Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD)

Physicians' Knowledge of Pulmonary Rehabilitation in China: A Cross-Sectional Study

Objective

To investigate the knowledge of pulmonary rehabilitation (PR) among physicians involved in pulmonary disease management.

Methods

This multi-regional cross-sectional survey was conducted from December 12, 2019 to January 22, 2020. The participants were enrolled and an electronic questionnaire was exclusively sent to the members of the Lung Cancer Special Committee of the China Medicine Education Association through the WeChat platform. Multivariable logistic regression analysis was performed to explore the associated factors of high PR knowledge scores (≥ 18 points).

Results

From the 858 valid questionnaires, the routine implementation of PR was only reported for 16.95% of physicians. The main reason hindering the implementation of PR for patients was the limited knowledge and awareness of PR among the physicians involved (69.1%). A total of 618 and 240 physicians had high and low knowledge scores, respectively. Multivariable analysis suggests that the self-perception of PR knowledge (OR = 1.89, 95% CI: 1.32-2.771, P = 0.001) was independently associated with high knowledge scores, while having no theoretical knowledge of PR was associated with poor knowledge scores (OR = 0.43, 95% CI: 0.26-0.72, P = 0.001).

Conclusion

Inadequate knowledge of pulmonary rehabilitation is evident among physicians who are involved in pulmonary disease management in China. This underscores the need for more comprehensive and standardized training to bolster their awareness and effective utilization of pulmonary rehabilitation.

The acceptability, practicality, implementation and efficacy of a physical and social activity intervention 'BreatheHappy' for people with long-term respiratory conditions: A feasibility study

OBJECTIVES

This study aimed to determine the feasibility of a group-based pilot programme of low-to-moderate physical activity training, education and social activities, by investigating acceptability, practicality, implementation and efficacy testing. We offer suggestions on programme adaptions for future study.

METHODS

People with a range of chronic respiratory diseases were invited to participate in a pilot 12 week group activity programme. Activities included outdoor walking, tai-chi, education and a range of social activities. Acceptability was determined by participant experiences determined during interviews. Practicality was determined by programme and outcome measure completion, cost and adverse events. Implementation was determined according to whether the programme ran as planned. Efficacy was determined by statistical analyses of outcomes including hand grip strength, timed up and go test, COPD Helplessness Index, COPD Assessment Test, and measures of physical activity via accelerometry.

RESULTS

Thematic analysis indicated that the "BreatheHappy" programme was acceptable. Seven of nine participants completed eight out of 10 sessions and the majority completed all outcome measures. "BreatheHappy" was therefore considered practical. The programme was not implemented as planned, with only 10 sessions running rather than the 12 intended. There was a significant increase in daily step counts (MD: 1284 95% CI: 240-2329 p: 0.024 effect size: 0.988), stepping time (MD: 16 min 95% CI: 5-27 min p: 0.011 effect size: 1.36) and daily minutes completing light physical activity (MD: 23 95% CI: 6-38 p: 0.006 effect size: 1.6). However, time spent sitting for ≥30 min but ≤60 min significantly increased (MD: 26 95% CI: 0.2-52 min p: 0.049 effect size: 0.931), showing signs of efficacy and changing physical activity behaviour patterns.

DISCUSSION

A 10-week programme of low-moderate physical activity training, education and social activities shows signs of feasibility for future research. Suggested adaptions for future study include using physical activity measures such as daily step count or light physical activity for a primary outcome, and mental health and social health related outcome measures relatable to participant's beneficial experiences of the programme. Recruitment in future studies will try and reach both those less socially active and possibly those who have completed pulmonary rehabilitation (PR). Venues should be close to efficient transport links whilst different frequencies and durations of programme delivery should be trialled. Adequate funding should be provided for both staff running the programme and blinded research staff for outcome measurement.

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.

Development of a physical activity counseling intervention for people with chronic respiratory disease based on the health action process approach

BACKGROUND

Physical activity (PA) counseling holds promise for increasing PA levels in people with chronic respiratory disease, though little long-term change has been shown to date. Here, we describe the development of a Health Action Process Approach-based PA counseling intervention that aims to promote PA and exercise in people with chronic respiratory disease who are enrolled in pulmonary rehabilitation.

METHODS

To collaborate in defining and refining the intervention, we convened a varied team of authors that included a panel of five stakeholder partners: three patients, one clinician, and one health behavior change researcher. We completed three steps in the intervention development process: (1) initial intervention creation, (2) iterative intervention refinement, and (3) assessment of intervention acceptability. In step 1, we created an initial draft of the PA counseling intervention based on the HAPA theoretical framework, previous evidence in people with chronic respiratory disease, and clinical experience. In step 2, we used qualitative methods of focus groups and interviews to further develop and refine the intervention. Fifteen meetings occurred with the five-member stakeholder partner panel (six focus groups with the three patient partners, four interviews with the clinician partner, and five interviews with the researcher partner) over 5 months to systematically elicit input and incorporate it into the intervention. In step 3, we measured the intervention acceptability using five-point Likert scale ratings.

RESULTS

Intervention materials included the eligibility screen, participant workbook, and leader guide. We identified key themes in the input from the stakeholder partners and incorporated this input into the intervention content and methods. Ratings of the intervention by the stakeholder partners (n=5) were high with mean ratings ranging 4.0-5.0 on a five-point scale.

CONCLUSIONS

This development process successfully engaged an intervention development team with diverse perspectives and resulted in a PA counseling intervention for people with chronic respiratory disease. The intervention's strong theoretical underpinning, person-centeredness, and the contributions from varied perspectives during intervention development position it well for future evaluations of feasibility, efficacy, and effectiveness.

Sustaining training effects through physical activity coaching (STEP): a randomized controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) programs improve physical fitness, symptoms and quality of life (QoL) of patients with COPD. However, improved physical activity (PA) is not guaranteed after PR and the clinical benefits fade off after PR discharge. We aimed to investigate whether a 9 months PA-telecoaching program is able to improve PA of patients with COPD, after 3 months of PR and if this leads to maintenance of PR-acquired benefits.

METHODS

Patients with COPD enrolled in a 6-month PR program were randomized to a (semi-automated) PA-telecoaching program or usual care, 3 months after PR initiation. The intervention consisted of a smartphone application with individual targets and feedback (for 6 months) and self-monitoring with a step counter (for 9 months). Patients were followed up for 9 months after randomization. Primary outcome was PA (daily step count by accelerometery), secondary outcomes were exercise tolerance, quadriceps force, dyspnea and QoL.

RESULTS

Seventy-three patients were included (mean ± SD: 65 ± 7 years, FEV1 49 ± 19%, 6MWD 506 ± 75 m, PA 5225 ± 2646 steps/day). The intervention group presented a significant improvement in steps/day at every visit compared to usual care (between-group differences mean ± SE: 1431 ± 555 steps/day at 9 months after randomization, p = 0.01). Secondary outcomes did not differ between the groups.

CONCLUSION

The semi-automated PA-telecoaching program implemented after 3 months of PR was effective to improve the amount of PA (steps/day) during PR and after follow-up. However, this was not accompanied by the maintenance of other PR-acquired benefits.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT02702791. Retrospectively registered on March 9, 2016. Start study October 2015. https://clinicaltrials.gov/ct2/show/NCT02702791?term=NCT02702791&draw=2&rank=1 .

Development of a complex exercise rehabilitation intervention for people with pulmonary hypertension: the supervised pulmonary hypertension exercise rehabilitation (SPHERe) trial

BACKGROUND

People with pulmonary hypertension (PH) are not routinely referred for exercise rehabilitation despite the potential for reducing breathlessness and improving quality of life. We describe the development of a supervised pulmonary hypertension exercise rehabilitation (SPHERe) programme for people with PH.

METHODS

Development was completed in three phases: (1) systematic review, (2) stakeholder engagement with consensus from patients and experts and (3) prepilot intervention acceptability testing. We completed systematic reviews to identify international cardiopulmonary rehabilitation guidance and trials of exercise-based interventions for people with PH. Evidence from systematic reviews and stakeholder consensus shaped the SPHERe intervention, including addition of individual behavioural support sessions to promote exercise adherence. The draft SPHERe intervention was ratified through discussions with multidisciplinary professionals and people living with PH. We acceptability tested the centre-based intervention with eight participants in a prepilot development phase which identified a number of condition-specific issues relating to safety and fear avoidance of activity. Comprehensive intervention practitioner training manuals were produced to ensure standardised delivery. Participant workbooks were developed and piloted. Trial recruitment began in January 2020 but was subsequently suspended in March 2020 further to COVID-19 pandemic 'lockdowns'. In response to the pandemic, we undertook further development work to redesign the intervention to be suitable for exclusively home-based online delivery. Recruitment to the revised protocol began in June 2021.

DISCUSSION

The final SPHERe intervention incorporated weekly home-based online group exercise and behavioural support 'coaching' sessions supervised by trained practitioners, with a personalised home exercise plan and the optional loan of a stationary exercise bike. The intervention was fully manualised with clear pathways for assessment and individualised exercise prescription. The clinical and cost-effectiveness of the SPHERe online rehabilitation intervention is currently being tested in a UK multicentre randomised controlled trial.

TRIAL REGISTRATION NUMBER

ISCRTN10608766.

The effects of an innovative GP-physiotherapist partnership in improving COPD management in primary care

BACKGROUND

Evidence suggests that management of people with Chronic Obstructive Pulmonary Disease (COPD) in primary care has been suboptimal, in particular, with low referral rates to pulmonary rehabilitation (PR). The aim of this study was to evaluate the effectiveness of a GP-physiotherapist partnership in optimising management of COPD in primary care.

METHODS

A pragmatic, pilot, before and after study was conducted in four general practices in Australia. A senior cardiorespiratory physiotherapist was partnered with each general practice. Adults with a history of smoking and/or COPD, aged ≥ 40 years with ≥ 2 practice visits in the previous year were recruited following spirometric confirmation of COPD. Intervention was provided by the physiotherapist at the general practice and included PR referral, physical activity and smoking cessation advice, provision of a pedometer and review of inhaler technique. Intervention occurred at baseline, one month and three months. Main outcomes included PR referral and attendance. Secondary clinical outcomes included changes in COPD Assessment Test (CAT) score, dyspnoea, health activation and pedometer step count. Process outcomes included count of initiation of smoking cessation interventions and review of inhaler technique.

RESULTS

A total of 148 participants attended a baseline appointment where pre/post bronchodilator spirometry was performed. 31 participants with airflow obstruction on post-bronchodilator spirometry (mean age 75yrs (SD 9.3), mean FEV₁% pred = 75% (SD 18.6), 61% female) received the intervention. At three months, 78% (21/27) were referred to PR and 38% (8/21) had attended PR. No significant improvements were seen in CAT scores, dyspnoea or health activation. There was no significant change in average daily step count at three months compared to baseline (mean difference (95% CI) -266 steps (-956 to 423), p = 0.43). Where indicated, all participants had smoking cessation interventions initiated and inhaler technique reviewed.

CONCLUSION

The results of this study suggest that this model was able to increase referrals to PR from primary care and was successful in implementing some aspects of COPD management, however, was insufficient to improve symptom scores and physical activity levels in people with COPD.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx .

Pulmonary Rehabilitation in Persons With COPD

Pulmonary rehabilitation (PR) is a high-value intervention for persons with COPD and other chronic lung diseases. It is associated with improvement in exercise capacity, dyspnea, health-related quality of life, and depression as well as a reduction in hospitalization and improved survival when PR follows COPD-related hospitalizations. PR is underused in the United States and other countries despite strong evidence of both clinical effectiveness and cost-effectiveness. Additional challenges include a lack of equitable reimbursement and poor access, particularly in rural settings. Models, for example, virtual PR, may be an option for improving access but coverage in the United States by Medicare is tenuous. In addition, virtual PR models have considerable heterogeneity, which challenges uniform efficacy and selection of optimal candidates.

An overview of Cochrane systematic reviews for pulmonary rehabilitation interventions in people with chronic obstructive pulmonary disease: a mapping synthesis

INTRODUCTION

There is a global unmet need for rehabilitation to meet which the World Health Organization, in collaboration with Cochrane Rehabilitation, is developing the Package of Interventions for Rehabilitation with the aim of identifying rehabilitation interventions relevant to a range of key health conditions, including chronic obstructive pulmonary disease (COPD). The purpose of this paper is to describe the best available evidence on pulmonary rehabilitation interventions for people with COPD.

EVIDENCE ACQUISITION

An Overview of Cochrane Systematic Reviews (CSRs). Through the search strategy, COPD-related systematic reviews published from January 2009 to November 2021 were identified. Data were extracted on each reported outcome related to an intervention and judgements about the quality of evidence were made, using the GRADE approach.

EVIDENCE SYNTHESIS

Seventeen reviews were analyzed, for a total of 314 primary studies that included 22,206 participants. CSRs provided information on the effectiveness of rehabilitation on functioning, activity, quality of life, anxiety, depression, mortality, and health care resource utilization.

CONCLUSIONS

Our findings report that comprehensive pulmonary rehabilitation programs and water exercises improve the exercise capacity and quality of life (QoL) in people with COPD. Different exercise modalities, intensities, and settings for different muscle groups, breathing exercises, and counseling can improve exercise capacity, QoL, dyspnea, hospitalizations, and physical activity. It is uncertain whether breathing exercise, low-intensity exercise, neuromuscular electrical stimulation, and psychological intervention have an effect on exercise capacity, dyspnea, QoL, and physical activity. The protocol was registered on OSF (registration DOI: 10.17605/OSF.IO/8A26Q).

Experiences of Using an Electronic Health Tool Among Health Care Professionals Involved in Chronic Obstructive Pulmonary Disease Management: Qualitative Analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the most common and deadliest chronic diseases of the 21st century. eHealth tools are seen as a promising way of supporting health care professionals in providing evidence-based COPD care, for example, by reinforcing information and interventions provided to the patients and providing easier access and support to the health care professional themselves. Still, knowledge is scarce on the experience of using eHealth tools from the perspective of the health care professional involved in COPD management.

OBJECTIVE

The study explored the experiences of using an eHealth tool among health care professionals that worked with patients with COPD in their daily clinical practice.

METHODS

This exploratory qualitative study is part of a process evaluation in a parallel group, controlled, pragmatic pilot trial. Semistructured interviews were performed with 10 health care professionals 3 and 12 months after getting access to an eHealth tool, the COPD Web. The COPD Web, developed using cocreation, is an interactive web-based platform that aims to help health care professionals provide health-promoting strategies. Data from the interviews were analyzed using qualitative content analysis with an inductive approach.

RESULTS

The main results reflected health care professionals' experiences in 3 categories: receiving competence support and adjusting practice, improving quality of care, and efforts required for implementation. These categories highlighted that using an eHealth tool such as the COPD Web was experienced to provide knowledge support for health care professionals that led to adaptation and facilitation of working procedures and person-centered care. Taken together, these changes were perceived to improve the quality of care through enhanced patient contact and encouragement of interprofessional collaboration. In addition, health care professionals expressed that patients using the COPD Web were better equipped to tackle their disease and adhered better to provided treatment, increasing their self-management ability. However, structural and external barriers bar the successful implementation of an eHealth tool in daily praxis.

CONCLUSIONS

This study is among the first to explore experiences of using an eHealth tool among health care professionals involved in COPD management. Our novel findings highlight that using an eHealth tool such as the COPD Web may improve the quality of care for patients with COPD (eg, by providing knowledge support for health care professionals and adapting and facilitating working procedures). Our results also indicate that an eHealth tool fosters collaborative interactions between patients and health care professionals, which explains why eHealth is a valuable means of encouraging well-informed and autonomous patients. However, structural and external barriers requiring time, support, and education must be addressed to ensure that an eHealth tool can be successfully implemented in daily praxis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02696187; https://clinicaltrials.gov/ct2/show/NCT02696187.

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.

Dyspnea: a map of Cochrane evidence relevant to rehabilitation for people with post COVID-19 condition

INTRODUCTION

Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective on the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in their Guidelines. With this overview of reviews with mapping we aimed to synthesize in a map the Cochrane evidence relevant to rehabilitation for dyspnea due to PCC.

EVIDENCE ACQUISITION

We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "dyspnea" and its synonyms in the Cochrane Library. We extracted and summarized all the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence.

EVIDENCE SYNTHESIS

We found 371 CSRs published between 2016 and 2021 and included 15 in this overview. We found eight studies on chronic obstructive pulmonary disease, two on cancer, and one for bronchiectasis, chronic respiratory disease, cystic fibrosis, idiopathic pulmonary fibrosis and interstitial lung disease. Effective interventions included pulmonary rehabilitation, also in combination with exercise training, non-invasive ventilation, upper limb training and multicomponent integrated interventions, with very low- to moderate-quality evidence.

CONCLUSIONS

These results are the first step of indirect evidence to generate helpful hypotheses for clinical practice and future research on dyspnea in adults with PCC. They served as the basis for one recommendation on treatments for dyspnea as a PCC symptom published in the current WHO Guidelines for clinical practice.

Fatigue, post-exertional malaise and orthostatic intolerance: a map of Cochrane evidence relevant to rehabilitation for people with post COVID-19 condition

INTRODUCTION

Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post-COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective for the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in their Guidelines. With this overview of reviews with mapping, we aimed to synthesize in a map the Cochrane evidence relevant to rehabilitation for fatigue, post-exertional malaise and orthostatic intolerance due to PCC.

EVIDENCE ACQUISITION

We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "fatigue," "orthostatic intolerance," "rehabilitation" and their synonyms in the Cochrane Library. We extracted and summarized the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence.

EVIDENCE SYNTHESIS

Out of 1397 CSRs published between 2016 and 2021, we included 32 for fatigue and 4 for exercise intolerance. They provided data from 13 health conditions, with cancer (11 studies), chronic obstructive pulmonary disease (7 studies), fibromyalgia (4 studies), and cystic fibrosis (3 studies) being the most studied. Effective interventions for fatigue included exercise training and physical activities, telerehabilitation and multicomponent and educational interventions. Effective interventions for exercise intolerance included combined aerobic/anaerobic training and integrated disease rehabilitation management. The overall quality of evidence was low to very low and moderate in very few cases. We did not identify CSRs that specifically addressed post-exertional malaise or orthostatic intolerance.

CONCLUSIONS

These results are the first step of indirect evidence able to generate helpful hypotheses for clinical practice and future research. They served as the basis for the three recommendations on treatments for these PCC symptoms published in the current WHO Guidelines for clinical practice.

Individually tailored home-based physiotherapy program makes sustainable improvement in exercise capacity and daily physical activity in patients with pulmonary arterial hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare, chronic, progressive, and life-threatening cardiopulmonary disease. This study investigated the impact of an individually tailored 12 weeks home-based physiotherapy program in PAH patients, with the aim to evaluate change in exercise capacity and daily physical activity level.

METHODS

This was an analysis of secondary outcomes from a prospective, randomized, controlled intervention study. Twenty-one participants were recruited from the Latvian PH registry based on inclusion criteria and randomized in a training group (TG) and control group (CG). Both groups continued a medical target therapy, but for TG, the individually tailored home-based physiotherapy program was added including physical exercises, relaxation, self-control, education, and supervision with telehealth elements. Outcomes included a 6-min walk test (6MWT) (m) and daily physical activity based on accelerometry results assessed at baseline, after 12 weeks, and at follow-up 6 months after commencement of intervention.

RESULTS

6MWT distance significantly (p < 0.05) and clinically (>33 m) increased within TG after 12 weeks (51.8 m, 95% CI = 25.7-77.9 m, Cohen's d = 1.7) and at follow-up (75.5 m, 95% CI = 46.1-104.8 m, Cohen's d = 2.1). A significant difference in 6MWT results between the groups at 12 weeks and follow-up was approved. In TG, low-intensity activities significantly (p < 0.05) increased both after 12 weeks (Cohen's d = 1.6) and at follow-up (Cohen's d = 1.2), moderate-intensity activities significantly (p < 0.05) increased at follow-up (Cohen's d = 1.3), and no significant improvements were present in CG.

CONCLUSION

The individually tailored 12 weeks home-based physiotherapy program comprising comprehensive physical exercise training, relaxation, self-control skills training, and education, added to stable medical target therapy and supervised by physiotherapist through telehealth elements, is effective in improving exercise capacity and increasing daily time in low or moderate physical activities 6 months after commencement of the intervention in patients with PAH.

Daily Physical Activity in Asthma and the Effect of Mepolizumab Therapy

For the various asthma-specific beneficial effects of physical activity, daily physical activity (DPA) and the potential of asthma therapies on DPA require better characterization. Hence, we aimed to determine (a) the DPA of asthma patients, and (b) the effect of add-on mepolizumab on the DPA of severe asthma patients. Methods: Adult outpatients with mild-to-moderate or severe asthma had accelerometer assessment of DPA. Severe asthma patients who were commenced on mepolizumab had their DPA reassessed after 12 months. Results: For the total cohort (n = 36), daily step count, time in moderate-to-vigorous physical activity (MVPA), MVPA volume and Movement Intensity (MI) were 7806 ± 3823 steps, 123 (interquartile range, 63) min, 657 ± 255 MET·min and 1.96 (0.45) m/s², respectively. All patients met at least one recommendation for DPA but less than half met recommendations for vigorous DPA. Patients on mepolizumab therapy increased daily step count (646 steps; 9%), time in MVPA (20 min; 21%), MVPA volume (87 MET·min; 17%) and MI (0.11 m/s²; 6%) for the same amount of moving time; lung function, asthma control and health-related quality of life also improved. Conclusions: Analysis of the first national data on DPA in asthma and novel comparison against current applicable guidelines and identified beneficial thresholds showed borderline levels of DPA with room for improvement especially for severe asthma patients. In a non-sedentary cohort of severe asthma patients, mepolizumab conferred significant and meaningful improvements in DPA.

Pharmacological, Nutritional, and Rehabilitative Interventions to Improve the Complex Management of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease: A Narrative Review

Osteoporosis is a highly prevalent condition affecting a growing number of patients affected by chronic obstructive pulmonary disease (COPD), with crucial implications for risk of fragility fractures, hospitalization, and mortality. Several risk factors have been identified to have a role in osteoporosis development in COPD patients, including corticosteroid therapy, systemic inflammation, smoke, physical activity levels, malnutrition, and sarcopenia. In this scenario, a personalized multitarget intervention focusing on the pathological mechanisms underpinning osteoporosis is mandatory to improve bone health in these frail patients. Specifically, physical exercise, nutritional approach, dietary supplements, and smoke cessation are the cornerstone of the lifestyle approach to osteoporosis in COPD patients, improving not only bone health but also physical performance and balance. On the other hand, pharmacological treatment should be considered for both the prevention and treatment of osteoporosis in patients at higher risk of fragility fractures. Despite these considerations, several barriers still affect the integration of a personalized approach to managing osteoporosis in COPD patients. However, digital innovation solutions and telemedicine might have a role in optimizing sustainable networking between hospital assistance and community settings to improve bone health and reduce sanitary costs of the long-term management of COPD patients with osteoporosis.

Pulmonary rehabilitation versus usual care for adults with asthma

BACKGROUND

Asthma is a respiratory disease characterised by variable airflow limitation and the presence of respiratory symptoms including wheeze, chest tightness, cough and/or dyspnoea. Exercise training is beneficial for people with asthma; however, the response to conventional models of pulmonary rehabilitation is less clear.

OBJECTIVES

To evaluate, in adults with asthma, the effectiveness of pulmonary rehabilitation compared to usual care on exercise performance, asthma control, and quality of life (co-primary outcomes), incidence of severe asthma exacerbations/hospitalisations, mental health, muscle strength, physical activity levels, inflammatory biomarkers, and adverse events.

SEARCH METHODS

We identified studies from the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, from their inception to May 2021, as well as the reference lists of all primary studies and review articles.

SELECTION CRITERIA

We included randomised controlled trials in which pulmonary rehabilitation was compared to usual care in adults with asthma. Pulmonary rehabilitation must have included a minimum of four weeks (or eight sessions) aerobic training and education or self-management. Co-interventions were permitted; however, exercise training alone was not.  DATA COLLECTION AND ANALYSIS: Following the use of Cochrane's Screen4Me workflow, two review authors independently screened and selected trials for inclusion, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. We contacted study authors to retrieve missing data. We calculated between-group effects via mean differences (MD) or standardised mean differences (SMD) using a random-effects model. We evaluated the certainty of evidence using GRADE methodology.

MAIN RESULTS

We included 10 studies involving 894 participants (range 24 to 412 participants (n = 2 studies involving n > 100, one contributing to meta-analysis), mean age range 27 to 54 years). We identified one ongoing study and three studies awaiting classification. One study was synthesised narratively, and another involved participants specifically with asthma-COPD overlap. Most programmes were outpatient-based, lasting from three to four weeks (inpatient) or eight to 12 weeks (outpatient). Education or self-management components included breathing retraining and relaxation, nutritional advice and psychological counselling. One programme was specifically tailored for people with severe asthma.  Pulmonary rehabilitation compared to usual care may increase maximal oxygen uptake (VO2 max) after programme completion, but the evidence is very uncertain for data derived using mL/kg/min (MD between groups of 3.63 mL/kg/min, 95% confidence interval (CI) 1.48 to 5.77; 3 studies; n = 129) and uncertain for data derived from % predicted VO2 max (MD 14.88%, 95% CI 9.66 to 20.1%; 2 studies; n = 60). The evidence is very uncertain about the effects of pulmonary rehabilitation compared to usual care on incremental shuttle walk test distance (MD between groups 74.0 metres, 95% CI 26.4 to 121.4; 1 study; n = 30). Pulmonary rehabilitation may have little to no effect on VO2 max at longer-term follow up (9 to 12 months), but the evidence is very uncertain (MD -0.69 mL/kg/min, 95% CI -4.79 to 3.42; I2 = 49%; 3 studies; n = 66). Pulmonary rehabilitation likely improves functional exercise capacity as measured by 6-minute walk distance, with MD between groups after programme completion of 79.8 metres (95% CI 66.5 to 93.1; 5 studies; n = 529; moderate certainty evidence). This magnitude of mean change exceeds the minimally clinically important difference (MCID) threshold for people with chronic respiratory disease. The evidence is very uncertain about the longer-term effects one year after pulmonary rehabilitation for this outcome (MD 52.29 metres, 95% CI 0.7 to 103.88; 2 studies; n = 42). Pulmonary rehabilitation may result in a small improvement in asthma control compared to usual care as measured by Asthma Control Questionnaire (ACQ), with an MD between groups of -0.46 (95% CI -0.76 to -0.17; 2 studies; n = 93; low certainty evidence); however, data derived from the Asthma Control Test were very uncertain (MD between groups 3.34, 95% CI -2.32 to 9.01; 2 studies; n = 442). The ACQ finding approximates the MCID of 0.5 points. Pulmonary rehabilitation results in little to no difference in asthma control as measured by ACQ at nine to 12 months follow-up (MD 0.09, 95% CI -0.35 to 0.53; 2 studies; n = 48; low certainty evidence). Pulmonary rehabilitation likely results in a large improvement in quality of life as assessed by the St George's Respiratory Questionnaire (SGRQ) total score (MD -18.51, 95% CI -20.77 to -16.25; 2 studies; n = 440; moderate certainty evidence), with this magnitude of change exceeding the MCID. However, pulmonary rehabilitation may have little to no effect on Asthma Quality of Life Questionnaire (AQLQ) total scores, with the evidence being very uncertain (MD 0.87, 95% CI -0.13 to 1.86; 2 studies; n = 442). Longer-term follow-up data suggested improvements in quality of life may occur as measured by SGRQ (MD -13.4, 95% CI -15.93 to -10.88; 2 studies; n = 430) but not AQLQ (MD 0.58, 95% CI -0.23 to 1.38; 2 studies; n = 435); however, the evidence is very uncertain. One study reported no difference between groups in the proportion of participants who experienced an asthma exacerbation during the intervention period. Data from one study suggest adverse events attributable to the intervention are rare.  Overall risk of bias was most commonly impacted by performance bias attributed to a lack of participant blinding to knowledge of the intervention. This is inherently challenging to overcome in rehabilitation studies.  AUTHORS' CONCLUSIONS: Moderate certainty evidence shows that pulmonary rehabilitation is probably associated with clinically meaningful improvements in functional exercise capacity and quality of life upon programme completion in adults with asthma. The certainty of evidence relating to maximal exercise capacity was very low to low. Pulmonary rehabilitation appears to confer minimal effect on asthma control, although the certainty of evidence is very low to low. Unclear reporting of study methods and small sample sizes limits our certainty in the overall body of evidence, whilst heterogenous study designs and interventions likely contribute to inconsistent findings across clinical outcomes and studies. There remains considerable scope for future research.

Physical activity and chronic obstructive pulmonary disease: a scoping review

Background

Reduced physical activity (PA) was the strongest predictor of all-cause mortality in patients with chronic obstructive pulmonary disease (COPD). This scoping review aimed to map the evidence on the current landscape of physical activity, barriers and facilitators, and assessment tools across COPD patients.

Methods

Arksey and O’Malley’s scoping review methodology framework guided the conduct of this review. An electronic search was conducted on five English databases (PubMed, Cochrane Library, PsycINFO, CINAHL and Web of Science) and three Chinese databases (CNKI, CQVIP and WAN-FANG) in January 2022. Two authors independently screened the literature, extracted the studies characteristics.

Results

The initial search yielded 4389 results, of which 1954 were duplicates. Of the remaining 135 articles, 42 studies met the inclusion criteria. Among the reviewed articles, there were 14 (33.3%) cross-sectional study, 9 (21.4%) cohort study, 4 (9.5%) longitudinal study, 3 qualitative study, 12 (28.7%) randomized control trials. The main barriers identified were older age, women, lung function, comorbidities, COPD symptoms (fear of breathlessness and injury, severe fatigue, anxiety and depression), GOLD stage, frequency of exacerbation, oxygen use, lack of motivation and environment-related (e.g., season and weather). Twelve studies have evaluated the effects of physical exercise (e.g., walking training, pulmonary rehabilitation (PR), pedometer, self-efficacy enhancing intervention and behavioral modification intervention) on PA and showed significant positive effects on the prognosis of patients. However, in real life it is difficult to maintain PA in people with COPD.

Conclusions

Changing PA behavior in patients with COPD requires multidisciplinary collaboration. Future studies need to identify the best instruments to measure physical activity in clinical practice. Future studies should focus on the effects of different types, time and intensity of PA in people with COPD and conduct randomized, adequately-powered, controlled trials to evaluate the long-term effectiveness of behavioral change interventions in PA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02099-4.

Supporting Behavior Change After AECOPD - Development of a Hospital-Initiated Intervention Using the Behavior Change Wheel

After hospitalization due to acute COPD exacerbations, patient-manageable behaviors influence rehospitalization frequency. This study's aim was to develop a hospital-ward-initiated Behaviour-Change-Wheel (BCW)-based intervention targeting patients' key health behaviors, with the aim to increase quality of life and reduce rehospitalization frequency. Intervention development was performed by University Hospital Zurich working groups and followed the three BCW stages for each of the three key literature-identified problems: insufficient exacerbation management, lack of physical activity and ongoing smoking. In stage one, by analyzing published evidence - including but not limited to patients' perspective - and health professionals' perspectives regarding these problems, we identified six target behaviors. In stage two, we identified six corresponding intervention functions. As our policy category, we chose developing guidelines and service provision. For stage three, we defined eighteen basic intervention packages using 46 Behaviour Change Techniques in our basic intervention. The delivery modes will be face-to-face and telephone contact. In the inpatient setting, this behavioral intervention will be delivered by a multi-professional team. For at least 3 months following discharge, an advanced nursing practice team will continue and coordinate the necessary care package via telephone. The intervention is embedded in a broader self-management intervention complemented by integrated care components. The BCW is a promising foundation upon which to develop our COPD intervention. In future, the interaction between the therapeutic care team-patient relationships and the delivery of the behavioral intervention will also be evaluated.

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.

Behaviour change and physical activity interventions for physical activity engagement in community dwelling adults with chronic obstructive pulmonary disease: protocol for a systematic review

Background: Chronic obstructive pulmonary disease (COPD) is a complex respiratory disease and the third leading cause of death worldwide. Pulmonary rehabilitation is recognised as the gold standard of care in the management of COPD, however engagement with pulmonary rehabilitation is low and maintenance of a physically active lifestyle in community dwelling adults with COPD is poor. Supporting positive behaviour change in people with COPD could help to increase their engagement with physical activity. This systematic review will examine behaviour change and physical activity interventions delivered to community dwelling adults with COPD with the aim of increasing physical activity engagement. Interventions will be mapped against Michie’s theoretical domains framework (TDF) to inform clinical practice and health policy.

Methods: The following databases will be searched from inception until December 2021: Web of Science, CENTRAL, MEDLINE (via EBSCO), EMBASE, APA PsychINFO, CINAHL (via EBSCO), AMED, PROSPERO, Cochrane Airways Trials Register. Reference lists of the relevant studies and grey literature will be searched using Grey Literature Report, Open Grey and Google Scholar search engines. Relevant studies will be systematically reviewed and subject to quality appraisal to determine the impact of behaviour change and physical activity interventions on outcomes of community-dwelling adults with COPD. Interventions will be mapped to Michie’s TDF and a narrative synthesis with respect to nature, effectiveness on target population and setting/environment will be provided. Findings will be reported in relation to the generalisability of the primary results and research question, and will include secondary findings on quality of life, self-reported participation in physical activity, exercise capacity, adverse events and intervention adherence. The review will be presented according to the PRISMA guidelines 2020.

Conclusions: This systematic review is necessary to explain the impact of behaviour change and physical activity interventions on outcomes of community dwelling people with COPD.

PROSPERO registration: CRD42021264965 (29.06.2021)

Prediction of Low-intensity Physical Activity in Stable Patients with Chronic Obstructive Pulmonary Disease

OBJECTIVE

To develop an equation of the predicted amount of low-intensity physical activity (LPA) by analyzing clinical parameters in patients with chronic obstructive pulmonary disease (COPD).

METHODS

In this cross-sectional study, we analyzed the assessments of clinical parameters evaluated every 6 months from the start of pulmonary rehabilitation in 53 outpatients with stable COPD (age 77 ± 6 yrs; 46 men; body mass index 21.8 ± 4.1 kg/m²; forced expiratory volume in one second 63.0 ± 26.4% pred). An uniaxial accelerometer was used to measure the number of steps and the time spent in LPA of 1.8-2.3 metabolic equivalents during 14 consecutive days. We also evaluated body composition, respiratory function, skeletal muscle strength, inspiratory muscle strength, exercise capacity, and gait speed. Factors associated with the time spent in LPA were examined by multivariate regression analysis. Internal validity between the predicted amount of LPA obtained by the equation and the measured amount was examined by regression analysis.

RESULTS

Multivariate regression analysis revealed that gait speed (β = 0.369, p = 0.007) and maximum inspiratory mouth pressure (PI_max) (β = 0.329, p = 0.016) were significant influence factors on LPA (R² = 0.354, p <0.001). The stepwise regression analysis showed a moderate correlation between the measured amount and predicted amount of LPA calculated by the regression equation (r = 0.609, p <0.001; LPA = 31.909 × gait speed + 0.202 × PI_max - 20.553).

CONCLUSION

Gait speed and PI_max were extracted as influence factors on LPA, suggesting that the regression equation could predict the amount of LPA.

Linguistic Validation of the Japanese Version of the Multidimensional Dyspnea Profile and Relation to Physical Activity in Patients with COPD

Purpose

This study aimed to develop a linguistically validated Japanese translation of the multidimensional dyspnea profile (MDP) and assess whether worsening of dyspnea’s sensory and affective domains during exercise had detrimental effects on physical activity in stable outpatients with chronic obstructive pulmonary disease (COPD).

Materials and Methods

The Japanese version of the MDP was prepared in collaboration with Mapi Research Trust (Lyon, France) after the approval of the developer. Physical activity was assessed using a 3-axis accelerometer. Dyspnea upon exertion was investigated using a 3-minute step test.

Results

The Japanese version of the MDP was obtained and validated linguistically. Air-hunger was significantly associated with total calories from walking (r = − 0.47, p < 0.05), while anxiety and depression were significantly correlated with both the amount and intensity of physical activity (r = − 0.49, p < 0.05, and r = − 0.46, p < 0.05, respectively).

Conclusion

The Japanese version of the MDP was suggested to reflect both pulmonary functions, ventilatory response during exercise, and intensity and amount of physical activity in patients with COPD.

Effect of a New Tele-Rehabilitation Program versus Standard Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease

In chronic obstructive pulmonary disease (COPD), rehabilitation is recommended, but attendance rates are low. Tele-rehabilitation may be key. We evaluate the effect of a tele-rehabilitation program vs. standard rehabilitation on COPD. A randomized, non-inferiority study comparing eight weeks of tele-rehabilitation (physiotherapist video/chat-consultations and workout sessions with a virtual-autonomous-physiotherapist-agent (VAPA)) and standard rehabilitation in stable patients with COPD. At baseline, after 8 weeks and 3 and 6 months of follow-up, 6 min walk test distance (6MWTD), 7-day pedometry, quality of life, exercise tolerance, adherence, patient satisfaction and safety were assessed. Fifty-four patients (70 ± 9 years, male 57%, FEV1% 34.53 ± 11.67, FVC% 68.8 ± 18.81, 6MWT 376.23 ± 92.02) were included. Twenty-seven patients were randomized to tele-rehabilitation. Non-inferiority in Δ6MWTD at 8 weeks (47.4 ± 31.4), and at 3 (56.0 ± 38.0) and 6 (95.2 ± 47.1) months follow-up, was observed. No significant difference was observed in 7-day pedometry or quality of life. In the intervention group, 6MWTD increased by 25% and 66% at 3 and 6 months, respectively; adherence was 81%; and patient satisfaction was 4.27 ± 0.77 (Likert scale 0-5). Non-inferiority between groups and high adherence, patient satisfaction and safety in the intervention group were found after rehabilitation and at 3 and 6 months of follow-up. Tele-rehabilitation with VAPA seems to be a promising alternative.

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

Background

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

Method

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

Results

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

Conclusion

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

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.

The ability of physical activity in reducing mortality risks and cardiovascular loading and in extending life expectancy in patients with COPD

For chronic obstructive pulmonary disease (COPD), the role of physical activity in reducing COPD mortality and heart loading and in extending life expectancy remains unclear. Participants in comprehensive medical screening were recruited with spirometry on everyone. We analyzed physical activity volume calculated from intensity, duration and frequency of self-reported exercise history. Deaths were identified from the National Death File. The impacts of physical activity on mortality, heart rate and life expectancy were analyzed. Among the cohort of 483,603 adults, 32,535 had spirometry-determined COPD, indicating an adjusted national prevalence of 11.4% (male) and 9.8% (female). On the average, COPD increased all-cause mortality with a hazard ratio of 1.44 and loss of 6.0 years in life expectancy. Almost two thirds (65%) of the causes of deaths were extra-pulmonary, such as cardiovascular disease, diabetes, cancer and kidney diseases. In addition, COPD was associated with increases in heart rate proportionate to its severity, which led to higher mortality. Participants with COPD who were fully active physically could reduce mortality and have improved heart rates as compared with those without physical activity. In addition, their life expectancy could be extended close to those of the no COPD but inactive cohort. Fully active physical activity can help patients with COPD overcome most of the mortality risks, decrease heart rate, and achieve a life expectancy close to that of patients without COPD. The effectiveness of physical activity on COPD is facilitated by its systemic nature beyond lung disease.

Behaviour change and physical activity interventions for physical activity engagement in community dwelling adults with chronic obstructive pulmonary disease: protocol for a systematic review

Background: Chronic obstructive pulmonary disease (COPD) is a complex respiratory disease and the third leading cause of death worldwide. Pulmonary rehabilitation is recognised as the gold standard of care in the management of COPD, however engagement with pulmonary rehabilitation is low and maintenance of a physically active lifestyle in community dwelling adults with COPD is poor. Supporting positive behaviour change in people with COPD could help to increase their engagement with physical activity. This systematic review will examine behaviour change and physical activity interventions delivered to community dwelling adults with COPD with the aim of increasing physical activity engagement. Interventions will be mapped against Michie’s theoretical domains framework (TDF) to inform clinical practice and health policy. Methods: The following databases will be searched from inception until December 2021: Web of Science, CENTRAL, MEDLINE (via EBSCO), EMBASE, APA PsychINFO, CINAHL (via EBSCO), AMED, PROSPERO, Cochrane Airways Trials Register. Reference lists of the relevant studies and grey literature will be searched using Grey Literature Report, Open Grey and Google Scholar search engines. Relevant studies will be systematically reviewed and subject to quality appraisal to determine the impact of behaviour change and physical activity interventions on outcomes of community-dwelling adults with COPD. Interventions will be mapped to Michie’s TDF and a narrative synthesis with respect to nature, effectiveness on target population and setting/environment will be provided. Findings will be reported in relation to the generalisability of the primary results and research question, and will include secondary findings on quality of life, self-reported participation in physical activity, exercise capacity, adverse events and intervention adherence. The review will be presented according to the PRISMA guidelines 2020. Conclusions: This systematic review is necessary to explain the impact of behaviour change and physical activity interventions on outcomes of community dwelling people with COPD. PROSPERO registration: CRD42021264965 (29.06.2021)

High 24-Hour Respiratory Symptoms and Low Physical Activity in the Stable COPD Romanian Cohort of SPACE Study

Objective

This study assessed the characteristics and the relationship between symptoms in any part of the 24-hour (24-h) day, physical activity level (PAL), and other clinical and functional outcomes in stable COPD patients.

Patients and Methods

Out of the 2162 patients enrolled in the SPACE study (The Symptoms and Physical Activity in COPD patients in Europe, clinicaltrials.gov NCT03031769), 406 (18.8%) were recruited from Romania. Here, we present the Romanian cohort results. Eligible patients were adults with age at least 40 years, confirmed diagnosis of stable COPD, current or former smokers with a smoking history of minimum 10 pack-years. The 24-h respiratory symptoms were assessed using Early Morning Symptoms of COPD Instrument (EMSCI), Evaluating Respiratory Symptoms in COPD (E-RS™: COPD) and Nighttime Symptoms of COPD Instrument (NiSCI). During clinical interview, patients self-evaluated PAL through Exercise as Vital Sign (EVS) and Yale Physical Activity Survey (YPAS). Physicians assessed PAL through their clinical judgment.

Results

For each combination of 2 between the early morning (EM), daytime (DT) and night-time (NT) symptoms of the 24-h day, there was a significant association (p < 0.001 for each). All symptoms significantly correlated with exacerbation history (p < 0.001 for EM and NT, p=0.002 for DT), and number of severe exacerbations (p < 0.001 for DT, p=0.001 for EM and p=0.026 for NT, respectively). The 24-h symptoms correlated negatively and significantly with PAL (p < 0.001), irrespective of the assessment used. Self-reported PAL negatively correlated with dyspnea, symptom burden, severity of disease and number of exacerbations (p < 0.001). Patients spent an average (standard deviation) of 25.8 (21.0) hours/week performing physical activity. Physicians overestimated their patients' daily PAL.

Conclusion

A negative and significant correlation between the 24-h day symptoms and PAL was identified in stable COPD patients. Physicians need to routinely assess PAL using adequate tools and start educating inactive COPD patients to optimize their disease outcomes.

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

Objective

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

Patients and Methods

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

Results

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

Conclusion

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

Clinical Trial Registration

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

Long-Term Benefits of Adding a Pedometer to Pulmonary Rehabilitation for COPD: The Randomized Controlled STAR Trial

Purpose

This Stay Active after Rehabilitation (STAR) study examined the effects of a pedometer-based behavioral intervention for individuals with COPD during three weeks of inpatient pulmonary rehabilitation (PR) on patients' physical activity levels six weeks and six months after PR, including steps (primary outcome), moderate-intensity physical activity, and sedentary time as well as patient quality of life, symptoms, and other psychological and clinical variables.

Patients and Methods

Rehabilitation patients with COPD wore a triaxial accelerometer (ActiGraph wGT3X) for seven days two weeks before (T0) as well as six weeks (T3) and six months (T4) after PR. In addition to the three-week inpatient PR (control group, CG), the randomly allocated intervention group (IG) received a brief pedometer-based behavioral intervention with the application of the following behavior-change techniques: performing the behavior, individual goal-setting, self-monitoring, and feedback. The effects were analyzed using analysis of covariance with an intention-to-treat approach.

Results

A total of 327 patients (69% male, age: 58 years, FEV₁ (%): 53.5, six-minute walk distance: 447.8 m) were randomly allocated to either the IG (n = 167) or CG (n = 160). Although both groups increased their daily steps after PR (IG: M_T3-T0 = 1152, CG: M_T3-T0 = 745; IG: M_T4-T0 = 795, CG: M_T4-T0 = 300), the slightly higher increases in daily steps in the IG compared to the CG at T3 (Δ388 steps, d = 0.16) and T4 (Δ458 steps, d = 0.15) were not statistically significant (p > 0.05 for all). Patients in both groups showed moderate to high pre-post-changes in terms of secondary outcomes, but no advantage favoring the IG was found.

Conclusion

The results show that adding a pedometer-based behavioral intervention to standard German three-week inpatient PR for COPD patients did not result in more physical activity in terms of steps and moderate-intensity physical activity or less sedentary time. However, both groups (IG and CG) showed remarkably enhanced physical activity levels six weeks and six months after PR, as well as improvements in other secondary outcomes (eg, quality of life).

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

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

Digital interventions for the management of chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with dyspnoea, cough or sputum production (or both) and affects quality of life and functional status. More efficient approaches to alternative management that may include patients themselves managing their condition need further exploration in order to reduce the impact on both patients and healthcare services. Digital interventions may potentially impact on health behaviours and encourage patient engagement.

OBJECTIVES

To assess benefits and harms of digital interventions for managing COPD and apply Behaviour Change Technique (BCT) taxonomy to describe and explore intervention content.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 28 April 2020). We found other trials at web-based clinical trials registers.

SELECTION CRITERIA

We included RCTs comparing digital technology interventions with or without routine supported self-management to usual care, or control treatment for self-management. Multi-component interventions (of which one component was digital self-management) compared with usual care, standard care or control treatment were included.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. Discrepancies were resolved with a third review author. We assessed certainty of the evidence using the GRADE approach. Primary outcomes were impact on health behaviours, self-efficacy, exacerbations and quality of life, including the St George's Respiratory Questionnaire (SGRQ). The minimally important difference (MID) for the SGRQ is 4 points. Two review authors independently applied BCT taxonomy to identify mechanisms in the digital interventions that influence behaviours.

MAIN RESULTS

Fourteen studies were included in the meta-analyses (1518 participants) ranging from 13 to 52 weeks duration. Participants had mild to very severe COPD. Risk of bias was high due to lack of blinding. GRADE ratings were low to very low certainty due to lack of blinding and imprecision. Common BCT clusters identified as behaviour change mechanisms in interventions were goals and planning, feedback and monitoring, social support, shaping knowledge and antecedents. Digital technology intervention with or without routine supported self-management Interventions included mobile phone (three studies), smartphone applications (one study), and web or Internet-based (five studies). Evidence is very uncertain about effects on impact on health behaviours as measured by six-minute walk distance (6MWD) at 13 weeks (mean difference (MD) 26.20, 95% confidence interval (CI) -21.70 to 74.10; participants = 122; studies = 2) or 23 to 26 weeks (MD 14.31, 95% CI -19.41 to 48.03; participants = 164; studies = 3). There may be improvement in 6MWD at 52 weeks (MD 54.33 95% CI -35.47 to 144.12; participants = 204; studies = 2) but studies were varied (very low certainty). There may be no difference in self-efficacy on managing Chronic Disease Scale (SEMCD) or pulmonary rehabilitation adapted index of self-efficacy tool (PRAISE). Evidence is very uncertain. Quality of life may be slightly improved on the chronic respiratory disease questionnaire (CRQ) at 13 weeks (MD 0.45, 95% CI 0.01 to 0.90; participants = 123; studies = 2; low certainty), but is not clinically important (MID 0.5). There may be little or no difference at 23 or 52 weeks (low to very low certainty). There may be a clinical improvement on SGRQ total at 52 weeks (MD -26.57, 95% CI -34.09 to -19.05; participants = 120; studies = 1; low certainty). Evidence for COPD assessment test (CAT) and Clinical COPD Questionnaire (CCQ) is very uncertain. There may be little or no difference in dyspnoea symptoms (CRQ dyspnoea) at 13, 23 weeks or 52 weeks (low to very low certainty evidence) or mean number of exacerbations at 26 weeks (low-certainty evidence). There was no evidence for the number of people experiencing adverse events. Multi-component interventions Digital components included mobile phone (one study), and web or internet-based (four studies). Evidence is very uncertain about effects on impact on health behaviour (6MWD) at 13 weeks (MD 99.60, 95% CI -15.23 to 214.43; participants = 20; studies = 1). No evidence was found for self-efficacy. Four studies reported effects on quality of life (SGRQ and CCQ scales). The evidence is very uncertain. There may be no difference in the number of people experiencing exacerbations or mean days to first exacerbation at 52 weeks with a multi-component intervention compared to standard care. Evidence is very uncertain about effects on the number of people experiencing adverse events at 52 weeks.

AUTHORS' CONCLUSIONS

There is insufficient evidence to demonstrate a clear benefit or harm of digital technology interventions with or without supported self-management, or multi-component interventions compared to usual care in improving the 6MWD or self-efficacy. We found there may be some short-term improvement in quality of life with digital interventions, but there is no evidence about whether the effect is sustained long term. Dyspnoea symptoms may improve over a longer duration of digital intervention use. The evidence for multi-component interventions is very uncertain and as there is little or no evidence for adverse events, we cannot determine the benefit or harm of these interventions. The evidence base is predominantly of very low certainty with concerns around high risk of bias due to lack of blinding. Given that variation of interventions and blinding is likely to be a concern, future, larger studies are needed taking these limitations in consideration. Future studies are needed to determine whether the small improvements observed in this review can be applied to the general COPD population. A clear understanding of behaviour change through the BCT classification is important to gauge uptake of digital interventions and health outcomes in people with varying severity of COPD. Currently there is no guidance for interpreting BCT components of a digital intervention for changes to health outcomes. We could not interpret the BCT findings to the health outcomes we were investigating due to limited evidence that was of very low certainty. In future research, standardised approaches need to be considered when designing protocols to investigate effectiveness of digital interventions by including a standardised approach to BCT classification in addition to validated behavioural outcome measures that may reflect changes in behaviour.

Comparison of Effect of High-Intensity Interval Training and Aerobic Training on Respiratory Volumes in Female Students

Background

Sedentary lifestyle can cause the deterioration of respiratory indices. The interventions, such as physical activity programs, might prevent such deterioration. This study aimed to compare the effect of high-intensity interval training (HIIT) and aerobic training on the respiratory volumes in female students.

Materials and Methods

In this semi-experimental study, 30 healthy inactive volunteer female students (age: 26.3±4.30 years; height: 1.63±8.36 m; body mass index: 20-28 kg/m²) were divided randomly into two HIIT and aerobic training groups. The aerobic training consisted of three sessions of 50-60 minutes of exercise with an intensity of 70-85% of the maximum heart rate per week for 4 weeks. Additionally, the HIIT program included six repetitions of 4 minutes with an intensity of 90-95% of maximum heart rate for 4 weeks on a treadmill. Spirometry tests were performed to determine lung function before and after the training protocols. The data were analyzed by the independent and dependent t-tests at p < 0.05.

Results

The results showed that aerobic training significantly improved the forced expiratory volume in one second (P=0.045), forced expiratory flow (FEF) within 25-75% (P=0.002), and peak expiratory flow (P=0.003); however, HIIT did not have a significant effect on these indicators. There was no significant difference between the two types of training in any of the indicators except for FEF within 25-75%.

Conclusion

According to the study results, aerobic training might be more effective in the improvement of pulmonary parameters than intense training.

A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) who are less active have lower quality of life, greater risk of exacerbations, and greater mortality than those who are more active. The effectiveness of physical activity interventions may facilitate the addition of game elements to improve engagement. The use of a co-design approach with people with COPD and clinicians as co-designers may also improve the effectiveness of the intervention.

OBJECTIVE

The primary aim of this study is to evaluate the feasibility of a co-designed mobile game by examining the usage of the game, subjective measures of game engagement, and adherence to wearing activity trackers. The secondary aim of this study is to estimate the effect of the game on daily steps and daily moderate-to-vigorous physical activity (MVPA).

METHODS

Participants with COPD who were taking part in the co-design of the active video game (n=9) acted as the experiment group, spending 3 weeks testing the game they helped to develop. Daily steps and MVPA were compared with a control group (n=9) of participants who did not co-design or test the game.

RESULTS

Most participants (8/9, 89%) engaged with the game after downloading it. Participants used the game to record physical activity on 58.6% (82/141) of the days the game was available. The highest scores on the Intrinsic Motivation Inventory were seen for the value and usefulness subscale, with a mean of 6.38 (SD 0.6). Adherence to wearing Fitbit was high, with participants in both groups recording steps on >80% of days. Usage of the game was positively correlated with changes in daily steps but not with MVPA.

CONCLUSIONS

The co-designed mobile app shows promise as an intervention and should be evaluated in a larger-scale trial in this population.

The Gini Coefficient: A New Approach to Assess Physical Activity Inequality in COPD

Increasing physical activity (PA) is a complex and challenging task in patients with chronic obstructive pulmonary disease (COPD). However, some questions are raised regarding the evaluation of PA in these patients: Have all aspects of PA evaluation in patients with COPD already been explored in the scientific literature and clinical practice? What is the clinical importance of assessing PA inequality? PA inequality is defined as the Gini coefficient (Gini_coef) of the PA distribution of a population and is already shown to have implications for public health in the general population. It is a simple tool that might allow a better understanding of PA disparities among different COPD populations, although to our knowledge there is no previous investigation of PA inequality in patients with COPD using the Gini_coef. In this perspective study we have provided examples of the Gini_coef use in different scenarios. Future studies might try to apply it in order to identify subpopulations with higher PA inequality, and perhaps are therefore more prone to benefit most from interventions specifically tailored to promote PA. In summary, we propose the quantification of PA inequality with the Gini_coef as a tool that might allow us to see PA even more comprehensively than we already do, expanding our perspective on PA in patients with COPD.

Long-Term Effects of Pedometer-Based Physical Activity Coaching in Severe COPD: A Randomized Controlled Trial

Background and Objective

Limited evidence on long-term effects of physical activity programs in COPD is available. The aim of the study was to investigate the effects of a three-month program combining physical activity counselling and pedometer-based feedback in addition to usual care, followed by a nine-month unsupervised observation period as compared to usual care in participants with severe to very severe COPD.

Methods

Participants were randomized to either a control group receiving usual care or an intervention group receiving motivational support, an activity diary with an individual step count goal (ie, an increase of ≥15% from baseline) and a pedometer in addition to usual care. The intervention ended after three months and an unsupervised observational period followed until twelve months. Primary outcome was daily step count after one year.

Results

Seventy-four participants were included, 61 (82%) completed the study. Linear regression modelling, adjusted for baseline step count, showed no significant difference in change in step count after 12 months between the groups (Β = 547.33, 95% CI = −243.55/1338.20).

Conclusion

A three-month program combining physical activity counselling and pedometer-based feedback in addition to usual care does not attenuate the declining course of physical activity in participants with severe and very severe COPD during a long term follow-up of one year as compared to usual care. This result was primarily determined by the low intervention response rates to the combined program.

Clinical Trial Registration

www.ClinicalTrials.gov, NCT03114241.

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

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

Patterns of Physical Activity Progression in Patients With COPD

INTRODUCTION

Although mean physical activity in COPD patients declines by 400-500steps/day annually, it is unknown whether the natural progression is the same for all patients. We aimed to identify distinct physical activity progression patterns using a hypothesis-free approach and to assess their determinants.

METHODS

We pooled data from two cohorts (usual care arm of Urban Training [NCT01897298] and PROactive initial validation [NCT01388218] studies) measuring physical activity at baseline and 12 months (Dynaport MoveMonitor). We identified clusters (patterns) of physical activity progression (based on levels and changes of steps/day) using k-means, and compared baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics across patterns.

RESULTS

In 291 COPD patients (mean±SD 68±8 years, 81% male, FEV₁ 59±19%_pred) we identified three distinct physical activity progression patterns: Inactive (n=173 [59%], baseline: 4621±1757 steps/day, 12-month change (Δ): -487±1201 steps/day), ActiveImprovers (n=49 [17%], baseline: 7727±3275 steps/day, Δ:+3378±2203 steps/day) and ActiveDecliners (n=69 [24%], baseline: 11 267±3009 steps/day, Δ: -2217±2085 steps/day). After adjustment in a mixed multinomial logistic regression model using Active Decliners as reference pattern, a lower 6-min walking distance (RRR [95% CI] 0.94 [0.90-0.98] per 10m, P=.001) and a higher mMRC dyspnea score (1.71 [1.12-2.60] per 1 point, P=.012) were independently related with being Inactive. No baseline variable was independently associated with being an Active Improver.

CONCLUSIONS

The natural progression in physical activity over time in COPD patients is heterogeneous. While Inactive patients relate to worse scores for clinical COPD characteristics, Active Improvers and Decliners cannot be predicted at baseline.

How do healthcare professionals perceive physical activity prescription for community-dwelling people with COPD in Australia? A qualitative study

OBJECTIVES

Clinical practice guidelines recommend that people with chronic obstructive pulmonary disease (COPD) should be encouraged to increase their physical activity levels. However, it is not clear how these guidelines are applied in clinical practice. This study aimed to understand the perspectives of respiratory healthcare professionals on the provision of physical activity advice to people with COPD. These perspectives may shed light on the translation of physical activity recommendations into clinical practice.

DESIGN

A qualitative study using thematic analysis.

SETTING

Healthcare professionals who provided care for people with COPD at two major tertiary referral hospitals in Victoria, Australia.

PARTICIPANTS

30 respiratory healthcare professionals including 12 physicians, 10 physical therapists, 4 nurses and 4 exercise physiologists.

INTERVENTIONS

Semistructured voice-recorded interviews were conducted, transcribed verbatim and analysed by two independent researchers using an inductive thematic analysis approach.

RESULTS

Healthcare professionals acknowledged the importance of physical activity for people with COPD. They were conscious of low physical activity levels among such patients; however, few specifically addressed this in consultations. Physicians described limitations including time constraints, treatment prioritisation and perceived lack of expertise; they often preferred that physical therapists provide more comprehensive assessment and advice regarding physical activity. Healthcare professionals perceived that there were few evidence-based strategies to enhance physical activity. Physical activity was poorly differentiated from the prescription of structured exercise training. Although healthcare professionals were aware of physical activity guidelines, few were able to recall specific recommendations for people with COPD.

CONCLUSION

Practical strategies to enhance physical activity prescription may be required to encourage physical activity promotion in COPD care.

Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease: Highly Effective but Often Overlooked

Patients with chronic obstructive pulmonary disease receive a range of treatments including but not limited to inhaled bronchodilators, inhaled and systemic corticosteroids, supplemental oxygen, and pulmonary rehabilitation. Pulmonary rehabilitation is a multidisciplinary intervention that seeks to combine patient education, exercise, and lifestyle changes into a comprehensive program. Programs 6 to 8 weeks in length have been shown to improve health, reduce dyspnea, increase exercise capacity, improve psychological well-being, and reduce healthcare utilization and hospitalization. Although the use of pulmonary rehabilitation is widely supported by the literature, controversy still exists regarding what should be included in the programs. The goal of this review was to summarize the evidence for pulmonary rehabilitation and identify the areas that hold promise in improving its utilization and effectiveness.

Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far.

OBJECTIVES

In people with COPD, which interventions are effective at improving objectively-assessed physical activity?

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies.

SELECTION CRITERIA

We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data.

MAIN RESULTS

We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta2-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training.

AUTHORS' CONCLUSIONS

A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.