Innovation and excellence in health and care Addenbrooke’s Hospital I Rosie Hospital

Exercise Maintenance Following PR

and the BLF Report

Dr Frances Early

Research & Evaluation Lead

Centre for Self Management Support

Addenbrooke’s Hospital

frances.early@addenbrookes.nhs.uk

Background

• Report commissioned by BLF – call to action• Authors FE, LJ, RB, Dr Jonathan Fuld• Summary of evidence: 3 systematic reviews (12 RCTs) plus 2

further RCTs• Consultation with

– Lyndsey Hughes, Rehabilitation Programme Lead, NHS England– Professor Mike Morgan, Respiratory National Clinical Director; Consultant Physician in

Respiratory Medicine, University Hospitals of Leicester NHS Trust– Professor Sally Singh, Professor of Pulmonary and Cardiac Rehabilitation, Centre for

Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust

COPD, physical activity and exercise

• Low levels of PA are common• Linked to:

– Cardiovascular and skeletal muscle de-conditioning, poorer quality of life and increased use of healthcare services independent of abnormal lung function

• Benefits of exercise:– Reduced: breathlessness, leg tiredness, number of days in hospital,

stress, risk of heart disease, incidence of infection.– Improved: energy levels, exercise ability, mood, muscle strength, self-

esteem, bone strength, immune system, suppleness, regulated appetite, energy levels.

– Increased: quality of life, ability to do daily activities that are important to the individual, possibility of returning to work.

Challenges and barriers to being active

• Challenges:– Breathlessness, anxiety, fatigue– Persistent cough, chest infections, exacerbations– Feels unpleasant– Vicious cycle of declining activity, loss of muscle mass and

increasing symptoms, extending to social isolation and depression

• Barriers:– Lack of support– Living alone– Weather– Lack of transport to activities

Things that help• Things that help:

– Personal motivation– Meaningful and achievable goals– Support from professionals and peers– Regaining control of one’s condition

• Levels of PA are not related to disease severity• Important to address behavioural and social factors when

encouraging more activity

Impact of PR• 3 mths after: improvements in breathlessness, fatigue, exercise capacity,

emotional function, feeling more in control of condition (McCarthy et al, 2015)

• Without further intervention benefits decline over 12 to 24 months due to: – disease progression, co-morbidities, exacerbations and failure to maintain sufficient

levels of PA and exercise (Spruit et al, 2013; Bourbeau 2010)• How can we transfer gains made in exercise capacity during PR into more PA

in daily life? • PA behaviour is complex. Influenced by:

– health beliefs, personality characteristics, exercise-associated symptoms, mood, past behaviours, social and cultural factors and external factors, e.g. climate

• People with COPD report that structured, on-going support for exercise following PR is important and desirable

• Current PR does not support self-regulation needed for long-term behaviour change and durable exercise habits.

Exercise maintenance programmesExample programmes:• Unsupervised walking programme with music: 8 wks (Bauldoff et al 2002)• Group supervised exercise plus telephone calls and home exercise prescription:

52 wks (Brooks et al 2002)• Individualised walking plan, plus pedometer, diary and telephone: 26 wks (du

Moulin et al 2009)• Home care plan, supervised exercise reinforcement sessions: 52 wks (Ries et al

2003)• Unsupervised home exercise, plus tapered supervised training: 52 wks

(Ringbaek et al 2010)• Supervised walking and cycling plus home exercise: 52 wks (Spencer et al 2010)• Home and community walking programme, plus telephone support, self-

monitoring, pedometer: 12 wks (Steele et al 2008)• Telephone follow-up calls: 64 wks (Waterhouse et al 2010)

The evidence for maintenance programmes – exercise capacity

• 12 RCTs• Post-PR supervised exercise programmes are superior to usual

care for sustaining benefits in exercise capacity in the medium-term for patients with moderate to severe COPD, but there is no consistent evidence for effects being sustained at 12 months (Beauchamp et al 2013). Over time, most intervention participants returned to their original downward trajectories (Busby et al 2014).

The evidence for maintenance programmes – exercise capacity

Unpicking the evidence• Programme content:

• Is intensity and frequency of exercise sufficient?• Would health mentoring increase the benefits?• Is intervention designed on a theory of behaviour change?• Post-exacerbation strategies to minimise drop out?

• Improvement in initial PR:• Outcomes from maintenance programmes may be linked to magnitude of

improvement following PR, achieving the MCID

• Progressive nature of COPD:• Can be a barrier to sustaining improvements in exercise capacity

• Quality of the studies:• Results may be better in well designed studies that minimise bias; high drop-out

leading to insufficient data• Studies had variable follow-up period, difficult to compare outcomes

The evidence for maintenance programmes – exercise capacity

ConclusionThe majority of evidence indicates that exercise maintenance programmes containing certain features can maintain post-PR gains in exercise capacity during, and in the short-term following, the intervention but that capacity declines in the longer term.

BTS Guideline on Pulmonary Rehabilitation in Adults6 : “Continuation of supervised exercise training beyond PR protects the patient from a decline in exercise capacity compared with a control group…….all patients completing PR should be encouraged to continue to exercise beyond the programme”

The evidence for maintenance programmes – HRQoL

• 10 RCTs

• No consistent evidence

• Some participants maintained post-PR improvements

• Data pooled in meta-analyses: no clear evidence of benefit compared to usual care (Soysa et al 2012; Beauchamp et al 2013).

• Mixed findings could be due to:– Programmes vary in make-up– Exercise alone may be insufficient without more comprehensive support,

e.g. phone support– Degree of improvement following PR may affect maintenance outcomes– Studies showing sustained benefit were of better methodological quality

The evidence for maintenance programmes – other outcomes

• PA in daily life (3 studies)– No evidence of increased activity following maintenance programmes

• Self-efficacy for walking (2 studies) – No benefit from maintenance programmes

• Physical disability (1 study) – Less self-reported disability at 15 months (during an 18 month

maintenance programme) compared to no supervised support.

• Health care use (4 studies)– Inconclusive evidence for hospital days

• Exacerbations (4 studies)– No impact on number of exacerbations

Making sense of the evidence• Few studies compared to the large body of evidence for PR

• Results interpreted with caution: – Variation in programme design and in how studies are conducted,

e.g. follow-up intervals, how they measure outcomes, different procedures for handling drop-out and measuring adherence

– Small number of studies overall; sub-group analysis, to find out if certain participant factors are associated with outcomes, is not possible

– Maintenance is complicated by disease progression and exacerbations.

– Outcomes tended to be better when patients attended regularly and followed the recommended advice

• Insufficient evidence to make strong recommendations

Programmes are likely to be more effective if….

• Exercise is supervised and at least weekly; frequency is important

• If supervision is limited, then feedback and follow-up strategies are important

• Combine exercise training with self-management support

• Promote good adherence

• Preceded by well-designed PR

Outstanding research questions

• How do we define effective maintenance?• How do we promote increased PA and support people to

maintain it?• What is the best design for maintenance programmes?• What factors are associated with variable outcomes?• The role of e-health

Issues around integrating PA into the COPD pathway

• No specific guidance for PA• Maintenance provision is variable across the country• No cost-benefits analysis of maintenance programmes• Possible service models could build on:

• Expertise in the community, integrated working• Home exercise programmes• Programmes to address co-morbidities

• Inadequate PR provision

BLF Next Steps

• Considering strategic options for launching the report, e.g. exercise maintenance conference

• Keep Active, Keep Well programme (BLF/Sport England)– 3 year programme– Aim to enable more people with lung conditions to feel

confident to take up sporting and exercise opportunities– behaviour change intervention for those with COPD and

other lung conditions who will benefit from exercise. The programme will be accessed through primary and secondary care referrals or through self-referral

Systematic review coverage Soysa et al. (2012) Beauchamp et al.

(2013)Busby et al. (2014)

Wijkstra et al. (1995) y

Foy et al. (2001) y

Brooks et al. (2002) y y Y

Berry et al. (2003) y y

Ries et al. (2003) y y Y

Elliott et al. (2004) y

Steele et al. (2008) y Y

du Moulin et al. (2009) Y

Ringbaek et al. (2010) y y Y

Spencer et al. (2010) y y Y

Waterhouse et al. (2010) y Y

Bauldoff et al. (2012) y

Roman et al. (2013)

Wilson et al. (2015)

Systematic Reviews

• Beauchamp MK, Evans R, Janaudis-Ferreira T, Goldstein RS, Brooks D. Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with COPD. Chest 2013; 144(4);1124-1133.

• Busby AK, Reese RL, Simon SR. Pulmonary rehabilitation maintenance interventions: A systematic review. Am J Health Beh 2014; 38(3);321-330.

• Soysa S, McKeough Z, Spencer L, Alison J. Effects of maintenance programs on exercise capacity and quality of life in chronic obstructive pulmonary disease. Phys Ther Rev 2012; 17(5);335-345.

RCTsBauldoff GS, Hoffman LA, Zullo TG, Sciurba FC. Exercise maintenance following pulmonary rehabilitation: effect of distractive stimuli. Chest 2002; 122(3):948-954.Berry MJ, Rejeski WJ, Adair NE, Ettinger WH Jr et al. A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2003; 23(1):60-68.Brooks D, Krip B, Mangovski-Alzamora S, Goldstein RS. The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. Eur Respir J 2002; 20(1):20-29.du Moulin M, Taube K, Wegscheider K et al. Home-based exercise training as maintenance after outpatient pulmonary rehabilitation. Respiration 2009; 77(2):139-145.Elliott M, Watson C, Wilkinson E et al. Short- and long-term hospital and community exercise programmes for patients with chronic obstructive pulmonary disease. Respirology 2004; 9(3):345-351.Foy CG, Rejeski WJ, Berry MJ et al. Gender moderates the effects of exercise therapy on health-related quality of life among COPD patients. Chest 2001; 119(1):70-6.Ries AL, Kaplan RM, Myers R, Prewitt LM. Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial. Am J Respir Crit Care Med 2003;167(6):880-8.Ringbaek T, Brondum E, Martinez G et al. Long-term effects of 1-year maintenance training on physical functioning and health status in patients with COPD: A randomized controlled study. J Cardiopulm Rehabil Prev 2010; 30(1):47-52.Román M, Larraz C, Gomez A et al. Efficacy of pulmonary rehabilitation in patients with moderate chronic obstructive pulmonary disease: a randomized controlled trial. BMC Fam Practice 2013; 14:21.Spencer LM, Alison JA, , and McKeough ZJ. Maintaining benefits following pulmonary rehabilitation: a randomised controlled trial. Eur Respir J 2010; 35(3):571-7.Steele BG, Belza B, Cain KC et al. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease . Arch Phys Med Rehabil 2008; 89(3):404-12.Waterhouse JC, Walters SJ, Oluboyede Y, Lawson RA. A randomised 2 x 2 trial of community versus hospital pulmonary rehabilitation, followed by telephone or conventional follow-up. Health Technol Assess 2010; 14(6):i-v, vii-xi, 1-140.Wijkstra PJ, Ten Vergert EM, van Altena R et al. Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease. Thorax 1995; 50:824-8.Wilson AM, Browne P, Olive S et al. The effects of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomised controlled trial. BMJ Open 2015;5:e005921.doi:10.1136/bmjopen-2014-005921