1 PULMONARY REHABILITATION Asthma/COPD Study Day 11/12/13 Fran Butler Respiratory Physiotherapist

Session Objectives Background of pulmonary rehabilitation How it runs in York Outcomes of recent York groups Barriers to rehab Service development projects 2

3 Definition of Pulmonary Rehabilitation (PR) ‘Pulmonary rehabilitation can be defined as an interdisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy. Programmes comprise individualised exercise programmes and education’. BTS (2013)

Guidelines NICE (2010) People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme 4

NICE GUIDELINES Structure a) Evidence of local arrangements to provide multidisciplinary pulmonary rehabilitation programmes. b) Evidence of local arrangements to ensure effectiveness of multidisciplinary pulmonary rehabilitation programmes, by collection and audit of health outcome data. c) Evidence of local arrangements to ensure multidisciplinary pulmonary rehabilitation programmes can be accessed in a timely manner. d) Evidence of local arrangements to ensure multidisciplinary pulmonary rehabilitation programmes are geographically accessible.

6 Aims of Pulmonary Rehabilitation  Increase exercise tolerance and reduce dyspnoea  Increase muscle strength and endurance (peripheral and respiratory)  Improve health related quality of life  Increase independence in daily functioning  Increase knowledge of lung condition and promote self-management  Promote long term commitment to exercise

Research The British Thoracic Society (BTS) guideline 2013 recommends that: A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation improves the symptom of dyspnea and improves Health Related Quality of Life in patients with COPD. Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. Both low- and high-intensity exercise training produce clinical benefits for patient with COPD. Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs.

Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower-intensity training in patients with COPD. The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations. Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD.

Examples of Effectiveness It has been found that following a course of pulmonary rehab patients demonstrated a significant reduction in health care utilization, both in hospital admissions and out patient attendances.

Cost Analysis For 1 patient to attend a rehab course costs approximately £375. Average or 1.85 inpatient days saved At a average cost of £ saved per patient Average of 1 clinic appointment per patient saved at a cost of £59 Total average saving per patient £ So reduction in spending of £ per patient

Current provision for Pulmonary Rehabilitation in York Capacity of 10 programmes a year 4 in Selby (40 places) 4 in Wigginton (48 places) 2 in Foxwood (24 places) Total capacity

Referral Sources Respiratory Consultants Respiratory Nurses GP’s Practice Nurses Physiotherapists 12

Triage appointment Explain concept of course to the patient Check mobility Check patient is on optimum treatment (not smoking) Offer choice of location Start home exercise programme and give breathing control advice Additional advice about Chest clearance Baseline SpO2 and Heart Rate MRC scale

Medical Research Council dyspnoea scale Grade Degree of breathlessness related to activities 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100m or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2:

15 Triaging Possible exclusion criteria: 1. Loco motor problems 2.Significant cardiac disease 3.Cognitive impairment 4.Preferably non-smokers Non-compliance 1.Behavioural 2.Lack of social support 3.Continued smoking 4.Location and transport

16 Programme Format Pre-course assessment Two sessions of exercise and one education session per week for a total of six weeks Post course assessment

17 Pulmonary Rehabilitation Programme Components  Exercise programme (to continue at home)  Education about the disease  Self management strategies  Breathing control techniques  Effective chest clearance techniques  Relaxation  Energy saving strategies  Benefits and social support  Dietary advice

18 Assessments for the Pulmonary Rehabilitation Programme 1.CRDQ-Chronic Respiratory Disease Questionnaire 2.Incremental Shuttle Walk test 3.Spirometry 4.Pulse Oximetry

19 CRDQ Measures the quality of life in patients with chronic lung disease. The questions are divided into four areas: Dyspnoea Fatigue Emotional function Mastery

20 Borg Scale Assessment of perceived breathlessness Level of breathlessness Score Nothing at all…………………………………………………………..0 Very, very slight (just noticeable)………………………………… Very slight……………………………………………………………...1 Slight……………………………………………………………………2 Moderate…………………………………………………………….…3 Somewhat severe……………………………………………………..4 Severe…………………………………………………………………..5 / 6 Very severe………………………………………………………… / 8 Very, very severe (almost maximal)………………………………… 9 Maximal…………………………………………………………………10

Exercises Timed Circuit based exercise class Try to be functional Alternate arms then leg based exercise Can be progressed to remain challenging for patients Able to adapt for patients with pre existing musculoskeletal problems Most exercises can be replicated within the patients home 21

Non Completers Change in social circumstances (job) Exacerbation / hospital admission Transport issues Not for them Other health problems Lack of motivation RIP before course starts Unwell family member

23 Maintenance of benefits Depends on: 1.Patient motivation 2.Disease deterioration 3.Lifestyle/Behavioural change 4.Frequency of exacerbations

On Going support York HEAL Programmes Breathe easy support and exercise group Re referral back to group at later date Home exercise programme/DVD 24

Pulmonary rehab in past 2 years 25 YearOffered Rehab Completed Rehab Drop out rate 2011/ % 2012/ %

Outcomes of programmes YearGreatest Improvement in Shuttle Walk Average improvement in Shuttle Walk % improved MRC by at least / m92m73% 2012/ m69m69%

CRDQ results % improvements 27 YearDyspnoeaFatigueEmotional Function Mastery %74%52%61% %72%63%69%

Limitations to the Service Limited to 3 locations Not a rolling programme Limited availability to maintenance courses Timing of referrals – patients having to wait several months for a course Limited places due to hall space and staff to patient ratio

Referrals to Rehab This data is for rehab referrals only Total referrals April April 2013 Total attended triage clinic Total DNA clinic Total invited to rehab

Audit review information April April 2013

Rehab Completion

Outcomes for DNA’s to rehab

Some patients do not fit the inclusion criteria therefore are given a home exercise programme only Some patients decline the programme and are also given a home exercise programme only Some patients repeatedly DNA clinic appointments so are never triaged or given a home exercise programme

Future Plans Continued audit of the service Starting a rolling programme in Selby – February 2014 Capture as many COPD patients on the ward and refer to triage clinic for Ax for suitability for rehab Education to referrers to improve uptake PhD study into adherence in Pulmonary Rehabilitation – literature review into adherence, motivational/behavioural assessment tools, use of CBT in PR.