Global trends and research hotspots in pulmonary rehabilitation for chronic obstructive pulmonary disease: a bibliometric analysis (2011–2024)

Introduction

Chronic obstructive pulmonary disease (COPD) is a heterogeneous pulmonary disorder that is marked by persistent respiratory symptoms, including dyspnea, cough, sputum production, and exacerbations. These symptoms result from airway abnormalities (such as bronchitis and bronchiolitis) and/or alveolar destruction (emphysema), and they lead to sustained and progressive airflow obstruction (1). COPD is currently the fourth leading cause of death worldwide and ranks eighth in terms of global economic burden, thus representing a significant public health challenge (2). Current pharmacological treatments for COPD include bronchodilators and inhaled corticosteroids (ICSs). Although effective, these treatments are associated with adverse effects; for example, Beta-Agonists significantly increase the risk of acute exacerbations in severe and very severe COPD (3), while prolonged ICS use raises the likelihood of the patient developing type 2 diabetes, cataracts, pneumonia, osteoporosis, and non-traumatic fractures (4). Further, acute exacerbations of COPD constitute one of the most critical mortality risks for affected patients (5). Preventing acute exacerbations of COPD is crucial to reduce hospitalization rates, lower mortality, and improve patients’ quality of life. Pulmonary rehabilitation (PR) is a key component of non-pharmacological treatment for COPD, as it offers an individualized treatment program based on a thorough patient assessment. PR encompasses several key components: patient evaluation, program design, implementation strategies, and quality assurance measures (6). Effective implementation of PR has been shown to alleviate symptoms, enhance exercise capacity, and improve the quality of life across all stages of COPD severity while also reducing both direct and indirect healthcare costs. Current clinical guidelines strongly recommend PR for all patients with stable COPD and those within four weeks of an exacerbation-related hospital discharge, and advise choosing either supervised maintenance programs or standard long-term exercise after initial rehab, according to individual needs (7).

Since its inception as an independent academic discipline in 1969, bibliometrics has been extensively employed to quantitatively analyze scientific literature (8,9) in order to reveal knowledge structures, collaborative networks, research hotspots, and development trends within specific fields (10). However, to date, no comprehensive bibliometric analysis of COPD PR has been conducted; thus, our understanding of the current state of the research field is incomplete. Accordingly, this study applied widely recognized bibliometric tools, namely, VOSviewer and CiteSpace, to conduct a visualization analysis of COPD PR literature from the Web of Science Core Collection (WoSCC), with the aim of providing reliable insights and evidence-based guidance for future in-depth research. We present this article in accordance with the BIBLIO reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-942/rc).

Methods

Data sources and search strategy

This study utilized the WoSCC as the data source as illustrated in Figure 1. The search strategy incorporated the following topic terms: (“pulmonary rehabilitation” OR “pulmonary recovery” OR “respiratory rehabilitation” OR “lung rehabilitation” OR “pulmonary rehabilitation therapy” OR “pulmonary rehabilitation training” OR “pulmonary rehabilitation program”) AND TS = (“COAD” OR “COPD” OR “Chronic Obstructive Lung Disease” OR “Chronic Airflow Obstruction” OR “Chronic Obstructive Airway Disease” OR “Chronic Obstructive Pulmonary Disease”), ensuring comprehensive coverage of the COPD PR domain. The search period spanned from the inception of the database to December 31, 2024.

Figure 1 Flowchart for bibliometric analysis. COAD, chronic obstructive airway disease; COPD, chronic obstructive pulmonary disease; WOSCC, Web of Science Core Collection.

Inclusion and exclusion criteria

Figure 1 shows an overview of the inclusion and exclusion criteria employed in this study. Inclusion criteria included: pertinence to COPD PR, article or review as the document type, and English language. Exclusion criteria included: duplicate publications, conference abstracts, newspaper articles, retracted papers, and studies irrelevant to the research focus.

Data analysis

As depicted in Figure 1, this study utilized a suite of bibliometric tools, including VOSviewer 1.6.2, CiteSpace 6.4.R1, Scimago Graphica, and Microsoft Excel 2019, to facilitate data analysis and visualization. VOSviewer 1.6.2 was used to construct network and overlay visualizations of contributing countries, institutions, journals, authors, and keywords within the field. CiteSpace 6.4.R1 facilitated keyword and reference clustering, as well as the generation of journal dual-map overlays. Scimago Graphica was applied to generate geographic visualizations depicting national collaboration networks. Microsoft Excel 2019 was used to produce line charts visualizing annual publication trends.

Results

Search results

A total of 2,536 English-language articles were initially retrieved from the WoSCC, with 2,132 articles ultimately included. These articles were authored by 8,369 individuals affiliated with 3,040 institutions across 78 countries. They were published in 384 journals and collectively cited 41,646 references from 9,451 source journals.

Annual publication trends

The earliest identified literature in the field of COPD rehabilitation was published in 2011; however, this may not represent the actual inception of research in this domain. As illustrated in Figure 2, the annual number of publications on COPD PR exhibited a sustained upward trajectory from 2011 to 2024, reflecting increasing scholarly interest in the field. Specifically, the period from 2011 to 2014 was one of steady growth. During this period, the number of publications increased steadily, reaching a peak of 158 articles in 2014—a 63% increase compared to that in 2011. This surge may be attributed to the inclusion of PR in the 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which heightened global attention to non-pharmacological interventions. However, the subsequent decline to 123 articles in 2015 underscores the volatility commonly observed in emerging research fields during their formative stages. The period from 2016 to 2022 marked a phase of accelerated growth, with the number of publications following a fluctuating upward trajectory and peaking at 205 articles in 2022, representing a 73.8% increase over 7 years. This growth phase was likely driven by advancements in telemedicine after 2016, innovations in wearable devices for rehabilitation monitoring (11), and the compounding effect of global population aging, which has increased the COPD disease burden (12). The years 2023 and 2024 reflected a plateau phase, with publication output slightly decreasing to 188 in 2023 before rebounding to 200 in 2024, potentially influenced by the post-coronavirus disease 2019 (COVID-19) reallocation of research resources. Notably, the average annual publication counts after 2020 (188 articles) exceeded the preceding decade’s average (135 articles) by 39%, thus highlighting the field’s growing prominence within respiratory rehabilitation research. The current volume of publications remains near the highest levels observed over the past decade, as it reflects both the maturation of scholarly interest and the imperative for clinical translation.

Figure 2 Annual publication trend analysis.

Country distribution

Table 1 presents the top 15 countries ranked by publication volume in this research field. Figure 3 shows a visualization of country contributions, in which node size reflects the number of articles published by every country, with larger nodes indicating greater publication volumes. The thickness of connecting lines indicates the intensity of international collaboration between countries. As illustrated in Figure 3A, the top five countries in COPD PR research were England (320 articles), the United States (292 articles), Australia (263 articles), Canada, and China. The field exhibited a distinct core-periphery structure, with England, the United States, and Australia forming a core knowledge production triangle accounting for 41.0% of global publications. Their citation impact per article (England: 32.1, the United States: 29.0) significantly exceeded the global average of 18.6. Figure 3B reveals China’s exponential growth in publication volume since 2020; yet, its citation impact (12.1 per article) has remained comparatively low, highlighting the imbalance between quantitative expansion and qualitative development in emerging research nations. The geographic visualization shown in Figure 3C further underscores Europe’s dominant position, with nine European countries ranking among the top 15 in publication output and demonstrating dense collaborative networks.

Figure 3 Country analysis. (A) Global country cooperation network diagram. (B) Global country cooperation time series diagram. (C) Distribution diagram of the world’s top 15 publication-producing countries.

Institutional distribution

A total of 3,040 institutions contributed to research on COPD PR, with 36 institutions publishing over 20 articles each. The top 10 institutions by publication volume are listed in Table 2. The three leading institutions in terms of publication volume were Maastricht University, the University of Toronto, and the University of Sydney, while La Trobe University, Alfred Health, and the University of Melbourne topped the list in total citation count. Balancing publication volume and citation impact, La Trobe University (63 articles, 38.78 citations per article) and Alfred Health (58 articles, 37.48 citations per article) emerged as highly cited benchmarks, while high-output institutions such as the University of Sydney (75 articles, 17.72 citations per article) exhibited an imbalance between quantity and quality. Figure 4A illustrates strong collaborative networks among the Institute for Breathing and Sleep, La Trobe University, Alfred Health, and the University of Melbourne. Mapping institutions to their respective countries revealed that collaborations have predominantly occurred domestically, with limited international partnerships. Australia dominated the top 10 rankings, contributing six institutions and 384 publications, underscoring its regional leadership in this field. Figure 4B shows that Monash University, despite being a relatively recent entrant, has demonstrated robust research output and growing academic influence, positioning it as an emerging leader in this field. Notably, institutions from developing countries are entirely absent from the top 10 rankings, emphasizing the need to enhance research infrastructure in emerging nations and promote balanced global development in this domain.

Figure 4 Analysis of research organizations. (A) Research organization cooperation network diagram. (B) Research organization cooperation time series diagram.

Author analysis

A total of 8,369 authors has contributed to research in the field of COPD PR. Analysis using VOSviewer identified Spruit as the most prolific author in the field. According to Lotka’s Law (13), the threshold M was approximately 7, indicating that authors with seven or more publications qualified as core contributors. A total of 192 core authors were identified, with the top 10 listed in Table 3. Authors with at least 15 publications were visualized and clustered into seven distinct groups (Figure 5). As illustrated in Figure 5A, among the top 10 core authors, Spruit, Franssen, Wouters, and Janssen have maintained close collaborative relationships. Figure 5B shows that Cox, a relatively recent entrant, has exhibited rapidly growing academic influence, surpassing Spruit in citation impact per article, thereby demonstrating considerable potential in the field.

Figure 5 Analysis of research authors and co-cited authors. (A) Research author collaboration network diagram. (B) Research author collaboration time series diagram.

Journals and co-cited journals

Research on COPD PR spans 384 journals, which play a vital role in disseminating knowledge in this field. Table 4 presents the top 15 journals by publication volume. The leading journal, the International Journal of Chronic Obstructive Pulmonary Disease, has published the highest number of articles [185], solidifying its status as the “flagship journal” in this field, likely due to its specialized focus and open-access model. Respiratory Medicine (109 articles) and Chronic Respiratory Disease (92 articles) follow as key platforms for disseminating research findings. A long-tail distribution is evident beyond the top three journals, indicating dominance by a select few yet broad interdisciplinary engagement across the remainder. Figure 6A illustrates five distinct journal clusters in COPD PR, each exhibiting leadership and representative influence. High-impact journal cluster (blue): exemplified by Thorax, journals in this cluster uphold high academic standards through rigorous manuscript selection and peer-review processes. Although their publication volumes are relatively low, they exhibit high citation rates per article, indicating strong research quality and innovativeness. Disease-specific journal cluster (green): represented by the International Journal of Chronic Obstructive Pulmonary Disease, this cluster is characterized by high publication output and total citation counts, largely attributed to its open-access model and clearly defined target readership. However, the citation rate per article is moderate, suggesting that while these journals focus extensively on COPD and its related subfields, the overall citation efficiency is comparatively lower. Rehabilitation medicine interdisciplinary cluster (red): represented by the Journal of Cardiopulmonary Rehabilitation, this cluster bridges cardiopulmonary rehabilitation and COPD research, highlighting its interdisciplinary nature. Although the number of COPD-related publications is moderate, this cluster exerts considerable influence within its respective domain. Open-access cluster (purple): exemplified by BMC Pulmonary Medicine, journals in this cluster facilitate the rapid dissemination of research findings through open-access publishing. While this model enhances the accessibility of articles, it is associated with relatively lower average citation rates, possibly due to trade-offs in perceived impact or journal prestige. Basic-clinical dual-driven cluster (yellow): represented by Respirology, this cluster encompasses journals that span the continuum from basic to clinical research in respiratory diseases. These journals provide essential theoretical support for diagnosis and treatment. Within the context of COPD PR, their focus includes lung function, inflammatory mechanisms, and evaluations of rehabilitation efficacy. Figure 6B highlights the rapid rise in prominence of the International Journal of Chronic Obstructive Pulmonary Disease. Additionally, a notable increase in the number of publications in recent years reflects the growing prominence of COPD PR as a sustained research hotspot. To elucidate patterns of academic interaction, a dual-map overlay (Figure 6C) was generated to illustrate citation trajectories between citing and cited journals. Two major citation trajectories emerged, namely, (I) molecular/biological/genetic → medical/clinical (z=2.294, f=30,324) and (II) health/nursing/medicine → medical/clinical (z=7.949, f=97,071). The convergence of these trajectories underscores the interdependence between basic scientific research and clinical practice in advancing COPD PR.

Figure 6 Journal analysis. (A) Journal cooperation network diagram. (B) Journal cooperation time series diagram. (C) Journal dual-map overlay.

Keyword analysis

Keywords serve as concise summaries of research themes, providing insight into the core topics of articles. Table 5 lists the top 20 keywords, with the top 10 being “COPD” [1,161], “pulmonary rehabilitation” [994], “chronic obstructive pulmonary disease” [631], “rehabilitation” [499], “exercise” [487], “disease” [426], “obstructive pulmonary-disease” [401], “quality-of-life” [334], “dyspnea” [266], and “physical-activity” [231]. Each of these keywords appeared over 200 times, underscoring their prominence in the literature. Visualization of keywords (Figure 7A) revealed five thematic clusters. After excluding search-related terms, dominant keywords included “systemic inflammation”, “sarcopenia”, “telerehabilitation”, “anxiety”, and “physical exercise”. A total of 2,124 keywords were classified into 15 distinct clusters using CiteSpace (Figure 7B). Analyzing these clusters, we summarized them using the following three themes: basic physiological mechanisms (e.g., #0 lung function, #2 muscle strength, and #12 dynamic hyperinflation), disease management and evaluation (e.g., #8 pulmonary disease, #13 lung cancer, #11 acute exacerbation, #4 noninvasive techniques, and #5 exercise tolerance), and intervention studies (e.g., #6 rehabilitation medicine, #14 intervention, #9 exercise training, #10 manual training, and psychological dimensions like #7 anxiety). Notably, Cluster #1, labeled “people”, emerged as a cross-cutting theme, indicating population-specific research orientations. Cluster analysis revealed that Cluster #3 (“physical activity”) and Cluster #6 (“rehabilitation medicine”) formed the largest clusters, suggesting a strong research emphasis on exercise–rehabilitation synergies. Network linkages among clusters—particularly between exercise-related themes (#3, #5, and #9) and disease management (#8, #11, and #13)—emphasize the central role of physical activity in respiratory disease care. The timeline analysis (Figure 7C) shows a shift from foundational research (e.g., lung function and pulmonary diseases) toward integrated approaches that incorporate exercise, rehabilitation, and psychological factors. This evolution is driven by clinical demands, interdisciplinary innovations, and methodological advancements. Emerging themes such as COPD exacerbations, COPD-lung cancer comorbidity, electrical stimulation, and manual therapy signal future research directions. Keyword burst analysis (Figure 7D) shows an evolution of research hotspots; early focus areas (2011–2014) such as basic care, pharmacotherapy, and rehabilitation planning have shifted toward telerehabilitation, chronic disease management, and implementation strategies in recent years (2022–2024) while maintaining continuous attention to quality of life and clinical trials.

Figure 7 Keyword analysis. (A) Keyword co-occurrence network diagram. (B) Keyword clustering diagram. (C) Keyword clustering time evolution diagram. (D) Keyword burst diagram.

References

We conducted a detailed analysis of the top 20 most cited references in the field of COPD PR (Table 6). All of these documents have been cited over 150 times, with the highest citation count reaching 814, highlighting their significant academic influence. Published between 1999 and 2016, these highly cited references comprise foundational studies and influential theoretical or methodological contributions that continue to shape the field. These references are published in authoritative journals such as the American Journal of Respiratory and Critical Care Medicine, the Cochrane Database of Systematic Reviews, and the European Respiratory Journal. They encompass official statements, clinical guidelines, systematic reviews, and original research studies, comprehensively reflecting research priorities, thematic trends, and developmental milestones, thereby offering critical insights for future research and clinical practice. Reference cluster analysis identified 17 thematic clusters (Figure 8A). Based on their topics and logical links, we further categorized these 17 clusters into eight groups: medical devices and assistive tools: #0 walking aid; health assessment tools: #4 to-stand test and #8 clinical COPD questionnaire; patient populations: #2 elderly patients, #3 Medicare beneficiaries, #6 chronic respiratory disease, and #7 stable chronic; disease management and interventions: #10 self-management intervention, #11 disease-specific fear, #12 complex management, and #13 Dutch model; physical function and rehabilitation: #5 skeletal muscle wasting, #14 physical function, #15 in-hospital PR, and #16 whole-body vibration training; physical activity and training: #1 physical activity; research methodologies: #9 qualitative study; and clinical efficacy: #17 clinical efficacy.

Figure 8 Literature co-citation analysis. (A) Clustering diagram of co-cited documents. (B) Time evolution diagram of clustering of co-cited documents. (C) Co-cited documents burst diagram.

Timeline analysis revealed that early themes (Figure 8B), such as Cluster #0 (walking aid) and Cluster #1 (physical activity), initially appeared in foundational research and have remained persistent focal areas. Emerging clusters, such as Cluster #11 (disease-specific fear), #12 (complex management), #13 (Dutch model), #14 (physical function), #15 (in-hospital PR), #16 (whole-body vibration training), and #17 (clinical efficacy), highlight recent research expansions and evolving thematic priorities. To identify the most influential citation bursts in COPD PR, CiteSpace was used to analyze the top 25 articles with the strongest citation bursts (Figure 8C). Matching DOIs and titles revealed the top three citation bursts: Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary, which interprets updated guidelines with new sections on management of COPD exacerbations; Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease, a systematic review comparing PR with conventional care, which demonstrated superior outcomes in health-related quality of life, functional exercise capacity, and maximal exercise capacity; and Defining Modern Pulmonary Rehabilitation: An Official American Thoracic Society Workshop Report, which highlighted the efficacy of PR for patients with chronic lung diseases and addressed issues of global underutilization, emphasizing innovations such as telerehabilitation and low-cost, home-based programs to enhance accessibility. It is readily apparent that this is fully consistent with GOLD 2023/2024 guidelines.

Discussion

Global research output and trend

Over the past two decades, COPD PR has experienced substantial advancements. This study analyzed 2,132 articles authored by 8,369 researchers affiliated with 3,040 institutions across 78 countries. England leads in publication volume, while Spain holds the highest number of citations per article among the top-ranking countries. Australia dominates institutional contributions, hosting six of the top 10 publishing institutions with strong collaborative networks. Notably, developing nations show limited output, with only China (5th in volume) and Brazil ranking in the top 15. In contrast, developing countries made limited contributions: only China and Brazil ranked among the top 15 in publication volume. Notably, China, despite being the fifth most prolific nation, recorded the lowest citation impact per article within this group, this may be due to limited international collaboration.

Technological advancements in telerehabilitation

Burst detection analysis of keywords further highlighted the prominent rise of telemedicine-related research in recent years. Studies have demonstrated the feasibility and effectiveness of delivering PR education through YouTube video platforms (14) and interactive 3D visualization technologies (15). The rapid development of telerehabilitation platforms—including smartphone/video conferencing systems (16), mHealth applications (17,18), myCOPD digital tools (19), and various mobile healthcare solutions (20,21)—has significantly improved patient adherence and enabled the implementation of more personalized rehabilitation programs. Besides, Cox’s research further highlighted comparable efficacy between home-based, primary care, and hospital-based PR for COPD patients (22), including during episodes of acute exacerbation (23). These findings suggest that telerehabilitation is both adaptable across various healthcare settings (24) and cost-effective (25); however, further economic evaluations and implementation studies are needed to assess its effectiveness in COPD PR (26).

Personalized and multidisciplinary PR approaches

Researchers spruit and Cox have played pivotal roles in advancing PR, their evolving work illustrates that the field is moving toward personalized, multidisciplinary approaches. Spruit—a pioneer in the field—has authored the highest number of publications, while Cox, a later entrant, holds the highest citation impact per article. A review of their academic work revealed that Spruit’s early research focused on exercise training, a foundational theme in COPD PR. Recent studies by spruit emphasize personalized rehabilitation programs (27), the development of core outcome sets (28), patient education tailored to individual needs (29,30), and the implementation of multidisciplinary rehabilitation frameworks (24). Cox’s research, initiated in the post-COVID-19 era (31), centers on telerehabilitation and referral pathways within PR programs. Concurrently, timeline analysis of reference clusters revealed a strong association between Cluster #2 (elderly patients) and Cluster #3 (Medicare beneficiaries), likely attributable to the predominant representation of elderly populations in Medicare coverage systems (32,33). This finding highlights the critical importance of considering Medicare policy frameworks and coverage dimensions when investigating healthcare interventions for elderly populations. Furthermore, a detailed examination of Cluster #13 (the Dutch model) elucidated its core principle as a patient-centered approach that achieves a seamless transition from acute care to long-term management through multidisciplinary collaboration and integration of community resources (34-36). The Dutch model provides valuable insights for future development trajectories in PR. Studies have shown that low physical activity levels in COPD patients represent an increasingly significant challenge (37). Exercise training has been demonstrated to enhance exercise capacity, muscle strength, and physical fitness in COPD patients by reducing Th17-mediated inflammatory responses and augmenting Treg cell-mediated immunosuppressive activity (38), whereas impaired ventilatory efficiency during exercise leads to exertional dyspnea (39). Comparative analysis suggests that high-intensity interval training (HIIT) may be more suitable for COPD patients than high-intensity continuous training (HICT) and moderate-intensity continuous training (MICT), as it induces less exertional dyspnea (40). Neuromuscular electrical stimulation (NMES) effectively addresses exercise reluctance caused by dyspnea in COPD patients (41), demonstrating significant improvements in maximal inspiratory pressure, maximal expiratory pressure, tidal volume, and decannulation success rate among mechanically ventilated patients (42). Furthermore, the combination of NMES with respiratory muscle training (RMT) significantly enhances pulmonary function, oxygenation capacity, and carbon dioxide elimination in COPD patients (43).

COPD comorbidities and psychological factor

COPD comorbidities, characterized by diagnostic complexities due to overlapping clinical factors, constitute a critical determinant of risk in COPD patients (44,45). Timeline analysis of keyword evolution indicated that research on COPD combined with musculoskeletal diseases, anxiety, and lung cancer is relatively mature. COPD patients can experience impaired body balance due to musculoskeletal problems (46,47). Targeted PR interventions have demonstrated efficacy in improving balance capacity (48), with low-intensity core training enhancing central nervous system–mediated muscle coordination and high-intensity regimens strengthening core muscle groups (49). Anxiety is recognized as one of the most prevalent psychiatric comorbidities among COPD patients (50), presenting considerable challenges for intervention (51). Preliminary evidence suggests that adjunctive therapies such as music therapy may alleviate anxiety symptoms, though these findings require further validation (52). Notably, although timeline visualizations suggest a decline in anxiety-related research since 2020, detailed analyses indicate ongoing investigations, with current classification algorithms erroneously categorizing such studies under manual therapy domains. The COPD-lung cancer comorbidity increases the symptomatic burden (53). Preoperative PR has been shown to improve recovery outcomes and clinical efficacy (54), while postoperative rehabilitation programs similarly exhibit favorable prognostic benefits (55). Moreover, integrated cardiopulmonary rehabilitation programs have been increasingly proposed for COPD patients with cardiovascular comorbidities (56). The emergence of Baduanjin within rehabilitation medicine timelines (Cluster #6) signifies growing interest in the application of traditional Chinese Qigong practices (57). Contemporary research suggests that Qigong may facilitate PR in COPD patients by modulating pulmonary function, immune regulation, and neural adaptation mechanisms (58-60).

Addressing global research inequities

Contributions from developing countries remain underrepresented, yet they offer critical insights for context-specific PR. For instance, Belloumi (61) demonstrated the feasibility of a home-based PR program in Tunisia, highlighting the need for scalable, resource-appropriate interventions to address global disparities. Future efforts should prioritize adaptable models for underrepresented regions.

In conclusion, the future development of PR should prioritize telerehabilitation and the implementation of personalized rehabilitation protocols. Key research directions include advancing research on the efficacy of telerehabilitation modalities in COPD management by integrating economic evaluations and implementation science to assess their contextual adaptability and cost-effectiveness across diverse healthcare systems; tailoring PR programs to individual patients by accounting for characteristics such as age, gender, disease severity, and comorbidities, in order to improve rehabilitation outcomes; conducting mechanistic studies on the therapeutic effects of PR for COPD comorbidities (e.g., musculoskeletal disorders, anxiety, lung cancer, and cardiovascular diseases), with an emphasis on personalized intervention design, and substantiating the anxiolytic effects of music-assisted rehabilitation and novel psychotherapeutic interventions; standardizing outcome measures and PR assessment methods to improve the accuracy of rehabilitation effectiveness evaluations, monitor disease progression effectively, and provide a basis for adjusting rehabilitation programs; elucidating the mechanistic superiority of HIIT compared with MICT in terms of enhancing exercise capacity and applicability in clinical settings; combining NMES with RMT to better improve pulmonary function, oxygenation capacity, and other indicators in COPD patients and to determine the best application methods and treatment durations; deciphering the mechanisms and effects of Qigong (such as Baduanjin) in COPD PR and its integration with conventional methods to enrich rehabilitation approaches; and promoting the Dutch model, which emphasizes patient-centered care and facilitates seamless transitions from the acute phase to long-term management through multidisciplinary teamwork and community resource integration. In addition, multidisciplinary collaboration models and resource integration strategies tailored to the specific needs of different regions should be explored. Moreover, current research has yet to clarify how different COPD phenotypes (e.g., chronic bronchitis vs. emphysema), disease severity (GOLD stages), or comorbidities (e.g., heart failure, lung cancer) affect PR outcomes; future studies should explore this area.

Implementation barriers and cultural considerations

While telerehabilitation and personalized rehabilitation protocols represent promising frontiers in COPD management, their widespread implementation faces significant practical barriers that must be systematically addressed. Moreover, the effectiveness of such interventions may vary across cultural contexts, necessitating deliberate adaptation and rigorous validation.

The transition to remote rehabilitation models is hindered by several key challenges. Technological barriers include limited digital literacy among older adults, inadequate access to reliable internet connectivity, and unfamiliarity with digital devices—a phenomenon commonly referred to as the “digital divide” (62). Economic constraints also play a critical role; the costs associated with telehealth equipment, software subscriptions, and data plans may be prohibitive for patients in low-resource settings or those with limited financial means. Additionally, clinical concerns—such as ensuring patient safety during unsupervised exercise, verifying adherence, and accurately assessing outcomes remotely—remain substantial hurdles. These issues demand innovative solutions and robust validation to ensure both safety and efficacy.

The success of personalized rehabilitation also depends on cultural acceptability. For instance, mind-body interventions such as Baduanjin or Qigong—which have emerged as areas of interest in our bibliometric analysis—are rooted in traditional Chinese medicine and may not be readily embraced by Western populations due to differing health beliefs, practices, and terminologies. Consequently, directly transferring such interventions without cultural modification may limit their uptake and effectiveness. Future studies should incorporate principles of cultural adaptation, which may involve modifying intervention materials, delivery methods, and explanatory frameworks to align with local values and norms. This process must be followed by rigorous efficacy testing within the target cultural context to ensure both relevance and impact.

In light of these considerations, future research should move beyond technological innovation to embrace implementation science and mixed-methods approaches that identify and address contextual barriers. Such efforts will ensure that advances in PR are both equitable and sustainable, reaching diverse patient populations across varying healthcare systems and cultural settings.

Limitations

This study has several limitations. First, some relevant literature was excluded due to language restrictions, time constraints, and limited database access, which may have affected the comprehensiveness and accuracy of the results. Second, the research results were primarily derived from bibliometrics-based machine algorithms, with only a portion of the data manually verified and summarized. Third, citation counts are subject to the effects of factors such as time accumulation, field size, and journal reputation. It is important to note that a high citation count does not necessarily equate to high research quality or innovation; it may simply reflect the popularity of certain research topics. Fourth, the potential underrepresentation of non-English or regional journals in WoSCC. Fifth, the influence of self-citations or citation cartels on author and institutional rankings (for example, Spruit’s prolific output).

Conclusions

Through bibliometric analysis, we systematically examined the research trends and hotspots in the field of COPD PR from 2011 to 2024. Using tools such as VOSviewer, CiteSpace, Scimago Graphica, and Microsoft Excel 2019, we constructed co-citation networks, collaborative networks, and cluster analyses to identify the core literature, research hotspots, and knowledge flow in this field. Australia holds the greatest influence in this domain, with leading institutions such as La Trobe University and Alfred Health producing numerous high-quality research publications. Spruit was identified as the most prolific author, whereas Cox leads in citation impact per publication. The International Journal of Chronic Obstructive Pulmonary Disease ranks first in publication volume on this topic. Looking ahead, the field is poised to embrace a more integrated research approach, combining insights from multiple domains, perspectives, and evaluation metrics. Traditional research focal points, such as pulmonary function, exercise endurance, and manual therapy, will continue to be refined. Meanwhile, emerging research trends, including telemedicine, personalized rehabilitation programs, and traditional Chinese Qigong practices like Baduanjin are expected to gain prominence. These innovations hold the potential to significantly enhance the effectiveness and accessibility of COPD PR, ultimately improving the quality of life for patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the BIBLIO reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-942/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-942/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-942/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2025 report). [2024-11-12]. Available online: https://goldcopd.org/2025-gold-report/#
2. The Global Health Observatory. Global health estimates: life expectancy and leading causes of death and disability. [2024-08-07]. Available online: https://www.who.int/data/gho/data/themes/theme-details/GHO/mortality-and-global-health-estimates
3. Ruzieh M, Baugh AD, Al Jebbawi L, et al. Beta-blocker use in patients with chronic obstructive pulmonary disease: A systematic review: A systematic review of βB in COPD. Trends Cardiovasc Med 2023;33:53-61. [Crossref] [PubMed]
4. Pace WD, Callen E, Gaona-Villarreal G, et al. Adverse Outcomes Associated With Inhaled Corticosteroid Use in Individuals With Chronic Obstructive Pulmonary Disease. Ann Fam Med 2025;23:127-35. [Crossref] [PubMed]
5. Qian Y, Cai C, Sun M, et al. Analyses of Factors Associated with Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Review. Int J Chron Obstruct Pulmon Dis 2023;18:2707-23. [Crossref] [PubMed]
6. Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2021;18:e12-29. [Crossref] [PubMed]
7. Rochester CL, Alison JA, Carlin B, et al. Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2023;208:e7-26. [Crossref] [PubMed]
8. Pritchard A. Statistical bibliography or bibliometrics. Journal of documentation 1969;25:348-9.
9. Mayr P, Scharnhorst A. Scientometrics and information retrieval: weak-links revitalized. Scientometrics 2015;102:2193-9.
10. Ma F, Xi M. Status and trends of bibliometric. Journal of Information Science 1992;13:7-17.
11. Wu CT, Li GH, Huang CT, et al. Acute Exacerbation of a Chronic Obstructive Pulmonary Disease Prediction System Using Wearable Device Data, Machine Learning, and Deep Learning: Development and Cohort Study. JMIR Mhealth Uhealth 2021;9:e22591. [Crossref] [PubMed]
12. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024;403:2100-32. [Crossref] [PubMed]
13. Lotka AJ. The frequency distribution of scientific productivity. Journal of the Washington academy of sciences 1926;16:317-23.
14. Choudhary OA, Dhawan J, Sohrabipour S, et al. Assessment of online YouTube videos as a source of information and instruction for pulmonary rehabilitation. Respir Med 2025;238:107968. [Crossref] [PubMed]
15. Sönnerfors P, Nordlin AK, Nykvist M, et al. Interactive 3D visualisation technique used in pulmonary rehabilitation in chronic obstructive pulmonary disease: A randomised controlled study evaluating quality of life, compliance and use of health care. Digit Health 2025;11:20552076241308940. [Crossref] [PubMed]
16. Ellis J, Gilworth G, Morgan T, et al. Delivery of Remote Pulmonary Rehabilitation: COVID-19 Service Evaluation in England. Int J Chron Obstruct Pulmon Dis 2025;20:533-8. [Crossref] [PubMed]
17. Ghaben SJ, Mat Ludin AF, Mohamad Ali N, et al. User-centred design of ChestCare: mHealth app for pulmonary rehabilitation for patients with COPD; a mixed-methods sequential approach. Digit Health 2025;11:20552076241307476. [Crossref] [PubMed]
18. Dale MT, Wootton SL, Alison J, et al. Development and evaluation of text messages designed for people with COPD on the mobile pulmonary rehabilitation (m-PR™) platform. Physiotherapy 2025;127:101455. [Crossref] [PubMed]
19. Davies H, Chappell M, Wang Y, et al. myCOPD App for Managing Chronic Obstructive Pulmonary Disease: A NICE Medical Technology Guidance for a Digital Health Technology. Appl Health Econ Health Policy 2023;21:689-700. [Crossref] [PubMed]
20. Rutherford H, Dale M, Wootton S, et al. Experiences of Home-Based Pulmonary Rehabilitation With mHealth and Centre-Based Pulmonary Rehabilitation in People With Chronic Obstructive Pulmonary Disease: A Qualitative Study. Health Expect 2025;28:e70181. [Crossref] [PubMed]
21. Sánchez-Romero EA, García-Barredo-Restegui T, Martínez-Rolando L, et al. Addressing post-COVID-19 musculoskeletal symptoms through pulmonary rehabilitation with an evidence-based eHealth education tool: Preliminary results from a pilot randomized controlled clinical trial. Medicine (Baltimore) 2025;104:e41583. [Crossref] [PubMed]
22. Dal Corso S, Holland AE, George J, et al. Fidelity of a home-based pulmonary rehabilitation program in people with COPD referred from primary care. Chron Respir Dis 2024;21:14799731241307247. [Crossref] [PubMed]
23. Burge AT, Cox NS, Ponnudurai A, et al. Incidence of acute exacerbations of chronic respiratory disease during pulmonary rehabilitation delivered at home or hospital. ERJ Open Res 2025;11:00209-2024. [Crossref] [PubMed]
24. Cox NS, McDonald C, Burge AT, et al. Comparison of Clinically Meaningful Improvements After Center-Based and Home-Based Telerehabilitation in People With COPD. Chest 2025;167:1003-11. [Crossref] [PubMed]
25. Burge AT, Cox NS, Holland AE, et al. Telerehabilitation Compared to Center-based Pulmonary Rehabilitation for People with Chronic Respiratory Disease: Economic Analysis of a Randomized, Controlled Clinical Trial. Ann Am Thorac Soc 2024;22:47-53. [Crossref] [PubMed]
26. Cox NS, Khor YH. Telerehabilitation in pulmonary diseases. Curr Opin Pulm Med 2023;29:313-21. [Crossref] [PubMed]
27. Machado A, Burtin C, Spruit MA. Alternative Modes of Delivery in Pulmonary Rehabilitation: A Critical Appraisal of the Literature. J Cardiopulm Rehabil Prev 2024;44:399-408. [Crossref] [PubMed]
28. Souto-Miranda S, Saraiva I, Spruit MA, et al. Core outcome set for pulmonary rehabilitation of patients with COPD: results of a modified Delphi survey. Thorax 2023;78:1240-7. [Crossref] [PubMed]
29. Muijsenberg AJ, Houben-Wilke S, Tatousek J, et al. Educational needs of people with COPD or asthma entering pulmonary rehabilitation and their significant others: A cross-sectional study. Chron Respir Dis 2025;22:14799731251316891. [Crossref] [PubMed]
30. Mendes MA, Rodrigues G, Janssen DJA, et al. Understanding the Determinants and Outcomes of Education in Pulmonary Rehabilitation: Moving Toward Person-Centered Care. Chest 2025;167:1615-27. [Crossref] [PubMed]
31. Cox NS, Bondarenko J, Chong M, et al. Rapid real-world implementation of pulmonary telerehabilitation: good fortune or COVID-19 luck? ERJ Open Res 2024;10:00820-2023. [Crossref] [PubMed]
32. Trefzer T, Brüggemann S, Weinbrenner S, et al. Rehabilitationen bei Post-COVID-Syndrom der Deutschen Rentenversicherung 2021. Rehabilitation (Stuttg) 2023;62:339-48. [Crossref] [PubMed]
33. Milcent C. The effect of patients’ socioeconomic status in rehabilitation centers on the efficiency and performance. Eur J Phys Rehabil Med 2024;60:919-28. [Crossref] [PubMed]
34. Ricke E, Lindeboom R, Dijkstra A, et al. Measuring Adherence to Pulmonary Rehabilitation: A Prospective Validation Study of the Dutch Version of the Rehabilitation Adherence Measure for Athletic Training (RAdMAT-NL). Patient Prefer Adherence 2023;17:1977-87. [Crossref] [PubMed]
35. Spruit MA, Van’t Hul A, Vreeken HL, et al. Profiling of Patients with COPD for Adequate Referral to Exercise-Based Care: The Dutch Model. Sports Med 2020;50:1421-9. [Crossref] [PubMed]
36. Huizinga F, Westerink NL, Berendsen AJ, et al. Implementation and evaluation of a physical activity counselling programme in primary care among cancer survivors: SoDA study protocol. BMJ Open 2022;12:e060098. [Crossref] [PubMed]
37. Burge AT, Cox NS, Abramson MJ, et al. Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2020;4:CD012626. [Crossref] [PubMed]
38. Ito JT, Alves LHV, Oliveira LM, et al. Effect of exercise training on modulating the TH17/TREG imbalance in individuals with severe COPD: A randomized controlled trial. Pulmonology 2025;31:2441069. [Crossref] [PubMed]
39. Phillips DB, Elbehairy AF, James MD, et al. Impaired Ventilatory Efficiency, Dyspnea, and Exercise Intolerance in Chronic Obstructive Pulmonary Disease: Results from the CanCOLD Study. Am J Respir Crit Care Med 2022;205:1391-402. [Crossref] [PubMed]
40. Qiao Z, Kou Z, Zhang J, et al. Optimal intensity and type of lower limb aerobic training for patients with chronic obstructive pulmonary disease: a systematic review and network meta-analysis of RCTs. Ther Adv Respir Dis 2025;19:17534666251323190. [Crossref] [PubMed]
41. LoMauro A, Gervasoni F. 20 years of neuromuscular electrical stimulation in COPD. Eur Respir Rev 2024;33:220247. [Crossref] [PubMed]
42. Xingyu X, Dandan Z, Shouzhen C. Effects of pulmonary rehabilitation on respiratory function in mechanically ventilated patients: a systematic review and meta-analysis. BMC Pulm Med 2025;25:4. [Crossref] [PubMed]
43. Jin S, Huang B, Kong Y, et al. Effect of neuromuscular electrical stimulation combined with respiratory rehabilitation training on pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. J Cardiothorac Surg 2025;20:79. [Crossref] [PubMed]
44. Raghavan S, Hatipoğlu U, Aboussouan LS. Goals of chronic obstructive pulmonary disease management: a focused review for clinicians. Curr Opin Pulm Med 2025;31:156-64. [Crossref] [PubMed]
45. Beghé B, Verduri A, Roca M, et al. Exacerbation of respiratory symptoms in COPD patients may not be exacerbations of COPD. Eur Respir J 2013;41:993-5. [Crossref] [PubMed]
46. Song Y, Han X, Wang Y, et al. Mitochondrial Quality Control: A New Perspective in Skeletal Muscle Dysfunction of Chronic Obstructive Pulmonary Disease. Aging Dis 2024;16:3291-310. [Crossref] [PubMed]
47. Han X, Li P, Jiang M, et al. Autophagy in skeletal muscle dysfunction of chronic obstructive pulmonary disease: implications, mechanisms, and perspectives. J Zhejiang Univ Sci B 2025;26:227-39. [Crossref] [PubMed]
48. Khosravi M, Naimi SS, Shokouhyan SM, et al. Exploring the Promising Impact of Pulmonary Rehabilitation on Gait and Balance in Patients With COPD: A Systematic Review and Meta-Analysis. J Cardiopulm Rehabil Prev 2025;45:20-8. [Crossref] [PubMed]
49. He R, Ren L. Evaluation of the benefits of respirator breathing and vomiting training and dynamic core training on improving respiratory muscle strength. Respir Med 2025;240:108029.
50. Moretta P, Cavallo ND, Candia C, et al. Psychiatric Disorders in Patients with Chronic Obstructive Pulmonary Disease: Clinical Significance and Treatment Strategies. J Clin Med 2024;13:6418. [Crossref] [PubMed]
51. Sohanpal R, Mammoliti KM, Barradell A, et al. Patient perspectives on the Tailored intervention for Anxiety and Depression Management in COPD (TANDEM): a qualitative evaluation. BMC Health Serv Res 2024;24:960. [Crossref] [PubMed]
52. Lee AL, Butler SJ, Jung P, et al. Participant-selected music listening during pulmonary rehabilitation in people with chronic obstructive pulmonary disease: A randomised controlled trial. Chron Respir Dis 2024;21:14799731241291065. [Crossref] [PubMed]
53. Butler SJ, Louie AV, Sutradhar R, et al. Impact of chronic obstructive pulmonary disease on lung cancer symptom burden: a population-based study in Ontario, Canada. Transl Lung Cancer Res 2023;12:2260-74. [Crossref] [PubMed]
54. Alzahrani M, Mehta R, Kadiri S, et al. Effect of pulmonary rehabilitation on lung cancer surgery outcomes: a matched-case analysis. Perioper Med (Lond) 2025;14:35. [Crossref] [PubMed]
55. Zhong J, Trinh I, Raju S, et al. Pulmonary Rehabilitation in Patients with Operable Non-Small Cell Lung Cancer. J Clin Med 2025;14:770. [Crossref] [PubMed]
56. Borghi-Silva A, Camargo PF, Caruso FCR, et al. Current perspectives on the rehabilitation of COPD patients with comorbidities. Expert Rev Respir Med 2025;19:11-28. [Crossref] [PubMed]
57. Yu Y, Wu T, Wu M, et al. Evidence map of traditional Chinese exercises. Front Public Health 2024;12:1347201. [Crossref] [PubMed]
58. Cheng YY, Lin SY, Hsu CY, et al. Respiratory Muscle Training Can Improve Cognition, Lung Function, and Diaphragmatic Thickness Fraction in Male and Non-Obese Patients with Chronic Obstructive Pulmonary Disease: A Prospective Study. J Pers Med 2022;12:475. [Crossref] [PubMed]
59. Yang HJ, Koh E, Sung MK, et al. Changes Induced by Mind-Body Intervention Including Epigenetic Marks and Its Effects on Diabetes. Int J Mol Sci 2021;22:1317. [Crossref] [PubMed]
60. Shen H, Chen LZ, Hu Z, et al. Integrating Chronic Obstructive Pulmonary Disease Treatment With 8-Week Tai Chi Chuan Practice: An Exploration of Mind-Body Intervention and Neural Mechanism. Front Hum Neurosci 2022;16:849481. [Crossref] [PubMed]
61. Belloumi N, Habouria C, Bachouch I, et al. Feasibility of a home-designed respiratory rehabilitation program for chronic obstructive pulmonary disease. Prim Health Care Res Dev 2024;25:e7. [Crossref] [PubMed]
62. Lythreatis S, Singh SK, El-Kassar A-N. The digital divide: A review and future research agenda. Technological Forecasting and Social Change 2022;175:121359.