A community model for exercise prescription for patients with chronic obstructive pulmonary disease and congestive heart failure

Elsie Hui, Jean Woo Division of Geriatrics, Department of Medicine and Therapeutics, The Chinese University of Hong Kong HSRF 02030711 1

Introduction

     Chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are the leading causes for admissions and bed occupancy in the Hospital Authority.

Exercise prescription improves: Physical performance Psychosocial well being Reduce hospital service utilization and costs Refs: Ferrari M, Vangelista A, Vedovi E et al. Minimally supervised home rehabilitation improves exercise capacity and health status in patients with COPD. Am J Phys Med Rehabil 2004; 83: 337-43.

Rees K, Taylor R, Singh S, Coats A, Ebrahim S. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2004; 3: CD003331.

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Purpose

 To test the feasibility of continuing exercise programmes for COPD or CHF patients:       Exercise Peer support Health education Promote self-motivation and compliance Based at community centres Led by health professionals or trained non-health

professionals

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Materials & Methods

COPD CHF

Quasi-experimental, ‘ Before and after ’ measurements

Study Design Subjects Setting Intervention Outcome measures

≥ 1 admission(s) in preceding 12 months 44 37 Community elderly centres 8 – 10 subjects per group 12 weekly 2-hour sessions + home exercise prescription Exercise training, educational talk, peer group support Lung function tests, 6 minute walk test (6MWT), General Health Questionnaire (GHQ), St. George discussions.

’ s Respiratory Symptom Questionnaire (SGRQ), COPD knowledge, programme evaluation using questionnaires, group 6MWT, muscle strength, Hospital Anxiety & Depression Scale (HADS), Medical Outcome Study Social Support Survey (MOSSS) Chronic Heart Failure Questionnaire (CHFQ) CHF knowledge test, programme evaluation 4

Intervention

COPD CHF Educational talk

(1 hour)

Peer group support

E.g., pathophysiology of COPD, exercise, breathing, sputum removal and relaxation techniques, medication and dyspnoea management, energy conservation, etc.

E.g., pathophysiology of heart disease, medication, surgical interventions, diet, signs & symptoms, exercise, emotion and relaxation, prevention of exacerbation, etc.

Q & A, group discussion, focus group (week 12)

Exercise training

(1 hour, step-up intensity to Borg scale ~ 13: moderately hard) Warm up Strengthening – upper (raise arms) & lower limb (sit to stand) Aerobic – dance Home programme 3 x / week Warm up Strengthening – upper & lower limb using Therabands Aerobic – dance Home programme 3 x / week 5

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Subject characteristics

Demographics Sex (M:F) Age (years) LTOT (%) FEV1/FVC (%) Disease severity (%) Attendance rate (%) Dropouts COPD (n = 44)

37: 7 74.2 (6.5) 25 49 (15.8) Moderate to severe 82 78 11 (25%) Frequent admissions (3); moved away (2); admitted to old age home (1); transport problem (2); comorbidity (1); refused exercise (2)

CHF (n = 37)

25:12 73.5 (7.8) NYHA Class II / III 89 91 5 (13.5%) Comorbidity (2); hospitalised for non-cardiac problem (2); transport problem (1) 7

COPD Results

Outcome measure Physical

6 MWT (m)

Psychological

GHQ (/28)

Baseline

285 (96) 20.6 (10.1)

12 weeks

303(98) 12.2 (6.0)

COPD knowledge (/10)

SGRQ (/99.99) 53.7 (19.6) 6.6 (2.0) 37.7 (14.1) 8.8 (1.1)

P-value

0.051

<0.001

<0.001

<0.001

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Outcome measure Physical Psychological*

6MWT

#

Biceps strength (right)

#

Quadriceps strength (right) HADS (anxiety)

CHF Results

Baseline

329.5 (103.2) 15.0 (6.6) 12.8 (5.0) 5.9 (3.8)

12 weeks

380.9 (90.3) 18.9 (6.2) 19.1 (5.3) 3.5 (3.0) MOS-SSS (tangible) CHQ (dyspnoea) 67.4 (24.7) 4.05 (0.95) 85.9 (14.0) 5.3 (0.9)

CHF knowledge (/10)

7.8 (1.7) 9.6 (1.4) # Significant changes were recorded on both the left and right side.

* Significant changes were observed for

all domains

of the HADS, MOS & CHQ.

P-value

<0.001

0.001

<0.001

<0.001

<0.001

<0.001

<0.001

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Programme evaluation

No.

Question

1 2 3 I will attend similar courses again I can complete all the prescribed exercises I prefer group exercise to home exercise 4 5 6 I feel that my physical health is better than before The group mates can help me handle my disease I did not have any problem travelling to the centre

COPD

13.8

3.4

20.7

0 0 10.3

Disagree (%) CHF

3.1

0 28.1

0 3.1

0

Ambiguous (%) COPD

10.3

0

CHF

15.6

9.4

27.6

3.4

24.1

3.4

18.8

6.3

9.4

3.1

Agree (%) COPD

75.9

96.6

CHF

81.3

90.6

51.7

53.1

96.6

75.9

86.2

93.8

87.6

96.9

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Focus group

(transcripts)

COPD group

 The exercise is helpful as it increases my daily activities tolerance.

 In the past, I used to go to the hospital whenever I felt breathless, which happens at least once or twice a year, but now I can somehow manage the crisis.

 Group learning can facilitate the exchange of ideas. It creates happiness and concern for others.

CHF group

 Learning in a group makes us more interactive. I seldom exercised in the past, but now I do it everyday. Group exercise is good for lazy people as they perform better and last longer as a group. I believe we have benefit from the programme and will live a healthier life.

 The educational talks gave me a lot of information on nutrition. In the past, doctors just told me to avoid high cholesterol foods, but I had no idea what cholesterol was and which foods were suitable for me. They didn't have time to explain things in detail.

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Conclusions and recommendations

 Patients with COPD and CHF have unmet needs in the community, disease-specific rehabilitation programmes being predominantly hospital based and of limited duration.

 The group community interventions described above have the advantage of being incorporated as regular programmes in the community or primary care setting. They help patients cope with their diseases through empowerment and mutual support, apart from achieving symptom improvement and other positive physical and psychosocial outcomes.

 This model could be an integral part of chronic disease management programmes in the community.

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References

Woo J, Chan W, Yeung F, et al. A Community model of group therapy for the older patients with COPD: a pilot study. 2006;12:523-531.

J Evaluation in Clin Practice,

Hui E, Yang H, Chan W, et al. A community model of group rehabilitation for older patients with chronic heart failure: a pilot study.

Disability and Rehab,

2006 (in press) [email protected]

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