Pulmonary rehabilitation is “a multidisciplinary programme of care for people with chronic respiratory impairment”, including Chronic Obstructive Pulmonary Disease (COPD). Pulmonary rehabilitation (PR) is tailored to the individual who has recently had an exacerbation, with the aim of optimising their respiratory function and therefore their quality of life (QOL) and participation in their everyday lives.
PR has been proven to significantly improve health related QOL and exercise capacity in individuals with COPD, compared to usual care.
What is PR
PR programmes vary from person to person and from centre to centre, depending on available resources, but in general will include:
- Multidisciplinary input
- Dietary advice
- Disease education
- Psychological intervention
- Behavioural intervention
Typically, a session will involve a group of people with COPD attending a class together at a gym or community hall where they partake in supervised exercise with a physiotherapist and then have an education session with a nurse or educator on topics such as bronchodilator technique, nutrition and managing COPD.
PR programmes can vary in length, anywhere from 6-8 weeks to a year. The British Thoracic Society’s guideline recommends 6-12 weeks with twice weekly supervised exercise sessions (with a third unsupervised session), at a minumum of 12 supervised sessions. PR can be based in hospital, in the community or in both. Research suggests that better outcomes are observed in inpatient-based PR compared to community-based PR as measured by the Chronic Respiratory Questionnaire which measures dyspnoea, fatigue, emotional function and mastery. Guidelines recommend that individuals be offered some sort of exercise programme after finishing PR (see below).
NICE guidelines recommend emphasising the importance of adherence to PR to individuals in order to achieve improvements in QOL and respiratory function. Specific ways to improve adherence include optimising access to PR, for example: suitable times for classes, clear access to facilities and near public transport, timely referrals to PR.
Guidelines recommend maintenance of exercise after PR to maintain gains made in respiratory function, exercise tolerance and QOL. A recent study has shown that gains made after an eight-week outpatient PR programme can be maintained at two years follow up in people with moderate to severe COPD with a maintenance programme. Individuals in this study showed better maintenance in scores for 6-minute-walk distance and body mass index, airflow obstruction, dyspnea score and exercise capacity. The maintenance programme was focused on exercise and included cycle ergometers in homes and hospital-based supervised exercise sessions every other week. Adherence to this maintenance programme was 66%.
According to the NICE guideline, the following people should not undergo PR:
- Those who are unable to walk
- Those who have unstable angina
- People who have had a recent myocardial infarction
Additionally, the British Thoracic Society's guideline recommends those with a Medical Research Council (MRC) Dyspnoea score of 3–5 who are functionally limited by breathlessness should not be referred to PR.
Other factors worth considering include:
- Unstable cardiac disease
- Locomotor issues
- Difficulties following instructions due to cognitive or psychiatric impairments
- The attendance of a support person to enable and encourage adherence
Physiotherapists play an important role in prescribing, supervising and measuring outcomes in exercise. Both functional and maximal exercise have shown statistically significant improvements after PR, compared with usual care.
Type of exercise prescribed should include supervised aerobic exercise and a progressive muscle resistance strengthening exercises. Exercise should be individually prescribed according to initial assessment and utilise goal-setting. Participants' exertion should also be monitored for chest pain or discomfort and breathlessness. For the latter, the BORG scale can be used.For exercise prescription ideas see here.
- National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019. Accessed 28 November 2019.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. DOI: 10.1002/14651858.CD003793.pub3. Accessed 28 November 2019.
- Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax 2013;68:ii1-ii30. Accessed 28 November 2019.
- Güell MR, Cejudo P, Ortega F, Puy MC, Rodríguez-Trigo G, Pijoan JI, Martinez-Indart L, Gorostiza A, Bdeir K, Celli B, et al. Benefits of long-term pulmonary rehabilitation maintenance program in patients with severe chronic obstructive pulmonary disease: three-year follow-up. Am J Respir Crit Care Med. 2017;195:622–629. Accessed 29 November 2019.