The IPCRG is working on a project, in response to our members' expressed interest, on describing how to refer to and set up pulmonary rehabilitation and making the case for change to policy makers.
Position paper: Pulmonary Rehabilitation for breathlessness
September 2017: at review stage.
Positioning PR as an effective treatment for COPD
COPD Value Pyramid from the London Respiratory Network (downloaded from http://thorax.bmj.com/content/early/2014/07/01/thoraxjnl-2014-205667. and also available from http://www.respiratoryfutures.org.uk/knowledge-portal/london-respiratory-network/copd-value-pyramid-thorax-publication/
The first product is the Desktop Helper No. 7 (click here to view and download). This desktop helper aims to be practical: it is based on the IPCRG network’s own experience of trying to implement best practice with limited resources in low, middle and high income countries. It was generated from the evidence, guidelines and experience shared at an experience-led care meeting in May 2017 attended by GPs, researchers, physiotherapists, a psychologist, health planners and managers. Further comments and contributions were received from GPs, nurses and physiotherapists in other countries.
Reviewer: Prof Sally Singh.
Boehringer Ingelheim funded the experience-led care meeting, writing and production. They took no part in the meeting or drafting.
This desktop helper is advisory; it is intended for general use and should not be regarded as applicable to a specific case.
Creative Commons Licence Attribution-NonCommercial-ShareAlike
Attendees at the experience-led care meeting (principal role and experience listed only - most are involved in research)
|Prof||Peymane||Adab||England||Professor of Chronic Disease Epidemiology and Public Health|
|Ms||Maria||Buxton||England||Consultant Respiratory Physiotherapist|
|Dr||Rupert||Jones||UK and Uganda||GP researcher|
|Dr||Ioanna||Tsiligianni||Crete||Assistant Professor, Primary care|
Those who contributed their experience in writing
|Ms||Monica||Ferrer||Spain||Primary care nurse|
GP colleagues Dr Monsur Habib
and Dr Rowshan Alam learning
how to implement PR, courtesy of
Prof Sally Singh, Leicester. September
Strategic frameworks for physical activity and rehabilitation
Development of a draft global action plan to promote physical activity by World Health Organization
In 2013, a global voluntary target was set by the World Health Assembly to reduce physical inactivity by 10% by 2025, but progress towards achieving this target has been slow. Although 86% of countries have developed national NCD action plans, which – in 71% of countries -- include operational plans for reducing physical inactivity, progress on implementation has been challenging. Now there will be a draft global action plan to promote physical activity for consideration by Member States at the 71st World Health Assembly in May 2018, through the 142nd Executive Board in January 2018.
The World Health Organization launched a call to action in Februrary 2017. Pulmonary rehabilitation is included in this.
Guidelines for Pulmonary Rehabilitation
- ATS/ERS statement
- ERS/ATS technical standard: field walking tests in chronic respiratory disease
- BTS Statement on pulmonary rehabilitation
- BTS Guideline on Pulmonary Rehabilitation in Adults
- BTS Quality Standards for Pulmonary Rehabilitation
Resources for patients about breathlessness and COPD
Written - general
- British Thoracic Society and Primary Care Respiratory Society UK Improving and Integrating Respiratory Services (IMPRESS) guide to breathlessness for patients
- British Lung Foundation information
- Respiratory Futures
- Living Well with COPD
- Cambridge Breathlessness Intervention Service (BIS) and the Breathing Thinking Functioning Model
Written - specific
- Can Only Plan Daily (UK)
- Video and audio from Cambridge Breathlessness Intervention Service (BIS) to help manage breathlessness:
Causes of breathlessness
Using a handheld fan to reduce breathlessness
Resources for patients about Pulmonary Rehabilitation
Peer to peer videos
- Changing lives videos by North East CLAHRC
- George’s story
- Susan’s story
- Ian’s story
- Wendy’s story
- Tom’s story
- COPD Move by EFA patients (Switzerland, Portugal, Ireland, Germany, Austria)
Resources for providers
There are some general toolkits:
- Lung Foundation Australia Pulmonary Rehabilitation toolkit
- Respiratory Futures pulmonary rehabilitation forum
Assessment tools (general)
- Lung Foundation Australia Pulmonary Rehabilitation toolkit has downloadable and linked resources
- Comparison of 2-min and 6-min walk test (Gloeckl R 2016)
- IMPRESS breathlessness assessment decision support tool
- IPCRG spirometry desktop helper
- MRC Breathlessness scale
- Breathing SPACE - an approach for every breathless patient: BMJ blog and paper by Nick Hopkinson and Noel Baxter
Smoking - smoking cessation support for all
Pulmonary disease - offer prompt spirometry and priority high value care (see value pyramid above)
Anxiety - identify and support psychosocial problems
Cardiac Disease - dual diagnoses are common; don't undertreat
Exercise (and fitness) - pulmonary rehabilitation and encourage physical activity
Assessing quality of life and disease control
- CAT COPD Assessment Test
- CCQ Clinical COPD Questionnaire
- ACT Asthma Control Test
- ACQ Asthma Control Questionnaire
- Activation levels (Judith Hibbard): NHS site, Kings Fund, Insignia, HIbbard J et al Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers.Health Serv Res. 2004 Aug; 39(4 Pt 1): 1005–1026. doi: 10.1111/j.1475-6773.2004.00269.x
Exercise guidelines and exercise prescription
- WHO guidelines and factsheets on physical activity
- Living well: UK physical activity guidelines adapted from WHO
- Exercise prescription table from Lung Foundation Australia PR toolkit
- Using the FITT principles (Maria Buxton presentation to download ):this includes a proposed schedule that can accommodate up to 16 people in one space. Idea for the aerobic component:
- Aim is 30 mins but probably start with 20 mins
- Try splitting the 20 mins of aerobic exercises into separate exercises:-
- 10 mins walking at prescribed pace
- 5 mins step ups / cycle
- 5 mins marching / star jacks
- Minimal transition time between exercises
- Exercise prescription (Fiatorone Singh et al)
The simplest is a visual analogue scale from 0-10 that you can make. Other tools are available but subject to copyright. These include
Self management plans
Cochrane review of COPD self-management education (effective, all include action plan for exacerbations and case management, but no clear recommendation about form and content of program
Treating tobacco dependence
Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the International Primary Care Respiratory Group (IPCRG), endorsed by WONCA Europe, World Organization of Family Doctors in Europe and applicable to global primary care.
Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC. Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: A randomized controlled trial. Eur J Cardiovasc Nurs [Internet]. 2014;13(3):201–10. Available from: https://doi.org/10.1177/1474515113491348
References from our desktop helper and position paper
Cochrane Review McCarthy B et al 2015 Issue 2This review highlights that pulmonary rehabilitation improves the health-related quality of life of people with COPD. Results strongly support inclusion of pulmonary rehabilitation as part of the management and treatment of patients with COPD. Future studies should concentrate on identifying the most important components of pulmonary rehabilitation, the ideal length of a programme, the intensity of training required and how long the benefits of the programme last.
Cochrane Review Puhan MA et et Cochrane 2011 (post-hospital admission)
Pulmonary rehabilitation reduced hospital admissions and mortality compared with usual community care (no rehabilitation). Quality of life was also improved and the effect was substantially larger than the minimal important difference. Pulmonary rehabilitation appears to be a highly effective and safe intervention in COPD patients after suffering an exacerbation.
Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.
Although results from RCTs suggested that PR reduces subsequent exacerbations, pooled results from the cohort studies did not favour PR, likely reflecting the heterogeneous nature of individuals included in observational research and the varying standards of PR programmes.
Cost-effectiveness and affordability - the business case
Glasziou P et al. Evidence for underuse of effective medical services around the world. Lancet. Elsevier Ltd; 2017;390(10090):169–77. Particularly wasteful is the global failure to capitalise on effective non-pharmalogical therapies, which, although less intensively marketed, are in many cases equally or more effective than their pharmacological counterparts. For example, pulmonary rehabilitation, which involves progressive exercise and education, has been shown to reduce hospital re-admissions and deaths for patients with chronic obstructive pulmonary disease by 70%; daily application of sunscreen can cut invasive melanoma rates by 50%; and insecticide impregnated bednets can prevent 50% of malaria cases.[McGlynn, EA, Asch, SM, Adams, J et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348: 2635–2645]. Unlike their pharmaceutical counterparts, non-drug treatments are less intensively studied, more poorly described in research, weakly regulated, and inadequately marketed, particularly when the treatment or prevention is cheap or free."
Griffiths et al 2001 This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service.
London Respiratory Network value pyramid
This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation.
Barriers to adherence
Steiner MC, Lowe D, Beckford K, et al. Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales. Thorax 2017;72:530-537.
In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations."
Note: there is now a published Cochrane protocol Young J et al 2017 Interventions to promote referral, uptake and adherence to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD)
Role of psychology and psychologists
The diverse and evolving role of a psychologist within a respiratory multidisciplinary team (MDT) is described, providing a working model for service provision. The rationale for appointing a psychologist within a respiratory MDT is presented first, citing relevant policy and research and outlining the wider psychosocial impact of respiratory disease. This is followed by an insight into the psychologist’s role by highlighting important areas, including key therapy themes and the challenge of patient engagement. The way in which the psychologist supports the collective aims and aspirations of respiratory colleagues to provide a more holistic package of care is illustrated throughout.