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Chronic obstructive pulmonary disease: exercise and rehabilitation

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S30 PROVISION OF PULMONARY REHABILITATION IN THE UK: RESULTS FROM THE NATIONAL CHRONIC OBSTRUCTIVE PULMONARY DISEASE AUDIT 2008

1P Mallia, 1A Patel, 1R Kaiser, 2RA Stone, 2R Buckingham, 1CMR Roberts. 1Whipp’s Cross University Hospital, London, UK, 2Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK

Background: Pulmonary rehabilitation has been established as an important therapy for chronic obstructive pulmonary disease (COPD) patients. However, not all patients who may benefit from pulmonary rehabilitation have access to it. We examined the availability of pulmonary rehabilitation and the standards of care for patients in respiratory medicine departments in the UK.

Methods: As part of the national COPD audit 2008 we surveyed 239 units in the UK using an online questionnaire to assess access to pulmonary rehabilitation and assess the standard of pulmonary rehabilitation programmes that exist.

Results: In 58% of units all eligible patients had access to pulmonary rehabilitation, in 32% of units only some patients were offered pulmonary rehabilitation and in 10% of units there was no access at all. In a similar survey undertaken in 2003, 64% of units had a formal pulmonary rehabilitation programme. The majority of programmes are funded by primary care organisations (43%), with 24% hospital funded, 18% joint funded and 14% not funded at all. We examined a number of standards for the pulmonary rehabilitation programmes offered. Staffing: the majority of programmes were delivered fully by a multidisciplinary team (71%) and 68% had a designated lead clinician and coordinator. However, only 41% of programmes had staff supervising the exercise component fully trained in advanced life support (ALS). Content of programmes: 63% had written inclusion and exclusion criteria for patients and 62% measured spirometry, exercise and health status before and after rehabilitation. The majority of programmes (79%) lasted a minimum of 6 weeks; however, only 30% had a continuation phase. The majority of programmes included education about living with COPD (73%) and provided written educational resources (77%). A minority of units (49%) fully audited their pulmonary rehabilitation service annually.

Conclusions: There has been some increase in units in the UK offering pulmonary rehabilitation programmes since 2003 and many are now community based. In nearly a half of units, however, access to pulmonary rehabilitation is restricted or unavailable. The majority of units are run by multidisciplinary teams and have a designated lead clinician. Further improvements are needed in the assessment of patients before commencing pulmonary rehabilitation, in training staff in ALS and providing continuation phases.

S31 IS A SHORTENED COURSE OF PULMONARY REHABILITATION EFFECTIVE FOLLOWING A HOSPITALISATION FOR AN EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE?

1O Revitt, 1L Sewell, 2SJ Singh. 1Pulmonary Rehabilitation Department, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK, 2Faculty of Health and Life Sciences, Coventry University, Coventry, UK

Introduction: The benefits of pulmonary rehabilitation are now firmly established. However, less is known about the provision and efficacy of pulmonary rehabilitation immediately after an acute exacerbation of chronic obstructive pulmonary disease (COPD). A randomised controlled trial (Man et al, 2004) suggested that a 7-week course of pulmonary rehabilitation following an exacerbation improved exercise capacity, health status and reduced healthcare utilisation. We have previously established the effectiveness of a 4-week programme in stable patients (Sewell et al, 2006) and propose to explore the effectiveness of this shortened course following an acute exacerbation of COPD.

Abstract S31 Table Mean changes post-pulmonary rehabilitation

Methods: Patients were assessed and commenced pulmonary rehabilitation within 4 weeks of discharge from hospital. Patients attended a twice weekly, 4-week hospital-based programme (exercise and education) followed by 3 weeks of unsupervised home exercise. Outcome measures included: the incremental shuttle walking test (ISWT), endurance shuttle walking test (ESWT), chronic respiratory questionnaire self-reported (CRQ-SR) and the hospital anxiety and depression scale (HADS). Patients were assessed at baseline and at 7 weeks (after the supervised and unsupervised components).

Results: 110 patients were assessed for pulmonary rehabilitation (61 men, mean (SD) age 70.25 years (9.10), FEV1 0.98 litres (0.38), ISWT 169.27 m (123.26), ESWT 151.86 s (116.73). 78 patients were assessed after 7 weeks (16 dropped out, six had a further exacerbation of COPD and 10 failed to attend the discharge appointment). A paired t test and Wilcoxon signed rank test were completed for parametric and non-parametric data, respectively, and are detailed in the table. ISWT and ESWT showed statistically significant improvements (p<0.001). There were also statistically (p<0.001) and clinically significant improvements in all domains of the CRQ-SR. HAD scores improved for both anxiety and depression (p<0.01).

Conclusions: Exercise capacity and health status improves following a shortened course of pulmonary rehabilitation in patients who have had an acute exacerbation of COPD. It should be considered as an effective treatment option for patients who have had an acute exacerbation of COPD.

S32 DOES THE ADDITION OF STRENGTH TRAINING TO AN ENDURANCE-BASED PULMONARY REHABILITATION PROGRAMME LEAD TO INCREASED DAILY ACTIVITY?

RA Evans, SJ Deacon, EE Vincent, SJ Singh, MC Steiner, MD Morgan. Glenfield Hospital, Leicester, UK

Background: Combined endurance and resistance training improves muscle strength and mass, but does not translate to greater improvements in exercise capacity or health status than endurance training alone.1 We investigated whether combined training leads to increased levels of activity compared with endurance training alone using the pulmonary functional status and dyspnoea questionnaire modified version (PFSDQ-M).

Methods: This is a retrospective analysis combining data from two concurrent studies. For both studies, patients with chronic obstructive pulmonary disease (COPD) attended the traditional, predominantly, endurance-based, pulmonary rehabilitation programme (ET). The second study included the addition of prescribed resistance training (ERT). The outcome measures used were the PFSDQ-M, the chronic respiratory questionnaire (CRQ), the incremental shuttle walking test (ISWT), endurance shuttle walking test (ESWT) and isometric quadriceps strength and were performed before and after 7 weeks of training. The PFSDQ-M has three main components the change in activity, dyspnoea with activity and fatigue with activity.

Results: 55 patients were recruited to ET and 50 patients to ERT; 62% male, mean (SD) age 68.5 years (8.7), FEV1 percentage predicted 43 (17), body mass index 26.8 (6.0), ISWT 228 m (127) and quadriceps peak torque 122 nm (45). There were no differences between the baseline demographics, except there were more men in the ERT group. 44 patients completed ET and 42 patients completed ERT. See table for the results of pulmonary rehabilitation. No differences were seen between the two groups in the improvements in the CRQ. The results were unchanged after multivariate analysis was performed for any baseline differences.

Conclusions: The addition of prescribed strength training to an endurance-based pulmonary rehabilitation programme did not result in additional improvements in activity assessed by the PFSDQ-M. Quadriceps strength was only increased with combined training, but did not lead to greater improvements in exercise performance or health status in this study.

Abstract 32 Table

References

S33 EFFECT OF REPETITIVE MAGNETIC STIMULATION TRAINING OF THE QUADRICEPS, COMPARED WITH EXERCISE THERAPY, ON QUADRICEPS STRENGTH IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

1SA Sathyapala, 1GS Marsh, 2JM Seymour, 2J Moxham, 1M. I. Polkey. 1Imperial College London, London, UK, 2Kings College London, London, UK

Introduction: Quadriceps muscle weakness is a poor prognostic factor in chronic obstructive pulmonary disease (COPD). Exercise increases quadriceps strength in some COPD patients, but is difficult to sustain for some. Repetitive electrical stimulation of the intramuscular branches of the femoral nerve increases quadriceps strength in research studies; repetitive magnetic stimulation (rMS) works on the same principle and appears better tolerated.

Aim: To investigate the effect of rMS versus exercise and no active treatment on quadriceps strength in COPD.

Methods: 58 GOLD grade I–IV COPD patients were randomly assigned to 8 weeks of either rMS of the quadriceps, exercise or no active treatment. Two weeks before and in the week following completion of the 8-week period, measurements of lung function, fat-free mass (FFM) using bioelectrical impedance and quadriceps strength (isometric maximal voluntary contraction (MVC) and twitch force (TwQ) using magnetic stimulation) in one leg in the exercise and control groups and in both legs in the rMS group, were made. Physical activity over 12 h/day for 2 days was assessed with the Dynaport ADL accelerometer; results were averaged to give locomotion time (Lot) and movement intensity (Mi). rMS involved stimulating the intramuscular branches of the femoral nerve of one leg (at 40 Hz, 1 s on, 4 s off) for 3 h twice a week using a rapid rate stimulator and mat coil. The exercise group performed a supervised 2-h resistance and endurance exercise programme twice a week. The “no active treatment” group continued their normal activities. 35 patients completed 8 weeks without severe exacerbations. In these, quadriceps strength change was calculated as the percentage change in twitch force (or MVC if twitch force was not supramaximal); in the rMS group, change in the untrained leg was subtracted from change in the trained leg.

Results The rMS group had greater increases in quadriceps strength than the exercise and control groups (see table).

Conclusions: 8 weeks rMS increases quadriceps strength in COPD patients who do not suffer an intervening exacerbation. The effect of rMS on quadriceps strength appears larger and more consistent than the effects of exercise. rMS may have potential as a clinical treatment for quadriceps weakness in COPD.

Abstract S33 Table

S34 INPATIENT PULMONARY REHABILITATION DURING ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: EFFECTS ON QUADRICEPS STRENGTH AND EXERCISE CAPACITY

1JC Burdon, 1EE Vincent, 1O Revitt, 1RJ Collier, 1H Prime, 1L Sewell, 2SJ Singh. 1Pulmonary Rehabilitation, Active Therapy Unit, Department of Respiratory Medicine, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK, 2School of Physiotherapy, Coventry University, Coventry, UK

Purpose: Patients with chronic obstructive pulmonary disease (COPD) have reduced skeletal muscle strength following hospitalisation (Spruit et al, 2003). The impact of an inpatient pulmonary rehabilitation programme on quadriceps peripheral muscle strength, in patients during an acute exacerbation of their COPD was therefore evaluated.

Abstract S34 Table

Methods: 90 patients with COPD were admitted with an acute exacerbation of their disease. Thirty-four were considered appropriate for a gym-based endurance and strength training (resistance equipment) programme, (21 men, mean (SD) FEV1 1.04 litres (0.79), age 68.23 years (11.05), body mass index (BMI) 25.13 (6.16)). The remaining 56 patients received a bedside strength and endurance programme on an acute therapy unit, (22 men, mean FEV1 0.83 litres (0.40), age 71.9 years (9.75) and BMI 22.73 (4.73)). Before commencing the programme the quadriceps muscle strength was measured (strain gauge at 90° flexion) as well as the 10-m incremental and endurance shuttle walking tests (ISWT, ESWT) were taken. These were repeated at the time of discharge from hospital.

Results: An independent t test determined significant between-group differences in the baseline ISWT, ESWT and the strain gauge results but not in any of the other baseline characteristics. The results of a paired t test are shown in the table. These demonstrate statistically significant improvements in all of the outcome measures for those patients attending a gym-based programme. The patients who received a bedside programme did not show a statistically significant change in the quadriceps strength (strain gauge). An independent t test was then carried out to look at the between-group differences for the shuttle walking test and strain gauge results. No significant difference was found between the two groups after training in quadriceps strength; however, there was in exercise capacity, p = 0.017 and p = 0.004 for the ISWT and ESWT, respectively.

Conclusions: Both strategies appear to improve exercise performance, although the group using resistance equipment also shows a trend towards greater improvements in quadriceps strength but this is not statistically significant.

S35 REDUCED QUADRICEPS STRENGTH IN EX-SMOKERS WITHOUT CHRONIC OBSTRUCTIVE PULMONARY DISEASE

1JM Seymour, 2N Hopkinson, 2A Jackson, 2WD-C Man, 1M-L Harris, 2SA Sathyapala, 3MA Spruit, 3EFM Wouters, 1J Moxham, 1MI Polkey. 1King’s College London School of Medicine, London, UK, 2Royal Brompton and Harefield Hospitals NHS Trust, London, UK, 3University of Maastricht, Maastricht, The Netherlands

Introduction: Reduced maximum voluntary quadriceps contraction strength (QMVC) is commonly observed in chronic obstructive pulmonary disease (COPD) and independently predicts mortality. Normal isometric QMVC strength has previously been related to body weight; however, fat-free mass (FFM) declines with age.

Hypothesis: We wished to explore if QMVC normalised for body weight (or FFM) changed with age and whether a smoking history in the absence of COPD had additional influence.

Methods: Isometric QMVC measurements of normal healthy volunteers aged 40–90 years, made between 2002 and 2008, were analysed. Healthy subjects were classified as “never” or “ex-smokers”. All had FEV1 >80% predicted (FEV1/FVC ratio >70%), no dyspnoea (MRC scale 1 equivalent), no chronic cough and no history of cardiac disease or chronic organ failure. FFM was measured by electrical bioimpedance. Isometric quadriceps twitch tension (TwQ) was measured following magnetic femoral nerve stimulation.

Results: 239 QMVC records were identified (mean (SD) age 65 years (9), 46% male). 212 and 109 subjects had parallel measurement of FFM and supramaximal TwQ. 132 had a smoking history with a mean (SD) of 20 (18) self-reported pack years. Mean (SD) QMVC for all subjects was 39.5 kg (12.1). Reduced QMVC correlated with lower body weight and height and increased age. Men demonstrated greater quadriceps strength than women. Allowing for the dependence of QMVC on these factors, multiple linear regression analysis (see table) suggested that quadriceps strength was significantly reduced in ex-smokers (−3.5 kg, 95% CI −5.8 kg to −1.2 kg, p = 0.003). The influence of sex was removed if FFM was substituted for weight (model r2  =  0.54). Sex (p<0.001) and smoking history (p = 0.028) were also found to be independent predictors of TwQ. QMVC/weight and QMVC/FFM fell with increasing age (see fig); QMVC normalised by either method was lower in ex-smokers (p = 0.001 and p = 0.007, respectively) across the age range studied. Neither QMVC nor TwQ exhibited a linear relationship with self-reported pack years.

Conclusions: QMVC normalised for weight or FFM falls with increasing age and is lower in individuals with a smoking history, in the absence of dyspnoea, obstructive spirometry or COPD. The underlying mechanism and functional significance of this observation are unclear, but may be relevant to future research.

Abstract S35 Table Multiple linear regression analysis of QMVC (dependent variable, n  =  239)
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