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A community model for exercise A community model for exercise prescription for patients with prescription for patients with

chronic obstructive pulmonary chronic obstructive pulmonary disease and congestive heart disease and congestive heart

failurefailureElsie Hui, Jean WooElsie Hui, Jean Woo

Division of Geriatrics, Department of Medicine and Division of Geriatrics, Department of Medicine and Therapeutics, Therapeutics,

The Chinese University of Hong KongThe Chinese University of Hong Kong

HSRF 02030711 HSRF 02030711

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IntroductionIntroduction

Chronic obstructive pulmonary disease (COPD) and Chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are the leading causes congestive heart failure (CHF) are the leading causes for admissions and bed occupancy in the Hospital Afor admissions and bed occupancy in the Hospital Authority.uthority.

Exercise prescription improves:Exercise prescription improves: Physical performancePhysical performance Psychosocial well beingPsychosocial well being Reduce hospital service utilization and costsReduce hospital service utilization and costs

Refs: Ferrari M, Vangelista A, Vedovi E et al. Minimally supervised home rehabilitation improves exercise caRefs: Ferrari M, Vangelista A, Vedovi E et al. Minimally supervised home rehabilitation improves exercise capacity and health status in patients with pacity and health status in patients with COPDCOPD. Am J Phys Med Rehabil 2004; 83: 337-43.. Am J Phys Med Rehabil 2004; 83: 337-43.Rees K, Taylor R, Singh S, Coats A, Ebrahim S. Exercise based rehabilitation for Rees K, Taylor R, Singh S, Coats A, Ebrahim S. Exercise based rehabilitation for heart failureheart failure. Cochr. Cochrane Database Syst Rev 2004; 3: CD003331.ane Database Syst Rev 2004; 3: CD003331.

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PurposePurpose

To test the feasibility of continuing To test the feasibility of continuing exercise programexercise programmesmes for COPD or CHF patients: for COPD or CHF patients: ExerciseExercise Peer supportPeer support Health educationHealth education Promote self-motivation and compliancePromote self-motivation and compliance Based at Based at community centrescommunity centres Led by health professionals or trained Led by health professionals or trained non-health professionon-health professio

nalsnals

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Materials & MethodsMaterials & MethodsCOPDCOPD CHFCHF

Study Study DesignDesign

Quasi-experimental, ‘Before and after’ measurementsQuasi-experimental, ‘Before and after’ measurements

SubjectsSubjects ≥ ≥ 1 admission(s) in preceding 12 months1 admission(s) in preceding 12 months4444 3737

SettingSetting Community elderly centresCommunity elderly centres

InterventioInterventionn

8 – 10 subjects per group8 – 10 subjects per group

12 weekly 2-hour sessions + home exercise prescription12 weekly 2-hour sessions + home exercise prescription

Exercise training, educational talk, peer group supportExercise training, educational talk, peer group support

Outcome Outcome measuresmeasures

Lung function tests, 6 minute walk teLung function tests, 6 minute walk test (6MWT), General Health Questionnst (6MWT), General Health Questionnaire (GHQ), St. George’s Respiratoraire (GHQ), St. George’s Respiratory Symptom Questionnaire (SGRQ), Cy Symptom Questionnaire (SGRQ), COPD knowledge, programme evaluaOPD knowledge, programme evaluation using questionnaires, group distion using questionnaires, group discussions.cussions.

6MWT, muscle strength, Hospital Anxiet6MWT, muscle strength, Hospital Anxiety & Depression Scale (HADS), Medical Oy & Depression Scale (HADS), Medical Outcome Study Social Support Survey (Mutcome Study Social Support Survey (MOSSS) Chronic Heart Failure QuestionnOSSS) Chronic Heart Failure Questionnaire (CHFQ) CHF knowledge test, prograire (CHFQ) CHF knowledge test, programme evaluation amme evaluation

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InterventionIntervention

COPDCOPD CHFCHF

Educational Educational talktalk(1 hour)(1 hour)

E.g., pathophysiology of E.g., pathophysiology of COPD, exercise, breathing, COPD, exercise, breathing, sputum removal and sputum removal and relaxation techniques, relaxation techniques, medication and dyspnoea medication and dyspnoea management, energy management, energy conservation, etc.conservation, etc.

E.g., pathophysiology of E.g., pathophysiology of heart disease, medication, heart disease, medication, surgical interventions, diet, surgical interventions, diet, signs & symptoms, signs & symptoms, exercise, emotion and exercise, emotion and relaxation, prevention of relaxation, prevention of exacerbation, etc.exacerbation, etc.

Peer group Peer group supportsupport

Q & A, group discussion, focus group (week 12)Q & A, group discussion, focus group (week 12)

Exercise Exercise trainingtraining(1 hour, step-up (1 hour, step-up intensity to Borg intensity to Borg scale scale ~ 13:~ 13: moderately hard)moderately hard)

Warm upWarm upStrengthening – upper (raise arStrengthening – upper (raise arms) & lower limb (sit to stand)ms) & lower limb (sit to stand)Aerobic – danceAerobic – danceHome programme 3 x / weekHome programme 3 x / week

Warm upWarm upStrengthening – upper & loweStrengthening – upper & lower limb using Therabandsr limb using TherabandsAerobic – danceAerobic – danceHome programme 3 x / weekHome programme 3 x / week

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Subject characteristicsSubject characteristics

DemographicsDemographics COPD (n = 44)COPD (n = 44) CHF (n = 37)CHF (n = 37)

Sex (M:F)Sex (M:F) 37: 737: 7 25:1225:12

Age (years)Age (years) 74.2 (6.5)74.2 (6.5) 73.5 (7.8)73.5 (7.8)

LTOT (%)LTOT (%) 2525 --

FEV1/FVC (%)FEV1/FVC (%) 49 (15.8)49 (15.8) --

Disease severity (%)Disease severity (%) Moderate to severeModerate to severe

8282NYHA Class II / IIINYHA Class II / III

8989

Attendance rate (%)Attendance rate (%) 7878 9191

Dropouts Dropouts 11 (25%)11 (25%)Frequent admissions (3); moved away (2); Frequent admissions (3); moved away (2); admitted to old age home (1); transport pradmitted to old age home (1); transport problem (2); comorbidity (1); refused exercisoblem (2); comorbidity (1); refused exercis

e (2)e (2)

5 (13.5%)5 (13.5%)Comorbidity (2); hospitalised foComorbidity (2); hospitalised for non-cardiac problem (2); transr non-cardiac problem (2); trans

port problem (1)port problem (1)

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COPD ResultsCOPD Results

Outcome Outcome measuremeasure

BaselineBaseline 12 weeks12 weeks P-valueP-value

PhysicalPhysical 6 MWT (m)6 MWT (m) 285 (96)285 (96) 303(98)303(98) 0.0510.051

PsychologicalPsychological GHQ (/28)GHQ (/28) 20.6 (10.1)20.6 (10.1) 12.2 (6.0)12.2 (6.0) <0.001<0.001

SGRQ SGRQ (/99.99)(/99.99)

53.7 (19.6)53.7 (19.6) 37.7 (14.1)37.7 (14.1) <0.001<0.001

COPD COPD knowledge knowledge

(/10)(/10)

6.6 (2.0)6.6 (2.0) 8.8 (1.1)8.8 (1.1) <0.001<0.001

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CHF ResultsCHF Results

Outcome Outcome measuremeasure

BaselineBaseline 12 weeks12 weeks P-valueP-value

PhysicalPhysical 6MWT6MWT 329.5 (103.2)329.5 (103.2) 380.9 (90.3)380.9 (90.3) <0.001<0.001

## Biceps strength Biceps strength (right)(right)

15.0 (6.6)15.0 (6.6) 18.9 (6.2)18.9 (6.2) 0.0010.001

## Quadriceps Quadriceps strength (right)strength (right)

12.8 (5.0)12.8 (5.0) 19.1 (5.3)19.1 (5.3) <0.001<0.001

PsychologicaPsychological*l*

HADS (anxiety)HADS (anxiety) 5.9 (3.8)5.9 (3.8) 3.5 (3.0)3.5 (3.0) <0.001<0.001

MOS-SSS MOS-SSS (tangible)(tangible)

67.4 (24.7)67.4 (24.7) 85.9 (14.0)85.9 (14.0) <0.001<0.001

CHQ (dyspnoea)CHQ (dyspnoea) 4.05 (0.95)4.05 (0.95) 5.3 (0.9)5.3 (0.9) <0.001<0.001

CHF CHF knowledge knowledge

(/10)(/10)

7.8 (1.7)7.8 (1.7) 9.6 (1.4)9.6 (1.4) <0.001<0.001

# # 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 evaluationProgramme evaluation

No.No. QuestionQuestion Disagree (%)Disagree (%) Ambiguous (%)Ambiguous (%) Agree (%)Agree (%)

COPDCOPD CHFCHF COPDCOPD CHFCHF COPD COPD CHFCHF

11 I will attend similar I will attend similar courses againcourses again

13.813.8 3.13.1 10.310.3 15.615.6 75.975.9 81.381.3

22 I can complete all the I can complete all the prescribed exercisesprescribed exercises

3.43.4 00 00 9.49.4 96.696.6 90.690.6

33 I prefer group I prefer group exercise to home exercise to home

exerciseexercise

20.720.7 28.128.1 27.627.6 18.818.8 51.751.7 53.153.1

44 I feel that my I feel that my physical health is physical health is

better than beforebetter than before

00 00 3.43.4 6.36.3 96.696.6 93.893.8

55 The group mates can The group mates can help me handle my help me handle my

diseasedisease

00 3.13.1 24.124.1 9.49.4 75.975.9 87.687.6

66 I did not have any I did not have any problem travelling to problem travelling to

the centrethe centre

10.310.3 00 3.43.4 3.13.1 86.286.2 96.996.9

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Focus groupFocus group(transcripts)(transcripts)

COPD groupCOPD group The exercise is helpful as it increases my daily activities tolerance.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 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.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.Group learning can facilitate the exchange of ideas. It creates happiness and concern for others.

CHF groupCHF group Learning in a group makes us more interactive. I seldom exercised in the past, but now 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 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 longer as a group. I believe we have benefit from the programme and will live a healthier life.healthier life.

The educational talks gave me a lot of information on nutrition. In the past, doctors just 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 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.which foods were suitable for me. They didn't have time to explain things in detail.

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Conclusions and Conclusions and recommendationsrecommendations

Patients with COPD and CHF have unmet needs in the community, disease-spePatients with COPD and CHF have unmet needs in the community, disease-specific rehabilitation programmes being predominantly hospital based and of licific rehabilitation programmes being predominantly hospital based and of limited duration.mited duration.

The group community interventions described above have the advantage of bThe group community interventions described above have the advantage of being incorporated as regular programmes in the community or primary care seeing incorporated as regular programmes in the community or primary care setting. They help patients cope with their diseases through empowerment and tting. They help patients cope with their diseases through empowerment and mutual support, apart from achieving symptom improvement and other positimutual support, apart from achieving symptom improvement and other positive physical and psychosocial outcomes.ve physical and psychosocial outcomes.

This model could be an integral part of chronic disease management programThis model could be an integral part of chronic disease management programmes in the community.mes in the community.

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ReferencesReferences

Woo J, Chan W, Yeung F, et al. A Community moWoo J, Chan W, Yeung F, et al. A Community model of group therapy for the older patients with del of group therapy for the older patients with COPD: a pilot study. COPD: a pilot study. J Evaluation in Clin PracticJ Evaluation in Clin Practice, e, 2006;2006;1212:523-531.:523-531.

Hui E, Yang H, Chan W, et al. Hui E, Yang H, Chan W, et al. A community A community model of group rehabilitation for older model of group rehabilitation for older patients with chronic heart failure: a pilot patients with chronic heart failure: a pilot study. study. Disability and Rehab, Disability and Rehab, 2006 (in press)2006 (in press)

huie@ha.org.hkhuie@ha.org.hk