Home-based neuromuscular electrical stimulation improves exercise tolerance and health-related quality of life in patients with COPD

A remote monitoring-enabled home exercise prescription for patients with interstitial lung disease at risk for exercise-induced desaturation

RATIONALE

Alternatives to center-based pulmonary rehabilitation are needed to improve patient access to this important therapy. A critical challenge to overcome is how to maximize safety of unsupervised exercise for at-risk patients. We investigated if a novel remote monitoring-enabled mobile health (mHealth) program is safe, feasible, and effective for patients who experience exercise-induced hemoglobin desaturation.

METHODS

An interstitial lung disease (ILD) commonly associated with pronounced exercise desaturation was investigated - the rare, female-predominant ILD lymphangioleiomyomatosis (LAM). Over a 12-week program, hemoglobin saturation (SpO2) was continuously recorded during all home exercise sessions. Intervention effects were assessed with 6-min walk test (6MWT), maximal cardiopulmonary exercise test (CPET), lower extremity computerized dynamometry, pulmonary function tests, and health-related quality of life (QoL) surveys. Safety was assessed by blood biomarkers of systemic inflammation and cardiac wall stress, and incidence of adverse events.

RESULTS

Fifteen LAM patients enrolled and 14 completed the intervention, with high adherence to aerobic (87 ± 15%) and strength (87 ± 12%) training components. An innovative characterization of exercise training SpO2 revealed that while mild-to-moderate desaturation was common during home workouts, participants were able to self-adjust exercise intensity and supplemental oxygen levels to maintain recommended exercise parameters. Significant improvements included 6MWT distance (+36 ± 34 m, p = 0.003), CPET time (p = 0.04), muscular endurance (p = 0.008), QoL (p = 0.009 to 0.03), and fatigue (p = 0.001 to 0.03). Patient acceptability and satisfaction indicators were high, blood biomarkers remained stable (p > 0.05), and no study-related adverse events occurred.

CONCLUSION

A remote monitoring-enabled home exercise program is a safe, feasible, and effective approach even for patients who experience exercise desaturation.

Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.

OBJECTIVES

This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.

RESULTS

We included 267 studies (43153 individuals with COPD). A broad range of domains (n=22), outcomes (n=163) and measures (n=217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n=218) assessed with the 6-min walk test (n=140), health-related quality of life (n=204) assessed with the Saint George's respiratory questionnaire (n=99), and symptoms (n=158) assessed with the modified Medical Research Council dyspnea scale (n=56). The least reported outcomes were comorbidities, adverse events and knowledge.

CONCLUSIONS

This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.

PROSPERO ID

CRD42017079935.

Effects of neuromuscular electrical stimulation on exercise capacity and quality of life in COPD patients: a systematic review and meta-analysis

Neuromuscular electrical stimulation (NMES) has been shown to produce benefits in the muscle function of chronic obstructive pulmonary disease (COPD) patients. The definite effectiveness of NMES, applied in isolation or concurrently with conventional pulmonary rehabilitation (PR) or exercise training, remains unclear. This review was to determine the effects of NMES on exercise capacity, functional performance, symptoms, and health-related quality of life (HRQoL) in COPD patients. Electronic databases (PubMed, Embase, Web of Science, the Cochrane Library) were searched for relevant randomized controlled trials (RCTs). Two investigators independently screened the eligible studies up to February 2020 that used NMES as the intervention group. The outcome measures were 6-min walking distance (6MWD), peak rate of oxygen uptake (VO₂ peak), St George’s Respiratory Questionnaire (SGRQ), and symptoms of dyspnoea and fatigue. Data were extracted using a predefined table and papers were appraised using Downs and Black tool. We analyzed 13 RCTs with 447 COPD patients. In the analysis of 6MWD, pooled estimates showed a significant increase in the NMES group, compared with the control group (mean difference (MD) = 27.05, 95% confidence interval (CI): 8.46–45.63, P<0.001). There were also improvements in symptoms of dyspnea or leg fatigue, and reduction in London Chest Activity of Daily Living (LCADL) scores. No statistically significant difference was observed in VO₂ peak, peak power, and SGRQ. NMES could improve exercise capacity and reduce perceived sensation of dyspnea during exercise in patients with COPD, but not to be recommended as an effective alternative training modality in the rehabilitation of stable COPD patients.

Measurement properties of step tests for exercise capacity in COPD: A systematic review

Objective:

To determine the level of evidence of the measurement properties (validity, reliability, and responsiveness) and interpretability of the step tests available for assessing the exercise capacity in patients with chronic obstructive pulmonary disease.

Data sources:

The data sources Web of Science, MEDLINE, PubMed, PEDro, CENTRAL of Cochrane Library, and Scopus were searched up to June 26, 2020.

Review methods:

Studies of any design that reported results for any measurement property of the step tests for assessing the exercise capacity in COPD patients were selected. One reviewer extracted the data, and two reviewers independently rated the level of evidence by using the Consensus-Based Standards for the Selection of Health Measurements Instruments recommendations.

Results:

Thirty-one studies were included in the data synthesis. Chester Step Test, Modified Incremental Step Test, two-, three-, four-, and six-Minute Step Test, Paced Step Test, and six-Minute Stepper Test were identified. A step test protocol was also found. The level of evidence of their results for the measurement properties was mostly determined as “low” to “very low.” The best level of evidence found was for the six-minute stepper test: “high” on construct validity (r = 0.56–0.71); and “moderate” on criterion validity (r = 0.36–0.69), and responsiveness (r = 0.26–0.34).

Conclusion:

The general level of evidence of the measurement properties of the step tests is “low” to “very low” for assessing exercise capacity in patients with chronic obstructive pulmonary disease, which can limit their application in clinical practice. The six-minute Stepper Test is currently the most appropriate step test available.

Long-Term Effectiveness of a Home-Based Pulmonary Rehabilitation in Older People with Chronic Obstructive Pulmonary Disease: A Retrospective Study

Background

Long-term effectiveness of pulmonary rehabilitation (PR) is still uncertain in older people with severe chronic obstructive pulmonary disease (COPD). The objective was to compare the effects of home-based PR in people with COPD above and below the age of 70 years.

Methods

In this retrospective study, 480 people with COPD were recruited and divided into those ≤70 (n=341) and those >70 years of age (n=139). All participants underwent an 8 weeks of home-based PR, consisting of a weekly supervised 90-minute home session. Six-minute stepper test (6MST), timed-up and go test (TUG), Hospital Anxiety and Depression Scale, and Visual Simplified Respiratory Questionnaire (VSRQ) were assessed at baseline (M0), at 2 (M2), 8 (M8), 14 (M14) months after baseline.

Results

The older group was described by fewer current smokers (p <0.001), more long-term oxygen therapy use (p = 0.024), higher prevalence of comorbidities (p<0.001), lower 6MST score and higher TUG score (p<0.001), compared to the younger group. Both groups improved every outcome at M2 compared to baseline. At M2, 88% of people ≤70 years of age and 79% of those above 70 were considered as responders in at least one evaluated parameter (p = 0.013). Both groups maintained the benefits at M14, except for the VSRQ score and the number of responders to this outcome in the older group.

Conclusion

Regardless of the age, personalized home-based PR was effective for people with COPD in the short term. Above 70 years, an ageing effect appeared on the long-term effectiveness of quality of life benefit.

Convergent Validity and Minimal Clinically Important Difference of the Maugeri Foundation Respiratory Failure Questionnaire (MRF-28) and the Chronic Obstructive Pulmonary Disease-Specific Health-Related Quality of Life questionnaire (VQ11)

Purpose

Short and easy questionnaires have been developed to assess the health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD), such as the Maugeri Foundation Respiratory Failure Questionnaire (MRF-28) and the COPD-specific HRQoL Questionnaire (VQ11). Both are valid, reliable, and sensitive, but their minimal clinically important differences (MCID) are unknown. Consequently, this study aimed to confirm the convergent validities of the MRF-28 and VQ11 and establish their MCID. A retrospective design was used to evaluate the effect of individual home-based pulmonary rehabilitation (PR) in 400 COPD patients.

Patients and methods

Exercise tolerance, anxiety and depression based on the Hospital Anxiety and Depression Scale (HADS), and HRQoL using three questionnaires (MRF-28, VQ11, and the Visual Simplified Respiratory Questionnaire: VSRQ) were assessed before and after an individualized home-based PR program (5 sessions of 30-45 mins/week for 8 weeks, including a weekly session supervised by a team member).

Results

PR improved all measured variables (p < 0.0001). The correlations were significant (p < 0.0001) between VSRQ and MRF-28 (r = -0.685 at baseline and r = -0.686 after the PR program), and between VSRQ and VQ11 (r = -0.691 at baseline and r = -0.753 after the PR program). Moreover, changes in score (delta between after and before PR program) of VSRQ were also significantly correlated (p < 0.0001) to changes in score of MRF-28 (r = -0.372) and VQ11 (r = -0.423). Last, we calculated MCID of -5.2 and -2.0 units for MRF-28 and VQ11, respectively.

Conclusion

The MRF-28 and VQ11 can be used in routine practice to evaluate the effects of PR on the HRQoL of COPD patients, with MCID of -5.2 and -2.0, respectively.

Utilization and outcomes of neuromuscular electric stimulation in patients with knee osteoarthritis: a retrospective analysis

Background

Knee osteoarthritis (OA) is a chronic debilitating condition that is estimated to affect approximately 12% of the current adult population in the United States, and is associated with severe pain and disability. Among these patients, quadriceps muscle atrophy and concomitant weakness are frequent findings that contribute significantly to the burden of this disease. One emerging method of quadriceps muscle strengthening and rehabilitation in knee OA patients is the use of neuromuscular electrical stimulation therapy (NMES). Among the currently available systems for NMES therapy are the mobile health (mHealth) platforms allowing clinicians to monitor patient compliance and utilization trends in addition to capturing certain clinical outcome points. The aim of this study was to analyze data collected by a commercially available mobile-app controlled NMES platform and to examine: (I) utilization trends, (II) range-of-motion (ROM) changes, (III) pain scores, and (IV) patient reported outcome scores in patients who used this device as part of management of their knee OA.

Methods

We retrospectively reviewed patients who received mobile-app controlled NMES therapy for knee OA who were enrolled in this multi-center study between April 2017 and July 2018 in a cloud-based provider online portal system. A total of 41 patients met all our inclusion and exclusion criteria and were included in our final analysis. For each patient, the total number of NMES sessions, the duration of NMES therapy, visual analogue pain scores, ROM, and the Knee injury Osteoarthritis Outcome Score (KOOS, JR) were collected and analyzed. Patient's utilization trends were reported through analyzing NMES sessions and therapy durations. Descriptive statistics were utilized to analyze all relevant values.

Results

Across all patients, NMES therapy was utilized for an average of 3.5 months (range, 2 weeks to 10 months). On average, 90 sessions (range, 6 to 487) of therapy were received by patients for an average of 1,819 minutes (range, 120 to 9,740 minutes). Overall, patients achieved a mean ROM of 99˚±4.3˚ at final follow-up. Pain scores reduced from a mean of 5 points prior to device use (range, 1 to 8 points) to 2.5 points after use (range, 0 to 6 points) (P<0.001). Evaluation of KOOS questionnaires available for 17 patients showed incremental improvement from 52.46 points when therapy was started, to 63 points at 6 months following NMES therapy. No complications or adverse events were reported from any of the participants.

Conclusions

Although NMES therapy has been reported on by multiple authors, including in knee OA, there are limited have been no studies that have reported on the compliance, feasibility, and patient outcomes of using a mobile-app controlled NMES therapy devices in the setting of knee OA. Furthermore, the incorporation of cloud-based provider online platform may offer an additional advantage by allowing clinicians to monitor the progress and compliance of their patients in real-time. Therefore, patients who are making sub-optimal progress may benefit from an early intervention to modify their therapy protocol to achieve the best outcome.

Effect of pulmonary rehabilitation with assistive use of short-acting β2 agonist in COPD patients using long-acting bronchodilators

Background: Assistive use of short-acting β2 agonists (SABAs) reportedly improves exercise tolerance, activities of daily living, and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD). However, the effect of SABA on physical activity (PA) is unclear.Objective: This study aimed to determine whether assistive use of SABA increases PA and whether additional pulmonary rehabilitation (PR) can aid further improvement.Methods: Twelve outpatients with COPD and dyspnea during daily activities despite regular use of long-acting bronchodilators were enrolled. This study comprised a 2-week pre-intervention investigation, a 12-week investigation of SABA effects, and an 8-week investigation of the additional effects of PR. Assistive use of SABA was allowed up to 4 times per day after the pre-intervention period. PA was measured for 14 consecutive days using an accelerometer sensor. Dyspnea, exercise tolerance, and HRQOL were evaluated at entry, at 4 and 12 weeks after initiating SABA use, and after completing PR.Results: Assistive use of SABA improved breathlessness during daily activities and increased PA (p < .001). PA and HRQOL were also improved following PR (p < .001 and p = .013, respectively).Conclusions: Combined therapy of SABA and PR can increase PA and HRQOL in COPD patients.

[The DISC tool improves communication and results in pulmonary rehabilitation]

INTRODUCTION

Competence in personal relationships is essential for a caregiver, especially in pulmonary rehabilitation (PR). Considering the behavioral profile of patients might help to optimize their management and the results of PR.

METHODS

We evaluated eight hundred and thirty-two consecutive patients with chronic respiratory disease who received eight weeks of home-based PR. Their exercise tolerance (six-minute stepper test, 6MST), mood (HAD), and quality of life (VSRQ, MRF28) were evaluated at the beginning and end of PR. For six hundred and ninety patients, a behavioral approach was implemented at the beginning of PR by using the DISC tool to identify four behavioral profiles: dominance, influence, steadiness, conscientiousness. The remaining 142 patients served as the control group.

RESULTS

Subjectively, the therapeutic alliance was more easily established with the behavioral approach. Compared with the control group, patients with the "steadiness" profile were younger (60.7±12 years) and mostly female (52.8%), whereas patients with the "conscientiousness" profile were older (67.5±10.6 years) and mostly male (85.5%). The four behaviorally profiled groups showed no differences in exercise tolerance, mood, or quality of life scores at baseline. Globally, all patients improved their exercise tolerance, mood and quality of life. The percentage of responders to 6MST and VSRQ (>MCID) was 7.5% and 5.3% higher with the behavioral approach. For non-responders to 6MST and VSRQ (<MCID), only patients benefiting from the behavioral approach improved the other parameters studied, patients from control group having exhibited no improvement at all.

CONCLUSIONS

The DISC-guided behavioral approach improves the patient-caregiver relationship and achieves better results at the end of PR.

Magnetic Stimulation Therapy in Patients with COPD: A Systematic Review

Magnetotherapy (MT) is a therapeutic treatment based on the use of magnetic fields (MF) that can have an anti-inflammatory and analgesic effect. MT represents a possible treatment or an ancillary therapeutic intervention for a wide range of diseases and it is often used in the field of physiotherapeutic practices. A crucial point in the treatment of chronic obstructive pulmonary disease (COPD) patients, to counteract muscular depletion and respiratory symptoms, is represented by physiotherapy. Nevertheless, the knowledge about the application of MF as a therapeutic option in COPD patients is very limited. The purpose of the present study was to define what is currently known about the use of MF in patients with COPD. A systematic review of the literature was conducted during the month of October 2017, searching three main databases. Only those citations providing detailed informations about the use of MF to treat COPD symptoms either during an acute or a chronic phase of the disease, were selected. Following the selection process three articles were included in the final analysis. The present review focused on a total of thirty-six patients with COPD, and on the effects of the application of MF. In the majority of cases, the treatment sessions with MF were carried-out in an outpatient setting, and they differed with regard to the duration; frequency of application; dosage; intensity of the applied MF. Basing on the available informations, it seems that MF is a feasible, well tolerated, safe therapeutic option, for the treatment of motor-related COPD symptoms.

Real-life feasibility and effectiveness of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease requiring medical equipment

Background

Pulmonary rehabilitation (PR) is a key treatment of chronic obstructive pulmonary disease (COPD) but studies are still needed to identify the most pertinent criteria to personalize this intervention and improve its efficacy.

Objective

This real-life retrospective study compared the effects of home-based PR on exercise tolerance, anxiety, depression, and health-related quality of life (HRQoL) in COPD patients, according to their medical equipment.

Methods

Exercise tolerance, anxiety, depression, and HRQoL were evaluated in 109 patients equipped with long-term oxygen therapy (LTOT), 84 patients with noninvasive ventilation (NIV), 25 patients with continuous positive airway pressure (CPAP), and 80 patients with no equipment (NE), before, just after, and 6 and 12 months after PR.

Results

At baseline, the body mass index in the CPAP and NIV groups was higher (p<0.05) than in the other two groups, and the forced expiratory volume in 1 second was lower in the LTOT and NIV groups (p<0.001). All parameters improved after PR in the four groups (p<0.05), but for exercise tolerance, only the 6-minute stepper test showed maintained improvement after 6 and 12 months, whereas the 10 times sit-to-stand and timed up-and-go tests were only improved just after PR. At every time point, exercise tolerance was lower in the LTOT group (p<0.05), with a similar trend in the NIV group.

Conclusion

Despite differences in the medical equipment to treat COPD, home-based PR showed comparable feasibility, safety, and efficacy in all equipment-based groups. Medical equipment should therefore not be a barrier to home-based PR.

A prescribed walking regimen plus arginine supplementation improves function and quality of life for patients with pulmonary arterial hypertension: a pilot study

Current evidence suggests that exercise training is beneficial in pulmonary arterial hypertension (PAH). Unfortunately, the standard supervised, hospital-based programs limit patient accessibility to this important intervention. Our proof-of-concept study aimed to provide insight into the usefulness of a prescribed walking regimen along with arginine supplementation to improve outcomes for patients with PAH. Twelve PAH patients (all women) in New York Heart Association (NYHA) functional class (FC) II (n = 7) or III (n = 5) and in stable condition for ≥ 3 months were enrolled. Patients performed home- and fitness-center- based walking at 65-75% heart rate (HR) reserve for 45 min, six sessions/week for 12 weeks. Concomitant L-arginine supplementation (6000 mg/day) was provided to maximize beneficial endothelial training adaptations. Cardiopulmonary exercise testing, 6-min walk testing (6MWT), echocardiography, laboratory studies, and quality of life (QoL) survey (SF-36) were performed at baseline and 12 weeks. Eleven patients completed the study (72 session adherence rate = 96 ± 3%). Objective improvement was demonstrated by the 6MWT distance (increased by 40 ± 13 m, P = 0.01), VO₂max (increased by 2 ± 0.7 mL/kg/min, P = 0.02), time-to-VO₂max (increased by 2.5 ± 0.6 min, P = 0.001), VO₂ at anaerobic threshold (increased by 1.3 ± 0.5 mL/kg/min, P = 0.04), HR recovery (reduced by 68 ± 23% in slope, P = 0.01), and SF-36 subscales of Physical Functioning and Energy/Fatigue (increased by 70 ± 34% and 74 ± 34%, respectively, P < 0.05). No adverse events occurred, and right ventricular function and brain natriuretic peptide levels remained stable, suggesting safety of the intervention. This proof-of-concept study indicates that a simple walking regimen with arginine supplementation is a safe and efficacious intervention for clinically stable PAH patients, with gains in objective function and QoL measures. Further investigation in a randomized controlled trial is warranted.

Early-Phase Recovery of Cardiorespiratory Measurements after Maximal Cardiopulmonary Exercise Testing in Patients with Chronic Obstructive Pulmonary Disease

Background. This study investigated respiratory gas exchanges and heart rate (HR) kinetics during early-phase recovery after a maximal cardiopulmonary exercise test (CPET) in patients with chronic obstructive pulmonary disease (COPD) grouped according to airflow limitation. Methods. Thirty control individuals (control group: CG) and 81 COPD patients (45 with "mild" or "moderate" airflow limitation, COPD_I-II, versus 36 with "severe" or "very severe" COPD, COPD_III-IV) performed a maximal CPET. The first 3 min of recovery kinetics was investigated for oxygen uptake ([Formula: see text]O₂), minute ventilation ([Formula: see text]), respiratory equivalence, and HR. The time for [Formula: see text]O₂ to reach 25% (T_1/4[Formula: see text]O₂) of peak value was also determined and compared. Results. The [Formula: see text]O₂, [Formula: see text], and HR recovery kinetics were significantly slower in both COPD groups than CG (p < 0.05). Moreover, COPD_III-IV group had significantly higher [Formula: see text]O₂ and [Formula: see text] during recovery than COPD_I-II group (p < 0.05). T_1/4[Formula: see text]O₂ significantly differed between groups (p < 0.01; 58 ± 18 s in CG, 79 ± 26 s in COPD_I-II group, and 121 ± 34 s in COPD_III-IV) and was significantly correlated with forced expiratory volume in one second in COPD patients (p < 0.001, r = 0.53) and with peak power output (p < 0.001, r = 0.59). Conclusion. The COPD groups showed slower kinetics in the early recovery period than CG, and the kinetics varied with severity of airflow obstruction.