Causes for lack of adherence to respiratory rehabilitation programs

Daniela Jipa, Alina Croitoru, Miron Bogdan



The respiratory rehabilitation is a non-pharmacologic therapy recommended by international guidelines for the treatment of symptomatic patients with chronic obstructive pulmonary disease (COPD), but also for other respiratory diseases. The rehabilitation comprises a series of evidence-based medicalinterventions and is conducted by a multidisciplinary team. The benefits of rehabilitation are: a better exercise tolerance, a decrease of exacerbation episodes, shorter hospitalization time and an overall improvement of the quality of life. Thus, the patient is given the opportunity to be socially reintegrated. The benefits of respiratory rehabilitation depend on the patient’s adherence to the program. We talk about adherence if the patient beliefs coincides with the medical advice. A non-adherent patient refuses to participate in a rehabilitation program or fails to complete the program. Non-compliance affects the efficacy and the medical results of the respiratory rehabilitation. We need a method to identify high-risk, nonadherent patients and to find methods to solve this problem.


respiratory rehabilitation, non-adherence  


The respiratory rehabilitation is a non-pharmacologic therapy recommended by international guidelines for the treatment of symptomatic respiratory patients. The rehabilitation is based on a series of evidence-based medical interventions and is conducted by a multidisciplinary team(1,2,3).

The new definition of pulmonary rehabilitation ATS/ERS  2013:  “Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors”(1).

The main factor which causes lack of physical activity in COPD patients is dyspnoea, which further causes muscular weakness (peripheral and respiratory muscles) and limited exercise tolerance. These factors lead to the aggravation of dyspnoea and physical inability, a vicious cycle being thus created. The negative consequences of the lack of physical activity could be avoided by resuming it progressively, while also initiating physical training under medical supervision(1,2).

The rehabilitation program includes physical training, respiratory kinesiotherapy, patient education, nutritional advice, psychological and antismoking counseling.  The rehabilitation benefits are: better effort tolerance, a decrease of relapses, hospitalization time and an overall improved quality of life. Thus the patient is given the opportunity to be socially reintegrated(2,3) .   

Although the respiratory rehabilitation benefits are based on a series of evidence, unfortunately, a considerable number of eligible patients never start or failed to complete the program.

Rehabilitation programs

The rehabilitation programmes has a variable duration (4 weeks – 6 months), most commonly 8 weeks. The respiratory rehabilitation is mainly based on physical training (endurance and strength training) and respiratory physiotherapy. The additional therapy is represented by nutritional support, psychological counseling and smoking cessation counseling(1).

There are different types of RR programs regarding to the location: inpatient, outpatient, home-based and community.

The most common type of program is outpatient, with 2 months duration (for example: 3 sessions/week; one session lasts 1 hour). But also an intensive program can be available - 5 days a week ( inpatient or outpatient).
Adherence/Non-adherence to the rehabilitation program

The central position of adherence in the rehabilitation program is highlighted from the beginning of the ERS/ATS statement (2013. In this new definition, one of the main purposes is „to promote the long-term adherence”(1).

We talk about adherence as the patient beliefs coincide with medical advice.  Adherence to rehabilitation it is the degree to which a patient 'sticks' to his rehabilitation program. An adherent patient is a voluntary one, active, open to collaboration. This is the first essential condition to obtain therapeutic results after a respiratory rehabilitation program. From the start,  the patient must understand that the program is a helpful therapy, such that adherence will not be a barrier in quality improvement(1,8,12,16).

The non-adherence has 2 components: the first one - patient do not attend the program and the second one - patient do not complete it.

The ratio of non-adherence varies from study to study: 10 to 32%(1).

The reasons for non-attendance and non-completion in respiratory rehabilitation program have not been well studied. A small number of studies was published and revealed a variety of factors that decrease the adherence. The causes of non-attendance can be different to the causes of non-completion.
The causes of non-adherence

1) Non-attendance
- Barriers to setting up the respiratory rehabilitation (RR) program: the most important barrier is represented by a lack of medical knowledge about what RR representing and the benefits of RR, or the referring doctor think that the RR in not useful. Doctor persuasion skills and more informations about what is RR can remove this barrier.
     The aim of a study published in 2016, in Saudi Arabia, was to determinate the barriers to setting up the RR program. It was a cross-sectional study and 123 health care providers were recruited (physicians 44, nurses n = 49, and respiratory therapists/technicians n = 30). For this peoples, the team used a questionnaire, in wich the most important question was if they had heard until that time about RR program. Of them, 3.2% never had heard about PR programs before.
The conclusion of this study was that the most important barriers were a lack of hospital capacity (75.6%), trained health care providers (72.4%), and funds (48.0%)(22).
  Another qualitative study was publish in 2009 and a small number of patient who had been referred to RR program were interviewed. The interview attended 3 themes; the third one was called 'Attributing value to pulmonary rehabilitation'. At this part of interview the patients answer was that the principal reason for attending RR program was health care providers influence. The conclusion was that the information and enthusiasm of referring clinician can have a powerful impact to increase the adherence(9).
- No hospitals and specialized medical team due to the limited number of RR centers(22).
- Disruption in daily routine: most of the patients already have a daily schedule and routine represent the central word. They are not available to lose their time and attend the RR program.  
Some patients need to take care of a family member, this representing also a reason for non-attendance(10,11).
 - Travel, transportation: the distance from home to the rehabilitation center, the lack of public transport, represents a barrier for attendance.  A big part of the patients is unable to move without help.  Respiratory failure and the lack of oxygen therapy during transportation to the RR center also is a barrier (10,11, 12,13,16).
   A study published in 2007 had the purpose to identify why patients decline to take part to the RR program. 39 patients were interviewed about several themes, among wich travel to and location of RR center. 19 patients answer that they are unable to travel alone because they have restricted mobility and they need oxygen therapy, they have problems with public transport and they don’t have a place of parking at the RR center. Also, they said that the distance between home and hospital is too high.(10).
- Inconvenient schedule of the RR program: some patients prefer to make exercises in the morning, others in the afternoon, because in the first part of the day they need to take their medicine or they have problems to wake up(16, 18).
- Program unlikely to be helpful:  the stage of disease is very severe and the patients do not expect to have benefits, or they think that the program is useless.
   Another qualitative study (2007) using home interviews regarding participation and drop-out RR programs (12 patient with COPD referred to RR) showed that first reason to drop-out was the difficulty of the program, the second one: transportation, the third one: they do not  notice any improvement and the last: psychosocial factors - eg. conflict with other patients(11).
- The lack of time: some patients are still working and the RR program overlaps the working hours.
- Financial reasons: patients do not have money to pay the public transport in the countries where this transportation is not covered by the insurance.
- Status of marriage: one study showed that married people had a higher ratio of attendance compared with divorced or widowed one.
   A study published in ERJ (2009) in New Zealand compared 2 groups of patients: an adherent one (55) and a non-adherent group (36), to find the predictors of non-adherence to respiratory rehabilitation. One of the objectives was to assess marriage status: in the non-adherent group the patients were more likely to be divorced (22 vs 2%), live alone (39 vs 14%) and live in rented accommodation (31 vs 6%)(12).
- Other reasons: illness and comorbidities, lack of social support, current smokers, discussions with other patients that attended the RR program and found it unuseful. RR is a group activity and many people prefer individual exercise(7,15,17).

2) Non-completion

Illness and comorbidities: the most important reason that they did not complete their program was exacerbations or other comorbidities associated with COPD(5,6,19,21).
      A study published in January 2017 about the impact of exacerbation on adherence and outcomes of RR program in patients with COPD, showed that patients with mild to moderate acute exacerbation (AE) do not drop out to RR program and AE do not affect the response to RR. On the contrary, patients with severe AE were dropout to RR(21).
      The purpose of another study (2010-USA) was to determinate the impact of COPD exacerbation to RR program adherence. 8 weeks outpatient program, 146 started RR, 112 completes it. 30 patients had at least 1 exacerbation during the program, 10 dropped out the program. The results showed that the exacerbators who completed the program had the same results compared with non-exacerbators. Is better to advise patients to continue the RR program after exacerbation(5).
-current smokers: the index of packet years represents an increased risk factor in non-completion at active smokers (higher index - higher non-completion)(5).
- Travel, transportation: the same reasons to not-attendance. Patient that usually complete RR program live near to RR center.
- Other barriers in non-completion are represented by depression, lack of motivation. This type of patient is also less compliant in other healthcare activities(16, 20).
- It is difficult to keep self-motivation when patients have a lack of social support.
- Patients who attend the RR program think that the results will appear quickly, but a lack of perceived benefits make some participants to stop the exercises(16).
- Difficulty of the RR program (complexity of procedures) represents another reason to non-completion(10).


The non-adherence with the 2 components: non-attendance and non-completion have for the most part common reasons. All this factors described above must be carefully analyzed and find the optimal method to minimize their effects to adherence.

One of the most common reason is represented by travel and transportation to RR centers.

Considering that the RR programs are mostly outpatient type, we think that, in order to increase the adherence, it is maybe better to use an inpatient program, especially for patient difficulties of transportation, mobility, lack of financial support and respiratory failure.

The lack of knowledge about what RR representing and the benefits of RR, or the referring doctor believe that RR in not useful, discussions with other patients that attended the RR program and found it unuseful are the reasons of patients fail to attend RR. This must be combated through better dissemination of knowledge about rehabilitation among health care providers and the general population(9,22).

Also, depression, lack of motivation, current smokers, lack of perceived benefits make patients to not complete the program. Using specific questionnaires to identify these cases may help further to referred to psychological counseling.

Currently there are no routine methods of noncompliant patients detection. In 2014 a clinical study showed that “Adherence to Pulmonary Rehabilitation Questionnaire (APRQ)" may be a valid method to screen adherence in chronic lung disease patients. This questionnaire it is designed in 6 main directions: disease management, treatment benefits, emotional factors, perceived severity of disease, barriers towards treatment, coping attitude. 109 patients participated in this study, wich analyzed the 18 items of APRQ. The study conclusion was that APRQ may be a valid method to identify non-adherent patients(4).

Non-adherence represents a serious problem that affects the efficacy of respiratory rehabilitation program. Almost 10-32% of patients referred to RR programs are non-adherent (1).


In conclusion, a high number of respiratory disease patients do not complete or attend the RR program. There is no universally valid method to solve this problem and must be analyzed carefully each case, in order to find personalized solutions to non-adherence effects on the efficacy and the medical results of the respiratory rehabilitation.

We need a method to identify high-risk, non-adherent patients in order to find methods of solving this problem.

Questionnaire APRQ may be a valid to screen adherence- chronic lung disease patients, but other studies are also needed(4).

Another potential tool can be utilized is tele medicine, especially in home-based pulmonary rehabilitation. Individual approach as email or telephones can be also used(14).

It is also important to increase the awareness of the health care providers on the pulmonary rehabilitation (medical conferences, internet and educational materials).


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