Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease

Prevalence and prognostic importance of exercise limitation and physical inactivity in COPD

Exercise limitation and physical inactivity are separate, but related constructs. Both are commonly present in individuals with COPD, contribute to disease burden over and above the respiratory impairments, and are independently predictive of adverse outcomes. Because of this, clinicians should consider assessing these variables in their patients with COPD. Field tests of exercise performance such as the 6-min walk test and the incremental and endurance shuttle walk tests require limited additional resources, and results correlate with negative outcomes. Laboratory measures of exercise performance using a treadmill or cycle ergometer assess exercise capacity, provide prognostic information and have the advantage of explaining physiological mechanisms (and their interactions) underpinning exercise limitation. Limitations in exercise capacity (i.e. "cannot do") and physical inactivity (i.e. "do not do") are both associated with mortality; exercise limitation appears to be the more important driver of this outcome.

Cognitive and Emotional Responses to Chronic Obstructive Pulmonary Disease Exacerbations and Patterns of Care Seeking

Rationale: Cognitive and emotional responses associated with care seeking for chronic obstructive pulmonary disease (COPD) exacerbations are not well understood.Objectives: We sought to define care-seeking profiles based on whether and when U.S. veterans seek care for COPD exacerbations and compare cognitive and emotional responses with exacerbation symptoms across the profiles.Methods: This study analyzes data from a 1-year prospective observational cohort study of individuals with COPD. Cognitive and emotional responses to worsening symptoms were measured with the Response to Symptoms Questionnaire, adapted for COPD. Seeking care was defined as contacting or visiting a healthcare provider or going to the emergency department. Participants were categorized into four care-seeking profiles based on the greatest delay in care seeking for exacerbations when care was sought: 0-3 days (early), 4-7 days (short delay), >7 days (long delay), or never sought care for any exacerbation. The proportion of exacerbations for which participants reported cognitive and emotional responses was estimated for each care-seeking profile, stratified by the timing of when care was sought.Results: There were 1,052 exacerbations among 350 participants with Response to Symptoms Questionnaire responses. Participants were predominantly male (96%), and the mean age was 69.3 ± 7.2 years. For the 409 (39%) exacerbations for which care was sought, the median delay was 3 days. Those who sought care had significantly more severe COPD (forced expiratory volume in 1 s, modified Medical Research Council dyspnea scale) than those who never sought care. Regardless of the degree of delay until seeking care at one exacerbation, participants consistently reported experiencing serious symptoms if they sought care compared with events for which participants did not seek care (e.g., among early care seekers when care was sought, 36%; when care was not sought, 25%). Similar findings were seen in participants' assessment of the importance of getting care (e.g., among early care seekers when care was sought, 90%; when care was not sought, 52%) and their assessment of anxiety about the symptoms (e.g., among early care seekers when care was sought, 33%; when care was not sought, 17%).Conclusions: Delaying or not seeking care for COPD exacerbations was common. Regardless of care-seeking profile, cognitive and emotional responses to symptoms when care was sought differed from responses when care was not sought. Emotional and cognitive response to COPD exacerbations should be considered when developing individualized strategies to encourage seeking care for exacerbations.Clinical trial registered with www.clinicaltrials.gov (NCT02725294).

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.

Discriminant Validity of a Single Clinical Question for the Screening of Inactivity in Individuals Living with COPD

Introduction

Quantifying physical activity in chronic obstructive pulmonary disease (COPD) with questionnaires and activity monitors in clinical practice is challenging. The aim of the present study was to analyse the discriminant validity of a single clinical question for the screening of inactive individuals living with COPD.

Methods

A multicentre study was carried out in stable COPD individuals both in primary and tertiary care. Patients wore the Dynaport accelerometer for 8 days and then answered 5 physical activity questions developed for the study, referring to the week in which their physical activity was monitored. Receiver operating characteristic (ROC) curve analysis with physical activity level (PAL) as the gold standard reference was used to determine the best cut-off point for each of the 5 clinical physical activity questions tested.

Results

A total of 86 COPD participants were analysed (males 68.6%; mean (SD) age 66.6 (8.5) years; FEV₁ 50.9 (17.3)% predicted; mean of 7305 (3906) steps/day). Forty-two (48.8%) participants were considered physically inactive (PAL ≤1.69). Answers to 4 out of 5 questions significantly differed in active vs inactive patients. The Kappa index and ROC curves showed that the answer to the question "On average, how many minutes per day do you walk briskly?" had the best discriminative capacity for inactivity, with an area under the curve (AUC) (95% Confidence interval (CI)) of 0.73 (0.63-0.84) and 30 min/day was identified as the best cut-off value (sensitivity (95% CI): 0.75 (0.60-0.87); specificity: 0.76 (0.61-0.88)).

Conclusion

The present results indicate that self-reported brisk walk time lower than 30 min/day may be a valid tool for the screening of inactivity in individuals living with COPD in routine care, if more detailed physical activity measures are not feasible.

We Walk: a person-centred, dyadic behaviour change intervention to promote physical activity through outdoor walking after stroke-an intervention development study

OBJECTIVES

To develop We Walk, a theoretically informed, 12-week person-centred dyadic behaviour change intervention to increase physical activity (PA) in community-dwelling people with stroke (PWS) through outdoor walking.

DESIGN

Three-phase intervention development study. Phase 1: we reviewed literature on barriers and facilitators to PA after stroke and mapped them to the Behaviour Change Wheel and Theoretical Domains Framework to define intervention components. The Health Action Process Approach determined intervention structure underpinned by person-centred principles. Phase 2: stakeholder focus groups involving PWS, their companions and health professionals reviewed the draft intervention, and experts in behaviour change were consulted. Phase 3: informed by phases 1 and 2, the intervention and form of delivery were refined, with final review through patient and public involvement.

SETTING

Three Scottish community rehabilitation stroke services.

PARTICIPANTS

Twenty-three ambulatory community-dwelling PWS and their companions, thirty-seven health and exercise professionals, seven behaviour change experts.

RESULTS

Phase 1 determined key intervention components: information about benefits of walking; developing motivation and confidence to walk; facilitating dyadic goal setting and making plans together; monitoring walking, overcoming challenges; and maintaining walking behaviour. Phase 2 review by stakeholder focus groups and behaviour change experts endorsed intervention components and structure, emphasising dyadic relational aspects as central to potential success. In phase 3, intervention content and handbooks for PWS and buddies were finalised. Healthcare professionals proposed third-sector delivery as most appropriate for intervention delivery. A detailed delivery manual was developed. Participants preferred facilitated face-to-face and telephone delivery.

CONCLUSIONS

Our multilens intervention development approach ensured this novel intervention was evidence-informed, person-centred, theoretically coherent provided appropriate social support, and addressed issues of concern to PWS. This study established intervention components and structure and identified operational issues critical to future success. Future research will pilot and refine We Walk and evaluate acceptability, feasibility, effectiveness and cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN34488928.

Sociodemographic Characteristics and Physical Activity in Patients with COPD: A 3-Month Cohort Study

Decreased physical activity (PA) is associated with morbidity and mortality in COPD patients. In this secondary analysis of data from a 12-week longitudinal study, we describe factors associated with PA in COPD. Participants completed the Physical Activity Checklist (PAC) daily for a 7- to 8-day period. PA was measured monthly using the Physical Activity Scale for the Elderly (PASE). At three different time points, daily step count was measured for one week with an Omron HJ-720ITC pedometer. The 35 participants were primarily male (94%) and White (91%), with an average age of 66.5 years and FEV₁ 44.9% predicted. Common activities reported on the PAC were walking (93%), preparing a meal (89%), and traveling by vehicle (96%). PA measured by both PASE score (p = 0.01) and average daily step count (p = 0.04) decreased during follow-up. In repeated measures multivariable modeling, participants living with others had a higher daily step count (ß = 942 steps, p = 0.01) and better PASE scores (ß = 46.4, p < 0.001). Older age was associated with decreased step count (ß = -77 steps, p < 0.001) whereas White race was associated with lower PASE scores (ß = -55.4, p < 0.001) compared to non-White race. Other demographic factors, quality of life, and medications were not associated with PA. A better understanding of the role of social networks and social support may help develop interventions to improve PA in COPD.

Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Objective

Hospital-outreach pulmonary rehabilitation (PR) can improve health status and reduce health-care utilization by patients with chronic obstructive pulmonary disease (COPD). However, its long-term effects and costs versus benefits are still not clear. This study was conducted to develop, deliver, and evaluate the effects and monetary savings of a hospital-outreach PR program for patients with COPD.

Methods

A randomized controlled trial was conducted. Patients with COPD (n=208) were randomly assigned to the hospital-outreach PR program (treatment) or treatment as usual (control). The treatment group received a 3-month intensive intervention, including supervised physical exercise, smoking cessation, self-management education, and psychosocial support, followed by long-term access to a nurse through telephone follow-up and home visits up to 24 months. The control group received routine care, including discharge education and a self-management education brochure. Main outcomes were collected at 3, 6, 12, and 24 -months postrandomization. Primary outcomes included health-care utilization (ie, readmission rates, times, and days, and emergency department visits) and medical costs. Secondary outcomes included lung function (ie, FEV1, FEV1% predicted, FVC), dyspnea (mMCR), exercise capacity (6MWD), impact on quality of life (CAT), and self-management (CSMS).

Results

At the end of 24 months, 85 (81.7%) in the treatment group and 89 (85.6%) in the control group had completed the whole program. Compared with the control group, patients in the treatment group had lower readmission rates, times, and days at 6 and 12 months and during 12-24 months. Regarding costs during the 2 years, the program achieved CN¥3,655.94 medical  savings per patient per year, and every ¥1 spent on the program led to ¥3.29 insavings. Patients in the treatment group achieved improvements in FEV1, FEV1% predicted, exercise capacity, and self-management. It also achieved relief of dyspnea symptoms and improvement in COPD's impact on quality of life.

Conclusion

The hospital-outreach PR program for patients with COPD achieved reductions in health-care utilization, monetary savings, and improvements in patient health outcomes. The effects of the program were sustained for at least 2 years.

Trial Registration

This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-TRC-14005108).

Feasibility and acceptability of active for life with COPD, an intervention to increase light physical activity in people with COPD

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are very sedentary; increasing light physical activity (LPA) may help to promote long-term maintenance of physical activity.

OBJECTIVES

We evaluated feasibility and acceptability of Active for Life with COPD, a self-efficacy-enhancing intervention designed to increase LPA.

METHODS

The 10-week intervention included walking, functional circuit training, and behavioral and educational strategies. Measures included attrition, adherence, objectively measured physical activity, and qualitative interviews.

RESULTS

Thirty-six subjects enrolled in the study; 26 completed the intervention and 19 completed the two-month follow-up. Subjects reported the intervention was enjoyable and beneficial, but disliked the activity log and buddy system. Subjects increased mean time spent standing/stepping by 36 (SD = 82) min/24 h (P > 0.05); they retained a gain of 21 (SD = 88) min/24 h at the two-month follow-up (P > 0.05).

CONCLUSIONS

The Active for Life with COPD intervention is feasible, acceptable, and may support long term maintenance of physical activity.

Associations between Physical Activity and Comorbidities in People with COPD Residing in Spain: A Cross-Sectional Analysis

There is a high prevalence of comorbidities among patients with chronic obstructive pulmonary disease (COPD). Comorbidities are likely common in patients with any COPD degree and are associated with increased mortality. The aim of this study was to determine the prevalence of thirty-one different COPD comorbidities and to evaluate the association between physical activity (PA) levels in people with COPD residing in Spain. Cross-sectional data from the Spanish National Health Survey 2017 were analysed. A total of 601 adults (52.2% females) with COPD aged 15 to 69 participated in this study. PA (exposure) was measured with the International Physical Activity Questionnaire (IPAQ) short form and comorbidities (outcomes) were self-reported in response to the question “Have you ever been diagnosed with…?” Multivariable logistic regression, in three different models, was used to assess this association. Results showed a high prevalence of comorbidities (94%), these being chronic lumbar back pain (38.9%), chronic allergy (34.8%), arthrosis (34.1%), chronic cervical back pain (33.3%), asthma (32.9%) and hypertension (32.8%) the most prevalent. Low PA level was significantly associated with urinary incontinence (2.115[1.213–3.689]), chronic constipation (1.970[1.119–3.459]), cataracts (1.840[1.074–3.153]), chronic anxiety (1.508[1.002–2.269]) and chronic lumbar back pain (1.489[1.044–2.125]). Therefore, people with COPD should increase their PA levels in order to reduce their risk of comorbidities and increase their quality of life.

Physical Activity Behaviour in People with COPD Residing in Spain: A Cross-Sectional Analysis

PURPOSE

Chronic obstructive pulmonary disease (COPD) represents a major public health problem due to its high prevalence, morbidity and health cost. It has been demonstrated that physical activity (PA) is one of the most beneficial measures to prevent chronic diseases. The aim of this study was to examine PA levels of adults with COPD residing in Spain, and to analyse the differences by sex, age, education, marital status, cohabiting, tobacco consumption, alcohol consumption and body mass index.

METHODS

A total of 615 adults aged 15 to 69 years participated in this study. Data from the Spanish National Health Survey 2017 were used. This survey included the short version of IPAQ to measure PA levels. PA was expressed in total volume (MET·min/week), classified as low, moderate and high, and analysed according to sample characteristics. Statistical significance was set at p < 0.05 (CI = 95%).

RESULTS

Level of PA was higher in men than in women (1808.8 vs. 1575.6 MET·min/week; p = 0.016), in those aged under 30 years than in those older than 60 years (2129.4 vs. 1381.4 MET·min/week; p = 0.047) and in those who drank alcohol than in those who did not drink (1912.8 vs. 1248.2 MET·min/week; p = 0.004). Also, underweight and obese participants participated in lower levels of PA than normal weight participants (p= 0.001). When classifying PA level, a total of 37.9% had a low level, 47.5% had a moderate level and only 14.6% had a high level of PA (p < 0.001).

CONCLUSION

It is recommendable to implement programs to raise awareness of the importance and benefits of PA in the control of COPD, and these programs should focus on those with lower levels of PA.

The impact of low forced vital capacity on behavior restrictions in a population with airflow obstruction

Background

Recent studies have suggested that low forced vital capacity (FVC) is related to respiratory symptoms with various comorbid conditions that eventually lead to physical inactivity and may be applied to subjects with airflow obstruction (AO). Therefore, this study aimed to evaluate the association between low FVC and behavior restrictions in subjects with AO.

Methods

A cross-sectional study was performed using data from the Korea National Health and Nutrition Survey conducted between 2007 and 2015. Participants aged 40 to 79 years with spirometry-defined AO (pre-bronchodilator forced expiratory volume in one second/FVC <70%) were analyzed to evaluate the association between low FVC (defined as FVC <80% predicted) and behavior restrictions.

Results

A total of 3,345 participants with AO were included. The proportion of subjects with low FVC varied widely according to severity of airflow limitation (0.9%, 35.5%, and 85.1% in the mild, moderate, and severe-to-very-severe AO groups, respectively). Compared to the moderate AO group with normal FVC, those with low FVC were more likely to be older, to be never- or ex-smokers, to have larger waist size with higher body mass index, and to have comorbidities such as diabetes, hypertension, dyslipidemia, and osteoporosis. Low FVC was independently associated with behavior restrictions [adjusted prevalence ratio (aPR), 1.72; 95% confidence interval (CI), 1.43-2.06] among all participants with AO, and this was most prominent in those with moderate AO (aPR, 1.65; 95% CI, 1.27-2.13).

Conclusions

In subjects with moderate AO, low FVC was independently associated with behavior restrictions even after adjusting for confounding factors.

Combination of assist use of short-acting beta-2 agonists inhalation and guidance based on patient-specific restrictions in daily behavior: Impact on physical activity of Japanese patients with chronic obstructive pulmonary disease

BACKGROUND

Assist use of inhaled short-acting beta 2 agonists (SABAs) is reportedly effective for preventing shortness of breath on exertion in chronic obstructive pulmonary disease (COPD) patients. However, it is unclear what strategy would be useful for improving physical activity in such patients. The aim is to investigate the effects of assisted use of SABA (procaterol) on physical activity in Japanese COPD patients targeting patient-specific restrictions in daily behavior.

METHODS

Fourteen patients with stable COPD (age: 72.1±1.5, %FEV₁: 55.6±4.5%) were asked to inhale 20 μg of procaterol 15 minutes before patient-specific daily physical activity that had been identified as limited by a questionnaire and document their usage in a diary. Physical activity was measured using a triaxial accelerometer and the results were collected every month for 2 months. In the first month, a clinician assessed whether inhalation of SABA was appropriate based on a usage diary and coached patients to conduct adequate assist use of SABA for limited physical activity.

RESULTS

The strategy significantly improved the physical activity level, assessed using the values of the metabolic equivalents (METs) multiplied by physical activity endurance, at ≥3.0 METs (p<0.05), and physical activity endurance at ≥2.5 and ≥3.0 METs, (p<0.05, p<0.05, respectively). The degree of improvement of physical activity level was significantly positively correlated with the baseline %FVC and %FEV₁ (p<0.05, p<0.05, respectively).

CONCLUSIONS

Assist use of SABA targeting patient-specific restrictions, particularly when better lung function is still preserved, could be a useful approach for improving physical activity in patients with COPD.

Facilitators and barriers to physical activity following pulmonary rehabilitation in COPD: a systematic review of qualitative studies

Pulmonary rehabilitation has short-term benefits on dyspnea, exercise capacity and quality of life in COPD, but evidence suggests these do not always translate to increased daily physical activity on a patient level. This is attributed to a limited understanding of the determinants of physical activity maintenance following pulmonary rehabilitation. This systematic review of qualitative research was conducted to understand COPD patients' perceived facilitators and barriers to physical activity following pulmonary rehabilitation. Electronic databases of published data, non-published data, and trial registers were searched to identify qualitative studies (interviews, focus groups) reporting the facilitators and barriers to physical activity following pulmonary rehabilitation for people with COPD. Thematic synthesis of qualitative data was adopted involving line-by-line coding of the findings of the included studies, development of descriptive themes, and generation of analytical themes. Fourteen studies including 167 COPD patients met the inclusion criteria. Seven sub-themes were identified as influential to physical activity following pulmonary rehabilitation. These included: intentions, self-efficacy, feedback of capabilities and improvements, relationship with health care professionals, peer interaction, opportunities following pulmonary rehabilitation and routine. These encapsulated the facilitators and barriers to physical activity following pulmonary rehabilitation and were identified as sub-themes within the three analytical themes, which were beliefs, social support, and the environment. The findings highlight the challenge of promoting physical activity following pulmonary rehabilitation in COPD and provide complementary evidence to aid evaluations of interventions already attempted in this area, but also adds insight into future development of interventions targeting physical activity maintenance in COPD.

Home-based Physical Activity Coaching, Physical Activity, and Health Care Utilization in Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial Secondary Outcomes

RATIONALE

Physical inactivity among patients with chronic obstructive pulmonary disease is associated with exacerbations requiring high-cost health care utilization including urgent, emergent, and hospital care.

OBJECTIVES

To examine the effectiveness of a behavioral lifestyle physical activity intervention combined with chronic obstructive pulmonary disease self-management education to prevent high-cost health care utilization.

METHODS

This was an analysis of secondary outcomes of the Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial, a two-arm randomized trial of stable adult outpatients with chronic obstructive pulmonary disease recruited from primary care and pulmonary clinics. Following a 6-week self-management education run-in period, participants were randomized to usual care or to a telephone-delivered home-based health coaching intervention over 20 weeks. Secondary outcomes of physical activity and health care utilization were determined by self-report 6, 12, and 18 months after randomization. Associations between treatment allocation arm and these secondary outcomes were examined using log-binomial and Poisson regression models.

RESULTS

A total of 325 outpatients with stable chronic obstructive pulmonary disease were enrolled in the trial. Their average age was 70.3 years (standard deviation, 9.5), and 50.5% were female; 156 were randomized to usual care and 149 to the intervention. A greater proportion of participants reported being persistently active over the 18-month follow-up period in the intervention group (73.6%) compared with the usual care group (57.8%) (mean difference, 15.8%; 95% confidence interval, 4.0-27.7%). This association varied by severity of forced expiratory volume in 1 second impairment (P for interaction = 0.09). Those in the intervention group with moderate impairment (forced expiratory volume in 1 second, 50-70% predicted), more frequently reported being persistently active compared with the usual care (86.0 vs. 65.1%; mean difference, 20.9%; 95% confidence interval, 5.7-36.1%). Patients with severe and very severe forced expiratory volume in 1 second impairment (forced expiratory volume in 1 second < 50% predicted) in the intervention group also reported being persistently active more frequently compared with usual care (63.3 vs. 50.8%; mean difference, 12.6%; 95% confidence interval, -4.7 to 29.8). The intervention was associated with a lower rate of lung-related utilization (adjusted rate ratio, 0.38; 95% confidence interval, 0.23-0.63) only among participants with severe spirometric impairment.

CONCLUSIONS

Our results demonstrate that a feasible and generalizable home-based coaching intervention may decrease sedentary behavior and increase physical activity levels. In those with severe chronic obstructive pulmonary disease, this intervention may reduce lung disease-related health care utilization. Clinical trial registered with www.clinicaltrials.gov (NCT01108991).

Smart watch-based coaching with tiotropium and olodaterol ameliorates physical activity in patients with chronic obstructive pulmonary disease

Combined therapy with tiotropium and olodaterol notably improves parameters of lung function and quality of life in patients with chronic obstructive pulmonary disease (COPD) compared to mono-components; however, its effect on physical activity is unknown. The present study evaluated whether combination therapy affects daily physical performance in patients with COPD under a smart watch-based encouragement program. This was a non-blinded clinical trial with no randomization or placebo control. A total of 20 patients with COPD were enrolled in the present study. The patients carried an accelerometer for 4 weeks; they received no therapy during the first 2 weeks but they were treated with combined tiotropium and olodaterol under a smart watch-based encouragement program for the last 2 weeks. The pulmonary function test, COPD assessment test, 6-min walk distance and parameters of physical activity were significantly improved (P<0.05) by combination therapy under smart watch-based coaching compared with values prior to treatment. To the best of our knowledge, the present study for the first time provides evidence that smart watch-based coaching in combination with tiotropium and olodaterol may improve daily physical activity in chronic obstructive pulmonary disease.

Which indicators for measuring the daily physical activity? An overview on the challenges and technology limits for Telehealth applications

BACKGROUND

Obesity is one of the biggest drivers of preventable chronic diseases and healthcare costs in Worldwide. Different prevention activities are suggested. By monitoring daily energy expenditure (EE) could be possible make personalized diets and programming physical activity. In this, physical inactivity is one of the most important public health problems. Some studies refer the effort of the international community in promoting physical activities. Physical activity can be promoted only by increasing citizens' empowerment on taking care of their health, and it passes from the improving of individual information. Technology can offer solutions and metrics for monitoring and measuring daily activity by interacting with individuals, sharing information and feedbacks.

OBJECTIVE

In this study we review indicators of total energy expenditure and weaknesses of available devices in assessing these parameters.

METHODS

Literature review and technology testing EuNetHta core model.

RESULTS

For the clinical aspects, it is fundamental to take into account all the factor that can influence the personal energy expenditure as: heart rate, blood pressure and thermoregulation (influenced by the body temperature).

DISCUSSION

In this study we focused the attention on the importance of tools to encourage the physical activity. We made an analysis of the factor that can influence the right analysis of energy expenditure and at the same time the energy regime. A punctual monitoring of the exercise regime could be helpful in Telemedicine application as Telemonitorig. More study are needed to value the impact of physical activity tracker in Telemonitorig protocols.

CONCLUSION

On the assessment of the energy expenditure, critical issues are related to the physiological data acquisition. Sensors connected with mobile devices could be important tools for disease prevention and interventions affecting health behaviors. New devices applications are potential useful for telemedicine assistance, but security of data and the related communication protocol limits should be taking into account.

Short-term and long-term effects of a self-managed physical activity program using a pedometer for chronic respiratory disease: a randomized controlled trial

[Purpose] The aim of this study was to evaluate the effects of a self-managed physical activity program using a pedometer and diary on physical function, ADL, and QOL in patients with chronic respiratory disease. [Subjects and Methods] 17 outpatients with chronic respiratory disease were assessed for dyspnea, muscle strength, exercise tolerance, ADL, and QOL at baseline, after 3-, and 6-months after the start of the program. Patients were randomly assigned to "Control" or "Diary" group. In the Diary group, the number of steps was counted with a pedometer and recorded in a diary together with self-evaluation of physical activity, while patients assigned to the Control group did not use a pedometer or keep a diary. [Results] The Diary group showed significant improvement in the daily step count over time. The Diary group showed significant improvement of the dyspnea, muscle strength, and exercise tolerance at 3 months, dyspnea and muscle strength at 6 months. Significant differences found between two groups with regard to the extent of change in the muscle strength, exercise tolerance, and QOL at 3 months. [Conclusion] This study suggests that a self-managed physical activity program using a pedometer and diary can increase the level of physical activity.

Development of a Conceptual Model of Disease Progression for Use in Economic Modeling of Chronic Obstructive Pulmonary Disease

BACKGROUND

To develop and validate a new conceptual model (CM) of chronic obstructive pulmonary disease (COPD) for use in disease progression and economic modeling. The CM identifies and describes qualitative associations between disease attributes, progression and outcomes.

METHODS

A literature review was performed to identify any published CMs or literature reporting the impact and association of COPD disease attributes with outcomes. After critical analysis of the literature, a Steering Group of experts from the disciplines of health economics, epidemiology and clinical medicine was convened to develop a draft CM, which was refined using a Delphi process. The refined CM was validated by testing for associations between attributes using data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE).

RESULTS

Disease progression attributes included in the final CM were history and occurrence of exacerbations, lung function, exercise capacity, signs and symptoms (cough, sputum, dyspnea), cardiovascular disease comorbidities, 'other' comorbidities (including depression), body composition (body mass index), fibrinogen as a biomarker, smoking and demographic characteristics (age, gender). Mortality and health-related quality of life were determined to be the most relevant final outcome measures for this model, intended to be the foundation of an economic model of COPD.

CONCLUSION

The CM is being used as the foundation for developing a new COPD model of disease progression and to provide a framework for the analysis of patient-level data. The CM is available as a reference for the implementation of further disease progression and economic models.

Telemonitoring of home exercise cycle training in patients with COPD

Background

Regular physical activity is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD). Interventions to reduce time spent in sedentary behavior could improve outcomes. The primary purpose was to investigate the impact of telemonitoring with supportive phone calls on daily exercise times with newly established home exercise bicycle training. The secondary aim was to examine the potential improvement in health-related quality of life and physical activity compared to baseline.

Methods

This prospective crossover-randomized study was performed over 6 months in stable COPD patients. The intervention phase (domiciliary training with supporting telephone calls) and the control phase (training without phone calls) were randomly assigned to the first or the last 3 months. In the intervention phase, patients were called once a week if they did not achieve a real-time monitored daily cycle time of 20 minutes. Secondary aims were evaluated at baseline and after 3 and 6 months. Health-related quality of life was measured by the COPD Assessment Test (CAT), physical activity by the Godin Leisure Time Exercise Questionnaire (GLTEQ).

Results

Of the 53 included patients, 44 patients completed the study (forced expiratory volume in 1 second 47.5%±15.8% predicted). In the intervention phase, daily exercise time was significantly higher compared to the control phase (24.2±9.4 versus 19.6±10.3 minutes). Compared to baseline (17.6±6.1), the CAT-score improved in the intervention phase to 15.3±7.6 and in the control phase to 15.7±7.3 units. The GLTEQ-score increased from 12.2±12.1 points to 36.3±16.3 and 33.7±17.3.

Conclusion

Telemonitoring is a simple method to enhance home exercise training and physical activity, improving health-related quality of life.

Effect of a hospital outreach intervention programme on decreasing hospitalisations and medical costs in patients with chronic obstructive pulmonary disease in China: protocol of a randomised controlled trial

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) often have multiple hospitalisations because of exacerbation. Evidence shows disease management programmes are one of the most cost-effective measures to prevent re-hospitalisation for COPD exacerbation, but lack implementation and economic appraisal in China. The aims of the proposed study are to determine whether a hospital outreach invention programme for disease management can decrease hospitalisations and medical costs in patients with COPD in China. Economic appraisal of the programme will also be carried out.

METHODS AND ANALYSIS

A randomised single-blinded controlled trial will be conducted. 220 COPD patients with exacerbations will be recruited from the Third Xiangya Hospital, Central South University, China. After hospital discharge they will be randomly allocated into an intervention or a control group. Participants in the intervention group will attend a 3-month hospital-based pulmonary rehabilitation intervention and then receive a home-based programme. Both groups will receive identical usual discharge care before discharge from hospital. The primary outcomes will include rate of hospitalisation and medical cost, while secondary outcomes will include mortality, self-efficacy, self-management, health status, quality of life, exercise tolerance and pulmonary function, which will be evaluated at baseline and at 3, 12 and 24 months after the intervention. Cost-effectiveness analysis will be employed for economic appraisal.

ETHICS AND DISSEMINATION

The study has been approved by the institutional review board (IRB) of the Third Xiangya Hospital, Central South University (IRB2014-S159). Findings will be shared widely through conference presentations and peer-reviewed publications. Furthermore, the results of the programme will be submitted to health authorities and policy reform will be recommended.

TRIAL REGISTRATION NUMBER

Chi CTR-TRC-14005108; Pre-results.

Benefits of physical activity on COPD hospitalisation depend on intensity

The present study aims to disentangle the independent effects of the quantity and the intensity of physical activity on the risk reduction of chronic obstructive pulmonary disease (COPD) hospitalisations.177 patients from the Phenotype Characterization and Course of COPD (PAC-COPD) cohort (mean±sd age 71±8 years, forced expiratory volume in 1 s 52±16% predicted) wore the SenseWear Pro 2 Armband accelerometer (BodyMedia, Pittsburgh, PA, USA) for eight consecutive days, providing data on quantity (steps per day, physically active days and daily active time) and intensity (average metabolic equivalent tasks) of physical activity. Information on COPD hospitalisations during follow-up (2.5±0.8 years) was obtained from validated centralised datasets. During follow-up 67 (38%) patients were hospitalised. There was an interaction between quantity and intensity of physical activity in their effects on COPD hospitalisation risk. After adjusting for potential confounders in the Cox regression model, the risk of COPD hospitalisation was reduced by 20% (hazard ratio (HR) 0.79, 95% CI 0.67-0.93; p=0.005) for every additional 1000 daily steps at low average intensity. A greater quantity of daily steps at high average intensity did not influence the risk of COPD hospitalisations (HR 1.01, p=0.919). Similar results were found for the other measures of quantity of physical activity. Greater quantity of low-intensity physical activity reduces the risk of COPD hospitalisation, but high-intensity physical activity does not produce any risk reduction.

Forecasting COPD hospitalization in the clinic: optimizing the chronic respiratory questionnaire

PURPOSE

Forecasting hospitalization in patients with COPD has gained significant interest in the field of COPD care. There is a need to find simple tools that can help clinicians to stratify the risk of hospitalization in these patients at the time of care. The perception of quality of life has been reported to be independently associated with hospitalizations, but questionnaires are impractical for daily clinical use. Individual questions from valid questionnaires can have robust predictive abilities, as has been suggested in previous reports, as a way to use patient-reported outcomes to forecast important events like hospitalizations in COPD. Our primary aim was to assess the predictive value of individual questions from the Chronic Respiratory Questionnaire Self-Assessment Survey (CRQ-SAS) on the risk of hospitalization and to develop a clinically relevant and simple algorithm that clinicians can use in routine practice to identify patients with an increased risk of hospitalization.

PATIENTS AND METHODS

A total of 493 patients with COPD prospectively recruited from an outpatient pulmonary clinic completed the CRQ-SAS, demographic information, pulmonary function testing, and clinical outcomes. The cohort had a mean age of 70 years, was 54% male, with forced expiratory volume in 1 second percentage predicted 42.8±16.7, and modified Medical Research Council dyspnea scale score of 2±1.13.

RESULTS

Our analysis validated the original CRQ-SAS domains. Importantly, recursive partitioning analysis identified three CRQ-SAS items regarding fear or panic of breathlessness, dyspnea with basic activities of daily living, and depressive symptoms that were highly predictive of hospitalization. We propose a robust (area under the curve =0.70) but short and easy algorithm for daily clinical care to forecast hospitalizations in patients with COPD.

CONCLUSION

We identified three themes - fear of breathlessness, dyspnea with basic activities of daily living, and depressive symptoms - as important patient-reported outcomes to predict hospitalizations, and propose a short and easy algorithm to forecast hospitalizations in patients with COPD.

Effects of pharmacologic treatment based on airflow limitation and breathlessness on daily physical activity in patients with chronic obstructive pulmonary disease

BACKGROUND

Improvement in the daily physical activity (PA) is important for the management of chronic obstructive pulmonary disease (COPD). However, the effects of pharmacologic treatment on PA are not well understood. We evaluated the effects of additional medications, including bronchodilator with or without inhaled corticosteroid, based on airflow limitation and breathlessness on the PA in COPD patients and the factors that could predict or affect the improvement in PA.

METHODS

A prospective non-randomized observational study was employed. Twenty-one COPD subjects without any other diseases that might reduce PA were recruited. The PA was measured with a triaxial accelerometer for 2 weeks, and pulmonary function tests and incremental shuttle walking tests were administered before and after 4-week treatment with an additional medication.

RESULTS

Bronchodilation was obtained by additional medication. The mean values of PA evaluated by metabolic equivalents (METs) at ≥3.0 METs and the duration of PA at ≥3.0 METs and ≥3.5 METs were improved by medication. The % change in the duration of PA at ≥3.5 METs was significantly correlated with the baseline functional residual capacity (FRC), residual volume, and inspiratory capacity/total lung capacity. However, the % change in the duration of PA at any intensity was not correlated with the % changes of any values of the pulmonary function tests or incremental shuttle walking test except the PA at ≥2.5 METs with FRC.

CONCLUSION

Medication could improve the PA in patients with COPD, especially at a relatively high intensity of activity when medication was administered based on airflow limitation and breathlessness. The improvement was seen in the patients with better baseline lung volume, but was not correlated with the improvements in the pulmonary function tests or exercise capacity.

Physical activity as a predictor of thirty-day hospital readmission after a discharge for a clinical exacerbation of chronic obstructive pulmonary disease

RATIONALE

Because physical inactivity in chronic obstructive pulmonary disease (COPD) predicts health care use and mortality, we prospectively evaluated the relationship of this variable to the frequency of 30-day readmissions after a hospitalization for an exacerbation.

METHODS

Consented patients discharged after an exacerbation of COPD were asked to wear a GT3X+ accelerometer (ActiGraph, Pensacola, FL) continuously on the wrist for 30 days after hospital discharge. Vector magnitude units (VMU), the sum of movements in three planes over each minute of use, were recorded. Higher physical activity for each minute was defined by a VMU threshold of at least 3,000 counts. Those patients with fewer than 60 minutes/day over the first week were considered inactive.

MEASUREMENTS AND MAIN RESULTS

Fifty-four study patients were discharged from the hospital and 38 underwent activity testing. In the latter subgroup, all-cause hospital readmissions within 30 days occurred in 12 patients (32%). Minutes of higher physical activity per day over the first week after discharge were considerably lower in those eventually readmitted than in those who remained as outpatients: 42 ± 14 (SE) versus 114 ± 19 minutes, respectively (P = 0.02). In addition, physical activity decreased over time in those who were eventually readmitted, but increased in those who were not readmitted. Those with lower physical activity over Week 1 after discharge were more likely to have 30-day all-cause readmissions than those with higher activity: odds ratio, 6.7, P = 0.02. In multivariate testing, both physical inactivity and a history of two or more hospitalizations for exacerbations in the preceding year predicted 30-day readmission.

CONCLUSIONS

These findings underscore the importance of physical activity as a predictor of this type of health care use outcome.

An official European Respiratory Society statement on physical activity in COPD

This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force of experts representing the ERS Scientific Group 01.02 "Rehabilitation and Chronic Care" determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5-8 years).

Self-efficacy enhancing intervention increases light physical activity in people with chronic obstructive pulmonary disease

BACKGROUND

People with chronic obstructive pulmonary disease lead sedentary lives and could benefit from increasing their physical activity. The purpose of this study was to determine if an exercise-specific self-efficacy enhancing intervention could increase physical activity and functional performance when delivered in the context of 4 months of upper body resistance training with a 12-month follow-up.

METHODS

IN THIS RANDOMIZED CONTROLLED TRIAL, SUBJECTS WERE ASSIGNED TO: exercise-specific self-efficacy enhancing intervention with upper body resistance training (SE-UBR), health education with upper body resistance training (ED-UBR), or health education with gentle chair exercises (ED-Chair). Physical activity was measured with an accelerometer and functional performance was measured with the Functional Performance Inventory. Forty-nine people with moderate to severe chronic obstructive pulmonary disease completed 4 months of training and provided valid accelerometry data, and 34 also provided accelerometry data at 12 months of follow-up. The self-efficacy enhancing intervention emphasized meeting physical activity guidelines and increasing moderate-to-vigorous physical activity.

RESULTS

Differences were observed in light physical activity (LPA) after 4 months of training, time by group interaction effect (P=0.045). The SE-UBR group increased time spent in LPA by +20.68±29.30 minutes/day and the other groups decreased time spent in LPA by -22.43±47.88 minutes/day and -25.73±51.76 minutes/day. Changes in LPA were not sustained at 12-month follow-up. There were no significant changes in moderate-to-vigorous physical activity, sedentary time, or functional performance. Subjects spent most of their waking hours sedentary: 72%±9% for SE-UBR, 68%±10% for ED-UBR, and 74%±9% for ED-Chair.

CONCLUSION

The self-efficacy enhancing intervention produced a modest short-term increase in LPA. Further work is needed to increase the magnitude and duration of effect, possibly by targeting LPA.

Predictors of hospital admission two months after emergency department evaluation of COPD exacerbation

BACKGROUND

Limited information is available regarding the factors related to short-term hospital admission following an exacerbation of chronic obstructive pulmonary disease (eCOPD).

OBJECTIVES

The aim of this study was to identify variables related to short-term admission in patients with an eCOPD.

METHODS

This was a prospective cohort study of patients with an eCOPD who attended an emergency department (ED) at 1 of 16 hospitals. Information on possible predictor variables was recorded during the ED stay, 24 h after admission to the hospital or after ED discharge home, and at hospital discharge or 1 week later if discharged home from the ED. An admission after an eCOPD within 2 months was the outcome of interest. Multivariate models were employed for patients admitted to the hospital or discharged home from the ED.

RESULTS

For patients discharged home from the ED, eCOPD-related hospital admissions in the previous year [odds ratio (OR) 1.98 and 2.33], pCO2 at ED admission (ORs 2.02 and 2.90), the number of ED visits within 1 week of the index ED visit (OR 5.14) and dyspnea level 1 week after the index ED visit (ORs 2.66 and 1.40) were predictors of short-term admission [area under the curve (AUC) 0.82]. For patients admitted to the hospital during the index ED visit, baseline FEV1% (ORs 1.32 and 1.88), eCOPD-related hospital admissions in the previous year (ORs 1.28 and 2.51), severe baseline dyspnea (OR 2.57) and dyspnea level 1 week after the index ED visit (ORs 2.15 and 1.74) were predictors of short-term readmission (AUC 0.73).

CONCLUSIONS

Just a few easily recorded parameters may allow clinicians to identify patients at a higher risk of short-term readmission and establish preventive strategies.

Disability and recovery of independent function in obstructive lung disease: the cardiovascular health study

BACKGROUND

Chronic obstructive lung disease frequently leads to disability. Older patients may experience transitions between states of disability and independence over time.

OBJECTIVE

To identify factors associated with transition between states of disability and independent function in obstructive lung disease.

METHODS

We analyzed data on 4,394 participants in the Cardiovascular Health Study who completed prebronchodilator spirometry. We calculated the 1-year probability of developing and resolving impairment in ≥1 instrumental activity of daily living (IADL) or ≥1 activity of daily living (ADL) using transition probability analysis. We identified factors associated with resolving disability using relative risk (RR) regression.

RESULTS

The prevalence of IADL impairment was higher with moderate (23.9%) and severe (36.9%) airflow obstruction compared to normal spirometry (22.5%; p < 0.001). Among participants with severe airflow obstruction, 23.5% recovered independence in IADLs and 40.5% recovered independence in ADLs. In the adjusted analyses, airflow obstruction predicted the development of IADL, but not ADL impairment. Participants with severe airflow obstruction were less likely to resolve IADL impairment [RR 0.67 and 95% confidence interval (CI) 0.49-0.94]. Compared to the most active individuals (i.e. who walked ≥28 blocks per week), walking less was associated with a decreased likelihood of resolving IADL impairment (7-27 blocks: RR 0.81 and 95% CI 0.69-0.86 and <7 blocks: RR 0.73 and 95% CI 0.61-0.86). Increased strength (RR 1.16 and 95% CI 1.05-1.29) was associated with resolving IADL impairment.

CONCLUSIONS

Disability is common in older people, especially in those with severe airflow obstruction. Increased physical activity and muscle strength are associated with recovery. Research is needed on interventions to improve these factors among patients with obstructive lung disease and disability.

Influence of changes in physical activity on frequency of hospitalization in chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

To evaluate whether changes in regular physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) affect the rate of hospitalizations for COPD exacerbation (eCOPD).

METHODS

Five hundred forty-three ambulatory clinic patients being treated for COPD were prospectively identified. PA was self-reported by patients, and the level was established by the distance they walked (km/day) at least 3 days per week. Hospitalizations were recorded from hospital databases. All patients with at least a 2-year follow-up after enrollment were included in the analysis. The response variable was the number of hospitalizations for eCOPD within the 3-year period from 2 to 5 years after study enrollment.

RESULTS

Three hundred ninety-one survivors were studied. Mean forced expiratory volume in 1 s was 52% (±14%) of the predicted value. Patients who maintained a lower level of PA had an increased rate of hospitalization (odds ratio 1.901; 95% confidence interval 1.090-3.317). After having had the highest level of PA, those patients who decreased their PA in the follow-up showed an increasing rate of hospitalizations (odds ratio 2.134; 95% confidence interval 1.146-3.977).

CONCLUSIONS

Patients with COPD with a low level of PA or who reduced their PA over time were more likely to experience a significant increase in the rate of hospitalization for eCOPD. Changes to a higher level of PA or maintaining a moderate or high level of PA over time, with a low intensity activity such as walking for at least 3-6 km/day, could reduce the rate of hospitalizations for eCOPD.

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Validation of the i-BODE index as a predictor of hospitalization and mortality in patients with COPD participating in pulmonary rehabilitation

Abstract The aim of this study was to examine the value of the i-BODE index to predict hospital admission and to confirm its usefulness to predict mortality in a Danish population. The incremental shuttle walking test (ISWT) is widely used in the UK and Europe and previous work has examined the replacement of the 6MWT with the ISWT within the BODE index for predicting the prognosis of COPD (i-BODE). The 674 patients included in the analysis participated in a 7-week pulmonary rehabilitation program from 2002 to 2011. The National Health Services Central Register ascertained vital status and provided information on all hospital admissions. The mean follow-up period was 66 months (range 11-118 months). Cox proportional hazards model was used to identify factors that significantly predicted mortality and time to first hospital admission. The i-BODE index as well as body mass index, MRC dyspnea grade, and exercise capacity (ISWT) were significantly associated with all-cause mortality. The adjusted hazard ratio for death per one point increase in the i-BODE score was 1.28 (95% confidence interval 1.20 to 1.37). The i-BODE index was also a significant predictor of hospitalization, both for all causes and COPD exacerbation. Patients in the highest i-BODE quartile had a median time to first hospitalization of 17 months compared to 51 months for patients in the lowest quartile. The i-BODE index is a significant predictor of hospital admission and thus health care utilization, and also mortality.

Factors to inform clinicians about the end of life in severe chronic obstructive pulmonary disease

CONTEXT

Palliative services have historically been offered to terminal patients with cancer, but much less so in other chronic illnesses such as chronic obstructive pulmonary disease (COPD) because of difficulties in predicting the trajectory to death.

OBJECTIVES

The goal of this study was to determine if the change over time of the key parameters (trajectory) in patients with severe COPD can independently predict short-term mortality.

METHODS

We analyzed data from 1218 patients with severe COPD. Multivariate models for trajectory change were used to forecast mortality at 12 months.

RESULTS

Changes in several variables by defined cutpoints increase significantly and independently the odds of dying in 12 months. The earliest and strongest predictors were the decrease in gait speed by 0.14 m/s or six-minute walk by 50 m (odds ratio [OR] 4.40, P<0.0001). Alternatively, if six-minute walk or gait speed were not used, change toward perceiving a very sedentary state using a single question (OR 3.56, P=0.0007) and decrease in maximal inspiratory pressure greater than 11 cmH2O (OR 2.19, P=0.0217) were predictive, followed by change toward feeling upset or downhearted (OR 2.44, P=0.0250), decrease in room air resting partial pressure of oxygen greater than 5 mmHg (OR 2.46, P=0.0156), and increase in room air resting partial pressure of carbon dioxide greater than 3 mmHg (OR 2.8, P=0.0039). Change over time models were more discriminative (higher c-statistics) than change from baseline models.

CONCLUSION

The changes in defined variables and patient-reported outcomes by defined cutpoints were independently associated with increased 12-month mortality in patients with severe COPD. These results may inform clinicians when to initiate end-of-life communications and palliative care.

Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies

BACKGROUND

Self-management is proposed as the standard of care in chronic obstructive pulmonary disease (COPD), but details of the process and training required to deliver effective self-management are not widely available. In addition, recent data suggest that patient engagement and motivation are critical ingredients for effective self-management. This article carefully describes a self-management intervention using motivational interviewing skills, aimed to increase engagement and commitment in severe COPD patients.

METHODS

The intervention was developed and pilot tested for fidelity to protocol, for patient and interventionist feedback (qualitative) and effect on quality of life. Engagement between patient and interventionists was measured by the Working Alliance Inventory. The intervention was refined on the basis of the results of the pilot study and delivered in the active arm of a prospective randomized study.

RESULTS

The pilot study suggested improvements in quality of life, fidelity to theory, and patient acceptability. The refined self-management intervention was delivered 540 times in the active arm of a randomized study. We observed a retention rate of 86% (patients missing or not available for only 14% the scheduled encounters).

CONCLUSIONS

A self-management intervention that includes motivational interviewing as the way if guiding patients into behavior change is feasible in severe COPD and may increase patient engagement and commitment to self-management. This provides a very detailed description of the process for the specifics of training and delivering the intervention, which facilitates replicability in other settings and could be translated to cardiac rehabilitation.

Improving physical activity in patients with COPD with urban walking circuits

BACKGROUND

Even after a rehabilitation program, levels of physical activity in COPD progressively decrease unless strategies to encourage activity are implemented. We analyzed the effects of the implementation of urban walking circuits on levels of physical activity and exercise capacity of patients with severe and very severe COPD after a rehabilitation program.

METHOD

A total of 83 patients were randomized to either urban circuits group (UCG) or usual care in the non-circuit group (NCG), after completing a 2-week rehabilitation program. Results were evaluated 9 months after completion of the rehabilitation program and were compared with a control group of 54 patients not enrolled in the rehabilitation program.

RESULTS

At the end of follow-up, UCG patients increased their physical activity by a mean of 32.4 (SE = 5.9) min per day and 1.09 (SE = 0.22) days walked per week; 33.9 (SE = 5.6) min per day and 1.12 (SE = 0.24) days per week more compared to the NCG (p < 0.001). There was a significant positive correlation between the results of the 6-min walking test and minutes walked per day in the UCG (r(2) = 0.52, p < 0.05) but not in the NCG (r(2) = 0.094, p > 0.05). Controls showed a significant decrease in exercise capacity and physical activity over the follow-up.

CONCLUSIONS

Urban circuits are an easy, inexpensive strategy, which demonstrated to be useful to stimulate physical activity in our population of severe and very severe COPD patients and resulted in increased exercise capacity even 9 months after completion of a rehabilitation program.

Reduced level of physical activity in Japanese patients with chronic obstructive pulmonary disease

BACKGROUND

There is increasing interest in the quantification of physical activity (PA) with an accelerometer for the management of chronic obstructive pulmonary disease (COPD). However, a detailed understanding of the PA in Japanese patients with COPD is lacking. We evaluated the levels of PA in terms of intensity in Japanese patients with COPD and evaluated the factors, which could influence the PA.

METHODS

Forty-three outpatients with COPD and 21 age-matched healthy subjects were monitored with a triaxial accelerometer, and their PA was compared. Furthermore, the effects of pulmonary function, ADO index (age, dyspnea, and airflow obstruction) and modified BODE index (body mass index, airflow obstruction, dyspnea, and exercise capacity) on the PA were evaluated.

RESULTS

The PA in COPD was significantly reduced at all intensities. The reduced levels of PA in COPD were 23.1% at ≥2.0 metabolic equivalents (METs), 33.0% at ≥2.5 METs, 50.9% at ≥3.0 METs, and 66.9% at ≥3.5 METs, compared with that of healthy subjects, and the reduction was significant at GOLD stage III. The values of FVC, FEV1.0, and DLCO/VA were correlated with that of the PA, but the lung volume parameters were not. The ADO and modified BODE indices were also well correlated with the PA.

CONCLUSIONS

The reduced levels of PA in Japanese patients with COPD were objectively demonstrated in terms of intensity that could provide us a new target for the management of COPD.

Physical activity in people with COPD, using the National Health and Nutrition Evaluation Survey dataset (2003-2006)

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are sedentary but the extent of the problem is not fully understood.

PURPOSES

This study examines sedentary time and physical activity (PA) and the relative effects of demographic and clinical characteristics on sedentary time and PA in a population-based sample of people with COPD and a comparison group from the general population.

METHODS

Subjects were drawn from the National Health and Nutrition Examination Survey dataset (2003-2006). Physical activity was measured by accelerometry.

RESULTS

People with COPD were sedentary and spent less time in most levels of PA. Age, gender, race, level of education, working status, shortness of breath, self-reported health, and body mass index were significantly associated with sedentary time or level of PA.

CONCLUSION

Findings emphasize the need to decrease sedentary time and increase PA in people with COPD.

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

Background

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

Methods

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

Results

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

Conclusions

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

Indacaterol improves daily physical activity in patients with chronic obstructive pulmonary disease

Background

The current mainstay of therapy for chronic obstructive pulmonary disease (COPD) is long-acting bronchodilators. To date, the effect of indacaterol, a β2-agonist, on activities of daily living in COPD patients is not well understood. The aim of this study was to evaluate the efficacy of indacaterol with regard to activities of daily living in patients with COPD.

Methods

In this nonrandomized open-label study, 23 patients with COPD were instructed to carry an accelerometer for 4 weeks without indacaterol therapy and then for another period of 4 weeks while receiving indacaterol therapy.

Results

The number of steps, duration of moderate or greater physical activity, and energy expenditure were significantly increased after treatment with indacaterol compared with baseline data in all patients with COPD; the metabolic equivalent of task was also significantly enhanced after treatment with indacaterol.

Conclusion

This study provides early evidence that indacaterol improves daily physical activity in patients with COPD.

Patient's perception of symptoms related to morning activity in chronic obstructive pulmonary disease: the SYMBOL Study

BACKGROUND/AIMS

Patients with chronic obstructive pulmonary disease (COPD) experience more problematic respiratory symptoms and have more trouble performing daily activities in the morning. The aim of this study was to assess the perception of COPD symptoms related to morning activities in patients with severe airflow limitation.

METHODS

Data of 133 patients with severe airflow limitation were analyzed in a prospective, non-interventional study. A clinical symptom questionnaire was completed by patients at baseline. In patients having morning symptoms, defined by at least one or more prominent or aggravating symptom during morning activities, a morning activity questionnaire was also completed at baseline and following 2 months of COPD treatment.

RESULTS

The most frequently reported COPD symptom was breathlessness (90.8%). Morning symptoms were reported in 76 (57%) patients; these had more frequent and severe clinical COPD symptoms. The most frequently reported morning activity was getting out of bed (82.9%). The long acting muscarinic antagonist (odds ratio [OR], 6.971; 95% confidence interval [CI], 1.317 to 11.905) and chest tightness (OR, 0.075; 95% CI, 0.011 to 0.518) were identified as significantly related to absence of morning symptoms. There was no significant correlation between the degree of forced expiratory volume in 1 second improvement and severity score differences of all items of morning activity after 2-month treatment.

CONCLUSIONS

Fifty-seven percent of COPD patients with severe airflow limitation have morning symptoms that limit their morning activities. These patients also have more prevalent and severe COPD symptoms. The results of this study therefore provide valuable information for the development of patient-reported outcomes in COPD.