1. Sexauer, William MD
  2. Crawford, Albert PhD
  3. Watson, Marcia DO

Article Content

The severe acute respiratory syndrome coronavirus 2 pandemic (COVID-19) caused major disruptions of many aspects of the health care system, including rehabilitation services.1,2 The pulmonary rehabilitation (PR) program at Thomas Jefferson University, a hospital-based outpatient program, had services abruptly interrupted on March 12, 2020. At the time, 13 patients were actively participating in PR. The PR program at Thomas Jefferson resumed 16 wk later, with pandemic-related restrictions that: (1) all patients would be screened for COVID-19 symptoms prior to reentry; (2) appropriate social distancing would be maintained while patients were actively engaged in the program, including exercise; and (3) patients wear face masks while exercising.


When the 13 patients were contacted to resume PR, only eight chose to return to the program. This study examines the clinical characteristics and attitudes of those choosing to resume PR (RES) versus those who elected not to resume (DIS). We hypothesized that those patients who elected not to resume would have more severe disease and/or higher COVID-19-related anxiety.



Demographic and clinical data were collected from the medical record on all patients from the time of their initial PR evaluation, as follows: age, sex, pulmonary diagnosis, home oxygen use (yes or no), and cardiac and psychiatric comorbidities collected from the electronic medical record problem list. Admission pulmonary function studies were collected: forced vital capacity (FVC) % predicted, forced expiratory volume in 1 sec (FEV1) % predicted, and FEV1/FVC. Results of standard program admission evaluations were assessed: 6-min walk test, chronic obstructive pulmonary disease assessment test, University of California San Diego Shortness of Breath Questionnaire, and Patient Health Questionnaire-9.


A six-question survey was administered to all patients (see the Supplemental Digital Content, available at: The RES patients completed this at the time of their first return visit. The DIS patients had the survey administered by mail; all five completed and returned the survey. No patient declined to participate. This study was approved by the Institutional Review Board at Thomas Jefferson (Control #20E.740). All patients provided verbal consent.



For the entire group, mean age was 66.6 +/- 11.6 yr. Ten carried a diagnosis of chronic obstructive pulmonary disease, two of interstitial lung disease, and one of asthma. Six of 13 were male, seven had home oxygen. The group means for FVC % predicted, FEV1 % predicted, and FEV1/FVC were 76.0 +/- 22.1, 45.8 +/- 24.8, and 44.8 +/- 17.3, respectively.


The Table shows comparison between the two groups. There was no statistically significant difference between any demographic or clinical variable examined, although the DIS group tended to be younger, had worse pulmonary function, and worse symptom scores than the RES group.

Table Characteristic... - Click to enlarge in new windowTable Characteristics of Patients Who Resumed and Did Not Resume PRa

Survey results indicated that all but one patient (in the RES group) had been wearing a face mask when leaving home during the pandemic. There was no difference between the groups in responses to questions about if dyspnea ratings and overall anxiety levels differed currently compared with when PR was discontinued. However, for the question "How has mask wearing with activities of daily living affected your breathing?" half the patients in the RES group indicated it had no effect, while all five patients in the DIS group indicated that it made their breathing worse.


When patients in the RES group were asked "Are you anxious about returning to pulmonary rehabilitation?" half indicated they were not anxious at all, one indicated they were "a little" anxious, one was "moderately" anxious, and two were "extremely" anxious. When patients in the DIS group were asked "Is your decision to not resume pulmonary rehabilitation related to anxiety about the pandemic?" all five indicated that "Yes, it is the main reason" they did not re-enroll.



It is well known that PR is greatly underutilized by the patient population that would benefit from participation, for a variety of reasons: lack of PR availability or proximity, inadequate PR reimbursement, cost (to institution and/or patient), lack of caregiver and/or patient awareness of PR and its benefits, lack of transportation to and from sessions, and insufficient motivation in some patients.3,4 The COVID-19 pandemic caused an unprecedented interruption of PR services for patients who had already overcome these obstacles. Some programs transitioned to remote PR during the pandemic utilizing telemedicine in a variety of program structures.5 In our program, which reopened as a hospital-based outpatient program with COVID-19-related safety precautions, 38% of patients chose not to resume at the time of reopening.


We hypothesized that anxiety related to the health threat posed by COVID-19 was a likely cause of this subset of patients declining to re-enroll in the program. Since that health risk would be greatest in patients with more severe lung disease, greater comorbidities, or older age, we postulated there may be a relationship between these factors and a patient decision to decline participation. We found no statistically significant difference in any demographic or clinical parameters between those who chose to re-enroll and those who did not.


Our survey results suggest that anxiety likely did play a role in patient decision-making, with 100% of patients in the DIS group indicating that COVID-19-related anxiety was the main reason for not resuming, while 50% of patients in the RES group indicated that they were not anxious at all. It is also possible that the sensation of dyspnea related to mask wearing,6 which was mandated to re-enroll in the program, may have contributed to that anxiety. All patients in the DIS group indicated that mask wearing worsened their sensation of dyspnea, whereas 50% of RES patients indicated it had no effect.


The major limitation of this study is the small number of patients, based on a one-moment-in-time convenience sample at a single institution. The small number of subjects may have obscured differences that could have become evident in a larger sample. In addition, anxiety was assessed subjectively in a semi-quantitative manner. The survey instrument utilized was rapidly and specifically developed for this study; the very short period between the decision to resume PR and the first return visit for the RES group did not permit extensive study or validation of the tool. Available validated generic tools for measuring anxiety did not appear appropriate, and specific tools for measuring anxiety related to COVID-19 were not yet published at the time this study was completed.7,8


William Sexauer, MD


Division of Pulmonary, Allergy, and Critical Care Medicine,


Department of Medicine, Jane and Leonard Korman


Respiratory Institute, Thomas Jefferson University,


Philadelphia, Pennsylvania


Albert Crawford, PhD


Jefferson College of Population Health, Thomas Jefferson


University, Philadelphia, Pennsylvania


Marcia Watson, DO


Division of Pulmonary, Allergy, and Critical Care


Medicine, Department of Medicine, Jane and Leonard


Korman Respiratory Institute, Thomas Jefferson University,


Philadelphia, Pennsylvania




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