The benefits of generic breathlessness rehabilitation in the UK and Canada - Dr Rachael Evans, Consultant Respiratory Physician Presentation from the Breathlessness Symposium held in London on 1 July 2014

1. Generic exercise rehabilitation
for breathlessness
Dr Rachael Evans PhD
Consultant Respiratory Physician/Honorary Senior Lecturer
Glenfield Hospital, Leicester, UK

2. 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

3. 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%)

4. Similar disability between COPD and CHF
 Common symptoms of exertional breathlessness
and fatigue
Anxiety and depression
Social isolation

5. 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

6. 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

7. Skeletal Muscle Dysfunction (locomotor)
Gosker et al Am J Clin Nutr 2000;71:1033-47
 Skeletal
muscle
performance
 Morphology
 Muscle fibre
type  Muscle
metabolism

8. 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.

9. Evidence for exercise training in CHF

10. 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)

11. 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: 872-979
2JAMA 2009; 301(14): 1439–1450
3Int J Clin Pract 2012;66 :782-79

12. 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

13. Why might the pulmonary
rehabilitation model be appropriate
for patients with CHF?

14. 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

15. 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”

16. 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)

17. 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 resistance
Mod- high maybe safe
Adjuncts Helium/hyperoxia/one-
legged/NIV
?
Evans 2011 Chronic Resp Dis 8 (4): 259-269

18. 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;63:487-492
2Eur J Cardiovasc Prev Rehabil. 2008 Aug;15(4):379-85.

19.  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

20. 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

21. MRC scale in CHF
 MRC scale in CHF  MRC in CHF and
COPD
ANOVA p=0.915
ERJ 2008; 32: suppl 52 1328

22. 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

23. 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

24. 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

25. 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

26. 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)

27. BMI and results of PR for COPD
Greening N CRD 2011; 9: 99 -106

28. 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

29. 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
*
*

30. Results of pulmonary rehabilitation
-health Status
COPD
CRQ
p CHF
CHQ
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

31. 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

32. 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

33. Theoretical symptom-based model for provision of
exercise rehabilitation programmes

34. Increasing choice of service delivery
Exercise
Rehabilitation

35. 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

36. 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

37. 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

38. 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%)

39. Similar disability between COPD and CHF
 Common symptoms of exertional breathlessness
and fatigue
Anxiety and depression
Social isolation

40. 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

41. 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

42. Skeletal Muscle Dysfunction (locomotor)
Gosker et al Am J Clin Nutr 2000;71:1033-47
 Skeletal
muscle
performance
 Morphology
 Muscle fibre
type  Muscle
metabolism

43. 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.

44. Evidence for exercise training in CHF

45. 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)

46. 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: 872-979
2JAMA 2009; 301(14): 1439–1450
3Int J Clin Pract 2012;66 :782-79

47. 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

48. Why might the pulmonary
rehabilitation model be appropriate
for patients with CHF?

49. 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

50. 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”

51. 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)

52. 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 resistance
Mod- high maybe safe3
Adjuncts Helium/hyperoxia/one-
legged/PAV
?
Evans 2011 Chronic Resp Dis 8 (4): 259-269

53. 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;63:487-492
2Eur J Cardiovasc Prev Rehabil. 2008 Aug;15(4):379-85.

54.  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

55. 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

56. 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

57. 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

58. 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)

59. 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

60. BMI and results of PR for COPD
Greening N CRD 2011; 9: 99 -106

61. 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
*
*

62. Results of pulmonary rehabilitation
-health Status
COPD
CRQ
p CHF
CHQ
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

63. 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

64. 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

65. Theoretical symptom-based model for provision of
exercise rehabilitation programmes
Could then concentrate on delivering
combined services in different settings

66. 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

67. Maintenance

68. 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