Pulmonary rehabilitation; what's in a name?

The therapeutic efficacy of pulmonary rehabilitation is now well established and supported by a substantial body of clinical trial evidence. 2 The place of pulmonary rehabilitation in the management of chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases has been enshrined in national and international guidelines including those recently produced by the British Thoracic Society. In recent years, attention has shifted from questions regarding the effectiveness of the intervention for those who successfully attend and complete a programme, to meeting challenges for the delivery of pulmonary rehabilitation to the wider population with disabling lung disease. A key driver of this focus is the perception in many quarters that uptake and adherence to rehabilitation is poor, and that a significant minority of patients do not fully respond, or quickly decline, once the programme is completed. As a result, there is considerable interest in developing and testing alternative delivery models of pulmonary rehabilitation and other behavioural interventions that aim to improve general health, knowledge of the disease and promote self-care. Dympna presents data from the PRINCE study which reports on the delivery of a structured education pulmonary rehabilitation programme (SEPRP) in a primary care setting. This is not the first study of pulmonary rehabilitation in the community, 6 but the PRINCE study has taken an alternative approach. The authors describe a tightly controlled cluster ramdomised controlled trial (RCT) of a rehabilitation intervention versus best usual care in a group of participants with moderate to severe COPD. The authors should be congratulated on conducting such a rigorous randomised controlled trial in a large study population. Participants underwent an 8-week programme, comprising weekly sessions of exercise and education, followed by a telephone call at 4 weeks postdischarge, and a 1 h group meeting at 12 weeks. The overall results, at 12 weeks were mixed; the primary outcome measure, the chronic respiratory disease questionnaire did achieve between group statistical significance, but the confidence intervals overlapped with the minimal clinically important difference for the measure leaving doubts about the importance of the population effect. This lack of clarity in this outcome is in part due to an improvement in health status in the control group, a frequently observed phenomenon in clinical trials. However, the intervention also failed to influence secondary outcomes including exercise tolerance and, overall, these results would have to been seen as rather disappointing when compared with conventional pulmonary rehabilitation and, indeed, to other recent community-based trials. 6 The authors suggest their population might have been ‘too good’, but although their mean performance on the incremental shuttle walking test (ISWT) was slightly higher than has previously been described, 8 values were well below the predicted normal range. Similarly, while the responsiveness of exercise testing may vary between populations and between the exercise outcomes frequently reported, there is a substantial body of evidence to suggest that the ISWT is responsive to rehabilitation across a range of disease severities including less disabled patients. 13 We think it more likely that there was a failure to intervene rather than a failure of the chosen outcome measures to detect an effect. The novelty of the paper is the approach taken with the educational component. Practice nurses, who potentially have limited knowledge about COPD, were enrolled on a 3-day course on adult education to equip them to deliver the educational package. However, there is now recognition that a collaborative approach to the educational component of rehabilitation, promoting and negotiating behaviour change is needed rather than a more traditional didactic approach. This may require more experience of the rehabilitation process on the part of the practitioner and an appreciation of motivational techniques. Equally, it has been a long held premise of rehabilitation that the programme should be delivered by a multidisciplinary team, and it is usually the educational component that reflects this. The programme would probably have benefitted from wider team involvement, most obviously an occupational therapist and dietician. The education programme appears to have been precisely defined, whereas the exercise programme was more loosely prescribed and did not meet the specified levels described in national or international guidelines where the current recommendation is for at least two supervised sessions a week, with accompanying unsupervised home training sessions. 14 When considering the delivery of pulmonary rehabilitation, there are two perspectives: that of the individual participating and that of the provider organisation. Both would want to facilitate better access to the service but may have a different outlook on the setting, content, supervision and cost of the programme. What, therefore, are the lessons that can be drawn from the PRINCE trial? The aim of pulmonary rehabilitation is to take a disabled patient with individual needs and priorities and provide an individually tailored intervention that improves symptoms and maximises physical and social functioning. The components and setting of rehabilitation may vary, but supervised exercise training conducted at least twice a week has consistently been shown to be the key to its effectiveness. It is possible that the supervision of the intervention that is required to bring about these objectives will vary considerably between patients and, therefore, home-based pulmonary rehabilitation or self-managed exercise programmes may offer an effective alternative for some people. Indeed such innovations may improve access to treatment for some (eg, patients who are still at work) and create capacity for more disabled patients to access formal programmes. Despite reservations about the ‘dose’ of pulmonary rehabilitation provided in the PRINCE trial some individuals might prefer the style and setting of a ‘non-traditional’ intervention, and may accrue important benefits which they might be denied if the only format offered is felt to be unmanageable or impractical by the patient. Offering a diversity of patient treatment choices is self-evidently desirable but this needs to be an informed choice of effective treatment options. One concern with less intensely supervised interventions is that patients may collude in the avoidance of a treatment whose benefits are at least Centre for Exercise and Rehabilitation Science, Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, UK