Pain in Veterans with COPD: relationship with physical activity and exercise capacity

Maintenance Pulmonary Rehabilitation: An Update and Future Directions

The Global Initiative for Chronic Obstructive Lung Disease guidelines recommend pulmonary rehabilitation (PR) for individuals with COPD to improve exercise capacity and health-related quality of life (HRQOL) and reduce symptoms of dyspnea. For cost-effectiveness in COPD care, PR is second only to smoking cessation. However, PR programs typically last 9-12 weeks. The benefits of PR in terms of exercise capacity and HRQOL often decrease toward pre-PR levels as early as 3-6 months after completing PR if patients do not continue to engage in exercise. This review will (1) briefly summarize the efficacy data that informed the 2023 American Thoracic Society (ATS) clinical practice guidelines for maintenance PR, (2) discuss exercise components of maintenance PR studied since 2020 when the last papers were included in the ATS guidelines, (3) explore future directions for delivery of maintenance PR using technology-mediated models, and (4) examine the need for behavior change techniques informed by theoretical models that underpin long-term behavior change. This review will focus on persons with COPD who have completed an out-patient core initial PR program as most of the data on maintenance PR have been published in this patient population. Core PR typically implies a facility-based initial intensive structured program. All patients who complete a core initial PR program should be counseled by PR staff at the discharge visit to engage in ongoing exercise. This usual care is equally as important as referral to a formal PR maintenance program. It is critical to emphasize that usual care after core initial PR means all patients should be supported to participate in regular ongoing exercise, regardless of whether supervised maintenance PR is available. Currently, the optimal frequency, exercise and/or physical activity content, and delivery mode for maintenance PR in persons with COPD and other chronic respiratory diseases remain unknown. Patient safety and degree of in-person supervision required due to the severity of the underlying lung disease need to be considered. Future research of maintenance PR should be underpinned by behavior change techniques. Finally, in the setting of finite resources, balancing the competing priorities of core initial programs with those of maintenance PR programs needs to be achieved.

Non-pharmacological and non-invasive interventions for chronic pain in people with chronic obstructive pulmonary disease: A systematic review without meta-analysis

OBJECTIVES

Chronic Obstructive Pulmonary Disease (COPD) is complicated by chronic pain. People with COPD report higher pain prevalence than the general population. Despite this, chronic pain management is not reflected in current COPD clinical guidelines and pharmacological treatments are often ineffective. We conducted a systematic review that aimed to establish the efficacy of existing non-pharmacological and non-invasive interventions on pain and identify behaviour change techniques (BCTs) associated with effective pain management.

METHODS

A systematic review was conducted with reference to Preferred Reporting Items for Systematic Review (PRISMA) [1], Systematic review without Meta analysis (SWIM) standards [2] and Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines [3]. We searched 14 electronic databases for controlled trials of non-pharmacological and non-invasive interventions where the outcome measure assessed pain or contained a pain subscale.

RESULTS

Twenty-nine studies were identified involving 3,228 participants. Seven interventions reported a minimally important clinical difference in pain outcomes, although only two of these reached statistical significance (p < 0.05). A third study reported statistically significant outcomes, but this was not clinically significant (p = 0.0273). Issues with intervention reporting prevented identification of active intervention ingredients (i.e., BCTs).

CONCLUSIONS

Pain appears to be a meaningful issue for many individuals with COPD. However, intervention heterogeneity and issues with methodological quality limit certainty about the effectiveness of currently available non-pharmacological interventions. An improvement in reporting is required to enable identification of active intervention ingredients associated with effective pain management.

Are Fatigue and Pain Overlooked in Subjects with Stable Chronic Obstructive Pulmonary Disease?

Although there have been many published reports on fatigue and pain in patients with chronic obstructive pulmonary disease (COPD), it is considered that these symptoms are seldom, if ever, asked about during consultations in Japanese clinical practice. To bridge this gap between the literature and daily clinical experience, the authors attempted to gain a better understanding of fatigue and pain in Japanese subjects with COPD. The Brief Fatigue Inventory (BFI) to analyse and quantify the degree of fatigue, the revised Short–Form McGill Pain Questionnaire 2 (SF-MPQ-2) for measuring pain and the Kihon Checklist to judge whether a participant is frail and elderly were administered to 89 subjects with stable COPD. The median BFI and SF-MPQ-2 Total scores were 1.00 [IQR: 0.11–2.78] and 0.00 [IQR: 0.00–0.27], respectively. They were all skewed toward the milder end of the respective scales. A floor effect was noted in around a quarter on the BFI and over half on the SF-MPQ-2. The BFI scores were significantly different between groups regarding frailty determined by the Kihon Checklist but not between groups classified by the severity of airflow limitation. Compared to the literature, neither fatigue nor pain are considered to be frequent, important problems in a real-world Japanese clinical setting, especially among subjects with mild to moderate COPD. In addition, our results might suggest that fatigue is more closely related to frailty than COPD.

The Role of Palliative Care in COPD

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished wellbeing. Despite the potential to confer significant quality of life benefits for patients and their care partners and to improve end-of-life care, specialist palliative care is rarely implemented in COPD and when initiated it often occurs only at the very end of life. Primary palliative care delivered by frontline clinicians is a feasible model, but is not routinely integrated in COPD. In this review, we discuss the following: 1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; 2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and, 3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. In the end, this review solidifies that palliative care is much more than hospice and end-of-life care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the end of life to provide comprehensive support for patients and their care partners and to better prepare them for the end of life.