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Pulmonary rehabilitation
Br. J. Dis. Chest (1988) 82, 220
Problems in Practice
PULMONARY ANNE Occupational
Health
REHABILITATION COCKCROFT
Unit, The Royal Free Hospital, London NW3 2QG
THE
Pond Street,
PROBLEM
It is well known that disabling chronic chest disease is common in Britain, mainly in the form of chronic obstructive airways disease. It is an important cause of loss of work time, premature retirement from work, severe disability and death. There are thus many people who could potentially benefit from pulmonary rehabilitation. There are various interpretations of ‘pulmonary rehabilitation’. In this article it means returning patients with respiratory disability to as normal a life as possible, aiming for them to achieve independent function in all their life activities. It is a wide-ranging undertaking, involving psychological as well as physical aspects of the disabled person’s life, and requires the application of several different therapeutic approaches. In North America pulmonary rehabilitation in the form of ‘comprehensive care programmes’ has been advocated for many years (1). Nevertheless, in Britain it remains relatively unpopular, unlike cardiac rehabilitation which is now widely available. Perhaps this is because cardiac patients are often relatively young and there may have been a sudden event, such as a myocardial infarction, from which a good recovery can be expected; there is a reasonable hope of returning them to a full, active life. On the other hand, patients with chronic respiratory disease are often elderly and have a progressive disability so that less dramatic effects can be expected from rehabilitation. The majority of respiratory patients receive nothing but treatment for intercurrent infections and perhaps bronchodilators (with variable degrees of benefit) long term. Some are still advised to ‘take it easy’ and they become even more disabled and limited as a result. This advice may be given because breathlessness is a distressing and frightening symptom for both patients and doctors and it is therefore avoided (by minimizing exertion) as far as possible. In addition, many doctors feel negative about the therapeutic possibilities for ‘respiratory cripples’ and this attitude readily communicates itself to patients so that both parties come to accept that ‘nothing can be done’. So it is against this background that pulmonary rehabilitation must be set: on the one hand a large population who could potentially benefit and on the other hand pessimism and fear about undertaking rehabilitation programmes. REHABILITATION Standard
METHODS
therapy
The first step in any rehabilitation programme is to ensure that optimal ‘standard’ therapy is being given and used appropriately. It is foolish to embark on a programme of exercise
COCKCROFT:
PULMONARY
REHABILITATION
221
training without first assessing and correcting any reversible airways obstruction. Quite simple improvements in therapy, including for example better delivery of a drug to patients with poor inhaler technique, can lead to a big improvement in exercise capacity for some patients. At this stage, it is necessary to tackle the question of smoking. Many elderly patients find it impossible to give up smoking altogether but can often manage to reduce the number they smoke. While there is evidence of a small benefit from giving up smoking, even in patients who already have advanced disease, there is no place for a punitive or authoritarian attitude on the part of the doctor. One hears of patients being dismissed by the doctor until they have given up smoking; this may help the doctor deal with his/her frustration but it does not make the patients give up smoking and tends to increase their feelings of hopelessness. I do not believe that it is justifiable to refuse to have a patient in a pulmonary rehabilitation programme because of failure to give up smoking. Some patients manage to give up smoking as a result of the continuing encouragement they receive during rehabilitation. The benefits of smoking cessation in these patients must be balanced against the weight gain that usually occurs, with its adverse effects on breathing and exericse tolerance. Exercise training programmes
Exercise training programmes are an important part of rehabilitation, having beneficial effects both physically and psychologically. There is no doubt that simple exercise programmes can produce measurable increases in exercise tolerance in respiratory patients (for example, an increase in 1Zminute walking distance) after as little as 2 months and this has been demonstrated in controlled trials (2,3). The increases are relatively small, in the region of 20%. Yet patients report benefit out of proportion to this. The reason is probably that the effects of a progressive disability on life style are not smooth; they occur in a series of steps. Figure 1 illustrates this concept. The same process can occur in reverse during rehabilitation, so that a small increase in exercise tolerance may result in a ‘step’ improvement in quality of life (4). Related to this, it is important to set goals with individual patients in their rehabilitation. For example, reaching the local club half a mile away may restore a social life to a patient so the aim would be for him to be able to walk this distance in a reasonable time. How do programmes of exercise training work in this group of patients? There is no evidence that they improve lung function. Nor, incidentally, is there evidence in adequately controlled trials that training the respiratory muscles has any beneficial effect. Perhaps this is not surprising, since the patients concerned are ‘training’ their respiratory muscles anyway by breathing against their own internal resistance. The exercises referred to in this article are aimed mainly at the muscles of locomotion. Because of their respiratory limitation, most patients cannot reach the level of work at which cardiovascular training would be expected. Young patients with asthma are different, reaching high workloads, but they are not the main group being discussed here. It has been suggested that increases in exercise tolerance are secondary to psychological improvement but in at least one controlled trial of exercise training the ‘control’ patients showed the same psychological improvement as the trained patients (5); so this seems unlikely to be the whole explanation. There is evidence that even the low workloads achieved by disabled patients can
222
BR.
J. DIS.
CHEST:
VOL.
82 NO. 3
A
At work; leading a full life
Getting out and about; socializing
house;
Confined or chair
occasional
trips out
to bed
Exercise
tolerance
Fig. 1. Schematic representation of ‘thresholds’ in quality of life in relation to changing exercise tolerance in patients with chronic obstructive airways disease. (Courtesy of Update-Sibert Publications Ltd)
produce training effects, leading to increased efficiency of exercise (i.e. less oxygen consumption and less ventilation for a given workload) (6, 7). Probably, this is mainly through improved coordination with less ‘unnecessary’ muscle contraction rather than through effects on muscle structure. Patients with respiratory disability, especially those who are also elderly, become immobile and unfit and a vicious circle of decreasing exercise tolerance ensues. The aim of the exercise training is to break into this circle and reverse some of the effects of immobility. Patients who have been underperforming due to being unfit can then perform up to the limits imposed by their respiratory disease. The extreme de-training of some of these patients is illustrated by the fact that initially they experience aching muscles after even the lightest of exercise sessions. Practical aspects of exercise training programmes. As implied earlier, complicated programmes of exercise training are not necessary to achieve benefit for respiratory patients. Simple programmes are also easier to manage and are more likely to be followed. The Chest, Heart and Stroke Association produces a booklet, entitled Coping with the problems of chronic chest disease that includes details of a simple programme of stair climbing exercises. Programmes involving level walking of increasing distances are also suitable. It is advisable for the patient to start each session with some warm-up exercises to stretch the muscles and help prevent injuries. The exercises should be personalized for each patient and there should be an element of progression, at a rate that suits each individual, so that patients can see how they are improving. Simple diary cards to record the exercises achieved each day are useful and can also be used to keep the doctor informed of progress. Light sessions repeated several times a day are better than attempting one heavy session which can leave the patient too exhausted to exercise the following
COCKCROFT:
PULMONARY
REHABILITATION
223
day and discourage further training. A good guide is to suggest to patients that they should exercise at a level that makes them moderately breathless for a few minutes several times a day and increase the time spent exercising as they feel able. The most convenient place for patients to exercise is in and around their own homes. This also allows them to measure their progress against real targets, such as the walk to the local post office, which gives more meaning to the exercise. When first beginning exercise training it is a good idea to have at least one supervised session to assess the patient’s capabilities formally and plan a suitable programme of exercise. Further sessions of this sort allow progress to be discussed and modifications to the programme to be suggested. These follow-up sessions can be at intervals of several months. They are an opportunity of measuring progress in some standard way, such as 12-minute walks (8) and questionnaires about daily activities. An obvious choice for supervised sessions is the physiotherapy department with the help of the physiotherapists. An additional benefit of an initial supervised session is that it allows patients to see others as bad as, or worse than, themselves taking exercise and helps to dispel their fears about taking exercise and making themselves breathless. Safety is an aspect that merits discussion. Most of the patients concerned will be elderly and many will have concomitant cardiovascular disease of some degree. However, their respiratory limitation usually means that they cannot reach a level of exercise that will stress the cardiovascular system, so they can exercise quite safely. They should, of course, be asked to report any untoward effects such as chest pain during exercise. Even in these cases, addition of a suitable anti-angina1 drug often relieves the symptom so that the exercise can be resumed. My own view is that even if an exercise programme carries a small element of risk, this is acceptable if it produces an improved quality of life in these elderly respiratory patients. Once embarked upon, a programme of exercises should be considered as being ‘for life’. Benefits are lost quite quickly if patients stop exercising. There will undoubtedly be setbacks because of intercurrent illnesses, mainly chest infections. Patients need to be told that this will happen and advised about re-starting exercises when they have recovered sufficiently. Motivation to continue can be a problem, as for anyone who tries to take regular exercise. Incorporating the exercises into the daily routine and making them serve a useful purpose, like going to the shops, helps. Involvement of the spouse is important; he or she can encourage the patient to exercise or even join in. Someone needs to have overall responsibility for the exercise programme, be it a doctor, a nurse or a physiotherapist. This is the person to whom the patient can turn for encouragement and advice when problems occur. But everyone involved in the patient’s care needs to know about the exercise programme so that conflicting advice can be avoided. Helping patients become independent
An important aspect of rehabilitation, not least for respiratory patients, is to attempt to reverse the damaging psychological effects of a chronic debilitating illness. Achieving physical indepenence through improved exercise tolerance helps in this respect but there are other problems to be addressed. Patients may feel worthless, no longer useful to those around them and in the hands of others (e.g. doctors) to determine their future. The way in which doctors have traditionally treated patients tends to make matters worse. Circumstances in the GP’s surgery or in the hospital rarely allow for an adequate explanation to
224
BR.
J. DIS.
CHEST:
VOL.
82 NO.
3
the patient of his or her condition and the drugs being prescribed for it. Patients are reduced to following instructions blindly and have no opportunity for making an input of their own. Medical interest tends to focus on diseases; for patients this focus on their disease rather than on them, and the way the disease affects their lives, further reduces their apparent worth. The elements of a programme to help patients feel more self-esteem and become more independent include: educating them about their condition and medications; giving them more control over their circumstances, such as encouraging them to modify their own routine therapy or start antibiotics when they recognize signs of infection; discussing with them emotional or social problems which have arisen directly or indirectly from the effects of their disability; helping them to take responsibility for their own health by stressing aspects within their control such as smoking, diet and exercise; suggesting to them the idea of health as a positive attribute rather than simply a lessening of the effects of disease. All this is difficult to include within the traditional medical relationship with patients. It is best undertaken in patients’ homes where they feel more relaxed and in control of events. And it requires a continuing commitment over months and years. A working party of the Royal College of Physicians recommended the creation of respiratory health workers to help in the management of respiratory patients (9). These workers can play an important role in a rehabilitation programme by tackling the difficult problems involved in returning independence to disabled patients. In a recent trial, a respiratory health worker (a respiratory nurse) visiting patients at home to give them support and advice was well received by the patients and may have helped to reduce mortality (10). Rehabilitation programmes need to include an approach such as this to the psychological problems of the patients as well as straightforward attempts to improve their physical capacities. SUMMARY Rehabilitation of patients with chronic respiratory disease has tended to be neglected in the past, partly because of a generally pessimistic view of their prospects. Simple programmes of exercise training can produce measurable increases in exercise tolerance and sometimes great improvements in quality of life for respiratory patients. The effects of exercise seem to be through improvement in exercise efficiency. A full rehabilitation programme also involves an attempt to deal with patients’ psychological problems and to help them regain independence in all aspects of their lives. The opportunity exists to improve the lot of a large group of people, at a relatively modest cost. ACKNOWLEDGEMENTS I am grateful to my colleagues in the MRC Pneumoconiosis Unit, Penarth and the Department of Medicine, Charing Cross and Westminster Medical School with whom I have discussed ideas about rehabilitation over a number of years. REFERENCES 1. Petty TL, Nett LM, Finigan MM, Brink GA, Corsello PR. A comprehensive care programme for chronic airway obstruction. Methods and preliminary evaluation of symptomatic and functional improvement. Ann Intern Med 1969;70:1109-1120.
COCKCROFT:
PULMONARY
REHABILITATION
225
2. McGavin CR, Gupta SP, Lloyd EL, McHardy GJR. Physical rehabilitation for the chronic bronchitic: results of a controlled trial of exercises in the home. Thorux 1977;32:307-11. 3. Cockcroft A, Saunders MJ, Berry G. Randomised controlled trial of rehabilitation in chronic respiratory disability. Thorax 1981;36:20&3. 4. Cockcroft A. Exercise for patients with respiratory disease. Update 1985 (1 February):2.5564. 5. Cockcroft A, Berry G, Brown EB, Exall C. Psychological changes during a controlled trial of rehabilitation in chronic respiratory disability. Thorax 1982;37:413-16. 6. Cockcroft A, Beaumont A, Guz A. Effect of exercise training on walking distance, exercise ventilation and breathlessness in patients with COAD. Cfin Sci 1985;69:7 p. 7. Pierce AK, Taylor HF, Archer RK, Miller WF. Responses to exercise training in patients with emphysema. Arch Intern Med 1964;113:28-36. 8. McGavin CR, Gupta SP, McHardy GJR. Twelve-minute walking test for assessingdisability in chronic bronchitis. Br Med J 1976;1:822-3. 9. Royal College of Physicians. Disabling chest disease: prevention and care. J R Co11 Physcns Lond 1981;15:69-87. 10. Cockcroft A, Bagnall P, Heslop A, et al. Controlled trial of a respiratory health worker visiting patients with chronic respiratory disability. Br Med J 1987;294:225-8.
Problems in Practice
PULMONARY ANNE Occupational
Health
REHABILITATION COCKCROFT
Unit, The Royal Free Hospital, London NW3 2QG
THE
Pond Street,
PROBLEM
It is well known that disabling chronic chest disease is common in Britain, mainly in the form of chronic obstructive airways disease. It is an important cause of loss of work time, premature retirement from work, severe disability and death. There are thus many people who could potentially benefit from pulmonary rehabilitation. There are various interpretations of ‘pulmonary rehabilitation’. In this article it means returning patients with respiratory disability to as normal a life as possible, aiming for them to achieve independent function in all their life activities. It is a wide-ranging undertaking, involving psychological as well as physical aspects of the disabled person’s life, and requires the application of several different therapeutic approaches. In North America pulmonary rehabilitation in the form of ‘comprehensive care programmes’ has been advocated for many years (1). Nevertheless, in Britain it remains relatively unpopular, unlike cardiac rehabilitation which is now widely available. Perhaps this is because cardiac patients are often relatively young and there may have been a sudden event, such as a myocardial infarction, from which a good recovery can be expected; there is a reasonable hope of returning them to a full, active life. On the other hand, patients with chronic respiratory disease are often elderly and have a progressive disability so that less dramatic effects can be expected from rehabilitation. The majority of respiratory patients receive nothing but treatment for intercurrent infections and perhaps bronchodilators (with variable degrees of benefit) long term. Some are still advised to ‘take it easy’ and they become even more disabled and limited as a result. This advice may be given because breathlessness is a distressing and frightening symptom for both patients and doctors and it is therefore avoided (by minimizing exertion) as far as possible. In addition, many doctors feel negative about the therapeutic possibilities for ‘respiratory cripples’ and this attitude readily communicates itself to patients so that both parties come to accept that ‘nothing can be done’. So it is against this background that pulmonary rehabilitation must be set: on the one hand a large population who could potentially benefit and on the other hand pessimism and fear about undertaking rehabilitation programmes. REHABILITATION Standard
METHODS
therapy
The first step in any rehabilitation programme is to ensure that optimal ‘standard’ therapy is being given and used appropriately. It is foolish to embark on a programme of exercise
COCKCROFT:
PULMONARY
REHABILITATION
221
training without first assessing and correcting any reversible airways obstruction. Quite simple improvements in therapy, including for example better delivery of a drug to patients with poor inhaler technique, can lead to a big improvement in exercise capacity for some patients. At this stage, it is necessary to tackle the question of smoking. Many elderly patients find it impossible to give up smoking altogether but can often manage to reduce the number they smoke. While there is evidence of a small benefit from giving up smoking, even in patients who already have advanced disease, there is no place for a punitive or authoritarian attitude on the part of the doctor. One hears of patients being dismissed by the doctor until they have given up smoking; this may help the doctor deal with his/her frustration but it does not make the patients give up smoking and tends to increase their feelings of hopelessness. I do not believe that it is justifiable to refuse to have a patient in a pulmonary rehabilitation programme because of failure to give up smoking. Some patients manage to give up smoking as a result of the continuing encouragement they receive during rehabilitation. The benefits of smoking cessation in these patients must be balanced against the weight gain that usually occurs, with its adverse effects on breathing and exericse tolerance. Exercise training programmes
Exercise training programmes are an important part of rehabilitation, having beneficial effects both physically and psychologically. There is no doubt that simple exercise programmes can produce measurable increases in exercise tolerance in respiratory patients (for example, an increase in 1Zminute walking distance) after as little as 2 months and this has been demonstrated in controlled trials (2,3). The increases are relatively small, in the region of 20%. Yet patients report benefit out of proportion to this. The reason is probably that the effects of a progressive disability on life style are not smooth; they occur in a series of steps. Figure 1 illustrates this concept. The same process can occur in reverse during rehabilitation, so that a small increase in exercise tolerance may result in a ‘step’ improvement in quality of life (4). Related to this, it is important to set goals with individual patients in their rehabilitation. For example, reaching the local club half a mile away may restore a social life to a patient so the aim would be for him to be able to walk this distance in a reasonable time. How do programmes of exercise training work in this group of patients? There is no evidence that they improve lung function. Nor, incidentally, is there evidence in adequately controlled trials that training the respiratory muscles has any beneficial effect. Perhaps this is not surprising, since the patients concerned are ‘training’ their respiratory muscles anyway by breathing against their own internal resistance. The exercises referred to in this article are aimed mainly at the muscles of locomotion. Because of their respiratory limitation, most patients cannot reach the level of work at which cardiovascular training would be expected. Young patients with asthma are different, reaching high workloads, but they are not the main group being discussed here. It has been suggested that increases in exercise tolerance are secondary to psychological improvement but in at least one controlled trial of exercise training the ‘control’ patients showed the same psychological improvement as the trained patients (5); so this seems unlikely to be the whole explanation. There is evidence that even the low workloads achieved by disabled patients can
222
BR.
J. DIS.
CHEST:
VOL.
82 NO. 3
A
At work; leading a full life
Getting out and about; socializing
house;
Confined or chair
occasional
trips out
to bed
Exercise
tolerance
Fig. 1. Schematic representation of ‘thresholds’ in quality of life in relation to changing exercise tolerance in patients with chronic obstructive airways disease. (Courtesy of Update-Sibert Publications Ltd)
produce training effects, leading to increased efficiency of exercise (i.e. less oxygen consumption and less ventilation for a given workload) (6, 7). Probably, this is mainly through improved coordination with less ‘unnecessary’ muscle contraction rather than through effects on muscle structure. Patients with respiratory disability, especially those who are also elderly, become immobile and unfit and a vicious circle of decreasing exercise tolerance ensues. The aim of the exercise training is to break into this circle and reverse some of the effects of immobility. Patients who have been underperforming due to being unfit can then perform up to the limits imposed by their respiratory disease. The extreme de-training of some of these patients is illustrated by the fact that initially they experience aching muscles after even the lightest of exercise sessions. Practical aspects of exercise training programmes. As implied earlier, complicated programmes of exercise training are not necessary to achieve benefit for respiratory patients. Simple programmes are also easier to manage and are more likely to be followed. The Chest, Heart and Stroke Association produces a booklet, entitled Coping with the problems of chronic chest disease that includes details of a simple programme of stair climbing exercises. Programmes involving level walking of increasing distances are also suitable. It is advisable for the patient to start each session with some warm-up exercises to stretch the muscles and help prevent injuries. The exercises should be personalized for each patient and there should be an element of progression, at a rate that suits each individual, so that patients can see how they are improving. Simple diary cards to record the exercises achieved each day are useful and can also be used to keep the doctor informed of progress. Light sessions repeated several times a day are better than attempting one heavy session which can leave the patient too exhausted to exercise the following
COCKCROFT:
PULMONARY
REHABILITATION
223
day and discourage further training. A good guide is to suggest to patients that they should exercise at a level that makes them moderately breathless for a few minutes several times a day and increase the time spent exercising as they feel able. The most convenient place for patients to exercise is in and around their own homes. This also allows them to measure their progress against real targets, such as the walk to the local post office, which gives more meaning to the exercise. When first beginning exercise training it is a good idea to have at least one supervised session to assess the patient’s capabilities formally and plan a suitable programme of exercise. Further sessions of this sort allow progress to be discussed and modifications to the programme to be suggested. These follow-up sessions can be at intervals of several months. They are an opportunity of measuring progress in some standard way, such as 12-minute walks (8) and questionnaires about daily activities. An obvious choice for supervised sessions is the physiotherapy department with the help of the physiotherapists. An additional benefit of an initial supervised session is that it allows patients to see others as bad as, or worse than, themselves taking exercise and helps to dispel their fears about taking exercise and making themselves breathless. Safety is an aspect that merits discussion. Most of the patients concerned will be elderly and many will have concomitant cardiovascular disease of some degree. However, their respiratory limitation usually means that they cannot reach a level of exercise that will stress the cardiovascular system, so they can exercise quite safely. They should, of course, be asked to report any untoward effects such as chest pain during exercise. Even in these cases, addition of a suitable anti-angina1 drug often relieves the symptom so that the exercise can be resumed. My own view is that even if an exercise programme carries a small element of risk, this is acceptable if it produces an improved quality of life in these elderly respiratory patients. Once embarked upon, a programme of exercises should be considered as being ‘for life’. Benefits are lost quite quickly if patients stop exercising. There will undoubtedly be setbacks because of intercurrent illnesses, mainly chest infections. Patients need to be told that this will happen and advised about re-starting exercises when they have recovered sufficiently. Motivation to continue can be a problem, as for anyone who tries to take regular exercise. Incorporating the exercises into the daily routine and making them serve a useful purpose, like going to the shops, helps. Involvement of the spouse is important; he or she can encourage the patient to exercise or even join in. Someone needs to have overall responsibility for the exercise programme, be it a doctor, a nurse or a physiotherapist. This is the person to whom the patient can turn for encouragement and advice when problems occur. But everyone involved in the patient’s care needs to know about the exercise programme so that conflicting advice can be avoided. Helping patients become independent
An important aspect of rehabilitation, not least for respiratory patients, is to attempt to reverse the damaging psychological effects of a chronic debilitating illness. Achieving physical indepenence through improved exercise tolerance helps in this respect but there are other problems to be addressed. Patients may feel worthless, no longer useful to those around them and in the hands of others (e.g. doctors) to determine their future. The way in which doctors have traditionally treated patients tends to make matters worse. Circumstances in the GP’s surgery or in the hospital rarely allow for an adequate explanation to
224
BR.
J. DIS.
CHEST:
VOL.
82 NO.
3
the patient of his or her condition and the drugs being prescribed for it. Patients are reduced to following instructions blindly and have no opportunity for making an input of their own. Medical interest tends to focus on diseases; for patients this focus on their disease rather than on them, and the way the disease affects their lives, further reduces their apparent worth. The elements of a programme to help patients feel more self-esteem and become more independent include: educating them about their condition and medications; giving them more control over their circumstances, such as encouraging them to modify their own routine therapy or start antibiotics when they recognize signs of infection; discussing with them emotional or social problems which have arisen directly or indirectly from the effects of their disability; helping them to take responsibility for their own health by stressing aspects within their control such as smoking, diet and exercise; suggesting to them the idea of health as a positive attribute rather than simply a lessening of the effects of disease. All this is difficult to include within the traditional medical relationship with patients. It is best undertaken in patients’ homes where they feel more relaxed and in control of events. And it requires a continuing commitment over months and years. A working party of the Royal College of Physicians recommended the creation of respiratory health workers to help in the management of respiratory patients (9). These workers can play an important role in a rehabilitation programme by tackling the difficult problems involved in returning independence to disabled patients. In a recent trial, a respiratory health worker (a respiratory nurse) visiting patients at home to give them support and advice was well received by the patients and may have helped to reduce mortality (10). Rehabilitation programmes need to include an approach such as this to the psychological problems of the patients as well as straightforward attempts to improve their physical capacities. SUMMARY Rehabilitation of patients with chronic respiratory disease has tended to be neglected in the past, partly because of a generally pessimistic view of their prospects. Simple programmes of exercise training can produce measurable increases in exercise tolerance and sometimes great improvements in quality of life for respiratory patients. The effects of exercise seem to be through improvement in exercise efficiency. A full rehabilitation programme also involves an attempt to deal with patients’ psychological problems and to help them regain independence in all aspects of their lives. The opportunity exists to improve the lot of a large group of people, at a relatively modest cost. ACKNOWLEDGEMENTS I am grateful to my colleagues in the MRC Pneumoconiosis Unit, Penarth and the Department of Medicine, Charing Cross and Westminster Medical School with whom I have discussed ideas about rehabilitation over a number of years. REFERENCES 1. Petty TL, Nett LM, Finigan MM, Brink GA, Corsello PR. A comprehensive care programme for chronic airway obstruction. Methods and preliminary evaluation of symptomatic and functional improvement. Ann Intern Med 1969;70:1109-1120.
COCKCROFT:
PULMONARY
REHABILITATION
225
2. McGavin CR, Gupta SP, Lloyd EL, McHardy GJR. Physical rehabilitation for the chronic bronchitic: results of a controlled trial of exercises in the home. Thorux 1977;32:307-11. 3. Cockcroft A, Saunders MJ, Berry G. Randomised controlled trial of rehabilitation in chronic respiratory disability. Thorax 1981;36:20&3. 4. Cockcroft A. Exercise for patients with respiratory disease. Update 1985 (1 February):2.5564. 5. Cockcroft A, Berry G, Brown EB, Exall C. Psychological changes during a controlled trial of rehabilitation in chronic respiratory disability. Thorax 1982;37:413-16. 6. Cockcroft A, Beaumont A, Guz A. Effect of exercise training on walking distance, exercise ventilation and breathlessness in patients with COAD. Cfin Sci 1985;69:7 p. 7. Pierce AK, Taylor HF, Archer RK, Miller WF. Responses to exercise training in patients with emphysema. Arch Intern Med 1964;113:28-36. 8. McGavin CR, Gupta SP, McHardy GJR. Twelve-minute walking test for assessingdisability in chronic bronchitis. Br Med J 1976;1:822-3. 9. Royal College of Physicians. Disabling chest disease: prevention and care. J R Co11 Physcns Lond 1981;15:69-87. 10. Cockcroft A, Bagnall P, Heslop A, et al. Controlled trial of a respiratory health worker visiting patients with chronic respiratory disability. Br Med J 1987;294:225-8.