Effectiveness of a community-based exercise training programme to increase physical activity level in patients with chronic obstructive pulmonary disease: A randomized controlled trial

Behaviour change interventions for physical activity in adults with chronic obstructive pulmonary disease; A systematic review and meta-analysis

BACKGROUND

Physical activity in adults with COPD is poor, but behaviour change interventions could help improve activity. This systematic review aims to examine behaviour change interventions to promote physical activity and health outcomes for adults with COPD.

METHODS

Eight databases were searched from inception until April 2023: Web of Science, CENTRAL, MEDLINE, EMBASE, APA PsychINFO, CINAHL, PROSPERO, Cochrane Airways Trials Register. Relevant studies were appraised to determine the impact of behaviour change interventions on physical activity outcomes. Interventions were mapped to Michie's Theoretical Domains Framework (TDF) and a meta-analysis and narrative synthesis conducted. The Cochrane risk of bias tool 2 and the GRADE criteria evaluated bias and the quality and certainty of the evidence.

RESULTS

Twelve randomized controlled trials (RCTs) were included in the review (n = 1211). The most frequently utilized behaviour change interventions included counselling, stepcount monitoring, social support and goal setting. The most commonly measured outcomes across studies were steps-per-day, physical activity levels, exercise capacity and quality of life. A meta-analysis of comparable studies demonstrated there was no difference in stepcount in favour of behaviour change interventions with respect to steps-per-day (SMD 0.16, 95 % CI -0.03, 0.36; p = 0.10). There was some evidence of short-term improvement in physical activity and quality of life, with behaviour change interventions related to goals, behaviour regulation and social influences.

CONCLUSIONS

People with COPD may benefit from behaviour change interventions to increase physical activity and quality of life in the short-term. The overall certainty and quality of the evidence is low.

Changes in physical activity, sedentary behaviour and sleep following pulmonary rehabilitation: a systematic review and network meta-analysis

BACKGROUND

The variety of innovations to traditional centre-based pulmonary rehabilitation (CBPR), including different modes of delivery and adjuncts, are likely to lead to differential responses in physical activity, sedentary behaviour and sleep.

OBJECTIVES

To examine the relative effectiveness of different pulmonary rehabilitation-based interventions on physical activity, sedentary behaviour and sleep.

METHODS

Randomised trials in chronic respiratory disease involving pulmonary rehabilitation-based interventions were systematically searched for. Network meta-analyses compared interventions for changes in physical activity, sedentary behaviour and sleep in COPD.

RESULTS

46 studies were included, and analyses were performed on most common outcomes: steps per day (k=24), time spent in moderate-to-vigorous physical activity (MVPA; k=12) and sedentary time (k=8). There were insufficient data on sleep outcomes (k=3). CBPR resulted in greater steps per day and MVPA and reduced sedentary time compared to usual care. CBPR+physical activity promotion resulted in greater increases in steps per day compared to both usual care and CBPR, with greater increases in MVPA and reductions in sedentary time compared to usual care, but not CBPR. Home-based pulmonary rehabilitation resulted in greater increases in steps per day and decreases in sedentary time compared to usual care. Compared to usual care, CBPR+physical activity promotion was the only intervention where the lower 95% confidence interval for steps per day surpassed the minimal important difference. No pulmonary rehabilitation-related intervention resulted in greater increases in MVPA or reductions in sedentary time compared to CBPR.

CONCLUSION

The addition of physical activity promotion to pulmonary rehabilitation improves volume of physical activity, but not intensity, compared to CBPR. High risk of bias and low certainty of evidence suggests that these results should be viewed with caution.

Efficacy of exercise treatments for chronic obstructive pulmonary disease: A systematic review

OBJECTIVE

To review the efficacy of exercise treatments on chronic obstructive pulmonary disease (COPD).

DATA SOURCES

PubMed, Scopus, Science Direct, Ebscohost, SPORTDiscus, ProQuest, Web of Science.

REVIEW METHODS

A systematic review was performed to identify the relevant studies published from 2011 to 2023. Studies were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 5170 articles were retrieved and assessed using the Physiotherapy Evidence Database (PEDro) scale. The risk of bias in individual studies was assessed with the Cochrane risk of bias tool.

RESULTS

A total of 38 eligible studies were included. Eight studies evaluated the effects of Tai Chi, followed by Liuzijue (five studies) and yoga (three studies). The duration of the exercise programmes ranged from 8 weeks to 3 years, and the frequency was between 2 and 7 times a week. Exercise sessions lasted between 20 and 90 min. Low-intensity exercise improved lung function after six months. Whole-body exercise improved dyspnea more than local exercise. Water-based exercise improved physical endurance more than land exercise, and quality of life was unaffected by long-term exercise.

CONCLUSION

This systematic review highlights the benefit of exercise treatments as a potential adjunct treatment for COPD patients.

Wearable technology interventions in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is associated with multiple medical and psychological comorbidities. Therefore, future strategies to improve COPD management and outcomes are needed for the betterment of patient care. Wearable technology interventions offer considerable promise in improving outcomes, but prior reviews fall short of assessing their role in the COPD population. In this systematic review and meta-analysis we searched ovid-MEDLINE, ovid-EMBASE, CINAHL, CENTRAL, and IEEE databases from inception to April 2023 to identify studies investigating wearable technology interventions in an adult COPD population with prespecified outcomes of interest including physical activity promotion, increasing exercise capacity, exacerbation detection, and quality-of-life. We identified 7396 studies, of which 37 were included in our review. Meta-analysis showed wearable technology interventions significantly increased: the mean daily step count (mean difference (MD) 850 (494-1205) steps/day) and the six-minute walk distance (MD 5.81 m (1.02-10.61 m). However, the impact was short-lived. Furthermore, wearable technology coupled with another facet (such as health coaching or pulmonary rehabilitation) had a greater impact that wearable technology alone. Wearable technology had little impact on quality-of-life measures and had mixed results for exacerbation avoidance and prediction. It is clear that wearable technology interventions may have the potential to form a core part of future COPD management plans, but further work is required to translate this into meaningful clinical benefit.

Cognitive behavioural therapy combined with physical activity behavioural modification strategies during pulmonary rehabilitation in patients with COPD

Introduction

Patients with COPD who exhibit elevated levels of anxiety and/or depression are typically less able to improve symptoms and physical activity levels following a programme of pulmonary rehabilitation (PR). The objective of the present study was to provide proof of concept that offering an intervention comprising cognitive behavioural therapy (CBT) alongside physical activity behavioural modification strategies (BPA) during PR is more effective in improving physical activity outcomes compared to PR and CBT alone.

Methods

32 patients with COPD (mean±sd forced expiratory volume in 1 s 42±14% predicted) were assigned 1:1 to receive PR+CBT+BPA or PR+CBT. BPA comprised motivational interviews, step-count monitoring, feedback using a pedometer and goal setting. Assessments included accelerometer-derived steps per day, movement intensity, 6-min walk distance (6MWD) and Hospital Anxiety and Depression Scale (HADS) scores.

Results

The magnitude of improvement across physical activity outcomes was greater for the PR+CBT+BPA compared to the PR+CBT intervention (by 829 steps per day (p=0.029) and by 80±39 vector magnitude units (p=0.042), respectively). Compared to PR and CBT alone, the PR+CBT+BPA intervention induced greater clinically meaningful improvements in HADS anxiety scores (by -2 units, 95% CI -4-1 units) and 6MWD (by 33±20 m).

Conclusions

Providing anxious and/or depressed patients with COPD with a combined intervention of CBT and BPA during PR presents more favourable improvements in physical activity outcome measures compared to CBT alone during PR.

The Effectiveness of Wearable Devices in Non-Communicable Diseases to Manage Physical Activity and Nutrition: Where We Are?

Wearable devices are increasingly popular in clinical and non-clinical populations as a tool for exercise prescription, monitoring of daily physical activity and nutrition, and health-related parameters management. In this regard, smart devices not only assist people in pursuing a healthier lifestyle, but also provide a constant stream of physiological and metabolic data for management of non-communicable diseases (NCDs). Although the benefits of lifestyle-based interventions (exercise and nutrition) for NCDs are well known, the potential of wearable devices to promote healthy behaviors in clinical populations is still controversial. In this narrative review, we aimed to discuss the current application of wearable devices in NCDs, highlighting their role in prescribing and monitoring daily physical activity and dietary habits in the population living with chronic diseases. None of the studies considered specifically addressed the efficacy of the use of wearable devices, and limited are those that incorporate monitoring of both physical activity and nutrition for NCDs. However, there is evidence that such devices have helped improve physical activity levels, physical fitness, body composition, and metabolic and psychological parameters. Therefore, the authors believe that the benefits obtained from the use of wearable devices are likely to translate to public health and represent one of the important tools for the development of prevention plans in everyday life and clinical practice for optimal patient management.

Physical activity promotion interventions in chronic airways disease: a systematic review and meta-analysis

Physical inactivity is common in people with chronic airways disease (pwCAD) and associated with worse clinical outcomes and impaired quality of life. We conducted a systematic review and meta-analysis to characterise and evaluate the effectiveness of interventions promoting step-based physical activity (PA) in pwCAD. We searched for studies that included a form of PA promotion and step-count outcome measure. A random-effects model was used to determine the overall effect size using post-intervention values. 38 studies (n=32 COPD; n=5 asthma; n=1 bronchiectasis; study population: n=3777) were included. Overall, implementing a form of PA promotion resulted in a significant increase in step-count: median (IQR) 705 (183-1210) when compared with usual standard care: -64 (-597-229), standardised mean difference (SMD) 0.24 (95% CI: 0.12-0.36), p<0.01. To explore the impact of specific interventions, studies were stratified into subgroups: PA promotion+wearable activity monitor-based interventions (n=17) (SMD 0.37, p<0.01); PA promotion+step-count as an outcome measure (n=9) (SMD 0.18, p=0.09); technology-based interventions (n=12) (SMD 0.16, p=0.01). Interventions promoting PA, particularly those that incorporate wearable activity monitors, result in a significant and clinically meaningful improvement in daily step-count in pwCAD.

The effectiveness of wearable activity trackers for increasing physical activity and reducing sedentary time in older adults: A systematic review and meta-analysis

Background

Traditional interventions such as education and counseling are successful in increasing physical activity (PA) participation, but are usually labor and resource intensive. Wearable activity trackers can objectively record PA and provide feedback to help users to achieve activity goals and are an increasingly popular tool among adults used to facilitate self-monitoring of PA. However, no reviews systematically explored the roles of wearable activity trackers in older populations.

Methods

We searched PubMed, Web of Science, Google Scholar, Embase, Cochrane Library, and Scopus from inception to September 10, 2022. Randomized controlled trials were included. Two reviewers independently conducted study selection, data extraction, risk of bias, and certainty of evidence assessment. A random-effects model was used to evaluate the effect size.

Results

A total of 45 studies with 7144 participants were included. A wearable activity tracker was effective in increasing daily steps (standard mean differences (SMD) = 0.59, 95% confidence interval (CI) (0.44, 0.75)), weekly moderate-to-vigorous PA (MVPA) (SMD = 0.54, 95% CI (0.36, 0.72)), and total daily PA (SMD = 0.21, 95% CI (0.01, 0.40)) and reducing sedentary time (SMD = -0.10, 95% CI (-0.19, -0.01)). Subgroup analysis showed that the effectiveness of wearable activity trackers for daily steps was not influenced by participants and intervention features. However, wearable activity trackers seemed more effective in promoting MVPA of participant's age <70 than participant's age ≥70. In addition, wearable activity trackers incorporated with traditional intervention components (e.g. telephone counseling, goal setting, and self-monitoring) could better promote MVPA than alone use. Short-term interventions potentially achieve better MVPA increase than long-term.

Conclusion

This review showed that wearable activity trackers are an effective tool to increase PA for the old population and also favor reducing sedentary time. When used together with other interventions, wearable activity trackers can achieve better MVPA increase, especially in the short term. However, how to more effectively improve the effectiveness of wearable activity trackers is an important direction of future research.

Naturalizing digital and quality of life in chronic diseases: Systematic review to research perspective into technological advancing and personalized medicine

The increasing of chronic diseases and related health management are the main clinical and public health challenges. The long-term nature and the need for continuous monitoring in chronic disease management gave rise to early technological innovations (mobile Health) to improve care management plans, therapeutic adherence, and psychological support to the patient. This review aimed to map the literature on the impact of the use of wearable device on quality of life in patients with chronic diseases. We performed a systematic search of MEDLINE through PubMed, Web of Science, and Scopus of all scientific literature published until January 2022. Based on inclusion and exclusion criteria, a total of 10 papers were included. This review pointed out the relevant focus on the use of wearable device in chronic disease patients highlighting the wearable device impact on several domains including quality of life, Self-Efficacy, Self-Management, and feelings on patients with chronic diseases. The available scientific literature related to the impact of the use of wearable device on quality of life and psychological features in patients with chronic diseases, general underline a need to develop professional healthcare guidelines and tailored intervention on patients with a chronic condition, using mobile Health solutions and trying to fill the lack of knowledge about the topic.

Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The present systematic review and meta-analysis of randomized clinical trials (RCTs) aimed to investigate the effects of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The RCTs of pulmonary rehabilitation programs published between 1999 and 2021 were retrieved from electronic databases (PubMed, Cochrane Library, and Embase). Two reviewers independently assessed the topical relevance and trial quality and extracted data for meta-analysis using the Stata software version 14.0.

RESULTS

A total of 39 trials involving 2,397 participants with COPD were evaluated. We found that patients who received pulmonary rehabilitation program had significant improvement in the 6-min walk test (6MWT), St. George Respiratory Questionnaire score, and the modified British Medical Research Council score as compared to those who received usual care. Yoga and Tai Chi showed significant improvement in the forced expiratory volume (FEV1)% in 1 s predicted value. However, no significant difference was detected in the modified Borg score, forced vital capacity (FVC), and FEV1/FVC predicted value between the pulmonary rehabilitation and usual care groups.

CONCLUSION

Yoga and Tai Chi showed a significant improvement in the FEV1% predicted value. Also, pulmonary rehabilitation program improved the exercise capacity, the quality of life, and dyspnoea in patients with COPD.Key messagesA total of 39 trials involving 2,397 participants with COPD were evaluated.We found that patients who received pulmonary rehabilitation program had significant improvement in the 6MWT, St. George Respiratory Questionnaire score, and the modified British Medical Research Council score as compared to those who received usual care.Yoga and Tai Chi showed significant improvement in the FEV1% predicted value.No significant difference was detected in the modified Borg score, FVC, and FEV1/FVC predicted value between the pulmonary rehabilitation and usual care groups.

Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis

INTRODUCTION

Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care.

METHODS AND ANALYSIS

Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence.

RESULTS

We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32-1.44; p=0.002) and HRQoL (SMD -0.62, 95% CI -0.88--0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD -0.10, 95% CI -0.25-0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI -0.15-0.17; p=0.87).

CONCLUSION

Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

The effectiveness of rehabilitation interventions including outdoor mobility on older adults' physical activity, endurance, outdoor mobility and falls-related self-efficacy: systematic review and meta-analysis

Objective

To determine the effectiveness of community-based rehabilitation interventions which incorporate outdoor mobility on physical activity, endurance, outdoor mobility and falls-related self-efficacy in older adults.

Design

MEDLINE, Embase, CINAHL, PEDro and OpenGrey were searched systematically from inception to June 2021 for randomised controlled trials (RCTs) of community-based rehabilitation incorporating outdoor mobility on physical activity, endurance, outdoor mobility and/or falls-related self-efficacy in older adults. Duplicate screening, selection, extraction and appraisal were completed. Results were reported descriptively and with random-effects meta-analyses stratified by population (proactive [community-dwelling], reactive [illness/injury]).

Results

A total of 29 RCTs with 7,076 participants were identified (66% high bias for at least one domain). The outdoor mobility component was predominantly a walking programme with behaviour change. Rehabilitation for reactive populations increased physical activity (seven RCTs, 587 participants. Hedge’s g 1.32, 95% CI: 0.31, 2.32), endurance (four RCTs, 392 participants. Hedges g 0.24; 95% CI: 0.04, 0.44) and outdoor mobility (two RCTs with 663 participants. Go out as much as wanted, likelihood of a journey) at intervention end versus usual care. Where reported, effects were preserved at follow-up. One RCT indicated a benefit of rehabilitation for proactive populations on moderate-to-vigorous activity and outdoor mobility. No effect was noted for falls-related self-efficacy, or other outcomes following rehabilitation for proactive populations.

Conclusion

Reactive rehabilitation for older adults may include walking programmes with behaviour change techniques. Future research should address the potential benefit of a walking programme for proactive populations and address mobility-related anxiety as a barrier to outdoor mobility for both proactive and reactive populations.

Embedding Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease in the Home and Community Setting: A Rapid Review

This paper presents a rapid review of the literature for the components, benefits, barriers, and facilitators of pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) people in-home and community-based settings. seventy-six studies were included: 57 home-based pulmonary rehabilitation (HBPR) studies and 19 community-based pulmonary rehabilitation (CBPR) studies. The benefits of HBPR on exercise capacity and health-related quality of life were observed in one-group studies, studies comparing HBPR to usual care, and studies comparing to hospital-based pulmonary rehabilitation, although the benefits were less pronounced in the latter. HBPR reduced hospital admissions compared to usual care and was more cost-effective than hospital pulmonary rehabilitation. Most HBPRs were designed with low-density or customized equipment, are minimally supervised, and have a low intensity of training. Although the HBPR has flexibility and no travel burden, participants with severe disease, physical frailty, and complex comorbidities had barriers to complying with HBPR. The telerehabilitation program, a facilitator for HBPR, is feasible and safe. CBPR was offered in-person supervision, despite being limited to physical therapists in most studies. Benefits in exercise capacity were shown in almost all studies, but the improvement in health-related quality of life was controversial. Patients reported the benefits that facilities where they attended the CBPR including social support and the presence of an instructor. They also reported barriers, such as poor physical condition, transport difficulties, and family commitments. Despite the minimal infrastructure offered, HBPR and CBPR are feasible, safe, and provide clinical benefits to patients with COPD. Home and community settings are excellent opportunities to expand the offer of pulmonary rehabilitation programs, as long as they follow protocols that ensure quality and safety following current guidelines.

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.

PERSISTE: a mixed methods protocol to identify barriers and levers to a sustainable physical activity practice among patients with chronic disease after physical activity resumption programs

Physical activity (PA) has evidence-based benefits for physical, social and mental health, but investigation of how PA interventions for patients with chronic disease affects their PA practice up to 1 year after programmes are rare. Moreover, few studies document how the context and intervention mechanisms of PA programmes affect sustainable PA practice and its determinants. The present protocol describes a mixed methods study comparing the effectiveness and conditions for the effectiveness of two PA resumption programmes (a hospital-led and a community-based programme). Using a comparative longitudinal study, 60 patients (3-month duration) will be followed for 1 year though four data collections: before (T0) and at the end (T1) of the intervention, 6 months (T2) and 1 year (T3) after the start of the programme. The primary outcome will be PA practice in min/week and categorised as light, moderate or vigorous (using International Physical Activity Questionnaire (IPAQ)), and secondary outcomes will include sedentary time in min/week (IPAQ), quality of life evaluated though the physical and mental composite scores ('Medical Outcome Study Short Form 12'), and enjoyment using four statements rated from 1 to 5, a high score being synonymous of enjoyment (Intrinsic Motivation Inventory). Qualitative data on further determinants of PA practice and intervention mechanisms will be collected. The expected results will offer the opportunity to understand how the intervention context contributes to a more effective, sustainable PA practice. Trial registration number: NCT04954209.

Integrated disease management interventions for patients with chronic obstructive pulmonary disease

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations.

OBJECTIVES

To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes.

SEARCH METHODS

We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region.

MAIN RESULTS

Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution.

AUTHORS' CONCLUSIONS

This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.

Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.

OBJECTIVES

This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.

RESULTS

We included 267 studies (43153 individuals with COPD). A broad range of domains (n=22), outcomes (n=163) and measures (n=217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n=218) assessed with the 6-min walk test (n=140), health-related quality of life (n=204) assessed with the Saint George's respiratory questionnaire (n=99), and symptoms (n=158) assessed with the modified Medical Research Council dyspnea scale (n=56). The least reported outcomes were comorbidities, adverse events and knowledge.

CONCLUSIONS

This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.

PROSPERO ID

CRD42017079935.

Wearable activity trackers for promoting physical activity: A systematic meta-analytic review

PURPOSE

Although wearable activity trackers hold a promise of nudging people toward a more active lifestyle, current research reveals inconsistent findings regarding the effectiveness of them. The objectives of this paper are two-fold: (1) to synthesize evidence on the effects of wearable activity trackers for improving physical activities, and (2) to identify potential moderators of effect size.

METHODS

A systematic meta-analytic review was conducted. Forty-eight eligible papers based on forty-four distinct trials were identified through a systematic literature search process. Two authors independently extracted information from each study based on predefined data fields. Random-effects meta-analysis, subgroup analysis, and meta-regression analysis were employed.

RESULTS

First, interventions with wearable activity trackers significantly increased daily steps and weekly moderate-to-vigorous physical activity but had no impact on light physical activity or sedentary behavior. Second, daily steps and weekly moderate-to-vigorous physical activity were associated with participants' characteristics (i.e., gender, age, medical condition, and baseline physical activity level) and intervention features (i.e., sensors, modes of expert support, and intervention duration). The identified factors explained 53 % of the total variance for weekly moderate-to-vigorous physical activity.

CONCLUSIONS

The use of wearable activity trackers effectively improves conscious exercise behavior, including daily steps and weekly moderate-to-vigorous physical activity, but not effective for modifying habitual behavior, such as light physical activity and sedentary behavior. We also explicitly show that the extent to which the interventions with wearable activity trackers help users is contingent on the type of users and the design and delivery of interventions. Future studies are called to validate the findings and to offer theoretical explanations.

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

Behavioural modification interventions alongside pulmonary rehabilitation improve COPD patients' experiences of physical activity

AIMS AND OBJECTIVES

The Clinical PROactive Physical Activity in COPD (C-PPAC) instrument, combines a questionnaire assessing the domains of amount and difficulty of physical activity (PA) with activity monitor data (steps/day and vector magnitude units) to assess patients' experiences of PA. The C-PPAC instrument is responsive to pharmacological and non-pharmacological interventions and to changes in clinically relevant variables. We compared the effect of PA behavioural modification interventions alongside pulmonary rehabilitation (PR) to PR alone on the C-PPAC scores in COPD patients with low baseline PA levels.

METHODS

In this randomised controlled trial, 48 patients (means ± SD: FEV₁: 50 ± 19%, baseline steps/day: 3450 ± 2342) were assigned 1:1 to receive PR alone, twice weekly for 8 weeks, or PA behavioural modification interventions (comprising motivational interviews, monitoring and feedback using a pedometer and goal setting) alongside PR (PR + PA). The C-PPAC instrument was used to assess PA experience, including a perspective of the amount and difficulty of PA.

RESULTS

There were clinically important improvements in favour of the PR + PA interventions compared to PR alone in: 1) the C-PPAC total score (mean [95% CI] difference: 8 [4 to 12] points, p = 0.001), the difficulty (mean [95% CI] difference: 8 [3 to 13] points, p = 0.002) and the amount (mean [95% CI] difference 8 [3 to 16] points, p = 0.005) domains and 2) the CAT score (mean [95% CI] difference: -2.1 [-3.8 to -0.3] points, p = 0.025).

CONCLUSION

PA behavioural modification interventions alongside PR improve the experiences of PA in patients with advanced COPD and low baseline PA levels. (NCT03749655).

Effect of pulmonary rehabilitation programs including lower limb endurance training on dyspnea in stable COPD: A systematic review and meta-analysis

Pulmonary rehabilitation (PR) is recommended as an effective treatment for patients with chronic obstructive pulmonary disease (COPD). Previous meta-analyses showed that PR improves exercise capacity and health-related quality of life (HRQOL). However, they did not evaluate the effect of PR on the sensation of dyspnea. We searched six databases in May 2019 for randomized controlled trials (RCTs) that examined PR, including supervised lower limb endurance training as a minimal essential component that was continued for 4-12 weeks, in patients with stable COPD, with changes from baseline dyspnea as a primary outcome. Secondary outcomes were changes in exercise capacity, HRQOL, activity of daily life (ADL), physical activity (PA), and adverse events. We calculated the pooled weighted mean difference (MD) using a random effects model. We identified 42 studies with 2150 participants. Compared with the control, PR improved dyspnea, as shown using the British Medical Research Council (MRC) questionnaire (MD, -0.64; 95% CI, -0.99 to -0.30; p = 0.0003), transitional dyspnea index (MD, 1.95; 95% CI, 1.09 to 2.81; p = 0.0001), modified Borg score during exercise (MD, -0.62; 95% CI, -1.10 to -0.14; p = 0.01), and Chronic Respiratory Questionnaire (CRQ) dyspnea score (MD, 0.91; 95% CI, 0.39 to 1.44; p = 0.0007). PR significantly increased exercise capacity measured by the 6 min walking distance time, peak workload, and peak VO₂. It improved HRQOL measured by the St. George's Respiratory Questionnaire and CRQ, but not on PA or ADL. These results indicated that PR programs including lower limb endurance training improve dyspnea, HRQOL, and exercise capacity in patients with stable COPD.

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.

Use of pedometers as a tool to promote daily physical activity levels in patients with COPD: a systematic review and meta-analysis

The aim of this study was to examine the use of pedometers as a tool to promote daily physical activity levels in patients with COPD.

A systematic review meta-analysis of pedometer physical activity promotion in patients with COPD was conducted. Medline/PubMed, Cochrane Library, Web of Science and CINAHL were searched from inception to January 2019. The search strategy included the following keywords: physical activity promotion, pulmonary rehabilitation and daily physical activity. The eligibility criteria for selecting studies were randomised controlled trials reporting pedometer physical activity promotion in patients with COPD.

Improvements in steps per day were found with pedometer physical activity promotion either standalone (n=12, mean 0.53 (95% CI 0.29–0.77); p=0.00001) or alongside pulmonary rehabilitation (n=7, 0.51 (0.13–0.88); p=0.006). A subgroup analysis reported significant differences in the promotion of physical activity based on baseline physical activity levels and the type of instrument used to assess levels of physical activity.

Future trials should consider the way in which pedometers are used to promote physical activity to inform clinical practice in the setting of pulmonary rehabilitation.

The past, present and future of pulmonary rehabilitation

Abundant evidence supports the use of pulmonary rehabilitation as a treatment for stable and exacerbated chronic obstructive pulmonary disease. Several questions around the science base of rehabilitation in other patient groups as well as the role of rehabilitation as a component in other comprehensive care trajectories remain to be addressed. The impact of a rehabilitation programme could also perhaps be enhanced if clear guidance would be available on how to individualize the components of a rehabilitation programme in individual patients. The rehabilitation community, in an attempt to increase access to programmes, has developed less rigorous interventions. These may serve specific patients (e.g. less severe patients or may be used as a maintenance programme), but in order to have conceptual clarity they should not be called substitutes for rehabilitation if they do not meet the definition of rehabilitation. Reaching clarity on the best format for maintenance programmes in order to achieve long-lasting health benefits for patients is another challenge. Furthermore, as many patients as possible should be referred to adequate rehabilitation programmes within their reach with fair reimbursement. Programmes should take into account the burden of the disease of a patient, the required components to tackle the problems, adequate assessment to document the outcome and the patient's preference. In summary, pulmonary rehabilitation is one of the most potent evidence-based therapies for patients with respiratory diseases. Researchers should continue to fine tune the interventions, get clarity on terminology as well as the ultimate outcomes for rehabilitation to ensure sustainable health effects.

Assessment of Self-Management Treatment Needs Among COPD Helpline Callers

Telephone quitlines are an effective population-based strategy for smoking cessation, particularly among individuals with tobacco-related diseases such as chronic obstructive pulmonary disease (COPD). Expanding quitline services to provide COPD-focused self-management interventions is potentially beneficial; however, data are needed to identify specific treatment needs in this population. We conducted a telephone-based survey (N = 5,772) to examine educational needs, behavioral health characteristics, and disease-related interference among individuals with COPD who received services from the American Lung Association (ALA) Lung Helpline. Most participants (73.7%) were interested in COPD-focused information, and few had received prior instruction in breathing exercises (33.9%), energy conservation (26.5%), or airway clearing (32.1%). About one-third of participants engaged in regular exercise, 16.3% followed a special diet, and 81.4% were current smokers. Most participants (78.2%) reported COPD-related interference in daily activities and 30.8% had been hospitalized within the past six months for their breathing. Nearly half of participants (45.4%) reported current symptoms of anxiety or depression. Those with vs. without anxiety/depression had higher rates of COPD-related interference (83.9% vs. 73.5%, p < .001) and past six-month hospitalization (33.4% vs. 28.3%, p < .001). In conclusion, this survey identified strong interest in disease-focused education; a lack of prior instruction in specific self-management strategies for COPD; and behavioral health needs in the areas of exercise, diet, and smoking cessation. Anxiety and depression symptoms were common and associated with greater disease burden, underscoring the importance of addressing coping with negative emotions. Implications for self-management treatments that target multiple behavioral needs of COPD patients are discussed.