A randomised trial of a web-based physical activity self-management intervention in COPD

Core characteristics, and effectiveness of mobile health interventions on dyspnoea and quality of life in older persons with chronic obstructive pulmonary disease: A systematic review and meta-analysis of randomised controlled trials

AIM

To systematically review the core characteristics, and effectiveness of mobile health interventions (MHIs) on dyspnoea and quality of life (QoL) in older persons with chronic obstructive pulmonary disease (COPD).

METHODS

A comprehensive search was conducted from inception to 21 February 2023 in Chinese and English databases, with an updated search performed on 30 April 2024. Randomised controlled trials (RCTs) involving MHIs with four core functions - customisation, self-monitoring, alerts, and goal-setting - in older persons with COPD were included. Two reviewers independently identified the core characteristics of MHIs using the Template for Intervention Description and Replication (TIDieR) checklist. The Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were used to assess the methodological quality of RCTs and the overall quality of evidence.

RESULTS

28 RCTs were included, with 43% of studies adequately reported core characteristics of MHIs according to the TIDieR checklist. Meta-analysis suggested that MHIs may alleviate dyspnoea and improve disease-specific QoL questionnaires (CRQ and CCQ) and generic-related QoL questionnaires (SF-36 and EQ-5D), but not other disease-specific QoL questionnaires (SGRQ and CAT). Subgroup analyses showed that multi-component MHIs were effective in improving dyspnoea. Dyspnoea showed statistically significant improvement at 3 months, 6 months and 12 months, whereas QoL improved at 4 months (SGRQ), 2 months (CAT) and 6 months (CAT).

CONCLUSION

Reporting on the core characteristics of MHIs is currently incomplete, and it is recommended that healthcare professionals develop and report multi-component MHIs based on the TIDieR checklist to help alleviate dyspnoea and enhance QoL in older persons with COPD.

Web-based pulmonary telehabilitation: a systematic review

Web-based pulmonary telerehabilitation (WBPTR) can serve as a valuable tool when access to conventional care is limited. This review assesses a series of studies that explore pulmonary telerehabilitation programmes delivered via web-based platforms. The studies involved participants with moderate to severe chronic obstructive pulmonary disease (COPD). Of the 3190 participants, 1697 engaged in WBPTR platforms, while the remaining 1493 comprised the control groups. Sixteen studies were included in the meta-analysis. Web-based pulmonary telerehabilitation led to an increase in daily step count (MD 446.66, 95% CI 96.47 to 796.86), though this did not meet the minimum clinically important difference. Additionally, WBPTR did not yield significant improvements in the six-minute walking test (MD 5.01, 95% CI - 5.19 to 15.21), health-related quality of life as measured by the St. George's Respiratory Questionnaire (MD - 0.15, 95% CI - 2.24 to 1.95), or the Chronic Respiratory Disease Questionnaire (MD 0.17, 95% CI - 0.13 to 0.46). Moreover, there was no significant improvement in dyspnoea-related health status, as assessed by the Chronic Respiratory Disease Questionnaire (MD - 0.01, 95% CI - 0.29 to 0.27) or the modified Medical Research Council Dyspnoea Scale (MD - 0.14, 95% CI - 0.43 to 0.14). Based on these findings, this review concludes that WBPTR does not offer substantial advantages over traditional care. While slight improvements in exercise performance were observed, no meaningful enhancements were noted in dyspnoea or quality of life metrics. Overall, WBPTR remains a complementary and accessible option for managing and monitoring COPD patients. However, further research and innovation are required to improve its efficacy and adapt it to various clinical environments.

Nudge theories and strategies influencing adult health behaviors and outcomes in COPD management: a systematic review

Objective

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with high prevalence and mortality, and self-management is a key component for better outcomes of COPD. Recently, nudging has shown promising potential in COPD management. In the present study, we conducted a systematic review to collate the list of nudges and identified the variables that influence nudging.

Methods

We undertook a systematic review. We employed database searches and snowballing. Data from selected studies were extracted. The risk of bias was assessed using the Cochrane Effective Practice and Organization of Care risk of bias tool. The study is registered with PROSPERO, CRD42023427051.

Results

We retrieved 4,022 studies from database searches and 38 studies were included. By snowballing, 5 additional studies were obtained. Nudges were classified into four types: social influence, gamification, reminder, and feedback. Medication adherence, inhalation technique, physical activity, smoking cessation, vaccination administration, exercise capacity, self-efficacy, pulmonary function, clinical symptoms, and quality of life were analyzed as targeted health behaviors and outcomes. We found medication adherence was significantly improved by reminders via mobile applications or text materials, as well as feedback based on devices. Additionally, reminders through text materials greatly enhance inhalation techniques and vaccination in patients.

Conclusion

This review demonstrates nudging can improve the health behaviors of patients with COPD and shows great potential for certain outcomes, particularly medication adherence, inhalation techniques, and vaccination. Additionally, the delivery modes, the patient characteristics, and the durations and seasons of interventions may influence the successful nudge-based intervention.

Clinical trial registration

This review has been registered in the international Prospective Registry of Systematic Evaluation (PROSPERO) database (identifier number CRD42023427051).

A systematic review on eHealth technology personalization approaches

Despite the widespread use of personalization of eHealth technologies, there is a lack of comprehensive understanding regarding its application. This systematic review aims to bridge this gap by identifying and clustering different personalization approaches based on the type of variables used for user segmentation and the adaptations to the eHealth technology and examining the role of computational methods in the literature. From the 412 included reports, we identified 13 clusters of personalization approaches, such as behavior + channeling and environment + recommendations. Within these clusters, 10 computational methods were utilized to match segments with technology adaptations, such as classification-based methods and reinforcement learning. Several gaps were identified in the literature, such as the limited exploration of technology-related variables, the limited focus on user interaction reminders, and a frequent reliance on a single type of variable for personalization. Future research should explore leveraging technology-specific features to attain individualistic segmentation approaches.

Tracking Real-World Physical Activity in Chronic Obstructive Pulmonary Disease Over One Year: Results from a Monocentric, Prospective, Observational Cohort Study

Introduction

Lung function constraints and comorbidities such as coronary heart disease, sarcopenia, and mood disorders make chronic obstructive pulmonary disease (COPD) patients avoid physical activity (PA). However, PA represents an important pillar of COPD management and is explicitly recommended by professional associations to enhance physical functioning and positively modulate disease progression.

Methods

In this monocentric, prospective, observational feasibility study, it was our primary objective to investigate the association between PA and the evolution of the COPD assessment test (CAT) and the occurrence of acute exacerbations of COPD (AECOPD), respectively. To this end, we equipped 42 COPD patients with an activity tracking wearable and telemonitored their daily PA levels over one year using a dedicated web-based interface. Patients additionally provided weekly CAT scores using the same telehealth platform and came in for 3 study visits to assess functional parameters and biochemical markers related to nutrition and inflammation.

Results

A principal study finding was that PA was inversely associated with CAT score (drop of 0.21 points associated with an increase of 1000 daily steps, p = 0.004), and that the 50% of patients with higher PA levels showed less CAT score progression over time (0.42 points per year) than the 50% of patients with lower PA levels (3.26 points per year) (p < 0.001). In addition, higher PA levels were significantly associated with a lower likelihood of experiencing a moderate-to-severe AECOPD (31% risk reduction associated with an increase of 1000 daily steps, p = 0.0097).

Discussion

Our study demonstrates the relevance of PA for key COPD outcome metrics in a real-world setting and underpins the importance of PA for COPD self-management in everyday life. Our study paves the way for future intervention trials to prospectively identify medically relevant PA thresholds and establish training recommendations for different patient subgroups.

Effect of kaempferol ingestion on physical activity and sleep quality: a double-blind, placebo-controlled, randomized, crossover trial

Background

Kaempferol (KMP), a flavonoid in edible plants, exhibits diverse pharmacological effects. Growing body of evidence associates extended lifespan with physical activity (PA) and sleep, but KMP's impact on these behaviors is unclear. This double-blind, placebo-controlled, crossover trial assessed KMP's effects on PA and sleep.

Methods

A total of 33 city workers (17 males and 16 females) participated in this study. They were randomly assigned to take either 10 mg of KMP or placebo for 2 weeks in the order allocated, with a 7-day washout period in between. All participants wore an accelerometer-based wearable device (Fitbit Charge 4), which monitored daily PA, heart rate (HR), and HR variability during sleep.

Results

The duration of wearing the device was 23.73 ± 0.04 h/day. HR decreased in each PA level, and the mean daily step count and distance covered increased significantly during KMP intake compared to placebo. The outing rate, number of trips, number of recreational activities, and time spent in recreation on weekends increased. Sleep quality improved following KMP intake. The decrease in HR and increase in RMSSD may be important in mediating the effects of these KMPs.

Conclusion

KMP leads to behavioral changes that subsequently improve sleep quality and potentially improve long-term quality of life.

Clinical Trial Registration

https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048447, UMIN000042438.

Physical Activity and Systemic Biomarkers in Persons With COPD: Insights from a Web-Based Pedometer-Mediated Intervention

Background

The relationships between physical activity (PA) and exercise performance and systemic biomarkers in persons with chronic obstructive pulmonary disease (COPD) have not been well characterized. The impact of PA promotion on biomarkers reflecting myocardial stress, systemic inflammation, and muscle injury is unclear.

Methods

This secondary analysis used 3 previously published studies in persons with COPD (2 examined a PA intervention that promoted community-based walking for 3 months) to explore these relationships. PA (daily step counts) and exercise performance (6-minute walk test [6MWT]) were assessed. Serum N-terminal pro-β-type natriuretic peptide (NT-proBNP), the soluble receptor for advanced glycation end products (sRAGE), and muscle-type creatine kinase (CKMM) were assayed at baseline and 3 months. General linear models examined associations between PA/exercise performance and systemic biomarkers at baseline and the effect of the PA intervention on change in biomarkers.

Results

Participants included 366 U.S. Veterans: 98% male, mean age 70±8 years, and forced expiratory volume in 1 second percentage predicted 59±21%. Lower baseline NT-proBNP, but not sRAGE or CKMM, was associated with higher daily step count (-0.95pg/ml per 1000 steps/day, p=.060) and higher 6MWT distance (-0.80pg/ml per 100 meters, p=.001). Change in daily step count, but not 6MWT, was significantly greater in the intervention (789±1864) compared to the control group (-174±1448; p=.002). The PA intervention had no significant impact on change in the systemic biomarkers.

Interpretation

Exercise performance is associated with NT-proBNP in persons with COPD. A 3-month community-based walking intervention is not associated with myocardial stress or muscle injury as assessed by NT-proBNP and CKMM, respectively. Clinical Trial Registration: NCT01772082 and NCT02099799.

Maintenance Pulmonary Rehabilitation: An Update and Future Directions

The Global Initiative for Chronic Obstructive Lung Disease guidelines recommend pulmonary rehabilitation (PR) for individuals with COPD to improve exercise capacity and health-related quality of life (HRQOL) and reduce symptoms of dyspnea. For cost-effectiveness in COPD care, PR is second only to smoking cessation. However, PR programs typically last 9-12 weeks. The benefits of PR in terms of exercise capacity and HRQOL often decrease toward pre-PR levels as early as 3-6 months after completing PR if patients do not continue to engage in exercise. This review will (1) briefly summarize the efficacy data that informed the 2023 American Thoracic Society (ATS) clinical practice guidelines for maintenance PR, (2) discuss exercise components of maintenance PR studied since 2020 when the last papers were included in the ATS guidelines, (3) explore future directions for delivery of maintenance PR using technology-mediated models, and (4) examine the need for behavior change techniques informed by theoretical models that underpin long-term behavior change. This review will focus on persons with COPD who have completed an out-patient core initial PR program as most of the data on maintenance PR have been published in this patient population. Core PR typically implies a facility-based initial intensive structured program. All patients who complete a core initial PR program should be counseled by PR staff at the discharge visit to engage in ongoing exercise. This usual care is equally as important as referral to a formal PR maintenance program. It is critical to emphasize that usual care after core initial PR means all patients should be supported to participate in regular ongoing exercise, regardless of whether supervised maintenance PR is available. Currently, the optimal frequency, exercise and/or physical activity content, and delivery mode for maintenance PR in persons with COPD and other chronic respiratory diseases remain unknown. Patient safety and degree of in-person supervision required due to the severity of the underlying lung disease need to be considered. Future research of maintenance PR should be underpinned by behavior change techniques. Finally, in the setting of finite resources, balancing the competing priorities of core initial programs with those of maintenance PR programs needs to be achieved.

Value of Information Analysis of a Web-Based Self-Management Intervention for Chronic Obstructive Pulmonary Disease

Objective: Technology-based programs can be cost-effective in the management of chronic obstructive pulmonary disease (COPD). However, cost-effectiveness estimates always contain some uncertainty, and decisions based upon them carry some risk. We conducted a value of information (VOI) analysis to estimate the value of additional research of a web-based self-management intervention for COPD to reduce the costs associated with uncertainty. Methods: We used a 10,000-iteration cost-effectiveness model from the health care payer perspective to calculate the expected value of perfect information (EVPI) at the patient- and population-level. An opportunity loss was incurred when the web-based intervention did not produce a greater net monetary benefit than usual care in an iteration. We calculated the probability of opportunity loss and magnitude of opportunity costs as a function of baseline health utility. We aggregated opportunity costs over the projected incident population of inpatient COPD patients over 10 years and estimated it as a function of the willingness-to-pay (WTP) threshold. Costs are in 2022 U.S. Dollars. Results: Opportunity losses were found in 22.7% of the iterations. The EVPIpatient was $78 per patient (95% confidence interval: $75-$82). The probability that the intervention was the optimal strategy varied across baseline health utilities. The EVPIpopulation was $506,666,882 over 10 years for a WTP of $50,000. Conclusions: Research estimated to cost up to $500 million would be warranted to reduce uncertainty. Future research could focus on identifying the impact of baseline health utilities to maximize the cost savings of the intervention. Other considerations for future research priorities include implementation efforts for technology-based interventions.

Diversity in pulmonary rehabilitation clinical trials: a systematic review of the literature

BACKGROUND

Underrepresentation of minority groups in clinical trials may hinder the potential benefits of pulmonary rehabilitation (PR) programs for individuals with chronic obstructive pulmonary disease (COPD). The aim of this work was to determine whether participants in PR randomized control trials (RCTs) conducted in the U.S.A., Canada, the UK, and Australia are representative of ethnicity, sex, gender, and sociodemographic characteristics.

RESEARCH DESIGN

A systematic search was performed for relevant literature from inception to December 2022. Titles and abstracts were screened before undergoing a full article review. Relevant data on reporting of age, sex, gender, ethnicity, and sociodemographic characteristics of participants was extracted.

RESULTS

Thirty-six RCTs met the inclusion criteria. Only 6% of publications reported on ethnicity, with ≥90% of participants reported as 'White.' All 36 papers reported on age, with the mean between 60 and 69 years old. Thirty-five studies reported on sex (97%), with the majority (67%) reporting more male than female participants. There was no mention of different genders in any paper. Other sociodemographic factors were reported in 7 (19%) papers.

CONCLUSIONS

Inclusivity and representation in clinical trials are essential to ensure that research findings are generalizable. Clinical trialists need to consider the demographics of today's society during recruitment.

Physical activity and outcomes in Japanese patients with chronic obstructive pulmonary disease: From the Ishinomaki COPD Network registry

BACKGROUND

Low physical activity levels are associated with an increased risk of exacerbations and all-cause mortality in patients with chronic obstructive pulmonary disease (COPD); however, evidence is limited in a population with a low frequency of exacerbations, such as the Japanese population. This study investigated the effects of physical activity on outcomes in Japanese patients with COPD.

METHODS

We conducted a prospective observational study in a cohort of Japanese patients with COPD between April 2018 and July 2020. Characteristics, frequency of exacerbations, and mortality were assessed during the 1-year follow-up period. Logistic regression analysis evaluated the relationship between physical activity and outcomes.

RESULTS

A total of 309 patients (294 males; median age, 75 years) with stable COPD were included, and 307 completed follow-up. Patients with lower levels of physical activity were older, and showed increased airflow obstruction, limited exercise capacity, increased dyspnea, depressive state, poor health status, muscle weakness, and more information needs for the disease. Patients with high levels of physical activity had a lower risk of exacerbation, including hospital admission, compared to those with low levels of activity (odds ratio [OR], 0.46; 95 % confidence interval [CI], 0.22-0.97; and OR, 0.21; 95 % CI, 0.09-0.50, respectively). High physical activity was associated with a reduced risk of all-cause mortality (OR, 0.07; 95 % CI, 0.01-0.55) and respiratory mortality (OR, 0.16; 95 % CI, 0.02-1.47).

CONCLUSIONS

These findings showed that higher physical activity is associated with better clinical outcomes, even in a COPD population with a low frequency of exacerbations.

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.

Exercise as a therapeutic intervention in chronic kidney disease: are we nearly there yet?

PURPOSE OF REVIEW

The opportunity to review the more recent evidence for prescribing exercise-based physical rehabilitation for people living with chronic kidney disease (CKD) is timely. There has been a recent global focus evaluating how physical activity interventions might improve health-related quality of life and outcomes for people living with chronic health conditions in a post-COVID era. There is finally a long overdue commitment from the kidney research and clinical community to deliver pragmatic interventions to help people living with CKD to be able to live well with their condition.

RECENT FINDINGS

This article reviews recent research, and discusses the challenges and potential solutions, for providing exercise-based therapeutic options for people living with CKD; including predialysis self-management interventions, options for both prehabilitation and posttransplant rehabilitation, pragmatic considerations for delivery of exercise therapy for people receiving haemodialysis treatment and the role of virtual kidney-specific rehabilitation.

SUMMARY

Whilst there remains a need for further research in this area of patient care, there is now a body of evidence and kidney-specific guidelines that firmly support a rollout of pragmatic and scalable exercise-based interventions for people living with CKD. We are indeed nearly there now.

Stakeholder Perceptions of a Web-Based Physical Activity Intervention for COPD: A Mixed-Methods Study

Technology-based physical activity interventions have been shown to be efficacious in chronic obstructive pulmonary disease (COPD), though their potential impact has not been fully realized due to ineffective implementation. We used a convergent, parallel mixed-methods design to identify patient- and provider-facing barriers and facilitators to implementing a rigorously studied web-based physical activity intervention for COPD. Quantitative surveys (based on the unified theory of acceptance and use of technology; range 1 (poor usability)-5 (high usability)) and semi-structured interviews (guided by the practical robust implementation and sustainability model) assessed the perspectives of 15 patients and 15 health care providers. The patients and providers rated the usability of the intervention as high (median = 5.0, IQR = 1.0). For both patients and providers, the main facilitators included: the potential high impact of the intervention on patient health, the usefulness of the intervention for unmet clinical needs, and the perceived ease of use of the intervention. The main barriers identified were digital literacy and its fit with current clinical workflows. Implementation efforts may benefit from supporting patients' use of the website and developing strategies to integrate referrals to the intervention and the monitoring of patients into current clinical infrastructures.

Depression Symptoms and Physical Activity in Veterans With COPD: Insights From a Web-Based, Pedometer-Mediated Physical Activity Intervention

BACKGROUND

Depression is known to limit physical activity (PA) among individuals with chronic obstructive pulmonary disease (COPD). However, whether and how depression influences the effectiveness of PA interventions is unknown.

PURPOSE

The study examined the association between baseline depression symptoms and change in daily step count and whether group assignment to a web-based, pedometer-mediated PA intervention moderated the association between baseline depression symptoms and change in daily step count.

METHODS

Secondary analysis included two cohorts of U.S. Veterans with COPD (n = 212; 97% male; mean age 69 ± 8 years) assessed at baseline and 3 months. Cohorts 1 and 2 were randomly assigned to the same PA intervention (n = 111) or a control group (n = 101). Multivariate regressions tested the main effects of baseline depression symptoms (BDI-II total and cognitive-affective and somatic subscales) on change in daily steps, as well as the interaction between baseline BDI-II and subscales and group assignment on change in daily steps.

RESULTS

Greater BDI-II total score (B = -31.8, SE = 14.48, p = .030) and somatic subscale scores (B = -99.82, SE = 35.76, p = .006) were associated with less improvement in daily step count. There was a significant interaction between baseline cognitive-affective subscale and the intervention predicting change in daily step count (B = -88.56, SE = 42.31, p = .038). When cognitive-affective subscale scores were ≥1 SD above the mean, the intervention was no longer associated with an increase in daily step count (p = .585).

CONCLUSIONS

Depression should be routinely assessed and targeted as part of PA promotion efforts.

Awareness of Chronic Obstructive Pulmonary Disease and Its Risk Factors Among the Adult Population of the Qassim Region, Saudi Arabia

BACKGROUND

Epidemiological studies are crucial in appraising the occurrence of chronic obstructive pulmonary disease (COPD) in a specific region, establishing benchmarks, and devising effective preventive measures. It is against this background that the study aims to evaluate adult awareness of COPD and its risk factors among adults in the Qassim Region, Saudi Arabia.

METHOD

This observational cross-sectional study was conducted in the Qassim Region and involved consenting adults who voluntarily participated. Between 20 May and 4 June 2023, a self-administered online survey was distributed through social media platforms, utilizing an anonymous, self-explanatory questionnaire to evaluate participants' awareness of COPD.

RESULTS

In our study, a total of 1,306 participants were enrolled, of which 27.6% (n=360) reported having ever heard of COPD. Among all respondents, 21.3% (n=278) stated that they study or work in medical-related fields, and out of them, 60.4% (n=168) had prior awareness of COPD. Upon excluding participants associated with medical-related fields, the overall awareness level decreased to 18.7%. The majority of respondents fell within the age range of 18 to 29 years, of whom 34.5% had ever heard of COPD. Regarding smoking habits, the majority were cigarette smokers (38.4%), and of all cigarette smokers, 22.4% had heard of COPD. The second highest proportion of smokers (35.8%) were electronic smokers, and among them, 24.1% were aware of COPD. The lowest proportion of smokers (25.8%) were shisha smokers, with 25.6% of them having heard of COPD. Among the 1,306 respondents, only 27.5% (n=360) had ever heard of COPD. When asked about the organ affected by COPD, 81% (n=292) of those who were aware of the condition correctly responded that it affects the lungs. On the other hand, 8.9% (n=32) incorrectly selected "heart" as the affected organ, while 2.5% (n=9) chose "I don't know," and none selected "throat."

CONCLUSION

The Qassim Region in Saudi Arabia exhibits a reduced level of COPD awareness among the general population. It is imperative to urgently address this situation and enhance awareness for improved COPD diagnosis and treatment. Considering the region's high prevalence of COPD and associated risk factors, it becomes vital to strengthen educational curricula and integrate COPD awareness into public forums and awareness campaigns. Moreover, conducting additional national research would be instrumental in assisting policymakers in developing effective preventive and therapeutic strategies.

Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions.

METHODS

We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up.

CONCLUSIONS

Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention.

TRIAL REGISTRATION

PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189028.

Role of digital health in pulmonary rehabilitation and beyond: shaping the future

Pulmonary rehabilitation (PR) is a cost-effective intervention with well-known benefits to exercise capacity, symptoms and quality of life in patients with chronic respiratory diseases. Despite the compelling evidence of its benefits, PR implementation is still suboptimal, and maintenance of PR benefits is challenging. To overcome these pitfalls, there has been a growing interest in developing novel models for PR delivery. Digital health is a promising solution, as it has the potential to address some of the most reported barriers to PR uptake and adherence (such as accessibility issues), help maintain the positive results following a PR programme and promote patients' adherence to a more active lifestyle through physical activity (tele)coaching. Despite the accelerated use of digital health to deliver PR during the coronavirus disease 2019 pandemic, there are still several factors that contribute to the resistance to the adoption of digital health, such as the lack of evidence on its effectiveness, low acceptability by patients and healthcare professionals, concerns about implementation and maintenance costs, inequalities in access to the internet and technological devices, and data protection issues. Nevertheless, the trend towards reducing technology costs and the higher availability of digital devices, as well as the greater ease and simplicity of use of devices, enhance the opportunities for future development of digitally enabled PR interventions. This narrative review aims to examine the current evidence on the role of digital health in the context of PR, including strengths and weaknesses, and to determine possible threats and opportunities, as well as areas for future work.

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.

Awareness of COPD and Its Risk Factors Among the Adult Population of the Aseer Region, Saudi Arabia

INTRODUCTION

Epidemiological studies are urgently needed to assess the prevalence of COPD in the region to determine the baseline, against which the future trends in the risk factor levels can be assessed and preventive strategies be planned to promote health among the population. Therefore, this study was undertaken to assess the awareness of COPD and its risk factors in Saudi Arabia.

MATERIALS AND METHODS

The cross-sectional study was conducted among the general adult population aged 18 years and above living in the Aseer region. A minimum sample of 385 was targeted, using the Raosoft sample size calculator. An online questionnaire was prepared in both English and Arabic language using Google forms and distributed among participants through social media.

RESULTS

It was observed that less than one-third (116, 30.12%) of the study population had ever heard about COPD. Nearly one-third spent time with smokers. Among all, 223 (57.3%) respondents had never heard and 46 (11.9%) respondents did not know anything about COPD. The majority correctly knew that the lungs are the primary organ affected by COPD (92, 79.3%). Age, sex, marital status, income, and occupation showed a significant association with COPD awareness. Nearly 41.4% knew that COPD progresses exclusively with age, COPD is more expensive for society than lung cancer (49.0%), cigarette smoking affects COPD (34.5%), COPD is fully recoverable with short-term antibiotics (35.0%), COPD lasts more than 18 months (48.1%), COPD can worsen with smoke exposure (37.4%), lead to disability (46.7%) and quitting smoking has an important role in preventing COPD (34.0%).

CONCLUSION

The awareness regarding the disease was low among the respondents. Only one-third correctly knew that quitting smoking has an important role in preventing COPD. This study projects an urgent need of improving awareness of COPD and its risk factors in the general population.

A Web-Based Mind-Body Intervention (Mindful Steps) for Promoting Walking in Chronic Cardiopulmonary Disease: Insights From a Qualitative Study

Background

Given the deleterious effects of physical inactivity in persons with chronic obstructive pulmonary disease (COPD) and/or heart failure (HF), interventions that promote long-term daily physical activity are needed. Mindful Steps, designed to promote walking behaviors in COPD and HF, is a multicomponent intervention that integrates mind-body content with other self-regulatory components. The aim of the current qualitative study was to characterize participants' experiences with Mindful Steps and understand the perceived influence of the intervention on walking and health.

Method

In the context of a pilot randomized controlled feasibility trial comparing the year-long Mindful Steps program to usual care among individuals with COPD and HF, semi-structured qualitative interviews were administered at 6- and 12-months. Interviews were audio recorded and transcribed. The constant comparative method was used to code transcripts, identify categories, and develop interrelated themes.

Results

Nineteen participants (63% female; Mage = 70.2 years, SD = 6.95) who were randomized to the intervention group completed the 6-month interview and 17 completed the 12-month interview. The pedometer with feedback, live group classes, and mind-body videos were described as the most helpful intervention components. Participants learned several strategies that helped their walking (e.g., breathing regulation and awareness, body awareness, mind-body techniques, pacing), described walking as enjoyable, and identified internal reasons for walking (e.g., to feel good). They also reported several physical and mental health benefits of the intervention. Some participants reported limited influence of the intervention on walking or health. Many participants continued to use the strategies they learned in the first half of the intervention at 12-months.

Conclusions

The mind-body content of Mindful Steps appeared to positively influence walking behaviors. Participants' experiences with the intervention helped to identify areas for future intervention refinement. Future quantitative work is needed to corroborate these qualitative findings and assess the efficacy of the intervention on long-term physical activity engagement.

Trial Registration

This trial is registered in Clinical Trials.gov, ID number NCT01551953.

Physical Activity, Exercise Capacity, and Body Composition in U.S. Veterans with Chronic Obstructive Pulmonary Disease

Rationale: Differences in body composition may contribute to variability in exercise capacity (EC) and physical activity (PA) in individuals with chronic obstructive pulmonary disease (COPD). Most studies have used bioimpedance-based surrogates of muscle (lean) mass; relatively few studies have included consideration of fat mass, and limited studies have been performed using dual X-ray absorptiometry (DXA) to assess body composition. Objectives: To determine whether DXA-assessed muscle (lean) and fat mass exhibit differential correlations with EC and PA in subjects with COPD. Methods: U.S. veterans with COPD (defined as forced expiratory volume in 1 second/forced vital capacity < 0.7 or emphysema on clinical chest computed tomography) had DXA-assessed body composition, EC (6-minute-walk distance), objective PA (average daily step counts), and self-reported PA measured at enrollment. Associations among EC, PA, and body composition were examined using Spearman correlations and multivariable models adjusted a priori for age, sex, race, and lung function. Results: Subjects (n = 98) were predominantly White (90%), obese (mean body mass index, 30.2 ± 6.2 kg/m2), and male (96%), with a mean age of 69.8 ± 7.9 years and moderate airflow obstruction (mean forced expiratory volume in 1 second percentage predicted, 68 ± 20%). Modest inverse correlations of EC and PA with fat mass were observed (Spearman's rho range, -0.20 to -0.34), whereas measures of muscle (lean) mass were not significantly associated with EC or PA. The ratio of appendicular skeletal muscle mass (ASM) to weight, which considers both muscle (lean) and fat mass, was consistently associated with EC (8.4 [95% confidence interval, 2.9-13.8] meter increase in 6-minute walk distance per 1% increase in ASM-to-weight ratio), objective PA (194.8 [95% confidence interval, 15.2-374.4] steps per day per 1% increase in ASM-to-weight ratio), and self-reported PA in multivariable-adjusted models. Conclusions: DXA-assessed body composition measures that include consideration of both lean and fat mass are associated with cross-sectional EC and PA in COPD populations. Clinical trial registered with www.clinicaltrials.gov (NCT02099799).

Validation of Simple Prediction Equations for Step Count in Japanese Patients with Chronic Obstructive Pulmonary Disease

Physical activity is decreased in patients with chronic obstructive pulmonary disease, and decreased physical activity leads to a poor prognosis. To determine an individual’s target step count from the measured step counts and predicted step counts, simple and detailed prediction equations for step count were developed. To verify the validity of the simple prediction equation, the validity of the simple equation was evaluated in a different cohort and the correlation between the step counts calculated by the simple equation and those by the detailed prediction equation were evaluated. When the step counts calculated by the simple prediction equation for all participants were compared with the measured step counts, a significant correlation was obtained among them, and the calculated values were found to be reproducible with the measured values in patients with a measured step count of <6500 by Bland−Altman plots. Furthermore, the values calculated by the simple prediction equation and those calculated by the detailed prediction equation showed a significant correlation. In conclusion, the simple prediction equation was considered reasonable.

Cost savings associated with a web-based physical activity intervention for COPD

OBJECTIVE

To estimate the cost savings associated with a pedometer-based, web-mediated physical activity intervention in a cohort of US veterans with chronic obstructive pulmonary disease (COPD).

STUDY DESIGN

Economic analysis.

METHODS

We constructed a decision tree from the health care system perspective incorporating adjusted relative risk of a pedometer-based, web-mediated intervention for COPD-related acute exacerbations, acute exacerbation-related costs (ie, emergency department visits and hospitalizations), and intervention-related costs. Total COPD-related costs were estimated per patient across 12 months. Probabilistic sensitivity analysis with Monte Carlo simulation was used to estimate uncertainty in the model findings.

RESULTS

In the deterministic (base case) model, the model estimated costs to be $4236 per participant who used the pedometer-based, web-mediated intervention compared with $7913 per participant in the control group (estimated $3677 saved in 1 year compared with the control group). The model findings were robust to probabilistic sensitivity analysis, with a difference in mean costs of $4582 (95% probability interval, $4084-$5080; P < .001). Cost savings in the model were driven by the adjusted relative risk of the web-based intervention, probability of a COPD-related acute exacerbation, rate of hospitalization, probability of hospitalization, and cost of hospitalization.

CONCLUSIONS

A pedometer-based, web-mediated physical activity intervention yielded substantial cost savings. Increased implementation of the intervention could markedly reduce the economic burden of COPD for payers and patients.

Improving Physiological, Physical, and Psychological Health Outcomes: A Narrative Review in US Veterans with COPD

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States (US) providing healthcare to an increasing number of middle-aged and older adults who remain at greater risk for chronic obstructive pulmonary disease (COPD) compared to their civilian counterparts. The VHA has obligated research funds, drafted clinical guidelines, and built programmatic infrastructure to support the diagnosis, treatment, and care management of Veterans with COPD. Despite these efforts, COPD remains a leading cause of morbidity and mortality in Veterans. This paper provides a narrative review of research conducted with US Veteran samples targeting improvement in COPD outcomes. We review key physiological, physical, and psychological health outcomes and intervention research that included US Veteran samples. We conclude with a discussion of directions for future research to continue advancing the treatment of COPD in Veterans and inform advancements in COPD research within and outside the VHA.

Performance of bioelectrical impedance analysis compared to dual X-ray absorptiometry (DXA) in Veterans with COPD

We examined the performance of a commercially-available handheld bioimpedance (BIA) device relative to dual X-ray absorptiometry (DXA) to assess body composition differences among Veterans with chronic obstructive pulmonary disease (COPD). Body composition was measured using DXA and BIA (Omron HBF-306C) at a single time point. Correlations between BIA- and DXA-assessed percent fat, fat mass, and fat-free mass were analyzed using Spearman (ρ) and Lin Concordance Correlation Coefficients (ρ_c). Mean differences in fat mass were visualized using Bland–Altman plots. Subgroup analyses by obesity status (BMI < 30 versus ≥ 30) were performed. Among 50 participants (96% male; mean age: 69.5 ± 6.0 years), BIA-assessed fat mass was strongly correlated (ρ = 0.94) and demonstrate excellent concordance (ρ_c = 0.95, [95%CI: 0.93–0.98]) with DXA, with a mean difference of 2.7 ± 3.2 kg between BIA and DXA. Although Spearman correlations between BIA- and DXA-assessed percent fat and fat-free mass were strong (ρ = 0.8 and 0.91, respectively), concordance values were only moderate (ρ_c = 0.67 and 0.74, respectively). Significantly stronger correlations were observed for obese relative to non-obese subjects for total percent fat (ρ_obese = 0.85 versus ρ_non-obese = 0.5) and fat mass (ρ_obese = 0.96 versus ρ_non-obese = 0.84). A handheld BIA device demonstrated high concordance with DXA for fat mass and moderate concordance for total percent fat and fat-free mass.

ClinicalTrials.gov: NCT02099799.

Using Telemedicine to Provide Education for the Symptomatic Patient with Chronic Respiratory Disease

Technology-enabled learning, using computers, smartphones, and tablets, to educate patients on their respiratory disease and management has grown over the last decade. This shift has been accelerated by the global COVID-19 pandemic and the need to socially distance for public health. Thirteen recently published papers examined experience, knowledge, skills and attitude acquisition, behaviour change, and impact on health outcomes of patient education using technology (websites and mobile device applications) for people with chronic respiratory disease. Technology-enabled patient education that includes relevant information, with activities that encourage the patient to interact with the digital platform, appears to lead to better patient experience and may increase learning and behaviour change with improved quality of life. Developing online relationships with healthcare providers, lower digital capabilities, and poor access to a computer/smartphone/tablet, appear to be barriers that need to be overcome for equity in access. Maintaining the principles of quality educational design, ensuring interactive experiences for patient involvement in the educational activities, patient co-design, healthcare professionals connecting with experts in the field of technology-enabled learning for development of education models, and ongoing research lead to the best patient outcomes in technology-enabled education for respiratory disease.

The Effect of a web-based physical activity intervention on COPD knowledge: A secondary cohort study

BACKGROUND

Novel strategies to complement current methods of education delivery by healthcare providers in clinic encounters or in pulmonary rehabilitation are needed to promote COPD self-management.

METHODS

We developed a COPD web-based platform that delivers education as part of a physical activity intervention. We examined COPD knowledge in persons with COPD who used a web-mediated, pedometer-based physical activity intervention. Knowledge was assessed with the Bristol COPD Knowledge Questionnaire (BCKQ) at baseline, 3, 6, 9, and 12 months. Scores range from 0 to 100, with higher scores indicating greater knowledge. Repeated measures ANOVA (PROC MIXED, SAS 9.4) examined trends across the 12 months and identified changes from baseline at 3, 6, 9, and 12 months.

RESULTS

We enrolled 72 participants with COPD, 93% males with mean ± sd age of 69 ± 7 years and FEV1% predicted of 60 ± 23%. There was a significant increase from baseline to 9 months (p = 0.012), although this increase did not persist at 12 months. Among the 13 topics, participants scored the highest at baseline on smoking knowledge (65.3 ± 17.4) and the lowest on inhaled steroids (9.7 ± 15.4). Across the 12 months, there were significant increases in knowledge about inhaled bronchodilators (p = 0.011) and inhaled steroids (p = 0.035). At 12 months, there were significant improvements in knowledge about exercise (p = 0.004), vaccination (p = 0.027), inhaled bronchodilators (p = 0.002), and inhaled steroids (p = 0.002).

CONCLUSION

An internet-mediated intervention may provide another option for COPD education delivery and support for disease self-management.