Progress: How should I adapt a pulmonary rehabilitation exercise programme based on patient response and other factors?

This learning resource forms part of a series: Pulmonary rehabilitation: How to prescribe individualised exercise programmes and activities.

Making adjustments based on how the patient responds to exercise

During all exercises, patients should be recording either Borg Breathlessness Scale level or their Rate of Perceived Exertion levels. Additionally, during supervised exercise, oxygen saturation and heart rate should be monitored as appropriate.

The aim of this monitoring is to ensure that exercise is within the intended level of intensity set out in the programme. If exercise is not intense enough, it will not deliver all the training benefits; if it is too intense it risks making the exercise unsafe and may impact recovery. You can modify intensity through increasing speed (for aerobic exercises) or weight (for resistance exercises).

Additionally, you must be aware of potential sensations or symptoms which brought on by exercise and could require you to adjust the exercise programme:

Oxygen Saturation

Exercise should be terminated if someone desaturates below 80%, and you should consider a referral for oxygen assessment if one has not already taken place. If desaturation occurs during exercise, you may be able to adjust the programme to mitigate the risk of it reoccurring – for example, using interval rather than continuous aerobic exercise.

Breathlessness or severe fatigue

The Borg breathlessness and RPE scale can justify modifications in intensity if someone is severely breathless or reporting severe fatigue. Alternative body positioning and breathing control techniques may also be helpful in reducing breathlessness.

Pain

The Borg breathlessness and RPE scale can justify modifications in intensity if someone is severely breathless or reporting severe fatigue. Alternative body positioning and breathing control techniques may also be helpful in reducing breathlessness.

• Chest pain. If your patient has chest pain during exercise, they should stop immediately and be assessed. Any patient with angina or another reason for using a GTN spray should ensure they use it during exercise.
• Pain after exercise. Some level of soreness after intense exercise might be expected. This is sometimes called Delayed Onset Muscle Soreness (DOMS). However, over-exercise may cause more significant pain or injury to joints. This may require you to adjust your exercise selection (for example, moving standing exercises to seated to accommodate a joint injury in the lower limbs).

Where safe to do so, it is always preferable to try and adjust the exercise programme (e.g. through reduced intensity or changes in exercise selection) rather than discontinue the programme entirely.

Making adjustments based on external factors

In some cases, you may also need to adjust the exercise programme or delivery of individual sessions based on factors outside the control of you or your patient. These could include:

• Warm weather, which is likely to require a reduction in exercise intensity
• Cold weather, which may necessitate exercises which can be performed indoors
• Availability of equipment