PULMONARY REHABILITATION Jane Simpson Abigail Asantewaa Clinical

PULMONARY REHABILITATION Jane Simpson & Abigail Asantewaa Clinical Lead & Senior Physiotherapist ARCa. Re Team, Tower Hamlets

Summary of this talk • • What is COPD like? What is Pulmonary rehabilitation? The exercise component Skeletal Muscle Dysfunction The education component Selling the Program Recent Projects Referring

Imagine a typical COPD patient… • What does it feel like to have COPD? ?

The Vicious cycle Reduced exercise tolerance Muscle weakness Fatigue, anxiety, isolation Fear of breathlessness Inactivity/Immobility

What can the patient do about it? • • Ignore it – that’s just the way it is… Keep trying different medication… Have a serious go at smoking cessation… Do something POSITIVE! – “This is not going to go away, but there is something that I can do to help myself and it will be worth putting in the effort”

Pulmonary rehabilitation ‘Is an evidence based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualised treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease’ ATS/ERS statement on pulmonary rehabilitation (2006) American journal of respiratory and critical care medicine, 173: 1390 -1413

WHAT IS PR? • A Multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise physical and social performance and autonomy. • BTS statement 2001

HOW DO YOU SELL IT?

HOW DO WE SELL IT? • Try to avoid just explaining it as “an exercise class” • Can take the approach of explaining the viscous cycle • Choose words carefully when explaining the class.

Explain Using the dyspnoea spiral When you have COPD you become a little more breathless… This causes you to become less active because you don’t feel able to do as much and getting breathless makes you feel a bit scared anxious… This causes your body to get unfit because its not as active as it was before… This makes you more EVEN MORE breathless… Meaning that you become EVEN LESS active Causing you to become MORE UNFIT and get EVEN MORE breathless

SELLING IT • Helpful to reinforce that although SOB becomes worse with worsening COPD severity, this vicious cycle is a significant contributor to worsening SOBOE. • Once they acknowledge and understand this, then explain that there is a way to reverse the process using some key phrases

SELLING IT • • • With some GENTLE exercise In a class with other people WHO ALSO HAVE COPD So everyone in the class is in the SAME POSITION as you Run by skilled PHYSIOTHERAPISTS who understand your disease and its impact. The class provides a SAFE & SUPPORTED environment to get fitter and be able to DO MORE Will REDUCE YOUR SENSATION OF BREATHLESNESS and the fear/anxiety associated with it. There are talks after the exercise with a CUP of TEA. OTHER SPECIALISTS are invited to talk to the group and answer your questions You will finish the course able to WALK FURTHER/DO MORE, feel more CONFIDENT managing your breathlessness and knowing MUCH MORE about COPD and how to MANAGE YOUR CONDITION

EXPLAINING IT • • 8 week course, attending twice a week Have the option of two types of class – more conventional circuits or T’ai-chi Only for people with breathing problems Run as a group (max 12) Gentle exercise to work on your fitness Lots of advice and support about self-management Choose your venue

THE EXERCISE COMPONENT • The BTS guidelines on pulmonary rehabilitation (BTS, 2013) – A combination of progressive muscle resistance and aerobic training should be delivered – Exercises should be completed at a minimum of 60% peak work rate – Two sessions of supervised exercise per week with a third unsupervised session of prescribed exercise – Encouragement of regular physical activity at least 5 x per week for 30 mins in line with standard healthy living guidelines by Do. H.

THE EXERCISE COMPONENT • Circuit of 8 exercises • Mixture of strength training, endurance training and cardiovascular work • Reinforcement of use of pacing and breathing techniques • Work on recognising “safe” dyspnoea • Repetitions and resistance documented each class and encouragement given to progress week on week • Adapted to comorbidities and goals. • Encourage to engage in a regular home exercise program

Let’s have a go!

Limiting symptoms in COPD patients at peak exercise Dyspnoea and leg fatigue 31% Dyspnoea 26% Killian KJ, et al. 1992. Leg fatigue 43%

Skeletal Muscle Dysfunction in COPD • “COPD goes beyond the lungs and incurs significant systemic effects among which muscle dysfunction/wasting in one of the most important” (Rabinovich & Vilaro, 2011) • Is a prominent contributor to exercise tolerance (Saey et al. 2003), healthcare utilisation (Decramer et al, 1997) and an independent predictor of morbidity and mortality (Agusti et al, 2003) • Is characterised by two related phenomena; malfunctioning of the muscle and a net loss of muscle mass (Agusti et al, 2003)

Skeletal Muscle Dysfunction Structural and Functional Changes of Peripheral Muscles in COPD Patients Rabinovich &Vilaro (2011)

Muscle Atrophy • Present in 18 -36% of patients and responsible for weight loss in 17 -25% • Responsible for losses in strength and endurance and independent of the degree of airway obstruction a) Normal 118. 5 cm 2 b) COPD 79. 6 cm 2 Casaburi (2006)

Fibre Type Redistribution • Increases in some fibre types to the detriment of others • Evidence indicates that fibres convert from one type to another and that some selectively atrophy Couillard & Prefait (2005) • Similar patterns of fibre redistribution present in hypoxia and anorexia, indicating that factors other than disuse are contributing to atrophy, eg diet and ABG’s. Proportion of Type 1 fibres almost 50% lower in COPD patients, reinforcing that disuse is unlikely to be the only mechanism causing muscle abnormalities in these patients

Pathogenic Mechanisms • Protein synthesis/breakdown balance – Skeletal muscle mass maintained by a delicate balance between protein synthesis and protein breakdown. – COPD patients have an abnormal turnover of protein thus muscle mass is lost • Nutritional Abnormalities – COPD patients have a higher resting energy expenditure – This is often not compensated for with an increased calorific intake – This calorific imbalance makes it difficult to maintain muscle mass.

Pathogenic Mechanisms • Muscle Disuse – Due to reduced participation in activities of daily living – Changes in work loads has a detrimental effect on muscle size • Systemic Corticosteroids – Can cause corticosteroid associated myopathy – Has a prominent effect on fibre type IIb – Close relationship between the duration and doses of the treatment and the functional and structural changes

Pathogenic Mechanisms • Tissue Hypoxia and Hypercapnia – Chronic/intermittent alterations in ABG composition is a common feature in COPD – Tissue hypoxia limits the production of energy and affects the protein synthesis leading to muscle loss – Hypercapnia results in processes which induce protein degradation

Pathogenic Mechanisms • Inflammation – COPD is recognised as an inflammatory disease & evidence of systemic inflammation has been shown in several studies – Elevated pro-inflammatory cytokines have been associated with reduced lean mass, muscle wasting & increased rest energy expenditure • Mitochondrial abnormalities – Reduced mitochondrial density in muscle – Leading to a reduced oxidative capacity of muscles and subsequently a reduced ability to work aerobically

The Education Component • An essential component of treatment as it facilitates reduction of risk factors and improves patient’s ability to independently cope with the disease. • These education sessions will inevitably improve adherence to exercise and medication, reduce admissions, improve mortality and improve quality of life.

The Education Component • • • • What is COPD? How breathing works Why Exercise? Understanding medications and inhaler techniques Managing breathlessness How to keep your chest clear Goal setting Energy conservation & sleep (OT) Stress management and relaxation (OT) Emotions and breathlessness (psychologist) What is being healthy? Healthy eating (dietician) Plan of Action for exacerbations Air pollution Holiday and travel Role of Primary care (Saturday class)

What do we do in Tower Hamlets? • • • Currently 5 choices of venue T’ai Chi as alternative to circuit training 1 physiotherapist and one RSW Bengali speaking RSW’s Heart failure/IPF/ chronic asthma patients included Home exercise programme option available for genuinely housebound (limited) • Maintenance Program terminated due to poor adherence

Referring for Pulmonary rehabilitation • • • Fill in referral form Fax it to number on form Inclusion criteria: – Stable chronic lung disease – Limited functional ability due to breathlessness – Motivated to exercise – Optimised respiratory management

Exclusion criteria • Unstable angina/hypertension • Angina more than once weekly • Angina at rest/at night • Uncontrolled cardiac arrhythmias • Severe heart failure • Cardiac event within past 6 weeks • Capacity Please include additional information to help us plan.

Weekend PR Project • To assess the feasability of a 6 week Multi-disciplinary Weekend Pulmonary Rehabilitation service for patients with weekday work commitments. • Currently evaluating outcomes • If positive will be starting something similar early 2017 and will be a performed as standalone cohort programs due to low numbers

Recent PR Feedback Project • AIMS – To explore patient and staff experiences within ARCa. Re pulmonary rehabilitation classes in Tower Hamlets. – To see if what we are offering is what is needed (Demands have changed over the past 6 years – To identify themes from reported experiences to improve the ARCa. Re pulmonary rehabilitation pathway and service – Highlight areas of good practice within the ARCa. Re pulmonary rehabilitation pathway and service

Pulmonary Rehabilitation review. • OUTCOMES Ø Overall results very positive Ø Amend communication pathways with pts. Ø Re design exercise record sheets with prompts for reflection Ø Social interaction was a major enjoyment factor Ø More structure to ending and exploration of a way forward Ø Staff induction Ø Location and logistics were the main negatives

PATIENT QUOTES – – – “Gets you out of the house” “Meeting people with same condition was nice” “Enjoyed the discussion with other patients” – “My depression and anxiety was improved by being there” – “I really found the breathing exercises & calming of my mind helpful” – “Up until then I didn’t know what COPD was, now I’m informed of what it is all about” – “Its nice to have that space and time to understand what’s happening”

In summary…. for the patient • Improve independence in daily functioning • Improve knowledge of lung condition and promote self-management • Increase muscle strength and endurance (peripheral and respiratory) • Increase exercise tolerance and reduce dyspnoea • Reduce length of hospital stay • Improve health related quality of life • Promote long term commitment to exercise. Garrod 2003 (Chartered society of Physiotherapy briefing)

Thank you! • Any Questions?

References • Agustí AG, Noguera A, Sauleda J, Sala E, Pons J, Busquets X (2003). Review Systemic effects of chronic obstructive pulmonary disease. European Respiratory Journal, Feb; 21(2), 347 -60. • ATS/ERS statement on pulmonary rehabilitation (2006). American Journal of Respiratory and Critical Care Medicine, 173, 1390 -1413. • Bernard et al. (1998). Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 158(2), 629 -634. • BTS statement (2001). British Thoracic Society standards of care subcommittee on pulmonary rehabilitation. Thorax, 56, 827 -834. • British Thoracic Society guideline on pulmonary rehabilitation in adults (2013) • Casaburi R (2006). Impacting patient-centred outcomes in COPD: deconditioning. European Respiratory Review 15, 42 -46.

References • Couillard A, Prefaut C (2005). From muscle disuse to myopathy in COPD: potential contribution of oxidative stress. European Respiratory Journal, 26, 703 -719. • Decramer M, Gosselink R, Troosters T, Verschueren M, Evers G (1997). Muscle weakness is related to utilization of health care resources in COPD patients. European Respiratory Journal, 10(2), 417 -23. • Jobin et al. (1998). COPD: capillarity and fibre-type characteristics of skeletal muscle. Journal of Cardiopulmonary Rehabilitation, 18(6), 432 -427. • Killian, KJ et al. (1992). Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. The American Review of Respiratory Disease, 146(4), 935 -940. • NICE (2010) Chronic Obstructive Pulmonary Disease (update)

References • Rabinovich RA and Vilaro J (2010). Structural and Functional Changes of Peripheral Muscles in COPD Patients. Current Opinion in Pulmonary Medicine. 16(2), 123 -33. • Richardson RS, Leek BT, Gavin TP, Haseler LJ, Mudaliar SR, Henry R, Mathieu-Costello O, Wagner PD (2004). Reduced mechanical efficiency in chronic obstructive pulmonary disease but normal peak VO 2 with small muscle mass exercise American Journal of Respiratory Critical Care Medicine, 169(1), 89 -96 • Saey D, Debigare R, Le. Blanc P, Mador MJ, Cote CH, Jobin J, Maltais F (2003). Contractile leg fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive pulmonary disease. American Journal of Respiratory Critical Care Medicine, 168(4), 425 -30.