Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease

Prognostic value of the objective measurement of daily physical activity in patients with COPD

BACKGROUND

Subjective measurement of physical activity using questionnaires has prognostic value in COPD. However, their lack of accuracy and large individual variability limit their use for evaluation on an individual basis. We evaluated the capacity of the objective measurement of daily physical activity in patients with COPD using accelerometers to estimate their prognostic value.

METHODS

In 173 consecutive subjects with moderate to very severe COPD, daily physical activity was measured using a triaxial accelerometer providing a mean of 1-min movement epochs as vector magnitude units (VMUs). Patients were evaluated by lung function testing and 6-min walk, incremental exercise, and constant work rate tests. Patients were followed for 5 to 8 years, and the end points were all-cause mortality, hospitalization for COPD exacerbation, and annual declining FEV(1).

RESULTS

After adjusting for relevant confounders, a high VMU decreased the mortality risk (adjusted hazard ratio [HR], 0.986; 95% CI, 0.981-0.992), and in a multivariate model, comorbidity, endurance time, and VMU were retained as independent predictors of mortality. The time until first admission due to COPD exacerbation was shorter for the patients with lower levels of VMU (adjusted HR, 0.989; 95% CI, 0.983-0.995). Moreover, patients with higher VMU had a lower hospitalization risk than those with a low VMU (adjusted incidence rate ratio, 0.099; 95% CI, 0.033-0.293). In contrast, VMU was not identified as an independent predictor of the annual FEV(1) decline.

CONCLUSION

The objective measurement of the daily physical activity in patients with COPD using an accelerometer constitutes an independent prognostic factor for mortality and hospitalization due to severe exacerbation.

Breathing exercises for chronic obstructive pulmonary disease

BACKGROUND

Breathing exercises for people with chronic obstructive pulmonary disease (COPD) aim to alter respiratory muscle recruitment, improve respiratory muscle performance and reduce dyspnoea. Although some studies have reported positive short-term physiological effects of breathing exercises in people with COPD, their effects on dyspnoea, exercise capacity and well being are unclear.

OBJECTIVES

To determine whether breathing exercises in people with COPD have beneficial effects on dyspnoea, exercise capacity and health-related quality of life compared to no breathing exercises in people with COPD; and to determine whether there are any adverse effects of breathing exercises in people with COPD.

SEARCH METHODS

The Cochrane Airways Group Specialised Register of trials and the PEDro database were searched from inception to October 2011.

SELECTION CRITERIA

We included randomised parallel trials that compared breathing exercises to no breathing exercises or another intervention in people with COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias. Primary outcomes were dyspnoea, exercise capacity and health-related quality of life; secondary outcomes were gas exchange, breathing pattern and adverse events. To determine whether effects varied according to the treatment used, we assessed each breathing technique separately.

MAIN RESULTS

Sixteen studies involving 1233 participants with mean forced expiratory volume in one second (FEV(1)) 30% to 51% predicted were included. There was a significant improvement in six-minute walk distance after three months of yoga involving pranayama timed breathing techniques (mean difference to control 45 metres, 95% confidence interval 29 to 61 metres; two studies; 74 participants), with similar improvements in single studies of pursed lip breathing (mean 50 metres; 60 participants) and diaphragmatic breathing (mean 35 metres; 30 participants). Effects on dyspnoea and health-related quality of life were inconsistent across trials. Addition of computerised ventilation feedback to exercise training did not provide additional improvement in dyspnoea-related quality of life (standardised mean difference -0.03; 95% CI -0.43 to 0.49; two studies; 73 participants) and ventilation feedback alone was less effective than exercise training alone for improving exercise endurance (mean difference -15.4 minutes; 95% CI -28.1 to -2.7 minutes; one study; 32 participants). No significant adverse effects were reported. Few studies reported details of allocation concealment, assessor blinding or intention-to-treat analysis.

AUTHORS' CONCLUSIONS

Breathing exercises over four to 15 weeks improve functional exercise capacity in people with COPD compared to no intervention; however, there are no consistent effects on dyspnoea or health-related quality of life. Outcomes were similar across all the breathing exercises examined. Treatment effects for patient-reported outcomes may have been overestimated owing to lack of blinding. Breathing exercises may be useful to improve exercise tolerance in selected individuals with COPD who are unable to undertake exercise training; however, these data do not suggest a widespread role for breathing exercises in the comprehensive management of people with COPD.

New clinical insights into chronic obstructive pulmonary disease and their implications for pharmacoeconomic analyses

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death and disability worldwide, but before the development of several new pharmacological treatments little could be done for COPD patients. Recognition that these new treatments could significantly improve the prognosis for COPD patients has radically changed clinical management guidelines from a palliative philosophy to an aggressive approach intended to reduce chronic symptoms, improve quality of life and prolong survival. These new treatments have also sparked interest in COPD cost-effectiveness research. Most COPD cost-effectiveness studies have been based on clinical trial populations, limited to direct medical costs, and used standard analysis methods such as Markov modelling, and they have usually found that newer therapies have favourable cost effectiveness. However, new insights into the clinical progression of COPD bring into question some of the assumptions underlying older analyses. In this review, we examine clinical factors unique to COPD and recent changes in clinical perspectives that have important implications for pharmacoeconomic analyses. The main parameters explored include (i) the high indirect medical costs for COPD and their relevance in assessing the societal benefits of new therapy; (ii) the importance of acute deteriorations in COPD, known as exacerbations, and approaches to modelling the cost benefit of exacerbation reduction; (iii) quality/utility instruments for COPD; (iv) the prevalence of co-morbid conditions and confounding between COPD and co-morbid disease utilization; (v) the limitations of Markov modelling; and (vi) the problem of outliers.

A pilot study of an Internet walking program and pedometer in COPD

BACKGROUND

Higher levels of physical activity are associated with better functional status, fewer hospital admissions, and lower mortality. In this pilot study, we examined the feasibility and safety of a novel program that combines a pedometer with a website to increase walking.

METHODS

27 persons with stable COPD wore the Omron HJ-720ITC pedometer and used the website for 90 days. They uploaded step-count data to the study server using their home computer and received an email each week with their individualized step-count goal. The website provided step-count feedback, education, and motivational content. Subjects participated in a monthly semi-structured interview by telephone. Subjects reported changes in medical condition by telephone or on the website. Paired T-tests assessed change in daily step counts.

RESULTS

Subjects were males, mean age 72 ± 8 years, with moderate COPD, FEV(1) 1.57 ± 0.48 L (55 ± 16% predicted). 87% and 65% reported no problems using the pedometer and website, respectively. At month 3, 96% reported it was true that they knew their step count goal every day, and 52% reported that they were able to reach their goal. 95% of participants said they would recommend the walking program to another person with COPD. Eight subjects experienced breathing problems unrelated to the intervention. In 24 subjects with step counts at baseline and month 3, there was a significant increase of 1263 steps per day (approximately 1.0 km), p = 0.0054.

CONCLUSIONS

The use of a website and pedometer was feasible and safe, and persons increased their daily walking.

Fitness memberships and favorable selection in Medicare Advantage plans

BACKGROUND

Because Medicare Advantage plans must pay for covered services, they may design insurance benefits to appeal to healthier beneficiaries.

METHODS

We identified 11 Medicare Advantage plans that offered new fitness-membership benefits in 2004 or 2005 and matched these plans to 11 Medicare Advantage control plans that did not offer coverage for fitness memberships. Using a difference-in-differences approach, we compared the self-reported health status of persons who enrolled after the fitness benefit was added to the plan with the self-reported health status of persons entering the same plan before the fitness benefit was offered.

RESULTS

The proportion of enrollees reporting excellent or very good health was 6.1 percentage points higher (95% confidence interval [CI], 2.6 to 9.7) among the 755 new enrollees in plans that added fitness benefits than among the 4097 earlier enrollees. The proportion of new enrollees reporting activity limitation was 10.4 percentage points lower (95% CI, 6.6 to 14.3) and the proportion reporting difficulty walking was 8.1 percentage points lower (95% CI, 4.4 to 11.7), as compared with earlier enrollees. Within control plans, the differences between the 1154 new enrollees and the 3910 earlier enrollees were 1.5 percentage points or less for each measure. The adjusted differences between the fitness-benefit plans and the control plans were 4.7 percentage points higher for general health (95% CI, 0.2 to 9.2), 9.2 percentage points lower for activity limitation (95% CI, 5.1 to 13.3), and 7.4 percentage points lower for difficulty walking (95% CI, 4.5 to 10.4). These differences persisted at 2 years for activity limitation and difficulty walking.

CONCLUSIONS

Medicare Advantage plans offering coverage for fitness memberships may attract and retain a healthier subgroup of the Medicare population. (Funded by the National Institute on Aging.).

The role of physical inactivity in increasing disability among older adults with obstructive airway disease

PURPOSE

: The independent contribution of physical inactivity to disability in obstructive lung disease (OLD) is difficult to study, partly because inactivity may reflect disease severity. We examined the relationship of physical inactivity to disability progression over a 1-year period among a group of older adults with OLD.

METHODS

: A population-based cohort with self-reported physician-diagnosed emphysema, chronic obstructive pulmonary disease, or chronic bronchitis (n = 206) completed baseline interviews and in-person spirometry, with 1-year followup interviews. The Community Health Activities Model Program for Seniors physical activity questionnaire provided estimates of energy expenditure; we defined inactivity as no expenditure in moderate- or vigorous-intensity activities. Disability was measured with the Valued Life Activity (VLA) disability scale; increased disability was defined as a 10% or greater increase in VLA disability score over 1-year followup. Logistic regression tested the relationship between baseline inactivity and disability increase, controlling for age, sex, baseline VLA disability, comorbidities, smoking, and pulmonary function (forced expiratory volume in 1 second, % predicted).

RESULTS

: Of 206 subjects, 48 (27%) were physically inactive at baseline; 42.9% of individuals whose disability increased were inactive at baseline compared with 23.4% of those who did not experience a disability increase. With adjustment for covariates, increased disability after 1 year was significantly (P = .04) more likely among individuals who were inactive at baseline (Odds Ratio =2.4; 95% confidence interval, 1.02-5.9).

CONCLUSIONS

: Physically inactive individuals with OLD had more than double the odds of an increase in disability, even after controlling for baseline disability, lung function, and other covariates. These results provide strong support for the importance of maintaining physical activity among individuals with OLD.

Validation of a compact motion sensor for the measurement of physical activity in patients with chronic obstructive pulmonary disease

BACKGROUND

The DynaPort Activity Monitor (DAM) has been reported to be useful to evaluate the activity in healthy subjects and patients with chronic obstructive pulmonary disease (COPD). However, it is difficult to estimate the activity of COPD patients using DAM, because its battery works only for several hours and sensors should be worn at two parts of the body. A newly developed compact, single-position triaxial accelerometer (Actimarker) can measure the activity for >1 month, but has not been validated for COPD patients.

OBJECTIVES

The validity of the Actimarker was evaluated in COPD patients.

METHODS

In study 1, the validity of the device was tested in 14 stable COPD patients by comparing it with DAM. In study 2, the influence of the weather on activity was examined. In study 3, the number of measurement days required to ensure repeatability was determined.

RESULTS

The durations of activity measured by the Actimarker and DAM were significantly correlated at intensity values ≥2.0, ≥2.5 and ≥3.0 METs. The duration of activity on rainy days was significantly shorter than that on non-rainy days. The values of intraclass correlation coefficients were >0.8 in 3-, 4- or 5-day measurements, and there was no systematic bias at any number of days or intensities with Bland-Altman plots.

CONCLUSIONS

The validity of the Actimarker was confirmed, and repeatability was obtained when the data from at least 3 non-rainy weekdays were analyzed. Actimarker appears to be useful as a simplified method to evaluate the physical activity of COPD patients.

Lung volume reduction surgery: nonpharmacological approach

PURPOSE OF REVIEW

To revise the current nonpharmacologic methods used in the care of patients undergoing lung volume reduction surgery (LVRS).

RECENT FINDINGS

A recent report of the unquestionable palliative role of LVRS awakened a renewed interest in the procedure as a valid treatment alternative in selected patients with severe emphysema.

SUMMARY

A detailed description of the foundations of the approach to patients undergoing LVRS is described to provide guidance for daily practice.

Chronic obstructive pulmonary disease patient well-being and its relationship with clinical and patient-reported outcomes: a real-life observational study

BACKGROUND

Quality of life is an umbrella concept that refers to all aspects of a person's life, including health status and well-being. While health status measure focuses on the impact of the disease on physical functioning, well-being represents the self-representation of the emotional states related to the disease itself.

OBJECTIVES

The objective of this study was to evaluate the psychological well-being and its determining factors in a real-life chronic obstructive pulmonary disease (COPD) population and to evaluate if patients with a different well-being differ in illness perception, health status and alexithymia.

METHODS

Psychological well-being (Psychological General Well-Being Index), health status (SF-36), illness perception (Illness Perception Questionnaire), alexithymia (Toronto Alexithymia Scale), as well as clinical parameters were assessed in COPD out-patients.

RESULTS

One hundred and sixty-four patients, with a mean forced expiratory volume in 1 s of 58.5%, were recruited. Forty percent of them had a moderately/severely impaired well-being, not correlated with forced expiratory volume in 1 s and the Charlson index value but significantly with the Medical Research Council score (p = 0.0001) that appeared to be the dominant factor. Patients with impaired well-being showed a different illness perception in terms of correct identification of symptoms, disease consequences, emotional representation and confidence in treatment compared with those having a positive well-being. The latter presented a lower alexithymia prevalence and a better health status.

CONCLUSIONS

In order to minimize the disease-negative effects on patients' lives, assessment of well-being and its determining factors, as well as planning specific behavioural, educational and therapeutic interventions seem to be relevant and useful.

[Physical activity and its relationship with the state of health of stable COPD patients]

INTRODUCTION

Previous studies have shown that physical activity (PA) in COPD is associated with a better quality of life and less morbidity and mortality. Our aim was to study the daily PA in the lives of stable COPD patients, outside the setting of a pulmonary rehabilitation program.

MATERIAL AND METHODS

Observational, descriptive and transversal multi-center study in patients with stable COPD controlled in an outpatient clinic by pneumologists. In order to determine the Physical Activity Index (PAI), the Minnesota Leisure Time Physical Activity Questionnaire (MLTPAQ) was used to differentiate the following groups according to the energy expenditure: inactive (less than 1,000 kilocalories per week), moderately active (between 1,000 and 3,000 kilocalories per week) and very active (more than 3,000 kilocalories per week). We analyzed the relationship between PAI and disease severity, health level and socioeconomic variables of the patients.

RESULTS

A total of 132 patients (121 men) were included in the study. Mean age was 66; mean FEV1 was 45%. Regarding PA, 32.6% had energy expenditures of less than 1,000 kilocalories/week, 38.6% between 1,000 and 3,000 and 28.8% more than 3,000. The most inactive COPD patients had more bronchial obstruction, more severe disease, more dyspnea and walked fewer meters in the 6MWT.

CONCLUSIONS

Stable COPD patients perform low levels of PA. Lower PA is associated with poorer health and with more severe disease.

Consequences of physical inactivity in chronic obstructive pulmonary disease

The many health benefits of regular physical activity underline the importance of this topic, especially in this period of time when the prevalence of a sedentary lifestyle in the population is increasing. Physical activity levels are especially low in patients with chronic obstructive pulmonary disease (COPD). Regular physical activity and an active lifestyle has shown to be positively associated with outcomes such as exercise capacity and health-related quality of life, and therefore could be beneficial for the individual COPD patient. An adequate level of physical activity needs to be integrated into daily life, and stimulation of physical activity when absent is important. This article aims to discuss in more detail the possible role of regular physical activity for a number of well-known outcome parameters in COPD.