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Clinical guidelines have been developed recognizing pulmonary rehabilitation (PR) as a key component in the management of patients with chronic lung disease. The medical director of a PR program is a key player in every program and is a requirement for operation of the program. The medical director must be a licensed physician who has experience in respiratory physiology management. The purpose of this document is to provide an update regarding the clinical, programmatic, legislative, and regulatory issues that impact PR medical directors in North America. It describes the clinical rationale for physician involvement, relevant legislative and regulatory requirements, and resources available that the medical director can utilize to promote evidence-based and cost-effective PR services. All pulmonary rehabilitation (PR) programs must include a medical director. There are many clinical, programmatic, legislative, and regulatory issues that impact the PR medical director. The purpose of this document is to concentrate on the unique roles and responsibilities of the PR medical director.

PURPOSE To determine whether an as-needed repeated pulmonary rehabilitation (PR) intervention produces a clinically important improvement in exercise capacity. METHODS The study included a retrospective analysis of characteristics and 6-minute walk distance (6MWD) of patients with chronic obstructive pulmonary disease (COPD) who completed PR at 2 centers. Data were abstracted from all patients with COPD completing 2 courses of rehabilitation and those of randomly sampled patients completing only 1 course of PR. RESULTS We identified 37 repeaters and selected 69 nonrepeaters for analysis. No significant differences between the 2 groups with regard to age, FEV1 percent predicted, gender, initial 6MWD, improvement in 6MWD, and the percentage of patients achieving the minimal important difference (MID) of ≥ 35 m were observed with the completion of the first rehabilitation. The time between the first and second PR interventions was a mean of 45 ± 24 months. Repeating patients had a decrease of 90 ± 76 m in 6MWD at the beginning of the second rehabilitation course compared with the end of the first intervention (P = .001). Twenty-four (65%) of repeating patients achieved the MID in 6MWD at the end of the second course of PR. Those who achieved the MID in 6MWD during the second course of rehabilitation also tended to have attained greater improvement in this outcome during the first course (P = .07). CONCLUSION Two-thirds of patients with COPD undergoing repeat PR experienced significant improvement in exercise capacity. Offering PR to patients with COPD on an as-needed basis appears to be beneficial even after a prolonged period of time between the interventions.

BACKGROUND Patients hospitalized with decompensated heart failure are at high risk for readmission within 30 days of discharge. Since physical inactivity is associated with increased health care utilization in other diseases, it may predict rehospitalization in heart failure. METHODS In a single-center, prospective study, physical activity was measured following hospital discharge using an accelerometer on the wrist. We then related this activity to the 30-day all-cause rehospitalization rate in heart failure. Each minute of activity was dichotomized into higher or lower intensity, based on a threshold of 3000 vector magnitude units. Counts above this threshold corresponded to a higher level of physical activity. Logistic regression and Kaplan-Meier survival analyses were used to relate the activity group to 30-day readmissions. RESULTS Ninety-five patients admitted to a heart failure unit were screened; 61 met inclusion criteria and provided consent. Fifty patients were evaluated. Forty-six percent were male, mean age was 71 ± 15 years, and 46% had left ventricular ejection fraction

Patients with chronic obstructive pulmonary disease (COPD) are physically inactive, and this predicts poor outcome. Factors influencing activity levels in COPD patients are poorly understood. Depression is common in COPD patients and may influence activity. Accordingly, in this pilot study, we evaluated the relationship between depressive symptoms and activity in clinically stable COPD (forced expiratory volume in 1 second [FEV(1)]/forced vital capacity0.70, FEV(1)80%). An additional inclusion criterion was the Hospital Anxiety and Depression Scale depression score, which had to be ≤7 or ≥10, representing low and high levels of depressive symptoms, respectively.Sixteen patients with high depression scores (DEPR) and 20 with low depression scores (non-DEPR), were studied. Physical activity was measured over 7 consecutive days, using the SenseWear armband (BodyMedia Inc, Pittsburgh, PA) worn on the arm.The mean age was 69 ± 9 years and the FEV(1) was 49 ± 16%. The Hospital Anxiety and Depression Scale depression scores in DEPR and non-DEPR patients were 12.0 ± 2.3 and 3.7 ± 2.0, respectively. There were no significant between-group differences in age, gender, body mass index, FEV(1), supplemental oxygen requirement, and walk distance. DEPR and non-DEPR patients did not differ in estimated steps per day (3490 ± 2020 vs 3634 ± 2000; P = .83) or minutes per day, with activity3 metabolic equivalents (11 ± 7 vs 13 ± 9; P = .42). Steps correlated with the FEV(1) (r = 0.49; P = .002) and the 6-minute walk distance (r = 0.69; P = .0001).We were unable to demonstrate a relationship between depressive symptoms and directly measured physical activity level in patients with COPD.

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that interdisciplinary health care professionals providing pulmonary rehabilitation services need to have certain core competencies. This statement updates the previous clinical competency guidelines for pulmonary rehabilitation professionals, and it complements the AACVPR's Guidelines for Pulmonary Rehabilitation Programs. These competencies provide a common core of 13 professional and clinical competencies inclusive of multiple academic and clinical disciplines. The core competencies include patient assessment and management; dyspnea assessment and management; oxygen assessment, management, and titration; collaborative self-management; adherence; medication and therapeutics; non-chronic obstructive pulmonary diseases; exercise testing; exercise training; psychosocial management; tobacco cessation; emergency responses for patient and program personnel; and universal standard precautions.

PURPOSE: Pulmonary rehabilitation (PR) improves anxiety and depression in patients with chronic obstructive pulmonary disease. However, little is known regarding its ability to produce clinically meaningful improvements in these outcomes. METHODS: We retrospectively analyzed 366 patients who participated in our 8-week outpatient PR program. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression symptoms (HADA and HADD, respectively); for both, a score of >= 10 was considered abnormal, and a change of 1.5 units or greater in magnitude was considered the threshold for a minimal clinically important difference (MCID). Other outcomes included the Chronic Respiratory Disease Questionnaire and the 6-Minute Walk Test. RESULTS: Of the 366 patients, 257 (70%) completed the program and 235 (64%) completed final outcome evaluation. At program entry, 25% had abnormal anxiety scores and 17% had abnormal depression scores; these dropped to 9% and 6%, respectively, in those patients completing outcome analyses (P < .0001). Abnormal HADA and HADD scores predicted noncompletion of the program. Among patients who completed PR, there were significant improvements on all dimensions (increased walk distance, increased quality of life, and reduced symptoms of depression and anxiety). Of the total group, the MCID was exceeded in 41% and 46% for HADA and HADD, respectively. Of those with abnormal anxiety scores at baseline who completed outcome analysis (n = 44), 91% surpassed the MCID, while of those with abnormal depression scores at entry (n = 30), 93% surpassed the MCID. CONCLUSIONS: Pulmonary rehabilitation results in substantial and clinically meaningful changes in both anxiety and depression.

PURPOSE: To test the effectiveness of a home exercise program based on a user-friendly, computer system, the Nintendo Wii Fit. METHODS: In this longitudinal study, 25 clinically stable patients with chronic obstructive pulmonary disease began a 6-week nonintervention (baseline) period followed by 12 weeks of Wii exercise training at home. Patients were instructed to exercise 5 or more days per week. Exercise capacity, health status, and dyspnea were evaluated after home exercise training. RESULTS: Evaluable data were available in 20 patients after home exercise training; their force expiratory volume in 1 second was 45 +/- 16%. Following 12 weeks of Wii exercise training, the Endurance Shuttle Walk Test increased by 131 +/- 183 seconds over the baseline determination (P = .005). Significant improvements were also noted in arm-lift and sit-to-stand repetitions, the total score, and the emotion dimension of the Chronic Respiratory Questionnaire. Men had significantly greater increases in the Endurance Shuttle Walk Test than women, although their self-reported exercise durations were similar. There were no significant adverse outcomes. CONCLUSION: This study suggests that 12 weeks of regular, home exercise based on an interactive entertainment computer system can lead to positive short-term outcomes.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a systemic disease with various outcomes of importance, for example, exercise capacity and dyspnea. These variables may follow different trajectories over time. It is established that physical activity decreases in COPD, although its process over time has not been evaluated. Accordingly, we compared longitudinal changes in physical activity with changes in standard outcome assessments: forced expiratory volume in 1 second (FEV1), 6-minute walk distance, and dyspnea. METHODS: Physical activity was measured with tri-axial accelerometers worn on a lateral position at the waist for 7 consecutive days. Nonuse was eliminated using a computer algorithm for this device. Activity was assessed in 2 ways: (1) as vector magnitude units (VMU), the sum of movements per minute in 3 planes, and (2) VM250, the percent of time worn when VMU was 250 or more counts per minute. Eighteen patients with COPD (FEV1 61 +/- 17% predicted) from a larger population were restudied. The interval between the baseline and followup assessments was 609 +/- 58 days. RESULTS: Mean VMU at followup was less than at baseline: 146 +/- 70 vs 198 +/- 85 counts per minute, respectively (P = .002). VM250 was also reduced: 19 +/- 9% vs 25 +/- 11%, respectively (P = .003). There was no significant longitudinal change in FEV1. The 6-minute walk distance decreased by 39 m (P = .04). The Medical Research Council dyspnea increased by 0.5 units (P = .04). CONCLUSION: Directly measured physical activity decreases over time in COPD, similar to other outcomes of importance.

The multidisciplinary treatment of pulmonary rehabilitation (PR), which includes exercise training, self-management education, and psychosocial and nutritional intervention, is now a standard of care for chronic obstructive pulmonary disease (COPD) and has been incorporated into major guidelines. We must now focus efforts on improving its impact and widening its applicability. What is the direction of PR; where does it fit in the comprehensive care of the COPD patient; and how can clinicians best apply this important intervention? This was the charge of the roundtable discussion, Pulmonary Rehabilitation: Moving Forward, involving 20 experts from North America and Europe, which was convened in Fort Lauderdale, Florida, in early 2008. It is not meant to be an exhaustive review; rather, this report summarizes the roundtable proceedings, while providing direction to best position PR into the continuum of COPD care. By consensus, it was agreed upon that although PR is effective for other chronic respiratory diseases, the discussion focus was COPD since most of the evidence base and patient referral are for this disease. These proceedings provide insight into 3 broad areas appropriate for investigation or implementation: positioning PR in an integrated care model for COPD patients; improving the effectiveness of this intervention; and expanding the recognition, application, and accessibility to PR. It is the hope that this document will provide a catalyst for clinicians, investigators, and healthcare policy makers to help realize these goals as well as serve to suggest important areas for future research and development in PR.