Pearls for putting patients in pulmonary rehab

The who, when, what, and why of rehabilitation.

Plato would have understood the benefits of pulmonary rehabilitation. Speaker Aiman Tulaimat, MD, quoted the ancient thinker to attendees at Internal Medicine Meeting 2016: “Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.”

The activity of pulmonary rehabilitation is actually best suited to a specific group of patients with chronic respiratory conditions, especially with chronic obstructive pulmonary disease (COPD), Dr. Tulaimat explained during his session titled “Pulmonary Rehabilitation: What Is It, and Who Exactly Benefits?” He is a pulmonologist with Cook County Health and Hospitals System in Chicago.

Which patients to send

“In general, we refer patients with moderate to severe COPD to a rehab program when they are stable,” said Dr. Tulaimat. The Medical Research Council (MRC) dyspnea scale, which ranges from 1 to 5, is a helpful tool to decide whether patients are likely to benefit. “We consider pulmonary rehabilitation to be good when the MRC dyspnea scale is anywhere between 2 and 4. When the MRC dyspnea score is more than 4—basically they're homebound because of shortness of breath—they're unlikely to benefit from rehabilitation,” Dr. Tulaimat said.

Aiman Tulaimat MD Photo by Kevin Berne
Aiman Tulaimat, MD. Photo by Kevin Berne

Pulmonary experts also look at a few other issues before beginning a patient on a rehab program, he explained. “Remember, we have to make sure that the exercise program is safe. So the physician running the rehab program has to make sure there isn't active cardiac disease, that their COPD is maximally treated...and identify any other barriers, like if they have musculoskeletal disease or severe osteoarthritis.”

Patients entering the rehab program at Cook County Hospital undergo a stress EKG, and about 1 in 10 show changes and have to be referred to a cardiologist before they can begin the program. “We don't want patients to have an MI during the exercise program,” said Dr. Tulaimat.

In addition to cardiac health, mental health should be evaluated at the start of a rehab program, according to Dr. Tulaimat, who recommended the Hospital Anxiety and Depression Scale as a measurement tool.

“It's important to measure mental health because 57% of patients with severe COPD have depressive symptoms, and almost 20% of them have severe depressive symptoms,” he said, citing a 2001 study in the Journal of Cardiopulmonary Rehabilitation. “Measuring mental health is important for measuring the burden of symptoms in those patients, but it's also important because it actually predicts adherence with the program.” There's also evidence that pulmonary rehabilitation programs can lead to improvements in anxiety and depression lasting at least a year, he noted, citing a 2002 study in The Lancet.

Last but not least, the patient's functional status needs to be assessed at the start and end of rehab in order to see how it improves with treatment. “One of the simple ways we use to assess their functional capacity is the 6-minute walk test,” said Dr. Tulaimat. Two cones are placed on the floor 30 meters apart, and patients are instructed to walk around them for 6 minutes.

In addition to providing a baseline for the rehab program, this test predicts mortality. “Patients who walk less than 300 or 350 meters in the 6 minutes have much higher mortality than patients who walk more than 350 meters,” Dr. Tulaimat said.

Mortality can also be predicted by patients' oxygen saturation after the 6-minute walk. “Many of those patients maintain good saturation throughout the walk test, and some of them actually desaturate during the walk test,” he said. The latter have a mortality rate 20 percentage points higher than patients that do not desaturate, according to a study published in CHEST in 2008.

When patients should go

Given the need for some ability to exercise, it's typical for patients to be referred to rehab when they're not at their sickest, but researchers have experimented with beginning rehab shortly after or even during hospitalization, Dr. Tulaimat reported.

A trial of rehabilitation beginning within 3 weeks of discharge from a COPD exacerbation successfully reduced readmissions. Only 7% of patients in the program were readmitted, compared to 33% of controls, according to the study published in Thorax in 2002. Beginning rehab during hospitalization did not provide benefit, however, found another study, published by The BMJ on July 8, 2014. “There was no reduction in rehospitalizations. In fact, if you look at the survival curve, the exercise group had higher mortality within 1 year,” Dr. Tulaimat said.

In addition to knowing when to start a rehab program, it's important to consider how to make sure it has lasting effects, according to Dr. Tulaimat. Typical programs include 4 components: education, psychosocial interventions, nutrition, and exercise. The exercise and education need to be continued after the 6- to 8-week rehab program wraps up, or the benefits accrued will be only temporary.

“Rehabilitation increases exercise tolerance, but this exercise benefit decreases over time if you don't continue exercise,” he said. “It's very important to have some form of maintenance exercise, as little as once a month, for patients with COPD.”

Follow-up phone calls to patients can help encourage them to keep exercising, Dr. Tulaimat said. His program does that, as well as providing a video to exercise with at home. “It is their trainer doing the video where they train—very personal,” he said. “The patients love it and they actually continue to exercise. Many of our patients who come back have actually maintained a lot of the gains they made with the exercise.”