Gender difference in coping strategies among patients enrolled in an inpatient rehabilitation program

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1 Gender difference in coping strategies among patients enrolled in an inpatient rehabilitation program Grégory Ninot, PhD, a Marina Fortes, PhD, a Magali Poulain, PhD, b Audrey Brun, Psychologist, b Jacques Desplan, MD, b Christian Préfaut, MD, Professor, c and Alain Varray, PhD, Professor, d Montpellier and Osseja, France BACKGROUND: Previous research has not addressed gender differences in coping strategies among patients with mild to moderate chronic obstructive pulmonary disease (COPD) who are enrolled in inpatient and multidisciplinary rehabilitation programs. METHODS: The coping strategies of 182 consecutive patients (61 women aged 61.1 years; 121 men aged 62.7 years) with mild to moderate COPD were assessed on admission and then at discharge after 29 days of pulmonary rehabilitation, using the Coping Inventory for Stressful Situations. A one-way analysis of variance for repeated measures was used to test the differences in coping scores. RESULTS: During the rehabilitation program, problem-focused strategies increased ( 2.54 [95% confidence interval: ] with F 23.77, P.0001), emotion-focused strategies decreased ( 2.75 [95% confidence interval: 4.06, 1.45], F 15.37, P.001), and avoidance strategies were differently (t 2.97, P.05) influenced in women ( 2.43 [95% confidence interval: ]) compared with men ( 1.30 [95% confidence interval: ]). The prevalence of COPD in women is increasing, and rehabilitation professionals need a greater awareness of how women cope differently than men with this disease. (Heart Lung 2006;35: ) The increasing prevalence of chronic obstructive pulmonary disease (COPD) worldwide, particularly in women, places an increasing burden on public health services, 1 as well as on the patients families 2 One means of managing this problem has been to create individualized exercisetraining programs to improve pulmonary function, exercise tolerance, and dyspnea. 2 Today s multidisciplinary rehabilitation programs also try to improve quality of life 2,3 and decrease reliance on health services. 2,4 Pulmonary rehabilitation is an accepted From the a Laboratory Symbolic Process for Health and Sport, University of Montpellier I, Montpellier, France; b Clinique du Souffle La Solane, Osséja, France; c Laboratory Physiology of Interactions, Faculty of Medicine, University of Montpellier I, Montpellier, France; d Laboratory Motor Efficiency and Deficiency, University of Montpellier I, Montpellier, France. Reprint requests: Grégory Ninot, JE 2416, Laboratory Symbolic Process for Health and Sport, University of Montpellier I, 700 avenue du Pic St-Loup Montpellier, France /$ see front matter Copyright 2006 by Mosby, Inc. doi: /j.hrtlng therapeutic intervention that has been shown to result in important benefits in health self-management. A particular aim of the rehabilitation program is to educate patients about self-management of COPD. 2,4 The way patients cope with COPD greatly influences physical health, psychologic well-being, and life expectancy. 5 Coping is a constantly changing cognitive and behavioral effort to manage specific external and/or internal demands 6 to enhance well-being 7 Three coping strategies are generally distinguished. 8 The problem-focused strategies, which are characterized as being active and expressive and by positive thinking, result in significantly higher levels of functioning, as well as more positive scores on clinical measures of disease and higher levels of psychologic well-being. 6 Emotion-focused coping is a passive strategy; nothing is done to reduce the threat itself. 8,9 Examples of passive strategies are responding to situations with anxiety, anger, wishful thinking, or helplessness. Avoidance-focused coping is a 130 MARCH/APRIL 2006 HEART & LUNG

2 Ninot et al Gender difference in coping strategies defensive reappraisal or behavior. 8 Examples of defensive strategies are responding with avoidance or distraction. The pulmonary and physiologic impairments of COPD are accompanied by psychologic disturbances such as depression, anxiety, and coping difficulties. 2,9,10,11 Patients with COPD have been found to rely most heavily on emotion-focused coping, 12,13 avoidance-focused coping, 14 or both. 15 Anxieties caused by the unpredictability of symptom exacerbation (especially dyspnea) activate emotion-focused strategies. 11 Avoidancecoping characterizes those patients who attempt to be less influenced by symptoms and tends to preserve the activities of daily living. 16 Avoidance strategies also characterize patients with COPD who try both to calculate and plan every movement with minimal effort and to stay away from stressful situations. 11 One study using the Freiburg Coping Questionnaire showed that reliance on problem-focused coping strategies increased over a period of inpatient rehabilitation. 17 Moreover, patients with COPD who participated in a systematic exercise program used fewer emotion-focused coping strategies than did nonexercisers. 14 A study, however, showed no significant difference in coping scores between admission and discharge after inpatient rehabilitation with a nonvalidated version of the Asthma Coping Questionnaire. 18 The steep increase of COPD in women compared with men could be changing the general way we understand the psychosocial consequences of COPD, and thus the work of physicians, behavioral scientists, and other health care personnel. A qualitative study indicated that women with COPD used emotion-focused strategies more often than men. 13 According to Western stereotypes, 6 women can more easily express emotional and irrational reactions (crying, expecting help, hoping for a miracle), and men must remain stoic and in control (never expressing emotion, showing rational, and constructive thinking). No studies were found that used quantitative measures of coping strategies in a large sample distinguishing women and men with COPD. The question of which patients show greater improvement in coping strategies after pulmonary rehabilitation remains to a large extent unanswered. 2,18 During a rehabilitation program, it is important to make patients with COPD aware of the risks associated with chronic stress exposure and help them to develop adaptive responses. We explored the influence of gender on the coping styles of patients with COPD over the rehabilitation period. METHODS Participants Patients with COPD entered the study on admission to the inpatient pulmonary rehabilitation center. Criteria for inclusion were diagnosis of COPD according to American Thoracic Society guidelines, 2 age between 40 and 80 years, and ability to read in French. A patient was defined as having stable disease if he or she had had no change in symptoms or medication for 2 months before entry. 2 A total of 182 patients with mild to moderate COPD, 61 women and 121 men, took part in this study. Nineteen males and 9 females presented with a comorbidity criterion of obesity. The participants represented all parts the country equally. They were for the most part long-time smokers (75%), and most were not working (60%) because of long-term disease or retirement. In regard to marital status, 67% were married or living together and 29% were single, separated, widowed, or divorced. Patients were excluded if they were oxygen-dependent or if they had any pharmacologically treated psychiatric disorder or major illness that would affect psychologic or physiologic function. No difference between groups (women vs men) was found for age, body mass index, forced expiratory volume in 1 second (FEV 1 ), and FEV 1 /forced vital capacity (measured the day after admission). Descriptive data on the participants are shown in Table I. Study design The descriptive study included consecutive patients admitted to an inpatient rehabilitation program between August and December During the first medical visit in the rehabilitation center, participants completed the coping questionnaire. After completion of testing, participants began a facility-based 4-week program of rehabilitation based on individualized exercise. 19 Before discharge, the participants completed the same coping questionnaire. The protocol was approved by the institutional review board, and all patients gave informed written consent to participate. No patients refused to participate in the study. Rehabilitation program The patients participated in the 4-week rehabilitation program in small groups of 8 to 10 (including men and women) who met 5 days per week (20 sessions) in HEART & LUNG VOL. 35, NO

3 Gender difference in coping strategies Ninot et al Table I Baseline characteristics of participants with mild to moderate COPD Women (n 61) Men (n 121) t test P Chi-square Age (y) Weight (kg) Height (cm) Body mass index FEV 1 (% predicted) FEV 1 /FVC (%) Mild/moderate (n/n) 34/27 63/58 NS Single/marital status (n/n) 40/21 82/39 NS NS, Not significant; FEV 1, forced expiratory volume in 1 second; FEV 1 /FVC, ratio of forced expiratory volume in 1 second to forced vital capacity. Values are mean SD. P indicates whether the difference between the two groups were significant (independent tests). a rehabilitation center in France following a typical pulmonary rehabilitation program reported in randomized controlled trials. 2 The program included the following: (1) individualized exercise training (4 hours/ day), (2) respiratory therapy with aerosol and/or drainage if necessary (1 hour/day), (3) health education (2 hours/week) with information on pulmonary disease, medications, and healthful daily living strategies, (4) psychosocial support (discussion group 1 hour/week), and (5) dietary monitoring (1 hour/week). The training included cycling, mountain walking, general exercises (strength training, breathing exercise, team sports, circuit training, swimming moderate effort), and relaxation. The cycling component consisted of 45 minutes on a cycle ergometer with three successive pedaling periods of 10 minutes separated by 5 minutes of active recovery. The intensity of work was individualized for each patient with COPD and was determined by the heart rate corresponding to the ventilatory threshold assessed throughout an incremental test. 20 After cycling, patients stretched for 10 minutes and then had 30 minutes of relaxation. The second component was 2 hours of nature walking with 45 minutes at ventilatory threshold intensity and 75 minutes at lower walking speed. Cycling, general exercises, and relaxation were done in the same half-day, and walking was done in the other half-day. The goal was to ensure that all patients could perform the exercise program components without experiencing more than mild pain and without significant dyspnea. Program compliance was thus very high (of 182 patients, only 5 with bronchial infection stopped for 1 week). The group dynamic, active pedagogical approach, and adapted environment all had a major impact on individual motivation. Coping strategies assessment Originally, Endler and Parker 21 developed the Multidimensional Coping Inventory; then on the basis of a series of factor analyses, they further revised this measure and renamed it the Coping Inventory for Stressful Situations (CISS). 8,22 The CISS is a 48-item measure composed of three scales assessing problem-focused behaviors, emotion-focused behaviors, and avoidance strategies, which are three of the most-robust dimensions identified in the general coping literature. 23 Endler and Parker 24 reported that the CISS has a stable factor structure, excellent internal consistency, and adequate test retest reliability, and they provided support for its construct validity. The CISS, validated in French, 25 is a Likert-type scale that identifies behaviors as ranging from 1 for never to 5 for very often. The coping strategies are grouped into three 16-item subscale measures. The problem-focused strategies describe task-oriented efforts to resolve a problem, restructure a task, or modify a situation. The emotion-focused strategies describe ego-oriented efforts to decrease stress with emotional reactions (culpability, fear, anger, or tension), personal preoccupations, or daydreaming. The avoidance strategies include activity and cognitive modifications to avoid stressful situations (distractions, social diversion). The total scores on each scale indicate individual response rate. Moreover, the results are presented as relative scores with subscale scores indicating the percentage (or proportion) of each strategy used MARCH/APRIL 2006 HEART & LUNG

4 Ninot et al Gender difference in coping strategies Table II Measures of coping strategies at admission to and discharge from in patient rehabilitation in the two groups of participants with mild to moderate COPD Domain Time Women Men P value Problemfocused Emotionfocused Avoidance strategies Admission Discharge Difference 4.13 (1.84, 6.42) 1.74 (.49, 2.98).047 (t 1.99) P value.001 (t 3.60).007 (t 2.75) Admission Discharge Difference 2.75 ( 5.41,.97) 2.75 ( 4.22, 1.29).997 (t.001) P value.042 (t 2.07).001 (t 3.72) Admission Discharge Difference 2.43 (.66, 4.19) 1.30 ( 2.82,.22).034 (t 2.97) P value.008 (t 2.75).094 (t 1.69) Values are mean SD. The different values are absolute differences from admission to discharge and include 95% confidence intervals. P indicates whether the difference from admission to discharge was significant (post-hoc Scheffe tests) in the Time column. P value column indicates whether the differences between the two groups were significant (independent test). Increases in problem-focused coping are indicative of improved use of active strategies fo cope with stressful situations. Decreases in emotion-focused coping are indicative of limited use of passive strategies. Increases in avoidance strategies are indicative of intention and behavior to keep away from stressful situations. Decrease in avoidance strategies are indicative of motivation and behavior to struggle with stressful situations. Statistical analyses Internal consistency reliability was assessed for each scale using Cronbach s alpha. To test the factor structure, the data were also submitted to principal components factor analysis with varimax rotation. This factor analysis is important to determine that scales are capable of measuring independent constructs. The Shapiro-Wilk W test showed the normal distribution of the coping scores. A one-way analysis of variance (ANOVA) for repeated measures was used to test the differences in coping scores (group, time, and/or interaction). When the test revealed a significant difference, the Scheffé test was used to display the significant variations prominently. Significance was set at the.05 level for all analyses. RESULTS Overall scale scores returned internal consistency reliabilities using Cronbach s alpha. The alpha coefficients for the present study were.90,.83, and.85, respectively. The principal components factor analysis with varimax rotation showed excellent coefficients for each dimension (problem-focused:.46.74; emotion-focused:.42.75; avoidance strategies:.41.74), which explained 39.9% of the variance. The questionnaire measures independent and consistent dimensions. For the problem-focused coping scores (Table II), the one-way ANOVA for repeated measures showed an increase between admission and discharge (F[1,180] 23.77, P.0001). Women with COPD showed an increase in the use of this strategy after the rehabilitation period (P.05). Compared with men, women used this coping style less regularly (F[1,180] 14.22, P.0003) at the two periods (P.05). Nevertheless, the increase in the men s use of this strategy was significantly lower compared with that of the women (P.05). For the emotion-focused coping scores (Table II), the one-way ANOVA for repeated measures showed significant differences for time indicating an overall decrease of this coping style between admission and discharge (F[1,180] 15.37, P.001) and for gender (F[1,180] 11.90, P.001). The independent t test showed significantly lower scores for men compared with women (P.05). For the avoidance scores (Table II), the one-way ANOVA for repeated measures showed significant differences for interaction between gender and time (F[1,180] 8.84, P.004). The analysis of interaction showed that women with COPD showed an HEART & LUNG VOL. 35, NO

5 Gender difference in coping strategies Ninot et al increased use of avoidance between admission and discharge (P.05). In contrast, no significant differences were shown for the men, although a trend toward decrease was noted. The change in the use of this strategy was significantly different between the men and women (P.05). DISCUSSION The aim of the study was to explore coping strategies among males and females with mild to moderate COPD in an inpatient rehabilitation program. The results showed a difference between men and women with mild to moderate COPD regarding coping strategies. Compared with the men, the women used fewer problem-focused strategies and more emotion-focused strategies. This gender difference regarding coping strategies could be explained by findings that women generally show higher anxiety than men, 26,27 especially regarding dyspnea, and less knowledge of disease-management techniques 15 and/or by conformism to Western stereotypes about masculine and feminine behaviors. 6 The women with COPD coped with their disease in ways that were more deleterious, because an emotional coping style can amplify the consequences of COPD. Coping in a very emotional way is not favorable for a feeling of wellbeing. 16 Classic emotion-focused coping includes anger toward self or others. This strategy can be related to depression and emotional dysfunction. 28 Moreover, avoidance strategies increased over the rehabilitation session in these women. The decrease in emotion-focused coping may thus have been compensated by increased reliance on avoidance strategies, indicating a motivation to be less influenced by disease symptoms in daily life. The men, on the other hand, wanted to more actively control the outcome of the disease. They refused to accept limitations on their capacities for physical and sexual performance or losses in social and family position. 29 This investigation thus provides practical information for physicians, behavioral scientists, and other health care personnel on how men and women with COPD differ in the ways they cope with their disease. This information will help rehabilitation professionals and patients work toward common goals based on the patients coping style rather than make decisions solely on the basis of pulmonary function and exercise tolerance. During the health education sessions, the men requested information on disease functioning, the specific skills needed to control symptoms like dyspnea, and the steps to take to prevent exacerbations like infection. Conversely, the women needed to express their emotions and exchange feelings about the disease and its consequences in their lives. For women, psychosocial group sessions emphasizing dialogue, the expression of feelings, and the exchange of behavioral solutions would be more appropriate. In a large number of patients, the results showed an increased reliance on problem-focused coping strategies and a decrease in emotion-focused coping strategies between admission and discharge. Men and women made equal improvements in terms of emotion-focused coping. These results, which respectively support two qualitative studies 17,14 can indicate that the inpatient rehabilitation program based on individualized and methodical exercise over a 4-week period fostered positive adjustment in the coping style of patients with COPD. However, randomized controlled trials are needed to determine whether such coping styles are the result of the program or of other factors in patients lives. Problem-focused coping is an active attempt to reduce threat either by eliminating the problem or by changing its meaning. Desensitization to dyspnea with reduction in fear and anxiety as a result of repeated exercise has been suggested as a possible mechanism for this change. 2,3,30 Reduction in anxiety or distress associated with dyspnea could result in global decrease of the frame of reference from which the patient perceives the symptom. This would be analogous to desensitization training for phobias in which repeated exposure to a graded stimulus over time in a safe environment gradually lessens fear and anxiety associated with the stimulus. 31 Although the COPD itself is uncontrollable, patients rediscover their own abilities to tolerate exercise and thus decrease emotion-focused coping strategies linked to the fear of dyspnea. 12,14,16 Moreover, the health education sessions included in the rehabilitation program helped patients to understand their disease better and cope with stressors more effectively. The social support of other participants with COPD in small groups 32 and the encouragement of rehabilitation professionals further encouraged attempts to reduce emotional reactions and choose adaptive behaviors. Therefore, this may facilitate postrehabilitation exercise and ultimately reduce avoidance of feared (unsafe) situations. Both may be important in maintaining physical fitness and general well-being in patients with COPD. Taking into account that the coping scale is a significant predictor of hospitalization for COPD, 33 the 134 MARCH/APRIL 2006 HEART & LUNG

6 Ninot et al Gender difference in coping strategies improvement of patients capabilities to cope with their COPD could potentially prevent major anxiety events. Nevertheless, the results showed that men and women made opposite changes regarding avoidance strategies: The men decreased and the women increased their reliance on this coping style. Avoidance strategies, which restrain anxiety and other extreme emotions, can reduce the incidences of dyspnea and increase functional performance. Rehabilitation professionals need to pay particular attention to this coping style during the program and should be ready to offer specific advice before discharge regarding both its usefulness and its dangers. Men may have the desire to provoke dyspnea in an ultimately self-defeating attempt to struggle against stimuli and surpass their limits. This means of coping reflects the persistence of both denial (which is very frequent during the first period of the disease) and self-destructive behaviors, and it contradicts the goals of rehabilitation, which are to promote self-management and improve the quality of life and autonomy of individuals with chronic disease (COPD). In the long term, the adherence to health care recommendations can be arbitrary, sporadic, and finally unfavorable. In contrast, the women developed a better ability during the program to recognize symptom-provoking situations in advance and then choosing to stay away from them. This classic coping style (avoidance and catastrophic withdrawal) is used more by patients with COPD than by patients with any other chronic illness. 10,34 Although it is useful in the short term, professionals need to determine whether this style of functioning will increase over time (especially after several rehabilitation sessions). If women develop an overreliance on avoidance, they risk becoming more vulnerable to unpredictable events and more dependent on external conditions (drugs, health professionals, the safety of staying at home). Overall, rehabilitation professionals have to detect coping failure based on maladaptive physical responses (common physical signs and symptoms of stress) and/or observable indictors of inadequate stress coping skills (irritability, fear, anger, anxiety, and depression). For a comprehensive assessment, a battery of questionnaires, a structured interview, and an interview with the spouse or family will be useful to obtain more detailed information about the coping ability of the individual in stress. Without a randomized controlled clinical trial design, the benefits of the rehabilitation program in coping strategies cannot be concluded in this study. Other factors may have contributed to improvement in coping styles. Further randomized controlled clinical trials are needed to confirm this hypothesis. CONCLUSION Our study described relationships between a program of intensive inpatient rehabilitation session and coping styles in patients with mild to moderate COPD. The results suggest that a program improves the use of problem-focused strategies, decreases reliance on emotion-focused strategies, and influences the use of avoidance strategies differently in men and women. Randomized controlled trials are needed to confirm these changes, which were probably the result of rehabilitation programs. The results suggest that inpatient pulmonary rehabilitation programs can promote the use of more appropriate coping strategies that the patient with COPD can then incorporate into his or her lifestyle. More studies are needed to determine whether these coping strategies lead to healthier behaviors. Longitudinal investigations will be useful to determine the stability of new healthy behaviors and their cost-effectiveness. 35 REFERENCES 1. Rutten-van-Molken MP, Postma MJ, Joore MA, Van Genugten ML, Leid R, Jager JC. Current and future medical cost of asthma and chronic obstructive pulmonary disease in the Netherlands. Respir Med 1999;93: American Thoracic Society. Pulmonary rehabilitation. Am J Respir Crit Care Med 1999;159: Lacasse Y, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996;26: Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, et al. Results at 1 year of oupatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000;335: Maes S, Leventhal H, De Ridder DT. Coping with chronic diseases. In: Zeiner M, Endler NS, eds. Handbook of coping. New York: Wiley; pp Lazarus RS, Folkman S. Stress, appraisal and coping. 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7 Gender difference in coping strategies Ninot et al 11. McSweeny AJ, Grant I, Heaton RK, Adams KM, Timms RM. Life quality of patients with chronic obstructive pulmonary disease. Arch Intern Med 1982;142: Narsavage GL, Weaver TE. Physiologic status, coping, and hardiness as predictors of outcomes in chronic obstructive pulmonary disease. Nurs Res 1994;43: Unger, DG, Jacobs SB. Couples and chronic obstructive airway diseases: the role of gender in coping and depression. Women Health 1995;1: Gift A, Austin D. The effects of a program of systematic movement on COPD patients. Rehabil Nurs 1992;136: Small S, Lamb M. Fatigue in chronic illness: the experience of individuals with chronic obstructive pulmonary disease and with asthma. J Adv Nurs 1999;30: Ketelaars CA, Schlösser MA, Mostert R, Abu-Saad HH, Halfens RJ, Wouters EF. Determinants of health related quality of life in patients with COPD. Thorax 1996;51: Buchi S, Villiger B, Sensky T, Schwarz F, Wolf C, Buddeberg C. Psychosocial predictors of long-term success of in-patient pulmonary rehabilitation of patients with COPD. Eur Respir J 1997;10: Ketelaars CA, Abu-Saad HH, Schlösser MA;Mostert R, Wouters EF. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest 1997;112: Vallet G, Ahmaidi S, Serres I, Fabre C, Bourgoin D, Desplan J, et al. Comparison of two training programs in chronic airway limitation patients: standardized and individualized method. Eur Respir J 1997;10: Préfaut C, Varray A, Vallar G. Pathophysiological basis of exercise training in patients with chronic obstructive lung disease. Eur Respir J 1995;5: Endler NS, Parker JD. The assessment of coping: The Multidimensional Coping Inventory. Toronto: York University; Endler NS, Parker JD. Assessment of multidimensional coping: task, emotions, and avoidance strategies. Psychol Assessment 1994;6: McWilliams LA, Cox BJ, Enns MW. Use of the Coping Inventory for Stressful Situations in a clinically depressed sample: factor structure, personality correlates, and prediction of distress. J Clin Psychol 2003;59: Endler NS, Parker JD. Coping Inventory for Stressful Situations (CISS): manual. Toronto: Multi-Health Systems; Rolland JP. Inventaire de coping pour situations stressantes. Paris: Editions du Centre de Psychologie Appliquée; Leidy NK, Traver GA. Psychophysiologic factors contributing to functional performance in people with COPD: are there gender differences? Res Nurs Health 1995;18: Gurney-Smith B, Cooper MJ, Wallace LM. Anxiety and panic in chronic obstructive pulmonary disease: the role of catastrophic thoughts. Cognit Ther Res 2002;26: Curtis JR, Deyo RA, Hudson LD. Health-related quality of life among patients with chronic obstructive pulmonary disease. Thorax 1994;49: Dudley DI, Glaser EM, Jorgenson BN, Logan DL. Psychosocial concomitants to rehabilitation in chronic obstructive pulmonary disease. Part. I, Psychosocial and psychological considerations. Chest 1980;77: Carrieri-Kohlman V, Gormley JM, Douglas MK, Paul SM, Stulbarg MS. Exercise training decreases dyspnea and the distress and anxiety associated with it. Chest 1996;110: Williams SL. Guided mastery treatment of agoraphobia: beyond stimulus exposure. Prog Behav Modif 1990;26: Worth H, Dhein Y. Does patient education modify behaviour in the management of COPD? Patient Educ Couns 2004;52: Fan VS, Curtis JR, Tu SP, McDonell MB, Fihn SD. Using quality of life to predict hospitalization and mortality in patients with obstructive lung diseases. Chest 2002;122: Wempe JB, Wijkstra PJ. The influence of rehabilitation on behaviour modification in COPD. Patient Educ Couns 2004; 52: Goldstein RS, Gort EH, Guyatt GH, Feeny D. Economic analysis of respiratory rehabilitation. Chest 1997;112: MARCH/APRIL 2006 HEART & LUNG

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