Pulmonary Rehab in COPD: Combining Exercise and Education


Key Takeaways

  • Pulmonary rehabilitation (PR) programs should be individualised
  • Programs should be varied and include exercise, education and support
  • Highlight the benefits to your patient and emphasise the importance of adhering to a tailored program
  • It is recommended that PR is included as part of the management and treatment of COPD1-3

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What is Pulmonary Rehabilitation?

Pulmonary Rehabilitation is a multidisciplinary program of care that you can offer to your patient to help improve their health status.1,2

PR programs should incorporate:2

  • Physical training
  • Disease education
  • Nutritional support
  • Behavioural and psychological intervention
Identify your patient’s personal goals and assess your patient prior to enrolment.  When referring a patient for PR you can also use the opportunity to educate, assess comorbidities and refer for additional treatment if necessary. 1,3

Before referral you can:

  • Ask if they smoke and help them quit 1
  • Make a nutritional assessment 1
  • Discuss their personal challenges and how to overcome them 3
Remember, don’t offer PR to patients who can’t walk, have unstable angina or have recently had a myocardial infarction. 2

Why offer PR and how can it help? The evidence

GOLD recommend the use of PR as it can improve symptoms, quality of life, and physical and emotional participation in everyday activities.3

Most COPD patients benefit from PR but further research is needed to better refine the components of PR, predict treatment success or failure, understand how long treatment effects persist, and assess ideal program duration, intensity and location.4,5

The table below shows the expected benefits of PR for key outcomes.

Outcome Evidence for expected improvements
Breathlessness
+++
Exercise tolerance +++
Health-related quality of life +++
Respiratory muscle function ++
Health resource consumption ++
Survival +
Lung function _

Expected results of PR +++: based on randomised clinical trials and meta-analyses; ++: encouraging results but further evidence is needed; +: indirect evidence; -: no improvement.
Adapted from ERS, 20134

In addition to the symptom-reducing benefits, PR also ranks as one of the most cost-effective treatment strategies for COPD. 3

If your COPD patient has recently been hospitalised for an acute exacerbation, refer your patient for PR.2

What are the options

GOLD recommend supervised exercise training occurs at least twice weekly. This can include endurance, interval or resistance/strength training. Remember that upper and lower limbs should be included in training as well as walking exercise. In addition, flexibility, inspiratory muscle training and neuromuscular electrical stimulation can be incorporated into sessions. 3

Optimum benefits are achieved from programs lasting 6 to 8 weeks. Current evidence suggests that there are no additional benefits to extending PR to 12 weeks. 3

Fitting PR around your patient’s day to day life is important and may improve adherence. This can be achieved by ensuring: 2

  • PR sessions are held at a time that suit patients
  • Buildings used to host sessions are easy to locate
  • PR sessions have places available within a reasonable time following referral
  • Buildings used to host sessions have good access for people with disabilities
When considering the type of training, the British Thoracic Society (BTS) recommend combining  progressive muscle resistance with aerobic training such as walking or cycling when delivering a  program. While exercises should remain generic, intensity should be individualised for each patient. 1

Ensure that your patient is regularly assessed to grade improvement and remember to seek their feedback to inform your treatment decisions.1

It is key to individualise a PR program for each patient, emphasising that they may need to change their behaviour over a long period of time in order to improve their physical functionality and reduce the psychological impact of COPD. 3

Tools for Implementation

The Charted Society for Physiotherapy have developed the Pulmonary Rehabilitation Impact Model on Exacerbations (PRIME) to show the potential impact of PR on reducing COPD exacerbations.6 It includes a combination of data from Randomised Controlled Trials (RCTs), Clinical Practice Research Datalink data (CPRD) and the BTS/Royal College of Physicians (RCP) audit to help you improve your PR services.6

Summary

Offer pulmonary rehabilitation to all appropriate patients with symptomatic COPD, ensuring exercise training is a key component. It’s important that you emphasise PR is a long-term behavioural change and educate your patient on comorbidities. Encourage your patient by reminding them that rehabilitation has been shown to be the most effective therapeutic strategy to improve shortness of breath, health status and exercise tolerance.3


References
  1. Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax. 2013;68(Suppl 2):ii1-ii30. doi:10.1136/thoraxjnl-2013-203808
  2. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. December 2018. https://www.nice.org.uk/guidance/ng115/chapter/Recommendations#inhaled-combination-therapy. Accessed January 24, 2019.
  3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2019 Report). https://www.goldcopd.org Published 2018. Accessed January 24, 2019.
  4. Hill NS. Pulmonary Rehabilitation. European Lung White Book. 2013:340-347. https://www.erswhitebook.org/files/public/Chapters/29_rehabilitation.pdf
  5. McCarthy B, Casey D, Devane D, Murphy K, Murphy E LY. Cochrane Library: Pulmonary rehabilitation for chronic Obstructive Pulmonary Disease (Review). Cochrane Collab. 2015;1. doi:10.1002/14651858.CD003793.pub3. https://www.cochranelibrary.com
  6. Pulmonary Rehabilitation in COPD. https://www.csp.org.uk/professional-clinical/professional-guidance/pulmonary-rehabilitation-copd. Accessed March 14, 2019.

PM-GB-CPU-WCNT-190004 - April 2019

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PM-GB-CAU-WCNT-190006
March 2019