Evaluation of multidimensional COPD-related subjective fatigue following a Pulmonary Rehabilitation programme

Time-Course of Changes in Multidimensional Fatigue and Functional Exercise Capacity and Their Associations during a Short Inpatient Pulmonary Rehabilitation Program

This study aimed to assess the time-course of changes in multidimensional fatigue and functional exercise capacity and their associations during an inpatient pulmonary rehabilitation (PR) program. Seventy COPD patients from three centres were enrolled for a four-week PR program and were evaluated before (T0) and at the end of each week (T1, T2, T3, and T4). Weekly change in multidimensional fatigue was assessed by the multidimensional inventory questionnaire (MFI-20) and functional exercise capacity by the 6-minute walking distance (6MWD). Reaction time (RT) and heart rate variability (HRV) were also assessed as complementary markers of fatigue. HRV did not change during the study (all p > 0.05). MFI-20 score and RT decreased during the first part of the program (p < 0.001) and levelled off at T2 (all p > 0.05 compared with each preceding time). While 6MWD improved by almost 70% during the first part of the PR, it continued to increase, albeit at a greatly reduced pace, between T2 and T4 (p < 0.05). In parallel, a negative association was found between MFI-20 score and 6MWD at each evaluation time (r ranged from 0.43 to 0.71), with a significantly stronger T3 correlation compared with the other time periods (all p < 0.05). The strengthening of the association between fatigue and functional exercise capacity at T3, which occurred concomitantly with the slowdown of functional exercise capacity improvement, is consistent with a role for fatigue in the limitation of performance changes during PR. The limitation of fatigue during PR is thus an interesting aspect to improve the magnitude of performance changes.

Non-pharmacological Management in Palliative Care for Patients With Advanced COPD

Chronic obstructive pulmonary disease (COPD) is a disabling condition associated with progressive airflow limitation and lung tissue damage; its main symptoms are breathlessness, fatigue, cough, and sputum production. In the advanced stage of the disease, these symptoms may severely impact on a person's physical and psychological functioning, with some also developing chronic respiratory failure, associated with blood gas abnormalities. Non-pharmacological interventions can improve quality of life and functioning in the management of people living with advanced COPD. This article will provide an overview of common non-pharmacological methods used in the symptomatic management of severe COPD, including: breathlessness and fatigue management strategies, anxiety management, pulmonary rehabilitation (PR) and physical activity (PA), neuromuscular electrical stimulation (NMES), airway clearance techniques (ACTs), nutrition and non-invasive ventilation (NIV). The importance of a holistic and multi-disciplinary approach to people living with COPD will be discussed.

Dissecting the fatigue experience: A scoping review of fatigue definitions, dimensions, and measures in non-oncologic medical conditions

Introduction

Fatigue is a prevalent and potentially debilitating symptom that impacts the health-related quality-of-life of individuals diagnosed with acute and chronic medical conditions. Yet, its etiologic mechanism is not fully understood. Additionally, the assessment and determination of the clinical meaning of fatigue and its multidimensionality may vary by medical condition.

Methods

A scoping literature review was conducted to investigate how fatigue is defined and measured, including its dimensions, in non-oncologic medical conditions. The PubMed database was searched using keywords.

Results

Overall, 8376 articles were screened at the title/abstract levels, where 293 articles were chosen for full-text review that mentioned fatigue or included fatigue measures. The review of the full text excluded 246 articles that did not assess at least one fatigue dimension using validated questionnaires and clinical tests. The final set included 47 articles. Physical fatigue was the most assessed fatigue dimension and the Multidimensional Fatigue Inventory was the most widely used questionnaire to assess fatigue in this review.

Limitations

This review was limited by including only English-language publications and using PubMed as the sole database for the search.

Conclusions

This review affirms that fatigue is a multidimensional construct, agnostic of medical condition, and that individual fatigue dimensions can be measured by validated clinical measures. Future research should focus on expanding the repertoire of clinical measures to assess specific fatigue dimensions.

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The 27 different validated clinical measures used to assess fatigue and its dimensions; 20 instruments assessed the physical, 8 for mental, 7 cognitive, 5 for motivational, 2 for emotional, 1 peripheral, 1 for central, 1 psychosocial.

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Physical was the most measured dimension, as assessed in 42 of 47 included articles.

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This review affirms that fatigue is a multidimensional construct, agnostic of medical condition, and that individual fatigue dimensions can be measured by validate clinical measures.

Rehabilitation effects of land and water-based aerobic exercise on lung function, dyspnea, and exercise capacity in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

We sought to synthesize the evidence about aerobic exercise intervention during pulmonary rehabilitation, and to further explore the difference in rehabilitation effects between water and land-based aerobic exercise. This review's purpose is to provide a basis by which practitioners and therapists can select and create appropriate therapeutic programs.

METHODS

Data of randomized and quasi-randomized controlled trials comparing training group (TG, aerobic exercise in water or land) and control group (CG, usual care) in chronic obstructive pulmonary disease (COPD) patients (January 1, 2000-December 28, 2019) were obtained from the Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, and Wanfang databases. Two researchers independently reviewed the literature, extracted the data, and evaluated the quality of the literature. Review Manager software (Rev Man 5.3; Cochrane, London, UK) was used for meta-analysis. The rehabilitation effect of water- or land based aerobic exercise was evaluated by subgroup analysis. The proposed systematic review details were registered in PROSPERO (CRD 42020168331).

RESULTS

Eighteen studies (1311 cases of COPD) were included. Meta-analysis results show that compared with the control group, the dyspnea level and functional and endurance exercise capacity in COPD patients were significantly improved after aerobic exercise (P < .05), but there was no significant change in lung function (P > .05). Compared with land-based aerobic exercise, water-based aerobic exercise significantly improved the endurance exercise capacity in COPD patients (mean difference [MD]: 270.18, 95% CI: 74.61-465.75).

CONCLUSION

Medium to high-quality evidence shows that aerobic exercise can effectively improve dyspnea and exercise capacity in COPD patients. Compared with land-based aerobic exercise, water-based aerobic exercise had a significant additional effect in improving the endurance exercise capacity of COPD patients.

Effects of low and high resistance training intensities on clinical outcomes in patients with COPD - a randomized trial

AIM

To compare the effects of two different intensities of combined resistance and aerobic training on physical-functional aspects and perceptual aspects of health status in patients with Chronic Obstructive Pulmonary Disease (COPD).

DESIGN

This was a randomized parallel group trial.

METHODS

Thirty-one patients were assessed regarding: symptoms (COPD Assessment Test - CAT), quality of life (Saint George's Respiratory Questionnaire - SGRQ); exercise capacity (six-minute walk test and constant-workload resistance test - CWRT); and muscle strength (one-repetition maximum test and isometric muscle strength for knee extensors - Kext and elbow flexors - EFlex). Patients were randomized in two groups to perform a combined training: 1) LL/HR = Low-load/high-repetition resistance training (n = 16; 68 ± 9.3 years; FEV₁ = 50.0 ± 15.7%pred); and 2) HL/LR = High-load/low-repetition resistance training (n = 15; 70 ± 6.5 years; FEV₁ = 46.8 ± 14.5%pred), and underwent 36 sessions.

RESULTS

Symptoms, quality of life and exercise capacity presented significant improvement (p < .05) in both groups. Both intensities of resistance training improved symptoms (∆CAT: LL/HR = -3.9; HL/LR = -2.8) and exercise capacity (∆ tolerance time in CWRT: LL/HR = +450.9s; HL/LR = +583.4s) above minimal clinically important difference value. Nevertheless, improvement in quality of life (∆SGRQ: LL/HR = -3.8; HL/LR = -10) and in isometric muscle strength (∆KExt: LL/HR = +15.8 N; HL/LR = +37.7 N and (∆EFlex: LL/HR = +9.5 N; HL/LR = +29.9 N) was observed only in the HL/LR group, which also presented a larger number of responders considering isometric muscle strength.

CONCLUSION

High-intensity resistance training in a combined training was more effective in ameliorating several aspects of patients with COPD, responding more and better to physical-functional aspects and perceptual aspects of health status.

Extra-pulmonary manifestations of COPD and the role of pulmonary rehabilitation: a symptom-centered approach

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogenous disease that is associated with a range of respiratory and non-respiratory symptoms, which highly contribute to the daily burden of the disease. Symptoms burden remains high despite optimal bronchodilator therapy, but pulmonary rehabilitation (PR) is an effective intervention to improve patients' symptoms. A comprehensive interdisciplinary approach within the framework of a PR program is warranted to tackle these complex symptoms and their consequences. Areas covered: This narrative review describes how symptoms of dyspnea, fatigue, cough, sputum, anxiety, depression, pain, sleep disturbances, and cognitive decline arise in COPD and can contribute to several non-pulmonary manifestations of the disease. It also describes evidence of the effectiveness of interdisciplinary PR programs to counteract these symptoms. A literature search was performed on PubMed and Scopus between June and July 2020. Expert opinion: Respiratory and non-respiratory symptoms are highly prevalent, often not comprehensively assessed, and result in several extra-pulmonary manifestations of the disease (physical, emotional and social). Interdisciplinary PR programs can improve these negative manifestations through different pathways, contributing for an effective symptoms' management. A thorough assessment of symptoms (beyond dyspnea) should be routinely performed and may support the identification of treatable traits, allowing the tailoring of PR interventions and assessment of their real-life impact.

Minimal Clinically Important Differences for Patient-Reported Outcome Measures of Fatigue in Patients With COPD Following Pulmonary Rehabilitation

BACKGROUND

Fatigue is a burdensome and prevailing symptom in patients with COPD. Pulmonary rehabilitation (PR) improves fatigue; however, interpreting when such improvement is clinically relevant is challenging. Minimal clinically important differences (MCIDs) for instruments assessing fatigue are warranted to better tailor PR and guide clinical decisions.

RESEARCH QUESTION

This study estimated MCIDs for the Functional Assessment of Chronic Illness Therapy-Fatigue Subscale (FACIT-FS), the modified FACIT-FS, and the Checklist Individual Strength-Fatigue Subscale in patients with COPD following PR.

STUDY DESIGN AND METHODS

Data from patients with COPD who completed a 12-week community-based PR program were used to compute the MCIDs. The pooled MCID was estimated by calculating the arithmetic weighted mean, resulting from the combination of anchor-based (weight, two-thirds) and distribution-based (weight, one-third) methods. Anchors were patients' and physiotherapists' Global Rating of Change Scale, COPD Assessment Test, St. George's Respiratory Questionnaire (SGRQ), and exacerbations. To estimate MCIDs, we used mean change, receiver-operating characteristic curves, and linear regression analysis for anchor-based approaches, and 0.5 × SD, SE of measurement, 1.96 × SE of measurement, and minimal detectable change for distribution-based approaches.

RESULTS

Fifty-three patients with COPD (79% male, 68.4 ± 7.6 years of age, and FEV₁ 48.7 ± 17.4% predicted) were included in the analysis. Exacerbations and the SGRQ-impact and the SGRQ-total scores fulfilled the requirements to be used as anchors. Pooled MCIDs were 4.7 for FACIT-FS, 3.8 for the modified FACIT-FS, and 9.3 for the Checklist Individual Strength-Fatigue Subscale.

INTRPRETATION

The MCIDs proposed in this study can be used by different stakeholders to interpret PR effectiveness.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03799666; URL: www.clinicaltrials.gov.

The responsiveness of the Manchester Chronic Obstructive Pulmonary Disease Fatigue Scale to pulmonary rehabilitation

Background:

We examined the responsiveness of the Manchester Chronic Obstructive Pulmonary Disease (COPD) Fatigue Scale (MCFS) in patients with COPD following 8 weeks of pulmonary rehabilitation (PR).

Methods:

Patients (n = 273) with clinically stable COPD completed 8 weeks of outpatient multidisciplinary PR, comprising 2 h (1 h exercise and 1 h education) weekly. Anxiety, exercise capacity, quality of life, dyspnea, fatigue were measured pre- and post-PR, utilizing the Anxiety Inventory for Respiratory Disease (AIR), Incremental Shuttle Walk Test (ISWT), St. George’s Respiratory Questionnaire (SGRQ), and modified Medical Research Council (mMRC) scale and MCFS, respectively.

Results:

The mean (SD) age of participants was 72 (8) years, and 50% were women. Total MCFS score fell after PR mean (95% confidence interval) −4.89 (–7.90 to −3.79) as did domain scores: physical −1.89 (–2.33 to −1.46), cognition −1.37 (–1.65 to −1.09), and psychosocial −1.62 (–2.00 to −1.62). Total MCFS effect size (ES) was 0.55; and for domains, physical was 0.52, cognition was 0.59, and psychosocial was 0.51. The ES for AIR was 0.30, mMRC was 0.38, SGRQ was 0.66, and ISWT was 1.19. MCFS changes correlated with changes in both SGRQ (p < 0.002) and AIR (p < 0.004), but not ISWT (p = 0.30) or mMRC (p = 0.18). The AIR, SGRQ, mMRC, and ISWT all improved after PR (all, p < 0.001).

Conclusion:

The MCFS scale is a valid and responsive scale to measure fatigue in patients with COPD after pulmonary rehabilitation.

Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis

To date, it remains unknown which patients report a clinically-relevant improvement in fatigue following pulmonary rehabilitation (PR). The purpose of this study was to identify and characterize these responders. Demographics, lung function, anxiety (anxiety subscale of the 90-item symptom checklist (SCL-90-A)), depression (Beck depression inventory for primary care (BDI-PC)), exercise tolerance (six-minute walking distance test (6MWD)), and health status (Nijmegen clinical screening instrument (NCSI)) were assessed before and after a 12-week PR programme. Fatigue was assessed using the checklist individual strength (CIS)-Fatigue. Patients with a decline ≥ 10 points (minimally clinically important difference, MCID) on the CIS-Fatigue were defined as responders. Chronic obstructive pulmonary disease (COPD) patients (n = 446, 61 ± 9 years, 53% male, forced expiratory volume in 1 s (FEV1) 43% ± 18% predicted, 75% severe fatigue) were included. Mean change in fatigue after PR was 10 ± 12 points (p < 0.01) and exceeded the MCID. In total, 56% were identified as fatigue responders. Baseline CIS-Fatigue (45 ± 7 vs. 38 ± 9 points, respectively, p < 0.001) and health-related quality-of-life (HRQoL; p < 0.001) were different between responders and non-responders. No differences were found in demographics, baseline anxiety, depression, lung function, 6MWD, and dyspnoea (p-values > 0.01). Responders on fatigue reported a greater improvement in anxiety, depression, 6MWD, dyspnoea (all p-values < 0.001), and most health status parameters. PR reduces fatigue in COPD. Responders on fatigue have worse fatigue and HRQoL scores at baseline, and are also likely to be responders on other outcomes of PR.

Effects of exercise training in water and on land in patients with COPD: a randomised clinical trial

OBJECTIVES

To compare the effects of two similar 6-month protocols of high-intensity exercise training, in water and on land, in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Randomised controlled trial.

SETTING

University-based outpatient clinic.

PARTICIPANTS

Thirty-six patients with predominantly moderate-to-severe COPD completed the study.

INTERVENTION

Patients were evaluated at baseline, at 3 months and at the end of the programme (i.e. 6 months). For both groups, the 6-month protocol consisted of high-intensity endurance and strength exercises with gradual increase in time and/or workload, totalling 60 sessions.

MAIN OUTCOMES

Objective monitoring of physical activity in daily life (PADL, primary outcome), lung function, peripheral and respiratory muscle strength, body composition, maximal and submaximal exercise capacity, functional status, quality of life, and symptoms of anxiety and depression.

RESULTS

After 6 months of training, a significant improvement in PADL was seen for both groups [mean difference (95% confidence interval): land group 993 (358 to 1628) steps/day; water group 1669 (404 to 2934) steps/day]. Significant improvements were also seen in inspiratory, expiratory and peripheral muscle strength; maximal and submaximal exercise capacity; quality of life and functional status for both groups. There were no significant improvements in lung function, body composition, and symptoms of anxiety and depression for either group. No difference was found in the magnitude of improvement between the two types of training for any outcome.

CONCLUSION

High-intensity exercise training in water generates similar effects compared with training on land in patients with moderate-to-severe COPD, rendering it an equally beneficial therapeutic option for this population.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01691131.

Relationship between Physical Activity and Fatigue in Adults with Cystic Fibrosis

Purpose: We examined the relationship between the amount of physical activity and level of fatigue in adults with cystic fibrosis (CF). Method: Participants were recruited from the Toronto Adult Cystic Fibrosis Centre at St. Michael's Hospital. Participants completed the Habitual Activity Estimation Scale, the Multidimensional Fatigue Inventory, and the Depression subscale of the Hospital Anxiety and Depression Scale, in that order. Descriptive statistics and linear and multiple regressions were computed. Results: Over a 6-month period, 51 individuals were approached, and 22 (10 men, 12 women) participated in this study. The participants' median age was 33, and forced expiratory volume in 1 second (FEV₁) was 64% predicted. When holding both FEV₁ and depression constant, a significant negative correlation was found between total active hours per weekday and general fatigue (β=-0.735, p=0.03); there was a negative trend between total active hours per weekday and physical fatigue (β=-0.579, p=0.09). Conclusions: This study is the first to demonstrate that among adults with CF, a higher level of physical activity is associated with a lower level of general and physical fatigue when controlling for lung function and level of depression. Physical activity may be used as a means of mitigating the levels of general and physical fatigue in people with CF.

Factors associated with the effect of pulmonary rehabilitation on physical activity in patients with chronic obstructive pulmonary disease

AIM

Although the effects of pulmonary rehabilitation (PR) have been well defined for chronic obstructive pulmonary disease (COPD), it remains controversial whether PR improves physical activity (PA). The purpose of the present study was to identify factors associated with the effect of PR on PA.

METHODS

This was a prospective study of 29 patients with COPD. They underwent pulmonary rehabilitation twice weekly for 12 weeks, and were assessed using the hospital anxiety and depression score, 6-min walk distance (6MWD), and the St. George Respiratory Questionnaire (SGRQ) before and after they underwent PR. The PA of patients was measured by a three-axis accelerometer. Physical activity level (PAL) was calculated by dividing each patient's total energy expenditure by basal metabolic rate. Correlations between changes in PAL after PR and 6MWD, St. George Respiratory Questionnaire, and hospital anxiety and depression score scores, and clinical parameters, including forced expiratory volume in 1 s were determined.

RESULTS

6MWD was significantly increased, but PAL was unchanged after PR. PAL was positively correlated with 6MWD, but not with percent predicted forced expiratory volume in 1 s nor St. George Respiratory Questionnaire scores before PR. The increase in PAL was negatively correlated with changes in hospital anxiety and depression score anxiety and depression scores, but was not correlated with the change in 6MWD.

CONCLUSIONS

A PR program for COPD patients improved results of the 6MWD, but not PAL. Increased PAL was associated with improvements in anxiety and depression, but not with increased exercise capacity. Treating the depression and anxiety of patients with COPD might not only reduce emotional distress, but also improve their PAL. Geriatr Gerontol Int 2017; 17: 17-23.

Are 30 minutes of rest between two incremental shuttle walking tests enough for cardiovascular variables and perceived exertion to return to baseline values?

Objective:

To verify whether 30 minutes of rest between two incremental shuttle walking tests (ISWT) are enough for cardiovascular variables and perceived exertion to return to baseline values in healthy subjects in a broad age range.

Method:

The maximal exercise capacity of 334 apparently healthy subjects (age ≥18) was evaluated using the ISWT. The test was performed twice with 30 minutes of rest in between. Heart rate (HR), arterial blood pressure (ABP), dyspnea, and leg fatigue were evaluated before and after each test. Subjects were allocated to 6 groups according to their age: G1: 18-29 years; G2: 30-39 years; G3: 40-49 years; G4: 50-59 years; G5: 60-69 years and G6: ≥70 years.

Results:

All groups had a good performance in the ISWT (median >90% of the predicted distance). The initial HR (HRi) of the second ISWT was higher than the first ISWT in the total sample (p<0.0001), as well as in all groups (p<0.0001). No difference was observed in the behavior of ABP (systolic and diastolic) and dyspnea between the two tests, but this difference occurred for leg fatigue (greater before the second ISWT) in G1 (p<0.05). Most subjects (58%) performed better in the second test.

Conclusion:

30 minutes of rest between two ISWTs are not enough for all cardiovascular variables and perceived exertion to return to baseline values. However, this period appears to be sufficient for blood pressure and performance to recover in most subjects.

Measuring fatigue as a symptom in COPD: From descriptors and questionnaires to the importance of the problem

Fatigue is a symptom commonly diagnosed in cancers and in many other chronic debilitating diseases and is one of the main therapeutic targets for various pharmacologic and non-pharmacologic interventions. However, in chronic obstructive pulmonary disease (COPD), this symptom, which can be considered as the main extrapulmonary clinical feature of the disease, can impact significantly on the health-related quality of life of the patients. The aims of this review are to discuss the issues related to fatigue assessment in COPD and to highlight the importance of this symptom in this setting based on the data retrieved from articles published between 1987 through August 2014 available on MEDLINE database. Fatigue can be measured by various scales or questionnaires that are designed for generic purposes or for COPD-related purposes but is still underdiagnosed and undertreated. This is due to the fact that its clinical and prognostic relevance are not appropriately acknowledged. The early identification of fatigue clinical descriptors from patients' reports could help with better management of this symptom.