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Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
Benefits of breathlessness rehab in UK and Canada
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Benefits of breathlessness rehab in UK and Canada

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The benefits of generic breathlessness rehabilitation in the UK and Canada - Dr Rachael Evans, Consultant Respiratory Physician …

The benefits of generic breathlessness rehabilitation in the UK and Canada - Dr Rachael Evans, Consultant Respiratory Physician
Presentation from the Breathlessness Symposium held in London on 1 July 2014

Published in: Healthcare, Health & Medicine
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  • 1. Generic exercise rehabilitation for breathlessness Dr Rachael Evans PhD Consultant Respiratory Physician/Honorary Senior Lecturer Glenfield Hospital, Leicester, UK
  • 2. Content 1) Similar symptoms and disability between COPD and CHF 2) Rationale for a combined service 3) Is combined exercise rehabilitation feasible and effective? 4) Implementation 5) Conclusion
  • 3. Extent of the problem  900 000 people in the UK have heart failure and 30-40% die in the first year of diagnosis  1 million inpatient bed days – 2% of all NHS inpatient bed-days and 5% of all emergency medical admissions to hospital  900 000 people in the UK suffer with COPD – 1 million bed days per yr and 1/8 emergency admissions  Both conditions are likely under-diagnosed – ‘the missing millions’  COPD and CHF commonly co-exist (15 -30%)
  • 4. Similar disability between COPD and CHF  Common symptoms of exertional breathlessness and fatigue Anxiety and depression Social isolation
  • 5. Organ impairment and exercise capacity  Degree of primary organ impairment correlates poorly with exercise capacity in COPD and CHF Gosker et al Chest 2003; 123: 1416-1424
  • 6. Secondary alterations of COPD and CHF  Skeletal muscle dysfunction  Anxiety and depression  Osteoporosis  Hormonal imbalance  Anaemia  Physical inactivity  Systemic inflammation  Oxidative stress  Nutritional abnormalities  Neurohumeral activation Many of which contribute to exercise limitation
  • 7. Skeletal Muscle Dysfunction (locomotor) Gosker et al Am J Clin Nutr 2000;71:1033-47  Skeletal muscle performance  Morphology  Muscle fibre type  Muscle metabolism
  • 8. Exercise training and skeletal muscle dysfunction  CHF  COPD Hambrecht et al JACC 1997 (5):1067–73 Whittom et al Med Sci Sports Exerc. 1998;30(10):1467-74.
  • 9. Evidence for exercise training in CHF
  • 10. Exercise training for CHF  No change in short term mortality but decrease at > 12 months  Further analysis of HF-ACTION trial2 reported for every 6% increase in VO2 was associated with 5% decrease in mortality  Reduced hospital admission  RR 0.75 [0.62 -0.92], p<0.005  Improves exercise performance  6MWD 41m, Peak VO2 2.2 ml/min/kg  Improved HRQOL 6.1 units (>MCID MLWHFQ 4 units)
  • 11. Safety of exercise training in CHF  1999 CHANGE STUDY – no adverse events  2004 Cochrane Database Syst Rev– few adverse events  2009 HF-ACTION included NYHA IV and ICDs – no increase in adverse events  Evidence that beneficial LV remodelling occurs with ET3 1Eur Heart J 1999; 20: 872-979 2JAMA 2009; 301(14): 1439–1450 3Int J Clin Pract 2012;66 :782-79
  • 12. Exercise rehabilitation for CHF – current provision in the UK  National COPD audit 2008 ; 90% acute UK sites have a PR programme  NACR UK 2013 reported:  only 2% of patients with CHF have access to CR  15% of CR programmes decline patients with HF  16% of centres offer separate CR programmes – …. Most of the CHF trials were not part of CR programmes BMJ Open 2012; 2: e000787
  • 13. Why might the pulmonary rehabilitation model be appropriate for patients with CHF?
  • 14. The Model of Pulmonary Rehabilitation  Targets the extra-pulmonary manifestation of chronic respiratory disease  Key Components (symptom-based) – Exercise training , Multi-disciplinary education, Psychological support, Self Management – International guidelines ATS/ERS 2006 updated 2013 ACCP/AACVPR 2007
  • 15. What does NICE say?  NICE COPD 2004 (updated 2010)  5 detailed recommendations  NICE CHF 2008 (updated 2013)  “Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure”  “The programme may be incorporated within an existing cardiac rehabilitation programme”
  • 16. Why not Cardiac Rehabilitation?  Main focus is secondary prevention (asymptomatic)  Typically for post MI, CABG, Valve Sx and stable angina  Traditional CR population have a good functional status JCPR 1995; 15 (4):277-282 ISWT (m)
  • 17. Similarities in exercise training prescription COPD CHF Aerobic LL training High intensity (60-80% peak VO2 ) High intensity (40-70% peak VO2 ) Duration Min 6-12 weeks Min 12 weeks Frequency Min x3/week Min x3/week Interval √ √ Additional Strength training √ High resistance √ Low resistance Mod- high maybe safe Adjuncts Helium/hyperoxia/one- legged/NIV ? Evans 2011 Chronic Resp Dis 8 (4): 259-269
  • 18. Co-existent disease  COPD and CHF commonly co-exist and are often undiagnosed  In a PR cohort 15% of patients with COPD also had heart failure1  19% of in-patients post CABG attending CR had COPD 2  Existing model of disease-specific services are never exclusive 1Thorax 2008;63:487-492 2Eur J Cardiovasc Prev Rehabil. 2008 Aug;15(4):379-85.
  • 19.  Would the symptom based model be beneficial for patients with CHF? – RCT of PR vs UC in CHF  Is combined PR for COPD and CHF effective and feasible? – Longitudinal study
  • 20. Measures of disability  MRC Dyspnoea Scale 1 I get breathless only with strenuous exercise 2 I get breathless when hurrying or walking uphill 3 I walker slower than people of the same age on the level or I have to stop because of breathlessness on the level 4 I can only walk 100 yards before stopping because of breathlessness or after a few minutes on the level 5 I am breathless when dressing or undressing or I am too breathless to leave the house  Described in 1959 (BMJ) in the ‘working class’ population Advantages over the NYHA  Self assessed  Standardised descriptions  Assessment of dyspnoea on activity limitation
  • 21. MRC scale in CHF  MRC scale in CHF  MRC in CHF and COPD ANOVA p=0.915 ERJ 2008; 32: suppl 52 1328
  • 22. Generic outcome measures Physical performance  Incremental Shuttle Walk Test (ISWT)  Endurance Shuttle Walk Test (ESWT) Health Status  Disease specific questionnaire – CRQ or CHQ  Generic questionnaire – SF36  Cardiopulmonary Exercise test (CPX)  Isometric Quadriceps Strength
  • 23. Development of a self reported version of the CHQ  Comparable with interview led version  Construct validity  Repeatability  Responsiveness Evans et al JCPR 2011; 31(6): 365-72
  • 24. Intervention: Pulmonary Rehabilitation  Two hospital visits a week for 7 weeks – 1 hour of physical training – 1 hour of multi- disciplinary education  Daily endurance training at 85% VO2 peak predicted derived from the ISWT
  • 25. RCT of PR vs usual care (UC) in CHF PR: 62 (35 to 89)m vs. UC: -6 (-11 to 33)m p<0.001 d=0.57 PR: 351 (203 to 498) vs. UC: -36 (-77 to 4) p<0.001 d=0.95 Evans et al Resp Med 2010; 104: 1473 - 1481
  • 26. Results COPD vs CHF -baseline demographics – CHF mean (SD) LVEF 32.9 (9.6)% – COPD mean (SD) FEV1 % predicted 42.9 (14.6) COPD (n=55) CHF (n=44) p Age (yrs) 69.1 (8.3) 70.6 (10.7) 0.423 Gender (% male) 54.5 % 65.9% 0.255 MRC scale* 3 (3-4) 3 (3-4) 0.302 BMI 27.4 (5.2) 31.6 (6.2) <0.001 Mean (SD) * Median (IQ range)
  • 27. BMI and results of PR for COPD Greening N CRD 2011; 9: 99 -106
  • 28. Results -baseline exercise performance COPD CHF p ISWT (m) 225 (114) 234 (148) 0.767 ESWT (secs) 247 (154) 211 (81) 0.181 CPX Peak VO2 (L/min) 0.89 (0.29) 0.95 (0.4) 0.394 Knee extensor strength (Nm) 114.6 (43.9) 117.7 (51.4) 0.753 Mean (SD) • There were no adverse events in either group • Comparable limiting symptoms
  • 29. Results of pulmonary rehabilitation -exercise performance  44 COPD and 32 CHF completed pulmonary rehabilitation *p<0.0005 * *p<0.001 * *p<0.001 ISWT distance ESWT time * *
  • 30. Results of pulmonary rehabilitation -health Status COPD CRQ p CHF CHQ p Dyspnoea 0.94 <0.001 0.66 0.001 Fatigue 1.24 <0.001 0.36 0.016 Emotional Function 0.92 <0.001 0.35 0.035 Mastery 0.78 <0.001 0.36 0.014  Both groups made statistically significant improvements in all four domains of the disease specific questionnaires *All scores presented as mean change in units
  • 31. Adjustments  Adjustments – cardiac monitoring for the initial exercise assessments – adaptation of the education programme – education for the PR team: CHF and the symptoms and signs of decompensation  Combined exercise rehabilitation, in the same location, by the same therapists is feasible and effective for patients with COPD and CHF
  • 32. Symptom Based vs Disease Specific Models for Exercise Rehabilitation PRO  Concentrates the therapy on disability  Feasible  PR populations are becoming increasingly diverse (ILD, Bronchiectasis, Asthma, Obesity, Pulmonary Hypertension)  Multiple co-morbidities  Therapists experts in exercise prescription and training for breathless patients CON  Disease specific education is more difficult to deliver  Patients may wish to be in groups with similar disease  Training of staff in other disease areas
  • 33. Theoretical symptom-based model for provision of exercise rehabilitation programmes
  • 34. Increasing choice of service delivery Exercise Rehabilitation
  • 35. Clinical Implementation  Currently run a separate HF-ER service based on the PR model at GGH – Different funding stream  Post-doctoral fellowship in Toronto – further challenges is Canada due to geography – keen to enrol patients with heart failure to the out-patient PR programme – difficulty crossing boundary specialities  Combined programmes in UK but limited data
  • 36. Summary  Patients with COPD & CHF suffer similar symptoms and resultant disability  The symptom based model of pulmonary rehabilitation can be successfully applied to patients with CHF  Combined exercise rehabilitation is feasible and effective for patients with COPD and CHF  Further work to assess – Cost-effectiveness of a combined symptom-based strategy
  • 37. Content 1) Similar symptoms and disability between COPD and CHF 2) Rationale for a combined service 3) Is combined exercise rehabilitation feasible and effective? 4) Implementation 5) Conclusion
  • 38. Extent of the problem  900 000 people in the UK have heart failure and 30-40% die in the first year of diagnosis  1 million inpatient bed days – 2% of all NHS inpatient bed-days and 5% of all emergency medical admissions to hospital  1 million people in the UK suffer with COPD  Both conditions are likely under-diagnosed – ‘the missing millions’  COPD and CHF commonly co-exist (15 -30%)
  • 39. Similar disability between COPD and CHF  Common symptoms of exertional breathlessness and fatigue Anxiety and depression Social isolation
  • 40. Organ impairment and exercise capacity  Degree of primary organ impairment correlates poorly with exercise capacity in COPD and CHF Gosker et al Chest 2003; 123: 1416-1424
  • 41. Secondary alterations of COPD and CHF  Skeletal muscle dysfunction  Anxiety and depression  Osteoporosis  Hormonal imbalance  Anaemia  Physical inactivity  Systemic inflammation  Oxidative stress  Nutritional abnormalities  Neurohumeral activation Many of which contribute to exercise limitation
  • 42. Skeletal Muscle Dysfunction (locomotor) Gosker et al Am J Clin Nutr 2000;71:1033-47  Skeletal muscle performance  Morphology  Muscle fibre type  Muscle metabolism
  • 43. Exercise training and skeletal muscle dysfunction  CHF  COPD Hambrecht et al JACC 1997 (5):1067–73 Whittom et al Med Sci Sports Exerc. 1998;30(10):1467-74.
  • 44. Evidence for exercise training in CHF
  • 45. Exercise training for CHF  No change in short term mortality but decrease at > 12 months  Further analysis of HF-ACTION trial2 reported for every 6% increase in VO2 was associated with 5% decrease in mortality  Reduced hospital admission  RR 0.75 [0.62 -0.92], p<0.005  Improves exercise performance  6MWD 41m, Peak VO2 2.2 ml/min/kg  Improved HRQOL 6.1 units (>MCID MLWHFQ 4 units)
  • 46. Safety of exercise training in CHF  1999 CHANGE STUDY – no adverse events  2004 Cochrane Database Syst Rev– few adverse events  2009 HF-ACTION included NYHA IV and ICDs – no increase in adverse events  Evidence that beneficial LV remodelling occurs with ET3 1Eur Heart J 1999; 20: 872-979 2JAMA 2009; 301(14): 1439–1450 3Int J Clin Pract 2012;66 :782-79
  • 47. Exercise rehabilitation for CHF – current provision in the UK  National COPD audit 2008 ; 90% acute UK sites have a PR programme – NACR UK 2013 reported:  only 2% of patients with CHF have access to CR  15% of CR programmes decline patients with HF  16% of centres offer separate CR programmes – …. Most of the CHF trials were not part of CR programmes BMJ Open 2012; 2: e000787
  • 48. Why might the pulmonary rehabilitation model be appropriate for patients with CHF?
  • 49. The Model of Pulmonary Rehabilitation  Targets the extra-pulmonary manifestation of chronic respiratory disease  Key Components (symptom-based) – Exercise training , Multi-disciplinary education, Psychological support, Self Management – International guidelines ATS/ERS 2006 updated 2013 ACCP/AACVPR 2007
  • 50. What does NICE say?  NICE COPD 2004 (updated 2010)  5 detailed recommendations  NICE CHF 2008 (updated 2013)  “Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure”  “The programme may be incorporated within an existing cardiac rehabilitation programme”
  • 51. Why not Cardiac Rehabilitation?  Main focus is secondary prevention (asymptomatic)  Typically for post MI, CABG, Valve Sx and stable angina  Traditional CR population have a good functional status JCPR 1995; 15 (4):277-282 ISWT (m)
  • 52. Similarities in exercise training prescription COPD1 CHF2 Aerobic LL training High intensity (60-80% peak VO2 ) High intensity (40-70% peak VO2 ) Duration Min 6-12 weeks Min 12 weeks Frequency Min x3/week Min x3/week Interval √ √ Additional Strength training √ High resistance √ Low resistance Mod- high maybe safe3 Adjuncts Helium/hyperoxia/one- legged/PAV ? Evans 2011 Chronic Resp Dis 8 (4): 259-269
  • 53. Co-existent disease  COPD and CHF commonly co-exist and are often undiagnosed  In a PR cohort 15% of patients with COPD also had heart failure1  19% of in-patients post CABG attending CR had COPD 2  Application of existing model of disease-specific services are never exclusive 1Thorax 2008;63:487-492 2Eur J Cardiovasc Prev Rehabil. 2008 Aug;15(4):379-85.
  • 54.  Would the symptom based model be beneficial for patients with CHF? – RCT of PR vs UC in PR  Is combined PR for COPD and CHF effective and feasible? – Observational trial
  • 55. Generic outcome measures Physical performance  Incremental Shuttle Walk Test (ISWT)  Endurance Shuttle Walk Test (ESWT) Health Status  Disease specific questionnaire – CRQ or CHQ  Generic questionnaire – SF36  Cardiopulmonary Exercise test (CPX)  Isometric Quadriceps Strength
  • 56. Intervention: Pulmonary Rehabilitation  Two hospital visits a week for 7 weeks – 1 hour of physical training – 1 hour of multi- disciplinary education  Daily endurance training at 85% VO2 peak predicted derived from the ISWT
  • 57. RCT of PR vs usual care (UC) in CHF PR: 62 (35 to 89)m vs. NC: -6 (-11 to 33)m p<0.001 d=0.57 PR: 351 (203 to 498) vs. NC: -36 (-77 to 4) p<0.001 d=0.95 Evans Resp Med 2010; 104: 1473 - 1481
  • 58. Results COPD vs CHF -baseline demographics – CHF mean (SD) LVEF 32.9 (9.6)% – COPD mean (SD) FEV1 % predicted 42.9 (14.6) COPD (n=55) CHF (n=44) p Age (yrs) 69.1 (8.3) 70.6 (10.7) 0.423 Gender (% male) 54.5 % 65.9% 0.255 MRC scale* 3 (3-4) 3 (3-4) 0.302 BMI 27.4 (5.2) 31.6 (6.2) <0.001 Mean (SD) * Median (IQ range)
  • 59. Results -baseline exercise performance COPD CHF p ISWT (m) 225 (114) 234 (148) 0.767 ESWT (secs) 247 (154) 211 (81) 0.181 CPX Peak VO2 (L/min) 0.89 (0.29) 0.95 (0.4) 0.394 Knee extensor strength (Nm) 114.6 (43.9) 117.7 (51.4) 0.753 Mean (SD) • There were no adverse events in either group • Comparable limiting symptoms
  • 60. BMI and results of PR for COPD Greening N CRD 2011; 9: 99 -106
  • 61. Results of pulmonary rehabilitation -exercise performance  44 COPD and 32 CHF completed pulmonary rehabilitation *p<0.0005 * *p<0.001 * *p<0.001 ISWT distance ESWT time * *
  • 62. Results of pulmonary rehabilitation -health Status COPD CRQ p CHF CHQ p Dyspnoea 0.94 <0.001 0.66 0.001 Fatigue 1.24 <0.001 0.36 0.016 Emotional Function 0.92 <0.001 0.35 0.035 Mastery 0.78 <0.001 0.36 0.014  Both groups made statistically significant improvements in all four domains of the disease specific questionnaires *All scores presented as mean change in units
  • 63. Adjustments  Adjustments – cardiac monitoring for the initial exercise assessments – adaptation of the education programme – education for the PR team: CHF and the symptoms and signs of decompensation
  • 64. Symptom based vs Disease specific models for Exercise Rehabilitation PRO  Concentrates the therapy on disability  PR populations are becoming increasingly diverse (ILD, Bronchiectasis, Asthma, Obesity, NMD, Pulmonary Hypertension)  Therapists experts in breathlessness and exercise prescription CON  Disease specific education is more difficult to deliver  Patients may wish to be in groups with similar disease  Training of staff in other disease areas
  • 65. Theoretical symptom-based model for provision of exercise rehabilitation programmes Could then concentrate on delivering combined services in different settings
  • 66. Clinical Implementation  Currently run a separate HF-ER service based on the PR model at GGH – Different funding stream  Post-doctoral fellowship in Toronto – keen to start adding patients with heart failure to the out- patient PR programme – difficulty crossing boundary specialities
  • 67. Maintenance
  • 68. Summary  Patients with COPD & CHF suffer similar symptoms and resultant disability  The symptom based model of pulmonary rehabilitation can be successfully applied to patients with CHF  Combined exercise rehabilitation is feasible and effective for patients with COPD and CHF  Further work to assess – Cost-effectiveness of a combined symptom-based service delivery strategy

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