Desktop Helper No. 7 - Pulmonary rehabilitation in the community - online

What is the essence of Pulmonary Rehabilitation?

Pulmonary rehabilitation (PR) is a structured programme tailored to an individual’s needs to reduce their breathlessness, improve their quality of life (including their fear of breathlessness), and improve their exercise capacity. The intervention therefore improves people’s ability to participate in daily life. It is an exercise-based programme accompanied by self-management education to help people live better with chronic lung disease. It is fundamental to, and should be integrated into, their overall care. PR has also been shown to reduce the use of expensive
services such as hospital inpatient care. It can be delivered safely in the community, outside of hospital. Despite its proven clinical and costeffectiveness, PR is widely underused. (1,2)

Who is PR for?

PR is for adults of all ages who are functionally limited by their breathlessness despite current management.

Why is it important?

People with chronic lung conditions like COPD become breathless with little exertion and this can be very frightening for them and their families or carers. As a result, people may avoid activities which make them breathless, leading to physical deconditioning, demotivation and potentially social isolation.

There are two essential messages to communicate, even if difficult for many breathless people to understand and healthcare professionals to convey:

“Breathlessness whilst moving around is NORMAL.”
“It is not harmful or dangerous to feel short of breath whilst moving.”

See the examples at www.ipcrg.org/PR

ASK about breathlessness “How has breathlessness changed your life?” “What troubles you most about being breathless?” Use a Breathlessness Scale e.g. MRC

ADVISE: “PR helps you breathe better, feel good, do more/return to work [if applicable] and I strongly recommend it. Have a look at what other breathless people say about it.”

ACT: Patients interested in going to PR will require support. What you say to them will depend on what support is available and accessible. But every patient can be congratulated and informed about the next step:

“That is an important decision, well done. I will now refer you...” either “... to the Pulmonary Rehabilitation programme” or “... to see an expert who can assess your breathlessness and decide on the right programme for you.” or

ACT: If they say no/not yet “It is your choice of course so let me know if you change your mind and I will ask again when we next meet. It is a great opportunity to meet others with a similar experience, to learn to control your breathlessness and to reduce the impact of your breathlessness on your life.”

Provide information and education about their condition and how they can best live with and manage their problems and medications e.g. Living Well and IPCRG. This will be reinforced in the programme.

Setting up a Pulmonary Rehabilitation service from zero to help people breathe better, feel good and do more

View guidelines at www.ipcrg.org/PR and note conclusions from recent systematic reviews suggest there is no “right” way to provide it. Therefore we advocate adaptation to local circumstances: e.g. assessment, programme of prescribed exercises preferably face-to-face but possibly structured home-based with telephone or internet support, and flexible educational approaches. (4) We have used our network’s experience to offer guidance on how they do it.

The basic elements can be relatively easy to set up:

1. Location: accessible. Assessment sites and group classes can be held in different locations. If transport is unavailable, consider homebased. Spread of locations may increase uptake.
2. Facilities: a. For assessment: space for initial walk test. b. For programme: aim for a space for groups of 6 or more, available for a minimum of 1.5 hours twice a week (1 hour exercise, 30 mins education) for a minimum of 6 weeks. Replicate normal life as far as possible e.g. air-conditioning is not necessary; run programmes outdoors. Non-healthcare environments are acceptable. Consider including induction in a facility participants might use afterwards.
3. Timing: should be flexible based on the needs of the participants to ensure maximum participation. Allow a rest day between exercise classes.
4. Equipment: can be varied and low-tech as long as it delivers aerobic and strength training e.g. walking aids, dumbbells, bottles with sand, resistance bands, ankle weights; a phone or clickers for timing and to count; printed scoring systems for perceived difficulty of exercise, self-recording sheets and diaries for home sessions. Add pulse oximeters for assessment. For the education sessions: inhalers and inhaler technique training devices.
5. Referral and feedback processes: negotiate this locally and aim for as many referral sources as possible. Write down the referral process and educate referrers about who, how and when to refer individuals (include current smokers and people using portable oxygen). Request referrer’s direct phone number/email to enable easy communication especially about attendance and post PR performance.
6. Templates and tools: have simple templates and tools to support the assessment, prescription and progression of exercise and education for patients. 
7. Staff: use trained, knowledgeable staff e.g. physical therapist, nurse specialist, family physician. There is no right answer to the skillmix required to assess, deliver and support ongoing rehabilitation safely. It will depend on the local context and standards. Aim to create a team who can travel to different locations.

PR is an individually-tailored programme

A standard programme should be tailored to patient-specific physical, social, cognitive and psychological needs.

Assessment: also see www.ipcrg.org/PR

Holistic assessment is necessary to identify patients who will benefit and provide a baseline using validated assessment tools that can be used to evaluate the efficacy of the programme for individual and group outcomes. Therefore, assessment requires trained professional leadership to select and apply the right tools depending on the setting, systems and performance indicators. It should include:

• Exercise testing to measure exercise capacity and strength. The choice of test will allow for individualised exercise prescription e.g. incremental shuttle walk, sit to stand, grip strength
• Psychological: mood tends to improve during PR e.g. PHQ4 or HADS
• Quality of life e.g. for COPD: CCQ or CAT or CRQ
• Confidence/knowledge and understanding about COPD and/or level of activation

Examples at www.ipcrg.org/PR

Teach breathing control techniques to be used during and after exercise. Offer psychological support to enhance coping (e.g. with fear of breathlessness, illness exacerbations, adjustment to lifestyle and identify changes) and to address barriers to adherence and completion, e.g. Cambridge model.

Also include:

• What is the condition and its cause(s);
• how to protect your lungs: smoking cessation and avoiding indoor biomass smoke, the role of physical activity;
• goal setting;
• relaxation;
• diet and nutrition;
• medicines optimisation;
• exacerbation plans;
• communication with the health team; advanced care and end of life;
• relapse prevention and maintaining changes.

1. Glasziou 2017, Evidence for underuse of effective medical services around the world
2. Griffiths 2001, Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme
3. McCarthy 2015, Pulmonary rehabilitation for chronic obstructive pulmonary disease
4. Mathar 2015, Why do patients with COPD decline rehabilitation