Generic exercise rehabilitation for breathlessness
Dr Rachael Evans PhDConsultant Respiratory Physician/Honorary Senior Lecturer Glenfield Hospital, Leicester, UK
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
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%)
Similar disability between COPD and CHF
Common symptoms of exertional breathlessness and fatigue
Anxiety and depression
Social isolation
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
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
Skeletal Muscle Dysfunction (locomotor)
Gosker et al Am J Clin Nutr 2000;71:1033-47
Skeletal muscle performance
Morphology
Muscle fibre type Muscle
metabolism
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.
Evidence for exercise training in CHF
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)
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: 872-9792JAMA 2009; 301(14): 1439–14503Int J Clin Pract 2012;66 :782-79
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
Why might the pulmonary rehabilitation model be appropriate for patients with CHF?
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
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”
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)
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 resistanceMod- high maybe safe
Adjuncts Helium/hyperoxia/one-legged/NIV
?
Evans 2011 Chronic Resp Dis 8 (4): 259-269
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;63:487-4922Eur J Cardiovasc Prev Rehabil. 2008 Aug;15(4):379-85.
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
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
MRC scale in CHF
MRC scale in CHF MRC in CHF and COPD
ANOVA p=0.915
ERJ 2008; 32: suppl 52 1328
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
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
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
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
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)
BMI and results of PR for COPD
Greening N CRD 2011; 9: 99 -106
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
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
* *
Results of pulmonary rehabilitation-health Status
COPD CRQ
p CHFCHQ
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
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
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
Theoretical symptom-based model for provision of exercise rehabilitation programmes
Increasing choice of service delivery
Exercise Rehabilitation
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
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
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
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%)
Similar disability between COPD and CHF
Common symptoms of exertional breathlessness and fatigue
Anxiety and depression
Social isolation
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
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
Skeletal Muscle Dysfunction (locomotor)
Gosker et al Am J Clin Nutr 2000;71:1033-47
Skeletal muscle performance
Morphology
Muscle fibre type Muscle
metabolism
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.
Evidence for exercise training in CHF
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)
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: 872-9792JAMA 2009; 301(14): 1439–14503Int J Clin Pract 2012;66 :782-79
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
Why might the pulmonary rehabilitation model be appropriate for patients with CHF?
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
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”
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)
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 resistanceMod- high maybe safe3
Adjuncts Helium/hyperoxia/one-legged/PAV
?
Evans 2011 Chronic Resp Dis 8 (4): 259-269
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;63:487-4922Eur J Cardiovasc Prev Rehabil. 2008 Aug;15(4):379-85.
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
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
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
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
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)
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
BMI and results of PR for COPD
Greening N CRD 2011; 9: 99 -106
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
* *
Results of pulmonary rehabilitation-health Status
COPD CRQ
p CHFCHQ
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
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
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
Theoretical symptom-based model for provision of exercise rehabilitation programmes
Could then concentrate on delivering combined services in different settings
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
Maintenance
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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