INVITED REVIEW SERIES:
REHABILITATION IN CHRONIC RESPIRATORY DISEASES
SERIES EDITORS: FRITS M.E. FRANSSEN AND JENNIFER A. ALISON
Maintaining the benefits following pulmonary rehabilitation:
Achievable or not?
LISSA M. SPENCER1
1
Physiotherapy Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia; 2Faculty of Health Sciences, The University
of Sydney, Sydney, NSW, Australia
ABSTRACT
Pulmonary rehabilitation (PR) improves exercise capac-
ity, health-related quality of life (HRQoL) and dyspnoea
in patients with COPD and other lung conditions. Once
PR is completed, the benefits gained begin to decline
unless patients continue to exercise regularly. Due to
limited evidence in other lung conditions, this review
aims to examine the current evidence regarding main-
tenance exercise programmes for patients with COPD
and to determine the types of programmes that are able
to maintain the benefits gained from PR to 12 months
and longer. A number of factors may affect the ability
to maintain exercise capacity and HRQoL in the long
term including: frequency of supervised maintenance
exercise; strategies used to improve adherence to main-
tenance exercise; facilitators and barriers to long-term
exercise training; and initial PR programme itself. The
current evidence for maintenance exercise programmes
that included supervised maintenance exercise was
weak, and for those programmes that included unsuper-
vised maintenance exercise (with and without support)
were difficult to interpret and in many instances were
no better than usual care. New research using technol-
ogy has provided some promising results for the future
and surveys have revealed important features that may
help in the development of maintenance programmes
from a participant perspective such as ongoing therapist
support. How to best maintain the benefits gained from
PR remains unclear. Therefore, it is likely that no one
model of maintenance is ideal for all patients with
COPD and that individually adapted maintenance exer-
cise programmes need to be considered.
Key words: benefits, chronic obstructive pulmonary disease,
exercise training, maintenance, pulmonary rehabilitation.
Correspondence: Lissa M. Spencer, Physiotherapy
Department, Royal Prince Alfred Hospital, Missenden Road,
Camperdown, Sydney, NSW 2050, Australia. Email: lissa.
spencer@health.nsw.gov.au
Received 11 September 2018; invited to revise 17 October
2018 and 7 January 2019; revised 11 November 2018 and 30
January 2019; accepted 13 February 2019.
© 2019 Asian Pacific Society of Respirology
AND ZOE J. MCKEOUGH2
INTRODUCTION
Pulmonary rehabilitation (PR), consisting of exercise
training, self-management education and psycholog-
ical support, improves exercise capacity, health-
related quality of life (HRQoL) and dyspnoea in
patients with COPD with no change to lung func-
tion.1 In fact, PR is one of the most effective man-
agement strategies for patients with COPD.
However, once the PR programme is complete, the
benefits begin to decline unless patients with COPD
continue to exercise.2,3 The benefits from PR are
also seen in patients with other lung conditions
such as interstitial lung disease (ILD) and bronchi-
ectasis.4,5 However, there is limited evidence about
maintaining the benefits gained from PR in these
groups and therefore, the focus of this review will
be on patients with COPD.
Maintenance programmes for patients with COPD
largely involve exercise training but may also include
continued self-management education particularly
around exacerbation management and nutritional
needs. There may be several factors that affect the
success of maintenance exercise programmes and the
ability of patients with COPD to maintain the benefits
gained from the initial PR programme in terms of
exercise capacity and HRQoL. These factors include
the frequency of supervised maintenance exercise;
the strategies used to improve adherence to mainte-
nance exercise; facilitators and barriers to long-term
exercise training; and the initial PR programme itself.
This narrative review aims to examine the current
evidence regarding maintenance exercise pro-
grammes for patients with COPD and to determine
the types of programmes that are able to maintain
the benefits gained from PR to 12 months and
longer.
FREQUENCY OF SUPERVISED
MAINTENANCE EXERCISE
Ongoing exercise should be encouraged after comple-
tion of PR; however, the exact frequency of supervised
maintenance exercise necessary to maintain the
Respirology (2019)
doi: 10.1111/resp.13518
2 L Spencer and ZJ McKeough
benefits gained from the initial PR programme in the
long term remains unclear.
Weekly supervised exercise as a
maintenance exercise programme
The recently published Australian and New Zealand
Pulmonary Rehabilitation Guidelines6 provided a sys-
tematic review of supervised maintenance exercise
programmes in COPD. The guideline identified 11 ran-
domized controlled trials which examined supervised
maintenance exercise programmes to 12 months, of
which six studies used weekly supervised maintenance
exercise.7–12 Evidence from these studies was rated as
low quality but indicated no added benefit to symp-
toms, exercise capacity or HRQoL from weekly super-
vised maintenance exercise compared to standard care
or from unsupervised maintenance exercise with regu-
lar review. The guideline concluded that more research
was needed particularly around whether an ideal level
of supervision was required for maintenance exercise.
Since the publication of the guidelines,6 another
large trial has been published of 143 patients with
COPD randomized, following an 8-week PR pro-
gramme, to fortnightly supervised maintenance exer-
cise plus unsupervised home exercise or a control
group (unsupervised home exercise).2 Results showed
that the BODE index (i.e. a score of body mass index,
airflow obstruction, dyspnoea score and exercise
capacity) was maintained from post-PR to 2 years in
the supervised group compared to the control. How-
ever, HRQoL, measured by the Chronic Respiratory
Questionnaire (CRQ), was not maintained. This trial is
significant in having one of the longest follow-up
periods and in showing that a combination of regular
home exercises with fortnightly hospital visits and reg-
ular phone calls may be a successful model to help sus-
tain benefits following PR. Interestingly, cycling
exercise was promoted as the mode of leg training, so
cycle ergometers were placed in all homes. This may
be costly and not a feature transferrable to all health
systems.
Monthly supervised exercise as a
maintenance exercise programme
Of the 11 studies reviewed in the Australian and
New Zealand Pulmonary Rehabilitation Guidelines,6
5 performed supervised maintenance exercise at a
lower frequency (between monthly and three
monthly).3,13–16 This level of supervision was not suffi-
cient to maintain the benefits following PR or result in
improvements from baseline levels compared to the
control groups. The guideline concluded with a weak
recommendation based on low-quality evidence that
maintenance programmes of monthly or less supervi-
sion should not be offered.
Effect of supervised maintenance exercise on
health use outcomes
A recent systematic review17 that explored the effects of
supervised maintenance exercise (varying frequency of
supervision) compared to usual care on health use
© 2019 Asian Pacific Society of Respirology
outcomes in patients with COPD 12 months following
PR reported a significant reduction in the risk of a hos-
pital admission for a respiratory cause (risk ratio: 0.62,
95% CI: 0.47–0.81 (5 studies)). However, there was no
significant effect on the overall risk of an exacerbation
(risk ratio: 0.79, 95% CI: 0.52–1.19; 2 studies) or mortal-
ity (risk ratio: 0.57, 95% CI: 0.17–1.92; 2 studies),
although the mean effect estimates were clinically sig-
nificant. This systematic review reported promising
results in that supervised maintenance exercise suc-
cessfully reduced the risk of hospital admissions in
patients with COPD.
Unsupervised maintenance exercise training
Unsupervised maintenance exercise may provide an
alternative training mode to supervised maintenance
exercise and may be less expensive to deliver and eas-
ier for participants to perform in a home or community
setting.
Unsupervised maintenance exercise has been used
in a number of studies in patients with COPD.18–25
Many of these studies had additional features to sup-
port the unsupervised programmes such as regular
phone calls,18,19,21,22 diaries19,21,23 and pedometers.18,19,21
The variation in terms of extra support makes it diffi-
cult to draw conclusions about the effectiveness of
unsupervised home exercise alone as a maintenance
exercise programme. Extra support will be discussed
further in Support phone calls and follow-up section.
Only a few studies have used unsupervised exer-
cise training alone with no added support as a main-
tenance exercise training programme in patients with
COPD.22,24–26 Unsupervised home exercise following
the completion of a 6-month PR programme
(n = 54) maintained both 6-min walk distance
(6MWD) and HRQoL (P < 0.05) to 18 months in the
training group compared to the control group.25 Sim-
ilarly, advice to continue to exercise (30 min per day
of walking and strength exercises) following a
3-month home-based PR programme maintained
maximum work rate (measured by an incremental
cycle test to peak exercise capacity) (20.7% greater
than baseline) and 4-min walk distance (13.6%
greater than baseline) to 18 months. However, com-
pared to standard care, there were no between-group
differences.26 Interestingly, in these two studies, the
initial PR programme was of longer duration (3 and
6 months) which in itself may have affected the out-
comes at 18 months by providing a greater initial
gain than might have been achieved in a shorter PR
programme.
Following shorter PR programmes of 8-week dura-
tion, unsupervised walking training compared to
usual care did not maintain exercise capacity but did
maintain HRQoL.22,24 From the limited research avail-
able, it appears that unsupervised exercise training
alone is not effective as a maintenance exercise pro-
gramme unless it follows the completion of a PR pro-
gramme of 3 or 6 months or the maintenance
programme has regular review as an important com-
ponent. The initial PR programme will be discussed
in a further section.
Respirology (2019)
Maintenance exercise programmes: What works?
STRATEGIES TO IMPROVE
ADHERENCE TO MAINTENANCE
EXERCISE TRAINING
Despite the importance of continuing to exercise after
the completion of a supervised PR programme, adher-
ence to maintenance programmes is difficult to achieve
for patients with COPD and 12-month completion rates
have been reported to be as low as 50% in some
studies.7,13,23,25
Maintenance exercise diaries
Exercise diaries combined with unsupervised mainte-
nance exercise training programmes8,18,19,21,23 or
monthly supervised exercise3,14 in patients with COPD
have been used to improve motivation and measure
adherence to the prescribed exercise (distance walked
and time spent walking) and, in some cases, to record
daily minutes of activity.14,21 HRQoL was maintained to
6 months when diary use was combined with monthly
supervised exercise14 and with unsupervised walking
exercise.19 There were no studies that maintained exer-
cise capacity and HRQoL to 12 months that used dia-
ries to improve adherence to ongoing exercise.
Support phone calls and follow-up
Studies that used support phone calls to improve
adherence to exercise also used other modes of sup-
port which made it difficult to determine the impact of
support phone calls alone. HRQoL but not exercise
capacity was maintained to 12 months when support
phone calls were combined with unsupervised exercise
training with18,19 and without pedometers27; when sup-
port phone calls were combined with monthly super-
vised exercise sessions3,13; and when support phone
calls were combined with a 12-week adherence inter-
vention that incorporated the use of activity monitors,
diaries and weekly home visits.21
Follow-up assessments after the completion of PR
programmes were included in a number of studies and
provided the opportunity for monitoring of progress,
verbal encouragement and support to keep exercis-
ing.3,8,13,18,27,28 Participants who had completed a
12-month maintenance study (intervention of super-
vised weekly exercise compared to control of unsuper-
vised home exercise) completed a survey about their
experiences. Interestingly, both groups felt that regular
assessment (at 3, 6 and 12 months) and contact with
the same physiotherapist were important factors in
helping them to continue to exercise.29 However, other
studies have reported that follow-up assessments did
not improve adherence3,13 and that attendance at
monthly sessions was as low as 39%13 and 25%.30
Combination of interventions (phone calls,
diaries and pedometers)
The idea of combining therapies was initially investi-
gated in a 12-week adherence intervention (weekly
phone calls and one home visit with pedometers for
self-monitoring) that followed an 8-week PR pro-
gramme compared to usual care.21 Measures were
Respirology (2019)
3
taken directly after completion of the adherence inter-
vention and at 12 months and were compared to post-
PR values. Whilst there was a significant improvement
in self-reported minutes of activity and less decline in
6MWD in the intervention group compared to usual
care group (immediately after the intervention), there
were no differences between groups at 12 months. A
more recent study has extended these ideas to examine
the combination of diaries, telephone support and
pedometers over a 12-month period to promote home-
based walking training following an 8-week supervised
centre-based walking training programme, compared
to a control group (encouraged to continue home-
based walking plus diaries).18 Despite the maintenance
intervention continuing with high levels of feedback for
the full 12-month period, there were no between-group
differences in the magnitude of change in HRQoL or
endurance exercise capacity at 12 months. The authors
commented that there was limited engagement by par-
ticipants with the exercise diaries over the intervention
period and adherence was also relatively poor (52%
based on phone call records).
On the basis of the complexities of the above-
mentioned studies in terms of small numbers and dif-
ferent forms of support (phone calls, diaries and
follow-up assessments), it is difficult to recommend
one support intervention over the other when com-
bined with unsupervised maintenance exercise. How-
ever, one key element that was reported to be helpful
by participants was receiving support and encourage-
ment from the same physiotherapist throughout the
12 months.29
Use of technology
In the emerging technological age, using some form of
technology may appeal to people of all ages and be an
effective adjunct to a maintenance exercise pro-
gramme. At the simplest level, technology can be used
as distractive stimuli,31 for self-monitoring of physical
activity in the maintenance period using a pedome-
ter18,21,32 or can act as a coach to reinforce exercise
behaviours through a mobile phone.32 In the latter pilot
study, mobile phone with self-monitoring (n = 8) was
compared to mobile phone with additional nurse
coaching (n = 9). The study showed that it was feasible
to use a mobile phone to deliver care in the mainte-
nance period and, in fact, the group who self-
monitored their symptoms with an exercise plan and a
pedometer showed greater improvements in physical
activity than the coached group at 6 months; however,
the study was not well powered to detect such
differences.
More complex technology using telerehabilitation
platforms has been used to support maintenance exer-
cise training.33,34 The telerehabilitation approach may
promote better integration of exercise training during
the maintenance period compared to attendance at
centre-based programmes. One pilot study examined
the use of telerehabilitation over a 2-year period during
which time unsupervised treadmill and strength train-
ing were encouraged (three times per week with the
support of a website) as well as weekly videoconferenc-
ing sessions with a physiotherapist.34 Preliminary
© 2019 Asian Pacific Society of Respirology
4 L Spencer and ZJ McKeough
results indicated that participants (n = 10) felt they had
succeeded in maintaining their exercise programme
with, on average, two training sessions per week regis-
tered on the website. This study has now been
extended to a larger randomized controlled trial across
Norway, Denmark and Australia (the iTrain study).34 It
is important to note that the intervention did not have
a distinct short-term PR component with a mainte-
nance exercise component but encouraged the same
frequency of exercise training throughout the entire
2-year period. Another study used a more conventional
approach of an initial 8-week hospital-based PR pro-
gramme followed by 12 months maintenance telereh-
abilitation (at home, three times per week) compared
to either a twice weekly hospital maintenance exercise
programme or usual care.33 The maintenance telereh-
abilitation involved unsupervised walking, arm and leg
exercises with remote monitoring of data which was
then transferred to a web-based platform, access to a
call centre and scheduled weekly contact to a range of
health professionals over the phone or through video-
conferencing for self-management advice. The primary
end point of this study was hospital utilization mea-
sures. The two maintenance exercise groups had a sig-
nificantly lower rate of hospitalization for an acute
exacerbation of COPD than the usual care group and
were equally effective at maintaining exercise and
HRQoL benefits. Although more work is needed in this
area, these results support the idea of using a telereh-
abilitation approach in the maintenance exercise
period following an initial supervised PR programme. It
is conceivable that more telerehabilitation platforms
will be developed in a variety of countries to help sup-
port maintenance exercise programmes and should
undergo rigorous research to determine overall
effectiveness.
FACILITATORS AND BARRIERS TO
LONG-TERM EXERCISE TRAINING
A recent systematic review of qualitative studies (semi-
structured interviews) in patients with COPD (n = 167)
reported subjective experience about perceived facilita-
tors and barriers to long-term physical activity follow-
ing PR. All participants had previously completed PR
(4–12 weeks duration); however, it was unclear if they
were actively involved in maintenance exercise training
programmes. The themes that were identified included:
(i) beliefs (intentions, self-efficacy and feedback of
capabilities); (ii) social support (relationship to health-
care professionals and peer interaction); and
(iii) environment (opportunities following PR and rou-
tine).35 Consequently, the facilitators to long-term exer-
cise were identified as participants having a positive
belief about their disease along with good self-efficacy,
and ongoing support from health clinicians in an envi-
ronment where routine and opportunities to exercise
were provided.35 The barriers to long-term exercise
were identified as lack of social support, inability to
access community exercise programmes and exacerba-
tions and anxiety.35 If clinicians understand the barriers
and facilitators to maintenance exercise programmes
from a patient perspective, it may help with the design
© 2019 Asian Pacific Society of Respirology
of maintenance exercise programmes that are more
acceptable to the participant. For example, strategies
might involve motivating and praising achievement in
order to improve the participant’s belief that they will
be able to continue to exercise at home and in the
community; assisting in the transfer from the PR pro-
gramme to community classes by providing informa-
tion and even attending the classes with reluctant
patients; and improving knowledge about managing
exacerbations.35 As has been suggested by others,
designing maintenance exercise programmes should
not be a ‘one model suits all’ approach.36,37 Mainte-
nance exercise programmes need to be adapted to the
individual needs, taking into consideration any external
factors in the participant’s life that may affect their abil-
ity to continue to exercise and remain physically active.
INITIAL PR PROGRAMME
Focusing on the maintenance exercise training pro-
gramme itself may not be the only important factor in
maintaining benefits in the long term. If patients with
COPD and ILD do well in terms of gains in 6MWD and
HRQoL following the completion of the initial PR pro-
gramme, the participants may have more chance of
maintaining exercise capacity and HRQoL in the long
term.8,25,37
Improvement in exercise capacity
Studies that have shown a mean improvement in
6MWD (between 52 and 80 m) resulting from an initial
PR of 8 weeks,8 12 weeks27 and 6 months duration
maintained exercise capacity and HRQoL for
12 months in patients with COPD25,28 and ILD.37 On the
other hand, studies of PR of 6–8 week’s duration that
reported small improvements of 11,22 1413 and 23 m3
did not maintain exercise capacity and HRQoL for
12 months. The above-mentioned studies show that an
important consideration in achieving the maintenance
of long-term benefits may be the mean improvement
in 6MWD resulting from the initial PR itself.
INTO THE FUTURE: MORE RESEARCH
NEEDED
Adapting maintenance exercise programmes
to suit individuals
As the population ages and more patients with COPD
and other lung conditions present with multiple co-
morbidities (e.g. anxiety, pain, frailty, osteoarthritis,
cardiovascular disease, osteoporosis, obesity and
fatigue), adapting the PR programme itself and the
maintenance exercise programmes to the individual
needs may be the way of the future. An adaptable
model is often used by clinicians but is yet to be evalu-
ated. In achieving an individually designed PR and
maintenance exercise programme that is evidence-
based and includes supervised exercise training, sup-
port, education and regular follow-up, the importance
of experienced health professionals cannot be over-
stated. Health professionals who work in PR need the
Respirology (2019)
Maintenance exercise programmes: What works?
experience and knowledge to be able to offer different
programmes for different participants.
Examples of adapting maintenance exercise
programmes to suit the individual
Alternative modes of exercise training (e.g. water-based
exercise38 and Tai Chi,39 and balance training)40 have
been shown to be effective as part of PR programmes
but have been less well studied as maintenance exer-
cise programmes in patients with lung conditions.
Alternative modes of training may allow the mainte-
nance exercise programme to be adapted to the indi-
vidual giving participants a choice of maintenance
exercise programmes, for example a participant with:
• Poor exercise capacity, frailty and risk of falling—
may benefit from a longer PR programme and a
maintenance exercise programme that includes bal-
ance exercises (e.g. Tai Chi) that is supervised in a
hospital outpatient or community setting.
• Physical co-morbidities such as osteoarthritis with
joint and back pain—may benefit from a mainte-
nance exercise programme in a community pool.
• High anxiety—may benefit from a maintenance exer-
cise programme in the community with regular
review and support from the PR programme and
psychologist.
• Cardiovascular disease—may benefit from PR with
specific education about cardiac risk factors or refer-
ral to a cardiac rehabilitation programme.
These are suggestions based on clinical experience
and are yet to be trialled as maintenance exercise pro-
grammes in patients with COPD or other lung
conditions.
Empowering individuals
Another factor that may be important in creating suc-
cessful maintenance exercise programmes is the ability
to motivate and empower participants early in the PR
programme to recognize that exercise training is safe
and effective for them. Participants have reported high
anxiety,41 poor self-efficacy in their ability to perform
exercise35 and so commencing a home exercise pro-
gramme early with positive feedback from the supervis-
ing health professional may help confidence grow.
Lung Foundation Australia has developed a pro-
gramme of community-based maintenance exercise
programmes (Lungs in Action) and supports groups for
patients with respiratory disease.42 The Lungs in Action
exercise trainers complete online and face to face train-
ing with supervision from local PR programmes.
Patients meet the trainers and when PR is complete,
participants have the option of going to the Lungs in
Action programme for a minimal cost or continuing
with a home exercise programme with regular review.
SUMMARY OF RESULTS
The evidence in this review has focused on mainte-
nance exercise programmes in patients with COPD
because to date, there is very limited evidence in
Respirology (2019)
5
Table 1 What is known about maintaining the benefits
gained from PR
Maintaining the gains: what is known
Exercise capacity and HRQoL decline 12 months following
PR2,3
Ongoing exercise is necessary as a maintenance
programme6
Weekly supervised maintenance exercise to improve
exercise capacity and HRQoL has weak evidence6
Weekly supervised maintenance exercise reduces risk of
readmission5
The length of the initial PR programme and the degree of
improvement in exercise capacity may be
important25,27,28,37
Monthly supervised maintenance exercise or less is
ineffective6
Technology shows promising results to assist ongoing
exercise32,33
Participants report benefits from ongoing support and
encouragement by the same physiotherapist/health
professional29
Participants report that low self-efficacy, lack of social
support and limited access to programmes affects the
ability to exercise in the long term35
HRQoL, health-related quality of life; PR, pulmonary
rehabilitation.
Table 2 What is not known about maintaining the
benefits gained from PR
Maintaining the gains: what is not known
The most effective maintenance exercise programme for
patients with COPD and other lung conditions
The combination of phone calls, diaries and pedometers that
is most effective
The best location for maintenance exercise programmes:
home, community or hospital
How best to use technology
How best to motivate and support individuals
PR, pulmonary rehabilitation.
people with other lung conditions. The evidence dis-
cussed has provided us with information about what is
known about maintaining the benefits following com-
pletion of PR (Table 1) and what is not known.
(Table 2) Continuing to exercise is an important aspect
of maintaining exercise capacity, HRQoL and reducing
healthcare costs following completion of PR pro-
grammes; however, the frequency of ongoing supervi-
sion remains unclear. Supervised monthly exercise as a
maintenance exercise programme has shown no long-
term benefits and is not recommended. The variation
in the studies that used unsupervised maintenance
exercise training programmes in terms of added sup-
port (e.g. diaries, phone calls and pedometers) makes
it difficult to interpret and more work is needed in this
area before unsupervised exercise training could be
recommended as a maintenance exercise programme.
However, some interesting ideas that may hold the
© 2019 Asian Pacific Society of Respirology
6 L Spencer and ZJ McKeough
answer to the monumental challenge of maintaining
the benefits gained from PR in the long term include:
the degree of benefits gained from the initial PR pro-
gramme; support and motivation from the supervising
physiotherapist and health professional to improve
patient confidence and self-efficacy; emerging technol-
ogy platforms to support maintenance exercise; and
maintenance exercise programmes that are tailored to
individual needs and provide regular review.
CONCLUSION
It is indeed a monumental task to help patients with
COPD and other lung conditions to maintain the bene-
fits that they have gained following completion of a PR
programme. No effective model of maintenance exer-
cise has been identified as the ideal model in patients
with COPD. However, there have been promising
results in studies that have used regular supervised
exercise, encouragement from experienced health pro-
fessionals and exercise supported by technology. With
continued research in this area, it is hopeful that stron-
ger evidence will emerge for effective maintenance
exercise programmes for patients with COPD and other
lung conditions. This will ensure that the important
benefits gained from PR will be maintained in the
long term.
The Authors
Associate Professor L.M.S. is senior physiotherapist in pulmo-
nary and cardiac rehabilitation at Royal Prince Alfred Hospital,
Sydney, with a particular interest in maintenance exercise pro-
grammes following completion of PR. Associate Professor
Z.J.M. is an academic at The University of Sydney with a partic-
ular interest in PR and the emerging area of sedentary behaviour
and physical activity in patients with COPD.
Abbreviations: 6MWD, six-minute walk distance; COPD,
chronic obstructive pulmonary disease; HRQoL, health-related
quality of life; ILD, interstitial lung disease; PR, pulmonary
rehabilitation.
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