Pulmonary Rehabilitation Exercise Prescriptions



Supplemental Digital Content

The topics and findings below were part of the survey beyond the specifics of exercise prescrption.

Oxygen Titration

There was a modest increase in respondents providing oxygen titration during exercise in 2016 vs. 2013 (94.7% vs. 92.7%; p = 0.302). 6MWT was added to the 2016 survey as an option for oxygen titration and was the most frequent method used followed by treadmill walking and stationary bicycle. Oxygen systems used during titration showed a modest but non-significant increase in use of the patient’s system, continuous and pulse dose systems in 2016 vs. 2013 (Figure 1).

Additional Patient Education Topics

A new question in the 2016 survey asked about patient education topics. In addition to formal exercise classes, over 90% of respondents reported providing educational sessions on oxygen use, prescription, and safety, exacerbation prevention and management, medication management, inhaler and nebulizer use, self-management education, and activities of daily living management and pacing. Fewer reported providing formal education on secretion clearance, dietician counseling, traveling with lung disease, managing panic and mood disorders, and communication with the medical team, with only 66.6% reporting the provision of a class on advanced directives.

Staff Role and Discipline

In the 2016 survey, exercise physiologists (EP) surpassed respiratory therapists (RT) and registered nurses (RN) as the discipline most frequently developing the exercise prescription. In the 2013 survey, RT was most frequent, followed by RN and EP. Over 50% of programs included RT, RN, EP and physicians, with significant increase in EP (p ≤ 0.001) in 2016 vs. 2013 in their core PR team. Use of RT, physical therapists, physicians, occupational therapists, social workers, dieticians, and psychologists declined non-significantly in 2016 vs. 2013 (see Figure 2). There was an increase in use of EPs developing PR exercise prescriptions. This may reflect the greater emphasis of exercise prescription in EP education and certification vs. other disciplines. There was a decrease in proportion of programs involving occupational therapists, social workers, and psychologists, and physicians and dieticians are lacking in 40 to 50% of the programs, respectively. This trend is concerning given the clinical complexity of patients with chronic lung disease, such as COPD, requiring the involvement of diverse healthcare disciplines. Even though exercise training is the corner stone of improvement in physical performance, varied healthcare disciplines are necessary to improve health-related behaviors.

PR Program Demographics

All respondents reported including patients with COPD, with over 80% of programs including patients with interstitial lung disease (e.g., idiopathic pulmonary fibrosis, sarcoid, scleroderma), asthma, and pulmonary hypertension. Fewer programs included neuromuscular disorders (amyotrophic lateral sclerosis, Parkinson’s, etc.) and 6.7% included pediatric patients (Figure 3). Other observational trends in the 2016 survey included an increase in programs caring for patients with chest wall abnormalities and thoracic surgery. New patient diagnoses in the 2016 survey included patients immediately post exacerbation and/or hospitalization, pediatric lung diseases and pulmonary hypertension (Figure 3).

Program Size and Setting

Over 95% of programs identified themselves as hospital based vs. less than 4% as free standing. One percent described their program as having an academic affiliation, with slight non-significant changes compared to 2013. Observations regarding the size of the program based on the number of PR patients (excludes maintenance patients) per year showed an increase in medium and very large size programs vs. the 2013 survey (Figure 4). A new question in 2016 asked about providing PR vs. cardiac rehabilitation (CR) vs. both programs. The vast majority (82.3%) provide both vs. 17.4% PR only and 0.3% CR only. Only two thirds of programs offer training on advance directives. PR patients identify a strong interest in advanced care planning that strongly suggests an important opportunity for PR clinicians to increase provision of this essential component of self-management training.1

SDC References

1. Gardiner C, Gott M, Small N, Payne S, Seamark D, Barnes S, Halpin D, Ruse C. Living with advanced chronic obstructive pulmonary disease: patients concerns regarding death and dying. Palliat Med. 2009;23:691–697.

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SDC Figure 1: Oxygen system during for titration (expressed in %)

Continuous flow = continuous flow oxygen; Pulse = pulse flow oxygen; Patient’s system = patient’s ambulatory oxygen system

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SDC Figure 2: Staff disciplines in Pulmonary Rehabilitation (expressed in %)

RT = respiratory therapist; RN = registered nurse; EP = exercise physiologist; MD = physician; Diet = dietician; SW = social worker; PT = physical therapist; OT = occupational therapist; Psycho = psychologist; NP = nurse practitioner

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SDC Figure 3: Patient’s diagnoses in PR Program (expressed in %)

COPD = chronic obstructive pulmonary disease; ILD = interstitial lung disease; Lung CA = lung cancer; CWA = chest wall abnormalities; TS = thoracic surgery; NMD = neuromuscular disorders; PH = pulmonary hypertension; Pedi = pediatric patients; Immed. post AE / hosp. = immediately post-acute exacerbation / hospitalization.

* new for 2016

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SDC Figure 4: Total phase II PR patients per year (expressed in %)

SDC Table 1: Summary of oxygen titration, staff disciplines, patient diagnosis, program volume and size.

|Question |2013 Survey |2016 Survey Results|

| |Results | |

|Yes |92.7% (290) |94.7% (301) | | |

|No |7.3% (23) |5.3% (17) | | |

|If yes, describe method of exercise used during titration: | | |

|(2013 n = 196) (2016 n = 265) | | |

|Treadmill |96.0% (188) |23.4% (62) | | |

|Cycle |48.0% (94) |7.5% (20) | | |

|6MWT (new for 2016) |N/A |69.1% (183) | | |

|What oxygen system(s) are used? Check all that apply. | | |

|(2013 n = 279) (2016 n = 297) | | |

|Continuous flow |92.5% (258) |94.3% (280) |0.759 |0.384 |

|Pulse |29.7% (83) |34.7% (103) |1.600 |0.206 |

|Patient's ambulatory oxygen system |47.0% (131) |52.2% (155) |1.577 |0.209 |

|Who develops exercise prescription? Check all that apply. | | |

|(2013 n = 307) (2016 n = 311) | | |

|RT |57.3% (176) |57.2% (178) |0.001 |0.981 |

|RN |45.3% (139) |47.6% (148) |0.332 |0.565 |

|ET |44.3% (136) |62.4% (194) |20.294 | ................
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