Comparison of effects of supervised versus self-monitored training programmes in patients with chronic obstructive pulmonary disease

The Role of Illness Perceptions in Dyspnoea-Related Fear in Chronic Obstructive Pulmonary Disease

Dyspnoea is often the most distressing symptom described by people with a chronic respiratory condition. The traditional biomedical model of neuromechanical uncoupling that explains the physiological basis for dyspnoea is well accepted. However, in people with chronic obstructive pulmonary disease (COPD), measures that are linked with neuromechanical uncoupling are poorly related to the restriction in activity during daily life attributed to dyspnoea. This suggests that activity restriction that results from dyspnoea is influenced by factors other than expiratory airflow limitation and dynamic pulmonary hyperinflation, such as the ways people perceive, interpret and respond to this sensation. This review introduces the common-sense model as a framework to understand the way an individual's lay beliefs surrounding sensations can lead to these sensations being perceived as a health threat and how this impacts their emotional and behavioural responses. The aim is to provide insight into the nuances that can shape an individual's personal construct of dyspnoea and offer practical suggestions to challenge unhelpful beliefs and facilitate cognitive re-structuring as a pathway to reduce distress and optimise health behaviours and outcomes.

The minimal important difference of the constant work rate cycle test in severe COPD

BACKGROUND

The Constant Work Rate Cycle Test (CWRT) is a commonly used and sensitive test to detect treatment success in patients with Chronic Obstructive Pulmonary Disease (COPD). Earlier, the Minimal Important Difference (MID) of the CWRT was estimated at 101 s (or 34%) change from baseline based on one well executed study. However, this study was performed in a population of patients with mild-to-moderate COPD, and we have learned that MIDs might be quite different in patients with severe COPD. Therefore, we aimed to establish the MID of the CWRT in patients with severe COPD.

METHODS

We included 141 patients with severe COPD, who underwent either pulmonary rehabilitation, bronchoscopic lung volume reduction with endobronchial valves, or a sham bronchoscopy as a control group. CWRT workload was set at 75% of the peak work capacity, as determined by an incremental cycle test. We used the change in 6-min walking test (6-MWT), forced expiratory volume in 1s (FEV₁), residual volume (RV), and St. George's Respiratory Questionnaire (SGRQ) total score as anchors to calculate the MID.

RESULTS

All anchors had an association of ≥0.41 with change in CWRT. The MID estimates for the different anchors were: 6-MWT 278 s (95%), FEV₁ 273 s (90%), RV 240 s (84%), and SGRQ 208 s (71%). The average of these four MID estimates resulted in an MID of 250 s (or 85%).

CONCLUSION

We established the MID for CWRT at 250 s (or 85%) change from baseline in patients with severe COPD.

Physical clinical care and artificial-intelligence-guided core resistance training improve endurance and patient-reported outcomes in subjects with lower back pain

BACKGROUND

Low back pain is an extremely prevalent issue with an extensive impact, ranging from decreased quality of life to lost years of productivity. Many interventions have been developed to alleviate chronic lower back pain, yet it remains a widespread problem. The objective of this study was to examine the role of artificial intelligence guided resistance training relative to clinical variables in subjects experiencing lower back pain.

METHODS

69 out of 108 enrolled and 92 accrued subjects completed the 8-week intervention. Subjects were randomized into four groups (Control, Training, Clinical, or Combined). The Training cohort received supervised artificial-intelligence-guided core-focused resistance training while the Clinical group received clinical care. The Combined group received both clinical care and artificial-intelligence-guided training and the Control group received no treatment. Participants were evaluated using functional testing and patient-reported outcomes at baseline, 4 weeks, and 8 weeks.

FINDINGS

In the clinical tests, the Clinical and Combined cohorts showed increased total time for isometric extensor endurance and the Clinical cohort increased total distance traveled in the 6-min walk test at 8 weeks. The Training, Clinical, and Combined groups showed improvements in Patient-reported outcomes after 8 weeks. Most of the significant improvements were only seen at the 8-week evaluation for both the clinical evaluations and Patient-reported outcomes. The Control group did not show significant improvements in any outcome measures.

INTERPRETATION

The present data indicate that core-focused interventions, including artificial-intelligence-guided moderate-resistance exercise, can increase objective functional outcomes and patient satisfaction using Patient-reported outcomes in individuals with lower back pain.

Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis

INTRODUCTION

Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care.

METHODS AND ANALYSIS

Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence.

RESULTS

We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32-1.44; p=0.002) and HRQoL (SMD -0.62, 95% CI -0.88--0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD -0.10, 95% CI -0.25-0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI -0.15-0.17; p=0.87).

CONCLUSION

Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

Measuring intensity during free-living physical activities in people with chronic obstructive pulmonary disease: a systematic literature review

BACKGROUND

Measuring intensity of physical activity (PA) is important to ensure safety and the effectiveness of PA interventions in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

This systematic review identified which outcomes, outcome measures and instruments have been used to assess single free-living PA-related intensity in people with COPD and compared the intensity level (light, moderate, vigorous) obtained by different outcome measures.

METHODS

PubMed, Scopus, Web of Science, Cochrane Library and EBSCO were searched for original studies of COPD and assessing single free-living PA-related intensity were included. Agreement was calculated as the number of agreements between 2 measures [same intensity level]/ number of comparisons using both measures*100.

RESULTS

We included 43 studies (1282 people with COPD, mean age 66 years, 65% men, 49% FEV_1%pred) and identified 13 outcomes, 46 outcome measures and 22 instruments. The most-reported outcomes, outcome measures and instruments were dyspnoea with the Borg scale 0-10; cardiac function, via heart rate (HR) using HR monitors; and pulmonary gas exchange, namely oxygen consumption (VO₂), using portable gas analysers, respectively. The most frequently assessed PAs were walking and lifting, changing or moving weights/objects. Agreement between the outcome measures ranged from 0 (%VO_2peak vs metabolic equivalent of task [MET]; %HR_peak vs Fatigue Borg; MET vs walking speed) to 100% (%HR_reserve vs dyspnoea Borg; fatigue and exertion Borg vs walking speed). %VO_{2peak/reserve} elicited the highest intensity. Hence, Borg scores, %HR_reserve and MET may underestimate PA-related intensity.

CONCLUSIONS

Various methodologies are used to assess single free-living PA-related intensity and yield different intensity levels for the same PA. Future studies, further exploring the agreement between the different outcome measures of PA-related intensity and discussing their advantages, disadvantages and applicability in real-world settings, are urgent. These would guide future worldwide recommendations on how to assess single free-living PA-related intensity in COPD, which is essential to optimise PA interventions and ensure patient safety.

Factors influencing participation in educational workshops as part of a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease: a retrospective study

BACKGROUND

Pulmonary rehabilitation (PR) (primarily composed of an exercise training program (ET) and educational workshops) is an effective intervention for patients with chronic obstructive pulmonary disease. Although factors which influence participation in the full PR program have been reported, specific data on the educational component of PR have not been published. We aimed to identify factors which predict refusal to participate in the educational component of PR.

RESEARCH DESIGN AND METHODS

201 patient charts were retrospectively included in the analysis. Patients were classified according to their acceptance or refusal to participate in the educational workshops.

RESULTS

The location of ET outside the center was independently related to refusal to participate in the educational workshops (OR = 0.01 [95%CI 0.00 to 0.17]). Patients who refused the workshops were less disabled according to the number of prescriptions of noninvasive ventilation, use of medical transport, oxygen consumption and workload achieved during cardiopulmonary exercise testing.

CONCLUSIONS

The location of exercise sessions during PR influences patients' decisions to refuse or accept center-based educational workshops. When center-based PR programs are limited, and the ET is relocated to the patient's home, the educational workshops should also be relocated.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov (NCT04301245).

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

Effect of inspiratory muscle training on dyspnea-related kinesiophobia in chronic obstructive pulmonary disease: A randomized controlled trial

BACKGROUND

The major symptom of chronic obstructive pulmonary disease (COPD) is dyspnea, which causes dyspnea-related kinesiophobia resulting in avoidance of activities associated with dyspnea or compensation by reducing the rate of activity. The aim of this study was to assess dyspnea-related kinesiophobia and determine the effect of inspiratory muscle training (IMT) on dyspnea-related kinesiophobia in COPD.

METHODS

Forty COPD subjects were randomly allocated to either the IMT or sham group. Both groups' maximal inspiratory pressure (MIP) was assessed weekly. All patients were instructed to perform the training exercises for 15 min twice a day, 5 days a week for a total of 8 weeks. In the IMT group, intensity was set at 30% of MIP and adjusted according to weekly MIP value. In the sham group, intensity remained constant at 15% of initial MIP. Pulmonary function test (PFT), respiratory muscle strength, 6-min walk test (6 MWT), Breathlessness Beliefs Questionnaire (BBQ), Modified Medical Research Council scale (MMRC), modified Borg scale, Hospital Anxiety and Depression Scale (HADS), Saint George's Respiratory Questionnaire (SGRQ), and COPD Assessment Test (CAT) were assessed before and after the intervention.

RESULTS

BBQ scores ranged from 18 to 51, with mean values in the IMT and sham groups of 39.80 ± 7.62 and 43.00 ± 6.58, respectively. When between-group differences of all outcome scores were compared, there was a statistically significant improvement in the IMT group than in the sham group (p < 0.05). After IMT, statistically significant decreases in BBQ and modified Borg scores were observed in within groups (p ≤ 0.001). These decreases were significantly greater in the IMT group (p ≤ 0.001). MMRC decreased significantly only in the IMT group (p < 0.001). There was a statistically significant increase in PFT values in the IMT group (p = 0.007-0.045), but no difference in the sham group (p = 0.129-0.886). Both groups showed statistically significant improvement in respiratory muscle strength, 6 MWT distance, and CAT score after 8 weeks (p < 0.05). All HADS and SGRQ scores decreased significantly in the IMT group (p < 0.001), whereas only the SGRQ activity score decreased significantly in the sham group (p = 0.017).

CONCLUSIONS

Our study provides data on the presence and level of dyspnea-related kinesiophobia in COPD patients. All patients had BBQ scores higher than 11, indicating dyspnea-related kinesiophobia. IMT reduced BBQ score and improved respiratory function, and exercise capacity. Our results also support the other known benefits of IMT such as reduced dyspnea and symptom perception, decreased anxiety and depression, and improved quality of life.

Effectiveness of Non-Presential Individualized Exercise Training PrOgram(NIETO) in Lower Limb Physical Performance in Advanced COPD

Muscle training, a component of pulmonary rehabilitation (PR), improves the physical performance of patients with chronic obstructive pulmonary disease (COPD). Despite the existing evidence, the traditional center-based PR model is applied to a small percentage of patients and presents numerous problems of accessibility, adherence, and costs. This study presents a home model of simple muscle training, non-presential, monitored by telephone and individualized, according to the severity of the COPD. In addition, to evaluate the results, simple tests associated with the physical performance of the lower limbs, previously validated in COPD, have been used, such as the four-meter walk, speed test (4MGS) and the five-repetition test sitting and standing (5STS). The objective was to evaluate whether the Individualized Non-Presential Exercise Training PrOgram (NIETO) induces improvements in the 4MGS, 5STS and quadriceps muscle strength (QMS) tests in outpatients with advanced COPD (FEV1 ≤ 50%). After one year, the QMS was significantly higher in the intervention group (IG) than in the control group (CG) (2.44 ± 4.07 vs. 0.05 ± 4.26 kg; p = 0.009). The 4MGS and 5STS tests were significantly shorter in IG than in CG (−0.39 ± 0.86 vs. 0.37 ± 0.96 s; p = 0.001) and (−1.55 ± 2.83 vs. 0.60 ± 2.06 s; p = 0.001), respectively. A home model of simple muscle training monitored by telephone such as NIETO, can improve 4MGS, 5STS, and quadriceps strength tests in outpatients with advanced COPD.

Effect of home-based pulmonary rehabilitation on health-related quality of life, lung function, exercise tolerance, and dyspnea in chronic obstructive pulmonary disorder patients in a tertiary care center in South India

Context:

Home-based pulmonary rehabilitation (PR) can increase compliance in chronic obstructive pulmonary disorder (COPD). There is paucity of data on this in India.

Aims:

To study the effectiveness of home-based PR on lung function, health-related quality of life, exercise tolerance and dyspnea among patients with COPD.

Setting:

The Department of Pulmonary Medicine, Christian Medical College, Vellore.

Subjects and Methods:

This was a quasi-experimental study which included COPD patients who found hospital-based PR impractical. Those willing for home-based PR constituted the intervention group and those unwilling, constituted the control group. Both groups received standard of care otherwise. At 6 weeks, forced expiratory volume in 1 sec (FEV1), St. George Respiratory Questionnaire (SGRQ), six-minute walk test distance (6MWD), COPD assessment test (CAT) score and modified Borg dyspnea scale were compared with their baseline values.

Statistical Analysis:

Student paired t-test.

Results:

A total of 42 patients completed the study, 21 in each arm. The baseline characteristics were comparable. The improvement in FEV1 was 90 ml in the intervention group and 4 ml in the control group (P = 0.01). There was no significant difference in 6MWD change. SGRQ score, Borg scale and CAT score improved significantly by 10.4, 2.4, and 3.4, respectively, in the intervention group when compared to the control group (P = 0.01).

Conclusions:

Home-based PR effectively provides tangible benefits in FEV1, QOL, exercise tolerance and dyspnea. It should be offered to those who are unable to avail institution-based PR, especially in this era of COVID pandemic.

Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease: Highly Effective but Often Overlooked

Patients with chronic obstructive pulmonary disease receive a range of treatments including but not limited to inhaled bronchodilators, inhaled and systemic corticosteroids, supplemental oxygen, and pulmonary rehabilitation. Pulmonary rehabilitation is a multidisciplinary intervention that seeks to combine patient education, exercise, and lifestyle changes into a comprehensive program. Programs 6 to 8 weeks in length have been shown to improve health, reduce dyspnea, increase exercise capacity, improve psychological well-being, and reduce healthcare utilization and hospitalization. Although the use of pulmonary rehabilitation is widely supported by the literature, controversy still exists regarding what should be included in the programs. The goal of this review was to summarize the evidence for pulmonary rehabilitation and identify the areas that hold promise in improving its utilization and effectiveness.

Effectiveness and Safety of Supervised Home-Based Physical Training in Patients With COPD on Long-term Home Oxygen Therapy: A Randomized Trial

BACKGROUND

Patients with COPD in advanced stages who need long-term home oxygen therapy (LTHOT) have difficulty participating in outpatient pulmonary rehabilitation (PR) programs. This difficulty is due to the severity of their disease, limitations involving transportation and mobility, high costs, and issues related to patients' safety and individual needs. Unsupervised home-based physical training (PT) is frequently used.

RESEARCH QUESTION

The main objective of this study was to investigate the effectiveness of a supervised home-based PT program on exercise capacity and other outcomes in patients with COPD receiving LTHOT.

STUDY DESIGN AND METHODS

In a randomized clinical trial, patients with COPD who were on LTHOT were allocated into two groups: the supervised physical training (PT) group, consisting of patients who received home-based supervised muscle strength and endurance training in twice-weekly 60-min sessions for 12 weeks; and the unsupervised activity booklet group, consisting of patients who received a booklet advising them to perform exercise twice a week for 12 weeks. All participants were assessed prior to and following the intervention in terms of exercise capacity (6-min step-test and the 1-min sit-to-stand test); dyspnea (Medical Research Council scale); fatigue (Brazilian Portuguese version of the Fatigue Severity Scale); and health status (COPD Assessment Test).

RESULTS

A total of 44 patients were assessed (mean age, 70 ± 8 years; FEV₁, 33 ± 14% predicted) (PT group, n = 22; booklet group, n = 22). Only the PT group patients presented significant improvement in the 6-min step-test (21 ± 9 vs 14 ± 11; P = .001), Medical Research Council scale (3.3 ± 1.0 vs 3.9 ± 0.9; P = .013), Brazilian Portuguese version of the Fatigue Severity Scale (5.0 ± 1.4 vs 5.2 ± 1.3; P = .015), and COPD Assessment Test (21 ± 8 vs 26 ± 6; P = .001). No adverse effects were observed.

INTERPRETATION

Supervised home-based PT was effective and safe in improving exercise capacity, dyspnea, fatigue, and health status in patients with COPD on LTHOT.

CLINICAL TRIAL REGISTRATION

Brazilian Registry of Clinical Trials; No.: RBR-535smn; URL: http://www.ensaiosclinicos.gov.br.

Effect of 8-week Pulmonary Rehabilitation Program on Dyspnea and Functional Capacity of Patients on Waiting List for Lung Transplantation

OBJECTIVES

The aim of this study was to evaluate the effect of comprehensive, 8-week outpatient pulmonary rehabilitation (PR) programme consisting of 60-min sessions twice a week under supervision on dyspnea and exercise capacity of patients who were lung transplantation (LTx) candidates.

MATERIALS AND METHODS

Between March 2012 and December 2014, medical data of 23 patients on the waiting list for LTx who were referred to our PR unit and completed 16-session outpatient under direct supervision were retrospectively analyzed. Data on exercise capacity as assessed by 6-minute walking test (6MWT) and the rate of perceived dyspnea as assessed by the Borg scale and Medical Research Council (MRC) dyspnea scale were recorded.

RESULTS

Of 23 patients 57% were males; the mean age was 35±10 (range: 16-48) years. Four patients were operated early, as an appropriate donor was available. Diagnosis was as follows: bronchiectasis (n=10, 44%), silicosis (n=7, 30%), sarcoidosis (n=2, 9%), idiopathic pulmonary fibrosis (n=1, 4%), chronic obstructive pulmonary disease (n=1, 4%), and others (n=2, 9%). At the end of the program, there was a significant improvement (median: 60 m) in 6MWT scores (360 [70-254] m vs. 300 [139-489] m; p=0.018). In addition, a clinical improvement was observed in Borg (p=0.000) and MRC scores (p=0.008).

CONCLUSION

Our study results suggest that 8-week outpatient PR programme consisting of training twice a week is effective to decrease perceived dyspnea and to improve exercise capacity in patients who are on the waiting list for LTx.

Comparison of unsupervised home-based pulmonary rehabilitation versus supervised hospital outpatient pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Background: Pulmonary rehabilitation (PR) is an effective treatment in patients with chronic obstructive pulmonary disease (COPD) but still underutilized. The aim of this study was to compare unsupervised home PR with supervised outpatient PR in terms of various clinical variables in COPD patients.Methods: We conducted retrospective study consisting of 247 patients with COPD who were categorized into three group. 127 patients underwent unsupervised home PR, of whom 60 (47%) completed program (finishers), 67(53%) were lost to follow-up (non-finishers), 120 completed supervised outpatient PR. We compared baseline, post-treatment changes in demographic, clinical variables.Results: Sex, age were statistically similar between groups. Finishers of home PR had higher exercise capacity (p = 0.003), quality of life (p = 0.045), FEV1 (p = 0.001), lower pack-year smoking (p < 0.001) than outpatient PR.After home PR, exercise capacity (p < 0.05), quality of life (p < 0.001), dyspnea(p < 0.05), anxiety (p < 0.001), depression (p < 0.001) were improved except endurance shutte test. Improvements in exercise capacity (p < 0.05), quality of life (p < 0.001), dyspnea (p = 0.023), anxiety (p < 0.001), depression (p = 0.001) scores were different between completed PR programs, in favor of supervised outpatient PR. Non-finishers of home PR had more pack-year smoking than finishers of home PR (p = 0.039); other baseline parameters were similar.Conclusion: Unsupervised home PR was effective in terms of improving exercise capacity, quality of life, dyspnea, psychological status, but less than supervised outpatient programs.

The perceptions of physical therapists about facilitators and challenges in the use of different tools for resistance training in COPD patients: a mixed-method study

ABSTRACT This study sought to quantify and qualitatively analyze the perception of physical therapists about facilitators and the challenges in the use of different types of tools for resistance training in chronic obstructive pulmonary disease (COPD) patients. This was a mixed-model study with qualitative analysis developed in a rehabilitation center. Six physical therapists who performed a randomized clinical trial were interviewed. The protocol consisted of the evaluation of three types of resistance training: elastic tubes, elastic bands, and training with conventional weight machines. After completion of the randomized trial, therapists were invited to participate in a focus group to collect qualitative data. Physical therapists also answered a quantitative questionnaire containing closed questions. The main outcome measures were the opinion of physical therapists about the advantages and disadvantages in clinical practice of each of the analyzed tools. The focus group analysis resulted in eight themes: Insecurities regarding load and handling tools, implementation of home-based treatment, improvements of tools, advantages and disadvantages of tools, incidence of injuries with elastic tools, patient’s preferences, and particularities of the tools. Physical therapists pointed out different challenges and facilitators for resistance training. Characteristics of the tools such as costs, portability, handling and practicality were cited as factors that influence clinical practice. In the quantitative analysis, no differences were observed when comparing the scores of each instrument. The three tools analyzed are applicable and feasible in the clinical practice of physical therapists; moreover, they present different characteristics and particularities that should be considered, such as cost, clinical applicability, portability and perception of the patient and therapists.

[Effectiveness of an educational program for respiratory rehabilitation of Chronic Obstructive Pulmonary Disease patients in Primary Care in improving the quality of life, symptoms, and clinical risk]

AIM

To determine the impact of an educational program to improve the management of chronic obstructive pulmonary disease (COPD) that contributes to an increase of the quality of life, exercise capacity, level of dyspnoea, and clinical risk.

DESIGN

Intervention study without controls.

LOCATION

Primary Healthcare Centre.

PARTICIPANTS

193 patients with COPD were invited, 73 accepted and 55 participated in the educational program.

INTERVENTIONS

Respiratory rehabilitation educational program with basic concepts of pulmonary and respiratory pathophysiology, respiratory physiotherapy exercises, practical workshop on the use of the most frequent inhalation devices, understanding of chronic disease and self-care measures in case of exacerbation.

MAIN MEASUREMENTS

The quality of life (the COPD assessment test), exercise tolerance (the Six-Minute Walk Test), rating of perceived exertion (Borg Dyspnoea Score) and clinical risk (BODE index) were assessed by means of validated questionnaires in Spanish.

RESULTS

A total of 43 (78.2%) participants completed the program. An improvement in the quality of life by a mean of 3.3 points was observed (95%CI; 1.76-4.84). Just over half (53.5%) of the participants obtained a clinically relevant improvement. Participants also improved their physical exercise capacity at post-intervention by increasing the distance that they walked in 6min by a mean of 20.76m (95%CI; 2.57-38.95). Improvements in the level of dyspnoea and clinical risk were also observed.

CONCLUSIONS

The educational program shows a statistically significant and clinically relevant improvement in the quality of life, fatigue, symptomatology, exercise capacity, level of dyspnoea, and clinical risk. The program is adaptable to the health care routine of healthcare centres.

Home-Based, Moderate-Intensity Exercise Training Using a Metronome Improves the Breathing Pattern and Oxygen Saturation During Exercise in Patients With COPD

PURPOSE

One of the well-known but less-investigated effects of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) is the change in breathing pattern toward a more efficient one (higher tidal volume [VT], lower breathing frequency). Evidence suggests this change can be obtained only with supervised, high-intensity exercise training (ExTr). However, some patients either do not have such programs available or are unable to exercise at higher intensity. We evaluated the effects of a 12-wk, moderate-intensity, home-monitored ExTr program using a metronome on the breathing pattern, oxygen saturation (SpO2), and dyspnea during exercise in patients with COPD.

METHODS

Twenty-one patients with COPD (7 female, aged 64-85 yr) performed spirometry, incremental, and endurance walking tests (at 60% of maximal walking speed) on a treadmill before and after training. During the endurance test, patients were equipped with an instrument that continuously monitored ventilation ((Equation is included in full-text article.)E), breathing pattern, and SpO2. Patients trained at home for 12 wk, 30 min/d for at least 4 d/wk at moderate intensity. A metronome paced the walking speed.

RESULTS

Sixteen patients completed the program. After training, a significant change was observed in breathing pattern (lower (Equation is included in full-text article.)E and (Equation is included in full-text article.)E/VT ratio; P < .001), a higher SpO2 (P < .001), and a lower dyspnea perception at the same work intensity (P < .01). The (Equation is included in full-text article.)E/VT ratio and SpO2 during exercise were significantly related (r = 0.56, P = .001).

CONCLUSION

A change in breathing pattern towards more efficient ventilation can be obtained with a moderate, home-monitored ExTr program with a pace that is controlled by a metronome. Decreased (Equation is included in full-text article.)E/VT was associated with an improved SpO2 during exercise.

Telerehabilitation versus traditional centre-based pulmonary rehabilitation for people with chronic respiratory disease: protocol for a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation is an effective therapeutic intervention for people with chronic respiratory disease. However, fewer than 5% of eligible individuals receive pulmonary rehabilitation on an annual basis, largely due to limited availability of services and difficulties associated with travel and transport. The Rehabilitation Exercise At Home (REAcH) study is an assessor-blinded, multi-centre, randomised controlled equivalence trial designed to compare the efficacy of home-based telerehabilitation and traditional centre-based pulmonary rehabilitation in people with chronic respiratory disease.

METHODS

Participants will undertake an 8-week group-based pulmonary rehabilitation program of twice-weekly supervised exercise training, either in-person at a centre-based pulmonary rehabilitation program or remotely from their home via the Internet. Supervised exercise training sessions will include 30 min of aerobic exercise (cycle and/or walking training). Individualised education and self-management training will be delivered. All participants will be prescribed a home exercise program of walking and strengthening activities. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and 12-months post intervention. The primary outcome is change in dyspnea score as measured by the Chronic Respiratory Questionnaire - dyspnea domain (CRQ-D). Secondary outcomes will evaluate the efficacy of telerehabilitation on 6-min walk distance, endurance cycle time during a constant work rate test, physical activity and quality of life. Adherence to pulmonary rehabilitation between the two models will be compared. A full economic analysis from a societal perspective will be undertaken to determine the cost-effectiveness of telerehabilitation compared to centre-based pulmonary rehabilitation.

DISCUSSION

Alternative models of pulmonary rehabilitation are required to improve both equity of access and patient-related outcomes. This trial will establish whether telerehabilitation can achieve equivalent improvement in outcomes compared to traditional centre-based pulmonary rehabilitation. If efficacious and cost-effective, the proposed telerehabilitation model is designed to be rapidly deployed into clinical practice.

TRIAL REGISTRATION

Clinical trial registered with the Australian and New Zealand Clinical Trials Register at ( ACTRN12616000360415 ). Registered 21 March 2016.

Influence of Disease Severity and Exercise Limitation on Exercise Training Intensity and Load and Health Benefits From Pulmonary Rehabilitation in Patients With COPD: AN EXPLORATORY STUDY

PURPOSE

Some patients with chronic obstructive pulmonary disease (COPD) fail to achieve health benefits with pulmonary rehabilitation (PR). Exercise intensity and load represent stimulus for adaptation but it is unclear whether inappropriate exercise intensity and/or load are affected by severity of COPD, which may affect health benefits. The purpose was to determine whether COPD severity and/or the severity of pulmonary limitation to exercise (PLE) impacted exercising intensity or load and whether resultant intensity/load affected health outcomes derived from PR.

METHODS

Patients with COPD (n = 58, age = 67 ± 7 y, forced expiratory volume in the first second of expiration [FEV1] % predicted = 52 ± 21%) were recruited upon referral to PR. Primary health outcomes evaluated were 6-min walk distance and St George's Respiratory Questionnaire. Patients were stratified for disease severity using Global Initiative for Obstructive Lung Disease (GOLD) staging and PLE severity by change in inspiratory capacity during exercise. Exercise intensity and load were calculated from daily exercise records.

RESULTS

Participants achieved comparable training duration and load regardless of GOLD severity. Patients with more severe PLE achieved greater training duration (more severe: 546 ± 143 min., less severe: 451 ± 109 min., P = .036), and relative training load (more severe: 2200.8 ± 595.3 kcal, less severe: 1648.3 ± 597.8 kcal, P = .007). Greater overall training load was associated with greater improvements in 6-min walk distance (r = 0.24, P = .035). No significant relationships were observed between PLE, GOLD severity, training parameters, and St George's Respiratory Questionnaire response.

CONCLUSIONS

Improvements in exercise tolerance can be explained by achieving greater training loads, demonstrating the importance of appropriate training load to maximize health outcomes in PR.

A Simplified Approach to Select Exercise Endurance Intensity for Interventional Studies in COPD

Time to exercise limitation (Tlim) in response to constant work rate (CWR) is sensitive to interventions in chronic obstructive pulmonary disease (COPD). This is particularly true when the pre-intervention test lasts between 3 and 8 min (Tlim_3'-8'). There is, however, no simple method to select a work rate which is consistently associated with Tlim_3'-8' across the spectrum of COPD severity. We assessed 59 GOLD stages II-IV patients who initially cycled to Tlim at 75% peak. In case of short (<3 min, low-endurance) or long (>8 min, high-endurance) tests, patients exercised after 60 min at 50% or 90%, respectively (CWR_{50%⇐75%⇒90%}). Critical mechanical constraints and limiting dyspnea at 75% were reached within the desired timeframe in 27 "mid-endurance" patients (46%). Increasing work rate intensity to 90% hastened the mechanical-ventilatory responses leading to Tlim_3'-8' in 23/26 (88%) "high-endurance" patients; conversely, decreasing exercise intensity to 50% slowed those responses leading to Tlim_3'-8' in 5/6 (83%) "high-endurance" patients. Repeating the tests at higher (60%) or lower (80%) intensities fail to consistently produce Tlim_3'-8' in "low-" and "high-endurance", respectively (p > 0.05). Compared to a fixed work rate at 75%, CWR_{50%⇐75%⇒90%} significantly decreased Tlim's coefficient of variation; consequently, the required N to detect 100 s or 33% improvement in Tlim decreased from 82 to 26 and 41 to 14, respectively. This simplified approach to individualized work rate adjustment (CWR_{50%⇐75%⇒90%}) might allow greater sensitivity in evaluating interventional efficacy in improving respiratory mechanics and exercise tolerance while simultaneously reducing sample size requirements in patients with COPD.

A Lifestyle Physical Activity Intervention for Patients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial

RATIONALE

Physical inactivity is associated with poor outcomes among patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To determine effectiveness of a behavioral intervention intended to increase daily physical activity with the goal of improving health-related quality of life and functional performance.

METHODS

We conducted a randomized trial among patients with COPD cared for in primary care and pulmonary clinics. The patients were at least 45 years of age and eligible for pulmonary rehabilitation. All patients received self-management education during a 6-week run-in period. Subsequently, patients were randomized to usual care or the intervention delivered over 20 weeks.

MEASUREMENTS AND MAIN RESULTS

Co-primary outcomes were change from baseline in Chronic Respiratory Questionnaire dyspnea domain score and 6-minute-walk distance measured at 6, 12, and 18 months after randomization. A total of 325 patients were enrolled, with 156 randomized to receive usual care and 149 to receive the intervention. At 18 months, there was no overall statistical or clinically significant change in the dyspnea domain in either group. However, for 6-minute-walk distance, there were statistically significant declines in both groups. In contrast, 6-minute-walk distance remained stable (5.3 m; P = 0.54) among patients in the intervention group with moderate spirometric impairment, but it was associated with clinically and statistically significant declines (-28.7 m; P = 0.0001) among usual care patients with moderate spirometric impairment. Overall, there was no increase in adverse events associated with the intervention, which was associated with a lower prevalence of hospitalization for COPD exacerbations (28.3%) compared with usual care (49.5%).

CONCLUSIONS

During this 18-month trial among outpatients with COPD, a health coach-based behavioral intervention did not improve scores in the dyspnea domain of the Chronic Respiratory Questionnaire or 6-minute-walk test distance. However, subgroup analyses suggested that there may be differential effects for specific outcomes that vary with severity of COPD. Specifically, benefits of this low-intensity intervention may be limited to 6-minute walk distance among patients with moderate spirometric impairment. Clinical trial registered with www.clinicaltrials.gov (NCT1108991).

Effect of exercise type on smoking cessation: a meta-analysis of randomized controlled trials

Background

Exercise is one choice of additional treatment for smoking cessation by relieving nicotine withdrawal symptoms and smoking craving. The possible mechanism of the effect of exercise on relieving nicotine withdrawal symptoms and smoking craving is including affect, biological, and cognitive hypotheses. Evidence suggests that different types of exercise have different effects on these mechanisms. Therefore, type of exercise might have effect on smoking cessation. The purpose of this study is to systematically review randomized controlled trials to gain insight into which types of exercise are effective for smoking cessation.

Methods

Publications were systemically searched up to November 2016 in several databases (PubMed, ScienceDirect, PEDro, Web of Science, Scopus and Cochrane Library), using the following keywords: “physical activity”, “exercise”, “smoking”, “tobacco” and “cigarette”. The methodological quality was assessed independently by two authors. Meta-analysis was conducted to examine the effectiveness of the type of exercise on smoking cessation. The quality of the evidence was assessed and rated according to the GRADE approach.

Results

20 articles on 19 studies were judged to meet the selection criteria (seven low-risk of bias RCTs and 12 high-risk of bias RCTs). The findings revealed low quality evidence for the effectiveness of yoga for smoking cessation at the end of the treatment. The evidence found for no effect of aerobic exercise, resisted exercise, and a combined aerobic and resisted exercise program on smoking cessation was of low to moderate quality. Furthermore, very low to low quality evidence was found for no effect of physical activity on smoking cessation.

Conclusions

There was no effect of aerobic exercise, resisted exercise, physical activity and combined aerobic and resisted exercise on smoking cessation. There was a positive effect on smoking cessation at the end of treatment in the program where yoga plus cognitive-behavioral therapy (CBT) was used. However, which of the two work is still to be studied.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2762-y) contains supplementary material, which is available to authorized users.

Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: a randomised non-inferiority trial

BACKGROUND

Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD.

METHODS

A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV₁% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units.

RESULTS

There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: -0.24, 95% CI -0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks.

CONCLUSIONS

The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation.

TRIAL REGISTRATION NUMBER

ISRCTN81189044.

A Novel Remote Rehabilitation System with the Fusion of Noninvasive Wearable Device and Motion Sensing for Pulmonary Patients

Chronic obstructive pulmonary disease is a type of lung disease caused by chronically poor airflow that makes breathing difficult. As a chronic illness, it typically worsens over time. Therefore, pulmonary rehabilitation exercises and patient management for extensive periods of time are required. This paper presents a remote rehabilitation system for a multimodal sensors-based application for patients who have chronic breathing difficulties. The process involves the fusion of sensory data-captured motion data by stereo-camera and photoplethysmogram signal by a wearable PPG sensor-that are the input variables of a detection and evaluation framework. In addition, we incorporated a set of rehabilitation exercises specific for pulmonary patients into the system by fusing sensory data. Simultaneously, the system also features medical functions that accommodate the needs of medical professionals and those which ease the use of the application for patients, including exercises for tracking progress, patient performance, exercise assignments, and exercise guidance. Finally, the results indicate the accurate determination of pulmonary exercises from the fusion of sensory data. This remote rehabilitation system provides a comfortable and cost-effective option in the healthcare rehabilitation system.

Australian and New Zealand Pulmonary Rehabilitation Guidelines

BACKGROUND AND OBJECTIVE

The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts.

METHODS

The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts.

RESULTS

The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary.

CONCLUSION

The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial

BACKGROUND

Pulmonary rehabilitation is a cornerstone of care for COPD but uptake of traditional centre-based programmes is poor. We assessed whether home-based pulmonary rehabilitation, delivered using minimal resources, had equivalent outcomes to centre-based pulmonary rehabilitation.

METHODS

A randomised controlled equivalence trial with 12 months follow-up. Participants with stable COPD were randomly assigned to receive 8 weeks of pulmonary rehabilitation by either the standard outpatient centre-based model, or a new home-based model including one home visit and seven once-weekly telephone calls from a physiotherapist. The primary outcome was change in 6 min walk distance (6MWD).

RESULTS

We enrolled 166 participants to receive centre-based rehabilitation (n=86) or home-based rehabilitation (n=80). Intention-to-treat analysis confirmed non-inferiority of home-based rehabilitation for 6MWD at end-rehabilitation and the confidence interval (CI) did not rule out superiority (mean difference favouring home group 18.6 m, 95% CI -3.3 to 40.7). At 12 months the CI did not exclude inferiority (-5.1 m, -29.2 to 18.9). Between-group differences for dyspnoea-related quality of life did not rule out superiority of home-based rehabilitation at programme completion (1.6 points, -0.3 to 3.5) and groups were equivalent at 12 months (0.05 points, -2.0 to 2.1). The per-protocol analysis showed the same pattern of findings. Neither group maintained postrehabilitation gains at 12 months.

CONCLUSIONS

This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation. Neither model was effective in maintaining gains at 12 months. Home-based pulmonary rehabilitation could be considered for people with COPD who cannot access centre-based pulmonary rehabilitation.

TRIAL REGISTRATION NUMBER

NCT01423227, clinicaltrials.gov.

The trajectory of change over multiple outcome areas during comprehensive outpatient pulmonary rehabilitation

Although pulmonary rehabilitation has proven effectiveness in multiple outcome areas, the optimum duration of this intervention is not clear. We evaluated in an observational study the trajectory of change in upper and lower extremity exercise performance, exertional dyspnea and health status over the course of 12 weeks (24 sessions) of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease. Demonstrating a plateau in response in these areas might be of practical use for pulmonary rehabilitation programs. We measured outcomes at baseline and at four session (two week) intervals over the course of our comprehensive outpatient pulmonary rehabilitation program. These included treadmill endurance time at approximately 85% of initial maximal workrate, the number of arm lifts per minute, dyspnea at isotime during treadmill walking and the Chronic Respiratory Disease Questionnaire (CRQ) total score. Thirteen patients with chronic obstructure pulmonary disease (COPD) (five male, eight female) were studied; their age was 66 ± 8 years and their FEV1 was 34 ± 1% of predicted. Improvement was noted in all four outcome areas very early in the course of pulmonary rehabilitation. Treadmill endurance time and arm lifts increased significantly over baseline by the fourth and eighth session, respectively, and both increased in a near linear fashion throughout pulmonary rehabilitation. Exertional dyspnea and CRQ also improved very early, with each showing a significant change from baseline by the fourth session. Their improvement, however, appeared to plateau relatively early during the course of pulmonary rehabilitation. Although the numbers studied are small and the applicability of these results to other programs is undetermined, this study does suggest that 20 or more sessions are needed for optimal acute changes in exercise performance, but improvement in dyspnea and quality of life may occur earlier.

High versus low intensity exercise training in pulmonary rehabilitation: is more better?

Background:Exercise training is considered a necessary component of comprehensive pulmonary rehabilitation. However, to date, there is no consensus on an exercise training strategy for pulmonary rehabilitation, and this has resulted in varied approaches to this intervention in its literature. As in healthy individuals, the effect of exercise training on patients with chronic lung disease is dose dependent, with higher intensities resulting in greater physiological adaptations than lower intensities. Results:It is not clear from our review of the literature that these enhanced physiological effects from higher levels of exercise training translate into a reduced burden of symptoms, hence a better quality of life. Indeed, there is some evidence that pulmonary rehabilitation approaches incorporating lower intensities of exercise training are at least as good in improving questionnaire rated symptoms of health status. This provides food for thought, since the prominent goal of pulmonary rehabilitation should be to reduce bothersome symptoms or enhance health status, not simply increase endurance time on a cycle ergometer.

REABILITAÇÃO DOMICILIAR COM EXERCÍCIO NÃO SUPERVISIONADO NA DPOC: REVISÃO SISTEMÁTICA

RESUMO O objetivo desta revisão sistemática foi verificar os efeitos de programas de reabilitação pulmonar com exercícios domiciliares não supervisionados em pacientes com doença pulmonar obstrutiva crônica (DPOC), uma vez que a baixa disponibilidade de centros especializados no país, alto custo e outros fatores fazem com que poucos doentes tenham acesso a programas de reabilitação supervisionados em ambiente ambulatorial. Foram selecionados pelos autores oito ensaios clínicos controlados e randomizados que atendiam aos critérios de inclusão, atingiram pontuação mínima de cinco pontos na escala PEDro, publicados até novembro de 2014 na base de dados PubMed. Cinco desses trabalhos compararam um grupo de reabilitação domiciliar não supervisionado (GRNS) com um controle sem exercício (GC) e três compararam GRNS com um grupo que participou de reabilitação supervisionada (GRS) como controle. Os principais desfechos avaliados foram: capacidade funcional, função pulmonar, dispneia e qualidade de vida. De acordo com a análise realizada foi possível demonstrar que o treinamento não supervisionado em ambiente domiciliar ou na comunidade pode ser uma alternativa para pacientes estáveis com DPOC moderada à grave, visando sobretudo os benefícios relacionados à qualidade de vida e à dispneia; não foi possível verificar melhora em outros desfechos. Além disso, parece que esta forma de reabilitação no tratamento desses pacientes é segura e viável, porém mais estudos são necessários para averiguar os efeitos do treinamento automonitorado em outros desfechos.

Outpatient-based physical rehabilitation for survivors of prolonged critical illness: A randomized controlled trial

INTRODUCTION

The physical and psychological impact of critical illness is well documented. Recovery may take many months and is often incomplete. The optimal way of addressing these important sequelae following hospital discharge remains unclear.

METHODS

Single center, randomized controlled trial in patients invasively ventilated for ≥5 days. The treatment group (TG) underwent a 7-week, outpatient-based exercise and education program, with the control group (CG) receiving no intervention during the study period. Primary outcome measures were changes in functional capacity assessed using the cardiopulmonary exercise testing parameters, peak VO2, and anaerobic threshold (AT). Secondary outcome measures were changes in and health-related quality of life assessed using the Short Form 36 version 2 questionnaire. Assessors remained blinded to group allocation.

RESULTS

Sixty-three patients completed the study (target n = 90). Improvements in both peak VO2 and AT were seen in both TG and CG but no significant difference between groups was evident. AT improved by 11.7% in CG (baseline 10.3 ml O2 kg(-1) min(-1), follow-up 11.5 ml O2 kg(-1) min(-1)), and by 14.6% in TG (baseline 10.3 ml O2 kg(-1) min(-1), follow-up 11.8 ml O2 kg(-1) min(-1); ANCOVA p = 0.74). Peak VO2 improved by 14.0% in CG (baseline 13.6 ml O2 kg(-1) min(-1), follow-up 15.5 ml O2 kg(-1) min(-1)), and by 18.8% in TG (baseline 13.8 ml O2 kg(-1) min(-1), follow-up 16.4 ml O2 kg(-1) min(-1); ANCOVA p = 0.68). Significant improvements were seen in both groups for physical component summary scores (PCS) (TG 39.6 versus 31.0; CG 36.1 versus 32.6) and mental component summary scores (MCS) (TG 48.6 versus 38.4; CG 41.3 versus 37.0). The degree of improvement was significantly higher in the treatment group in comparison to control subjects (PCS p = 0.048; MCS p = 0.017). This improvement was most marked in the subgroup ventilated for >14 days.

CONCLUSIONS

A 7-week, outpatient-based exercise and education program resulted in improved health-related quality of life scores but not improved exercise capacity.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Use of exercise testing in the evaluation of interventional efficacy: an official ERS statement

This document reviews 1) the measurement properties of commonly used exercise tests in patients with chronic respiratory diseases and 2) published studies on their utilty and/or evaluation obtained from MEDLINE and Cochrane Library searches between 1990 and March 2015.

Exercise tests are reliable and consistently responsive to rehabilitative and pharmacological interventions. Thresholds for clinically important changes in performance are available for several tests. In pulmonary arterial hypertension, the 6-min walk test (6MWT), peak oxygen uptake and ventilation/carbon dioxide output indices appear to be the variables most responsive to vasodilators. While bronchodilators do not always show clinically relevant effects in chronic obstructive pulmonary disease, high-intensity constant work-rate (endurance) tests (CWRET) are considerably more responsive than incremental exercise tests and 6MWTs. High-intensity CWRETs need to be standardised to reduce interindividual variability. Additional physiological information and responsiveness can be obtained from isotime measurements, particularly of inspiratory capacity and dyspnoea. Less evidence is available for the endurance shuttle walk test. Although the incremental shuttle walk test and 6MWT are reliable and less expensive than cardiopulmonary exercise testing, two repetitions are needed at baseline. All exercise tests are safe when recommended precautions are followed, with evidence suggesting that no test is safer than others.

Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Abstract: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide, and outpatient pulmonary rehabilitation (OPR) has shown positive results. The aim of this study was to investigate the effects of home or community-based pulmonary rehabilitation (HCPR) in individuals with COPD. This systematic review and meta-analysis of randomized clinical trials compared HCPR to controls and HCPR to OPR according to functional capacity, dyspnea, and quality of life in individuals with COPD. 3,172 citations were identified in databases, and 23 were included in this review. HCPR proved superior to controls based on functional capacity in the 6-Minute Walk Test and Incremental Shuttle Walk Test, and based on dyspnea and quality of life in the Saint George's Respiratory Questionnaire and the Chronic Respiratory Questionnaire. When HCPR and OPR were compared, there were no effect differences in functional capacity or quality of life. Improvement was greater in patients with more bronchial obstruction measured by FEV1. HCPR improves functional capacity and quality of life and decreases the sensation of dyspnea. Its benefits in functional capacity and quality of life are comparable to those obtained with OPR in individuals with COPD.

Efficacy of Tiotropium Bromide and Rehabilitation Treatment on Pulmonary Function of Patients With Sulfur Mustard Lung Injury

Background:

Chronic pulmonary complication is the most common delayed toxic effect of sulfur mustard (SM) and it has no treatment so far.

Objectives:

To evaluate short-term therapeutic effects of inhaled tiotropium bromide and pulmonary rehabilitation on pulmonary function of patients with SM induced lung injury.

Patients and Methods:

In a randomized clinical trial, using convenient sampling method, 54 patients with chronic lung disease due to SM exposure were recruited in Baqiyatallah General Hospital, Tehran, Iran for a period of 2-month study. They were randomly divided into 3 groups of 18 participants each. Group 1 received routine drugs (Serevent, Flixotide), pulmonary rehabilitation 30 minutes/2 times a week, and tiotropium bromide 18 µg/day. Group 2 was treated with routine drugs and pulmonary rehabilitation and group 3 was only on the routine drugs. cardiopulmonary exercise test (CPET), plethysmographic measurements, and respiratory symptoms evaluation were performed before and after medical intervention.

Results:

In group 1, compared to group 3, significant differences were found with regard to symptoms of cough ([difference between the first and last visit in group 1: Diff 1] = -1.6, Diff 3 = -0.3, P = 0.01) and nocturnal dyspnea (Diff 1 = -1.9, Diff 3 = 0.0, P = 0.01), likewise, compared to group 2, significant differences were found with regard to lung function parameters of forced vital capacity (Diff 1 = 3.0, Diff 2 = -3.5, P = 0.03), forced expiratory volume in one second (Diff 1 = 3.9, Diff 2 = -5.6, P = 0.009), maximal mid-expiratory flow rate 25% - 75% (Diff 1 = 1.5, Diff 2 = -3.2, P = 0.007) and peak expiratory flow (Diff 1 = -2.06, Diff 2 = -4.3, P = 0.04). Total lung capacity (Diff 2 = 9.28, Diff 3 = -12.07, P = 0.02) and residual volume (Diff2 = 32.1, Diff3 = -27.6, P = 0.04) were increased in group 2 compared to group 3. There were no significant differences with regard to CPET results among all groups (P > 0.05).

Conclusions:

Inhalation of tiotropium bromide in combination with pulmonary rehabilitation could improve some plethysmographic lung volumes and clinical outcomes in patients with chronic pulmonary disease due to SM. Short-term prescription of pulmonary rehabilitation has no effect on CPET of patients.

Long-term evaluation of home-based pulmonary rehabilitation in patients with COPD

Introduction

Personalized, global pulmonary rehabilitation (PR) management of patients with COPD is effective, regardless of the place in which this rehabilitation is provided. The objective of this retrospective observational study was to study the long-term outcome of exercise capacity and quality of life during management of patients with COPD treated by home-based PR.

Methods

Home-based PR was administered to 211 patients with COPD (mean age, 62.3±11.1 years; mean forced expiratory volume in 1 second, 41.5%±17.7%). Home-based PR was chosen because of the distance of the patient’s home from the PR center and the patient’s preference. Each patient was individually managed by a team member once a week for 8 weeks with unsupervised continuation of physical exercises on the other days of the week according to an individual action plan. Exercise conditioning, therapeutic patient education, and self-management were included in the PR program. The home assessment comprised evaluation of the patient’s exercise capacity by a 6-minute stepper test, Timed Up and Go test, ten times sit-to-stand test, Hospital Anxiety and Depression score, and quality of life (Visual Simplified Respiratory Questionnaire, VQ11, Maugeri Respiratory Failure 28).

Results

No incidents or accidents were observed during the course of home-based PR. The 6-minute stepper test was significantly improved after completion of the program, at 6 months and 12 months, whereas the Timed Up and Go and ten times sit-to-stand test were improved after PR and at 6 months but not at 12 months. Hospital Anxiety and Depression and quality of life scores improved after PR, and this improvement persisted at 6 months and 12 months.

Conclusion

Home-based PR for unselected patients with COPD is effective in the short term, and this effectiveness is maintained in the medium term (6 months) and long term (12 months). Home-based PR is an alternative to outpatient management provided all activities, such as exercise conditioning, therapeutic education, and self-management are performed.

A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN)

Background

Self-management support interventions can improve health outcomes, but their impact is limited by the numbers of patients able or willing to access them. Men’s attendance at, and engagement with, self-management support appears suboptimal despite their increased risk of developing serious and disabling long-term conditions (LTCs).

Objectives

To assess the effectiveness, cost-effectiveness, accessibility and acceptability of self-management support interventions in men with LTCs.

Methods

A quantitative systematic review with meta-analysis and a qualitative review using a metaethnography approach. The findings of the two reviews were integrated in parallel synthesis.

Data sources

In the quantitative review, the Cochrane Database of Systematic Reviews was searched to identify published reviews of self-management support interventions. Relevant reviews were screened to identify randomised controlled trials (RCTs) of self-management support interventions conducted in men alone, or which analysed the effects of interventions by gender. In the qualitative review, the databases Cumulative Index to Nursing and Allied Health Literature, EMBASE, Medical Literature Analysis and Retrieval System Online, PsycINFO and Social Science Citation Index (July 2013) were searched from inception to July 2013.

Review methods

In the quantitative review, data on relevant outcomes, patient populations, intervention type and study quality were extracted. Quality appraisal was conducted independently by two reviewers using the Cochrane risk of bias tool. Meta-analysis was conducted to compare the effects of interventions in male, female and mixed-sex groups. In the metaethnography, study details, participant quotes (first-order constructs) and study authors’ themes/concepts (second-order constructs) were extracted. Quality appraisal was conducted independently by two reviewers using the Critical Appraisal Skills Programme tool. Data were synthesised according to a metaethnography approach. Third-order interpretations/constructs were derived from the extracted data and integrated to generate a ‘line-of-argument’ synthesis.

Results

Forty RCTs of self-management support interventions in male-only samples, and 20 RCTs where an analysis by gender was reported, were included in the quantitative review. Meta-analysis suggested that interventions including physical activity, education and peer support have a positive impact on quality of life in men, and that men may derive more benefit than women from them, but there is currently insufficient evidence to draw definitive conclusions. Thirty-eight qualitative studies relevant to men’s experiences of, and perceptions of, self-management support were included in the qualitative review. The metaethnography identified four concepts: (1) need for purpose; (2) trusted environments; (3) value of peers; and (4) becoming an expert. Findings indicated that men may feel less comfortable engaging in support if it is perceived to be incongruous with valued aspects of masculine identities. Men may find support interventions more attractive when they have a clear purpose, are action-oriented and offer practical strategies that can be integrated into daily life. Support delivered in an environment that offers a sense of shared understanding can be particularly appealing to some men.

Conclusions

Health professionals and those involved in designing interventions may wish to consider whether or not certain components (e.g. physical activity, education, peer support) are particularly effective in men, although more research is needed to fully determine and explore this. Interventions are most likely to be accessible and acceptable to men when working with, not against, valued aspects of masculine identities.

Study registration

This study is registered as PROSPERO CRD42013005394.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Guidelines for the evaluation and treatment of muscle dysfunction in patients with chronic obstructive pulmonary disease

In patients with chronic obstructive pulmonary disease (COPD), skeletal muscle dysfunction is a major comorbidity that negatively impacts their exercise capacity and quality of life. In the current guidelines, the most recent literature on the various aspects of COPD muscle dysfunction has been included. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) scale has been used to make evidence-based recommendations on the different features. Compared to a control population, one third of COPD patients exhibited a 25% decline in quadriceps muscle strength, even at early stages of their disease. Although both respiratory and limb muscles are altered, the latter are usually more severely affected. Numerous factors and biological mechanisms are involved in the etiology of COPD muscle dysfunction. Several tests are proposed in order to diagnose and evaluate the degree of muscle dysfunction of both respiratory and limb muscles (peripheral), as well as to identify the patients' exercise capacity (six-minute walking test and cycloergometry). Currently available therapeutic strategies including the different training modalities and pharmacological and nutritional support are also described.

Four patients with a history of acute exacerbations of COPD: implementing the CHEST/Canadian Thoracic Society guidelines for preventing exacerbations

The American College of Chest Physicians and Canadian Thoracic Society have jointly produced evidence-based guidelines for the prevention of exacerbations in chronic obstructive pulmonary disease (COPD). This educational article gives four perspectives on how these guidelines apply to the practical management of people with COPD. A current smoker with frequent exacerbations will benefit from support to quit, and from optimisation of his inhaled treatment. For a man with very severe COPD and multiple co-morbidities living in a remote community, tele-health care may enable provision of multidisciplinary care. A woman who is admitted for the third time in a year needs a structured assessment of her care with a view to stepping up pharmacological and non-pharmacological treatment as required. The overlap between asthma and COPD challenges both diagnostic and management strategies for a lady smoker with a history of asthma since childhood. Common threads in all these cases are the importance of advising on smoking cessation, offering (and encouraging people to attend) pulmonary rehabilitation, and the importance of self-management, including an action plan supported by multidisciplinary teams.

The effects of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomised controlled trial

OBJECTIVES

Pulmonary rehabilitation (PR) provides benefit for patients with chronic obstructive pulmonary disease (COPD) in terms of quality of life (QoL) and exercise capacity; however, the effects diminish over time. Our aim was to evaluate a maintenance programme for patients who had completed PR.

SETTING

Primary and secondary care PR programmes in Norfolk.

PARTICIPANTS

148 patients with COPD who had completed at least 60% of a standard PR programme were randomised and data are available for 110 patients. Patients had greater than 20 pack year smoking history and less than 80% predicted forced expiratory volume in 1 s but no other significant disease or recent respiratory tract infection.

INTERVENTIONS

Patients were randomised to receive a maintenance programme or standard care. The maintenance programme consisted of 2 h (1 h individually tailored exercise training and 1 h education programme) every 3 months for 1 year.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Chronic Respiratory Questionnaire (CRQ) (primary outcome), endurance shuttle walk test (ESWT), EuroQol (EQ5D), hospital anxiety and depression score (HADS), body mass index (BMI), body fat, activity levels (overall score and activity diary) and exacerbations were assessed before and after 12 months.

RESULTS

There was no statistically significant difference between the groups for the change in CRQ dyspnoea score (primary end point) at 12 months which amounted to 0.19 (-0.26 to 0.64) units or other domains of the CRQ. There was no difference in the ESWT duration (-10.06 (-191.16 to 171.03) seconds), BMI, body fat, EQ5D, MET-minutes, activity rating, HADS, exacerbations or admissions.

CONCLUSIONS

A maintenance programme of three monthly 2 h sessions does not improve outcomes in patients with COPD after 12 months. We do not recommend that our maintenance programme is adopted. Other methods of sustaining the benefits of PR are required.

TRIAL REGISTRATION NUMBER

NCT00925171.

Chronic obstructive pulmonary disease self-management activation research trial (COPD-SMART): results of recruitment and baseline patient characteristics

OBJECTIVE

To describe the recruitment methods, study participation rate, and baseline characteristics of a representative sample of outpatients with COPD eligible for pulmonary rehabilitation participating in a trial of a lifestyle behavioral intervention to increase physical activity.

SETTING AND DESIGN

A patient registry was developed for recruitment using an administrative database from primary care and specialty clinics of an academic medical center in northeast Texas for a parallel group randomized trial.

RESULTS

The registry was comprised of 5582 patients and over the course of the 30 month recruitment period 325 patients were enrolled for an overall study participation rate of 35.1%. After a 6-week COPD self-management education period provided to all enrolled patients, 305 patients were randomized into either usual care (UC; n=156) or the physical activity self-management intervention (PASM; n=149). There were no clinically significant differences in demographics, clinical characteristics, or health status indicators between the randomized groups.

CONCLUSION

The results of this recruitment process demonstrate the successful use of a patient registry for enrolling a representative sample of outpatients eligible for pulmonary rehabilitation with COPD from primary and specialty care. Moreover, this approach to patient recruitment provides a model for future studies utilizing administrative databases and electronic health records.

Pulmonary rehabilitation for COPD: are programs with minimal exercise equipment effective?

Pulmonary rehabilitation is an essential component of chronic obstructive pulmonary disease (COPD) management with strong evidence supporting the efficacy of pulmonary rehabilitation to improve exercise capacity and quality of life, as well as reduce hospital admissions. However, it is estimated that only 2-5% of people with COPD who could benefit from pulmonary rehabilitation have access to programs. Most research on the benefits of pulmonary rehabilitation has used equipment such as cycle ergometers and treadmills for endurance training and weight machines for resistance training. To enable greater availability of pulmonary rehabilitation, the efficacy of exercise training using minimal equipment needs to be evaluated. Randomised controlled trials that used minimal, low cost equipment for endurance (eight trials) and strength training (three trials) compared to no training in people with COPD were evaluated. Statistically and clinically significant differences in functional exercise capacity and quality of life, as well as improvements in strength were demonstrated when exercise training with minimal equipment was compared to no training [six-minute walk test: mean difference 40 (95% CI: 13 to 67) metres; St George's Respiratory Questionnaire: mean difference -7 (95% CI: -12 to -3) points]. While the number of studies is relatively small and of variable quality, there is growing evidence that exercise training using minimal, low cost equipment may be an alternative to equipment-intensive pulmonary rehabilitation programs.

Pedometers to enhance physical activity in COPD: a randomised controlled trial

Physical inactivity is a cardinal feature of chronic obstructive pulmonary disease (COPD), and is associated with increased morbidity and mortality. Pedometers, which have been used in healthy populations, might also increase physical activity in patients with COPD. COPD patients taking part in a 3-month individualised programme to promote an increase in their daily physical activity were randomised to either a standard programme of physical activity encouragement alone, or a pedometer-based programme. Assessments were performed by investigators blinded to treatment allocation. Change in average 1-week daily step count, 6-min walking distance (6MWD), modified Medical Research Council scale, St George's respiratory questionnaire (SGRQ) and COPD assessment test (CAT) were compared between groups. 102 patients were recruited, of whom 97 completed the programme (pedometer group: n=50; control group: n=47); 60.8% were male with a mean±sd age of 68.7±8.5 years, and forced expiratory volume in 1 s (FEV1) 66.1±19.4% and FEV1/forced vital capacity 55.2±9.5%. Both groups had comparable characteristics at baseline. The pedometer group had significantly greater improvements in: physical activity 3080±3254 steps·day(-1) versus 138.3±1950 steps·day(-1) (p<0.001); SGRQ -8.8±12.2 versus -3.8±10.9 (p=0.01); CAT score -3.5±5.5 versus -0.6±6.6 (p=0.001); and 6MWD 12.4±34.6 versus -0.7±24.4 m (p=0.02) than patients receiving activity encouragement only. A simple physical activity enhancement programme using pedometers can effectively improve physical activity level and quality of life in COPD patients.