Pulmonary Rehabilitation 118 Journal of Cardiopulmonary Rehabilitation and Prevention 2018;38:118-123 www.jcrpjournal.com P ulmonary rehabilitation (PR) has become a fundamen- tal part of the nonpharmacological treatment of pa- tients with chronic obstructive pulmonary disease (COPD), and it is recognized as the most reliable method to improve exercise performance and health-related quality of life (HRQOL) status. 1,2 The majority of patients with COPD have frequent exacerbations (up to 3 per year) and other comorbidities, which along with dyspnea are variables that might have a role in decreasing HRQOL in these patients. 3 Yeo et al 4 reported a significant correlation in persons with COPD between a greater number of comorbidities and poorer HRQOL ( r = 0.45, P < .05), as well as a significant negative correlation between comorbidity and primary care visit attendances ( r = −0.41, P < .05) and a significant positive correlation between worsening HRQOL and sec- ondary care visit attendances ( r = 0.46, P < .05). Patients with COPD (moderate to severe airflow obstruc- tion) usually present with poor health-related quality of life, and some factors associated with this finding can be dys- pnea, chronic cough/fatigue, gender, and advanced age. 5 It has been shown that patients with a St George Respiratory Questionnaire (SGRQ) score above 39 present with severe airflow limitations and severe dyspnea. However, increased exercise tolerance and decreased dyspnea were reported in these patients with COPD after PR. 6-9 Interestingly, not all patients improve quality of life during a PR program. 10,11 It is not well understood why these patients do not improve their HRQOL despite improving physical capacity. Thus, we aimed to evaluate the differences between patients with COPD whose quality of life improved and those who did not improve after a PR program; in ad- dition, we aimed to evaluate the training response and the physiological adaptations in patients with COPD after a PR. METHODS We recruited a convenience sample of 73 patients with COPD referred to the PR program at the Pulmonary Re- habilitation Center of the Federal University of São Pau- lo (UNIFESP/Lar Escola São Francisco). The protocol was submitted and approved by the Institutional Review Board (#CEP 0369/10) of the Federal University of São Paulo (UNIFESP/Lar Escola São Francisco). The inclusion crite- ria were patients with a diagnosis of COPD older than 40 years, a history of smoking for at least 10 packs/y, and com- pletion of the PR program. Exclusion criteria were recent COPD exacerbation (within 2 mo before starting the pro- gram), myocardial infarction (within the last 6 mo), uncon- trolled hypertension, angina pectoris, or a neuromuscular condition that could interfere with exercise testing. Baseline data evaluated before the beginning of the PR program included age; body mass index (BMI); fat-free mass (FFM); baseline dyspnea index (BDI); post-bronchodilator forced vital capacity (FVC); and forced expiratory volume in 1 sec (FEV 1 ) in absolute and percent predicted values (Koko Spi- rometer, PDS Instrumentation) performed according to Ameri- can Thoracic Society/European Respiratory Society (ATS/ERS) guidelines. 12 Maximal inspiratory (MIP) and expiratory (MEP) mouth pressures were also measured using a respiratory mus- cle dynamometer (Vital Power KH-101 Chest). 13 All patients performed two 6-min walk tests (6MWTs) according to the ATS guideline, and the greater of the 2 distances walked was Variability in Quality of Life Outcomes Following a Pulmonary Rehabilitation Program in Patients With COPD Elias F. Porto, PT, PhD; Antonio A. M. Castro, PT, PhD; Felipe Cortopassi, PT, RPFT, MBA; Gerson F. de Souza, PT, PhD; José R. Jardim, MD, PhD Author Affiliations: Pulmonary Rehabilitation Center, Respiratory Division, Escola Paulista de Medicina, Federal University of Sao Paulo (Unifesp/Lar Escola Sao Francisco), São Paulo, Brazil (Drs Porto, Castro, de Souza, and Jardim and Mr Cortopassi); Adventist University, São Paulo, Brazil (Drs Porto and Castro); Federal University of Pampa, Rio Grande do Sul, Brazil (Dr Castro); Pulmonary Department, State University of Rio de Janeiro, Rio de Janeiro, Brazil (Mr Cortopassi). All authors have read and approved the article. The authors declare no conflicts of interest. Correspondence: Elias F. Porto, PT, PhD, Adventist University, São Paulo, SP, Brazil (eliasfporto@gmail.com). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/HCR.0000000000000292 Purpose: Pulmonary rehabilitation (PR) improves exercise tol- erance in patients with chronic obstructive pulmonary disease. However, it is unclear why some patients do not improve quality of life during a training program. Our objective was to evaluate the differences between patients with chronic obstructive pulmo- nary disease who improve and those who do not improve quality of life during a pulmonary rehabilitation program. Methods: Seventy-three patients underwent a PR program. All patients trained at 80% (legs) and 50% (arms) of their maxi- mum load. Incremental and endurance tests, 6-min walk test, and health-related quality of life with the St George Respirato- ry Questionnaire (SGRQ) were measured. We subdivided the groups based on a decrease ≥4 points in the pre- and post-PR SGRQ total score (G1); <4-point change in the SGRQ total score (G2); and an increase in scores ≥4 points (G3). Results: Exacerbation frequency ( P = .004) and SGRQ total scores ( P < .001) were lower in G1 and G2 than in G3. G1 ( P = .0007) and G2 ( P = .0005) significantly improved 6-min walk test distance. Before PR, G1 and G2 walked greater distances than G3 ( P = .003); however, the difference was no longer sig- nificant after PR ( P = .34). A significant load increase was seen after PR for the 3 groups ( P < .05). We found a significant cor- relation between the SGRQ and the Charlson index ( r = 0.78, P < .0001), exacerbation frequency ( r = 0.72, P < .0001), and basal dyspnea index ( r = −0.48, P < .0001). Conclusion: Patients whose quality of life did not improve af- ter comprehensive PR presented a higher number of disease-re- lated exacerbations with comorbidities. Key Words: COPD • exercise training • health-related quality of life • pulmonary rehabilitation • St George Respiratory Questionnaire Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.