How to carry out a field walking test in chronic respiratory disease

The Bed Bridge Test: a new functional test for hospital inpatients - a feasibility and measurement study

PURPOSE

To develop and assess the Bed Bridge Test's (BBT) feasibility, safety, and clinimetric properties and evaluate functional capacity in hospitalised patients.

MATERIALS AND METHODS

This feasibility and measurement study examined four BBT versions, including the timed-limited at 30 and 60 s and repetition-limited at 5 and 10 times, in hospitalised patients in a university hospital in Brazil. Ninety-two functionally stable patients with respiratory, gastrointestinal, or post-surgical conditions participated. Participants completed the BBT versions in a random order. BBT concurrent criterion validity was evaluated using the Short Physical Performance Battery (SPPB), Sit-to-Stand (STS) test, and Functional Status Score (FSS).

RESULTS

The participants were 51 ± 17 years old, 60% female, and 66% with clinical conditions. All participants completed the BBT versions without adverse events. Test-retest reliability was good-excellent (intraclass correlation coefficient >0.87) for all BBT versions, with acceptable agreement parameters and minimal detectable changes. The time-limited versions of the BBT might be affected by a ceiling effect. Floor effects were minimal for all BBT versions. BBT showed moderate associations with SPPB and STS and weak associations with FSS.

CONCLUSIONS

The BBT is feasible and has promising measurement properties.

In-Person Versus Remote 6-Minute Walk and Incremental Shuttle Walk Distances in Advanced Lung Disease

BACKGROUND

Field-based walk tests conducted remotely may provide an alternative method to a facility-based assessment of exercise capacity for people with advanced lung disease. This prospective study evaluated the level of agreement in the distance walked between a 6-min walk test (6MWT) and an incremental shuttle walk test performed by using standard in-person procedures and test variations and settings.

METHODS

Adults with advanced lung disease underwent 4 study visits: (i) one in-person standard 6MWT (30-m corridor) and one in-person treadmill 6MWT, (ii) a remote 6MWT in a home setting (10-m corridor), (iii) 2 in-person standard incremental shuttle walk tests (10-m corridor), and (iv) a remote incremental shuttle walk test in a home setting (10-m corridor). A medical-grade oximeter measured heart rate and oxygen saturation before, during, and for 2 min after the tests.

RESULTS

Twenty-eight participants were included (23 men [82%]; 64 (57-67) y old; 19 with interstitial lung disease [68%] and 9 with COPD [32%]; and 26 used supplemental oxygen (93%) [exertional [Formula: see text] of 0.46 ± 0.1]). There was no agreement between the tests. Greater walking distances were achieved with standard testing procedures: in-person 6MWT versus treadmill 6MWT (355 ± 68 vs 296 ± 97; P = .001; n = 28), in-person 6MWT versus remote 6MWT (349 ± 68 vs 293 ± 84; P = .001; n = 24), and in-person incremental shuttle walk test versus remote incremental shuttle walk test (216 ± 62 vs 195 ± 63; P = .03; n = 22).

CONCLUSIONS

Differences in the distance walked may have resulted from different track lengths, widths, and walking surfaces. This should be considered in test interpretation if tests are repeated under different conditions.

Qualitative interviews of patients with COPD and muscle weakness enrolled in a clinical trial evaluating a new anabolic treatment: patient perspectives of disease experience, trial participation and outcome assessments

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and muscle weakness can cause impaired physical function, significantly impacting patients' health-related quality of life (HRQoL). Loss of muscle strength is usually assessed through clinical and performance outcome (PerfO) assessments, which consists of tasks performed in a standardized manner, providing evidence of a patient's functional ability. However, evidence documenting the patient experience of COPD and muscle weakness is limited.

METHODS

This two-stage qualitative study used semi-structured interviews in patients aged 45-80 years with COPD (post-bronchodilator forced expiratory volume in 1s [FEV1]/forced vital capacity ratio < 0.70, and FEV1% predicted of 30-80%) and muscle weakness. In Stage 1, 30-minute concept elicitation interviews were conducted with participants recruited across three US sites to explore impacts on physical functioning and activities of daily living. In Stage 2, interviews were performed with participants exiting a Phase IIa trial investigating the efficacy of a selective androgen receptor modulator (GSK2881078) on leg strength, whereby PerfOs were used to evaluate strength and physical functioning endpoints. These participants completed either 60-minute in-depth (n = 32) or 15-minute confirmatory (n = 35) interviews exploring trial experience, completion of outcome measures, disease experience and treatment satisfaction.

RESULTS

In Stage 1 (n = 20), most participants described their muscles as weak (83.3%). Difficulties with walking (100%) and lifting heavy objects (90%) were reported. In Stage 2, 60-minute interviews, all participants (n = 32) reported a positive trial experience. Most participants reported that the home exercise program was easy to fit into daily life (77.8%), the PROactive daily diary was easy to complete (100%) and wearable sensors were easy to use (65.6%). However, technical issues were reported (71%), and few participants (19.4%) found physical assessments easy to complete. Improvements in muscle strength and functional limitations were reported by most participants. The shorter 15-minute confirmatory interviews (n = 35) supported the in-depth interview results.

CONCLUSION

The qualitative interviews generated in-depth evidence of key concepts relevant to patients with COPD and muscle weakness and support the assessments of patient strength and physical function as outcome measures in this population in future studies.

TRIAL NUMBER

GSK Stage 1: 206869; Stage 2: 200182, NCT03359473; Registered December 2, 2017, https://clinicaltrials.gov/ct2/show/NCT03359473 .

Association of phase angle with sarcopenia and muscle function in patients with COPD: a case-control study

BACKGROUND AND AIMS

The predictive value of phase angle for sarcopenia diagnosis has been discussed for years. The present investigation was conducted to determine the association between phase angle and sarcopenia in patients with COPD.

METHODS

In this case-control study, 222 smoker men were divided into healthy and COPD groups. COPD was diagnosed by a pulmonologist through spirometry. Anthropometric indices, phase angle, muscle function, sarcopenia, and dietary intake were assessed.

RESULTS

A significant inverse association was observed between phase angle and sarcopenia after adjustment for age and energy intake (OR: 0.31, 95% CI 0.18-0.52) and after adjustment for BMI (OR: 0.31, 95% CI 0.18-0.52). A significant decrease was detected in anthropometric indices and indicators of sarcopenia and muscle function in COPD cases compared to the healthy controls.

CONCLUSIONS

Although further studies are suggested, phase angle might be considered an indicator of sarcopenia and muscle function in COPD patients.

Assessment of the feasibility of 1-min sit-to-stand test in evaluating functional exercise capacity in interstitial lung disease patients

Six-min walk test (6MWT) is widely used exercise test for the evaluation of interstitial lung disease (ILD). However, the long test duration and need for long and flat surface hinder its routine use. One-min sit-to-stand test (1-STST) is devoid of such limitations, but has been scarcely evaluated. The study was conducted to evaluate the performance of 1-STST by correlating it with 6MWT in ILD patients. Stable ILD patients were prospectively enrolled. After initial spirometry, all patients performed 6MWT and 1-STST following the standard recommendations. Exercise capacity and physiological parameters (heart rate, pulse oxygen saturation, blood pressure and dyspnea [modified Borg scale]) including peripheral oxygen saturation (SpO2) were correlated after the tests using Pearson correlation, Intraclass correlation coefficient (ICC) and kappa (κ) coefficient. The results showed that the mean age of the patients (n=60) was 58.8±11.5 years (male:female=1:1). Repetitions after 1-STST showed significant correlation with 6MWT (r=0.48; P<0.001). Changes in the physiological variables were similar (P>0.05) with good consistency (ICC=0.68-0.95) between 6MWT and 1-STST. Both lowest SpO2 and difference in SpO2 also showed good agreement (ICC=0.86; 95% confidence interval [CI], 0.77-0.92 and ICC=0.68; 95% CI, 0.47-0.81 respectively) and significant correlation (r=0.76 and r=0.52, respectively). 1-STST and 6MWT were consistent in identifying patients having oxygen desaturation ≥4% (κ=0.56; 96% CI, 0.30-0.82). The results demonstrated that the performance of 1-STST was consistent with 6MWT in terms of exercise capacity and change in physiological parameters. 1-STST can be a valid alternative to 6MWT in the assessment of ILD patients, especially in peripheral health centers.

The Effects of Exercise Training in Patients With Persistent Dyspnea Following Pulmonary Embolism: A Randomized Controlled Trial

BACKGROUND

Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited.

RESEARCH QUESTION

Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea?

STUDY DESIGN AND METHODS

This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72 months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8 weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire).

RESULTS

A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95% CI, 17.7-88.3; P = .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95% CI, -0.09 to 0.00; P = .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention.

INTERPRETATION

In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03405480; URL: www.

CLINICALTRIALS

gov.

Frequency and Functional Consequences of Low Appendicular Lean Mass and Sarcopenic Obesity in Patients with Asthma Referred for Pulmonary Rehabilitation

INTRODUCTION

One of the most prominent extrapulmonary manifestations in patients with chronic respiratory disease is changes in body weight and composition. However, the frequency and functional consequences of low appendicular lean mass (ALM) or sarcopenic obesity (SO) in patients with asthma are largely unknown. Therefore, the aim of the current study was to assess the frequency and functional consequences of low appendicular lean mass index (ALMI) and SO in patients with asthma.

METHODS

A retrospectively analyzed cross-sectional study was conducted in 687 patients with asthma (60% female, 58 ± 13 years, FEV1 76 ± 25% pred) referred for comprehensive pulmonary rehabilitation (PR). Body composition, pulmonary function, exercise capacity, quadriceps muscle function, and quality of life were assessed. Patients were classified as presenting low ALMI according to the 10th percentiles of age-sex-body mass index (BMI)-specific reference values and as having SO according to the diagnostic procedure proposed by the 2022 ESPEN/EASO consensus. In addition, clinical outcomes between patients with normal and low ALMI or with and without SO were compared.

RESULTS

The frequency of patients classified as low ALMI was 19%, whereas 45% of the patients were obese. Among the obese patients, 29% had SO. In patients with normal weight, those with low ALMI were younger and had worse pulmonary function, exercise capacity and quadriceps muscle function than those with normal ALMI (all p < 0.05). Overweight patients with low ALMI presented poorer pulmonary function and quadriceps muscle function (both strength and total work capacity). In obese class I patients, those with low ALMI showed lower quadriceps strength and maximal oxygen uptake acquired during cardiopulmonary exercise testing. Both male and female patients with SO showed lower quadriceps muscle function and reduced maximal exercise capacity compared to non-SO asthma patients.

CONCLUSION

Approximately one in five asthma patients presented low ALM when age-sex-BMI-specific ALMI cutoffs were applied. Obesity is common among patients with asthma referred for PR. Among the obese patients, a significant proportion presented SO. Low ALM and SO were associated with worse functional outcomes.

In adults with advanced lung disease, the 1-minute sit-to-stand test underestimates exertional desaturation compared with the 6-minute walk test: an observational study

QUESTION

In adults with advanced lung disease, do the 6-minute walk test (6MWT) and 1-minute sit-to-stand test (1minSTS) elicit similar cardiorespiratory responses? Can the 6-minute walk distance (6MWD) be estimated from the 1minSTS result?

DESIGN

Prospective observational study using data collected during routine clinical practice.

PARTICIPANTS

Eighty adults (43 males) with advanced lung disease, a mean age of 64 years (SD 10) and a mean forced expiratory volume in 1 second of 1.65 L (SD 0.77).

OUTCOME MEASURES

Participants completed a 6MWT and a 1minSTS. During both tests, oxygen saturation (SpO2), pulse rate, dyspnoea and leg fatigue (Borg 0 to 10) were recorded.

RESULTS

Compared with the 6MWT, the 1minSTS resulted in higher nadir SpO2 (MD 4%, 95% CI 3 to 5), lower end-test pulse rate (MD -4 beats/minute, 95% CI -6 to -1), similar dyspnoea (MD -0.3, 95% CI -0.6 to 0.1) and greater leg fatigue (MD 1.1, 95% CI 0.6 to 1.6). Among the participants who demonstrated severe desaturation (SpO2 nadir < 85%) on the 6MWT (n = 18), five and ten participants were classified as moderate (nadir 85 to 89%) or mild desaturators (nadir ≥ 90%), respectively, on the 1minSTS. The relationship between the 6MWD and 1minSTS was: 6MWD (m) = 247 + (7 × number of transitions achieved during the 1minSTS) with poor predictive ability (r2 = 0.44).

CONCLUSION

The 1minSTS elicited less desaturation than the 6MWT and classified a smaller proportion of people as 'severe desaturators' on exertion. It is therefore inappropriate to use the nadir SpO2 recorded during a 1minSTS to make decisions about whether strategies are needed to prevent severe transient exertional desaturation during walking-based exercise. Further, the extent to which performance on the 1minSTS can estimate a person's 6MWD is poor. For these reasons, the 1minSTS is unlikely to be helpful when prescribing walking-based exercise.

Exercise and Airway Clearance Techniques in Cystic Fibrosis

Exercise and airway clearance techniques (ACTs) have been a cornerstone of treatment for people with cystic fibrosis (pwCF) for many decades. Exercise may confer both respiratory and nonrespiratory benefits for pwCF, with greater exercise capacity associated with improved survival. A wide variety of exercise interventions for pwCF have been investigated. ACTs may assist in reducing respiratory symptoms for pwCF and are currently recommended to be performed daily, with the types of ACTs used varying globally. While recommended components of care, both exercise and ACTs are time-intensive and maintaining adherence to the recommendations over the longer term can be challenging. It has been proposed that with advances in the therapeutic options for pwCF, a rationalization of the therapeutic regimen may be possible. We summarize the current evidence for the use of exercise and ACTs by pwCF, discuss the implications of the introduction of cystic fibrosis transmembrane conductance regulator modulators on both exercise and ACTs, and highlight areas for further research.

Early diagnostic BioMARKers in exacerbations of chronic obstructive pulmonary disease: protocol of the exploratory, prospective, longitudinal, single-centre, observational MARKED study

INTRODUCTION

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) play a pivotal role in the burden and progressive course of chronic obstructive pulmonary disease (COPD). As such, disease management is predominantly based on the prevention of these episodes of acute worsening of respiratory symptoms. However, to date, personalised prediction and early and accurate diagnosis of AECOPD remain unsuccessful. Therefore, the current study was designed to explore which frequently measured biomarkers can predict an AECOPD and/or respiratory infection in patients with COPD. Moreover, the study aims to increase our understanding of the heterogeneity of AECOPD as well as the role of microbial composition and hostmicrobiome interactions to elucidate new disease biology in COPD.

METHODS AND ANALYSIS

The 'Early diagnostic BioMARKers in Exacerbations of COPD' study is an exploratory, prospective, longitudinal, single-centre, observational study with 8-week follow-up enrolling up to 150 patients with COPD admitted to inpatient pulmonary rehabilitation at Ciro (Horn, the Netherlands). Respiratory symptoms, vitals, spirometry and nasopharyngeal, venous blood, spontaneous sputum and stool samples will be frequently collected for exploratory biomarker analysis, longitudinal characterisation of AECOPD (ie, clinical, functional and microbial) and to identify host-microbiome interactions. Genomic sequencing will be performed to identify mutations associated with increased risk of AECOPD and microbial infections. Predictors of time-to-first AECOPD will be modelled using Cox proportional hazards' regression. Multiomic analyses will provide a novel integration tool to generate predictive models and testable hypotheses about disease causation and predictors of disease progression.

ETHICS AND DISSEMINATION

This protocol was approved by the Medical Research Ethics Committees United (MEC-U), Nieuwegein, the Netherlands (NL71364.100.19).

TRIAL REGISTRATION NUMBER

NCT05315674.

Chinese (Mandarin) translation of the incremental shuttle walk test and its validity and reliability: A cross-sectional study

BACKGROUND/PURPOSE

To date, there are no published validated Chinese versions of the incremental shuttle walk test (ISWT) instructions despite its wide clinical applications. Translation of the Chinese ISWT instruction is done in an ad-hoc manner within the Chinese-speaking populations, affecting the test's reliability and validity since translation can differ significantly between individuals. This warrants the need for psychometric testing of such translation.

OBJECTIVES

To develop a Chinese (Mandarin) version of the ISWT instructions (ISWT-CHN) that is conceptually equivalent to the original English version (ISWT-ENG) and establish its reliability and validity.

METHODS

Forward and backward translations from the ISWT-ENG were done to generate the ISWT-CHN. Face and content validity was determined during the translation process. Intra-rater and inter-rater reliability of the ISWT-CHN, construct and criterion validity were established by analysing the ISWT and the gold standard cardiopulmonary exercise test results.

RESULTS

The Item-Content validity index (I-CVI), Scale-level-Content validity index (S-CVI), and content validity ratio (CVR) of the ISWT-CHN were 1.0. Intra-class Correlation Coefficient (ICC) for inter-rater reliability between two raters were excellent (ICC = 0 . 99 , 95% CI 0.97-1.0, p < 0 . 001 ; SEM = 0 . 85 m, MDC = 2 . 35 m). The intra-rater reliability of both Raters A (ICC = 0 . 92 , 95% CI 0.53-0.98, p = 0 . 003 ; SEM = 35 m, MDC = 97 m) and B (ICC = 0 . 90 , 95% CI 0.76-0.96, p < 0 . 001 ; SEM = 32 m, MDC = 88 m) were good. In a sample of 32 healthy participants, both ISWT-CHN and ISWT-ENG instruction results showed low-positive correlations with the VO2 max determined from the cardiopulmonary exercise test (r = 0.439, p < 0 . 001 ; r = 0 . 448 , p < 0 . 001 ). There is a very high correlation between ISWT-ENG and ISWT-CHN results with no statistically significant differences (r = 0 . 967 , p < 0 . 001 ). The construct and criterion validity of the ISWT-CHN were established.

CONCLUSION

This study developed the ISWT-CHN and showed that it is a valid and reliable measure conceptually comparable to the ISWT-ENG. It will benefit the determination of functional exercise capacity in Chinese-speaking populations.

KEY MESSAGES

•This study is aimed to develop a Chinese (Mandarin) version of the ISWT instructions.•The ISWT Chinese translation is valid and reliable that is conceptually comparable to the original English instruction.•The translated ISWT-Chinese instruction will enable the use of ISWT among the Chinese-speaking populations.

Urban environment and physical activity and capacity in patients with chronic obstructive pulmonary disease

BACKGROUND

Physical activity and exercise capacity are key prognostic factors in chronic obstructive pulmonary disease (COPD) but their environmental determinants are unknown.

OBJECTIVES

To test the association between urban environment and objective physical activity, physical activity experience and exercise capacity in COPD.

METHODS

We studied 404 patients with mild-to-very severe COPD from a multi-city study in Catalonia, Spain. We measured objective physical activity (step count and sedentary time) by the Dynaport MoveMonitor, physical activity experience (difficulty with physical activity) by the Clinical visit-PROactive (C-PPAC) instrument, and exercise capacity by the 6-min walk distance (6MWD). We estimated individually (geocoded to the residential address) population density, pedestrian street length, slope of terrain, and long-term (i.e., annual) exposure to road traffic noise, nitrogen dioxide (NO₂) and particulate matter (PM_2.5). We built single- and multi-exposure mixed-effects linear regressions with a random intercept for city, adjusting for confounders.

RESULTS

Patients were 85% male, had mean (SD) age 69 (9) years and walked 7524 (4045) steps/day. In multi-exposure models, higher population density was associated with fewer steps, more sedentary time and worse exercise capacity (-507 [95% CI: 1135, 121] steps, +0.2 [0.0, 0.4] h/day and -13 [-25, 0] m per IQR). Pedestrian street length related with more steps and less sedentary time (156 [9, 304] steps and -0.1 [-0.1, 0.0] h/day per IQR). Steeper slope was associated with better exercise capacity (15 [3, 27] m per IQR). Higher NO₂ levels related with more sedentary time and more difficulty in physical activity. PM_2.5 and noise were not associated with physical activity or exercise capacity.

DISCUSSION

Population density, pedestrian street length, slope and NO₂ exposure relate to physical activity and capacity of COPD patients living in highly populated areas. These findings support the consideration of neighbourhood environmental factors during COPD management and the attention to patients with chronic diseases when developing urban and transport planning policies.

From Inception to Implementation: Strategies for Setting Up Pulmonary Telerehabilitation

Background

The emergence of innovative technology-enabled models of care is an opportunity to support more efficient ways of organizing and delivering healthcare services and improve the patient experience. Pulmonary telerehabilitation started as a promising area of research and became a strategic pandemic response to patients' decreased accessibility to rehabilitation care. Still, in the pre-COVID-19 era, we conducted a participatory study aiming to develop strategies for setting up pulmonary telerehabilitation as a person-centered digitally-enabled model of care.

Methods

We performed operational participatory research between June 2019 and March 2020 with the engagement of all stakeholders involved in the implementation of pulmonary telerehabilitation, including 14 people with Chronic Obstructive Pulmonary Disease. Patients were assessed subjectively and objectively pre and post a 3-month pulmonary rehabilitation program including exercise and education, which started in a face-to-face hospital setting during the first month and continued as a home-based, remotely supervised exercise training intervention.

Results

Five major groups of requirements targeted operational strategies for setting up pulmonary telerehabilitation: (1) pulmonary rehabilitation core principles, (2) quality and security standards, (3) technological functionality, (4) home environment appropriateness, and (5) telesetting skills. There was a statistical significance in the median change in the CAT score from 15.5 to 10.5 (p = 0.004) and in the PRAISE score from 49.5 to 53.0 (p = 0.006). Patients' mean levels of satisfaction regarding rehabilitation goals achievements were 88.1 ± 8.6% and the mean levels of satisfaction regarding the telerehabilitation experienced as a model of care were 95.4% ± 6.3%.

Conclusions

The success of telerehabilitation implementation was grounded on stakeholder engagement and targeted strategies for specific setup requirements, achieving patients' high satisfaction levels. Such operational experiences should be integrated into the redesigning of upgraded telerehabilitation programs as part of the solution to improve the effectiveness, accessibility, and resilience of health systems worldwide.

Clinical Resources for Assessing Mobility of People with Lower-Limb Amputation: Interviews with Rehabilitation Clinicians

Introduction

Mobility tests are increasingly used in prosthetic rehabilitation to evaluate patient outcomes. Knowledge of the space, equipment, and time resources available to clinicians who work in different settings can guide recommendations for which tests are most clinically-feasible and promote coordination of mobility testing among members of the rehabilitation team. The primary aim of this study was to characterize the different resources available to clinicians for measuring mobility of people with lower limb amputation. A secondary aim was to identify performance tasks that clinicians use to evaluate prosthetic mobility.

Materials and methods

Semi-structured interviews were conducted with prosthetists, physical therapists, and physiatrists who treat people with lower limb amputation. Researchers used convenience and snowball sampling to identify participants. Interviews included questions about the resources available for conducting mobility tests, as well as questions about which tasks clinicians deemed valuable to assessing mobility of patients with lower limb amputation. Interviews were audio-recorded and transcribed. Summary and frequency statistics were calculated for quantitative data; explanatory comments were summarized.

Results

Interviews were conducted with 25 clinicians (8 prosthetists, 9 physical therapists, and 8 physiatrists). Participants had access to multiple spaces and basic measurement equipment. The maximum time participants were willing to spend on performance tests varied. Physiatrists reported less time available (median=10 minutes, range 5-30 minutes) than prosthetists and physical therapists (median=30 minutes, range 5-60 minutes for both professions). Mobility tasks commonly used to evaluate patients with lower limb amputation included sit-to-stand, standing balance, walking, and varying speed. Participant comments suggested that mobility tests need to be quick, simple, and add value; existing mobility tests are beneficial but challenging to incorporate into practice; mobility tests should reflect real-world activities; and technological advancements could improve mobility testing.

Conclusions

Clinicians generally had small-to-medium spaces, basic measurement equipment, and sufficient training to administer mobility tests in their clinics. A limiting factor was time, which can be addressed through selection of efficient measures and collaboration within the rehabilitation team.

The importance of standard operating procedures in physical fitness assessment: a brief review

Background

Physical fitness status is a key aspect of health and, consequently, it is important to create and adopt appropriate interventions to maintain or improve it, and assess it using valid measures. While in other testing contexts, standard operating procedures (SOPs) are commonly and widely adopted, in physical fitness testing, a variety of unstandardized testing protocols are proposed.

Aims

The topic of this review was to evaluate the existing literature on SOPs in physical fitness assessment and to provide guidelines on how SOPs could be created and adopted.

Method

The electronic databases PubMed, Web of Science and Scopus were screened and original, peer-reviewed studies that included SOPs, related to physical fitness, were recorded.

Results

After the inclusion and exclusion criteria screening, a total of six studies were included and these were critically and narratively analyzed.

Conclusions

Standard operating procedures are rarely adopted in the field of physical fitness and a step by step guide has been provided in this manuscript. In the future, it is suggested to follow protocols as a routine, because this is the only way to generalize and contextualize findings.

Accompanied versus unaccompanied walking for continuous oxygen saturation measurement during 6-min walk test in COPD: a randomised crossover study

The aim of this study was to determine if there is a difference in 6-min walk test (6MWT) distance when the assessor accompanies the patient to continuously measure peripheral oxygen saturation (S_pO2) compared to the patient walking unaccompanied.

 We conducted a randomised crossover study to evaluate the impact of the assessor walking with the patient during the 6MWT (6MWT_with) versus the patient walking alone (6MWT_without). At the end of a pulmonary rehabilitation programme, each patient performed two 6MWTs in random order and separated by a 30-min rest.

 49 patients with chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease classification II–IV) were included. In a regression model adjusting for period and subject, accompanying the patient resulted in a lower walking distance (mean difference −9.1 m, 95% CI −13.9– −4.3, p=0.0004). Notably, six patients walked more than 30 m farther (minimal important difference) in one of the two conditions (6MWT_with: n=1, 6MWT_without: n=5). There were no between-sequence-group differences in heart rate, dyspnoea, leg fatigue and S_pO2. The median (interquartile range) number and duration of S_pO2 signal artefacts were high but not different between the experimental conditions (6MWT_with: 17 (4–24), 34 s (7–113 s); 6 MWT_without: 11 (3–26), 24 s (4–62 s)).

 At a study population level, we observed a statistically significant difference in 6MWT distance between the two experimental conditions; however, the magnitude of difference was small and may not be clinically relevant. Nevertheless, in a clinical setting, unaccompanied walking resulted in a substantially higher walking distance in individual patients, pointing towards strictly standardised testing methodology, in particular in pre–post study designs.

Accompanied walking during a 6MWT versus unaccompanied walking results in shorter walked distance (mean difference −9.1 m, 95% CI −13.9– −4.3 m). No differences in nadir S_pO2 or oximetry artefacts were noted between accompanied and unaccompanied walking.https://bit.ly/3tBjfCq

Maximal Exercise Testing Using the Incremental Shuttle Walking Test Can Be Used to Risk-Stratify Patients with Pulmonary Arterial Hypertension

Rationale: Exercise capacity predicts mortality in pulmonary arterial hypertension (PAH), but limited data exist on the routine use of maximal exercise testing.

Objectives: This study evaluates a simple-to-perform maximal test (the incremental shuttle walking test) and its use in risk stratification in PAH.

Methods: Consecutive patients with pulmonary hypertension were identified from the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre) registry (2001–2018). Thresholds for levels of risk were identified at baseline and tested at follow-up, and their incorporation into current risk stratification approaches was assessed.

Results: Of 4,524 treatment-naive patients with pulmonary hypertension who underwent maximal exercise testing, 1,847 patients had PAH. A stepwise reduction in 1-year mortality was seen between levels 1 (≤30 m; 32% mortality) and 7 (340–420 m; 1% mortality) with no mortality for levels 8–12 (≥430 m) in idiopathic and connective tissue disease–related PAH. Thresholds derived at baseline of ≤180 m (>10%; high risk), 190–330 m (5–10%; intermediate risk), and ≥340 m (<5%; low risk of 1-yr mortality) were applied at follow-up and also accurately identified levels of risk. Thresholds were incorporated into the REVEAL (Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management) 2.0 risk score calculator and French low-risk approach to risk stratification, and distinct categories of risk remained.

Conclusions: We have demonstrated that maximal exercise testing in PAH stratifies mortality risk at baseline and follow-up. This study highlights the potential value of the incremental shuttle walking test as an alternative to the 6-minute walking test, combining some of the advantages of maximal exercise testing and maintaining the simplicity of a simple-to-perform field test.

Correlates of variability in endurance shuttle walk test time in patients with chronic obstructive pulmonary disease

Background

The endurance shuttle walk test (ESWT) is used to evaluate exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). The recommended pre-intervention tolerated duration (Tlim) is between 3–8 minutes for optimal interpretation of treatment effects. However, this window may be exceeded and factors determining ESWT Tlim are not completely understood. Therefore, we aimed to determine whether pulmonary function, physical and incremental shuttle walk test (ISWT) performance measures are associated with ESWT Tlim in COPD patients.

Methods

Assessment data from patients eligible for pulmonary rehabilitation was retrospectively analyzed. Inclusion criteria were: diagnosis of COPD and complete data availability regarding ESWT and ISWT. Patients performed an ESWT at 85% of ISWT speed and were divided into three groups (ESWT Tlim: <3 minutes, 3–8 minutes, >8 minutes). Subject characteristics, severity of complaints, pulmonary function, physical capacity and activity, exercise tolerance and quadriceps muscle strength were evaluated.

Results

245 COPD patients (FEV₁ 38 (29–52)% predicted) were included. Median ESWT Tlim was 6.0 (3.7–10.3) minutes, 41 (17%) patients walked <3 minutes and 80 (33%) patients walked >8 minutes. Body mass index, maximal oxygen consumption, Tlim on constant work rate cycle test, physical activity level, maximal ISWT speed, dyspnoea Borg score at rest and increase of leg fatigue Borg score during ISWT independently predicted Tlim in multivariate regression analysis (R² = 0.297, p<0.001).

Conclusion

This study reported a large variability in ESWT Tlim in COPD patients. Secondly, these results demonstrated that next to maximal ISWT speed, other ISWT performance measures as well as clinical measures of pulmonary function, physical capacity and physical activity were independent determinants of ESWT Tlim. Nevertheless, as these determinants only explained ~30% of the variability, future studies are needed to establish whether additional factors can be used to better adjust individual ESWT pace in order to reduce ESWT Tlim variability.

Automated fall risk assessment of elderly using wearable devices

Introduction

Falls cause major expenses in the healthcare sector. We investigate the ability of supporting a fall risk assessment by introducing algorithms for automated assessments of standardized fall risk-related tests via wearable devices.

Methods

In a study, 13 participants conducted the standardized 6-Minutes Walk Test, the Timed-Up-and-Go Test, the 30-Second Sit-to-Stand Test, and the 4-Stage Balance Test repeatedly, producing 226 tests in total. Automatedalgorithms computed by wearable devices, as well as a visual analysis of the recorded data streams, were compared to the observational results conducted by physiotherapists.

Results

There was a high congruence between automated assessments and the ground truth for all four test types (ranging from 78.15% to 96.55%), with deviations ranging all well within one standard deviation of the ground truth. Fall risk (assessed by questionnaire) correlated with the individual tests.

Conclusions

The automated fall risk assessment using wearable devices and algorithms matches the validity of the ground truth, thus providing a resourceful alternative to the effortful observational assessment, while minimizing the risk of human error. No single test can predict overall fall risk; instead, a much more complex model with additional input parameters (e.g., fall history, medication etc.) is needed.

Repeatability of the 6-min walk test in non-cystic fibrosis bronchiectasis

Non-cystic fibrosis bronchiectasis (NCFB) is a chronic lung disease characterized by progressive and irreversible changes of the bronchial tree. The evaluation of exercise capacity is essential to manage this disease. This study aims to determine the within-subject repeatability of two Six Minute Walk Test (6MWT) in adults with NCFB. NCFB. This cross-sectional observational study included 66 NCFB subjects above 18 years-old (mean of 55 ± 17 years old, 68% women). 73% of the participants presented moderate to severe clinical condition classified by Bronchiectasis Severity Index. It showed that these participants walked 16.6 m less (95%CI 3.8 to 29.4; p < 0.01) in the second 6MWT when compared to the first test, with a within-subject coefficient variation of 9.4% (95%CI 7.2–11.2%) and an intra-test reliability with a high intraclass correlation coefficient of 0.88 (95%CI 0.80–0.93). Bland–Altman plot showed an agreement regarding test repeatability, besides presented a large limit of agreement (− 85 to 116 m). Respiratory rate and systolic blood pressure were significantly higher before starting the second test. In conclusion, 6MWT seems to be reproducible in NCFB subjects and vital sign verification should be attentively checked to assess if the patient is fully recovered to perform a second test, as well as the disease severity score. Other studies on this matter should be conducted with a larger number of participants to confirm the findings of the present study.

Beta-alanine supplementation in patients with COPD receiving non-linear periodised exercise training or neuromuscular electrical stimulation: protocol of two randomised, double-blind, placebo-controlled trials

INTRODUCTION

Exercise intolerance is common in patients with chronic obstructive pulmonary disease (COPD) and, although multifactorial, it is largely caused by lower-limb muscle dysfunction. Research has shown that patients with severe to very severe COPD have significantly lower levels of muscle carnosine, which acts as a pH buffer and antioxidant. Beta-alanine (BA) supplementation has been shown to consistently elevate muscle carnosine in a variety of populations and may therefore improve exercise tolerance and lower-limb muscle function. The primary objective of the current studies is to assess the beneficial effects of BA supplementation in enhancing exercise tolerance on top of two types of exercise training (non-linear periodised exercise (NLPE) training or neuromuscular electrical stimulation (NMES)) in patients with COPD.

METHODS AND ANALYSIS

Two randomised, double-blind, placebo-controlled trials have been designed. Patients will routinely receive either NLPE (BASE-TRAIN trial) or NMES (BASE-ELECTRIC trial) as part of standard exercise-based care during their 8-to-10 week pulmonary rehabilitation (PR) programme. A total of 222 patients with COPD (2×77 = 154 patients in the BASE-TRAIN trial and 2×34 = 68 patients in the BASE-ELECTRIC trial) will be recruited from two specialised PR centres in The Netherlands. For study purposes, patients will receive 3.2 g of oral BA supplementation or placebo per day. Exercise tolerance is the primary outcome, which will be assessed using the endurance shuttle walk test (BASE-TRAIN) or the constant work rate cycle test (BASE-ELECTRIC). Furthermore, quadriceps muscle strength and endurance, cognitive function, carnosine levels (in muscle), BA levels (in blood and muscle), markers of oxidative stress and inflammation (in blood, muscles and lungs), physical activity and quality of life will be measured.

ETHICS AND DISSEMINATION

Both trials were approved by CMO Regio Arnhem-Nijmegen, The Netherlands (NL70781.091.19. and NL68757.091.19).

TRIAL REGISTRATION NUMBER

NTR8427 (BASE-TRAIN) and NTR8419 (BASE-ELECTRIC).

Validation of 4-meter-gait-speed test and 5-repetitions-sit-to-stand test in patients with pulmonary fibrosis: a clinimetric validation study

Background and objective: Patients with pulmonary fibrosis (PF) have a clear exercise intolerance. The 4-meter-gait-speed (4MGS) test and the 5-repetitions-sit-to-stand (5STS) test are easy, inexpensive and reliable measures of functional performance. Both tests have been validated in healthy adults and patients with chronic obstructive pulmonary disease. 4MGS test and 5STS test have not been studied in patients with PF. Methods: In this cross-sectional clinimetric validation study 51 PF patients conducted in random order the 4MGS test, 5STS test and the 6-min walk test (6MWT) on a single day. Additionally, body weight, height, lean body mass, health-related quality of life, disease severity, handgrip strength, dyspnoea and leg fatigue were assessed. The setting was a tertiary referral center for Interstitial Lung Diseases. Results: Patients had a diagnosis of idiopathic pulmonary fibrosis (IPF, 37%), PF other than IPF (47%), or unclassified (16%). Patients walked 453±111m in six minutes. Moreover, it took the patients 2.0±0.5s to walk 4 m, and 12.0±3.8s for the 5STS test. The 4MGS test (r = 0.77; p<0.01) and the 5STS test (r = -0.41; p<0.01) correlated significantly with the distance walked in 6MWT. Indeed, 4MGS combined with handgrip strength and Medical Research Council dyspnoea grade could explain 75% of the variance in 6MWD. Conclusions: 4-meter-gait-speed and 5-repetitions sit-to-stand are significantly and independently correlated with the 6-minute walk distance in patients with pulmonary fibrosis. Indeed, 4-meter-gait-speed test may serve as a simple initial field test to assess exercise performance in patients with pulmonary fibrosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 317-326)

Protocol for a multicentre randomised controlled trial to investigate the effect on asthma-related quality of life from breathing retraining in patients with incomplete asthma control attending specialist care in Denmark

INTRODUCTION AND AIM

Uncontrolled asthma is a global health challenge with substantial impact on quality of life (QoL) and overall healthcare costs. Unrecognised and/or unmanaged comorbidities often contribute to presence of uncontrolled asthma. Abnormalities in breathing pattern are termed dysfunctional breathing and are not only common in asthma but also lead to asthma-like symptoms and reduced QoL, and, in keeping with this, improvement with breathing normalisation. Evidence-based guidelines recommend breathing retraining interventions as an adjuvant treatment in uncontrolled asthma. Physiotherapy-based breathing pattern modification interventions incorporating relaxation have been shown to improve asthma-related QoL in primary care patients with impaired asthma control. Despite anecdotal reports, effectiveness of breathing retraining in patients referred to secondary care with incomplete asthma control has not been formally assessed in a randomised controlled trial (RCT). We aim to investigate the effect of breathing exercises on asthma-related QoL in patients with incomplete asthma control despite specialist care.

METHODS AND ANALYSIS

This two-armed assessor-blinded multicentre RCT will investigate the effect of physiotherapist-delivered breathing retraining on asthma QoL questionnaire (MiniAQLQ) in addition to usual specialist care, recruiting from seven outpatient departments and one specialised clinic representing all regions of Denmark during 2017-2019. We will include 190 consenting adults with incomplete asthma control, defined as Asthma Control Questionnaire 6-item score ≥0.8. Participants will randomly be allocated to either breathing exercise programme in addition to usual care (BrEX +UC) or UC alone. BrEX compiles three physiotherapy sessions and encouragement to perform home exercise daily. Both groups continue usual secondary care management. Primary outcome is between-group difference in MiniAQLQ at 6 months. Secondary outcomes include patient-reported outcome measures, spirometry and accelerometer.

ETHICS AND DISSEMINATION

Ethics Committee, Region Zealand (SJ-552) and Danish Data Protection Agency (REG-55-2016) approved the trial. Results will be reported in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03127059; Pre-results.

Outdoor Walking Training Compared To Cycle Ergometer Training in Severe COPD: A Randomized Controlled Feasibility Trial

Exercise can improve walking capacity in persons with chronic obstructive pulmonary disease (COPD). However, most endurance training programs use cycle ergometers. The objectives of this study were: (i) to evaluate the feasibility of a randomized controlled trial (RCT) comparing outdoor walking training (OWT) to cycle ergometer training (CT) during inpatient rehabilitation in persons with severe COPD; (ii) to estimate the effect of OWT and CT on health-related quality of life, physical capacity and physical activity; and (iii) to estimate the required sample size for a RCT. A single-blind randomized controlled feasibility trial was conducted with three months' follow-up in the rehabilitation center in Walenstadtberg, Switzerland. Sixteen patients were included in the study, which had a recruitment rate of 33% (16/48). Patients were allocated to an OWT (n = 8) or CT (n = 8) group. Participants completed 75% of scheduled training and the follow-up rate was 75%. All participants in the OWT group were satisfied with the training. The OWT group had better health-related quality of life after three weeks' training compared to the CT group (p = 0.042, 95% confidence interval (95% CI) 1.06-49.94, effect size (d)=1.19). No exacerbations occurred in the OWT group, but three occurred in the CT group after three months' follow-up. There was no significant difference in the other outcomes. In conclusion, the study design and the OWT are feasible. Health-related quality of life improved in the OWT group compared to the CT group after three weeks' inpatient rehabilitation. A minimum of 46 participants is needed for a RCT. Trial registration: www.who.int/trialsearch DRKS00010977.

A 1-Month Physical Therapy-Based Outpatient Program for Adults Awaiting Lung Transplantation: A Retrospective Analysis of Exercise Capacity, Symptoms, and Quality of Life

Purpose

Rehabilitation can improve health outcomes in candidates for lung transplantation. The purpose of this study was to retrospectively evaluate the effect of a one-month physical therapy (PT)-based outpatient program on exercise capacity, symptoms, quality of life and examine predictors of functional outcome changes in adults awaiting lung transplantation.

Methods

Participants (n=141) completed a 23-session exercise and educational program over one month. Outcomes included 6-minute walk distance (6MWD), San Diego Shortness of Breath Questionnaire (SOBQ), Center for Epidemiological Studies-Depression Scale (CESD), and Ferrans and Powers Quality of Life Index Pulmonary Version III (QOL).

Results

Participants were older (median age 63) with restrictive (59%) or obstructive (24%) disease. Moderate-to-large improvements in 6MWD were observed (69 m, p < 0.001, d = 0.72), independent of demographics, symptoms, and QOL. Lower initial 6MWD and lower oxygen utilization were associated with greater 6MWD improvements, with largest gains occurring in initial 6MWD < 305 m. Small-to-moderate improvements were observed on CESD (p < 0.001, d = 0.26) and in overall QOL (p < 0.001, d = 0.27), with a non-significant improvement observed on SOBQ (p = 0.248, d = 0.13).

Conclusions

Completion of a one-month PT-based outpatient rehabilitation program was associated with improved exercise capacity, depressive symptoms and QOL.

Incremental shuttle walk test performed in a hallway and on a treadmill: are they interchangeable?

ABSTRACT The performances of healthy individuals in an incremental shuttle walking test performed in a hallway (ISWT-H) and on a treadmill (ISWT-T) were compared to assess their physiological responses during aerobic training sessions with the speeds estimated from both tests. This was a cross-sectional study with 55 healthy subjects, who were randomized to perform the ISWT tests with 24 hours between them. Training sessions were held using a treadmill at 75% of the speeds obtained from the ISWT-H and ISWT-T. Measurements included walking distance, oxygen uptake (VO2), carbon dioxide (VCO2) production, heart rate (HR), and ventilation (VE). There was a significant difference between walking distances (ISWT-T: 823.9±165.2 m and ISWT-H:685.4±141.4 m), but similar physiological responses for VO2 (28.6±6.6 vs. 29.0±7.3 ml-1.kg-1.min-1), VCO2 (1.9±0.7 vs. 1.9±0.5 1), HR (158.3±17.8 vs. 158.6±17.7 bpm), and VE (41.5±10.4 vs. 43.7±12.9 1). The estimated speeds were different for the training sessions (5.5±0.5 km/h and 4.9±0.3 km/h), as well as the VO2, VCO2, VE, and HR. It was concluded that in healthy young adults, ISWTs carried out in a hallway and on a treadmill are not interchangeable. Since the ISWT-H was determined to have lower speed, the training intensity based on this test may underestimate a patient’s responses to aerobic training.

Comparison of effectiveness of temporary positive expiratory pressure versus oscillatory positive expiratory pressure in severe COPD patients

INTRODUCTION

In chronic obstructive pulmonary disease (COPD) patients few modalities of airway clearance have demonstrated effectiveness in reducing hypersecretion and bronchial obstruction. Positive expiratory pressure (PEP) is one of these.

OBJECTIVE

Our goal was to compare the effectiveness of 2 devices Temporary PEP (T-PEP) and Oscillatory PEP (O-PEP) which use PEP applied at a low expiratory pressure of 1 cm H₂ O which creates oscillations that decrease bronchial obstruction in reducing COPD exacerbations and improving respiratory and health status assessment parameters. Each has different mechanism of action.

METHODS

A 26 week randomized controlled study evaluated their efficacy in reducing exacerbations and improving health status assessment tests as well as respiratory function parameters in severe to very severe COPD patients. One hundred-twenty patients were enrolled: 40 patients received T-PEP therapy; 40 underwent treatment with O-PEP; 40 constituted the control group. The primary outcome was the reduction of exacerbations after 1, 3 and 6 months; secondary outcomes were improvement of lung function and health status assessment tests [Modified Medical Research Council (MMRC) scale, Breathlessness, Cough, and Sputum Scale (BCSS) scale, and COPD Assessment Test (CAT) score].

RESULTS

Only T-PEP statistically reduced the exacerbations after 1 and 3 months compared to the control group. Both the 2 devices improved dyspnea scale (MMRC), lung function parameters, and health status assessment (CAT) tests compared to the control group. Both interventions were well-tolerated by our patients.

CONCLUSIONS

O-PEP and T-PEP are useful for COPD treatment but only T-PEP reduces exacerbations. Adding tools for airway clearance to medical therapy can help the management of COPD.

Evaluation of determinants of walking fitness in patients attending cardiac rehabilitation

AIM

This study aims to investigate the ability of patients' baseline characteristics to predict the distance walked during the incremental shuttle walk test (ISWT) in the cardiac rehabilitation (CR) population and to produce reference values to guide practice.

METHODS

Secondary analysis was conducted on National Audit Cardiac Rehabilitation data collected between 2010 and 2015. Patients (n=8863) were included if they were aged ≥18 years and had a recorded ISWT score assessed before starting CR. Stepwise regression was used to identify factors predicting the ISWT distance. Age, gender, body mass index, height, weight; presence of hypertension, dyslipidemia or diabetes; smoking and physical activity were independent variables. ISWT distance was the dependent variable. The 25th, 50th and 75th percentiles of the ISWT distance were used as reference values.

RESULTS

Age and gender explained 27% of the variance of the distance covered in the ISWT (R2=0.27, adjusted R2=0.27,Standard Error of the Estimate (SEE) = 148.7, p<0.001). Reference values using age and gender categories were developed.

CONCLUSION

Age and gender were the significant factors for predicting the walking fitness in the CR population, with age being the best predictor. The age and gender reference values produced represent a potentially valuable tool to be used in the clinical setting.