Simple functional performance tests and mortality in COPD

The 1-min sit-to-stand test as a screening tool to assess exercise-induced oxygen desaturation in normoxemic people with interstitial lung disease

BACKGROUND

In patients with interstitial lung disease (ILD), exercise-induced desaturation during the 6-min walk test (6MWT), specifically nadir oxygen saturation (nSpO2) of ≤88 % is a negative prognostic marker. As the 6MWT is often impractical for ILD patients, the aim of this study is to compare the 1-min sit-to-stand test (1minSTS) with the 6MWT to detect exercise-induced desaturation.

METHODS

Participants were recruited from a tertiary referral clinic with both tests performed on the same day. Utilising Bland-Altman analysis, the relationship between nSpO2 on 1minSTS and 6MWT was determined. An area under the receiver operating characteristic curve (AUC) determined the ability of nSpO2 on 1minSTS test to predict SpO2 ≤88 % on 6MWT.

RESULTS

Fifty participants completed the study (idiopathic pulmonary fibrosis n = 24, 48 %; connective tissue disease associated ILD n = 20, 40 %; other ILD n = 6, 12 %). Mean (SD) FVC%pred was 73 ± 16 %, mean DLCO%pred 57 ± 16 % and resting SpO2 99 ± 1 %. The 1minSTS resulted in less exercise-induced oxygen desaturation, with a median IQR nSpO2 of 95 % (89-98) and 93 % (85-96) respectively (p < 0.001). Moderate agreement was determined between the nSpO2 on both tests, with a mean difference of 3.2 % [-14 to +3.0 %]. The 1minSTS test accurately identified participants with nSpO2 ≤88 % on 6MWT (AUC 0.96). Oxygen desaturation ≤94 % during the 1minSTS test provided 100 % sensitivity and 87 % specificity for oxygen desaturation ≤88 % at 6MWT.

CONCLUSION

This study demonstrates that exercise-induced oxygen desaturation during the 1minSTS test correlates with oxygen desaturation on 6MWT. The 1minSTS may be a practical screening tool for ILD patients who would benefit from further exercise testing.

Functional capacity using sit-to-stand tests in people with chronic obstructive pulmonary disease and its relationship with disease severity-a cross-sectional study with matched controls

BACKGROUND

Functional capacity impairment is a crucial consequence of chronic obstructive pulmonary disease (COPD). Although it can be identified with simple tests, such as the sit-to-stand tests, its prevalence, relation with disease severity, and the characteristics of people presenting this impairment remain unknown.

OBJECTIVE

To explore the functional capacity of people with COPD.

METHODS

A cross-sectional study with people with COPD and age-/sex-matched healthy controls was conducted. Functional capacity was assessed with the 5-repetitions (5-STS) and the 1-minute (1-minSTS) sit-to-stand tests. People with COPD were grouped according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifications. Comparisons between people with COPD and healthy controls, and among GOLD groups were established. Associations between symptoms, muscle strength, quality of life, and measures of functional capacity were explored.

RESULTS

302 people with COPD [79% male; mean (SD) 68 (10) years old] and 304 healthy controls [75% male; 66 (9) years old] were included. 23% of people with COPD presented impairment in the 5-STS and 33% in the 1-minSTS. People with COPD from all GOLD classifications presented significantly lower functional capacity than healthy controls (5-STS: COPD median [1st quartile; 3rd quartile] 8.4 [6.7; 10.6] versus healthy 7.4 [6.2; 9.3] s; 1-minSTS: COPD 27 [21; 35] vs healthy 35 [29; 43] reps). Correlations with symptoms, muscle strength, and quality of life were mostly weak (5-STS: rs [-0.34; 0.33]; 1-minSTS: rs [-0.47; 0.40]).

CONCLUSION

People with COPD have decreased functional capacity independently of their GOLD classifications. The prevalence of functional impairment is 23-33%. Because impaired functional capacity is a treatable trait not accurately reflected by other outcomes, comprehensive assessment and management is needed.

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.

The one-minute sit-to-stand-test performance is associated with health-related quality of life in patients with pulmonary hypertension

INTRODUCTION

Patients with pulmonary hypertension (PH) have an impaired functional capacity and poor health-related quality of life (HRQoL). The one-minute sit-to-stand test (1-min STST) can be used for the assessment of functional capacity.

AIMS

Our aim was to evaluate the 1-min STST performance and its association with patient-reported HRQoL in patients with PH.

METHODS

We prospectively assessed functional capacity in 98 PH patients (mean age 66 ± 15 years, 55% female) using the 1-min STST. Patients had to stand up and sit down from a chair as many times as possible within one minute. Patients' HRQoL was evaluated with the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) questionnaire, which consists of the three subcategories symptoms, activities and quality of life (QoL).

RESULTS

We observed a significant correlation of the 1-min STST performance with all HRQoL subcategories assessed with the CAMPHOR questionnaire: A lower number of 1-min STST repetitions correlated with more symptoms (rs = -.398, p < .001), worse functioning (rs = -.551, p < .001) and a decreased QoL (rs = -.407, p < .001). Furthermore, in the multivariable linear regression analysis, adjusted for age, sex, body mass index (BMI) and mean pulmonary artery pressure (mPAP), lower 1-min STST performance was an independent predictor for worse symptoms (est. β = -0.112, p = .003), activities (est. β = -0.198, p < .001) and QoL (est. β = -0.130, p < .001) assessed with the CAMPHOR questionnaire.

CONCLUSION

Our results indicate that regardless of age, sex, BMI and mPAP the 1-min STST performance is associated with all CAMPHOR HRQoL subcategories in patients with PH. Therefore, the 1-min STST performance might be a new option to assess functional capacity correlated to HRQoL in patients with PH.

Core Function in Adults With Severe Asthma and Its Relationship With Breathing Symptoms

BACKGROUND

People with asthma may have skeletal muscle dysfunction but data describing core function in severe asthma are limited.

OBJECTIVE

To compare core function between people with severe asthma and healthy controls and to determine the difference between males and females. Furthermore, we aimed to investigate the association between core function and breathing symptoms.

METHOD

Adults with a diagnosis of severe asthma and healthy controls undertook an assessment that included 3 core function tests: partial sit-up, Biering-Sorensen, and side bridge. Breathing symptoms were assessed by the modified Medical Research Council dyspnea scale, modified Borg scale, and Nijmegen questionnaire.

RESULTS

People with severe asthma (n = 136) (38% male, age median [Q1-Q3] 59 y [45-68], body mass index 30 kg/m2 [26-37]) were compared with 66 people without respiratory disease (47% male, age 55 y [34-65], body mass index 25 kg/m2 [22-28]). There was no difference between groups in the partial sit-up (P = .09). However, participants with severe asthma performed worse with the Biering-Sorensen (P < .001), and the left and right side bridge test (P < .001 for both) than the healthy comparison group. Similar results were found when comparing males and females separately. Males with severe asthma had increased function compared with their female counterparts in the left side bridge test. Core function tests correlated with the breathing symptom measures, the modified Medical Research Council, modified Borg scale, and Nijmegen questionnaire (-0.51 > r > -0.19; P ≤ .03).

CONCLUSIONS

Adults with severe asthma have worse core function than their control counterparts, independent of sex. Furthermore, as core function decreases, breathing symptoms increase.

Assessment of frailty and its predictors in chronic obstructive pulmonary disease

BACKGROUND

Frailty represents a state of risk in which a relatively small stressor results in a disproportionate decline in health status. This study aims to determine the prevalence of frailty among patients with COPD in the Indian population and its associated risk factors.

METHODS

A descriptive cross-sectional study was conducted in 150 COPD patients. Frailty was assessed using the frailty phenotype method.

RESULTS

The mean age (SD) of the study population was 60.59 (5.9) years with 88.67% males and 53.33% ex-smokers. The prevalence of frailty was 51.33% (n = 77). Most of the frail patients belonged to GOLD group D (66.23%) (P < 0.0001). Post-bronchodilator FEV1(%) was lowest in the frail group (40 [36-47]%) (P < 0.0001). Risk of frailty significantly correlated with smoking pack years (1.036; 1.001-1.074), history of 1 exacerbation in last year (6.810; 2.036-22.779), post-bronchodilator FVC(%) (0.955; 0.926-0.985), post-bronchodilator FEV1(%) (0.940; 0.913-0.968), distance covered in 6-minute walk test [0.975; 0.965-0.986] and dyspnoea severity [1.044; 1.024-1.063]. In multivariate regression, 6-minute walk distance and GOLD group B were the independent predictors of frailty in COPD.

CONCLUSION

The prevalence of frailty in Indian patients with COPD was 51.33%. Six-minute walk distance is an important predictor of frailty. Early identification of frailty will lead to prompt intervention and rehabilitation.

One-minute sit-to-stand test in patients with pulmonary arterial hypertension associated with congenital heart disease: A single-center prospective study

BACKGROUND

Patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) have reduced exercise capacity. Recently, the 1-minute sit-to-stand test (1MSTST), which measures the number of repetitions from sitting to standing position in 1 minute, has been proposed as an alternative test to the 6-minute walking test (6MWT). The aim of our study was to assess the safety and results of the 1MSTST in comparison to the 6MWT in patients with PAH-CHD.

METHODS

Consecutive adult patients with PAH-CHD underwent the 6MWT and the 1MSTST on the same day. The 6-minute walking distance in meters and the number of repetitions on the 1MSTST were measured. Heart rate, peripheral oxygen saturations, Borg dyspnea score, and lower limb fatigue were recorded before and immediately after testing. Correlations between both tests and clinical, laboratory, and imaging parameters were statistically analyzed.

RESULTS

The study included 40 patients (50% female, mean age 43 ± 15 years), of whom 29 (72%) had Eisenmenger syndrome and 14 (35%) had Down syndrome. The number of 1MSTST repetitions correlated significantly with 6MWT distance (r = 0.807, p = 0.000). There were no adverse events, and the 1MSTST results correlated with the WHO functional class. Heart rate increase and oxygen desaturation after both tests correlated significantly, but less desaturation was observed after 1MSTST.

CONCLUSIONS

Our study showed that the 1MSTST is a safe and easily applicable test in adult patients with PAH-CHD, including patients with Down syndrome. The results of the 1MSTST correlate significantly with the 6MWT, providing an alternative tool for exercise capacity assessment in patients with PAH-CHD.

Validity, Reproducibility, and Minimal Detectable Difference of the Functional Upper Extremity Function Test - Simplified Version - for Adults With Moderate to Severe Asthma and COPD

BACKGROUND

Upper-limbs (ULs) functional tests which are valid and reliable for individuals with chronic respiratory disease (CRD) are scarce. The aim of this study was to investigate the intra-rater reproducibility, validity, minimal detectable difference (MDD), and learning effect of the Upper Extremity Function Test - simplified version (UEFT_S) functional test and to characterize its performance for adults with moderate-severe asthma and COPD.

METHODS

The UEFT_S was performed twice, and the number of elbow flexions in 20 s was the outcome. In addition, spirometry, 6-min walk test (6MWT), handgrip dynamometry (HGD), and usual and maximum timed-up-and-go tests (TUG_usual and TUG_max) were also performed.

RESULTS

Eighty-four individuals with moderate-severe CRD and 84 control individuals matched by anthropometric data were analyzed. Individuals with CRD presented better performance in the UEFT_S than controls (P = .023). UEFT_S correlated significantly with HGD, TUG_usual, TUG_max, and 6MWT (P < .047 for all). The test-retest intraclass correlation coefficient was 0.91 [0.86-0.94], and the MDD was 0.4%.

CONCLUSIONS

The UEFT_S is a valid and reproducible tool to assess the functionality of the ULs in people with moderate-severe asthma and COPD. When applied in the modified form, the test can be considered simple, fast, and inexpensive, with an easy outcome to interpret.

The Role of Pulmonary Function Testing in the Diagnosis and Management of COPD

Pulmonary function testing (PFT) has a long and rich history in the definition, diagnosis, and management of COPD. For decades, spirometry has been regarded as the standard for diagnosing COPD; however, numerous studies have shown that COPD symptoms, pathology, and associated poor outcomes can occur, despite normal spirometry. Diffusing capacity and imaging studies have called into question the need for spirometry to put the "O" (obstruction) in COPD. The role of exercise testing and the ability of PFTs to phenotype COPD are reviewed. Although PFTs play an important role in diagnosis, treatment decisions are primarily determined by symptom intensity and exacerbation history. Although a seminal study positioned FEV1 as the primary predictor of survival, numerous studies have shown that tests other than spirometry are superior predictors of mortality. In years past, using spirometry to screen for COPD was promulgated; however, this only seems appropriate for individuals who are symptomatic and at risk for developing COPD.

Breathlessness and exercise performance to predict mortality in long-term oxygen therapy - The population-based DISCOVERY study

BACKGROUND

Patients with chronic respiratory failure treated with long-term oxygen therapy (LTOT) often have severe breathlessness, impaired exercise performance, and high but variable mortality that is difficult to predict. We aimed to evaluate breathlessness and exercise performance upon starting LTOT as predictors of overall and short-term mortality.

METHODS

This was a longitudinal, population-based study of patients who initiated LTOT between 2015-2018 in Sweden. Breathlessness was measured using the Dyspnea Exertion Scale, and exercise performance using the 30s-Sit-To-Stand test. Associations with overall and three-month mortality were analyzed using Cox-regression. Subgroup analyses were performed for patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) respectively. The predictive capacity of models was assessed using a C-statistic.

RESULTS

A total of 441 patients (57.6% female, aged 75.4 ± 8.3 years) were analyzed, of whom 141 (32%) died during a median follow-up of 260 (IQR 75-460) days. Both breathlessness and exercise performance were independently associated with overall mortality in the crude models, but only exercise performance remained independently associated with overall mortality when models were adjusted for other predictors, when short-term mortality was analyzed, or when breathlessness and exercise capacity were analyzed concurrently. The multivariable model including exercise performance but not breathlessness provided a relatively high predictive capacity for overall mortality, C-statistic 0.756 (95% CI 0.702-0.810). Similar results were seen in the COPD and ILD subgroups.

CONCLUSION

Exercise performance as measured by the 30s-STS may be useful to identify patients with higher mortality on LTOT for optimized management and follow-up.

Validity and clinical applicability of the 60-secondecond sit-to-stand test in people with acute exacerbations of COPD

BACKGROUND

The 60-second sit-to-stand test (60STS) is a simple and increasingly popular test of physical function, however evidence to support its appropriateness for assessing people with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is lacking.

AIMS

To evaluate the concurrent, convergent, predictive and discriminant validity, and responsiveness of the 60STS against the six-minute walk test (6MWT) in people hospitalised due to AECOPD.

METHODS

Prospective cohort study involving 54 inpatients with AECOPD (53% males, mean age 69.0 years, FEV1 46.5% predicted). 60STS was performed 30 min after a six-minute walk test (6MWT) upon discharge, with follow-up testing repeated one-month later (n = 39). Outcome measures included 60STS repetitions (60STSr), six-minute walk distance (6MWD), heart rate, oxyhaemoglobin saturation (SpO2), perceived dyspnoea (Borg scale), and rate of perceived exertion (RPE). Concurrent validity was assessed via correlation, convergent validity via Bland-Altman plots, predictive validity via multivariate linear regression (adjusted for confounders), discriminant validity via unpaired t tests and responsiveness via Chi (Jenkins, 2007) [2] tests.

RESULTS

Discharge 60STSr and 6MWD were strongly correlated (r = 0.61). Bland-Altman plots for nadir SpO2, peak HR, Borg and RPE scores showed acceptable agreement in terms of mean differences, but wide limits of agreement. Poor 60STSr performers were older, had weaker quadriceps, and had lower 6MWD than high performers (p < 0.05 for all). 60STSr was not retained as a significant predictor of 6MWD in multivariate regression analyses. 80% of 60STSr improvers also improved >30m on 6MWT at follow-up.

CONCLUSION

The 60STS demonstrates satisfactory validity and responsiveness as a measure of exercise performance in people with AECOPD.

A Study of the Reliability, Validity, and Physiological Changes of Sit-to-Stand Tests in People With Heart Failure

PURPOSE

The objective of this study was to describe the psychometric properties and physiological response of the five times sit-to-stand (STST-5) and 60-sec sit-to-stand test (STST-60) in adults with heart failure (HF).

METHODS

People with HF enrolled in a 12-wk exercise rehabilitation program completed two STST-5 and two STST-60 as part of their usual baseline and follow-up assessments. Test-retest reliability, validity, and responsiveness of the two STSTs were described. Results were correlated with the 6-min walk test (6MWT) and timed up and go test (TUGT), and rating of perceived exertion and physiological responses were compared between all tests. Feasibility was also reported according to the presence of adverse events and adherence to the protocol.

RESULTS

Forty-nine adults with HF participated in this study. Intraclass correlation coefficients of the STST-5 and STST-60 were 0.91 (95% CI, 0.78-0.96) and 0.96 (95% CI, 0.93-0.98), respectively. The STST-60 was strongly associated with both the 6MWT ( r = 0.76) and the TUGT ( rs =-0.77). The STST-5 was strongly associated with the TUGT ( rs = 0.79) and moderately associated with the 6MWT ( rs =-0.70). Rating of perceived exertion and lower limb fatigue were greater in the STST-60 than in the 6MWT ( P < .001) or STST-5 ( P < .001). Adverse events occurred in five participants undertaking the STST-60 and one participant undertaking the STST-5.

CONCLUSIONS

The STST-5 and STST-60 are reliable and valid measures of functional exercise capacity in people with HF.

One-minute sit-to-stand test as a quick functional test for people with COPD in general practice

Assessing changes in functional exercise capacity is highly relevant in the treatment of people with Chronic Obstructive Pulmonary Disease (COPD), as lung function is often static. In Denmark, most people with COPD are followed in general practice where traditional functional tests, like six-minute walk test, require too much time and space. Therefore, there is an urgent need for a quick functional exercise capacity test that can be performed in a limited setting, such as general practice. This study aimed to identify a quick test to measure functional exercise capacity in people with COPD and identify which factors could affect the implementation of such a test in general practice. A mixed method feasibility study composed of a literature review and qualitative interviews was used. Quick functional tests for people with COPD were identified and evaluated through the COSMIN methodology. For the interviews, 64 general practices were included, and 50 staff members and 14 general practitioners (GPs) participated in the interviews. Responses were categorized and thematically analyzed. The 1 min sit-to-stand-test (1 M STST) was found suitable for a general practice setting. The COSMIN methodology rated it "sufficient" in reliability (ICC 0.90-0.99), measurement error (MID 2.5-3), construct validity and responsiveness (AUC 0.72), and found a moderate to strong correlation in criterion validity (r = 0.4-0.75). Several GPs wished for a quick functional test and emphasized evidence, information, and limitations as essential when deciding on implementation. Other factors identified included time, other tests, and economy. 1 M STST is a valid test to assess functional exercise capacity in people with COPD. The test is quick and can easily be performed in a standard consultation, and several GPs wished for such a test.

Associations Between Muscle Weakness and Clinical Outcomes in Current and Former Smokers

Introduction

Smokers with chronic obstructive pulmonary disease (COPD) are at increased risk of muscle weakness. There are limited data describing weakness in smokers with normal spirometry and preserved ratio-impaired spirometry (PRISm), 2 subgroups at risk of respiratory symptom burden and activity limitations. In this study, we evaluated the associations of 2 weakness measures, sit-to-stand (STS) and handgrip strength (HGS), with clinical outcomes in smokers with COPD, normal spirometry, and PRISm.

Methods

We evaluated 1972 current and former smokers from the COPD Genetic Epidemiology (COPDGene®) cohort with STS and HGS measurements at their 10-year study visit. Multivariable regression modeling was used to assess associations between weakness measures and the 6-minute walk distance (6MWD) test, the St George's Respiratory Questionnaire (SGRQ), the Short-Form-36 (SF-36), severe exacerbations, and prospective mortality, reported as standardized coefficients (β), odds ratios (ORs), or hazard ratios (HRs).

Results

Compared with HGS, STS was more strongly associated with the 6MWD (β=0.45, p<0.001 versus. β=0.25, p<0.001), SGRQ (β=-0.24, p<0.001 versus β=-0.18, p<0.001), SF-36 Physical Functioning (β=0.36, p<0.001 versus β=0.25, p<0.001), severe exacerbations (OR 0.95, p=0.04 versus OR 0.97, p=0.01), and prospective mortality (HR 0.83, p=0.001 versus HR 0.94, p=0.03). Correlations remained after stratification by spirometric subgroups. Compared with males, females had larger magnitude effect sizes between STS and clinical outcomes.

Conclusions

STS and HGS are easy to perform weakness measures that provide important information about functional performance, health-related quality of life, severe exacerbations, and survival in smokers, regardless of spirometric subgroup. This iterates the importance of screening current and former smokers for weakness in the outpatient setting.

Transitions in Frailty and 4-Year Mortality Risk in Taiwan Longitudinal Study on Aging

OBJECTIVES

To explore the associations of (1) the frailty phenotype or frailty index transition with cause-specific mortality, and (2) different combinations of transition in frailty phenotype and frailty index with all-cause mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data from 3529 respondents aged >50 years who completed the 1999 and 2003 surveys of the Taiwan Longitudinal Study on Aging were analyzed.

METHODS

Cox regression and subdistribution hazard models were constructed to investigate frailty phenotype or frailty index transitions (by categories of frailty phenotype, absolute and percentage changes in frailty index, and combined categories of the 2 measurements) and subsequent 4-year all-cause and cause-specific mortality, respectively.

RESULTS

Among the frailty phenotype transition groups, the improved frailty group had overall mortality risk comparable to that of the maintained robustness/prefrailty group [hazard ratio (HR): 0.9; 95% CI: 0.7-1.2] and lower risk of mortality due to organ failure (HR: 0.4; 95% CI: 0.2-0.8; P = .015), whereas the worsened frailty group had the highest risk of all-cause mortality and death from infection, malignancy, cardiometabolic/cerebrovascular diseases, and other causes (HR: 1.8-3.7; all P < .03). The rapidly increased frailty index group had significantly higher all-cause and every cause-specific mortality than the decreased frailty index group (HR: 1.8-7.7; all P < .05). When frailty phenotype and frailty index transition groups were combined, participants with worsened frailty/rapidly increased frailty index had increased risk under the same frailty index/frailty phenotype transition condition, particularly for large changes in each factor (HR: 1.5-2.2; P < .01 for worsened frailty; 1.7-4.5, P < .03 for rapidly increased frailty index).

CONCLUSIONS AND IMPLICATIONS

We found that considering both frailty phenotype and frailty index provided best mortality prediction. These associations were independent of baseline frailty status and comorbidities. Nevertheless, even capturing transitions in frailty phenotype or frailty index only can provide good mortality prediction, which supported adopting these approaches in different clinical settings.

The Impact of Frailty Status on Pulmonary Function and Mortality in Older Patients with Chronic Obstructive Pulmonary Disease

OBJECTIVES

We aimed to evaluate the effect of frailty on lung function and disease outcomes in older adults with chronic obstructive pulmonary disease (COPD).

DESIGN

Retrospective observational cohort.

SETTING AND PARTICIPANTS

At baseline, comprehensive geriatric assessment and pulmonary function tests were extracted from the case management care system of the geriatric department of a tertiary medical center.

MEASUREMENTS

Frailty was assessed by the modified Rockwood frailty index. Kaplan-Meier survival and Cox proportional hazard analyses were used to analyze the primary outcome. Both the Friedman test and generalized estimating equations were used to evaluate the rate of decline in lung function.

RESULTS

Among 151 enrolled older patients, comprising 69 non-COPD and 82 COPD subjects, the mean age was 80.9±8.3 years. After a median follow-up of 2.87 years, the serial forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC), and forced expiratory flow at 25-75% of FVC (FEF25-75%) showed significantly different slope changes between older COPD patients with and without frailty. The mortality hazard ratio (HR) was 2.53 for COPD without frailty and 3.62 for COPD with frailty, versus those without COPD. Among COPD patients, the factors most strongly associated with mortality were timed up-and-go, activities of daily living (ADLs), instrumental ADLs, FEV1/FVC, and serum HCO3-. After adjustment for potential confounders, ADLs and FEV1/FVC remained independent mortality predictors.

CONCLUSION

Among older patients with COPD, frailty was common and associated with pulmonary function decline, and mortality risk was higher in frail than in non-frail subjects.

Correlation between Hand Grip Strength and Peak Inspiratory Flow Rate in Patients with Stable Chronic Obstructive Pulmonary Disease

Optimal peak inspiratory flow rate (PIFR) is required for effective drug delivery to distal airways when using dry powder inhalers (DPIs). This study aimed to examine the association between PIFR and hand grip strength (HGS) in stable COPD patients. A cross-sectional study was conducted. PIFR was measured using the In-check DIAL to assess for Accuhaler and Turbuhaler DPIs. HGS was measured using a handheld dynamometer. A PIFR of <60 L/min was considered suboptimal PIFR. Demographics, clinical data, and spirometric data were collected and compared. Eighty-one patients (86% men) were included. Mean age was 73.3 ± 8.9 years. FEV1 was 65.3 ± 23.7%. The prevalence of suboptimal PIFR was 38% and 59% for Accuhaler and Turbuhaler, respectively. HGS in the suboptimal PIFR group was lower than in the optimal PIFR group for Accuhaler (22.8 ± 4.7 vs. 33.2 ± 6.9 kg, p < 0.001) and for Turbuhaler (25.3 ± 6.4 vs. 35.1 ± 6.3 kg, p < 0.001). The equation for predicted Accuhaler PIFR (L/min) was −30.340 + (0.274 × hand grip strength) − (0.206 × age) + (0.219 × height) + (1.019 × FVC). The equation for predicted Turbuhaler PIFR (L/min) was 56.196 + (0.321 × hand grip strength) − (0.196 × female) − (0.224 × age) + (0.304 × FVC). The best cutoff values of HGS for predicting optimal PIFR in Accuhaler and Turbuhaler were 26.8 kg (with 82% sensitivity and 84% specificity) and 31.9 kg (with 79% sensitivity and 90% specificity), respectively. In conclusion, HGS correlated with PIFR in patients with clinically stable COPD, especially in the group with pronounced symptoms without frequent exacerbations. HGS threshold values associated with suboptimal PIFR were identified. HGS may be used as an alternative tool to assess an optimal inspiratory force for DPIs.

Use of different reference values for handgrip strength in individuals with COPD: analysis of agreement, discriminative capacity, and main clinical implications

Objective: To identify reference values for handgrip strength through a literature search and compare the agreement of reference values from Brazil with others for handgrip strength in a sample of COPD patients in Brazil, as well as to determine which set of reference values is more discriminative regarding differences in clinical characteristics between individuals with low handgrip strength and normal handgrip strength. Methods: To identify reference values for handgrip strength, a literature search was performed; a retrospective cross-sectional analysis of baseline-only data from two unrelated studies was then performed. Individuals were evaluated for handgrip strength, peripheral muscle strength, respiratory muscle strength, pulmonary function, body composition, exercise capacity, dyspnea, and functional status. Results: Of the 45 studies that were initially selected, 9 met the criteria for inclusion in the analysis, which included 99 COPD patients in Brazil (52% of whom were male with GOLD stage II-IV COPD). The prevalence of low handgrip strength varied across studies (from 9% to 55%), the set of reference values for handgrip strength in a sample of individuals in Brazil having classified 9% of the study sample as having low handgrip strength. The level of agreement between the reference values for a sample of individuals in Brazil and the other sets of reference values varied from weak to excellent. The reference values for a sample of individuals in Brazil showed the highest number of significantly different characteristics between individuals with low and normal handgrip strength. Conclusions: The level of agreement between national and international sets of reference values for handgrip strength varied from weak to excellent in COPD patients in Brazil. Reference values for handgrip strength with higher discriminative capacity are not necessarily those that identify more individuals as having low handgrip strength.

Six-Minute Walking Test and 30 Seconds Chair-Stand-Test as Predictors of Mortality in COPD - A Cohort Study

Background

Physical inactivity is strongly associated with worse prognosis in Chronic Obstructive Pulmonary Disease (COPD), and assessment of physical function is very important. The six minute walking test (6MWT) is an established test known to predict mortality in COPD, and 30 seconds chair stand test (30sCST) is a potential alternative test. The study aimed to investigate and compare the associations of 6MWT and 30sCSTs with mortality.

Methods

Data on patient demographics, established mortality predictors and results from 6MWT and 30sCST were collected from 2016 to 2019 from 97 consecutively included patients with COPD. In August 2021, mortality data were retrieved from patient records. Correlation analysis of 6MWT and 30sCST was performed. The predictive abilities of 6MWT and 30sCST, respectively, were analyzed using Kaplan Meyer-curves and Cox regression with adjustment for sex, age, body mass index below 22 and comorbid cardiovascular disease.

Results

A positive correlation between 6MWT and 30sCST was shown (r = 0.61, p < 0.0001). Independent associations with mortality were found for 6MWD 250–349 (HR (95% CI) 3.19 (1.12 to 9.10), p = 0.030) and 6MWD <250 (4.27 (1.69 to10.8), p = 0.002) compared with 6MWD ≥350 meters, and for 30sCST <4 (3.31 (1.03 to 10.6), p = 0.045) compared with 30sCST≥11 risings. When both 6MWT and 30sCST were included in the multivariable model, 6MWD 250–349 (3.09 (1.02 to 9.37), p = 0.046) and 6MWD <250 (3.57 (1.26 to 10.1), p = 0.016) compared with 6MWD ≥350 meters predicted mortality.

Conclusion

30sCST and 6MWT correlates moderately and are independently associated with mortality in patients with COPD. Although 6MWT is the best predictor of mortality, 30sCST may be used as an alternative to identify patients at risk.

Measurement of hand grip strength: A cross-sectional study of two dynamometry devices

Background

Grip strength has been identified as an important indicator of health status and predictor of clinical outcomes. The gold standard for measuring grip strength is the JAMAR® Hydraulic Hand Dynamometer. Less expensive dynamometers are available but have not been validated within a hospital setting.

Objectives

To validate the Camry Digital Handgrip Dynamometer (Model EH101) against the validated JAMAR® Dynamometer (Model J00105) in a hospital population.

Methods

A cross-sectional observational study with a randomised single-blind cross-over component was conducted on consenting adult patients admitted to general hospital wards. The best of three measurements taken using the dominant hand was used for analysis.

Results

Fifty-one participants (median [interquartile range] age 42 [30–58] years; n = 27 [52.9%] female) were included. The mean difference between the Jamar® and Camry measurements was 1.9 kg ± 3.6 kg (t-value 0.9; p = 0.4). There was a strong positive correlation between the Jamar® and the Camry devices (R = 0.94; r² = 0.88; p < 0.0001). Excellent agreement was found between Jamar® and Camry measurements (interclass correlational coefficient 0.97, 95% CI 0.94–0.99, p < 0.0001). Hand dominance significantly affected the agreement between devices (p = 0.002).

Conclusions

The Camry Digital Handgrip Dynamometer is a valid tool for assessing grip strength in hospitalised adult patients.

Clinical implications

The Camry Digital Handgrip Dynamometer could be used as an inexpensive tool to measure grip strength.

One-minute sit-to-stand test is practical to assess and follow the muscle weakness in cystic fibrosis

BACKGROUND

Quadriceps muscle weakness and reduced exercise tolerance are prevalent and associated with a worse prognosis in patients with cystic fibrosis (CF). The one-minute sit-to-stand test (1STST) has been proposed to evaluate functional exercise capacity and quadriceps strength.

RESEARCH QUESTION

The aim of the study was to verify the relationship between the 1STST and the maximal isometric voluntary contraction of the quadriceps (MVCQ) evaluated by the dynamometer in stable patients with CF and to evaluate the impact of intravenous (IV) antibiotherapy.

METHODS

Dynamometer and 1STST were performed in stable patients with CF at a routine visit, the admission and the discharge of an IV antibiotherapy. Patients wore an activity monitor during 72 h during IV treatment.

RESULTS AND SIGNIFICANCE

51 stable patients with CF at a routine visit and 30 treated with IV antibiotherapy were recruited. In stable patients, the 1STST was reduced to a mean of 2101 nxkg (657-SD), representing a median of 79% (7; 142-min; max)) of the predicted values (%PV) as well as the MVCQ to 78.64 N-m (23.21; 170.34), representing 57%PV (26). The 1STST was correlated to MVCQ (r = 0.536; p < 0.0001) and lung function (r = 0.508; p = 0.0001). Over the IV antibiotherapy course, the 1STST improves significantly like lung function and body mass index while a positive trend for MVCQ was observed. The gain of 1STST was correlated to the change in MVCQ (r = 0.441; p = 0.02) and was significantly higher in hospitalized patients versus home therapy. The 1STST is a good alternative to the dynamometer to evaluate and assess muscular weakness for the routine visit and IV antibiotherapy.

Exercise capacity assessed with the one-minute sit-to-stand test (1-min STST) and echocardiographic findings in patients with heart failure with preserved ejection fraction (HFpEF)

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a major cause of morbidity and mortality. Precise risk stratification remains challenging. The one-minute sit-to-stand-test (1-min STST), a quick, objective test of functional capacity may be helpful for stratification of clinical profile in HFpEF patients.

OBJECTIVE

The aim of this initial investigation was to prospectively examine whether the 1-min STST can be used for the evaluation of exercise capacity in HFpEF patients and whether it is in line with echocardiographic as well as quality of life (QoL) findings.

METHODS

39 HFpEF patients were prospectively studied. Functional performance was examined with the 1-min STST and QoL with the CAMPHOR questionnaire. Clinical parameters including echocardiographic measurements [estimated pulmonary artery systolic pressure (ePASP), tricuspid regurgitation velocity (TRV)] were obtained. Patients were divided into two groups based on their number of 1-min STST repetitions (Group I: ≤50% of predicted 1-min STST repetitions using the norm-reference values developed by Strassmann et al. for healthy people, N=24; Group II: >50% of predicted 1-min STST repetitions, N=15).

RESULTS

Patients in group I with limited 1-min STST performance showed worse echocardiographic parameters [higher ePASP (p=0.038), higher TRV (p=0.018) and more reduced tricuspid annular plane systolic excursion (TAPSE) (p=0.001)], worse six-minute walk test (6MWT) (p<0.001) and worse QoL (p<0.001) compared to patients in group II.

CONCLUSION

Our study shows potential usefulness of the 1-min STST as an evaluative tool for exercise capacity in HFpEF patients, because patients with worse 1-min STST performance have worse clinical parameters and QoL.

Reliability and validity of sit-to-stand test protocols in patients with coronary artery disease

Background

Sit-To-Stand (STS) tests are reported as feasible alternatives for the assessment of functional fitness but the reliability of these tests in people with coronary artery disease (CAD) has not been reported. This study explored the test-retest reliability, convergent and known-groups validity of the five times, 30-sec and 1-min sit-to-stand test (FTSTS test, 30-s STS test and 1-min STS test respectively) in patients with CAD. The feasibility of applying these tests to distinguish the level of risk for cardiovascular events in CAD patients was also investigated.

Methods

Patients with stable CAD performed a 6MWT and 3 STS tests in random order on the same day. Receiver operating characteristic (ROC) curve analyses were conducted using STS test data to differentiate patients with low or high risk of cardiovascular events based on the risk level determined by distance covered in the 6MWT as &gt; or ≤ 419 m. Thirty patients repeated the 3 STS tests on the following day.

Results

112 subjects with diagnoses of atherosclerosis or post-percutaneous coronary intervention, or post-acute myocardial infarction (post-AMI) participated in the validity analysis. All 3 STS tests demonstrated moderate and significant correlation with the 6MWT (coefficient values r for the FTSTS, 30-s STS and 1-min STS tests were−0.53, 0.57 and 0.55 respectively). Correlations between left ventricular ejection fraction (LVEF) and all STS tests and between 6MWT and LVEF were only weak (r values ranged from 0.27 to 0.31). Subgroup analysis showed participants in the post-AMI group performed worse in all tests compared to non-myocardial infarction (non-MI) group. The area under the curve (AUC) was 0.80 for FTSTS (sensitivity: 75.0%, specificity: 73.8%, optimal cut-off: &gt;11.7 sec), and the AUC, sensitivity, specificity and optimal cut-off for 30-s STS and 1-min STS test were 0.83, 75.0%, 76.2%, ≤ 12 repetitions and 0.80, 71.4%, 73.8%, ≤ 23 repetitions respectively. The intraclass correlation coefficients (ICC) for repeated measurements of the FTSTS, 30-s STS and 1-min STS tests were 0.96, 0.95 and 0.96 respectively, with the minimal detectable change (MDC95) computed to be 1.1 sec 1.8 repetitions and 3.9 repetitions respectively.

Conclusions

All STS tests demonstrated good test-retest reliability, convergent and known-groups validity. STS tests may discriminate low from high levels of risk for a cardiovascular event in patients with CAD.

The impact of seat height on 1-min sit-to-stand test performance in COPD: a randomised crossover trial

Study question

Is there a difference in the number of repetitions in the 1-minute sit-to-stand (1MSTS) test using an individually adapted seat height to 90° knee flexion (1MSTS_IND), compared with the commonly used standard chair seat height of 46 cm (1MSTS_STD), in people with COPD?

Methods

We conducted a single-centre, single-blinded, randomised crossover trial in people with COPD between August 2020 and March 2021 at a specialised rehabilitation clinic in Switzerland. After a learning 1MSTS test, all participants performed two 1MSTS tests in random order on consecutive days. Participants were blinded, as they did not receive detailed information on the testing protocols.

Results

49 individuals with COPD (47% female) participated. In a regression model adjusted for sequence period and subject, 1MSTS test performance was lower on 1MSTS_IND compared to 1MSTS_STD (−0.78 repetitions, 95% CI −1.47 to −0.11). In a second regression model additionally including the knee angle and an interaction term (1MSTS_IND×knee angle), the interaction term was significant: 0.18 (95% CI 0.05 to 0.30). The limits of agreement were between −5.5 and 4 repetitions.

Conclusion

Although we observed a statistically significant difference between 1MSTS_IND and 1MSTS_STD on a population level, the difference is negligible. Further studies may be needed to determine whether individual adaptation of seat height is needed for very tall or short people to ensure a valid assessment of 1MSTS test performance in COPD.

Performing the 1MSTS test on an individually adjusted chair versus a standard chair results in fewer repetitions (mean difference −0.78, 95% CI −1.47 to −0.11). However, the difference in repetitions is clinically negligible.https://bit.ly/3Oc8Rvp

Hand Grip Strength and Likelihood of Moderate-to-Severe Airflow Limitation in the General Population

Background and Objective

Sarcopenia is mainly results from aging; however, it is more prevalent in chronic airway disease such as obstructive pulmonary disease (COPD). Hand grip strength (HGS) can be used as an indicator to evaluate sarcopenia. We aimed to assess the association between HGS and severity of airflow limitation (AFL) in the general population.

Methods

We conducted a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey (KNHANES) from 2014 to 2018. Subjects aged ≥40 years who underwent both spirometry and HGS tests were included. AFL was defined by spirometry revealed forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) <0.70). A propensity score-matched comparison was performed, and the risk for moderate-to-very severe AFL was analyzed using logistic regression analysis.

Results

Among 15,950 subjects, 2277 (14.3%) had AFL with mean FEV₁ was 77.1% of the predicted value. Male was predominant in both individuals without AFL and with AFL (74.2% vs 73.5%, p = 0.613). The HGS was 32.9 ± 9.5 kg and 33.3 ± 9.5 kg in participants without AFL and with AFL (p = 0.109). However, HGS was significantly decreased as AFL getting more severe: 34.0 ± 9.6 kg in mild, 33.0 ± 9.5 kg in moderate, and 30.8 ± 8.5 kg in severe to very severe AFL group (p<0.001). As HGS decreased, adjusted odds for moderate-to-very severe AFL increased compared to those with mild AFL (adjusted odds ratio [aOR], 0.97; 95% confidence interval [CI], 0.951–0.987) and both without AFL and mild AFL group (aOR, 0.98; 95% CI, 0.967–0.995) in age-, sex-, and body mass index (BMI)-matched comparisons.

Conclusion

Lower HGS is significantly associated with moderate-to-very severe AFL in age-, sex-, and BMI-matched comparisons.

Predictors of mortality in chronic obstructive pulmonary disease: a systematic review and meta-analysis

Background

Better insight in patients’ prognosis can help physicians to timely initiate advance care planning (ACP) discussions with patients with chronic obstructive pulmonary disease (COPD). We aimed to identify predictors of mortality.

Methods

We systematically searched databases Embase, PubMed, MEDLINE, Web of Science, and Cochrane Central in April 2020. Papers reporting on predictors or prognostic models for mortality at 3 months and up to 24 months were assessed on risk-of-bias. We performed a meta-analysis with a fixed or random-effects model, and evaluated the discriminative ability of multivariable prognostic models.

Results

We included 42 studies (49–418,251 patients); 18 studies were included in the meta-analysis. Significant predictors of mortality within 3–24 months in the random-effects model were: previous hospitalization for acute exacerbation (hazard ratio [HR] 1.97; 95% confidence interval [CI] 1.32–2.95), hospital readmission within 30 days (HR 5.01; 95% CI 2.16–11.63), cardiovascular comorbidity (HR 1.89; 95% CI 1.25–2.87), age (HR 1.48; 95% CI 1.38–1.59), male sex (HR 1.68; 95% CI 1.38–1.59), and long-term oxygen therapy (HR 1.74; 95% CI 1.10–2.73). Nineteen previously developed multicomponent prognostic models, as examined in 11 studies, mostly had moderate discriminate ability.

Conclusion

Identified predictors of mortality may aid physicians in selecting COPD patients who may benefit from ACP. However, better discriminative ability of prognostic models or development of a new prognostic model is needed for further large-scale implementation.

Registration: PROSPERO (CRD42016038494), https://www.crd.york.ac.uk/prospero/.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01911-5.

Predictors of changes in 6-min walking distance following pulmonary rehabilitation in COPD patients: a retrospective cohort analysis

BACKGROUND

Pulmonary rehabilitation (PR) is fundamental in chronic obstructive pulmonary disease (COPD) management but not all patients may show functional benefits from PR.

AIM

The aim of this study was to identify predictors of non-response in functional capacity to PR.

DESIGN

Observational study.

SETTING

Inpatient pulmonary rehabilitation center.

POPULATION

COPD patients.

METHODS

This single center study is a retrospective analysis of data in COPD patients admitted to a PR center between January 2012 and December 2017. Post-PR change in 6-min walking distance (6MWD) was used to determine the functional response to PR. Patients characteristics and pre-PR 6-min walking test responses were analyzed to determine factors associated with post-PR changes in 6MWD.

RESULTS

Data from 835 patients were analyzed as well as a subgroup of 190 patients with additional variables available. Eighty percent of the patients showed clinically significant 6MWD improvement post-PR. The predictors of 6MWD response to PR were age, pre-PR 6MWD, pre-PR end-of-test dyspnea and long-term oxygen therapy. Older patients, longer pre-PR 6MWD, higher pre-PR end-of-test dyspnea score and the use of oxygen supplementation were associated with lesser post-PR 6MWD improvement.

CONCLUSIONS

This study identified four important clinical variables predicting a lack of 6MWD response to PR.

CLINICAL REHABILITATION IMPACT

Patients with such clinical characteristics may require specific PR modalities to improve their functional benefit.

The 6-minute stepper test and the sit-to-stand test predict complications after major pulmonary resection via minimally invasive surgery: a prospective inception cohort study

QUESTIONS

How well do the 6-minute stepper test (6MST) and sit-to-stand test (STST) predict complications after minimally invasive lung cancer resection? Do the 6MST and STST provide supplementary information on the risk of postoperative complications in addition to the prognostic variables that are currently used, such as age and the American Society of Anesthesiology (ASA) score?

DESIGN

Prospective inception cohort study with follow-up for 90 days.

PARTICIPANTS

Consecutive sample of adults undergoing major lung resection with video-assisted thoracic surgery (VATS) or robot-assisted thoracic surgery (RATS).

OUTCOME MEASURES

Patients had a preoperative functional evaluation with the 6MST and STST. The number of steps, heart rate change, saturation and dyspnoea during the 6MST and the number of lifts during the STST were recorded. Complications graded ≥ 2 on the Clavien-Dindo classification were recorded for 90 days after surgery.

RESULTS

Between November 2018 and November 2019, 118 patients with a mean age of 65 years (SD 9) were included and analysed. Their surgeries were via VATS in 88 (75%) and via RATS in 30 (25%). For predicting a postoperative complication graded ≥ 2 on the Clavien-Dindo classification, the area under the Receiver Operating Characteristic curve was: 0.82 (95% CI 0.75 to 0.90) for the number of steps during the 6MST, with an optimum cut-off of 140 steps; and 0.85 (95% CI 0.77 to 0.93) for the number of lifts during the STST, with an optimum cut-off of 20 lifts.

CONCLUSION

The 6MST and STST predicted morbidity and mortality after lung cancer resection via minimally invasive surgery. The preoperative use of these exercise tests in clinical practice may be useful for risk stratification.

REGISTRATION

NCT03824977.

Physical Activity Capacity Assessment of Patients With Chronic Disease and the 1-Minute Sit to Stand Test: Is There an Interest?

Objective

This study aimed to evaluate the efficacy of the 1-minute Sit to Stand test (1MSTS) to determine physical activity capacities for patients with chronic disease.

Methods

For this cross-sectional study, we studied fifty patients with chronic disease and no beta-blocker treatment. They systematically performed a cardiopulmonary exercise test to determine maximal oxygen uptake (V'O₂max). We considered two groups of patients based on the results of the functional evaluation of exercise performance: (1) No limitation in exercise performance (V'O₂max greater or equal to 80% of the theoretical reference) and (2) limited exercise performance (V'O₂max <80% of the theoretical value). All patients also received an 1MSTS on the same day.

Results

We found 22 (44.0%) patients with normal exercise capacity and 28 (56.0%) patients with limited exercise performance. In this sample, mean 1MSTS repetitions were 27.1 (7.1) and 25.2 (8.7), respectively. There were no significant differences between the two groups for repetition and Borg Scale end test. The correlation between V'O₂max measured during the exercise test and 1MSTS repetitions displayed a positive slope [r = 0.401 (95% CI 0.114–625)].

Conclusion

This study demonstrated a moderate relationship between 1MSTS and V'O₂max for patients with chronic disease. 1MSTS did not permit the precise determination of physical activity capacities in this sample.

Improving the Reliability Between the BODE Index and the BODS Index in Which the 6-Min Walk Test Was Replaced with the Five-Repetition Sit-to-Stand Test

Purpose

The BODS index has been confirmed to have predictive properties similar to the original BODE index for mortality in COPD. We evaluated the agreement between the BODS index and the BODE and explored with an updated BODS how this agreement could be improved and its ability to correctly discriminate individual participants’ mortality in a prospective cohort study.

Patients and Methods

We included prospectively a consecutive sample of 137 patients with COPD, between 40 and 80 years, during 2014 and followed for 5 years (2014–2019) in the Pneumology section of a public university hospital in Spain. They participated in the baseline data collection, which included BODE- and BODS-related measurements and prognostic factors, and were followed up for 5-year mortality. We used Bland–Altman plots and the kappa coefficient to analyze the agreement between both the original and updated BODS and the BODE index, and we used the areas under ROC curves (AUC) to compare their discriminative abilities for 5-year all-cause mortality.

Results

The original BODS index scores and quartiles had weak agreement with the BODE index, and our updated BODS strengthened these agreements (a small, statistically nonsignificant mean bias [<0.03] with LoAs<2 points, and a substantial Kappa coefficient [k =0.63; IC 95%: 0.53–0.73]). In addition, the updated BODS index scores had better summarized ability than the BODS index in discriminating participants’ mortality during the following 5 years (AUC: 0.768 versus 0.736; p=0.04).

Conclusion

The updated BODS index scores and quartiles may provide prognostic information similar to that provided by the BODE index in COPD. Future research should focus on index improvement through external validation, as well as the assessment of safety and effectiveness in clinical practice by means of impact studies.

Post-operative, inpatient rehabilitation after lung transplant evaluation (PIRATE): A feasibility randomized controlled trial

BACKGROUND

Postoperative rehabilitation is crucial following lung transplantation (LTx); however, it is unclear whether intensive rehabilitation is feasible to deliver in the acute setting. We aimed to establish the feasibility and safety of intensive acute physiotherapy post-LTx.

METHODS

This feasibility trial randomized 40 adults following bilateral sequential LTx to either standard (once-daily) or intensive (twice-daily) physiotherapy. Primary outcomes were feasibility (recruitment and delivery of intensive intervention) and safety. Secondary outcomes included six-minute walk test; 60-second sit-to-stand; grip strength; physical activity; pain; EQ-5D-5L; length of stay; and readmissions. Data were collected at baseline, week 3, and week 10 post-LTx. ClinicalTrials.gov #NCT03095859.

RESULTS

Of 83 LTx completed during the trial, 49% were eligible and 48% provided consent. Median age was 61 years {range 18-70}; waitlist time 85 days [IQR 35-187]. Median time to first mobilization was 2 days [2-3]. Both groups received a median of 10 [7-14] standard interventions post-randomization. A median of 9 [6-18] individual intensive interventions were attempted (86% successful), the most common barrier being medical procedures/investigations (67%). No intervention-related adverse events or between-group differences in secondary outcomes were observed.

CONCLUSIONS

Acute, intensive physiotherapy was feasible and safe post-LTx. This trial provides data to underpin definitive trials to establish efficacy.

Quadriceps physiological response during the 1-min sit-to-stand test in people with severe COPD and healthy controls

We compared quadriceps oxygenation and surface electromyography (sEMG) responses during the 1-min sit-to-stand (1STS) in 14 people with severe COPD and 12 controls, in whom cardiorespiratory response, near-infrared spectroscopy signals (oxy [Hb-Mb], deoxy [Hb-Mb], total [Hb-Mb], and SmO₂) and sEMG signals of the quadriceps were recorded. Time duration of each sit-to-stand cycle and the total work performed during the 1STS were measured. The quadriceps oxygenation parameters were normalized by reporting their values according to the total work during 1STS. The rate of sit-to-stand maneuvers decelerated in people with COPD leading to smaller total work compared with controls. The pattern of quadriceps oxygenation response during 1STS was similar between groups. However, in COPD, the recovery after 1STS was characterized by larger overshoots in oxy [Hb-Mb], total [Hb-Mb], and SmO₂. When corrected for the cumulative total work, the increase in muscle O₂ extraction (deoxy [Hb-Mb]) during the first 30 s of recovery was greater in people with COPD compared to controls. Quadriceps sEMG changes suggestive of a fatiguing contraction pattern was observed only in people with COPD. All together, these results highlighted physiological misadaptation of people with severe COPD to the 1STS.

The prognosis of pre-frail chronic obstructive pulmonary disease patients for hospitalizations and mortality depends on their level of functional physical performance

Objective

To determine if pre-frail Chronic obstructive pulmonary disease (COPD) patients with poor and non-poor performance in the five-repetition sit-to-stand test (5-STS) had a worse prognosis for hospitalization and mortality at 2 years and for mortality at 5 years than non-frail patients.

Methods

We prospectively included patients with stable COPD, between 40 and 80 years, from a hospital in Spain. Patients were classified according their performance on the 5-STS test and level of frailty. Timing, number of hospitalizations, length of stay, and timing and rate of mortality were outcome measures. Patients were followed for 2 years for exacerbations and for 5 years for mortality. Kaplan-Meier curves and univariate and multivariate Cox proportional-hazard analyses, ANOVA tests and univariate and multivariate linear and logistic regression models were used.

Results

Of the 125 patients included, 25.6% were pre-frail with poor performance, 57% pre-frail with non-poor performance, and 17.4% non-frail with non-poor performance. Pre-frail patients with poor performance had a higher number of hospitalizations (adjusted beta: 0.49; 95% CI: 0.01–0.96), mortality rates (odds ratio: 11.33; 95% CI: 1.15–110.81), and risk at 5 years (adjusted hazard ratio: 8.77; 95% CI: 1.02–75.51) than non-frail patients. Pre-frail patients with poor performance also had worse prognoses than non-frail patients with respect to length of hospital stays (increased by 4.16 days) and timing to first hospitalization (HR: 6.01) in unadjusted models, but not when adjusted.

Conclusion

The COPD prognosis of pre-frail patients with respect to the number of exacerbations with hospitalization and the timing and rate of mortality is dependent of functional performance.

Physical Tests Are Poorly Related to Patient-Reported Outcome Measures during Severe Acute Exacerbations of COPD

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have a negative impact on patients' health status, including physical function and patient-reported outcomes. We aimed to explore the associations between physical tests and patient-reported outcome measures (PROMs) in hospitalised patients for an AECOPD. Patients were assessed on the day of discharge. Quadriceps force, handgrip strength, short physical performance battery (SPPB), five-repetition sit-to-stand test (5STS), four-meter gait speed test (4MGS), balance test, six-minute walk test (6MWT), COPD Assessment Test (CAT), London Chest Activity of Daily Living scale (LCADL), modified Medical Research Council (mMRC) dyspnea scale, Checklist of Individual Strength (CIS)-fatigue subscale, and Patient Health Questionnaire (PHQ-9) were collected. Sixty-nine patients with an AECOPD were included (54% female; age 69 ± 9 years; FEV1 39.2 (28.6-49.1%) predicted). Six-minute walk distance was strongly correlated with mMRC (ρ: -0.64, p < 0.0001) and moderately correlated with LCADL total score, subscales self-care and household activities (ρ ranging from -0.40 to -0.58, p < 0.01). Moreover, 4MGS was moderately correlated with mMRC (ρ: -0.49, p < 0.0001). Other correlations were weak or non-significant. During a severe AECOPD, physical tests are generally poorly related to PROMs. Therefore, a comprehensive assessment combining both physical tests and PROMs needs to be conducted in these patients to understand their health status.

Nutritional Status and Body Composition in Patients Suffering From Chronic Respiratory Diseases and Its Correlation With Pulmonary Rehabilitation

As part of an individualized intervention to improve the physical, emotional, and social functioning of patients with chronic respiratory diseases in general and chronic obstructive pulmonary disease in particular, awareness of the presence and consequences of changes in body composition increased enormously during the last decades, and nutritional intervention is considered as an essential component in the comprehensive approach of these patients. This review describes the prevalence and the clinical impact of body composition changes and also provides an update of current intervention strategies. It is argued that body composition, preferentially a three-component evaluation of fat, lean, and bone mass, must become part of a thorough assessment of every patient, admitted for pulmonary rehabilitation.

Prognostic value of the five-repetition sit-to-stand test for mortality in people with chronic obstructive pulmonary disease

BACKGROUND

Prognostic studies suggest that some musculoskeletal and functional capacity tests are independently associated with mortality in chronic obstructive pulmonary disease (COPD), but comparing their prognostic value is difficult because of differences in the selected covariates for regression modelling in those studies.

OBJECTIVES

To assess the prognostic value of five musculoskeletal and functional capacity tests in predicting mortality risk in patients with COPD after adjusting for existing and confounding prognostic factors and to compare their ability to correctly discriminate the mortality of individual participants using the 6-min walk test (6MWT). We hypothesized that the examined tests have different prognostic value.

METHODS

Prospective and longitudinal study. A total of 137 patients with stable COPD (mean [SD] age 67 [8.33] years; 87% male) were recruited from a hospital in Spain during 2014 and followed for 5 years (2014-2019). No one refused and only one was lost to follow-up. The outcome measure was 5 year all-cause mortality.

RESULTS

A total of 37 patients died within 5 years. All musculoskeletal tests were associated with 5 year all-cause mortality in Cox proportional-hazards regression models. However, only the five-repetition sit-to-stand test (5-STS) score was an independent prognostic factor (hazard ratio 1.04 per sec, 95% confidence interval 1.01-1.08) after adjusting for history of heart disease, number of previous severe exacerbations, and dyspnoea. This model explained 50.7% of the variance in mortality. This test exhibited similar discriminative ability as the 6MWT for 5 year mortality (area under the receiver operating characteristic curve: 0.741vs 0.722; p = 0.92), and a highly prognostic cut-off for discriminating (15.98 s). This cut-off had higher likelihood ratios (LRs) than the 6MWT cut-off (∼350 m), especially for negative LRs (1/LR-: 7.69vs 2.00).

CONCLUSIONS

The 5-STS is an objective measure for predicting mortality in patients with COPD and has good discriminative ability, with a cut-off for discriminating survival slight better than the 6MWT. The prognostic value of the other tests remains to be confirmed.

Risk of all-cause mortality associated with chronic obstructive pulmonary disease and the role of healthy ageing trajectories: a population-based study of middle-aged and older adults

OBJECTIVES

The aims were to study the risk of all-cause mortality associated with chronic obstructive pulmonary disease (COPD) and healthy ageing trajectories (HAT) in three birth cohorts and to determine the moderating role of HAT in the association between COPD and all-cause mortality.

DESIGN

Prospective cohort study.

SETTING

Data from waves 1 to 5 of The Survey of Health, Ageing and Retirement in Europe.

PARTICIPANTS

The total sample was 28 857 community-dwelling individuals aged 50+ years.

MAIN OUTCOME

All-cause mortality associated with COPD and HAT adjusting for covariates. We performed Aalen additive hazards models to explore these associations. Interactions between COPD and HAT were also explored. Analyses were conducted separately in three birth cohorts (>1945, 1936-1945 and ≤1935). Latent class growth analysis was used to classify participants into HAT.

RESULTS

Three parallel HAT were found in the three birth cohorts ('low', 'medium' and 'high' healthy ageing). Participants with COPD had an increased mortality risk, but this effect was no longer significant after adjusting for covariates. The 'low' HAT was associated with increased mortality risk in the three subsamples, although this effect was lower after adjustment. The interaction between COPD and HAT was significant only in the ≤1935 birth cohort, indicating that those with COPD and a 'low' trajectory had a greater risk of mortality.

CONCLUSIONS

The healthy ageing scale may be a suitable tool to identify patients at higher risk to mitigate disease burden and improve patients' quality of life.

Handgrip Strength in People With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to systematically review the association between handgrip strength (HGS) and mortality, morbidity, and health-related quality of life (HRQL) in individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The following databases were used: CENTRAL, CINAHL, EMBASE, MEDLINE Ovid, SPORTDiscus, and PsycINFO. Studies published between 2000 and 2020 in English, Portuguese, or French that examined the association of HGS with mortality, morbidity, and HRQL in individuals with stable COPD were selected. Two authors independently extracted data and assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. The study effects were pooled using random effects meta-analysis models after assessing heterogeneity. The search generated 710 studies, and 18 were included in the review. Studies evaluated a total of 12,046 individuals with stable COPD (mean percent of the predicted forced expiratory volume in 1 second = 34%-80%) using over 10 diverse protocols for HGS measurement. Statistically significant, small, and negative relationships were found between HGS and mortality (r = -0.03; 95% CI = -0.05 to -0.02). Independent of the outcome measure used to assess morbidity, the estimate of the overall relationship was small to moderate and negative: Body Mass Index, Airflow Obstruction, Dyspnea, and Exercise Index Updated (r = -0.42; 95% CI = -0.61 to -0.03); exacerbations (r = -0.02; 95% CI = -0.04 to -0.00); and hospitalizations (r = -0.69; 95% CI = -1.70 to 0.32). Similarly, for HRQL, independent of the outcome measure, the estimate of the overall relationship was small to fair and negative: COPD Assessment Test (weighted r = -0.22; 95% CI = -0.32 to -0.12), Chronic Respiratory Disease Questionnaire domains (-0.24 < r < -0.14), EuroQol Five-Dimension Questionnaire (utility score) (r = -0.17; 95% CI = -0.26 to -0.07), EuroQol Five-Dimension Questionnaire domains (-0.32 < r < -0.06), and St George Respiratory Questionnaire total (r = -0.26; 95% CI = -0.33 to -0.17). The quality of the evidence ranged from low to very low across outcomes.

CONCLUSION

Although heterogeneity was present among HGS measurement protocols, small to moderate associations were found, indicating that those with lower HGS have an increased likelihood of death, a higher risk of increased COPD morbidity (as assessed with Body Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity indexes), and poorer HRQL.

Specific Contribution of Quadriceps Muscle Strength, Endurance, and Power to Functional Exercise Capacity in People With Chronic Obstructive Pulmonary Disease: A Multicenter Study

OBJECTIVE

Various functional muscle properties affect different aspects of functional exercise capacity in people with chronic obstructive pulmonary disease (COPD). The purpose of this study was to investigate the contribution of quadriceps muscle strength, endurance, and power to 6-Minute Walking Distance (6MWD) and 1-minute sit-to-stand test (1STS) performance in people with COPD.

METHODS

The study was a prospective, multicenter, cross-sectional study. Anthropometrics, Medical Research Council dyspnea scale, lung function, 6MWD, and 1STS number of repetitions were assessed. Isometric quadriceps strength and endurance, isotonic quadriceps endurance, isokinetic quadriceps strength, and power were assessed on a computerized dynamometer while functional quadriceps power was determined during 5 sit-to-stand repetitions. Univariate and multivariate analyses were performed to determine the contribution of functional muscle properties to the 6MWD and the 1STS number of repetitions.

RESULTS

The study included 70 people with COPD (mean % predicted forced expiratory volume in 1 second = 58.9 [SD = 18.2]). The 6MWD correlated with each functional muscle property except the isometric quadriceps endurance. The number of repetitions during the 1STS correlated with each functional muscle property except isometric measurements. Multivariate models explained 60% and 39% of the variance in the 6MWD and 1STS number of repetitions, respectively, with quadriceps power determined during 5 sit-to-stand repetitions being the muscle functional property with the strongest contribution to the models.

CONCLUSION

Except for isometric endurance, quadriceps strength, endurance, and power were associated with functional exercise capacity in people with moderate COPD. Among these functional muscle properties, muscle power contributed the most to the 6MWD and 1STS number of repetitions, suggesting that muscle power is more relevant to functional exercise capacity than muscle strength or endurance in people with COPD.

IMPACT

Understanding the individual contribution of muscle properties to functional status is important to designing interventions. This study provides the guidance that muscle power may be more important to functional exercise capacity than muscle strength or endurance in people with COPD.

Frailty, a Dimension of Impaired Functional Status in Advanced COPD: Utility and Clinical Applicability

Background and Objectives: In advanced chronic obstructive pulmonary disease (COPD), functional status is significantly impaired mainly as a result of disease related respiratory symptoms such as dyspnea or as a result of fatigue, which is the extra-respiratory symptom the most prevalent in this setting. "Physical" frailty, considered to be an aging phenotype, has defining traits that can also be considered when studying impaired functional status, but little is known about this relationship in advanced COPD. This review discusses the relevance of this type of frailty in advanced COPD and evaluates it utility and its clinical applicability as a potential outcome measure in palliative care for COPD. Materials and Methods: A conceptual review on the functional status as an outcome measure of mortality and morbidity in COPD, and an update on the definition and traits of frailty. Results: Data on the prognostic role of frailty in COPD are rather limited, but individual data on traits of frailty demonstrating their relationship with mortality and morbidity in advanced COPD are available and supportive. Conclusions: Frailty assessment in COPD patients is becoming a relevant issue not only for its potential prognostic value for increased morbidity or for mortality, but also for its potential role as a measure of functional status in palliative care for advanced COPD.

Reference values and validation of the 1-minute sit-to-stand test in healthy 5-16-year-old youth: a cross-sectional study

OBJECTIVES

It is essential to have simple, reliable and valid tests to measure children's functional capacity in schools or medical practice. The 1-minute sit-to-stand (STS) test is a quick fitness test requiring little equipment or space that is increasingly used in both healthy populations and those with chronic disease. We aimed to provide age-specific and sex-specific reference values of STS test in healthy children and adolescents and to evaluate its short-term reliability and construct validity.

DESIGN SETTING AND PARTICIPANTS

Cross-sectional convenience sample from six public schools and one science fair in central Europe. Overall, 587 healthy participants aged 5-16 years were recruited and divided into age groups of 3 years each.

OUTCOMES

1-minute STS. To evaluate short-term reliability, some children performed the STS test twice. To evaluate construct validity, some children also performed a standing long jump (SLJ) and a maximal incremental exercise test.

RESULTS

Data from 547 youth aged 5-16 years were finally included in the analyses. The median number of repetitions in 1 min in males (females) ranged from 55 [95% CI: 38 to 72] (53 [95% CI: 35 to 76]) in 14-16-year olds to 59 [95% CI: 41 to 77] (60 [95% CI: 38 to 77]) in 8-10-year olds. Children who repeated STS showed a learning effect of on average 4.8 repetitions more than the first test (95% limits of agreement: -6.7 to 16.4). Moderate correlations were observed between the STS and the SLJ (r=0.48) tests and the maximal exercise test (r=0.43).

CONCLUSIONS

The reported STS reference values can be used to interpret STS test performance in children and adolescents. The STS appears to have good test-retest reliability, but a learning effect of about 10%. The association of STS with other measures of physical fitness should be further explored in a larger study and technical standards for its conduct are needed.

Whole-body vibration training versus conventional balance training in patients with severe COPD-a randomized, controlled trial

BACKGROUND

Whole-body vibration training (WBV) performed on a vibration platform can significantly improve physical performance in patients with chronic obstructive pulmonary disease. It has been suggested that an important mechanism of this improvement is based on an improvement in balance. Therefore, the aim of this study was to investigate the effects of WBV compared to conventional balance training.

METHODS

48 patients with severe COPD (FEV₁: 37 ± 7%predicted) and low exercise performance (6 min walk distance (6MWD): 55 ± 10%predicted) were included in this randomized controlled trial during a 3 week inpatient pulmonary rehabilitation. All patients completed a standardized endurance and strength training program. Additionally, patients performed 4 different balance exercises 3x/week for 2 sets of 1 min each, either on a vibration platform (Galileo) at varying frequencies (5-26 Hz) (WBV) or on a conventional balance board (BAL). The primary outcome parameter was the change in balance performance during a semi tandem stance with closed eyes assessed on a force measurement platform. Muscular power during a countermovement jump, the 6MWD, and 4 m gait speed test (4MGST) were secondary outcomes. Non-parametric tests were used for statistical analyses.

RESULTS

Static balance performance improved significantly more (p = 0.032) in favor of WBV (path length during semi-tandem stand: - 168 ± 231 mm vs. + 1 ± 234 mm). Muscular power also increased significantly more (p = 0.001) in the WBV group (+ 2.3 ± 2.5 W/kg vs. - 0.1 ± 2.0 W/kg). 6MWD improved to a similar extent in both groups (WBV: 48 ± 46 m, p < 0.001 vs. BAL: 38 ± 32 m; p < 0.001) whereas the 4MGST increased significantly only in the WBV-group (0.08 ± 0.14 m/s², p = 0.018 vs. 0.01 ± 0.11 m/s², p = 0.71).

CONCLUSIONS

WBV can improve balance performance and muscular power significantly more compared to conventional balance training.

TRIAL REGISTRATION

Clinical-Trials registration number: NCT03157986; date of registration: May 17, 2017. https://clinicaltrials.gov/ct2/results?cond=&term=NCT03157986&cntry=&state=&city=&dist  = .

Follow-up of functional exercise capacity in patients with COVID-19: It is improved by telerehabilitation

BACKGROUND

The impact of the COVID-19 pandemic on functional exercise capacity seemed quickly clinically evident. The objective of this study was to assess the functional exercise capacity of patients with severe COVID-19 and to evaluate the effect of a telerehabilitation program in the specific context of the COVID-19 pandemic.

METHOD

Patients hospitalized for severe or critical COVID-19 were recruited. The functional exercise capacity (1-min sit-to-stand test (STST)) was prospectively quantified at discharge. A telerehabilitation program was then proposed. A control group was composed with the patients refusing the program.

RESULTS

At discharge, none of the 48 recruited patients had a STST higher than the 50th percentile and 77% of them were below the 2.5th percentile. SpO2 was 92.6 ± 3.0% after STST and 15 patients had oxygen desaturation. After 3-months of follow-up, the number of repetitions during STST significantly increased either in telerehabilitation (n = 14) (p < 0.001) or in control groups (n = 13) (p = 0.002) but only one patient had a result higher than the 50th percentile (in Telerehabilitation group) and 37% of them were still under the 2.5th percentile for this result. The improvement was significantly and clinically greater after the telerehabilitation program (p = 0.005). No adverse events were reported by the patients during the program.

CONCLUSIONS

Patients hospitalized for COVID-19 have a low functional exercise capacity at discharge and the recovery after three months is poor. The feasibility and the effect of a simple telerehabilitation program were verified, this program being able to substantially improve the functional recovery after three months.

Validation and Cardiorespiratory Response of the 1-Min Sit-to-Stand Test in Interstitial Lung Disease

PURPOSE

To assess the 1-min sit-to-stand test (1STS) test-retest reliability and construct validity and its associated cardiorespiratory response in comparison to the 6-min walk test (6MWT) and symptom-limited cycling cardiopulmonary exercise test (CPET) in people with interstitial lung disease (ILD).

METHODS

Fifteen participants with ILD performed two 1STS tests, a 6MWT and a CPET. The three tests were administered on three separate visits, and cardiorespiratory parameters were continuously recorded during the tests.

RESULTS

The number of repetitions during both 1STS tests was 22 ± 4 and 22 ± 4 (mean difference of 0.53 ± 2.00 repetitions, P = 0.32) with an intraclass correlation of 0.937 (95% confidence interval, 0.811-0.979]) and a minimal detectable change of 2.9 repetitions. The number of 1STS repetitions was highly correlated with the 6MWT distance (r = 0.823, P < 0.001) and with the peak cycling power output expressed in % predicted values (r = 0.706, P < 0.003). Oxygen consumption (V˙O2) peak during the 1STS reached 83% and 78% of V˙O2 peak during 6MWT and CPET, respectively. Peak 1STS HR, minute ventilation (V˙E,), V˙O2 values, as well as nadir SpO2 were achieved during the recovery phase of the test, whereas peak 6MWT and CPET HR, V˙E, V˙O2 and nadir SpO2 always occurred at the end of the test. The three tests elicited a similar fall in SpO2 ranging between 8% and 12%. Symptom scores after the 1STS were similar to those seen at the end of the 6MWT but lower than those of CPET.

CONCLUSIONS

The 1STS showed excellent test-retest reliability in patients with ILD in whom it elicited a substantial, but submaximal cardiorespiratory response. Our data also support the construct validity of the 1STS to assess functional exercise capacity in patients with ILD and to detect exercise-induced O2 desaturation.

Feasibility of an online platform delivery of pulmonary rehabilitation for individuals with chronic respiratory disease

Introduction

SARS-CoV-2 has restricted access to face-to-face delivery of pulmonary rehabilitation (PR). Evidence suggests that telehealth-PR is non-inferior to outpatient PR. However, it is unknown whether patients who have been referred to face-to-face programmes can feasibly complete an online-PR programme.

Methods

This service evaluation used a mixed-methods approach to investigate a rapid PR service remodelling using the University of Gloucestershire eLearn Moodle platform. Quantitative baseline demographic and PR outcome data were collected from online-PR participants, and semistructured interviews were completed with PR staff and participants.

Results

Twenty-five individuals were eligible from a PR waiting list. Thirteen declined participation and 14 completed PR. Significant pre-post online PR improvements were achieved in 1 min sit-to-stand (CI 2.1 to 9 (p=0.004)), Generalised Anxiety Disorder (CI −0.3 to −2.6 (p=0.023)), Primary Health Questionnaire-9 (CI −0.3 to −5.1 (p=0.029)), Chronic Respiratory Questionnaire dyspnoea (CI 0.5 to 1.3 (p=0.001)), fatigue (CI 0.7 to 2 (p=0.0004)), emotion (CI 0.7 to 1.7 (p=0.0002)), mastery (CI 0.4 to 1.3 (p=0.001)). Interviews indicated that patient PR inclusion was made possible with digital support and a PR introduction session improved participant engagement and safety. Incremental progression of exercise was perceived as more successful online compared with face-to-face PR. However, perceptions were that education sessions were less successful. Online-PR required significant staff time resource.

Discussion

Online-PR improves patient outcomes and is feasible and acceptable for individuals referred for face-to-face PR in the context of a requirement for social distancing. Face-to-face programmes can be adapted in a rapid fashion with both staff and participants perceiving benefit. Future pragmatic trials are now warranted comparing online-PR including remote assessments to centre-based PR with suitably matched outcomes, and patient and staff perceptions sought regarding barriers and facilitators of online delivery.

Association of daily physical activity with psychosocial aspects and functional capacity in patients with pulmonary arterial hypertension: a cross-sectional study

Pulmonary arterial hypertension impairs exercise tolerance and daily physical activity. Aside from the hemodynamic limitations, physical, cognitive, and emotional factors may play a relevant and as yet unexplored role. We investigated whether there is an association between the physical activity level and psychological disorders, health-related quality of life, and daily activities. We also searched for an association of the physical activity level with clinical factors and functional capacity. This was an analytical, cross-sectional, observational study conducted in a Brazilian University Hospital. Twenty stable pulmonary arterial hypertension subjects wore an accelerometer for a week and completed an activity diary. They answered the quality of life questionnaire (SF-36), as well as the Hospital Anxiety and Depression scale, and the Manchester Respiratory Activities of Daily Living questionnaire. Transthoracic echocardiography, the six-minute walk test, the one-minute sit-to-stand test, and spirometry were performed. For statistical analysis, we used Chi-square tests or Fisher's test as appropriate and the Mann-Whitney test to compare numerical values between two groups. The relationship between the parameters was assessed using the Spearman correlation test. The mean age was 44.3 years, 80% were women, 80% had idiopathic pulmonary arterial hypertension, and 20% had connective tissue disease. The mean daily step count was 4280 ± 2351, and the mean activity time was 41.6 ± 19.3 min. The distance covered (six-minute walk test) was 451.5 m, and the number of movements (one-minute sit-to-stand test) was 23.8. Thirty percent scored positive for anxiety, and 15% for depression (Hospital Anxiety and Depression scale). There was a significant correlation between accelerometer data and walking distance (six-minute walk test), number of movements (one-minute sit-to-stand test), level of daily physical activity (Manchester Respiratory Activities of Daily Living questionnaire), and depression symptoms. Our findings support the hypothesis that other aspects beyond physical and hemodynamic ones might impact the daily physical activity of patients with pulmonary arterial hypertension.