Pulmonary rehabilitation and qualitative research.

Dear Sirs,

I would like to address two papers published in the December 2012 issue of the PCRJ. The first paper, by Wortz et al.,[1] was a qualitative study on patients' goals and expectations for self-managing COPD. The second, by Moore et al.,[2] assessed the obstacles to patient participation in a community-based pulmonary rehabilitation (PR) programme.

Wortz and colleagues reach the conclusion that self-management support for patients with COPD should focus on addressing patients' fears associated with the uncertainty and progression of their disease.[1] This certainly mirrors the basis on which we based the pulmonary rehabilitation component in our outpatient clinic at St Heliers Hospital, Surrey, as reported in 1999.[3]

Our PR programme followed the guidelines laid out by the UK National Institute for Health and Clinical Excellence (NICE),[4] even before these had been published. The exercise part of the rehabilitation programme[3] was based on exposing patients to the very thing they were frightened of — breathlessness; i.e. this was “exposure in vivo” using cognitive behavioural therapy (CBT). However, our PR programme was for two hours once-weekly for six weeks, as opposed to twice-a-week for six to 12 weeks as recommended by NICE.[4] We believed that our timeframe would be more acceptable for patients and would therefore aid compliance; this proved to be the case, since we had very few dropouts, and any patients who didn't complete the PR programme because of a COPD exacerbation usually wanted to attend a further course when they were free of infection.

Of course, no one seems to be questioning the exercise component of PR programmes. Pulmonary rehabilitation has recognised benefits in terms of exercise endurance, and improvements in dyspnoea and quality of life,[5] and there are potentially hidden benefits in that patients may actually like the added attention. Furthermore, the average functional exercise capacity following our PR programme was 48 metres — almost identical to the 49 metres included in the NICE guideline[4] — and this was maintained at 12 months.

It is interesting that, in our experience, few patients failed to complete the PR programme, which was initiated in one general practice surgery. However, Moore et al. report that less than 50% of their patients completed PR treatment,[2] and they suggest that patients would welcome an experienced patient who could introduce them to the PR programme. This is exactly what we did in our programme,[3] and the introduction was performed by a patient who had previously gone through the PR programme and then gone on to join ‘Breathe Easy,’ a UK self-help group. Patients were thus encouraged to become members.

We also undertook a questionnaire survey on 100 patients who had completed our PR programme. The question was simple: “What benefit or otherwise did you gain from the rehab programme?”. The results are shown in Table 1. Replies were anonymous, and 44% replied. Significantly, 15 patients (30%) said they had gained the most from the PR programme, and these 15 had actually continued the exercises regularly at home. Our PR programme was designed for its simplicity, and the only equipment needed for the exercises was a chair, something ubiquitous to every home. The rationale was that the programme could translate to any venue, be it the GP surgery, clinic or home.

Table 1

Patient benefits of Pulmonary Rehabilitation — responses from questionnaire survey

We did not expect our patients to become COPD athletes. We just wanted them to accept their breathlessness, adjust to their disability, and help them achieve their goals. We did not use treadmills, exercise bikes or expensive equipment; self management was the key aim. Our PR programme could translate to any community setting, organised by a practice nurse with a PR physiotherapist.