Patients support exercise training and rehabilitation—what more should we be doing to ensure cardiopulmonary rehabilitation is more readily available for those with pulmonary hypertension?
Babu AS and Morris NR.
Abstract: “You need to exercise and stay active…a little breathlessness is alright…there is evidence to support its use … . visit your physiotherapist for a detailed exercise program”—How often have we said this to our patients with pulmonary hypertension (PH), without realizing what it is that they feel about it or trying to understand why they have difficulties to carry out their exercise regime? A new paper by Chia and colleagues1 in the current issue of Pulmonary Circulation has done just that—to identify the behaviors toward exercising, the potential barriers and facilitators, and the accessibility of these services through an international, online survey.
Exercise intolerance is a cardinal feature of PH that is brought about the various physiological mechanisms.2 Considering the benefits of exercise training on these physiological systems,3 it has gained popularity as an adjunct to medical therapies with evidence from high-quality meta-analysis showing significant benefits on function and quality of life among those participating in exercise programs.4 The availability of the growing body of evidence5 has now resulted in exercise training receiving evidence-based recommendations in the recent PH guidelines, albeit of low quality.6 Despite the growing popularity for exercise training in PH, not many centers still offer exercise training to those with PH. This has been thought to be due to the lack of awareness of the benefits of exercise among both healthcare professionals and patients. It is in this context that this study by Chia et al. elucidates to the patient and their experiences with exercise.
The online survey conducted by Chia and colleagues1 reached 202 participants from 19 countries around the world. With respondents coming mainly from Australia and New Zealand (over 60%) and targeted at well-educated, computer-literate individuals, the survey may represent a somewhat rosier view. However, the authors were able to collect both quantitative and qualitative data and reported that 77% of patients received information on the benefits of exercise—a surprisingly high percentage given the past reluctance to recommend exercise. Walking was most used by those with PH followed by supervised exercise sessions in the gym. Disconcertingly, more than half the respondents reported a previous adverse event during exercise and these individuals reported greater levels of anxiety regarding exercise participation. This anxiety may well impact enrollment and adherence to exercise programs. Therefore, the need to reassure patients on the safety of exercise in the real world setting, despite the low rates of adverse events with exercise training.7
The authors have highlighted the need for a multidisciplinary rehabilitation service for PH as well, which supports the current evidence on exercise training.3 Ideally, the multidisciplinary team should include various healthcare professionals (physiotherapists, exercise physiologists, psychologists, nurses, dieticians) and be tasked to perform various health-related assessments which would be beneficial to meet the rehabilitation needs of the patient and the primary physician (Table 1).3 The fact that patients feel education, physiotherapy (i.e. exercise training), psychological support, and occupational therapy are important to the smooth delivery of a rehabilitation program suggests that the time is ripe for establishing multidisciplinary rehabilitation teams for PH lead by physical medicine specialists or cardiologists.