Si d'autres chercheurs font etat de meilleurs taux d'amelioration, c'est peut-etre que nous avons considere des malades consecu- tifs, que nous les avons suivis ...
I Original Research
Long-term outcome after respiratory rehabilitation Gordon H. Guyatt, MD Leslie B. Berman, MB Marie Townsend, BA
To determine the long-term effect of respiratory rehabilitation, we followed up for 6 months after discharge 31 consecutive patients enrolled in a multidisciplinary inpatient rehabilitation program lasting 4 to 6 weeks. Of the 31, 24 showed improvement in quality of life (as measured with a previously validated questionnaire) and in functional exercise capacity (as measured with the 6-minute walk test) 2 weeks after discharge. The improvement was sustained for 6 months in 11 of the 24. Other investigators have found higher response rates than those that we report. The differences are likely due to our enrolment of consecutive patients, the length and completeness of follow-up, and the objective measurement of quality of life by an interviewer not associated with the rehabilitation program. Controlled trials of respiratory rehabilitation measuring both costs and benefits are warranted. In the meantime, strategies to maintain the initial improvement seen after rehabilitation should be developed and studied.
Curieux de connaitre les effets a longue echeance de notre plan pluridisciplinaire de readaptation respiratoire, nous suivons pendant 6 mois, 'a compter du depart de l'hopital, 31 malades qui ont ete soumis a cette readaptation pendant 4 a 6 semaines. Deux semaines apres leur sortie, 24 sujets jouissent d'une meilleure qualitd de vie, selon les reponses a un questionnaire prdalablement valide, et d'une meilleure toldrance k From the departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
requests to: Dr. Gordon H. Guyatt, Department of Clinical Epidemiology and Biostatistics, Rm. 3H7, Health Sciences Centre, McMaster University, 1200 Main St. W, Hamilton, Ont. L8N 3Z5
page 1 100
l'exercice (soit la marche de 6 minutes). Chez 11 de ces 24 personnes, l'amelioration se maintient pendant 6 mois. Si d'autres chercheurs font etat de meilleurs taux d'amelioration, c'est peut-etre que nous avons considere des malades consecutifs, que nous les avons suivis de pres et longtemps, et que nous avons fait apprecier objectivement leur qualite de vie par une personne qui ne fait pas partie de notre equipe de readaptation. Il y a lieu d'instituer des essais comparatifs de la readaptation respiratoire afin d'en determiner les cotits aussi bien que les avantages. D'ici la il faut s'efforcer de trouver et de mettre a l'essai des moyens de faire durer l'amdlioration precoce qu'elle produit. here have been a large number of studies reporting the results of respiratory rehabilitation programs.1-24 Whether the programs focused on exercise1-13 or used a more comprehensive approach, including education, occupational therapy, counselling and a focus on psychosocial function,14-24 positive findings have consistently been reported. As a result, official organizations in Britain and the United States have endorsed respiratory rehabilitation programs and have published guidelines for their implementation.2526 However, there have been only two randomized controlled trials of rehabilitation,27'28 and the methodologically stronger of the two showed no difference between treatment and control groups in the primary measure of outcome 4 months after enrolment.28 Only a minority of the studies followed patients over the long term, and those that did5'9'12'13'15'18'20'2' were marred by incomplete or unspecified follow-up rates and unstandardized measures of quality of life or functional status. Our involvement in a comprehensive respiratory rehabilitation program over the last 8 years led to an impression that while most patients CMAJ, VOL. 137, DECEMBER 15, 1987
demonstrate an early, often dramatic improvement in both quality of life and capacity for exercise as a result of rehabilitation, in some patients the benefit may be decreased or lost over the subsequent 6 months. Because of the limitations of the previous studies, we wished to evaluate the long-term outcome of respiratory rehabilitation using quantitative methods and minimizing bias. We therefore followed up a cohort of consecutive patients enrolled in our program for 6 months after discharge. Since we believe that the main purpose of rehabilitation is to improve participants' quality of life, our primary measure of outcome was a questionnaire on quality of life designed specifically for patients with chronic lung disease.
principles of pacing, energy conservation, work simplification and relaxation during activities of daily living. A social worker is involved in the care of patients if problems with emotional function, family relationships or welfare issues are identified. One or more members of the team meet with the patient and family to discuss issues of common concern, and each patient's progress is reviewed at a weekly team meeting. The typical inpatient stay is 4 to 6 weeks. Discharge plans may include an outpatient exercise program, home care involvement with physiotherapy, occupational therapy and public health nurses, involvement with a local support group administered and run by patients with chronic lung disease and outpatient follow-up with the program physician.
Methods Patients were eligible for the study if they were eligible for enrolment in the rehabilitation program (see program description), experienced shortness of breath during at least three frequently performed activities of daily living, had a forced expiratory volume in 1 second (FEV1) less than 70% of the predicted value and gave informed consent. Patients were excluded if they had previously been admitted to the program, were unable to complete the primary measures of outcome (the questionnaire on quality of life and the 6-minute walk test) or were unwilling to make a commitment to continue with the program for at least 4 weeks. Reasons for inability to complete the questionnaire included inadequate English, psychiatric and cognitive problems, and extremely poor hearing or eyesight. Patients were unable to complete the walk test if they had severe lower extremity arthritis or were confined to a wheelchair.
Program description Patients referred to the rehabilitation program by respiratory physicians, general internists or family physicians undergo outpatient assessment, including history-taking, physical examination and assessment of psychosocial function. Suitable patients are admitted and undergo further assessment by other team members, including nurses, physiotherapists, occupational therapists and social workers, as well as pulmonary function and exercise testing. Educational aspects of the program include individual and group sessions, audiovisual materials and handouts, all of which focus on practical aspects of coping with chronic lung disease. The physiotherapy program includes general body exercises, breathing and breathing control exercises, relaxation classes and an exercise program with a prescription based on performance in the initial progressive cycle ergometer exercise test. The occupational therapy program focuses on applying 1090
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Measures of outcome
All measures of outcome were administered within 2 days of the patient's admission to hospital and before participation in the program. We attempted to repeat these tests 2, 6, 12 and 24 weeks after discharge. When this was not possible, we put particular emphasis on obtaining full measures 2 and 24 weeks after discharge. If the subject was not available for follow-up tests on the scheduled date, the tests were administered on the nearest date that could be arranged. The primary measures of outcome were always administered by one of us (M.T.), who was not otherwise associated with the rehabilitation program. Encouragement was delivered in a standardized fashion for all tests in which the results were dependent on the patient's effort.29 Chronic respiratory disease questionnaire: The chronic respiratory disease questionnaire (CRQ) was developed specifically to measure quality of life in patients with chronic airflow limitation. Its 20 items measure two dimensions, physical function (which includes shortness of breath and fatigue) and emotional function (including depression, anxiety, frustration and the extent to which the subject feels in control of, or able to cope with, the illness). Each item is presented with seven response options, a score of 7 indicating the best possible function and a score of 1 the worst possible function. The CRQ was developed on the basis of patients' statements about how their lives were adversely affected by their lung disease. It has been extensively tested and found to be reproducible, valid and responsive (that is, it detects a clinically important change in quality of life when it has occurred).30 Six-minute walk test: The 6-minute walk test is administered by asking subjects to cover as much ground as they can in 6 minutes. The 6-minute walk correlates well with the previously more widely used 12-minute walk31 and bears moderate correlations to conventional exercise tests and to a number of measures of functional status.32 The 6-minute walk was administered in an en-
closed corridor 30 m long. Two practice walk tests were done beforehand.
Other measures: We considered the CRQ and the 6-minute walk to be our primary measures of outcome indicating the extent to which the program might have influenced a patient's quality of life and functional exercise capacity.32 Additional measures included spirometry, which was performed before and 20 minutes after inhalation of a bronchodilator at each clinic visit. We also attempted to administer sequential progressive exercise tests on the cycle ergometer using an established protocol33 in which the work load is increased by 100 kpm each minute. Although all patients underwent the cycle ergometer exercise test before entering the program, most were reluctant to undergo follow-up testing. Results Patient recruitment began on Sept. 26, 1983, and ended on July 9, 1984; the final follow-up visit was completed in February 1985. During the recruitment period 36 patients entered the rehabilitation program, of whom 31 (23 men and 8 women) were deemed eligible for the study at the time of their admission. Of the remaining five, two were confined to a wheelchair, two had previously been enrolled in the program, and one was deaf and thus could not complete the measures of outcome. The characteristics of the 31 patients and their baseline values before they started the program are presented in Table I. Of the 31 patients 28 finished the 4- to 6-week inpatient regimen. Of the three patients who did not complete the program, one was dissatisfied with the program, and the other two were judged by rehabilitation staff to be incapable of comprehending the program. At each follow-up visit the patients were asked about the extent to which they were continuing with exercise. Of the 28, 5 reported that they continued with home exercises for at least 6 weeks after leaving the program, 10 attended an organized outpatient exercise program for at Table I - Characteristics of 31 patients with chronic lung disease at the time of admission to a respiratory rehabilitation program
Characteristic Age, yr Forced expiratory volume in 1 s, L* Vital capacity, L* Distance walked in 6-min walk test, m Result on cycle ergometer test, kpm
Mean (and standard deviation) 64.6 (4.1)
1.10 (0.45)t 2.60 (0.68)t 322 (102) 395 (195)
*Twenty minutes after inhalation of a bronchodilator. t37.6% of predicted value. i67.9% of predicted value.
least 6 weeks after leaving the program, and 13 stopped exercising within a month of discharge from the program.
Quality of life All 28 patients who completed the program also completed the CRQ 2 weeks after discharge. Subsequently, 5 patients dropped out, and of the 23 remaining patients 3 missed the follow-up visit at 6 weeks. Between weeks 6 and 12, 1 additional patient dropped out; of the 22 remaining patients 12 missed the visit at 12 weeks. Finally, between weeks 12 and 24, 1 further patient dropped out. Reasons for dropout included death, carcinoma of the lung, hip fracture, admission to hospital for exacerbation of other health problems and refusal to remain in the study. Reasons for missing a follow-up visit included cataract removal, bowel resection, poor weather, exacerbation of respiratory disease and being out of town for an extended period. The mean scores for physical function and emotional function before the start of the program and during follow-up are shown in Figs. 1 and 2 respectively. For each dimension the scores have been standardized so that they fall between 0 and 10, 10 representing optimal function. Data from the follow-up visits at weeks 6 and 12 are difficult to interpret because of the large number of missing subjects. Nevertheless, it is clear that the group as a whole experienced a major improvement in both dimensions of quality of life after the rehabilitation program. At 2 weeks the mean physical function score had improved by approximately 30% and the mean emotional function score by 25%. A paired t-test comparing baseline and 2-week physical and emotional function scores showed p values of less than 0.00001 for both dimensions. However, the improvement was considerably attenuated over the subsequent 6 months. The scores depicted in Figs. 1 and 2 require supplementation for two reasons. First, the 21 patients who completed the CRQ at 24 weeks were far better off compared with their baseline status than were the other 10. Second, the mean values represent a composite of patients whose quality of life improved initially and remained improved, improved and then deteriorated or did not improve at all. To deal with these problems we classified the patients at each follow-up visit into those whose quality of life was improved from the baseline visit and those whose quality of life was not improved. Improvement was defined as an increase of at least four points in the raw score for physical or emotional function on the CRQ (with an overall increase of at least four points). While this choice is somewhat arbitrary, our impression from extensive clinical experience with the CRQ is that patients with these results do have improved quality of life, whereas those with lesser changes in score on the CRQ describe their quality of life as CMAJ, VOL. 137, DECEMBER 15, 1987
minimally improved or not improved at all. The quality of life of patients who did not complete the CRQ at each follow-up visit was classified as improved or unimproved according to a global rating of information obtained during follow-up telephone interviews. Patients were asked about their level of activity, their dyspnea in day-to-day activities and their emotional function in relation to their status before entering the program. This procedure is far less precise and more subject to bias than is administration of the CRQ. However, in most cases the decision was sufficiently clear-cut to make misdassification unlikely: when patients were not available for followup it was usually because their condition had deteriorated to the point that they were unable to attend the clinic. Classification of subjects according to whether they were temporary or long-term responders or experienced treatment failure confirmed that 24 of the 31 patients (77%) received an initial benefit from the rehabilitation program (Fig. 3). At times the improvement was dramatic: the scores of 11 patients improved by 10 or more points on both dimensions of the CRQ between the baseline visit and the follow-up visit at 2 weeks. However, of the 24 patients who showed initial improvement, 8
only 11 still showed improvement at 6 months. Deterioration occurred between 2 and 6 weeks in 9 patients, between 6 and 12 weeks in 2, and between 12 and 24 weeks in 3 (Fig. 3). Walk test All 31 subjects underwent a walk test before starting the program, 28 underwent it at the follow-up visit at 2 weeks, 17 underwent it at 6 weeks, 6 underwent it at 12 weeks, and 17 underwent it at 24 weeks. The reasons why subjects were not tested were in most cases identical to the reasons why CRQs were not completed. In cases in which we had data from the CRQ but not from the walk test the patient was able to answer the questionnaire but did not feel well enough to undertake the walk test. The mean walk test results are presented in Fig. 4 for the 17 subjects for whom results were available at 6 months. The results parallel those for the measures of quality of life: an initial substantial improvement, then some decrease over the follow-up period. The fact that the decrease during the follow-up period was not as dramatic as that of the measures of quality of life reflects, at least in part, the greater bias in walk test results: results were not available for patients who were not well
c cn c
Fig. 1 - Mean scores for physical function on chronic respiratory disease questionnaire (CRQ) before respiratory rehabilitation program (baseline) and during follow-up. + = standard error of mean (SEM).
Fig. 3 - Numbers of patients whose quality of life improved (bold typeface) or deteriorated (regular typeface) over the follow-up period. 475 .
E 425 +
0h Baeline (n=31)
2 wk (n=2S)
Fig. 2- Mean scores for emotional function on CRQ. 1092
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2 wk (n=17)
Fig. 4- Mean results of 6-minute walk test.
enough to undertake the test, which systematically improved the mean scores.
Other measures For the group as a whole the results of spirometry were essentially unchanged during the program and the follow-up period (Fig. 5). Thus, improvement in quality of life and in capacity for exercise was not secondary to changes in pulmonary function, an almost universal observation in the rehabilitation literature.1-24 By the same token, functional deterioration during follow-up cannot be attributed to worsening pulmonary function. The stability of pulmonary function is further reflected in the fact that only three of the subjects showed an improvement of greater than 20% of their baseline FEV1 at any follow-up visit, and only seven showed a decrease of greater than 20% at any time during follow-up. There was a trend toward improvement in the results of cycle ergometer exercise testing (mean 395 kpm [standard deviation (SD) 195] at the baseline visit, compared with 431 kpm [SD 181] at the time of discharge) that was not statistically significant. Very few subjects were willing to undergo follow-up testing (for example, only five at the 6-month follow-up visit).
rehabilitation (p < 0.05); no pther variable was associated with initial response. None of the variables tested was found to be related to sustained improvement. Of the 11 patients who showed dramatic improvement 2 weeks after discharge, 7 still showed improvement at 6 months.
Discussion Our results suggest a considerably lower incidence of long-term response to respiratory rehabilitation than do most published studies.1-24 We found that although 77% of our subjects showed improved quality of life and capacity for exercise 2 weeks after discharge (and in approximately half of these subjects the improvement was dramatic), more than half of the 77% showed deterioration during the subsequent 6 months. Possible explanations for the discrepancy include differences in our patient population, methods of rehabilitation or study methods. We believe that our patient population does not account for the discrepancy because our patients were moderately to severely disabled, and in all cases the respiratory disease was the primary cause of the disability. Furthermore, their impairment in pulmonary function and exercise capacity was comparable to that of other patient populations in the literature. 1-24
Determinants of initial and sustained response We examined what factors may be related to initial and to sustained response to the program. Regression equations were constructed in which the independent variables included initial FEV1, walk test results, sex, age, living alone versus not living alone, working versus not working, and participation in exercise programs during the follow-up period versus no participation; the dependent variables were initial response versus no initial response and sustained improvement versus subsequent deterioriation. Subjects with a higher percentage of the predicted FEV1 at the baseline visit were more likely to show improvement with -4 L 1..It
X 1.3 c E
:f 1.2 +
2 wk (n=28)
Fig. 5- Mean forced expiratory volume in 1 second.
Many of the programs reporting improvement in exercise capacity and functional status focused largely on exercise and physiotherapy.1-13 Our approach is more closely comparable to other comprehensive programs14-24 and includes patient education, counselling (including social work and, if necessary, psychiatric input) and occupational therapy (including retraining in breathing, pacing, energy conservation and work simplification). Our inpatient program runs for 4 to 6 weeks, and at discharge patients are provided with an exercise prescription and an opportunity to attend organized outpatient exercise and rehabilitation sessions. At the time the study was conducted the program had been in operation for almost a decade, and the staff, including specialized nurses, a physiotherapist, an occupational therapist, a social worker and the program coordinator, all had a number of years of training and experience in the field and were applying standard techniques. Thus, the fact that we found a lower incidence of long-term response than other investigators cannot be attributed to anomalies of our patient population or deficiencies in our program. A more likely explanation is differences in study methods. Most of the investigators described experience with fewer than 20 patients1-6'8'9'11'1214'16 and follow-up of less than 6 months.1-4,6-8,11,14,19,24 Many of those with longer follow-up did not specify the proportion of initially enrolled patients their population represented or the reasons for loss to follow-up. Our experience suggests that it is patients who have done well who return for repeat
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testing. This creates a bias that tends to make programs look more successful than they actually are. Finally, no other group has used a rigorously standardized questionnaire administered by someone not involved in the program to measure subjective outcomes such as quality of life. Less formal assessments of sustained improvement administered by study personnel may introduce the opportunity for bias in favour of positive outcomes. We believe that these methodologic differences are the likely explanation for differences between our work and previous reports. Our results may not be surprising when one considers that chronic respiratory disease tends to be progressive and that patients often have deeply ingrained maladaptive patterns of reaction and behaviour to which they tend to return. If all 11 patients who continued to do well would have done badly had it not been for the rehabilitation program, the long-term response rate of 34% could be considered successful. This is especially true when one considers the difficulty of establishing and maintaining changes in behaviour and psychosocial function in patients with other chronic conditions such as obesity and chronic pain syndromes. On the other hand, the long-term response rate of 34% is low enough that it might have been achieved without the rehabilitation program. Patients tend to be referred to rehabilitation at the low point of what is often a cyclic illness, and spontaneous improvement would be expected in some. Other less intensive and less expensive interventions might have achieved the same results. Indeed, in a randomized trial of respiratory rehabilitation, differences between treatment and control groups evident at 2 months disappeared by 4 months not because of major deterioration in the treatment group but because of spontaneous improvement in the control group.28 Therefore, our results suggest that further controlled trials of rehabilitation are warranted. Such trials would be particularly helpful if both costs and benefits were measured in a manner that allowed comparison with other types of rehabilitation programs for chronic disease. Pending such trials, there is a clear need for strategies to maintain the benefits seen in the first weeks after rehabilitation. These may include continued outpatient exercise, individual counselling, and group or family therapy. Indeed, it could be argued that had we been more vigorous in insisting that patients return regularly for follow-up, their outcome might have been better. However, our inability to detect differences in the rate of deterioration between subjects who did and subjects who did not attend outpatient exercise sessions after the inpatient program suggests that these strategies should be rigorously tested before being disseminated. We thank Fred Clarke, Debbie Lambert, Shirley Miller, Jane O'Callaghan, Ellen Sawesky, Mary Tremblay and 1094
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Barbara Wood for their help in recruiting patients and for their valuable support of the project. We also thank Jana Keller, Debbie Maddock, Christine Kendry and Denise Short for their help in collecting and collating data and in the preparation of the manuscript. This work was supported in part by the Ontario Ministry of Health and by the St. Joseph's Hospital Foundation, Hamilton, Ont. Dr. Guyatt is a career scientist of the Ontario Ministry of Health.
References 1. Paez PN, Phillipson EA, Masangkay M et al: The physiologic basis of training patients with emphysema. Am Rev Respir Dis 1967; 95: 944-953 2. Christie D: Physical training in chronic obstructive lung disease. Br Med J 1968; 2: 150-151 3. Woolf CR, Suero JT: Alterations in lung mechanics and gas exchange following training in chronic obstructive lung disease. Chest 1969; 55: 37-44 4. Bass H, Whitcomb JF, Forman R: Exercise training: therapy for patients with chronic obstructive pulmonary disease. Chest 1970; 57: 116-121 5. Nicholas JJ, Gilbert R, Gabe R et al: Evaluation of an exercise therapy program for patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1970; 102: 1-9 6. Vyas MN, Banister EW, Morton JW et al: Response to exercise in patients with chronic airway obstruction. Am Rev Respir Dis 1971; 103: 390-400 7. Chester EH, Belman MJ, Bahler RC et al: Multidisciplinary treatment of chronic pulmonary insufficiency. Chest 1977; 72: 695-702 8. Alpert JS, Bass H, Szucs MM et al: Effects of physical training on hemodynamics and pulmonary function at rest and during exercise in patients with chronic obstructive pulmonary disease. Chest 1974; 66: 647-651 9. Mertens DJ, Shephard RJ, Kavanagh ST: Long-term exercise therapy for chronic obstructive lung disease. Respiration 1978; 35: 96-107 10. Loke J, Mahler DA, Man SFP et al: Exercise impairment in chronic obstructive pulmonary disease. Clin Chest Med 1981; 5:121-143 11. Degre S, Sergysels R, Messin R et al: Hemodynamic response to physical training in patients with chronic lung disease. Am Rev Respir Dis 1974; 110: 395-402 12. Sergysels R, De Coster A, Denolin H: Functional evaluation of a physical rehabilitation program including breathing exercises and bicycle training in chronic obstructive lung disease. Respiration 1979; 38: 105-111 13. Sinclair DJM, Ingram CG: Controlled trial of supervised exercise training in chronic bronchitis. Br Med J 1980; 1: 519-521 14. Pierce AK, Taylor HF, Archer RK et al: Responses to exercise training in patients with emphysema. Arch Intern Med 1964; 113: 28-36 15. Haas A, Cardon H: Rehabilitation in chronic obstructive pulmonary disease; a 5-year study of 252 male patients. Med Clin North Am 1969; 53: 593-606 16. Petty TL, Brink GA, Miller MW et al: Objective functional improvement in chronic airway obstruction. Chest 1970; 57: 216-223 17. Kimbel P, Kaplan AS, Alkalay I et al: An inhospital program for rehabilitation of patients with chronic obstructive pulmonary disease. Chest 1971; 60: 6S-1OS 18. Fishman DB, Petty TL: Physical, symptomatic and psychological improvement in patients receiving comprehensive care for chronic airway obstruction. J Chronic Dis 1971; 24: 775-785 19. Lustig FM, Haas A, Castillo R: Clinical and rehabilitation regime in patients with chronic obstructive pulmonary diseases. Arch Phys Med Rehabil 1972; 53: 315-322 20. Agle DP, Baum GL, Chester ER et al: Multidiscipline
21. 22. 23.
treatment of chronic pulmonary insufficiency. 1. Psychologic aspects of rehabilitation. Psychosom Med 1973; 35: 4149 Sahn SA, Nett LM, Petty TL: Ten year follow-up of a comprehensive rehabilitation program for severe COPD. Chest 1980; 77: 311-314 Dudley DL, Glaser EM, Jorgenson BN et al: Psychosocial concomitants to rehabilitation in chronic obstructive pulmonary disease. Part 2. Psychosocial treatment. Ibid: 544-551 Idem: Psychosocial concomitants to rehabilitation in chronic obstructive pulmonary disease. Part 3. Dealing with psychiatric disease (as distinguished from psychosocial or psychophysiologic problems). Ibid: 677-684 Moser KM, Bokinsky GE, Savage RT et al: Results of a comprehensive rehabilitation program; physiologic and functional effects on patients with chronic obstructive pulmonary disease. Arch Intern Med 1980; 140: 1596-1601 ATS Executive Committee, Medical Section of the American Lung Association: Pulmonary rehabilitation. Am Rev Respir Dis 1981; 124: 663-666 Disabling chest disease: prevention and care. A report of the Royal College of Physicians by the College Committee
27. 28. 29. 30.
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on Thoracic Medicine. J R Coll Physicians Lond 1981; 15: 69-87 McGavin CR, Gupta SP, Lloyd EL et al: Physical rehabilitation for the chronic bronchitic: results of a controlled trial of exercises in the home. Thorax 1977; 32: 307-311 Cockcroft AE, Saunders MJ, Berry G: Randomized controlled trial of rehabilitation in chronic respiratory disability. Thorax 1981; 36: 200-203 Guyatt GH, Pugsley SO, Sullivan MJ et al: Effect of encouragement on walking test performance. Thorax 1984; 39: 818-822 Guyatt GH, Berman LB, Townsend M et al: A measure of quality of life for clinical trials in chronic lung disease. Thorax (in press) Butland RJA, Pang J, Gross ER et al: Two-, six-, and twelve-minute walking test in respiratory disease. Br Med J 1982; 284: 1007-1008 Guyatt GH, Thompson PJ, Berman LB et al: How should we measure function in patients with chronic heart and lung disease?J Chronic Dis 1985; 38: 517-524 Jones ML, Campbell EJM: Clinical Exercise Testing, Saunders, Philadelphia, 1982: 89-100
Screening for psychosocial problems among primary care patients: a pilot study Ian McDowell, PhD
The symptoms that a patient presents to the doctor are often not the underlying concern that prompted the consultation. The success of consultations involving a hidden diagnosis depends on how well the patient can express his or her concerns to the doctor and on how skilfully the doctor can encourage this. This study tested the feasibility and acceptability of having patients complete a brief health index questionnaire designed to help them describe their underlying concerns to the doctor. In two family medicine centres 996 patients were asked to complete a questionnaire while waiting to see the doctor; 724 (73%) did so. An evaluation of their responses showed the method to be acceptable to most. The doctors judged that it added valuable information in 41% of all consultations and in 73% of consultations in which the patient presented with psychologic complaints. There was, nevertheless, considerable variation among the physicians in their acceptance of the approach. This variability is discussed in the light of From the Department of Epidemiology and Community Medicine, University of Ottawa
Reprint requests to: Dr. Ian McDowell, Department of Epidemiology and Community Medicine, Faculty of Health Sciences, University of Ottawa, 451 Smyth Rd., Ottawa, Ont. KZH 8M5
alternative models of how, in practical terms, to treat the psychosocial dimensions of a patient's complaint. Quand un malade se presente au medecin, il arrive souvent que les symptomes qu'il accuse ne representent pas la raison sous-jacente de la consultation. Le succes de celle-ci dans un tel cas depend de la maniere dont le malade exprime ses inquietudes et de l'habilete du medecin a l'y aider. Le bref questionnaire sur les indices de sante, dont nous avons fait l'essai afin de savoir s'il est pratique et s'il plait au malade, a pour objet de lui rendre plus facile de decrire au medecin ces soucis caches. Dans deux centres de medecine familiale on propose ce questionnaire en salle d'attente a 996 patients; 724 (soit 73%) y repondent. L'analyse des reponses montre que cette maniere de faire plait k la majorite des patients; d'apres les medecins elle apporte un utile supplement d'information dans 41% de l'ensemble des cas et dans 73% de ceux ou il existe des symptomes d'appel d'ordre psychologique. Mais les medecins different beaucoup quant a leur acceptation de cette methode. A partir de la nous epiloguons sur les diverses manieres pratiques de faire ressortir les c6tes psycho-sociaux des sympt6mes qu'accuse un malade. CMAJ, VOL. 137, DECEMBER 15, 1987