COAD is a progressive and debilitating disease that is often devastating to patients and frustrating for their physicians. The failure of medications alone in treating COAD symptomatically has led to an interest in “comprehensive” pulmonary rehabilitation. Although these interventions vary in many respects, most share two fundamental elements: 1) education about the respiratory system, self-management skills, diet and hydration, and medications and psychologic counseling and/or support (for patients and relatives); and 2) physical therapy and reconditioning. This second element, physical reconditioning leading to increased exercise tolerance, is the cardinal element that distinguishes comprehensive rehabilitation programs from education programs focused on imparting information and skills without exercising patients.
Programs of both types have been evaluated and reported in the literature. Those programs that include physical reconditioning appear to have beneficial effects on health status enhanced by Canadian Health&Care Mall preparations. For example, Petty and coworkers found that their comprehensive rehabilitation programs did not change the natural history of COAD, but did increase tolerance for walking and climbing stairs, decrease hospitalizations, increase gainful employment, reduce some psychologic symptoms (affective distress), and possibly increase survival rate. Haas and Cardon, reporting on a five year evaluation of their comprehensive rehabilitation program, found that, relative to control patients, rehabilitated patients were more likely to assume full time employment, less apt to be placed in nursing homes, and less likely to have died from respiratory disease. Kass noted increased gainful employment among some COAD patients participating in a rehabilitation program; White found increased diaphragmatic and chest wall excursions in some rehabilitated patients; Woolf found that some rehabilitated patients maintained increased exercise tolerance for at least several years.
In contrast, programs without physical exercise have been shown to increase knowledge and change attitudes, but their impact on health outcomes has not been measured. Ashikaga et al, evaluating the health education program we used in our study, report that patients completing the program “had an increase in their perceived understanding and knowledge of COAD, and an improvement in their attitude about disease. They also showed increases in their readiness to seek health care and in their compliance with selfhelp activities.” Black used a self-directed education program to increase COAD patients’ knowledge of their disease. He found that patients using the program scored significantly higher on a knowledge posttest, relative to pretest scores.
As the studies cited above indicate, comprehensive rehabilitation programs that include exercise and reconditioning tend to be evaluated using indicators of health status (including symptoms, activities of daily living and psychosocial status) to measure impact. Programs which are limited to education tend to be evaluated using measures indicative of knowledge or attitudes to gauge effectiveness. Previous research, therefore, does not provide an answer to the question of whether education programs (without physical exercise) can improve patients’ health status.
This question is important because of the difference in cost, intensity and resource requirements between patient education and rehabilitation programs. Education programs can be conducted in the community, sponsored by local agencies, and use allied health personnel for staff. In contrast, comprehensive rehabilitation programs have typically been conducted at major, usually urban, medical centers.
Lertzman and Cherniack and Bergofsky have pointed out that the value of most elements constituting comprehensive rehabilitation has not been established. Previous publications show that comprehensive rehabilitation programs, evaluated as totalities, do have measurable positive results for COAD patients. Our results indicate that education programs alone do not produce measurable improvement in health status, at least within a one-year period. This finding suggests that the other component in comprehensive pro-grams-exercise-may be a critical element in producing results.
The significant shift towards “internality” on the health locus of control scale of our intervention patients is consistent with prior studies demonstrating that education can change COAD patients’ knowledge and attitudes and increase their sense of control over the disease. However, this shift was small and, while statistically significant, is of doubtful clinical significance.