Lana Melendres-Groves, MD - phaware® interview 593

The Impact of Exercise and Fitness on Improving Patient Outcomes

Pulmonary hypertension patients are often handed powerful medications, but rarely something just as transformative: movement. Dr. Lana Melendres-Groves reveals a shocking truth that fewer than half of PH patients are ever referred to pulmonary rehab, even though research proves it can dramatically improve strength, breathing, and quality of life. This missing prescription may be the one that gives patients their lives back.

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I'm Lana Melendres-Groves, and I am the medical director at the University of New Mexico, where I am a professor of medicine and really excited to be here today to talk about pulmonary hypertension, but more specifically, talk about exercise training, fitness, and pulmonary rehab in regard to pulmonary hypertension, which is just a tremendous opportunity for our patients.

I think very frequently we're in a position that once we diagnose our patients with pulmonary hypertension, we immediately jump to the next steps, which are what is their risk assessment and how will we treat them with medications. We often neglect the ability to really give our patients an opportunity through exercise training, through pulmonary rehab, to also engage and benefit from the profound changes and adaptations that come from exercise.

I think, most importantly, it really is thinking about it in terms of systems of the body. We know in regular exercise, when people do routine exercise, those without any of the underlying medical conditions, that what we see is improvements in people's heart rate, in their cardiac output, in their VO2 max. We see that their muscles become stronger, that they become more capable and that their ability to engage with just their emotional side of themselves, their mental health, those all improve. Our pulmonary hypertension patients suffer in all of those ways because they can't exercise, and that starts to debilitate them.

I will say that just innumerable number of patients, when I first meet them, their question on the very first time in clinic is, "Well, I'm afraid to do anything. I'm afraid to exercise. Is it safe to exercise? When do I stop?" A lot of it is a fear base for my patients. I think that this is where really making and normalizing exercise for our pulmonary hypertension patients is so essential. But it's where pulmonary rehab really bridges that gap, because when I'm able to tell a patient, "I'm going to refer you to a program that will be supervised, that there will be an individual there who understands your medical condition, they understand the needs, and they're going to be able to create a program that will allow you to start exercising at the level that you need to as an individual with the capacity over this 12 week program to find and achieve improvements and be able to see that functionally," all of a sudden, that fear can turn into hope, and that is really what we need for our patients.

It really should be a standard of care, and that if we're not discussing the potential for pulmonary rehab, that there should be a really good reason why we are not sending our patients. For me, it is one of those where I have put it into my algorithm in terms of what my template for my clinic looks like, because we can become very engrossed in other minutiae that is necessary, right. Telling about dangers, telling about medications, telling about side effects. So we don't want to then neglect something that we clearly see time and time again through meta-analysis, through systematic reviews, that exercise improves patients' outcomes.

So my colleague, Hilary DuBrock, and her group did some really nice looks into, "Are we doing enough for our patients?" The initial was simply to ask these patients, and they did this at the PHA in 2022. They looked at and went and surveyed patients, about 430 patients, and asked them if they had been involved in pulmonary rehab and if they hadn't been involved. Then, really, the more important portion was for those who had not been involved. It was really trying to understand why. Was it because they chose not to? It was actually really shocking and enlightening that here are these patients who are going to a conference for pulmonary hypertension that only 41% of them had actually heard or been told about the opportunities. And that of those who hadn't been referred or participated said, "We'd be very interested in that." So we were missing this encatchment of people that clearly would have been engaged to do pulmonary rehab simply because we were not discussing it.

I think that then that was followed up by DuBrock and her group by saying, "Well, we're going to take a look at our PHAR data." Here are specialty centers for pulmonary hypertension. They know that tiptop literature, they understand the importance of exercise, and really look to say, "Maybe it's the timeframe. Maybe we don't do it initially because of concerns of getting medications started or stability of our patient." But when they looked, they said, "Well, it's only about 17% that were referred by that first follow-up visit. Then by the second, only by about 26%. Then, throughout the entirety of the longevity of that person in the program, less than 40% of them were ever referred to pulmonary rehab." So this is really a failure on the provider part. I think a lot of topics that get brought up is that maybe there's not reimbursement for pulmonary rehab, or maybe they're in a rural location, and so there's not opportunity to get them involved.

I think that, excuse me, for saying this, but those are excuses, right. Those are excuses as to why something didn't happen. I think we are very clever in our ability to overcome that, whether that be we need to state something different for the referral process so that that is reimbursed, whether that be that we need to be clever and we can design a program. Maybe they only need to go once to, and this is what I have in our program, where they may present once to the pulmonary rehab for the initial intake, and then they're actually designed a program that's done at home and that home program is then by phone or by virtual are able to indicate what they're doing and how they're doing it. So I think there's a lot of ground to make up in this area.

We've actually come a long way over the last probably four or five years through the PHA, through the PAH initiative, that there are actually videos that are specific to pulmonary arterial hypertension patients in terms of exercises that can be done. Chair yoga, etc. It is meeting the patient where they are. Those have been sort of tested, and they are supported, and we feel that very confident that we could give those to any of our patients to try to give them ideas as to what to do.

But the second part of that for me is really talking to my patient and saying, "It's time for you to understand what your body's telling you. We need you to really listen to what your body is saying." Because if we can give them some guidance as to, "These are things you can do if you start to feel dizzy. If you start to feel that you're having chest discomfort or that you're not able to then pretty quickly catch your breath, you should slow down, you should sit down." But we start with very small, and I try to never say, "I'm going to ask you to do exercise." I ask my patients to do movement. "I want you to move more. I don't need you running. I don't need you going up flights of stairs or lifting weights. I just need you to move a bit more each day." I think that that is something that is manageable for them.

I think for our walk, what was amazing was that we had so many patients with their families. Obviously, each person can do something different. Some of those patients weren't able to go on the full walk, but they were there, understanding that we're supportive of movement, of exercise, and those are opportunities to normalize something like that.

We're not bringing them into a conference room and sitting them down. We're getting them outside. Just that participation of outdoors, being part of a community, understanding that they're supported, gives them confidence to do more things. So my husband, he's a professional soccer coach, coaches youth soccer, and he says, "If you bring kids to a practice and you say it's a drill, that has a negative connotation to it.” But if you talk about it's an activity, it's a game. He would change soccer into Sonic the Hedgehog. We would change soccer into a Little Red Riding Hood game. So it is actually changing the mindset of people.

I will say physicians are not good marketers. We don't know about that, but we need to remarket exercise and pulmonary rehab. By just saying, "Stand up, play this game," people are doing more than they would've done, and they don't even realize that. I think in summary, for me, we think about the heart and lungs when it comes to pulmonary hypertension, and absolutely those are affected, but this is a systemic disease, and exercise is the only treatment we have that treats the system as opposed to the specifics of a medication.

It was such a pleasure to be here. I'm Lana Melendres-Groves, and I am aware that my patients are rare.

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