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

1
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

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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
Study Design Quasi-experimental, Before and after measurements Quasi-experimental, Before and after measurements
Subjects 1 admission(s) in preceding 12 months 1 admission(s) in preceding 12 months
Subjects 44 37
Setting Community elderly centres Community elderly centres
Intervention 8 10 subjects per group 8 10 subjects per group
Intervention 12 weekly 2-hour sessions home exercise prescription 12 weekly 2-hour sessions home exercise prescription
Intervention Exercise training, educational talk, peer group support Exercise training, educational talk, peer group support
Outcome measures Lung function tests, 6 minute walk test (6MWT), General Health Questionnaire (GHQ), St. Georges Respiratory Symptom Questionnaire (SGRQ), COPD knowledge, programme evaluation using questionnaires, group discussions. 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
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Intervention
COPD CHF
Educational talk (1 hour) 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.
Peer group support Q A, group discussion, focus group (week 12) 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
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(No Transcript)
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Subject characteristics
Demographics COPD (n 44) CHF (n 37)
Sex (MF) 37 7 2512
Age (years) 74.2 (6.5) 73.5 (7.8)
LTOT () 25 -
FEV1/FVC () 49 (15.8) -
Disease severity () Moderate to severe 82 NYHA Class II / III 89
Attendance rate () 78 91
Dropouts 11 (25) Frequent admissions (3) moved away (2) admitted to old age home (1) transport problem (2) comorbidity (1) refused exercise (2) 5 (13.5) Comorbidity (2) hospitalised for non-cardiac problem (2) transport problem (1)
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COPD Results
Outcome measure Baseline 12 weeks P-value
Physical 6 MWT (m) 285 (96) 303(98) 0.051
Psychological GHQ (/28) 20.6 (10.1) 12.2 (6.0) lt0.001
Psychological SGRQ (/99.99) 53.7 (19.6) 37.7 (14.1) lt0.001
COPD knowledge (/10) 6.6 (2.0) 8.8 (1.1) lt0.001
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CHF Results
Outcome measure Baseline 12 weeks P-value
Physical 6MWT 329.5 (103.2) 380.9 (90.3) lt0.001
Physical Biceps strength (right) 15.0 (6.6) 18.9 (6.2) 0.001
Physical Quadriceps strength (right) 12.8 (5.0) 19.1 (5.3) lt0.001
Psychological HADS (anxiety) 5.9 (3.8) 3.5 (3.0) lt0.001
Psychological MOS-SSS (tangible) 67.4 (24.7) 85.9 (14.0) lt0.001
Psychological CHQ (dyspnoea) 4.05 (0.95) 5.3 (0.9) lt0.001
CHF knowledge (/10) 7.8 (1.7) 9.6 (1.4) lt0.001
Significant changes were recorded on both the
left and right side. Significant changes were
observed for all domains of the HADS, MOS CHQ.
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Programme evaluation
No. Question Disagree () Disagree () Ambiguous () Ambiguous () Agree () Agree ()
No. Question COPD CHF COPD CHF COPD CHF
1 I will attend similar courses again 13.8 3.1 10.3 15.6 75.9 81.3
2 I can complete all the prescribed exercises 3.4 0 0 9.4 96.6 90.6
3 I prefer group exercise to home exercise 20.7 28.1 27.6 18.8 51.7 53.1
4 I feel that my physical health is better than before 0 0 3.4 6.3 96.6 93.8
5 The group mates can help me handle my disease 0 3.1 24.1 9.4 75.9 87.6
6 I did not have any problem travelling to the centre 10.3 0 3.4 3.1 86.2 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. J Evaluation in Clin
  Practice, 200612523-531.
• 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)
• huie_at_ha.org.hk