British Journal of General Practice, July 2002539
Feasibility and effectiveness of a pulmonary
rehabilitation programme in a community
Janet A Ward, Gill Akers, David G Ward, Margaret Pinnuck, Sue Williams, Jayne Trott and David M G Halpin
erance and at reducing symptoms in patients with chronic
obstructive pulmonary disease (COPD). Randomised con-
trolled trials have shown sustained improvements in walking
performance and quality of life following both hospital and
home-based rehabilitation.1-13Programmes are widely avail-
able in North America and Europe, and both the American
Thoracic Society and the European Respiratory Society
have published official statements describing the benefits
and essential components of a rehabilitation programme
and recommending patient selection criteria.14-15The British
Thoracic Society has also published a statement on the ben-
efits of pulmonary rehabilitation,16but a recent survey sug-
gested that it is only available in one quarter of United
Kingdom (UK) hospitals.17Eighty per cent of those offering
a programme ran outpatient programmes, but 5.5% also
offered a home-based programme.
Rehabilitation aims to prevent deconditioning and allow
the patient to cope with their disease. Most programmes are
hospital-based and comprise individualised exercise pro-
grammes and educational talks, but a major component is
the sharing of experiences among participants and their
spouses. Pulmonary rehabilitation can reduce symptoms,
increase mobility, and improve quality of life,14,16and it may
also reduce hospital readmission rates. The optimal duration
of rehabilitation programmes and the optimum frequency of
the exercise sessions remains uncertain.16
Although they are effective, programmes based in sec-
ondary care suffer from a high dropout rate and patients
may be deterred from attending because of frequent jour-
neys to the hospital.6Those based in the home may be less
effective because patients do not perform the prescribed
exercises and they miss out on the group therapy aspects of
hospital-based programmes.18There has been interest in
running programmes in primary care, but we are not aware
of a programme that has been established in a community
hospital. In the UK these hospitals are the successors to the
cottage hospitals,19and the term does not mean the same in
North America. They are now primarily staffed by general
practitioners (GPs), and one of their roles is rehabilitation.
They often have good physiotherapy facilities. There has
been a pulmonary rehabilitation programme based at the
Royal Devon and Exeter Hospital since 1995, but we wanted
to investigate the feasibility of establishing and running a pri-
mary care-led programme at the community hospital in
HERE is now a general recognition of the effectiveness of
pulmonary rehabilitation, both at increasing exercise tol-
J A Ward, MRCGP, DFFP, general practitioner; D G Ward, general
practitioner; M Pinnuck, RGN, practice nurse; S Williams, RGN,
research nurse, Honiton Surgery, Devon. G Akers, Dip Grad Phys,
MCSP, physiotherapist, Honiton Hospital, Devon. J Trott, BSc, MCSP,
physiotherapist; D M G Halpin, MA, DPhil, FRCP, consultant physician
and senior lecturer in respiratory medicine, Department of
Respiratory Medicine, Royal Devon and Exeter Hospital, Devon.
Address for correspondence
Dr D G Halpin, Department of Respiratory Medicine, Royal Devon
and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW.
Submitted: 17 October 2001; Editor’s response: 25 February 2002;
final acceptance: 23 April 2002.
©British Journal of General Practice, 2002, 52, 539-542.
Background: Pulmonary rehabilitation programmes run in sec-
ondary care have proved to be one of the most effective interven-
tions for patients with chronic obstructive pulmonary disease
Aim: To assess whether a pulmonary rehabilitation programme,
similar to that run in secondary care, could be established in a
primary care-run community hospital and whether it could
achieve similar benefits in patients with moderately severe COPD.
Design of study: Uncontrolled prospective intervention study.
Setting: A primary care-run community hospital.
Method: Thirty-four patients with COPD aged between 53 and
80 years of age (mean = 70 years) with a forced expiratory vol-
ume (FEV1) of 30 to 50% (mean = 40%) predicted were enrolled
in a programme established in the activities room at Honiton
Community Hospital. Patients were assessed at the start, on com-
pletion of the programme, and six months after completion, using
spirometry, shuttle-walking distance, and short form-36 (SF-
36) and chronic respiratory questionnaire (CRQ) scores.
Results: All but one patient completed the programme. There
were significant improvements in the walking distance (by a
mean of 100 m), in the SF-36, and in all domains of the CRQ.
There was no significant change in the FEV1 or forced vital
Conclusion: Pulmonary rehabilitation programmes can be run in
community hospitals. They appear to be as effective as those run
in secondary care and patients may find them easier to access.
Keywords: COPD; hospitals; community; respiratory function
Honiton is a small market town in east Devon. It is 18 miles
from Exeter which has the nearest secondary care centre.
Medical care in Honiton is provided by a single group prac-
tice serving a population of over 15 000. The partners also
supervise inpatients in the hospital. One of the partners pro-
vided the medical lead for the programme.
Honiton hospital has 25 medical beds, a casualty depart-
ment, and outpatient, physiotherapy and occupational ther-
apy facilities. It is located a short distance from the town cen-
tre and has excellent parking facilities.
Patients were identified from their practice records and invit-
ed to attend for spirometry, reversibility testing, and an inter-
view with the nurse.
Patients were considered suitable for the rehabilitation
programme if they met the following criteria: diagnosis of
COPD, forced expiratory volume (FEV1) 30% to 50% predict-
ed; breathlessness interfering with daily living activities; abil-
ity to provide own transport to the hospital; sufficient mobil-
ity to travel to the hospital; and no other unstable medical
conditions. Patients meeting these criteria were asked if they
wished to participate.
During confirmation of the diagnosis, the patients were
advised on the best use of their medication and suggestions
were made to the patients’ GPs regarding possible changes
to their drug regimens.
Once they had agreed to participate in the rehabilitation pro-
gramme, patients were assessed by a research nurse and a
physiotherapist, who administered quality-of-life question-
naires (chronic respiratory questionnaire [CRQ] and short
form-36 questionnaire [SF-36])20,21and performed a shuttle-
walking test.22Patients entered the programme shortly after
assessment. Assessments were repeated at the end of the
programme and six months after finishing the programme.
Both the CRQ and the SF-36 questionnaires produce scores
in a number of domains which reflect different aspects of
health status, such as dyspnoea or vitality, as well as an
overall summary score. Higher scores reflect worse health
The programme was based on the Exeter programme,
which was itself based on the Leicester programme,9and
comprised a 45-minute exercise programme; a 30-minute
coffee break, to allow rest and socialisation; and a 45-minute
educational session. A physiotherapist and physiotherapy
aide supervised each session. Patients attended for two
hours twice a week for eight weeks. We aimed to enrol ten
patients in each programme. Three courses were run as part
of this feasibility study. The sessions were held in the activi-
ties room at Honiton Hospital.
The exercise sessions began with a short warm-up and
stretch. Patients then performed exercises at ten different
stations in rotation. Some of these exercises worked arms,
others worked the upper body, and others the legs. Some
were designed to be performed aerobically, while others
were more anaerobic. The exercises were timed in 30-sec-
ond bursts and patients recorded the number of repetitions
on their charts, together with their breathlessness scores.
The topics covered in the educational sessions were sim-
ilar to those used in the Exeter programme and were in line
with those recommended by the ATS and ERS.14,15The
speakers were health care workers from the local communi-
ty, some of whom were already known to the patients, and
members of the local social services, sports centre, and self-
help groups. They all gave their services free of charge.
The study did not include a control group. The significance
and magnitude of differences between the baseline, com-
pletion, and follow-up assessment spirometric values, walk-
ing distances, and CRQ and SF-36 scores, were calculated
using paired t-tests with the aid of SPSS for Windows 9.0.
Thirty-four patients were asked if they wished to take part in
the programme. Twenty-eight were enrolled: nine in the first
programme, ten in the second, and nine in the third. The
average age of the patients was 70.3 years, and the range
was from between 53 and 80 years of age. There were 25
men and three women. The patients’ baseline lung function,
shuttle walk distances, and SF-36 and CRQ scores are
shown in Table 1. Two of the patients were current smokers.
Only one patient dropped out before completing the pro-
gramme. This individual was unconvinced of the potential
benefits of the programme and failed to participate fully in
the exercises. All the other patients completed the pro-
gramme. One patient had been offered a place in the Exeter
programme but had declined because of perceived difficul-
ties in travelling to Exeter twice per week and parking at the
hospital. He completed the community-based programme.
The effect of the programme on lung function, walking dis-
tance, and quality of life are shown in Table 2. There was no
significant change in the FEV1or forced vital capacity (FVC)
between the baseline and completion assessments, or
between the completion and follow-up assessments. There
were significant improvements in the distance walked during
the shuttle test and in disease-specific quality of life as
540British Journal of General Practice, July 2002
J A Ward, G Akers, D G Ward, et al
HOW THIS FITS IN
What do we know?
Pulmonary rehabilitation programmes
based in secondary care have been shown
to be effective ways of improving exercise
tolerance and quality of life in patients with COPD, but patients
often find it difficult to get to a hospital and up to 20% of patients
do not complete the programme.
What does this paper add?
This study shows that pulmonary rehabilitation programmes
can be established in a primary care setting and they can
achieve just as good results as those based in secondary care.
Primary care trusts should consider establishing programmes.
assessed by the chronic respiratory questionnaire. With the
exception of emotional functioning, there were no significant
changes in quality of life at the six-month follow-up. There
were clinically and statistically significant improvements in
the physical function, vitality and mental health domains of
the SF-36 immediately following the programme, and these
were also maintained at follow-up.
The aim of this study was to determine whether a pulmonary
rehabilitation programme could be run at a community hos-
pital that could produce similar benefits to those reported
from secondary care-based programmes. It did not include
a control group, therefore the magnitude of the benefits pro-
duced must be viewed with caution, but our principal con-
clusion is that it is feasible to run pulmonary rehabilitation
programmes in the community. The results suggest that clin-
ically-significant benefits can be achieved, and it appeared
that running the programme in a primary care setting also
resulted in very low dropout rates, unlike in most secondary
No significant difficulties were encountered in establishing
the programme, although inevitably it required a lot of work
on the part of the lead clinician. The hospital was able to pro-
vide a large room to accommodate the sessions. We were
unable to use the physiotherapy department, as this would
have disrupted the work there. Only very small amounts of
additional equipment were required, such as clipboards for
the patients to record their progress. The lead GP co-ordi-
nated the education programme and liased with the other
partners about selection of the patients. All of those involved
with the programme described great satisfaction at the
response of the patients to the programmes.
The programme was enthusiastically received by the
patients and their partners and it generated considerable
interest in the community. The local newspaper ran a feature
about the programme and the hospital League of Friends
were keen to offer support for further programmes.
Recruitment to the first programme relied on the enthusi-
asm of the nurses and the lead GP in explaining to patients
the nature and potential benefits of pulmonary rehabilitation.
Thereafter, recruitment of suitable screened patients was
more straightforward, as many of them had heard about the
programme by word of mouth or had read an article pub-
lished in the local newspaper. Thus, they already knew a lit-
tle about the concept of a pulmonary rehabilitation pro-
The patients who entered into this programme appear to
have been similar to those entering hospital-based pro-
grammes. The baseline lung function results and shuttle
British Journal of General Practice, July 2002541
Table 2. Changes in spirometry, shuttle walk distances, and CRQ domains between baseline and completion of the rehabilitation pro-
gramme and between completion and the six-month follow-up assessment.
Mean difference (95% CI)
Baseline versus completionCompletion versus follow-up
Shuttle walk (m)
0.10 (–0.02 to 0.21)
0.23 (0 to 0.45)
100 (61 to 139)a
0.04 (–0.01 to 0.10)
0.04 (–0.21 to 0.13)
25 (–20 to 70)
0.71 (0.21 to 1.23)b
0.60 (0.14 to 1.05)c
0.63 (0.22 to 1.04)b
0.58 (0.18 to 0.98)b
0.11 (–0.14 to 0.38)
–0.18 (–0.50 to 0.15)
–0.56 (–0.93 to –0.18)b
–0.12 (–0.42 to 0.18)
6.7 (0.8 to 12.5)c
5.4 (–13.6 to 24.4)
4.0 (–5.5 to 13.4)
1.2 (–6.7 to 9.1)
6.1 (1.2 to 10.5)c
2.3 (–5.9 to 10.5)
10.7 (–6.1 to 27.4)
10.8 (6.2 to 15.5)a
–0.7 (–5.5 to 4.1)
–3.6 (–30.0 to 22.9)
7.0 (–1.8 to 15.8)
–1.1 (–8.4 to 6.3)
–1.2 (–9.3 to 6.9)
0.8 (–9.1 to 10.7)
7.1 (–13.1 to 27.4)
–2.5 (–9.5 to 4.4)
aP<0.001; bP<0.05; cP<0.01.
Table 1. Baseline characteristics (n = 27).
Mean (± SEM)
FVC (% predicted)
FEV1/FVC ratio (%)
Shuttle walk distance (m)
0.99 ± 0.05
40 ± 2
2.36 ± 0.15
66 ± 4
44 ± 2
199 ± 22
3.5 ± 0.2
4.0 ± 0.2
5.1 ± 0.2
5.2 ± 0.2
Role — physical
Role — emotional
38.6 ± 3.9
27.7 ± 6.6
65.9 ± 5.6
42.9 ± 3.5
47.3 ± 3.3
67.6 ± 5.6
57.3 ± 8.9
69.5 ± 2.6
SEM = standard error of the mean
542 British Journal of General Practice, July 2002 Download full-text
J A Ward, G Akers, D G Ward, et al
walk distances of the patients entering this programme were
similar to those reported for patients enrolled in secondary
care-based programmes.7-9The baseline SF-36 scores were
similar to those reported in other groups of patients with sta-
ble COPD, with the exception of the physical functioning and
role physical domains, which were worse.23,24The baseline
CRQ scores were also similar to those reported for patients
entering pulmonary rehabilitation programmes.26
The benefits achieved in this community programme are
at least as good as those reported from secondary care-
based programmes. The improvement in walking distance
was similar to that reported in other programmes7-9 and was
of considerable clinical importance. The improvements in
the CRQ scores were both clinically and statistically signifi-
cant and were similar to those previously reported.26The
improvements in the SF-36 scores were similar to those
seen, following pulmonary rehabilitation, in a group of
patients awaiting lung volume reduction surgery.25
Running rehabilitation programmes in community hospi-
tals offers advantages over secondary care-based pro-
grammes in terms of access and local ownership. They offer
advantages over home-based programmes by maintaining
motivation and ensuring compliance with the exercise pro-
gramme, and they also provide peer support. Similar advan-
tages could be gained by running programmes in other
community settings using rooms large enough to accom-
modate the exercise stations. These could include sports
centres, schools, and village or church halls. In fact, the
sports centre in Honiton is now offering a follow-on pro-
gramme for graduates of the group. Community-based
rehabilitation programmes run by physiotherapists at their
practices, involving between three and four patients only,
have been reported from Holland and have also been shown
to be effective.27
The East Devon Primary Care Trust, too, has agreed to
fund the programme on a permanent basis as a result of the
success of the programme. Programmes will be run in rota-
tion at a number of the community hospitals in East Devon.
We would like to thank all the staff involved in establishing
and running the programme and all the GPs at Honiton
Surgery for allowing us to recruit their patients into the pro-
gramme. We would particularly like to thank Dr D Seamark,
lead research GP at Honiton Surgery, for his support, and Dr
R Powell, co-ordinator, Exeter and North Devon Research
and Support Unit, for his assistance with the analysis and
interpretation of the results.
We are grateful to the League of Friends at Honiton
Hospital, and Innovex UK Ltd for making an educational
grant to support the establishment of this programme.
1. Goldstein RS, Gort EH, Stubbing D, et al. Randomised controlled
trial of respiratory rehabilitation. Lancet 1994; 344: 1394-1397.
2. Reardon J, Awad E, Normandin E, et al. The effect of comprehen-
sive outpatient pulmonary rehabilitation on dyspnoea. Chest 1994;
3. Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Effects of pul-
monary rehabilitation on physiologic and psychosocial outcomes
in patients with chronic obstructive pulmonary disease. Ann Intern
Med 1995; 122: 823-832.
4. Wijkstra PJ, van Altena R, Krann J, et al. Quality of life in patients
with chronic obstructive pulmonary disease improves after rehabil-
itation at home. Eur Respir J 1994; 7: 269-273.
5. Wijkstra PJ, van der Mark TW, Kraan J, et al. Effects of home reha-
bilitation on physical performance in patients with chronic
obstructive pulmonary disease (COPD). Eur Respir J 1996; 9: 104-
6. Strijbos JH, Postma DS, van Altena R, et al. A comparison
between an outpatient hospital-based pulmonary rehabilitation
program and a home-care pulmonary rehabilitation program in
patients with COPD. Chest 1996; 109: 366-372.
7. Bendstrup KE, Ingemann Jensen J, et al. Out-patient rehabilitation
improves activities of daily living, quality of life and exercise toler-
ance in chronic obstructive pulmonary disease. Eur Respir J 1997;
8. Wedzicha JA, Bestall JC, Garrod R, et al. Randomized controlled
trial of pulmonary rehabilitation in severe chronic obstructive pul-
monary disease patients, stratified with the MRC dyspnoea scale.
Eur Respir J 1998; 12: 363-369.
9. Singh SI, Smith DL, Hyland ME, Morgan MD. A short outpatient
pulmonary rehabilitation programme: immediate and longer-term
effects on exercise performance and quality of life. Respir Med
1998; 92(9): 1146-1154.
10. Troosters T, Gosselink R, Decramer M. Short- and long-term
effects of outpatient rehabilitation in patients with chronic obstruc-
tive pulmonary disease: a randomized trial. Am J Med 2000; 109:
11. Lacasse Y, Wong E, Guyatt GH, et al. Meta-analysis of respiratory
rehabilitation in chronic obstructive pulmonary disease. Lancet
1996; 348: 1115-1119.
12. Hernandez MT, Rubio TM, Ruiz FO, et al. Results of a home-based
training program for patients with COPD. Chest 2000; 118: 106-
13. Wijkstra PJ, van der Mark TW, Kraan J, et al. Long-term effects of
home rehabilitation on physical performance in chronic obstruc-
tive pulmonary disease. Am J Respir Crit Care Med 1996; 153:
14. American Thoracic Society. Pulmonary rehabilitation—1999. Am J
Respir Crit Care Med 1999; 159: 1666-1682.
15. Rehabilitation and Chronic Care Scientific Group of the European
Respiratory Society. Donner CF, Muir JF. Selection criteria and
programmes for pulmonary rehabilitation in COPD patients. Eur
Respir J 1997; 10: 744-757.
16. BTS Standards of Care Committee. Pulmonary rehabilitation.
Thorax 2001; 56: 827-834.
17. Davidson AC, Morgan MDL. A UK survey of the provision of pul-
monary rehabilitation. Thorax 1998; 53(suppl 4): A86.
18. Tregonning M, Roberts S, Langley C, et al. Randomised controlled
trial of home exercise and education in chronic obstructive pul-
monary disease (COPD). Thorax 2000; 55(suppl 3): A7.
19. Seamark D, Moore B, Tucker H, et al. Community hospitals for the
new millennium. Br J Gen Pract 2001; 51: 125-127.
20. Guyatt GH, Berman LB, Townsend M, et al. A measure of quality
of life for clinical trials in chronic lung disease. Thorax 1987; 42:
21. Ware JE, Sherbourne CD, Davies AR, Steward AL. The MOS short-
form general health survey. Santa Monica: The RAND Corporation,
22. Singh SJ, Morgan MDL, Scott S, et al. Development of a shuttle
walking test of disability in patients with chronic airways obstruc-
tion. Thorax 1992; 47: 1019-1024.
23. Mahler DA, Mackowiak JI. Evaluation of the short-form 36-item
questionnaire to measure health-related quality of life in patients
with COPD. Chest 1995; 107: 1585-1589.
24. Jones PW, Bosh TK. Quality of life changes in COPD patients
treated with salmeterol. Am J Respir Crit Care Med 1997; 155:
25. Moy ML, Ingenito EP , Mentzner SJ, et al. Chest 1999; 115: 383-
26. Guell R, Casan P , Belda J, et al. Long-term effects of outpatient
rehabilitation of COPD. A randomized trial. Chest 2000; 117: 976-
27. Cambach W, Chadwick-Straver RVM, Wagenaar RC, et al. The
effects of a community-based pulmonary rehabilitation pro-
gramme on exercise tolerance and quality of life: a randomized
controlled trial. Eur Respir J 1997; 10: 104-113.