VOL: 100, ISSUE: 38, PAGE NO: 53
Yvonne Henderson, BSc, is clinical specialist physiotherapist in COPD, Cardiothoracic Centre, Liverpool NHS Trust, and module leader in pulmonary rehabilitation at the National Respiratory Training Centre, WarwickYvonne Henderson, BSc, is clinical specialist physiotherapist in COPD, Cardiothoracic Centre, Liverpool NHS Trust, and module leader in pulmonary rehabilitation at the National Respiratory Training Centre, Warwick
Despite the numbers of patients with COPD, there is still no national service framework for the disease and, as a result, it has not attracted the funding and service development afforded to other conditions. Current UK service provision is inadequate and is now behind the rest of the western world.
However, the General Medical Services contract (GMS) (Department of Health, 2004), and the National Collaborating Centre for Chronic Conditions guidelines for COPD are helping to focus attention on this patient group (NCCCC, 2004).
What is pulmonary rehabilitation?
Pulmonary rehabilitation is a multidisciplinary exercise and education programme for people with COPD and their families and/or carers. In conjunction with optimal medical management, it has been shown to be an effective and cost-effective intervention in managing this complex group of patients and improving their quality of life (NCCCC, 2004; BTS, 2001).
A paper by the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation (1997) reviews and summarises the substantial evidence base for pulmonary rehabilitation programmes (PRP). The benefits are summarised in Box 1.
Many studies have also demonstrated that these benefits are maintained for up to two years following the completion of the PRP, with improvements in health status being the most sustained change (Singh et al, 1998; Foglio et al, 1999; Troosters et al, 2000).
A common misconception is that PRPs will improve lung function. However, they cannot alter the underlying disease process or permanent pathological changes that have occurred in the lungs.
The aims of pulmonary rehabilitation
COPD has a significant impact on both the physical and psychological well-being of patients. It is impossible to separate these two factors, and health care providers must address both of them throughout the pulmonary rehabilitation programme.
The overall aim of pulmonary rehabilitation is to enable patients to be in control of their own condition rather than their symptoms controlling them. The complex nature of COPD means that a range of strategies must be employed, incorporating the skills and knowledge of a wide range of health professionals.
This overall aim is achieved by a combination of smaller, more precise objectives (Box 2).
Who can benefit from pulmonary rehabilitation?
Historically, PRPs have been designed for patients with COPD as they are the largest group of patients with chronic lung disease.
The programmes are often considered when all other treatments have been tried and failed.
However, there is a growing body of evidence to support the use of pulmonary rehabilitation with all patients who have a chronic respiratory disease that impacts on their quality of life (BTS, 2001). The NCCCC guidelines (2004) recommend that pulmonary rehabilitation should be available to all patients who feel they are limited by their breathlessness.
There is particular interest in providing pulmonary rehabilitation for patients who undergo surgical treatments for chronic lung disease such as lung volume reduction surgery or transplantation, and for other chronic lung diseases such as asthma or interstitial diseases such as pulmonary fibrosis (ACCP/AACVPR, 1997).
How are the benefits of PRPs achieved?
Organising the service The evidence shows that PRPs are equally effective in hospitals and the community (BTS, 2001). With the introduction of the GMS contract (DoH, 2004) and the NCCCC (2004) COPD guidelines earlier this year, there are now significant moves towards setting up services based in primary care.
There is also research looking at the development of home-based pulmonary rehabilitation. It seems that the content of the PRP is more important than the location (BTS, 2001).
Content of the programme The optimal programme length is 6-8 weeks, with patients attending twice a week for supervised exercise and education sessions. A home exercise programme should be carried out on at least one other occasion during the week. Patients are encouraged to increase their activity on other days.
The exercise component The idea of starting an exercise programme can be daunting for people with COPD. They are often afraid that they will lose control of their breathing.
As a result, many fall into a downward spiral of inactivity. With this in mind, all programmes have to be tailored to the needs of the individual patient.
The design of the exercise component is dependent on the availability of space and equipment, although a circuit-based programme is commonly used. The main emphasis is on aerobic exercise at a level that challenges the cardiovascular system, including walking, step-ups, static bikes or climbing the stairs.
Educational component The course must have a comprehensive, multidisciplinary educational component that addresses the need for the patient to make lifestyle changes. This must be taught at an appropriate level by staff with a specialist interest in respiratory disease.
Patients' families and/or carers should be given the opportunity to attend. Family and carers are invaluable in reinforcing the information learnt when the patient is at home and carrying out day-to-day activities. The main topic areas that should be covered are shown in Box 3.
Many of the changes achieved through PRP cannot be measured using standard assessment tools. However, small seemingly insignificant changes can have a considerable impact on quality of life.
With such strong evidence to support its use, there is no reason pulmonary rehabilitation should not be available to all patients who could benefit.