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Pulmonary rehabilitation: assessment and outcome (this set runs into txdec08abs7)

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I Hill, AJ Williams, TJ Shaw. Royal Bournemouth Hospital, Bournemouth, UK

Pulmonary rehabilitation has an established role in the treatment of chronic lung disease reducing dyspnoea, improving both quality of life and exercise tolerance. However, although NICE guidelines state that smoking cessation is an integral part of pulmonary rehabilitation the inclusion of current smokers is a contentious issue, with many programmes precluding their attendance.

Patients and Methods: We have therefore analysed results from an established twice weekly, 7-week pulmonary rehabilitation programme comparing chronic obstructive pulmonary disease patients who are ex-smokers with current smokers. Forty-six patients were recruited, forming two study groups that were matched for age, sex, lung function and breathlessness (MRC score). All patients completed pre and post-incremental shuttle walk test (ISWT), endurance shuttle walk test (ESWT), predicted VO2 max (pVO2) quality of life questionnaire (QOL) and FEV1.

Results: The mean age was 65 years (range 55–77), 14/23 men per group; FEV1 mean 0.92 litres predicted, range 0.35–1.88 litres. Both groups showed significant post compared with pre improvements in ISWT, ESWT and predicted VO2 max. However, significant QOL scores were only seen in the current smokers group, whereas improvements in FEV1 were only seen in the non-smoking group. When comparing post-rehabilitation improvements no significant differences were seen in all measures between groups.

Analysis of Data: This study demonstrates that physical improvements made by smokers are just as great as non-smokers. Interestingly, current smokers showed a significantly greater improvement in pre to post-rehabilitation QOL than non-smokers, although this was not significant between groups. An explanation of this could be the non-stigmatic environment of pulmonary rehabilitation and the self-efficacy that they are enrolling in something positive associated with their chronic lung disease. This study provides evidence that smokers should not be excluded from pulmonary rehabilitation. Furthermore, the benefits of pulmonary rehabilitation coupled with the core concept of smoking cessation may enhance the overall rehabilitation of this subgroup.

Abstract P41 Table Effects of pulmonary rehabilitation on current smokers and ex-smokers


1MA Spruit, 2JM Seymour, 2J Moxham, 3MI Polkey, 1EFM Wouters. 1University of Maastricht, Maastricht, The Netherlands, 2King’s College London School of Medicine, London, UK, 3Royal Brompton and Harefield Hospitals NHS Trust, London, UK

Introduction: Six-minute walking test (SMWT) performance has previously been related to anthropomorphic characteristics, including body mass index (BMI, which incorporates elements of height and weight), as well as quadriceps strength and peak oxygen consumption. Reduced SMWT distances have been described among current compared with ex-smokers with peripheral vascular disease. Reduced quadriceps endurance in otherwise healthy smokers has also been reported.

Hypothesis: We hypothesised that SMWT distance would be reduced in the presence of current tobacco smoke exposure in chronic obstructive pulmonary disease (COPD).

Methods: Records of COPD patients attending for SMWT assessment at a clinical rehabilitation hospital in The Netherlands were analysed. Variables of interest related to exercise capacity and the SMWT were identified: anthropomorphic data (age, sex, BMI, fat-free mass index; FFMI); measures of activity and activity-related dyspnoea (MRC dyspnoea scale score, St George’s respiratory questionnaire activity domain, quadriceps strength); pulmonary function (FEV1, TLCO, RV/TLC ratio, resting PaO2) and peak incremental cycle exercise capacity (Wpeak). Quadriceps strength was quantified by maximal isometric voluntary contraction strength (QMVC). Arterial carboxyhaemoglobin levels of ⩾2% were used to indicate active smoke exposure.

Results: Complete data were identified for 221 subjects (63% men) with a mean (SD) age of 64 years (10) and median MRC dyspnoea scale score of 3. Mean (SD) % predicted FEV1 was 47.1% (16.8). 44% of subjects had an carboxyhaemoglobin level of ⩾2%; this group had a significantly reduced SMWT compared with those with a low carboxyhaemoglobin level (−33 m, 95% CI −63 m to −4 m; p = 0.026). The table shows group data and the result of a multiple linear regression analysis: allowing for the dependence of the SMWT on the variables described, subjects with an carboxyhaemoglobin level ⩾2% still had a significantly shorter SMWT distance. The independent effect of sex was removed when FFMI was substituted for BMI; current exposure to tobacco smoke remained significantly related to SMWT performance (p = 0.010).

Conclusions: SMWT performance is independently related to the degree of resting hyperinflation and clinical measures of activity related dyspnoea in COPD. Current exposure to tobacco smoke was associated with a reduced SMWT performance of 24 m and appeared independent of FFMI or quadriceps strength.

Abstract P42 Table The effect of smoking status on SMWT distance


1D Earley, 1B O’Neill, 2J MacMahon, 1JM Bradley. 1University of Ulster, Newtownabbey, UK, 2Belfast Health and Social Care Trust, Belfast, UK

Introduction: Currently few questionnaires exist that assess knowledge and satisfaction with the education component of pulmonary rehabilitation. The aim of this study was to develop a questionnaire that could be used to assess the benefit of education in pulmonary rehabilitation.

Methods: Stage 1: The questionnaire (section A: knowledge—three components; section B: satisfaction) was developed following focus groups of patients with chronic obstructive pulmonary disease (COPD), a review of relevant literature and consultation with healthcare professionals and patients with COPD. Stage 2: The questionnaire was piloted in 30 patients with COPD for content and readability. Stage 3: The test–retest reliability was assessed in 20 patients with COPD. The mean (SD) time between visits was 7 days (1). Stage 4: The questionnaire was assessed for plain English and reading age using the drivel defence and simple measure of gobbledygook (SMOG) indices. The drivel defence index calculates the number of sentences below and above 20 words and provides potential alternative words. The SMOG index estimates the years of education required to understand written text.

Results: Section A had good test–retest reliability. 16/18 questions had an ICC >0.70 (range 0.64–0.92). The three components of section A showed good internal consistency (Cronbach’s alpha range 0.67–0.97). Section B could only be completed by those patients who had previously attended pulmonary rehabilitation (n  =  10). Wilcoxon signed rank test showed no significant difference between the scores on the two occasions for section B. Amendments were made to the questionnaire following results from the initial drivel defence and SMOG indices. The final drivel defence index showed that the mean length of question was 16 words and 19/24 questions were below 20 words. The final SMOG index showed that the majority of questions required an education level of secondary school education or below. The mean (SD) length of time taken to complete the questionnaire was 7 minutes (2).

Conclusion: The questionnaire is short, easy to administer and reliable. Further research focusing on the responsiveness of the questionnaire is underway.


1NS Gale, 2E Hilsden, 2T Lines, 1S Enright, 3DJ Shale, 3CE Bolton. 1School of Healthcare Studies, Cardiff University, Cardiff, UK, 2Llandough Hospital, Cardiff, UK, 3Department of Respiratory Medicine, Cardiff University, Cardiff, UK

Background: Fatigue is an important symptom described by patients with chronic obstructive pulmonary disease (COPD), but can be difficult to quantify and assess. We explored fatigue in such patients attending pulmonary rehabilitation and hypothesised that fatigue scores would attenuate following pulmonary rehabilitation.

Methods: We evaluated 33 patients (11 men), median age (range) 65 years (49–80), mean (SD) FEV1 % predicted 42.5% (14.7) and body mass index 26.1 kg/m2 (7.4), as part of a larger study investigating comorbidities in patients with COPD undertaking pulmonary rehabilitation. The multi-dimensional fatigue inventory,1 which determines fatigue scores for five domains of fatigue (each scored out of 20, with a higher score indicating more fatigue), was completed in addition to standard outcome measures pre and post-pulmonary rehabilitation. The multidisciplinary pulmonary rehabilitation programme has previously been described. To date, 19 patients have completed pulmonary rehabilitation and are representative of the 33 baseline patients.

Results: At baseline, general and physical fatigue together with feelings of reduced motivation and activity were worse than previously published data in healthy individuals of similar age, see table;2 mental fatigue was similar. All domains of fatigue, except mental, were related to total quality of life (St George’s respiratory questionnaire); and depression (hospital anxiety and depression score; HADS) was related to general and physical fatigue and reduced activity, all p<0.05 but not anxiety (HADS). Only feelings of reduced activity (r  =  −0.371) and reduced motivation (r  =  −0.359), both p<0.05, were related to the incremental shuttle walk test (ISWT). With pulmonary rehabilitation, mean (95% CI) change in general fatigue was −2.1 (−0.3 to −3.9), feeling of reduced activity −2.6 (−0.7 to −4.5) and reduced motivation −1.8 (−0.01 to −3.57), with a similar trend to improved physical fatigue, p = 0.05. Clinical parameters such as age, FEV1 % predicted, body mass index and ISWT did not predict change in any of the fatigue domains.

Conclusions: Several domains of fatigue are increased in patients with COPD and improved by pulmonary rehabilitation in parallel with other accepted outcome measures such as the St George’s respiratory questionnaire and post-incremental shuttle walk test distance. The lack of association with other clinical parameters highlights either the complex subjective nature of fatigue or its independent contribution to the patients’ welfare.

Abstract P44 Table



1SE Raywood, 2E Hilsden, 2T Lines, 1CE Bolton. 1Respiratory Medicine, Cardiff University, Cardiff, UK, 2Llandough Hospital, Cardiff, UK

Background: Pulmonary rehabilitation has established itself as integral to the management of patients with chronic obstructive pulmonary disease (COPD) and offers benefit to patients with other chronic lung diseases. Depression is common in patients with chronic lung disease. Does depression allow similar outcomes with pulmonary rehabilitation—can patients accept the multidisciplinary input or should the depression be treated first? Withers et al (1999) studied some outcomes in patients with severe COPD, n  =  95. We explored various outcomes in an unselected group of patients entering pulmonary rehabilitation.

Abstract P45 Table Mean (95% CI) change in each outcome parameter

Methods: 206 consecutive records of patients entering pulmonary rehabilitation (mid-2006–end 2007). Details of the multidisciplinary 20 session pulmonary rehabilitation programme have been detailed before. Hospital anxiety and depression score (HADS) and the St George’s respiratory questionnaire (SGRQ) together with the incremental shuttle walk test (ISWT) were conducted pre and post-pulmonary rehabilitation.

Results: 185 completed pulmonary rehabilitation, with a similar proportion of depressed/non depressed dropping out. Of the 185 (103 men, mean age 67 years, 80% with a primary diagnosis of COPD), 21 (11%) had depression (HADS ⩾11). At the outset, patients with depression had worse SGRQ (activity, impact and total) and shorter ISWT. Improvements in SGRQ were greater in the depressed group, whereas ISWT changes were similar (see table). 17/21 patients who were initially depressed had HAD scores <11 at completion.

Conclusions: Multidisciplinary pulmonary rehabilitation offers benefits of a similar or greater benefit in patients with chronic lung disease who are depressed compared with those not depressed.


1J Moore, 1A Grant, 1L Moore, 2WD-C Man, 3J Seymour, 3CJ Jolley, 2MI Polkey, 3BJ Gray, 3RD Barker, 3J. Moxham. 1Lambeth and Southwark Pulmonary Rehabilitation Team, London, UK, 2Royal Brompton and Harefield NHS Trust, London, UK, 3King’s College Hospital, London, UK

Introduction and Objectives: Most guidelines state that old age is not a valid exclusion criterion for pulmonary rehabilitation. This is based on historical data demonstrating that pulmonary rehabilitation leads to similar improvements in exercise capacity in older patients compared with younger patients with similar lung function abnormalities. However, these studies involved a small number of patients in either an inpatient rehabilitation or hospital-based outpatient setting. The objective of the present study was to determine whether octogenarian chronic obstructive pulmonary disease (COPD) patients gain similar benefits to younger patients from community-based pulmonary rehabilitation.

Methods: All COPD patients over the age of 80 years (elderly) participating in a community pulmonary rehabilitation programme in Lambeth and Southwark between the years 2004 and 2007 were included in the study. The control group consisted of COPD patients under the age of 65 years participating in the same classes (control). Outcomes were defined as changes in incremental shuttle walk distance (ISW) and breathlessness (as measured by the chronic respiratory disease dyspnoea domain; CRQ-D) pre and post-pulmonary rehabilitation.

Results: There were 99 patients in the elderly group (47 men, mean age 82.9 years, FEV1 57.4% predicted) and 250 patients in the control group (106 men, mean age 58.4 years, FEV1 51.4% predicted). Elderly showed smaller improvements in ISW and CRQ-D than controls (see table).

Conclusions: Octogenarian COPD patients show smaller improvements in exercise capacity and dyspnoea following community pulmonary rehabilitation compared with patients under the age of 65 years. This warrants further investigation.

Abstract P46 Table


1F Abell, 2C Potter, 2S Purcell, 2H Broomfield, 3M Griffin, 2L Restrick, 2A Erskine, 2M Stern. 1Department of Health Psychology, Camden and Islington Mental Health and Social Care Trust, Archway Campus, London, UK, 2Department of Respiratory Medicine, Whittington Hospital NHS Trust, London, UK, 3Department of Primary Care and Population Sciences, Archway Campus, University College London, London, UK

Introduction and Objectives: Pulmonary rehabilitation programmes for patients with chronic obstructive pulmonary disease (COPD) commonly report high attrition rates. Completion of pulmonary rehabilitation is associated with functional benefits and decreased acute exacerbations requiring admission. In contrast, we have previously shown that patients who do not complete pulmonary rehabilitation are more likely to be admitted with acute exacerbations of COPD and also have higher self-reported levels of anxiety and depression (Thorax 60 (Suppl II): ii67). The aim of this study was to assess the impact of including a clinical psychologist in pulmonary rehabilitation on patient-related outcomes including admissions and bed-days.

Methods: Outcomes for patients with moderate to severe COPD (n  =  52, mean (SD) age 70.1 ± 7.9 years, FEV1 0.86 ± 0.89 litres) who attended a traditional-style pulmonary rehabilitation programme were retrospectively compared with outcomes for COPD patients (n  =  25, mean (SD) age 69.8 ± 8.8 years, FEV1 1.13 ± 0.52 litres) who attended a series of pulmonary rehabilitation programmes modified to include a cognitive behavioural therapy-based psychological component aimed at addressing psychosocial issues and building patient empowerment and self-efficacy. Outcomes included completion rate, functional measures (6-minute walk or shuttle walk test, MRC dyspnoea score), emotional measures (chronic respiratory questionnaire, hospital anxiety and depression score) and measures of hospital resource utilisation (hospital admission rate and bed-day utilisation in the year following pulmonary rehabilitation).

Results: For all patients who completed pulmonary rehabilitation, with or without a psychological component, there were significant (p<0.05) improvements in functional and emotional outcome measures other than anxiety. However, the inclusion of a targetted psychological component in pulmonary rehabilitation was associated with a highly significant (p = 0.02) improvement in completion rates from 50% to 92%. Completion of pulmonary rehabilitation was, in turn, associated with a signficantly (p = 0.05) lower mean annual admission rate in the year following pulmonary rehabilitation (0.2 admissions/patient/year for completers compared with 1.4 admissions/patient/year for those who did not complete) and consequently a significantly lower bed-day usage (2.6–3.2 bed-days/patient/year for completers compared with 15–18.5 bed-days/patient/year for non-completers in the 12 months following pulmonary rehabilitation).

Conclusions: Inclusion of psychological input into pulmonary rehabilitation improves the quality of patient care and experience by facilitating completion of the programme. This study indicates that there are, in addition, clear cost-benefits in terms of hospital resource utilisation.


1L Moore, 1J Moore, 1A Grant, 2WD-C Man, 3J Seymour, 1CJ Jolley, 2MI Polkey, 3BJ Gray, 3RD Barker, 3J Moxham. 1Lambeth and Southwark Pulmonary Rehabilitation Team, London, UK, 2Royal Brompton and Harefield NHS Trust, London, UK, 3King’s College Hospital, London, UK

Introduction and Objectives: There are hypothetical reasons why pulmonary rehabilitation may be less effective in winter months. Poor weather may discourage patients from uptake of pulmonary rehabilitation and regular attendance of classes. The higher incidence of exacerbations and hospitalisations may reduce completion rates and response to pulmonary rehabilitation. The objective of this study was to assess the efficacy of pulmonary rehabilitation in the winter months (December to February) compared with the rest of the year by comparing uptake rates, completion rates, improvements in incremental shuttle walk distance (ISW) and changes in the chronic respiratory questionnaire dyspnoea score (CRQ-D).

Methods: All patients referred to the Lambeth and Southwark pulmonary rehabilitation team between the years 2004 and 2007 were included in the study. All appropriate patients were offered pulmonary rehabilitation at one of seven hospital or community programmes. Each programme consisted of two supervised sessions per week for 8 weeks. Take-up rate was defined as the percentage of appropriate patients who consented to and started a pulmonary rehabilitation programme. Completion rate was defined as the percentage of patients starting pulmonary rehabilitation who completed a minimum of eight sessions. Uptake and completion rates were compared between winter and other months using Fisher’s exact test. Changes in ISW and CRQ-D pre and post-pulmonary rehabilitation were compared between winter patients and other patients using unpaired t tests.

Results: In total, 1222 patients were assessed and deemed appropriate for pulmonary rehabilitation, with 817 patients starting pulmonary rehabilitation and 675 patients completing. No statistically significant difference was found between take-up rates, completion rates, mean ISW improvement and CRQ-D change between winter months and the rest of the year (see table).

Conclusions: There is no evidence to suggest that pulmonary rehabilitation is less efficacious in the winter months.

Abstract P48 Table


L Cornish, F Dyer, J Bott. Surrey PCT, Chertsey, UK

Introduction: There is limited evidence for the relationship between the severity of chronic obstructive pulmonary disease (COPD) and benefit from pulmonary rehabilitation. ACCP/AACVPR guidelines (2007) report benefit for “any stable patient with COPD disabled by respiratory symptoms” and ATS/ERS guidelines (2006) suggest that rehabilitation is beneficial for MRC grades 3–5. COPD patients comprise the largest proportion of referrals for pulmonary rehabilitation but there is increasing evidence that pulmonary rehabilitation is beneficial for patients with other chronic lung diseases (ACCP/AACVPR guidelines 2007).

Abstract P49 Table ESWT pre and post-pulmonary rehabilitation

Aim: To evaluate the effectiveness of pulmonary rehabilitation on exercise tolerance by disease, both COPD and non-COPD, and by classification of COPD severity (NICE COPD guidelines, 2004).

Method: Pre and post-pulmonary rehabilitation endurance shuttle walk test (ESWT) data were analysed for all our patients completing pulmonary rehabilitation from October 2002 to March 2008. Data were analysed for within-group change and between group differences.

Results: See table. Three groups contained outliers with considerably higher than average improvements and therefore these patients were excluded from analysis.

Conclusion: Every group achieved a significant improvement in ESWT, with no difference in percentage change between groups, despite expected differences in actual distances walked. All groups had large variance with the greatest in the severe COPD group. These data confirm that all types of patient, both non-COPD and COPD of all severities, benefit equally from PR, but with wide variation in individual outcome.


E Ward, F Dyer, J Bott. Surrey PCT, Chertsey, UK

Introduction: Previous published work from another UK centre demonstrated a significant difference in pulmonary rehabilitation outcome between three different sites, where client groups were the same and therapists differed. ATS/ERS guidelines (2006) suggest pulmonary rehabilitation is effective across various settings. Our service spans three sites; two acute and one community hospital, with different therapists at each site.

Aim: To evaluate the effectiveness of pulmonary rehabilitation outcome in the endurance shuttle walk test (ESWT) across three different sites within the same service.

Method: Pre and post-pulmonary rehabilitation ESWT data were analysed for all patients completing pulmonary rehabilitation in October 2002–March 2008 both within and between sites.

Results: Complete data were available for n  =  303; analysed with Wilcoxon signed-rank test for within and Kruskal–Wallis for between-site data.

Conclusion: A significant improvement in ESWT was demonstrated at each site. There was no significant difference in percentage change between sites, despite a significant difference in baseline spirometry and ESWT. This may be accounted for by differences in socioeconomics around the three sites. All sites had large variance in baseline levels and outcome post-pulmonary rehabilitation. This service is well supported by senior clinicians, with regular team meetings to ensure consistency between programmes, which may account for our findings.

Abstract P50 Table ESWT pre and post-pulmonary rehabilitation by site with baseline FEV1


SG Radford, A Price, K Siskoglou. Tower Hamlets Primary Care Trust, London, UK

Backgound: Pulmonary rehabilitation (PR) is an integral part of the management of patients with chronic obstructive pulmonary disease (COPD). However, the provision of PR is limited and often catering for patients from black and minority ethnic (BME) groups can be difficult. Tower Hamlets is a culturally diverse area of east London, where 34% of the population is Bangladeshi. Service data showed that in 2006–7, only 5% of all PR referrals were for Bangladeshi men. In 2007 new measures were put in place to improve access to PR for Bangladeshi patients with COPD. An audit was carried out to establish whether more Bangladeshi men were able to attend PR, following the introduction of these new measures.

Abstract P51 Table Comparison of PR service data for 2006–7 and 2007–8

Method: The design of an existing PR programme in Tower Hamlets was adapted for the Bangladeshi male population. User involvement, via a focus group meeting, was important in informing change. Changes included creating single sex classes, held in a mosque, using bilingual rehabilitation support workers, omitting music during exercising, modifying education sessions and maintaining regular telephone contact with patients. Promotional work to publicise this service was also carried out in local GP surgeries. Data were collected before and after the new measures were introduced, for 2006–7 and 2007–8, respectively.

Results: The number of Bangladeshi men completing a PR programme increased by eight times following the introduction of changes to the PR service.

Conclusion: Adapting PR to suit a BME group better brought about improved equality in service provision to patients with COPD in Tower Hamlets. By making small changes to the PR programmes, many more male Bangladeshi patients with COPD were able to access PR. This suggests that a similar model would also be effective in enabling Bangladeshi women to participate in PR programmes.


1A Grant, 1J Moore, 1L Moore, 2WD-C Man, 3J Seymour, 3CJ Jolley, 2MI Polkey, 3BJ Gray, 3RD Barker, 3J Moxham. 1Lambeth and Southwark Pulmonary Rehabilitation Team, London, UK, 2Royal Brompton and Harefield NHS Trust, London, UK, 3King’s College Hospital, London, UK

Introduction and Objectives: The majority of pulmonary rehabilitation (PR) programmes in the UK occur in hospital-based outpatient settings. Potential advantages include cost-effectiveness, a safe clinical environment and availability of trained staff. However, limited space and exercise facilities may restrict the capacity of hospital-based PR programmes. Community-based PR programmes have the potential to increase capacity and improve accessibility for patients. Although there is a supportive evidence base for PR, the most recent meta-analysis identified only one study that was based in the community. The objective of the present study was to determine whether community-based PR leads to clinically significant improvements in exercise capacity and breathlessness, and how the magnitude of these improvements compare with PR in a hospital setting.

Methods: Chronic obstructive pulmonary disease (COPD) patients referred to the Lambeth and Southwark Pulmonary Rehabilitation Team between the years 2004 and 2007 were included in the study. All appropriate patients were offered the choice of PR at either King’s College Hospital (hospital) or at one of six community programmes in Lambeth and Southwark (community). Those with a baseline MRC dyspnoea score of 5 were preferentially allocated to hospital and were therefore excluded from the current study. Primary outcomes were defined as changes in incremental shuttle walk distance (ISWD) and breathlessness (as measured by the chronic respiratory disease dyspnoea domain; CRQ-D) pre and post-PR. Secondary outcomes were take-up rates (the percentage of appropriate patients who started a PR programme) and completion rates (the percentage of patients starting PR who completed a minimum of eight sessions).

Results: Take-up rates were similar between community and hospital (67% vs 62%, respectively), as were completion rates (83% vs 77%). In total, 630 patients completed PR (community n  =  505; hospital n  =  125). Both community and hospital PR led to improvements in ISWD and CRQ-D (see table).

Conclusions: Supervised community PR programmes result in clinically significant improvements in exercise capacity and breathlessness.

Abstract P52 Table
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