Strength training to improve walking after stroke: how physiotherapist, patient and workplace factors influence exercise prescription

Background:Muscle weakness is well established as the primary impairment that affects walking after stroke and strength training is an effective intervention to improve this muscle weakness. Observation of clinical practice however has highlighted an evidence-practice gap in the implementation of evidence-based strength training guidelines. Objective: To explore perceived barriers and facilitators that influence Australian physiotherapy practices when prescribing strength training with stroke survivors undergoing gait rehabilitation. Methods: Semi-structured interviews were conducted with a convenience sample of physiotherapists currently providing rehabilitation services to patients following stroke in Australia. Interviews were transcribed verbatim and line-by-line thematic analysis was undertaken to create themes and sub-themes. Results: Participants were 16 physiotherapists (12 females) with 3 months - 42 years experience working with people after stroke. Major themes identified were1) patient factors influence the approach to strength training; 2) interpretation and implementation of strength training principles is diverse; and 3) workplace context affects the treatment delivered. Physiotherapists displayed wide variation in their knowledge, interpretation and implementation of strength training principles and strength training exercise prescription was seldom evidence or guideline based. Workplace factors included the clinical preference of colleagues, and the need to modify practice to align with workforce resources. Conclusions: Implementation of strength training to improve walking after stroke was diverse. Therapist-related barriers to the implementation of effective strength training programs highlight the need for improved knowledge, training and research engagement. Limited resourcing demonstrates the need for organizational prioritization of stroke education and skill development. Narrowing the evidence-practice gap remains a challenge.

Home Oxygen Therapy for Adults with Chronic Lung Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD).Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations.Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement).Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

Effect of eccentric exercise on quality of life and function in people with chronic heart failure: a pilot randomised controlled trial

PURPOSE

To determine if eccentric exercise was effective, safe and feasible in increasing function and quality of life in people with heart failure compared to usual care and a waitlist control group.

METHODS

A prospective, three-armed, parallel-design, assessor-blind, pilot randomised controlled trial with 1:1:1 allocation. Forty-seven participants (16 female; mean age 66 years) with mild to moderate heart failure were randomly allocated to either eccentric exercise, concentric exercise or a waitlist control group. Participants in the exercise groups completed twice-weekly exercise for eight weeks. Primary outcome was walking capacity. Secondary outcomes were quality of life, leg strength and fatigue. Outcomes were assessed at baseline, post intervention and three-month follow-up. Attendance, tolerability and adverse events were used to determine safety and feasibility.

RESULTS

Intention-to-treat analysis showed no differences between eccentric exercise and either concentric exercise or waitlist for any outcome. Per-protocol analysis found improvements identified by the Minnesota living with heart failure questionnaire were significantly greater post-intervention for eccentric exercise compared to concentric exercise (-17.99 units, 95% confidence interval -35.96 to -0.01). No major adverse events were reported.

CONCLUSION

In this small trial, eccentric exercise did not demonstrate superior outcomes to concentric exercise or a waitlist control group.

CLINICAL TRIAL REGISTRATION

The protocol for this trial was registered at clinicaltrials.gov, registration number: NCT02223624, registration date: 22 August 2014.IMPLICATIONS FOR REHABILITATIONRegular physical activity and referral to rehabilitation is recommended for people with chronic heart failure, however exercise can be challenging for this group.Eccentric exercise was safe and tolerable for participants with heart failure.Documentation of exercise progression is important to demonstrate a dose-response relationship.In this study there were no differences between groups who received eccentric exercise, concentric exercise or no exercise.

Physical activity for cystic fibrosis: perceptions of people with cystic fibrosis, parents and healthcare professionals

Background

The benefits of physical activity (PA) for people with cystic fibrosis (pwCF) are widely accepted, yet how PA is promoted and utilised by pwCF is unclear.

Method

An online questionnaire to explore attitudes, practices and promotion of PA in cystic fibrosis was completed by healthcare providers (HCP), pwCF and parents/caregivers.

Results

351 respondents (105 HCP, 120 pwCF, and 126 parents/caregivers) from 12 countries completed the survey. Importance of PA was rated highly by the majority of respondents. Physical (e.g. health), psychological (e.g. enjoyment) and social (e.g. social interaction) factors were motives for PA for 82%, 49% and 37% of pwCF, respectively, irrespective of country. Common barriers to PA included time (49% and 36%) and tiredness (61% and 7%) for pwCF and parents/carers, respectively. pwCF also reported psychosocial barriers (e.g. stigma, demoralisation), while parents/caregivers reported structural barriers (e.g. cost). Clinical teams varied substantially in terms of the emphasis placed on PA, facilities available, staff and training, and advice given to pwCF.

Conclusion

Despite the majority of participants rating the importance of PA highly, substantial variability was evident regarding the facilities and clinical support available to them, as well as why and how people were active. There remains a need to identify what constitutes “best practice” for PA promotion within clinics.

Despite rating the importance of physical activity for cystic fibrosis highly, substantial variation is evident in why and how people are active, and facilities and support availablehttps://bit.ly/392i8Cn

Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: A rapid review

Objectives:

To identify exercise tests that are suitable for home-based or remote administration in people with chronic lung disease.

Methods:

Rapid review of studies that reported home-based or remote administration of an exercise test in people with chronic lung disease, and studies reporting their clinimetric (measurement) properties.

Results:

84 studies were included. Tests used at home were the 6-minute walk test (6MWT, two studies), sit-to-stand tests (STS, five studies), Timed Up and Go (TUG, 4 studies) and step tests (two studies). Exercise tests administered remotely were the 6MWT (two studies) and step test (one study). Compared to centre-based testing the 6MWT distance was similar when performed outdoors but shorter when performed at home (two studies). The STS, TUG and step tests were feasible, reliable (intra-class correlation coefficients >0.80), valid (concurrent and known groups validity) and moderately responsive to pulmonary rehabilitation (medium effect sizes). These tests elicited less desaturation than the 6MWT, and validated methods to prescribe exercise were not reported.

Discussion:

The STS, step and TUG tests can be performed at home, but do not accurately document desaturation with walking or allow exercise prescription. Patients at risk of desaturation should be prioritised for centre-based exercise testing when this is available.

Early home-based pulmonary rehabilitation following acute exacerbation of COPD: A feasibility study using an action research approach

Objective:

Pulmonary rehabilitation (PR) improves function, reduces symptoms and decreases healthcare usage in people with chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AECOPD). However, rehabilitation uptake rates are low. This study aimed to address barriers to uptake and completion of PR following AECOPD.

Methods:

An action research approach was used to reflect on study feasibility, and to plan and implement an improved protocol. Phase I tested the feasibility of home-based PR started early after AECOPD. Phase II used qualitative interviews to identified potential barriers to program uptake. Phase III re-tested the program with changes to recruitment and assessment strategies.

Results:

Phase I: From 97 screened patients, 26 were eligible and 10 (38%) started home-based PR. Eight participants undertook ≥70% of PR sessions, achieving clinically meaningful improvement in 6-minute walk distance (mean (SD) change 76 (60) m) and chronic respiratory disease questionnaire total score (15 (21) units). Phase II: Potential barriers to uptake of home-based PR included access issues, confidence to exercise, and lack of information about PR benefits. Phase III: From 77 screened patients, 23 were eligible and 5 (22%) started the program.

Discussion:

Home-based PR improved clinical outcomes, but program eligibility and uptake remain challenging. Efforts should be made to ensure PR program eligibility criteria are broad enough to accommodate patient needs, and new ways of engaging patients are needed to improve PR uptake after AECOPD.

How do healthcare professionals perceive physical activity prescription for community-dwelling people with COPD in Australia? A qualitative study

OBJECTIVES

Clinical practice guidelines recommend that people with chronic obstructive pulmonary disease (COPD) should be encouraged to increase their physical activity levels. However, it is not clear how these guidelines are applied in clinical practice. This study aimed to understand the perspectives of respiratory healthcare professionals on the provision of physical activity advice to people with COPD. These perspectives may shed light on the translation of physical activity recommendations into clinical practice.

DESIGN

A qualitative study using thematic analysis.

SETTING

Healthcare professionals who provided care for people with COPD at two major tertiary referral hospitals in Victoria, Australia.

PARTICIPANTS

30 respiratory healthcare professionals including 12 physicians, 10 physical therapists, 4 nurses and 4 exercise physiologists.

INTERVENTIONS

Semistructured voice-recorded interviews were conducted, transcribed verbatim and analysed by two independent researchers using an inductive thematic analysis approach.

RESULTS

Healthcare professionals acknowledged the importance of physical activity for people with COPD. They were conscious of low physical activity levels among such patients; however, few specifically addressed this in consultations. Physicians described limitations including time constraints, treatment prioritisation and perceived lack of expertise; they often preferred that physical therapists provide more comprehensive assessment and advice regarding physical activity. Healthcare professionals perceived that there were few evidence-based strategies to enhance physical activity. Physical activity was poorly differentiated from the prescription of structured exercise training. Although healthcare professionals were aware of physical activity guidelines, few were able to recall specific recommendations for people with COPD.

CONCLUSION

Practical strategies to enhance physical activity prescription may be required to encourage physical activity promotion in COPD care.

COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force

BACKGROUND

Patients with COVID-19 or post-COVID-19 will most probably have a need for rehabilitation during and directly after the hospitalisation. Data on safety and efficacy are lacking. Healthcare professionals cannot wait for published randomised controlled trials before they can start these rehabilitative interventions in daily clinical practice, as the number of post-COVID-19 patients increases rapidly. The Convergence of Opinion on Recommendations and Evidence process was used to make interim recommendation for the rehabilitation in the hospital and post-hospital phase in COVID-19 and post-COVID-19 patients, respectively.

METHODS

93 experts were asked to fill out 13 multiple choice questions. Agreement of directionality was tabulated for each question. At least 70% agreement on directionality was necessary to make consensus suggestions.

RESULTS

76 experts (82%) reached consensus on all questions based upon indirect evidence and clinical experience on the need for early rehabilitation during the hospital admission, the screening for treatable traits with rehabilitation in all patients at discharge and 6-8 weeks after discharge, and around the content of rehabilitation for these patients. It advocates for assessment of oxygen needs at discharge and more comprehensive assessment of rehabilitation needs including physical as well as mental aspects 6-8 weeks after discharge. Based on the deficits identified multidisciplinary rehabilitation should be offered with attention for skeletal muscle and functional as well as mental restoration.

CONCLUSIONS

This multinational task force recommends early, bedside rehabilitation for patients affected by severe COVID-19. The model of pulmonary rehabilitation may suit as a framework, particularly in a subset of patients with long term respiratory consequences.

Prognosis of idiopathic pulmonary fibrosis without anti-fibrotic therapy: a systematic review

In addition to facilitating healthcare delivery planning, reliable information about prognosis is essential for treatment decisions in patients with idiopathic pulmonary fibrosis (IPF). This review aimed to evaluate the prognosis of patients with IPF without anti-fibrotic therapy. We included all cohort studies and the placebo arms of randomised controlled trials (RCTs) in IPF and follow-up of ≥12 months. Two reviewers independently evaluated studies for inclusion, assessed risk of bias and extracted data. A total of 154 cohort studies and 16 RCTs were included. The pooled proportions of mortality were 0.12 (95% CI 0.09–0.14) at 1–2 years, 0.38 (95% CI 0.34–0.42) between 2–5 years, and 0.69 (95% CI 0.59–0.78) at ≥5 years. The pooled mean overall survival was 4 years (95% CI 3.7–4.6) for studies with a follow-up duration of 10 years. At <2 years, forced vital capacity and diffusing capacity of the lung for carbon monoxide declined by a mean of 6.76% predicted (95% CI −8.92 −4.61) and 3% predicted (95% CI −5.14 −1.52), respectively. Although heterogeneity was high, subgroup analyses revealed lower pooled proportions of mortality at 1 year in the RCT participants (0.07 (95% CI 0.05–0.09)) versus cohort study participants (0.14 (95% CI 0.12–0.17)). This review provides comprehensive information on the prognosis of IPF, which can inform treatment discussions with patients and comparisons for future studies with new therapies.

Without anti-fibrotic therapy, patients with IPF have a mortality rate of 31% at ≥5 years, and a mean overall survival of 4 years over 10 years of follow-uphttp://bit.ly/2SDiZSb

The Utility of the Sit-to-Stand Test for Inpatients in the Acute Hospital Setting After Lung Transplantation

OBJECTIVE

Measurement of physical function is important to guide physical therapy for patients post-lung transplantation (LTx). The Sit-to-Stand (STS) test has proven utility in chronic disease, but psychometric properties post-LTx are unknown. The study aimed to assess reliability, validity, responsiveness, and feasibility of the 60-second STS post-LTx.

METHODS

This was a measurement study in 62 inpatients post-LTx (31 acute postoperative; 31 medical readmissions). Interrater reliability was assessed with 2 STS tests undertaken by different assessors at baseline. Known group validity was assessed by comparing STS repetitions in postoperative and medical groups. Content validity was assessed using comparisons to knee extensor and grip strength, measured with hand-held dynamometry. Criterion validity was assessed by comparison of STS repetitions and 6-minute walk distance postoperatively. Responsiveness was assessed using effect sizes over inpatient admission.

RESULTS

Median (interquartile range) age was 62 (56-67) years; time post-LTx was 5 (5-7) days postoperative and 696 (244-1849) days for medical readmissions. Interrater reliability was excellent (intraclass correlation coefficient type 2,1 = 0.96), with a mean learning effect of 2 repetitions. Repetitions were greater for medical at baseline (mean 18 vs 8). More STS repetitions were associated with greater knee extensor strength (postoperative r = 0.57; medical r = 0.47) and 6-minute walk distance (postoperative r = 0.68). Effect sizes were 0.94 and 0.09, with a floor effect of 23% and 3% at baseline (postoperative/medical) improving to 10% at discharge. Patients incapable of attempting a STS test were excluded, reducing generalizability to critical care. Physical rehabilitation was not standardized, possibly reducing responsiveness.

CONCLUSIONS

The 60-second STS demonstrated excellent interrater reliability and moderate validity and was responsive to change postoperatively.

IMPACT

The 60-second STS represents a safe, feasible functional performance tool for inpatients post-LTx. Two tests should be completed at each time point.

The impact of obesity in rehabilitation: a mismatch between staff perception and hospital outcomes

Purpose: To establish the prevalence of obesity in an inpatient rehabilitation setting, examine its impact on hospital outcomes, and explore staff perceptions of caring for patients with obesity.Methods: A retrospective audit of inpatients admitted to a sub-acute rehabilitation hospital over 12 months. Hospital outcomes included length of stay (LOS), Functional Independence measure (FIM), and discharge destination. Linear regression models were used to determine whether obesity was associated with hospital outcomes. Staff working on rehabilitation wards were invited to complete a survey exploring their perceptions on caring for those who are obese.Results: Of 1280 episodes of care, 359 (28%) patients were classified as obese with a body mass index ≥30 kg/m². Obesity was not associated with LOS or functional improvement after controlling for age, gender, and admission FIM. One hundred and twelve hospital staff (response rate 71%) completed the survey. Most rated their bariatric care knowledge as average (45%) or good (36%). The majority (60%) perceived that patients with obesity have longer LOS than those who are non-obese.Conclusion: One-third of patients admitted to inpatient subacute rehabilitation were classified as obese. Whilst obesity was not associated with poorer hospital outcomes, staff perceived that obesity negatively impacts on care requirements and LOS.Implications for rehabilitationA third of patients admitted to a public, inpatient rehabilitation setting may be classified as obese based on their body mass index.Although staff perceived that obesity negatively impacts on length of stay and functional gains, there was no evidence that obesity was associated with poorer hospital outcomes.Patients who are classified as obese were able to achieve comparable hospital outcomes including length of stay in the rehabilitation setting to those who are not obese.

The supportive care needs of people living with pulmonary fibrosis and their caregivers: a systematic review

BACKGROUND

People with pulmonary fibrosis often experience a protracted time to diagnosis, high symptom burden and limited disease information. This review aimed to identify the supportive care needs reported by people with pulmonary fibrosis and their caregivers.

METHODS

A systematic review was conducted according to PRISMA guidelines. Studies that investigated the supportive care needs of people with pulmonary fibrosis or their caregivers were included. Supportive care needs were extracted and mapped to eight pre-specified domains using a framework synthesis method.

RESULTS

A total of 35 studies were included. The most frequently reported needs were in the domain of information/education, including information on supplemental oxygen, disease progression and prognosis, pharmacological treatments and end-of-life planning. Psychosocial/emotional needs were also frequently reported, including management of anxiety, anger, sadness and fear. An additional domain of "access to care" was identified that had not been specified a priori; this included access to peer support, psychological support, specialist centres and support for families of people with pulmonary fibrosis.

CONCLUSION

People with pulmonary fibrosis report many unmet needs for supportive care, particularly related to insufficient information and lack of psychosocial support. These data can inform the development of comprehensive care models for people with pulmonary fibrosis and their loved ones.

The impact of frailty in critically ill patients after trauma: A prospective observational study

BACKGROUND

As our population ages, older adults are increasingly exposed to trauma. Frailty could be a useful measure to identify patients at risk of a poor outcome. This study aimed to determine the impact of frailty in an Australian trauma intensive care unit (ICU) population.

METHODS

A prospective observational study of critically ill trauma patients ≥50 years of age. Frailty was determined on admission to the ICU using the frailty phenotype. Demographic and hospital data were collected, and patients were followed up at 6 and 12 months. The primary outcome was 12-month mortality, and multiple regression was used to determine associated factors.

RESULTS

One hundred thirty-eight patients were included, whose mean age was 68 years; 78.2% (108/138) were classified as major trauma (Injury Severity Score >12). Twenty-two percent (30/138) of patients were identified as frail. Patients with frailty were significantly older: however, they were less severely injured and required lower rates of surgical interventions and mechanical ventilation. Frailty was independently associated with mortality at 6 and 12 months (odds ratio: 5.9, 95% confidence interval: 1.9-18.1 and odds ratio: 7.3, 95% confidence interval: 2.5-21.9, respectively). Patients with frailty had lower measures of global functioning (Glasgow Outcome Scale-Extended frail 3 [1-5] vs nonfrail 6 [(5-7], p = 0.002) and health status (Euro Qol 5Q-5D-5L utility score 0.6 [0.5-0.7] vs 0.7 [0.6-0.9], p = 0.02) at 12 months than patients without frailty.

CONCLUSION

Frailty is a useful predictor of poor outcomes in critically ill trauma patients.

REGISTRATION OF PROTOCOL NUMBER

ACTRN12615000039583.

Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far.

OBJECTIVES

In people with COPD, which interventions are effective at improving objectively-assessed physical activity?

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies.

SELECTION CRITERIA

We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data.

MAIN RESULTS

We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta2-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training.

AUTHORS' CONCLUSIONS

A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.

Peer Connect Service for people with pulmonary fibrosis in Australia: Participants' experiences and process evaluation

BACKGROUND AND OBJECTIVE

People living with pulmonary fibrosis (PF) report unmet needs for information and support. Lung Foundation Australia (LFA) have developed the Peer Connect Service to facilitate telephone support for people with PF across Australia. This project documented the experiences of participants and the resources required to support the service.

METHODS

Consenting participants took part in semi-structured interviews by telephone. Primary peers (peers who agreed to initiate contact) and secondary peers (eligible patients who sought a peer match) were interviewed. Thematic analysis was undertaken by two independent researchers. Data were collected on the number of matches and contacts required to establish each match.

RESULTS

Interviews were conducted with 32 participants (16 primary peers, 15 secondary peers and 1 who was both), aged from 53 to 89 years with 56% being male. Major themes included the value of shared experiences, providing mutual support and the importance of shared personal characteristics (e.g. gender and hobbies) in allowing information and emotional support needs to be met. Participants saw face-to-face contact with peers as highly desirable whilst acknowledging the practical difficulties. Primary peers were cognizant that their role was not to provide medical advice but to listen and share experiences. In the 12-month period, 60 peer matches were made, each match requiring a minimum of seven staff contacts.

CONCLUSION

The Peer Connect Service provides a unique opportunity for people with PF to share experiences and offer mutual support. This telephone matching model may be useful in providing peer support for individuals with rare diseases who are geographically dispersed.

Diagnosis and treatment of lung disease associated with alpha one-antitrypsin deficiency: A position statement from the Thoracic Society of Australia and New Zealand

AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD-associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD-related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD-related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non-pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.

Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures

OBJECTIVES

To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes.

DESIGN

Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data.

SETTING, PARTICIPANTS

Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016.

MAIN OUTCOME MEASURES

Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome.

RESULTS

Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%).

CONCLUSIONS

Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials.

Physiological Responses During Field Walking Tests in Adults with Bronchiectasis

BACKGROUND

Field walking tests are commonly used in patients with chronic pulmonary diseases for assessment of functional capacity. However, the physiological demands and magnitude of desaturation on 6-min walk test (6MWT), incremental shuttle walk test (ISWT), and endurance shuttle walk test (ESWT) have not been investigated in patients with bronchiectasis. The objective of this study was to compare the physiological responses and the magnitude of desaturation of subjects with bronchiectasis when performing the 6MWT, ISWT, and ESWT.

METHODS

Thirty-two subjects underwent the 6MWT, ISWT, and ESWT on 3 different days. Pulmonary gas exchange, heart rate, and [Formula: see text] were measured in all tests.

RESULTS

There were no differences in the peak rate of oxygen uptake, ventilation, dyspnea, and leg fatigue between the tests. Equivalent cardiac demand (ie, heart rate at peak) was observed with the 6MWT (137 ± 21 beats/min) and the ESWT (142 ± 21 beats/min), but this was lower in the ISWT (135 ± 19 beats/min) compared to ESWT (P < .05). Most subjects achieved a vigorous exercise intensity (heart rate of 70-90% of predicted) in all tests. There was no difference in desaturation among the tests (6MWT: -6.8 ± 6.6%, ISWT: -6.1 ± 6.0%, and ESWT: -7.0 ± 5.4%).

CONCLUSIONS

The 6MWT, ISWT, and ESWT induced similar physiological responses at the peak of exercise, eliciting a vigorous exercise intensity. The magnitude of desaturation was similar across tests. This means these tests can be used interchangeably for evaluation of exercise-induced desaturation.

The impact of home-based pulmonary rehabilitation on people with mild chronic obstructive pulmonary disease: A randomised controlled trial

INTRODUCTION

People with mild chronic obstructive pulmonary disease (COPD) experience exercise intolerance, dyspnoea and poor quality of life. However, the role of pulmonary rehabilitation (PR) in this group is unclear.

OBJECTIVES

This randomised controlled trial aimed to explore the effects of home-based PR in people with mild COPD.

METHODS

People with mild COPD (FEV₁ /FVC < 70%; FEV₁  > 80%predicted) with a smoking history of ≥10 packet years were randomised to either 8 weeks of home-based PR (one home visit and seven once-weekly telephone calls) or standard care (weekly social telephone calls). Six minute walk distance (6MWD), and Modified Medical Research Council Dyspnoea Scale (mMRC) and Chronic Respiratory Disease Questionnaire (CRQ) scores were compared.

RESULTS

A total of 58 participants (34 males, mean age 68 (SD 9) years, FEV₁ %predicted 90 (7), 6MWD 496 (105) m) were included with 31 participants randomised to home-based PR. Participants attended an average of 6.8 of the 8 scheduled sessions, ranging from 3 to 8 sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life (HRQoL) over time, however there was no difference in 6MWD at end-intervention (mean difference -3 m, 95% confidence interval (CI) -64 to 58) or 6 months (7 m, 95% CI -59 to 72). At 6 months home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, P < 0.001) and CRQ total score (45% vs 17%, P = 0.05).

CONCLUSION

For people with mild COPD, home-based PR did not improve exercise capacity more than standard care. The trial was registered at the Australia New Zealand clinical trial registry (https://www.anzctr.org.au, Trial ID: ACTRN12616000965404).

Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties

Introduction

It is well recognised that organised trauma systems reduce trauma patient mortality. As established systems mature, there is an increasing need to better understand the patient recovery trajectory. Mobility and physical function are key aspects of recovery, but the optimal instruments for measurement in the acute hospital setting remain unclear.

Methods

A systematic review was undertaken to identify and describe mobility and physical function instruments scored by direct patient assessment, in adult trauma patients in an acute hospital setting. Databases were searched with no date restrictions. Instruments that were specific to subgroups or related to individual conditions, diseases or joints were excluded. The consensus-based standards for the selection of health measurement instruments checklist was used to assess risk of bias where relevant. Clinimetric properties were reported where possible, including reliability, validity and responsiveness.

Results

Fourteen thousand one hundred and fourteen articles were identified with 37 eligible for final review, including six instruments. None had been specifically designed for use in a heterogeneous range of trauma patients. The Functional Independence Measure was the most commonly cited (n = 10 studies), with evidence of construct validity, responsiveness and minimal floor/ceiling effects (<3%). The Acute Care Index of Function (n = 1 study) was found to be valid and responsive whilst the modified Iowa Level of Assistance (n = 2 studies) was reliable and responsive, but ceiling effects ranged from 26% to 37%. Little clinimetric data were available for other measures.

Conclusion

Evidence from a few studies show promise for the use of the Functional Independence Measure, Acute Care Index of Function and modified Iowa Level of Assistance to measure mobility and physical function in trauma patients, however comprehensive clinimetric data are lacking. Future research should test these scores in specifically designed clinimetric property studies in defined trauma patient populations. This would enable the identification of a gold standard measure for evaluating treatment effectiveness, enabling benchmarking between centres, allow prediction of recovery pathways and optimise trauma patient outcomes.

A web-based intervention to promote physical activity in adolescents and young adults with cystic fibrosis: protocol for a randomized controlled trial

BACKGROUND

Regular participation in physical activity by people with cystic fibrosis (CF) promotes positive clinical and health outcomes including reduced rate of decline in lung function, fewer hospitalizations and greater wellbeing. However adherence to exercise and activity programs is low, in part due to the substantial daily therapy burden for young people with CF. Strict infection control requirements limit the role of group exercise programs that are commonly used in other clinical groups. Investigation of methods to promote physical activity in this group has been limited. The Active Online Physical Activity in Cystic fibrosis Trial (ActionPACT) is an assessor-blinded, multi-centre, randomized controlled trial designed to compare the efficacy of a novel web-based program (ActivOnline) compared to usual care in promoting physical activity participation in adolescents and young adults with CF.

METHODS

Adolescents and young adults with CF will be recruited on discharge from hospital for a respiratory exacerbation. Participants randomized to the intervention group will have access to a web-based physical activity platform for the 12-week intervention period. ActivOnline allows users to track their physical activity, set goals, and self-monitor progress. All participants in both groups will be provided with standardised information regarding general physical activity recommendations for adolescents and young adults. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and at 3-months followup. Healthcare utilization will be assessed at 12 months from intervention completion. The primary outcome is change in moderate-to-vigorous physical activity participation measured objectively by accelerometry. Secondary outcomes include aerobic fitness, health-related quality of life, anxiety and depression and sleep quality.

DISCUSSION

This trial will establish whether a web-based application can improve physical activity participation more effectively than usual care in the period following hospitalization for a respiratory exacerbation. The web-based application under investigation can be made readily and widely available to all individuals with CF, to support physical activity and exercise participation at a time and location of the user's choosing, regardless of microbiological status.

TRIAL REGISTRATION

Clinical trial registered on July 13, 2017 with the Australian and New Zealand Clinical Trials Register at (ACTRN12617001009303).

Beyond forest plots: clinical gestalt and its influence on COPD telemonitoring studies and outcomes review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive chronic condition. Improvements in therapies have resulted in better patient outcomes. The use of technology such as telemonitoring as an additional intervention is aimed at enhancing care and reducing unnecessary acute hospital service use. The influence of verbal communication between health staff and patients to inform decision making regarding use of acute hospital services within telemonitoring studies has not been assessed.

METHOD

A systematic overview of published systematic reviews of COPD and telemonitoring was conducted using an a priori protocol to ascertain the impact of verbal communication in telemonitoring studies on health service outcomes such as emergency department attendances, hospitalisation and hospital length of stay. The search of the following electronic databases: Cochrane Library, Medline, Pubmed, CINAHL, Embase, TROVE, Australian Digital Thesis and Proquest International Dissertations and Theses was conducted in 2017 and updated in September 2019.

RESULTS

Six systematic reviews were identified. All reviews involved home monitoring of COPD symptoms and biometric data. Included reviews reported 5-28 studies with sample sizes ranging from 310 to 2891 participants. Many studies reported in the systematic reviews were excluded as they were telephone support, cost effectiveness studies, and/or did not report the outcomes of interest for this overview. Irrespective of group assignment, verbal communication with the health or research team did not alter the emergency attendance or hospitalisation outcome. The length of stay was longer for those who were assigned home telemonitoring in the majority of studies.

CONCLUSION

This overview of telemonitoring for COPD had small sample sizes and a wide variety of included studies. Communication was not consistent in all included studies. Understanding the context of communication with study participants and the decision-making process for referring patients to various health services needs to be reported in future studies of telemonitoring and COPD.

Factors predicting progression of exercise training loads in people with interstitial lung disease

In ILD, adherence to the training sessions in pulmonary rehabilitation predicts progression of exercise training loads; declining lung function is an independent predictor of failure to progress training loads http://bit.ly/2Z4x9Nw.

Clinical Characteristics Of Patients With Asthma COPD Overlap (ACO) In Australian Primary Care

Purpose

Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices.

Patients and methods

Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George’s Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone.

Results

Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p<0.001), but no difference was found in post-bronchodilator spirometry. Demographic and clinical characteristics, dyspnoea, quality of life, comorbidities and treatment prescribed did not differ significantly between groups.

Conclusion

This is the first study describing the clinical characteristics of ACO patients in Australian general practices. Our finding of lower pre-bronchodilator lung function in the ACO group compared to those with COPD reinforces the importance of spirometry in primary care to inform management.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Low gait speed is associated with low physical activity and high sedentary time following stroke

PURPOSE

This study describes physical activity levels and factors associated with physical activity at the end of stroke rehabilitation.

METHODS

Primary stroke survivors were assessed at completion of physical rehabilitation. Outcomes included physical activity (e.g. step count, moderate-vigorous physical activity duration) and sedentary time measured with the Sensewear Armband, gait speed, and cognition. The number of participants meeting physical activity recommendations was calculated. Differences in physical activity were examined between household ambulators (gait speed <0.4 m/s), limited community ambulators (0.4-0.8 m/s), and unlimited community ambulators (>0.8 m/s). The influence of age, cognition, and gait speed on physical activity was determined by multiple regression.

RESULTS

Seventy-nine stroke survivors participated. Twenty-one participants achieved 30 min/day of moderate-vigorous physical activity accumulated in 10 min bouts. Unlimited community ambulators took more steps/day (median 4975 vs. 469 limited, 355 household, p < 0.001), had higher moderate-vigorous physical activity (median 74 min/day vs. 22 limited, 31 household, p < 0.001) and lower sedentary time (mean 1105 vs. 1239 limited, 1232 household minutes/day, p < 0.001). Age, gait speed, and cognition predicted 21.3% of the variance in moderate-vigorous physical activity (p = 0.001); adding employment status to the model predicted 57.3% of the variance in step count (p < 0.001).

CONCLUSIONS

Physical activity is low following stroke and should be a target for treatment, particularly in those with gait speeds ≤0.8 m/s.Implications for rehabilitationSeventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day.Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts.Despite relatively good physical ability, daily step count was low in this sample.Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time.

Exercise-Based Rehabilitation to Improve Exercise Capacity and Quality of Life in Pulmonary Arterial Hypertension

<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions-medications, surgery, education, nutrition, exercise-and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature. Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on people diagnosed with pulmonary arterial hypertension. Can exercise-based rehabilitation programs improve exercise capacity and quality of life in people with pulmonary arterial hypertension?

Frailty in Patients With Trauma Who Are Critically Ill: A Prospective Observational Study to Determine Feasibility, Concordance, and Construct and Predictive Validity of 2 Frailty Measures

BACKGROUND

As the older population increases, more older people are exposed to trauma. Frailty can be used to highlight patients at risk of a poorer outcome.

OBJECTIVE

The objectives of this study were to compare 2 frailty measures with regard to concordance, floor and ceiling effects, and construct and predictive validity and to determine which is more valid and clinically applicable in a critically ill trauma population.

DESIGN

This was a prospective observational study.

METHODS

Patients were included if admitted to an intensive care unit (ICU) under a trauma medical unit and ≥ 50 years old. Frailty was determined using 2 frailty measures, the Frailty Phenotype (FP) and Clinical Frailty Scale (CFS).

RESULTS

One hundred people were enrolled; their mean age was 69.2 years (SD = 10.4) and 81% had major trauma (as determined with the Injury Severity Score). Frailty was identified with the FP in 22 participants and with the CFS in 13 participants. The 2 frailty measures had an excellent correlation (Spearman rank correlation coefficient = 0.77; 95% confidence interval = 0.66-0.85). Both the FP and the CFS had large floor effects but no ceiling effects. The FP and CFS showed construct validity, with frailty being significantly associated with increasing age, requiring an aid to mobilize, and more falls and hospital admissions. Frailty on the FP was predictive of ICU and hospital mortality, whereas frailty on the CFS was predictive of hospital mortality.

LIMITATIONS

The limitations of this study include the use of a single site, small sample size, and collection of frailty measures retrospectively.

CONCLUSIONS

Measuring frailty in a trauma ICU population was feasible, with excellent correlation between the 2 frailty measures. Both showed aspects of construct and predictive validity; however, the FP identified frailty in more participants and was associated with more comorbidities and higher mortality at ICU discharge. Therefore, the FP might be more clinically relevant in this population.

Seasonal variations in objectively assessed physical activity among people with COPD in two Nordic countries and Australia: a cross-sectional study

Purpose: Seasons and weather conditions might influence participation in physical activity and contribute to differences between countries. This study aimed at investigating whether there were differences in physical activity levels between Norwegian, Danish and Australian people with chronic obstructive pulmonary disease (COPD), and establishing if any variations in physical activity were attributable to seasons.

Patients and methods: A cross-sectional study where study subjects were people with COPD who participated in two separate clinical trials: the iTrain study (Norway, Denmark, and Australia) and the HomeBase study (Australia). Physical activity was objectively assessed with an activity monitor; variables were total energy expenditure, number of daily steps, awake sedentary time, light, and moderate-to-vigorous intensity physical activity. Differences in physical activity between countries and seasons were compared, with adjustment for disease severity.

Results: In total, 168 participants were included from Norway (N=38), Denmark (N=36) and Australia (N=94). After controlling for disease severity, time spent in awake sedentary time was greater in Danish participants compared to the other countries (median 784 minutes/day [660–952] vs 775 minutes/day [626–877] for Norwegians vs 703 minutes/day [613–802] for Australians, P=0.013), whilst time spent in moderate to vigorous physical activity was lower (median 21 minutes/day [4–73] vs 30 minutes/day [7–93] for Norwegians vs 48 minutes/day [19–98] for Australians, P=0.024). Participants walked more during summer (median 3502 [1253–5407] steps/day) than in spring (median 2698 [1613–5207] steps/day), winter (median 2373 [1145–4206] steps/day) and autumn (median 1603 [738–4040] steps/day), regardless of geography. The median difference between summer and other seasons exceeded the minimal clinically important difference of 600 steps/day. However, the differences were not statistically significant (P=0.101).

Conclusion: After controlling for disease severity, Danish participants spent more time in an awake sedentary state and less time in moderate to vigorous physical activity than their counterparts in Norway and Australia. People with COPD increased their physical activity in summer compared to other seasons. Weather conditions and seasonal variations may influence outcomes in clinical trials and health registries measuring physical activity over time, irrespective of the interventions delivered, and should be taken into account when interpreting results.

Comprehensive pulmonary rehabilitation for interstitial lung disease: A consensus approach to identify core education topics

OBJECTIVE

To achieve consensus amongst health professionals and people with interstitial lung disease (ILD) on core educational topics for pulmonary rehabilitation (PR) in ILD.

METHODS

Health professionals with expertise in ILD and/or PR took part in a 2-round online Delphi process. Potential educational topics for PR were rated on a 4-point Likert scale with anchors of 'completely unimportant' and 'very important'. Results of each Delphi round were discussed and refined by focus groups of people with ILD, to achieve final approval of topics.

RESULTS

Health professional participants (n = 43) represented six disciplines from five continents. Focus group participants (n = 10) had a range of ILDs and disease severity. Consensus was reached on six core education topics: (1) Staying well with ILD; (2) Keeping fit and strong after PR; (3) Oxygen Therapy; (4) Managing breathlessness and cough; (5) Overcoming fatigue; (6) Managing anxiety, depression and panic.

CONCLUSION

This study has identified core educational topics for people with ILD who undertake PR, incorporating the perspectives of both patients and health professionals. This is a step towards comprehensive PR for people with ILD.

PRACTICE IMPLICATIONS

This study provides PR clinicians with guidance on ILD-specific education topics that can be delivered in existing PR programs.

Oxygen compared to air during exercise training in COPD with exercise-induced desaturation

Almost half the patients referred to pulmonary rehabilitation with chronic obstructive pulmonary disease (COPD) desaturate during exercise. Although oxygen supplementation may ameliorate oxygen desaturation, the effects on outcomes of exercise training have not been rigorously evaluated. This study aimed to determine whether supplemental oxygen during exercise training was more effective than medical air in improving exercise capacity and health-related quality of life (HRQoL) in people with COPD.People with COPD who demonstrated oxygen desaturation <90% during the 6-min walk test were recruited to this multicentre trial with randomisation (independent, concealed allocation) to either an Oxygen group or Air group, blinding (participants, exercise trainers and European Respiratory Journal assessors) and intention-to-treat analysis. Both groups received the respective gas from concentrators via nasal prongs at 5 L·min^-1 during exercise training consisting of treadmill and cycle exercise, three times per week for 8 weeks. Primary outcomes were the endurance shuttle walk test (ESWT) time and Chronic Respiratory Disease Questionnaire (CRQ)-Total score.111 participants (60 males), mean±sd age 69±7 years, with moderate to severe COPD were recruited and 97 completed (Oxygen group n=52; Air group n=45). At the end of the 8-week training programme there were no between-group differences in change in ESWT (mean difference 15 s (95% CI -106-136 s) or change in CRQ-Total (0.0 points (95% CI -0.3-0.3 points)). Within-group changes at end-training were significant for ESWT and CRQ-Total (all p<0.01).Exercise capacity and HRQoL improved in both groups, with no greater benefit from training with supplemental oxygen than medical air.

Oxygen in patients with fibrotic interstitial lung disease: an international Delphi survey

Rationale

Patients with fibrotic interstitial lung disease (ILD) frequently develop resting or exertional hypoxaemia. There is heterogeneity in clinical practice and a paucity of evidence guiding supplemental oxygen use in this patient population. The objectives of this study were to build international expert-based consensus on the indications and goals of supplemental oxygen from the perspective of healthcare providers, and identify potential barriers to its access.

Methods

Semistructured interviews and a comprehensive literature search informed items for the Delphi survey, with items not meeting consensus included in round 2. Round 3 contained survey questions regarding regional funding coverage for oxygen therapy. A priori definitions of consensus were median scores of 4 (agree) to 5 (strongly agree) for “agreement”, 1 (strongly disagree) to 2 (disagree) for “disagreement” or 3 (unsure) with an interquartile range of 0–1.

Results

42 out of 45 (93%) experts completed all three survey rounds, representing 17 countries. 20 out of 36 items met consensus for agreement or disagreement, 10 items met consensus for unsure and four items did not meet consensus. Experts agreed that oxygen should be recommended for patients with severe resting hypoxaemia and in cases of exertional desaturation to <85–89%, particularly with attributable symptoms or exercise limitation. There are regional differences in funding coverage for oxygen, based on desaturation thresholds, clinical symptoms and testing requirements.

Conclusions

Experts achieved consensus on 20 items guiding supplemental oxygen use in fibrotic ILD. These findings may inform research, clinical recommendations and funding policy.

Treatable traits: a new paradigm for 21st century management of chronic airway diseases: Treatable Traits Down Under International Workshop report

"Treatable traits" have been proposed as a new paradigm for the management of airway diseases, particularly complex disease, which aims to apply personalised medicine to each individual to improve outcomes. Moving new treatment approaches from concepts to practice is challenging, but necessary. In an effort to accelerate progress in research and practice relating to the treatable traits approach, the Treatable Traits Down Under International Workshop was convened in Melbourne, Australia in May 2018. Here, we report the key concepts and research questions that emerged in discussions during the meeting. We propose a programme of research that involves gaining international consensus on candidate traits, recognising the prevalence of traits, and identifying a potential hierarchy of traits based on their clinical impact and responsiveness to treatment. We also reflect on research methods and designs that can generate new knowledge related to efficacy of the treatable traits approach and consider multidisciplinary models of care that may aid its implementation into practice.

A novel counterbalanced implementation study design: methodological description and application to implementation research

Background

Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy.

Methods

In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition.

Results

An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of ‘video-based’ and ‘written-based’ evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts.

Conclusion

A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0896-0) contains supplementary material, which is available to authorized users.

Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial

We evaluated the effectiveness of an interdisciplinary, primary care-based model of care for chronic obstructive pulmonary disease (COPD).A cluster randomised controlled trial was conducted in 43 general practices in Australia. Adults with a history of smoking and/or COPD, aged ≥40 years with two or more clinic visits in the previous year were enrolled following spirometric confirmation of COPD. The model of care comprised smoking cessation support, home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase). Main outcomes included changes in St George's Respiratory Questionnaire (SGRQ) score, COPD Assessment Test (CAT), dyspnoea, smoking abstinence and lung function at 6 and 12 months.We identified 272 participants with COPD (157 intervention, 115 usual care); 49 (31%) out of 157 completed both HMR and HomeBase. Intention-to-treat analysis showed no statistically significant difference in change in SGRQ at 6 months (adjusted between-group difference 2.45 favouring intervention, 95% CI -0.89-5.79). Per protocol analyses showed clinically and statistically significant improvements in SGRQ in those receiving the full intervention compared to usual care (difference 5.22, 95% CI 0.19-10.25). No statistically significant differences were observed in change in CAT, dyspnoea, smoking abstinence or lung function.No significant evidence was found for the effectiveness of this interdisciplinary model of care for COPD in primary care over usual care. Low uptake was a limitation.

Practical approach to establishing pulmonary rehabilitation for people with non-COPD diagnoses

Pulmonary rehabilitation is a core aspect in the management of patients with chronic respiratory diseases. This paper describes a practical approach to establishing pulmonary rehabilitation for patients with non-COPD diagnoses using examples from the interstitial lung disease (ILD), pulmonary hypertension (PH), bronchiectasis and lung cancer patient populations. Aspects of pulmonary rehabilitation, including the rationale, patient selection, setting of programmes, patient assessment and training components (both exercise and non-exercise aspects), are discussed for these patient groups. Whilst there are many similarities in the rationale and application of pulmonary rehabilitation across these non-COPD populations, there are also many subtle differences, which are discussed in detail in this paper. With consideration of these factors, pulmonary rehabilitation programmes can be adapted to facilitate the inclusion of respiratory patients with non-COPD diagnoses.

Exercise as a therapeutic intervention for people with cystic fibrosis

INTRODUCTION

The complex multisystem nature of cystic fibrosis (CF) commonly results in reduced exercise tolerance, which is independently associated with poor clinical outcomes. Exercise is routinely recommended as part of the therapeutic regimen in CF to improve both respiratory and non-respiratory impairments. Areas covered: This article summarises the most recent evidence regarding the use of exercise as a therapeutic intervention in CF and discusses some of the practical considerations for exercise prescription in this setting. Clinical trials in progress and future research priorities are outlined. Expert opinion: On the balance of available evidence, exercise is likely to assist in improving physical fitness and health-related quality of life (HRQOL) and may be associated with a slower rate of decline in respiratory function in CF. Limitations to current studies include small sample sizes, study durations insufficient to achieve a training effect and difficulty distinguishing the effects of exercise training from that of other interventions implemented as part of a package of care. Larger, multi-centred trials are required to clarify the role of exercise in CF in improving physical fitness, respiratory function, HRQOL, as a substitute for traditional airway clearance techniques and in the management of common CF-related comorbidities.

Pulmonary Rehabilitation does not Improve Objective Measures of Sleep Quality in People with Chronic Obstructive Pulmonary Disease

Abnormal sleep duration is associated with poor health. Upwards of 50% of people with chronic obstructive pulmonary disease (COPD) report poor sleep quality. The effect of pulmonary rehabilitation on self-reported sleep quality is variable. The aim of this study was to assess the effect of pulmonary rehabilitation on objectively measured sleep quality (via actigraphy) in people with COPD. Sleep quality was assessed objectively using the SenseWear Armband (SWA, BodyMedia, Pittsburgh, PA), worn for ≥4 days before and immediately after completing an 8-week pulmonary rehabilitation program. Sleep characteristics were derived from accelerometer positional data and registration of sleep state by the SWA, determined from energy expenditure. Forty-eight participants (n = 21 male) with COPD (mean (SD), age 70 (10) years, mean FEV₁ 55 (20) % predicted, mean 45 (24) pack year smoking history) contributed pre and post pulmonary rehabilitation sleep data to this analysis. No significant differences were seen in any sleep parameters after pulmonary rehabilitation (p = 0.07-0.70). There were no associations between sleep parameters and measures of quality of life or function (all p > 0.30). Sleep quality, measured objectively using actigraphy, did not improve after an 8-week pulmonary rehabilitation program in individuals with COPD. Whether on-going participation in regular exercise training beyond the duration of pulmonary rehabilitation may influence sleep quality, or whether improving sleep quality could enhance rehabilitation outcomes, is yet to be determined.