CAN PULMONARY REHABILITATION ACHIEVE FULL REMISSION OF ANXIETY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE?

A.M. Yohannes¹, S. Dryden², N.A. Hanania³

Background: Anxiety is common in patients with chronic obstructive pulmonary disease (COPD), with an estimated prevalence range of 6 –74%; and associated with impaired quality of life (QOL) and hospital readmission. A pulmonary rehabilitation (PR) program improves perceived dyspnea, exercise capacity and quality of life in patients with COPD.  However, a limited number of studies have examined the effect of PR on anxiety symptoms in patients with COPD.

Purpose: To date, little is known about the percentage of COPD patients with comorbid anxiety that achieve full remission following PR. We examine the efficacy of eight weeks of PR on anxiety in patients with COPD.  We used the Anxiety Inventory for Respiratory Disease (AIR) to determine:
1) the percentage of patients achieving full remission of anxiety symptoms and
2) predictors of change in anxiety symptoms.

Methods: We prospectively conducted an eight-week comprehensive PR in COPD patients demonstrating comorbid anxiety with an AIR score > 8.  COPD patients were referred to PR by general practitioners and respiratory consultants, and excluded for unstable angina or exercise intolerance.  PR occurred weekly for eight weeks, comprising two hours of combined circuit aerobic exercise therapy and muscle strengthening exercises supplemented with an educational program covering nutrition, relaxation therapy, counselling, and managing inhalers. Pre- and post-PR outcome measures included: exercise capacity, assessed by incremental shuttle walk test (ISWT); QOL, measured using the St. Georges Respiratory Questionnaire (SGRQ); and dyspnoea severity, assessed using the Medical Research Council scale. Data analysis: We used descriptive statistics to describe the groups, and differences between means were examined using t-tests. Full remission was achieving an AIR score <8. Prediction of response to PR on anxiety was examined using logistic regression. Significance was set at p <0.05.

Results: One hundred sixty-five COPD patients completed PR. The mean (SD) age of COPD patients was 71.5 (8.8) years.  The AIR score decreased after PR, from 12.3 to 8.2 (t=9.20,p< 0.001).  One hundred nineteen COPD patients (72%) experienced a change in AIR score. Of these 119 patients, 55% (n=66) achieved full remission in their anxiety symptoms, with an AIR score < 8. However, 46(28%) did not show response to PR, [12% (n=20) did not change their AIR Score >8, and 16% (n=26) worsened following PR]. Logistic regression analysis revealed baseline exercise capacity (odds ratio [95% CI] 1.004 [1.001–1.007], p=0.022) and high anxiety symptoms (odds ratio 1.191 [1.061–1.339], p<0.003) predicted improvement in anxiety symptoms following PR. Gender, age, lung function and QOL did not predict response to anxiety symptoms after PR.

Conclusion(s): Forty percent of COPD (n= 66) patients with high levels of anxiety symptoms (AIR score > 8) achieved full remission following PR. Twenty-eight percent of COPD patients no response or got worse in their anxiety symptoms. Patients with COPD with high anxiety symptoms and better exercise capacity at baseline are most likely to achieve full remission after PR.

Implications: Some patients with COPD moderate anxiety and/or poor exercise capacity who are unlikely to respond to PR may benefit with additional input (e.g. cognitive behavioural therapy) is worthy of consideration.

Funding, acknowledgements: None.

Keywords: Pulmonary rehabilitation, Anxiety, Exercise capacity

Topic: Community based rehabilitation

Did this work require ethics approval? Yes

Institution: Blackpool Teaching Foundation National Health Service Trust

Committee: Research Ethics Committee of the Blackpool Teaching Foundation

Ethics number: Ref:SE/0390