PULMONARY
REHABILITATION
Jane Simpson & Abigail Asantewaa
Clinical Lead & Senior Physiotherapist
ARCaRe Team, Tower Hamlets
Summary of this talk
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What is COPD like?
What is Pulmonary rehabilitation?
The exercise component
Skeletal Muscle Dysfunction
The education component
Selling the Program
Recent Projects
Referring
Imagine a typical COPD
patient…
• What does it feel like to have COPD??
The Vicious cycle
Reduced exercise
tolerance
Muscle weakness
Fatigue, anxiety,
isolation
Fear of breathlessness
Inactivity/Immobility
What can the patient do about it?
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Ignore it – that’s just the way it is…
Keep trying different medication…
Have a serious go at smoking cessation…
Do something POSITIVE!
– “This is not going to go away, but there is something
that I can do to help myself and it will be worth
putting in the effort”
Pulmonary rehabilitation
‘Is an evidence based, multidisciplinary, and
comprehensive intervention for patients with chronic
respiratory diseases who are symptomatic and often have
decreased daily life activities.
Integrated into the individualised treatment of the patient,
pulmonary rehabilitation is designed to reduce symptoms,
optimise functional status, increase participation, and
reduce health care costs through stabilising or reversing
systemic manifestations of the disease’
ATS/ERS statement on pulmonary rehabilitation (2006) American journal of respiratory and critical care medicine, 173:1390-1413
WHAT IS PR?
• A Multidisciplinary programme of care for
patients with chronic respiratory impairment that
is individually tailored and designed to optimise
physical and social performance and autonomy.
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BTS statement 2001
HOW DO YOU SELL IT?
HOW DO WE SELL IT?
• Try to avoid just explaining it as “an exercise
class”
• Can take the approach of explaining the viscous
cycle
• Choose words carefully when explaining the
class.
Explain Using the dyspnoea spiral
When you have COPD you become a little more breathless…
This causes you to become less active because you don’t feel able to do as much
and getting breathless makes you feel a bit scared anxious…
This causes your body to get unfit because its not as active as it was before…
This makes you more EVEN MORE breathless…
Meaning that you become EVEN LESS active
Causing you to become MORE UNFIT and get EVEN MORE breathless
SELLING IT
• Helpful to reinforce that although SOB becomes worse
with worsening COPD severity, this vicious cycle is a
significant contributor to worsening SOBOE.
• Once they acknowledge and understand this, then
explain that there is a way to reverse the process using
some key phrases
SELLING IT
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With some GENTLE exercise
In a class with other people WHO ALSO HAVE COPD
So everyone in the class is in the SAME POSITION as you
Run by skilled PHYSIOTHERAPISTS who understand your disease and its
impact.
The class provides a SAFE & SUPPORTED environment to get fitter and be
able to DO MORE
Will REDUCE YOUR SENSATION OF BREATHLESNESS and the
fear/anxiety associated with it.
There are talks after the exercise with a CUP of TEA.
OTHER SPECIALISTS are invited to talk to the group and answer your
questions
You will finish the course able to WALK FURTHER/DO MORE, feel more
CONFIDENT managing your breathlessness and knowing MUCH MORE
about COPD and how to MANAGE YOUR CONDITION
EXPLAINING IT
• 8 week course, attending twice a week
• Have the option of two types of class – more
conventional circuits or T’ai-chi
• Only for people with breathing problems
• Run as a group (max 12)
• Gentle exercise to work on your fitness
• Lots of advice and support about self-management
• Choose your venue
THE EXERCISE COMPONENT
• The BTS guidelines on pulmonary rehabilitation (BTS,
2013)
– A combination of progressive muscle resistance and aerobic
training should be delivered
– Exercises should be completed at a minimum of 60% peak work
rate
– Two sessions of supervised exercise per week with a third
unsupervised session of prescribed exercise
– Encouragement of regular physical activity at least 5 x per week for
30 mins in line with standard healthy living guidelines by DoH.
THE EXERCISE COMPONENT
• Circuit of 8 exercises
• Mixture of strength training, endurance training and
cardiovascular work
• Reinforcement of use of pacing and breathing techniques
• Work on recognising “safe” dyspnoea
• Repetitions and resistance documented each class and
encouragement given to progress week on week
• Adapted to comorbidities and goals.
• Encourage to engage in a regular home exercise program
Let’s have a go!
Limiting symptoms in COPD
patients at peak exercise
Dyspnoea and leg
fatigue
31%
Dyspnoea
26%
Killian KJ, et al. 1992.
Leg fatigue
43%
Skeletal Muscle Dysfunction in
COPD
• “COPD goes beyond the lungs and incurs significant
systemic effects among which muscle dysfunction/wasting
in one of the most important” (Rabinovich & Vilaro, 2011)
• Is a prominent contributor to exercise tolerance (Saey et al.
2003), healthcare utilisation (Decramer et al, 1997) and an
independent predictor of morbidity and mortality (Agusti et al,
2003)
• Is characterised by two related phenomena; malfunctioning
of the muscle and a net loss of muscle mass (Agusti et al, 2003)
Skeletal Muscle Dysfunction
Structural and Functional Changes of Peripheral Muscles in COPD Patients
Rabinovich &Vilaro (2011)
Muscle Atrophy
• Present in 18-36% of
patients and responsible
for weight loss in 1725%
• Responsible for losses in
strength and endurance
and independent of the
degree of airway
obstruction
a) Normal 118.5cm2
b) COPD 79.6cm2
Casaburi (2006)
Fibre Type Redistribution
• Increases in some fibre types to the
detriment of others
• Evidence indicates that fibres
convert from one type to another
and that some selectively atrophy
Couillard & Prefait (2005)
• Similar patterns of fibre
redistribution present in hypoxia
and anorexia, indicating that
factors other than disuse are
contributing to atrophy, eg diet and
ABG’s.
Proportion of Type 1 fibres almost 50% lower in
COPD patients, reinforcing that disuse is unlikely
to be the only mechanism causing muscle
abnormalities in these patients
Pathogenic Mechanisms
• Protein synthesis/breakdown balance
– Skeletal muscle mass maintained by a delicate balance between
protein synthesis and protein breakdown.
– COPD patients have an abnormal turnover of protein thus muscle
mass is lost
• Nutritional Abnormalities
– COPD patients have a higher resting energy expenditure
– This is often not compensated for with an increased calorific intake
– This calorific imbalance makes it difficult to maintain muscle mass.
Pathogenic Mechanisms
• Muscle Disuse
– Due to reduced participation in activities of daily living
– Changes in work loads has a detrimental effect on muscle size
• Systemic Corticosteroids
– Can cause corticosteroid associated myopathy
– Has a prominent effect on fibre type IIb
– Close relationship between the duration and doses of the treatment
and the functional and structural changes
Pathogenic Mechanisms
• Tissue Hypoxia and Hypercapnia
– Chronic/intermittent alterations in ABG composition is a common
feature in COPD
– Tissue hypoxia limits the production of energy and affects the
protein synthesis leading to muscle loss
– Hypercapnia results in processes which induce protein degradation
Pathogenic Mechanisms
• Inflammation
– COPD is recognised as an inflammatory disease & evidence of
systemic inflammation has been shown in several studies
– Elevated pro-inflammatory cytokines have been associated with
reduced lean mass, muscle wasting & increased rest energy
expenditure
• Mitochondrial abnormalities
– Reduced mitochondrial density in muscle
– Leading to a reduced oxidative capacity of muscles and
subsequently a reduced ability to work aerobically
The Education Component
• An essential component of treatment as it facilitates reduction of
risk factors and improves patient’s ability to independently cope
with the disease.
• These education sessions will inevitably improve adherence to
exercise and medication, reduce admissions, improve mortality
and improve quality of life.
The Education Component
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What is COPD?
How breathing works
Why Exercise?
Understanding medications and inhaler techniques
Managing breathlessness
How to keep your chest clear
Goal setting
Energy conservation & sleep (OT)
Stress management and relaxation (OT)
Emotions and breathlessness (psychologist)
What is being healthy?
Healthy eating (dietician)
Plan of Action for exacerbations
Air pollution
Holiday and travel
Role of Primary care (Saturday class)
What do we do in Tower Hamlets?
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Currently 5 choices of venue
T’ai Chi as alternative to circuit training
1 physiotherapist and one RSW
Bengali speaking RSW’s
Heart failure/IPF/ chronic asthma patients included
Home exercise programme option available for
genuinely housebound (limited)
• Maintenance Program terminated due to poor
adherence
Referring for Pulmonary
rehabilitation
• Fill in referral form
• Fax it to number on form
• Inclusion criteria:
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Stable chronic lung disease
Limited functional ability due to breathlessness
Motivated to exercise
Optimised respiratory management
Exclusion criteria
• Unstable angina/hypertension
• Angina more than once weekly
• Angina at rest/at night
• Uncontrolled cardiac arrhythmias
• Severe heart failure
• Cardiac event within past 6 weeks
• Capacity
Please include additional information to help us
plan.
Weekend PR Project
• To assess the feasability of a 6 week Multi-disciplinary
Weekend Pulmonary Rehabilitation service for patients with
weekday work commitments.
• Currently evaluating outcomes
• If positive will be starting something similar early 2017 and
will be a performed as standalone cohort programs due to
low numbers
Recent PR Feedback Project
• AIMS
– To explore patient and staff experiences within ARCaRe
pulmonary rehabilitation classes in Tower Hamlets.
– To see if what we are offering is what is needed (Demands
have changed over the past 6 years
– To identify themes from reported experiences to improve the
ARCaRe pulmonary rehabilitation pathway and service
– Highlight areas of good practice within the ARCaRe
pulmonary rehabilitation pathway and service
Pulmonary Rehabilitation review.
• OUTCOMES
 Overall results very positive
 Amend communication pathways with pts.
 Re design exercise record sheets with prompts for reflection
 Social interaction was a major enjoyment factor
 More structure to ending and exploration of a way forward
 Staff induction
 Location and logistics were the main negatives
PATIENT QUOTES
– “Gets you out of the house”
– “Meeting people with same condition was nice”
– “Enjoyed the discussion with other patients”
– “My depression and anxiety was improved by being there”
– “I really found the breathing exercises & calming of my
mind helpful”
– “Up until then I didn’t know what COPD was, now I’m
informed of what it is all about”
– “Its nice to have that space and time to understand what’s
happening”
In summary….for the patient
• Improve independence in daily functioning
• Improve knowledge of lung condition and
promote self-management
• Increase muscle strength and endurance (peripheral and
respiratory)
• Increase exercise tolerance and reduce
dyspnoea
• Reduce length of hospital stay
• Improve health related quality of life
• Promote long term commitment to exercise.
Garrod 2003 (Chartered society of Physiotherapy
briefing)
Thank you!
• Any Questions?
References
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Agustí AG, Noguera A, Sauleda J, Sala E, Pons J, Busquets X (2003). Review Systemic effects of
chronic obstructive pulmonary disease. European Respiratory Journal, Feb; 21(2),347-60.
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ATS/ERS statement on pulmonary rehabilitation (2006). American Journal of Respiratory and Critical
Care Medicine, 173,1390-1413.
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Bernard et al. (1998). Peripheral muscle weakness in patients with chronic obstructive pulmonary
disease. American Journal of Respiratory and Critical Care Medicine, 158(2), 629-634.
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BTS statement (2001). British Thoracic Society standards of care subcommittee on pulmonary
rehabilitation. Thorax, 56, 827-834.
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British Thoracic Society guideline on pulmonary rehabilitation in adults (2013)
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Casaburi R (2006). Impacting patient-centred outcomes in COPD: deconditioning. European
Respiratory Review 15, 42-46.
References
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Couillard A, Prefaut C (2005). From muscle disuse to myopathy in COPD: potential contribution
of oxidative stress. European Respiratory Journal, 26, 703-719.
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Decramer M, Gosselink R, Troosters T, Verschueren M, Evers G (1997). Muscle weakness is
related to utilization of health care resources in COPD patients. European Respiratory Journal,
10(2),417-23.
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Jobin et al. (1998). COPD: capillarity and fibre-type characteristics of skeletal muscle. Journal of
Cardiopulmonary Rehabilitation, 18(6), 432-427.
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Killian, KJ et al. (1992). Exercise capacity and ventilatory, circulatory, and symptom limitation in
patients with chronic airflow limitation. The American Review of Respiratory Disease, 146(4),
935-940.
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NICE (2010) Chronic Obstructive Pulmonary Disease (update)
References
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Rabinovich RA and Vilaro J (2010). Structural and Functional Changes of Peripheral Muscles in
COPD Patients. Current Opinion in Pulmonary Medicine. 16(2),123-33.
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Richardson RS, Leek BT, Gavin TP, Haseler LJ, Mudaliar SR, Henry R, Mathieu-Costello O,
Wagner PD (2004). Reduced mechanical efficiency in chronic obstructive pulmonary disease but
normal peak VO2 with small muscle mass exercise American Journal of Respiratory Critical Care
Medicine, 169(1),89-96
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Saey D, Debigare R, LeBlanc P, Mador MJ, Cote CH, Jobin J, Maltais F (2003). Contractile leg
fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive
pulmonary disease. American Journal of Respiratory Critical Care Medicine, 168(4),425-30.