Can Respir J Vol 18 No 4 July/August 2011216
Using Telehealth technology to deliver pulmonary
rehabilitation to patients with chronic obstructive
Michael K Stickland PhD1,2, Tina Jourdain RRT2, Eric YL Wong MD1,2, Wendy M Rodgers PhD3,
Nicholas G Jendzjowsky MSc3, G Fred MacDonald MD2
1Division of Pulmonary Medicine, Department of Medicine, University of Alberta; 2Centre for Lung Health (Covenant Health), Edmonton General
Continuing Care Centre; 3Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Alberta
Correspondence: Dr Michael K Stickland, Division of Pulmonary Medicine, Department of Medicine, 8334B Aberhart Centre, University of Alberta, Edmonton,
Alberta T6G 2J3. Telephone 780-407-7845, fax 780-407-6384, e-mail firstname.lastname@example.org
monary disease (COPD) (1,2). As recently reviewed (3), PR has been
shown to improve functional exercise capacity and quality of life,
while reducing acute exacerbations, hospitalizations and health care
costs. In fact, PR has been shown to be a more effective therapeutic
strategy for improving health outcomes in patients with COPD than
traditional pharmacological management (3-5).
As noted recently (6), there is insufficient PR capacity to serve the
COPD population. Furthermore, the majority of PR programs are
located within large urban centres, thus limiting access for rural
patients. Accordingly, an outpatient PR program delivered via
Telehealth technology (Telehealth-PR) was developed to deliver PR
ulmonary rehabilitation (PR) is a low-cost, vital component of
long-term management of patients with chronic obstructive pul-
to rural patients. The purpose of the present study was to examine the
efficacy of Telehealth-PR compared with PR delivered in person
through a standard outpatient hospital-based program (Standard-PR).
It was hypothesized that Telehealth-PR was as effective as Standard-PR
at improving quality of life and exercise capacity.
Design and patient selection
The present study was a parallel group, noninferiority trial examining
the efficacy of Telehealth-PR compared with delivering ‘standard’ out-
patient hospital-based PR in person within the main rehabilitation
clinic (ie, Standard-PR) at the Centre for Lung Health, Edmonton,
Alberta. Enrollment in the study was from January 2006 to December
©2011 Pulsus Group Inc. All rights reserved
MK Stickland, T Jourdain, EYL Wong, WM Rodgers, NG Jendzjowsky,
GF MacDonald. Using Telehealth technology to deliver pulmonary
rehabilitation to patients with chronic obstructive pulmonary
disease. Can Respir J 2011;18(4):216-220.
BaCKGROUND: Pulmonary rehabilitation (PR) is an effective thera-
peutic strategy to improve health outcomes in patients with chronic
obstructive pulmonary disease (COPD); however, there is insufficient PR
capacity to service all COPD patients, thus necessitating creative solutions
to increase the availability of PR.
OBJECTIVE: To examine the efficacy of PR delivered via Telehealth
(Telehealth-PR) compared with PR delivered in person through a standard
outpatient hospital-based program (Standard-PR).
METHODS: One hundred forty-seven COPD patients participated in an
eight-week rural PR program delivered via Telehealth-PR. Data were com-
pared with a parallel group of 262 COPD patients who attended
Standard-PR. Education sessions were administered two days per week via
Telehealth, and patients exercised at their satellite centre under direct
supervision. Standard-PR patients viewed the same education sessions in
person and exercised at the main PR site. The primary outcome measure
was change in quality of life as evaluated by the St George’s Respiratory
Questionnaire (SGRQ). A noninferiority analysis was performed using
both intention-to-treat and per-protocol approaches.
RESULTS: Both Telehealth-PR and Standard-PR resulted in clinically and
statistically significant improvements in SGRQ scores (4.5±0.8% versus
4.1±0.6%; P<0.05 versus baseline for both groups), and the improvement in
SGRQ was not different between the two programs. Similarly, exercise
capacity, as assessed by 12 min walk test, improved equally in both
Telehealth-PR and Standard-PR programs (81±10 m versus 82±10 m;
P<0.05 versus baseline for both groups).
CONCLUSION: Telehealth-PR was an effective tool for increasing
COPD PR services, and demonstrated improvements in quality of life and
exercise capacity comparable with Standard-PR.
Key Words: COPD; Exercise; Pulmonary rehabilitation; Telehealth
L’utilisation de la technologie de la télésanté pour
offrir une réadaptation pulmonaire aux patients
ayant une maladie pulmonaire obstructive
HISTORIQUE : La réadaptation pulmonaire (RP) est une stratégie
thérapeutique efficace pour améliorer les issues de santé chez les patients
ayant une maladie pulmonaire obstructive chronique (MPOC). Cependant,
la capacité de la RP est insuffisante pour servir tous les patients atteints
d’une MPOC, ce qui exige des solutions créatives pour accroître la
disponibilité de la RP.
OBJECTIF : Examiner l’efficacité de la RP offerte par télésanté
(RP-télésanté) par rapport à la RP offerte en personne au moyen d’un pro-
gramme ambulatoire en milieu hospitalier (RP-standard).
MÉTHODOLOGIE : Cent quarante-sept patients atteints de MPOC
ont participé à un programme de RP-télésanté de huit semaines en milieu
rural. Les chercheurs ont comparé les données avec un groupe parallèle
de 262 patients atteints de MPOC qui participaient à une RP-standard. Les
séances étaient données deux fois par semaine par télésanté, et les patients
s’exerçaient à leur centre satellite sous une supervision directe. Les patients
recevant la RP-standard avaient droit aux mêmes séances, en salle, et
s’exerçaient à l’établissement principal de la RP. La mesure d’issue primaire
était un changement de la qualité de vie évalué par le questionnaire respi-
ratoire de St George (SGRQ). Les chercheurs ont effectué une analyse de
non-infériorité au moyen des démarches d’intention de traiter et de respect
RÉSULTaTS : Tant la RP-télésanté que la RP-standard ont suscité des
améliorations cliniques statistiquement significatives selon les indices de
SGRQ (4,5±0,8 % par rapport à 4,1±0,6 %; P<0,05 par rapport aux don-
nées de départ dans les deux groupes). Cependant, il n’y avait pas
d’amélioration aux indices de SGRQ entre les deux programmes. De
même, la capacité à l’exercice, évaluée par un test à l’effort de 12 min, s’est
autant améliorée dans le programme de RP-télésanté que dans celui de
RP-standard (81±10 m par rapport à 82±10 m; P<0,05 par rapport aux
données de départ dans les deux groupes).
CONCLUSION : La RP-télésanté était un outil efficace pour accroître les
services de RP en MPOC et a suscité des améliorations de la qualité de vie
et une capacité à l’exercice comparables à la RP-standard.
Standard versus Telehealth pulmonary rehabilitation
Can Respir J Vol 18 No 4 July/August 2011217
2008. Patients in the Telehealth-PR group were all referred by their
physician to attend Telehealth-PR at their local health centre within
nine small communities (population 1000 to 50,000) in central and
northern Alberta. Patients within the Standard-PR group were simi-
larly referred by their physician to attend PR at the Centre for Lung
Health (Covenant Health), located within Metropolitan Edmonton
(population approximately one million). University and hospital
research ethics board approval was granted for the present study.
All enrolled patients had COPD confirmed by lung function testing
and patient history as reviewed by a pulmonologist. Patients included
in both groups were deemed suitable for enrollment in PR. Exclusion
criteria for both groups were unstable cardiovascular disease and
dementia. Patients who were dependent on oxygen or those with com-
orbidities were included. A total of 147 COPD patients were enrolled
in the Telehealth-PR program, while a total of 262 COPD patients
were enrolled in the Standard-PR program over the same period.
Patient characteristics are presented in Table 1.
On referral, all patients were seen by a pulmonologist. Patient history
was obtained, baseline lung function and chest x-rays were reviewed
and a cardiopulmonary exercise stress test (7) was performed.
The PR program was conducted two days per week for eight weeks.
The patients participated in group exercise for 2 h, and attended group
education for 1 h per session. The exercise program was supervised by
respiratory therapists or other qualified health professionals, and fol-
lowed PR guidelines for exercise training (3). Exercise programs
included aerobic exercise consisting of track or treadmill walking,
cycling and arm ergometer training. The exercise intensity was person-
alized based on patient symptoms and baseline exercise capacity.
Patients performed resistance exercise training that included hand
weights and/or elastic bands/tubes. In addition, patients performed
flexibility and breathing retraining.
Educational modules directed toward patient self-management (3)
were offered for 1 h each day, with topics including basic pathophysiol-
ogy of lung disease, pulmonary hygiene, exercise training, respiratory
medications, inhaler devices and technique, nutrition, relaxation/
stress management, travel/home care and oxygen therapy.
Patients referred to the Telehealth-PR program travelled to their local
hospital/health clinic and were seen by a pulmonologist at the Centre
for Lung Health via Telehealth (ie, video conferencing). Baseline lung
function (minimum spirometry), chest x-ray and resting 12-lead elec-
trocardiogram were reviewed by the pulmonologist at the main PR
site. The pulmonologist subsequently discussed with the patient their
history and symptoms via videoconferencing. The patient was assisted
by the respiratory therapist/health professional at the local
Telehealth-PR site during their initial consultation.
Patients attended the Telehealth-PR program twice a week for
eight weeks within their local community. Identical to Standard-PR,
patients performed group exercise for 2 h, and attended group educa-
tion for 1 h per session. The exercise program was designed similarly to
the main program, with the primary difference being that the main
program typically involved eight to 12 patients, while each local PR
site had two to six patients. Similar to Standard-PR, the exercise pro-
gram was supervised by a respiratory therapist or other qualified health
professional and included personalized aerobic and resistance exercise
training, flexibility exercises and breathing retraining. Local
Telehealth-PR staff were given training and guidance from the
Standard-PR supervising respiratory therapist (T Jourdain).
Telehealth-PR patients viewed education sessions that were identi-
cal to the main program, delivered to the local sites via video confer-
encing. At the end of each lecture, patients from all sites were offered
the opportunity to ask questions to the main site via Telehealth. The
local respiratory therapist/health professional was present at each site
to help facilitate program delivery and assist with questions.
Patients were assessed before and after PR, and all patients were
invited to six-month follow-up testing. A priori, the primary out-
come measure was set as the change in self-administered St George’s
Respiratory Questionnaire (SGRQ) total score (8) immediately fol-
lowing PR. A secondary outcome measure was 12 min walk distance.
A minimum of two self-paced 12 min walk tests were performed both
before and after PR, with mean distance calculated and recorded. A
previous study (9) has shown that 12 min walk distance correlates
highly (r=0.955) with 6 min walk distance in patients.
Baseline standardized spirometry was performed on all patients within
their community, with patients subsequently stratified according to
Global initiative for chronic Obstructive Lung Disease (GOLD)
forced expiratory volume in 1 s (FEV1) criteria (10). Where available,
lung volume and diffusion capacity were also reported.
Data management and data analysis
Data obtained for both Standard-PR and Telehealth-PR were all man-
aged centrally in a common database (Windows Access [Microsoft
Corporation, USA]). Data were subsequently extracted electronically
into a common spreadsheet and verified. It was observed that 13.9% of
scores were missing following PR (T2) compared with baseline (T1),
and that 68.4% of scores were missing at six-month follow-up (T3)
compared with baseline. It was, therefore, decided that data imputa-
tion to replace missing values at T2 was reasonable, but not for T3. A
conservative imputation procedure (last observation carried forward)
A series of c2 analyses were performed to determine whether there
were significant differences between Standard-PR and Telehealth-PR
in the incidences of comorbidity, GOLD category, supplemental oxy-
gen and program completion. For analysis purposes, patients were
defined as having completed the PR program if they attended a min-
imum of nine of 16 sessions.
To examine change over time with PR, two analytical strategies
were used. First, an intention-to-treat analysis was performed using a
repeated measures multiple ANOVA (R-MANOVA) for multiple
dependent variables, and R-ANOVA for single dependent variables
using the data with replacement (T2 only). Second, a per-protocol
analysis was conducted using only those individuals who provided
complete data at both T1 and T2, and then again at T3. Due to the
high level of attrition at T3 (68%), only a per-protocol analysis was
performed between T1 and T3. To evaluate noninferiority between
baseline patient characteristics
Pulmonary rehabilitation program
Women/men, n/n (%/%)
Body mass index, kg/m2
Smoking history, pack years
Supplemental oxygen therapy, n (%)
Comorbid illness, n (%)
Coronary artery disease
Data presented as mean ± SD unless otherwise indicated. Note: No significant
differences were found between the Standard and Telehealth rehabilitation
Stickland et al
Can Respir J Vol 18 No 4 July/August 2011218
programs, a difference of 4% in SGRQ total score was recognized as
the minimum clinically important difference (11) and used to distin-
guish PR delivered via Telehealth versus Standard-PR. Group data for
each variable were expressed as means and SEs. For all inferential
analyses, the probability of type I error was set at 0.05.
No significant difference was observed between Standard-PR and
Telehealth-PR in age, weight, body mass index, baseline FEV1, preva-
lence of comorbidities or use of supplemental oxygen (Tables 1 and 2).
The distribution of GOLD stages was also similar in the two programs
(Table 2). Despite similarities in FEV1 at baseline, patients in the
Telehealth-PR group had higher SGRQ scores in the activities and
impacts subscores, and a higher total score (ie, poorer quality of life)
compared with Standard-PR. Similarly, distance travelled in the 12 min
walk was less in patients in the Telehealth-PR program at baseline
compared with patients undergoing Standard-PR (Table 3).
Patients in the Standard-PR group attended an average of 13.2 PR
sessions, while attendance in Telehealth-PR averaged 12.6 PR ses-
sions. No differences were seen in program adherence between the
Standard-PR and Telehealth-PR groups (Table 4).
Quality of life (before and after PR)
Using intention-to-treat analysis, an R-MANOVA was conducted
using Telehealth-PR versus Standard-PR as the independent vari-
able; the dependent variables were the three SGRQ subscale scores at
baseline and program end, with repeated measures for time to control
for the baseline scores in the consideration of change. An R-ANOVA
was performed separately for SGRQ total score. Both programs
demonstrated a clinically and statistically significantly improvement
in SGRQ subscale and total scores with PR (Table 4). Despite an
improvement in SGRQ score, patients in the Telehealth-PR group
still had lower quality of life than Standard-PR after PR. Figure 1
shows that Telehealth-PR was not inferior to Standard-PR because
the 95% CI for the change in SGRQ in both groups was similar and
not greater than the prespecified range that defined noninferiority.
Similar improvements were observed in symptoms, impact and activity
subscales of the SGRQ. Consistent with the intention-to-treat analy-
sis, the per-protocol analysis found that both programs demonstrated
a clinically and statistically significant improvement in SGRQ total
score with PR, and that the improvement with Telehealth-PR was not
inferior to the main program.
12 min walk distance (before and after PR)
An R-ANOVA was conducted using Telehealth-PR versus Standard-PR
programs as the between-subjects variable, and 12 min walk distance
at each of the three time points as the dependent variable with
repeated measures. Both groups increased their walk distances sig-
nificantly with PR; however, Standard-PR maintained an advantage
over Telehealth-PR both before and after PR (Table 3). As shown in
Figure 2, the 95% CI for the difference in 12 min walk distance was
similar between groups, indicating that both programs yielded similar
improvement in 12 min walk distance. Consistent with the intention-
to-treat analysis, the per-protocol analysis showed that individuals in
both programs increased their walk distance similarly over time; how-
ever, Standard-PR patients walked further than Telehealth-PR patients
at both time points.
Six-month follow-up data
Baseline scores of participants who provided data at six months were
compared with those who did not, with no significant differences
observed in baseline SGRQ score or walk distance. The improvement
in SGRQ total score with PR was maintained at six months, with no
baseline lung function
Pulmonary rehabilitation program
FEV1, % predicted
FVC, % predicted
Total lung capacity, L
Total lung capacity, % predicted
Residual capacity, L
Diffusion capacity, L
GOLD stage, n (%)
Data presented as mean ± SD unless otherwise indicated. Note: Spirometry
was performed in all patients. Full lung function testing was performed in
235 patients in the Standard program, and in 48 Telehealth program patients.
No differences were found between groups. FEV1 Forced expiratory volume in
1 s; FVC Forced vital capacity; GOLD Global initiative for chronic Obstructive
St George’s Respiratory Questionnaire (SGRQ) and 12 min walk data before, immediately following and six months after
Standard rehabilitation program
Telehealth rehabilitation program
after after (imputed)6 months after before
6 months after
6 months after
12 min walk
Data presented as mean ± SD. *Missing scores were given the same value as obtained before pulmonary rehabilitation (ie, intention-to-treat analysis). †P<0.05
versus before rehabilitation; ‡P<0.05 versus Standard program
Standard versus Telehealth pulmonary rehabilitation
Can Respir J Vol 18 No 4 July/August 2011219
between-group difference in SGRQ change (Table 4). At six months,
12 min walk distance was lower compared with immediately following
PR. No between-group differences were observed, indicating similar
response at six months with Standard-PR and Telehealth-PR.
The purpose of the present study was to examine the efficacy of PR
delivered via Telehealth compared with PR delivered in person
through a standard outpatient hospital-based program. Telehealth-PR
and Standard-PR resulted in similar clinically and statistically signifi-
cant improvements in quality of life. Similarly, exercise capacity
improved equally with Telehealth-PR and Standard-PR. These find-
ings indicate that Telehealth-PR is effective at improving quality of
life and exercise capacity in patients with COPD, and provides a
viable option to increase capacity and deliver PR services to patients
in remote locations who do not have access to PR.
A concern with a noninferiority trial is that the study be suf-
ficiently powered to detect a difference between therapies (12). A
difference of 4% in SGRQ total score is recognized as the minimum
clinically important difference for the SGRQ (11), and was used as
our evaluation criterion. Previous work from our clinic has shown that
the SD of the change in SGRQ with PR is approximately 10% (13).
Using these data, and an alpha level of 0.025 and beta of 0.1 (12),
131 patients in each group would be required to detect a clinically
significant difference in SGRQ response between programs. With
a sample size of 147 in Telehealth-PR and 262 in Standard-PR, the
lack of between-group difference found in our study is unlikely to be
explained by insufficient statistical power.
The exercise program within both PR programs included aerobic exer-
cise, resistance training, flexibility exercises and breathing retraining.
Some of the Telehealth-PR sites had limited equipment, and primarily
used walking, as well as simple hand weights and/or elastic bands/tubes
for resistance training. Despite the relatively simple approach to exer-
cise, no consistent difference in health outcomes was seen between
sites or between the Telehealth-PR and Standard-PR programs.
Similarly, recent studies (14,15) have shown that home-based PR is as
effective as hospital-based outpatient PR at improving exercise cap-
acity and dyspnea. Home-based and Telehealth-PR approaches can
provide effective alternatives to standard outpatient PR. Future studies
should examine the efficacy of home-based PR delivered, at least par-
tially, via Telehealth technology as a way of increasing PR access and
reducing overall program cost.
A recently published economic analysis from our Standard-PR pro-
gram (16) demonstrated that patients completing PR used less health
care resources in the year following PR, resulting in a net reduction
of health care costs. Because both Standard-PR and Telehealth-PR
demonstrated similar improvements in quality of life and exercise
capacity, we would expect a similar reduction in health care use in
both programs following PR. Telehealth-PR classes were typically
conducted with two to six patients, whereas Standard-PR had eight
to 12 patients per class; thus, the cost per patient may be higher in
Telehealth-PR. However, with central data collection/oversight,
as well as one site delivering the lectures, overall costs were likely
minimized. Furthermore, we found that Telehealth-PR provided an
invaluable support system as remote centres worked to establish PR
and COPD management services in their area. Given the positive
outcomes of Telehealth-PR, future researchers may wish to specifically
examine the economic implications of Telehealth-PR.
Patients in the present study were not randomly assigned to either
Standard-PR or Telehealth-PR; thus, it is possible that baseline
between-group differences may have biased the results. Some studies
have shown that patients with severe COPD improve less with PR
compared with patients with less severe disease (17-19). No difference
was observed in baseline lung function between our two groups; how-
ever, Telehealth-PR demonstrated lower quality of life and exercise
capacity at baseline. Based on this, Telehealth-PR may have shown
less response to PR compared with Standard-PR; however, we detected
no between-group difference in response to PR. These results would
indicate that the noninferiority finding was unlikely to be influenced
by the lack of patient randomization.
Figure 1) Mean change (± 95% CI) in St George’s Respiratory
Questionnaire (SGRQ) with the Standard and Telehealth pulmonary
rehabilitation programs. Note: Data presented using intention-to-treat
analysis. MCID Minimum clinically important difference
Figure 2) Mean change (± 95 CI) in 12 min walk distance with the
Standard and Telehealth pulmonary rehabilitation programs. Data presented
using intention-to-treat analysis
Change in SGRQ (%)
Change in Walk Distance (m)
-150-100 -500 50 100150
Patient dropout during pulmonary rehabilitation in the
Standard and Telehealth rehabilitation programs
Pulmonary rehabilitation program
Data presented as n. Note: No significant differences were found between the
Standard and Telehealth rehabilitation programs
Stickland et al Download full-text
Can Respir J Vol 18 No 4 July/August 2011220
An additional limitation of the present study was the amount of
missing data at six months, which is likely explained by our follow-up
procedures. Patients were invited to follow-up either via a telephone
call or letter mailed to their home, but were not further encouraged
due to funding constraints of the study. Importantly, baseline scores of
participants who did provide data at six months were compared with
those who did not, and no significant differences were observed in
baseline SGRQ scores or walk distance. These findings suggest that
patients returning to follow-up at six months in both programs were
representative of the original sample. In addition, the primary out-
come of the study was the change in SGRQ score immediately after
PR, which would not have been affected by missing data at six months.
There remains a significant need for stronger evidence regarding the
longer-term effects of PR, regardless of mode of delivery.
The purpose of the present study was to examine the effectiveness of
PR delivered via Telehealth. Telehealth-PR was not inferior to
Standard-PR – similar improvements in quality of life and exercise
capacity were observed in both programs. Telehealth PR is an effective
option to increase PR capacity and deliver PR services to patients in
remote locations who do not have access to standard PR.
FUNDING: Funding for this project was obtained from the Alberta
Health Services Telehealth Clinical Grant Fund & Covenant Health
DISCLOSURE: Dr Stickland is funded by a Canadian Institutes of
Health Research New Investigator Award and has received speaking hono-
raria from GlaxoSmithKline. T Jourdain has no conflicts of interest to
disclose. Dr Wong has received speaking honoraria from AstraZeneca,
GlaxoSmithKline, Pfizer and Boehringer Ingelheim. Dr Rodgers has no
conflicts of interest to disclose. N Jendzjowsky has no conflicts of interest
to disclose. Dr MacDonald has no conflicts of interest to disclose.
aCKNOWLEDGEMENTS: The authors thank the participating
Telehealth sites and their staff, as well as Drs J Archibald, M Bhutani,
A Liu, S Marcushamer, L Melenka, W Ramesh, D Stollery, and the staff at
the Centre for Lung Health for their assistance in this project. Funding for
this project was obtained from the Alberta Health Services Telehealth Clinical
Grant Fund & Covenant Health Research Foundation. Dr Stickland is
funded by a Canadian Institutes of Health Research New Investigator
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