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Two become one

Is generic rehab the way forward? Jennifer Trueland explores the concept for cardiac and pulmonary patients.

Sally Singh has a vision, and it’s one that involves turning received ideas about rehabilitation on their head.

Rather than building services round disease types, she would like to see rehab programmes based on patients’ symptoms and level of disability. That’s why Professor Singh is exploring the possibility of running joint programmes for patients with pulmonary disease or chronic heart failure.

It’s an idea that may have found its time, for philosophical and practical reasons. As health services struggle with tightening budgets, there is an attraction in achieving economies of scale by combining programmes.

But the drivers are not only fiscal. Services that are patient-centred should surely look at the symptoms and deal with them, rather than expect one (disease-based) size to fit all, the theory goes.

The big question is: what does this mean in practice? Rehabilitation programmes for people with cardiac problems have been around for a long time. Most have concentrated on patients after an acute episode, such as a heart attack or bypass operation. In the past few years, however, evidence has emerged which suggests that rehabilitation should be extended to those with CHF.

In 2004, a Cochrane review found that exercise training improves exercise tolerance and quality of life in people with mild to moderate heart failure, concluding that it improved fitness and quality of life without causing harm. Meanwhile, pulmonary rehabilitation received a boost in 2001, when British Thoracic Society guidelines were published in Thorax saying it should be considered at all stages where patients noticed symptoms.

Until now, however, programmes have largely developed on separate tracks. ‘Broadly people have looked at the disease, so you have cardiac rehabilitation or pulmonary rehabilitation,’ explains Prof Singh, who is head of cardiac and pulmonary rehabilitation at Glenfield hospital in Leicester, and professor of pulmonary and cardiac rehabilitation at Coventry University.

‘But we were looking at how chronic heart failure fitted in. These patients are much more disabled than other cardiac patients – the main symptoms are breathlessness and fatigue. So it didn’t make sense to us to put them together. On the other hand, the symptoms are similar to those of chronic obstructive pulmonary disease.’

Being in the fortunate position of managing both services, Prof Singh began looking for evidence to back the idea of combining pulmonary and CHF rehab programmes. While rehab is less commonly offered for CHF, it’s a disease where there is a growing need. According to Prof Singh, heart failure affects one to

two per cent of the population, accounts for five per cent of hospital admissions, and 40 per cent of patients die within a year of diagnosis.

Pulmonary rehabilitation programmes are geared to reducing ongoing symptoms and helping patients get back to daily activities – exactly the purpose of

CHF rehab. There is also some crossover in the patients, with at least a fifth of patients diagnosed with CHF also reporting mild to moderate COPD, she says.

And, if you look closely at the way that these conditions manifest themselves, there are great similarities, in particular, in terms of skeletal muscle dysfunction.

In both, there is a reduction in muscle strength and endurance, a reduction in muscle mass, and similar changes in fibre type and muscle metabolism.

ENCOURAGING RESEARCH

In Leicester, Prof Singh and her team decided to offer the pulmonary rehabilitation programme to patients with CHF (see panel: Preliminary studies positive). The results were good, with both sets of patients showing a marked improvement.

‘We concluded the pulmonary rehabilitation model is suited to patients with CHF, in a way cardiac rehabilitation [such as post-coronary bypass] isn’t,’ says Prof Singh. ‘The advantages are the patients have similar symptoms and disability, and benefit from a similar exercise strategy and education session.’ Differences in the educational requirements of the programme do exist, and some of these sections are disease specific.

Prof Singh believes combined programmes should not stop at these two conditions. She would like to see if the pulmonary rehabilitation model might work for other chronic diseases where breathlessness is an issue. ‘It could be generic rehabilitation is the way forward, whatever the primary cause,’ she says.

The Leicester approach is backed in other European countries, at least in theory. In the Netherlands, Martijn Spruit of the Centre for Integrated Rehabilitation of Organs says: ‘We believe the similarities in pathologies are bigger than their differences and therefore they may be suitable to be combined.’

Here the same rehab programme is used for COPD and CHF patients. This has three stages: baseline assessment, interventions and outcome assessment.

The team combines baseline and outcome assessments of COPD and CHF patients (their model was published in The Lancet in January 2008). However, they do not combine COPD and CHF patients during the intervention period, although Dr Spruit says: ‘I believe a rehab team specialised in rehabilitation of patients with chronic organ failure can manage different diseases at the same time during the intervention period.’

Last October at the CSP’s Congress, Thierry Troosters, chair of the Belgian Society for Respiratory Physiotherapy, said efforts should be made to introduce rehab programmes for COPD and CHF patients.  ‘Although there are (traditional) differences in the approach to rehabilitation in patients with CHF and COPD, the concept of the exercise training programmes is remarkably similar,’ Dr Troosters said.

In the US, however, programmes are very definitely run separately. Marie Bass, executive director of the American Association of Cardiovascular and Pulmonary Rehabilitation, says while around half their members worked with both patient groups, programmes were run separately. ‘You can have the same staff treating both groups in the same facility, but there will be different programmes for pulmonary and cardiac patients.’

The US insurance-based system works against combining them, she says, because reimbursement for cardiac and pulmonary patients comes under

different codes.

FINANCIAL BENEFITS

In the UK, the main drivers for combining programmes include reducing costs and making better use of resources. Although the Leicester study did not look specifically at cost-effectiveness, intuitively combining services has to make financial sense. It can also help employers to meet national guidelines on staff ratios, by using the same staff for both.

But would the physios be happy with such an arrangement? Prof Singh admits there could be some anxiety among staff asked to manage different diseases. But she adds: ‘The patients’ needs are broadly similar and so is the management. And there has to be an advantage in economies of scale and using people’s skills and expertise in a sensible way.’

From a medical point of view, combining the programmes makes perfect sense. Rachael Evans, a specialist registrar in respiratory medicine, ran the Leicester trial along with Prof Singh and her team. ‘We didn’t find any adverse events at all,’ she says. ‘The patients didn’t mind – there were no adverse interactions – and it makes sense from a practical point of view.’

She would like to see the concept broadened – perhaps taking in patients with chronic renal failure, and the approach used with inpatient programmes as well as outpatient and community-based services. She sees the pulmonary model as the one to base others on, as a lot of work has already been done on it.

‘There’s lots of expertise in pulmonary rehabilitation,’ says Dr Evans. ‘We should be using that, rather than starting up another disease-based programme.’

The first steps have been made in combining rehab programmes, basing them on symptoms and disability level rather than disease. Now it’s up to physios to explore further about two or more becoming one.  FL

FURTHER INFO

Reesk et al. ‘Exercise based rehabilitation for heart failure’, Cochrane Database of Systematic Reviews (2004), Issue 3 www.cochrane.org/reviews/en/ab003331.html

BTS statement. ‘Pulmonary rehabilitation’, Thorax  (2001), 56(11):827 Gosker H R et al. ‘Skeletal muscle dysfunction in chronic obstructive pulmonary disease and chronic heart failure: underlying mechanisms and therapy perspectives’,

American Journal of Clinical Nutrition (2000), 71(5):1033 Spruit M. ‘Integration of pulmonary rehabilitation in COPD’, Lancet (2008), 371 (9606): 12

Preliminary studies positive

The Leicester study involved running a combined rehabilitation programme for patients with chronic obstructive pulmonary disease and with chronic heart disease.

The study recruited 55 patients with COPD and 44 with CHF. Demographically the groups were similar, although there was a higher percentage of women with CHF, and the CHF group also had a higher average body mass index (36.6 compared to 27.4).

The programme involved seven weeks of mainly endurance training, including two hospital visits a week, with one hour of physical training and one on education.

All patients were assessed for their exercise capacity, including peak VO2 (maximum oxygen uptake) and field tests, such as the six-minute walk test.

The COPD patients started and finished at a higher level than the CHF patients, but in general the improvements were at a similar and significant rate.

They were also asked to fill out questionnaires covering how they perceived their physical and emotional health and again, both groups showed significant improvement.

‘We are all in it together’

When Kathleen Spencer was asked to go on a rehabilitation programme she didn’t quite know what to expect. The mother of five , who has chronic heart failure, had virtually given up on exercise and could barely climb the stairs in her Leicester home, when she took part in the joint CHF/pulmonary rehab programme.

It made a tremendous difference, however. ‘I really enjoyed the programme and didn’t want it to stop. I think exercise really opens up life.’

Mrs Spencer says she didn’t mind at all being in a group with patients with different illnesses – in most cases she didn’t know why people were there, unless they told her, or, in the case of COPD patients who needed oxygen, were carrying bottles.

‘We were all in it together and did what we could do. There were some who were quite bad, with bottles of oxygen, and I felt a bit sorry for them. It made me think however bad I was, there were people who were worse off.’

Mrs Spencer, who is now 67, also found the education sessions helpful. She didn’t particularly notice the pulmonary patients received different information, until talking about it and comparing notes with other patients afterwards.

Time to combine?

The cardiac rehabilitation programme run by Calderdale and Huddersfield foundation trust is an exemplary service on many levels. It’s effective, the patients like it and it demonstrates good partnership working with, among others, local authority colleagues.

Hardly surprising, then, that therapy services coordinator Monica Slocombe and colleagues have set up a virtually identical service for pulmonary patients. Already the programmes are being run in the same space – a large room in a local leisure centre – and at the same time.

At the moment they are run by different teams of staff, but now Ms Slocombe is looking to see if they could be combined. The drivers, she says, are making better use of staff time and the rented room at the leisure centre.

The cardiac programme, which sees patients with heart failure as well as those who have had heart attacks or other acute events, lasts eight weeks and leads into a further 10 weeks of a free exercise programme. It also includes education sessions.

The pulmonary rehabilitation programme follows the same pattern and deals mainly with COPD patients and some who have had lung transplants. If they were combining the services, Ms Slocombe says, they would probably start by putting the heart failure patients with the pulmonary programme, for the same reasons as the Leicester group.

Running the services together could have several benefits, from improving staff to patient ratios, to the practicality of making patient transport easier, she says. ‘There may be some nervousness around it but nobody is saying it’s not a good idea,’ adds Ms Slocombe, who is a physiotherapist by background. ‘I think there are real possibilities there, but what I want to know is whether there is evidence and does it show we should be doing it.’

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