1. PULMONARY REHABILITATION - in practice
Vicki Masey
Respiratory Physiotherapist
Community respiratory, pulmonary rehabilitation and home oxygen service
Oxford health NHS Foundation trust

2. What is Pulmonary Rehabilitation?
PR is a
Comprehensive intervention based on a
Thorough patient assessment followed by
Patient tailored therapies which include but are not limited to
Exercise training
Education and
Behaviour change
Designed to improve the physical and psychological condition of people with chronic respiratory disease and to
Promote the long-term adherence to health-enhancing behaviours
ATS / ERS Statement 2013

3. What is Pulmonary Rehabilitation?

4. Pulmonary Rehabilitation – WHO should be referred?
BTS Quality Standards 2014
Pulmonary Rehabilitation should be offered to all COPD patients with MRC 3, with a view to improving exercise capacity, dyspnoea and health status by a clinically important amount.
Patients who are functionally limited by chronic respiratory diseases other than COPD – ILD, non-CF bronchiectasis, asthma (and symptomatic MRC2’s)

5. Oxfordshire SErvice
PR team sits within Oxford Health’s Community Respiratory, Pulmonary Rehabilitation and Home Oxygen Service.
PR is provided at 15 locations throughout the county:
Abingdon x 2, Banbury, Bicester, Carterton, Didcot, Faringdon, Henley, Kidlington, Oxford x 3, Wallingford, Wantage and Witney.
7 courses running consecutively – 2 sessions per week for 6 weeks.
Commissioned for 530 patients/year.
‘Success’ determined by number of patients who achieve MCID in an exercise outcome measure (ISWT, 6MWT, 4MGS) – 84% August 2017
Also measure
CAT (symptom score), HADs (psychological measure), Likert (patient reported measures)

6. Local Referral criteria
Must have a diagnosis of chronic respiratory disease AND
be functionally limited by breathlessness
Should have an MRC score of 3 or more
Symptomatic 2’s considered.
Priority given to patients post respiratory associated in-pt admission
? Post-op lung resection?
? General deconditioning? – GP exercise referral more appropriate

7. Exercise Goals PR team: Patient:
Improve the aerobic capacity of the individual.
Reduce the fatigability of muscles
Increase the amount of force a muscle can generate, and the speed at which it contracts
Improve quality of life
Patient:
Improve the ability to do every day activities with less effort.
Improve confidence to do things

8. Exercise prescription
Patients exercise WITHIN a group environment rather than AS a group.
All exercises individualised for each patient
Current ability / co-morbidities
Patient goals
Patient’s perception
Combination of aerobic and strength training
Aim is to gradually increase resistance levels, speed, duration etc as fitness improves

9. Aerobic training vs strength training
Breathless not speechless
Moderate shortness of breath
Talk test – ‘hello my name is..’
Breathlessness variable day to day – work at current level
Alter speed, distance, time, gradient to always challenge.
Mainly big locomotor muscle groups
quads, calves, glutes
How much weight?
Normally 10RM
Usually 3 x 10 reps
Can personalise according to goals

10. Education sessions / discussions
After being served tea/ coffee/ biscuits:
Managing breathlessness
Airway clearance
Understanding your lung condition
Benefits of exercise and Home Exercise Programme
Managing flare-ups
What medications am I taking and why?
Stress, worry and managing your mood.
Healthy eating and COPD
How can I continue exercising? (Breakout session)

11. End of course Repeat assessment
Any improvements – identified and discussed with patient
Discuss options going forward
Exercise on referral given to ALL patients
Alternative exercise options discussed.
Emphasis on role of patient to continue to exercise to maintain / optimise physical improvements
Referral to other services (if not already done)
Talking Space Plus, Dietetics, Community Therapy Service etc

12. results
Increasing percentage of those being assessed actually start the course.
Target starters / year reached for the last 5 years (adjusted )
Increasing number of those starting manage to finish
National median – 60% completion rate (of those assessed)
Local is 82%
Increasing number of finishers achieving a MCID in exercise outcome measure:
National median – 57%
Local – 84%
Biggest drop out rate locally CONTINUES to occur between referral and assessment

13. The referral process
Discuss PR with your patient at the time of the referral – and ensure patient has an understanding of the commitment required from them to benefit from the course.
Provide all information requested – the referral is delayed if we need to contact the referrer to clarify missing information.
Waiting list times – patient SHOULD hear from us within 3 months of receipt of referral. (Priority patients within 4 weeks.)
PR location MAY lengthen this, unless patient is willing to travel further.
Patients are sent 2 invitation letters – if NO response to these, they will be discharged from the waiting list (does not apply to those requesting deferral).
Due to high rate of non-responders, approximately double the number of invitations are sent out for the number of places on each course

14. Patients’ perceptions pre-course
Often no clear understanding that they will be expected to perform physical exercise.
They do not consider PR to be an essential part of their disease management
Anxiety about attending the gym environment / body image / co-morbidities limiting ability to exercise
Leisure centres are available to all, not just fit 25 year olds.
Exercise as an individual within a group, no comparison or competition.
Core exercises can be adapted or alternative exercises are available.
If we can achieve face to face contact with an individual, the chance of them starting a course increases significantly.

15. How can you help?
The enthusiasm of the referrer and the information given to the individual during first mention of Pulmonary Rehabilitation can make all the difference.
Ensuring the patient understands that Pulmonary Rehabilitation is the most effective part of their treatment – not an optional extra.
Emphasis on the benefit of physical activity in the management of their condition – during rehab and afterwards.
Be specific – ‘exercises for your breathing’ creates misconceptions.

16. PR – the future How do we engage with the ‘dis-engaged’?
Suggestions welcomed!
Young, working CLD population –
Early bird, twilight or weekend sessions?
Rolling programmes to reduce waiting lists?
Geographical / logistical challenges
Benefits of a predominantly strength-based training programme?
Watch this space…
Functional exercise programme?
hoovering, making beds, carrying shopping bags
Improving the uptake of Continuing Exercise in the ‘graduate’ cohort
Encouraging the commitment of leisure centres to accommodate and welcome these individuals