REHABILITATION APPROACHES AND FRAILTY IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: TRADITIONAL REVIEW
Year 2024,
Volume: 33 Issue: 3, 420 - 426
Ahmet Uncu
,
Eylem Tütün Yümin
,
Mert Uysal
,
Berker Can
,
Pakize Nurgül Sarı
,
Ramazan Çevik
Abstract
Chronic obstructive pulmonary disease (COPD) represents a major global health problem with a high prevalence and increasing incidence. COPD is a leading cause of mortality and morbidity world wide, which causes significant social and economic burdens. Dyspnea, cough, sputum, and wheezing are common symptoms in individuals with COPD. As age and disease progress, a decline in cognitive functions, decreased muscle mass, sarcopenia, and frailty may accompany the clinical picture, and the functional capacity of patients decreases. Especially with the addition of the frailty diagnosis to the clinical picture, individuals with COPD experience difficulty in maintaining their daily living activities, and their quality of life is adversely affected. Hence, we think that a comprehensive evaluation of individuals with COPD in terms of frailty will be important in preparing an individual-specific pulmonary rehabilitation program.
References
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- Park HY, Kang D, Lee H, et al. Impact of chronic obstructive pulmonary disease on mortality: A large national cohort study. Respirology. 2020;25(7):726-734. doi:10.1111/resp.13678
- Adeloye D, Song P, Zhu Y, Campbell H, Sheikh A, Rudan I. Global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med. 2022;10(5):447-458. doi:10.1016/S2213-2600(21)00511-7
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- Sepúlveda-Loyola W, Osadnik C, Phu S, Morita AA, Duque G, Probst VS. Diagnosis, prevalence, and clinical impact of sarcopenia in COPD: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle. 2020;11(5):1164-1176. doi:10.1002/jcsm. 12600
- Beaudart C, Zaaria M, Pasleau F, Reginster JY, Bruyère O. Health outcomes of sarcopenia: A systematic review and meta-analysis. PLoS One. 2017;12(1):1-16. doi:10.1371/journal.pone.0169 548
- Morley J. NIH Public Access Frailty consensus. J Am Med Dir Assoc. 2014;14(6):392-397. doi:10.1016/j.jamda.2013.03.022.Frailty
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. Journals Gerontol - Ser A Biol Sci Med Sci. 2001;56(3):146-157. doi:10.1093/gerona/56.3.m146
- Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: A systematic review. J Am Geriatr Soc. 2012;60(8):1487-1492. doi:10.1111/j.1532-5415.2012.04054.x
- Milne KM, Kwan JM, Guler S, et al. Frailty is common and strongly associated with dyspnoea severity in fibrotic interstitial lung disease. Respirology. 2017;22(4):728-734. doi:10.1111/resp.12944
- Hanlon P, Guo X, McGhee E, Lewsey J, McAllister D, Mair FS. Systematic review and meta-analysis of prevalence, trajectories, and clinical outcomes for frailty in COPD. npj Prim Care Respir Med. 2023;33(1):1-12. doi:10.1038/s41533-022-00324-5
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- YOLTAY HE, DEMİR KORKMAZ F. Kalp Cerrahisinde Kırılgan Hasta Ve Hemşirelik Bakımı. Cumhur Üniversitesi Sağlık Bilim Enstitüsü Derg. 2021;6(2):82-92. doi:10.51754/cusbed.807484
- Cicutto LC. Frailty: Is This a New Vital Sign? Chest. 2018;154(1):1-2. doi:10.1016/j.chest.2018.03.041
- Pansarasa O, Mimmi MC, Davin A, Giannini M, Guaita A, Cereda C. Inflammation and cell-to-cell communication, two related aspects in frailty. Immun Ageing. 2022;19(1):1-12. doi:10.1186/s12 979-022-00306-8
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- Angulo J, El Assar M, Rodríguez-Mañas L. Frailty and sarcopenia as the basis for the phenotypic manifestation of chronic diseases in older adults. Mol Aspects Med. 2016;50(2016):1-32. doi:10.1016/j.mam.2016.06.001
- Lahousse L, Ziere G, Verlinden VJA, et al. Risk of Frailty in Elderly With COPD: A Population-Based Study. Journals Gerontol - Ser A Biol Sci Med Sci. 2016;71(5):689-695. doi:10.1093/gerona/glv154
- Hong Y, Deng M, Hu W, et al. Weak cough is associated with increased mortality in COPD patients with scheduled extubation: a two-year follow-up study. Respir Res. 2022;23(1):1-8. doi:10.1186/s12931-022-02084-9
- Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Rodríguez-Torres J, González-Jiménez E, Muñoz-Casaubon T. Physical activity as a predictor of absence of frailty in subjects with stable COPD and COPD exacerbation. Respir Care. 2016;61(2):212-219. doi:10.4187/respcare.04118
- Naval E, González MC, Giraldós S, et al. Frailty Assessment in a Stable COPD Cohort: Is There a COPD-Frail Phenotype? COPD J Chronic Obstr Pulm Dis. 2021;18(5):525-532. doi:10.1080/15412555. 2021.1975670
- Verduri A, Carter B, Laraman J, et al. Frailty and its influence on mortality and morbidity in COPD: A Systematic Review and Meta-Analysis. Intern Emerg Med. 2023;18(8):2423-2434. doi:10.1007/s11739-023-03405-6
- Tarazona-Santabalbina FJ, Naval E, De la Cámara-de las Heras JM, Cunha-Pérez C, Viña J. Is Frailty Diagnosis Important in Patients with COPD? A Narrative Review of the Literature. Int J Environ Res Public Health. 2023;20(3). doi:10.3390/ijerph20031678
- Roberts MH, Mapel DW, Ganvir N, Dodd MA. Frailty Among Older Individuals with and without COPD: A Cohort Study of Prevalence and Association with Adverse Outcomes. Int J COPD. 2022;17:701-717. doi:10.2147/COPD.S348714
- Attwell L, Vassallo M. Response to pulmonary rehabilitation in older people with physical frailty, sarcopenia and chronic lung disease. Geriatr. 2017;2(1):5-11. doi:10.3390/geriatrics2010009
- Finamore P, Scarlata S, Delussu AS, Traballesi M, Incalzi RA, Laudisio A. Frailty Impact during and after Pulmonary Rehabilitation. COPD J Chronic Obstr Pulm Dis. 2021;18(5):518-524. doi:10.1080/15412555.2021.1967915
- Wang Z, Hu X, Dai Q. Is it possible to reverse frailty in patients with chronic obstructive pulmonary disease? Clinics. 2020;75:1-6. doi:10.6061/CLINICS/2020/E1778
- Torres-Sánchez I, Valenza MC, Cabrera-Martos I, López-Torres I, Benítez-Feliponi Á, Conde-Valero A. Effects of an Exercise Intervention in Frail Older Patients with Chronic Obstructive Pulmonary Disease Hospitalized due to an Exacerbation: A Randomized Controlled Trial. COPD J Chronic Obstr Pulm Dis. 2017;14(1):37-42. doi:10.1080/15412 555.2016.1209476
- Neunhäuserer D, Reich B, Mayr B, et al. Impact of exercise training and supplemental oxygen on submaximal exercise performance in patients with COPD. Scand J Med Sci Sport. 2021;31(3):710-719. doi:10.1111/sms.13870
- Langer D, Ciavaglia C, Faisal A, et al. Inspiratory muscle training reduces diaphragm activation and dyspnea during exercise in COPD. J Appl Physiol. 2018;125(2):381-392. doi:10.1152/japplphysiol. 01078.2017
- Cabral LF, D’Elia TDC, Marins DDS, Zin WA, Guimarães FS. Pursed lip breathing improves exercise tolerance in COPD: a randomized crossover study. Eur J Phys Rehabil Med. 2015;51(1):79-88.
- Zanini A, Aiello M, Cherubino F, et al. The one repetition maximum test and the sit-to-stand test in the assessment of a specific pulmonary rehabilitation program on peripheral muscle strength in COPD patients. Int J COPD. 2015;10(1):2423-2430. doi:10.2147/COPD.S91176
- Silva CM da S e., Gomes Neto M, Saquetto MB, Conceição CS da, Souza-Machado A. Effects of upper limb resistance exercise on aerobic capacity, muscle strength, and quality of life in COPD patients: a randomized controlled trial. Clin Rehabil. 2018;32(12):1636-1644. doi:10.1177/02 69215518787338
- Chuatrakoon B, Uthaikhup S, Ngai SP, Liwsrisakun C, Pothirat C, Sungkarat S. The effectiveness of home-based balance and pulmonary rehabilitation program in individuals with chronic obstructive pulmonary disease: a randomized controlled trial. Eur J Phys Rehabil Med. 2022;58(3):478-486. doi:10.23736/S1973-9087.22.07383-X
- Maddocks M, Kon SSC, Canavan JL, et al. Physical frailty and pulmonary rehabilitation in COPD: A prospective cohort study. Thorax. 2016;71(11):988-995. doi:10.1136/thoraxjnl-2016-208460
- Neo HY, Yap CW, Teo LM, et al. Palliative Rehabilitation Improves Health Care Utilization and Function in Frail Older Adults with Chronic Lung Diseases. J Am Med Dir Assoc. 2021;22(12):2478-2485.e1. doi:10.1016/j.jamda.2021.05. 031
- Cerdán de las Heras J, Tulppo M, Kiviniemi AM, et al. Augmented reality glasses as a new tele-rehabilitation tool for home use: patients’ perception and expectations. Disabil Rehabil Assist Technol. 2022;17(4):480-486. doi:10.1080/1748 3107.2020.1800111
- Benzo RP, Ridgeway J, Hoult JP, et al. Feasibility of a Health Coaching and Home-Based Rehabilitation Intervention With Remote Monitoring for COPD. Respir Care. 2021;66(6):960-971. doi:10.4187/respcare.08580
- Gephine S, Saey D, Grosbois JM, Maltais F, Mucci P. Home-based Pulmonary Rehabilitation is Effective in Frail COPD Patients with Chronic Respiratory Failure. Chronic Obstr Pulm Dis. 2022;9(1):15-25. doi:10.15326/JCOPDF.2021.0250
- de Oliveira TMD, Pereira AL, Costa GB, et al. Embedding Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease in the Home and Community Setting: A Rapid Review. Front Rehabil Sci. 2022;3:1-12. doi:10.3389/fresc.2022.780736
- Nair A, Alaparthi GK, Krishnan S, et al. Comparison of Diaphragmatic Stretch Technique and Manual Diaphragm Release Technique on Diaphragmatic Excursion in Chronic Obstructive Pulmonary Disease: A Randomized Crossover Trial. Pulm Med. 2019;2019. doi:10.1155/2019/6364376
- Buran Cirak Y, Yilmaz Yelvar GD, Durustkan Elbasi N. Effectiveness of 12-week inspiratory muscle training with manual therapy in patients with COPD: A randomized controlled study. Clin Respir J. 2022;16(4):317-328. doi:10.1111/crj.13486
- Rutkowski S, Rutkowska A, Kiper P, et al. Virtual reality rehabilitation in patients with chronic obstructive pulmonary disease: A randomized controlled trial. Int J COPD. 2020;15:117-124. doi:10.2147/COPD.S223592
KRONİK OBSTRÜKTİF AKCİĞER HASTALIĞINDA REHABİLİTASYON YAKLAŞIMLARI VE KIRILGANLIK: GELENEKSEL DERLEME
Year 2024,
Volume: 33 Issue: 3, 420 - 426
Ahmet Uncu
,
Eylem Tütün Yümin
,
Mert Uysal
,
Berker Can
,
Pakize Nurgül Sarı
,
Ramazan Çevik
Abstract
Kronik obstrüktif akciğer hastalığı (KOAH), yüksek prevalansı ve artan insidansı ile önemli bir küresel sağlık sorunudur. KOAH, önemli sosyal ve ekonomik yüklere neden olan dünya çapında önde gelen mortalite ve morbidite nedenidir. KOAH’lı bireylerde dispne, öksürük, balgam, hırıltılı solunum sıkça gözlenen semptomlardır. Yaş ve hastalık ilerledikçe bilişsel fonksiyonlarda gerileme, kas kütlesinde azalma, sarkopeni ve kırılganlık da tabloya eşlik edebilmekte ve hastaların fonksiyonel kapasitesi azalmaktadır. Özellikle tabloya kırılganlık tanısının da eklenmesiyle KOAH’lı bireyler günlük yaşam aktivitelerini sürdürmekte zorlanmakta ve yaşam kalitesi olumsuz etkilenmektedir. Bu nedenle KOAH’lı bireylerin kırılganlık bakımından kapsamlı olarak değerlendirilmesinin bireye özgü pulmoner rehabilitasyon programının oluşturulmasında önemli olacağı görüşündeyiz.
References
- Rodriguez-Roisin R, Rabe KF, Vestbo J, Vogelmeier C, Agustí A. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 20th Anniversary: A brief history of time. Eur Respir J. 2017;50(1): 1700671. doi:10.1183/13993003.00 671-2017
- Park HY, Kang D, Lee H, et al. Impact of chronic obstructive pulmonary disease on mortality: A large national cohort study. Respirology. 2020;25(7):726-734. doi:10.1111/resp.13678
- Adeloye D, Song P, Zhu Y, Campbell H, Sheikh A, Rudan I. Global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med. 2022;10(5):447-458. doi:10.1016/S2213-2600(21)00511-7
- Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Arch Bronconeumol. 2023;59(4):232-248. doi:10.1016/j.arbres.2023. 02.009
- Sepúlveda-Loyola W, Osadnik C, Phu S, Morita AA, Duque G, Probst VS. Diagnosis, prevalence, and clinical impact of sarcopenia in COPD: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle. 2020;11(5):1164-1176. doi:10.1002/jcsm. 12600
- Beaudart C, Zaaria M, Pasleau F, Reginster JY, Bruyère O. Health outcomes of sarcopenia: A systematic review and meta-analysis. PLoS One. 2017;12(1):1-16. doi:10.1371/journal.pone.0169 548
- Morley J. NIH Public Access Frailty consensus. J Am Med Dir Assoc. 2014;14(6):392-397. doi:10.1016/j.jamda.2013.03.022.Frailty
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. Journals Gerontol - Ser A Biol Sci Med Sci. 2001;56(3):146-157. doi:10.1093/gerona/56.3.m146
- Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: A systematic review. J Am Geriatr Soc. 2012;60(8):1487-1492. doi:10.1111/j.1532-5415.2012.04054.x
- Milne KM, Kwan JM, Guler S, et al. Frailty is common and strongly associated with dyspnoea severity in fibrotic interstitial lung disease. Respirology. 2017;22(4):728-734. doi:10.1111/resp.12944
- Hanlon P, Guo X, McGhee E, Lewsey J, McAllister D, Mair FS. Systematic review and meta-analysis of prevalence, trajectories, and clinical outcomes for frailty in COPD. npj Prim Care Respir Med. 2023;33(1):1-12. doi:10.1038/s41533-022-00324-5
- ÖZŞAKER E. Yaşlı Cerrahi Hastaları ve Kırılganlık Sendromu. Samsun Sağlık Bilim Derg. 2023;8(1):49-62. doi:10.47115/jshs.1118004
- KAPUCU S. Kırılgan Yaşlı ve Hemşirelik Bakımı. OSMANGAZİ J Med. 2017;39(1). doi:10.20515/otd.288967
- YOLTAY HE, DEMİR KORKMAZ F. Kalp Cerrahisinde Kırılgan Hasta Ve Hemşirelik Bakımı. Cumhur Üniversitesi Sağlık Bilim Enstitüsü Derg. 2021;6(2):82-92. doi:10.51754/cusbed.807484
- Cicutto LC. Frailty: Is This a New Vital Sign? Chest. 2018;154(1):1-2. doi:10.1016/j.chest.2018.03.041
- Pansarasa O, Mimmi MC, Davin A, Giannini M, Guaita A, Cereda C. Inflammation and cell-to-cell communication, two related aspects in frailty. Immun Ageing. 2022;19(1):1-12. doi:10.1186/s12 979-022-00306-8
- Soysal P, Stubbs B, Lucato P, et al. Corrigendum to “Inflammation and frailty in the elderly: A systematic review and meta-analysis” (Ageing Research Reviews (2016) 31 (1–18) (S1568163716301106) (10.1016/j.arr.2016.08.006)). Ageing Res Rev. 2017;35:364-365. doi:10.1016/j.arr.2016.12.007
- Angulo J, El Assar M, Rodríguez-Mañas L. Frailty and sarcopenia as the basis for the phenotypic manifestation of chronic diseases in older adults. Mol Aspects Med. 2016;50(2016):1-32. doi:10.1016/j.mam.2016.06.001
- Lahousse L, Ziere G, Verlinden VJA, et al. Risk of Frailty in Elderly With COPD: A Population-Based Study. Journals Gerontol - Ser A Biol Sci Med Sci. 2016;71(5):689-695. doi:10.1093/gerona/glv154
- Hong Y, Deng M, Hu W, et al. Weak cough is associated with increased mortality in COPD patients with scheduled extubation: a two-year follow-up study. Respir Res. 2022;23(1):1-8. doi:10.1186/s12931-022-02084-9
- Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Rodríguez-Torres J, González-Jiménez E, Muñoz-Casaubon T. Physical activity as a predictor of absence of frailty in subjects with stable COPD and COPD exacerbation. Respir Care. 2016;61(2):212-219. doi:10.4187/respcare.04118
- Naval E, González MC, Giraldós S, et al. Frailty Assessment in a Stable COPD Cohort: Is There a COPD-Frail Phenotype? COPD J Chronic Obstr Pulm Dis. 2021;18(5):525-532. doi:10.1080/15412555. 2021.1975670
- Verduri A, Carter B, Laraman J, et al. Frailty and its influence on mortality and morbidity in COPD: A Systematic Review and Meta-Analysis. Intern Emerg Med. 2023;18(8):2423-2434. doi:10.1007/s11739-023-03405-6
- Tarazona-Santabalbina FJ, Naval E, De la Cámara-de las Heras JM, Cunha-Pérez C, Viña J. Is Frailty Diagnosis Important in Patients with COPD? A Narrative Review of the Literature. Int J Environ Res Public Health. 2023;20(3). doi:10.3390/ijerph20031678
- Roberts MH, Mapel DW, Ganvir N, Dodd MA. Frailty Among Older Individuals with and without COPD: A Cohort Study of Prevalence and Association with Adverse Outcomes. Int J COPD. 2022;17:701-717. doi:10.2147/COPD.S348714
- Attwell L, Vassallo M. Response to pulmonary rehabilitation in older people with physical frailty, sarcopenia and chronic lung disease. Geriatr. 2017;2(1):5-11. doi:10.3390/geriatrics2010009
- Finamore P, Scarlata S, Delussu AS, Traballesi M, Incalzi RA, Laudisio A. Frailty Impact during and after Pulmonary Rehabilitation. COPD J Chronic Obstr Pulm Dis. 2021;18(5):518-524. doi:10.1080/15412555.2021.1967915
- Wang Z, Hu X, Dai Q. Is it possible to reverse frailty in patients with chronic obstructive pulmonary disease? Clinics. 2020;75:1-6. doi:10.6061/CLINICS/2020/E1778
- Torres-Sánchez I, Valenza MC, Cabrera-Martos I, López-Torres I, Benítez-Feliponi Á, Conde-Valero A. Effects of an Exercise Intervention in Frail Older Patients with Chronic Obstructive Pulmonary Disease Hospitalized due to an Exacerbation: A Randomized Controlled Trial. COPD J Chronic Obstr Pulm Dis. 2017;14(1):37-42. doi:10.1080/15412 555.2016.1209476
- Neunhäuserer D, Reich B, Mayr B, et al. Impact of exercise training and supplemental oxygen on submaximal exercise performance in patients with COPD. Scand J Med Sci Sport. 2021;31(3):710-719. doi:10.1111/sms.13870
- Langer D, Ciavaglia C, Faisal A, et al. Inspiratory muscle training reduces diaphragm activation and dyspnea during exercise in COPD. J Appl Physiol. 2018;125(2):381-392. doi:10.1152/japplphysiol. 01078.2017
- Cabral LF, D’Elia TDC, Marins DDS, Zin WA, Guimarães FS. Pursed lip breathing improves exercise tolerance in COPD: a randomized crossover study. Eur J Phys Rehabil Med. 2015;51(1):79-88.
- Zanini A, Aiello M, Cherubino F, et al. The one repetition maximum test and the sit-to-stand test in the assessment of a specific pulmonary rehabilitation program on peripheral muscle strength in COPD patients. Int J COPD. 2015;10(1):2423-2430. doi:10.2147/COPD.S91176
- Silva CM da S e., Gomes Neto M, Saquetto MB, Conceição CS da, Souza-Machado A. Effects of upper limb resistance exercise on aerobic capacity, muscle strength, and quality of life in COPD patients: a randomized controlled trial. Clin Rehabil. 2018;32(12):1636-1644. doi:10.1177/02 69215518787338
- Chuatrakoon B, Uthaikhup S, Ngai SP, Liwsrisakun C, Pothirat C, Sungkarat S. The effectiveness of home-based balance and pulmonary rehabilitation program in individuals with chronic obstructive pulmonary disease: a randomized controlled trial. Eur J Phys Rehabil Med. 2022;58(3):478-486. doi:10.23736/S1973-9087.22.07383-X
- Maddocks M, Kon SSC, Canavan JL, et al. Physical frailty and pulmonary rehabilitation in COPD: A prospective cohort study. Thorax. 2016;71(11):988-995. doi:10.1136/thoraxjnl-2016-208460
- Neo HY, Yap CW, Teo LM, et al. Palliative Rehabilitation Improves Health Care Utilization and Function in Frail Older Adults with Chronic Lung Diseases. J Am Med Dir Assoc. 2021;22(12):2478-2485.e1. doi:10.1016/j.jamda.2021.05. 031
- Cerdán de las Heras J, Tulppo M, Kiviniemi AM, et al. Augmented reality glasses as a new tele-rehabilitation tool for home use: patients’ perception and expectations. Disabil Rehabil Assist Technol. 2022;17(4):480-486. doi:10.1080/1748 3107.2020.1800111
- Benzo RP, Ridgeway J, Hoult JP, et al. Feasibility of a Health Coaching and Home-Based Rehabilitation Intervention With Remote Monitoring for COPD. Respir Care. 2021;66(6):960-971. doi:10.4187/respcare.08580
- Gephine S, Saey D, Grosbois JM, Maltais F, Mucci P. Home-based Pulmonary Rehabilitation is Effective in Frail COPD Patients with Chronic Respiratory Failure. Chronic Obstr Pulm Dis. 2022;9(1):15-25. doi:10.15326/JCOPDF.2021.0250
- de Oliveira TMD, Pereira AL, Costa GB, et al. Embedding Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease in the Home and Community Setting: A Rapid Review. Front Rehabil Sci. 2022;3:1-12. doi:10.3389/fresc.2022.780736
- Nair A, Alaparthi GK, Krishnan S, et al. Comparison of Diaphragmatic Stretch Technique and Manual Diaphragm Release Technique on Diaphragmatic Excursion in Chronic Obstructive Pulmonary Disease: A Randomized Crossover Trial. Pulm Med. 2019;2019. doi:10.1155/2019/6364376
- Buran Cirak Y, Yilmaz Yelvar GD, Durustkan Elbasi N. Effectiveness of 12-week inspiratory muscle training with manual therapy in patients with COPD: A randomized controlled study. Clin Respir J. 2022;16(4):317-328. doi:10.1111/crj.13486
- Rutkowski S, Rutkowska A, Kiper P, et al. Virtual reality rehabilitation in patients with chronic obstructive pulmonary disease: A randomized controlled trial. Int J COPD. 2020;15:117-124. doi:10.2147/COPD.S223592