Royal Derby Hospital

Empowering patients to be their own personal trainers to improve function and strength


Summary

The Progressive Resistance Training (PRT) programme at the Royal Derby Hospital provides specialised exercise provision for patients with rheumatoid arthritis (RA). This gym-based programme educates patients on how to safely carry out suitable exercises to avoid joint damage and has been shown to improve muscle mass, quality of life and confidence in a cost-efficient manner.
  • Almost all patients evaluated after using the service showed strength gains 
  • 65% of patients demonstrated improvements in quality of life 
  • Cost-efficient with an estimated cost of only £171 per patient 
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The Challenge

  • Patients with RA experience significant, rapid muscle loss (rheumatoid cachexia) as a direct result of the disease. Not surprisingly, this muscle loss has a marked effect on physical strength, function and activity, and may be a contributor to increased mortality.
  • 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

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.

Commissioning Implications


The Royal Derby Hospital’s PRT Programme is an example of best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:

 

  • Active support for self-management – the PRT programme places a strong emphasis on supporting the self-management of muscle loss as a result of RA, and provides patients with the tools they need to do this effectively
  • Guideline compliant – the PRT programme was developed based on recommendations in national RA guidelines. For instance:
    • ­Improve general fitness – patients in the PRT programme are encouraged to exercise regularly to improve general fitness
    • ­Physiotherapy education – patients are educated on safe and clinically beneficial exercises and are encourage to manage their own fitness-programme on completion of the course
  • Primary prevention - by encouraging safe and effective exercise strategies to increase the strength and improve the general fitness of patients with RA, the PRT can improve lifestyle and reduce the risk of co-morbidities

This service is a best practice model for the management of muscle-loss and reduced strength caused by RA. The PRT programme at the Royal Derby Hospital is an excellent example of how patients can be empowered to manage their own disease in a clinically- and cost-efficient manner.


Service diagram