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

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

What is Pulmonary Rehabilitation?

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)

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)

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

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

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

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

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)

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

results Increasing percentage of those being assessed actually start the course. Target starters / year reached for the last 5 years (adjusted 2016-17) 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

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

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.

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.

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