Physical activity patterns and clusters in 1001 patients with COPD

Movement Patterns in Older Adults Recovering From Hip Fracture

The aim of this study was to quantify physical activity and sedentary behavior in older adults recovering from hip fracture and to identify groups based on movement patterns. In this cross-sectional cohort study, older adults (≥70 years) were included 3 months after surgery for proximal femoral fracture. Patients received an accelerometer for 7 days. Demographics and outcomes related to physical function, mobility, cognitive functions, quality of life, and hip fracture were assessed. In total, 43 patients with sufficient accelerometer wear time were included. Across all groups, participants engaged in very low levels of physical activity, spending an average of 11 hr/day in prolonged sedentary behavior. Based on the extracted components from a principal component analysis, three groups with substantial differences in levels of physical activity and sedentary behavior could be distinguished.

What kind of non-pharmacological strategy for reducing sedentary behavior in COPD? Data from a scoping review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is usually associated with sedentary behavior (SB). Literature reports a harmful impact of SB on the physical, mental, and social health of individuals with COPD. However, Pulmonary Rehabilitation (PR) programs seem to have no clear effect on changing SB. Therefore, our study aimed to identify the strategies used in the literature to reduce SB among individuals with COPD.

METHOD

A scoping review was conducted to summarize the current literature regarding the proposed strategies to reduce SB in individuals with COPD. Searches were conducted in PUBMED; SCOPUS and COCHRANE LIBRARY for studies published from 2010 to march 2024.

RESULTS

Twenty four articles were retained for our review. Most of the identified strategies in the literature (21/24 articles) are based on behavioral approaches, with various forms: promoting self-efficacy, self-management and self-regulation of one's own behavior (12 articles), goal setting (10 articles), constant feedback (11 articles), therapeutic education (8 articles), motivational strategies (6 articles), re-engagement in meaningful activities (4 articles), promoting light intensity physical activity (LPA) (6 articles) and social support (6 articles). In association with the behavioral strategies, wearable connected technologies have been used in 4 articles, alone or combined with physical exercise programs included or not in a PR program. The home is associated with 83% of interventions as a place for initial and continuous implementation of behavioral strategies.

CONCLUSION

It would seem appropriate to focus on combined strategies to reduce SB in individuals with COPD (improvement of physical abilities and behavioral strategies). Further research is needed to only target the reduction of SB and to evaluate the effects of various interventions.

Physical Behavior Profiles Among Older Adults and Their Associations With Physical Capacity and Life-Space Mobility

We identified data-driven multidimensional physical activity (PA) profiles using several novel accelerometer-derived metrics. Participants aged 75, 80, and 85 (n = 441) wore triaxial accelerometers for 3-7 days. PA profiles were formed with k-means cluster analysis based on PA minutes, intensity, fragmentation, sit-to-stand transitions, and gait bouts for men and women. Associations with physical capacity and life-space mobility were examined using age-adjusted general linear models. Three profiles emerged: "Exercisers" and "actives" accumulated relatively high PA minutes, with actives engaging in lighter intensity PA. "Inactives" had the highest activity fragmentation and lowest PA volume, intensity, and gait bouts. Inactives showed lower scores in physical capacity and life-space mobility compared with exercisers and actives. Exercisers and actives had similar physical capacity and life-space mobility, except female exercisers had higher walking speed in the 6-min walk test. Our findings demonstrate the importance of assessing PA as multidimensional behavior rather than focusing on a single metric.

Oral nitrate supplementation improves cardiovascular risk markers in COPD: ON-BC, a randomised controlled trial

BACKGROUND

Short-term studies suggest that dietary nitrate (NO3 -) supplementation may improve the cardiovascular risk profile, lowering blood pressure (BP) and enhancing endothelial function. It is not clear if these beneficial effects are sustained and whether they apply in people with COPD, who have a worse cardiovascular profile than those without COPD. Nitrate-rich beetroot juice (NR-BRJ) is a convenient dietary source of nitrate.

METHODS

The ON-BC trial was a randomised, double-blind, placebo-controlled parallel group study in stable COPD patients with home systolic BP (SBP) measurement ≥130 mmHg. Participants were randomly allocated (1:1) using computer-generated, block randomisation to either 70 mL NR-BRJ (400 mg NO3 -) (n=40) or an otherwise identical nitrate-depleted placebo juice (0 mg NO3 -) (n=41), once daily for 12 weeks. The primary end-point was between-group change in home SBP measurement. Secondary outcomes included change in 6-min walk distance (6MWD) and measures of endothelial function (reactive hyperaemia index (RHI) and augmentation index normalised to a heart rate of 75 beats·min-1 (AIx75)) using an EndoPAT device. Plasma nitrate and platelet function were also measured.

RESULTS

Compared with placebo, active treatment lowered SBP (Hodges-Lehmann treatment effect -4.5 (95% CI -5.9- -3.0) mmHg), and improved 6MWD (30.0 (95% CI 15.7-44.2) m; p<0.001), RHI (0.34 (95% CI 0.03-0.63); p=0.03) and AIx75 (-7.61% (95% CI -14.3- -0.95%); p=0.026).

CONCLUSIONS

In people with COPD, prolonged dietary nitrate supplementation in the form of beetroot juice produces a sustained reduction in BP, associated with an improvement in endothelial function and exercise capacity.

Investigating the prognostic value of digital mobility outcomes in patients with chronic obstructive pulmonary disease: a systematic literature review and meta-analysis

BACKGROUND

Reduced mobility is a central feature of COPD. Assessment of mobility outcomes that can be measured digitally (digital mobility outcomes (DMOs)) in daily life such as gait speed and steps per day is increasingly possible using devices such as pedometers and accelerometers, but the predictive value of these measures remains unclear in relation to key outcomes such as hospital admission and survival.

METHODS

We conducted a systematic review, nested within a larger scoping review by the MOBILISE-D consortium, addressing DMOs in a range of chronic conditions. Qualitative and quantitative analysis considering steps per day and gait speed and their association with clinical outcomes in COPD patients was performed.

RESULTS

21 studies (6076 participants) were included. Nine studies evaluated steps per day and 11 evaluated a measure reflecting gait speed in daily life. Negative associations were demonstrated between mortality risk and steps per day (per 1000 steps) (hazard ratio (HR) 0.81, 95% CI 0.75-0.88, p<0.001), gait speed (<0.80 m·s-1) (HR 3.55, 95% CI 1.72-7.36, p<0.001) and gait speed (per 1.0 m·s-1) (HR 7.55, 95% CI 1.11-51.3, p=0.04). Fewer steps per day (per 1000) and slow gait speed (<0.80 m·s-1) were also associated with increased healthcare utilisation (HR 0.80, 95% CI 0.72-0.88, p<0.001; OR 3.36, 95% CI 1.42-7.94, p=0.01, respectively). Available evidence was of low-moderate quality with few studies eligible for meta-analysis.

CONCLUSION

Daily step count and gait speed are negatively associated with mortality risk and other important outcomes in people with COPD and therefore may have value as prognostic indicators in clinical trials, but the quantity and quality of evidence is limited. Larger studies with consistent methodologies are called for.

Physical Activity Pattern of Adults With Metabolic Syndrome Risk Factors: Time-Series Cluster Analysis

Background

Physical activity plays a crucial role in maintaining a healthy lifestyle, and wrist-worn wearables, such as smartwatches and smart bands, have become popular tools for measuring activity levels in daily life. However, studies on physical activity using wearable devices have limitations; for example, these studies often rely on a single device model or use improper clustering methods to analyze the wearable data that are extracted from wearable devices.

Objective

This study aimed to identify methods suitable for analyzing wearable data and determining daily physical activity patterns. This study also explored the association between these physical activity patterns and health risk factors.

Methods

People aged >30 years who had metabolic syndrome risk factors and were using their own wrist-worn devices were included in this study. We collected personal health data through a web-based survey and measured physical activity levels using wrist-worn wearables over the course of 1 week. The Time-Series Anytime Density Peak (TADPole) clustering method, which is a novel time-series method proposed recently, was used to identify the physical activity patterns of study participants. Additionally, we defined physical activity pattern groups based on the similarity of physical activity patterns between weekdays and weekends. We used the χ2 or Fisher exact test for categorical variables and the 2-tailed t test for numerical variables to find significant differences between physical activity pattern groups. Logistic regression models were used to analyze the relationship between activity patterns and health risk factors.

Results

A total of 47 participants were included in the analysis, generating a total of 329 person-days of data. We identified 2 different types of physical activity patterns (early bird pattern and night owl pattern) for weekdays and weekends. The physical activity levels of early birds were less than that of night owls on both weekdays and weekends. Additionally, participants were categorized into stable and shifting groups based on the similarity of physical activity patterns between weekdays and weekends. The physical activity pattern groups showed significant differences depending on age (P=.004) and daily energy expenditure (P<.001 for weekdays; P=.003 for weekends). Logistic regression analysis revealed a significant association between older age (≥40 y) and shifting physical activity patterns (odds ratio 8.68, 95% CI 1.95-48.85; P=.007).

Conclusions

This study overcomes the limitations of previous studies by using various models of wrist-worn wearables and a novel time-series clustering method. Our findings suggested that age significantly influenced physical activity patterns. It also suggests a potential role of the TADPole clustering method in the analysis of large and multidimensional data, such as wearable data.

Demystification of artificial intelligence for respiratory clinicians managing patients with obstructive lung diseases

INTRODUCTION

Asthma and chronic obstructive pulmonary disease (COPD) are leading causes of morbidity and mortality worldwide. Despite all available diagnostics and treatments, these conditions pose a significant individual, economic and social burden. Artificial intelligence (AI) promises to support clinical decision-making processes by optimizing diagnosis and treatment strategies of these heterogeneous and complex chronic respiratory diseases. Its capabilities extend to predicting exacerbation risk, disease progression and mortality, providing healthcare professionals with valuable insights for more effective care. Nevertheless, the knowledge gap between respiratory clinicians and data scientists remains a major constraint for wide application of AI and may hinder future progress. This narrative review aims to bridge this gap and encourage AI deployment by explaining its methodology and added value in asthma and COPD diagnosis and treatment.

AREAS COVERED

This review offers an overview of the fundamental concepts of AI and machine learning, outlines the key steps in building a model, provides examples of their applicability in asthma and COPD care, and discusses barriers to their implementation.

EXPERT OPINION

Machine learning can advance our understanding of asthma and COPD, enabling personalized therapy and better outcomes. Further research and validation are needed to ensure the development of clinically meaningful and generalizable models.

Determinants of Activity Phenotype in Patients with Chronic Obstructive Pulmonary Disease

Introduction

Physical activity (PA) and sedentary behavior (SB) have attracted attention in chronic obstructive pulmonary disease (COPD), and there have been efforts to evaluate PA and SB separately. The factors associated with the characteristics of the four activity phenotypes defined by the durations of PA and SB are largely unknown. The aim of this study was to clarify the factors that could differentiate each activity phenotype.

Materials and Methods

Study subjects were outpatients with stable COPD who were ≥40 years of age. We investigated the influence of 26 different factors on the activity phenotypes of COPD and extracted the factors that showed significant differences among the four activity phenotypes.

Results

Two hundred sixteen patients were included in the analysis. Exercise capacity and dyspnea were determinants that distinguished the low PA groups from the high PA groups. The pulmonary function and desaturation during exercise were factors that distinguished the high PA with low SB group from the low PA with high SB group. BMI, grip strength, upper arm circumference and HbA1c were higher in the low PA and low SB group than in the low PA and high SB group.

Conclusion

These factors could be the determinants discriminating activity phenotypes of patients with COPD.

COPD: Providing the right treatment for the right patient at the right time

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Physical activity pattern of patients with interstitial lung disease compared to patients with COPD: A propensity-matched study

INTRODUCTION

Physical activity (PA) is reduced in patients with interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD). Evidence about the PA pattern of patients with ILD is scarce. If PA of patients with ILD would be comparable to COPD, it is tempting to speculate that existing interventions focusing on enhancing PA could be as effective in ILD as already shown in COPD. Therefore, we aimed to compare PA and the correlates with PA in matched patients with ILD, COPD, and healthy subjects.

MATERIALS AND METHODS

Patients with ILD (n = 45), COPD (n = 45) and healthy subjects (n = 30) were propensity matched. PA level, pattern, and PA correlations with lung function and physical performance (6-minute walking distance and quadriceps force) were compared between groups.

RESULTS

Daily number of steps was similar in both patient groups (mean±SE: 5631±459 for ILD, 5544±547 for COPD, p = 0.900), but significantly lower compared to healthy subjects (10031±536, p<0.001 for both). Mean intensity of PA tended to be lower in the ILD group (mean±SE metabolic equivalents of task per day: 1.41±0.04) compared to COPD (1.52±0.05, p = 0.074) and healthy individuals (1.67±0.04, p<0.001). The pattern of PA over one day was found to be similar between the three groups. Lastly, the correlation between PA and 6-minute walking distance was significantly weaker in patients with ILD compared to patients with COPD (respectively r = 0.348 and r = 0.739; p<0.05 for both).

CONCLUSIONS

For a given functional reserve, patients with ILD perform an equal amount of steps but perform PA at lower intensity compared to patients with COPD. Both groups are less active compared to healthy control subjects. Functional exercise capacity was shown to be only moderately related to PA. This can potentially influence the effectiveness of PA interventions that can be expected.

Health-Related Quality of Life and Daily Physical Activity Level in Patients with COPD- a Cluster Analysis

Patients with chronic obstructive pulmonary disease (COPD) may have a limited level of physical activity in daily life (PADL) and health-related quality of life (HRQOL). The interrelationships of these variables should be measure by cluster analysis to characterize this population and enable rehabilitation programs to target each patient profile identified. This study investigates different phenotypes in COPD according to PADL and HRQOL. A cross-sectional study with cluster analysis was done, in which 76 people with COPD were submitted to measurements to characterize the sample on first day, followed by used of physical activity monitor, which was worn for 7 days. After 7 days, the six-minute walk test (6MWT) and HRQOL questionnaires were applied (St. George's Respiratory Questionnaire). The main results: three phenotypes were identified (A, B and C), with phenotype A who exhibited an inactive physical activity level and HRQOL scores above the value deemed satisfactory, phenotype B those with active physical activity level and poor HRQOL scores, and phenotype C subjects with inactive physical activity level and HRQOL scores but the value is close to cutoff point. To conclude, three phenotypes were found, with one indicating disproportionality between PADL and HRQOL.

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

RATIONALE

Differences in body composition may contribute to variability in exercise capacity (EC) and physical activity (PA) in chronic obstructive pulmonary disease (COPD). Most studies have employed 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)-assessed body composition.

OBJECTIVE

To determine whether DXA-assessed muscle (lean) and fat mass exhibit differential correlations with EC and PA in COPD Methods: US Veterans with COPD (defined as FEV1/FVC<0.7 or emphysema on clinical chest computed tomography) had DXA-assessed body composition, EC (6-minute walk distance; 6MWD), objective PA (average daily step counts), and self-reported PA measured at enrollment. Associations between 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 (88%), obese (mean BMI 30.2±6.2), and male, (94%) with a mean age (±SD) of 69.9±7.9 years and moderate airflow obstruction (mean FEV1% 68±20). Modest inverse correlations between EC and PA with fat mass were observed (Spearman's rho range [-0.20]-[-0.34]) while measures of muscle (lean) mass were not significantly associated with EC or PA. The appendicular skeletal muscle (ASM)-to-weight ratio, which considers both muscle (lean) and fat mass, was consistently associated with EC (8.4 [95%CI=2.9-13.8] meter increase on 6MWD per 1% increase in ASM-to-weight ratio), objective PA (194.8 [95%CI=15.2-374.4] steps per day per 1% increase in ASM-to-weight ratio), and self-reported PA in multivariable-adjusted models.

CONCLUSION

DXA-assessed body composition measures which include consideration of both lean and fat mass are associated with cross-sectional EC and PA in COPD populations. Clinical trial registered at ClinicalTrials.gov (NCT02099799).

Physical Activity Patterns among Individuals with Prediabetes or Type 2 Diabetes across Two Years-A Longitudinal Latent Class Analysis

Background: This study aimed to identify distinct profiles of physical activity (PA) patterns among individuals with prediabetes or type 2 diabetes participating in a two-year PA trial and to investigate predictors of the profiles. Methods: Data (n = 168, collected 2013–2020) from the cohort of a randomized trial aimed at increasing PA in individuals with prediabetes and type 2 diabetes were used. PA and sedentary behaviours were assessed by waist-worn ActiGraph GT1M accelerometers at baseline and at 6, 12, 18 and 24 months. Fifteen PA and sedentary variables were entered into a latent class mixed model for multivariate longitudinal outcomes. Multinominal regression analysis modelled profile membership based on baseline activity level, age, gender, BMI, disease status and group randomisation. Results: Two profiles of PA patterns were identified: “Increased activity” (n = 37, 22%) included participants increasing time in PA and decreasing sedentary time. “No change in activity” (n = 131, 78%) included participants with no or minor changes. “Increased activity” were younger (p = 0.003) and more active at baseline (p = 0.011), compared to “No change in activity”. No other predictor was associated with profile membership. Conclusions: A majority of participants maintained PA and sedentary patterns over two years despite being part of a PA intervention. Individuals improving PA patterns were younger and more active at baseline.

COPD profiles and treatable traits using minimal resources: identification, decision tree and stability over time

Background and objective

Profiles of people with chronic obstructive pulmonary disease (COPD) often do not describe treatable traits, lack validation and/or their stability over time is unknown. We aimed to identify COPD profiles and their treatable traits based on simple and meaningful measures; to develop and validate a decision tree and to explore profile stability over time.

Methods

An observational, prospective study was conducted. Clinical characteristics, lung function, symptoms, impact of the disease (COPD Assessment Test—CAT), health-related quality of life, physical activity, lower-limb muscle strength and functional status were collected cross-sectionally and a subsample was followed-up monthly over six months. A principal component analysis and a clustering procedure with k-medoids were applied to identify profiles. A decision tree was developed and validated cross-sectionally. Stability was explored over time with the ratio between the number of timepoints that a participant was classified in the same profile and the total number of timepoints (i.e., 6).

Results

352 people with COPD (67.4 ± 9.9 years; 78.1% male; FEV1 = 56.2 ± 20.6% predicted) participated and 90 (67.6 ± 8.9 years; 85.6% male; FEV1 = 52.1 ± 19.9% predicted) were followed-up. Four profiles were identified with distinct treatable traits. The decision tree included CAT (< 18 or ≥ 18 points); age (< 65 or ≥ 65 years) and FEV1 (< 48 or ≥ 48% predicted) and had an agreement of 71.7% (Cohen’s Kappa = 0.62, p < 0.001) with the actual profiles. 48.9% of participants remained in the same profile whilst 51.1% moved between two (47.8%) or three (3.3%) profiles over time. Overall stability was 86.8 ± 15%.

Conclusion

Four profiles and treatable traits were identified with simple and meaningful measures possibly available in low-resource settings. A decision tree with three commonly used variables in the routine assessment of people with COPD is now available for quick allocation to the identified profiles in clinical practice. Profiles and treatable traits may change over time in people with COPD hence, regular assessments to deliver goal-targeted personalised treatments are needed.

The Association of Health-Related Factors with Leisure-Time Physical Activity among Adults with COPD: A Cross-Sectional Analysis

This study aimed to examine the association of health attitudes, health appraisals and affective experience to leisure-time physical activity in adults with chronic obstructive pulmonary disease (COPD). Cross-sectional analyses were conducted with a sample of 274 adults with COPD drawn from the second wave of the Midlife in the United States (MIDUS 2) Study. Chi-square analyses and independent t-tests were used to test the differences between physically active and inactive COPD patients (active group versus inactive group) for all study variables. Multiple logistic regression was used to examine the association of each study variable with leisure-time physical activity. The results showed that there were significant differences between the active and inactive groups in terms of age, education, functional limitations, health attitudes, health appraisals and affective experience. After controlling for socio-demographic variables and functional limitations, beliefs about the importance of physical fitness and strength for a good life and comparative health appraisals were significantly related to physical activity. However, neither negative nor positive affect was associated with physical activity status. Modifiable factors, such as health attitudes toward physical fitness and strength, as well as health appraisals, should be considered for developing effective physical activity promotion interventions among COPD patients.

Walking distance in incremental shuttle walking test as a predictor of physical activity in patients diagnosed with low-risk chronic obstructive pulmonary disease

Objectives

Research on the determinants of physical activity in mildly symptomatic patients with chronic obstructive pulmonary disease is lacking. This study examined the predictors of physical activity in patients with low-risk chronic obstructive pulmonary disease.

Methods

A total of 41 male patients with chronic obstructive pulmonary disease belonging to Group A of the Global Initiative for Chronic Obstructive Lung Disease were included. Regarding the objective index, the physical activity (number of steps/day and the amount of Ex (metabolic equivalent × hours)/day) of the participants was measured with a tri-axis accelerometer. In addition, regarding the evaluation index, respiratory function and dynamic lung hyperinflation were measured by a spirometer, skeletal muscle mass was measured using bioelectrical impedance analysis, skeletal muscle strength (grip and lower limb muscle strength) was measured using a dynamometer, exercise capacity was measured by the incremental shuttle walking test, and health-related quality of life was measured.

Results

Significant correlations were found between the number of steps per day and age (ρ = -0.501, p < 0.01), forced vital capacity predictive values (ρ = 0.381, p < 0.05), dynamic lung hyperinflation (ρ = 0.454, p < 0.01), grip strength (ρ = 0.318, p < 0.05), and walking distance in incremental shuttle walking test (ρ = 0.779, p < 0.01), but not skeletal muscle mass, lower limb muscle strength, or health-related quality of life. A multiple-regression analysis with the number of steps per day as the dependent variable extracted only walking distance in incremental shuttle walking test, yielding a moderate single-regression equation (steps/day = -934.909 + 11.052 × walking distance in incremental shuttle walking test, adjusted R² = 0.548, p < 0.001).

Conclusion

It was suggested that the amount of physical activity of patients with low-risk chronic obstructive pulmonary disease could be predicted by walking distance in incremental shuttle walking test.

Understanding perspectives and choices for sedentary behaviour and physical activity in older adults’ post-acute exacerbation of chronic obstructive pulmonary disease

Background

Individuals recovering from acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are most likely to exhibit sedentary behaviour (SB) and low levels of physical activity (PA). This study seeks to explore their choices for adopting current patterns of SB and PA post AECOPD and add to current literature on stable COPD.

Method

A semi-structured interview, based on the broad framework of the Behaviour Change Wheel, was conducted on patients post AECOPD. A phenomenological approach was utilised inductively.

Results

Six participants were interviewed at their homes. Four major themes were identified: (1) low perceived capabilities for engaging in PA; (2) limited understanding on COPD and PA; (3) lack of translation of health knowledge and intentions into actions; and (4) poor adherence to movement-advice from physiotherapist.

Conclusion

Our findings revealed largely psychological and behavioural deficits influencing SB and PA in people post AECOPD, similar to those in stable COPD.

Reference Equations for Assessing the Physical Activity of Japanese Patients with Chronic Obstructive Pulmonary Disease

Background

To improve physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD), providing a target PA value based on the individual patient's condition may be a useful interventional strategy. However, to determine the target value, a predictive PA value for each patient is required.

Research Question

What is the reference equation consisting of PA-related factors to determine the predictive PA value for each patient with COPD?

Material and Methods

In this prospective cross-sectional observational study, we measured the PA with a triaxial accelerometer and several other factors including demographic factors, pulmonary function, dyspnea, exercise capacity, muscle strength, nutrition, and indicators of several comorbidities in stable Japanese outpatients with COPD aged ≥40 years old and detected PA-related factors by a multiple regression analysis and stepwise method. We created reference equations for four indices of PA using multiple linear regression equations.

Results

Two hundred and twenty-seven patients were registered. The equations of duration at ≥2.0 metabolic equivalents (METs) and step count consisted of 4 factors: 6-minute walk distance, modified Medical Research Council dyspnea scale, anxiety score of the Hospital Anxiety and Depression Scale, and the forced expiratory volume in 1 second % of predicted value. Those of duration at ≥3.0 METs and total activity at ≥3.0 METs consisted of 5 factors: the above 4 factors and age or brain natriuretic peptide. There was no fixed bias or proportional bias between the measured and predictive values in patients with non-high measured PA values.

Conclusion

We determined reference equations for four indicators of PA using PA-related factors in Japanese patients with COPD. The predictive values calculated using the equations could be useful for deciding target PA values for each patient.

Clinical Trial Registration

UMIN-CTR; No.: UMIN000025459; URL: https://www.umin.ac.jp/ctr/index.htm.

Physical Activity Patterns in Frail and Nonfrail Patients With End-Stage Liver Disease

BACKGROUND

Frailty commonly complicates cirrhosis and is associated with poorer outcomes. While patients with cirrhosis may be sedentary, there are few comprehensive descriptions of their physical activity (PA) patterns related to frailty. Our aim was to identify PA characteristics that may be used in interventions to improve PA and reduce frailty.

METHODS

In a cross-sectional cohort study, forty patients with cirrhosis (mean age 63; 30 nonfrail, 10 frail) wore an accelerometer/thermal sensing armband for 7 days. Postural status (e.g., upright movement, upright sedentary, lying down), Metabolic Equivalent of Tasks (METs) and active bouts were identified.

RESULTS

Patients were highly sedentary most of the time (89 ± 7% and 85 ± 10% of the day, in frail and nonfrail cirrhotics, respectively). Compared with nonfrail cirrhotics, frail patients spent significantly shorter amount of time moving in an upright position (7% ± 5 vs. 12% ± 5, P = 0.013 in frail and nonfrail cirrhotics, respectively), had significantly fewer and shorter durations of active bouts per day (number of active bouts: 9 ± 12 vs. 19 ± 14; duration: 13.2 ± 1.5 min and 15.9 ± 2.6 min in frail and nonfrail cirrhotics, respectively), and had a lower amount of steps per wear time hours (41.7 ± 37.1 vs. 116.8 ± 85.4, P = 0.003 in frail and nonfrail, respectively). Traditional measures such as METs or aerobic bouts did not differ between groups.

CONCLUSIONS

Active bout measures, as opposed to more traditional measures such as METs, differentiate between frail and nonfrail cirrhotics suggesting they may be used to assess changes resulting from targeted interventions to improve physical activity.

[Physical activity and pulmonary rehabilitation]

INTRODUCTION

Physical activity in daily life (PA) in patients with chronic respiratory disease is reduced. Inactivity is associated with an increased risk of hospitalisation and mortality. Even though pulmonary rehabilitation (PR) is associated with improved quality of life (fewer symptoms, greater exercise capacity…), its benefits with regard to PA remain unclear.

STATE OF THE ART

For each patient, it is important during a respiratory rehabilitation (RR) programme to evaluate PA and its determinants. Only programs aimed at improved self-management and including educational therapy (ETP) have shown a short-term increase of PA following PR. Several studies have reported better long-term adherence when professionals help the patient to construct a personalised PA project, with regular follow-up and an array of activities (local facilities, urban walking…) chosen by the patient and adapted to the environment.

PERSPECTIVES

The ongoing SARS-CoV2 pandemic has highlighted the importance of human interaction, even at a distance using information and communication technologies, as a means of sustaining patient motivation. Future controlled and randomized studies should focus on the long-term impact on PA of innovative strategies in patients with chronic respiratory diseases. Moreover, it would be interesting to quantify the socioeconomic impact as well as the sustainable health benefits of the different strategies outlined in this review.

CONCLUSION

It is not possible to offer a single solution likely to maintain RR benefits over an extended lapse of time. However, follow-up with an ETP and/or regular and customized support during the post-training period facilitates the long-term adoption of active behavior.

The Influence of Pulmonary Rehabilitation and Counselling on Perceptions of Physical Activity in Individuals with COPD - A Qualitative Study

Objective

The aim of this study was to explore to what extent a combined counselling and pulmonary rehabilitation program (PR) influences the perception of physical activity (PA) and motivation for behavioral change in PA in individuals with COPD. The results of previous quantitative trial that investigated the effect of this combined treatment on daily PA were inconclusive. It is conjectured that a more targeted tailoring of the counselling and PR intervention could improve its effectiveness.

Patients and Methods

Eighteen individuals with COPD (median age 69, 8 females) who had participated in the PneumoReha program were interviewed twice (following PR and at three-month follow-up). These interviews were transcribed and analyzed thematically. Based on the codes thus identified, three categories 'perception of PA intensity', 'quality of motivation to perform PA', and 'strategies to cope with barriers' were used to differentiate 'types' of participants.

Results

Four different types of COPD individuals were distinguished. Study findings indicate that those individuals who participated in the PR program combined with embedded counselling tended to be more active and intrinsically motivated.

Conclusion

A typology of four types of people with COPD was developed, characterized by their perception of activity, individual motivation and strategies for managing barriers. The patients' physical activity level might be influenced by their concept of physical activity and the quality of motivation. Recognizing patients' different activity behaviors is important for improving the quality of outpatient PR programs and developing tailored (according to each type) counselling interventions embedded in outpatient PR programs.

Clinical Trial Registration

The study was registered on the website of https://www.clinicaltrials.gov/ with the identifier NCT02455206 (27/05/2015), as well as on the Swiss National Trails Portal SNCTP000001426 (05/21/2015).

Longitudinal changes in total and regional body composition in patients with chronic obstructive pulmonary disease

Background and objective

Low fat‐free mass (FFM) is common in patients with chronic obstructive pulmonary disease (COPD) and contributes to morbidity and mortality. Few studies have evaluated longitudinal changes in body composition in patients with COPD compared with non‐COPD controls. This study aimed to compare longitudinal changes in total and regional body composition between patients with COPD and non‐COPD controls and investigate predictors of changes in body composition in COPD.

Methods

Patients with COPD and non‐COPD controls participating in the Individualized COPD Evaluation in relation to Ageing (ICE‐Age) study, a single‐centre, longitudinal, observational study, were included. Subjects were assessed at baseline and after 2 years of follow‐up. Among other procedures, body composition was measured by dual‐energy X‐ray absorptiometry scan. The number of exacerbations/hospitalizations 1 year before inclusion and during follow‐up were assessed in patients with COPD.

Results

A total of 405 subjects were included (205 COPD, 87 smoking and 113 non‐smoking controls). Patients with COPD and smoking controls presented a significant decline in total FFM (mean [95% CI]: −1173 [−1527/−820] g and −486 [−816/−156] g, respectively) while body composition remained stable in non‐smoking controls. In patients with COPD, the decline in FFM was more pronounced in legs (−174 [−361/14] g) and trunk (−675 [−944/406] g) rather than in arms (54 [−19/126] g). The predictors of changes in total and regional FFM in patients with COPD were gender, number of previous hospitalizations, baseline values of FFM and BMI.

Conclusion

Patients with COPD present a significant decline in FFM after 2 years of follow‐up, this decline is more pronounced in their legs and trunk.

Patients with chronic obstructive pulmonary disease (COPD) present a significant decline in total, leg and trunk low fat‐free mass (FFM), while arms FFM remains stable after 2 years of follow‐up. We identified a subgroup of patients with preserved FFM at baseline and history of previous hospitalizations that present greater decline in total and leg FFM compared to other patients with COPD.

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Isotonic quadriceps endurance is better associated with daily physical activity than quadriceps strength and power in COPD: an international multicentre cross-sectional trial

Knowledge about modifiable determinants of daily physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) is crucial to design effective PA interventions. The present study aimed to determine the contribution of quadriceps strength, power and endurance to daily PA in COPD. Additionally, for quadriceps endurance, we also aimed to determine to what extent the association varies according to the mode of movement (isotonic, isometric, or isokinetic). Using a multicentre cross-sectional trial design we determined the contribution of quadriceps function to daily PA (steps, sedentary time and time spent doing moderate-to-very-vigorous physical activity [MVPA]) using bivariate and partial Pearson correlation analysis (r) and multiple linear regression models (ΔR²). Pre-determined controlling factors were sex, age, body mass index (BMI), COPD-assessment test, forced expiratory volume in one second in percent of the predicted value (FEV_1pred), and distance walked on the 6-minute walk test. Eighty-one patients with COPD (mean ± SD: age 67 ± 8 years, FEV_1pred 57 ± 19%, daily steps 4968 ± 3319, daily sedentary time 1016 ± 305 min, and MVPA time 83 ± 45 min) were included. Small to moderate bivariate correlations (r = .225 to .452, p < .05) were found between quadriceps function and measures of PA. The best multiple linear regression models explained 38–49% of the variance in the data. Isotonic endurance was the only muscle contributor that improved all PA models; daily steps (ΔR² = .04 [relative improvement 13%] p = .026), daily sedentary time (ΔR² = .07 [23%], p = .005) and MVPA-minutes (ΔR² = .08 [20%], p = .001). Isotonic endurance was also independently associated with most PA variables, even when controlling for strength, power or isometric-isokinetic endurance properties of the muscle (r = .246 to .384, p < .05). In contrast, neither strength, power, isometric-or isokinetic endurance properties of the muscle was independently associated with PA measures when controlling for isotonic endurance (r = .037 to .219, p > .05). To conclude, strength, power, and endurance properties of the quadriceps were low to moderately associated with PA in patients with COPD. Isotonic quadriceps endurance was the only quadriceps property that was independently associated with the different measures of PA after controlling for a basic set of known determinants of PA, quadriceps strength or power, or isometric or isokinetic quadriceps endurance. Future longitudinal studies should investigate its potential as a modifiable determinant of PA.

The Maugeri daily activity profile: a tool to assess physical activity in patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) report reduced physical activity (PA). There are only few tools available to assess PA and sedentary behavior in these patients, and none of them aims to differentiate between sedentary and active patterns. The aim of the study was to evaluate an easy tool to profile daily activity time in a cohort of patients with COPD, compared to healthy subjects; the study was set at the Istituti Clinici Scientifici Maugeri (ICS), IRCCS of Tradate and Lumezzane, Italy, and at the Ente Ospedaliero Cantonale Novaggio, Switzerland (Italian Speaking). The populations were inpatients with COPD, healthy subjects. The items of the Maugeri Daily Activity (MaDA) profile were chosen based on literature, interviews with patients and health professionals. Time spent during sleep (ST), when awake (AT), active (ACT) or in sedentary behavior (SET) were recorded. Lung function tests, arterial blood gases, the modified Medical Research Council (mMRC), the six-minute walking distance test (6MWD), the COPD Assessment Test (CAT), and the body-mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index were also assessed in patients. Sixty patients with COPD and 60 healthy controls filled in the questionnaire. As compared to controls, patients showed longer AT and SET. Active time of patients was significantly correlated with mMRC, CAT, Bode Index and 6MWD, but not with demographics, anthropometrics or stages of disease. Using this tool, we found that patients with COPD spent longer time awake and in sedentary behavior. The MaDA may be useful to evaluate PA in patients with COPD.

Profiling of Patients with COPD for Adequate Referral to Exercise-Based Care: The Dutch Model

A loss of physical functioning (i.e., a low physical capacity and/or a low physical activity) is a common feature in patients with chronic obstructive pulmonary disease (COPD). To date, the primary care physiotherapy and specialized pulmonary rehabilitation are clearly underused, and limited to patients with a moderate to very severe degree of airflow limitation (GOLD stage 2 or higher). However, improved referral rates are a necessity to lower the burden for patients with COPD and for society. Therefore, a multidisciplinary group of healthcare professionals and scientists proposes a new model for referral of patients with COPD to the right type of exercise-based care, irrespective of the degree of airflow limitation. Indeed, disease instability (recent hospitalization, yes/no), the burden of disease (no/low, mild/moderate or high), physical capacity (low or preserved) and physical activity (low or preserved) need to be used to allocate patients to one of the six distinct patient profiles. Patients with profile 1 or 2 will not be referred for physiotherapy; patients with profiles 3-5 will be referred for primary care physiotherapy; and patients with profile 6 will be referred for screening for specialized pulmonary rehabilitation. The proposed Dutch model has the intention to get the right patient with COPD allocated to the right type of exercise-based care and at the right moment.

Physical activity behavior in people with asthma and COPD overlap residing in Spain: a cross-sectional analysis

OBJECTIVES

To identify levels of physical activity (PA) among the Spanish population with asthma and chronic obstructive pulmonary disease overlap (ACO). A further aim was to analyze differences in PA levels by sex, age, education, marital status, cohabiting, smoking habits, alcohol consumption and body mass index (BMI).

METHODS

In this cross sectional study, data from the Spanish National Health Survey 2017 were analyzed. A total of 198 people with ACO aged 15-69 years were included in the analyses. The short version of the international physical activity questionnaire (IPAQ) was used to measure total PA (MET·min/week). PA was further classified as low, moderate and high, and analyzed according to sample characteristics. Data were analyzed using the Mann-Whitney U test, Kruskal-Wallis H test and chi squared test. Statistical significance was set at p < 0.05.

RESULTS

People with ACO engaged in a mean volume of 2038.1 MET·min/week. Those aged 30-60 years and those with normal weight were significantly more active than those aged ≥60 and those with obesity. When classifying PA level in low, moderate and high, results showed no significant differences between sample characteristics. Overall, moderate and high levels of PA were the most and least frequent levels (48.0% and 16.2%, respectively).

CONCLUSIONS

More than three out of ten Spanish adults with ACO do not achieve PA recommendations. Therefore, it is recommended to implement programs that promote the importance and benefits of PA among the Spanish population with ACO, and such programs should focus on older adults and those who are obese.

Physical activity profiles in Parkinson's disease

Background

Identifying physical activity (PA) profiles of people with Parkinson’s Disease (PD) could provide clinically meaningful knowledge concerning how to tailor PA interventions. Our objectives were therefore to i) identify distinct PA profiles in people with PD based on accelerometer data, ii) explore differences between the profiles regarding personal characteristics and physical function.

Methods

Accelerometer data from 301 participants (43% women, mean age: 71 years) was analysed using latent profile analyses of 15 derived PA variables. Physical function measurements included balance performance, comfortable gait speed and single and dual-task functional mobility.

Results

Three distinct profiles were identified; “Sedentary” (N = 68), “Light Movers” (N = 115), “Steady Movers” (N = 118). “Sedentary” included people with PD with high absolute and relative time spent in Sedentary behaviour (SB), little time light intensity physical activity (LIPA) and negligible moderate-to-vigorous physical activity (MVPA). “Light Movers” were people with PD with values close to the mean for all activity variables. “Steady Movers” spent less time in SB during midday, and more time in LIPA and MVPA throughout the day, compared to the other profiles. “Sedentary” people had poorer balance (P = 0.006), poorer functional mobility (P = 0.027) and were more likely to have fallen previously (P = 0.027), compared to “Light Movers. The Timed Up and Go test, an easily performed clinical test of functional mobility, was the only test that could distinguish between all three profiles.

Conclusion

Distinct PA profiles, with clear differences in how the time awake is spent exist among people with mild-moderate PD.

Towards a better understanding of physical activity in people with COPD: predicting physical activity after pulmonary rehabilitation using an integrative competence model

The integrative Physical Activity-related Health Competence (PAHCO) model specifies competences (movement competence, control competence, and self-regulation competence) that enable people to lead a physically active lifestyle. This longitudinal study analyses the predictive quality of a multidimensional PAHCO assessment for levels of physical activity (PA) and their relevance for quality of life in COPD patients after pulmonary rehabilitation. At the end of an inpatient pulmonary rehabilitation (T2), 350 COPD patients participating in the Stay Active after Rehabilitation (STAR) study underwent assessments, including a six-factor measurement of PAHCO. PA (triaxial accelerometry) and quality of life (Saint George's Respiratory Questionnaire) were recorded 6 weeks (T3) and 6 months (T4) after rehabilitation. Structural equation modelling (SEM) was used to regress the PAHCO assessment on PA, which should, in turn, influence quality of life. In univariable analysis, five and six factors of the PAHCO model were related to PA and quality of life, respectively. Multivariate modelling showed that the predictive analyses for the PA level were dominated by the 6-minute walking test representing movement competence (0.562 ≤ |β| ≤ 0.599). Affect regulation as an indicator of control competence co-predicted quality of life at T3 and levels of PA at T4. The PA level was, in turn, significantly associated with patients' quality of life (0.306 ≤ |β| ≤ 0.388). The integrative PAHCO model may be used as a theoretical framework for predicting PA in COPD patients following pulmonary rehabilitation. The results improve our understanding of PA behaviour in COPD patients and bear implications for person-oriented PA promotion.

Different Clusters in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Two-Center Study in Brazil

Background

Chronic obstructive pulmonary disease (COPD) has a functional definition. However, differences in clinical characteristics and systemic manifestations make COPD a heterogeneous disease and some manifestations have been associated with different risks of acute exacerbations, hospitalizations, and death.

Objective

Therefore, the objective of the study was to evaluate possible clinical clusters in COPD at two study centers in Brazil and identify the associated exacerbation and mortality rate during 1 year of follow-up.

Methods

We included patients with COPD and all underwent an evaluation composed of the Charlson Index, body mass index (BMI), current pharmacological treatment, smoking history (packs-year), history of exacerbations/hospitalizations in the last year, spirometry, six-minute walking test (6MWT), quality of life questionnaires, dyspnea, and hospital anxiety and depression scale. Blood samples were also collected for measurements of C-reactive protein (CRP), blood gases, laboratory analysis, and blood count. For the construction of the clusters, 13 continuous variables of clinical importance were considered: hematocrit, CRP, triglycerides, low density lipoprotein, absolute number of peripheral eosinophils, age, pulse oximetry, BMI, forced expiratory volume in the first second, dyspnea, 6MWD, total score of the Saint George Respiratory Questionnaire and packs-year of smoking. We used the Ward and K-means methods and determined the best silhouette value to identify similarities of individuals within the cluster (cohesion) in relation to the other clusters (separation). The number of clusters was determined by the heterogeneity values of the cluster, which in this case was determined as four clusters.

Results

We evaluated 301 COPD patients and identified four different groups of COPD patients. The first cluster (203 patients) was characterized by fewer symptoms and lower functional severity of the disease, the second cluster by higher values of peripheral eosinophils, the third cluster by more systemic inflammation and the fourth cluster by greater obstructive severity and worse gas exchange. Cluster 2 had an average of 959±3 peripheral eosinophils, cluster 3 had a higher prevalence of nutritional depletion (46.1%), and cluster 4 had a higher BODE index. Regarding the associated comorbidities, we found that only obstructive sleep apnea syndrome and pulmonary thromboembolism were more prevalent in cluster 4. Almost 50% of all patients presented an exacerbation during 1 year of follow-up. However, it was higher in cluster 4, with 65% of all patients having at least one exacerbation. The mortality rate was statistically higher in cluster 4, with 26.9%, vs 9.6% in cluster 1.

Conclusion

We could identify four clinical different clusters in these COPD populations, that were related to different clinical manifestations, comorbidities, exacerbation, and mortality rate. We also identified a specific cluster with higher values of peripheral eosinophils.

Data Reproducibility and Effectiveness of Bronchodilators for Improving Physical Activity in COPD Patients

Increasing physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) is an important issue, however, the effect of bronchodilators on PA is still controversial. The indicators of PA, as measured by an accelerometer, can easily fluctuate based on several factors, which might cause inconsistent results. In this review, we listed the indicators of PA and the factors influencing the reproducibility of indicators of PA, and reviewed reports in which the effects of bronchodilators on PA were evaluated by an accelerometer. Then, we investigated the association between the processing of influencing factors and the effectiveness of bronchodilators for improving the PA of COPD patients. Fifteen reports were extracted using the PubMed database. In all seven reports in which adjustment was performed for at least two of four influencing factors (non-wear time, data from days with special behavior, environmental factors, and number of valid days required to obtain reproducible data), bronchodilators showed beneficial effects on PA. No adjustment was made for any of these factors in any of the four bronchodilator-ineffective reports. This suggests that the processing of influencing factors to secure reproducibility might affect the results regarding the effectiveness of bronchodilators for improving PA in COPD patients.

Movement behaviour patterns in patients with hip and/or knee osteoarthritis in the physical therapy setting: a cross-sectional study

Background

Osteoarthritis is one of the most common chronic joint diseases, mostly affecting the knee or hip through pain, joint stiffness and decreased physical functioning in daily life. Regular physical activity (PA) can help preserve and improve physical functioning and reduce pain in patients with osteoarthritis. Interventions aiming to improve movement behaviour can be optimized by tailoring them to a patients’ starting point; their current movement behaviour. Movement behaviour needs to be assessed in its full complexity, and therefore a multidimensional description is needed.

Objectives

The aim of this study was to identify subgroups based on movement behaviour patterns in patients with hip and/or knee osteoarthritis who are eligible for a PA intervention. Second, differences between subgroups regarding Body Mass Index, sex, age, physical functioning, comorbidities, fatigue and pain were determined between subgroups.

Methods

Baseline data of the clinical trial ‘e-Exercise Osteoarthritis’, collected in Dutch primary care physical therapy practices were analysed. Movement behaviour was assessed with ActiGraph GT3X and GT3X+ accelerometers. Groups with similar patterns were identified using a hierarchical cluster analysis, including six clustering variables indicating total time in and distribution of PA and sedentary behaviours. Differences in clinical characteristics between groups were assessed via Kruskall Wallis and Chi² tests.

Results

Accelerometer data, including all daily activities during 3 to 5 subsequent days, of 182 patients (average age 63 years) with hip and/or knee osteoarthritis were analysed. Four patterns were identified: inactive & sedentary, prolonged sedentary, light active and active. Physical functioning was less impaired in the group with the active pattern compared to the inactive & sedentary pattern. The group with the prolonged sedentary pattern experienced lower levels of pain and fatigue and higher levels of physical functioning compared to the light active and compared to the inactive & sedentary.

Conclusions

Four subgroups with substantially different movement behaviour patterns and clinical characteristics can be identified in patients with osteoarthritis of the hip and/or knee. Knowledge about these subgroups can be used to personalize future movement behaviour interventions for this population.

Trial registration

Dutch clinical trial registration number of e-Exercise Osteoarthritis: NTR4224.

Effect of Sustained-Release Morphine for Refractory Breathlessness in Chronic Obstructive Pulmonary Disease on Health Status: A Randomized Clinical Trial

IMPORTANCE

Morphine is used as palliative treatment of chronic breathlessness in patients with advanced chronic obstructive pulmonary disease (COPD). Evidence on respiratory adverse effects and health status is scarce and conflicting.

OBJECTIVE

To assess the effects of regular, low-dose, oral sustained-release morphine on disease-specific health status (COPD Assessment Test; CAT), respiratory outcomes, and breathlessness in patients with COPD.

INTERVENTIONS

Participants were randomly assigned to 10 mg of regular, oral sustained-release morphine or placebo twice daily for 4 weeks, with the possibility to increase to 3 times daily after 1 or 2 weeks.

DESIGN, SETTING, AND PARTICIPANTS

The Morphine for Treatment of Dyspnea in Patients With COPD (MORDYC) study was a randomized, double-blind, and placebo-controlled study of a 4-week intervention. Patients were enrolled between November 1, 2016, and January 24, 2019. Participants were recruited in a pulmonary rehabilitation center and 2 general hospitals after completion of a pulmonary rehabilitation program. Outpatients with COPD and moderate to very severe chronic breathlessness (modified Medical Research Council [mMRC] breathlessness grades 2-4) despite optimal pharmacological and nonpharmacological treatment were included. A total of 1380 patients were screened, 916 were ineligible, and 340 declined to participate.

MAIN OUTCOMES AND MEASURES

Primary outcomes were CAT score (higher scores represent worse health status) and arterial partial pressure of carbon dioxide (Paco2). Secondary outcome was breathlessness in the previous 24 hours (numeric rating scale). Data were analyzed by intention to treat. Subgroup analyses in participants with mMRC grades 3 to 4 were performed.

RESULTS

A total of 111 of 124 included participants were analyzed (mean [SD] age, 65.4 [8.0] years; 60 men [54%]). Difference in CAT score was 2.18 points lower in the morphine group (95% CI, -4.14 to -0.22 points; P = .03). Difference in Paco2 was 1.19 mm Hg higher in the morphine group (95% CI, -2.70 to 5.07 mm Hg; P = .55). Breathlessness remained unchanged. Worst breathlessness improved in participants with mMRC grades 3 to 4 (1.33 points lower in the morphine group; 95% CI, -2.50 to -0.16 points; P = .03). Five participants of 54 in the morphine group (9%) and 1 participant of 57 in the placebo group (2%) withdrew because of adverse effects. No morphine-related hospital admissions or deaths occurred.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, regular, low-dose, oral sustained-release morphine for 4 weeks improved disease-specific health status in patients with COPD without affecting Paco2 or causing serious adverse effects. The worst breathlessness improved in participants with mMRC grades 3 to 4. A larger randomized clinical trial with longer follow-up in patients with mMRC grades 3 to 4 is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02429050.

Novel Input for Designing Patient-Tailored Pulmonary Rehabilitation: Telemonitoring Physical Activity as a Vital Sign-SMARTREAB Study

Physical inactivity may be a consequence of chronic diseases but also a potential modifiable risk factor. Therefore, it should be clinically assessed as a vital sign of patients’ general physical condition prior to any exercise-based intervention. This cross-sectional study describes physical activity in the daily life of 100 chronic respiratory patients before pulmonary rehabilitation, comparing subjective and objective measures. The assessment combined the International Physical Activity Questionnaire (IPAQ) and 4-day accelerometer and oximeter telemonitoring with SMARTREAB technology, assessing heart rate, transcutaneous oxygen saturation and activity-related energy expenditure by metabolic equivalent of task (MET). According to IPAQ, 49% of patients had a moderate level of physical activity in daily life (PADL), a weekly mean level of 2844 ± 2925 MET.min/week, and a mean sedentary time of 5.8 ± 2.7 h/day. Alongside this, SMARTREAB telemonitoring assessed maximum activity ranging from 1.51 to 4.64 METs, with 99.6% daytime spent on PADL below 3 METs and 93% of patients with daily desaturation episodes. Regardless of the self-reported IPAQ, patients spend at least 70% of daytime on PADL below 2 METs. SMARTREAB was demonstrated to be an innovative methodology to measure PADL as a vital sign, combining oximetry with accelerometry, crossmatched with qualitative patient data, providing important input for designing patient-tailored pulmonary rehabilitation.

Cluster Analysis of Physical Activity Patterns, and Relationship with Sedentary Behavior and Healthy Lifestyles in Prepubertal Children: Genobox Cohort

Sedentary habits during childhood are associated with adverse health outcomes. The aim of this work was to cluster lifestyle behaviors and metabolic biomarkers to establish different patterns in children. Their physical and sedentary activities were evaluated by accelerometry, and questionnaires that included lifestyle behaviors, such as adherence to a Mediterranean diet, anthropometry and blood biochemical markers. Cluster analysis was performed to establish different groups based on physical activity levels. A total of 489 children were finally selected. Cluster 1 included children with a mostly sedentary state, whereas Cluster 3 included the most active children and Cluster 2 included children that did not fit into either the sedentary or the highly active groups. In Cluster 3, 56% of children were in a sports club, and a lower percentage used electronic devices in their rooms compared to the other groups. Cluster 1 children exhibited higher insulin, HOMA-IR and triacylglycerides with respect to the other groups. No differences were found regarding adherence to a Mediterranean diet. The choice to practice an extracurricular sport could be an influencing factor to increase exercise and ensure an active lifestyle in children. Reducing or limiting screen time mainly in children’s rooms could contribute to an active lifestyle.

Physical Activity in Patients with Chronic Obstructive Pulmonary Disease on Long-Term Oxygen Therapy: A Cross-Sectional Study

Background and aim

There are few studies evaluating physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT).

Aim

To assess PA in hypoxemic COPD patients on LTOT.

Methods

In this cross-sectional study, we compared lung function, arterial blood gases, respiratory and peripheral muscle strength, 6-min walking distance (6MWD), daily energy expenditure and steps, and health-related quality of life (HRQL) in COPD patients on LTOT (LTOT group) versus two groups of control patients not needing LTOT: with (HYPOX) and without (COPD) exercise-induced desaturations.

Results

Groups did not differ as regards demographics, anthropometrics, peripheral or respiratory muscle strength. Compared to the other groups, LTOT patients had more severe airway obstruction and lung hyperinflation, greater number and severity of comorbidities, shorter 6MWD, as well as lower mean SpO₂ during 6MWD and worse quality of life. LTOT patients had a lower daily energy expenditure, shorter time spent > 3.0 METs and longer sedentary time compared to the COPD group, and less daily steps compared to the other groups. No significant difference in any parameter of PA was found between COPD and HYPOX. In LTOT patients, daily steps showed a strong correlation with 6MWD, and a moderate correlation with airway obstruction, level of oxygenation, comorbidities and quality of life but not with peripheral and respiratory muscle strength. In COPD and HYPOX patients, daily steps were strongly correlated with 6MWD and level of oxygenation as assessed by PaO₂/FiO₂. There was no significant correlation between mean SpO₂ and 6MWD in any group.

Conclusion

COPD patients on LTOT perform less physical activity than patients not needing LTOT, both with and without exercise-induced desaturations. Patients with exercise-induced desaturations do not perform less physical activity than those without.

Clustering of Physical Activity and Sedentary Behavior Associated to Risk for Metabolic Syndrome in Older Adults

This study aimed to investigate the clustering patterns of physical activity, sedentary time (ST), and breaks in ST, and the association between the identified clusters at risk for metabolic syndrome associated with obesity in older adults. Participants included 212 users of community health centers in Brazil. A questionnaire about sociodemographic characteristics was used to describe the sample, and physical activity, ST, and breaks in ST were evaluated using accelerometers. Waist circumference was measured as an indicator of the risk for metabolic syndrome. A two-step cluster analysis and logistic regression analysis were conducted. The following four clusters were identified: sitters (37.7%), inactive (28.3%), active (25.5%), and all-day sitters/lightly active (8.5%). Participants in the active cluster were 60% less likely to be at risk for metabolic syndrome. This study may contribute to a comprehensive understanding of which older adult groups need more attention in the context of community health centers.

Physical Activity Behaviour in People with COPD Residing in Spain: A Cross-Sectional Analysis

PURPOSE

Chronic obstructive pulmonary disease (COPD) represents a major public health problem due to its high prevalence, morbidity and health cost. It has been demonstrated that physical activity (PA) is one of the most beneficial measures to prevent chronic diseases. The aim of this study was to examine PA levels of adults with COPD residing in Spain, and to analyse the differences by sex, age, education, marital status, cohabiting, tobacco consumption, alcohol consumption and body mass index.

METHODS

A total of 615 adults aged 15 to 69 years participated in this study. Data from the Spanish National Health Survey 2017 were used. This survey included the short version of IPAQ to measure PA levels. PA was expressed in total volume (MET·min/week), classified as low, moderate and high, and analysed according to sample characteristics. Statistical significance was set at p < 0.05 (CI = 95%).

RESULTS

Level of PA was higher in men than in women (1808.8 vs. 1575.6 MET·min/week; p = 0.016), in those aged under 30 years than in those older than 60 years (2129.4 vs. 1381.4 MET·min/week; p = 0.047) and in those who drank alcohol than in those who did not drink (1912.8 vs. 1248.2 MET·min/week; p = 0.004). Also, underweight and obese participants participated in lower levels of PA than normal weight participants (p= 0.001). When classifying PA level, a total of 37.9% had a low level, 47.5% had a moderate level and only 14.6% had a high level of PA (p < 0.001).

CONCLUSION

It is recommendable to implement programs to raise awareness of the importance and benefits of PA in the control of COPD, and these programs should focus on those with lower levels of PA.

Physical Activity and Sedentary Behaviour Patterns in 326 Persons with COPD before Starting a Pulmonary Rehabilitation: A Cluster Analysis

This study applies a cluster analysis to identify typical physical activity (PA) and sedentary behaviour (SB) patterns in people with chronic obstructive pulmonary disease (COPD) before starting pulmonary rehabilitation (PR). We implemented an observational design which assessed baseline data of objectively measured PA and SB from the STAR (Stay Active after Rehabilitation) study. A total of 355 persons wore an accelerometer (Actigraph wGT3X) for seven days before the start of their PR. Sociodemographic and disease-related parameters were assessed at the start of PR. We applied cluster analysis and compared clusters applying univariate variance analyses. Data was available for 326 persons (31.6% women; age ø = 58 years). Cluster analysis revealed four movement clusters with distinct PA and SB patterns: Sedentary non-movers (28.5%), sedentary occasional movers (41.7%), sedentary movers (19.6%), and sedentary exercisers (10.1%). The four clusters displayed varying levels of moderate PA before rehabilitation (Ø daily min: 9; 28; 38; 70). Notably, all four clusters displayed considerably long average sedentary time per day (Ø daily minutes: 644; 561; 490; 446). The clusters differed significantly in disease-related parameters of GOLD severity, FEV1, CAT, and 6-Min-Walk-Test. In addition to PA promotion, PR programs should consider the reduction of sedentary behaviour as a valuable goal.

Three distinct physical behavior types in fatigued patients with multiple sclerosis

Background

Multiple sclerosis often leads to fatigue and changes in physical behavior (PB). Changes in PB are often assumed as a consequence of fatigue, but effects of interventions that aim to reduce fatigue by improving PB are not sufficient. Since the heterogeneous nature of MS related symptoms, levels of PB of fatigued patients at the start of interventions might vary substantially. Better understanding of the variability by identification of PB subtypes in fatigued patients may help to develop more effective personalized rehabilitation programs in the future. This study aimed to identify PB subtypes in fatigued patients with multiple sclerosis based on multidimensional PB outcome measures.

Methods

Baseline accelerometer (Actigraph) data, demographics and clinical characteristics of the TREFAMS-ACE participants (n = 212) were used for secondary analysis. All patients were ambulatory and diagnosed with severe fatigue based on a score of ≥35 on the fatigue subscale of the Checklist Individual Strength (CIS20r). Fifteen PB measures were used derived from 7 day measurements with an accelerometer. Principal component analysis was performed to define key outcome measures for PB and two-step cluster analysis was used to identify PB types.

Results

Analysis revealed five key outcome measures: percentage sedentary behavior, total time in prolonged moderate-to-vigorous physical activity, number of sedentary bouts, and two types of change scores between day parts (morning, afternoon and evening). Based on these outcomes three valid PB clusters were derived.

Conclusions

Patients with severe MS-related fatigue show three distinct and homogeneous PB subtypes. These PB subtypes, based on a unique set of PB outcome measures, may offer an opportunity to design more individually-tailored interventions in rehabilitation.

Trial registration

Clinical trial registration no ISRCTN 82353628, ISRCTN 69520623 and ISRCTN 58583714.

Electronic supplementary material

The online version of this article (10.1186/s12984-019-0573-1) contains supplementary material, which is available to authorized users.

Pulmonary rehabilitation, physical activity, respiratory failure and palliative respiratory care

The CIRO Academy in Horn (the Netherlands) organised a 2-day meeting to present and discuss the studies published in 2017 pertaining to key priority areas of respiratory and critical care medicine. This review summarises studies focussing on pulmonary rehabilitation and exercise training, physical activity, chronic respiratory failure and palliative respiratory care published in 2017.

Changes in physical activity during hospital admission for chronic respiratory disease

BACKGROUND AND OBJECTIVE

Establishing the amount of inpatient physical activity (PA) undertaken by individuals hospitalized for chronic respiratory disease is needed to inform interventions. This observational study investigated whether PA changes when a person is an inpatient, how long is required to obtain representative PA measures and whether PA varies within a day and between patients of differing lengths of stay.

METHODS

A total of 389 participants were recruited as early as possible into their hospitalization. Patients wore a PA monitor from recruitment until discharge. Step count was extracted for a range of wear time criteria. Single-day intraclass correlation coefficients (ICC) were calculated, with an ICC ≥ 0.80 deemed acceptable.

RESULTS

PA data were available for 259 participants. No changes in daily step count were observed during the inpatient stay (586 (95% CI: 427-744) vs 652 (95% CI: 493-812) steps/day for day 2 and 7, respectively). ICC across all wear time criteria were > 0.80. The most stringent wear time criterion, retaining 80% of the sample, was ≥11 h on ≥1 day. More steps were taken during the morning and afternoon than overnight and evening. After controlling for the Medical Research Council (MRC) grade or oxygen use, there was no difference in step count between patients admitted for 2-3 days (short stay) and those admitted for 7-14 days (long stay).

CONCLUSION

Patients move little during their hospitalization, and inpatient PA did not increase during their stay. A wear time criterion of 11 waking hours on any single day was representative of the entire admission whilst retaining an acceptable proportion of the initial sample size. Patients may need encouragement to move more during their hospital stay.

24-hour accelerometry in COPD: Exploring physical activity, sedentary behavior, sleep and clinical characteristics

Background

The constructs and interdependency of physical behaviors are not well described and the complexity of physical activity (PA) data analysis remains unexplored in COPD. This study examined the interrelationships of 24-hour physical behaviors and investigated their associations with participant characteristics for individuals with mild–moderate airflow obstruction and healthy control subjects.

Patients and methods

Vigorous PA (VPA), moderate-to-vigorous PA (MVPA), light PA (LPA), stationary time (ST), average movement intensity (vector magnitude counts per minute), and sleep duration for 109 individuals with COPD and 135 healthy controls were obtained by wrist-worn accelerometry. Principal components analysis (PCA) examined interrelationships of physical behaviors to identify distinct behavioral constructs. Using the PCA component loadings, linear regressions examined associations with participant (+, positive correlation; -, negative correlation), and were compared between COPD and healthy control groups.

Results

For both groups PCA revealed ST, LPA, and average movement intensity as distinct behavioral constructs to MVPA and VPA, labeled “low-intensity movement” and “high-intensity movement,” respectively. Sleep was also found to be its own distinct behavioral construct. Results from linear regressions supported the identification of distinct behavioral constructs from PCA. In COPD, low-intensity movement was associated with limitations with mobility (−), daily activities (−), health status (+), and body mass index (BMI) (−) independent of high-intensity movement and sleep. High-intensity movement was associated with age (−) and self-care limitations (−) independent of low-intensity movement and sleep. Sleep was associated with gender (0= female, 1= male; [−]), lung function (−), and percentage body fat (+) independent of low-intensity and high-intensity movement.

Conclusion

Distinct behavioral constructs comprising the 24-hour day were identified as “low-intensity movement,” “high-intensity movement,” and “sleep” with each construct independently associated with different participant characteristics. Future research should determine whether modifying these behaviors improves health outcomes in COPD.

Daily Objective Physical Activity and Sedentary Time in Adults with COPD Using Spirometry Data from Canadian Measures Health Survey

Chronic obstructive pulmonary disease (COPD) is expected to be the third leading cause of premature death and disability in Canada and around the world by the year 2020. The study aims to compare objective physical activity (PA) and sedentary time in a population-based sample of adults with chronic obstructive pulmonary disease (COPD) and compare a group, and to investigate whether these behaviors differ according to COPD severity. From the 2007–2013 Canadian Health Measures Survey dataset, accelerometer and prebronchodilator spirometry data were available for 6441 participants, aged 35 to 79. Two weighted analyses of covariance were performed with adjustments for age, sex, body mass index, accelerometer wearing time, season, work, smoking (cotinine), education level, and income. A set of sensitivity analyses were carried out to examine the possible effect of COPD and type of control group. A cross-sectional weighted analysis indicated that 14.6% of study participants had a measured airflow obstruction consistent with COPD. Time in PA (moderate-vigorous and light PA), number of steps, and sedentary duration were not significantly different in participants with COPD, taken together, compared to controls. However, moderate to severe COPD participants (stages ≥2) had a significantly lower daily time spent in PA of moderate and vigorous intensity level compared to controls. Canadian adults with COPD with all disease severity levels combined did not show lower daily duration of light, moderate, and vigorous PA, and number of steps and higher daily sedentary time than those without airflow obstruction. Both groups are extremely sedentary and have low PA duration. Thus, “move more and sit less” public health strategy could equally target adults with or without COPD.