Pulmonary Rehabilitation You Can Teach a COPD Patient New Tricks

1. Pulmonary RehabilitationYou Can Teach a COPD Patient New Tricks! Evidence Based Rehabilitation for COPD Helen M. Sorenson MA RRT FAARC UT Health Science Center sorenson@uthscsa.edu

2. Objectives Discuss justification for pulmonary rehabilitation List critical aspects of pulmonary rehabilitation Review assessment criteria for rehabilitation Describe components of a PR Program Summarize existing evidence for rehabilitation Look to the future Explore additional research needed

3. History of Rehabilitation 1942 Council on Rehabilitation of The American College of Chest Physicians (ACCP) �The restoration of the individual to the fullest medical, mental, emotional, social and vocational potential of which he/she is capable�. 1974 - ACCP formed Committee on Pulmonary Rehabilitation

4. History of Rehabilitation 1977 AARC formed Continuing Care-Rehabilitation Section 1983 American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) was formed 1987 AACVPR and AARC conducted 1st national survey to determine extent of PR programs in the US

5. Justification for Rehabilitation Estimated that 10% of US population are living with some type of chronic respiratory disease Since 1979 mortality for all lung disease has increased Direct cost of treating/managing COPD in 2002, $32.1 billion Want vs. Need: In the past we WANTED to keep COPD patients home and functioning. In 2008 and beyond we NEED to keep COPD patients home and functioning

6. Definition of Rehabilitation Program of exercise and education Focus is on reconditioning, restoring Hospital-based, outpatient (ORF) comprehensive (CORF), home based? Physician prescribed plan of care Therapist led sessions, goals set by patient Outcomes reported Maintenance/support groups essential

7. Critical Aspects of Pulmonary Rehabilitation Pursed-lip breathing Education Exercise training (endurance and strength) Upper and lower extremity training Duration 6 � 12 weeks Use of supplemental O2 when indicated

8. Case Study 61 year old female, 45 pack year history, quit 1 year ago DOE x 2 years (progressive, especially on stairs) COPD diagnosed last year, put on inhaled medications Sedentary, weight gain of 15 lbs, BMI 32 Spirometry � moderate airway obstruction Echocardiogram is normal

9. Assessment Criteria for Rehabilitation 6-minute walk test (do at least two times) Spirometry; poorly predictive of exercise ability (Solway, 2001) Borg Scale - subjective measure of dyspnea Stationery bicycle exercise Treadmill test Sit-to-stand test/6MWT strongly correlated with each other (Ozalevli, 2007)

10. How will rehab help her? Education Commitment to 6- 8 weeks Medication management Activity Socialization Smoking ? Nutrition? Motivation?

11. What are expected gains? Will improve Level of dyspnea Endurance Management of disease Self-reported quality of life Nutrition/weight loss May not improve Pulmonary function Disease status Habits ? Attitude? Motivation?

12. Rehabilitation at the start can be daunting, frightening, overwhelming and anxiety laden Understanding their fears and anxiety is vital Patients must first find a comfort zone Providing patients with a smile, oxygen, a glass of water or a cup of coffee will make a difference Informal support from seasoned patients to new patients is an unbelievable asset Cardiopulmonary Rehabilitation of the COPD Patient

13. Warming up (Literally)

14. Exercise Training Two basic varieties Endurance - walking, cycling, stair climbing Strength training/resistance - weights, balance, rising from a chair There is good evidence that endurance training ?DOE and ? exercise tolerance and ?HRQoL Endurance is central focus of most PR programs

16. Lifting Dumbells

17. Pursed-Lipolympics

18. Pursed-Lip Breathing Increases ventilation Releases trapped air in lungs Keeps airways open longer (?WOB) Prolongs exhalation � slows breathing Improves breathing patterns - old air out, new air in! Relieves shortness of breath and causes general relaxation Rescue breathing for acute dyspnea Bianchi B et al. Chest 2004; (125): p. 459-465.

19. Educational Components Pursed-lip breathing Cardiopulmonary pathophysiology (what�s MY disease) Diaphragm-strengthening techniques Medication devices/ medication management Nutritional guidance Collaborative self-management (HEP) Prevention/treatment of exacerbations

20. Educational Components Pre-test at the start Education about their disease Videotapes while they exercise Informal education while they exercise �Brown-bag� medication education �What would you do if� education PR education post-test

21. Educational Components Support groups provide education and socialization and psychological support Maintenance after PR requires patient to check their own weight, vitals (HR, RR, BP) and chart their own progress Graduates are invaluable in supporting the �new kids� to rehab

22. Stand-up, Sit-down (fight, fight, fight)

23. Shoot the Hoops

24. Arm Training COPD patients often experience ?dyspnea with upper extremity use Unsupported arm activities that require raising arms above shoulder level require competitive use of accessory muscles of breathing Raising arms ? both O2 uptake and CO2 production Consistent arm exercise leads to reduced ventilatory requirement and gradual improvement in ADLs with less dyspnea

26. The Treadmill Trot

27. Arm �Ergomometer�

28. Summary of Existing Evidence for PR in COPD Strong evidence (1A) exists that: Exercise training and ambulation be recommended as mandatory components of PR for COPD patients PR improves HRQoL 6-12 weeks of PR produce benefits in several outcomes that gradually decline over 12-18 months (HRQoL remains above control after 12 to18 months)

29. Strong evidence (1A) exists that: Both low and high intensity exercise produce clinical benefits Strength training in PR increases muscle strength and mass Unsupported endurance training of upper arm is beneficial PR improves the symptoms of dyspnea

30. Summary of Existing Evidence for PR in COPD Strong evidence (1B) exists that: Leg exercises at higher intensity produces more benefit than lower intensity training The use of inspiratory muscle trainers is NOT considered an essential component of PR

31. Summary of Existing Evidence for PR in COPD Education should be an integral component of PR PR is beneficial for some patients with chronic respiratory disease other than COPD

32. What�s In the Future National Pulmonary Rehabilitation Reimbursement July 2008; the Pulmonary and Cardiac Rehabilitation Act included in Public Law 110-275

33. The recently enacted Medicare Improvements for Patients and Providers Act of 2008 directs the Centers for Medicare & Medicaid Services (CMS) to develop, by Jan 01, 2010, a national, uniform coverage policy for pulmonary rehabilitation provided to Medicare beneficiaries. 

34. What�s In the Future Recognition of the value More research Ring and peg board (unsupported upper arm) DAS (distractive auditory stimulus) TCEMS (electrical stimulation of muscles) Post-program studies

35. What�s In the Future Reimbursement for Smoking Cessation Medicare tobacco specific counseling 3 to 10 minutes #90805 � 90809 > 10 minutes #99407 99xxx � can only be used by physicians Non-approved provider : Incident to physician referral Health Behavior Assessment and Intervention 96150 � 96155* * No reimbursement

36. What�s In the Future Other codes that may be reimbursable 96150 Assess health/behavior initial 96151 Assess health/behavior subsequent 96152 Intervene health/behavior individual 96153 Intervene health/behavior group 96154 Intervene health/behav fam w/pt 94250, 94350, 94720 Expired gas collection (Breath CO measurement)

37. Questions?