Interpretation of treatment changes in 6-minute walk distance in patients with COPD

The minimal important difference of the pulmonary functional status and dyspnea questionnaire in patients with severe chronic obstructive pulmonary disease

Background

The modified version of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M) is used in patients with COPD to obtain information about their functional status. It consists of 3 components (change in activities, dyspnea and fatigue) ranging from 0 to 100 and has been shown to be responsive following pulmonary rehabilitation (PR). The interpretation of changes in PFSDQ-M score after an intervention is difficult in the absence of the minimal important difference (MID) of the PFSDQ-M. This study aims at investigating the MID of the PFSDQ-M.

Methods

We enrolled 301 patients with COPD (FEV₁ 42 ± 15%pred) that completed the PFSDQ-M before and after a 3-month PR program (∆Chronic Respiratory Disease Questionnaire (CRDQ) +16 ± 12 points, ∆Six-minute walking distance (6MWD) +47 ± 89 m, both p < 0.001). An anchor-based approach consisted of calculating the correlation between the ∆PFSDQ-M and anchors with an established MID (∆CRDQ and ∆6MWD). Linear regression analyses were performed to predict the MID from these anchors. Secondly several distribution-based approaches (Cohen’s effect size, empirical rule effect size and standard error of measurement method) were used.

Results

Anchor-based estimates for the different PFSDQ-M-components were between −3 and −5 points based on CRDQ score and −6 (only calculated for change in activities) based on 6MWD. Using the distribution-based methods, the estimates of MID ranged from −3 to −5 points for the different components.

Conclusions

We concluded that the estimate of MID of the PFSDQ-M after pulmonary rehabilitation corresponds to a change of 5 points (range - 3 to −6) in each component in patients with severe COPD.

A novel approach to long-term respiratory care: results of a community-based post-rehabilitation maintenance program in COPD

BACKGROUND

Although the short-term benefits of pulmonary rehabilitation (PR) are well established, improvements in exercise tolerance and health status diminish over time. The objectives of this study were to determine the feasibility and within-subject effects of a 1-year community-based maintenance exercise program for patients with COPD following completion of hospital-based PR.

METHODS

A single-arm longitudinal study was undertaken. After completion of PR, consecutive patients with COPD were recruited to attend a twice weekly exercise program supervised by fitness consultants at a local community centre. The transition from hospital to the community was facilitated by a case manager. Outcome measurements at baseline (pre-PR), post-PR, 6-months and 1-year included the 6-minute walk test (6MWT) for exercise capacity and the Chronic Respiratory Questionnaire (CRQ) for health-related quality of life. Feasibility was assessed primarily through subject adherence.

RESULTS

A total of 29 patients (mean age 66.8 ± 7.8 years, mean FEV1 45.1 ± 18.8 percent predicted) were enrolled in the program. Mean compliance to twice weekly exercise was 70%. No adverse events were reported. Statistically significant and clinically important improvements in the 6MWT and CRQ total and dyspnea domain were observed at 6-months and 1-year after PR compared to baseline (all p < 0.01).

CONCLUSIONS

A community-based maintenance exercise program is feasible and can successfully preserve exercise capacity and health-related quality of life following institutionally-based PR in patients with moderate to severe COPD. A more formal evaluation of this approach is warranted.

Randomized clinical trial of 3 types of physical exercise for patients with Parkinson disease

OBJECTIVE

To compare the efficacy of treadmill exercises and stretching and resistance exercises in improving gait speed, strength, and fitness for patients with Parkinson disease.

DESIGN

A comparative, prospective, randomized, single-blinded clinical trial of 3 types of physical exercise.

SETTING

The Parkinson's Disease and Movement Disorders Center at the University of Maryland and the Baltimore Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center.

PATIENTS

A total of 67 patients with Parkinson disease who had gait impairment were randomly assigned to 1 of 3 arms of the trial. INTERVENTIONS; (1) A higher-intensity treadmill exercise (30 minutes at 70%-80% of heart rate reserve), (2) a lower-intensity treadmill exercise (50 minutes at 40%-50% of heart rate reserve), and (3) stretching and resistance exercises (2 sets of 10 repetitions on each leg on 3 resistance machines [leg press, leg extension, and curl]). These exercises were performed 3 times a week for 3 months.

MAIN OUTCOME MEASURES

The primary outcome measures were gait speed (6-minute walk), cardiovascular fitness (peak oxygen consumption per unit time [$$ VO2], and muscle strength (1-repetition maximum strength).

RESULTS

All 3 types of physical exercise improved distance on the 6-minute walk: lower-intensity treadmill exercise (12% increase; P=.001), stretching and resistance exercises (9% increase; P<.02), and higher-intensity treadmill exercise (6% increase; P=.07), with no between-group differences. Both treadmill exercises improved peak $$ VO2 (7%-8% increase; P<.05) more than did the stretching and resistance exercises. Only stretching and resistance improved muscle strength (16% increase; P<.001).

CONCLUSIONS

The effects of exercise were seen across all 3 exercise groups. The lower-intensity treadmill exercise resulted in the greatest improvement in gait speed. Both the higher- and lower-intensity treadmill exercises improved cardiovascular fitness. Only the stretching and resistance exercises improved muscle strength. Therefore, exercise can improve gait speed, muscle strength, and fitness for patients with Parkinson disease. The combination of treadmill and resistance exercises may result in greater benefit and requires further investigation.

Daily step count predicts acute exacerbations in a US cohort with COPD

Background

COPD is characterized by variability in exercise capacity and physical activity (PA), and acute exacerbations (AEs). Little is known about the relationship between daily step count, a direct measure of PA, and the risk of AEs, including hospitalizations.

Methods

In an observational cohort study of 169 persons with COPD, we directly assessed PA with the StepWatch Activity Monitor, an ankle-worn accelerometer that measures daily step count. We also assessed exercise capacity with the 6-minute walk test (6MWT) and patient-reported PA with the St. George's Respiratory Questionnaire Activity Score (SGRQ-AS). AEs and COPD-related hospitalizations were assessed and validated prospectively over a median of 16 months.

Results

Mean daily step count was 5804±3141 steps. Over 209 person-years of observation, there were 263 AEs (incidence rate 1.3±1.6 per person-year) and 116 COPD-related hospitalizations (incidence rate 0.56±1.09 per person-year). Adjusting for FEV₁ % predicted and prednisone use for AE in previous year, for each 1000 fewer steps per day walked at baseline, there was an increased rate of AEs (rate ratio 1.07; 95%CI = 1.003–1.15) and COPD-related hospitalizations (rate ratio 1.24; 95%CI = 1.08–1.42). There was a significant linear trend of decreasing daily step count by quartiles and increasing rate ratios for AEs (P = 0.008) and COPD-related hospitalizations (P = 0.003). Each 30-meter decrease in 6MWT distance was associated with an increased rate ratio of 1.07 (95%CI = 1.01–1.14) for AEs and 1.18 (95%CI = 1.07–1.30) for COPD-related hospitalizations. Worsening of SGRQ-AS by 4 points was associated with an increased rate ratio of 1.05 (95%CI = 1.01–1.09) for AEs and 1.10 (95%CI = 1.02–1.17) for COPD-related hospitalizations.

Conclusions

Lower daily step count, lower 6MWT distance, and worse SGRQ-AS predict future AEs and COPD–related hospitalizations, independent of pulmonary function and previous AE history. These results support the importance of assessing PA in patients with COPD, and provide the rationale to promote PA as part of exacerbation-prevention strategies.

Exercise and COPD: therapeutic responses, disease-related outcomes, and activity-promotion strategies

Chronic obstructive pulmonary disease (COPD) reduces patients' exercise capacities and their abilities to perform daily physical activities, thereby increasing morbidity and mortality rates. The cycle of dyspnea, deconditioning, and declining physical activity not only accelerates the progression of COPD but also increases the risk for developing or aggravating metabolic and cardiovascular diseases. Cardiovascular and metabolic comorbidities also limit physical function, and their disabling effects in combination with COPD may be greater than the effects of each disease alone. The impact of COPD and its treatment on the ability to exercise, and the degree of physical activity in daily life, can be measured by field-based tests (eg, the 6-minute walk test or incremental and endurance shuttle-walk test), laboratory-based tests (eg, incremental or constant work-rate treadmill and cycle-ergometer tests), and physical activity assessments (eg, questionnaires and accelerometers). Walking tests increase oxygen consumption and desaturation in patients with COPD more than cycling tests with similar work-rate profiles and may more closely resemble patients' normal activities. Despite the questionable relevance of exercise testing to patients' daily functionality, exercise parameters remain important predictors of survival in patients with COPD. Treatment of COPD (pharmacotherapy, pulmonary rehabilitation, or both) can increase exercise capacity and physical activity in daily life, which potentially slows the decline of lung function, reduces the frequencies of exacerbations and hospitalizations, decreases mortality, slows the progression of comorbidities, improves health-related quality of life, and increases the activity reserve for routine function. This article examines the interactions of reduced physical activity and decreased exercise capacity with the progression of COPD, comorbidities, and mortality. The article also describes the available exercise tests for patients with COPD and reviews the evidence indicating that treating COPD improves exercise capacity. Notably, it appears that even mild COPD reduces exercise capacity and daily physical activity, indicating the need for early intervention.

Responsiveness of Various Exercise-Testing Protocols to Therapeutic Interventions in COPD

Exercise intolerance is a key element in the pathophysiology and course of Chronic Obstructive Pulmonary Disease (COPD). As such, evaluating exercise tolerance has become an important part of the management of COPD. A wide variety of exercise-testing protocols is currently available, each protocol having its own strengths and weaknesses relative to their discriminative, methodological, and evaluative characteristics. This paper aims to review the responsiveness of several exercise-testing protocols used to evaluate the efficacy of pharmacological and nonpharmacological interventions to improve exercise tolerance in COPD. This will be done taking into account the minimally important difference, an important concept in the interpretation of the findings about responsiveness of exercise testing protocols. Among the currently available exercise-testing protocols (incremental, constant work rate, or self-paced), constant work rate exercise tests (cycle endurance test and endurance shuttle walking test) emerge as the most responsive ones for detecting and quantifying changes in exercise capacity after an intervention in COPD.

Mild asthma and chronic bronchitis seem to influence functional exercise capacity: a multi-case control study

BACKGROUND

In the Genes Environment Interaction in Respiratory Diseases population-based multi-case control study, we investigated whether asthma, chronic bronchitis (CB) and rhinitis were associated with a reduced 6-minute walk distance (6MWD), and whether the 6MWD determinants were similar for subjects with/without respiratory diseases.

METHODS

Cases of asthma (n = 360), CB (n = 120), rhinitis (n = 203) and controls (no respiratory diseases: n = 302) were recruited. The variation in the 6MWD across the groups was analyzed by ANCOVA, adjusting for gender, age, height, weight and comorbidity. The 6MWD determinants were studied by linear regression, and heterogeneity across the cases and controls was investigated.

RESULTS

The 6MWD differed across cases and controls (p = 0.01). It was shorter for cases of asthma (-17.1, 95% CI -28.3 to -5.8 m) and CB (-20.7, 95% CI: -36.6 to -4.8 m) than for controls (604 ± 68 m on average), but not for cases of rhinitis. The negative association between age and the 6MWD was significant for cases of CB, but not for the other groups (p = 0.001).

CONCLUSIONS

Even at the level of severity found in the general population, asthma and CB could influence the 6MWD, which seems to reflect the functional exercise level for daily physical activities. The negative association between ageing and the 6MWD was particularly strong in subjects with CB. Our report adds to the mounting evidence that CB is not a trivial condition, especially in the ageing adult population, and it supports the importance of monitoring functional capacity and of physical reconditioning in mild asthma.

Interval versus continuous training in lung transplant candidates: a randomized trial

BACKGROUND

Interval (IT) and continuous training (CT) represent well-established exercise modalities in patients with moderate to severe chronic obstructive pulmonary disease (COPD). However, their effects and feasibility in patients with end-stage COPD remain unclear.

METHODS

Sixty patients (53 ± 6 years, 53% women) being evaluated for lung transplantation where randomly assigned either to IT (n = 30, cycling at 100% peak work rate for 30 seconds alternating with 30 seconds of rest) or CT (n = 30, cycling at 60% of peak work rate) during a 3-week inpatient rehabilitation program. Both exercise protocols yielded an equivalent amount of total work. Patients had a mean forced expiratory volume at 1 second (FEV(1)) of 25% ± 8% of predicted value.

RESULTS

Patients in both groups achieved similar clinically relevant improvements in 6-minute walking distance of 35 ± 29 meters for IT and 36 ± 43 meters for CT, with a between-group difference of 0.3 meters (95% confidence interval, -18.2 to 18.8). Changes in lung function parameters were not significant. Perceived intensity of dyspnea was significantly (p < 0.05) lower in IT (Borg 6.2 ± 1.8) compared with CT (Borg 7.1 ± 1.7). Patients required a median of 5 unintended breaks (interquartile range, 2-28) during IT exercise and 29 (interquartile range, 6-68) during CT (p < 0.001).

CONCLUSIONS

IT is associated with a lower intensity of dyspnea during exercise and fewer unintended breaks but achieves similar improvements in exercise capacity compared with CT in pre-lung transplant COPD patients.

Evaluation of self-management interventions for chronic obstructive pulmonary disease

AIM

To evaluate the benefits of self-management interventions on the quality of life of patients with chronic obstructive pulmonary disease.

BACKGROUND

Chronic obstructive pulmonary disease is one of the most widespread chronic conditions worldwide, and it is predicted to increase over the next decade. Although previous review studies have demonstrated the benefits of self-management interventions on health-care utilisation, their benefits on quality of life are still unclear.

METHOD

In this systematic review, we examined four randomised controlled trials undertaken between 2000 and 2011 to evaluate the benefits of chronic obstructive pulmonary disease self-management interventions on patient quality of life.

RESULTS

The main theme that emerged was that self-management interventions improved patient well-being, with three minor themes: reducing the burden on patients, improved patient activity and improved total patient health.

CONCLUSION

Self-management interventions tend to improve the quality of life of patients with chronic obstructive pulmonary disease. Further randomised controlled trials are recommended to evaluate self-management interventions in chronic obstructive pulmonary disease to confirm these benefits.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing management in health services is involved in caring for patients with chronic obstructive pulmonary disease and is responsible for liaising with other members of the health-care team. We recommend that nursing management be engaged in health-care services to develop and implement self-management interventions for chronic obstructive pulmonary disease patients to improve their quality of life.

Randomized controlled crossover trial of a new oscillatory device as add-on therapy for COPD

A new oscillatory device administers predetermined pressure oscillation sequences into the chest cavity over inhaled/exhaled air streams at low positive pressure. We assessed device safety and effect on 6MW performance, pulmonary function, and health-related quality-of-life (HRQOL) in moderate-to-very severe COPD in a randomized, double-blind, controlled, crossover study. Outcomes with an oscillatory device (Pulsehaler(TM), Respinova Ltd, Herzliya, Israel) and a "muted" sham device (control) of identical appearance that delivered continuous positive air pressure were compared in two groups receiving opposite treatment sequences: 2-week oscillatory device/control, 2-week washout, 2-week control/oscillatory device, 2-week washout. The clinical trial was registered ( www.clinicaltrials.gov , NCT00821418) and approved by the Hadassah-Hebrew University Medical Center Institutional Review Board (08-608). All participants signed informed consent; 22 patients completed the study with no marked differences in COPD exacerbations or side effects. A total of 91% of patients treated with the oscillatory device had a clinically significant improvement (increase >40 m) in 6MW performance. The 6MW distance with the oscillatory device increased significantly after 1 week of treatment (51.6 ± 7.6 m, +13.5 ± 2.3%, p < 0.001), and more after 2 weeks (61.8 ± 9.0 m, 16.3 ± 2.7%, p < 0.001). This increase with the oscillatory device was significantly greater (p < 0.001) than the 15.4 ± 10.4 m increase (4.2 ± 2.6%, NS) with control. FVC and inspiratory capacity (IC) improved significantly (p = 0.03 for each) with the oscillatory device but not with control. HRQL improved markedly (≥1 point) for dyspnea and mastery with the oscillatory device (p = 0.02) but not control. Treatment with a new oscillatory device appears to be safe, and to improve 6MW performance, pulmonary function, and HRQL in COPD. Further evaluation is warranted.

Repeatability of the six-minute walk test and relation to physical function in survivors of a critical illness

BACKGROUND

The Six-Minute Walk Test (6MWT) is widely used as an outcome measure in exercise rehabilitation. However, the repeatability of the 6MWT performed at home in survivors of a critical illness has not been evaluated.

OBJECTIVE

The purpose of this study was to evaluate, in survivors of a critical illness: (1) the repeatability of the 6MWT performed at home, (2) the effect on estimates of change in functional exercise capacity if only one 6MWT was performed at follow-up assessments, and (3) the relationship between the physical functioning (PF) score of the 36-Item Short-Form Health Survey questionnaire (SF-36) and the 6MWT.

DESIGN

Repeated measures of the 6MWT and SF-36 were obtained.

METHODS

Eligible participants had an intensive care unit (ICU) length of stay of ≥48 hours and were mechanically ventilated for ≥24 hours. Two 6MWTs and the SF-36 were conducted in participants' homes at weeks 1, 8, and 26 after hospital discharge.

RESULTS

One hundred seventy-three participants completed the study. The participants had a mean age of 57 years (SD=16), a mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission of 19 (SD=10), a mean ICU length of stay of 9 days (SD=8), and a mean mechanical ventilation time of 140 hours (SD=137). Of the 173 participants, 110 performed two 6MWTs at weeks 1, 8, and 26. There were significant mean increases in 6-minute walk distance in the second test of 15 m (P<.0001) at week 1, 13 m (P<.0001) at week 8, and 9 m (P=.04) at week 26. If only one 6MWT was performed at weeks 8 and 26, the estimate of change in 6-minute walk distance from week 1 was 19 m less (P<.001) at both weeks 8 and 26. There was a moderate to strong correlation between SF-36 PF score and 6-minute walk distance at each assessment (week 1: r=.62, P<.001; week 8: r=.55, P<.001; and week 26: r=.47, P<.001).

LIMITATIONS

Some study participants were unable to perform a second 6MWT, and these participants may have differed in important aspects of function compared with those individuals who completed two 6MWTs.

CONCLUSIONS

In survivors of a critical illness, the 6MWT in the home environment should be performed twice at each assessment to give an accurate reflection of change in exercise capacity over time. The SF-36 PF score was a strong indicator of 6-minute walk distance in early recovery from a critical illness.

Ataluren as an agent for therapeutic nonsense suppression

The interplay of translation and mRNA turnover has helped unveil how the regulation of gene expression is a continuum in which events that occur during the birth of a transcript in the nucleus can have profound effects on subsequent steps in the cytoplasm. Exemplifying this continuum is nonsense-mediated mRNA decay (NMD), the process wherein a premature stop codon affects both translation and mRNA decay. Studies of NMD helped lead us to the therapeutic concept of treating a subset of patients suffering from multiple genetic disorders due to nonsense mutations with a single small-molecule drug that modulates the translation termination process at a premature nonsense codon. Here we review both translation termination and NMD, and our subsequent efforts over the past 15 years that led to the identification, characterization, and clinical testing of ataluren, a new therapeutic with the potential to treat a broad range of genetic disorders due to nonsense mutations.

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.

[Cost-effectiveness of lung volume reduction coil treatment in emphysema. STIC REVOLENS]

BACKGROUND

Medical therapeutic options for the treatment of emphysema remain limited. Lung volume reduction surgery is infrequently used because of its high morbi-mortality. Endobronchial lung volume reduction coil (LVRC(®), PneumRx, Mountain View, CA) treatment has been recently developed and has been shown to be feasible and associated with an acceptable safety profile, while resulting in improvements in dyspnea, exercise capacity and lung function. The objective of this study is to analyze the cost effectiveness of LVRC treatment in severe emphysema.

METHODS

This prospective, multicenter study, randomized with a 1:1 ratio (LVRC vs conventional treatment) will include 100 patients who will be followed up for 1year. The primary outcome measure is the 6-month improvement of the 6-minute walk test: the percentage of patients showing an improvement of at least 54m will be compared between groups. A cost-effectiveness study will estimate the cost of LVRC treatment, the global cost of this therapeutic option and will compare the cost between patients treated by LVRC and by medical treatment alone.

EXPECTED RESULTS

This study should allow validating the clinical efficacy of LVRC in severe emphysema. The cost-effectiveness study will assess the medical-economic impact of the LVRC therapeutic option.

Responsividade do teste do degrau de seis minutos a um programa de treinamento físico em pacientes com DPOC

OBJETIVO: Avaliar a responsividade do teste do degrau de seis minutos (TD6) a um programa de treinamento físico (PTF) aeróbio e verificar a eficácia do PTF quanto às variáveis ergoespirométricas no TD6, assim como ao desempenho físico, sensação de dispneia e SpO2 no TD6 e no teste de caminhada de seis minutos (TC6) em pacientes com DPOC. MÉTODOS: Estudo controlado, prospectivo e randomizado com pacientes com diagnóstico clínico de DPOC que apresentassem relação VEF1/CVF < 70% e condições clinicamente estáveis nos últimos dois meses. Os pacientes foram randomizados em grupo PTF, que realizaram um PTF em esteira por seis semanas, três vezes por semana, e grupo controle. Todos os participantes receberam cuidados usuais de fisioterapia respiratória durante o período de estudo e foram submetidos a anamnese, exame físico, espirometria antes e após o uso de broncodilatador, teste cardiopulmonar incremental sintoma limitado, TD6 e TC6 nos momentos basal e final. RESULTADOS: Dos 36 pacientes que completaram o estudo, 21 e 15 foram distribuídos nos grupos PTF e controle, respectivamente. Verificou-se um aumento significativo do número de subidas no degrau no TD6, da distância percorrida no TC6 (em m e % do previsto), assim como uma redução significativa da sensação de dispneia durante o TC6 somente no grupo PTF. CONCLUSÕES: O TD6 apresentou responsividade ao PTF. No entanto, acreditamos que o TC6 seja mais responsivo ao PTF proposto.

Does the mode of exercise influence recovery of functional capacity in the early postoperative period after coronary artery bypass graft surgery? A randomized controlled trial

OBJECTIVES

The purpose of this study was to compare the effectiveness of moderate-intensity stationary cycling and walking exercise programmes in the early postoperative period after first-time coronary artery bypass graft surgery.

METHODS

In this prospective trial, 64 patients (57 men, 7 women, mean age = 66 ± 9 years) performed twice daily, moderate-intensity exercise sessions, of 10-min duration, from postoperative day 3 until discharge from hospital. Patients were randomly assigned to stationary cycling or walking exercise intervention groups. Preoperative and discharge functional exercise capacity and health-related quality of life were assessed using 6-min walk and cycle assessments and the SF-36 version 2.0 questionnaire. Compliance with exercise was calculated as the proportion of scheduled exercise sessions completed.

RESULTS

There were no significant differences between intervention groups at hospital discharge for 6-min walk distance (cyclists: 402 ± 93 m vs walkers: 417 ± 86 m, P = 0.803), 6-min cycle work (cyclists: 15.0 ± 6.4 kJ vs walkers: 14.0 ± 6.3 kJ, P = 0.798) or health-related quality of life. There was no significant difference between intervention groups for postoperative length of hospital stay (P = 0.335). Compliance rates for intervention groups were cyclists: 185/246 (75%) scheduled exercise sessions completed vs walkers: 199/242 (82%) scheduled exercise sessions completed (P = 0.162).

CONCLUSIONS

Stationary cycling provides a well-tolerated and clinically effective alternative to walking in the early postoperative period after coronary artery bypass graft surgery. The optimal frequency, intensity and duration of exercise in the early postoperative period require further investigation. (Clinical trials register: Australian New Zealand Clinical Trials Registry; identification number: ACTRN12608000359336; http://www.anzctr.org.au/trial_view.aspx?ID=82978).

Modifying the course of chronic obstructive pulmonary disease: looking beyond the FEV1

COPD is defined by airflow limitation that is not fully reversible and is usually progressive. Thus, airflow obstruction (measured as FEV(1)) has traditionally been used as the benchmark defining disease modification with therapy. However, COPD exacerbations and extrapulmonary effects are common and burdensome and generally become more prominent as the disease progresses. Therefore, disease progression should be broader than FEV(1) alone. Interventions that reduce the frequency or severity of exacerbations or ameliorate extrapulmonary effects should also be considered disease modifiers. A narrow focus on FEV(1) will fail to capture all the beneficial effects of therapy on disease modification. Although smoking cessation has been unequivocally demonstrated to slow the rate of FEV(1) decline, inhaled corticosteroid-long-acting bronchodilator therapy may also have modest effects according to post hoc analysis. Maintenance pharmacotherapy with inhaled long-acting anti-muscarinic or β-adrenergic agents or combined β-adrenergic--inhaled corticosteroid reduces symptoms, improves lung function, reduces the frequency of exacerbations, and improves exercise capacity and HRQL. Pulmonary rehabilitation reduces symptom burden, increases exercise capacity, improves HRQL, and reduces health care utilization, probably through reducing the severity of exacerbations. Smoking cessation, lung volume reduction surgery, inhaled maintenance pharmacotherapy, and pulmonary rehabilitation administered in the post-exacerbation period may reduce mortality in COPD. These improvements over multiple outcome areas and over relatively long durations suggest that disease modification is indeed possible with existing therapies for COPD. Therefore, therapeutic nihilism in COPD is no longer warranted.

Udenafil improves exercise capacity in patients with chronic obstructive pulmonary disease: a prospective study

Pulmonary hypertension (PH) is a serious complication of chronic obstructive pulmonary disease (COPD), and there is no effective pharmacological treatment for COPD-associated PH. We evaluated the effect of udenafil, a phosphodiesterase-5 (PDE-5) inhibitor, on the exercise capacity of patients with severe COPD. Patients with severe and very severe COPD (forced expiratory volume in one second (FEV(1)) <50% of predicted) received udenafil (50 mg daily) for 8 weeks. A 6-min walk test (6MWT), lung function test, Doppler echocardiography, and Saint George's Respiratory Questionnaire (SGRQ) were completed before and after therapy. The primary outcome was a change in the 6-min walk distance (6MWD). Thirty-eight patients were screened for eligibility, and 23 completed the study. After 8 weeks of udenafil treatment, the mean 6MWD increased from 315 to 348 m (p = 0.02), and median PASP decreased from 36 to 30 mmHg (p = 0.02). There were no changes in the SGRQ score, Borg dyspnea score, or pulmonary function parameters. The PDE-5 inhibitor udenafil improved exercise capacity and decreased pulmonary artery pressure in patients with severe COPD. However, due to the small sample size, uncontrolled design and high dropout rate, the efficacy of udenafil in severe COPD needs to be confirmed in a large-scale randomized controlled study. This study was registered at ClinicalTrials.gov (number: NCT01364181).

Concerns about exercise are related to walk test results in pulmonary rehabilitation for patients with COPD

Background

Although international guidelines on pulmonary rehabilitation acknowledge that psychological factors contribute to exercise intolerance in patients with chronic obstructive pulmonary disease (COPD), the few empirical studies investigating this association have found inconsistent results.

Purpose

The purpose of this study is to investigate whether negative affect and beliefs about exercise of patients with COPD would be related to baseline 6-min walk (6-MW) test results in a pulmonary rehabilitation setting, after correction for physical variables (sex, age, height, weight, and lung function). A second aim was to examine whether patients' beliefs are associated with treatment outcomes, as measured by an improvement in 6-MW distance.

Method

A 12-week pulmonary rehabilitation program was completed by 166 patients. Beliefs (perceived necessity and concerns) about exercise and negative affect were assessed by a questionnaire. Clinical data were obtained from medical records.

Results

Baseline 6-MW distance was positively related to younger age, male gender, better pulmonary function, and having fewer concerns about exercise. After rehabilitation, patients had increased their walk distance by 12% (32 m), on average. Baseline physiological and psychological variables were unrelated to patients' response to treatment (increase in walk distance). However, subgroup analysis showed that for patients with mild to moderate airflow obstruction, concerns about exercise were negatively related to response to treatment.

Conclusion

We conclude that patients' beliefs about the negative consequences of exercise are associated with baseline 6-MW test performance and response to treatment for patients with mild to moderate COPD. We recommend that patients' concerns about exercise are discussed and, if necessary, corrected during the intake phase.

The minimal important difference in the 6-minute walk test for patients with pulmonary arterial hypertension

RATIONALE

Although commonly used as the primary outcome measure of clinical trials in pulmonary arterial hypertension (PAH), the minimal important difference (MID) of the 6-minute walk test (6MWT) has not been well defined for this population of patients.

OBJECTIVES

To estimate the MID in the 6MWT in patients with PAH.

METHODS

Study subjects from the clinical trial of tadalafil in PAH, a 16-week, parallel-group, randomized clinical trial of patients who were treatment naive or on background therapy with an endothelin receptor antagonist, were eligible. 6MWT was performed using a standardized protocol. Distributional and anchor-based methods were used to estimate the MID; the latter method used the Physical Component Summary Score (PCS) of the Medical Outcomes Study 36-item short form (SF-36).

MEASUREMENTS AND MAIN RESULTS

Four hundred five subjects were analyzed. Domains of the SF-36 were weakly to modestly associated with 6MWT. Change in the PCS of the SF-36 was most strongly associated with change in 6MWT (r = 0.40, P < 0.001) and thus was selected as the anchor for subsequent anchor-based analyses. Distributional analyses yielded estimates of the MID ranging from 25.1 to 38.5 m, whereas anchor-based analyses yielded an estimate of 38.6 m.

CONCLUSIONS

Using both distributional and anchor-based methods, the estimated consensus MID in the 6MWT for PAH is approximately 33 m. These results have important implications for (1) assessing treatment responses from clinical trials and metaanalyses of specific PAH therapy, and (2) sample size calculations for future study design.

Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial

The effects of exercise training after lung transplantation have not been studied in a randomized controlled trial so far. We investigated whether 3 months of supervised training, initiated immediately after hospital discharge, improve functional recovery and cardiovascular morbidity of patients up to 1 year after lung transplantation. Patients older than 40 years, who experienced an uncomplicated postoperative period, were eligible for this single blind, parallel group study. Sealed envelopes were used to randomly allocate patients to 3 months of exercise training (n = 21) or a control intervention (n = 19). Minutes of daily walking time (primary outcome), physical fitness, quality of life and cardiovascular morbidity were compared between groups adjusting for baseline assessments in a mixed models analysis. After 1 year daily walking time in the treated patients (n = 18) was 85 ± 27 min and in the control group (n = 16) 54 ± 30 min (adjusted difference 26 min [95%CI 8-45 min, p = 0.006]). Quadriceps force (p = 0.001), 6-minute walking distance (p = 0.002) and self-reported physical functioning (p = 0.039) were significantly higher in the intervention group. Average 24 h ambulatory blood pressures were significantly lower in the treated patients (p ≤ 0.01). Based on these results patients should be strongly encouraged to participate in an exercise training intervention after lung transplantation.

Pulmonary rehabilitation program including respiratory conditioning for chronic obstructive pulmonary disease (COPD): Improved hyperinflation and expiratory flow during tidal breathing

BACKGROUND

Pulmonary rehabilitation has generally relieved symptoms, strengthened exercise endurance and improved health-related quality of life (QOL) in patients with COPD, but recovery of pulmonary function remains questionable. This analysis of our innovative rehabilitation program is directed at documenting changes in patients' expiratory airflow limitation, pulmonary symptoms and QOL. This program is designed to provide "respiratory conditioning", a physical therapist-assisted intensive flexibility training that focuses on stretching and rib cage mobilization.

METHODS

Thirty-one patients with COPD who attended rehabilitation sessions at Juntendo University Hospital from 1999 to 2006 were analyzed. Pulmonary function, expiratory flow limitation during tidal breathing, six minute walk distance (6MWD), respiratory muscle strength, and St. George Respiratory Questionnaire (SGRQ) were measured before and after pulmonary rehabilitation.

RESULTS

In participants ages 68±7 years, the FEV(1)% predicted was 39.3±15.7%. 6MWD, SGRQ and respiratory muscle strength were significantly improved after pulmonary rehabilitation. Although neither FEV(1)% predicted nor FEV(1)/FVC was affected to a significant extent, indicating little effect on airflow limitation, expiratory flow limitation in supine as well as seated during tidal breathing improved significantly. Moreover, rehabilitation significantly diminished TLC% predicted, FRC% predicted, RV% predicted and RV/TLC values, thus indicating a reduction of hyperinflation of the lungs at rest.

CONCLUSIONS

The present results suggest that our rehabilitation program with respiratory conditioning significantly lowered the hyperinflation of lungs at rest as well as the expiratory flow limitation during tidal breathing. In patients with COPD, overall pulmonary function improved, exercise endurance increased and health-related QOL was enhanced.

Muscle function, physical performance and body composition changes in men with prostate cancer undergoing androgen deprivation therapy

Prostate cancer (PCa) is the most common visceral malignancy in men with androgen deprivation therapy (ADT) the preferred therapy to suppress testosterone production and hence tumor growth. Despite its effectiveness in lowering testosterone, ADT is associated with side effects including loss of muscle mass, diminished muscle strength, decrements in physical performance, earlier fatigue and declining quality of life. This review reports a survey of the literature with a focus on changes in muscle strength, physical function and body composition, due to short-term and long-term ADT. Studies in these areas are sparse, especially well-controlled, prospective randomized trials. Cross-sectional and longitudinal data (up to 2 years) for men with PCa treated with ADT as well as patients with PCa not receiving ADT and age-matched healthy men are presented when available. Based on limited longitudinal data, the adverse effects of ADT on muscle function, physical performance and body composition occur shortly after the onset of ADT and tend to persist and worsen over time. Exercise training is a safe and effective intervention for mitigating these changes and initial guidelines for exercise program design for men with PCa have been published by the American College of Sports Medicine. Disparities in study duration, types of studies and other patient-specific variables such as time since diagnosis, cancer stage and comorbidities may all affect an understanding of the influence of ADT on health, physical performance and mortality.

Comparison of inspiratory muscle strength training effects between older subjects with and without chronic obstructive pulmonary disease

BACKGROUND/PURPOSE

Inspiratory muscle strength training (IMST) has been traditionally recommended for patients with chronic obstructive pulmonary disease (COPD) to improve respiratory strength. Respiratory strength is reduced as age increases. However, few studies have focused on the effects of IMST on older adults without COPD.

METHODS

Subjects were divided into training non-COPD (TNC, n = 24) and training COPD (TC, n = 12) according to their forced expiratory volume in 1 second (% predicted). Both groups received 6 weeks of IMST, with training at 75-80% of maximal inspiratory pressure using pressure threshold trainers. A second group of COPD subjects served as controls (CC, n = 24), which received no training. Dyspnea was measured using the basic dyspnea index. Health-related quality of life was measured using the SF-36. The SF-36 subcategories, physical component summary and mental component summary were compared. A 6-minute walk test was performed to determine functional status. Two-way repeated measures analysis of variance was used to compare group effects and training effects of IMST.

RESULTS

Maximal inspiratory pressure was increased in both training groups (TNC: 59.1 cmH(2)O pre-IMST to 82.5 cmH(2)O post-IMST; TC: 53.2 to 72.6), but not in the CC group. Therefore, the basic dyspnea index was improved in both training groups (TNC: 9.6 to 10.8; TC: 6.2 to 7.3). Functional status was improved in the TNC group (TNC: 392.1 m to 436.3 m), but not in the TC or CC groups. Quality of life was improved in the physical component summary in both training groups.

CONCLUSION

IMST increases maximal inspiratory pressure, relieves dyspnea and improves health-related quality of life in older adults. IMST especially improves functional status in subjects without COPD. IMST benefits subjects with COPD and those without COPD. Therefore, IMST as a treatment tool is not confined to patients with COPD.

Impact of a telephone-based physical activity intervention upon exercise behaviors and fitness in cancer survivors enrolled in a cooperative group setting

Observational studies demonstrate an association between physical activity and improved outcomes in breast and colon cancer survivors. To test these observations with a large, randomized clinical trial, an intervention that significantly impacts physical activity in these patients is needed. The Active After Cancer Trial (AACT) was a multicenter pilot study evaluating the feasibility of a telephone-based exercise intervention in a cooperative group setting. Sedentary (engaging in <60 min of recreational activity/week) breast and colorectal cancer survivors were randomized to a telephone-based exercise intervention or usual care control group. The intervention was delivered through the University of California at San Diego; participants received ten phone calls over the course of the 16-week intervention. All participants underwent assessment of physical activity, fitness, physical functioning, fatigue and exercise self-efficacy at baseline and after the 16-week intervention. One hundred and twenty-one patients were enrolled through ten Cancer and Leukemia Group B (CALGB) institutions; 100 patients had breast cancer and 21 had colorectal cancer. Participants randomized to the exercise group increased physical activity by more than 100 versus 22% in controls (54.5 vs. 14.6 min, P = 0.13), and experienced significant increases in fitness (increased 6-min walk test distance by 186.9 vs. 81.9 feet, P = 0.006) and physical functioning (7.1 vs. 2.6, P = 0.04) as compared to the control group. Breast and colorectal cancer survivors enrolled in a multicenter, telephone-based physical activity intervention increased physical activity and experienced significant improvements in fitness and physical functioning. Lifestyle intervention research is feasible in a cooperative group setting.

Effects of whole body vibration in patients with chronic obstructive pulmonary disease--a randomized controlled trial

INTRODUCTION

To date endurance and strength training are established and evidence-based exercise methods in patients with chronic obstructive pulmonary disease (COPD). There is an unmet need for further research in new and complementary exercise modalities. Additional whole body vibration training during pulmonary rehabilitation may be such a new approach that has not yet been investigated in patients with COPD.

METHODS

Eighty-two patients (65 ± 9 yrs, FEV(1) pred. 38 ± 11%, female 51%) with COPD in GOLD stage III to IV assessed for a 3-week inpatient multidisciplinary rehabilitation program were on top randomly assigned to one of two intervention groups: (1) 3 × 3 min of bilateral dynamic squat exercises on a side-alternating vibration platform at 24-26 Hz three times per week (WBV) and (2) a control group (CON) with the same amount of exercise time without WBV.

RESULTS

Thirty-six patients completed the study in each group. The improvement in 6-min walking distance was significantly higher in the WBV-group when compared to the CON-group (WBV: 64 ± 59 m, CON: 37 ± 52 m with a between-group difference of 27 m [95% CI, 1-53], p = 0.046). The time required for a sit-to-stand test also decreased more markedly in the WBV-group than in the CON-group (WBV: -4.0 ± 4.8 s, CON: -2.0 ± 3.1 s with a between-group difference of -1.9 s [95% CI, -4.0 to 0.1], p = 0.067). Improvements in health-related quality of life were similar in both groups.

CONCLUSIONS

WBV training seems to be a promising new exercise modality for patients with COPD and may enhance the effects of a multidisciplinary rehabilitation program.

Optimal intensity and type of leg exercise training for people with chronic obstructive pulmonary disease

BACKGROUND

Intensity of exercise is considered a key determinant of training response, however, no systematic review has investigated the effects of different levels of training intensity on exercise capacity, functional exercise capacity and health-related quality of life (HRQoL) in people with chronic obstructive pulmonary disease (COPD). As type of training (continuous or interval) may also affect training response, the effects of the type of training in COPD also require investigation.

OBJECTIVES

To determine the effects of training intensity (higher versus lower) or type (continuous versus interval training) on primary outcomes in exercise capacity and secondary outcomes in symptoms and HRQoL for people with COPD.

SEARCH METHODS

We searched for studies in any language from the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and PubMed. Searches were current as of June 2011.

SELECTION CRITERIA

We included randomised controlled trials comparing higher training intensity to lower training intensity or comparing continuous training to interval training in people with COPD. We excluded studies that compared exercise training with no exercise training.

DATA COLLECTION AND ANALYSIS

We pooled results of comparable groups of studies and calculated the treatment effect and 95% confidence intervals (CI) using a random-effects model. We made two separate comparisons of effects between: 1) higher and lower training intensity; 2) continuous and interval training. We contacted authors of missing data.

MAIN RESULTS

We analysed three included studies (231 participants) for comparisons between higher and lower-intensity training and eight included studies (367 participants) for comparisons between continuous and interval training. Primary outcomes were outcomes at peak exercise (peak work rate, peak oxygen consumption, peak minute ventilation and lactate threshold), at isowork or isotime, endurance time on a constant work rate test and functional exercise capacity (six-minute walk distance). When comparing higher versus lower-intensity training, the pooled primary outcomes were endurance time and six-minute walk distance. There were no significant differences in endurance time improvement (mean difference (MD) 1.07 minutes; 95% CI -1.53 to 3.67) and six-minute walk distance improvement (MD 2.8 metres; 95% CI -10.1 to 15.6) following higher or lower-intensity training. However, heterogeneity of the endurance time results between studies was significant. When comparing continuous and interval training, there were no significant differences in any of the primary outcomes, except for oxygen consumption at isotime (MD 0.08; 95% CI 0.01 to 0.16) but the treatment effect was not considered clinically important. According to the GRADE system, studies were of low to moderate quality.

AUTHORS' CONCLUSIONS

Comparisons between the higher and lower training intensity were limited due to the small number of included studies and participants. Consequently, there are insufficient data to draw any conclusions on exercise capacity, symptoms and HRQoL for this comparison. For comparisons between continuous and interval training, both appear to be equally effective in improving exercise capacity, symptoms and HRQoL.

Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease--practical issues: a Canadian Thoracic Society Clinical Practice Guideline

Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts. The evidence reveals there are no differences in major patient-related outcomes of PR between nonhospital- (community or home sites) or hospital-based sites. There is strong support to recommend that COPD patients initiate PR within one month following an acute exacerbation due to benefits of improved dyspnea, exercise tolerance and health-related quality of life relative to usual care. Moreover, the benefits of PR are evident in both men and women, and in patients with moderate, severe and very severe COPD. The current review also suggests that longer PR programs, beyond six to eight weeks duration, be provided for COPD patients, and that while aerobic training is the foundation of PR, endurance and functional ability may be further improved with both aerobic and resistance training.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established.

OBJECTIVES

To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity).

SEARCH STRATEGY

Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010.

SELECTION CRITERIA

Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS

We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies.

MAIN RESULTS

We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies.

AUTHORS' CONCLUSIONS

Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.

The future of chronic obstructive pulmonary disease treatment--difficulties of and barriers to drug development

Although chronic obstructive pulmonary disease (COPD) is a major global health problem with a rising incidence and morbidity, few pharmacotherapeutic advances have been made over the past several decades. The challenges of development of such agents are multifactorial and include rudimentary understanding of the biological genesis of human disease, inadequate in-vitro and in-vivo models, unvalidated biomarkers, inefficient physiological and clinical endpoints, and variable regulatory review worldwide. Blockade of various inflammatory pathways and mediators is a reasonable therapeutic strategy to alter the natural history of COPD. Substantial heterogeneity is evident with respect to clinical presentation, physiology, imaging, response to therapy, decline in lung function, and survival. Numerous endpoints have been proposed for clinical studies in COPD, with new approaches under study. The novel strategy that seems most promising is the use of biomarkers. We hope that with these approaches novel pharmacotherapies will be developed in the near future.

[The validity and sensitivity to change of the Spanish self-administered version of the chronic respiratory questionnaire (CRQ-SAS)]

INTRODUCTION

The interviewer-administered chronic respiratory questionnaire (CRQ-IA) is widely used and has demonstrated excellent properties for measuring health-related quality of life (HRQL) in patients with chronic obstructive pulmonary disease (COPD). However, the self-administered version (CRQ-SAS) in Spanish has not been validated. The aim of this trial was to evaluate the validity and the sensitivity of the Spanish version of the CRQ-SAS in patients with COPD.

MATERIAL AND METHODS

We randomized 40 patients with COPD (33 treated with pulmonary rehabilitation and 7 with liquid oxygen therapy) to one of the two methods of administration of CRQ (SAS vs. IA) both before and 8 weeks after the treatment. In addition, patients completed the SF-36 questionnaire, pulmonary function tests, and six-minute walk test.

RESULTS

The CRQ-SAS demonstrated good longitudinal construct validity on all domains with a range of correlations, for the change scores, between 0.46 (P=.05) and 0.71 (P=.01). Regarding sensitivity to change, we observed a minimal clinically significant change in most domains (fatigue 0.71 [P=.02], emotional factor 0.62 [P=.04], control of the disease 0.83 [P=.06]).

CONCLUSIONS

The Spanish version of CRQ-SAS is valid for evaluating HRQL in COPD patients. The correlations of the CRQ-SAS with other tools provide construct validity and show good sensitivity to change.

Effects of pulmonary rehabilitation on activity levels in patients with chronic obstructive pulmonary disease

PURPOSE

The purpose of this study was to determine whether patients with chronic obstructive pulmonary disease (COPD) increase physical activity immediately after a short course (8 weeks) of pulmonary rehabilitation (PR). Activity levels in patients with COPD were also compared with those in healthy controls.

METHODS

Consecutive patients with COPD (n = 24, aged 71.9 ± 7.7 years, forced expiratory ventilation in 1 second 44.1 ± 17.9% predicted, who completed PR) and 8 aged-matched controls (aged 66.6 ± 7.2 years) were studied. Activity was monitored with a triaxial accelerometer for 5 days before and after PR. Activity was expressed as vector magnitude units (VMU) per minute and time spent at VMU above 250 and 500, respectively.

RESULTS

Overall activity was significantly less in patients with COPD compared with that in controls (117 ± 63 compared with 242 ± 103 VMU/min, P = .0003). Time spent at VMU above 250 and 500 was also less in patients with COPD (166 ± 71 vs 227 ± 37 min, P = .028 and 39 ± 43 vs 124 ± 26 min, P < .0001, respectively). After PR, overall VMU activity was not significantly increased (117 ± 63 vs 120 ± 63 VMU/min). Time spent at VMU above 250 and 500 was also not significantly increased after PR. Increases in activity levels after PR did not correlate with improvements in exercise performance, quality of life, or quadriceps strength.

CONCLUSIONS

Despite significant improvements in exercise capacity and quality of life after PR, this did not translate into a significant increase in activity level. Improving function in patients with copd may not translate into behavioral change.

Validation of the treadmill Six-Minute Walk Test in people following cardiac surgery

BACKGROUND

The Six-Minute Walk Test (6MWT) often is used to measure exercise capacity in people with cardiopulmonary diseases but has some disadvantages. The 6MWT administered on a treadmill (Tr6MWT) requires less physical space and allows for easier monitoring of vital parameters than the traditional 6MWT.

OBJECTIVE

The objectives of this study were: (1) to analyze the validity of the Tr6MWT in people who underwent cardiac surgery; (2) to compare the reliability, responsiveness, and people's tolerance of the Tr6MWT with those of the 6MWT; and (3) to evaluate the agreement between the 2 tests.

DESIGN

This study was designed to assess reliability and validity.

METHODS

Twenty-six participants who were inpatients were assessed before a 2-week rehabilitation program. Twenty of them also were assessed after rehabilitation. All participants performed 3 Tr6MWT trials and 3 6MWT trials that were randomly assigned on 2 consecutive days.

RESULTS

The Pearson r correlation coefficient between the Tr6MWT and the 6MWT was .72, indicating satisfactory concurrent validity. The Tr6MWT was as well tolerated as the 6MWT. The Tr6MWT produced reproducible results after 2 practice tests, whereas the 6MWT did so after only 1 practice test. Both tests showed high test-retest reliability (intraclass correlation coefficient of >.94; standard errors of measurement of 23 m for the Tr6MWT and 18.5 m for the 6MWT). The Tr6MWT showed better responsiveness than the 6MWT (effect sizes of 0.9 for the Tr6MWT and 0.6 for the 6MWT). The distance covered during the Tr6MWT was significantly shorter (X=62 m, SD=91) before rehabilitation but not after rehabilitation.

LIMITATIONS

A crossover randomized procedure could have improved the reliability of the Tr6MWT in people who performed the 6MWT first.

CONCLUSIONS

The Tr6MWT appears to be an instrument with adequate concurrent validity and to be tolerable, reliable, and responsive for the evaluation of exercise capacity in people after cardiac surgery even though it is not interchangeable with the 6MWT.

Pulmonary rehabilitation reduces depression and enhances health-related quality of life in COPD patients--especially in patients with mild or moderate disease

The first objective of the study was to evaluate a 4-week inpatient pulmonary rehabilitation program on exercise capacity, health-related quality of life (HRQL) and psychological distress in patients with COPD. The second objective was to investigate the influence of gender, age, disease severity, co-morbidity, anxiety and depression on improved HRQL after rehabilitation. The study comprised 136 consecutive patients from baseline to follow-up with mild-to-severe COPD. Exercise capacity was measured by the 6-min walking distance test, disease severity by spirometric tests, HRQL by The St. George's Respiratory Questionnaire and psychological distress by the The Hospital Anxiety and Depression Scale. Variables on socio-demography and co-morbidity were self-reported. Exercise capacity was improved from baseline to follow-up with a score difference of +44 metres (p = 000). Except for the activity score, HRQL was significantly improved: a change of -3.5 for the symptom score (p = 014), -3.1 for the total score (p = 003) and a clinical significant change of - 4.0 for the impact score (p = 002). The anxiety score did not change significantly after rehabilitation (-0.1, p = 545), though there was a significant reduction of the depression score (-0.8, p = 002) and a 10.4% reduction in the prevalence of possible depression cases (p = 017). Patients with forced expiratory volume in 1 second ≥50% predicted were 4.2 times more likely to achieve a clinical significant improved HRQL after rehabilitation than patients with forced expiratory volume in 1 second <50% predicted (95% confidence interval [CI] 1.7-10.3, p = 002). A 4-week inpatient rehabilitation program improves HRQL and exercise capacity and reduces depression in COPD patients. Patients with mild or moderate disease are more likely to achieve an improved HRQL after rehabilitation than patients with severe or very severe disease.

Effects of pulmonary rehabilitation in bronchiectasis: A retrospective study

There is limited information about the benefits of pulmonary rehabilitation (PR) in patients with bronchiectasis. This study aimed to evaluate the effects of an out-patient PR program in patients with a primary diagnosis of bronchiectasis and to compare them with a matched COPD group who completed the same PR program. A retrospective review was conducted of patients with bronchiectasis or COPD who completed 6 to 8 weeks of PR at two tertiary institutions. The outcome measures were the 6-minute walk distance (6MWD) and Chronic Respiratory Disease Questionnaire (CRQ). Ninety-five patients with bronchiectasis completed the PR (48 male; FEV1 63 [24] % predicted; age 67 [10] years). Significant improvements in 6MWD (mean change 53.4 m, 95% CI 45.0 to 61.7) and CRQ total score (mean change 14.0 units, 95% CI 11.3 to 16.7) were observed immediately following PR. In patients with complete follow-up (n = 37), these improvements remained significantly higher than baseline at 12 months (20.5 m, 95% CI 1.4 to 39.5 for 6MWD; 12.1 points, 95% CI 5.7 to 18.4 for CRQ total score). The time trend and changes in the 6MWD and CRQ scores were not significantly different between the bronchiectasis and the COPD groups (all p > 0.05). This study supports the inclusion of patients with bronchiectasis in existing PR programs. Further prospective RCTs are warranted to substantiate these findings.