Intended for healthcare professionals

Rapid response to:

Clinical Review State of the Art Review

Advances in rehabilitation for chronic diseases: improving health outcomes and function

BMJ 2019; 365 doi: (Published 17 June 2019) Cite this as: BMJ 2019;365:l2191

Rapid Response:

Re: Advances in rehabilitation for chronic diseases: improving health outcomes and function

We read with great interest the state of the art review by Caroline R. Richardson and colleagues[1] synthesizing previous and ongoing trials in cardiac and pulmonary rehabilitation. The authors outlined the core components of cardiac and pulmonary rehabilitation, and summarized the evidence for their effectiveness in reducing the risk of adverse outcomes. Despite their clear benefit, rehabilitation programs are underutilized and it is those who are in poorer health who do not attend; these patients are likely to have the most to gain in maintaining or improving their health. To address this, the authors advocate for primary care providers to maximize the use of rehabilitation and to maintain patient communication and assessment. Furthermore, the authors rightly emphasize the need for alternative rehabilitation delivery models using eHealth strategies to maximize utilization for personal and societal benefit.

But what of rehabilitation for health problems other than cardiovascular and pulmonary diseases? With age, the probability of developing health problems other than (and in combination with) cardiovascular and pulmonary disease increases: “the diseases of old age come as a package”.[2] In consequence, we join the authors in support of implementing rehabilitation for the management of other chronic conditions. Still, we see more to be done. The multimodal nature of both cardiac and pulmonary rehabilitation (see fig 1 and fig 2 of Richardson et al.[1]) lend themselves to comprehensive management of age-related health problems. Even so, what is often seen in rehabilitation remains a model of care that treat diseases and their risk factors individually. As with acute care management, other problems of ageing are typically present and most often interact with the target conditions. In consequence, broader approaches to health conditions are required, especially with older adults.

One way to capture the overall health of an individual is to understand their level of frailty. Frailty reflects an individual’s state of vulnerability to adverse health outcomes; it can be quantified in relation to the degree of health deficit accumulation.[3] This approach takes a broader view of health than (cardiac and pulmonary) disease alone, and encompasses chronic disease, disabilities, clinically observable signs and symptoms, and biomarkers.[4] The expression of these illnesses is often greatest in those who are also socially vulnerable, which represents another important set of factors to take into account to optimize care.[5]

People living in poor health typically require higher levels of care and resources.6 Understanding their degree of frailty can inform treatment intensity, especially the need for a programmatic approach to rehabilitation to encompass a range of health and social conditions. This aligns with the authors’ suggestion to maximize rehabilitation enrollment, possibly through primary care provider support,1 where much of the information about other such challenges will be known.

At this point, whether the core components of cardiac and pulmonary rehabilitation can be modified to address frailty either through centre-based rehabilitation or using eHealth technology is motivating further inquiry.


1. Richardson CR, Franklin B, Moy ML, Jackson EA. Advances in rehabilitation for chronic diseases: improving health outcomes and function. Bmj. 2019;365:l2191.
2. Fontana L, Kennedy BK, Longo VD, Seals D, Melov S. Medical research: treat ageing. Nature. 2014;511(7510):405-407.
3. Rockwood K, Howlett SE. Age-related deficit accumulation and the diseases of ageing. Mech Ageing Dev. 2019;180:107-116.
4. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. TheScientificWorldJournal. 2001;1:323-336.
5. Andrew MK, Keefe JM. Social vulnerability from a social ecology perspective: a cohort study of older adults from the National Population Health Survey of Canada. BMC Geriatr. 2014;14:90.
6. Gilbert T, Neuburger J, Kraindler J, et al. Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study. Lancet. 2018;391(10132):1775-1782.

Competing interests: KR is President and Chief Science Officer of DGI Clinical, which in the last five years has contracts with pharma and device manufacturers (Baxter, Baxalta, Shire, Hollister, Nutricia, Roche, Otsuka) on individualized outcome measurement. In 2017 he attended an advisory board meeting with Lundbeck. Otherwise any personal fees are for invited guest lectures and academic symposia, received directly from event organizers, chiefly for presentations on frailty. He is Associate Director of the Canadian Consortium on Neurodegeneration in Aging, which is funded by the Canadian Institutes of Health Research, and with additional funding from the Alzheimer Society of Canada and several other charities, as well as, in its first phase (2013–2018), from Pfizer Canada and Sanofi Canada. DSK has no competing interests.

15 July 2019
Dustin S Kehler
Postdoctoral Research Fellow
Kenneth Rockwood
Dalhousie University
Queen Elizabeth II Health Sciences Centre - Camp Hill Veterans Memorial Building