Activity monitoring and energy expenditure in COPD patients: a validation study

Machine Learning-Based 30-Day Hospital Readmission Predictions for COPD Patients Using Physical Activity Data of Daily Living with Accelerometer-Based Device

Chronic obstructive pulmonary disease (COPD) is a significantly concerning disease, and is ranked highest in terms of 30-day hospital readmission. Generally, physical activity (PA) of daily living reflects the health status and is proposed as a strong indicator of 30-day hospital readmission for patients with COPD. This study attempted to predict 30-day hospital readmission by analyzing continuous PA data using machine learning (ML) methods. Data were collected from 16 patients with COPD over 3877 days, and clinical information extracted from the patients’ hospital records. Activity-based parameters were conceptualized and evaluated, and ML models were trained and validated to retrospectively analyze the PA data, identify the nonlinear classification characteristics of different risk factors, and predict hospital readmissions. Overall, this study predicted 30-day hospital readmission and prediction performance is summarized as two distinct approaches: prediction-based performance and event-based performance. In a prediction-based performance analysis, readmissions predicted with 70.35% accuracy; and in an event-based performance analysis, the total 30-day readmissions were predicted with a precision of 72.73%. PA data reflect the health status; thus, PA data can be used to predict hospital readmissions. Predicting readmissions will improve patient care, reduce the burden of medical costs burden, and can assist in staging suitable interventions, such as promoting PA, alternate treatment plans, or changes in lifestyle to prevent readmissions.

Validity study of a triaxial accelerometer for measuring energy expenditure in stroke inpatients of a physical medicine and rehabilitation center

PURPOSE

Establish the validity of a triaxial accelerometer (Dynaport®) for evaluating the energy expenditure of patients with stroke sequelae at a rehabilitation hospital.

METHODS

This is a cross-sectional study with 24 stroke inpatients of a rehabilitation hospital. The participants were assessed on energy expenditure by an ergospirometer system and the triaxial accelerometer simultaneously during a walk test. The data collected by both devices were compared by intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement.

RESULTS

An almost perfect agreement (ICC = 0,94) in the energy expenditure measured by the accelerometer compared to the results of the ergospirometer system was found during the exercise test. The Bland-Altman analysis has shown suitable limits of agreement. Post hoc analyses with the maximum volume of oxygen and the total energy expenditure measured by the ergospirometer system evidenced significant correlation with the energy expenditure measurements by the accelerometer.

CONCLUSION

Our results evidence that the triaxial accelerometer Dynaport® and its built-in software are valid for estimating the energy expenditure of stroke sequelae during a walk exercise.

Monitoring Physical Activity with a Wearable Sensor in Patients with COPD during In-Hospital Pulmonary Rehabilitation Program: A Pilot Study

Accelerometers have become a standard method of monitoring physical activity in everyday life by measuring acceleration in one, two, or three axes. These devices provide reliable and objective measurements of the duration and intensity of physical activity. We aimed to investigate whether patients undertake physical activity during non-supervised days during stationary rehabilitation and whether patients adhere to the rigor of 24 h monitoring. The second objective was to analyze the strengths and weaknesses of such kinds of sensors. The research enrolled 13 randomly selected patients, qualified for in-patient, 3 week, high-intensity, 5 times a week pulmonary rehabilitation. The SenseWear armband was used for the assessment of physical activity. Participants wore the device 24 h a day for the next 4 days (Friday-Monday). The analysis of the number of steps per day, the time spent lying as well as undertaking moderate or vigorous physical activity (>3 metabolic equivalents of task (METs)), and the energy expenditure expressed in kcal showed no statistically significant difference between the training days and the days off. It seems beneficial to use available physical activity sensors in patients with chronic obstructive pulmonary disease (COPD); measurable parameters provide feedback that may increase the patient's motivation to be active to achieve health benefits.

Tossing and turning: association of sleep quantity-quality with physical activity in COPD

The association between characteristics of sleep and physical activity in daily life (PADL) has not yet been investigated in depth in subjects with COPD. This study evaluated whether time spent per day in physical activity (PA) and sedentary behaviour are associated with sleep quantity and quality in this population.

Sleep and PADL were objectively assessed by an activity monitor for 7 days and analysed on a minute-by-minute basis. Subjects also underwent spirometry and 6-min walking test (6MWT).

Fifty-five subjects with moderate-to-severe COPD (28 male, 67±8 years) were studied. Subjects with total time in bed (TIB) per night ≥9 h had higher wake-after-sleep onset than TIB 7–9 h and TIB ≤7 h (195 (147–218) versus 117 (75–167) and 106 (84–156) min) and more fragmented sleep than TIB ≤7 h (8.2 (6.7–14.3) versus 6.3 (5.6–6.9) sleeping bouts; p<0.05 for all). Subjects with TIB ≥9 h also spent more time per day in sedentary behaviour and less time per day in PA of light and moderate-to-vigorous intensity than those with TIB 7–9 h and ≤7 h. In multiple linear regression, TIB ≥9 h was the only significant predictor of physical inactivity (β=−3.3 (−5.1, −1.6), p≤0.0001), accounting for 20% of its variation. Sleep fragmentation was frequent and more pronounced in physically inactive than active patients (7.5 (6.3–9.6) versus 6.4 (5.5–7.3) sleeping bouts; p=0.027).

In summary, subjects with COPD with TIB ≥9 h·night⁻¹ have more fragmented sleep, are more sedentary and less physically active than those with <9 h·night⁻¹, independently of the awake time. Sleep quality is frequently poor and even worse in patients classified as physically inactive.

This study shows, for the first time, that sleep quantity is a determinant factor of objectively assessed level of physical activity in subjects with COPDhttps://bit.ly/3diOIlC

Physical activity and inactivity among different body composition phenotypes in individuals with moderate to very severe chronic obstructive pulmonary disease

BACKGROUND

The phenotype profiling of individuals with chronic obstructive pulmonary disease (COPD) according to impairments in body composition and level of physical activity in daily life (PADL) needs to be determined.

OBJECTIVE

To verify if individuals with COPD classified as physically active/inactive present different characteristics within different body composition phenotypes.

METHODS

Individuals with COPD were cross-sectionally stratified into four groups according to fat-free and fat mass indexes: Normal Body Composition (NBC), Obese (Ob), Sarcopenic (Sarc), and Sarcopenic/Obese (Sarc/Ob). Additionally, individuals had their PADL level objectively assessed through activity monitoring during two weekdays for at least 10h/day, and then were classified as physically active (Act) or inactive (Inact) according to international recommendations. Lung function (spirometry), exercise capacity (6-minute walking test [6MWT]) and peripheral muscle strength (1-repetition maximum [1RM]) were also assessed.

RESULTS

176 individuals with COPD (mean±standard deviation age: 67±8 years, body mass index 26±6kg/m², FEV1 47±16%predicted) were classified as: NBC+Act (17%), NBC+Inact (22%), Ob+Act (6%), Ob+Inact (10%), Sarc+Act (12%), Sarc+Inact (9%), Sarc/Ob+Act (8%) and Sarc/Ob+Inact (16%). The Sarc/Ob+Inact group presented lower 6MWT and 1RM for knee extension compared to NBC+Act, NBC+Inact, and Ob+Act groups (p<0.05). The Sarc/Ob+Inact group also presented lower FEV1% predicted, 1RM for elbow flexion and elbow extension compared to the NBC+Act and NBC+Inact groups and lower 1RM for elbow extension compared to Ob+Inact group (p<0.05).

CONCLUSION

The combination of sarcopenia, obesity, and physical inactivity was shown to be detrimental in individuals with COPD. Therefore, this profile is a main therapeutic target for improving PADL level and/or body composition.

Endoscopic Lung Volume Reduction in COPD: The Impact of Coil Implantation on Patients' Physical Activity

Endoscopic lung volume reduction (ELVR) is an emerging therapy option for the treatment of severe emphysema in COPD. To which extent patients profit from lung volume reduction via coils (LVRC) regarding morbidity, mortality, and quality of life is not clear yet. In this monocentric prospective cohort study, 13 COPD patients with severe emphysema (residual volume [RV] >225%) were enrolled at the University Hospital of Bonn. Activity measurements were assessed by a validated accelerometer wristband. By LVRC, RV could be reduced by 0.13 L to 5.54 ± 1.29 L. We could show a clinically relevant improvement in patients' physical activity after LVRC, measured as daily step count (497.7 ± 72.6 vs. 1,913.7 ± 182.7 steps/day, p = 0.03) and mean daily active energy expenditure (714.4 ± 73.6 vs. 2,321.3 ± 163.9 joules, p = 0.03). This improvement in physical activity is possibly associated with a positive effect on patients' morbidity and mortality.

Validity and Reliability of Accelerometers in Patients With COPD: A SYSTEMATIC REVIEW

PURPOSE

Reduced physical activity is associated with poor prognosis in chronic obstructive pulmonary disease (COPD). Accelerometers have greatly improved quantification of physical activity by providing information on step counts, body positions, energy expenditure, and magnitude of force. The purpose of this systematic review was to compare the validity and reliability of accelerometers used in patients with COPD.

METHODS

An electronic database search of MEDLINE and CINAHL was performed. Study quality was assessed with the Strengthening the Reporting of Observational Studies in Epidemiology checklist while methodological quality was assessed using the modified Quality Appraisal Tool for Reliability Studies.

RESULTS

The search yielded 5392 studies; 25 met inclusion criteria. The SenseWear Pro armband reported high criterion validity under controlled conditions (r = 0.75-0.93) and high reliability (ICC = 0.84-0.86) for step counts. The DynaPort MiniMod demonstrated highest concurrent validity for step count using both video and manual methods.

DISCUSSION

Validity of the SenseWear Pro armband varied between studies especially in free-living conditions, slower walking speeds, and with addition of weights during gait. A high degree of variability was found in the outcomes used and statistical analyses performed between studies, indicating a need for further studies to measure reliability and validity of accelerometers in COPD.

CONCLUSION

The SenseWear Pro armband is the most commonly used accelerometer in COPD, but measurement properties are limited by gait speed variability and assistive device use. DynaPort MiniMod and Stepwatch accelerometers demonstrated high validity in patients with COPD but lack reliability data.

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.

Impairments in dyspnea, exercise capacity, physical activity and quality of life of allogeneic hematopoietic stem cell transplantation survivors compared with healthy individuals: a cross sectional study

Background: A limited number of studies have reported impairments in physical activity, exercise capacity and quality of life (QOL) in allogeneic hematopoietic stem cell transplantation (allogeneic-HSCT) recipients. We aimed to compare dyspnea, exercise capacity, physical activity and QOL in allogeneic-HSCT recipients with age-gender matched healthy individuals, since this has not been investigated hitherto. Methods: A total of 80 allogeneic-HSCT recipients (>100 days status post-transplantation) (38.88 ± 13.25 years) and 60 healthy individuals (35.92 ± 10.83 years) were compared. Exercise capacity [6-minute walk test (6-MWT)], physical activity level (total and active energy expenditure, moderate and severe physical activity duration, number of steps, average metabolic equivalent, lying down and sleeping duration) [metabolic holter], QOL [European Organization for Research and Treatment of Cancer QOL Questionnaire (EORTCQOL)], dyspnea [Modified Medical Research Council Dyspnea scale] and pulmonary functions [spirometry] were evaluated. Clinical trials #NCT03606005. Results: Six-MWT distance, energy expenditure, physical activity duration, number of steps, average metabolic equivalent, global health status, functional and social function subscales of EORTCQOL were significantly lower in recipients compared with controls; dyspnea score, lying down, sleep durations, symptom and fatigue subscales of EORTCQOL were significantly higher in recipients compared with controls (p < 0.05). Conclusion: Dyspnea during daily living activities, exercise capacity, physical activity level and QOL are considerably impaired in allogeneic-HSCT recipients during post-engraftment period. To improve impaired outcomes, allogeneic-HSCT recipients should be oriented to cardiopulmonary rehabilitation programs.

Activity monitors in pulmonary disease

Physical activity is reduced in patients with chronic pulmonary diseases. Activity monitors can measure physical activity objectively and accurately over prolonged periods of time. Research grade and commercially available devices, using accelerometer technology, are being increasingly used in clinical studies. Physical activity levels have been found to have a moderate to strong correlation with important measures such as pulmonary function, exercise capacity, quality of life, and mortality and hospitalizations in patients with COPD, interstitial lung disease, pulmonary arterial hypertension and cystic fibrosis. Their use as a clinical trial end-point and as a tool to augment rehabilitation efforts has also been explored in patients with COPD with variable results. Due to the ease of use, economic viability, widespread availability and good patient compliance, their use in adult and pediatric medicine is expanding. This narrative review summarizes the current evidence of use of activity monitors in COPD, interstitial lung disease, asthma, pulmonary arterial hypertension, cystic fibrosis and lung transplant patients for the purposes of prognostication, monitoring, outcome measures and intervention.

Quadriceps Muscle Strength and Body Mass Index Are Associated With Estimates of Physical Activity Postheart Transplantation

BACKGROUND

Although exercise capacity improves postheart transplantation (HTx), it remains unclear if the level of physical activity (PA) shows similar improvement. The purpose of this study was to (1) describe PA levels and (2) identify factors which may be associated with levels of PA post-HTx.

METHODS

A prospective observational cross-sectional study was conducted at a single center HTx outpatient clinic. Medically stable adult recipients 6 months or longer post-HTx were recruited. Physical activity level (PAL) and average daily time spent at least moderately active (≥3 metabolic equivalents) were estimated using a multisensor device. Factors investigated were demographic (age, sex, body mass index [BMI], time post-HTx, and reason for HTx), corticosteroid use, exercise capacity (6-min walk distance), and quadriceps muscle strength corrected for body weight (QS%).

RESULTS

The mean post-HTx time of the 75 participants was 9.2 ± 7.0 years (0.5-26 y). Twenty-seven (36%) participants were classified as extremely inactive (PAL, <1.40), 26 (34.6%) sedentary (1.40 ≤ PAL ≤ 1.69), and 22 (29.3%) active (PAL, ≥1.70). Multivariable analysis showed greater QS% (β = 0.004 (0.002-0.006) P = 0.001) to be independently associated with increased PAL. For increased time, 3 or more metabolic equivalents both greater QS% (β = 0.0164 [0.003-0.029]; P = 0.014) and lower BMI (β = -0.0626 [-0.115 to -0.0099]; P = 0.021) were independently associated.

CONCLUSIONS

The degree of observed sedentary behavior post-HTx is surprising, with the majority of participants not reaching levels of PA recommended for health benefits. QS% and BMI were the only factors found to be independently associated with estimates of PA. Further quality trials are required to demonstrate the long-term benefits of regular PA and investigate ways of increasing adherence to PA post-HTx.

The effects of home oxygen therapy on energy metabolism in patients with COPD

Background

COPD is preventable and treatable and is characterized by completely nonreversible airflow obstruction. In this study, we aimed to investigate the effect of long-term oxygen therapy on patients with stage 4 COPD who were followed up and treated at the polyclinic or clinic service. We evaluated the effects of oxygen therapy on energy metabolism and physical activity in patients with COPD.

Methods

Nineteen patients with COPD (16 male/3 female), treated with oxygen therapy for the first time, were included in this study. Analysis of arterial blood gases and pulmonary function test was performed. Metabolic Holter device (SenseWear^® Armband) was placed pre- and post-oxygen therapy on the patients’ arm for at least 3 days. This device captures Holter data in a digitized electronic system, and the daily average value was calculated from the data.

Results

Post-oxygen treatment showed a significant increase in energy expenditure by patients with COPD (pretreatment, 1,497±596 joule; posttreatment, 2,977±5,985 joule; P=0.044). Moreover, number of steps during walking (pretreatment, 2,056±256; posttreatment, 2,120±195; P=0.03), resting (pretreatment, 6.36±3.31 hours; posttreatment, 3.47±2.19 hours; P<0.03), and sleeping (pretreatment, 4.23±2.13 hours; posttreatment, 2.33±1.42 hours; P<0.00) showed significant differences. Increased daily energy expenditure in patients with respiratory failure was detected with long-term oxygen therapy. In addition, the immobility of patients decreased and duration of physical activity increased in patients with COPD.

Conclusion

In this study, positive effects of long-term oxygen therapy have been demonstrated with respect to energy metabolism and physical activity of patients with COPD. Thus, we recommend that medication adherence and long-term oxygen therapy should begin early in patients with COPD.

O tempo de uso do sensor de movimento interfere na escolha do desfecho de atividade física na vida diária em pacientes com DPOC?

RESUMO Este estudo analisa a atividade física na vida diária (AFVD) de pacientes com doença pulmonar obstrutiva crônica (DPOC), quantificada em três diferentes períodos de uso diário do sensor de movimento: 8 horas, 12 horas e período de tempo acordado, a fim de identificar se os desfechos de AFVD diferem entre si. Trata-se de um estudo transversal com 45 pacientes (66±8 anos) classificados com DPOC de moderada a grave. A AFVD foi avaliada utilizando-se o monitor de atividade física SenseWear Armband (SAB) durante 7 dias consecutivos, 24 horas por dia. Compararam-se os resultados de AFVD fornecidos pelo monitor nos três períodos de avaliação dentro das 24 horas de uso. Os desfechos de sedentarismo e de atividade física (número de passos e gasto energético total) foram diferentes nos três períodos de utilização do SAB, com maiores valores na avaliação por período de tempo acordado. Quanto aos desfechos de atividade física estratificados por idade - 3 ou 2 equivalentes metabólicos (MET) -, os resultados foram similares na avaliação por 12 horas e por período de tempo acordado. Concluiu-se, afinal, que o uso do monitor de atividade física durante o tempo acordado é o desfecho mais indicado para monitoração acurada e completa de sedentarismo e atividade física em pacientes com DPOC.

Monitoring Energy Expenditure Using a Multi-Sensor Device-Applications and Limitations of the SenseWear Armband in Athletic Populations

In order to monitor their energy requirements, athletes may desire to assess energy expenditure (EE) during training and competition. Recent technological advances and increased customer interest have created a market for wearable devices that measure physiological variables and bodily movement over prolonged time periods and convert this information into EE data. This mini-review provides an overview of the applicability of the SenseWear armband (SWA), which combines accelerometry with measurements of heat production and skin conductivity, to measure total daily energy expenditure (TDEE) and its components such as exercise energy expenditure (ExEE) in athletic populations. While the SWA has been shown to provide valid estimates of EE in the general population, validation studies in athletic populations indicate a tendency toward underestimation of ExEE particularly during high-intensity exercise (>10 METs) with an increasing underestimation as exercise intensity increases. Although limited information is available on the accuracy of the SWA during resistance exercise, high-intensity interval exercise, or mixed exercise forms, there seems to be a similar trend of underestimating high levels of ExEE. The SWA, however, is capable of detecting movement patterns and metabolic measurements even at high exercise intensities, suggesting that underestimation may result from limitations in the proprietary algorithms. In addition, the SWA has been used in the assessment of sleep quantity and quality as well as non-exercise activity thermogenesis. Overall, the SWA provides viable information and remains to be used in various clinical and athletic settings, despite the termination of its commercial sale.

Benefits of home-based multidisciplinary exercise and supportive care in inoperable non-small cell lung cancer - protocol for a phase II randomised controlled trial

Background

Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC.

Methods

This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference.

Discussion

There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting.

Trial registration

This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614001268639: (4/12/14).

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3651-4) contains supplementary material, which is available to authorized users.

Annual progression of endothelial dysfunction in patients with COPD

BACKGROUND

The risk to die from cardiovascular disease is particularly high in patients with COPD. This longitudinal study aims to evaluate changes of endothelial function over time and identify underlying mechanisms in COPD patients.

METHODS

In stable COPD patients we performed annual assessments of endothelial function by flow-mediated dilatation (FMD), lung function, systemic inflammation and cholesterol, sympathetic activation, oxygenation, physical activity and exercise capacity. Associations between annual changes of potential predictors and FMD were investigated in mixed analysis.

RESULTS

76 patients (41% GOLD stage 1/2, 30% 3, 29% 4) were included. Endothelial function significantly decreased annually by -0.14% (95%CI -0.25/-0.04), equal to a relative decrease of -5.6%. Yearly change in 6-min walking distance was significantly associated with FMD in univariable analysis (Coef. -0.00, p = 0.045). Progressive airway obstruction and increase in level of total cholesterol were borderline significant with a greater decrease in FMD (Coeff. -0.02, p = 0.097 and Coeff. -0.16, p = 0.080, respectively). In multivariable analysis a greater annual decline in FEV1 tends to be independently associated with a decrease in FMD (p = 0.085).

CONCLUSION

The findings of this study demonstrated that COPD patients experience a significant decrease in endothelial function over time. A greater annual decline in lung function tends to be associated with greater decrease in FMD. However, no other independent predictors for endothelial dysfunction could be identified.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, NCT01527773.

Effect of counselling during pulmonary rehabilitation on self-determined motivation towards physical activity in people with chronic obstructive pulmonary disease - protocol of a mixed methods study

BACKGROUND

Physical activity promotion in people with Chronic Obstructive Pulmonary Disease (COPD) is focus of research and public health. Patient-centred interventions like counselling are promising approaches to help patients reducing sedentary behaviour. Aim of the present study is to investigate if a physical activity counselling program during pulmonary rehabilitation increases physical activity level in daily life in people with COPD.

METHODS

A two-armed, single blind randomised controlled trial including 56 people with COPD will be conducted in an outpatient pulmonary rehabilitation. Patients will participate in a 12-week-rehabilitation program; individuals randomized to the interventional group will additionally participate in five counselling sessions with a physiotherapist, based on the principles of motivational interviewing. The participants' physical activity level will be measured using an accelerometer (SenseWear Pro®) before, directly and 3 months after pulmonary rehabilitation. Semi-structured interviews will be conducted to learn more about barriers and facilitators regarding daily physical activity.

DISCUSSION

If the strategy successfully improves the physical activity level in people with COPD, counselling might be implemented in pulmonary rehabilitation.

TRIAL REGISTRATION

Clinical Trials.gov NCT02455206 (05/21/2015), Swiss National Trails Portal SNCTP000001426 (05/21/2015).

Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization. A Randomized Study

RATIONALE

Hospital readmission for chronic obstructive pulmonary disease (COPD) has attracted attention owing to the burden to patients and the health care system. There is a knowledge gap on approaches to reducing COPD readmissions.

OBJECTIVES

To determine the effect of comprehensive health coaching on the rate of COPD readmissions.

METHODS

A total of 215 patients hospitalized for a COPD exacerbation were randomized at hospital discharge to receive either (1) motivational interviewing-based health coaching plus a written action plan for exacerbations (the use of antibiotics and oral steroids) and brief exercise advice or (2) usual care.

MEASUREMENTS AND MAIN RESULTS

We evaluated the rate of COPD-related hospitalizations during 1 year of follow-up. The absolute risk reductions of COPD-related rehospitalization in the health coaching group were 7.5% (P = 0.01), 11.0% (P = 0.02), 11.6% (P = 0.03), 11.4% (P = 0.05), and 5.4% (P = 0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. The odds ratios for COPD hospitalization in the intervention arm compared with the control arm were 0.09 (95% confidence interval [CI], 0.01-0.77) at 1 month postdischarge, 0.37 (95% CI, 0.15-0.91) at 3 months postdischarge, 0.43 (95% CI, 0.20-0.94) at 6 months postdischarge, and 0.60 (95% CI, 0.30-1.20) at 1 year postdischarge. The missing value rate for the primary outcome was 0.4% (one patient). Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire emotional score (emotion and mastery domains) and physical score (dyspnea and fatigue domains) (P < 0.05). There were no differences between groups in measured physical activity at any time point.

CONCLUSIONS

Health coaching may represent a feasible and possibly effective intervention designed to reduce COPD readmissions. Clinical trial registered with www.clinicaltrials.gov (NCT01058486).

Measuring Habitual Physical Activity in Neuromuscular Disorders: A Systematic Review

BACKGROUND

Free-living or habitual physical activity (HPA) refers to someone's performance in his or her free-living environment. Neuromuscular disorders (NMD) manifest through HPA, and the observation of HPA can be used to identify clinical risks and to quantify outcomes in research. This review summarizes and analyses previous studies reporting the assessment of HPA in NMD, and may serve as the basis for evidence-based decision-making when considering assessing HPA in this population.

METHODS

A systematic review was performed to identify all studies related to HPA in NMD, followed by a critical appraisal of the assessment methodology and a final review of the identified HPA tools.

RESULTS

A total of 22 studies were selected, reporting on eight different direct tools (or activity monitors) and ten structured patient-reported outcomes. Overall, HPA patterns in NMD differ from healthy control populations. There was a noticeable lack of validation studies for these tools and outcome measures in NMD. Very little information regarding feasibility and barriers for the application of these tools in this population have been published.

CONCLUSIONS

The variety and heterogeneity of tools and methods in the published literature makes the comparison across different studies difficult, and methodological guidelines are warranted. We propose a checklist of considerations for the assessment and reporting of HPA in NMD.

Are Physical activity and Benefits Maintained After Long-Term Telerehabilitation in COPD?

This study investigated whether physical activity levels and other outcomes were maintained at 1-year from completion of a 2-year telerehabilitation intervention in COPD. During the post-intervention year, nine patients with COPD (FEV1 % of pred. 42.4±19.8%; age 58.1±6 years) were encouraged to exercise on a treadmill at home and monitor daily symptoms and training sessions on a webpage as during the intervention. Participants were not provided supervision or motivational support. Physical activity levels decreased from 3,806 steps/day to 2,817 steps/day (p= 0.039). There was a decline in time spent on light physical activity (p=0.009), but not on moderate-to-vigorous activity (p=0.053). Adherence to registration of symptoms and training sessions decreased significantly. Other outcomes including health status, quality of life, anxiety and depression, self-efficacy, and healthcare utilization did not change significantly. In conclusion, provision of equipment for self-management and unsupervised home exercise might not be enough to maintain physical activity levels.

Evaluation of a non-invasive multisensor accelerometer for calculating energy expenditure in ventilated intensive care patients compared to indirect calorimetry and predictive equations

Continuous measurement of resting energy expenditure (REE) in critically ill patients remains challenging but is required to prevent malnutrition. SenseWear Pro 3 Armband (SWA) is a research grade accelerometer for assessment of REE with the advantage of easy handling. In a prospective study we compared SWA with indirect calorimetry (IC) and predictive equations in critically ill, ventilated patients. REE was measured by SWA, IC and calculated by predictive formulas. Potential confounding factors that influence REE were also recorded. Results of SenseWear Armband and indirect calorimetry were compared using the Bland-Altman method. 34 ICU patients were investigated. SWA underestimated resting energy expenditure compared to IC with a mean bias of ΔREE = -253.6 ± 333.2 kcal, equivalent to -11.7 % (p = 0.025). This underestimation was seen in both, medical (-14.9 %) and surgical (-12.9 %) patients and the bias was greater in patients with fever (-19.0 %), tachycardia (-18.7 %) or tachypnea (-26.2 %). Differences were also noted when SWA was compared to predictive formulas. At present, SWA cannot be regarded as an alternative to indirect calorimetry. Individual measurements are often inaccurate and should be used with caution until improved algorithms, based on the results of this study, have been implemented.

Armband activity monitor data do not correlate with reported pain scores in patients receiving vertebroplasty

BACKGROUND

Prior research on the efficacy of vertebroplasty has focused primarily on subjective, patient-reported outcomes.

OBJECTIVE

To apply an armband activity monitor (SenseWear by BodyMedia Inc, USA) to patients presenting for consideration for vertebroplasty and to determine the correlation between patient-reported outcomes and quantitative activity metrics at baseline and 30 days after presentation.

MATERIALS AND METHODS

Nineteen patients were enrolled (15 receiving vertebroplasty, 4 not receiving vertebroplasty). Patients reported their average pain over the past 24 hours and completed the Roland-Morris disability questionnaire at baseline and 30 days. Patients wore the SenseWear Armband activity monitor for a median of 4 days at baseline and at the 30-day time period to assess steps, metabolic equivalents expended, sedentary activity time, moderate activity time, sleep efficiency, and total sleep time. Pain and disability scores were correlated with activity monitor metrics using linear regression analysis.

RESULTS

Changes in reported average pain in the past 24 hours and disability scores were not significantly different between vertebroplasty and non-vertebroplasty groups (p>0.05). Changes in activity monitor data were not significantly different between the vertebroplasty and non-vertebroplasty groups (p>0.05). None of the correlations between the reported pain or disability scores and the activity monitor data were significant.

CONCLUSIONS

Activity monitors can be used to objectively record changes in activity following vertebroplasty procedures. Patient-reported pain or disability scores do not correlate with activity monitor-measured activity or sleep metrics.

Functional Status Assessment of Patients With COPD: A Systematic Review of Performance-Based Measures and Patient-Reported Measures

Presently, there is no recommendation on how to assess functional status of chronic obstructive pulmonary disease (COPD) patients. This study aimed to summarize and systematically evaluate these measures.Studies on measures of COPD patients' functional status published before the end of January 2015 were included using a search filters in PubMed and Web of Science, screening reference lists of all included studies, and cross-checking against some relevant reviews. After title, abstract, and main text screening, the remaining was appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) 4-point checklist. All measures from these studies were rated according to best-evidence synthesis and the best-rated measures were selected.A total of 6447 records were found and 102 studies were reviewed, suggesting 44 performance-based measures and 14 patient-reported measures. The majority of the studies focused on internal consistency, reliability, and hypothesis testing, but only 21% of them employed good or excellent methodology. Their common weaknesses include lack of checks for unidimensionality, inadequate sample sizes, no prior hypotheses, and improper methods. On average, patient-reported measures perform better than performance-based measures. The best-rated patient-reported measures are functional performance inventory (FPI), functional performance inventory short form (FPI-SF), living with COPD questionnaire (LCOPD), COPD activity rating scale (CARS), University of Cincinnati dyspnea questionnaire (UCDQ), shortness of breath with daily activities (SOBDA), and short-form pulmonary functional status scale (PFSS-11), and the best-rated performance-based measures are exercise testing: 6-minute walk test (6MWT), endurance treadmill test, and usual 4-meter gait speed (usual 4MGS).Further research is needed to evaluate the reliability and validity of performance-based measures since present studies failed to provide convincing evidence. FPI, FPI-SF, LCOPD, CARS, UCDQ, SOBDA, PFSS-11, 6MWT, endurance treadmill test, and usual 4MGS performed well and are preferable to assess functional status of COPD patients.

Physical activity and exercise capacity in patients with moderate COPD exacerbations

Little is known about changes in physical activity during moderate (out-patient managed) exacerbations.

6-min walking distance (6MWD) was measured during 50 exacerbations when the patients were stable, and at 3 and 7 days post-exacerbation presentation. At similar time points, quadriceps maximum voluntary contraction (QMVC) was measured during 47 different exacerbations. Physical activity (SenseWear; Bodymedia Inc., Pittsburgh, PA, USA) was recorded over 2 consecutive-week periods post-presentation.

6MWD fell from a median 422 m when stable to 373 m on day 3 (p=0.001). Similarly, QMVC fell from 32.6 versus 29.7 kg (p=0.026). Falls in 6MWD were associated with a rise in C-reactive protein (r= −0.364; p=0.041) and increased Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) (r= −0.44; p=0.013). Light physical activity was 2.18 h·day−1 during the first week post-exacerbation and was less over week 2 (1.98 h·day−1; p=0.009). Patients who had attended pulmonary rehabilitation had smaller changes in 6MWD than those who had not attended (−35.0 versus −114.9 m; p=0.013). Falls in physical activity were correlated with higher depression scores (rho= −0.51; p=0.006).

These findings indicate that exercise capacity and muscle strength fall at exacerbation in chronic obstructive pulmonary disease patients who are treated at home and are free to maintain normal activity.

Measurement of daily physical activity using the SenseWear Armband: Compliance, comfort, adverse side effects and usability

Little is known about the acceptability of wearing physical activity-monitoring devices. This study aimed to examine the compliance, comfort, incidence of adverse side effects, and usability when wearing the SenseWear Armband (SWA) for daily physical activity assessment. In a prospective study, 314 participants (252 people with COPD, 36 people with a dust-related respiratory disease and 26 healthy age-matched people) completed a purpose-designed questionnaire following a 7-day period of wearing the SWA. Compliance, comfort levels during the day and night, adverse side effects and ease of using the device were recorded. Non-compliance with wearing the SWA over 7 days was 8%. The main reasons for removing the device were adverse side effects and discomfort. The SWA comfort level during the day was rated by 11% of participants as uncomfortable/very uncomfortable, with higher levels of discomfort reported during the night (16%). Nearly half of the participants (46%) experienced at least one adverse skin irritation side effect from wearing the SWA including itchiness, skin irritation and rashes, and/or bruising. Compliance with wearing the SWA for measurement of daily physical activity was found to be good, despite reports of discomfort and a high incidence of adverse side effects.

A randomised controlled trial of supplemental oxygen versus medical air during exercise training in people with chronic obstructive pulmonary disease: supplemental oxygen in pulmonary rehabilitation trial (SuppORT) (Protocol)

BACKGROUND

Oxygen desaturation during exercise is common in people with chronic obstructive pulmonary disease (COPD). The aim of the study is to determine, in people with COPD who desaturate during exercise, whether supplemental oxygen during an eight-week exercise training program is more effective than medical air (sham intervention) in improving exercise capacity and health-related quality of life both at the completion of training and at six-month follow up.

METHODS/DESIGN

This is a multi-centre randomised controlled trial with concealed allocation, blinding of participants, exercise trainers and assessors, and intention-to-treat analysis. 110 people with chronic obstructive pulmonary disease who demonstrate oxygen desaturation lower than 90 % during the six-minute walk test will be recruited from pulmonary rehabilitation programs in seven teaching hospitals in Australia. People with chronic obstructive pulmonary disease on long term oxygen therapy will be excluded. After confirmation of eligibility and baseline assessment, participants will be randomised to receive either supplemental oxygen or medical air during an eight-week supervised treadmill and cycle exercise training program, three times per week for eight weeks, in hospital outpatient settings. Primary outcome measures will be endurance walking capacity assessed by the endurance shuttle walk test and health-related quality of life assessed by the Chronic Respiratory Disease Questionnaire. Secondary outcomes will include peak walking capacity measured by the incremental shuttle walk test, dyspnoea via the Dyspnoea-12 questionnaire and physical activity levels measured over seven days using an activity monitor. All outcomes will be measured at baseline, completion of training and at six-month follow up.

DISCUSSION

Exercise training is an essential component of pulmonary rehabilitation for people with COPD. This study will determine whether supplemental oxygen during exercise training is more effective than medical air in improving exercise capacity and health-related quality of life in people with COPD who desaturate during exercise.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000395831, 5th Jan,2012.

A Mobile Phone App to Stimulate Daily Physical Activity in Patients with Chronic Obstructive Pulmonary Disease: Development, Feasibility, and Pilot Studies

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) demonstrate reduced levels of daily physical activity (DPA) compared to healthy controls. This results in a higher risk of hospital admission and shorter survival. Performing regular DPA reduces these risks.

OBJECTIVE

To develop an eHealth intervention that will support patients with COPD to improve or maintain their DPA after pulmonary rehabilitation.

METHODS

The design process consisted of literature research and the iterative developing and piloting phases of the Medical Research Council (MRC) model for complex clinical interventions and the involvement of end users. Participants were healthy adults and persons with COPD.

RESULTS

The mobile phone interface met all the set requirements. Participants found that the app was stimulating and that reaching their DPA goals was rewarding. The mean (SD) scores on a 7-point scale for usability, ease of use, ease of learning, and contentment were 3.8 (1.8), 5.1 (1.1), 6.0 (1.6), and 4.8 (1.3), respectively. The mean (SD) correlation between the mobile phone and a validated accelerometer was 0.88 (0.12) in the final test. The idea of providing their health care professional with their DPA data caused no privacy issues in the participants. Battery life lasted for an entire day with the final version, and readability and comprehensibility of text and colors were favorable.

CONCLUSIONS

By employing a user-centered design approach, a mobile phone was found to be an adequate and feasible interface for an eHealth intervention. The mobile phone and app are easy to learn and use by patients with COPD. In the final test, the accuracy of the DPA measurement was good. The final version of the eHealth intervention is presently being tested by our group for efficacy in a randomized controlled trial in COPD patients.

Physical Activity Counselling during Pulmonary Rehabilitation in Patients with COPD: A Randomised Controlled Trial

Background

Pulmonary rehabilitation programs only modestly enhance daily physical activity levels in patients with chronic obstructive pulmonary disease (COPD). This randomised controlled trial investigates the additional effect of an individual activity counselling program during pulmonary rehabilitation on physical activity levels in patients with moderate to very severe COPD.

Methods

Eighty patients (66±7 years, 81% male, forced expiratory volume in 1 second 45±16% of predicted) referred for a six‐month multidisciplinary pulmonary rehabilitation program were randomised. The intervention group was offered an additional eight-session activity counselling program. The primary outcomes were daily walking time and time spent in at least moderate intense activities.

Results

Baseline daily walking time was similar in the intervention and control group (median 33 [interquartile range 16–47] vs 29 [17–44]) whereas daily time spent in at least moderate intensity was somewhat higher in the intervention group (17[4–50] vs 12[2–26] min). No significant intervention*time interaction effects were observed in daily physical activity levels. In the whole group, daily walking time and time spent in at least moderate intense activities did not significantly change over time.

Conclusions

The present study identified no additional effect of eight individual activity counselling sessions during pulmonary rehabilitation to enhance physical activity levels in patients with COPD.

Trial Registration

clinicaltrials.gov NCT00948623

Disease Progression and Changes in Physical Activity in Patients with Chronic Obstructive Pulmonary Disease

RATIONALE

Little is known about the role of physical activity in the course of chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To assess changes in physical activity in COPD in relation to severity stages and changes in other disease components, and to evaluate the longitudinal association between sustained physical inactivity and disease progression.

METHODS

In this prospective cohort study, we measured physical activity (multisensory armband), airflow obstruction (FEV1), health status (St. George's Respiratory Questionnaire), exercise capacity (6-min-walk distance [6MWD]), muscle mass (fat-free mass [FFM]), and systemic inflammation (fibrinogen and high-sensitivity C-reactive protein) over a 3-year period in 137 patients with COPD and 26 with chronic bronchitis (normal spirometry).

MEASUREMENTS AND MAIN RESULTS

Independent of baseline disease severity, steps per day, total daily energy expenditure, and (daily) physical activity level (PAL) decreased by 393, 76 kcal, and 0.04 per year, respectively. The decline in PAL was significantly associated with a decline in FEV1 and an increase in St. George's Respiratory Questionnaire total score. Changes in 6MWD, FFM, and inflammatory markers were not associated with changes in PAL. Independent of FEV1, sustained physical inactivity (i.e., PAL(T0andT1)  < 1.40) was related to a greater decline in 6MWD and FFM compared with that in patients with some level of activity (i.e., PAL(T0and/orT1) ≥ 1.40; difference, 17 m/yr and 0.87 kg/yr, respectively).

CONCLUSIONS

Over time, physical activity substantially decreases across all severity stages of COPD, and this decline is paralleled by a worsening of lung function and health status. Sustained physical inactivity is associated with a progression of exercise intolerance and muscle depletion.

Respiratory muscle training with normocapnic hyperpnea improves ventilatory pattern and thoracoabdominal coordination, and reduces oxygen desaturation during endurance exercise testing in COPD patients

Background

Few data are available about the effects of respiratory muscle training with normocapnic hyperpnea (NH) in COPD. The aim is to evaluate the effects of 4 weeks of NH (Spirotiger^®) on ventilatory pattern, exercise capacity, and quality of life (QoL) in COPD patients.

Methods

Twenty-six COPD patients (three females), ages 49–82 years, were included in this study. Spirometry and maximal inspiratory pressure, St George Respiratory Questionnaire, 6-minute walk test, and symptom-limited endurance exercise test (endurance test to the limit of tolerance [tLim]) at 75%–80% of peak work rate up to a Borg Score of 8–9/10 were performed before and after NH. Patients were equipped with ambulatory inductive plethysmography (LifeShirt^®) to evaluate ventilatory pattern and thoracoabdominal coordination (phase angle [PhA]) during tLim. After four supervised sessions, subjects trained at home for 4 weeks – 10 minutes twice a day at 50% of maximal voluntary ventilation. The workload was adjusted during the training period to maintain a Borg Score of 5–6/10.

Results

Twenty subjects completed the study. After NH, maximal inspiratory pressure significantly increased (81.5±31.6 vs 91.8±30.6 cmH₂O, P<0.01); exercise endurance time (+150 seconds, P=0.04), 6-minute walk test (+30 meters, P=0.03), and QoL (−8, P<0.01) all increased. During tLim, the ventilatory pattern changed significantly (lower ventilation, lower respiratory rate, higher tidal volume); oxygen desaturation, PhA, and dyspnea Borg Score were lower for the same work intensity (P<0.01, P=0.02, and P<0.01, respectively; one-way ANOVA). The improvement in tidal volume and oxygen saturation after NH were significantly related (R²=0.65, P<0.01).

Conclusion

As expected, NH improves inspiratory muscle performance, exercise capacity, and QoL. New results are significant change in ventilatory pattern, which improves oxygen saturation, and an improvement in thoracoabdominal coordination (lower PhA). These two facts could explain the reduced dyspnea during the endurance test. All these results together may play a role in improving exercise capacity after NH training.

Predicting energy requirement with pedometer-determined physical-activity level in women with chronic obstructive pulmonary disease

BACKGROUND

In clinical practice, in the absence of objective measures, simple methods to predict energy requirement in patients with chronic obstructive pulmonary disease (COPD) needs to be evaluated. The aim of the present study was to evaluate predicted energy requirement in females with COPD using pedometer-determined physical activity level (PAL) multiplied by resting metabolic rate (RMR) equations.

METHODS

Energy requirement was predicted in 18 women with COPD using pedometer-determined PAL multiplied by six different RMR equations (Harris-Benedict; Schofield; World Health Organization; Moore; Nordic Nutrition Recommendations; Nordenson). Total energy expenditure (TEE) was measured by the criterion method: doubly labeled water. The predicted energy requirement was compared with measured TEE using intraclass correlation coefficient (ICC) and Bland-Altman analyses.

RESULTS

The energy requirement predicted by pedometer-determined PAL multiplied by six different RMR equations was within a reasonable accuracy (±10%) of the measured TEE for all equations except one (Nordenson equation). The ICC values between the criterion method (TEE) and predicted energy requirement were: Harris-Benedict, ICC =0.70, 95% confidence interval (CI) 0.23-0.89; Schofield, ICC =0.71, 95% CI 0.21-0.89; World Health Organization, ICC =0.74, 95% CI 0.33-0.90; Moore, ICC =0.69, 95% CI 0.21-0.88; Nordic Nutrition Recommendations, ICC =0.70, 95% CI 0.17-0.89; and Nordenson, ICC =0.40, 95% CI -0.19 to 0.77. Bland-Altman plots revealed no systematic bias for predicted energy requirement except for Nordenson estimates.

CONCLUSION

For clinical purposes, in absence of objective methods such as doubly labeled water method and motion sensors, energy requirement can be predicted using pedometer-determined PAL and common RMR equations. However, for assessment of nutritional status and for the purpose of giving nutritional treatment, a clinical judgment is important regarding when to accept a predicted energy requirement both at individual and group levels.

Examining the role of activity, exercise, and pharmacology in mild COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and, although it is a preventable and treatable disease, it often remains undiagnosed in patients with mild disease. It is now evident that pathologic changes and physiologic impairment start early in disease progression, and even patients with mild airflow limitation have impairment in the form of exertional dyspnea, general fatigue, and exercise intolerance. Primary care physicians are optimally positioned to recognize these progressive activity restrictions in their patients, usually involving little more than a detailed patient history and a simple symptom questionnaire. Once a patient with persistent activity-related dyspnea has been diagnosed with COPD, bronchodilators can effectively address expiratory airflow limitation and lung hyperinflation that underlie symptoms. These pharmacologic interventions work in conjunction with nonpharmacologic interventions, including smoking cessation, exercise training, and pulmonary rehabilitation. Although the benefits of exercise intervention are well established in patients with more severe COPD, a small amount of new data is emerging that supports the benefits of both pharmacologic treatment and exercise training for improving exercise endurance in patients with mild-to-moderate COPD. This review examines the growing body of data that suggests that early identification-most likely by primary care physicians-and appropriate intervention can favorably impact the symptoms, exercise tolerance, health status, quality of life, hospitalizations, and economic costs of COPD.

An official European Respiratory Society statement on physical activity in COPD

This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force of experts representing the ERS Scientific Group 01.02 "Rehabilitation and Chronic Care" determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5-8 years).

Validity and usability of low-cost accelerometers for internet-based self-monitoring of physical activity in patients with chronic obstructive pulmonary disease

Background

The importance of regular physical activity for patients with chronic obstructive pulmonary disease (COPD) is well-established. However, many patients do not meet the recommended daily amount. Accelerometers might provide patients with the information needed to increase physical activity in daily life.

Objective

Our objective was to assess the validity and usability of low-cost Internet-connected accelerometers. Furthermore we explored patients’ preferences with regards to the presentation of and feedback on monitored physical activity.

Methods

To assess concurrent validity we conducted a field validation study with patients who wore two low-cost accelerometers, Fitbit and Physical Activity Monitor (PAM), at the same time along with a sophisticated multisensor accelerometer (SenseWear Armband) for 48 hours. Data on energy expenditure assessed from registrations from the two low-cost accelerometers were compared to the well validated SenseWear Armband which served as a reference criterion. Usability was examined in a cross-over study with patients who, in succession, wore the Fitbit and the PAM for 7 consecutive days and filled out a 16 item questionnaire with regards to the use of the corresponding device

Results

The agreement between energy expenditure (METs) from the SenseWear Armband with METs estimated by the Fitbit and PAM was good (r=.77) and moderate (r=.41), respectively. The regression model that was developed for the Fitbit explained 92% whereas the PAM-model could explain 89% of total variance in METs measured by the SenseWear. With regards to the usability, both the Fitbit and PAM were well rated on all items. There were no significant differences between the two devices.

Conclusions

The low-cost Fitbit and PAM are valid and usable devices to measure physical activity in patients with COPD. These devices may be useful in long-term interventions aiming at increasing physical activity levels in these patients.

Energy Expenditure in Institutionalized Older Adults: Validation of SenseWear Mini

PURPOSE

Objective methods to quantify physical activity (PA) and predict energy expenditure (EE) are needed in the old and old-old. The aim of the present study was to evaluate the validity of EE estimates by the SenseWear Mini (SWMini) compared with indirect calorimetry during daily life activities in institutionalized older adults.

METHODS

Sixty nursing home residents (mean age = 85.5 ± 5.5 yr) wore the SWMini during rest (sitting quietly) and three activity tasks (walking, sitting/rising/walking, and moving objects). SWMini data were processed using software version 7.0. The criterion EE (kcal·min⁻¹) was estimated by a portable gas analyzer, Oxycon Mobile (OM).

RESULTS

The analyses revealed high correlations (rsitting = 0.68, ractivity tasks = 0.88) between EE estimated by OM and SWMini. EE increased between sitting periods and activity tasks for EE estimated by OM (mean difference = 61.5% ± 8.9%), as well as for EE estimated by SWMini (mean difference = 58.2% ± 7.4%) (P < 0.001). However, SWMini significantly underestimated EE, with an overall absolute percent error of 14.1% ± 7.9%. The largest absolute percent differences were observed during sitting periods compared with activity tasks (P < 0.05). Older age significantly reduced accuracy, explaining 12% of the variance in total percent error (β = 0.42, t = 2.84, P < 0.05).

CONCLUSIONS

The high percent error scores indicate that the SWMini is of limited value for quantifying EE in the old and old-old. The accuracy could be improved by developing accurate age- and activity-specific algorithms. On the other hand, the SWMini can be used as a suitable device for researchers interested in specific levels and patterns of PA and sedentary behavior.

Association between peripheral muscle strength and daily physical activity in patients with COPD: a systematic literature review and meta-analysis

BACKGROUND

Patients with chronic obstructive pulmonary disease have skeletal muscle dysfunction and reduced daily physical activity (PA). Whether the reduction in quadriceps strength (QS) is directly linked to physical inactivity remains to be elucidated.

METHODS

A systematic review and a meta-analysis were conducted to determine the potential relationship between QS and the level of PA. The overall estimate of the correlation coefficient (r*) was calculated, and a subgroup analysis was conducted to analyze the association between QS and indices of PA separately.

RESULTS

A total of 8 studies were included in the meta-analysis. The overall association between QS and PA was low but highly significant (r * = 0.288, 95% CI = 0.180-0.389; P < .001). In the subgroup analysis, the association between QS and the number of steps per day was low (r = 0.260; 95% CI = 0.060-0.440) and the association between QS and the time spent walking was moderate (r = 0.418; 95% CI = 0.229-0.576).

CONCLUSIONS

Peripheral muscle strength is associated with PA as assessed by the number of steps per day and the time spent walking in patients with chronic obstructive pulmonary disease. The overall association between QS and PA was low to moderate and highly significant.

Association between peripheral muscle strength, exercise performance, and physical activity in daily life in patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Resistance training of peripheral muscles has been recommended in order to increase muscle strength in patients with Chronic Obstructive Pulmonary Disease (COPD). However, whether peripheral muscle strength is associated with exercise performance (EP) and physical activity in daily life (PADL) in these patients needs to be investigated. The aim of this study is to evaluate whether strength of the quadriceps muscle (QS) is associated with EP and daily PADL in patients with COPD.

METHODS

We studied patients with COPD (GOLD A-D) and measured maximal isometric strength of the left QS. PADL was measured for 7 days with a SenseWear-Pro® accelerometer. EP was quantified by the 6-minute walk distance (6MWD), the number of stands in the Sit-to-Stand Test (STST), and the handgrip-strength. Univariate and multivariate analyses were used to examine possible associations between QS, PADL and EP.

RESULTS

In 27 patients with COPD with a mean (SD) FEV1 of 37.6 (17.6)% predicted, QS was associated with 6MWD, STST, and handgrip-strength but not with PADL. Multiple linear regression analyses showed that QS was independently associated with the 6MWD (β = 0.42, 95% CI 0.09 to 0.84, p = 0.019), STST (β = 0.50, 95% CI 0.11 to 0.86, p = 0.014) and with handgrip-strength (β = 0.45, 95% CI 0.05 to 0.84, p = 0.038).

CONCLUSIONS

Peripheral muscle strength may be associated with exercise performance but not with physical activity in daily life. This may be due to the fact that EP tests evaluate patients' true abilities while PADL accelerometers may not.

Physical comorbidities affect physical activity in chronic obstructive pulmonary disease: a prospective cohort study

BACKGROUND AND OBJECTIVE

The prevalence of physical comorbidities such as obesity, musculoskeletal or neurological conditions in people with chronic obstructive pulmonary disease (COPD) is high, yet little is known about the impact of these physical comorbidities on physical activity. The primary aim of the study was to compare the physical activity levels of people with COPD with physical comorbidities (COPD + PC) to people with COPD without physical comorbidities (COPD) and healthy age-matched volunteers (control group).

METHODS

Twenty-five people with COPD + PC (mean (standard deviation (SD)) age 73 (11) years, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II-IV), 25 people with COPD (70 (8) years, GOLD stage II-IV) and 25 controls (70 (7) years) wore the SenseWear Pro3 Armband for 7 days.

RESULTS

Engagement in light intensity physical activity (1.5-3.0 metabolic equivalents (MET)) (140 (76) minutes per day (min/day)) and moderate intensity physical activity (3.0-6.0 MET) (25 (35) min/day) in the COPD + PC group was significantly reduced compared with the COPD (231 (76) and 104 (106), respectively) and control group (259 (75) and 114 (57), respectively). In the 16 daytime hours between 6 am and 10 pm, people with COPD + PC spent a mean (SD) of 771 (98) min/day engaged in sedentary behaviour (<1.5 MET). This was significantly greater than the group with COPD (603 (148) min/day) and the control group (567 (76) min/day) (P < 0.001).

CONCLUSIONS

People with COPD + PC had significantly lower daily physical activity levels compared with people with COPD without physical comorbidities and healthy people.

Activity restriction in mild COPD: a challenging clinical problem

Dyspnea, exercise intolerance, and activity restriction are already apparent in mild chronic obstructive pulmonary disease (COPD). However, patients may not seek medical help until their symptoms become troublesome and persistent and significant respiratory impairment is already present; as a consequence, further sustained physical inactivity may contribute to disease progression. Ventilatory and gas exchange impairment, cardiac dysfunction, and skeletal muscle dysfunction are present to a variable degree in patients with mild COPD, and collectively may contribute to exercise intolerance. As such, there is increasing interest in evaluating exercise tolerance and physical activity in symptomatic patients with COPD who have mild airway obstruction, as defined by spirometry. Simple questionnaires, eg, the modified British Medical Research Council dyspnea scale and the COPD Assessment Test, or exercise tests, eg, the 6-minute or incremental and endurance exercise tests can be used to assess exercise performance and functional status. Pedometers and accelerometers are used to evaluate physical activity, and endurance tests (cycle or treadmill) using constant work rate protocols are used to assess the effects of interventions such as pulmonary rehabilitation. In addition, alternative outcome measurements, such as tests of small airway dysfunction and laboratory-based exercise tests, are used to measure the extent of physiological impairment in individuals with persistent dyspnea. This review describes the mechanisms of exercise limitation in patients with mild COPD and the interventions that can potentially improve exercise tolerance. Also discussed are the benefits of pulmonary rehabilitation and the potential role of pharmacologic treatment in symptomatic patients with mild COPD.

Accuracy of three activity monitors in patients with chronic obstructive pulmonary disease: a comparison with video recordings

Low physical activity and sedentary behaviour characterise the lives of patients with chronic obstructive pulmonary disease (COPD). Using activity monitors, assessment of both aspects are possible, but many outcomes are not well validated. The aim of this study was to assess the accuracy and equivalency of three activity monitors regarding steps, body position and their ability to differentiate between periods of physical activity and inactivity. Fifteen patients with COPD (8 females; median (interquartile range, IQR) age, 64 (59-69) years; forced expiratory volume in 1 second, 37 (28-48)% predicted; 6-minute walk distance, 444 (410-519) m) were enrolled. The DynaPort ADL-monitor, the DynaPort MiniMod monitor and the SenseWear Armband Pro 3 monitor were assessed. Subjects performed a structured protocol alternating physical activity and inactivity while simultaneously wearing all three monitors and being video recorded. The mean difference (limits of agreement) in step count from monitors compared to manual step count was -69 (-443 to 305) for the ADL-monitor, -19 (-141 to 103) for the MiniMod and -479 (-855 to -103) for the SenseWear Armband. Compared to the video, the sitting time was 97 (94-100)% when measured by the ADL-monitor and 121 (110-139)% by the MiniMod. Standing time was 114 (107-122)% when measured by the ADL-monitor and 68 (47-106)% by the MiniMod. Activity monitors are not equivalent in their abilities to detect steps or body positions. The choice of monitor should be based on the particular outcome of interest.