Pulmonary rehabilitation in lung transplantation: Its effects on pulmonary function, physical fitness, and quality of life

Table 2 Summary of studies on effects of pulmonary rehabilitation on functioning in lung transplantation recipients

No.	Ref.	Study design	Study objective	Study population	Pulmonary rehabilitation intervention	Outcomes assessed	Main results
1	Ambrosino et al[29], 1996	Prospective longitudinal	To evaluate the trajectory of exercise capacity and skeletal and respiratory muscle function after heart-lung transplantation	11 HLT patients (age 38 ± 13 years)	Maximal treadmill exercise, resistive inspiratory training, limb strength training	Pulmonary function; 6MWD; VO2 peak; MIP/MEP; lower-limb muscle strength	No significant change in pulmonary function; gradual improvements in VO2 peak, 6MWD, and muscle strength, but values remained below normal
2	Andrianopoulos et al[17], 2019	Pre-post study	To assess the short-term effects of post-LTx PR on pulmonary function, exercise capacity, and cognitive function	24 LTx recipients with COPD	Comprehensive inpatient PR for 3 weeks	DLCO; RV/TLC; 6MWD; cognitive function	DLCO increased, hyperinflation decreased, 6MWD improved significantly (+ 86 m), and cognitive function improved
3	Candemir et al[22], 2019	Pre-post study	To evaluate the effectiveness of outpatient PR after bilateral LTx	23 bilateral LTx recipients	Multidisciplinary outpatient PR for 8 weeks	Exercise capacity; muscle strength; pulmonary function; QoL; psychological status	Significant improvements in exercise capacity, muscle strength, QoL, and psychological status; static pulmonary function did not change
4	Kerti et al[21], 2021	Pre-post study	To evaluate the effectiveness of PR before and after transplantation	63 LTx candidates and 14 LTx recipients	Four-week PR: Personalized breathing and aerobic exercise	Pulmonary function; 6MWD; CWE; dyspnea; QoL	Pre-LTx PR improved CWE, CAT score, and 6MWD; post-LTx PR improved pulmonary function and quality of life
5	Munro et al[18], 2009	Prospective repeated-measures	To describe functional changes during post-LTx PR	36 LTx recipients	Outpatient PR for 12 weeks (3 times per week)	6MWD; FEV1; FVC; QoL (SF-36)	Significant improvements in pulmonary function, 6MWD, and all SF-36 domains
6	Langer et al[23], 2012	Randomized controlled trial	To evaluate the effect of early supervised exercise after LTx on functional recovery	40 LTx patients (intervention n = 21; control n = 19)	Supervised exercise for 3 months	Daily activity; physical fitness; QoL	The exercise group showed greater daily walking time, higher 6MWD, and greater muscle strength
7	Maury et al[20], 2008	Cohort study	To assess the impact of post-LTx rehabilitation on muscle function and exercise tolerance	36 LTx patients	Outpatient PR for 3 months	Quadriceps strength; 6MWD; pulmonary function	Significant improvements in 6MWD and muscle strength, but values did not reach normal levels
8	Ulvestad et al[31], 2020	Randomized controlled trial	To evaluate the effects of HIIT on fitness and muscle strength after LTx	54 LTx recipients	Supervised HIIT for 20 weeks	VO2 peak; muscle strength; QoL; pulmonary function	No significant difference in VO2 peak (ITT); improvements in muscle strength and mental components of QoL
9	Bartels et al[33], 2011	Observational study	To compare pulmonary function and exercise capacity before and after LTx	153 LTx recipients	Post-LTx PR and physical exercise	Pulmonary function; CPET	Pulmonary function improved significantly, but VO2 peak remained < 50% of predicted values
10	van Adrichem et al[34], 2015	Longitudinal cohort	To analyze changes in 6MWD and its predictors after LTx	108 LTx recipients	Recommendation for regular exercise after LTx	6MWD; pulmonary function; muscle strength	6MWD improved significantly; FEV1 and muscle strength predicted optimal functional recovery
11	Ulvestad et al[24], 2020	Cohort study	To assess respiratory fitness, physical activity, and factors contributing to exercise intolerance after LTx	54 LTx recipients	Postoperative PR up to 6 months	Cardiorespiratory fitness; physical activity	VO2 peak after BLTx remained low due to deconditioning, ventilatory limitation, and impaired gas exchange; most patients were physically inactive
12	Mei et al[25], 2024	Quasi-experimental	To evaluate the effectiveness of early comprehensive PR after LTx	LTx patients at Shanghai Pulmonary Hospital	Multidisciplinary comprehensive PR initiated 24 hours postoperatively	Pulmonary function; 6MWD; QoL; clinical outcomes	Shorter ICU LOS and better pulmonary function, 6MWD, and QoL compared with controls
13	Schneeberger et al[30], 2017	Retrospective cohort	To evaluate PR outcomes in SLTx and DLTx	722 LTx recipients	Multimodal inpatient PR (approximately 6 weeks)	6MWD; HRQoL	Significant improvements in 6MWD and HRQoL with no difference between SLTx and DLTx
14	Orens et al[36], 1995	Prospective	To evaluate exercise responses during the first year after single and double lung transplantation	14 SLTx and 11 DLTx recipients, stable ≥ 3 months post-LTx	Incremental cycle ergometer CPET every 3 months for 1 year	CPET variables; spirometry; DLCO; MVV	Lung function differed between groups, but exercise responses were similar; VO2 peak increased at 3-6 months then declined at 9-12 months
15	Dierich et al[32], 2013	Prospective observational cohort	To observe the influence of postoperative clinical course on inpatient PR success	Single, double, and combined LTx recipients (≥ 18 years)	Three-week inpatient PR: Interval training, strength training, respiratory physiotherapy, education, psychological support	PWR; VO2 peak; 6MWD; VC; FEV1; ADL; HRQoL	All physical function parameters and HRQoL improved significantly; differences observed in PWR, 6MWD, and SF-36 physical functioning
16	Byrd et al[19], 2024	Retrospective non-inferiority	To compare group-based vs individual PR	110 LTx recipients	Outpatient group-based vs individual PR	6MWD; physical function; QoL	Individual PR was non-inferior to group-based PR
17	Song et al[39], 2018	Retrospective cohort	To evaluate feasibility and outcomes of early PR initiated in the ICU after LTx	22 LTx recipients	Early ICU PR: Chest physiotherapy, limb ROM, position changes, functional progression (G1-G4)	Physical functional level	PR initiated at a median of 7.5 days post-LTx without complications; 64% achieved ambulation before discharge
18	Wu et al[35], 2022	Randomized controlled trial	To evaluate the effects of early extubation combined with physical exercise after LTx	96 LTx patients (intervention n = 48; control n = 48)	Early extubation plus early physical exercise 3-5 times per week for 4 weeks	Pulmonary function; 6MWD; MBI; LOS; satisfaction	Intervention group showed better pulmonary function, 6MWD, and MBI (P < 0.001), shorter intubation duration and LOS, and higher satisfaction
19	Fuller et al[38], 2017	Randomized controlled trial	To compare short-duration (7 weeks) vs long-duration (14 weeks) PR after LTx	66 LTx recipients	Supervised PR 3 times per week: Aerobic and resistance training	6MWD; quadriceps/hamstring strength; QoL	Both groups improved in 6MWD and muscle strength with no significant difference between program durations

LTx: Lung transplantation; PR: Pulmonary rehabilitation; HIIT: High-intensity interval training; 6MWD: Six-minute walk distance; SLTx: Single lung transplantation; DLTx: Double lung transplantation; ICU: Intensive care unit; HLT: Heterotopic liver transplantation; COPD: Chronic obstructive pulmonary disease; CPET: Cardiopulmonary exercise testing; ROM: Range of motion; VO₂ peak: Peak oxygen uptake; MIP: Maximal inspiratory pressure; MEP: Maximal expiratory pressure; ; DLCO: Diffusing capacity of the lung for carbon monoxide; MVV: Maximal voluntary ventilation; RV: Residual volume; TLC: Total lung capacity; QoL: Quality of life; CWE: Constant work-rate exercise; FEV1: Forced expiratory volume in one second; FVC: Forced vital capacity; SF-36: Short Form 36; CPET: Cardiopulmonary exercise testing; HRQoL: Health-related quality of life; PWR: Peak work rate; VC: Vital capacity; ADL: Activities of daily living; MBI: Modified Barthel Index; LOS: Length of stay; CAT: Chronic obstructive pulmonary disease assessment test; ITT: Intention-to-treat; BLTx: Bilateral lung transplantation.