The effect of walking aids on exercise capacity and oxygenation in elderly patients with chronic obstructive pulmonary disease

Non-pharmacological Management in Palliative Care for Patients With Advanced COPD

Chronic obstructive pulmonary disease (COPD) is a disabling condition associated with progressive airflow limitation and lung tissue damage; its main symptoms are breathlessness, fatigue, cough, and sputum production. In the advanced stage of the disease, these symptoms may severely impact on a person's physical and psychological functioning, with some also developing chronic respiratory failure, associated with blood gas abnormalities. Non-pharmacological interventions can improve quality of life and functioning in the management of people living with advanced COPD. This article will provide an overview of common non-pharmacological methods used in the symptomatic management of severe COPD, including: breathlessness and fatigue management strategies, anxiety management, pulmonary rehabilitation (PR) and physical activity (PA), neuromuscular electrical stimulation (NMES), airway clearance techniques (ACTs), nutrition and non-invasive ventilation (NIV). The importance of a holistic and multi-disciplinary approach to people living with COPD will be discussed.

Accompanied versus unaccompanied walking for continuous oxygen saturation measurement during 6-min walk test in COPD: a randomised crossover study

The aim of this study was to determine if there is a difference in 6-min walk test (6MWT) distance when the assessor accompanies the patient to continuously measure peripheral oxygen saturation (S_pO2) compared to the patient walking unaccompanied.

 We conducted a randomised crossover study to evaluate the impact of the assessor walking with the patient during the 6MWT (6MWT_with) versus the patient walking alone (6MWT_without). At the end of a pulmonary rehabilitation programme, each patient performed two 6MWTs in random order and separated by a 30-min rest.

 49 patients with chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease classification II–IV) were included. In a regression model adjusting for period and subject, accompanying the patient resulted in a lower walking distance (mean difference −9.1 m, 95% CI −13.9– −4.3, p=0.0004). Notably, six patients walked more than 30 m farther (minimal important difference) in one of the two conditions (6MWT_with: n=1, 6MWT_without: n=5). There were no between-sequence-group differences in heart rate, dyspnoea, leg fatigue and S_pO2. The median (interquartile range) number and duration of S_pO2 signal artefacts were high but not different between the experimental conditions (6MWT_with: 17 (4–24), 34 s (7–113 s); 6 MWT_without: 11 (3–26), 24 s (4–62 s)).

 At a study population level, we observed a statistically significant difference in 6MWT distance between the two experimental conditions; however, the magnitude of difference was small and may not be clinically relevant. Nevertheless, in a clinical setting, unaccompanied walking resulted in a substantially higher walking distance in individual patients, pointing towards strictly standardised testing methodology, in particular in pre–post study designs.

Accompanied walking during a 6MWT versus unaccompanied walking results in shorter walked distance (mean difference −9.1 m, 95% CI −13.9– −4.3 m). No differences in nadir S_pO2 or oximetry artefacts were noted between accompanied and unaccompanied walking.https://bit.ly/3tBjfCq

Clinical and Physiological Effects of Rollators in Individuals With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW

PURPOSE

To determine the effects of using a rollator in people with chronic obstructive pulmonary disease (COPD).

METHODS

Studies were systematically identified from literature searches of MEDLINE, CINAHL, PEDro, PubMed, EMBASE, and the Cochrane Library databases and the reference lists of included studies. Two reviewers independently selected randomized controlled or crossover studies examining the effects of rollator usage compared with no aid in individuals with COPD. Methodologic quality was assessed by 2 reviewers independently using the Cochrane Risk of Bias tool. Two reviewers also used a customized form to extract characteristics of and outcomes for subjects related to exercise capacity, symptoms, health-related quality of life (HRQOL), physiological, and gait parameters. Weighted mean differences (WMD) with 95% CI were calculated using a fixed-effects model.

RESULTS

A total of 7 studies (126 participants) were included. Use of a rollator during a 6-Minute Walk Test (6MWT) improved distance walked (WMD = 13 m; 95% CI, 5-22) and lowered end-6MWT dyspnea rating (WMD = 0.97; 95% CI, 0.63-1.32). Longer-term use did not appear to impact exercise capacity or HRQOL, although this may be related to the frequency of use.

CONCLUSIONS

When used in the short-term, rollators resulted in a small increase in 6MWT and a reduction in dyspnea. Details on patient adherence are required to accurately evaluate the longer-term effects of rollator usage.

Feature reduction and multi-classification of different assistive devices according to the gait pattern

Total knee arthroplasty (TKA) is a surgical procedure used in patients with Osteoarthritis to improve their state. An understanding about how gait patterns differ from patient to patient and are influenced by the assistive device (AD) that is prescribed is still missing. This article focuses on such purpose. Standard walker, crutches and rollator were tested. Symmetric indexes of spatiotemporal and postural control features were calculated. In order to select the important features which can discriminate the differences among the ADs, different techniques for feature selection are investigated. Classification is handled by Multi-class Support Vector Machine. Results showed that rollator provides a more symmetrical gait and crutches demonstrated to be the worst. Relatively to postural control parameters, standard walker is the most stable and crutches are the worst AD. This means that, depending on the patient's problem and the recovery goal, different ADs should be used. After selecting a set of 16 important features, through correlation, it was demonstrated that they provide important quantitative information about the functional capacity, which is not represented by velocity, cadence and clinical scales. Also, they were capable of distinguishing the gait patterns influenced by each AD, showing that each patient has different needs during recovery. Implications of Rehabilitation An understanding about how gait patterns of post-surgical patients differ from person to person and how they are influenced by the type of device that is prescribed during their recovery might help in physical therapy. Research specifically addressing these issues is still missing. Inter-limb asymmetry and postural control features can be evaluated in an outpatient setting, supplying important additional information about individual gait pattern, which is not represented by gait velocity, cadence and scales usually used. The features calculated in this study are able to provide complementary information to gait velocity, cadence and clinical scales to assess the functional capacity of patients that passed through TKA. The selected parameters make a new clinical tool useful for tracking the evolution of patients' recovery after TKA.

How to carry out a field walking test in chronic respiratory disease

EDUCATIONAL AIMS

To provide recommendations for conducting field walking tests in people with chronic respiratory disease, from the new European Respiratory Society/American Thoracic Society Technical StandardTo provide information to assist in selecting a field walking test in people with chronic respiratory disease.

KEY POINTS

The 6MWT, ISWT and ESWT are valid and reliable tests of functional exercise capacity in people with COPD. The 6MWT is also widely used in other chronic respiratory disorders.There is a learning effect for the 6MWT and ISWT, so two tests must be performed if the tests are being used to measure change over time, with the best distance recorded.The 6MWT is very sensitive to changes in the way it is conducted, including use of encouragement, provision of supplemental oxygen, changes in track layout and length, and use of wheeled walkers. These factors should be held constant when the test is repeated.The 6MWT, ISWT and ESWT are strenuous tests, with cardiorespiratory responses that are similar to those during a maximal incremental exercise test. As a result, the contraindications and precautions for these field walking tests should be the same as for a laboratory-based incremental exercise test.

SUMMARY

The European Respiratory Society (ERS) and American Thoracic Society (ATS) have recently published a Technical Standard which documents the standard operating procedures for the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT). The Technical Standard shows that all three tests are valid and reliable measures of functional exercise capacity in people with chronic respiratory disease and makes recommendations for standardising their performance. Key findings and recommendations of the Technical Standard include: The 6MWT, ISWT and ESWT are strenuous tests which elicit cardiorespiratory responses that are similar to those observed during a maximal incremental exercise test. As a result, the contraindications and precautions for field walking tests should be consistent with those used for a laboratory-based incremental exercise test.There is strong evidence of a learning effect for the 6MWT and ISWT. Two tests should be performed when the 6MWT or ISWT are used to measure change over time.The 6MWT, ISWT and ESWT are responsive to treatment effects in people with chronic respiratory disease, particularly for rehabilitation.The 6MWT is very sensitive to variations in methodology, including use of encouragement, provision of supplemental oxygen, changes in track layout and length, and use of wheeled walkers. These factors should be documented and held constant on repeat testing.The lowest S pO2 recorded during a 6MWT is an important marker of disease severity and prognosis. Continuous pulse oximetry is recommended during the 6MWT, to ensure that the lowest S pO2 is recorded.In adults with chronic respiratory disease, a change in 6-min walk distance of 30 m or more indicates a clinically significant change has occurred.

An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease

Field walking tests are commonly employed to evaluate exercise capacity, assess prognosis and evaluate treatment response in chronic respiratory diseases. In recent years, there has been a wealth of new literature pertinent to the conduct of the 6-min walk test (6MWT), and a growing evidence base describing the incremental and endurance shuttle walk tests (ISWT and ESWT, respectively). The aim of this document is to describe the standard operating procedures for the 6MWT, ISWT and ESWT, which can be consistently employed by clinicians and researchers. The Technical Standard was developed by a multidisciplinary and international group of clinicians and researchers with expertise in the application of field walking tests. The procedures are underpinned by a concurrent systematic review of literature relevant to measurement properties and test conduct in adults with chronic respiratory disease. Current data confirm that the 6MWT, ISWT and ESWT are valid, reliable and responsive to change with some interventions. However, results are sensitive to small changes in methodology. It is important that two tests are conducted for the 6MWT and ISWT. This Technical Standard for field walking tests reflects current evidence regarding procedures that should be used to achieve robust results.

An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disease

This systematic review examined the measurement properties of the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT) in adults with chronic respiratory disease.

Studies that report the evaluation or use of the 6MWT, ISWT or ESWT were included. We searched electronic databases for studies published between January 2000 and September 2013.

The 6-min walking distance (6MWD) is a reliable measure (intra-class correlation coefficients ranged from 0.82 to 0.99 in seven studies). There is a learning effect, with greater distance walked on the second test (pooled mean improvement of 26 m in 13 studies). Reliability was similar for ISWT and ESWT, with a learning effect also evident for ISWT (pooled mean improvement of 20 m in six studies). The 6MWD correlates more strongly with peak work capacity (r=0.59–0.93) and physical activity (r=0.40–0.85) than with respiratory function (r=0.10–0.59). Methodological factors affecting 6MWD include track length, encouragement, supplemental oxygen and walking aids. Supplemental oxygen also affects ISWT and ESWT performance. Responsiveness was moderate to high for all tests, with greater responsiveness to interventions that included exercise training.

The findings of this review demonstrate that the 6MWT, ISWT and ESWT are robust tests of functional exercise capacity in adults with chronic respiratory disease.

WITHDRAWN: Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

This review is now out of date although it is correct as of the date of publication [Issue 2, 2008]. The authors are developing a new protocol which will replace this review. Publication of the protocol is expected in 2014, and serves to update the existing review and incorporate the latest evidence into a new Cochrane Review. The latest version of this review (available in 'Other versions' tab on The Cochrane Library) may still be useful to readers until the new review is published.

In 2016, the replacement review titled 'Non‐pharmacological interventions for breathlessness in advanced stages of malignant and non‐malignant diseases' was deregistered and split into four separate reviews of individual interventions: Respiratory interventions for breathlessness in adults with advanced diseases; Physical interventions for breathlessness in adults with advanced diseases; Cognitive‐emotional interventions for breathlessness in adults with advanced diseases; Multi‐dimensional interventions for breathlessness in adults with advanced diseases.

At September 2020, these replacement titles were deregistered (Multi‐dimensional interventions) or the protocols withdrawn (Cognitive‐emotional interventions; Multi‐dimensional interventions; Respiratory interventions) as they did not meet Cochrane standards or expectations.

The editorial group responsible for this previously published document have withdrawn it from publication.

Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

BACKGROUND

Breathlessness is a common and distressing symptom in the advanced stages of malignant and non-malignant diseases. Appropriate management requires both pharmacological and non-pharmacological interventions.

OBJECTIVES

The primary objective was to determine the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease.

SEARCH STRATEGY

We searched the following databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, PsycINFO, Science Citation Index Expanded, AMED, The Cochrane Pain, Palliative and Supportive Care Trials Register, The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effectiveness in June 2007. We also searched various websites and reference lists of relevant articles and textbooks.

SELECTION CRITERIA

We included randomised controlled and controlled clinical trials assessing the effects of non-pharmacological and non-invasive interventions to relieve breathlessness in participants described as suffering from breathlessness due to advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure or motor neurone disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed relevant studies for inclusion. Data extraction and quality assessment was performed by three review authors and checked by two other review authors. Meta-analysis was not attempted due to heterogeneity of studies.

MAIN RESULTS

Forty-seven studies were included (2532 participants) and categorised as follows: single component interventions with subcategories of walking aids (n = 7), distractive auditory stimuli (music) (n = 6), chest wall vibration (CWV, n = 5), acupuncture/acupressure (n = 5), relaxation (n = 4), neuro-electrical muscle stimulation (NMES, n = 3) and fan (n = 2). Multi-component interventions were categorised in to counselling and support (n = 5), breathing training (n = 3), counselling and support with breathing-relaxation training (n = 2), case management (n = 2) and psychotherapy (n = 2). There was a high strength of evidence that NMES and CWV could relieve breathlessness and moderate strength for the use of walking aids and breathing training. There is a low strength of evidence that acupuncture/acupressure is helpful. There is not enough data to judge the evidence for distractive auditory stimuli (music), relaxation, fan, counselling and support, counselling and support with breathing-relaxation training, case management and psychotherapy. Most studies have been conducted in COPD patients, only a few studies included participants with other conditions.

AUTHORS' CONCLUSIONS

Breathing training, walking aids, NMES and CWV appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.

Effects of a Walking Aid in COPD Patients Receiving Oxygen Therapy

STUDY OBJECTIVES

To elucidate whether a simple walking aid may improve physical performance in COPD patients with chronic respiratory insufficiency who usually carry their own heavy oxygen canister.

DESIGN

Randomized crossover trial.

SETTING

Physiopathology laboratory of three rehabilitation centers.

PATIENTS AND INTERVENTIONS

We studied 60 stable COPD patients (mean age, 70.6 +/- 7.9 years; FEV(1), 44.8 +/- 14.3% of predicted [+/- SD]) with chronic respiratory insufficiency who randomly performed, on 2 consecutive days, a standardized 6-min walking test using two different modalities: a full-weight oxygen canister transported using a small wheeled cart and pulled by the patient (Aid modality) or full-weight oxygen canister carried on the patient's shoulder (No-Aid modality).

MEASUREMENTS AND RESULTS

The distance walked, peak effort dyspnea, and leg fatigue scores as primary outcomes, and other cardiorespiratory parameters as secondary outcomes were recorded during both tests. A significant difference (p < 0.05) between the two tests occurred for all the measured outcomes in favor of the Aid modality. Most importantly, significant changes for distance (+ 43 m, p < 0.001), peak effort dyspnea (- 2.0 points, p < 0.001), leg fatigue (- 1.4 points, p < 0.001), as well as for mean and nadir oxygen saturation and heart rate with the Aid modality (but not with the No-Aid modality) were recorded in the subgroup of patients walking < 300 m at baseline.

CONCLUSIONS

This study suggests that a simple walking aid may be helpful in COPD patients receiving long-term oxygen therapy, particularly in those with lower residual exercise capacity.

Early mobilization with walking aids following hospital admission with acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

We hypothesized that early ambulation with a gutter frame (GF) in elderly patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may reduce physical disability and allow earlier discharge.

DESIGN

Blinded, randomized parallel groups trial.

SUBJECTS

One hundred and ten consecutive AECOPD inpatients.

INTERVENTIONS

Participants were recruited two days post admission and randomly allocated to four groups: GF with supplemental oxygen (GFSO), GF with supplemental air (GFSA), rollator with supplemental air (RSA) and rollator with supplemental oxygen (RSO) (air/oxygen was double-blinded to patients and investigators). Patients exercised three times daily (maximum of 15 minutes per session) with a physiotherapist or nurse.

OUTCOME MEASURES

Physical disability measured by Barthel Index and perceived respiratory effort by Borg Scale.

RESULTS

After intervention no significant difference was observed between the four groups in length of hospital stay (F= 0.78; p = 0.50), changes in mean Barthel score (F= 2.08; p = 0.11) and Borg score (F= 0.35; p = 0.79). However, improvement in Barthel score (mean 1.22 combined gutter frame group air/oxygen) was greater than the combined rollator group (mean 0.55; p = 0.003). Baseline Barthel score and nurses' assessment of compliance were associated with improvement in Barthel score (p < 0.0001 and p < 0.002). Barthel score was predicted by use of gutter frame (F = 6.17; p = 0.01), not by use of rollator. Use of air/oxygen group was not related to improvement in Barthel score.

CONCLUSION

Short-term exercise therapy with gutter frame after AECOPD admission reduces physical disability in older patients but does not affect length of hospital stay. Use of supplemental oxygen during exercise has no additional benefits.

The short-term effect of a rollator on functional exercise capacity among individuals with severe COPD

STUDY OBJECTIVES

This study was conducted to examine the short-term effects of using a rollator on functional exercise capacity among individuals with COPD and to characterize which individuals benefit most from its use.

DESIGN

Repeated-measures randomized crossover design using the 6-min walk test (6MWT) as the primary outcome measure.

SETTING

Respiratory rehabilitation center.

PATIENTS

Forty stable subjects who had received a diagnosis of COPD.

INTERVENTIONS

Two 6MWTs were performed on each study day. One 6MWT was performed unaided, and the other was performed with a rollator. The order was randomized on the first day and reversed on the second day.

RESULTS

Use of the rollator was associated with a significant reduction in dyspnea (p < 0.001) and duration of rest (reduction for the total group, 19 s; and reduction for those who walked < 300 m unaided, 40 s; p = 0.001) during the 6MWT. For subjects who walked < 300 m unaided, there was also a significant improvement in distance walked (p = 0.02). No changes were found for the measures of cardiorespiratory function or gait (p > 0.05). The requirement to rest during an unaided 6MWT was a significant predictor of improved functional exercise capacity with the use of the rollator (p < 0.005). The majority of subjects whose unaided 6MWT distance was < 300 m preferred using the rollator to walking unaided.

CONCLUSIONS

Use of a rollator was effective in improving functional exercise capacity by reducing dyspnea and rest duration among stable individuals with severe COPD. Individuals who walked < 300 m and individuals who required a rest during an unaided 6MWT benefited the most from using a rollator in terms of reduced dyspnea, reduced rest time, and improved distance walked.