The feasibility of conducting successful pulmonary rehabilitation in India
Article information
Abstract
Pulmonary rehabilitation (PR) is a highly effective evidence-based treatment with multidisciplinary and comprehensive individualized interventions that reduce morbidity by improving functional capacity and managing respiratory symptoms. It can contribute to overall wellness, reduce symptoms related to respiratory conditions, and facilitate routine work and social activities. Hence, it is a vital component of integrated care for patients with chronic respiratory diseases. In India, PR faces several challenges arising from patients, society, and hospitals. Recent evidence suggests that PR has significant benefits in chronic respiratory diseases, including reduced morbidity and mortality, improved quality of life, and cost savings. Nevertheless, it has been significantly underutilized and has not received the necessary attention in India. The lack of proper utilization of PR can be attributed to several factors, including a lack of awareness and understanding among healthcare professionals regarding its advantages, insufficient referrals to PR programs, scarcity of specialized professionals trained in PR, and a general lack of awareness among patients about its benefits. This article aims to outline the obstacles to PR, identify the factors that influence its successful implementation, and propose possible solutions to overcome these barriers.
Introduction
Among noncommunicable diseases (NCDs), chronic respiratory diseases (CRDs) account for considerable burden and are a major cause of premature mortality worldwide [1]. The umbrella term CRDs includes chronic diseases such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, bronchiectasis, cystic fibrosis, asthma, pulmonary hypertension, and lung cancer. The most common diseases are asthma and COPD, with global prevalence rates of 6.2% and 4.9%, respectively [2]. These chronic conditions are difficult to treat, reduce lifespan, and compromise quality of life. The global burden of disease survey data from 1990 to 2016 have shown that low-middle income countries (LMICs) bear a disproportionate burden of death and disability. The World Health Organization has shown that almost 90% of COPD deaths occur in LMICs, and recent estimates show that COPD will be one of the leading causes of death globally and in India by 2030 [3,4].
At present, various forms of treatment are available that help reduce symptoms, prevent deterioration, and improve quality of life. Sustainable Development Goals (SDGs) aim to reduce premature mortality from NCDs, including CRDs, by one-third by 2030 [5]. Pulmonary rehabilitation (PR) is crucial in managing CRDs, aiming to reduce symptoms, improve participation and functional status, reduce health expenditure, and improve quality of life [6,7]. PR comprises several elements: patient assessment, maximizing the benefits of medical treatment, physical exercise, understanding self-care and disease management, dietary support, and psychosocial support [8,9]. Exercise training plays a pivotal role in developing effective PR strategies [10].
In India, there are various implementation-related challenges for PR rooted in patients, society, and hospital practices. Rehabilitation services are lacking, particularly in LMICs. More than 50% of patients do not receive the rehabilitation services that they need, and the current prevention modalities are not adequate and are unsuccessful in reducing the severity of the disease or related disability [11]. An integrated approach to the prevention and management of CRDs is required to achieve SDG targets. Hence, this review discusses the factors that determine the feasibility of implementing successful PR programs in India.
Pulmonary rehabilitation at a glance
PR is a comprehensive intervention program that aims to increase the physical and psychological well-being of patients and promote their lasting adherence to health-enhancing behaviors [8]. It can be delivered in inpatient, outpatient, and home settings. Each setting has its own benefits and drawbacks in terms of convenience for participants, cost of services, available resources, and societal-level opportunities [6,9,10]. Efficient and safe PR programs [12] require an appropriate environment and multidisciplinary teams to provide effective care.
PR should be provided in a multidisciplinary context by physicians and other healthcare professionals (e.g., physiotherapists, occupational therapists, rehabilitation nurses, exercise physiologists, respiratory therapists, psychologists, behavioral specialists, nutritionists, and social workers). The specific professional requirements vary among rehabilitation programs [10,13].
Most patients are referred for PR when they have symptoms of dyspnea causing disability and an inability to perform activities of daily living. Research has shown that PR is beneficial for patients of all ages and at all disease severity levels, with strong evidence supporting its advantages [14-16]. Unfortunately, many individuals are not referred to PR until their condition advances to a later stage. Apart from this, there are other risk factors for the development of pulmonary diseases such as smoking, environmental exposures, occupational dust and chemicals, allergies, asthma, and genetic history related to cystic fibrosis and α1-antitrypsin, while some gestational and childhood factors should also be considered. Other conditions characterized by respiratory symptoms should not be excluded from PR programs [17-19].
According to the American Association of Cardiovascular and Pulmonary Rehabilitation [10], a complete PR program includes the following components (Fig. 1): (1) patient evaluation and goal establishment, (2) exercise-based evaluation and training, (3) education on self-management, (4) dietary intervention, and (5) management of psychosocial aspects.
Components of pulmonary rehabilitation. BODE, body mass Index, airflow obstruction, dyspnea, and exercise capacity; CRQ, Chronic Respiratory Questionnaire; SGRQ, St. George’s Respiratory Questionnaire; SF-36, Short Form-36 Health Survey; VO2, volume of oxygen consumption; ABG, arterial blood gas analysis; BMI, body mass index.
1. Patient assessment and goal setting
Patient assessment is an integral part of individualized PR programs; each patient is different and deserves a tailored plan. Primary assessment with a comprehensive health history review by reading medical records and personal interviews provides a snapshot of the disease course and comorbidities. Such an assessment includes an accurate interpretation of pulmonary diagnostic tests such as the 6-minute walk test, exercise testing, pulmonary function tests, arterial blood gas analysis, and imaging. A review of diagnostic tests provides details about the treatment plans and adjuncts to treatment (i.e., supplemental oxygen, exercise tolerance, and special precautions for exercise).
Creating a welcoming environment and conducting thorough patient interviews are crucial for establishing a sense of ease with the staff and the rehabilitation environment. This approach can help alleviate fears about therapy, foster open communication, build trust, and establish a positive relationship between the patient and the rehabilitation team. These factors are key to gathering information for symptom assessment, including dyspnea, fatigue, coughing with productive sputum, wheezing, chest discomfort, gastroesophageal reflux, pain, anxiety, and depression.
2. Exercise and functional training
Exercise training encompasses various components such as resistance/strength training, chest physiotherapy for breathing and airway clearance, cardiovascular endurance training, inspiratory muscle training, and flexibility training. Chest physiotherapy techniques consist of postural drainage, chest percussion, vibration, and directed cough, as well as breath retraining exercises such as diaphragmatic breathing and pursed-lip breathing. Additionally, energy conservation strategies such as efficient eating, stair climbing, and proper body positioning may be recommended during these sessions.
Endurance exercise training, such as cycling or walking, is the most commonly used form of exercise [20-22]. Lower extremity exercises often involve treadmill walking or cycling, whereas upper extremity exercises may include arm ergometry, arm weightlifting, or throwing. According to the American College of Sports Medicine guidelines, individuals with CRD should participate in endurance exercise training three to five times per week. The target training intensity is typically based on a modified Borg dyspnea or fatigue scale [23]. Interval training, which alternates between high-intensity exercise and rest periods or lower-intensity exercise, is another option. Even individuals with severe COPD and cachexia may benefit from interval training because it can lead to reduced symptom scores while maintaining the training effects of endurance exercise [24-27].
Resistance/strength training is essential for adults to promote healthy aging and has been shown to be beneficial for individuals with chronic respiratory conditions, such as COPD, who often have reduced muscle mass and strength compared to healthy individuals [28-30]. According to the American College of Sports Medicine, adults should perform up to three sets of eight to 12 repetitions of resistance exercises 2 or 3 days per week to increase muscle strength. The initial loads should be set at 60% to 70% of the one-repetition maximum or a weight that causes fatigue after eight to 12 repetitions. Given that upper limb function is crucial for daily activities in individuals with CRDs, upper limb training is typically included in exercise routines [31].
Flexibility training is a key element of various exercise programs, including those used in PR. Postural abnormalities can contribute to reduced pulmonary function, diminished quality of life, decreased bone mineral density, and heightened respiratory effort, leading to back pain, which may affect breathing mechanics [32,33]. It is advisable to include upper- and lower-body flexibility exercises in the regimen at least two to three times per week. Studies have shown that neuromuscular electrical stimulation (NMES) can improve limb muscle strength and exercise capacity and reduce dyspnea in stable outpatients with severe COPD and low initial exercise tolerance [34,35]. Furthermore, the use of NMES has been proposed during acute COPD exacerbations [36,37].
3. Psychosocial intervention
Patient psychosocial well-being is a key factor in the customization of educational and exercise interventions. Anxiety and depression are common in chronic respiratory conditions and lead to increased morbidity and mortality risks [38]. Psychosocial support such as disability evaluation, vocational guidance, and ongoing education for patients and families is essential. PR has been shown to effectively alleviate anxiety and depression in patients with COPD [39].
4. Nutritional interventions
Nutritional interventions are essential because patients with respiratory diseases frequently have symptoms of nutritional impact (e.g., anorexia and early satiety). Patients with CRD may lose weight and have higher resting energy expenditure owing to factors such as systemic inflammation, tissue hypoxia, medications, restricted dietary intake, higher respiratory muscle resistive load, and catabolic/anabolic ratios [40]. Based on each patient’s assessment, the nutritionist will provide adequate education regarding diet to the patient and caregiver.
5. Self-management education
Self-management education is a key element in managing the condition of the patient and improving their quality of life [41]. Assessing the patient’s understanding and management of their condition is important. The physiotherapist will create an educational plan and assess progress following the intervention. Educational topics may include the anatomy and pathophysiology of CRDs, disease-specific information, medication management, oxygen use, airway clearance techniques, breathing exercises, and postures for symptom relief.
Barriers to pulmonary rehabilitation in India
Many barriers have been identified in PR programs. Even the most recognized rehabilitation centers have a completion rate ranging between 50% and 80% [42,43], and adherence to PR is even lower in well-developed countries. In India, numerous challenges have been identified regarding institutional-, patient-, and society-based factors when establishing and delivering a PR program.
For non-completion, the major issues include the presence of illness and comorbidities, distance of travel and transportation, lack of awareness, smoking, psychological symptoms, lack of support, deprivation, and perceived impairment [44,45]. In India, most of the population resides in rural rather than urban areas; consequently, if these individuals want to participate in a PR program, they must consider travel, assistance, and the economic burden.
Very few professionals and organizations deliver PR, which is mostly available in well-established institutions and hospitals located in developed cities and is sparse in small cities and towns. Medical professionals may not fully appreciate the benefits of PR due to limited exposure to its concepts and usefulness during training, which could result in delays in referral during medical practice [46].
Overcoming the barriers
This article identified the barriers as awareness barriers (Table 1 [45,47-50]), practical barriers (Table 2), and socioeconomic barriers (Table 3 [42,46,50,51]) and suggested potential elements to overcome these obstacles to the development of PR.
Awareness barriers to pulmonary rehabilitation (PR) in India
Practical barriers to pulmonary rehabilitation (PR) in India
Socioeconomic barriers to pulmonary rehabilitation (PR) in India
In India, rules and policies related to PR are still at an embryonic stage and have not been fully integrated into the healthcare system. Some regions have limited coverage for PR programs and long-term oxygen therapy, even from health insurance companies. Patients in India often must navigate through these services on their own, unlike in some countries where healthcare is fully government-funded. There is a need to establish more public relation-specific centers throughout the country.
Awareness of the benefits of PR programs is increasing. Larger cities and specialty hospitals have already placed a certain degree of focus on it. Rural areas and their healthcare facilities must begin to promote PR concepts. Starting a PR program with limited resources and then expanding the facility over time will help lower healthcare usage and enhance the quality of life of patients with chronic respiratory conditions in the long term [50].
Conclusion
PR is an essential component of holistic care for individuals with chronic respiratory conditions. It is integral to achieving universal health coverage and is a vital tool for advancing SDGs. The positive effects and advantages of PR are well-established. However, additional efforts should be made to address the challenges and obstacles affecting the feasibility and implementation of PR in the Indian healthcare system and among healthcare professionals and patients. Much work remains to be done to address these factors in the field of PR in India. Overcoming these barriers will lead to better outcomes in patients with CRDs.
Notes
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
The authors sincerely thank Dr. Narasimman Swaminathan, Professor at the School of Rehabilitation and Medical Sciences, University of Nizwa, Sultanate of Oman, for his guidance, support, and encouragement. We also thank the staff of the Pulmonary Rehabilitation Unit, Department of Pulmonary Medicine, PSG Hospitals, Coimbatore, Tamil Nadu, India, for their support.
Funding
None.
Author contributions
Conceptualization, Formal analysis, and Supervision: MA, PG; Data curation, Methodology, and Investigation: MA; Writing–original draft: MA; Writing–review & editing: SR, PG, MM.