Empowering patients to be their own personal trainers to improve function and strength - Implementing NICE NG100

Patients with Rheumatoid Arthritis experience significant, rapid muscle loss (rheumatoid cachexia) as a direct result of the disease. This muscle loss has a marked effect on physical strength, function and activity, and may be a contributor to increased mortality.

Our therapy team developed a gym-based Progressive Resistance Training (PRT) programme with the aims of enabling patients to:

• experience the strength and functional gains which follow high-intensity training
• become their own ‘personal trainers’ to safely initiate; progress and adhere long-term to a strength training programme
• develop additional self-management skills

Background: The majority of patients with rheumatoid arthritis (RA) will suffer Rheumatoid Cachexia (RC) which results in loss of lean muscle mass with or without increased fat mass (Rajbhandry et al 2011).

These changes have a significant negative effect on physical activity (Summers et al 2008) and may be a contributor to increased mortality (Rajbhandry et al 2011). Currently, there does not appear to be an effective drug or dietary therapy which can reverse the negative changes in body composition (Lemmey et al 2015). However, high-intensity, progressive resistance training (PRT) does appear to be able to reverse these changes (Lemmey et al 2009, Strasser et al 2011, Hakkinen et al 2005) and results in improvements in physical function with little risk of adverse events (Cooney et al 2011, Jong and Vlieland 2005).

However, current NHS service provision does not appear to consistently favour this provision (Munneke et al 2004, Prodinger et al 2015). Specialised exercise provision for patients with RA was limited to group hydrotherapy sessions and one-to-one sessions with senior physiotherapists, both of which are costly and can be associated with long waiting lists, or Tai Chi.

The Solution:

The PRT programme was developed in 2012 by the physiotherapy team at the Royal Derby Hospital after conducting a literature review into effective exercise strategies and engaging with experts in the field. To deliver the programme, a physiotherapy assistant with an interest in physical exercise and the gym was trained to Central YMCA Qualification (CYQ) Level 2 (band 3 gym technician).

The programme explicitly aims to enable patients to:

• ­ Experience the functional gains and improvement in muscular strength that results from high-intensity training
• ­ Become their own ‘personal trainers’
• ­ Safely initiate, progress and adhere to a PRT programme in the long-term
• ­Develop additional self-management skills

Service Pathway

• Patients with RA are offered an individualised programme of ten, once weekly, 1 hour sessions of group-supervised, gym-based exercise training with each session catering for 4–5 people.

Each session involves a ten minute warm-up, joint and muscle stretches, seven upper and lower limb muscle strengthening exercises, and a ten minute ‘cool-down’.

Patients are educated during the programme on the benefits of exercise, guided on good technique during exercise performance, advised on how to safely and sequentially increase their exercises, and helped to self-manage their programme through completion of an exercise logbook.

• After completion, patients are invited to become a member of the gym at the Royal Derby Hospital to continue their PRT programme unsupervised.

We liaised with the team leader of the MSK physiotherapy team to allow the assistant to attend the course. Agreement was made that the member of staff would be able to use transferrable skills for treating MSK out patients therefore agreed quite quickly. We had to get agreement from rheumatology department and Physiotherapy management to use part of their Charitable funds to pay for the course £500.

We also had to agree the exclusive use of the physiotherapy gym for 2 hours a week for the programme. For assessments the gym is available at any other time as shared with other physiotherapists, which was not a problem.

Service Performance and Outcomes

• Almost all patients evaluated after using the service showed gains in strength across a variety of muscle groups. There were also improvements in the sit-to-stand test.
• 65% of patients demonstrated improvements in their quality of life (measured on the EQ5D-5L scale) and a similar proportion of patients reported an improvement in confidence.
• As a result of specialist guidance and supervision, no significant adverse events such as tendon rupture, falls, or cardiovascular events have been reported.

Financial Performance and Outcomes

• The PRT programme is estimated to cost £171 per patient, taking into account staff, administration and overhead costs.
• The PRT programme was estimated to be a cost-saving option versus group hydrotherapy, should the maintenance and depreciation costs of hydrotherapy be greater than £182,000 annually. This was considered likely given the high costs of heating, filtration, chlorine checks, daily maintenance, and staff costs associated with hydrotherapy.

Patient Focus and Satisfaction

• The PRT programme aims to help patients experience improvements in strength and functional gains, and develop the skills and confidence to manage their own exercise and their RA in the future.
• The site runs an educational programme which is used to raise awareness of the importance of exercise and the PRT programme in particular.
• An initial survey of the first patients who attended the service suggest that patients are very satisfied with the PRT programme, and subsequent surveys suggest that the programme continues to be highly received.

Cost Efficiency:

We trained a physiotherapy assistant to level 2 (CYG) gym instructor level in order to provide expert and safe instruction in exercise at sustainable costs. This also freed up physiotherapy staff to focus their time on patient assessment, treatment and referral to the programme.

Income Generation:

We negotiated a patient (and family member) hospital gym membership scheme with the Trust legal team to encourage long-term adherence to the programme and to income generate.

Long-term Patient Adherence:

Family members are encouraged to accompany patients to the programme as support from significant others has been shown to facilitate engagement in exercise. Our programme could be replicated and adapted to suit other NHS Trusts with suitable hospital gyms or strength training equipment. Alternatively, Trusts may have cardiac rehabilitation gyms or gyms in other departments e.g. elderly care - shared use could be negotiated. Institutions without this facility could instruct patients in a home-based, progressive strength training programme using graded elastic tubing or bands or home-made equipment. Alternatively, links could be made with community gyms such as Council-run or University gyms to explore patient access and staff training.