Feasibility and effectiveness of a pulmonary rehabilitation programme in a community hospital setting.
ABSTRACT Pulmonary rehabilitation programmes run in secondary care have proved to be one of the most effective interventions for patients with chronic obstructive pulmonary disease (COPD).
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 patents with moderately severe COPD.
Uncontrolled prospective intervention study
A primary care-run community hospital.
Thirty-four patients with COPD aged between 5 and 80 years of age (mean = 70years) with a forced expiratory volume (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 completion 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.
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 capacity.
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.
- SourceAvailable from: Allison Mandrusiak[Show abstract] [Hide abstract]
ABSTRACT: Pulmonary rehabilitation is an effective treatment for people with chronic obstructive pulmonary disease. However, access to these services is limited especially in rural and remote areas. Telerehabilitation has the potential to deliver pulmonary rehabilitation programs to these communities. The aim of this study was threefold: to establish the technical feasibility of transmitting real-time pulse oximetry data, determine the validity of remote measurements compared to conventional face-to-face measures, and evaluate the participants' perception of the usability of the technology. Thirty-seven healthy individuals participated in a single remote pulmonary rehabilitation exercise session, conducted using the eHAB telerehabilitation system. Validity was assessed by comparing the participant's oxygen saturation and heart rate with the data set received at the therapist's remote location. There was an 80% exact agreement between participant and therapist data sets. The mean absolute difference and Bland and Altman's limits of agreement fell within the minimum clinically important difference for both oxygen saturation and heart rate values. Participants found the system easy to use and felt confident that they would be able to use it at home. Remote measurement of pulse oximetry data for a pulmonary rehabilitation exercise session was feasible and valid when compared to conventional face-to-face methods.International Journal of Telemedicine and Applications 01/2012; 2012:798791.
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ABSTRACT: To assess the feasibility and acceptability of swimming pool-based exercise as pulmonary rehabilitation (PR) for COPD sufferers. 101 patients with mild or moderate COPD registered with a South London general practice were invited to a swimming pool-based PR programme. Participants completed spirometry, the Chronic Respiratory Questionnaire (CRQ-SR), and the Incremental Shuttle Walk Test (ISWT) before and after the programme. A qualitative interview was used to assess participants' views. 24 patients (24%) expressed interest; 18 were recruited and 16 (16%) completed the PR programme. Their mean age was 69 yrs, seven were female, and mean % predicted FEV1 was 59%. The mean number of sessions attended was 10.6 out of 12. Significant improvements in dyspnoea score (difference 4.9; 95% CI -8.27 to -1.48) and walking distance (difference 32 metres; 95% CI -52.63 to -11.36) were observed, and all other findings were in the direction of improvement. Most patients enjoyed being in the water, were happy to expose themselves in swimsuits, overcame their fears, valued learning about COPD and socializing with fellow sufferers, and were positive about their physical improvement. The swimming pool is a feasible and positive alternative venue for PR for COPD patients in primary care.Primary care respiratory journal: journal of the General Practice Airways Group 10/2008; 18(2):90-4.
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ABSTRACT: The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients. A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts. The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.BMC Public Health 03/2009; 9:68. · 2.08 Impact Factor
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
540 British 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
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.
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