We caught up with our clinical lead, Sally Singh, to discuss the PRSAS accreditation guidance on a frequently asked question ‘lower limb strength testing in pulmonary rehabilitation (PR)’. She discusses the importance of reviewing strength testing in PR, and how the upcoming standards review will impact the evidence required by services. 

How was strength testing recognised by the PRSAS team as an area to be explored?

We identified resistance training as a core component of PR – it’s consistently identified in national and international guidance, consequently a measure of strength at baseline is important, to help prescribe the training load and evaluate overall the PR programme.  Over a number of accreditation assessments, we, the team of assessors, identified that there was a wide variation in clinical practice – currently the PRSAS standards do not explicitly require a measurement of strength, but it must be acknowledged that this would be good practice. 

How might the accreditation standards change in the future and how does it link to the British Thoracic Society’s (BTS) statement (2023)?

A group of expert clinician, clinical academics and service users participated in updating the 2013 BTS Pulmonary Rehabilitation Statement. Topics were identified where there was new evidence to inform practice or areas.  One area of clinical practice discussed was the exercise component of PR and the importance of resistance training, and hence a measure of strength is advocated. This updated statement went out for public consultation and subsequently revised where appropriate. The statement has subsequently been peer reviewed and published in Thorax in September 2023. This publication dovetails with the scheduled 5-year review of the PRSAS accreditation standards and will be reflected in the revised standards. The development of this guidance and the revised standards will ensure that there is no discrepancy between accreditation requirements and BTS statement.

The statement focuses on lower limb strength – why?

Lower limb function is really important in terms of general mobility for example getting up and down stairs, getting out of chairs and maintaining independence. It is likely that the disease process alongside a sedentary lifestyle, the lower limb strength to become weaker and will be compromised to compared to healthy age matched adults.

If you compared upper limb strength to age match controls, the deficit would be less noticeable. Upper limb strength is relatively well preserved, it is thought that this is because we need to use our arms to eat, wash, lift, etc. However, when you are breathless you can avoid using your legs, to any great extent – by doing things like moving beds downstairs, avoiding climbing stairs, etc. So then proportionately your lower limb strength is less. Therefore, the focus of resistance training in the context of PR should focus on the lower limb.

How can services best implement a measure of lower limb strength?

There is some guidance around the best method to use to assess lower limb strength in a recently published FAQ fact sheet hosted in the PRSAS resource library, this was developed by the team of assessors in collaboration with the BTS Pulmonary Rehabilitation Specialist Advisory Group. The information mirrors the content of the BTS Fundamentals of PR course.  

Looking at standards 3.8 and 5.1, what evidence would link this guidance to the standards requirements? What would you expect to see in a service’s submission?

So, at the moment, we are undergoing standards review which we are conducting as part of the Royal College of Physician’s requirement to review an accreditation programme’s standards every 5 years, we expect to be slightly clearer about the expectation soon. There will then be a much clearer and more transparent expectation around the measurement of lower limb strength.
This will then become a standard for not only services submitting their evidence for their first assessment, but also will be picked up as part of the annual review process for services already accredited – where historically, these services haven’t had to submit that piece of evidence.