise‐based rehabilitation programmes for pulmonary hypertension

Review

Norman R Morris, Fiona D Kermeen, Arwel W Jones, Joanna YT Lee, Anne E Holland

https://doi.org/10.1002/14651858.CD011285.pub3

2017 Jan 18

Exercise‐based rehabilitation programmes for pulmonary hypertension

Review

Norman R Morris, Fiona D Kermeen, Anne E Holland

https://doi.org/10.1002/14651858.CD011285.pub2

2014 Oct 10

Exercise‐based rehabilitation programmes for pulmonary hypertension

Protocol

Norman R Morris, Fiona D Kermeen, Anne E Holland

https://doi.org/10.1002/14651858.CD011285

Differences between protocol and review

We had intended to perform a subgroup analysis according to severity of PH, but insufficient data were available. We performed an additional subgroup analysis for setting of exercise rehabilitation programme, as there was marked heterogeneity in exercise outcomes that could have been affected by the programme model.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram
Figures and Tables -
Figure 1

Study flow diagram

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figures and Tables -
Figure 2

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

Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figures and Tables -
Figure 3

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

Forest plot of comparison: 1 Exercise vs control, outcome: 1.1 Exercise capacity: 6MWD
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Exercise vs control, outcome: 1.1 Exercise capacity: 6MWD

Comparison 1 Exercise vs control, Outcome 1 Exercise capacity: 6MWD.
Figures and Tables -
Analysis 1.1

Comparison 1 Exercise vs control, Outcome 1 Exercise capacity: 6MWD.

Comparison 1 Exercise vs control, Outcome 2 Exercise capacity: VO2peak.
Figures and Tables -
Analysis 1.2

Comparison 1 Exercise vs control, Outcome 2 Exercise capacity: VO2peak.

Comparison 1 Exercise vs control, Outcome 3 Exercise capacity: Peak power.
Figures and Tables -
Analysis 1.3

Comparison 1 Exercise vs control, Outcome 3 Exercise capacity: Peak power.

Comparison 1 Exercise vs control, Outcome 4 Exercisecapacity: Anaerobic threshold.
Figures and Tables -
Analysis 1.4

Comparison 1 Exercise vs control, Outcome 4 Exercisecapacity: Anaerobic threshold.

Comparison 1 Exercise vs control, Outcome 5 HRQoL SF36: Physical component score.
Figures and Tables -
Analysis 1.5

Comparison 1 Exercise vs control, Outcome 5 HRQoL SF36: Physical component score.

Comparison 1 Exercise vs control, Outcome 6 HRQoL SF36: Mental component score.
Figures and Tables -
Analysis 1.6

Comparison 1 Exercise vs control, Outcome 6 HRQoL SF36: Mental component score.

Comparison 1 Exercise vs control, Outcome 7 Adverse events.
Figures and Tables -
Analysis 1.7

Comparison 1 Exercise vs control, Outcome 7 Adverse events.

Comparison 1 Exercise vs control, Outcome 8 HRQoL SF36: Physical function.
Figures and Tables -
Analysis 1.8

Comparison 1 Exercise vs control, Outcome 8 HRQoL SF36: Physical function.

Comparison 1 Exercise vs control, Outcome 9 HRQoL SF36: Role physical.
Figures and Tables -
Analysis 1.9

Comparison 1 Exercise vs control, Outcome 9 HRQoL SF36: Role physical.

Comparison 1 Exercise vs control, Outcome 10 HRQoL SF36: Bodily pain.
Figures and Tables -
Analysis 1.10

Comparison 1 Exercise vs control, Outcome 10 HRQoL SF36: Bodily pain.

Comparison 1 Exercise vs control, Outcome 11 HRQoL SF36: General health.
Figures and Tables -
Analysis 1.11

Comparison 1 Exercise vs control, Outcome 11 HRQoL SF36: General health.

Comparison 1 Exercise vs control, Outcome 12 HRQoL SF36: Mental health.
Figures and Tables -
Analysis 1.12

Comparison 1 Exercise vs control, Outcome 12 HRQoL SF36: Mental health.

Comparison 1 Exercise vs control, Outcome 13 HRQoL SF36: Role emotional.
Figures and Tables -
Analysis 1.13

Comparison 1 Exercise vs control, Outcome 13 HRQoL SF36: Role emotional.

Comparison 1 Exercise vs control, Outcome 14 HRQol SF36: Vitality.
Figures and Tables -
Analysis 1.14

Comparison 1 Exercise vs control, Outcome 14 HRQol SF36: Vitality.

Comparison 1 Exercise vs control, Outcome 15 HRQoL SF36: Social function.
Figures and Tables -
Analysis 1.15

Comparison 1 Exercise vs control, Outcome 15 HRQoL SF36: Social function.

Comparison 1 Exercise vs control, Outcome 16 HRQoL: CAMPHOR activities.
Figures and Tables -
Analysis 1.16

Comparison 1 Exercise vs control, Outcome 16 HRQoL: CAMPHOR activities.

Comparison 1 Exercise vs control, Outcome 17 HRQoL: CAMPHOR symptoms.
Figures and Tables -
Analysis 1.17

Comparison 1 Exercise vs control, Outcome 17 HRQoL: CAMPHOR symptoms.

Comparison 1 Exercise vs control, Outcome 18 HRQoL: CAMPHOR QoL.
Figures and Tables -
Analysis 1.18

Comparison 1 Exercise vs control, Outcome 18 HRQoL: CAMPHOR QoL.

Comparison 1 Exercise vs control, Outcome 19 Cardiopulmonary haemodynamics.
Figures and Tables -
Analysis 1.19

Comparison 1 Exercise vs control, Outcome 19 Cardiopulmonary haemodynamics.

Comparison 1 Exercise vs control, Outcome 20 Functional class.
Figures and Tables -
Analysis 1.20

Comparison 1 Exercise vs control, Outcome 20 Functional class.

Comparison 1 Exercise vs control, Outcome 21 B‐type natriuretic peptide.
Figures and Tables -
Analysis 1.21

Comparison 1 Exercise vs control, Outcome 21 B‐type natriuretic peptide.

Comparison 1 Exercise vs control, Outcome 22 Exercise capacity: 6MWD, sensitivity analysis.
Figures and Tables -
Analysis 1.22

Comparison 1 Exercise vs control, Outcome 22 Exercise capacity: 6MWD, sensitivity analysis.

Comparison 1 Exercise vs control, Outcome 23 Exercise capacity: VO2peak, sensitivity analysis.
Figures and Tables -
Analysis 1.23

Comparison 1 Exercise vs control, Outcome 23 Exercise capacity: VO2peak, sensitivity analysis.

Comparison 1 Exercise vs control, Outcome 24 Exercise capacity: Peak power, sensitivity analysis.
Figures and Tables -
Analysis 1.24

Comparison 1 Exercise vs control, Outcome 24 Exercise capacity: Peak power, sensitivity analysis.

Comparison 1 Exercise vs control, Outcome 25 Exercise capacity 6MWD, PAH subgroup only.
Figures and Tables -
Analysis 1.25

Comparison 1 Exercise vs control, Outcome 25 Exercise capacity 6MWD, PAH subgroup only.

Comparison 1 Exercise vs control, Outcome 26 Exercise capacity: VO2peak, PAH subgroup only.
Figures and Tables -
Analysis 1.26

Comparison 1 Exercise vs control, Outcome 26 Exercise capacity: VO2peak, PAH subgroup only.

Comparison 1 Exercise vs control, Outcome 27 Exercise capacity: Peak power, PAH subgroup only.
Figures and Tables -
Analysis 1.27

Comparison 1 Exercise vs control, Outcome 27 Exercise capacity: Peak power, PAH subgroup only.

Comparison 1 Exercise vs control, Outcome 28 Exercise capacity: Anaerobic threshold, PAH subgroup only.
Figures and Tables -
Analysis 1.28

Comparison 1 Exercise vs control, Outcome 28 Exercise capacity: Anaerobic threshold, PAH subgroup only.

Comparison 1 Exercise vs control, Outcome 29 Exercise capacity: 6MWD, subgroup analysis for setting of rehabilitation.
Figures and Tables -
Analysis 1.29

Comparison 1 Exercise vs control, Outcome 29 Exercise capacity: 6MWD, subgroup analysis for setting of rehabilitation.

Summary of findings for the main comparison. Exercise compared to control for pulmonary hypertension

Exercise compared to control for pulmonary hypertension

Patient or population: people with pulmonary hypertension
Settings: inpatient or outpatient rehabilitation, or both
Intervention: exercise training
Comparison: control: people that had usual care and did not undertake exercise training programme

Outcomes

Illustrative comparative effects* (95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Response on control

Treatment effect

Control

Exercise

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

Median change = 5 m

The mean exercise capacity 6MWD in the intervention groups was 60.12 higher
(30.17 to 90.07 higher)

165
(5 studies)

⊕⊕⊝⊝
low1,2

Subgroup PAH: (2 studies, n = 36), mean 6MWD for intervention group was 33.84 m higher (0.95 to 66.73 higher); these studies used outpatient exercise rehabilitation whilst other studies contributing to meta‐analysis had an inpatient training component

Minimal important difference was 30 metres

Exercise capacity: VO2peak

Oxygen uptake, ml/kg/min
Follow‐up median 13.5 weeks

Median change = ‐0.25 ml/kg/min

The mean VO2peak in the intervention groups was 2.41 ml/kg/min higher
(1.38 to 3.44 higher)

145
(4 studies)

⊕⊕⊝⊝
low1,2

Subgroup PAH (2 studies, n = 36), the mean VO2peak in the intervention groups was 1.28 ml/kg/min higher (‐0.19 to 2.75 higher); these two studies used outpatient exercise rehabilitation whilst other studies contributing to meta‐analysis had an inpatient training component

Exercise capacity: peak power

watts
Follow‐up median 13.5 weeks

Median change = 1 watt

The mean exercise capacity: peak power in the intervention groups was 16.44 W higher
(10.90 to 21.99 higher)

145
(4 studies)

⊕⊕⊝⊝
low1,2

Subgroup PAH (2 studies, n = 36), the mean peak power in the intervention groups was 14.24 watts higher (5.78 to 22.70 higher); these two studies used outpatient exercise rehabilitation whilst other studies contributing to meta‐analysis had an inpatient training component

HRQoL SF‐36: PCS

units

Follow‐up median 11 weeks

Median change = ‐0.49 units

The mean HRQoL SF‐36: PCS in the intervention groups was 4.63 higher (0.80 to 8.47 higher)

33
(2 studies)

⊕⊕⊝⊝
low2,3

Both studies were only PAH

HRQoL SF‐36: MCS

units

Follow‐up median 11 weeks

Median change = ‐0.31 units

The mean HRQoL SF‐36: MCS in the intervention groups was 4.17 higher (0.01 to 8.34 higher)

33
(2 studies)

⊕⊕⊝⊝
low2,3

Both studies were only PAH

*The basis for the response on control is the median control group response across studies

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.

1 Two studies did not report random sequence generation, no studies reported allocation concealment
2 Indirectness: 2 studies did not report number of people assessed to achieve sample size; trial participants may represent a highly selected subgroup of people with PH

3 Imprecision (2 small studies of 33 participants) and neither reported allocation concealment

Figures and Tables -
Summary of findings for the main comparison. Exercise compared to control for pulmonary hypertension
Comparison 1. Exercise vs control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Exercise capacity: 6MWD Show forest plot

5

165

Mean Difference (IV, Random, 95% CI)

60.12 [30.17, 90.07]

2 Exercise capacity: VO2peak Show forest plot

4

145

Mean Difference (IV, Random, 95% CI)

2.41 [1.38, 3.44]

3 Exercise capacity: Peak power Show forest plot

4

145

Mean Difference (IV, Random, 95% CI)

16.44 [10.90, 21.99]

4 Exercisecapacity: Anaerobic threshold Show forest plot

3

66

Std. Mean Difference (IV, Random, 95% CI)

1.05 [0.53, 1.58]

5 HRQoL SF36: Physical component score Show forest plot

2

33

Mean Difference (IV, Random, 95% CI)

4.63 [0.80, 8.47]

6 HRQoL SF36: Mental component score Show forest plot

2

33

Mean Difference (IV, Random, 95% CI)

4.17 [0.01, 8.34]

7 Adverse events Show forest plot

5

165

Risk Difference (M‐H, Random, 95% CI)

0.00 [‐0.04, 0.04]

8 HRQoL SF36: Physical function Show forest plot

4

118

Mean Difference (IV, Random, 95% CI)

6.13 [‐3.73, 16.00]

9 HRQoL SF36: Role physical Show forest plot

4

116

Mean Difference (IV, Random, 95% CI)

21.81 [14.40, 29.23]

10 HRQoL SF36: Bodily pain Show forest plot

3

88

Mean Difference (IV, Random, 95% CI)

5.64 [‐3.09, 14.36]

11 HRQoL SF36: General health Show forest plot

3

84

Mean Difference (IV, Random, 95% CI)

5.76 [‐0.80, 12.32]

12 HRQoL SF36: Mental health Show forest plot

3

87

Mean Difference (IV, Random, 95% CI)

6.21 [‐1.85, 14.27]

13 HRQoL SF36: Role emotional Show forest plot

3

87

Mean Difference (IV, Random, 95% CI)

2.79 [‐7.43, 13.01]

14 HRQol SF36: Vitality Show forest plot

4

115

Mean Difference (IV, Random, 95% CI)

13.47 [7.55, 19.40]

15 HRQoL SF36: Social function Show forest plot

4

118

Mean Difference (IV, Random, 95% CI)

14.01 [9.82, 18.21]

16 HRQoL: CAMPHOR activities Show forest plot

2

33

Mean Difference (IV, Random, 95% CI)

‐1.33 [‐3.56, 0.90]

17 HRQoL: CAMPHOR symptoms Show forest plot

2

36

Mean Difference (IV, Random, 95% CI)

‐3.08 [‐7.78, 1.62]

18 HRQoL: CAMPHOR QoL Show forest plot

2

36

Mean Difference (IV, Random, 95% CI)

‐5.42 [‐8.03, ‐2.81]

19 Cardiopulmonary haemodynamics Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

20 Functional class Show forest plot

2

40

Mean Difference (IV, Random, 95% CI)

‐0.60 [‐0.85, ‐0.35]

21 B‐type natriuretic peptide Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

22 Exercise capacity: 6MWD, sensitivity analysis Show forest plot

4

86

Mean Difference (IV, Random, 95% CI)

67.91 [27.12, 108.69]

23 Exercise capacity: VO2peak, sensitivity analysis Show forest plot

3

66

Mean Difference (IV, Random, 95% CI)

1.94 [0.86, 3.01]

24 Exercise capacity: Peak power, sensitivity analysis Show forest plot

3

66

Mean Difference (IV, Random, 95% CI)

15.27 [8.57, 21.97]

25 Exercise capacity 6MWD, PAH subgroup only Show forest plot

2

36

Mean Difference (IV, Random, 95% CI)

33.84 [0.95, 66.73]

26 Exercise capacity: VO2peak, PAH subgroup only Show forest plot

2

36

Mean Difference (IV, Random, 95% CI)

1.28 [‐0.19, 2.75]

27 Exercise capacity: Peak power, PAH subgroup only Show forest plot

2

36

Mean Difference (IV, Random, 95% CI)

14.24 [5.78, 22.70]

28 Exercise capacity: Anaerobic threshold, PAH subgroup only Show forest plot

2

36

Mean Difference (IV, Random, 95% CI)

41.31 [‐52.05, 134.67]

29 Exercise capacity: 6MWD, subgroup analysis for setting of rehabilitation Show forest plot

5

Mean Difference (IV, Random, 95% CI)

Subtotals only

29.1 Inpatient exercise training

3

129

Mean Difference (IV, Random, 95% CI)

72.79 [28.09, 117.49]

29.2 Outpatient exercise training

2

36

Mean Difference (IV, Random, 95% CI)

33.84 [0.95, 66.73]

Figures and Tables -
Comparison 1. Exercise vs control