Physical activity level and its clinical correlates in chronic obstructive pulmonary disease: a cross-sectional study

Update on the Etiology, Assessment, and Management of COPD Cachexia: Considerations for the Clinician

Cachexia is a commonly observed but frequently neglected extra-pulmonary manifestation in patients with chronic obstructive pulmonary disease (COPD). Cachexia is a multifactorial syndrome characterized by severe loss of body weight, muscle, and fat, as well as increased protein catabolism. COPD cachexia places a high burden on patients (eg, increased mortality risk and disease burden, reduced exercise capacity and quality of life) and the healthcare system (eg, increased number, length, and cost of hospitalizations). The etiology of COPD cachexia involves a complex interplay of non-modifiable and modifiable factors (eg, smoking, hypoxemia, hypercapnia, physical inactivity, energy imbalance, and exacerbations). Addressing these modifiable factors is needed to prevent and treat COPD cachexia. Oral nutritional supplementation combined with exercise training should be the primary multimodal treatment approach. Adding a pharmacological agent might be considered in some, but not all, patients with COPD cachexia. Clinicians and researchers should use longitudinal measures (eg, weight loss, muscle mass loss) instead of cross-sectional measures (eg, low body mass index or fat-free mass index) where possible to evaluate patients with COPD cachexia. Lastly, in future research, more detailed phenotyping of cachectic patients to enable a better comparison of included patients between studies, prospective longitudinal studies, and more focus on the impact of exacerbations and the role of biomarkers in COPD cachexia, are highly recommended.

The association of objectively measured physical activity and sedentary behavior with skeletal muscle strength and muscle power in older adults: A systematic review and meta-analysis

BACKGROUND

Engaging in physical activity (PA) and avoiding sedentary behavior (SB) are important for healthy ageing with benefits including the mitigation of disability and mortality. Whether benefits extend to key determinants of disability and mortality, namely muscle strength and muscle power, is unclear.

AIMS

This systematic review aimed to describe the association of objective measures of PA and SB with measures of skeletal muscle strength and muscle power in community-dwelling older adults.

METHODS

Six databases were searched from their inception to June 21^st, 2020 for articles reporting associations between objectively measured PA and SB and upper body or lower body muscle strength or muscle power in community dwelling adults aged 60 years and older. An overview of associations was visualized by effect direction heat maps, standardized effect sizes were estimated with albatross plots and summarized in box plots. Articles reporting adjusted standardized regression coefficients (β) were included in meta-analyses.

RESULTS

A total of 112 articles were included representing 43,796 individuals (range: 21 to 3726 per article) with a mean or median age from 61.0 to 88.0 years (mean 56.4 % female). Higher PA measures and lower SB were associated with better upper body muscle strength (hand grip strength), upper body muscle power (arm curl), lower body muscle strength, and lower body muscle power (chair stand test). Median standardized effect sizes were consistently larger for measures of PA and SB with lower compared to upper body muscle strength and muscle power. The meta-analyses of adjusted β coefficients confirmed the associations between total PA (TPA), moderate-to-vigorous PA (MVPA) and light PA (LPA) with hand grip strength (β = 0.041, β = 0.057, and β = 0.070, respectively, all p ≤ 0.001), and TPA and MVPA with chair stand test (β = 0.199 and β = 0.211, respectively, all p ≤ 0.001).

CONCLUSIONS

Higher PA and lower SB are associated with greater skeletal muscle strength and muscle power, particularly with the chair stand test.

A systematic review and meta-analysis of the effectiveness of virtual reality as an exercise intervention for individuals with a respiratory condition

BACKGROUND

Respiratory diseases impose an immense health burden worldwide and affect millions of people on a global scale. Reduction of exercise tolerance poses a huge health issue affecting patients with a respiratory condition, which is caused by skeletal muscle dysfunction and weakness and by lung function impairment. Virtual reality systems are emerging technologies that have drawn scientists' attention to its potential benefit for rehabilitation.

METHODS

A systematic review and meta-analysis following the PRISMA guidelines was performed to explore the effectiveness of virtual reality gaming and exergaming-based interventions on individuals with respiratory conditions.

RESULTS

Differences between the virtual reality intervention and traditional exercise rehabilitation revealed weak to insignificant effect size for mean heart rate (standardized mean difference, SMD = 0.17; p = 0.002), peak heart rate (SMD = 0.36; p = 0.27), dyspnea (SMD = 0.32; p = 0.13), and oxygen saturation SpO2 (SMD = 0.26; p = 0.096). In addition, other measures were collected, however, to the heterogeneity of reporting, could not be included in the meta-analysis. These included adherence, enjoyment, and drop-out rates.

CONCLUSIONS

The use of VRS as an intervention can provide options for rehabilitation, given their moderate effect for dyspnea and equivalent to weak effect for mean and maximum peak HR and SpO2. However, the use of virtual reality systems, as an intervention, needs further study since the literature lacks standardized methods to accurately analyze the effects of virtual reality for individuals with respiratory conditions, especially for duration, virtual reality system type, adherence, adverse effects, feasibility, enjoyment, and quality of life.

Easy to Perform Physical Performance Tests to Identify COPD Patients with Low Physical Activity in Clinical Practice

Background

The study investigates which physical performance or muscle function/mass tests significantly correlate with objectively measured physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) and could potentially serve to identify physically inactive COPD patients in routine clinical practice.

Methods

A cross-sectional, observational study was conducted in outpatients with moderate to very severe COPD. PA was measured during one week with the StepWatch Activity Monitor^®, an ankle-worn accelerometer, and expressed in steps per day. Physical fitness and peripheral muscle function/mass were evaluated by the 4-meter gait speed (4MGS) test, the 6-minute walk distance (6MWD), the 30-second chair stand test (30sCST), the timed up and go test (TUGT), handgrip strength, arm muscle area, calf circumference, the fat-free mass index (FFMI), and ultrasound measurement of the quadriceps muscle. Spearman’s rank correlation analysis and ROC analysis were performed.

Results

The study population (N=111, 69% men, mean age 68 years) walked a mean of 8059 steps/day. The daily step count strongly correlated with the 6MWD (rho=0.684, p<0.001) and moderately with the 4MGS (rho=0.464, p<0.001), the TUGT (rho= −0.463, p<0.001), and the 30sCST (rho=0.402, p<0.001). The correlation with the FFMI was weak (rho=0.210, p=0.027), while the other parameters did not significantly correlate with the daily step count. The 6MWD had the best discriminative power to identify patients with very low PA defined as <5000 steps/day (AUC=0.802 [95% CI: 0.720–0.884], p<0.001), followed by the TUGT, the 4MGS, and the 30sCST.

Conclusion

The 6MWD, the 4MGS, the TUGT, and the 30sCST are easy to perform in any clinical setting and may be used by clinicians in the screening of physically inactive COPD patients.

Videogames in the Treatment of Obstructive Respiratory Diseases: A Systematic Review

Introduction: Millions of people suffer from obstructive respiratory conditions globally. Including videogames in rehabilitation programs can be an interesting alternative to traditional programs or a complementary activity. Objective: To explore the use of videogames in the treatment of patients with obstructive respiratory diseases. Methods: A systematic literature search was performed to identify randomized clinical trials evaluating the effects of videogames on health outcomes in patients with respiratory obstructive diseases. The following databases were searched: PubMed, Web of Science, ScienceDirect, and Scopus. The methodological quality of the studies included was assessed with the Downs and Black quality assessment method. Results: Nine articles were included, of which three used videogames as physical training methods and managed to improve exercise capacity, strength, quality of life, and symptoms. The remaining six articles used videogames to educate patients about the disease and showed slight improvements in knowledge of the disease and use of medication. Conclusion: The results of this review show that videogames are a very useful complementary therapy. They can contribute to enhance rehabilitation programs, as they improve exercise capacity, muscle strength, quality of life, severity, control, and knowledge of the disease. Videogames should be supervised by a professional so that programs can be tailored to patients, proposing different activities in the game and controlling the correct performance, and generating an increase in adherence to treatment. Registry: prospective register of systematic reviews (PROSPERO) CRD42018094094.

Sarcopenia in COPD: a systematic review and meta-analysis

COPD is associated with a progressive loss of muscle mass and function. However, there is an unmet need to define and standardise methods to estimate the prevalence of sarcopenia in COPD patients.

We performed a systematic review and meta-analysis of the prevalence of this extrapulmonary manifestation in COPD patients. We searched Embase, Medline (Ovid), CINAHL (EBSCO), Web of Science, Scopus and Google Scholar for studies published up to January 17, 2019, assessing sarcopenia in COPD patients based on low muscle mass and decreased muscle function. Interventional studies, in vitro experiments, protocols or reviews and meta-analyses were excluded. We estimated heterogeneity (I²) and assessed significance (Q) using a Chi-squared test for estimates obtained from random-effects models.

4465 articles were initially identified. After removing the duplicates and applying the selection criteria, we reviewed 62 full-text articles. Finally, 10 articles (n=2565 COPD patients) were included in this systematic review and meta-analyses. Overall, the prevalence of sarcopenia in patients with COPD was 21.6% (95% CI 14.6–30.9%, I²=94%), ranging from 8% in population-based to 21% in clinic-based studies, and 63% in COPD patients residing in nursing homes.

Sarcopenia is frequently observed in COPD patients, with varying prevalence across population settings. Sarcopenia in COPD should be assessed using standardised tests and cut-off points from sarcopenia consensus criteria for clinical practice and international comparisons.

We confirmed a high prevalence of sarcopenia in COPD patients, with varying prevalence across population settings. We recommend adhering to the sarcopenia consensus criteria to systematically evaluate the muscle health of COPD patients.http://bit.ly/2KA6weh

Inhaled therapies in patients with moderate COPD in clinical practice: current thinking

COPD is a complex, heterogeneous condition. Even in the early clinical stages, COPD carries a significant burden, with breathlessness frequently leading to a reduction in exercise capacity and changes that correlate with long-term patient outcomes and mortality. Implementation of an effective management strategy is required to reduce symptoms, preserve lung function, quality of life, and exercise capacity, and prevent exacerbations. However, current clinical practice frequently differs from published guidelines on the management of COPD. This review focuses on the current scientific evidence and expert opinion on the management of moderate COPD: the symptoms arising from moderate airflow obstruction and the burden these symptoms impose, how physical activity can improve disease outcomes, the benefits of dual bronchodilation in COPD, and the limited evidence for the benefits of inhaled corticosteroids in this disease. We emphasize the importance of maximizing bronchodilation in COPD with inhaled dual-bronchodilator treatment, enhancing patient-related outcomes, and enabling the withdrawal of inhaled corticosteroids in COPD in well-defined patient groups.

Fat-free mass depletion in patients with COPD in Brazil: development of a new cutoff point and its relation with mortality and extrapulmonary manifestations

BACKGROUND/OBJECTIVES

None of the cutoff points for fat-free mass index (FFMI) were tested for the Brazilian population, and it is unknown whether the available ones are able to discriminate extrapulmonary disease manifestations. This cross-sectional study aims to develop and validate a cutoff point for FFM depletion based on Brazilian patients with chronic obstructive pulmonary disease (COPD) and to verify its association and of previously published cutoffs with extrapulmonary manifestations.

SUBJECTS/METHODS

A new cutoff point was obtained from the best FFMI value for discrimination of preserved exercise capacity in a sample of patients (n=57). The discriminative capacity was assessed in another sample (n=96). The new cutoff point and other previously published ones were tested to discriminate low exercise capacity, physical inactivity, sedentary lifestyle and low quality of life. A receiver operation characteristics curve with area under the curve (AUC) value was plotted and each cutoff points' discriminative capacity was calculated. Cox regression and Kaplan-Meier method assessed the association between the cutoff points and mortality.

RESULTS

The new cutoff points for FFMI were 14.65 kg/m² for women (AUC=0.744; sensitivity (Se)=0.88; specificity (Sp)=0.60) and 20.35 kg/m² for men (AUC=0.565; Se=0.36; Sp=0.81). The new cutoffs were the best to discriminate poor exercise capacity assessed by walked distance in % predicted and quality of life. Only the new cutoff point was associated with mortality (HR=2.123; 95% CI: 1.03-4.33, P=0.039, log rank P=0.035).

CONCLUSIONS

Only the new cutoff point was associated with all-cause mortality, and it had the highest discriminating capacity for exercise capacity and quality of life in Brazilian patients with COPD.

Survey of the Relationship Between Activity Energy Expenditure Metabolic Equivalents and Barrier Factors of Physical Activity in the Elderly in Kashan

BACKGROUND

Physical activity in the elderly is influenced by aspects of aging that cause personal, mental, environmental, and social changes. Increases in factors that are barriers to activity cause physical energy expenditure to decrease.

OBJECTIVES

The aim of the present study was to survey the relationship between energy expenditure in metabolic equivalent units (MET) and factors that are barriers to physical activity in elderly people in Kashan, Iran.

METHODS

This is a descriptive analysis done in 2014. The study population was 400 people above 60 years old in medical facilities in Kashan. Multistage sampling was used in 10 clinics in 5 areas of Kashan. The sample size was varied according to gender and elderly population. Contributors were given questionnaires concerning energy expenditure levels in physical activity and factors that are barriers to being active.

RESULTS

The average age among the study population was 67.6 ± 6.8 years median, and the interquartile range (IQR) of barriers to physical activity among Kashan's elderly was (8.75) ± 33. Average energy expenditure was 326.21 ± 364.84 based on metabolic equivalent units (MET). In fact, 340 persons (85%) were practically without any active energy expenditure. The most common barrier was the lack of an appropriate place for doing physical activity; 298 (74%) of the participants cited this barrier. The results show the Spearman rank-order correlation is significant (P = 0.038, r = 0.104) between barriers to physical activity and activity energy expenditure in Kashan's elderly.

CONCLUSIONS

Decreasing barriers to physical activity among the elderly causes physical activities to increase; therefore, energy expenditure is increased. Decreasing social and environmental problems for the elderly is effective in increasing physical activity and energy expenditure.

Asymptomatic peripheral artery disease can limit maximal exercise capacity in chronic obstructive pulmonary disease patients regardless of airflow obstruction and lung hyperinflation

Background Silent/asymptomatic peripheral artery disease may occur in patients with chronic obstructive pulmonary disease, but it is poorly investigated. The primary aim of this study was to evaluate in chronic obstructive pulmonary disease patients the impact of asymptomatic/silent peripheral artery disease on maximal exercise capacity; the secondary aim was to search for predictors of peripheral artery disease. Methods We prospectively enrolled chronic obstructive pulmonary disease outpatients. Data on anthropometric characteristics, lung function, cardiopulmonary exercise test and ankle-brachial index were recorded. The cut-off of ankle-brachial index used to define patients with peripheral artery disease was ≤0.90. Results We studied 47 patients and found 24 patients (51%) who showed peripheral artery disease. As compared to patients without peripheral artery disease, patients with peripheral artery disease had lower values of peak oxygen uptake, peak workload, energy expenditure (metabolic equivalents) and heart rate recovery, but showed the same degree of airflow obstruction and static and dynamic hyperinflation. In a multivariate linear regression model performed to identify variables predicting metabolic equivalents, ankle-brachial index (β 2.59; 95% confidence interval 0.51-4.67; p = 0.016) was an independent variable. In the search for predictors of peripheral artery disease, heart rate recovery (odds ratio 8.80; 95% confidence interval 1.30-59.35; p = 0.026) increased the risk of peripheral artery disease, whereas metabolic equivalents (odds ratio 0.50; 95% confidence interval 0.26-0.94, p = 0.033) and inhaled corticosteroids+long-acting β₂ agonists (odds ratio 0.13; 95% confidence interval 0.02-0.83; p = 0.030) reduced this risk. Conclusions In chronic obstructive pulmonary disease outpatients, asymptomatic/silent peripheral artery disease affects the maximal exercise capacity regardless of airflow obstruction and lung hyperinflation. A delay of heart rate recovery increase the risk of peripheral artery disease, whereas high values of metabolic equivalents and the use of inhaled corticosteroids+long-acting β₂ agonists reduces this risk.

DNA damage and repair capacity in lymphocyte of chronic obstructive pulmonary diseases patients during physical exercise with oxygen supplementation

BACKGROUND

We hypothesized that the use of oxygen supplementation during aerobic exercise induces less DNA damage than exercise alone. The aim of this study is to assess the level of DNA damage induced by physical exercise with and without oxygen supplementation in chronic obstructive pulmonary diseases (COPD) patients.

METHODS

Peripheral blood was collected before and after aerobic exercise in two conditions: (I) aerobic exercise without oxygen supplementation (AE group) and (II) with oxygen supplementation (AE-O2 group). Lymphocytes were collected to perform the alkaline version of the Comet Assay. To assess the susceptibility to exogenous DNA damage, the lymphocytes were treated with methyl methanesulphonate (MMS) for 1-h or 3-h. After 3-h treatment, the percentage of residual damage was calculated assuming the value of 1-h MMS treatment as 100%.

RESULTS

AE group showed lower induced damage (1 h of MMS treatment) and consequently less DNA repair compared to AE-O2 group. AE-O2 group showed an increase in the induced DNA damage (1 h of MMS treatment) and an increased DNA repair capacity. Within the AE-O2 group, in the post-exercise situation the induced DNA damage after 1 h of MMS treatment was higher (p = 0.01) than in the pre-exercise.

CONCLUSION

COPD patients who performed physical exercise associated with oxygen supplementation had a better response to DNA damage induced by MMS and a better DNA repair when compared to the condition of physical exercise without oxygen supplementation.

TRIAL REGISTRATION

UNISC N374.298. Registered 04 JUN 2013 (retrospectively registered).

Cachexia in chronic obstructive pulmonary disease: new insights and therapeutic perspective

Cachexia and muscle wasting are well recognized as common and partly reversible features of chronic obstructive pulmonary disease (COPD), adversely affecting disease progression and prognosis. This argues for integration of weight and muscle maintenance in patient care. In this review, recent insights are presented in the diagnosis of muscle wasting in COPD, the pathophysiology of muscle wasting, and putative mechanisms involved in a disturbed energy balance as cachexia driver. We discuss the therapeutic implications of these new insights for optimizing and personalizing management of COPD-induced cachexia.

Dietary intake of patients with moderate to severe COPD in relation to fat-free mass index: a cross-sectional study

BACKGROUND

Fat-free mass (FFM) depletion has been shown to be a better predictor of mortality than BMI in chronic obstructive pulmonary disease (COPD) patients. The specific aim of the current study was to assess the nutritional status of stable COPD patients in relation to fat free mass index profiles.

METHODS

We investigated 65 male moderate-to-severe stable COPD patients. A self-reported questionnaire was applied about general characteristics and smoking history. Nutritional intake was assessed by using a 54-item quantitative food frequency questionnaire. Weight, height, mid-upper arm circumference (MUAC), waist circumference (WC), handgrip strength and body composition measurements were taken by a trained dietitian. The data were analyzed with SPSS 15.0 software.

RESULTS

The mean age of the patients was 62.1 ± 8.9 years. Among all of the patients 13.8% was underweight (BMI < 21 kg/m(2)) and 18.5% had a low fat-free mass index (FFMI < 16 kg/m(2)). The percentages of the patients who did not meet the daily recommended intakes (RNI) were highest for magnesium (93.8%) and calcium (92.3%). Mean daily consumptions of milk-yogurt, red meat and fruits were significantly low in the low FFMI group compared to normal FFMI group (for all; p < 0.05). Patients with normal FFMI had significantly higher weight, height, WC, MUAC, handgrip strength, fat and fat-free mass than the patients with low FFMI (for all; p < 0.05).

CONCLUSIONS

Dieticians should be aware of COPD patients with low FFMI in order to evaluate the nutritional intake and therefore plan nutritional strategies to improve prognosis of the disease.

Chronic obstructive pulmonary disease and the metabolic syndrome: Consequences of a dual threat

The metabolic syndrome is found to be more frequent in chronic obstructive pulmonary disease (COPD). The presence of inflammatory markers in circulation, sputum, and broncho-alveolar fluid suggest systemic inflammation is one of the potential mechanisms responsible for both COPD and metabolic syndrome. Physical inactivity, skeletal muscle dysfunction, hypogonadism, and steroid use are also important causes of the metabolic syndrome in COPD. Obesity and insulin resistance is found to be more common in mild to moderate stages (I and II) of COPD. Patients with COPD and the metabolic syndrome have increase risk of morbidity and mortality due to cardiovascular disease. This review describes in details the various components of metabolic syndrome and its impact on long outcomes in COPD patients.