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