Benefits obtained following a 12 week Pulmonary Rehabilitation programme - One Year follow up.

1. Benefits obtained following a 12 week Pulmonary Rehabilitation programme - One Year follow up. A Sciriha, D Bilocca, C Fsadni, P Fsadni, E Gerada, C Gouder, L Camilleri S Lungaro-Mifsud, S Montefort

2. Introduction • Pulmonary rehabilitation (PR) : - Scientifically based diagnostic management and evaluation option - Multidisciplinary programme - Exercise and education.

3. Recommended standard of care • Based on a growing body of scientific evidence. • Benefits recognised in numerous guidelines and listed in the top priorities for improving the care of COPD patients.

4. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation – Nici et al (2005) Pulmonary Rehabilitation – Joint ACCP/AACVPR Evidence Based Clinical Practice Guidelines – Ries et al (2009) Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease – practical issues: A Canadian Thoracic Society Clinical Practice Guideline – Marcinuk et al (2010) The British Thoracic Society Guideline on Pulmonary Rehabilitation in Adults British Thoracic Society Pulmonary Rehabilitation Guideline Development Group (2013)

5. - No consensus of opinion reached regarding optimal duration with programmes: - as short as 10 days (Votto et al 1996) - as long as 18 months (Berry et al 2003; Foy et al 2001; Green et al 2001; Troosters et al 2000). - Short term studies have not established the manner in which the benefits decrease over time. - A patient’s severity acting as part of the inclusion criteria for such programmes is still debatable. • In this study a 12 week rehabilitation programme was looked into.

6. Method - 75 patients: (59 male; 16 female) - Age: 40 to 75 years. - 60 of these 75 subjects eligible to participate • A baseline assessment was carried out before the patients were enrolled • Re assessed at 4, 8 and 12 weeks during rehabilitation and 28 and 52 weeks on completion. - Two classes per week for twelve weeks

7. Outcome measures • Spirometry readings • DLCO and plethysmography • 6 minute walking test • Blood investigations -CRP, ESR, CBC, TFTs, LFTs, Hba1c, VitaminB12, Ferritin, Folate. • MRC score • Bode index • Body Mass Index • Borg Scale • Heart Rate • St George’s Respiratory Questionnaire • Hospital anxiety and depression score

8. Patient baseline characteristics

9. p < 0.041 p < 0.002 p < 0.000 p < 1.000 p < 0.955

10. 6 Minute walk test per Medical Respiratory Council (MRC) Score

11. p < 0.000 p < 0.000 p < 1.000 p < 0.999

12. St George’s Respiratory Questionnaire Total score per MRC grading

13. St George’s Respiratory Questionnaire Symptom score per MRC grading

14. St George’s Respiratory Questionnaire Activity score per MRC grading

15. St George’s Respiratory Questionnaire Impact score per MRC grading

16. Dyspnoea ratings p < 0.048 p < 0.000 p < 0.000 p < 0.000 p < 0.012

17. p < 0.006

18. BODE Index per MRC score

19. p < 0.001 p < 0.000 p < 0.000 p < 1.000 p < 1.000

20. Hospital Anxiety and Depression Scale p < 0.017 p < 0.000 p < 0.001 p < 0.000

21. Conclusions • This study shows that a multidisciplinary programme: - increases the walking distance - improves HRQL - improves anxiety and depression scores. • Most of the changes were noticeable by the 8th week of rehabilitation. • At weeks 28 and 52 there were no significant improvements or deteriorations in the patients conditions.

22. Patients with mild to moderate severity: - improvements after 4 weeks of rehabilitation - further improvements after 8 and 12 weeks in their 6 minute walk test. • Those with severe COPD: - no significant changes at 12 weeks except for health related quality of life measures

23. Acknowledgements • Supervisor: Prof S Montefort • Co – Supervisor: Dr Stephen LungaroMifsud • Physiotherapy Department FHS: Dr Mark Sacco Mr TonioAgius Ms Nadine SpiteriGingell Mr John Xerri De Caro • Medical Team: Dr David Bilocca Dr Eleanor Gerada Dr Carolyn Gouder • MDT PR Team • Family • Colleagues and friends