Objectively Measured Physical Activity in Patients with COPD: Recommendations from an International Task Force on Physical Activity

Effects of inspiratory muscle training on thoracoabdominal volume regulation in older adults: a randomised controlled trial

OBJECTIVES

We investigated the effect of inspiratory muscle training (IMT) on inspiratory muscle strength, functional capacity and respiratory muscle kinematics during exercise in healthy older adults.

METHODS

24 adults were randomised into an IMT or SHAM-IMT group. Both groups performed 30 breaths, twice daily, for 8 weeks, at intensities of ~50% maximal inspiratory pressure (PImax; IMT) or <15% PImax (SHAM-IMT). Measurements of PImax, breathing discomfort during a bout of IMT, six-minute walk distance, physical activity levels, and balance were assessed pre- and post-intervention. Respiratory muscle kinematics were assessed via optoelectronic plethysmography (OEP) during constant work rate cycling.

RESULTS

PImax was significantly improved (by 20.0±11.9 cmH2O; p=0.001) in the IMT group only. Breathing discomfort ratings during IMT significantly decreased (from 3.5±0.9 to 1.7±0.8). Daily sedentary time was decreased (by 28.0±39.8min; p=0.042), and reactive balance significantly improved (by 1.2±0.8; p<0.001) in the IMT group only. OEP measures showed a significantly greater contribution of the pulmonary and abdominal rib cage compartments to total tidal volume expansion post-IMT.

CONCLUSIONS

IMT significantly improves inspiratory muscle strength and breathing discomfort in this population. IMT induces greater rib cage expansion and diaphragm descent during exercise, thereby suggesting a less restrictive effect on thoracic expansion and increased diaphragmatic power generation.

Short-term effects of air pollution and weather on physical activity in patients with chronic obstructive pulmonary disease (COPD)

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) accumulate low levels of physical activity. How environmental factors affect their physical activity in the short-term is uncertain.

AIM

to assess the short-term effects of air pollution and weather on physical activity levels in COPD patients.

METHODS

This multi-center panel study assessed 408 COPD patients from Catalonia (Spain). Daily physical activity (i.e., steps, time in moderate-to-vigorous physical activity (MVPA), locomotion intensity, and sedentary time) was recorded in two 7-day periods, one year apart, using the Dynaport MoveMonitor. Air pollution (nitrogen dioxide (NO2), particulate matter below 10 μm (PM10) and a marker of black carbon (absorbance of PM2.5: PM2.5ABS), and weather (average and maximum temperature, and rainfall) were estimated the same day (lag zero) and up to 5 days prior to each assessment (lags 1-5). Mixed-effect distributed lag linear regression models were adjusted for age, sex, weekday, public holidays, greenness, season, and social class, with patient and city as random effects.

RESULTS

Patients (85% male) were on average (mean ± SD) 68 ± 9 years old with a post-bronchodilator forced expiratory volume in 1 s (FEV1) of 57 ± 18% predicted. Higher NO2, PM10 and PM2.5ABS levels at lag four were associated with fewer steps, less time in MVPA, reduced locomotion intensity, and longer sedentary time (e.g., coefficient (95% CI) of -60 (-105, -15) steps per 10 μg/m3 increase in NO2). Higher average and maximum temperatures at lag zero were related to more steps and time in MVPA, and less sedentary time (e.g., +85 (15, 154) steps per degree Celsius). Higher rainfall at lag zero was related to fewer steps and more sedentary time.

CONCLUSION

Air pollution affects the amount and intensity of physical activity performed on the following days in COPD patients, whereas weather affects the amount of physical activity performed on the same day.

The Association between Objectively Measured Physical Activity and the Prevalence of Comorbidities in Lung Transplant Recipients

INTRODUCTION

Lung transplant recipients are often physically inactive and are at risk of developing comorbidities. We investigated whether objectively measured physical activity was associated with the prevalence of comorbidities.

METHODS

Physical activity (accelerometry) and the presence of cardiovascular disease, symptoms of depression and anxiety, diabetes, dyslipidaemia, hypertension, lower extremity artery disease, muscle weakness, obesity, and osteoporosis were assessed in 108 lung transplant recipients. Patients were divided into four groups based on daily step count.

RESULTS

A cohort of 108 patients (60 ± 7 years, 51% male, 20 ± 14 months since transplantation) was included. Active patients (>7,500 steps/day) had significantly fewer comorbidities (4 comorbidities) compared to severely inactive patients (<2,500 steps/day, 6 comorbidities), and muscle weakness and high symptoms of depression were less prevalent. Severely inactive patients had significantly more cardiovascular comorbidities compared to all other groups. No other significant differences were observed.

CONCLUSION

Physically active lung transplant recipients have fewer comorbidities, lower prevalence of muscle weakness, and fewer symptoms of depression compared to very inactive patients.

Effects of ActiGraph's filter, epoch length and non-wearing time algorithm on step counts in people with COPD

The influence of the ActiGraph® processing criteria on estimating step counts in chronic obstructive pulmonary disease (COPD) remains uncertain. This study aimed to assess the influence of filters, epoch lengths and non-wearing time (NWT) algorithms on steps/day in people with COPD. ActiGraph GT3X+ was worn on the waist for seven days. Steps were detected using different filters (normal and low-frequency extension [LFE]), epoch lengths (15s and 60s), and NWT algorithms (Choi and Troiano). Linear mixed-effects model was applied to assess the effects of filter, epoch length, NWT algorithm on steps/day. Lin's concordance correlation and Bland-Altman were used to measure agreement. A total of 136 people with COPD (107 male; 69 ± 8 years; FEV1 51 ± 17% predicted) were included. Significant differences were found between filters (p < 0.001), but not between epoch lengths or NWT algorithms. The LFE increased, on average, approximately 7500 steps/day compared to the normal filter (p < 0.001). Agreement was poor (<0.3) and proportional bias was significant when comparing steps/day computed with different filters, regardless of the epoch length and NWT algorithm. Filter choice but not epoch lengths or NWT algorithms seem to impact measurement of steps/day. Future studies are needed to recommend the most accurate technique for measuring steps/day in people with COPD.

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.

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.

Heart rate and oxygen uptake kinetics obtained from continuous measurements with wearable devices during outdoor walks of patients with COPD

Objective

Continuous physiological measurements during a laboratory-based exercise test can provide physiological biomarkers, such as heart rate (HR) and oxygen uptake (V̇O₂) kinetics, that carry clinically relevant information. In contrast, it is not clear how continuous data generated by wearable devices during daily-life routines could provide meaningful biomarkers. We aimed to determine whether valid HR and V̇O₂ kinetics can be obtained from measurements with wearable devices during outdoor walks in patients with chronic obstructive pulmonary disease (COPD).

Methods

HR (Polar Belt) and V̇O₂(METAMAX3B) were measured during 93 physical activity transitions performed by eight patients with COPD during three different outdoor walks (n_tr= 77) and a 6-minute walk test (n_tr= 16). HR and V̇O₂ kinetics were calculated every time a participant started a walk, finished a walk or walked upstairs. HR and V̇O₂ kinetics were considered valid if the response magnitude and model fit were adequate, and model parameters were reliable.

Results

Continuous measurements with wearable devices provided valid HR kinetics when COPD patients started or finished (range 63%-100%) the different outdoor walks and valid V̇O₂ kinetics when they finished (range 63%-100%) an outdoor walk. The amount of valid kinetics and kinetic model performance was comparable between outdoor walks and a laboratory-based exercise test (p > .05).

Conclusion

We envision that the presented approach could improve telemonitoring applications of patients with COPD by providing regular, unsupervised assessments of HR kinetics during daily-life routines. This could allow to early identify a decline in the patients' dynamic physiological functioning, physical fitness and/or health status.

A Call for Action on Chronic Respiratory Diseases within Physical Activity Policies, Guidelines and Action Plans: Let's Move!

Global policy documents for the promotion of physical activity (PA) play an important role in the measurement, evaluation, and monitoring of population PA levels. The World Health Organisation (WHO) guidelines include, for the first time, recommendations for specific populations, including individuals living with a range of non-communicable diseases. Of note, is the absence of any chronic respiratory diseases (CRDs) within the recommendations. Globally, CRDs are highly prevalent, are attributable to significant individual and societal burdens, and are characterised by low PA. As a community, there is a need to come together to understand how to increase CRD representation within global PA policy documents, including where the evidence gaps are and how we can align with PA research in other contexts. In this commentary, the potential for synergy between evidence into the relationships between PA in CRDs globally and the relevance to current policies, guidelines and action plans on population levels of PA are discussed. Furthermore, actions and considerations for future research, including the need to harmonize and promote PA assessment (particularly in low- and middle-income countries) and encompass the synergistic influences of PA, sedentary behaviour and sleep on health outcomes in CRD populations are presented.

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.

Physical Activity, Muscle Oxidative Capacity, and Coronary Artery Calcium in Smokers with and without COPD

Introduction

Severe chronic obstructive pulmonary disease (COPD) is partly characterized by diminished skeletal muscle oxidative capacity and concurrent dyslipidemia. It is unknown whether such metabolic derangements increase the risk of cardiovascular disease. This study explored associations among physical activity (PA), muscle oxidative capacity, and coronary artery calcium (CAC) in COPDGene participants.

Methods

Data from current and former smokers with COPD (n = 75) and normal spirometry (n = 70) were retrospectively analyzed. Physical activity was measured for seven days using triaxial accelerometry (steps/day and vector magnitude units [VMU]) along with the aggregate of self-reported PA amount and PA difficulty using the PROactive D-PPAC instrument. Muscle oxidative capacity (k) was assessed via near-infrared spectroscopy, and CAC was assessed via chest computerized tomography.

Results

Relative to controls, COPD patients exhibited higher CAC (median [IQR], 31 [0–431] vs 264 [40–799] HU; p = 0.003), lower k (mean ± SD = 1.66 ± 0.48 vs 1.25 ± 0.37 min⁻¹; p < 0.001), and lower D-PPAC total score (65.2 ± 9.9 vs 58.8 ± 13.2; p = 0.003). Multivariate analysis—adjusting for age, sex, race, diabetes, disease severity, hyperlipidemia, smoking status, and hypertension—revealed a significant negative association between CAC and D-PPAC total score (β, −0.05; p = 0.013), driven primarily by D-PPAC difficulty score (β, −0.03; p = 0.026). A 1 unit increase in D-PPAC total score was associated with a 5% lower CAC (p = 0.013). There was no association between CAC and either k, steps/day, VMU, or D-PPAC amount.

Conclusion

Patients with COPD and concomitantly elevated CAC exhibit greater perceptions of difficulty when performing daily activities. This may have implications for exercise adherence and risk of overall physical decline.

Feasibility and acceptability of a physical activity behavioural modification tele-coaching intervention in lung transplant recipients

BACKGROUND

Despite improvements in pulmonary function following lung transplantation (LTx), physical activity levels remain significantly lower than the general population. To date, there is little research investigating interventions to improve daily physical activity in LTx recipients. This study assessed the feasibility and acceptability of a novel, 12-weeks physical activity tele-coaching (TC) intervention in LTx recipients.

METHODS

Lung transplant recipients within 2 months of hospital discharge were recruited and randomised (1:1) to TC or usual care (UC). TC consists of a pedometer and smartphone app, allowing transmission of activity data to a platform that provides feedback, activity goals, education, and contact with the researcher as required. Recruitment and retention, occurrence of adverse events, intervention acceptability and usage were used to assess feasibility.

RESULTS

Key criteria for progressing to a larger study were met. Of the 15 patients eligible, 14 were recruited and randomised to TC or UC and 12 completed (67% male; mean ± SD age; 58 ± 7 years; COPD n = 4, ILD n = 6, CF n = 1, PH n = 1): TC (n = 7) and UC (n = 5). TC was well accepted by patients, with 86% indicating that they enjoyed taking part. Usage of the pedometer was excellent, with all patients wearing it for over 90% of days and rating the pedometer and telephone contact as the most vital aspects. There were no adverse events related to the intervention. After 12 weeks, only TC displayed improvements in accelerometry steps/day (by 3475 ± 3422; p = .036) and movement intensity (by 153 ± 166 VMU; p = .019), whereas both TC and UC groups exhibited clinically important changes in physical SF-36 scores (by 11 ± 14 and 7 ± 9 points, respectively).

CONCLUSION

TC appears to be a feasible, safe, and well-accepted intervention in LTx.

A More Intense Examination of the Intensity of Physical Activity in People Living with Chronic Obstructive Pulmonary Disease: Insights from Threshold-Free Markers of Activity Intensity

Physical activity (PA) intensity of people living with chronic obstructive pulmonary disease (COPD) is typically evaluated using intensity thresholds developed in younger, healthier populations with greater exercise capacity and free from respiratory symptoms. This study therefore compared (i) PA differences between COPD and non-COPD controls using both traditional intensity thresholds and threshold-free metrics that represent the volume and intensity of the whole PA profile, and (ii) explored the influence of exercise capacity on observed differences. Moderate-to-vigorous physical activity (MVPA), average acceleration (proxy for volume, mg) and intensity distribution of activity were calculated for 76 individuals with COPD and 154 non-COPD controls from wrist-worn ActiGraph accelerometry. PA profiles representing the minimum intensity (acceleration, mg) during the most active accumulated 5-960 min were plotted. Estimated VO_2peak and relative intensity were derived from the incremental shuttle walk test distance. Compared to the non-COPD control group, individuals with COPD recorded fewer MVPA minutes (59 vs. 83 min/day), lower overall waking activity (29.1 vs. 36.4 mg) and a poorer waking intensity distribution (-2.73 vs. -2.57). Individuals with COPD also recorded a lower absolute intensity (acceleration, mg) for their most active 5-960 min, but higher intensity relative to their estimated exercise capacity derived from the ISWT. People with COPD have a lower volume and absolute intensity of PA than controls but perform PA at a higher relative intensity. There is a need to move away from absolute intensity thresholds, and towards personalised or relative-intensity thresholds, to reflect reduced exercise capacity in COPD populations.

Patient-led development of digital endpoints and the use of computer vision analysis in assessment of motor function in rare diseases

Digital health technologies are transforming the way health outcomes are captured and measured. Digital biomarkers may provide more objective measurements than traditional approaches as they encompass continuous and longitudinal data collection and use of automated analysis for data interpretation. In addition, the use of digital health technology allows for home-based disease assessments, which in addition to reducing patient burden from on-site hospital visits, provides a more holistic picture of how the patient feels and functions in the real world. Tools that can robustly capture drug efficacy based on disease-specific outcomes that are meaningful to patients, are going to be key to the successful development of new treatments. This is particularly important for people living with rare and chronic complex conditions, where therapeutic options are limited and need to be developed using a patient-focused approach to achieve the biggest impact. Working in partnership with patient Organisation Duchenne UK, we co-developed a video-based approach, delivered through a new mobile health platform (DMD Home), to assess motor function in patients with Duchenne muscular dystrophy (DMD), a genetic, rare, muscular disease characterized by the progressive loss of muscle function and strength. Motor function tasks were selected to reflect the “transfer stage” of the disease, when patients are no longer able to walk independently but can stand and weight-bear to transfer. This stage is important for patients and families as it represents a significant milestone in the progression of DMD but it is not routinely captured and/or scored by standard DMD clinical and physiotherapy assessments. A total of 62 videos were submitted by eight out of eleven participants who onboarded the app and were analysed with pose estimation software (OpenPose) that led to the extraction of objective, quantitative measures, including time, pattern of movement trajectory, and smoothness and symmetry of movement. Computer vision analysis of video tasks to identify voluntary or compensatory movements within the transfer stage merits further investigation. Longitudinal studies to validate DMD home as a new methodology to predict progression to the non-ambulant stage will be pursued.

Implementing a choice of pulmonary rehabilitation models in chronic obstructive pulmonary disease (HomeBase2 trial): protocol for a cluster randomised controlled trial

INTRODUCTION

There is compelling evidence that either centre-based or home-based pulmonary rehabilitation improves clinical outcomes in chronic obstructive pulmonary disease (COPD). There are known health service and personal barriers which prevent potentially eligible patients from accessing the benefits of pulmonary rehabilitation. The aim of this hybrid effectiveness-implementation trial is to examine the effects of offering patients a choice of pulmonary rehabilitation locations (home or centre) compared with offering only the traditional centre-based model.

METHOD AND ANALYSIS

This is a two-arm cluster randomised, controlled, assessor-blinded trial of 14 centre-based pulmonary rehabilitation services allocated to intervention (offering choice of home-based or centre-based pulmonary rehabilitation) or control (continuing to offer centre-based pulmonary rehabilitation only), stratified by centre-based programme setting (hospital vs non-hospital). 490 participants with COPD will be recruited. Centre-based pulmonary rehabilitation will be delivered according to best practice guidelines including supervised exercise training for 8 weeks. At intervention sites, the home-based pulmonary rehabilitation will be delivered according to an established 8-week model, comprising of one home visit, unsupervised exercise training and telephone calls that build motivation for exercise participation and facilitate self-management. The primary outcome is all-cause, unplanned hospitalisations in the 12 months following rehabilitation. Secondary outcomes include programme completion rates and measurements of 6-minute walk distance, chronic respiratory questionnaire, EQ-5D-5L, dyspnoea-12, physical activity and sedentary time at the end of rehabilitation and 12 months following rehabilitation.Direct healthcare costs, indirect costs and changes in EQ-5D-5L will be used to evaluate cost-effectiveness. A process evaluation will be undertaken to understand how the choice model is implemented and explore sustainability beyond the clinical trial.

ETHICS AND DISSEMINATION

Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients across Australia with support from national lung charities and societies.

TRIAL REGISTRATION NUMBER

NCT04217330.

Quantifying the Effect of Monitor Wear Time and Monitor Type on the Estimate of Sedentary Time in People with COPD: Systematic Review and Meta-Analysis

In studies that have reported device-based measures of sedentary time (ST) in people with chronic obstructive pulmonary disease (COPD), we explored if the monitor type and monitor wear time moderated the estimate of this measure. Five electronic databases were searched in January 2021. Studies were included if >70% of participants had stable COPD, and measures of ST (min/day) were collected using wearable technology. Meta-regression was used to examine the influence of moderators on ST, monitor type, and wear time. The studies identified were a total of 1153, and 36 had usable data for meta-analyses. The overall pooled estimate of ST (mean [95% CI]) was 524 min/day [482 to 566] with moderate heterogeneity among effect sizes (I2 = 42%). Monitor wear time, as well as the interaction of monitor wear time and monitor type, were moderators of ST (p < 0.001). The largest difference (−318 min; 95% CI [−212 to −424]) was seen between studies where participants wore a device without a thigh inclinometer for 24 h (and removed sleep during analysis) (675 min, 95% CI [589 to 752]) and studies where participants wore a device with a thigh inclinometer for 12 h only (356 min; 95% CI [284 to 430]). In people with COPD, the monitor wear time and the interaction of the monitor wear time and the monitor type moderated the estimate of ST.

Does Telemedicine Promote Physical Activity?

Exercise capacity and physical activity are different concepts: the former refers to what an individual is capable of performing, while the latter refers to what the individual does in daily life. Low levels of physical activity (PA), which are very common in individuals with COPD, are associated with poor health outcomes, including increased symptoms, a more rapid decline in lung function, increased health care utilization and increased mortality risk. Because of these pervasive negative outcomes, attempts have been made to increase physical activity in individuals with COPD, hoping that success in this area will mitigate the negative effects of inactivity. Based on its ability to increase exercise capacity and reduce dyspnea in COPD and other chronic respiratory diseases, pulmonary rehabilitation (PR) would be expected also increase physical activity in these patients. However, accessibility to pulmonary rehabilitation programs is problematic in some areas, and studies testing its effectiveness in this outcome area have had inconsistent results. Using telehealth interventions using technology to provide medical care conveniently over a distance would have the benefit of reaching a larger proportion of individuals with COPD. A systematic review of clinical trials testing telehealth to promote physical activity had mixed results and low-certainty evidence, resulting in the inability to recommend any single type of intervention. Thus, using telehealth interventions to promote physical activity for individuals with chronic respiratory diseases, while promising, remains an area where future investigations are needed to identify its optimal modalities and clarify its benefits.

The untapped potential of physical activity monitoring for quality assurance of field-based walking tests in clinical respiratory trials

Field-based walking tests are well-established outcome measures in clinical research trials and in the evaluation of routine clinical services, including pulmonary rehabilitation. Despite widespread use, there has been little attention to, or reporting of, the quality assurance of these tests. Physical activity monitoring has become increasingly popular and data from activity monitors could be used for quality assurance of field-based walking tests. We provide examples in this article of data-driven insights possible with this approach, using data from waist-worn accelerometry, for the incremental shuttle walking test (ISWT), endurance shuttle walk test (ESWT) and six-minute walk test (6MWT). Given the multitude of devices to measure physical activity and the range metrics to describe physical activity, we also comment on some of the technical considerations to using activity monitors for walking test quality assurance. Data-driven approaches to quality assurance are already commonplace for other outcome measures in clinical respiratory trials, but little is known about this approach for field-based walking tests. The application of physical activity monitoring may be extended to other field-based exercise tests and additional rehabilitation services. This may be more challenging for self-paced walking tests such as the 6MWT. Future work should apply this approach to research trials and service evaluations to explore the impact of field-based walking test quality on performance (e.g. distance on the ISWT or time achieved for the ESWT), responsiveness to interventions (e.g. pulmonary rehabilitation) and effectiveness of training procedures (e.g. remote training for multi-site trials).

Exercise capacity and physical activity in COPD patients treated with a LAMA/LABA combination: a systematic review and meta-analysis

BACKGROUND

Persistent airflow limitation and dyspnoea may reduce chronic obstructive pulmonary disease (COPD) patients exercise capacity and physical activity, undermining their physical status and quality of life. Long-acting muscarinic antagonists and long-acting beta-2 agonists (LAMA/LABA) combinations are amongst moderate-to-severe COPD recommended treatments. This article analyses LAMA/LABA combinations effect on COPD patients exercise capacity and physical activity outcomes.

METHODS

A systematic review and meta-analysis of double-blind randomized controlled trials comparing LAMA/LABA combinations against monotherapy or placebo was conducted.

RESULTS

Seventeen articles were identified (N = 4041 patients). In endurance shuttle walk test and constant work rate cycle ergometry, LAMA/LABA combinations obtained better results than placebo, but not monotherapy, whereas in 6-min walking test, results favoured LAMA/LABA over monotherapy (four studies), but not over placebo (one study). Moreover, LAMA/LABA combinations obtained better results than placebo in number of steps per day, reduction in percentage of inactive patients and daily activity-related energy expenditure, and better than monotherapy when measuring time spent on ≥ 1.0-1.5, ≥ 2.0 and ≥ 3.0 metabolic equivalents of task activities.

CONCLUSIONS

LAMA/LABA combinations in COPD patients provided better results than monotherapy or placebo in most exercise capacity and physical activity outcomes.

Listen to Me! - A Mixed-Methods Study of Thoughts and Attitudes Towards Participation in Pulmonary Telerehabilitation Among People with Severe and Very Severe COPD Who Declined Participation in Pulmonary Rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) is a key standard treatment for people with chronic obstructive pulmonary disease (COPD) with documented effect on symptom relief, improved physical function, and quality of life. However, referral, uptake and adherence rates remain low. Pulmonary telerehabilitation (PTR) is a safe and effective alternative to conventional PR. This study explores associations, thoughts and attitudes towards PTR in patients with COPD who decline referral to outpatient hospital-based routine PR.

METHODS

A mixed-methods study with integration of survey data (n=84) and semi-structured interviews (n=9).

RESULTS

We found a significant association between belief of effect of PTR and willingness to participate. Increasing age was significantly associated with reduced odds of daily use of central processing unit (CPU) or tablet. One-third of the participants were undecided about potential participation in PTR. Qualitative findings highlight that participants perceived participating in PTR as more convenient and had preferences for individualized, supervised, and monitored rehabilitation.

CONCLUSION

Those willing to participate in a PTR program believed in the benefits, were comfortable with technological devices, had preferences for exercising at home, and saw opportunities in the social setting. Future PTR programs should include monitoring, preferably managed by a familiar health care professional (HCP).

What Motivates Patients with COPD to Be Physically Active? A Cross-Sectional Study

Motivation can be broadly defined as what moves people to act. Low motivation is a frequently reported factor for the reduced physical activity (PA) levels observed in patients with chronic obstructive pulmonary disease (COPD). This study assessed patients’ motives to be physically active, according to three pulmonary rehabilitation (PR) participation groups (Never PR, Previous PR and Current PR) and explored whether these motives were related to the PA levels and clinical characteristics. The motives to be physically active were assessed with the Exercise Motivation Inventory-2 (EMI-2, 14 motivational factors, five dimensions) and PA with accelerometry (PA groups: <5000 steps/day vs. ≥5000 steps/day). The clinical variables included symptoms, impact of the disease, exercise capacity and comorbidities. Ninety-two patients (67.4 ± 8.1 years, 82.6% male, forced expiratory volume in 1s (FEV₁) 48.3 ± 18.9% predicted; 30.4% Never PR, 51% Previous PR and 18.5% Current PR) participated. The motivational dimensions related to health/fitness presented the highest scores (3.8 ± 1.1; 3.4 ± 1.3). The motives to be active were not significantly different between PA groups (p > 0.05) but having less symptoms and ≥two comorbidities were associated with higher scores in psychological/health and body-related motives, respectively (p < 0.05). The findings may encourage health professionals to actively explore with patients their motives to be physically active to individualise PA promotion.