Exercise-based rehabilitation in pulmonary hypertension

What is pulmonary hypertension? Pulmonary hypertension is a condition in which the blood pressure in the arteries that carry blood from the heart to the lungs is elevated well above normal. Often with a gradual onset, it affects individuals of all ages, significantly reduces quality of life and results in premature death.

Bottom Line. We reviewed randomised controlled trials to determine whether exercise training improved short- and long-term patient outcomes in people with pulmonary hypertension. The number of participants in randomised controlled trials of exercise-based rehabilitation for pulmonary hypertension was relatively small. These studies all reported large increases in exercise capacity as evaluated by six-minute walk distance, maximal oxygen consumption and peak power. Health-related quality of life was also improved, but to a lesser extent. Serious adverse events were rare with only one report of a participant being required to stop exercise training due to feeling lightheaded. There were no reports of death or other adverse events with exercise training.

What evidence did we find and how good was it? The review included six studies on 206 people with pulmonary hypertension and we could combine data from five of these studies. We could only use data for 165 participants, however not all of these data could be included in the analysis for all outcome measures. The majority of studies implemented an inpatient exercise rehabilitation programme with only a small number of studies examining an outpatient programme. The methods used to conduct these trials were of low quality. Given this low-quality evidence, it was not possible to generalise the results of this review across the spectrum of people with pulmonary hypertension.

Authors' conclusions: 

In people with PH, exercise-based rehabilitation results in clinically relevant improvements in exercise capacity. Exercise training was not associated with any serious adverse events. Whilst most studies reported improvements in HRQoL, these may not be clinically important. Overall, we assessed the quality of the evidence to be low. The small number of studies and lack of information on participant selection makes it difficult to generalise these results across the spectrum of people with PH.

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Background: 

Individuals with pulmonary hypertension (PH) have reduced exercise capacity and quality of life. Despite initial concerns that exercise training may worsen symptoms in this group, several studies have reported improvements in functional capacity and well-being following exercise-based rehabilitation in PH.

Objectives: 

To assess the efficacy and safety of exercise-based rehabilitation for people with PH. Primary outcomes were exercise capacity, adverse events during the intervention period and health-related quality of life (HRQoL). Secondary outcomes included cardiopulmonary haemodynamics, functional class, clinical worsening during follow-up, mortality and changes in B-type natriuretic peptide.

Search strategy: 

We searched the Cochrane Airways Specialised Register of Trials up to August 2016, which is based on regular searches of CINAHL, AMED, Embase, PubMed, MEDLINE, PsycINFO and registries of clinical trials. In addition we searched CENTRAL and the PEDro database up to August 2016 and handsearched relevant journals.

Selection criteria: 

All randomised controlled trials (RCTs) focusing on exercise-based rehabilitation programmes for PH.

Data collection and analysis: 

Two reviewers extracted data independently. For binary outcomes, we calculated odds ratios and their 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

Main results: 

We included six RCTs and were able to extract data from five studies. The total number of included participants was 206. The majority of participants were Group I pulmonary artery hypertension (PAH). Study duration ranged from three to 15 weeks. Exercise programmes included both inpatient- and outpatient-based rehabilitation that incorporated both upper and lower limb exercise. The mean six-minute walk distance following exercise training was 60.12 metres higher than control (30.17 to 90.07 metres, n = 165, 5 RCTs, low-quality evidence; minimal important difference was 30 metres), the mean peak oxygen uptake was 2.4 ml/kg/minute higher (1.4 to 3.4 ml/kg/min, n = 145, 4 RCTs, low-quality evidence) and the mean peak power in the intervention groups was 16.4 W higher (10.9 to 22.0 higher, n = 145, 4 RCTs, low-quality evidence). The mean change in HRQoL for the SF-36 physical component score was 4.63 points higher (0.80 to 8.47 points, n = 33, 2 RCTs, low-quality evidence) and for the SF-36 mental component score was 4.17 points higher (0.01 to 8.34 points; n = 33; 2 RCTs, low-quality evidence). One study reported a single adverse event, where a participant stopped exercise training due to lightheadedness.

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