We need to shout about the benefits of pulmonary rehabilitation
Dr Alison Cook, Chair of the Taskforce for Lung Health, describes how pulmonary rehabilitation, an exercise and education treatment which offers life-changing results for people with lung disease, was developed and why we now need to improve access for everyone eligible.
How it began
At the time that Elvis was shaking it all about behind bars in Jailhouse Rock, there was another interesting experiment with movement, except this one was beginning in respiratory medicine. Rock and roll wasn’t the only thing gaining ground in the States in the 1950s. Pulmonary rehabilitation was being born.
In Columbia University in New York, Doctor Alvan L Barach noticed that his patients’ leg muscles were wasting away as their lung disease developed. Thinking ahead of his time, he wanted to see if he could treat the whole patient, not just the lung disease. Doctor Barach recruited a group of patients to start a tailor-made progressive training regime like those seen to improve performance in athletes. Starting with 50-100 steps on the first day, he gradually increased how far they were able to walk. It was through this simple regimen that he was able to teach his patients to not be afraid of being breathless.
This was ground breaking in the 1950s. Until then, people with lung disease were told to avoid anything which left them out of breath. Some of Barach’s patients could manage the exercise without oxygen, but for others, Barach invented portable oxygen systems, so that people could breathe concentrated oxygen while on the move.
‘When I see a patient, then, whose pulse on walking back and forth 2 or 3 times in the hallway in my office increases to 140, it is evident that he hasn’t walked enough to maintain cardiovascular efficiency. It may seem unusual perhaps to suggest exercise to these breathless people, but in fact it is one of the ways by which they can restore physical fitness. I am unhappy about patients who always use an elevator to go upstairs. I will say from now on you can practice walking up the stairs....’ 1
- Doctor Alvan L Barach
Bringing pulmonary rehabilitation back to centre stage has been an uphill battle
What happened next is not uncommon in medicine – there can often be a setback when a new idea for a better treatment is getting off the ground. Things were going well for pulmonary rehab, with medics and researchers spending the next 40 years accumulating the evidence that treatments such as pulmonary rehabilitation could improve quality of life.
But there was a setback in the 1980s when several influential research papers looked for changes in biochemical markers in muscle tissue but couldn’t find anything to suggest that the muscles were actually changing.2 Even when the paper was published, there were comments from other researchers that the exercise regime used wasn’t intensive enough to be able to see any changes. Changing practice in medicine is incredibly difficult to do, at best it takes a long time for the knowledge to percolate through to the frontline, and when practice is just beginning to change, any negative finding can take its toll. It has taken a lot of effort to get pulmonary rehabilitation back where it belongs, centre stage in NHS respiratory treatment.
And now we know that Pulmonary rehabilitation is one of the best, if not the best treatment for COPD (chronic obstructive pulmonary disease), ILD (interstitial lung disease) and other lung conditions. It reduces breathlessness, improves the ability to exercise, and raises health-related quality of life generally.
Studies show that the treatment, which incorporates exercise lessons and guidance on managing symptoms and living with a lung condition, is more effective than some drug-based treatments in its track record for improving the wellbeing of patients.3
Access to this treatment is still patchy, with people all around the country who are never offered pulmonary rehab or can’t get to classes because provision in their area is so poor. But is it the cost of pulmonary rehabilitation that is holding the NHS back? Arguably, giving everyone access to pulmonary rehabilitation who could benefit from it would save money. If eligible people with COPD had access to pulmonary rehabilitation, NHS England could see a reduction of 150,924 GP appointments, and 26,633 fewer hospital admissions per year, all of which currently costs the NHS £69 million every year, according to the Taskforce for Lung Health.4
This pulmonary rehabilitation week, we need to raise awareness of the power of this treatment
It’s ‘Pulmonary Rehabilitation Week’ (21-27 June), which aims to raise awareness of the life-changing treatment for people with lung conditions. This is an opportunity to reflect on the need for increased access to this life-changing treatment, which not only benefits people with COPD but has the potential to support tens of thousands of people with other lung diseases, too.
Sadly, the pandemic has meant that we have seen classes cancelled and referrals to pulmonary rehabilitation treatment stalled. When classes fully resume, there will be a backlog of classes to deliver, to get people fitter again, alongside lengthy waiting lists to get new patients started. Technology has come a long way since the 1950s and we now have the ability to combine face to face classes with on line support, with some parts of the NHS already working to deliver this combination well, getting the best of both worlds for each individual patient.
We now need to celebrate the pulmonary rehab pioneers of the past and support the NHS heroes we have today, who are giving it their all to make sure that everyone who would benefit from pulmonary rehab gets the chance to try it and the support to stick with it. This week, let’s bang the drum loud for everyone working in pulmonary rehab so that the NHS gives them and their patients the financial support they need to really fly.
1. Noehren TH, Barach AL, Brantigan OC, Smart RH. Pulmonary emphysema – Prevention and care. Dis Chest 1964;45:492-502
2. Casaburi R, Respiratory Care September 2008; vol 53 No 9: 1185-1189
3. COPD Value Pyramid, https://www.networks.nhs.uk/nhs-networks/london-lungs/latest-edition-of-thorax-publication. 4. Lung Health Data Tracker, Taskforce for Lung Health, 2021. https://www.blf.org.uk/taskforce/data-tracker/pulmonary-rehabilitation/pulmonary-rehabilitation-for-people-with-copd