Use of pedometers as a tool to promote daily physical activity levels in patients with COPD: a systematic review and meta-analysis

The experiences of people with chronic obstructive pulmonary disease (COPD) using activity monitors in everyday life: an interpretative phenomenological study

PURPOSE

Understanding the experiences of people with Chronic Obstructive Pulmonary Disease (COPD) using activity monitors in daily life could support the utilisation of technology within healthcare to increase physical activity and support self-management. This qualitative study aimed to explore the experiences of people with COPD using activity monitors at home in everyday life.

METHODS

Semi-structured face-to-face or telephone interviews were conducted with seven people with COPD between August 2018 and June 2020. Participants had all used an activity monitor within the last year (Fitbit, Garmin, or Apple Watch). Interviews were analysed in-depth using Interpretative Phenomenological Analysis (IPA).

RESULTS

Four themes, developed using IPA, highlight participants' engagement with activity monitors and integrating them into their lives: (1) Motivational features to monitor activity, (2) Importance of setting achievable goals, (3) Developing knowledge and awareness, and (4) Integration into everyday life for self-management.

CONCLUSION

Activity monitors were perceived to be beneficial and useful to people with COPD, not just for monitoring their activity, but also helping to self-manage their condition. Activity monitors may be a useful tool within rehabilitation and healthcare services for COPD.

Short-term effects on physical activity level with web-based self-management support in people with COPD: a randomised controlled trial

We aimed to evaluate short-term effects of a web-based self-management support on objectively measured physical activity (PA) compared to usual care in people with chronic obstructive pulmonary disease (COPD). We conducted a pragmatic randomised controlled trial including people with stable COPD within primary healthcare. Participants were randomised to intervention group, IG (access to the COPD Web, an interactive website to support self-management with focus on PA), or to control group, CG (usual care). Primary outcome at 3 months was change in accelerometry-measured daily steps analysed with ANCOVA, and secondary outcomes were self-reported PA, disease-related symptoms, and quality of life. Missing data in intention-to-treat (ITT) analyses were multiply imputed. One hundred and forty-six participants (n = 73/group), mean (SD) age 69.5 (6.7) years, FEV1pred 60.7 (19.1)% were included. The ITT analysis showed no significant difference in steps between the groups: 1295 steps (95% CI: [-365, 2955], p = 0.12), while the complete case analysis (n = 98) revealed a significant difference of 1492 steps (95% CI: [374, 2609], p = 0.01) in favour of IG. A significant increase in self-reported PA was seen in IG in both the ITT and complete case analysis. In summary, access to the COPD Web was insufficient to increase short-term PA level compared to usual care. However, among participants with complete step data, a clinically relevant effect on daily steps exceeding the minimal important difference was observed, partly explained by higher baseline PA than among dropouts. This indicates that access to the COPD Web may increase PA levels for some people with COPD.

Increasing exercise capacity and physical activity in the COPD patient

Higher levels of exercise capacity and physical activity are desired outcomes in the comprehensive management of the COPD patient. In addition, improvements in exercise capacity and physical activity are instrumental to optimising other important therapeutic goals, such as improved health status, reduced healthcare utilisation and increased survival. Four general approaches towards increasing exercise capacity and physical activity in individuals with COPD will be discussed in this review: 1) pharmacological intervention, especially the administration of long-acting bronchodilators; 2) pulmonary rehabilitation, including exercise training and collaborative self-management; 3) behavioural interventions; and 4) web-based interventions. These are by no means the only approaches, nor are they mutually exclusive: indeed, combining them, as necessary, to meet the needs of the individual respiratory patient may promote optimal outcomes, although further research is necessary in this area.

Effectiveness of a home-based pulmonary rehabilitation maintenance programme: the Rehab2Life study protocol

Pulmonary rehabilitation (PR) is the bedrock of non-pharmacological treatment for people with COPD. Nonetheless, it is well described in the literature that unless the patient changes his behaviour, the benefits of PR programmes will decline in six to twelve months after finishing the programme. Therefore, maintenance programmes can address the problem of PR programmes' effect loss over time.Community care units can provide multidisciplinary care in the current Portuguese primary health care context. These units have an interdisciplinary team that aims to develop competencies in COPD patients to self-manage the disease.This study aims to test the effectiveness of a 12-month home-based PR programme (Rehab2Life) compared to usual care through a single-blind randomised controlled trial with two parallel groups. The Rehab2Life programme includes two distinct phases. The first is an 8-week PR programme delivered to both groups, and the second is a PR maintenance programme delivered to the intervention group after the initial eight weeks. The control group receive the usual care and regular appointments. The primary outcome is functional capacity, and secondary outcomes are dyspnea, Health-Related Quality of Life (HRQoL), number of exacerbations, symptoms burden, anxiety and depression symptoms, and physical activity.We expect to observe that the home-based PR programme brings clinically relevant benefits to the participants at the end of the first eight weeks and that, at 12 months after the maintenance phase of the programme, benefits are less dissipated than in the control group. We expect to identify the characteristics of the patients who benefit the most from home-based programmes.The trial was registered on 7 April 2022 at ClinicalTrials.gov (NCT05315505).

Changes in physical activity, sedentary behaviour and sleep following pulmonary rehabilitation: a systematic review and network meta-analysis

BACKGROUND

The variety of innovations to traditional centre-based pulmonary rehabilitation (CBPR), including different modes of delivery and adjuncts, are likely to lead to differential responses in physical activity, sedentary behaviour and sleep.

OBJECTIVES

To examine the relative effectiveness of different pulmonary rehabilitation-based interventions on physical activity, sedentary behaviour and sleep.

METHODS

Randomised trials in chronic respiratory disease involving pulmonary rehabilitation-based interventions were systematically searched for. Network meta-analyses compared interventions for changes in physical activity, sedentary behaviour and sleep in COPD.

RESULTS

46 studies were included, and analyses were performed on most common outcomes: steps per day (k=24), time spent in moderate-to-vigorous physical activity (MVPA; k=12) and sedentary time (k=8). There were insufficient data on sleep outcomes (k=3). CBPR resulted in greater steps per day and MVPA and reduced sedentary time compared to usual care. CBPR+physical activity promotion resulted in greater increases in steps per day compared to both usual care and CBPR, with greater increases in MVPA and reductions in sedentary time compared to usual care, but not CBPR. Home-based pulmonary rehabilitation resulted in greater increases in steps per day and decreases in sedentary time compared to usual care. Compared to usual care, CBPR+physical activity promotion was the only intervention where the lower 95% confidence interval for steps per day surpassed the minimal important difference. No pulmonary rehabilitation-related intervention resulted in greater increases in MVPA or reductions in sedentary time compared to CBPR.

CONCLUSION

The addition of physical activity promotion to pulmonary rehabilitation improves volume of physical activity, but not intensity, compared to CBPR. High risk of bias and low certainty of evidence suggests that these results should be viewed with caution.

Wearable Devices to Improve Physical Activity and Reduce Sedentary Behaviour: An Umbrella Review

BACKGROUND

Several systematic reviews (SRs), with and without meta-analyses, have investigated the use of wearable devices to improve physical activity, and there is a need for frequent and updated syntheses on the topic.

OBJECTIVE

We aimed to evaluate whether using wearable devices increased physical activity and reduced sedentary behaviour in adults.

METHODS

We conducted an umbrella review searching PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, MedRxiv, Rxiv and bioRxiv databases up to February 5th, 2023. We included all SRs that evaluated the efficacy of interventions when wearable devices were used to measure physical activity in adults aged over 18 years. The primary outcomes were physical activity and sedentary behaviour measured as the number of steps per day, minutes of moderate to vigorous physical activity (MVPA) per week, and minutes of sedentary behaviour (SB) per day. We assessed the methodological quality of each SR using the Assessment of Multiple Systematic Reviews, version 2 (AMSTAR 2) and the certainty of evidence of each outcome measure using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). We interpreted the results using a decision-making framework examining the clinical relevance and the concordances or discordances of the SR effect size.

RESULTS

Fifty-one SRs were included, of which 38 included meta-analyses (302 unique primary studies). Of the included SRs, 72.5% were rated as 'critically low methodological quality'. Overall, with a slight overlap of primary studies (corrected cover area: 3.87% for steps per day, 3.12% for MVPA, 4.06% for SB) and low-to-moderate certainty of the evidence, the use of WDs may increase PA by a median of 1,312.23 (IQR 627-1854) steps per day and 57.8 (IQR 37.7 to 107.3) minutes per week of MVPA. Uncertainty is present for PA in pathologies and older adults subgroups and for SB in mixed and older adults subgroups (large confidence intervals).

CONCLUSIONS

Our findings suggest that the use of WDs may increase physical activity in middle-aged adults. Further studies are needed to investigate the effects of using WDs on specific subgroups (such as pathologies and older adults) in different follow-up lengths, and the role of other intervention components.

Physical activity coaching in patients with interstitial lung diseases: A randomized controlled trial

OBJECTIVES

Physical activity is reduced in patients with interstitial lung disease (ILD) and physical inactivity is related to poor health outcomes. We investigated the effect of a telecoaching intervention to improve physical activity in patients with ILD.

METHODS

Eighty patients with ILD were randomized into the intervention or control group. Patients in the intervention group received a 12-week telecoaching program including a step counter, a patient-tailored smartphone application, and coaching calls. Patients in the control group received usual care. Physical activity (primary outcome), physical fitness and quality of life were measured at baseline and 12 weeks later with an accelerometer, 6-min walking test and quadriceps muscle force and the King's Brief Interstitial Lung Disease questionnaire (K-BILD).

RESULTS

Participation in telecoaching did not improve physical activity: between-group differences for step count: 386 ± 590 steps/day, p = .52; sedentary time: 4 ± 18 min/day, p = .81; movement intensity: 0.04 ± 0.05 m/s2, p = .45). Between-group differences for the 6-min walking test, quadriceps muscle force and K-BILD were 14 ± 10 m, p = .16; 2 ± 3% predicted, p = .61; 0.8 ± 1.7 points, p = .62 respectively.

CONCLUSIONS

Twelve weeks of telecoaching did not improve physical activity, physical fitness or quality of life in patients with ILD. Future physical or behavioural interventions are needed for these patients to improve physical activity.

Wearable technology interventions in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is associated with multiple medical and psychological comorbidities. Therefore, future strategies to improve COPD management and outcomes are needed for the betterment of patient care. Wearable technology interventions offer considerable promise in improving outcomes, but prior reviews fall short of assessing their role in the COPD population. In this systematic review and meta-analysis we searched ovid-MEDLINE, ovid-EMBASE, CINAHL, CENTRAL, and IEEE databases from inception to April 2023 to identify studies investigating wearable technology interventions in an adult COPD population with prespecified outcomes of interest including physical activity promotion, increasing exercise capacity, exacerbation detection, and quality-of-life. We identified 7396 studies, of which 37 were included in our review. Meta-analysis showed wearable technology interventions significantly increased: the mean daily step count (mean difference (MD) 850 (494-1205) steps/day) and the six-minute walk distance (MD 5.81 m (1.02-10.61 m). However, the impact was short-lived. Furthermore, wearable technology coupled with another facet (such as health coaching or pulmonary rehabilitation) had a greater impact that wearable technology alone. Wearable technology had little impact on quality-of-life measures and had mixed results for exacerbation avoidance and prediction. It is clear that wearable technology interventions may have the potential to form a core part of future COPD management plans, but further work is required to translate this into meaningful clinical benefit.

Minute level smartphone derived exposure to greenness and consumer wearable derived physical activity in a cohort of US women

BACKGROUND

Inconsistent results have been found in the literature on associations of greenness, or vegetation quantity, and physical activity. However, few studies have assessed associations between mobility-based greenness and physical activity from mobile health data from smartphone and wearable devices with fine spatial and temporal resolution.

METHODS

We assessed mobility-based greenness exposure and wearable accelerometer data from participants in the US-based prospective Nurses' Health Study 3 cohort Mobile Health (mHealth) Substudy (2018-2020). We recruited 500 female participants with instructions to wear devices over four 7-day sampling periods equally spaced throughout the year. After restriction criteria there were 337 participants (mean age 36 years) with n = 639,364 unique observations. Normalized Difference Vegetation Index (NDVI) data were derived from 30 m x 30 m Landsat-8 imagery and spatially joined to GPS points recorded every 10 min. Fitbit proprietary algorithms provided physical activity summarized as mean number of steps per minute, which we averaged during the 10-min period following a GPS-based greenness exposure assessment. We utilized Generalized Additive Mixed Models to examine associations (every 10 min) between greenness and physical activity adjusting for neighborhood and individual socioeconomic status, Census region, season, neighborhood walkability, daily mean temperature and precipitation. We assessed effect modification through stratification and interaction models and conducted sensitivity analyses.

RESULTS

Mean 10-min step count averaged 7.0 steps (SD 14.9) and greenness (NDVI) averaged 0.3 (SD 0.2). Contrary to our hypotheses, higher greenness exposure was associated non-linearly with lower mean steps per minute after adjusting for confounders. We observed statistically significant effect modification by Census region and season.

DISCUSSION

We utilized objective physical activity data at fine temporal and spatial scales to present novel estimates of the association between mobility-based greenness and step count. We found higher levels of greenness were inversely associated with steps per minute.

Views and experiences of healthcare practitioners supporting people with COPD who have used activity monitors: "More than just steps"

INTRODUCTION

Activity monitors (apps and wearables) are increasingly used by the general population, including people with Chronic Obstructive Pulmonary Disease (COPD). There is potential for activity monitors to support increases in physical activity for people with COPD and healthcare practitioners (HCPs) are likely to be key in supporting their use, but little is currently known about HCPs' views or experiences. This qualitative research aimed to explore HCPs' views and experiences of supporting people with COPD who have used activity monitors.

METHODS

Seventeen semi-structured telephone or online interviews were conducted with HCPs between September 2020 and May 2021. HCPs included two nurses, an occupational therapist, a physician, and 13 physiotherapists. Participants were recruited via social media advertisements. They all had experience of supporting people with COPD who had used activity monitors. Interviews were analysed using reflexive thematic analysis.

FINDINGS

Four themes were developed highlighting the challenges and benefits of HCPs supporting patients with using activity monitors and utilising patient-collected activity data; 1) Skills and experience are needed to increase accessibility and engagement, 2) Objectively monitored physical activity can support exercise prescription, 3) Applications of activity monitors vary across different settings, and 4) Support is needed for future use of activity monitors.

DISCUSSION

HCPs recognised the potential for activity monitors to impact patients' ability to self-manage their COPD. However, there is a lack of guidance and information to support integration within practice. Future research is needed to co-develop information and guidelines for people with COPD and HCPs.

Effects of Pedometer-Based Step-Feedback on Physical Activity of Severe COPD Patients

Purpose

This study investigated whether adding step-feedback (step-FB) from a pedometer to pulmonary rehabilitation (PR) programs could increase the physical activity (PA) of low-activity patients with severe chronic obstructive pulmonary disease (COPD).

Patients and Methods

We included low-activity patients with severe COPD (step-FB group: 14 patients; control group: 17 patients) who underwent PR for the first time. The usual PR program for patients with severe COPD consisted of two 8-week sessions (PR session 1: PR1, PR session 2: PR2). The step-FB group was provided a program with step-FB added to PR2 (PR2+step-FB). Furthermore, all patients were evaluated at pre-intervention (baseline), PR1, and PR2. The primary outcome of this study was the number of daily steps (steps) and energy expenditure from activity (energy expenditure), as measured by a pedometer. The secondary outcomes were dyspnea and exercise tolerance.

Results

In PR1, dyspnea, exercise tolerance, steps, and energy expenditure were significantly improved as compared to baseline, in both groups. During PR2, dyspnea and exercise tolerance were significantly improved as compared to PR1, in both groups. Steps and energy expenditure were significantly improved in the step-FB group, but not in the control group.

Conclusion

PR improved PA by improving physical function in severe COPD patients. Adding step-FB improved PA in severe COPD patients by presenting an activity goal for improving PA. Therefore, pedometer-based step-FB is a viable addition to PR and has the potential to improve PA continuously in these patients.

Cognitive behavioural therapy combined with physical activity behavioural modification strategies during pulmonary rehabilitation in patients with COPD

Introduction

Patients with COPD who exhibit elevated levels of anxiety and/or depression are typically less able to improve symptoms and physical activity levels following a programme of pulmonary rehabilitation (PR). The objective of the present study was to provide proof of concept that offering an intervention comprising cognitive behavioural therapy (CBT) alongside physical activity behavioural modification strategies (BPA) during PR is more effective in improving physical activity outcomes compared to PR and CBT alone.

Methods

32 patients with COPD (mean±sd forced expiratory volume in 1 s 42±14% predicted) were assigned 1:1 to receive PR+CBT+BPA or PR+CBT. BPA comprised motivational interviews, step-count monitoring, feedback using a pedometer and goal setting. Assessments included accelerometer-derived steps per day, movement intensity, 6-min walk distance (6MWD) and Hospital Anxiety and Depression Scale (HADS) scores.

Results

The magnitude of improvement across physical activity outcomes was greater for the PR+CBT+BPA compared to the PR+CBT intervention (by 829 steps per day (p=0.029) and by 80±39 vector magnitude units (p=0.042), respectively). Compared to PR and CBT alone, the PR+CBT+BPA intervention induced greater clinically meaningful improvements in HADS anxiety scores (by -2 units, 95% CI -4-1 units) and 6MWD (by 33±20 m).

Conclusions

Providing anxious and/or depressed patients with COPD with a combined intervention of CBT and BPA during PR presents more favourable improvements in physical activity outcome measures compared to CBT alone during PR.

Physical activity monitoring-based interventions in geriatric patients: a scoping review on intervention components and clinical applicability

OBJECTIVE

To identify and analyze the components applied in interventions using physical activity (PA) monitoring in geriatric patients and determine their feasibility and applicability.

METHODS

A systematic search in six databases (PubMed, Embase, SPORTDiscus, CINAHL, Web of Science, and GeroLit) was conducted to identify studies reporting interventions that included the application of a PA monitor in adults aged ≥ 60 years with a clinical diagnosis. PA monitor interventions were analyzed regarding their feedback, goal-setting and behavior change technique (BCT) components. To determine the feasibility and applicability of interventions, the participants' adherence to the intervention, their experience as well as adverse events were analyzed.

RESULTS

Seventeen eligible studies, applying 22 interventions, were identified. Studies included a total of 827 older patients with a median age of 70.2 years. In thirteen interventions (59%), the PA monitor was embedded in a structured behavioral intervention, an indication-specific intervention or usual care. Most frequently applied intervention components were goal setting and self-monitoring (n = 18), real-time PA monitor feedback complemented by feedback from the study team (n = 12), use of further BCTs (n = 18), and regular counseling with the study team (n = 19). Comprehensive information on the participants' intervention adherence and experience were reported for 15 (68%) and 8 (36%) interventions, respectively.

CONCLUSION

The components included in PA monitoring-based interventions varied considerably especially regarding the extent, frequency, and content of feedback, goal setting and BCTs counseling. Future research should evaluate which components are most effective and clinically applicable to promote physical activity in geriatric patients. To be able to precisely analyze the effects, trials should seek to report details on intervention components, adherence and adverse events, while future reviews may use the findings of this scoping review to conduct analyses with less heterogeneity in study characteristics and intervention strategies.

A scoping review of co-creation practice in the development of non-pharmacological interventions for people with Chronic Obstructive Pulmonary Disease: A health CASCADE study

BACKGROUND

Incorporating co-creation processes may improve the quality of outcome interventions. However, there is a lack of synthesis of co-creation practices in the development of Non-Pharmacological Interventions (NPIs) for people with Chronic Obstructive Pulmonary Disease (COPD), that could inform future co-creation practice and research for rigorously improving the quality of care.

OBJECTIVE

This scoping review aimed to examine the co-creation practice used when developing NPIs for people with COPD.

METHODS

This review followed Arksey and O'Malley scoping review framework and was reported according to the PRISMA-ScR framework. The search included PubMed, Scopus, CINAHL, and Web of Science Core Collection. Studies reporting on the process and/or analysis of applying co-creation practice in developing NPIs for people with COPD were included.

RESULTS

13 articles complied with the inclusion criteria. Limited creative methods were reported in the studies. Facilitators described in the co-creation practices included administrative preparations, diversity of stakeholders, cultural considerations, employment of creative methods, creation of an appreciative environment, and digital assistance. Challenges around the physical limitations of patients, the absence of key stakeholder opinions, a prolonged process, recruitment, and digital illiteracy of co-creators were listed. Most of the studies did not report including implementation considerations as a discussion point in their co-creation workshops.

CONCLUSION

Evidence-based co-creation in COPD care is critical for guiding future practice and improving the quality of care delivered by NPIs. This review provides evidence for improving systematic and reproducible co-creation. Future research should focus on systematically planning, conducting, evaluating, and reporting co-creation practices in COPD care.

Physical activity promotion interventions in chronic airways disease: a systematic review and meta-analysis

Physical inactivity is common in people with chronic airways disease (pwCAD) and associated with worse clinical outcomes and impaired quality of life. We conducted a systematic review and meta-analysis to characterise and evaluate the effectiveness of interventions promoting step-based physical activity (PA) in pwCAD. We searched for studies that included a form of PA promotion and step-count outcome measure. A random-effects model was used to determine the overall effect size using post-intervention values. 38 studies (n=32 COPD; n=5 asthma; n=1 bronchiectasis; study population: n=3777) were included. Overall, implementing a form of PA promotion resulted in a significant increase in step-count: median (IQR) 705 (183-1210) when compared with usual standard care: -64 (-597-229), standardised mean difference (SMD) 0.24 (95% CI: 0.12-0.36), p<0.01. To explore the impact of specific interventions, studies were stratified into subgroups: PA promotion+wearable activity monitor-based interventions (n=17) (SMD 0.37, p<0.01); PA promotion+step-count as an outcome measure (n=9) (SMD 0.18, p=0.09); technology-based interventions (n=12) (SMD 0.16, p=0.01). Interventions promoting PA, particularly those that incorporate wearable activity monitors, result in a significant and clinically meaningful improvement in daily step-count in pwCAD.

The effectiveness of wearable activity trackers for increasing physical activity and reducing sedentary time in older adults: A systematic review and meta-analysis

Background

Traditional interventions such as education and counseling are successful in increasing physical activity (PA) participation, but are usually labor and resource intensive. Wearable activity trackers can objectively record PA and provide feedback to help users to achieve activity goals and are an increasingly popular tool among adults used to facilitate self-monitoring of PA. However, no reviews systematically explored the roles of wearable activity trackers in older populations.

Methods

We searched PubMed, Web of Science, Google Scholar, Embase, Cochrane Library, and Scopus from inception to September 10, 2022. Randomized controlled trials were included. Two reviewers independently conducted study selection, data extraction, risk of bias, and certainty of evidence assessment. A random-effects model was used to evaluate the effect size.

Results

A total of 45 studies with 7144 participants were included. A wearable activity tracker was effective in increasing daily steps (standard mean differences (SMD) = 0.59, 95% confidence interval (CI) (0.44, 0.75)), weekly moderate-to-vigorous PA (MVPA) (SMD = 0.54, 95% CI (0.36, 0.72)), and total daily PA (SMD = 0.21, 95% CI (0.01, 0.40)) and reducing sedentary time (SMD = -0.10, 95% CI (-0.19, -0.01)). Subgroup analysis showed that the effectiveness of wearable activity trackers for daily steps was not influenced by participants and intervention features. However, wearable activity trackers seemed more effective in promoting MVPA of participant's age <70 than participant's age ≥70. In addition, wearable activity trackers incorporated with traditional intervention components (e.g. telephone counseling, goal setting, and self-monitoring) could better promote MVPA than alone use. Short-term interventions potentially achieve better MVPA increase than long-term.

Conclusion

This review showed that wearable activity trackers are an effective tool to increase PA for the old population and also favor reducing sedentary time. When used together with other interventions, wearable activity trackers can achieve better MVPA increase, especially in the short term. However, how to more effectively improve the effectiveness of wearable activity trackers is an important direction of future research.

Digital Biomarker-Based Interventions: Systematic Review of Systematic Reviews

BACKGROUND

The introduction of new medical technologies such as sensors has accelerated the process of collecting patient data for relevant clinical decisions, which has led to the introduction of a new technology known as digital biomarkers.

OBJECTIVE

This study aims to assess the methodological quality and quality of evidence from meta-analyses of digital biomarker-based interventions.

METHODS

This study follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline for reporting systematic reviews, including original English publications of systematic reviews reporting meta-analyses of clinical outcomes (efficacy and safety endpoints) of digital biomarker-based interventions compared with alternative interventions without digital biomarkers. Imaging or other technologies that do not measure objective physiological or behavioral data were excluded from this study. A literature search of PubMed and the Cochrane Library was conducted, limited to 2019-2020. The quality of the methodology and evidence synthesis of the meta-analyses were assessed using AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) and GRADE (Grading of Recommendations, Assessment, Development, and Evaluations), respectively. This study was funded by the National Research, Development and Innovation Fund of Hungary.

RESULTS

A total of 25 studies with 91 reported outcomes were included in the final analysis; 1 (4%), 1 (4%), and 23 (92%) studies had high, low, and critically low methodologic quality, respectively. As many as 6 clinical outcomes (7%) had high-quality evidence and 80 outcomes (88%) had moderate-quality evidence; 5 outcomes (5%) were rated with a low level of certainty, mainly due to risk of bias (85/91, 93%), inconsistency (27/91, 30%), and imprecision (27/91, 30%). There is high-quality evidence of improvements in mortality, transplant risk, cardiac arrhythmia detection, and stroke incidence with cardiac devices, albeit with low reporting quality. High-quality reviews of pedometers reported moderate-quality evidence, including effects on physical activity and BMI. No reports with high-quality evidence and high methodological quality were found.

CONCLUSIONS

Researchers in this field should consider the AMSTAR-2 criteria and GRADE to produce high-quality studies in the future. In addition, patients, clinicians, and policymakers are advised to consider the results of this study before making clinical decisions regarding digital biomarkers to be informed of the degree of certainty of the various interventions investigated in this study. The results of this study should be considered with its limitations, such as the narrow time frame.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/28204.

Increasing physical activity in severe asthma: a systematic review and meta-analysis

INTRODUCTION

Physical inactivity is common in asthma and is recognised as an important modifiable risk for poor clinical outcomes such as impaired asthma control and health-related quality of life (HRQoL). Despite evidence supporting the role of physical activity in reducing the risk of these outcomes, little is known about optimal interventions for increasing physical activity in those with severe disease. This systematic review and meta-analysis evaluates the effectiveness of interventions in increasing physical activity in severe asthma.

METHODS

MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Embase, PubMed, Informit, SPORTDiscus and Cochrane databases were searched up to September 2021 for physical activity-based intervention studies that assessed physical activity outcomes (e.g. steps per day, time spent undertaking physical activity) in adults with severe asthma. Data on asthma-related (e.g. asthma control) and health-related outcomes (e.g. HRQoL) were assessed as secondary outcomes. The revised Cochrane Risk of Bias tool was used to assess risk of bias. Random-effects meta-analyses synthesised data where possible.

RESULTS

Four randomised controlled trials (all 12 weeks in duration) including 176 adults with moderate-to-severe asthma were included. An increase in physical activity was reported with a moderate-vigorous intensity aerobic and resistance training intervention (steps per day and time spent undertaking physical activity), and an unsupervised pedometer-based intervention (steps per day). Meta-analyses showed that physical activity interventions had an overall positive effect on steps per day (mean difference (MD) 1588, 95% CI 399-2778; p=0.009, I2=23), asthma control (MD -0.65, 95% CI -0.95--0.35; p<0.0001, I2=0%) and HRQoL (MD 0.56, 95% CI 0.10-1.01; p=0.02, I2=16%) compared to control.

CONCLUSION

While there is some evidence supporting the effectiveness of interventions in improving physical activity in adults with severe asthma, higher-quality, large-scale studies of longer duration are needed to determine the optimal intervention.

Frailty and Quality of Life among Older Adults in Communities: The Mediation Effects of Daily Physical Activity and Healthy Life Self-Efficacy

As the global population ages, frailty, which has been shown to affect and predict the quality of life (QoL) of older adults, has become a central issue. The aim of this study was to explore the mediating effects of daily physical activity (DPA) and healthy life self-efficacy (HLSE) on the relationship between frailty and QoL in older adults using a serial multiple mediation model. The cross-sectional study was conducted among 210 community-dwelling older adults in Taiwan. Data were collected using the Taiwanese version of the Tilburg Frailty Indicator, the EuroQoL visual analog scale, the Kihon Checklist, and the Chronic Disease Self-Efficacy Scales. The PROCESS macro for SPSS based on the bootstrap method was used to determine the mediating effects of DPA and HLSE on the relationship between frailty and QoL. The results showed that frailty was found to have both direct and indirect effects on QoL. As predicted, DPA and HLSE partially mediated the relationship between frailty and quality of life (DPA: B = −0.71, p < 0.001; HLSE: B = −0.32, p < 0.001). In addition, serial mediation analyses indicated that the association between frailty and QoL was partially mediated by DPA and HLSE in a sequential manner (B = −0.16, p < 0.001). The serial mediation has a causal chain linking DPA and HLSE, with a specified direction of causal flow. According to the results of the serial multiple mediation model, the elderly should be encouraged to continue their activities in daily life, which not only improves self-efficacy and confidence in maintaining health but also reduces the negative impact of frailty on QoL.

Digital Biomarker-Based Studies: Scoping Review of Systematic Reviews

BACKGROUND

Sensors and digital devices have revolutionized the measurement, collection, and storage of behavioral and physiological data, leading to the new term digital biomarkers.

OBJECTIVE

This study aimed to investigate the scope of clinical evidence covered by systematic reviews (SRs) of randomized controlled trials involving digital biomarkers.

METHODS

This scoping review was organized using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. With the search limited to English publications, full-text SRs of digital biomarkers included randomized controlled trials that involved a human population and reported changes in participants' health status. PubMed and the Cochrane Library were searched with time frames limited to 2019 and 2020. The World Health Organization's classification systems for diseases (International Classification of Diseases, Eleventh Revision), health interventions (International Classification of Health Interventions), and bodily functions (International Classification of Functioning, Disability, and Health [ICF]) were used to classify populations, interventions, and outcomes, respectively.

RESULTS

A total of 31 SRs met the inclusion criteria. The majority of SRs studied patients with circulatory system diseases (19/31, 61%) and respiratory system diseases (9/31, 29%). Most of the prevalent interventions focused on physical activity behavior (16/31, 52%) and conversion of cardiac rhythm (4/31, 13%). Looking after one's health (physical activity; 15/31, 48%), walking (12/31, 39%), heart rhythm functions (8/31, 26%), and mortality (7/31, 23%) were the most commonly reported outcomes. In total, 16 physiological and behavioral data groups were identified using the ICF tool, such as looking after one's health (physical activity; 14/31, 45%), walking (11/31, 36%), heart rhythm (7/31, 23%), and weight maintenance functions (7/31, 23%). Various digital devices were also studied to collect these data in the included reviews, such as smart glasses, smartwatches, smart bracelets, smart shoes, and smart socks for measuring heart functions, gait pattern functions, and temperature. A substantial number (24/31, 77%) of digital biomarkers were used as interventions. Moreover, wearables (22/31, 71%) were the most common types of digital devices. Position sensors (21/31, 68%) and heart rate sensors and pulse rate sensors (12/31, 39%) were the most prevalent types of sensors used to acquire behavioral and physiological data in the SRs.

CONCLUSIONS

In recent years, the clinical evidence concerning digital biomarkers has been systematically reviewed in a wide range of study populations, interventions, digital devices, and sensor technologies, with the dominance of physical activity and cardiac monitors. We used the World Health Organization's ICF tool for classifying behavioral and physiological data, which seemed to be an applicable tool to categorize the broad scope of digital biomarkers identified in this review. To understand the clinical value of digital biomarkers, the strength and quality of the evidence on their health consequences need to be systematically evaluated.

Promotion of physical activity after hospitalization for COPD exacerbation: A randomized control trial

BACKGROUND AND OBJECTIVE

Physical activity worsens during exacerbations of chronic obstructive pulmonary disease (COPD) and notably after hospitalizations. Pedometer-based interventions are useful to increase physical activity in stable patients with COPD. However, there is little information concerning the implementation of such programs following severe exacerbation. This study assessed the efficacy of a physical activity program after hospitalization for a COPD exacerbation.

METHODS

We performed a prospective, 12-week, parallel group, assessor-blinded, randomized control trial in COPD patients hospitalized for an exacerbation. After discharge, physical activity and other secondary variables were assessed. Patients were allocated (1:1) to a physical activity promotion program (intervention group, IG) or usual care (control group, CG). Based on a motivational interview and accelerometer physical activity assessment, a patient-tailored, pedometer-based, progressive and target-driven program was designed. Linear mixed effect models were used to analyse between-group differences.

RESULTS

Forty-six out of 61 patients recruited were randomized and 43 (IG = 20, CG = 23) completed the study. In-hospital and baseline characteristics were similar in both groups. After 12 weeks of intervention, the mean steps difference between groups was 2093 steps/day, p = 0.018, 95% CI 376-4012, favouring the IG. Only the IG significantly increased the number of steps/day compared to baseline (mean difference [95% CI] 2932 [1069-4795] steps; p = 0.004). There were no other between-group differences.

CONCLUSION

After hospitalization for a COPD exacerbation, a patient-tailored physical activity program based on a motivational interview and the use of pedometers, with progressive and customized targets, improved the number of steps/day.

A meta-analysis on the structure of pulmonary rehabilitation maintenance programmes on COPD patients' functional capacity

Pulmonary rehabilitation (PR) improves functional capacity, health-related quality of life (HRQoL) in COPD patients, and maintenance programmes are relevant in preserving those improvements. However, little is known about the structure of maintenance programmes after PR. We performed a systematic review and meta-analysis of experimental and quasi-experimental studies evaluating individuals with COPD admitted to a maintenance PR programme, delivered after an initial PR programme. We reported functional capacity evaluation (6-minute-walking-test), HRQoL, dyspnoea and symptom control. Searches were performed on the 11th April 2021 using MEDLINE, Embase, EBSCO, CINAHL, Web of Science and Cochrane Library. We extracted summary-level data from trial publications and used a random-effects model, predicting that severe heterogeneity was detected. The protocol was registered in PROSPERO (CRD42021247724). Fifteen studies were included in the meta-analysis, with 1151 participants. Maintenance programmes were associated with a pooled mean increase of 27.08 meters in 6mWT (CI: 10.39 to 43.77; I2 = 93%; p < 0.0001), being better in supervised, long (>12 month) home-based programmes; and having a potential MD of -4.20 pts in SGRQ (CI: -4.49 to -3.91; I2 = 0%; p = 0.74). Regarding dyspnoea and exacerbations, we found a nonsignificant trend for improvement after maintenance PR programmes. Severe COPD patients showed smaller improvements in programmes up to a year. Overall, the strength of the underlying evidence was moderate. Despite limitations of risk of bias and heterogeneity, our results support that home-based, supervised, long-term maintenance PR programmes may significantly improve functional capacity in COPD patients and HRQoL.

Physical activity and chronic obstructive pulmonary disease: a scoping review

BACKGROUND

Reduced physical activity (PA) was the strongest predictor of all-cause mortality in patients with chronic obstructive pulmonary disease (COPD). This scoping review aimed to map the evidence on the current landscape of physical activity, barriers and facilitators, and assessment tools across COPD patients.

METHODS

Arksey and O'Malley's scoping review methodology framework guided the conduct of this review. An electronic search was conducted on five English databases (PubMed, Cochrane Library, PsycINFO, CINAHL and Web of Science) and three Chinese databases (CNKI, CQVIP and WAN-FANG) in January 2022. Two authors independently screened the literature, extracted the studies characteristics.

RESULTS

The initial search yielded 4389 results, of which 1954 were duplicates. Of the remaining 135 articles, 42 studies met the inclusion criteria. Among the reviewed articles, there were 14 (33.3%) cross-sectional study, 9 (21.4%) cohort study, 4 (9.5%) longitudinal study, 3 qualitative study, 12 (28.7%) randomized control trials. The main barriers identified were older age, women, lung function, comorbidities, COPD symptoms (fear of breathlessness and injury, severe fatigue, anxiety and depression), GOLD stage, frequency of exacerbation, oxygen use, lack of motivation and environment-related (e.g., season and weather). Twelve studies have evaluated the effects of physical exercise (e.g., walking training, pulmonary rehabilitation (PR), pedometer, self-efficacy enhancing intervention and behavioral modification intervention) on PA and showed significant positive effects on the prognosis of patients. However, in real life it is difficult to maintain PA in people with COPD.

CONCLUSIONS

Changing PA behavior in patients with COPD requires multidisciplinary collaboration. Future studies need to identify the best instruments to measure physical activity in clinical practice. Future studies should focus on the effects of different types, time and intensity of PA in people with COPD and conduct randomized, adequately-powered, controlled trials to evaluate the long-term effectiveness of behavioral change interventions in PA.

Experience of physical activity in patients with COPD: A systematic review and qualitative meta-synthesis

OBJECTIVE

To systematically evaluate and integrate the qualitative research on physical activity (PA) experience of patients with chronic obstructive pulmonary disease (COPD).

METHODS

Web of Science, Cochrane Library, Embase, CINAHL and other databases were searched, and the qualitative research on PA experience of patients with COPD was collected. The systematic review was conducted in line with Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence.

RESULTS

12 studies were included and 3 themes were summarized, included: COPD patients experience more barriers while participating in physical activities than facilitators; COPD patients experience more positive effects post-physical activities than negative effects; Guaranteeing safety, goal setting, and establishing a professional support group improve compliance in COPD patients.

CONCLUSION

Health care professionals should help patients overcome the obstacles of PA, pay attention to the PA experience of patients, adopt diversified PA methods, improve PA participation and compliance, and make patients develop good PA habits.

The impact of endoscopic lung volume reduction on physical activity coaching in patients with severe emphysema

Introduction

Endoscopic lung volume reduction (ELVR) aims to improve pulmonary function in severe emphysema. Physical activity (PA) coaching is expected to improve daily life PA. When improving ventilatory constrains in severe COPD, a better response to PA coaching is expected. The present study investigated the impact of PA coaching in addition to ELVR in severe emphysema.

Methods

Patients allocated, based on fissure integrity, in the ELVR or no-ELVR cohort, received the PA coaching intervention with a step counter and smartphone application from 3 to 6 months follow-up. The primary end-point of this research question was the change in daily step count from baseline to 6 months follow-up compared between the ELVR and no-ELVR cohort. The secondary end-points were time spent in moderate to vigorous PA, movement intensity and patient-reported experience with PA between ELVR and no-ELVR.

Results

At 6 months, PA in both ELVR+coaching (1479±460 steps·day-1; p=0.001) and no-ELVR+coaching (1910±663 steps·day-1; p=0.004) improved within group, without significant between-group differences (-405±781 steps·day-1; p=0.60). Patients in the ELVR group tended to experience less difficulty with PA compared to no-ELVR+coaching (7±4 points, p=0.08).

Conclusion

We found that PA coaching is feasible and can help to enhance PA in patients with severe emphysema. Improving the ventilatory capacity through ELVR is not a prerequisite for a successful coaching intervention to increase objectively measured PA, although it alleviates patients' experienced difficulty with PA in those with severe COPD.

Effect and feasibility of wearable physical activity trackers and pedometers for increasing physical activity and improving health outcomes in cancer survivors: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the effect of wearable devices for improving physical activity and health-related outcomes in cancer survivors.

METHODS

CINAHL, Cochrane, Ebscohost, MEDLINE, Pubmed, ProQuest Health and Medical Complete, ProQuest Nursing and Allied Health Source, ScienceDirect, and SPORTDiscus databases were searched for randomized controlled trials published before September 1, 2020, that evaluated interventions involving wearable devices in cancer survivors. Standardized mean differences (SMDs) were calculated to assess effects on physical activity and health-related outcomes. Subgroup analyses were conducted to assess whether the effects differed by interventions and cancer characteristics. Risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS

Thirty-five trials were included (breast cancer, n = 15, 43%). Intervention durations ranged between 4 weeks and 1 year. Most trials (n = 25, 71%) involved pedometer-based physical activity interventions. Seven (20%) involved Fitbit-based interventions, and 3 (9%) involved other wearable physical activity trackers (e.g., Polar, Garmin). Compared to usual care, wearable devices had moderate-to-large effects (SMD range 0.54-0.87, p < 0.001) on moderate-intensity physical activity, moderate-to-vigorous-intensity physical activity, total physical activity, and daily steps. Compared to usual care, those in the intervention had higher quality of life, aerobic fitness, physical function, and reduced fatigue (SMD range = 0.18-0.66, all p < 0.05).

CONCLUSION

Wearable physical activity trackers and pedometers are effective tools that increase physical activity and improve health-related outcomes in individuals with cancer. Identifying how these devices can be implemented for longer-term use with other intervention components remains an area for future research.

What Are the Experiences of People with COPD Using Activity Monitors?: A Qualitative Scoping Review

Physical activity monitoring technology (e.g. smartphone apps or wearables) can objectively record physical activity levels, potentially support interventions to increase activity levels, and support the self-management of Chronic Obstructive Pulmonary Disease (COPD). Insight into patients' experiences of monitoring physical activity is needed to inform future healthcare practice and policy utilizing this technology to support long-term positive health behavior change. This scoping review aimed to explore the experiences of using technology for monitoring physical activity among people with COPD. The Joanna Briggs Institute scoping review methodological framework was used. Relevant scientific databases (CINAHL Complete, MEDLINE, PsycINFO, SPORTDiscus, Cochrane Library and Scopus) were searched from 1st January 2016 to 16th March 2021. Thematic synthesis was used to analyze the data. Twelve studies exploring the experiences of people with COPD using technology for monitoring physical activity were included in the synthesis. Seven themes were developed and summarize experiences: 1) Monitoring and keeping track of their activity and health, 2) Supporting motivation to be active, 3) Acceptability of the device, 4) Experiencing technical issues with the device, 5) Setting appropriate and achievable goals for their health condition, 6) Integrating the device into their life and daily routine, and 7) Perceived physical and psychological benefits of using the device. Further high-quality research is needed to understand the experiences of people with COPD using technology to monitor physical activity in everyday life and better self-manage their health condition. Supporting people with COPD to monitor their physical activity could enable them to better self-manage their health condition.

Effectiveness of physical activity monitors in adults: systematic review and meta-analysis

OBJECTIVE

To estimate the effectiveness of physical activity monitor (PAM) based interventions among adults and explore reasons for the heterogeneity.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

The electronic databases MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched on 4 June 2021. Eligible randomised controlled trials compared interventions in which adults received feedback from PAMs with control interventions in which no feedback was provided. No restrictions on type of outcome measurement, publication date, or language were applied.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were used to synthesise the results. The certainty of evidence was rated by the Grading of Recommendations Assessment and Evaluation (GRADE) approach.

MAIN OUTCOME MEASURES

The three primary outcomes of interest were physical activity, moderate to vigorous physical activity, and sedentary time.

RESULTS

121 randomised controlled trials with 141 study comparisons, including 16 743 participants, were included. The PAM based interventions showed a moderate effect (standardised mean difference 0.42, 95% confidence interval 0.28 to 0.55) on physical activity, equivalent to 1235 daily steps; a small effect (0.23, 0.16 to 0.30) on moderate to vigorous physical activity, equivalent to 48.5 weekly minutes; and a small insignificant effect (-0.12, -0.25 to 0.01) on sedentary time, equal to 9.9 daily minutes. All outcomes favoured the PAM interventions.

CONCLUSIONS

The certainty of evidence was low for the effect of PAM based interventions on physical activity and moderate for moderate to vigorous physical activity and sedentary time. PAM based interventions are safe and effectively increase physical activity and moderate to vigorous physical activity. The effect on physical activity and moderate to vigorous physical activity is well established but might be overestimated owing to publication bias.

STUDY REGISTRATION

PROSPERO CRD42018102719.

Prediction of Low-intensity Physical Activity in Stable Patients with Chronic Obstructive Pulmonary Disease

OBJECTIVE

To develop an equation of the predicted amount of low-intensity physical activity (LPA) by analyzing clinical parameters in patients with chronic obstructive pulmonary disease (COPD).

METHODS

In this cross-sectional study, we analyzed the assessments of clinical parameters evaluated every 6 months from the start of pulmonary rehabilitation in 53 outpatients with stable COPD (age 77 ± 6 yrs; 46 men; body mass index 21.8 ± 4.1 kg/m²; forced expiratory volume in one second 63.0 ± 26.4% pred). An uniaxial accelerometer was used to measure the number of steps and the time spent in LPA of 1.8-2.3 metabolic equivalents during 14 consecutive days. We also evaluated body composition, respiratory function, skeletal muscle strength, inspiratory muscle strength, exercise capacity, and gait speed. Factors associated with the time spent in LPA were examined by multivariate regression analysis. Internal validity between the predicted amount of LPA obtained by the equation and the measured amount was examined by regression analysis.

RESULTS

Multivariate regression analysis revealed that gait speed (β = 0.369, p = 0.007) and maximum inspiratory mouth pressure (PI_max) (β = 0.329, p = 0.016) were significant influence factors on LPA (R² = 0.354, p <0.001). The stepwise regression analysis showed a moderate correlation between the measured amount and predicted amount of LPA calculated by the regression equation (r = 0.609, p <0.001; LPA = 31.909 × gait speed + 0.202 × PI_max - 20.553).

CONCLUSION

Gait speed and PI_max were extracted as influence factors on LPA, suggesting that the regression equation could predict the amount of LPA.

The effectiveness of exercise interventions to increase physical activity in Cystic Fibrosis: A systematic review

Physical activity (PA) and exercise have numerous benefits in Cystic Fibrosis (CF) including improved lung function, exercise capacity and quality of life. Despite these benefits, the effectiveness of interventions to promote PA in this population are still largely unknown. The objective of this review was to synthesise existing research and determine whether exercise interventions are effective in promoting PA in people with CF. Using the PRISMA guidelines, a comprehensive search was conducted. Fifteen studies (463 participants) met the inclusion criteria. Eleven studies demonstrated improvements in PA in both short- and long-term interventions. However, the interventions were variable across the included studies, with a large inconsistency in PA assessment tools used. Aerobic training and activity counselling were the two elements identified in this review which most consistently improved PA. Future research should consider larger sample sizes and the use of accurate instruments to assess and track PA levels longitudinally.

An Exploration of the Application of Step Counter-Based Physical Activity Promotion Programs in Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review

Objective: This paper aimed to systematically review the application methods and components of step counter-based physical activity (PA) promotion programs in patients with chronic obstructive pulmonary disease (COPD). The effects of longer-duration (≥12 weeks) programs on PA, exercise capacity, quality of life, and dyspnea were discussed.

Methods: This review was performed in accordance with the preferred reporting items for systematic reviews and meta-analysis. Online data resources PubMed, Web of Science, Embase, and EBSCO were searched. The publication year was limited between January 2000 to August 2020. All randomized controlled trials with ≥12-week duration of step counter-based PA promotion programs of COPD were included. Two researchers independently assessed the quality of the included studies and extracted their characteristics.

Results: Nine studies involving 1,450 participants were included. Step counters, counseling, exercise goals, diaries, and tele-communicational approaches were common components of these programs. The PA feedback tools were mostly pedometers (n = 8), whereas accelerometers were often used as assessment tools of PA (n = 5). All studies implemented counseling: five applied behavioral change theories, and three reported motivational interview techniques simultaneously. Six studies reported detailed exercise goals. The usual exercise goal was to reach a total of 8,000–10,000 steps/day. Three research studies used diaries, and five applied tele-communication approaches to deliver interventions. The programs could be implemented alone (n = 4), in combination with exercise training (n = 2), or with pulmonary rehabilitation (n = 2). All studies showed a significant increase in the PA (≥793 steps/day). Three studies observed a significant improvement in exercise capacity (≥13.4 m), and two reported a significant increase in the quality of life (p < 0.05). No study showed significant between-group differences in dyspnea.

Conclusion: There are a few studies assessing the impact of long-duration (≥12 weeks) step counter-based interventions in COPD, with different methodologies, although all studies included counseling and exercise goal setting. These interventions seem to have a positive effect on PA. A few studies also showed benefit on exercise capacity and quality of life.

Long-Term Benefits of Adding a Pedometer to Pulmonary Rehabilitation for COPD: The Randomized Controlled STAR Trial

Purpose

This Stay Active after Rehabilitation (STAR) study examined the effects of a pedometer-based behavioral intervention for individuals with COPD during three weeks of inpatient pulmonary rehabilitation (PR) on patients' physical activity levels six weeks and six months after PR, including steps (primary outcome), moderate-intensity physical activity, and sedentary time as well as patient quality of life, symptoms, and other psychological and clinical variables.

Patients and Methods

Rehabilitation patients with COPD wore a triaxial accelerometer (ActiGraph wGT3X) for seven days two weeks before (T0) as well as six weeks (T3) and six months (T4) after PR. In addition to the three-week inpatient PR (control group, CG), the randomly allocated intervention group (IG) received a brief pedometer-based behavioral intervention with the application of the following behavior-change techniques: performing the behavior, individual goal-setting, self-monitoring, and feedback. The effects were analyzed using analysis of covariance with an intention-to-treat approach.

Results

A total of 327 patients (69% male, age: 58 years, FEV₁ (%): 53.5, six-minute walk distance: 447.8 m) were randomly allocated to either the IG (n = 167) or CG (n = 160). Although both groups increased their daily steps after PR (IG: M_T3-T0 = 1152, CG: M_T3-T0 = 745; IG: M_T4-T0 = 795, CG: M_T4-T0 = 300), the slightly higher increases in daily steps in the IG compared to the CG at T3 (Δ388 steps, d = 0.16) and T4 (Δ458 steps, d = 0.15) were not statistically significant (p > 0.05 for all). Patients in both groups showed moderate to high pre-post-changes in terms of secondary outcomes, but no advantage favoring the IG was found.

Conclusion

The results show that adding a pedometer-based behavioral intervention to standard German three-week inpatient PR for COPD patients did not result in more physical activity in terms of steps and moderate-intensity physical activity or less sedentary time. However, both groups (IG and CG) showed remarkably enhanced physical activity levels six weeks and six months after PR, as well as improvements in other secondary outcomes (eg, quality of life).

Behavioural modification interventions alongside pulmonary rehabilitation improve COPD patients' experiences of physical activity

AIMS AND OBJECTIVES

The Clinical PROactive Physical Activity in COPD (C-PPAC) instrument, combines a questionnaire assessing the domains of amount and difficulty of physical activity (PA) with activity monitor data (steps/day and vector magnitude units) to assess patients' experiences of PA. The C-PPAC instrument is responsive to pharmacological and non-pharmacological interventions and to changes in clinically relevant variables. We compared the effect of PA behavioural modification interventions alongside pulmonary rehabilitation (PR) to PR alone on the C-PPAC scores in COPD patients with low baseline PA levels.

METHODS

In this randomised controlled trial, 48 patients (means ± SD: FEV₁: 50 ± 19%, baseline steps/day: 3450 ± 2342) were assigned 1:1 to receive PR alone, twice weekly for 8 weeks, or PA behavioural modification interventions (comprising motivational interviews, monitoring and feedback using a pedometer and goal setting) alongside PR (PR + PA). The C-PPAC instrument was used to assess PA experience, including a perspective of the amount and difficulty of PA.

RESULTS

There were clinically important improvements in favour of the PR + PA interventions compared to PR alone in: 1) the C-PPAC total score (mean [95% CI] difference: 8 [4 to 12] points, p = 0.001), the difficulty (mean [95% CI] difference: 8 [3 to 13] points, p = 0.002) and the amount (mean [95% CI] difference 8 [3 to 16] points, p = 0.005) domains and 2) the CAT score (mean [95% CI] difference: -2.1 [-3.8 to -0.3] points, p = 0.025).

CONCLUSION

PA behavioural modification interventions alongside PR improve the experiences of PA in patients with advanced COPD and low baseline PA levels. (NCT03749655).

A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) who are less active have lower quality of life, greater risk of exacerbations, and greater mortality than those who are more active. The effectiveness of physical activity interventions may facilitate the addition of game elements to improve engagement. The use of a co-design approach with people with COPD and clinicians as co-designers may also improve the effectiveness of the intervention.

OBJECTIVE

The primary aim of this study is to evaluate the feasibility of a co-designed mobile game by examining the usage of the game, subjective measures of game engagement, and adherence to wearing activity trackers. The secondary aim of this study is to estimate the effect of the game on daily steps and daily moderate-to-vigorous physical activity (MVPA).

METHODS

Participants with COPD who were taking part in the co-design of the active video game (n=9) acted as the experiment group, spending 3 weeks testing the game they helped to develop. Daily steps and MVPA were compared with a control group (n=9) of participants who did not co-design or test the game.

RESULTS

Most participants (8/9, 89%) engaged with the game after downloading it. Participants used the game to record physical activity on 58.6% (82/141) of the days the game was available. The highest scores on the Intrinsic Motivation Inventory were seen for the value and usefulness subscale, with a mean of 6.38 (SD 0.6). Adherence to wearing Fitbit was high, with participants in both groups recording steps on >80% of days. Usage of the game was positively correlated with changes in daily steps but not with MVPA.

CONCLUSIONS

The co-designed mobile app shows promise as an intervention and should be evaluated in a larger-scale trial in this population.

Construct validity of the brief physical activity assessment tool for clinical use in COPD

INTRODUCTION

Low physical activity (PA) levels are associated with poor health-related outcomes in Chronic Obstructive Pulmonary Disease (COPD). Thus, PA should be routinely assessed in clinical practice.

OBJECTIVES

This study assessed the construct validity of the Brief Physical Activity Assessment Tool (BPAAT) for clinical use in COPD and explored differences in age, sex and COPD grades.

METHODS

After linguistic adaptation of the tool to Portuguese, 110 patients (66.4 ± 9.6yrs, 72.7% male, FEV₁  = 59.3 ± 25.5%predicted) completed the BPAAT and received an accelerometer. The BPAAT includes two questions assessing the weekly frequency and duration of vigorous- and moderate-intensity PA/walking, classifying individuals as insufficiently or sufficiently active. The BPAAT was correlated with accelerometry (moderate PA, MPA = 1952-5724 counts-per-min [CPM]); vigorous PA, VPA = 5725-∞CPM; moderate-to-vigorous PA, MVPA = 1952-∞CPM; daily steps), through: Spearman's correlations (ρ) for continuous data; %agreement, Kappa, sensitivity and specificity, positive and negative predictive values (PPV, NPV) for categorical data.

RESULTS

The BPAAT identified 73.6% patients as "insufficiently active" and 26.4% as "sufficiently active". The BPAAT was weakly to moderately correlated with accelerometry (0.394 ≤ ρ ≤ 0.435, P < 0.05), except for VPA (P = 0.440). This was also observed in age (<65/≥65yrs), COPD grades (GOLD 1-2/3-4) and in male patients (0.363 ≤ ρ ≤ 0.518, P < 0.05 except for VPA). No significant correlations were found in female patients (P > 0.05). Agreement was fair to moderate (0.36 ≤ κ ≤ 0.43; 73.6% ≤ %agreement ≤ 74.5%; 0.50 ≤ sensitivity ≤ 0.52; 0.84 ≤ specificity ≤ 0.91, 0.55 ≤ PPV ≤ 0.79, 0.72 ≤ NPV ≤ 0.82).

CONCLUSION

The BPAAT may be useful to screen patients' PA, independently of age and COPD grade, and identify male patients who are insufficiently active. Care should be taken when using this tool to assess vigorous PA or female patients.

Adherence to walking exercise prescription during pulmonary rehabilitation in COPD with a commercial activity monitor: a feasibility trial

BACKGROUND

Regular exercise is important in the management of COPD. Pulmonary rehabilitation (PR) facilitates a more physically active lifestyle through exercise participation, ideally without compromising non-exercise physical activity (PA). During PR patients are advised to perform exercise defined by duration and intensity. The extent to which PR attendees participate in unsupervised exercise bouts and their adherence to the exercise prescription provided during PR is unclear. Commercially available devices have the potential to support patients to exercise at their individually prescribed intensity. Study aims were to (1) assess how adherent patients are to their prescribed walking intensity; (2) examine the pattern of overall PA and walking exercise during the course of PR; (3) determine the feasibility of prescribing exercise to PR attendees using an activity monitor; and (4) explore the relationship between exercise and non-exercise PA with routine PR outcome measures.

METHODS

19 patients wore an activity monitor during routine walking tests and 6 weeks of PR, recording in a diary when they exercised. Exercise intensity (cadence) was prescribed from the Endurance Shuttle Walk Test. Patients completed questionnaires, walking tests and a lower limb strength test before and after PR. Repeated ANOVA compared changes in outcomes between weeks 1-6.

RESULTS

Patients wore the monitor every day during PR (median 42 days). Exercise steps increased by 56% (Δ332 [95% CI 54-611] steps/day, p = 0.009) between weeks 1 and 6, with no significant change in non-exercise steps (Δ79 [95% CI - 22 to - 179] steps/day, p = 0.13). Patients reported exercising on 70% of days. Adherence to prescribed cadence was achieved 55% of time spent exercising, and did not change across the 6 weeks (p = 0.907). Change in total daily steps was associated with improved dyspnea (p = 0.027), Chronic Respiratory Questionnaire (CRQ) Dyspnea domain (p = 0.019), CRQ Emotional Functioning domain (p = 0.001) and CRQ Mastery domain scores (p = 0.001) but not with exercise capacity or lower limb muscle strength.

CONCLUSIONS

Improvements in exercise participation, not at the expense of non-exercise PA, throughout a PR course was observed in attendees provided with a commercially available activity monitor. Wearable technology may be able to support effective remote walking exercise prescription and participation during PR. Trial registration (retrospectively registered): http://www.isrctn.com/ISRCTN15892972 .

Perspectives of older adults with chronic disease on the use of wearable technology and video games for physical activity

BACKGROUND

There is increasing interest in technology to deliver physical rehabilitation and allow clinicians to monitor progress. Examples include wearable activity trackers and active video games (AVGs), where physical activity is required to play the game. However, few studies have explored what may influence the effectiveness of these as technology-based physical activity interventions in older adults with chronic diseases.

OBJECTIVE

This study aimed to explore: 1) perceptions about wearable physical activity trackers; 2) perceptions about using technology to share physical activity information with clinicians; 3) barriers and motivators to playing games, including AVGs for rehabilitation.

METHODS

Qualitative study based on semi-structured interviews with older adults (n = 19) with chronic obstructive pulmonary disease (COPD).

RESULTS

Wearable activity trackers were perceived as useful to quantify activity, facilitate goal-setting, visualize long-term improvements and provide reminders. Participants generally wished to share data with their clinicians to gain greater accountability, receive useful feedback and improve the quality of clinical care. Participants were motivated to play games (including AVGs) by seeking fun, social interaction and health benefits. Some felt that AVGs were of no benefit or were too difficult. Competition was both a motivator and a barrier.

CONCLUSIONS

The findings of the present study seek to inform the design of technology to encourage physical activity in older adults with chronic diseases.

Current developments and future directions in respiratory physiotherapy

Respiratory physiotherapists have a key role within the integrated care continuum of patients with respiratory diseases. The current narrative review highlights the profession's diversity, summarises the current evidence and practice, and addresses future research directions in respiratory physiotherapy. Herein, we describe an overview of the areas that respiratory physiotherapists can act in the integrated care of patients with respiratory diseases based on the Harmonised Education in Respiratory Medicine for European Specialists syllabus. In addition, we highlight areas in which further evidence needs to be gathered to confirm the effectiveness of respiratory therapy techniques. Where appropriate, we made recommendations for clinical practice based on current international guidelines.

Current developments and future directions in COPD

The European Respiratory Society journals publish respiratory research and policy documents of the highest quality, offering a platform for the exchange and promotion of scientific knowledge. In this article, focusing on COPD, the third leading cause of death globally, we summarise novel research highlights focusing on the disease's underlying mechanisms, epidemiology and management, with the aim to inform and inspire respiratory clinicians and researchers.

Current developments and future directions in COPD: a critical summary of some of the most recent ground-breaking research studies and policy documents from @ERSpublicationshttps://bit.ly/3oW0xDM

Multimorbidity in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a complex disease manifested primarily as airflow limitation that is partially reversible as confirmed by spirometry. COPD patients frequently develop systemic manifestations, such as skeletal muscle wasting and cachexia. COPD patients often develop other comorbid diseases, such as ischemic heart disease, heart failure, osteoporosis, anemia, lung cancer, and depression. Comorbidities complicate management of COPD and need to be evaluated because detection and treatment have important consequences. Novel approaches aimed at integrating the multiple morbidities seen in COPD and other chronic diseases will provide new avenues of research and allow developing more comprehensive and effective therapeutic approaches.

Can consumer wearable activity tracker-based interventions improve physical activity and cardiometabolic health in patients with chronic diseases? A systematic review and meta-analysis of randomised controlled trials

Background

To date, it is unclear if consumer wearable activity trackers (CWATs), with or without behaviour multi-component strategies, effectively improve adherence to physical activity and health outcomes under free living conditions in populations with chronic diseases. Therefore, we systematically evaluated the efficacy of CWAT-based interventions to promote physical activity levels and cardiometabolic health in populations with chronic diseases.

Methods

Randomised controlled trials were collected from five bibliographic databases (PubMed, Embase, Web of Science, The Cochrane Central Register of Controlled Trials and CINAHL). Studies were eligible for inclusion if they evaluated a CWAT-based counselling intervention versus control intervention among patients with chronic respiratory diseases, type 2 diabetes mellitus, cardiovascular diseases, overweight/obesity, cognitive disorders, or sedentary older adults. Data were pooled using a random-effects model.

Results

After deduplication 8147 were identified of which 35 studies met inclusion criteria (chronic respiratory diseases: 7, type 2 diabetes mellitus: 12, cardiovascular diseases: 6, overweight/obesity: 3, cognitive disorders: 1, sedentary older adults: 6). Compared to control groups, CWAT-based interventions significantly increased physical activity by 2123 steps per day (95% confidence interval [CI], [1605–2641]; p < 0.001). In addition, CWAT-based interventions in these populations significantly decreased systolic blood pressure (− 3.79 mm Hg; 95% CI: [− 4.53, − 3.04] mm Hg; p < 0.001), waist circumference (− 0.99 cm; 95% CI: [− 1.48, − 0.50] cm; p < 0.001) and low-density lipoprotein cholesterol concentration (− 5.70 mg/dl; 95% CI: [− 9.24, − 2.15] mg/dl; p = 0.002).

Conclusion

CWAT-based interventions increase physical activity and have beneficial effects on important health-related outcomes such as systolic blood pressure, waist circumference and LDL cholesterol concentration in patients with chronic diseases.

Therapist Driven Rehabilitation Protocol for Patients with Chronic Heart and Lung Diseases: A Real-Life Study

Therapist driven protocols may help to tailor rehabilitation programs to individual patients. We aimed to test the feasibility, safety, and clinical usefulness of a therapist driven protocol for rehabilitation including exercise training of patients with heart or lung diseases. An internal audit elaborated the Cardio-Respiratory Exercise Maugeri Algorithm (CREMA) based on: (a) standardized baseline assessments, (b) decision-making pathways, and (c) frequency/intensity/time/type (FITT) of prescription for each exercise. Outpatients (n = 620) with chronic heart disease (CHD), recent myocardial revascularization (REVASC), chronic airway (Obstructive), and restrictive lung (Restrictive) diseases underwent exercise training according to CREMA during 4 years. Peripheral muscle strengthening was the most prescribed exercise (83.6%), while arm endurance training was the least frequently (0.75%). Exercise prescription varied widely among the disease groups (interval training 19-47%, balance 35-49%, lower limb muscle training 6-15%). After training, REVASC patients were the best improvers in the 6 min walking distance (+48.7 (56.1) m), maximal inspiratory pressure (+9.6 (15.4) cmH2O), and daily steps (+1087.2 (3297.1) n/day). Quadriceps and biceps strength, maximal expiratory pressure, and balance improved in all groups, without significant differences. Minor side effects were observed in 11.2% of the patients. The CREMA therapist driven protocol was feasible, safe, and useful for prescribing tailored training programs. Exercise prescriptions and training response differed among diseases.

The Wenckebach phenomenon

Background

The introduction of new medical technologies such as sensors has accelerated the process of collecting patient data for relevant clinical decisions, which has led to the introduction of a new technology known as digital biomarkers.

Objective

This study aims to assess the methodological quality and quality of evidence from meta-analyses of digital biomarker–based interventions.

Methods

This study follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline for reporting systematic reviews, including original English publications of systematic reviews reporting meta-analyses of clinical outcomes (efficacy and safety endpoints) of digital biomarker–based interventions compared with alternative interventions without digital biomarkers. Imaging or other technologies that do not measure objective physiological or behavioral data were excluded from this study. A literature search of PubMed and the Cochrane Library was conducted, limited to 2019-2020. The quality of the methodology and evidence synthesis of the meta-analyses were assessed using AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) and GRADE (Grading of Recommendations, Assessment, Development, and Evaluations), respectively. This study was funded by the National Research, Development and Innovation Fund of Hungary.

Results

A total of 25 studies with 91 reported outcomes were included in the final analysis; 1 (4%), 1 (4%), and 23 (92%) studies had high, low, and critically low methodologic quality, respectively. As many as 6 clinical outcomes (7%) had high-quality evidence and 80 outcomes (88%) had moderate-quality evidence; 5 outcomes (5%) were rated with a low level of certainty, mainly due to risk of bias (85/91, 93%), inconsistency (27/91, 30%), and imprecision (27/91, 30%). There is high-quality evidence of improvements in mortality, transplant risk, cardiac arrhythmia detection, and stroke incidence with cardiac devices, albeit with low reporting quality. High-quality reviews of pedometers reported moderate-quality evidence, including effects on physical activity and BMI. No reports with high-quality evidence and high methodological quality were found.

Conclusions

Researchers in this field should consider the AMSTAR-2 criteria and GRADE to produce high-quality studies in the future. In addition, patients, clinicians, and policymakers are advised to consider the results of this study before making clinical decisions regarding digital biomarkers to be informed of the degree of certainty of the various interventions investigated in this study. The results of this study should be considered with its limitations, such as the narrow time frame.

International Registered Report Identifier (IRRID)

RR2-10.2196/28204