1
|
Cheng SWM, Guan C, Dennis S, Alison J, Stamatakis E, McKeough Z. A behaviour change intervention to reduce sedentary behaviour in chronic obstructive pulmonary disease: a qualitative study. Physiotherapy 2024; 124:9-20. [PMID: 38795529 DOI: 10.1016/j.physio.2024.04.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 03/06/2024] [Accepted: 04/16/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES To document the experiences of people with chronic obstructive pulmonary disease (COPD) who underwent a behaviour change intervention to reduce sedentary behaviour (SB) in a clinical trial. DESIGN AND PARTICIPANTS Qualitative study using semi-structured interviews to explore perspectives of the behaviour change intervention and specific intervention components in people with stable COPD on the waitlist for pulmonary rehabilitation. SETTING Three outpatient pulmonary rehabilitation programmes in Sydney, Australia. INTERVENTIONS The six-week behaviour change intervention with once weekly contact with a physiotherapist aimed to reduce SB by replacing it with light-intensity physical activity (PA) and by breaking up prolonged SB. MAIN OUTCOME MEASURES Of 30 participants who completed the behaviour change intervention, interviews were conducted with 13 participants and analysed using the 'capability, opportunity, motivation, behaviour (COM-B)' framework of behaviour change. RESULTS Intervention components regarded as most helpful by participants were verbal education on health consequences on SB, goal setting, and self-monitoring of, and feedback on, step count using activity trackers. There was a clear preference during goal setting to increase PA rather than to reduce SB. Physical limitations and enjoyment of SB were the most reported barriers to reducing SB. CONCLUSIONS Goal setting, verbal education, and self-monitoring of, and feedback on step count, were viewed positively by people with COPD and may show promise for reducing SB and increasing PA based on individual preference. CONTRIBUTION OF THE PAPER.
Collapse
Affiliation(s)
- Sonia Wing Mei Cheng
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Catherine Guan
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Physiotherapy, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, Australia
| | - Sarah Dennis
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; South West Sydney Allied Health Research Collaboration, South Western Sydney Local Health District, Sydney, Australia
| | - Jennifer Alison
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Allied Health Professorial Unit, Sydney Local Health District, Sydney, Australia
| | - Emmanuel Stamatakis
- Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Zoe McKeough
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
2
|
Younes A, Mandigout S, Robin L, Borel B. What kind of non-pharmacological strategy for reducing sedentary behavior in COPD? Data from a scoping review. Respir Med 2024; 228:107662. [PMID: 38759875 DOI: 10.1016/j.rmed.2024.107662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is usually associated with sedentary behavior (SB). Literature reports a harmful impact of SB on the physical, mental, and social health of individuals with COPD. However, Pulmonary Rehabilitation (PR) programs seem to have no clear effect on changing SB. Therefore, our study aimed to identify the strategies used in the literature to reduce SB among individuals with COPD. METHOD A scoping review was conducted to summarize the current literature regarding the proposed strategies to reduce SB in individuals with COPD. Searches were conducted in PUBMED; SCOPUS and COCHRANE LIBRARY for studies published from 2010 to march 2024. RESULTS Twenty four articles were retained for our review. Most of the identified strategies in the literature (21/24 articles) are based on behavioral approaches, with various forms: promoting self-efficacy, self-management and self-regulation of one's own behavior (12 articles), goal setting (10 articles), constant feedback (11 articles), therapeutic education (8 articles), motivational strategies (6 articles), re-engagement in meaningful activities (4 articles), promoting light intensity physical activity (LPA) (6 articles) and social support (6 articles). In association with the behavioral strategies, wearable connected technologies have been used in 4 articles, alone or combined with physical exercise programs included or not in a PR program. The home is associated with 83 % of interventions as a place for initial and continuous implementation of behavioral strategies. CONCLUSION It would seem appropriate to focus on combined strategies to reduce SB in individuals with COPD (improvement of physical abilities and behavioral strategies). Further research is needed to only target the reduction of SB and to evaluate the effects of various interventions.
Collapse
Affiliation(s)
- A Younes
- Univ. Limoges, ILFOMER - Readaptation Sciences Institute, F-87000 Limoges, France
| | - S Mandigout
- Univ. Limoges, HAVAE, UR 20217, F-87000, Limoges, France; Univ. Limoges, ILFOMER - Readaptation Sciences Institute, F-87000 Limoges, France
| | - L Robin
- Univ. Limoges, HAVAE, UR 20217, F-87000, Limoges, France
| | - B Borel
- Univ. Limoges, HAVAE, UR 20217, F-87000, Limoges, France.
| |
Collapse
|
3
|
Liou HL, Lai ZY, Huang YT, Chu WT, Tsai YC, Chen MS, Tsai PC. The effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease. Int J Nurs Pract 2023; 29:e13185. [PMID: 37515349 DOI: 10.1111/ijn.13185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
AIMS To assess the effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease (COPD). BACKGROUND A few recent studies have shown that unsupervised home-based pulmonary rehabilitation can improve the clinical outcome of patients with COPD. More studies are needed to prove its benefits. DESIGN This study used a quasi-experimental design. METHODS Seventy-two admitted COPD patients were assigned to experimental group or control group through purposeful sampling. Data were collected from March 2016 to November 2017 in the Thoracic Intensive Care Unit of a Medical Center in Taiwan. The Medical Research Council dyspnea scale, the COPD Self-Efficacy Scale and the Clinical COPD Questionnaire were measured before education and at the first, second and third months after discharge. RESULTS The Medical Research Council dyspnea scale and COPD Self-Efficacy Scale results in the experimental group were significantly improved compared with the control group in the third month after discharge. The Clinical COPD Questionnaire score continued to improve in both groups in the third month after discharge, and there was no difference between the two groups. CONCLUSION A short-term unsupervised home-based pulmonary rehabilitation with self- management program had significant benefits for patients with COPD. The long-term effects need to be confirmed.
Collapse
Affiliation(s)
- Huey L Liou
- Department of Living Sciences, National Open University, New Taipei City, Taiwan (R.O.C.)
| | - Zi Y Lai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan (R.O.C.)
| | - Yu T Huang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan (R.O.C.)
| | - Wan T Chu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan (R.O.C.)
| | - Ya C Tsai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan (R.O.C.)
| | - Mei S Chen
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan (R.O.C.)
| | - Pei C Tsai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan (R.O.C.)
| |
Collapse
|
4
|
Yi QF, Yang GL, Yan J. Self-Efficacy Intervention Programs in Patients with Chronic Obstructive Pulmonary Disease: Narrative Review. Int J Chron Obstruct Pulmon Dis 2021; 16:3397-3403. [PMID: 34955635 PMCID: PMC8694112 DOI: 10.2147/copd.s338720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/14/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common chronic disease whose development is irreversible, which leads to more than six million deaths each year. There is no treatment confirmed effective for the improvement of impaired lung function, but the combination of drug therapy with non-drug therapy such as pulmonary rehabilitation training has demonstrated a great potential in reducing the occurrence of complications and delaying the progression of COPD. Self-efficacy is the core of cognitive theory, which is crucial for chronic disease management. It has been proposed as an important component of disease management to help people develop skills to manage diseases more effectively. This study reviewed the development of self-efficacy and its application in patients with COPD, with the purpose of providing a better clinical reference for the treatments of COPD.
Collapse
Affiliation(s)
- Qi-Feng Yi
- Nursing Teaching and Research Department, Third Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Guo-Li Yang
- Department of Respiration, Third Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Jin Yan
- The Nursing Department, Third Xiangya Hospital of Central South University, Changsha, People's Republic of China
| |
Collapse
|
5
|
Fortune J, Norris M, Stennett A, Kilbride C, Lavelle G, Hendrie W, Victor C, Ryan JM. Patterns and correlates of sedentary behaviour among people with multiple sclerosis: a cross-sectional study. Sci Rep 2021; 11:20346. [PMID: 34645876 PMCID: PMC8514488 DOI: 10.1038/s41598-021-99631-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022] Open
Abstract
High levels of sedentary behaviour are associated with poor health outcomes in people with multiple sclerosis (MS). Identifying modifiable correlates of sedentary behaviour for people with MS is essential to design effective intervention strategies to minimise sedentary time. This study aimed to quantify patterns and identify correlates of sedentary behaviour among adults with MS. Fatigue, self-efficacy, walking capability, the physical and psychological impact of MS, health-related quality of life, and participation and autonomy were assessed by questionnaire. Participants wore an activPAL monitor. Total (min/day), prolonged bouts (≥ 30 min) and breaks in sedentary time were calculated. Associations were examined using regression analysis adjusted for demographic and clinical confounders. Fifty-six adults with MS participated (mean ± SD age: 57.0 ± 9.25 years; 66% female). Self-efficacy for control over MS was associated with sedentary time (β = 0.16, 95% CI 0.01, 0.30). Self-efficacy in function maintenance (β = 0.02, 95% CI 0.00, 0.04), health-related quality of life (EuroQol-5D) (β = 31.60, 95% CI 7.25, 55.96), and the autonomy indoors subscale of the Impact on Participation and Autonomy Questionnaire (β = − 5.11, 95% CI − 9.74, − 0.485) were associated with breaks in sedentary time. Future studies should consider self-efficacy, health-related quality of life and participation and autonomy as potential components of interventions to reduce sedentary behaviour.
Collapse
Affiliation(s)
- Jennifer Fortune
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland.,Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Meriel Norris
- Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK.
| | - Andrea Stennett
- Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK.,Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Cherry Kilbride
- Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Grace Lavelle
- Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Christina Victor
- Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Jennifer Mary Ryan
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland.,Ageing Studies Theme, Institute of Environment, Health and Societies, Brunel University London, London, UK
| |
Collapse
|
6
|
Souto-Miranda S, Rodrigues G, Spruit MA, Marques A. Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: a systematic review. Ann Phys Rehabil Med 2021; 65:101564. [PMID: 34329794 DOI: 10.1016/j.rehab.2021.101564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sara Souto-Miranda
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; iBiMED: Institute of Biomedicine, University of Aveiro, Aveiro, Portugal; Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Guilherme Rodrigues
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal
| | - Martijn A Spruit
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands; Department of Research and Development, CIRO, Horn, Netherlands
| | - Alda Marques
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; iBiMED: Institute of Biomedicine, University of Aveiro, Aveiro, Portugal.
| |
Collapse
|
7
|
Janjua S, Banchoff E, Threapleton CJ, Prigmore S, Fletcher J, Disler RT. Digital interventions for the management of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2021; 4:CD013246. [PMID: 33871065 PMCID: PMC8094214 DOI: 10.1002/14651858.cd013246.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | | | | | - Samantha Prigmore
- Respiratory Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joshua Fletcher
- Medical School, St George's, University of London, London, UK
| | - Rebecca T Disler
- Department of Rural Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
8
|
Alsubheen SA, Wshah A, Goldstein R, Brooks D. Psychometric Properties of Patient-Reported Outcome Measures Assessing Self-Efficacy in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Systematic Review. COPD 2021; 18:254-263. [PMID: 33709848 DOI: 10.1080/15412555.2021.1897559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This systematic review aimed to synthesize the evidence of the psychometric properties of self-efficacy patient-reported outcome measures (PROMs) in patients with chronic obstructive pulmonary disease (COPD). We conducted a systematic search of MEDLINE and other common databases from inception until September 2020. Studies that reported psychometric properties of self-efficacy outcome measures in COPD patients were included. We used the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 2018 guidelines for data extraction and evidence synthesis. Eighteen studies that assessed nine self-efficacy PROMs were eligible for inclusion. The assessment of structural validity indicated sufficient results rating for the Exercise Self-Regulatory Efficacy Scale and the Self-Care-Self-Efficacy Scale, and insufficient rating for the COPD Self-Efficacy Scale and the Pulmonary Rehabilitation Adaptation Index for Self-Efficacy (PRAISE). Construct validity measures displayed sufficient results rating with correlations ranging from -0.48 to - 0.71 between self-efficacy PROMs and other PROMs such as St. George's Respiratory Questionnaire, Hospital Anxiety and Depression Scale and Chronic Respiratory Questionnaire. Internal consistency measures indicated sufficient rating for all self-efficacy PROMs with a Cronbach's alpha range of 0.71 - 0.98. Responsiveness was assessed for the PRAISE with an overall sufficient rating (effect sizes of 0.21 - 0.37). The evidence regarding the psychometric properties of self-efficacy PROMs in COPD is variable. The PRAISE is responsive to changes in self-efficacy in COPD patients attending a pulmonary rehabilitation program. When using self-efficacy PROMs in clinical practice or research, clinicians and researchers should consider the psychometric properties and choose the appropriate outcome measure based on the purpose.
Collapse
Affiliation(s)
- Sanaa A Alsubheen
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Adnan Wshah
- Department of Respiratory Medicine, Toronto, Ontario, Canada.,Department of Physical and Occupational Therapy, The Hashemite University, Zarqa, Jordan
| | - Roger Goldstein
- Department of Respiratory Medicine, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dina Brooks
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.,Department of Respiratory Medicine, Toronto, Ontario, Canada.,Department of Physical Therapy and Rehabilitation Science, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review. J Physiother 2021; 67:27-40. [PMID: 33358547 DOI: 10.1016/j.jphys.2020.12.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/01/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022] Open
Abstract
QUESTIONS How effective is home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) for people with chronic obstructive pulmonary disease (COPD) compared with: no exercise therapy (ET), in/outpatient ET, and home-based ET without ATT? DESIGN Systematic review and meta-analysis of randomised trials. PARTICIPANTS People with stable COPD referred for ET. INTERVENTION ATT-ET. OUTCOME MEASURES Exercise capacity, quality of life, functional dyspnoea, cost-effectiveness and various secondary outcomes. RESULTS Fifteen eligible trials involved 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (four studies, 6-minute walk test MD 15 m, 95% CI 5 to 24) and probably improved quality of life (four studies, SMD 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in/outpatient ET on functional dyspnoea (two studies, SMD -0.05, 95% CI -0.39 to 0.29) and a similar or better effect on quality of life (two studies, SMD 0.23, 95% CI -0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (three studies, 6-minute walk test MD 6 m, 95% CI -26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (three studies, 6-minute walk test MD 2 m, 95% CI -16 to 19) and similar or better effects on quality of life (three studies, SMD 0.79, 95% CI -0.04 to 1.62) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator. CONCLUSION ATT-ET improves exercise capacity, functional dyspnoea and quality of life compared with no ET, although some benefits may be small. Its benefits are generally similar to in/outpatient ET and similar to or better than home-based ET without ATT. REGISTRATION PROSPERO CRD42020165773.
Collapse
|
10
|
The Impact of Pulmonary Rehabilitation on 24-Hour Movement Behavior in People With Chronic Obstructive Pulmonary Disease: New Insights From a Compositional Perspective. J Phys Act Health 2020; 18:13-20. [PMID: 33307537 DOI: 10.1123/jpah.2020-0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Physical activity levels are low in people with chronic obstructive pulmonary disease, and there is limited knowledge about how pulmonary rehabilitation transforms movement behaviors. This study analyzed data from a pulmonary rehabilitation trial and identified determinants of movement behaviors. METHODS Objectively assessed time in daily movement behaviors (sleep, sedentary, light-intensity physical activity, and moderate- to vigorous-intensity physical activity) from a randomized controlled trial (n = 73 participants) comparing home- and center-based pulmonary rehabilitation was analyzed using conventional and compositional analytical approaches. Regression analysis was used to assess relationships between movement behaviors, participant features, and response to the interventions. RESULTS Compositional analysis revealed no significant differences in movement profiles between the home- and center-based groups. At end rehabilitation, conventional analyses identified positive relationships between exercise capacity (6-min walk distance), light-intensity physical activity, and moderate- to vigorous-intensity physical activity time. Compositional analyses identified positive relationships between a 6-minute walk distance and moderate- to vigorous-intensity physical activity time, accompanied by negative relationships with sleep and sedentary time (relative to other time components) and novel relationships between body mass index and light-intensity physical activity/sedentary time. CONCLUSION Compositional analyses following pulmonary rehabilitation identified unique associations between movement behaviors that were not evident in conventional analyses.
Collapse
|
11
|
Burge AT, Cox NS, Abramson MJ, Holland AE. Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2020; 4:CD012626. [PMID: 32297320 PMCID: PMC7160071 DOI: 10.1002/14651858.cd012626.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Angela T Burge
- La Trobe UniversityDepartment of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and SportMelbourneVictoriaAustralia
- Institute for Breathing and SleepMelbourneAustralia
- Alfred HealthPhysiotherapyPO Box 315MelbourneAustraliaPrahran VIC 3181
- Monash UniversityDepartment of Allergy, Clinical Immunology and Respiratory MedicineMelbourneAustralia
| | - Narelle S Cox
- Institute for Breathing and SleepMelbourneAustralia
- Monash UniversityDepartment of Allergy, Clinical Immunology and Respiratory MedicineMelbourneAustralia
- School of Allied Health, Human Services and Sport, La Trobe UniversityDepartment of Physiotherapy, Podiatry and Prosthetics and OrthoticsMelbourneVictoriaAustralia3004
| | - Michael J Abramson
- Monash UniversitySchool of Public Health & Preventive MedicineMelbourneVictoriaAustralia3004
| | - Anne E Holland
- La Trobe UniversityDepartment of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and SportMelbourneVictoriaAustralia
- Institute for Breathing and SleepMelbourneAustralia
- Alfred HealthPhysiotherapyPO Box 315MelbourneAustraliaPrahran VIC 3181
- Monash UniversityDepartment of Allergy, Clinical Immunology and Respiratory MedicineMelbourneAustralia
| | | |
Collapse
|
12
|
Holland AE, Liacos A, McDonald CF, Mahal A, Hill CJ, Lee AL, Burge AT, Moore R, Nicolson C, O’Halloran P, Cox NS, Lahham A, Gillies R. Response to letter to the Editor re ‘Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) tool predicts reduction in sedentary time following pulmonary rehabilitation in people with Chronic Obstructive Pulmonary Disease (COPD)’. Physiotherapy 2020; 106:217-218. [DOI: 10.1016/j.physio.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Indexed: 10/25/2022]
|
13
|
Karloh M, Sousa Matias T, Fleig Mayer A. Lack of responsiveness of the PRAISE tool to pulmonary rehabilitation: instrument or protocol limitation? Physiotherapy 2020; 106:215-216. [PMID: 31992447 DOI: 10.1016/j.physio.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Manuela Karloh
- Centre for Assistance, Teaching and Research in Pulmonary Rehabilitation, Santa Catarina State University (UDESC), Florianópolis, Santa Catarina, Brazil; Department of Physiotherapy, Estácio University Centre, São José, Santa Catarina, Brazil; Department of Physiotherapy, Centre for Health Sciences and Sport, Santa Catarina State University (UDESC), Florianópolis, Santa Catarina, Brazil.
| | - Thiago Sousa Matias
- Department of Physical Education, School of Sports, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil; Graduate Program in Physical Education, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil.
| | - Anamaria Fleig Mayer
- Centre for Assistance, Teaching and Research in Pulmonary Rehabilitation, Santa Catarina State University (UDESC), Florianópolis, Santa Catarina, Brazil; Department of Physiotherapy, Centre for Health Sciences and Sport, Santa Catarina State University (UDESC), Florianópolis, Santa Catarina, Brazil; Graduate Program in Physiotherapy, Santa Catarina State University (UDESC), Florianópolis, Santa Catarina, Brazil; Graduate Program in Human Movement Sciences, Santa Catarina State University (UDESC), Florianópolis, Santa Catarina, Brazil.
| |
Collapse
|
14
|
Wan ES, Kantorowski A, Polak M, Kadri R, Richardson CR, Gagnon DR, Garshick E, Moy ML. Long-term effects of web-based pedometer-mediated intervention on COPD exacerbations. Respir Med 2020; 162:105878. [PMID: 32056676 DOI: 10.1016/j.rmed.2020.105878] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Technology-based physical activity (PA) interventions have been shown to improve daily step counts and health-related quality of life, but their effect on long-term clinical outcomes like acute exacerbations (AEs) is unknown in persons with COPD. METHODS U.S. Veterans with stable COPD were randomized (1:1) to either pedometer alone (control) or pedometer plus a website with feedback, goal-setting, disease education, and a community forum (intervention) for 3 months. AEs were assessed every 3 months over a follow-up period of approximately 15 months. Pedometer-assessed daily step counts, health-related quality-of-life (HRQL), and self-efficacy were assessed at baseline, end-of-intervention at 3 months, and during follow-up approximately 6 and 12 months after enrollment. Zero-inflated Poisson models assessed the effect of the intervention on risk for AEs, compared to controls. Generalized linear mixed-effects models for repeated measures examined between-group and within-group changes in daily step count, HRQL, and self-efficacy. RESULTS There were no significant differences in age, FEV1% predicted, baseline daily step count, AEs the year prior to enrollment, or duration of follow-up between the intervention (n = 57) and control (n = 52) groups. The intervention group had a significantly reduced risk of AEs (rate ratio = 0.51, [95%CI 0.31-0.85]), compared to the control group. There were no significant between-group differences in change in average daily step count, HRQL, or self-efficacy at 6 and 12 months after enrollment. CONCLUSIONS A 3-month internet-mediated, pedometer-based PA intervention was associated with reduced risk for AEs of COPD over 12-15 months of follow-up. ClinicalTrials.gov identifier: NCT01772082.
Collapse
Affiliation(s)
- Emily S Wan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ana Kantorowski
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Madeline Polak
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA
| | - Reema Kadri
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - David R Gagnon
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA; Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Eric Garshick
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
15
|
Wshah A, Selzler AM, Hill K, Brooks D, Goldstein R. Determinants of Sedentary Behaviour in Individuals with COPD: A Qualitative Exploration Guided by the Theoretical Domains Framework. COPD 2020; 17:65-73. [PMID: 31909650 DOI: 10.1080/15412555.2019.1708883] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In people with chronic obstructive pulmonary disease (COPD), there is increasing recognition that the prolonged accumulation of sedentary time (ST) is associated with adverse cardio-metabolic health outcomes. Nevertheless, changing this lifestyle, which has evolved over several decades, is likely to be challenging. This study reports the determinants, perceived by individuals with COPD, as being important for reducing ST. An in-depth understanding of this information is essential when planning an intervention to reduce ST. Fourteen individuals with COPD completed semi-structured one-on-one interviews, which were audio recorded and transcribed verbatim. Both the interview schedule and mapping of data items extracted from the interview transcripts were informed by the Theoretical Domains Framework (TDF). A total of 867 quotes were mapped to the 14 TDF domains. Seven of the fourteen domains were identified as being important determinants for reducing ST: knowledge, beliefs about consequences, beliefs about capabilities, environmental context and resources, social influences, social/professional role and identity, and behavioural regulation. There was a lack of knowledge regarding the meaning of sedentary behaviour. Participants' desire to be educated by knowledgeable health professionals in a formal programme was a dominant theme across multiple domains. The most frequently reported barriers to reducing ST related to the domains of social/professional role and identity and environmental context and resources, while the most frequently reported enablers were related to the domains pertaining to beliefs about consequences and social influences. Potential strategies to reduce ST among people with COPD include education and other determinants identified in this research.
Collapse
Affiliation(s)
- Adnan Wshah
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | | | - Kylie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Dina Brooks
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,School of Rehabilitation Science, McMaster University, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Roger Goldstein
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
16
|
Santos CD, Santos AJ, Santos M, Rodrigues F, Bárbara C. Pulmonary rehabilitation adapted index of self-efficacy (PRAISE) validated to Portuguese respiratory patients. Pulmonology 2019; 25:334-339. [PMID: 31540750 DOI: 10.1016/j.pulmoe.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/17/2019] [Accepted: 06/05/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Recent updates on Pulmonary Rehabilitation highlight the importance of patients' self-efficacy on long-term adherence to health-enhancing behaviors. The Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) is an adaptation of the General Self-Efficacy Scale. This study aimed to translate, culturally adapt and evaluate reliability and validity of PRAISE in Portuguese respiratory patients. PATIENTS OR MATERIALS AND METHODS Forward-backward translation and pilot testing were performed. Content validity was assessed by a multidisciplinary panel of expert judges. To evaluate reliability and validity, 150 respiratory outpatients on Pulmonary Rehabilitation participated in a cross-sectional study. Descriptive and reliability analyses, and exploratory factorial analysis using principal axis factoring, followed by oblique oblimin factor rotation were conducted to identify construct validity. IBM® SPSS® version 22 was used to perform statistical analysis. RESULTS 150 patients with a mean age of 67 years, 54% male and 83% currently on Pulmonary Rehabilitation participated in the study. These included mainly Chronic Obstructive Pulmonary Disease patients (46.7%) but also Bronchiectasis (20%), Interstitial Lung Disease (20%) and other respiratory diseases. PRAISE mean score was 49. Exploratory factor analysis extraction provided a 4-factor solution that cumulatively explained 52.3% of total variance (F1: 26.6%; F2: 9.7%; F3: 8.7%; F4: 7.3%). Portuguese PRAISE showed a reliability of 0.78 (Chronbach alpha). CONCLUSIONS The Portuguese version of PRAISE showed adequate psychometric properties for it to be used as an instrument to measure self-efficacy as a patient-centered outcome on Pulmonary Rehabilitation.
Collapse
Affiliation(s)
- Catarina Duarte Santos
- Universidade de Lisboa, Faculdade de Medicina, Instituto de Saúde Ambiental, Lisbon, Portugal; Centro Hospitalar Universitário Lisboa Norte, Hospital Pulido Valente, Unidade de Reabilitação Respiratória, Lisbon, Portugal.
| | - Ana João Santos
- Instituto Nacional de Saúde Doutor Ricardo Jorge, Departamento de Epidemiologia, Lisbon, Portugal
| | - Margarida Santos
- Instituto Politécnico de Lisboa, Escola Superior de Tecnologia da Saúde de Lisboa, Unidade de Ensino e Investigação em Psicologia e Sociologia; Universidade de Lisboa, Faculdade de Psicologia, Lisbon, Portugal
| | - Fátima Rodrigues
- Universidade de Lisboa, Faculdade de Medicina, Instituto de Saúde Ambiental, Lisbon, Portugal; Centro Hospitalar Universitário Lisboa Norte, Hospital Pulido Valente, Unidade de Reabilitação Respiratória, Lisbon, Portugal
| | - Cristina Bárbara
- Universidade de Lisboa, Faculdade de Medicina, Instituto de Saúde Ambiental, Lisbon, Portugal; Centro Hospitalar Universitário Lisboa Norte, Hospital Pulido Valente, Unidade de Reabilitação Respiratória, Lisbon, Portugal
| |
Collapse
|