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AmericanThoracicSocietyDocumentsAnOfficialAmericanThoracicSociety/EuropeanRespiratorySocietyStatement:KeyConceptsandAdvancesinPulmonaryRehabilitationMartijnA.Spruit,SallyJ.Singh,ChrisGarvey,RichardZuWallack,LindaNici,CarolynRochester,KylieHill,AnneE.Holland,SuzanneC.Lareau,WilliamD.-C.Man,FabioPitta,LouiseSewell,JonathanRaskin,JeanBourbeau,RebeccaCrouch,FritsM.E.Franssen,RichardCasaburi,JanH.Vercoulen,IoannisVogiatzis,RikGosselink,EnricoM.Clini,TanjaW.Effing,Franc¸oisMaltais,JobvanderPalen,ThierryTroosters,DaisyJ.A.Janssen,EileenCollins,JudithGarcia-Aymerich,DinaBrooks,BonnieF.Fahy,MiloA.Puhan,MartineHoogendoorn,RachelGarrod,AnnemieM.W.J.Schols,BrianCarlin,RobertoBenzo,PaulaMeek,MikeMorgan,MaureenP.M.H.Rutten-vanMo¨lken,AndrewL.Ries,BarryMake,RogerS.Goldstein,ClaireA.Dowson,JanL.Brozek,ClaudioF.Donner,andEmielF.M.Wouters;onbehalfoftheATS/ERSTaskForceonPulmonaryRehabilitationTHISOFFICIALSTATEMENTOFTHEAMERICANTHORACICSOCIETY(ATS)ANDTHEEUROPEANRESPIRATORYSOCIETY(ERS)WASAPPROVEDBYTHEATSBOARDOFDIRECTORS,JUNE2013,ANDBYTHEERSSCIENTIFICANDEXECUTIVECOMMITTEESINJANUARY2013ANDFEBRUARY2013,RESPECTIVELYCONTENTSOverviewIntroductionMethodsDefinitionandConceptExerciseTrainingIntroductionPhysiologyofExerciseLimitationVentilatorylimitationGasexchangelimitationCardiaclimitationLimitationduetolowerlimbmuscledysfunctionExerciseTrainingPrinciplesEnduranceTrainingIntervalTrainingResistance/StrengthTrainingUpperLimbTrainingFlexibilityTrainingNeuromuscularElectricalStimulationInspiratoryMuscleTrainingMaximizingtheEffectsofExerciseTrainingPharmacotherapyBronchodilatorsAnabolichormonalsupplementationOxygenandhelium–hyperoxicgasmixturesNoninvasiveventilationBreathingstrategiesWalkingaidsPulmonaryRehabilitationinConditionsOtherThanCOPDInterstitialLungDiseaseCysticFibrosisBronchiectasisNeuromuscularDiseaseAsthmaPulmonaryArterialHypertensionLungCancerLungVolumeReductionSurgeryLungTransplantationBehaviorChangeandCollaborativeSelf-ManagementIntroductionBehaviorChangeOperantconditioningChangingcognitionsEnhancementofself-efficacyAddressingmotivationalissuesCollaborativeSelf-ManagementAdvanceCarePlanningBodyCompositionAbnormalitiesandInterventionsIntroductionInterventionstoTreatBodyCompositionAbnormalitiesSpecialConsiderationsinObeseSubjectsPhysicalActivityTimingofPulmonaryRehabilitationPulmonaryRehabilitationinEarlyDiseasePulmonaryRehabilitationandExacerbationsofCOPDEarlyRehabilitationinAcuteRespiratoryFailurePhysicalactivityandexerciseintheunconsciouspatientPhysicalactivityandexerciseinthealertpatientRoleforrehabilitationinweaningfailureLong-TermMaintenanceofBenefitsfromPulmonaryRehabilitationMaintenanceexercisetrainingprogramsOngoingcommunicationtoimproveadherenceRepeatingpulmonaryrehabilitationOthermethodsofsupportPatient-centeredOutcomesQuality-of-LifeMeasurementsSymptomEvaluationDepressionandAnxietyFunctionalStatusExercisePerformancePhysicalActivityKnowledgeandSelf-EfficacyOutcomesinSevereDiseaseCompositeOutcomesProgramOrganizationPatientSelectionComorbiditiesAmJRespirCritCareMedVol188,Iss.8,ppe13–e64,Oct15,2013Copyrightª2013bytheAmericanThoracicSocietyDOI:10.1164/rccm.201309-1634STInternetaddress:www.atsjournals.orgRehabilitationSettingHome-basedandcommunity-basedexercisetrainingTechnology-assistedexercisetrainingProgramDuration,Structure,andStaffingProgramEnrollmentProgramAdherenceProgramAuditandQualityControlHealthCareUseProgramCostsImpactonHealthCareUseImpactonMedicalCostsCost-EffectivenessMovingForwardBackground:Pulmonaryrehabilitationisrecognizedasacorecompo-nentofthemanagementofindividualswithchronicrespiratorydisease.Sincethe2006AmericanThoracicSociety(ATS)/EuropeanRespiratorySociety(ERS)StatementonPulmonaryRehabilitation,therehasbeenconsiderablegrowthinourknowledgeofitsefficacyandscope.Purpose:ThepurposeofthisStatementistoupdatethe2006docu-ment,includinganewdefinitionofpulmonaryrehabilitationandhighlightingkeyconceptsandmajoradvancesinthefield.Methods:AmultidisciplinarycommitteeofexpertsrepresentingtheATSPulmonaryRehabilitationAssemblyandtheERSScientificGroup01.02,“RehabilitationandChronicCare,”determinedtheoverallscopeofthisupdatethroughgroupconsensus.Focusedliteraturereviewsinkeytopicareaswereconductedbycommitteememberswithrelevantclinicalandscientificexpertise.ThefinalcontentofthisStatementwasagreedonbyallmembers.Results:Anupdateddefinitionofpulmonaryrehabilitationispro-posed.Newdataarepresentedonthescienceandapplicationofpulmonaryrehabilitation,includingitseffectivenessinacutelyillindividualswithchronicobstructivepulmonarydisease,andinindi-vidualswithotherchronicrespiratorydiseases.Theimportantroleofpulmonaryrehabilitationinchronicdiseasemanagementishigh-lighted.Inaddition,theroleofhealthbehaviorchangeinoptimizingandmaintainingbenefitsisdiscussed.Conclusions:Theconsiderablegrowthinthescienceandapplicationofpulmonaryrehabilitationsince2006addsfurthersupportforitsefficacyinawiderangeofindividualswithchronicrespiratorydisease.Keywords:COPD;pulmonaryrehabilitation;exacerbation;behavior;outcomesOVERVIEWPulmonaryrehabilitationhasbeenclearlydemonstratedtore-ducedyspnea,increaseexercisecapacity,andimprovequalityoflifeinindividualswithchronicobstructivepulmonarydisease(COPD)(1).ThisStatementprovidesadetailedreviewofprogressinthescienceandevolutionoftheconceptofpulmonaryrehabil-itationsincethe2006Statement.Itrepresentstheconsensusof46internationalexpertsinthefieldofpulmonaryrehabilitation.Onthebasisofcurrentinsights,theAmericanThoracicSo-ciety(ATS)andtheEuropeanRespiratorySociety(ERS)haveadoptedthefollowingnewdefinitionofpulmonaryrehabilita-tion:“Pulmonaryrehabilitationisacomprehensiveinterventionbasedonathoroughpatientassessmentfollowedbypatient-tailoredtherapiesthatinclude,butarenotlimitedto,exercisetraining,education,andbehaviorchange,designedtoimprovethephysicalandpsychologicalconditionofpeoplewithchronicrespiratorydiseaseandtopromotethelong-termadherencetohealth-enhancingbehaviors.”SincethepreviousStatement,wenowmorefullyunderstandthecomplexnatureofCOPD,itsmultisystemmanifestations,andfrequentcomorbidities.Therefore,integratedcareprinciplesarebeingadoptedtooptimizethemanagementofthesecomplexpatients(2).Pulmonaryrehabilitationisnowrecognizedasacorecomponentofthisprocess(Figure1)(3).Healthbehaviorchangeisvitaltooptimizationandmaintenanceofbenefitsfromanyinterventioninchroniccare,andpulmonaryrehabilitationhastakenaleadinimplementingstrategiestoachievethisgoal.NoteworthyadvancesinpulmonaryrehabilitationthatarediscussedinthisStatementincludethefollowing:dThereisincreasedevidenceforuseandefficacyofavarietyofformsofexercisetrainingaspartofpulmonaryrehabil-itation;theseincludeintervaltraining,strengthtraining,upperlimbtraining,andtranscutaneousneuromuscularelectricalstimulation.dPulmonaryrehabilitationprovidedtoindividualswithchronicrespiratorydiseasesotherthanCOPD(i.e.,interstitiallungdisease,bronchiectasis,cysticfibrosis,asthma,pulmonaryhy-pertension,lungcancer,lungvolumereductionsurgery,andlungtransplantation)hasdemonstratedimprovementsinsymptoms,exercisetolerance,andqualityoflife.dSymptomaticindividualswithCOPDwhohavelesserdegreesofairflowlimitationwhoparticipateinpulmonaryrehabilitationderivesimilarimprovementsinsymptoms,exercisetolerance,andqualityoflifeasdothosewithmoreseveredisease.dPulmonaryrehabilitationinitiatedshortlyafterahospital-izationforaCOPDexacerbationisclinicallyeffective,safe,andassociatedwithareductioninsubsequenthospi-taladmissions.dExerciserehabilitationcommencedduringacuteorcriticalillnessreducestheextentoffunctionaldeclineandhastensrecovery.dAppropriatelyresourcedhome-basedexercisetraininghasproveneffectiveinreducingdyspneaandincreasingexer-ciseperformanceinindividualswithCOPD.dTechnologiesarecurrentlybeingadaptedandtestedtosupportexercisetraining,education,exacerbationman-agement,andphysicalactivityinthecontextofpulmonaryrehabilitation.dThescopeofoutcomesassessmenthasbroadened,allow-ingfortheevaluationofCOPD-relatedknowledgeandself-efficacy,lowerandupperlimbmusclefunction,bal-ance,andphysicalactivity.dSymptomsofanxietyanddepressionareprevalentinindi-vidualsreferredtopulmonaryrehabilitation,mayaffectoutcomes,andcanbeamelioratedbythisintervention.Inthefuture,weseetheneedtoincreasetheapplicabilityandaccessibilityofpulmonaryrehabilitation;toeffectbehaviorchangetooptimizeandmaintainoutcomes;andtorefinethisinterventionsothatittargetstheuniqueneedsofthecomplexpatient.INTRODUCTIONSincetheAmericanThoracicSociety(ATS)/EuropeanRespira-torySociety(ERS)StatementonPulmonaryRehabilitationwaspublishedin2006(1),thisinterventionhasadvancedinseveralways.First,ourunderstandingofthepathophysiologyunderly-ingchronicrespiratorydiseasesuchaschronicobstructivepulmonarydisease(COPD)hasgrown.WenowmorefullyappreciatethecomplexnatureofCOPD,itsmultisystemman-ifestations,andfrequentcomorbidities.Second,thescienceande14AMERICANJOURNALOFRESPIRATORYANDCRITICALCAREMEDICINEVOL1882013applicationofpulmonaryrehabilitationhaveevolved.Forex-ample,evidencenowindicatesthatpulmonaryrehabilitationiseffectivewhenstartedatthetimeorshortlyafterahospitaliza-tionforCOPDexacerbation.Third,asintegratedcarehasrisentoberegardedastheoptimalapproachtowardmanagingchronicrespiratorydisease,pulmonaryrehabilitationhasestablisheditselfasanimportantcomponentofthismodel.Finally,withtherecog-nitionthathealthbehaviorchangeisvitaltooptimizationandmaintenanceofbenefitsfromanyinterventioninchroniccare,pulmonaryrehabilitationhastakenaleadindevelopingstrategiestopromoteself-efficacyandthustheadoptionofahealthylifestyletoreducetheimpactofthedisease.OurpurposeinupdatingthisATS/ERSStatementonPulmo-naryRehabilitationistopresentthelatestdevelopmentsandconceptsinthisfield.Bydoingso,wehopetodemonstrateitsefficacyandapplicabilityinindividualswithchronicrespiratorydisease.Bynecessity,thisStatementfocusesprimarilyonCOPD,becauseindividualswithCOPDrepresentthelargestproportionofreferralstopulmonaryrehabilitation(4),andmuchoftheexistingscienceisinthisarea.However,effectsofexercise-basedpulmo-naryrehabilitationinpeoplewithchronicrespiratorydiseaseotherthanCOPDarediscussedindetail.Wehopetounderscorethepivotalroleofpulmonaryrehabilitationintheintegratedcareofthepatientwithchronicrespiratorydisease.METHODSAmultinational,multidisciplinarygroupof46clinicalandre-searchexperts(Table1)participatedinanATS/ERSTaskForcewiththechargetoupdatethepreviousStatement(1).TaskForcememberswereidentifiedbytheleadershipoftheATSPulmonaryRehabilitationAssemblyandtheERSScien-tificGroup01.02,“RehabilitationandChronicCare.”MemberswerevettedforpotentialconflictsofinterestaccordingtothepoliciesandproceduresofATSandERS.TaskForcemeetingswereorganizedduringtheATSInter-nationalCongress2011(Denver,CO)andduringtheERSAn-nualCongress2011(Amsterdam,TheNetherlands)topresentanddiscussthelatestscientificdevelopmentswithinpulmonaryrehabilitation.Inpreparation,theStatementwassplitupintovarioussectionsandsubsections.TaskForcememberswereappointedtooneormoresections,basedontheirclinicalandscientificexpertise.TaskForcemembersreviewednewscientificadvancestobeaddedtothethen-currentknowledgebase.Thiswasdonethroughidentifyingrecentlyupdated(publishedbe-tween2006and2011)systematicreviewsofrandomizedtrialsfromMedline/PubMed,EMBASE,theCochraneCentralReg-isterofControlledTrials,CINAHL,thePhysicalTherapyEvi-denceDatabase(PEDro),andtheCochraneCollaboration,andsupplementingthiswithrecentstudiesthataddedtotheevidencebasedonpulmonaryrehabilitation(Table2).TheTaskForcemembersselectedtherelevantpapersthemselves,irrespectiveofthestudydesignsused.Finally,theCo-Chairsreadallthesections,andtogetherwithanadhocwritingcommittee(thefourCo-Chairs,LindaNici,CarolynRochester,andJonathanRaskin)thefinaldocumentwascomposed.Afterward,allTaskForcemembershadtheopportunitytogivewrittenfeedback.Intotal,threedraftsoftheupdatedStatementwerepreparedbythefourCo-Chairs;thesewereeachreviewedandrevisediter-ativelybytheTaskForcemembers.Redundancieswithinandacrosssectionswereminimized.ThisdocumentrepresentstheconsensusoftheseTaskForcemembers.Thisdocumentwascreatedbycombiningafirmevidence-basedapproachandtheclinicalexpertiseoftheTaskForcemembers.ThisisaStatement,notaClinicalPracticeGuideline.Thelattermakesspecificrecommendationsandformallygradesstrengthoftherecommendationandthequalitythescientificev-idence.ThisStatementiscomplementarytotwocurrentdocu-mentsonpulmonaryrehabilitation:theAmericanCollegeofFigure1.Aspectrumofsupportforchronicobstructivepulmonarydis-ease.ReprintedbypermissionfromReference3.AmericanThoracicSocietyDocumentse15ChestPhysiciansandAmericanAssociationofCardiovascularandPulmonaryRehabilitation(AACVPR)evidence-basedguidelines(5),whichformallygradethequalityofscientificevidence,andtheAACVPRGuidelinesforPulmonaryRehabilitationPrograms,whichgivepracticalrecommendations(6).ThisStatementhasbeenendorsedbyboththeATSBoardofDirectors(June2013)andtheERSExecutiveCommittee(February2013).DEFINITIONANDCONCEPTIn2006(1),pulmonaryrehabilitationwasdefinedas“anevidence-based,multidisciplinary,andcomprehensiveinterventionforpatientswithchronicrespiratorydiseaseswhoaresymptomaticandoftenhavedecreaseddailylifeactivities.Integratedintotheindividualizedtreatmentofthepatient,pulmonaryrehabilitationisdesignedtore-ducesymptoms,optimizefunctionalstatus,increaseparticipation,andreducehealthcarecoststhroughstabilizingorreversingsystemicmanifestationsofthedisease.”Eventhoughthe2006definitionofpulmonaryrehabilitationiswidelyacceptedandstillrelevant,therewasconsensusamongthecurrentTaskForcememberstomakeanewdefinitionofpul-monaryrehabilitation.Thisdecisionwasmadeonthebasisofrecentadvancesinourunderstandingofthescienceandprocessofpulmonaryrehabilitation.Forexample,somepartsofacom-prehensivepulmonaryrehabilitationprogramarebasedonyearsofclinicalexperienceandexpertopinion,ratherthanevidence-based.Moreover,nowadayspulmonaryrehabilitationisconsideredtobeaninterdisciplinaryinterventionratherthanamultidisciplinaryapproach(7)tothepatientwithchronicrespiratorydisease.Fi-nally,the2006definitionemphasizedtheimportanceofstabilizingorreversingsystemicmanifestationsofthedisease,withoutspecificattentiontobehaviorchange.Onthebasisofourcurrentinsights,theATSandtheERShaveadoptedthefollowingnewdefinitionofpulmonaryreha-bilitation:“Pulmonaryrehabilitationisacomprehensiveinter-ventionbasedonathoroughpatientassessmentfollowedbypatient-tailoredtherapies,whichinclude,butarenotlimitedto,exercisetraining,education,andbehaviorchange,designedtoimprovethephysicalandpsychologicalconditionofpeoplewithchronicrespiratorydiseaseandtopromotethelong-termadher-enceofhealth-enhancingbehaviors.”Pulmonaryrehabilitationisimplementedbyadedicated,in-terdisciplinaryteam,includingphysiciansandotherhealthcareprofessionals;thelattermayincludephysiotherapists,respira-torytherapists,nurses,psychologists,behavioralspecialist,exer-cisephysiologists,nutritionists,occupationaltherapists,andsocialworkers.Theinterventionshouldbeindividualizedtotheuniqueneedsofthepatient,basedoninitialandongoingassessments,includingdiseaseseverity,complexity,andcomor-bidities.Althoughpulmonaryrehabilitationisadefinedinter-vention,itscomponentsareintegratedthroughouttheclinicalcourseofapatient’sdisease.Pulmonaryrehabilitationmaybeinitiatedatanystageofthedisease,duringperiodsofclinicalstabilityorduringordirectlyafteranexacerbation.Thegoalsofpulmonaryrehabilitationincludeminimizingsymptomburden,maximizingexerciseperformance,promotingautonomy,increas-ingparticipationineverydayactivities,enhancing(health-related)qualityoflife,andeffectinglong-termhealth-enhancingbehaviorchange.Thisdocumentplacespulmonaryrehabilitationwithintheconceptofintegratedcare.TheWorldHealthOrganizationdefinesintegratedcareas“aconceptbringingtogetherinputs,delivery,managementandorganizationofservicesrelatedtodiagnosis,treatment,care,rehabilitationandhealthpromotion”(8).Integrationofservicesimprovesaccess,quality,usersatis-faction,andefficiencyofmedicalcare.Assuch,pulmonaryreha-bilitationprovidesanopportunitytocoordinatecarethroughouttheclinicalcourseofanindividual’sdisease.EXERCISETRAININGIntroductionExercisecapacityinpatientswithchronicrespiratorydiseasesuchasCOPDisimpaired,andisoftenlimitedbydyspnea.Thelimitationtoexerciseiscomplexanditwouldappearthelimitationtoexerciseisdependentonthemodeoftesting(9).Theexertionaldyspneainthissettingisusuallymultifactorialinorigin,partlyreflectingperipheralmuscledysfunction,thecon-sequencesofdynamichyperinflation,increasedrespiratoryload,ordefectivegasexchange(10–12).Theselimitationsareaggra-vatedbythenatural,age-relateddeclineinfunction(13)andtheeffectsofphysicaldeconditioning(detraining).Inaddition,theyareoftencompoundedbythepresenceofcomorbidcon-ditions.Someofthesefactorswillbepartiallyamenabletophysicalexercisetrainingaspartofacomprehensivepulmonaryrehabilitationprogram.Consideredtobethecornerstoneofpulmonaryrehabilitation(1),exercisetrainingisthebestavailablemeansofimprovingmusclefunctioninCOPD(14–18).Eventhosepatientswithseverechronicrespiratorydiseasecanoftensustaintheneces-sarytrainingintensityanddurationforskeletalmuscleadapta-tiontooccur(16,19).Improvementsinskeletalmusclefunctionafterexercisetrainingleadtogainsinexercisecapacitydespitetheabsenceofchangesinlungfunction(20,21).Moreover,theTABLE1.MULTIDISCIPLINARYCOMPOSITIONOFTHEAMERICANTHORACICSOCIETY/EUROPEANRESPIRATORYSOCIETYTASKFORCEONPULMONARYREHABILITATIONdChestphysicians/respirologists/pulmonologistsdElderlycarephysiciandPhysiotherapistsdOccupationaltherapistdNursesdNutritionalscientistdExercisephysiologistsdMethodologistsdPsychologists/behavioralexpertsdHealtheconomistsTABLE2.METHODSCHECKLISTYesNoPanelassemblydIncludedexpertsfromrelevantclinicalandnonclinicaldisciplinesXdIncludedindividualwhorepresentsviewsofpatientsinsocietyatlargeXdIncludedmethodologistwithdocumentedexpertiseXLiteraturereviewdPerformedincollaborationwithlibrarianXdSearchedmultipleelectronicdatabasesXdReviewedreferencelistsofretrievedarticlesXEvidencesynthesisdAppliedprespecifiedinclusionandexclusioncriteriaXdEvaluatedincludedstudiesforsourcesofbiasXdExplicitlysummarizedbenefitsandharmsXdUsedPRISMAtoreportsystematicreviewXdUsedGRADEtodescribequalityevidenceXGenerationofrecommendationsdUsedGRADEtoratethestrengthofrecommendationsXDefinitionofabbreviations:GRADE¼GradingofRecommendationsAssess-ment,DevelopmentandEvaluation;PRISMA¼PreferredReportingItemsforSystematicReviewsandMeta-Analyses.e16AMERICANJOURNALOFRESPIRATORYANDCRITICALCAREMEDICINEVOL1882013improvedoxidativecapacityandefficiencyoftheskeletalmusclesleadstoareducedventilatoryrequirementforagivensubmaximalworkrate(22);thismayreducedynamichyperin-flation,therebyaddingtothereductioninexertionaldyspnea(23).Exercisetrainingmayhavepositiveeffectsinotherareas,includingincreasedmotivationforexercisebeyondtherehabil-itationenvironment,reducedmooddisturbance(24–26),lesssymptomburden(27),andimprovedcardiovascularfunction(28,29).Optimizingmedicaltreatmentbeforeexercisetrainingwithbronchodilatortherapy,long-termoxygentherapy,andthetreatmentofcomorbiditiesmaymaximizetheeffectivenessoftheexercisetrainingintervention.Beforestartinganexercisetrainingprogram,anexerciseas-sessmentisneededtoindividualizetheexerciseprescription,evaluatethepotentialneedforsupplementaloxygen,helpruleoutsomecardiovascularcomorbidities,andhelpensurethesafetyoftheintervention(30–35).Thispatientassessment(35)mayalsoincludeamaximalcardiopulmonaryexercisetesttoassessthesafetyofexercise,todefinethefactorscontributingtoexerciselimitation,andtoidentifyasuitableexerciseprescription(30).IdentifyingasinglevariablelimitingexerciseinindividualswithCOPDisoftendifficult.Indeed,manyfactorsmaycontrib-utedirectlyorindirectlytoexerciseintolerance.Becauseofthis,separatingthevariousmechanismscontributingtoexerciseintol-eranceisoftenalargelyacademicexerciseandisnotalwaysnec-essaryorfeasible.Forexample,deconditioningandhypoxiacontributetoexcessventilation,resultinginanearlierventila-torylimitation.Consequently,exercisetrainingandoxygentherapycoulddelayaventilatorylimittoexercisewithoutalteringlungfu