Effect of a Rehabilitation Garden on Rehabilitation Efficacy in Elderly Patients with Chronic Obstructive Pulmonary Disease

A total number of 70 patients with COPD admitted to the Fifth People’s Hospital of Foshan, Foshan, China, from July 2018 to March 2019, were randomly divided into an observation group (n=30) and a treatment group (n=30) using the PEMS3.1 software with reference to clinical trial protocols. As well, there were no significant differences in terms of gender, age, height, weight, and duration of disease between the two groups (P>0.05) (Table I).

There was no significant difference in terms of age, gender, height, weight, and duration of disease between the two study groups (P>0.05).

The inclusion criteria (Jeckins et al., 2018) were patients: (i) in the stage II of stable COPD (i.e. moderate) as defined in the Guidelines for the Diagnosis and Treatment of COPD (2011 edition) issued by the Ministry of Health with forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)<70%, 50%≤FEV1<80% of the predicted value; (ii) who agreed to participate in the study and complete the trial; (iii) aged between 60 and 70 years; and (iv) with stable COPD for more than four weeks and no history of smoking, and hospitalized for the first time. This study was approved by the ethics committee of the cited hospital and all the subjects also signed an informed consent.

The exclusion criteria (Schultz et al., 2018) were patients: (i) with respiratory diseases other than COPD, (ii) with other cardiopulmonary diseases, (iii) with severe organ dysfunction or malignant tumors, (iv) with other disorders causing walking difficulty, and (v) with no ability to perform the study-related tests for any reasons.

A stable COPD medication-assisted treatment plan was designed based on the established guidelines for the observation group. The patients were thus asked to perform indoor function training for pulmonary rehabilitation including: (i) aerobic exercise i.e. indoor cycling ergometry (medium speed, rest for 1 min after every 4 min of exercise, 15 min/day); (ii) breathing exercises, namely, abdominal breathing exercise, pursed lip breathing, chest breathing exercise, and relaxation shoulder strap exercise repeated 10 times with each exercise; and (iii) cough training and resistance breath training for 15 min/day.

The patients in the treatment group also carried out the following outdoor rehabilitation training in the rehabilitation garden under the guidance of therapists: (i) outdoor-assisted walking training, namely, the patients performed walking training along a circular path with stainless steel handrails and plants on both sides (Fig. 1A). The training distance was 500 m per training and was done twice daily; (ii) unassisted walking training i.e. the patients performed walking training barefooted on a cobblestone path with an uneven surface (Fig. 1B). The training distance was 250 m per training and the exercise was performed twice daily; (iii) outdoor stair training, that is, the patients went up and down stairs on a 5-step stair with handrails on both sides (Fig. 1C). The training time was 10 min and the exercise was performed twice daily; and (iv) horizontal bar training, namely, the patients performed horizontal bar training in the rehabilitation garden with the help of therapists (Fig. 1D) including horizontal ladder movements, pull-ups, overhanging chest-expanding, and left-lifting (according to their abilities). The training time was 15 min, and the exercise was performed twice daily. The therapeutic effects were consequently observed after four weeks.

The exercise capacity was assessed using the 6-minute walk test (6MWT) (Yan et al., 2019) and the pulmonary function test (PFT) was conducted via a spirometer (Kadiri et al., 2017) which included measurements of the forced vital capacity (FVC) as well as the forced expiratory volume in 1 second (FEV1) and one second rate (FEV1/FVC). Symptom assessment was also performed through the Medical Research Council (MRC) Dyspnea Scale (Moore et al., 2016). Moreover, psychological state was assessed using the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A) (Kawagoshi et al., 2015). A comprehensive assessment was further made through BODE index, comprised of body mass index (B), airflow obstruction (O), dyspnea (D), and exercise (E) variables (Huang et al., 2019).

All the data were processed using the IBM SPSS Statistic software (version 21.0). The measurement data were also expressed as mean±standard deviation (SD). Comparison between normally distributed groups was correspondingly carried out by independent sample t-test and within-group comparisons were performed through paired t-test. The Wilcoxon rank-sum test was additionally utilized whenever normal distribution was not satisfied or equal variance was not assumed. Consequently, the Chi-square test was employed for the count data and the significance level was set by 0.05.

The inter-group comparison showed no significant differences in the 6MWT, the FVC, the FEV1, the FEV1/FVC, the MRC Dyspnea Scale, the HAM-D, the HAM-A, and the BODE comprehensive index before treatment (P>0.05). However, the intra-group comparison demonstrated significant differences in the 6MWT, the FEV1, the FEV1/FVC, the MRC Dyspnea Scale, the HAM-D, the HAM-A, and the BODE comprehensive index after treatment (P<0.05) although no significant difference was observed in the FVC (P>0.05). The inter-group comparison similarly revealed a statistical significance in the 6MWT, the FEV1/FVC, the HAM-D, the HAM-A, and the BODE comprehensive index after treatment (P<0.05), with no significant differences in the FVC, the FEV1, and the MRC Dyspnea Scale (P>0.05) (Table II).

The results of this study indicated that both groups of elderly patients with COPD had experienced some degrees of improvement in exercise capacity, lung function, dyspnea, depression and anxiety, and the BODE comprehensive index after treatment. The functional improvement of the patients in the treatment group with additional rehabilitation training in a garden setting was also more significant compared with that in the observation group, with statistical differences in the 6MWT, the FEV1/FVC, the HAM-D, the HAM-A, and the BODE index between the groups (P<0.05). It has been argued that, psychological states such as anxiety, depression, and lack of self-confidence may amplify patients’ feelings of painful dyspnea, raise their awareness of the problem, and prevent them from excessive activities during the process of clinical rehabilitation training. Studies had also reported that as the levels of anxiety had increased, patients had become more sensitive to discomfort. Moreover, as some patients with COPD had experienced pain and dyspnea, anxiety and panic developed because of that had led to more anxiety, limiting their physical activity even further (Im et al., 2018; Carbone et al., 2015).

A rehabilitation garden has a good plant landscape and a humanized rehabilitation environment. The research team thus designed the rehabilitation facilities and constructed the landscape nodes, types of spaces, and the composition of the landscape elements of the outdoor gardens in this rehabilitation garden. The rehabilitation garden was accordingly designed to meet the needs of rehabilitation training, while accommodating the physiological and psychological needs of elderly patients with COPD. The circular path, cobblestone path, five-step stair, rehabilitation horizontal bar, and other facilities were additionally designed and applied specifically to the rehabilitation of the patients suffering from COPD (Choi et al., 2016; Wen et al., 2019).

Comparison of each index between two study groups before treatment, P>0.05; intra-group comparisons in each index after treatment, *P<0.05, #P>0.05; and inter-group comparisons in each index after treatment, ∆P<0.05, ▲P>0.05.

FVC, forced vital capacity; FEV, forced expiratory volume; 6MWT, 6-minute walk test; HAM-D, Hamilton Depression Rating Scale; HAM-A, Hamilton Anxiety Rating Scale; BODE, Body-Mass Index, Airflow Obstruction-Dyspnea-and Exercise

The exercise capacity of knee joints, lung function, dyspnea, depression and anxiety, and the BODE comprehensive index also showed good levels of improvement after targeted outdoor rehabilitation training in the rehabilitation garden. One possible reason for the results is that rehabilitation training performed in the comfortable natural environment of the rehabilitation garden could reduce patients’ fears and anxiety regarding their disease, thus stimulating their interest in rehabilitation training, increasing patience, compliance, and initiative, and building optimism for disease recovery. Active participation in garden training activities had been similarly reported to augment rehabilitation amount and time, and subsequently raise generalized comprehensive exercise variables and strengthen respiratory function (Lai et al., 2017; Theodorakopoulou et al., 2017).

In summary, the functional training conducted outdoors in the rehabilitation garden designed for elderly patients with stable COPD alleviated the symptoms of COPD in the patients in the stable stage, increased exercise capacity, improved respiratory muscle function, reduced symptoms of depression and anxiety, enhanced rehabilitation, and augmented quality of life. Therefore, it is an effective method assisting sports rehabilitation and is worthy of clinical applications. The small sample size was, however, one limitation of this study. Comparison with other sports rehabilitation methods, use of indices associated with acute exacerbation, number of hospital admissions, and hospitalization days should be also included in future studies to track the long-term rehabilitation effects of outdoor rehabilitation for patients suffering from stable COPD.

The study was funded by the National Key R&D Program of China (2018YFC2002300) and the 13th Five-Year Key Specialty Construction Project of Foshan (No. FSZDZK135033).

The authors declare no conflict of interest.