Physical activity, sedentary behaviour and sleep in COPD guidelines: A systematic review

What kind of non-pharmacological strategy for reducing sedentary behavior in COPD? Data from a scoping review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is usually associated with sedentary behavior (SB). Literature reports a harmful impact of SB on the physical, mental, and social health of individuals with COPD. However, Pulmonary Rehabilitation (PR) programs seem to have no clear effect on changing SB. Therefore, our study aimed to identify the strategies used in the literature to reduce SB among individuals with COPD.

METHOD

A scoping review was conducted to summarize the current literature regarding the proposed strategies to reduce SB in individuals with COPD. Searches were conducted in PUBMED; SCOPUS and COCHRANE LIBRARY for studies published from 2010 to march 2024.

RESULTS

Twenty four articles were retained for our review. Most of the identified strategies in the literature (21/24 articles) are based on behavioral approaches, with various forms: promoting self-efficacy, self-management and self-regulation of one's own behavior (12 articles), goal setting (10 articles), constant feedback (11 articles), therapeutic education (8 articles), motivational strategies (6 articles), re-engagement in meaningful activities (4 articles), promoting light intensity physical activity (LPA) (6 articles) and social support (6 articles). In association with the behavioral strategies, wearable connected technologies have been used in 4 articles, alone or combined with physical exercise programs included or not in a PR program. The home is associated with 83 % of interventions as a place for initial and continuous implementation of behavioral strategies.

CONCLUSION

It would seem appropriate to focus on combined strategies to reduce SB in individuals with COPD (improvement of physical abilities and behavioral strategies). Further research is needed to only target the reduction of SB and to evaluate the effects of various interventions.

Association of resistance training and moderate-to-vigorous physical activity with clinical outcomes in men with airflow limitation: a nationwide population-based study

Aerobic moderate-to-vigorous physical activity (MVPA) is recommended for individuals with chronic diseases. However, the association between resistance training (RT) in addition to moderate to vigorous physical activity (MVPA) and sleep duration, as well as respiratory symptoms, in patients with chronic obstructive pulmonary disease has not been thoroughly investigated. This population-based cross-sectional study used data from the Korea National Health and Nutrition Examination Survey between 2014 and 2019. A total of 61,754 individuals were identified and men with airflow limitation (FEV1/FVC < 0.7) who engaged in aerobic MVPA were selected (n = 794). Weighted percentages and odds ratio (OR) of sleep problems (≤ 5 or ≥ 9 h), chronic cough, and chronic sputum were estimated. A multivariate-adjusted complex sample logistic regression model was used to calculate ORs and 95% confidence intervals (CI). Subgroup analyses were conducted using the forced expiratory volume (FEV1) % of the predicted value (%pred) ≥ 80 vs. < 80. The percentages of sleep problems, chronic cough, and chronic sputum production were lower in men who underwent aerobic MVPA + RT than in those who underwent aerobic MVPA alone. The multivariable-adjusted OR of sleep problems was 0.44 (95% CI 0.25-0.77) in individuals undergoing aerobic MVPA + RT compared to aerobic MVPA alone. The ORs of chronic cough and sputum were 0.35 (95% CI 0.13-0.94) and 0.51 (95% CI 0.30-0.87), respectively. These associations were only significant in individuals with FEV1 < 80% pred. Compared with aerobic MVPA alone, aerobic MVPA + RT was associated with appropriate sleep duration and a decrease in chronic cough and sputum in male with airflow limitation. This was more pronounced in individuals with a FEV1 < 80% pred.

Exploring the Link between Social Support and Patient-Reported Outcomes in Chronic Obstructive Pulmonary Disease Patients: A Cross-Sectional Study in Primary Care

We aimed to explore the link between social support and various patient-reported outcome measures (PROMs) in primary care patients with COPD. This was a cross-sectional study with 168 patients with COPD from six primary care centers in Crete, Greece. We collected data on sociodemographic characteristics, medical history, disease-specific quality of life, the COPD Assessment Test (CAT), fatigue, the Fatigue Severity Scale (FSS), phycological parameters, Patient Health Questionnaire-9, General Anxiety Disorder-7, sleep complaints, the Pittsburg Sleep Quality Index, the Athens Insomnia scale (AIS), and the Epworth Sleepiness Scale. Social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSS). Out of 168 patients with COPD, 114 (68.9%) exhibited low levels of social support. Low social support (MSPSS total ≤ 5) was positively associated with COPD symptoms (CAT score ≥ 10) (OR = 3.97, 95%CI:1.86-8.44; p < 0.01), fatigue (FSS ≥ 36) (OR = 2.74, 95%CI:1.31-5.74; p = 0.01), and insomnia symptoms (AIS ≥ 6) (OR = 5.17 95%CI:2.23-12.01; p < 0.01), while the association with depressive symptoms (PHQ-9 ≥ 10) was marginally significant (OR = 3.1, 95%CI:0.93-10.36; p = 0.07). Our results suggest that lower levels of social support are positively associated with PROMs in patients with COPD. Therefore, our findings show an additional way to improve the overall health of patients with COPD in primary care by putting social support at the epicenter of actions.

Exposure to ambient air pollution and chronic bronchitis: Findings from over 6.6 million adults in northwestern China

BACKGROUND

Ambient air pollution increases the risk of respiratory mortality and morbidity, but evidence concerning effects of air pollution on chronic bronchitis (CB) is scarce. This study aimed to evaluate the associations of a set of air pollutants with the burden of CB, and to explore potential modifiers on the associations.

METHODS

In 2020, a total of 6,556,440 adults living in the Northwestern region of China were recruited. The Space-Time Extra-Trees model was employed to assess the annual average concentrations of six air pollutants for the three years (2017-2019) before 2020 , and subsequently allocated to the participants based on the latitude and longitude of their home addresses. We investigated the associations between the levels of various air pollutants and the odds of CB using generalized linear mixed models, and conducted multiple sensitivity analyses and subgroup analyses.

RESULTS

The odds of CB displays an approximately linear association with particulate matter with aerodynamic diameter ≤2.5 μm (PM2.5), particulate matter with aerodynamic diameter ≤10 μm (PM10), while it shows a non-linear relationship with gaseous pollutants. In the adjusted model, the odds ratios and 95% confidence intervals for CB per 10 μg/m3 increase in PM2.5, PM10, and sulfur dioxide (SO2) were 1.297 (1.262-1.332), 1.072 (1.064-1.080), and 2.587 (2.186-3.063), respectively. Furthermore, several additional sensitivity analyses demonstrated the stability of these associations. Subgroup analyses found that the aforementioned associations were greater among participants aged below 50 years old and those who smoked and had no leisure time exercise.

CONCLUSION

Long-term exposure to ambient air pollutants may increase the odds of CB, especially among younger people and those with unhealthy lifestyles.

A Clustering Study of Dietary Patterns and Physical Activity among Workers of the Uruguayan State Electrical Company

Recent studies have shown that certain nutrients, specific food groups, or general dietary patterns (DPs) can promote health and prevent noncommunicable chronic diseases (NCCDs). Both developed and developing countries experience a high prevalence of NCCDs due to poor lifestyle habits, DPs, and low physical activity levels. This study aims to examine the dietary, physical activity, sociodemographic, and lifestyle patterns of Uruguayan State Electrical Company workers (the IN-UTE study). A total of 2194 workers participated in the study, providing information about their sociodemographics, lifestyles, and dietary habits through different questionnaires. To identify DPs from 16 food groups, principal component analysis (PCA) was performed. A hierarchical cluster algorithm was used to combine food groups and sociodemographic/lifestyle variables. Four DPs were extracted from the data; the first DP was related to the intake of energy-dense foods, the second DP to the characteristics of the job, the third DP to a Mediterranean-style diet, and the fourth DP to age and body mass index. In addition, cluster analysis involving a larger number of lifestyle variables produced similar results to the PCA. Lifestyle and sociodemographic factors, including night work, working outside, and moderate and intense PA, were significantly correlated with the dietary clusters, suggesting that working conditions, socioeconomic status, and PA may play an important role in determining DPs to some extent. Accordingly, these findings should be used to design lifestyle interventions to reverse the appearance of unhealthy DPs in the UTE population.

The Six Pillars of Lifestyle Medicine in Managing Noncommunicable Diseases - The Gaps in Current Guidelines

BACKGROUND

Noncommunicable diseases (NCDs), also known as chronic diseases that are long-lasting, are considered the major cause of death and disability worldwide, and the six pillars of lifestyle medicine (nutrition, exercise, toxic control, stress management, restorative sleep, and social connection) play an important role in a holistic management of their prevention and treatment. In addition, medical guidelines are the most accepted documents with recommendations to manage NCDs.

OBJECTIVE

The present study aims to analyze the lack of lifestyle pillars concerning the major Brazilian medical guidelines for NCDs and identify evidence in the literature that could justify their inclusion in the documents.

METHOD

Brazilian guidelines were selected according to the most relevant causes of death in Brazil, given by the Mortality Information System, published by the Brazilian Ministry of Health in 2019. Journals were screened in the PUBMED library according to the disease and non-mentioned pillars of lifestyle.

RESULTS

Relevant causes of deaths in Brazil are acute myocardial infarction (AMI), diabetes mellitus (DM), and chronic obstructive pulmonary diseases (COPD). Six guidelines related to these NCDs were identified, and all address aspects of lifestyle, but only one, regarding cardiovascular prevention, highlights all six pillars. Despite this, a literature search involving over 50 articles showed that there is evidence that all the pillars can help control each of these NCDs.

CONCLUSION

Rarely are the six pillars of lifestyle contemplated in Brazilian guidelines for AMI, DM, and COPD. The literature review identified evidence of all lifestyle pillars to offer a holistic approach for the management and prevention of NCDs.

Assessment of sedentary behaviour in individuals with COPD: how many days are necessary?

Objective

The objective of the present study was to define the minimum number of monitoring days required for the adequate cross-sectional assessment of sedentary behaviour in individuals with chronic obstructive pulmonary disease (COPD).

Methods

In this cross-sectional study, the sedentary behaviour of individuals with COPD was assessed using two physical activity monitors during awake time for seven consecutive days. Time spent per day in activities requiring ≤1.5 metabolic equivalents (METs) and in sitting, lying and sitting+lying positions was calculated taking into account the average of 7 days (as a reference in all analyses) and of all 119 possible combinations of 2---6 days. Intraclass correlation coefficients (ICCs) and linear regression analyses were performed for all combinations.

Results

91 individuals were analysed (47 female, 66±9 years, forced expiratory volume in 1 s 50±15% predicted). For the variables time spent per day in activities ≤1.5METs and sitting, the average of any combination of at least four assessment days was sufficient to adequately reflect the average of 7 days (adjusted R2≥0.929, ICC≥0.962, p<0.0001 for all). For time spent per day lying and sitting+lying, only two assessment days were enough (adjusted R2≥0.937, ICC≥0.968, p<0.0001 for all). Results were maintained independently of patient sex, disease severity, day of the week, daylight time or daytime naps.

Conclusions

The average of 4 days of objective monitoring was sufficient to adequately reflect the results of a 1-week assessment of the main outcomes related to sedentary behaviour in individuals with moderate to very severe COPD, regardless of sex, disease severity, day of the week, daylight time and occurrence of daytime naps.

Physical activity, physical capacity and sedentary behavior among asthma patients

BACKGROUND: Although exercise and daily physical activity (PA) have long been known to benefit patients with chronic disorders, knowledge is limited regarding asthma.

OBJECTIVE: In a Danish setting, our aim was to measure physical activity, sedentary behavior, and physical capacity among patients with asthma. We hypothesized that people with severe asthma would be less active and more sedentary than their mild-moderate counterparts.

METHODS: Adults with asthma were recruited through respiratory outpatient clinics and subsequently examined twice, 4 weeks apart. At each visit, participants underwent a series of lung function tests, questionnaires, and maximum oxygen uptake testing (VO₂max). Between the visits, participants wore an accelerometer continuously for 4 weeks, measuring sedentary time and daily steps. Sixty patients, 27 with mild-moderate asthma (GINA 1–3) and 33 with severe asthma (GINA 4–5), completed both visits and had valid accelerometer measurements.

RESULTS: No significant differences between the two groups were found in sedentary time, number of steps or VO₂max.   VO₂max was significantly correlated with FeNO (r = −0.30, p < 0.05), Short Form-12 Mental Health (r = 0.37, p < 0.05), Asthma Control Questionnaire (r = −0.35, p < 0.05), and Mini Asthma Quality of Life Questionnaire (r = 0.36, p < 0.05).

CONCLUSION: No differences were observed between patients with mild-moderate and severe asthma regarding sedentary behavior, daily steps or level of cardiopulmonary fitness. Furthermore, patients with the highest VO₂max had the higher quality of life scores.

Abbreviations: VO₂max: Maximal Oxygen Uptake; CPET: Cardiopulmonary Exercise Testing; BMI: Body Mass Index; FEV1: Forced Expired Volume in the First Second; FVC: Forced Vital Capacity; PEF: Peak Expiratory Flow; EIB: Exercise-Induced Bronchoconstriction; COPD: Chronic Obstructive Pulmonary Disease; ACQ: Asthma Control Questionnaire; Mini-AQLQ: Mini Asthma Quality of Life Questionnaire; SF-12: Short Form 12 Health Survey; SNOT-22: Sino-Nasal Outcome Test 22; GINA: The Global Initiative for Asthma; CRP: C-reactive Protein; Hgb:Hemoglobin count; EOS: Eosinophil count; EVH: Eucapnic Voluntary Hyperventilation; FeNO: Fractional Exhaled Nitric Oxide; PA: Physical Activity ERS: European Respiratory Society; ATS: American Thoracic Society; CRS: Chronic Rhinosinusitis; AHR: Airway Hyperresponsiveness

Relationships of Walking and non-Walking Physical Activities in Daily Life with Cognitive Function and Physical Characteristics in Male Patients with Mild Chronic Obstructive Pulmonary Disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is accompanied by dyspnea on exertion due to airflow limitation caused by bronchial stenosis, with afflicted patients being less physically active. Therefore, physical activity is important for disease management.

OBJECTIVES

This study aimed to examine the relationships of walking and non-walking physical activities with cognitive function or physical characteristics of patients with mild COPD in a community without respiratory rehabilitation.

DESIGN

Cross-sectional study.

DATA SOURCES AND METHODS

We included 40 male patients (mean age, 75.7 ± 6.7 years) with stable mild COPD. A three-axis accelerometer was used to evaluate walking and non-walking physical activities in daily life. Cognition, respiratory function, skeletal muscle mass, limb muscle strength, exercise capacity, and health-related quality of life were assessed.

RESULTS

Regarding daily exercise amount (metabolic equivalents × hours; Ex), 87.5% of the participants had walking activities of 0-2 Ex, while 67.5% had non-walking activities of 1-3 Ex. Walking activity was significantly correlated with cognitive function (P < .05), walking distance (P < .01), and health-related quality of life (P < .05), but not with muscle mass. However, non-walking activity was significantly correlated with the body mass index (P < .05), muscle mass (P < .05), and walking distance (P < .01), but not with cognitive function. Moreover, the relationship between non-walking activity and health-related quality of life was weaker than the corresponding relationship with walking activity.

CONCLUSION

In patients with mild COPD, walking and non-walking physical activities showed different relationships with cognitive function and physical characteristics. The findings suggest that self-management of such patients requires maintenance of both walking and non-walking activities in a balanced manner.

Sleep Quality and Self-Reported Symptoms of Anxiety and Depression Are Associated with Physical Activity in Patients with Severe COPD

Sleep quantity, quality and symptoms of depression or anxiety potentially affect the level of daily physical activity (PAL) and plausibly counteracts benefits from pulmonary rehabilitation programs. Their collective impact on PAL is sparsely investigated, particularly in patients with severely progressed chronic obstructive pulmonary disease (COPD). Aim: To investigate if sleep quantity, quality and symptoms from self-reported hospital anxiety and depression scores (HADS) are associated with PAL. Methods: In this exploratory cross-sectional study data were analysed from 148 participants with COPD; GOLD grade II-IV; GOLD group B to D (52% female, mean 69.7 ± SD of 8.4 years, FEV1% predicted 33.6 ± 10.9, 6MWD 327 ± 122 m, CAT 20 ± 7 points), eligible for conventional outpatient hospital-based pulmonary rehabilitation. Participants had sleep and PAL measured 24 h per day for five consecutive days with an activPAL monitor. Adjusted negative binomial regression was applied to investigate the associations with PAL. Results: Participants walked median (25th, 75th percentile) of 2358 (1325.75; 3822.25) steps per day and 14% walked >5000 steps per day on average. Time in bed (TIB) were a median (25th, 75th percentile) of 8.3 (7.1; 9.7) hours and numbers of nocturnal sleeping bouts (NSB) were 1.5 (0.8; 3), Anxiety (HADS-A) and depression (HADS-D) scores were median (25th, 75th percentile) of 5 (3; 8) points and 3 (2; 6) points, respectively, whereof 29% (HADS-A) and 15% (HADS-D) reported scores ≥8 points indicating significant symptoms. The fully adjusted rate ratio (RR) for steps per day for TIB (hours) [RR 0.97 (95% CI: 0.92; 1.02)], NSB (numbers) [RR 1.02 (95% CI: 0.97; 1.07)] were not significantly associated with number of steps per day, while there was a significantly association with number of steps per day for HADS-A [RR 1.04 (95% CI: 1.01; 1.07)] and HADS-D [RR 0.95 (95% CI: 0.91; 0.99)]. Conclusion: This exploratory cross-sectional study found a statistically significant association between HADS-A and HADS-D with numbers of steps per day in patients with severe COPD.

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

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

Association between physical activity and dynapenia in older adults with COPD: a nationwide survey

We aimed to examine the association between physical activity (PA) level and dynapenia in older adults with chronic obstructive pulmonary disease (COPD), and whether it varied with sex and obesity status. The current cross-sectional study included total of 1033 community-dwelling participants with COPD aged 65–79 from the Korean National Health and Nutrition Examination Survey. In the multivariable model, high and moderate PA levels were significantly associated with lower odds of dynapenia than low PA levels (high PA level: odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.09–0.74; moderate PA level: OR = 0.55, 95% CI = 0.35–0.87). This inverse association was observed only in males with COPD (high PA level: OR = 0.17, CI = 0.04–0.65; moderate PA level: OR = 0.49, 95% CI = 0.27–0.88) and the normal-weight group (18.5 ≤ body mass index (BMI) < 25 kg/m²; high PA level: OR = 0.21, 95% CI = 0.05–0.88; moderate PA level: OR = 0.48, 95% CI = 0.27–0.86). In older community-dwelling patients with COPD, a negative dose-dependent relationship exists between PA level and dynapenia. The independent associations between PA level and dynapenia was significant in men and in participants with normal weight.

Systematic Review of Physical Activity, Sedentary Behaviour and Sleep Among Adults Living with Chronic Respiratory Disease in Low- and Middle-Income Countries

Abstract

Physical activity (PA), sedentary behaviour (SB) and sleep are important lifestyle behaviours associated with chronic respiratory disease (CRD) morbidity and mortality. These behaviours need to be understood in low- and middle-income countries (LMIC) to develop appropriate interventions.

Purpose

Where and how have free-living PA, SB and sleep data been collected for adults living with CRD in LMIC? What are the free-living PA, SB and sleep levels of adults living with CRD?

Patients and Methods

The literature on free-living PA, SB and sleep of people living with CRD in LMIC was systematically reviewed in five relevant scientific databases. The review included empirical studies conducted in LMIC, reported in any language. Reviewers screened the articles and extracted data on prevalence, levels and measurement approach of PA, SB and sleep using a standardised form. Quality of reporting was assessed using bespoke criteria.

Results

Of 89 articles, most were conducted in Brazil (n=43). PA was the commonest behaviour measured (n=66). Questionnaires (n=52) were more commonly used to measure physical behaviours than device-based (n=37) methods. International Physical Activity Questionnaire was the commonest for measuring PA/SB (n=11). For sleep, most studies used Pittsburgh Sleep Quality Index (n=18). The most common ways of reporting were steps per day (n=21), energy expenditure (n=21), sedentary time (n=16), standing time (n=13), sitting time (n=11), lying time (n=10) and overall sleep quality (n=32). Studies revealed low PA levels [steps per day (range 2669-7490steps/day)], sedentary lifestyles [sitting time (range 283-418min/day); standing time (range 139-270min/day); lying time (range 76-119min/day)] and poor sleep quality (range 33-100%) among adults with CRD in LMIC.

Conclusion

Data support low PA levels, sedentary lifestyles and poor sleep among people in LMIC living with CRDs. More studies are needed in more diverse populations and would benefit from a harmonised approach to data collection for international comparisons.

The Association of Health-Related Factors with Leisure-Time Physical Activity among Adults with COPD: A Cross-Sectional Analysis

This study aimed to examine the association of health attitudes, health appraisals and affective experience to leisure-time physical activity in adults with chronic obstructive pulmonary disease (COPD). Cross-sectional analyses were conducted with a sample of 274 adults with COPD drawn from the second wave of the Midlife in the United States (MIDUS 2) Study. Chi-square analyses and independent t-tests were used to test the differences between physically active and inactive COPD patients (active group versus inactive group) for all study variables. Multiple logistic regression was used to examine the association of each study variable with leisure-time physical activity. The results showed that there were significant differences between the active and inactive groups in terms of age, education, functional limitations, health attitudes, health appraisals and affective experience. After controlling for socio-demographic variables and functional limitations, beliefs about the importance of physical fitness and strength for a good life and comparative health appraisals were significantly related to physical activity. However, neither negative nor positive affect was associated with physical activity status. Modifiable factors, such as health attitudes toward physical fitness and strength, as well as health appraisals, should be considered for developing effective physical activity promotion interventions among COPD patients.

Changes in systemic inflammation after pulmonary rehabilitation in patients with COPD and severe physical inactivity - an exploratory study

Background: Severe physical inactivity (SPI) in patients with COPD is associated with a poor prognosis. It is unknown whether there is a link between SPI and systemic inflammation, and if systemic inflammation in SPI changes following pulmonary rehabilitation (PR).

Methods: A prospective, observational study of patients referred for at least 7 weeks of PR comprising 2 h of exercise therapy and education twice weekly. At baseline and after PR, daily physical activity level (PAL) was measured with a validated activity monitor, SenseWear^® as well as systemic inflammation: b-eosinophils, p-fibrinogen, p-CRP, s-IL-6 and s-CD 163. SPI was defined as PAL <1.4.

Results: At baseline, SPI was present in 31 of the 57 patients included, and 23% (7/31) improved to non-SPI after PR. We observed no differences between patients with SPI and non-SPI, except baseline plasma fibrinogen level was slightly yet significantly higher in patients with SPI (median 13.3 [6.2–23.6] vs 11.2 [6.5–16.7] µmol/l) but change in fibrinogen levels differed insignificantly between patients who improved to non-SPI at follow-up compared to patients with persistent SPI (−0.6 [−16.9–9.9] vs −0.4 [−11.2–1.2] µmol/l).

Conclusion: SPI in COPD appears not to be associated with a distinct inflammatory profile compared to less sedentary COPD patients attending pulmonary rehabilitation. Currently biomarkers have no role in the detection of SPI in COPD.

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

Background

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

Method

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

Results

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

Conclusion

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

Phenotyping Adopters of Mobile Applications Among Patients With COPD: A Cross-Sectional Study

Effectiveness of technology-based interventions to improve physical activity (PA) in people with COPD is controversial. Mixed results may be due to participants' characteristics influencing their use of and engagement with mobile health apps. This study compared demographic, clinical, physical and PA characteristics of patients with COPD using and not using mobile apps in daily life. Patients with COPD who used smartphones were asked about their sociodemographic and clinic characteristics, PA habits and use of mobile apps (general and PA-related). Participants performed a six-minute walk test (6MWT), gait speed test and wore an accelerometer for 7 days. Data were compared between participants using (App Users) and not using (Non-App Users) mobile apps. A sub-analysis was conducted comparing characteristics of PA–App Users and Non-Users. 59 participants were enrolled (73% Male; 66.3 ± 8.3 yrs; FEV1 48.7 ± 18.4% predicted): 59% were App Users and 25% were PA-App Users. Significant differences between App Users and Non-App Users were found for age (64.2 ± 8.9 vs. 69.2 ± 6.3yrs), 6MWT (462.9 ± 91.7 vs. 414.9 ± 82.3 m), Gait Speed (Median 1.5 [Q1–Q3: 1.4–1.8] vs. 2.0 [1.0–1.5]m/s), Time in Vigorous PA (0.6 [0.2–2.8] vs. 0.14 [0.1–0.7]min) and Self-Reported PA (4.0 [1.0–4.0] vs. 1.0 [0.0–4.0] Points). Differences between PA–App Users and Non-Users were found in time in sedentary behavior (764.1 [641.8–819.8] vs. 672.2 [581.2–749.4] min) and self-reported PA (4.0 [2.0–6.0] vs. 2.0 [0.0–4.0] points). People with COPD using mobile apps were younger and had higher physical capacity than their peers not using mobile apps. PA-App Users spent more time in sedentary behaviors than Non-Users although self-reporting more time in PA.

Study of Food Intake and Physical Activity Patterns in the Working Population of the Uruguayan State Electrical Company (UTE): Design, Protocol and Methodology

Noncommunicable diseases are the main cause of death globally, and most are potentially preventable; they are long term diseases and generally evolve slowly. In Uruguay 64.9% of the population between 25 and 64 years of age are either overweight or obese. The available scientific data show that workplaces are good for developing food-intake interventions for a healthier life. The present study aims to report the design, protocol and methodology for the evaluation of the food intake and physical activity patterns of the Uruguayan State Electrical Company (UTE) workers, as it is distributed across the whole country, and has established associations with overweight and obesity in order to establish institutional strategies to improve the situation. This study uses a population and a cross-sectional, randomized, representative sample of UTE workers with a precision of 3% and a confidence level of 95%. The considered anthropometric variables are weight, height, waist circumference, percentage of fat mass and percentage of visceral fat. A questionnaire on frequency of consumption of different foods and two 24-h dietary recalls (24-h DR) will be performed to evaluate the food intake. Accelerometry will be used to evaluate physical activity, and the International physical activity questionnaire (IPAQ) will be applied. Clinical data will be obtained from the UTE clinical charts. This is the first study of its kind that will be undertaken in Uruguay. It is registered under ClinicalTrials.gov Identifier nº NCT04509908.

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

Objective

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

Patients and Methods

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

Results

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

Conclusion

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

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

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

Background

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

Materials and Methods

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

Results

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

Conclusion

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

Artificial Intelligence in the Healthcare System: An Overview

This chapter aims to present insights into the influence of artificial intelligence (AI) on medicine, public health, and the economy. PubMed and Google Scholar databases were used for the identification and collection of articles with search commands of "artificial intelligence" AND "public health" and "artificial intelligence" AND "medicine". A total of 273 articles specifically handling the issue of artificial intelligence, dating ten years back, in three major medical journals: Science, The Lancet, and The New England Journal of Medicine, were analyzed. Computational power gets stronger by the day, giving us new solutions and possibilities. Current medicine problems like personalized medicine, storage of data, and documentation overload will likely be replaced by AI shortly. The application of AI may also bring substantial benefits to other areas of medicine like the diagnostic and therapeutic processes. The development and spread of AI are inescapable as it lowers healthcare and administrative costs, improves medical efficiency, and predicts and prevents major disease complications. The use of AI in medicine seems destined to carry the day.

Contemporary perspectives in COPD: Patient burden, the role of gender and trajectories of multimorbidity

An individual's experience of COPD is determined by many factors in addition to the pathological features of chronic bronchitis and emphysema and the symptoms that derive directly from them. Multimorbidity is the norm rather than the exception, so most people with COPD are living with a range of other medical problems which can decrease overall quality of life. COPD is caused by the inhalation of noxious particles or gases, in particular tobacco smoke, but also by early life disadvantage impairing lung development and by occupations where inhaled exposures are common (e.g. industrial, farming and cleaning work). Wealthy people are therefore relatively protected from developing COPD and people who do develop the condition may have reduced resources to cope. COPD is also no longer a condition that predominantly affects men. The prevalence of COPD among women has equalled that of men since 2008 in many high-income countries, due to increased exposure to tobacco, and in low-income countries due to biomass fuels. COPD is one of the leading causes of death in women in the USA, and death rates attributed to COPD in women in some countries are predicted to overtake those of men in the next decade. Many factors contribute to this phenomenon, but in addition to socioeconomic and occupational factors, there is increasing evidence of a higher susceptibility of females to smoking and pollutants. Quality of life is also more significantly impaired in women. Although most medications (bronchodilators and inhaled corticosteroids) used to treat COPD demonstrate similar trends for exacerbation prevention and lung function improvement in men and women, this is an understudied area and clinical trials frequently have a preponderance of males. A better understanding of gender-based predictors of efficacy of all therapeutic interventions is crucial for comprehensive patient care. There is an urgent need to recognize the increasing burden of COPD in women and to facilitate global improvements in disease prevention and management in this specific population. Many individuals with COPD follow a trajectory of both lung function decline and also multimorbidity. Unfavourable lung function trajectories throughout life have implications for later development of other chronic diseases. An enhanced understanding of the temporal associations underlying the development of coexisting diseases is a crucial first step in unravelling potential common disease pathways. Lessons can be learned from exploring disease trajectories of other NCD as well as multimorbidity development. Further research will be essential to explain how early life risk factors commonly influence trajectories of COPD and other diseases, how different diseases develop in relation to each other in a temporal way and how this ultimately leads to different multimorbidity patterns in COPD. This review integrates new knowledge and ideas pertaining to three broad themes (i) the overall burden of disease in COPD, (ii) an unappreciated high burden in women and (iii) the contrast of COPD trajectories and different multimorbidity patterns with trajectories of other NCD. The underlying pathology of COPD is largely irreversible, but many factors noted in the review are potentially amenable to intervention. Health and social care systems need to ensure that effective treatment is accessible to all people with the condition. Preventive strategies and treatments that alter the course of disease are crucial, particularly for patients with COPD as one of many problems.

Reducing sedentary behavior in individuals with COPD: healthcare professionals' perspectives

Background: Reducing sedentary behavior (SB) in individuals with chronic obstructive pulmonary disease (COPD) is being increasingly recognized as a novel health target. Understanding healthcare professionals (HCPs) behavior that influences a reduction in SB in this population could facilitate achieving this target. Objective: To explore the determinants of behavior related to HCPs targeting a reduction in SB in people with COPD. Methods: We used a qualitative semi-structured interview approach informed by the Theoretical Domains Framework (TDF). Sixteen HCPs were interviewed. Interview transcripts were mapped against the relevant TDF domain(s) and then higher order themes were generated. Results: Directed content analysis resulted in mapping 949 quotes to the TDF domains with environmental context and resources being the most coded domain. Three higher order themes were identified: 1) HCPs need more knowledge on reducing SB; 2) Strategies suggested to include in pulmonary rehabilitation (PR) to reduce SB; and 3) Barriers to adding SB to PR. Domains of environmental context and resources, knowledge, social/professional role and identity, reinforcement, social influences, skills and beliefs about capabilities were relevant to the study population to reduce SB in people with COPD. Conclusion: Knowledge of SB varied across participants. This study provided information on potential behavioral targets for future interventions that involve HCPs and aim to reduce SB among people with COPD.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Construct validity of the brief physical activity assessment tool for clinical use in COPD

INTRODUCTION

Low physical activity (PA) levels are associated with poor health-related outcomes in Chronic Obstructive Pulmonary Disease (COPD). Thus, PA should be routinely assessed in clinical practice.

OBJECTIVES

This study assessed the construct validity of the Brief Physical Activity Assessment Tool (BPAAT) for clinical use in COPD and explored differences in age, sex and COPD grades.

METHODS

After linguistic adaptation of the tool to Portuguese, 110 patients (66.4 ± 9.6yrs, 72.7% male, FEV₁  = 59.3 ± 25.5%predicted) completed the BPAAT and received an accelerometer. The BPAAT includes two questions assessing the weekly frequency and duration of vigorous- and moderate-intensity PA/walking, classifying individuals as insufficiently or sufficiently active. The BPAAT was correlated with accelerometry (moderate PA, MPA = 1952-5724 counts-per-min [CPM]); vigorous PA, VPA = 5725-∞CPM; moderate-to-vigorous PA, MVPA = 1952-∞CPM; daily steps), through: Spearman's correlations (ρ) for continuous data; %agreement, Kappa, sensitivity and specificity, positive and negative predictive values (PPV, NPV) for categorical data.

RESULTS

The BPAAT identified 73.6% patients as "insufficiently active" and 26.4% as "sufficiently active". The BPAAT was weakly to moderately correlated with accelerometry (0.394 ≤ ρ ≤ 0.435, P < 0.05), except for VPA (P = 0.440). This was also observed in age (<65/≥65yrs), COPD grades (GOLD 1-2/3-4) and in male patients (0.363 ≤ ρ ≤ 0.518, P < 0.05 except for VPA). No significant correlations were found in female patients (P > 0.05). Agreement was fair to moderate (0.36 ≤ κ ≤ 0.43; 73.6% ≤ %agreement ≤ 74.5%; 0.50 ≤ sensitivity ≤ 0.52; 0.84 ≤ specificity ≤ 0.91, 0.55 ≤ PPV ≤ 0.79, 0.72 ≤ NPV ≤ 0.82).

CONCLUSION

The BPAAT may be useful to screen patients' PA, independently of age and COPD grade, and identify male patients who are insufficiently active. Care should be taken when using this tool to assess vigorous PA or female patients.

Tossing and turning: association of sleep quantity-quality with physical activity in COPD

The association between characteristics of sleep and physical activity in daily life (PADL) has not yet been investigated in depth in subjects with COPD. This study evaluated whether time spent per day in physical activity (PA) and sedentary behaviour are associated with sleep quantity and quality in this population. Sleep and PADL were objectively assessed by an activity monitor for 7 days and analysed on a minute-by-minute basis. Subjects also underwent spirometry and 6-min walking test (6MWT). Fifty-five subjects with moderate-to-severe COPD (28 male, 67±8 years) were studied. Subjects with total time in bed (TIB) per night ≥9 h had higher wake-after-sleep onset than TIB 7-9 h and TIB ≤7 h (195 (147-218) versus 117 (75-167) and 106 (84-156) min) and more fragmented sleep than TIB ≤7 h (8.2 (6.7-14.3) versus 6.3 (5.6-6.9) sleeping bouts; p<0.05 for all). Subjects with TIB ≥9 h also spent more time per day in sedentary behaviour and less time per day in PA of light and moderate-to-vigorous intensity than those with TIB 7-9 h and ≤7 h. In multiple linear regression, TIB ≥9 h was the only significant predictor of physical inactivity (β=-3.3 (-5.1, -1.6), p≤0.0001), accounting for 20% of its variation. Sleep fragmentation was frequent and more pronounced in physically inactive than active patients (7.5 (6.3-9.6) versus 6.4 (5.5-7.3) sleeping bouts; p=0.027). In summary, subjects with COPD with TIB ≥9 h·night-1 have more fragmented sleep, are more sedentary and less physically active than those with <9 h·night-1, independently of the awake time. Sleep quality is frequently poor and even worse in patients classified as physically inactive.

Physical Activity, Sedentary Behavior, and Sleep Quality in Adults with Primary Hypertension and Obesity before and after an Aerobic Exercise Program: EXERDIET-HTA Study

Background: The purposes of the study were to: analyze, by objective (accelerometry) and subjective (International Physical Activity Questionnaire, IPAQ) methodologies, the physical activity (PA) and sedentary behavior (SB) in healthy adults (HEALTHY, n = 30) and individuals with primary hypertension (HTN) and overweight/obesity (n = 218); assess the effects of an aerobic exercise intervention on physical activity (PA), sedentary behavior (SB), and sleep quality in the HTN group; and evaluate the relationship between objectively measured and subjectively reported PA and SB. Methods: The measurements were performed before a 16-week exercise intervention period in both HEALTHY and HTN groups and after the intervention period only in the HTN group, randomized to attention control or exercise training (ExT) subgroups. Results: The HEALTHY group showed more moderate-to-vigorous PA (p < 0.05) and better sleep quality (p < 0.05) than the HTN group, but no difference in SB. After the intervention, HTN participants’ PA and SB, objectively measured by accelerometry, were unchanged, but increased PA and decreased SB (p < 0.05) were observed through IPAQ in ExT. The intervention was effective in improving sleep quality in HTN participants. Conclusions: The differences in moderate-to-vigorous PA and SB may be useful in defining the health profile of a population. The supervised aerobic exercise program was effective in increasing PA, reducing SB, and improving sleep quality in overweight/obese adults with HTN. Accelerometer-measured and self-reported data were not comparable, but complementary.

Association between physical activity and risk of hospitalisation in bronchiectasis

Background

Patients with bronchiectasis have a less active lifestyle than healthy peers, but the association with hospital admission has not been explored. The aim of this study was to investigate the association between 1) any physical activity variable; and 2) sedentary time, with hospitalisation due to exacerbation in adults with bronchiectasis.

Methods

In this prospective observational study, baseline lung function, quality of life, exercise tolerance, severity of bronchiectasis and physical activity were recorded. Physical activity was objectively assessed over a week using a SenseWear armband and the results were expressed in steps·day–1 and sedentary time. Number of hospitalisations due to a bronchiectasis exacerbation and time to first event were recorded after 1-year follow-up.

Results

Sixty-four patients with bronchiectasis were analysed, of whom 15 (23%) were hospitalised during the follow-up. Hospitalised patients showed poor baseline clinical and severity outcomes, fewer steps walked per day and more sedentary behaviour than the non-hospitalised group. Patients who walked ≤6290 steps·day–1 or spent ≥7.8 h·day–1 in sedentary behaviour had an increased risk of hospital admission due to bronchiectasis exacerbation at 1-year follow-up. Specifically, ≥7.8 h·day–1 of sedentary behaviour was associated with a 5.9-fold higher risk of hospital admission in the following year.

Conclusions

Low levels of physical activity and high sedentary time at baseline were associated with a higher risk of hospitalisation due to bronchiectasis exacerbation. If these findings are validated in future studies, it might be appropriate to include physical activity and sedentary behaviour as an item in severity scores.

Recommendations for 24-Hour Movement Behaviours in Adults with Asthma: A Review of Current Guidelines

Background: Many countries have clinical practice guidelines (CPG) for asthma that serve as an important resource for healthcare professionals and inform the development of policies and practices relevant to asthma care. The purpose of this scoping review was to search for CPGs related to asthma to determine what recommendations related to the 24-h movement behaviours are provided. Methods: We searched for the most recent CPGs published by a national authoritative body from 195 countries. Guidelines were reviewed for all movement behaviours; that is, physical activity, sedentary behaviour, and sleep. Results: In total, 82 documents were searched for eligibility and 19 were included in our review. Of these, only 10 CPGs provided information on physical activity; none provided recommendations consistent with the FITT principle, while seven recommended activity levels similar to the general population. None of the guidelines included information on sedentary behaviour. Nine guidelines included information on sleep: recommendations mostly focused on changes to medication to reduce disruptions in sleep. Conclusions: It is recommended that future work be conducted to create comprehensive movement behaviour guidelines accompanied with relevant precautions and strategies to ensure that adults with asthma are able to safely and effectively engage in movement behaviours throughout the day.

Subjective sleep quality is associated with disease status in COPD patients. The cross-sectional Greek UNLOCK study

PURPOSE

The association of chronic obstructive pulmonary disease (COPD) severity and related health status with sleep quality remains unclear. We aimed to investigate the association between COPD and sleep quality in the Greek national branch of the UNLOCK cohort.

METHODS

A sample of 257 COPD patients enrolled cross-sectionally from primary care in Greece. Sleep quality was assessed by the COPD and Asthma Sleep Impact Scale (CASIS-7 items) questionnaire (higher score indicates worse sleep quality). We tested for associations of sleep impairment with health status (CAT and mMRC scores), exacerbations, hospitalizations, GOLD 2018 ABCD status, inhaler adherence, frailty, and sense of coherence, adjusting for age, gender, smoking status, and comorbidities.

RESULTS

The majority of patients reported uncontrolled symptoms (91% with ≥ 10 CAT or 61% with ≥ 2 mMRC). Mean (SD) age was 65 (12.3) with 79% males. CASIS-7 mean (SD) score was 37.7 (12.9). After adjustments, CASIS was significantly associated with worse health status (e.g., CASIS increased with CAT ≥ 10 [β = 12.53, (95% CI, 6.82, 18.25); p < 0.001], mMRC ≥ 2 [β = 4.96, (95% CI, 1.56, 8.34); p = 0.004]), COPD severity (CAT-based GOLD BD [β = 8.88 (95% CI, 2.50, 15.26); p = 0.007]), frailty [β = 8.85 (95% CI 4.45,13.25); p < 0.001], and sense of coherence [β = -0.14 (95% CI -0.21, -0.06), p < 001]. When using a CASIS cut-off score of 30 as indicator of sleep impairment, additional to the aforementioned associations, we found increased risk for sleep impairment with ≥ 2 exacerbations/year and poor inhaler adherence (p value < 0.05).

CONCLUSIONS

Our study suggests that worse health status and COPD severity are associated with poor sleep quality in COPD patients.

Determinants of Sedentary Behaviour in Individuals with COPD: A Qualitative Exploration Guided by the Theoretical Domains Framework

In people with chronic obstructive pulmonary disease (COPD), there is increasing recognition that the prolonged accumulation of sedentary time (ST) is associated with adverse cardio-metabolic health outcomes. Nevertheless, changing this lifestyle, which has evolved over several decades, is likely to be challenging. This study reports the determinants, perceived by individuals with COPD, as being important for reducing ST. An in-depth understanding of this information is essential when planning an intervention to reduce ST. Fourteen individuals with COPD completed semi-structured one-on-one interviews, which were audio recorded and transcribed verbatim. Both the interview schedule and mapping of data items extracted from the interview transcripts were informed by the Theoretical Domains Framework (TDF). A total of 867 quotes were mapped to the 14 TDF domains. Seven of the fourteen domains were identified as being important determinants for reducing ST: knowledge, beliefs about consequences, beliefs about capabilities, environmental context and resources, social influences, social/professional role and identity, and behavioural regulation. There was a lack of knowledge regarding the meaning of sedentary behaviour. Participants' desire to be educated by knowledgeable health professionals in a formal programme was a dominant theme across multiple domains. The most frequently reported barriers to reducing ST related to the domains of social/professional role and identity and environmental context and resources, while the most frequently reported enablers were related to the domains pertaining to beliefs about consequences and social influences. Potential strategies to reduce ST among people with COPD include education and other determinants identified in this research.

Physical Activity and Sedentary Behaviour Patterns in 326 Persons with COPD before Starting a Pulmonary Rehabilitation: A Cluster Analysis

This study applies a cluster analysis to identify typical physical activity (PA) and sedentary behaviour (SB) patterns in people with chronic obstructive pulmonary disease (COPD) before starting pulmonary rehabilitation (PR). We implemented an observational design which assessed baseline data of objectively measured PA and SB from the STAR (Stay Active after Rehabilitation) study. A total of 355 persons wore an accelerometer (Actigraph wGT3X) for seven days before the start of their PR. Sociodemographic and disease-related parameters were assessed at the start of PR. We applied cluster analysis and compared clusters applying univariate variance analyses. Data was available for 326 persons (31.6% women; age ø = 58 years). Cluster analysis revealed four movement clusters with distinct PA and SB patterns: Sedentary non-movers (28.5%), sedentary occasional movers (41.7%), sedentary movers (19.6%), and sedentary exercisers (10.1%). The four clusters displayed varying levels of moderate PA before rehabilitation (Ø daily min: 9; 28; 38; 70). Notably, all four clusters displayed considerably long average sedentary time per day (Ø daily minutes: 644; 561; 490; 446). The clusters differed significantly in disease-related parameters of GOLD severity, FEV1, CAT, and 6-Min-Walk-Test. In addition to PA promotion, PR programs should consider the reduction of sedentary behaviour as a valuable goal.

Importance of the relationship between symptoms and self-reported physical activity level in stable COPD based on the results from the SPACE study

Background

The burden of symptoms and risk of exacerbations are the main drivers of the overall assessment of the Chronic Obstructive Pulmonary Disease (COPD) and the adequate treatment approaches per current Global Initiative for Chronic Obstructive Lung Disease (GOLD). Physical activity has emerged as both functional outcome and non-pharmacological intervention in COPD patients, despite the lack of standardized measures or guidelines in clinical practice. This study aimed to explore in more depth the 24-h respiratory symptoms, the physical activity level (PAL) and the relationship between these two determinants in stable COPD patients.

Methods

This was a multinational, multicenter, observational, cross-sectional study conducted in ten European countries and Israel. Dedicated questionnaires for each part of the day (morning, daytime, night) were used to assess respiratory symptoms. PAL was evaluated with self- and interview-reported tools [EVS (exercise as vital sign) and YPAS (Yale Physical Activity Survey)], and physician’s judgement. Patients were stratified in ABCD groups by 2013 and 2017 GOLD editions using the questionnaires currently recommended: modified Medical Research Council dyspnea scale and COPD Assessment Test.

Results

The study enrolled 2190 patients (mean age: 66.9 years; male: 70.0%; mean % predicted FEV1: 52.6; GOLD groups II-III: 84.5%; any COPD treatment: 98.9%). Most patients (> 90%) reported symptoms in any part of the 24-h day, irrespective of COPD severity. PAL evaluations showed discordant results between patients and physicians: 32.9% of patients considered themselves completely inactive, while physicians judged 11.9% patients as inactive. By YPAS, the overall study population spent an average of 21.0 h/week performing physical activity, and 68.4% of patients were identified as sedentary. In any GOLD ABCD group, the percentage of inactive patients was high. Our study found negative, weak correlations between respiratory symptoms and self-reported PAL (p < 0.001).

Conclusions

Despite regular treatment, the majority of stable COPD patients with moderate to severe disease experienced daily variable symptoms. Physical activity level was low in this COPD cohort, and yet overestimated by physicians. With evidence indicating the negative consequences of inactivity, its adequate screening, a more active promotion and regular assessment of physical activity are urgently needed in COPD patients for better outcomes.

Trial registration

NCT03031769, retrospectively registered, 23 Jan 2017.

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1053-7) contains supplementary material, which is available to authorized users.

Use of time in chronic obstructive pulmonary disease: Longitudinal associations with symptoms and quality of life using a compositional analysis approach

Background and objectives

This study explored whether, for people with chronic obstructive pulmonary disease (COPD), changes to the 24-hour composition of physical activity (PA), sedentary behaviour (SB) and sleep were associated with changes in symptoms and health-related quality of life (HRQoL); and how time re-allocations between these behaviours were associated with changes in outcomes.

Methods

This study pools data on people with COPD drawn from two previous studies: a randomised controlled trial of cognitive behavioural therapy and pulmonary rehabilitation and a usual care cohort. Participants recalled behaviours and completed symptom and HRQoL assessments at baseline (T0) and four months (T1). Linear mixed-effects models (pooled control/intervention samples) predicted changes in outcomes from T0 to T1 with a change to the 24-hour behaviour composition; compositional isotemporal substitution predicted change in outcomes when re-allocating time between behaviours.

Results

Valid data were obtained for 95 participants (forced expiratory volume in one second %predicted = 49.6±15.3) at T0 and T1. A change in the 24-hour behaviour composition was associated with a change in anxiety (p<0.01) and mastery (p<0.01), but not breathlessness, depression or fatigue. When modelling time re-allocation with compositional isotemporal substitution, more time re-allocated to higher intensity PA or sleep was associated with favourable changes in outcomes; re-allocating time to SB or light PA was associated with unfavourable changes in outcomes. The direction of association, however, could not be determined.

Conclusion

To improve the overall health and wellbeing of people with COPD, intervention approaches that optimise the composition of PA, SB and sleep may be beneficial.

Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain?

Chronic pain is highly prevalent and more common in people with chronic obstructive pulmonary disease (COPD) than people of similar age/sex in the general population. This systematic review aimed to describe how frequently and in which contexts pain is considered in the clinical practice guidelines (CPGs) for the broad management of COPD. Databases (Medline, Scopus, CiNAHL, EMbase, and clinical guideline) and websites were searched to identify current versions of COPD CPGs published in any language since 2006. Data on the frequency, context, and specific recommendations or strategies for the assessment or management of pain were extracted, collated, and reported descriptively. Of the 41 CPGs (English n = 20) reviewed, 16 (39%) did not mention pain. Within the remaining 25 CPGs, pain was mentioned 67 times (ranging from 1 to 10 mentions in a single CPG). The most frequent contexts for mentioning pain were as a potential side effect of specific pharmacotherapies (22 mentions in 13 CPGs), as part of differential diagnosis (14 mentions in 10 CPGs), and end of life or palliative care management (7 mentions in 6 CPGs). In people with COPD, chronic pain is common; adversely impacts quality of life, mood, breathlessness, and participation in activities of daily living; and warrants consideration within CPGs for COPD.

Improving physical activity, sedentary behaviour and sleep in COPD: perspectives of people with COPD and experts via a Delphi approach

Background

Little is known about how to achieve enduring improvements in physical activity (PA), sedentary behaviour (SB) and sleep for people with chronic obstructive pulmonary disease (COPD). This study aimed to: (1) identify what people with COPD from South Australia and the Netherlands, and experts from COPD- and non-COPD-specific backgrounds considered important to improve behaviours; and (2) identify areas of dissonance between these different participant groups.

Methods

A four-round Delphi study was conducted, analysed separately for each group. Free-text responses (Round 1) were collated into items within themes and rated for importance on a 9-point Likert scale (Rounds 2–3). Items meeting a priori criteria from each group were retained for rating by all groups in Round 4. Items and themes achieving a median Likert score of ≥7 and an interquartile range of ≤2 across all groups at Round 4 were judged important. Analysis of variance with Tukey’s post-hoc tested for statistical differences between groups for importance ratings.

Results

Seventy-three participants consented to participate in this study, of which 62 (85%) completed Round 4. In Round 4, 81 items (PA n = 54; SB n = 24; sleep n = 3) and 18 themes (PA n = 9; SB n = 7; sleep n = 2) were considered important across all groups concerning: (1) symptom/disease management, (2) targeting behavioural factors, and (3) less commonly, adapting the social/physical environments. There were few areas of dissonance between groups.

Conclusion

Our Delphi participants considered a multifactorial approach to be important to improve PA, SB and sleep. Recognising and addressing factors considered important to recipients and providers of health care may provide a basis for developing behaviour-specific interventions leading to long-term behaviour change in people with COPD.

Patterns of Time Use across the Chronic Obstructive Pulmonary Disease Severity Spectrum

Descriptions of time use patterns in people with chronic obstructive pulmonary disease (COPD) are scarce and the relationship between use-of-time and COPD severity remains unclear. This study aimed to describe a typical day for people with COPD and to explore the differences in time-use patterns across the Body Mass-Index, Airflow Obstruction, Dyspnoea and Exercise Capacity (BODE) index using compositional analyses. Using a cross-sectional design, 141 adults with clinically stable COPD had their demographics, objective measures of function (pulmonary, exercise capacity and physical activity), and self-reported COPD-related impairment recorded. Daily time-use compositions were derived from 24-h accelerometry and 24-h use-of-time recall interviews. Compositional multiple linear regression models were used to explore the relationship between the BODE index and 24-h time-use compositions. These models were used to predict daily time (min/d) that is spent in time-use components across the BODE index. The BODE index score was clearly associated with 24-h accelerometry (p < 0.0001) and 24-h use-of-time recall (p < 0.0001) compositions. Relative to the remaining time-use components, higher BODE index scores were associated with greater sedentary behaviour (p < 0.0001), Quiet time (p < 0.0001), Screen time (p = 0.001) and Self-care (p = 0.022), and less daily Chores (p < 0.0001) and Household administration (p = 0.015) time. As the BODE index scores increased, time-use predictions were strongly associated with decreases in Chores (up to 206 min/d), and increases in Screen (up to 156 min/d) and Quiet time (up to 131 min/d). Time–use patterns may provide a basis for planning interventions relative to the severity of COPD.