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Pulmonary rehabilitation for patients with COPD

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Anne McDermott, BA (Hons), RN, DipN.

Transplant Nurse Consultant, Transplant Unit, Royal Brompton and Harefield NHS Trust

Most chronic lung diseases such as chronic obstructive pulmonary disease (COPD) develop slowly and it may be decades before damage results in noticeable symptoms. This contrasts with other conditions where there is a sudden event, such as a myocardial infarction and rehabilitation offers a road to recovery (Morgan, 1997). Cardiac rehabilitation programmes are now recognized as essential to the comprehensive care of patients with cardiovascular disease (Balady et al, 1994). However, this is not the case for respiratory patients.

Most chronic lung diseases such as chronic obstructive pulmonary disease (COPD) develop slowly and it may be decades before damage results in noticeable symptoms. This contrasts with other conditions where there is a sudden event, such as a myocardial infarction and rehabilitation offers a road to recovery (Morgan, 1997). Cardiac rehabilitation programmes are now recognized as essential to the comprehensive care of patients with cardiovascular disease (Balady et al, 1994). However, this is not the case for respiratory patients.The application of rehabilitation to patients with pulmonary disorders is relatively recent (Hodgkin, 2000). However, in 1981 the Royal College of Physicians recognised the benefits of pulmonary rehabilitation and recommended the establishment of specialist centres. Despite this there are very few centres in the UK that offer this service whereas, in the USA and Europe, the service is well established (Singh et al, 1998).There is no curative treatment for COPD; the management of the disease is directed at symptom control and improvement in functional status over and above that achieved by optimal medical treatment (American Thoracic Society, 1999; Morgan, 1997). Due to worsening dyspnoea during physical activity, patients with respiratory impairment usually respond to their disability by abstaining from activities, which in turn results in physical deconditioning and increased impairment.Exertional dyspnoea promotes increased levels of fear, anxiety and depression, which in turn leads to further inactivity. This results in greater intolerance to exercise with further loss of functional capacity, causing dyspnoea during minimal activities or even at rest (Murray, 1993). Pulmonary rehabilitation aims to redress this downward spiral.In the UK, pulmonary rehabilitation is not a well-recognised therapy for patients with COPD. The aim of this paper is to explore the benefits and limitations of pulmonary rehabilitation for people with this disabling disease.A literature search revealed that many papers have been written on various methods of pulmonary rehabilitation. In evidence-based healthcare the randomised controlled trial (RCT) is seen as the most rigorous way of determining whether a cause-effect relationship exists between a treatment and an outcome (Sibbald and Roland, 1998). In pulmonary rehabilitation the particular outcome measures observed have been:- Exercise tolerance- Dyspnoea- Quality of life- Health-care utilisation.For the purposes of this paper, RCTs have been included as they are acknowledged as being the ‘the gold standard’ for producing strong clinical evidence on which to base clinical practice (Muir-Gray, 1998).

Pulmonary rehabilitation
Pulmonary rehabilitation was born of the recognition that, while most chronic lung diseases are not curable, patients can still achieve an improved quality of life (Sridhar, 1997). There is increasing evidence that rehabilitation improves:- Performance- Exercise endurance- Quality of life.It also reduces symptoms and demand on healthcare resources (Ries, 1990; Lacasse et al, 1996; American Thoracic Society, 1999).Pulmonary rehabilitation generally consists of a variety of components, which take into account individual needs. Comprehensive programmes commonly focus on four main areas:- Exercise training- Education- Psychosocial/behavioural- Outcome assessment.A multidisciplinary team, which may include a respiratory physician, a physiotherapist, a nurse specialist, a pharmacist, a psychologist and a social worker, generally provide these interventions but this varies between programmes.Exercise tolerance, dyspnoea, quality of life and health-care utilisation are the outcome measures that are most commonly assessed, so these will be explored further.

Exercise training
Studies using exercise as an outcome measure have shown either an increase in exercise performed or a decrease in dyspnoea at a given level of exercise, or both. Simple exercise programmes can show a measurable increase in exercise tolerance; these increases can be relatively small yet patients have reported benefit out of proportion to the increase (Cockcroft, 1988). Goldstein et al (1994) in a trial of 89 subjects, found a significant difference after rehabilitation between the treatment and control groups in functional measurements of exercise capacity. At six months, improvements in exercise tolerance were reflected in the six-minute walking test and the cycle test.More recently Guell et al (2000) also found beneficial differences in the six-minute walking test. One year after the completion of the rehabilitation course, patients in this group had gained a mean increase of 81 metres in the distance they could walk compared to their baseline. Troosters et al (2000) reported similar results; these effects were maintained 18 months after the start of the programme, with an average improvement of 90 metres observed.Exercise training is the foundation of pulmonary rehabilitation programmes, as not only does it benefit the patient physically but also psychologically (American Thoracic Society, 1999; Lacasse et al, 1997). To someone who is healthy, these increases may seem very small, but to someone who is breathless these distances could be vast, and may mean the difference between being confined to a house or being able to go out and socialise.

Dyspnoea
Dyspnoea is the most common symptom experienced by people with COPD. Assessment of dyspnoea is difficult because it is subjective and is influenced by both emotional and environmental factors. Easily applied scales are required that can reveal either the functional impairment experienced as a result of the breathlessness or the magnitude of the sensation associated with a particular activity (Singh, 1997).Reardon et al (1994) evaluated the effect of outpatient pulmonary rehabilitation on dyspnoea. This involved recording information on a visual analogue scale during treadmill exercise and using the transitional dyspnoea indices to assess functional impairment. They concluded that outpatient rehabilitation led to a significant reduction in dyspnoea during exercise and also a significant decrease in overall dyspnoea.Strijbos et al (1996) also observed improvements in reported dyspnoea for the patients who attended either hospital-based or home-based rehabilitation. However the subjects who had received home-based rehabilitation maintained benefits for a longer period. Both Reardon et al (1994) and Stibjos et al (1996) claim that desensitisation to dyspnoea is an important mechanism in improving the exercise tolerance of COPD patients. The continuous supervised exercising of patients to a moderate-severe level of breathlessness may have a partially desensitising effect to what is an often emotionally charged and feared sensation.

Health-related quality of life
Improvement in quality of life has been documented in several studies; however, valid measurements of an individual’s quality of life are difficult to make. Despite this, the concept of quality of life can be a useful measure. Health-related quality of life measures the impact of an individual’s health on his or her ability to perform and enjoy the activities of daily life (Randall et al, 1996). Although it is possible to make specific measurements of symptoms, disability and so on, there is a need for an overall summary of benefit (American Thoracic Society, 1999).General quality of life or disease-specific questionnaires have been used as health measurement tools. The Chronic Disease Respiratory Questionnaire (CRDQ) is widely used in pulmonary rehabilitation assessment. It assesses quality of life using four domains - dyspnoea, fatigue, emotional function and mastery or control over the disease - and has been shown to be reproducible, valid and responsive (Guyatt et al, 1987).Using the CRDQ, Goldstein et al (1994) stated that, for those patients who had received rehabilitation, improvements in quality of life were achieved and sustained for six months. Both Wijkstra et al (1994) and Wedzicha et al (1998) found that patients with moderate dyspnoea showed a greater improvement in health status than their comparative study groups. Differences in all four domains of the CRDQ were still evident by the third month and continued, with somewhat diminished magnitude, in the second year of follow-up.COPD can severely affect quality of life. The results from the identified studies showed that health-related quality of life improved for participants following attendance on a pulmonary rehabilitation programme.

Health-care utilisation
Due to the nature of the disease, patients with COPD tend to be frequent users of healthcare resources either through hospitalisation or visits to their GP (Pauwels, 2000). Griffiths et al (2000) followed 200 patients for one year. They found that there was no difference in the control and rehabilitation groups for the number of admissions to hospital but what did differ significantly was the number of days spent in hospital. The number of days spent in hospital by the rehabilitation group was half that of the control group, which equated to a decrease in bed occupancy of four days per patient rehabilitated. Although the number of GP consultations was similar within the two groups, a more efficient use of the service was observed. The patients who had received rehabilitation had more consultations at the GP surgery and fewer home visits when compared with the control group.Ries et al (1995) found that there were slight but non-significant differences in duration of hospital stay and Guell et al (2000) observed a variation in the total number of hospitalisations and exacerbations experienced. The control group experienced 39 admissions to hospital, compared to the rehabilitation group, which experienced 18 admissions. However, this difference was not seen as statistically significant. What was more important was the number of patients who experienced exacerbations. In the control group there were 207 exacerbations, with an average of 6.9 (+/-3.9) per patient, whereas in the rehabilitation group there were 111 exacerbations with an average of 3.7 (+/2.2) per patient, which was classified as statistically significant.This information could have implications for resource management within the NHS. Trials have shown a decrease in the use of health-care resources after rehabilitation, assessed by the number of hospital days spent as an inpatient for pulmonary related illness, utilisation of GP resources or number of acute exacerbations. This could suggest that the monetary cost in terms of providing pulmonary rehabilitation may be offset by savings made from other resource intensive aspects of health care.The efficacy and scientific foundation of pulmonary rehabilitation has been firmly established. Pulmonary rehabilitation programmes should be an integral part of the clinical management and health maintenance for people with chronic respiratory disease who remain symptomatic despite standard medical management (American Thoracic Society, 1999).

Limitations
Pulmonary rehabilitation requires commitment and motivation from the patient and his or her family or carers. High dropout rates have been reported in various studies. Troosters et al (2000) reported that 31% of patients had dropped out of the study by six months and this had increased to 36% by 18 months after the onset of training. Similar results were reported by Goldstein et al (1994) and Wedzicha et al (1998).Patients may have unrealistic expectations of pulmonary rehabilitation. It must be made clear from the outset that rehabilitation is not a treatment for the disease but a means of training and educating patients to maximise quality of life (Murray, 1993). If exercising is not maintained after the programme has been completed then the benefits gained will not be sustained. Unless the programme is home-based, the patient will have to attend classes two to three times a week for the duration of the course, which may involve travelling long distances to specialised centres. For patients who are motivated, the benefits should firmly outweigh the limitations.

Evidence-based health care
The UKCC (1992) and, more recently, the Department of Health (1997) have emphasised the importance of research in guiding clinical practice. It has not been within the remit of this paper to critically analyse each of the research papers individually, therefore the health-care practitioner must be aware of the need to critically appraise research findings before applying them to clinical practice.Sackett et al (2000) provide comprehensive guidelines that appraise evidence for validity, impact and applicability. Health-care professionals can use this appraisal when consideration is being given to the applicability of research to a particular group of patients. Evidence-based healthcare provides considerable opportunities to change professional practice and to improve effectiveness and efficiency (Davies, 1999).

Conclusion
Pulmonary rehabilitation is a therapy that offers a validated benefit to patients with COPD, yet it is still not widely available. Although rehabilitation has been shown to be beneficial, the contributions of the components of the rehabilitation programme have been less well evaluated. It is unclear which particular components of rehabilitation are ‘essential’, and this has led to rehabilitation programmes of a disparate nature.The cost of providing pulmonary rehabilitation in terms of time, personnel, space and equipment should be assessed. Although these appear to be variable, Singh et al (1998) believe that the benefits that can be gained from a reduction in the use of health-care facilities would fully compensate for the costs of a rehabilitation programme.The expertise needed to provide pulmonary rehabilitation already exists in most trusts, especially those that already offer cardiac rehabilitation. However, there will always be restraints, with various projects competing for limited resources. The provision of pulmonary rehabilitation may not show immediate benefits but these will be realised in the longer term for both the patient and the health-care provider.Where available pulmonary rehabilitation has focused on patients with COPD; however, there is evidence to suggest that it can also be of benefit to patients with other chronic respiratory conditions (Simonds, 1996; Celli, 1997). Not every patient with respiratory disease would be a suitable candidate for pulmonary rehabilitation and not all would want to attend. However, the potential number of patients that could benefit from such a programme is immense.It is no longer acceptable for people with chronic respiratory disease to be told that there is nothing more that can be done for them (Clay, 1994). There is now convincing evidence to show that pulmonary rehabilitation programmes should be adopted as an integral part of long-term management for suitable patients with chronic respiratory disability.- See also ‘A nurse-led pulmonary rehabilitation programme for patients with COPD’ by Denise Gibbons, published in Professional Nurse (2001) (17: 3, 185-188).

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