Evidence Summary (Updated 2022)
A large body of good quality case-control and observational data shows a reduction in mortality.
An observational study of 611 participants found that the number of deaths in the lower activity groups was worse than that the active group (p=0.0007).(1) The same group published later data and found similar trends; a higher risk of mortality in lower physical activity groups.(2) A large cohort study of over 2000 COPD patients showed that physical activity reduces all-cause mortality (hazard ratio (HR) 0.76, 95% CI 0.65 to 0.90) and respiratory mortality (HR 0.70, 95% CI 0.48 to 1.02) in all groups except very low physical activity.(3) Adjusting for time-dependent confounders the same group, found that mod-high PA was associated with a reduced mortality (standard, hazard ratio 0.80, p=0.001; MSM, 0.81, p=0.008).(4) This was further shown in an observational study using accelerometers which found PA was an independent factor for mortality due to severe COPD exacerbation.(5)
A prospective cohort study by Waschki et al, found that physical activity level was associated was associated with a lower risk of death (HR 0.46; CI 0.33-0.64; p<0.001).(6)
A 13 study (n = 801) meta-analysis analysing the effects on mortality of early supervised pulmonary rehabilitation (PR) following EACOPD vs usual care showed a statistically significant reduction in mortality favouring PR (RR = 0.58 (95% CI: [0.35 to 0.98]). Subgroup analysis showed no difference in effect between trials with PR initiated during admission and after discharge (P = 0.70). The review concluded that moderate quality of evidence showed reductions in mortality, number of days in hospital and number of readmissions after early PR. However, the long-term effects on mortality were not statistically significant.(7)
An extensive review of 21 studies (n = 1799) assessing the effects of supervised maintenance PR programmes (ranging from 4-weeks to 3-years). 6 study meta-analysis (n = 755) of wide heterogeneity showed little to no difference between the maintenance programme and the usual care group in chance of death (OR for mortality 0.73, 95% CI 0.36 to 1.51). There were also similar results for exacerbations or all-cause hospitalisations. However, this review found improvements in QoL an exercise capacity were found at 6 and 12-months associated with a lack of adverse events.(8)
Quality of Evidence
Grade C– low quality.
Strength of recommendation
Grade 1 – strong recommendation.
This is a strong recommendation that this explanation is appropriate for most patients, but the supporting evidence base is of low quality. Advising patients to start or maintain their physical activity after diagnosis is advised and is likely to reduce the risk of death.
- Esteban C, Quintana JM, Aburto M, Moraza J, Capelastegui A. A simple score for assessing stable chronic obstructive pulmonary disease. QJM [Internet]. 2006 Nov [cited 2022 Oct 4];99(11):751–9. Available from: https://pubmed.ncbi.nlm.nih.gov/17030529/
- Esteban C, Quintana JM, Aburto M, Moraza J, Arostegui I, España PP, et al. The health, activity, dyspnea, obstruction, age, and hospitalization: prognostic score for stable COPD patients. Respir Med [Internet]. 2011 Nov [cited 2022 Oct 4];105(11):1662–70. Available from: https://pubmed.ncbi.nlm.nih.gov/21703842/
- Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax [Internet]. 2006 Sep 1 [cited 2022 Oct 4];61(9):772–8. Available from: https://thorax.bmj.com/content/61/9/772
- Garcia-Aymerich J, Lange P, Serra I, Schnohr P, Antó JM. Time-Dependent Confounding in the Study of the Effects of Regular Physical Activity in Chronic Obstructive Pulmonary Disease: An Application of the Marginal Structural Model. Ann Epidemiol. 2008 Oct 1;18(10):775–83.
- Garcia-Rio F, Rojo B, Casitas R, Lores V, Madero R, Romero D, et al. Prognostic Value of the Objective Measurement of Daily Physical Activity in Patients With COPD. Chest. 2012 Aug 1;142(2):338–46.
- Waschki B, Kirsten A, Holz O, Müller KC, Meyer T, Watz H, et al. Physical Activity Is the Strongest Predictor of All-Cause Mortality in Patients With COPD: A Prospective Cohort Study. Chest. 2011 Aug 1;140(2):331–42.
- Ryrsø CK, Godtfredsen NS, Kofod LM, Lavesen M, Mogensen L, Tobberup R, et al. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: A systematic review and meta-analysis 11 Medical and Health Sciences 1103 Clinical Sciences 11 Medical and Health Sciences 1117 Public Health and Health Services 11 Medical and Health Sciences 1102 Cardiorespiratory Medicine and Haematology. BMC Pulm Med [Internet]. 2018 Sep 15 [cited 2022 Oct 4];18(1):1–18. Available from: https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0718-1
- Malaguti C, Dal Corso S, Janjua S, Holland AE. Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease. Cochrane Database Syst Rev [Internet]. 2021 Aug 17 [cited 2022 Oct 4];2021(8). Available from: /pmc/articles/PMC8407510/