Designing a Pulmonary Rehabilitation Programme

Physiotherapists have an important role to play in the rehabilitation of patients with chronic obstructive pulmonary disease. Individuallytailored programmes including the following components, namely education, exercise, secretion removal, breathing 'training', home programmes, ventilatory muscle training, medications, support systems and counselling can provide subjective and objective benefits for these patients. A primary consideration is to involve patients in the planning, implementation and evaluation of the programme and to encourage them to develop self-help skills. Guidelines for designing a pulmonary rehabilitation programme are outlined, I and pertinent literature reviewed.

The American College of Chest Physicians in 1974 developed the following definition: Pulmonary rehabilitation may be defined as an art of medical practice wherein an individually tailored, multidisciplinary program is formulated which through accurate diagnosis, therapy, emotional support, and education stabilizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by his pulmonary handicap and overall life situation (Petty 1977 p. 68). The physiotherapist (in conjunction with the respiratory physician) has a major role to play in pulmonary rehabilitation either in an established multidisciplinary programme or in conducting a programme for an individual patient or a group of patients. This is 46

JOY HIGGS Joy Higgs, B.Sc., Grad. Dip. Phty, M.H.P.Ed., is the Education Officer of the New South Wales Branch of the Australian Physiotherapy Association

ALICE PATRICIA WETTENHALL Alice Wettenhall, B.App.Sc. (Phty), Grad.Dip. Manip.Ther., is a private practitioner in Sydney.

due to the nature and extent of his/ her Involvement in the rehabilitation process of patIents with chronic asthma, chronic bronchitis and pulmonary emphysema. (See Table 1 for definitions of these condItions.) This paper presents a review of pertinent literature and presents guidehnes and references for physiotherapists involved in, or responsible for, designing pulmonary rehabilItation programmes.

The Course and Prognosis of Patients with COPD1

Tomashefski (1977) describes chronic obstructive pulmonary disease as a major cause of pulmonary distress 1 The term Chromc Obstructive Pulmonary Dlsease(s) (COPD) Will be used throughout to refer to chromc asthma, chromc bronchitis and pulmonary emphysema collectively Each of these diseases IS characterized by the functional diSorder of chromc airflow lImitation (CAL)

The Australian Journal of Physiotherapy Vol 31, No 2, 1985

and disability occurring in about 3 per cent of the population and in about 30 per cent of men and women over 35 years of age in the United States of America. The course of moderate-severe COPD is commonly presented in textboo ks as being characterized by progressive deterioration, involving exacerbations of acute bronchitis pneumonia or acute episodes of bronchial reactivity, and generally culminating in premature death due to pulmonary and/or cardiac failure (Hass et al 1979, Petty 1974). These changes in CO P D are naturally compounded by the normal effects of ageing on the respiratory system. Such changes include loss of elastic reCOIl, decreased arterial oxygen tenSion, declIning strength of respiratory muscles, stiffening of the chest wall, loss of functional reserve and

Designing a Pulmonary Rehabilitation Programme

Table 1: COPD Definitions Chronic Asthma 'Th is disease is characterized by Interm ittent attacks of reversible airway obstruction, both Inspiratory and expiratory, which may follow a course of days, months, or years' (Tomashefskl 1977 p.88). 'In asthma the airflow obstruction IS usually partly reversible and changes In severity over short periods of time either spontaneously or as a result of treatment. Occasionally chronic asthma and chronic bronchitis occur together. Asthma is rarely complicated by emphysema' (Schonell 1980 p.12).

decreased compensatory mechanIsms (Campbell and Lefrak 1978). StudIes of the course and prognosIs of COPD IdentIfy a number of characterIstics and parameters WhICh support the textbook pIcture of COPD. Table 2 presents the findIngs (Ie COPD prognosIs) of some of these studIes and the predIctors used to determIne the prognosIs. These reports emphasIse that the value of prognosIs predIctIons and lung functIon evaluatIon lIes In provIding gUIdance to choose the most sUItable type of therapy and to IdentIfy persons who are at Increased risk of death or rapId deterIOratIon, and could benefIt from therapeutIc InterventIon. In theIr natural environment, persons wIth pulmonary emphysema have been found to manage theIr condItions best when there IS the presence of a signifIcant other persons (eg spouse) to support them (Barstow 1979).

Goals of Medical Management of COPO

Consldenng the chronIc and progressive nature of COPD conditions, W hat then are the general goals of medIcal management?

A principal characteristic of asthma IS hyperreactivlty of the airways. Chronic Bronchitis 'This disease Involves major as well as small airways and is characterized by Inflammation, edema, mucous gland hypertrophy with crypt formation, cough and hypersecretion. It can occur alone, sometimes as a severe disabling disease, or with asthma, emphysema or both' (Tomashefskl 1977 p. 88). 'The Medical Research Council of Great Britain defined chronic bronchitis as a disease characterized by cough productive

Schuman and Cohen (1982) reported that medIcal management of patients wIth COPD has resulted In beneficial changes In the patIent's qualIty of life, symptoms and longevity. By comparIson Sahn et al (1980) set less optimistic goals In reference partIcularly to patIents wIth disease severe enough to seek medIcal advIce. These authors found that patIents seeking medIcal advIce had generally entered the final decade of the thIrty to forty year course of their dIsease. At thIS stage they found that therapy was lImited to beIng able to reverse, stabIlIze or substantIally slow down the Inexorable downhIll course of the dIsease. AccordIng to GolIsh and Ahmad (1977) the goal of medical management IS to Improve the patIent's qualIty of hfe and sUbjectIve response to theIr Illness. SImIlarly Cotes (1978) conSIders that the ultImate rehabIlItatIon goal of the chronIC respIratory crIpple, of return to prevIous employment, IS pOSSible only for very few, but belIeves that much can be done to Improve the patIent's symptoms and abIlIty to take exerCIse.

of sputum on most days dUring at least 3 consecutive months of more than 2 successive years ... In practice, chronic bronchitis and em physema often co-exist' (Schonell 1980 p. 11). Pulmonary Emphysema 'This disease of the lung parenchyma is morphologically characterized by destruction of air spaces, with fenestrations and with loss of lung elasticity distal to the terminal bronchioles. Obstruction to airflow results from the loss of radical traction support of the small airways' (Tomashefskl 1977 p. 89).

In order to set realistIc goals for a pulmonary rehabl1Itation programme the level of dIsabIlity of the target group and the nature and components of the programme must be taken into conSIderation. These goals may need to be changed In response to findings on evaluatIon of the programme's effectIveness In achieving the goals.

Components of Pulmonary Rehabilitation Programmes Pulmonary rehabIlItatIon programmes Incorporating a wide range of therapeutIc measures have been In operatIon for over twenty years. Tables 3 and 4 are presented as an overVIew of the wealth of InSight and expenence represented by over fifty WrIters. These tables Include commonly supported features of pulmonary rehabIlItatIon (Table 3) and an hIstorIcal overview of the components dealt With In these studies (Table 4). OWIng to the dIfficultIes Involved In the study of the management of such a vaned and often very dIsabled group of people, the establIshment of conVIncIng eVIdence In support of the vanous measures adopted in these

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47

Designing a Pulmonary Rehabilitation Programme

Table 2: Predicting prognosis in COPO Reference (First Author)

COPD Prognosis

Prognosis predictors

Weitzenblum (1978)

Relative stability of pulmonary artery mean pressure over 3-10 years, despite a declining FEV 1 Large and temporary haemodynamlc changes durIng RHF and acute respiratory failure Haemodynamlc worsening determined by Increasing pulmonary vascular resistance, causing hypoxemia

Irreversible ECG changes Pulmonary artery hypertension FEV 1 Clinical and radiologic evolution

Postma (1979)

Slowly progressive Excess mortality For severe COPD (FEV 1 = 1000ml): 5 year survival rate 69% 10 year survival rate 400/0 (with continUing medical care)

FEV 1 (Age corrected)

Traver (1979)

Wide Individual variability Survival rate 52% at 5 yeats, 23% at 10 years and 12 °16 at 15 yrs

FEV 1 after bronchodilators Cor pulmonale in people under 65 years

Burrows (1980)

Mean yearly decline of 0100ml in FEV 1 over 10 years Considerable Individual variation

FEV 1 (Age corrected) Post bronchodilator FEV 1 Presence of cor pulmonale

Good (1980)

11 year follow up of COPD pat i e n t s 33 % m 0 rt aII t Y (Normal population mortality 70/0) Mean decline In FEV 1 73ml/year

FEV 1 Questionnaire on respiration symptoms

McSweeney (1980)

Negative changes in mood and social behaviour Restricted lifestyles

Chronic hypoxia

programmes IS difficult. Lack of control groups, small numbers, short-term studies and unsuItable or InsensitIve parameters form the major problems. In spite of thIS, some therapIes eg exercise training and bronchial hygiene 48

port. There IS also Increasing use of, and emphasIs on, the psychologIcal as well as the phYSIcal components of the management of COPD patients and on Improved educatIon of patIents, famIlIes, the communIty and staff In both management and prevention. In the early years, pulmonary rehabIhtation programmes were unable to supply eVIdence of benefIt In terms of lessenIng mortalIty, or the progressIve detenoration of these dIseases. Long term follow-up studIes are Just now startIng to alter thIS trend.

Table 3: Characteristics of pulmonary rehabilitation programmes

have become WIdely accepted, and others such as patient education, psychological support, breathing 'retrainlng', ventIlatory muscle traInIng, and relaxation therapy, are In common use and are continually gaining more sup-

The Australian Journal of PhySIotherapy Vol 31, No 2, 1985

Programme Alms To improve quality of life To Increase exercise capacity To Increase self-help ability To decrease symptoms To Improve lung function To Increase longevity Programme Components Breathing retraining Education Exercise Home programmes Medications and oxygen Secretion removal Support systems and counselling Ventilatory muscle training Relaxation training Programme Results Increased exercise tolerance Subjective Improvement Lifestyle improvement Improved lung function Decreased hospitalization Increased longevity Return to work

Designing a Pulmonary Rehabilitation Programme

Table 4: Pulmonary rehabilitation First author Miller 1 Haas Miller 1 Gandevia Pierce 1 Barach 2 Barach 2 Christie Miller 1 Burrows 3,4 Neff 4 Kimbel Segal Petty 4 Robertson Ruppel Lertzman Samios Shapiro Fergus McGavin Kolaczowski Parker Bradley Stanley Mertens Hale White Fox Setgysels Gimenez Anderson Peress Broussard Sinclair Windsor Davis May Belman Hepper Sahn 4 Ashikaga Dudley 5 Dudley 5 Erskine-Millis Braun 6 Post Petty 4 Peach Perry Carasso Braun 6 McDonald Reid

an historical overview

Year Paper type 62 63 63 63 64 64 67 68 71 71 71 71 73 73 74 76 76 77 77 77 77 77 77 78 78 78 78 79 79 79 b 79 79 79 79 80 80 80 80 80 80 80 80 80 a 80 b 81 81 81 81 81 81 82 82 82 83 a

s s

X

d

x x x x x

d s/f d

x x x x

d

x

d

s s

s s s

s s

x r

s s s s d d

s

d

s r

s

d

s s s

x/a

BH

BE

PE

x

x x

x x x

x

x

x x x x

x x

x

x x x

x x x

x x x

x

x

x

x

x

x x x

x x

x x x x x x x x x x x x

x

x

x

x

x

Components FE SE CE

x x

x x

r d

s

s d

sit s

x x

d d d s d d d s d s d 4

PS

RG

x x x x

x

x

x x x x

x

x x

x

x x

x x x x

x x x

x x

x

x x

x

x

x x x

x x

x

x x x

x

x

x x

x x

x

x x

x

x x

x x

x

x

x

x

x

x

x

x

x

x

x

x

x

x x

x

x x

VT

x

s

s s

R

x

x

x x x

x

x

x

x

x

x

x

x

x

x x

x x

x

Key Paper type: s=study, d=descriptive, f=follow-up, r=review. Components: X=exercise training, X/O=exercise with oxygen, BH=bronchial hygiene, BE=breathing 'exercises', PE=patient education, FE=family education, SE=staff education, CE=community education, R=relaxation training, VT=ventilatory muscle training, PS=psychological supportl management, RG=rehabilitation guidelines. Author numbers (1-6) indicate related studiesl papers. The Australian Journal of Physiotherapy Vol 31, No 2, 1985

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Designing a Pulmonary Rehabilitation Programme

Sahn et a1 (1980 p. 314) after a 10 year follow up study of a comprehensive rehabilitatIon programme, concluded 'that an individually tailored multidisciplinary rehabilitation programme for outpatIents with COPD utilizing existing hospItal personnel may stabilize or reverse the disease and return the indivIdual to hIS hIghest functional capacity'. TIme and further study will continue to evaluate and modify both techniques and programmes. In the meantlme there is a growing support for measures that will improve the patlent's self-reliance and wellbeing. Schuman and Cohen (1982 p. 76) further suggest that 'while the major progress in the last decade has been in the evaluation of the vanous therapeutic modalities currently In use, there is a significant possibility that clinical trials of agents that Interfere with the basic pathogenetIc mechanisms may be started In the next decade' . The following sectIons WIll deal wIth commonly-used and supported components of pulmonary rehabIlitation programmes. Patient Assessment Patient assessment serves a number of functions. It enables therapeutIc Intervention to be based on an evaluatIon of the patIent's Inltlal condItIon and capabIlIties, It allows for ongoIng monitoring of both posItive and negative changes in the patIent's condItIon due to treatment and thus IndIcates appropnate modIfIcatIons to treatment, and finally patient assessment pre and post-treatment enables the evaluation of treatment effectIveness. Such evaluatIon may be performed both for indIVIdual patIents and for purposes of research. Jette (1980) proposes a four-dimensIonal scheme for evaluatlng health status. He suggests that such evaluation should denve health IndIcators whIch have four characteristics: 1) they should address three conceptual fOCI le the patIent's symptoms or feeling states, signs and performance; 50

2) they should be chosen accordIng to thelf purpose or apphcablhty; 3) the evaluator should be aware of the relIablhty and valIdIty of the Instrument chosen; and 4) the operatIonal approach (eg selfassessment or observatIon) should be consIdered. In relation to assessment of symptoms, sIgns and performance, the physIotherapIst conductIng a pulmonary rehabIlItation programme IS Involved In asseSSIng a number of charactenstlcs of the patIent. These Include the patIent's attItudes, symptoms (such as dyspnoea, wheeze, cough, and exercise tolerance), sIgns (such as lung functions), performance (In relation to exerCIse capacity and actIVItIes of dally hVlng) and knowledge and understandIng of hIs/her condItIon. ShIm and WIlhams (1980) studIed the relative ablhty of patients and expenenced clInICIans to accurately estImate the patient's level of airways obstruction, and found that the patIent's estImatIons of theIr PEFR showed a hIgher correlation coeffiCIent (0.86) than dId the chnlclans (0.66), to the measured figures. Not all patIents can assess theIr condItion rehably; however, thIS study does demonstrate the Importance of IncludIng patients' sUbjectIve estImatIons of theIr condItIons In patient assessment procedures, in addition to more obJectIve measures. When the goal IS the accurate dIagnosIs of the patIent's condItIon pnor to entry Into the rehablhtatlon programme, tests such as laboratory studIes of ventIlatory functIon and exerCIse capacity are appropnate. On the other hand when the purpose IS to prOVide an ongOIng measure of exercise capabilIty, then the twelve minute walkIng test (McGaVIn et a1 1976) or other SimIlar tests are most useful. The twelve mInute distance test can be used as a gUide to maximum exercise tolerance (Ahson and Anderson 1981) and prOVIdes a Simple reproducible assessment of disabilIty which can be performed as a self-paced test (Webber

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1981) and has the advantage of allowIng the patient to assess hIS own Improvement. Thlfdly, the evaluator should be aware of the relIability and vahdlty of the Instrument chosen. A study by Mungal and HaInsworth (1979) Involved repeated measurements of a 12 minute walking test and a vanety of respiratory function tests on patients WIth stable chroniC obstructive airways dIsease. Thelf fIndIngs IndIcated a lack of relIablhty of many of the tests InvestIgated. For Instance the overall coeffiCIent of vanatlon for the walking test was ± 8.2070, for FEV 1 was ± 14.8070, and for FVC was ± 11.1070. However It was noted that the coeffICIent of vanatlon for a third repetitIon of the walkIng test was reduced to ± 4.2070. These fIndIngs caution the phYSiotherapIst who IS performing assessment, firstly to conSider whether the chosen assessment tool IS the most valId one (le whether It actually can measure what they WIsh to measure). Secondly, he/she should determine whether the tool IS capable of prOVIdIng relIable data and should make sure that the measunng Instruments are accurately calIbrated, regularly rechecked and used. FInally, the phYSiotherapIst should conSider what IS the preferred operational approach. For Instance, If dally monItOrIng of a patIent's progress at home IS required, then self-admInIstered peak flow tests performed by the patient are more SUItable than more complex procedures. TaplIn and Creer (1978) have found self-admInIstered peak expiratory flow rate tests to be successful In IncreasIng the patIent's abIlIty to predict asthma episodes, and Hetzel et a1 (1979) have shown that patIents are capable of recording these measurements relIably. Patient Education and Self Help The Importance of patIent educatIon In Improving the patIent's qualIty of lIfe and In redUCIng hospItalIzatIon has been emphaSised by Ruppel (1976) and WIndsor et a1 (1980). Perry (1981)

Designing a Pulmonary Rehabilitation Programme

considers the advantage of a successful educatIon programme IS ~that It assists the patIent to value and maintain hls/ her activity level and optImal level of health, by Increasing the range of behaviours he or she can use In selfmanagement. Green and Kolff (1980) also emphasise the Importance of producing changes In self-concept or selfperception In order to brIng about a corresponding behavioural change. Perry (1981) studied the pnnclples of adult education In a programme Involving 20 patients With chronic bronchitiS and emphysema. Table 5 lIsts some generally accepted factors Involved In adult learning Perry concluded that the patient Will develop a greater range of copIng behaViours when he/she feels the need to learn, the environment IS condUCive to lea01lng, the patient partiCipates In the learning process, and when the learnIng session IS related to, and makes use of, the patient's lIfe expenence. Patients In the programme were encouraged to set theIr own goals and problem solVing pnontles, and to be Involved In selecting approaches to theIr own care.

Table 5: Factors involved in adult learning The learner's self-concept is one of self-direction rather than dependency The learner's life experience IS used as a resource for learning The learner's readiness to learn becomes increasingly onented to his I her social role The learner's orientation to learning is problem-centred Patient education therefore Involves choosing teachIng methods (such as those lIsted In Table 6) which Will promote self-help, and choosing content WhICh Will enable the patIent to acquue the necessary knowledge and skills to perform these self-help activIties. Table 7 outlInes tOPiCS which should be Included In a patient edu-

catIon programme for COPD patients. Windsor et al (1980) pertInently stated that single Interventions aimIng to educate capo patients cannot be expected to have sIgnIfIcant and lasting Impact on health behaVIour unless reinforced over time by phySICians, staff and famtly. Shepherd (1975 p. 63) emphaSized the family's role In the management of patIents In stating that 'when patIents, especially those WIth long term or permanent physIcal disabIlities, leave an In-hospital treatment settIng, their famIlIes are usually Involved only cursonly In learning the needed health care skills to care for them'. HospItal staff, she maIntained, should assume the responsIbilIty for enablIng and educating relatives to perform an effective role In patIent care In order to prOVide transItional care after the patient leaves the secunty of the hospital and to aSSIst In prOVIding continuIty of care. Windsor et al (1980) reviewed five hospital-based respIratory disease programmes and reported that all conSidered patIent and family education to be essential and also perceIved that the relative degree of success or failure of these programmes depended upon the abIlIty of the phYSICIan to obtaIn the co-operatIon of the patient and hiS or her family. The Importance of famIly Involvement and educatIon IS perhaps even more sIgnIfIcant when the patient IS a chIld. ThIS IS well illustrated In two studies InvolVing the familIes of asthmatic children. Selner and Staudenmayer (1979) reported on a programme WhICh offered a personal and famIly approach to controllIng asthma. It focused on attitudes about the management of asthma and personal body control and the promotion of health care, self-relIance, and selfcare (Including aspects of prevention). Clark et al (1980) deSigned a programme to test the hypothesIs that better self-management of asthma can reduce the negative Impact of the disease. Their Initial data collection

centred on definIng current levels of self-management and in assessing needs for educational intervention. They Identified SIX major themes which were priorities of the children's families Ie use of medications, setting exercise limits, providing care in home attacks, communication with the doctor, keeping the child healthy and helping the chtld at school. Much of the Information derived from these studies is equally applicable to adult patients' education and family involvement.

Table 6: Methods of patient education Role modelling Reinforcement for performance of desired health behaviours Correct,on of inappropriate behavIours Inhospltal predischarge classes Group education classes - for patients, family, the public Newsletters Ind Ivid ualized instruction Use of patient education literature Use of audiovisuals eg films, tapeslide series Behaviour modification activities Use of written patient contracts to encourage compliance with therapy Group diSCUSSion Counselling In a recent reVIew of the physiotherapy management of patients With chroniC obstructIve airways disease Reid and Lovendge (1983a p. 192) concluded that 'patient education IS Imperative, because COAD is a hfelong progreSSIve Illness With vanous ensuing treatments requlnng a high degree of patient compliance.' An essential feature of a successful rehabilitatIon programme is thus the concept of self-help. Any person suffenng from a disablIng chroniC disease can benefit from developing not only an attitude of self-relIance and independence but also the skills and ca-

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51

Designing a Pulmonary Rehabilitation Programme

pabihtles to put these IntentIuns Into actIon. People involved In pulmonary rehabIlitation programmes can acquue the knowledge, understandIng and skills to achieve thIS aIm.

Table 7: Content of patient education programmes Knowledge Normal respiration - basic anatomy and physiology COPO diseases - causes, process, symptoms, prognosis Medical management of COPO Including drugs and testing procedures Reasons for use of drugs and oxygen Nutrition and hydration Planning and modifying dally routines and activities Where to obtain help when necessary Skills Breathing retraining exercises Removal of Secretions Self-assessment Symptom management Recognizing and avoiding precipitating factors Correct use of drugs/Inhalers Infection control Relaxation Home exercise programme Attitude Philosophy of self-help I self-reliance

Chest Care and Breathing Retraining On the baSIS of the follOWIng argument the authors maIntaIn that routine deep breathIng exercIses have no place In the management of patIents WIth CO PD. Because an Increased work of breathIng IS a charactenstlc feature of COPD, patIents WIth COPD should be allowed, where possIble, to adopt the most natural and relaxed 52

pattern of breathIng whIch IS consIstent WIth theIr energy requIrements and lung functIon at the tIme. Procedures such as breathIng exerCIses whIch reqUire learnIng and conSCIOUS effort may counteract the body's natural abIlIty to achIeve the most effICIent breathIng pattern pOSSIble for the gIven cIrcumstances and should therefore be used WIth cautIon. For example, a study by Sergysels et al (1979a) found that whIle low frequency breathIng Improved alveolar ventIlatIon at rest, It could ImpaIr exercIse tolerance In patIents With severe chroniC obstructIve bronchitiS due to mechanIcal restnctlons causIng hypoventilation. Deep breathIng 'exercIses' or procedures, eIther adopted by the patient or taught by the therapIst, should therefore be used selectIvely rather than routInely. They may be most benefICIal In the follOWing ways: a) as an adjunct to other secretion clearance measures such as postural drainage, perCUSSion, chest VibratIons, forced expIratory technIque (Pryor and Webber 1979), and controlled or aSSIsted coughIng; b) as a component of relaxatIon traIning or technIques; c) as a mechanIsm for retraInIng respIratory muscles; d) as a prophylactIC measure In cases of severe hypoventllatlon; e) as an adJunt to relaxatIon and the use of relaxation posItIons In exercIse traIning programmes (Booker 1984). ReId and Lovendge (1983a), In revIewIng phySIotherapy technIques used With COPD patIents, descnbed the IndIscnmlnate use of postural draInage and percussIon as questIonable (partIcularly for patIents With small amounts of sputum), and stressed the advantages of coughIng and exercIse In sputum removal. These authors advocate further study to determIne the effIcacy and true potential of tradItional chest physiotherapeutIc techniques.

The Australian Journal of PhySiotherapy Vol 31, No 2, 1985

VentIlatory muscle traInIng

A second paper by ReId and Lovendge (1983b) reVIewed studies InvolvIng ventIlatory muscle endurance trainIng In patIents WIth chroniC obstructive aIrways dIsease. They conclude that 'ventilatory muscle endurance traInIng appears to be a valuable therapy for the decrease of dyspnea, the Improvement of exerCIse Intolerance and possIbly, for the preventIon of respIratory faIlure In COAD patlents', (p. 204). They also pOint out that whIle ventilatory muscle traIning may have more lImIted effects than general exerCIse traInIng, It does not Involve the same cardIovascular flsks as general exerCIse. These authors use the descnptlon of the respIratory system as beIng composed of two InteractIng parts, the lungs or gas exchange organ, and the pump whIch consIsts of the respIratory muscles and chest wall. In the past more emphaSIS has been placed on managIng the dysfunctIon of the lungs. They suggest that by ImprOVIng the performance of the pump, thIS may compensate for the abnormal functIonIng of the lungs. VentIlatory muscle edurance traInIng can be performed uSing normocapneiC hyperventIlatIon Ie hyperventIlatIon dunng WhICh a normal level of end-tIdal pC0 2 IS maIntaIned. ThIS method IS Illustrated by the work of LeIth and Bradley (1976), Keens et a/ (1977), Peress et a/ (1979), and Belman and MIttman (1980). Another commonly used ventIlatory muscle traIning method IS InspIratory reSIstIve breathIng, whIch Involves breathIng through deVices Into whIch an InspIratory resIstance has been placed. Successful work In thIS area has been performed by Andersen et al (1979), Pardy et al (1981), BJerre-Jepsen et al (1981) and Sonne and DaVIS (1982). Further eVIdence of the effectIveness of ventIlatory muscle trainIng IS reqUIred. PhYSIotherapists should view such traInIng as a potentIally valuable therapy for selected patIents.

Designing a Pulmonary Rehabilitation Programme

Shaffer et al (1981) suggested that a comprehensIve pulmonary rehabIlItatIon programme should focus on the followIng pOInts: 1) IncreasIng ventIlatory endurance, 2) IncreaSIng respIratory muscle strength, 3) redUCIng respIratory muscle fatIgue, 4) Improving cardIopulmonary function, and 5) demonstrating posItIve motIVatIonal benefIts. Relaxation Training Part of the self-help phIlosophy IS the goal of enablIng the patIent to achIeve (as far as pOSSIble) a 'relaxed way of hfe'. ThIS Involves IncorporatIng relaxatIon procedures and a deSIre to aVOid stress Into the patIent's lIfestyle To do thIS the patIent fIrstly needs to understand the reason for, and benefIts of thIS approach to copIng With a stressful dIsease, and secondly he or she needs to develop SkIlfs to relIeve or aVOId phYSIcal and psychologIcal stress. The patIent often has to learn relaxatIon technIques such dS progressIve muscular relaxatIon and/or medItatIon to be able to detect the presence of stress and relIeve thIS stress. SImIlarly, he or she must know how to adopt stress-relIeving measures (such as restIng In a relaxed pOSitIon on becomIng breathless dunng exerCIse) and to ensure that these measures become second nature. Exercise Training Early studIes by PIerce et al (1964) and Chnstle (1968) demonstrated the posItIve benefits of exerCIse In terms of Improved well-beIng and exerCIse tolerance. ThIS IS supported by more recent studIes by McGaVIn (1977), Ingram (1980), AlIson, Samlos and Anderson (1981), Booker (1984) and Tydeman et aJ (1984). ExerCise programmes should be both realIstIC and achIevable. These features have Important ImplIcatIons for the screenIng and referral of pa-

tlents, and for the goals set for IndIVIduals In such a programme. At the screenIng stage, patIents WIth dIsabIlIties such as severe acute or chronIC respIratory faIlure, acute myocardIal InfarctIon, Ischaemlc heart dIsease, severe congestIve heart faIlure and mItral stenOSIS should be excluded from a comprehensIve rehablhtatlon programme. In setting IndIVIdual exerCIse goals It should be remembered that 'the purpose of rehabIlItatIon of the chronIC breathless patIent IS to enable hIm to use hIS lImIted reserves to the full and thus Improve hIS qualIty of hfe' (Webber, 1981 p. 130). By ccmpanson, goals for the less dIsabled capo patient may focus more on return to former levels of actIvIty and redUCIng the frequency of hospItalIzatIon. Assessment of the patIent's exerCIse capaCIty prior to exerCIse IS essentIal to establIsh a reliable measure to: determIne the startIng pOInt for exerCIse; set goals for hIS exerCIse programme and for companson WIth later results; determIne progress; and warn of Impending SIde effects of exerCIse. Where pOSSIble assessment should be performed In a laboratory settIng to gaIn detaIled and accurate data. When necessary, laboratory data can be translated to SUIt eqUIpment or condItions avaIlable In the traInIng locatIon. Rles and Moser (1982) have developed a method for translatIng maXImal exerCIse performance from cycle ergometry to sustaIned treadmill/ walkIng speed. Also AlIson and Anderson (1981) found a SIgnIficant correlatIon between distance walked In 12 mInutes and the maXImum work capacIty patIents could achIeve on the cycle ergometer, in support of work by McGaVIn (1977). To set the IndIVIdual's startIng level of exerCIse Unger et aJ (1980) proposes that three factors be taken Into conSIderatIon. These are safety, SImplICIty and expectatIon of effectIveness. PotentIal complIcatIons (such as those assocIated WIth heart dIsease) and as-

soclated dIsabIlItIes need to be conSIdered. PrecautIons IncludIng close observatIon and mInImal goals are appropnate for 'at-nsk' patIents. SimplICIty IS a very practIcal conSIderatIon espeCIally when patIents are beIng asked to Incorporate the exercise Into theIr daIly routIne and hfestyle. In relation to expectatIon of effectIveness, the degree of the phYSIOlogIcal changes WhICh WIll result from an exerCIse programme aImIng to induce a traInIng effect will vary WIth the: • type of trainIng actIVIty • frequency of the actiVIty • duratlon of each traInIng session • IntenSIty of the actiVIty • InitIal fitness level of the subject • length of tIme over WhICh the programme IS maIntaIned (Morton 1981). SimIlarly Astrand and Rodahl (1977) state that exercise training must be of sufficient intensity, duration and frequency In order to expose the patient to a stress which is greater than the one regularly encountered during everyday hfe, and thus achieve a trainIng effect. The intenSIty of the exerCIse should depend upon the patient's age, severity of disease and the startIng inactiVIty level. It should always be submaxImal. Unger et al (1980) set theIr exerCIse level at 750/0 of predicted V0 2 max' while Alison et al (1981) set theIr level at 60010 of the load achieved during the W 1NH. test for their 'steady-state programme' and varyIng between 200/0 to 600/0 to 200/0 W max for their 'Interval training programme'2. In both of the programmes conducted by Alison and Anderson (1981) the exercise level was Increased to 750/0 of W max by the end of the programme. As a general rule, Astrand and Rodahl (1977) recommend that the exercIse traInIng heart rate should not exceed 195 mInus the age in years.

2V02 max refers to measured maXImal oxygen uptake W max refers to maXImum work capaCIty

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53

Designing a Pulmonary Rehabilitation Programme

For a person who has been bed-rIdden it IS advisable not to elevate the heart rate by more than 30 beats/minute above the resting value to about 100 beats/mInute. In addition to a certain mInImal level of intensity, the traIning stImulus must be of certaIn duration. Submaximal activIty with large muscles Involved for about three to five minutes and repeated after rest is effective for aerobic training. For a normal indivIdual activity at submaximal intensity lasting as long as thirty mInutes or more may develop endurance Ie the ability to tax a larger percentage of the indIvidual's maximal aerobIc power (A strand and Rodahl 1977). The number of patient ViSIts per week may need to be varied accordIng to patient, staff avaIlabilIty and transport etc. Four visits per week IS optimal to enable Significant physiolog ical improvement. Two ViSItS per week, however, can produce an improve/ment in previously sedentary individuals (Wicks et al 1978). Several considerations are Important during programme Implementation. • Warm up. The process of 'warming up' is important in order to raIse the temperature of the musculature and thus increase the metabolic rate, before commencing performance activities (Astrand and Rodahl 1977). • Monitoring the patIent. A regular check should be kept on the pulse rate, ensuring that It does not rIse above the recommended level. Observations of the patient's colour and respiration rate should be also made. Braun et al (1982) advocate that patients who exercise routinely should be observed carefully for signs of hypoxia, hypertenSIon, abnormal right-sided cardiac function, and air trappIng. • Regular patient assessments. Ongoing assessments are used to provide regular objectIve checks on progress and problems. They may also be used to motivate the patIent to continue training. 54

• ProgreSSIng. If no Improvement OC-

curs, then It IS necessary to Increase one of the vanables, namely IntensIty, duratIon or frequency, to promote greater benefIt from the tIme and energy the patIent IS expendIng. When Improvement has plateaued traInIng should be dIrected towards maIntaInIng thIS Improvement. Type of exerCIse. The ultImate goal of an exerCIse traInIng programme IS for the patIent to Incorporate thIS Improved exerCIse capabIlIty Into hIs/her daily lIfe. PhYSIotherapIsts should therefore endeavour to choose actIVItIes WhIch are InterestIng and conSIstent WIth the patIent's lIfestyle and should encourage the patIent to perform these regularly outSIde the hospItal envIronment.

• Home InstructIons. An essentIal part

of a traInIng programme IS to proVIde InstructIons to the patIent related to theIr home exerCIse programme. ThIS should not only Include what they should do, but also what they should not do, when to stop and when to seek help. The patIent must understand the ratIonale for theIr exerCIse and see ItS precautIons as well as ItS benefIts, or they may push themselves beyond safety levels In a deSIre to Improve rapIdly or to 'please theIr therapIst' .

• Supplemental oxygen. ThIS may be

adVIsed for some patIents (Bradley et al1978; GImenez et al1979). • A vallable support. In conductIng an exerCIse traInIng programme a phySIotherapIst should prOVIde support, reassurance and encouragement to promote patIent complIance and self-confIdence, both of WhICh are essentIal IngredIents for a successful outcome. Webber (1981) descnbes reassurance that breathlessness IS not harmful and adVIce to keep actIve as beIng Important reqUIrements for a successful traInIng programme. In deSCrIbIng the benefIts of exerCIse Braun et al (1982 p. 163) concluded that 'If done on a regular and progreSSIve baSIS, exerCIse Improves cen-

The Australian Journal of PhySiotherapy Vol 31, No 2, 1985

tral and perIpheral oxygen transport, muscle strength and endurance, and JOInt mobIlIty WIthIn eIght weeks ... SIgnIfIcant Increases In endurance and oxygen transport occur when the patIent exerCIses moderately three or four tImes weekly for 30 to 45 mInutes per day'. Webber (1981) maIntaIns that the benefIts of regular exerCIse are In IncreaSIng the abIlIty to exerCIse, In lessenIng the feelIng and fear of breathlessness and In breakIng the 'VICIOUS cycle' of InactIvIty. Evaluation of Pulmonary Rehabilitation Programmes PartICIpants In a pulmonary rehabIlItatIon programme, whether they are the therapy staff or the patIents, must naturally deSIre a pOSItIve outcome for theIr endeavours and expendIture. It IS true that any benefIt perceIved by the patIent, whether these are attItudInal, behaVIoural or Improvements In performance, JustIfIes the patIent's Involvement. However, for reasons of aCCl Llntablhty and also to derIve evaluatIve Input for the ongOIng modIfIcatIon and Improvement of the programme, the programme's organIsers should engage In ongOIng programme evaluatIon. A paper by Harasymlw and Albrecht (1979) presents a theoretIcal cost effectIveness model whIch was deSIgned to optImIze admISSIon and dIscharge deCISIons In comprehenSIve rehabIlItatIon centres. In thIS model, progress and outcomes of rehabIlItatIon are conceptualIzed In terms of functIonal gaIns due to treatment as related to three varIables: • functIonal level at admISSIon; • the functIonal Improvement per unIt cost; and • the percentage Improvement In functIon from admISSIon to dIScharge. Such a model, or other evaluatIon technIques InvolVIng measurements of Improved exerCIse tolerance and descreased hospItalIzatIon can prOVIde useful tools to evaluate the programme's effectiveness In relatIon to Its establIshed goals.

Designing a Pulmonary Rehabilitation Programme

Conclusion

ThIS paper has provIded some gUIdelInes for the development, Implementation and evaluation of pulmonary rehabilitation programmes A phYSiotherapist Involved In such a programme should consider both phIlosophical and practIcal Issues In the programme's Implementation. Above all, the chronic and debilitating nature of the COPD conditIons should form the stimulus to encourage and enable the patient to adopt an attitude of self-help and to acqUIre the skills and knowledge which Will allow them to achieve theIr highest pOSSible functional capacity. References

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56

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bronchitiS, BntIsh MedIcal Journal, 23 Feb ruary, 519 521 Sonne LJ and DaVIS JA (1982), Increased exerCIse performance m patIents wIth severe COPD followmg mspiratory reSIstIve trammg, Chest, 81, 436 439 Stanley L (1978), You really can teach COPD patIents to breathe better, RegIstered Nurse, Apr, 43 49 Taplm PS and Creer TL (1978), A procedure for usmg peak eXpIratory flow rates data to m crease the predictabilIty of asthma epIsodes, The Journal of Asthma Research, 16, 15-19 TomashefskI JF (1977), DefmItlOn, differentIa tlOn, and claSSIfIcatIOn of COPO, Post Graduate MedICIne, 62, 88 97 Traver GA, ClIne MG and Burrows B (1979), Predictors of mortalIty m chromc obstructIve pulmonary dIsease A 15 year follow up study, AmerIcan reVIew of RespIratory DIseases, 119, 895-902 Tydeman DE, Culot A, Chandler AR, HarrIson BOW and Graveling BM (1984), An mvestl gatIon mto the effects of exerCIse tolerance trammg on patIents WIth chromc aIrways ob structlon, PhYSIOtherapy, 70, 261 264 Unger KM, Moser KM and Hansen P (1980), SelectIOn of an exerCIse program for patIents WIth chromc obstructive pulmonary dIsease, Heart & Lung, 9, 68-76 Webber BA (1981), LIvmg to the LImIt ExerCise for the chromc breathless patient, PhySlO therapy, 67, 128-133 Weltzenbium E, Hirth C, Panm JP, Rasahohn janahary J and Oudet P (1978), Chmcal, functIOnal and pulmonary hemodynamiC course of patIents WIth chrome obstructIve pulmonary dIsease follow-up over 3 years, ReSpIratIOn, 36, 1-9 WIcks J FItzgerald S and SImpson A (1978), Post coronary assessment, In Russo P , and Gass G , ExerCIse - A workshop, Cumberland College of Health SCIences, Sydney Wmdsor RA, Green LWand Roseman JM (1980), Health promotIOn and mamtenance for patIents WIth chrome obstructIve pulmonary dIsease A reVIew, Journal of Chromc DIseases, 33,5 12 WhIte B, Andrews JL, Mogan JJ and DownesVogel P (1979), Pulmonary rehabIlItatIOn m an ambulatory group practice settmg, MedIcal ClImcs of North Amenca, 63, 379 390