1. 1 A community model for exercise prescription for patients with chronic obstructive pulmonary disease and congestive heart failure Elsie Hui, Jean Woo Division of Geriatrics, Department of Medicine and Therapeutics, The Chinese University of Hong Kong HSRF 02030711

2. 2 Introduction Chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are the leading causes for admissions and bed occupancy in the Hospital Authority. Chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are the leading causes for admissions and bed occupancy in the Hospital Authority. Exercise prescription improves: Exercise prescription improves: Physical performance Physical performance Psychosocial well being Psychosocial well being Reduce hospital service utilization and costs Reduce hospital service utilization and costs Refs: Ferrari M, Vangelista A, Vedovi E et al. Minimally supervised home rehabilitation improves exercise capacity and health status in patients with COPD. Am J Phys Med Rehabil 2004; 83: 337-43. Rees K, Taylor R, Singh S, Coats A, Ebrahim S. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2004; 3: CD003331.

3. 3 Purpose To test the feasibility of continuing exercise programmes for COPD or CHF patients: To test the feasibility of continuing exercise programmes for COPD or CHF patients: Exercise Exercise Peer support Peer support Health education Health education Promote self-motivation and compliance Promote self-motivation and compliance Based at community centres Based at community centres Led by health professionals or trained non-health professionals Led by health professionals or trained non-health professionals

4. 4 Materials & Methods COPDCHF Study Design Quasi-experimental, ‘ Before and after ’ measurements Subjects ≥ 1 admission(s) in preceding 12 months 4437 Setting Community elderly centres Intervention 8 – 10 subjects per group 12 weekly 2-hour sessions + home exercise prescription Exercise training, educational talk, peer group support Outcome measures Lung function tests, 6 minute walk test (6MWT), General Health Questionnaire (GHQ), St. George ’ s Respiratory Symptom Questionnaire (SGRQ), COPD knowledge, programme evaluation using questionnaires, group discussions. 6MWT, muscle strength, Hospital Anxiety & Depression Scale (HADS), Medical Outcome Study Social Support Survey (MOSSS) Chronic Heart Failure Questionnaire (CHFQ) CHF knowledge test, programme evaluation

5. 5 Intervention COPDCHF Educational talk (1 hour) E.g., pathophysiology of COPD, exercise, breathing, sputum removal and relaxation techniques, medication and dyspnoea management, energy conservation, etc. E.g., pathophysiology of heart disease, medication, surgical interventions, diet, signs & symptoms, exercise, emotion and relaxation, prevention of exacerbation, etc. Peer group support Q & A, group discussion, focus group (week 12) Exercise training (1 hour, step-up intensity to Borg scale ~ 13: moderately hard) Warm up Strengthening – upper (raise arms) & lower limb (sit to stand) Aerobic – dance Home programme 3 x / week Warm up Strengthening – upper & lower limb using Therabands Aerobic – dance Home programme 3 x / week

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7. 7 Subject characteristics Demographics COPD (n = 44) CHF (n = 37) Sex (M:F) 37: 7 25:12 Age (years) 74.2 (6.5) 73.5 (7.8) LTOT (%) 25- FEV1/FVC (%) 49 (15.8) - Disease severity (%) Moderate to severe 82 NYHA Class II / III 89 Attendance rate (%) 7891 Dropouts 11 (25%) Frequent admissions (3); moved away (2); admitted to old age home (1); transport problem (2); comorbidity (1); refused exercise (2) 5 (13.5%) Comorbidity (2); hospitalised for non-cardiac problem (2); transport problem (1)

8. 8 COPD Results Outcome measure Baseline 12 weeks P-value Physical 6 MWT (m) 285 (96) 303(98)0.051 Psychological GHQ (/28) 20.6 (10.1) 12.2 (6.0) <0.001 SGRQ (/99.99) 53.7 (19.6) 37.7 (14.1) <0.001 COPD knowledge (/10) 6.6 (2.0) 8.8 (1.1) <0.001

9. 9 CHF Results Outcome measure Baseline 12 weeks P-value Physical6MWT 329.5 (103.2) 380.9 (90.3) <0.001 # Biceps strength (right) 15.0 (6.6) 18.9 (6.2) 0.001 # Quadriceps strength (right) 12.8 (5.0) 19.1 (5.3) <0.001 Psychological* HADS (anxiety) 5.9 (3.8) 3.5 (3.0) <0.001 MOS-SSS (tangible) 67.4 (24.7) 85.9 (14.0) <0.001 CHQ (dyspnoea) 4.05 (0.95) 5.3 (0.9) <0.001 CHF knowledge (/10) 7.8 (1.7) 9.6 (1.4) <0.001 # # Significant changes were recorded on both the left and right side. * Significant changes were observed for all domains of the HADS, MOS & CHQ.

10. 10 Programme evaluation No.Question Disagree (%) Ambiguous (%) Agree (%) COPDCHFCOPDCHFCOPDCHF 1 I will attend similar courses again 13.83.110.315.675.981.3 2 I can complete all the prescribed exercises 3.4009.496.690.6 3 I prefer group exercise to home exercise 20.728.127.618.851.753.1 4 I feel that my physical health is better than before 003.46.396.693.8 5 The group mates can help me handle my disease 03.124.19.475.987.6 6 I did not have any problem travelling to the centre 10.303.43.186.296.9

11. 11 Focus group (transcripts) COPD group The exercise is helpful as it increases my daily activities tolerance. The exercise is helpful as it increases my daily activities tolerance. In the past, I used to go to the hospital whenever I felt breathless, which happens at least once or twice a year, but now I can somehow manage the crisis. In the past, I used to go to the hospital whenever I felt breathless, which happens at least once or twice a year, but now I can somehow manage the crisis. Group learning can facilitate the exchange of ideas. It creates happiness and concern for others. Group learning can facilitate the exchange of ideas. It creates happiness and concern for others. CHF group Learning in a group makes us more interactive. I seldom exercised in the past, but now I do it everyday. Group exercise is good for lazy people as they perform better and last longer as a group. I believe we have benefit from the programme and will live a healthier life. Learning in a group makes us more interactive. I seldom exercised in the past, but now I do it everyday. Group exercise is good for lazy people as they perform better and last longer as a group. I believe we have benefit from the programme and will live a healthier life. The educational talks gave me a lot of information on nutrition. In the past, doctors just told me to avoid high cholesterol foods, but I had no idea what cholesterol was and which foods were suitable for me. They didn't have time to explain things in detail. The educational talks gave me a lot of information on nutrition. In the past, doctors just told me to avoid high cholesterol foods, but I had no idea what cholesterol was and which foods were suitable for me. They didn't have time to explain things in detail.

12. 12 Conclusions and recommendations Patients with COPD and CHF have unmet needs in the community, disease- specific rehabilitation programmes being predominantly hospital based and of limited duration. Patients with COPD and CHF have unmet needs in the community, disease- specific rehabilitation programmes being predominantly hospital based and of limited duration. The group community interventions described above have the advantage of being incorporated as regular programmes in the community or primary care setting. They help patients cope with their diseases through empowerment and mutual support, apart from achieving symptom improvement and other positive physical and psychosocial outcomes. The group community interventions described above have the advantage of being incorporated as regular programmes in the community or primary care setting. They help patients cope with their diseases through empowerment and mutual support, apart from achieving symptom improvement and other positive physical and psychosocial outcomes. This model could be an integral part of chronic disease management programmes in the community. This model could be an integral part of chronic disease management programmes in the community.

13. 13 References Woo J, Chan W, Yeung F, et al. A Community model of group therapy for the older patients with COPD: a pilot study. J Evaluation in Clin Practice, 2006;12:523-531. Hui E, Yang H, Chan W, et al. A community model of group rehabilitation for older patients with chronic heart failure: a pilot study. Disability and Rehab, 2006 (in press) huie@ha.org.hk