Evidence shows pulmonary rehabilitation is highly effective in terms of reducing hospitalisations, but for many patients the barriers to participating in programs are high. Because of this we may need to re-think our approach, a forum has heard.
Simple practical measures can improve uptake
Despite a plethora of data showing that COPD patients who participate in low levels of physical activity are at higher risk of events such as hospitalisation and mortality, a decade of effort has failed to increase participation in physical activities among these patients, speakers told the respiratory insights forum sponsored by Menarini.
World Health Organisation guidelines1 recommend that all adults should undertake at least 150 minutes of moderate-intensity aerobic activity per week. The 2013 GOLD strategy2 recommends that all patients with COPD should participate in daily physical activity.
But studies3 have shown that patients with COPD are significantly less likely to reach recommended levels of physical activity compared to patients with other chronic diseases such as diabetes or rheumatoid arthritis.
Pulmonary rehabilitation aims to improve fitness and physical activity levels. According to the Agency for Clinical Innovation4, only 5 to 10% of people who would benefit from pulmonary rehabilitation – i.e. those with moderate to severe COPD – are receiving it at any stage in their disease. The uptake is even worse in rural and regional areas of Australia.
Professor Anne Holland, Clinical Chair in Physiotherapy at the Alfred Hospital and La Trobe University, said barriers to engaging in pulmonary rehabilitation programs included disruption to patients’ routine, travel and location, lack of perceived benefit and inconvenient timing.
Patients often failed to complete the program due to illness and comorbidities, smoking, depression and lack of support.
“[Pulmonary rehabilitation] is highly effective and cost effective in terms of reduction of hospitalisation, but the patients are telling us it comes at too much of a cost for them,” she told the seminar.
She said relatively simple ways of improving compliance involved understanding and addressing practical barriers, such as providing better parking or scheduling appointments in the afternoon; individualising programs to take into account comorbidities such as musculoskeletal conditions and obesity; and considering other exercise modalities such as tai chi and water-based exercises.
The influence of a doctor could be paramount, especially after an exacerbation, and pulmonary rehabilitation programs should be offered and re-offered, regardless of previous uptake.
“What does help is being confident they can make that change and helping them to understand what’s in it for them,” she said.
Reducing sedentary time
Associate Professor Kylie Hill of the School of Physiotherapy and Exercise Science at Curtin University said reducing sedentary time, rather than focusing on increasing physical activity, particularly moderate to vigorous intensity physical activity, is likely to be a more feasible target for patients with COPD.
“We know that patients5 with COPD are more likely to be sitting or lying down, and are far less likely to be standing or walking.
Pulmonary rehabilitation as we are currently offering it doesn’t change the level of physical activity in a patient, so we need to think about other strategies,” she said.
“Changing sedentary time is a new and exciting target for patients. If you reduce sedentary time you are likely to increase light intensity physical activity.”
She said light intensity physical activity was key for COPD patients, such as encouraging them to break up television viewing by walking around the room during every advertisement break.
Interventions needed to be tailored to each patient, and it was important that patients were able to believe they were capable of reaching an exercise goal, she said.
Regarding behaviour change strategies, multi-component interventions are more effective than single component intervention.
Approaches that incorporate counselling, education, self-monitoring, goal setting and feedback, barrier identification and problem solving are likely to be most effective, she said.
According to Dr Holland new models may offer hope for the future of physical activity in COPD patients.
She said a study of home-based pulmonary rehabilitation for patients with stable disease had shown they achieved similar benefits as a standard outpatient participating in a program of care.
A trial was currently underway to test videoconferencing with groups of patients, she said.
The Lung Foundation is currently waiting for a decision over its submission6 for a new MBS item number to enable pulmonary rehabilitation programs to be delivered in the community.
References:
1 World Health Organisation. Global recommendations on physical activity for health, 2010; http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/.
2 Global Initiative for Chronic Obstructive Pulmonary Disease. Pocket Guide to COPD Diagnosis, Management and Prevention, 2015; http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf
3 Arne M et al. Physical activity and quality of life in subjects with chronic disease: Chronic obstructive pulmonary disease compared with rheumatoid arthritis and diabetes mellitus. Scand J Prim Health Care. 2009; 27(3): 141–147.
4 NSW Agency for Clinical Innovation; www.aci.health.nsw.gov.au/resources/rehabilitation
5 Pitta F et al. Characteristics of Physical Activities in Daily Life in Chronic Obstructive Pulmonary Disease, Am J Respir Crit Care Med. 2005; 171(9): 972–977.
6 Lung Foundation Australia. Improving access to pulmonary rehabilitation through Medicare Benefit Scheme subsidies, 2015; www.lungfoundation.com.au