Development of a family-based pulmonary rehabilitation programme: an exploratory study

Pulmonary rehabilitation and family/friend caregivers: the hidden reciprocal relationship improving outcomes in chronic respiratory diseases

INTRODUCTION

The experiences and needs of living with chronic respiratory diseases (CRD) can be overwhelming. Individuals often rely on informal care for daily assistance and having a family/friend caregiver has been associated with better health outcomes. Nevertheless, family/friend caregivers frequently feel alone and unsupported. Pulmonary rehabilitation (PR) leads to multidimensional benefits across CRD and individuals have suggested improvements for PR. Family/friend caregivers highly support PR in practical and psychosocial ways and have identified this intervention as an opportunity to be supported. This reciprocal relationship between PR and the family/friend caregivers has been scarcely explored and its importance for the management of CRD is poorly understood.

AREAS COVERED

This perspective synthesizes the experiences and needs of living with CRD from the perspective of people with CRD and their family/friend caregivers; and proposes a vision of a reciprocal/symbiotic relationship, through PR, for optimizing care for people with CRD and their caregivers.

EXPERT OPINION

A deeper understanding/recognition of the extensiveness and somewhat overlap of the experiences and unmet needs of individuals with CRD and their family/friend caregivers; and of the reciprocal/symbiotic relationship between PR and the family/friend caregivers might be important to optimizing management and, ultimately, individuals and caregivers' outcomes in CRD.

The effects of a symptom management program on symptom experience and physical function in Thai adults with chronic obstructive pulmonary disease: A single-blind randomized controlled trial study

Background

Adults with Chronic Obstructive Pulmonary Disease (COPD) experience a range of unpleasant symptoms, including fatigue, dyspnea, sleep disturbances, anxiety, and depression, that are interrelated and impact one another. Developing a program to handle simultaneous symptoms poses challenges but offers advantages for adults with COPD in efficiently managing symptoms.

Objective

This study aimed to determine the effects of a symptom management program on symptom experience and physical function in Thai adults with COPD.

Methods

A randomized controlled trial (RCT) with a Repeated Measures design was performed. One hundred and two participants were allocated randomly to either the control group (n = 51) or the experimental group (n = 51). The experimental group received eight weeks of the symptom management program and usual care, while the control care group received only usual care. Data were collected from January 2023 to August 2023 at baseline, 4th weeks, and 8th weeks using the demographic data, the modified Medical Research Council (mMRC), the Pittsburgh Sleep Quality Index (PSQI), the Multidimensional Assessment of Fatigue (MAF), the Hospital Anxiety and Depression Assessment Scale (HADS), the COPD Assessment Test (CAT), and 6-Minute Walk Distance (6-MWD). The hypotheses were analyzed using Repeated Measures Multivariate Analysis of Variance (MANOVA).

Results

The symptom management program significantly impacted the experimental group's symptom experience and physical function at Weeks 4 and 8 (F = 5.257, p <0.001). There were significantly improved mean scores for the mMRC, MAF, 6MWD, and CAT (p <0.001, p <0.05). No statistically significant differences were observed in the PSQI, HADS-Anxiety, and HADS-Depression over time.

Conclusion

Implementing a symptom management program can help patients with COPD efficiently manage their symptoms. In clinical settings, nurses should integrate this program into routine nursing care to enhance the quality of life for patients suffering from COPD. The program can help patients preserve physical functionality while reducing dependence on family and society.

Trial Registry Number

Thai Clinical Trials Registry (TCTR20230111006).

Motivation and preferences for learning of patients with COPD or asthma and their significant others in pulmonary rehabilitation: a qualitative study

Introduction

An in-depth understanding of educational needs from the perspective of learners in pulmonary rehabilitation is lacking. To improve learning in pulmonary rehabilitation, understanding of factors that induce or enhance intrinsic motivation in both patients and their significant others is needed. Therefore, this study aims to gain in-depth understanding of what motivates patients with COPD or asthma referred for pulmonary rehabilitation and their significant others to learn and what their preferences are for education.

Methods

For this qualitative study, a sample was taken from a previous quantitative study. Data was collected through one-time face-to-face semi-structured interviews. The interviews were transcribed and independently analysed by two researchers using thematic analyses.

Results

Twelve patients and four significant others (56% female; age: 63±11 years) were interviewed. Participants expressed a variety of information needs and learning preferences. Subthemes that emerged within the theme of motivation for learning were: 1) curiosity, such as knowledge gaps and hope for new information; and 2) values and goals, such as own health, caring for loved ones and spending time with family.

Discussion

To enhance intrinsic motivation for learning within pulmonary rehabilitation, autonomy of individuals should be supported by offering several learning topics and education adapted to preferences, while curiosity should be fostered by targeting information needs. Moreover, health education programmes should match with the personal values and goals of individuals, such as own health, caring for loved ones and spending time with family.

Exercise-based interventions targeting balance and falls in people with COPD: a systematic review and meta-analysis

INTRODUCTION

This review quantifies the mean treatment effect of exercise-based interventions on balance and falls risk in people with COPD.

METHODS

A structured search strategy (2000-2023) was applied to eight databases to identify studies evaluating the impact of exercise-based interventions (≥14 days in duration) on balance or falls in people with COPD. Pooled mean treatment effects (95% confidence intervals (CIs), 95% prediction intervals (PIs)) were calculated for outcomes reported in five or more studies. Inter-individual response variance and the promise of behaviour change techniques (BCTs) were explored.

RESULTS

34 studies (n=1712) were included. There were greater improvements in balance post intervention compared to controls for the Berg Balance Scale (BBS) (mean 2.51, 95% CI 0.22-4.80, 95% PI -4.60-9.63), Timed Up and Go (TUG) test (mean -1.12 s, 95% CI -1.69- -0.55 s, 95% PI -2.78-0.54 s), Single-Leg Stance (SLS) test (mean 3.25 s, 95% CI 2.72-3.77 s, 95% PI 2.64-3.86 s) and Activities-specific Balance Confidence (ABC) scale (mean 8.50%, 95% CI 2.41-14.58%, 95% PI -8.92-25.92%). Effect on falls remains unknown. Treatment effects were larger in male versus mixed-sex groups for the ABC scale and SLS test, and in balance training versus other exercise-based interventions for the BBS and TUG test. Falls history was not associated with changes in balance. Meta-analysis of individual response variance was not possible and study-level results were inconclusive. Eleven promising BCTs were identified (promise ratio ≥2).

CONCLUSION

Evidence for the effect of exercise-based interventions eliciting clinically important improvements in balance for people with COPD is weak, but targeted balance training produces the greatest benefits. Future exercise interventions may benefit from inclusion of the identified promising BCTs.

Integrating palliative care education in pulmonary rehabilitation: a randomized controlled study protocol

BACKGROUND

Palliative care addresses multiple unmet needs of people with chronic obstructive pulmonary disease (COPD) or interstitial lung diseases (ILD) and their family and/or friend caregivers, but it remains highly underused. Pulmonary rehabilitation (PR) may provide a key opportunity to introduce palliative care. We aim to explore the effects of palliative care education as part of PR on knowledge about this field in people with COPD or ILD and their family and/or friend caregivers.

METHODS

A randomized controlled study will compare PR with palliative care education (experimental) with traditional PR (control) in people with COPD or ILD and their family and/or friend caregivers. Family and/or friend caregivers will be invited to take part in education and psychosocial support sessions. In addition to the usual educational content, the experimental group will have a session on palliative care, a "Peer-to-peer session", two "Get-apart sessions" and online sessions. The "Peer-to-peer session" and the "Get-apart sessions" will be discussions about topics suggested by participants. The "Get-apart sessions" will be dedicated to people with COPD or ILD apart from their family and/or friend caregivers and vice versa. The online sessions will be zoom meetings to discuss any health-related issues raised by participants, at a flexible time. A mixed-methods approach will be used to evaluate the outcomes. The primary outcome will be knowledge about palliative care. Secondary outcomes will include attitude towards palliative care referral, symptoms, disease impact, health-related quality of life, needs, knowledge about the disease, burden of providing care, adherence, adverse events and referral to a specialist palliative care team. Quantitative and qualitative data will be collected at baseline and end of PR. At 6-months post-PR, only patient-reported outcomes will be collected. For the primary outcome, time*group interaction will be analyzed with mixed analysis of variance.

DISCUSSION

This study aims to demonstrate the impact of integrating palliative care into the PR education program.

TRIAL REGISTRATION

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 1st September, 2023 (NCT06046547).

Developing a home-based pulmonary rehabilitation programme for patients with chronic respiratory diseases in Malaysia: A mixed-method feasibility study

Background

The COVID-19 pandemic has underscored the importance of remote healthcare and home-based interventions, including pulmonary rehabilitation, for patients with chronic respiratory diseases (CRDs). It has also heightened the vulnerability of individuals with underlying respiratory conditions to severe illness from COVID-19, necessitating exploration and assessment of the feasibility of delivering home - pulmonary rehabilitation (home-PR) programmes for CRD management in Malaysia and other countries. Home-based programmes offer a safer alternative to in-person rehabilitation during outbreaks like COVID-19 and can serve as a valuable resource for patients who may be hesitant to visit healthcare facilities during such times. We aimed to assess the feasibility of delivering a home-PR programme for patients with CRDs in Malaysia.

Methods

We recruited patients with CRDs from two hospitals in Klang Valley, Malaysia to a home-PR programme. Following centre-based assessment, patients performed the exercises at home (five sessions/week for eight weeks (total 40 sessions)). We monitored the patients via weekly telephone calls and asked about adherence to the programme. We measured functional exercise capacity (6-Minutes Walking Test (6MWT) and Health-Related Quality-of-Life (HRQoL) (COPD Assessment Test (CAT)) at baseline and post-PR at nine weeks. We conducted semi-structured interviews with 12 purposively sampled participants to explore views and feedback on the home-PR programme. The interviews were audio recorded, transcribed verbatim, and analysed thematically.

Results

We included 30 participants; two withdrew due to hospitalisation. Although 28 (93%) adhered to the full programme, only 11 (37%) attended the post-PR assessment because COVID-19 movement restrictions in Malaysia at that time prevented attendance at the centre. Four themes emerged from the qualitative analysis: involvement of family and caregivers, barriers to home-PR programme, interactions with peers and health care professionals, and programme enhancement.

Conclusion

Despite the COVID-19 pandemic, the home-PR programme proved feasible for remote delivery, although centre-based post-PR assessments were not possible. Family involvement played an important role in the home-PR programme. The delivery of this programme can be further improved to maximise the benefit for patients.

Comparing the effects of smartphone-based and face-to-face pulmonary rehabilitation education on caregiver burden and quality of life among the family caregivers of patients with chronic obstructive pulmonary disease: a randomized controlled field trial

BACKGROUND

Functional limitation among patients with chronic obstructive pulmonary disorder (COPD) and their dependence on their family caregivers (FCs) can significantly increase caregiver burden (CB) and reduce the quality of life (QOL) among FCs. Education of pulmonary rehabilitation (PR) to FCs is a strategy with potential positive effects on CB. This study was conducted to compare the effects of smartphone-based and face-to-face (FTF) PR education on CB and QOL among the FCs of patients with COPD.

METHODS

This randomized controlled field trial was conducted in 2021-2022. Participants were purposefully selected from the PR unit of Khorshid comprehensive respiratory care clinic in Isfahan, Iran, and randomly allocated to a control and an intervention group. Participants in the control group received PR education in twelve 30-60-min FTF sessions held twice weekly in six consecutive weeks. Their counterparts in the intervention group received PR education for 6 weeks through an android application. The Zarit Burden Interview and the 12-item Short Form Health Survey (SF-12) were used for data collection before and immediately after the study intervention. The SPSS software (v. 24.0) was used to analyze the data through the independent-sample t, paired-sample t, chi-square, and Fisher's exact tests.

RESULTS

The means of participants' age was 47.7 ± 13.8 years in the control group and 44.1 ± 14.8 years in the intervention group. Most participants in these groups were female (82.9% vs. 71.4%). The pretest mean scores of CB and QOL were respectively 50.77 ± 10.64 and 27.82 ± 3.9 in the control group and 49.77 ± 7.65 and 26.71 ± 3.5 in the intervention group with no significant between-group difference (P > 0.05). At the posttest, these values were respectively 51.57 ± 7.32 and 27.74 ± 3.28 in the control group and 37.31 ± 6.95 and 34.37 ± 2.8 in the intervention group, and between-group differences were significant (P < 0.05). The mean scores of CB and QOL did not significantly change in the control group (P > 0.05), but respectively decreased and increased significantly in the intervention group (P < 0.05).

CONCLUSIONS

Smartphone-based PR education is effective in significantly decreasing CB and improving QOL among the FCs of patients with COPD.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20161203031200N3.

Improving the wellbeing of caregivers of patients with COPD using a home-based pulmonary rehabilitation programme

Objectives

The aim of this study was to evaluate the effects of a home-based pulmonary rehabilitation (PR) programme on anxiety and depressive symptoms, general fatigue and burden in informal caregivers of patients with COPD. We also evaluated the baseline characteristics of both patients and caregivers that contributed to the change in caregiver's outcomes after PR.

Methods

In this retrospective study, patients with COPD were referred to an 8-week home-based PR programme consisting of a weekly supervised 90-min session. Informal caregivers were invited to participate in PR according to the patient's preference and its availability. Caregivers received educational support, behavioural therapies and self-management strategies using the same methods as for patients. Burden, anxiety and depressive symptoms, and general fatigue of caregivers were assessed at baseline and at the end of PR.

Results

241 patients with COPD and 138 (57.3%) caregivers were included. The majority of the caregivers were women (70.5%) and spouses (90.3%) and had at least three comorbidities (57.3%). A large proportion of caregivers showed baseline high burden, anxiety symptoms and abnormal fatigue (40%, 40% and 45%, respectively). Burden, anxiety and depressive symptoms, and general fatigue of informal caregivers were all improved after PR (p<0.05). Long-term oxygen therapy and/or noninvasive ventilation, coronaropathy and/or peripheral arterial disease and a higher baseline modified Medical Research Council Dyspnoea scale score in patients with COPD were associated with a decrease in caregiver's burden after PR.

Conclusion

A large proportion of caregivers of patients with COPD showed anxiety symptoms, fatigue and a high burden. These outcomes were improved by integrating the caregiver into a home-based PR programme.

Couple and family interventions for high mortality health conditions: A strategic review (2010-2019)

The earliest publications in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. This strategic review captures an evaluation of efficacy for 87 couple and family interventions published between 2010 and 2019 with a focus on the leading causes of mortality in the United States. These health conditions include chromosomal anomalies and accidents with infants aged 0-4 years; accidents and cancer among children aged 5-14; accidents among adolescents aged 15-24; and heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer's disease, diabetes, influenza/pneumonia, and nephritis/nephrosis among adults 25 and older. Results support the need for greater inclusion of couples and families in assessments and interventions. The greatest chasm in efficacy research was with minoritized couples and families. Implications include ways to initiate couple and family interventions in the context of health conditions with attention given to accessibility, recruitment, retention, and evaluation.

Systematic Review of Exercise for Caregiver-Care Recipient Dyads: What Is Best for Spousal Caregivers-Exercising Together or Not at All?

Background and Objectives

Though exercise for care recipients receives considerable emphasis, few dyadic studies focus on caregivers. This systematic review identified dyadic exercise interventions, which measured outcomes for older adult caregivers. Studies that met inclusion criteria were examined to better understand whether caregivers derived greater benefit from exercising with care recipients, or not exercising at all.

Research Design and Methods

PRISMA guidelines were followed to identify quantitative studies of dyadic exercise interventions in which caregivers enrolled with care recipients, and either coparticipated in exercise; or while their care recipients exercised independently, caregivers received a separate, nonexercise intervention or usual care (UC). To be included, studies had to measure physical or psychosocial outcomes for caregivers. Study quality was assessed via the Downs and Black checklist.

Results

Eleven studies met inclusion criteria. In six, the dyad exercised; in five, care recipients exercised while caregivers received a separate program, or UC. Results suggest that caregivers may improve both psychosocial and physical health when exercising together with care recipients. Caregivers who did not exercise but received a separate, nonexercise intervention, such as support, education, or respite, showed psychosocial benefits. Those who received UC were less likely to derive physical or psychosocial benefits. Included studies were fair to good quality with moderate to high risk of bias.

Discussion and Implications

Often examined secondarily, caregivers are overlooked for participation in interventions with care recipients. This analysis suggests that caregivers may benefit from dyadic interventions in which they either exercise together with their care recipients or receive a separate nonexercise intervention or respite.

Effects of Exercise-Based Interventions on Fall Risk and Balance in Patients With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease characterized by airflow limitation and is associated with decreased balance and increased fall risk. Since falls are related to increased mortality, interventions targeting balance and fall risk could reduce morbidity and mortality. The objective of this review was to systematically assess the effects of exercise-based interventions on fall risk and balance in patients with COPD.

METHODS

PubMed, Web of Science, EMBASE, and CINAHL were screened for randomized controlled trails and within-group studies evaluating effects of exercise-based interventions on fall risk or balance in patients with COPD. Data were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Fifteen studies were identified, 6 randomized controlled trails and 9 within-group studies. All interventions reported positive effects on balance outcomes. No studies reported fall risk. Taking current recommendations of balance outcome measures in patients with COPD into account, pulmonary rehabilitation combined with balance training had the highest effect size. Nine papers had concerns regarding bias, mostly due to the lack of blinding outcome assessors.

CONCLUSIONS

Exercise-based interventions have a positive effect on balance in patients with COPD. Pulmonary rehabilitation with balance training seems to have the most beneficial effect on balance. The effects on fall risk, as well as the long-term intervention effects remain unclear. A standardized balance assessment and research on long-term effects and fall risk are recommended.

Interventions to Support Informal Caregivers of People with Chronic Obstructive Pulmonary Disease: A Systematic Literature Review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) imposes tremendous challenges for both patients and informal caregivers. Caregivers are key players in the management of COPD. Recently, COVID-19 further increased reliance on informal caregivers who urgently need specific support. This systematic literature review aimed to systematically describe the content and explore the effects of interventions to support informal caregivers of people with COPD.

METHODS

A mixed-methods systematic review was conducted. PubMed, Scopus, Web of Science, and EBSCO were searched. Studies implementing interventions supporting informal caregivers of people with COPD were included. Data were extracted and analysed in outcome domains and categories using framework analysis.

RESULTS

Twenty (14 quantitative, 4 mixed-methods, and 2 qualitative) studies were included. Informal caregivers were mainly female (86%). Caregiving context was poorly/never described. Interventions included patient-caregiver dyads and never caregivers only. Informal caregivers were invited to participate if available. Interventions were delivered across all COPD phases (acute/stable/advanced) and settings (inpatient/outpatient/home), with a wide range of total length, frequency, and duration of sessions. All included education about the disease and its management. Discharge/action plans (n = 12); adherence to therapy and healthy lifestyles (n = 9); and family concerns and psychosocial issues (n = 7) were also commonly addressed. Only 9 (45%) studies reported caregiver-related outcomes, and overall positive effects were observed in 7/9 outcome domains, using a high variety of qualitative and qualitative methods. Often categories were addressed but not assessed.

CONCLUSION

Interventions have a narrow scope (i.e., education) and have not been specifically designed to support informal caregivers. Current evidence showed positive effects, but high methodological heterogeneity exists. Future studies need to explore caregiver-tailored, taking into consideration gender differences; multicomponent; and flexibly administered interventions to effectively support COPD caregivers.

Exercise Training in Patients with Chronic Respiratory Diseases: Are Cardiovascular Comorbidities and Outcomes Taken into Account?-A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD), asthma and interstitial lung diseases (ILD) frequently suffer from cardiovascular comorbidities (CVC). Exercise training is a cornerstone intervention for the management of these conditions, however recommendations on tailoring programmes to patients suffering from respiratory diseases and CVC are scarce. This systematic review aimed to identify the eligibility criteria used to select patients with COPD, asthma or ILD and CVC to exercise programmes; assess the impact of exercise on cardiovascular outcomes; and identify how exercise programmes were tailored to CVC. PubMed, Scopus, Web of Science and Cochrane were searched. Three reviewers extracted the data and two reviewers independently assessed the quality of studies with the Quality Assessment Tool for Quantitative Studies. MetaXL 5.3 was used to calculate the individual and pooled effect sizes (ES). Most studies (58.9%) excluded patients with both stable and unstable CVC. In total, 26/42 studies reported cardiovascular outcomes. Resting heart rate was the most reported outcome measure (n = 13) and a small statistically significant effect (ES = -0.23) of exercise training on resting heart rate of patients with COPD was found. No specific adjustments to exercise prescription were described. Few studies have included patients with CVC. There was a lack of tailoring of exercise programmes and limited effects were found. Future studies should explore the effect of tailored exercise programmes on relevant outcome measures in respiratory patients with CVC.

Improving access to community-based pulmonary rehabilitation: 3R protocol for real-world settings with cost-benefit analysis

Background

Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit.

Methods

A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR.

Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted.

Discussion

This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases.

Trial registration

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7045-1) contains supplementary material, which is available to authorized users.

Patients' and their family members' experiences of participation in care following an acute exacerbation in chronic obstructive pulmonary disease: A phenomenological-hermeneutic study

AIM AND OBJECTIVES

To explore the experiences of patients with chronic obstructive pulmonary disease and their family members relating both to participation in care during hospitalisation for an acute exacerbation in chronic obstructive pulmonary disease, and to the subsequent day-to-day care at home.

BACKGROUND

When recovering from an exacerbation, the challenges associated with an unpredictable health condition dominate everyday life for patients and can involve their family members. Proper patient and family participation in care during discharge and follow-up can help patients to improve self-management. However, knowledge of the significance of patient and family participation for recovery and subsequent everyday life is still limited.

DESIGN

This study adopted a longitudinal design informed by ethnographic fieldwork principles.

METHODS

Participant observations and interviews with 15 patients and 12 family members were conducted on a Danish hospital ward and twice at the participants' homes. A phenomenological-hermeneutic approach inspired by Ricoeur's theory of interpretation guided the data analysis.

RESULTS

Participation in care was perceived as valuable, but could be associated with tensions and increased uncertainty. While patients mostly demonstrated a reactive approach to care, family members strived to be more proactive. In hospital, preparing for discharge included an effort to find a balance between powerlessness and influence during interactions with healthcare professionals. At home, managing further recovery and self-management were characterised by navigating between mutual pressure and consideration within the family.

CONCLUSION

Family members play an important role in ensuring that patients are seen, heard and understood, but want to be acknowledged more by healthcare professionals. Appropriate interactions with healthcare professionals are crucial in order to support discharge and daily self-management.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the challenges that patients with chronic obstructive pulmonary disease and their family members face in participating in care activities could inform future development of family-centred care approaches tailored to individual needs.

Imaging and imagining chronic obstructive pulmonary disease (COPD): Uruguayans draw their lungs

PURPOSE

This anthropological study investigated what people imagined chronic obstructive pulmonary disease to look like in their lungs, what may be influencing these images and how this imagery shapes embodiment.

METHOD

Employing graphic elicitation, in one of multiple ethnographic interviews, participants were asked to draw their lungs: "If we could look inside your chest now, what would we see?" Lung drawings and accompanying narratives and fieldnotes from 14 participants were analyzed for themes and patterns.

RESULTS

The theme of "imaging/imagining" emerged and three distinct patterns within this theme were identified: the microscope perspective, the X-ray perspective and the reduced pulmonary capacity perspective. These patterns demonstrate how embodiment can be shaped by an integration and reinterpretation of the medical images that form part of everyday clinic visits and pulmonary rehabilitation.

CONCLUSIONS

Medical technology and images impact patients' embodiment. Understanding this is important for rehabilitation practitioners who work in a challenging space created by potentially conflicting medical narratives: on the one hand, chronic obstructive pulmonary disease is incurable permanent damage, and on the other, improvement is possible through rehabilitation. Drawing could be integrated into pulmonary rehabilitation and may help identify perceptions of the body that could hinder the rehabilitation process. Implications for rehabilitation Drawings, when combined with interviews, can lead to a deeper and more complex understanding of patients' perspectives and embodiment. Rehabilitation practitioners should be concerned with how patients embody the medical technology and imagery they are exposed to as part of the educational component of pulmonary rehabilitation and healthcare generally. Asking patients to visualize their illness through drawing may help pulmonary rehabilitation practitioners identify perceptions of the body which could hinder the patient's ability to reap the full benefit of their treatment.

Changes in lower limb muscle function and muscle mass following exercise-based interventions in patients with chronic obstructive pulmonary disease: A review of the English-language literature

Chronic obstructive pulmonary disease (COPD) patients often experience lower limb muscle dysfunction and wasting. Exercise-based training has potential to improve muscle function and mass, but literature on this topic is extensive and heterogeneous including numerous interventions and outcome measures. This review uses a detailed systematic approach to investigate the effect of this wide range of exercise-based interventions on muscle function and mass. PUBMED and PEDro databases were searched. In all, 70 studies (n = 2504 COPD patients) that implemented an exercise-based intervention and reported muscle strength, endurance, or mass in clinically stable COPD patients were critically appraised. Aerobic and/or resistance training, high-intensity interval training, electrical or magnetic muscle stimulation, whole-body vibration, and water-based training were investigated. Muscle strength increased in 78%, muscle endurance in 92%, and muscle mass in 88% of the cases where that specific outcome was measured. Despite large heterogeneity in exercise-based interventions and outcome measures used, most exercise-based trials showed improvements in muscle strength, endurance, and mass in COPD patients. Which intervention(s) is (are) best for which subgroup of patients remains currently unknown. Furthermore, this literature review identifies gaps in the current knowledge and generates recommendations for future research to enhance our knowledge on exercise-based interventions in COPD patients.

Measurement properties of the Timed Up & Go test in patients with COPD

We aimed to investigate the construct validity of the Timed Up & Go (TUG) test in chronic obstructive pulmonary disease (COPD), to identify characteristics related to an abnormal TUG time and to examine the responsiveness of the TUG to pulmonary rehabilitation (PR). TUG time was assessed before and after comprehensive PR in 500 COPD patients, and compared cross-sectionally in 100 non-COPD subjects. Physical health outcomes, mental health outcomes, symptom-related outcomes and multidimensional indices were assessed in COPD patients only. Good convergent and discriminant validity was demonstrated by fair-to-moderate correlation with physical health outcomes, symptom-related outcomes and multidimensional indices ( r_s = 0.18-0.70) and by little correlation with mental health outcomes ( r_s = 0.21-0.26). COPD patients had a worse TUG time than non-COPD subjects, demonstrating known-groups validity. A TUG time of 11.2 seconds had good sensitivity (0.75) and specificity (0.83) for identifying patients with a baseline 6-minute walk distance <350 m. TUG time improved after PR ( p < 0.0001) and a change of 0.9-1.4 seconds was identified as clinically important. The TUG is valid and responsive in COPD. An abnormal result is indicative of poor health outcomes. This simple test provides valuable information and can be adopted in clinical and research settings.