[[alternative]]Effects of Exercise Interventions for Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

[[abstract]]背景：慢性阻塞性肺疾病(chornic obstructive pulmonary disease, COPD)是一種因肺泡彈性受損及氣道狹窄造成持續性氣流受阻的疾病，急性惡化(exacerbation)是COPD病人住院及死亡的主要因素。呼吸困難是COPD病人最常見的呼吸道症狀，伴隨有活動耐力降低，增加焦慮、憂鬱的情緒，進而降低病人的生活品質。儘管已有許多實驗性研究結果強調復健運動介入之重要性與有效性，但復健運動種類眾多，各研究中復健運動所包含的範圍不盡相同，不同運動介入之成效與差異尚未確定 。 目的：本研究旨在運用系統性回顧暨統合分析，探討在隨機試驗中以不同運動介入對改善慢性阻塞性肺疾病病人在呼吸困難、活動耐力、情緒指標、生活品質及再入院率之成效。 方法：本研究搜尋2017年01月前之相關研究，使用Medline+Journal @ ovid、PudMed、EBSCO (CINAHL Plus with full text及SPORTDiscu with Full Text)、EMBASE、Cochrane Library、Airitilibrary華藝中文電子期刊資料庫、中國期刊全文資料庫(CNKI)等共八個中、英文資料庫，選取慢性阻塞性肺疾病病人以運動為介入措施之相關文獻，測量變項為呼吸困難、六分鐘步行試驗(6MWT)、情緒指標、生活品質及再入院率。 資料分析：符合納入及排除條件之文獻，以PEDro量表、偏差風險評估作為評讀研究文章品質，採用RevMan 5.3系統評估其偏差風險，並以CMA V3與Stata 15.0統計軟體分析運動介入之成效。 結果：共74篇符合評選標準，本研究之運動介入可分為呼吸訓練、運動訓練、及呼吸合併運動訓練，呼吸訓練對改善慢性阻塞性肺疾病病人之成效，包括：呼吸困難(SMD= -1.214, 95% CI: -1.729, -0.698)、6MWT (MD=44.596, 95% CI: 37.493, 51.679)、情緒指標(MD=4.217, 95% CI: 2.765, 5.668)、生活品質(SMD= -1.225, 95% CI: -1.786, -0.664)達顯著，但焦慮與憂鬱成效則未具顯著性；運動訓練對改善慢性阻塞性肺疾病病人之成效，包括：呼吸困難(SMD= -0.523, 95% CI: -0.797, -0.249)、6MWT (MD=55.052, 95% CI: 41.266, 68.837)、情緒指標(MD=1.459, 95% CI: 0.387, 2.531)、生活品質(SMD= -0.762, 95% CI: -1.126, -0.398)達顯著，但再入院率則未具顯著性；而呼吸合併運動訓練對改善慢性阻塞性肺疾病病人之成效，包括：呼吸困難(SMD= -0.641, 95% CI: -0.932, -0.350)、6MWT (MD=58.80, 95% CI: 34.997, 82.604)、情緒指標(MD=5.407, 95% CI: 3.545, 7.269)、憂鬱(SMD=-1.143, 95% CI: -2.581, -0.245)及生活品質(SMD= -0.903, 95% CI: -1.333, -0.472)達顯著，但焦慮成效則無。本研究之運動介入依文獻可區分為呼吸肌訓練(RMT)、呼吸訓練(BT)、運動訓練(Ex.)、呼吸肌合併運動訓練(RMT+Ex.)、呼吸合併運動訓練(BT+Ex.)、衛教(Edu.)、及常規照護(Routine)。不同的運動介入對於6MWT 之成效達顯著(WMD=46.831, 95% CI 34.421~59.241)，其中又以呼吸肌合併運動訓練成效最佳，其次依序是呼吸合併運動訓練、呼吸肌訓練、運動訓練與呼吸訓練。 結論：現有的證據支持運動介入對慢性阻塞性肺疾病之呼吸困難、活動耐力、生活品質等具有療效，但部分結果異質性偏高，而對於情緒指標(焦慮/憂鬱)與再入院率之結果評估則缺乏證據支持其療效。本研究結果可提供醫護人員及病人現有之最佳證據，針對病人個別性提供不同之運動介入措施的選擇。[[abstract]]Background: Chornic obstructive pulmonary disease(COPD) is a progressive disease causes the alveoli at the end of the smallest air passages of the lungs are destroyed as a result of damaging and obstructed airflow from the lungs. Acute exacerbation is major cause of hospitalization and mortality. Main symptom is dyspnea which cause lower exercise capacity, emotional, e.g anxiety, depression and poor quality of life. Although, exercises interventions with breathing training, exercise training is beneficial for patients who with COPD. However, the results were not consistency.Aim: To determine effects of exercise interventions on dyspnea, exercise capacity, emotional, quality of life and readmission in patients with COPD.Methods: This study was a systematic review of randomized controlled trials. Medline, PubMed, CINAHL, SPORTDiscu, EMBASE, Cochrane Library, AiritiLibrary, CNKI were systematically searched for studies up to January 2017. Randomized controlled trials(RCTs) compared exercise with sham exercise or routine care, and participants were COPD.Data analysis: The methodological quality of each selected study was assessed using the PEDro and the risk of bias. A meta-analysis was performed to evaluate the effect of the breathing exercises. Data were analyzed using the Review Manager 5.3 and STATA 15.0, the risk of bias was estimated using Review Manager 5.3 soft ware.Results: 74 studies were included. Exercises include breathing training, exercise training, and breathing plus exercise training. Breathing training compared to sham exercise or routine care, significantly improved the Dyspnea (SMD= -1.214, 95% CI: -1.729, -0.698), 6MWT (MD=44.596, 95% CI: 37.493, 51.679), emotional (MD=4.217, 95% CI: 2.765, 5.668) and quality of life (SMD= -1.225, 95% CI: -1.786, -0.664), but the anxiety and depression was not. Execise training significantly improved the Dyspnea (SMD= -0.523, 95% CI: -0.797, -0.249), 6MWT (MD=55.052, 95% CI: 41.266, 68.837), emotional (MD=1.459, 95% CI: 0.387, 2.531) and quality of life (SMD= -0.762, 95% CI: -1.126, -0.398), but readmission was not. Breathing plus execise training significantly improved the Dyspnea (SMD= -0.641, 95% CI: -0.932, -0.350), 6MWT (MD=58.80, 95% CI: 34.997, 82.604), emotional (MD=5.407, 95% CI: 3.545, 7.269), depression (SMD=-1.143, 95% CI: -2.581, -0.245) and quality of life (SMD= -0.903, 95% CI: -1.333, -0.472), but anxiety was not. The exercise interventions also divided into respiratory muscle training, breathing training, exercise, respiratory muscle training plus exercise, breathing training plus exercise, education and routine care. Different exercise significantly improved 6MWT (WMD=46.831, 95% CI: 34.421, 59.241) especially in respiratory muscle training plus exercise.Conclusions: This meta-analysis study supports significant but evidence with higher hetenogeneity that exercises could be effective in dyspnea, 6MWT, and quality of life. The lack of evidence for anxiety, depression and readmission. Results provide the individual intervention choices for healthcare staff and COPD patients