Clinical Investigations
Received: June 18, 2003
Respiration 2004;71:246–251
DOI: 10.1159/000077422
Occupational Therapy and
Pulmonary Rehabilitation of
Disabled COPD Patients
Cristina M. Lorenzi Carmela Cilione Roberta Rizzardi Vittoria Furino
Tommasina Bellantone Daniela Lugli Enrico Clini
Division of Pneumology and Pulmonary Rehabilitation, Fondazione Villa Pineta ONLUS (Pavullo, MO) and
University of Modena-Reggio Emilia, Modena, Reggio Emilia, Italy
Key Words
Disability W Activity of daily living W Pulmonary
rehabilitation
Abstract
Background: Occupational therapy (OT) has been de-
fined as a task of rehabilitation for disabled patients, giv-
ing them maximal function and independence to sustain
specific activities of daily living. Objectives: To evaluate
the effectiveness of OT as an adjunctive measuring dur-
ing pulmonary rehabilitation (PR) of hospitalized COPD
patients. Methods: A prospective clinical trial with paral-
lel groups was undertaken in severely disabled COPD
patients (n = 71, age 73 B 5 years). They were assigned
to either OT+PR (n = 47, FEV1 46 B 21%pred.) or PR (n =
24, FEV1 44 B 12%pred.). PR consisted of eighteen 3-
hour daily sessions, whilst OT (domestic activities) was
added 3 times a week up to nine 1-hour sessions. Six-
min walk (6MWD) with evaluation of BORG dyspnea (D)
and leg fatigue (F) scores at end of effort, breathlessness
sensation (B) by means of the MRC scale as well as the
number of functions lost in the Basic Activity of Daily Liv-
ing (BADL) categories were assessed as outcomes be-
fore (T0) and after (T1) rehabilitation. Results: 6MWD
(from 165 B 63 to 233 B 66 and from 187 B 52 to 234 B
© 2004 S. Karger AG, Basel
ABC 0025–7931/04/0713–0246$21.00/0
Fax + 41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/res
Accepted after revision: November 12, 2003
65 m in the OT+PR and PR groups, respectively), D (from
4.9 B 2.1 to 3.2 B 1.6 and from 5.3 B 2.1 to 3.4 B 2.1), F
(from 6.1 B 0.5 to 4.5 B 1.7 and from 5.9 B 0.8 to 4.3 B
0.8) and B (from 4.3 B 0.9 to 3.0 B 0.9 and from 4.2 B 1.0
to 3.2 B 0.8) had similarly improved (p ! 0.01) in both
groups at T1. The percentage distribution of patients
across the BADL categories significantly changed (p =
0.004) in OT+PR (from 17 to 61%, from 70 to 34% and
from 23 to 5% in categories A, B and C, respectively) but
not in the PR group. Conclusions: The addition of OT to
comprehensive PR is able to specifically improve the out-
come of severely disabled COPD inpatients.
Copyright © 2004 S. Karger AG, Basel
Introduction
Occupational therapy (OT) has been defined as a task
of rehabilitation for disabled patients, giving them maxi-
mal function and independence to sustain specific activi-
ties of daily living [1] and to improve the ability to cope
with working and social behaviours [2]. Therefore, the
most important goals of OT are strictly linked with the
patient’s autonomy, both to remedy deficient activities
and prevent any further deterioration [3]. Although most
occupational tasks are promoted to enhance activities of
Enrico Clini, MD, FCCP
Fondazione Villa Pineta ONLUS, Division of Pneumology and Pulmonary Rehabilitation
Via per Gaiato 252
IT–41020 Pavullo MO (Italy)
Tel./Fax +39 0536 42039, E-Mail eclini@qubisoft.it
the upper limbs, mainly due to the massive work-related
musculoskeletal complaints, a deficient muscular func-
tion of both upper and lower limbs clearly impairs the
patient’s overall independence during activities of daily
living.
Chronic obstructive pulmonary disease (COPD) is
commonly associated with decreased activity and partici-
pation [4] and with progressive muscle dysfunction [5],
chronic inactivity and deconditioning being important
factors in the loss of peripheral muscle mass and strength
[6]. Rehabilitation is a well-established and widely ac-
cepted means of enhancing standard therapy in COPD
patients [7–9] in order to alleviate symptoms, to optimize
function and to improve health-related quality of life [10],
notwithstanding the stage of the disease [11].
OT intervention during comprehensive pulmonary re-
habilitation (PR) must be promoted to specifically evalu-
ate and solve problems related with respiratory disability
(i.e. outdoor walking or efforts of the upper limbs in-
volved in activities of daily living such as dressing, bath-
ing, feeding, weight lifting). Occupational tasks should be
related to symptoms occurring during specific activities
[7–9]. Nevertheless, standardized protocols of OT during
PR and definition of outcomes during OT intervention
are lacking. The aim of the present study is to evaluate the
effectiveness of OT as an adjunctive measure to compre-
hensive PR for disabled hospitalized COPD patients.
Material and Methods
The local ethical committee approved the study; all the study pro-
cedures were conducted according to the declaration of Helsinki.
Patients gave their informed consent to participate in the study.
Patients
Patients with COPD as defined according to the GOLD staging
[12] consecutively admitted to the 85 beds of our rehabilitation unit
were studied. All the included patients had a history of smoking (1 20
pack-years) but they currently were non-smokers or ex-smokers.
They had been referred for inpatient rehabilitation by their general
practitioner while presenting relevant signs of physical decondition-
ing. At the time of the study, none of the patients received systemic
steroids; they were continuing their usual regimen with inhaled bron-
chodilators and steroids or long-term oxygen when prescribed.
Criteria for inclusion into the study were a distance ! 250 m at the
baseline time-walked test [13] and at least one of the following: pres-
ence of significant oxygen desaturation (SatO2 ^85%) during the
walk test despite oxygen supplementation (when used), a dyspnea
score 63 as assessed by the Borg scale [14] at end of effort, chronic
breathlessness score 64 as assessed by the MRC scale [15], disability
score 6B as assessed by number of functions lost in the modified
Basic Activity of Daily Living (BADL) scale [16].
Occupational Therapy in COPD
Patients with any unstable medical condition or concomitant
chronic diseases (i.e. severe left ventricular dysfunction, cancer) were
excluded from the study.
Pulmonary Function Tests
Baseline forced lung volumes (FEV1, FVC) were measured with a
spirometer (Masterscope, Jaeger GmbH, Hochberg, Germany). Pre-
dicted values were those of Quanjer [17].
Arterial blood was sampled at the radial artery with the patient in
the sitting position after breathing room air for at least 1 h to obtain
PaO2 and PaCO2, which were measured using an automated analyser
(Mod.850, Chiron Diagnostics Co., Medfield, USA).
Respiratory muscle strength was assessed by measuring MIP and
MEP [18] using a respiratory module system (Masterscope PIMAX/
PEMAX Module, Jaeger). The predicted values were according to
Bruschi et al. [19].
Outcome Measures
The 6-min walk distance (6MWD) [13] while patients breathed
room air or oxygen (when used), dyspnea sensation (D) and leg
fatigue (F) scores as assessed by the Borg scale [14] taken at the end of
effort, perceived chronic breathlessness (B) on daily activities mea-
sured by means of the MRC scale [15] were considered as nonspecific
outcomes.
The modified disability score as assessed by number of functions
lost in the BADL categories (from A to D with a progressively
increasing number of functions lost), as previously used [16], was
considered as a specific outcome. In the present version of the BADL,
the meanings of each category were as follows: A = loss of 1 function
among those explored; B = loss of 2 functions (bathing and another
function); C = loss of 3 functions (bathing, dressing and another func-
tion), and D = loss of more than 3 functions.
Study Protocol
The study is a prospective non-randomized parallel-group trial.
Patients who satisfied the inclusion criteria (see above) were eligible
for OT+PR. Forty-seven out of the 71 included patients underwent
the OT programme (OT+PR group). The remaining 24 patients were
excluded from this adjunctive treatment due to refusal (PR group)
and were considered as controls.
Pulmonary function tests were taken within 48 h from hospital
admission, whereas outcome measures were recorded at baseline (T0)
and at the end of the study (T1).
Occupational Therapy
OT was implemented with the goal to discharge the patient with
independent functions at the end of the programmed sessions. Initial
assessment of disability in activities of daily living was based on the
modified Italian version of the Canadian Occupational Performance
Measure [20]. The domestic areas evaluated in order to establish
priorities for intervention were: Mobility, cleaning, dressing, feeding
and self-care for respiratory treatments.
The OT programme included 9 sessions (3 days per week) of 1 h
each. Each session was attended by an expert respiratory therapist
and was held in a domestic environment. Patients performed consec-
utive activities among those included in the explored areas for which
they have shown a lack of independence. None of these activities
overlapped with those included in the PR intervention. This specific
programme and intervention was then monitored by the respiratory
therapist on a day-by day chart.
Respiration 2004;71:246–251 247
 Pulmonary Rehabilitation
All the patients were allocated to PR according to the institution-
al protocols (A–C of decreasing intensity). A specifically trained
respiratory therapist not aware of the study purpose decided on the
allocation to a similar PR protocol for all the patients (protocol B) by
triage and other specific respiratory measures (threshold, hyperinfla-
tion or incentive spirometry, assisted cough, use of supplemental
oxygen and monitoring during exercise), which were added on
request.
Protocol B included optimization of the pharmacological treat-
ment and 18 sessions (6 days per week) which were lasting for up to
3 h on a daily basis; nutritional and psychosocial counselling were
also included when appropriate. Each session included: (1) compen-
satory breathing techniques, energy conservation, stress management
and symptoms control; (2) supervised walking [21] and stair climb-
ing; (3) abdominal, upper and lower limb muscle activities lifting
500-mg weights [22], shoulder and full arm circling, and (4) patient
education and instruction in disease management.
Analysis
Values are expressed as mean and standard deviation (SD), fre-
quency and/or percentage distribution. All analyses were performed
using a specific software package (SPSS 8.0 for Windows). A p value
! 0.05 was considered significant.
Recorded data were analysed between times and groups; analysis
of group differences from baseline (before and after rehabilitation)
for the considered variables was also included. Differences for para-
metric variables were analysed with Student’s t test for repeated mea-
sures, whereas the Wilcoxon and the Mann-Whitney tests were used
to test differences between non-parametric variables.

Results

Patients were selected among 412 patients diagnosed

Table 1. Patient demographic and respiratory function characteris-
as having COPD (81% of the total patients) and admitted
tics (data are as means and SD, shown in parentheses)
to our unit for rehabilitative purposes between September
OT + PR (n = 47) PR (n = 24) and December 2002. Patients included in the study repre-
sented 17% of total COPD treated in the same period.
Sex (M/F) 26/21 14/10 Table 1 shows the demographic and respiratory func-
Age, years 73 (7) 75 (4)
tion characteristics of the patients studied. The character-
BMI, kg ! cm –2 23 (4) 22 (3)
FEV1, %pred. 46 (21) 44 (12) istics of patients were similar in the two groups: COPD
FVC, %pred. 61 (22) 63 (19) were in GOLD stage 2 (7 and 6 in OT+PR and PR groups,
MIP, cm H2O 45 (21) 48 (19) respectively), 3 (18 and 10, respectively) and 4 (22 and 8,
MEP, cm H2O 66 (21) 69 (25) respectively), whereas a similar percentage of patients on
PaCO2, mm Hg1 43 (9) 46 (7)
long-term oxygen was observed in the OT+PR and PR
PaO2, mm Hg1 63 (13) 62 (7)
LTOT, n/% 32/68 15/62 groups (68 and 62%, respectively).
All the measurements recorded as nonspecific out-
1 Data recorded breathing ambient air. comes of the rehabilitation programme in the two groups
BMI = Body mass index; FEV1 = pre-bronchodilator forced expi- are shown in table 2. At T0, the PR group showed similar
ratory volume in 1 s; FVC = forced vital capacity; MIP = maximal 6MWD, D, F and B mean values as compared with
inspiratory pressure; MEP = maximal expiratory pressure; PaO2 =
arterial oxygen tension; PaCO2 = arterial carbon dioxide tension;
OT+PR group. All these outcomes similarly improved
LTOT = long-term oxygen therapy. over time in the two groups. Analysis of difference from
baseline for these variables has shown that 6MWD tended

Table 2. Time course of non-specific

outcome measures of rehabilitation OT + PR (n = 47) PR (n = 24)
programmes in the studied patients (data T0 T1 T0 T1
are as means and SD, shown in parentheses)
6MWD, m 165 (63) 233 (66)* 187 (52) 234 (65)*
End of effort-D 4.9 (2.1) 3.2 (1.6)** 5.3 (2.1) 3.4 (2.1)**
End of effort-F 6.1 (0.5) 4.5 (1.7)** 5.9 (0.8) 4.3 (0.8)**
B 4.3 (0.9) 3.0 (0.9)** 4.2 (1.0) 3.2 (0.8)**

6MWD: 6-min walking capacity; End of effort-D: Borg score for dyspnoea after walking
test; End of effort-F: Borg score for leg fatigue after walking test; B: perceived breathlessness
at the MRC scale. * p ! 0.01 versus T0; ** p ! 0.005 versus T0.

248 Respiration 2004;71:246–251 Lorenzi/Cilione/Rizzardi/Furino/

Bellantone/Lugli/Clini
to increase more in the OT+PR than in the PR group (+68
with 95%CI 0 to +185 versus +48 with 95%CI +10 to
+110 m, respectively, p = 0.049). Changes from baseline
for D (–1.7 with 95%CI 0 to –4 versus –1.9 with 95%CI 0
to –4, respectively, p = 0.152), F (–1.6 with 95%CI –1 to
–5 versus –1.6 with 95%CI –1 to –3 respectively, p =
0.293) and B (–1.3 with 95%CI 0 to –2 versus –1.1 with
95%CI 0 to –2, respectively, p = 0.201) scores were simi-
lar in the OT+PR and PR groups.
Figure 1 shows the percentage distributions across the
BADL categories before (T0) and after (T1) the rehabilita-
tion programme in the two groups. BADL categories were
similar in the two groups at baseline (17, 70, 23, 0% and
12, 75, 9, 4% for categories A–D in the OT+PR and PR
group, respectively, n.s.) and changed significantly over
time (p = 0.004) in the OT+PR but not the PR group
(fig. 1). Moreover, the analysis of differences from base-
line has also shown that BADL categories A–D changed
significantly (p = 0.011) in the OT+PR (+43, –36, –18,
and 0%, respectively) as compared with the PR (+13, –8,
–5 and 0%, respectively) group.
There were no differences in any of the studied out-
comes between patients with or without long-term oxygen
therapy of both groups.
Discussion
This study shows that OT for basic domestic activities
during comprehensive pulmonary rehabilitation specifi-
cally improves the outcome of severely disabled COPD
inpatients.
All the patients included in our study showed (as pre-
requisite) a very high degree of disability as mirrored by a
lower performance on daily living activities. The relative
effectiveness of any specific activity of a comprehensive
PR programme on physiological outcomes remains to be
definitively clarified in these patients.
The value of PR (including physical activity) in COPD
patients has been generally well established, both in out-
patients or inpatients [7–11]. Overall, patients with
COPD of different degrees of severity may benefit from
PR in terms of physical performance, symptoms and
health-related quality of life [23]. In our study, parameters
considered as nonspecific outcomes of PR improved in
patients of both groups. Only 6MWD tended to change
more in the OT+PR group (+68 with 95%CI 0 to 185 m)
than in the PR group (+48; 95%CI 10–110 m). However,
this group difference is only slightly significant and pro-
vides no consistent clinical information.
Occupational Therapy in COPD
100
T0
T1
75
50
25
0
A B C D
100
T0
T1
75
50
25
0
A B C D
Fig. 1. Percentage distribution of patients in the OT+PR (above) and
PR (below) groups across the BADL categories before (T0, dashed
bars) and after (T1, solid bars) the rehabilitation programmes. p =
0.004 on the Wilcoxon test between times for OT+PR group
(above).
OT is most commonly used in institutional and non-
institutional care of stroke patients [24] with chronic ill-
ness. Overall, OT provides self-care, upper extremity
exercise, functional mobility, and neuromuscular training
as the four most frequently used types of activities [25],
but does not address the whole spectrum of the patient’s
occupational behaviours. As a matter of fact, domestic
independence appears to be an important goal of rehabili-
tation in disabled COPD patients; nonetheless, access to
individual OT is not a standardized procedure nor do pre-
vious results provide strong evidence for the efficacy of
this intervention in those patients [9].
In our protocol, the initial assessment of disability in
activities of daily living was based on a specific tool [20]
able to establish priority of intervention in areas ensuring
daily domestic independence. As independence in domes-
tic functions is an important goal to achieve after rehabili-
tation, we were confident that a standardized scale of
Respiration 2004;71:246–251 249
activities of daily living would describe the improvement over, the pre-defined criteria for including patients into
(if any) following OT more specifically. OT are related to the presence of multiple factors describ-
The major finding in our study is that only patients of ing severe disability. Each single factor was eventually
the OT+PR group went into significantly different BADL exclusive of the others apart from the 6MWD (below the
categories after the programme. At baseline, 17% of limit of 250 m). This could be criticised. However, no cri-
patients in the OT+PR group and about 12% of patients teria to define patient’s disability and indication to OT
in the PR group had lost 1 function according to BADL. are known from the literature on pulmonary rehabilita-
After the rehabilitation, there was a significantly higher tion. Due to these important limitations, results must be
percentage of patients with only 1 function lost (category interpreted with caution.
A) in the OT+PR but not in PR group (fig. 1), thus sug- However, despite this major limitation, all the vari-
gesting a positive effect due to OT intervention. ables considered for analysis (6MWD, D, F and B) were
Loss of daily living functions has been claimed as an similar at baseline in the two groups, thus excluding a pos-
important predictor of outcome for patients with COPD sible assignment bias (i.e. a different degree of disability
and respiratory failure [26] so that improving this aspect in the two groups). Nonetheless, BADL categories were
might be considered as one important issue of rehabilita- also similarly distributed at baseline in the two groups and
tion in these patients. Nonetheless, the BADL scale is changed only in the OT+PR group after the programme,
commonly used to assess disability in elderly hospitalized thus suggesting that this result was not influenced by the
patients [27] and measure the improvement after rehabili- patients’ characteristics at inclusion. Indeed, BADL
tation [28]. seems to be more sensitive to the application of OT.
Other scales might have been suitable to assess changes From a practical point of view, the present study would
in functional status after a specific occupational interven- suggest to include specific assessment and OT interven-
tion as in our study. The Barthel Index is still considered tion in the rehabilitation strategy of severely disabled
the most important among these [29]. However, this scale COPD inpatients.
is most commonly used to assess changes after rehabilita- To conclude, the addition of OT to a standard compre-
tion in post-stroke patients [30], although it is also reliable hensive PR is able to specifically improve the outcome of
and sensitive for evaluating changes in functional status severely disabled COPD patients. The present findings
in a more heterogeneous group of severely disabled pa- may warrant a larger multicentre randomized controlled
tients undergoing comprehensive rehabilitation [31]. A trial to confirm the results.
subgroup of patients in our study (15 out of 47 and 9 out
of 24 in the OT+PR and PR groups, respectively) were
also assessed by means of the Barthel Index before and Acknowledgments
after the rehabilitation programme: the results showed
We would like thank Mrs. Gloria Penn very much for her linguis-
that, compared with the BADL, a significant score reduc-
tic revision of the manuscript.
tion was recorded only in patients who performed the
adjunctive OT programme (data not shown).
People with chronic respiratory diseases may, how-
ever, have other challenges than patients with other disa-
bilities. Therefore, two disease-specific activities of daily
living scales, the London Chest Activity of Daily Living
(LCADL) [32] and the Manchester Respiratory Activity
of Daily Living (MRADL) [33], have been recently re-
ported for use in chronic lung disease. We did not consid-
er the use of these scales for our study purpose. However,
the LCADL failed to show any improvement in the
domestic component after 6 weeks’ outpatient rehabilita-
tion not specifically designed for an occupational inter-
vention [34].
The major limitation of our study is the protocol
design which is not randomized, although it does not have
the additional bias of a historical comparison [35]. More-

250 Respiration 2004;71:246–251 Lorenzi/Cilione/Rizzardi/Furino/

Bellantone/Lugli/Clini
 References
1 World Federation of Occupational Therapists:
Web site: www.wfot2002.com.
2 Seydel E, Taal E, Wiegman O: Risk-appraisal,
outcome and self-efficacy expectancies: Cogni-
tive factors in preventive behavior related to
cancer. Psychol Health 1990;4:99–109.
3 Bandura A: Self-efficacy. The exercise of con-
trol. New York, Freeman, 1997.
4 Jones PW: Health status measurement in
chronic obstructive pulmonary disease. Thorax
2001;56:880–887.
5 Gosselink R, Troosters T, Decramer M: Pe-
ripheral muscle weakness contributes to exer-
cise limitation in COPD. Am J Respir Crit
Care Med 1996;153:976–980.
6 Bernard S, Le Blanc P, Whittom F, et al:
Peripheral muscle weakness contributes to ex-
ercise limitation in COPD. Am J Respir Crit
Care Med 1998;158:629–634.
7 ACCP/AACVPR: Pulmonary rehabilitation.
Joint ACCP/AACVPR evidence-based guide-
lines. Chest 1997;112:1363–1396.
8 American Thoracic Society: Pulmonary reha-
bilitation 1999. Am J Respir Crit Care Med
1999;159:1666–1682.
9 BTS Statement: Pulmonary rehabilitation.
Thorax 2001;56:827–834.
10 Griffiths TL, Burr ML, Campbell IA, et al:
Results at 1 year of outpatient multidisciplin-
ary pulmonary rehabilitation: A randomised
controlled trial. Lancet 2000;355:362–368.
11 Berry MJ, Rejeski WJ, Adair NE, et al: Exercise
rehabilitation and chronic obstructive pulmo-
nary disease stage. Am J Respir Crit Care Med
1999;160:1248–1253.
12 NHLBI/WHO Workshop Summary: Global
strategy for the diagnosis, management and
prevention of Chronic Obstructive Pulmonary
Disease. Am J Respir Crit Care Med 2001;163:
1256–1276. (update 2003 in www.goldcopd.
com)
13 American Thoracic Society: Statement: Guide-
lines for the six-minute walk test. Am J Respir
Crit Care Med 2002;166:111–117.
14 Borg GAV: Psychophysical basis of perceived
exertion. Med Sci Sports Exerc 1992;14:377–
381.
Occupational Therapy in COPD
15 Fletcher CM: Standardised questionnaire on
respiratory symptoms: A statement prepared
and approved by the MRC Committee on the
aetiology of chronic bronchitis (MRC breath-
lessness score). Br Med J 1960;ii:1665.
16 Rozzini R, Frisoni GB, Bianchetti A, Zanetti
O, Trabucchi M: Physical performance test and
activities of daily living scales in the assess-
ment of health in elderly people. J Am Geriatr
Soc 1993;41:1109–1113.
17 Quanjer PH: Working party on ‘Standardiza-
tion of lung function test’. Bull Eur Physiopa-
thol Respir 1983;19 (suppl 5): 7–10.
18 Black L, Hyatt R: Maximal airway pressures:
Normal values and relationship to age and sex.
Am Rev Respir Dis 1969;99:696–702.
19 Bruschi C, Cerveri I, Zoia MC, et al: Reference
values of maximal respiratory mouth pres-
sures: A population-based study. Am Rev Res-
pir Dis 1992;146:790–793.
20 Law M, Polatajko H, Pollock N, et al: Pilot test-
ing of the Canadian Occupational Performance
Measure: Clinical and measurement issues.
Can J Occup Ther 1994;61 191–197.
21 Sinclair DJM, Ingram CG: Controlled trial of
supervised exercise training in chronic bron-
chitis. Br Med J 1980;i: 519–521.
22 Simpson K, Killian K, McCartney N, et al:
Randomised controlled trial of weightlifting
exercise in patients with chronic airflow limita-
tion. Thorax 1992;47:70–75.
23 Lacasse Y, Brosseau L, Milne S, et al: Pulmo-
nary rehabilitation for chronic obstructive pul-
monary disease (Cochrane review); In Coch-
rane Library, issue 3 (Oxford: update software).
2002.
24 Rijken PM, Dekker J: Clinical experience of
rehabilitation therapists with chronic diseases:
A quantitative approach. Clin Rehabil 1998;
12:143–150.
25 Neistadt ME, Seymour SG: Treatment activity
preferences of occupational therapists in adult
physical dysfunction settings. Am J Occup
Ther 1995;49:437–443.
Respiration 2004;71:246–251
26 Seneff MG, Wagner DP, Wagner RP, et al:
Hospital and 1-year survival of patients admit-
ted to intensive care units with acute exacerba-
tion of chronic obstructive pulmonary disease.
JAMA 1995;274:1852–1857.
27 Rozzini R, Frisoni GB, Bianchetti A, et al:
Physical Performance Test and Activities of
Daily Living scales in the assessment of health
in elderly people. J Am Geriatr Soc 1993;41:
1109–1113.
28 Rozzini R, Frisoni GB, Ferrucci L, et al: Who
are the older patients failing to recover mobili-
ty after rehabilitation? J Am Geriatr Soc 1997;
45:250–252.
29 Mahoney FI, Barthel DW: Functional evalua-
tion: The Barthel Index. Md State Med J 1965;
14:61–65.
30 Van der Putten JJ, Hobart JC, Freeman JA, et
al: Measuring change in disability after inpa-
tient rehabilitation: Comparison of the respon-
siveness of the Barthel Index and the Function-
al Independence Measure. J Neurol Neurosurg
Psychiatry 1999;66:480–484.
31 Granger CV, Albrecht GL, Hamilton BB: Out-
come of comprehensive medical rehabilitation:
Measurement by PULSES profile and the Bar-
thel Index. Arch Phys Med Rehabil 1979;60:
145–154.
32 Garrod R, Bestall JC, Paul EA, et al: Develop-
ment and validation of a standardized measure
of activity of daily living in patients with severe
COPD: The London Chest Activity of Daily
Living scale (LCADL). Respir Med 2000;94:
589–596.
33 Yohannes AM, Roomi J, Winn S, et al: The
Manchester Respiratory Activities of Daily
Living questionnaire: Development, reliability,
validity, and responsiveness to pulmonary re-
habiliation. J Am Geriatr Soc 2000;48:1496–
1500.
34 Garrod R, Paul EA, Wedzicha JA: An evalua-
tion of the reliability and sensitivity of the Lon-
don Chest Activity of Daily Living Scale
(LCADL). Respir Med 2002;96:725–730.
35 Sacks H, Chalmers TC, Smith H Jr: Random-
ized versus historical controls for clinical trials.
Am J Med 1982;72:233–240.
251
Copyright: S. Karger AG, Basel 2004. Reproduced with the permission of S. Karger AG, Basel. Further
reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright
holder.