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Aljama C, Granados G, Ramon M, Barrecheguren M, Loeb E, Nuñez A, Pleguezuelos E, García-Río F, Miravitlles M. Motivation and Confidence about Physical Activity in Chronic Obstructive Pulmonary Disease Patients: Health Benefits Matter to Patients. Respiration 2024; 103:378-387. [PMID: 38735281 DOI: 10.1159/000539206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/01/2024] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION Physical activity (PA) has shown great benefits in patients with chronic obstructive pulmonary disease (COPD); however, their PA is below average. Motivational factors associated with PA in COPD have not been widely studied and could be a target for improving adherence to PA. The objective of our study was to identify and understand the different motivational and confidence factors related to low levels of PA in a COPD cohort. METHOD Observational, prospective, multicenter study of COPD patients. Sociodemographic data, respiratory symptoms, comorbidities, spirometry, and exercise capacity were collected. PA was measured using the Dynaport accelerometer and patient motivation and confidence in PA were assessed by a questionnaire previously used in a COPD population in the USA. RESULTS Eighty six COPD patients were included, 68.6% being male, with a mean (SD) age of 66.6 (8.5) years and a mean forced expiratory volume in the first second (%) of 50.9% (17.3%). The mean walking time was 82.8 (37.8) minutes/day. Questions related to health benefits and enjoying exercise were ranked highest in the motivation questionnaire and statistically significant differences were found in PA measures between patients with low and high motivation. A lack of confidence regarding hot weather and health-related issues significantly influenced PA levels. Advice from third parties, including healthcare providers, was not associated with higher PA levels. CONCLUSIONS Improving the health of COPD patients is their main motivation to perform PA. Lack of confidence when it is hot or when they fear for their health is related to low levels of PA. Advice from third parties, including healthcare professionals, is not associated with higher PA. These results are relevant for developing strategies to increase the adherence of COPD patients to PA programs.
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Affiliation(s)
- Cristina Aljama
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain,
| | - Galo Granados
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Marian Ramon
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Eduardo Loeb
- Pneumology Department, Centro Médico Teknon, Grupo Quironsalud, Barcelona, Spain
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Eulogio Pleguezuelos
- Physical Medicine and Rehabilitation Department, Hospital de Mataró, Barcelona, Spain
- Department of Experimental Science and Healthcare, Faculty of Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Francisco García-Río
- Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Validation of Simple Prediction Equations for Step Count in Japanese Patients with Chronic Obstructive Pulmonary Disease. J Clin Med 2022; 11:jcm11195535. [PMID: 36233400 PMCID: PMC9571043 DOI: 10.3390/jcm11195535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/02/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
Physical activity is decreased in patients with chronic obstructive pulmonary disease, and decreased physical activity leads to a poor prognosis. To determine an individual’s target step count from the measured step counts and predicted step counts, simple and detailed prediction equations for step count were developed. To verify the validity of the simple prediction equation, the validity of the simple equation was evaluated in a different cohort and the correlation between the step counts calculated by the simple equation and those by the detailed prediction equation were evaluated. When the step counts calculated by the simple prediction equation for all participants were compared with the measured step counts, a significant correlation was obtained among them, and the calculated values were found to be reproducible with the measured values in patients with a measured step count of <6500 by Bland−Altman plots. Furthermore, the values calculated by the simple prediction equation and those calculated by the detailed prediction equation showed a significant correlation. In conclusion, the simple prediction equation was considered reasonable.
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Pimenta S, Silva CG, Flora S, Hipólito N, Burtin C, Oliveira A, Morais N, Brites-Pereira M, Carreira BP, Januário F, Andrade L, Martins V, Rodrigues F, Brooks D, Marques A, Cruz J. What Motivates Patients with COPD to Be Physically Active? A Cross-Sectional Study. J Clin Med 2021; 10:5631. [PMID: 34884333 PMCID: PMC8658241 DOI: 10.3390/jcm10235631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 01/03/2023] Open
Abstract
Motivation can be broadly defined as what moves people to act. Low motivation is a frequently reported factor for the reduced physical activity (PA) levels observed in patients with chronic obstructive pulmonary disease (COPD). This study assessed patients' motives to be physically active, according to three pulmonary rehabilitation (PR) participation groups (Never PR, Previous PR and Current PR) and explored whether these motives were related to the PA levels and clinical characteristics. The motives to be physically active were assessed with the Exercise Motivation Inventory-2 (EMI-2, 14 motivational factors, five dimensions) and PA with accelerometry (PA groups: <5000 steps/day vs. ≥5000 steps/day). The clinical variables included symptoms, impact of the disease, exercise capacity and comorbidities. Ninety-two patients (67.4 ± 8.1 years, 82.6% male, forced expiratory volume in 1s (FEV1) 48.3 ± 18.9% predicted; 30.4% Never PR, 51% Previous PR and 18.5% Current PR) participated. The motivational dimensions related to health/fitness presented the highest scores (3.8 ± 1.1; 3.4 ± 1.3). The motives to be active were not significantly different between PA groups (p > 0.05) but having less symptoms and ≥two comorbidities were associated with higher scores in psychological/health and body-related motives, respectively (p < 0.05). The findings may encourage health professionals to actively explore with patients their motives to be physically active to individualise PA promotion.
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Affiliation(s)
- Sara Pimenta
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
- School of Health Sciences (ESSLei), Polytechnic of Leiria, 2411-901 Leiria, Portugal
| | - Cândida G. Silva
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
- School of Health Sciences (ESSLei), Polytechnic of Leiria, 2411-901 Leiria, Portugal
- Coimbra Chemistry Centre, Department of Chemistry, University of Coimbra, 3004-535 Coimbra, Portugal
| | - Sofia Flora
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
| | - Nádia Hipólito
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
| | - Chris Burtin
- REVAL—Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, B-3590 Diepenbeek, Belgium;
- BIOMED—Biomedical Research Institute, Hasselt University, B-3590 Diepenbeek, Belgium
| | - Ana Oliveira
- School of Rehabilitation Science, McMaster University, Hamilton, ON L8S 1C7, Canada; (A.O.); (D.B.)
- Respiratory Medicine, West Park Healthcare Centre, Toronto, ON M6M 2J5, Canada
- Lab 3R—Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, 3810-193 Aveiro, Portugal;
| | - Nuno Morais
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
- School of Health Sciences (ESSLei), Polytechnic of Leiria, 2411-901 Leiria, Portugal
- Centre for Rapid and Sustainable Product Development (CDRSP), Polytechnic of Leiria, 2430-028 Leiria, Portugal
| | - Marcelo Brites-Pereira
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
| | - Bruno P. Carreira
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
- School of Health Sciences (ESSLei), Polytechnic of Leiria, 2411-901 Leiria, Portugal
- Unidade de Saúde Familiar Pedro e Inês, ACeS Oeste Norte, 2460-492 Alcobaça, Portugal
| | - Filipa Januário
- Physical Medicine and Rehabilitation Department, Leiria Hospital Center, 2410-197 Leiria, Portugal;
| | - Lília Andrade
- Pulmonology Department, Baixo Vouga Hospital Center, 3810-501 Aveiro, Portugal;
| | - Vitória Martins
- Pulmonology Department, District Hospital of Figueira da Foz, 3094-001 Figueira da Foz, Portugal;
| | - Fátima Rodrigues
- Pulmonology Department, Northern Lisbon University Hospital Centre (CHULN), 1769-001 Lisboa, Portugal;
- Environmental Health Behaviour Lab, Faculty of Medicine, University of Lisbon (ISAMB/FMUL), 1649-028 Lisboa, Portugal
| | - Dina Brooks
- School of Rehabilitation Science, McMaster University, Hamilton, ON L8S 1C7, Canada; (A.O.); (D.B.)
- Respiratory Medicine, West Park Healthcare Centre, Toronto, ON M6M 2J5, Canada
| | - Alda Marques
- Lab 3R—Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, 3810-193 Aveiro, Portugal;
- Institute of Biomedicine (iBiMED), University of Aveiro, 3810-193 Aveiro, Portugal
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2410-541 Leiria, Portugal; (S.P.); (C.G.S.); (S.F.); (N.H.); (N.M.); (M.B.-P.); (B.P.C.)
- School of Health Sciences (ESSLei), Polytechnic of Leiria, 2411-901 Leiria, Portugal
- Lab 3R—Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, 3810-193 Aveiro, Portugal;
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Raphaely RA, Mongiardo MA, Goldstein RL, Robinson SA, Wan ES, Moy ML. Pain in Veterans with COPD: relationship with physical activity and exercise capacity. BMC Pulm Med 2021; 21:238. [PMID: 34266401 PMCID: PMC8280683 DOI: 10.1186/s12890-021-01601-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is a common but underappreciated symptom experienced by people with Chronic Obstructive Pulmonary Disease (COPD). The relationships between pain and physical activity (PA) and exercise capacity are poorly understood. METHODS This retrospective secondary analysis includes three cohorts of Veterans with COPD who participated in longitudinal studies evaluating PA and exercise capacity with objective measures of daily step counts and 6-min walk test (6MWT) distance, respectively. Pain was assessed using the bodily pain domain of the Veterans RAND-36. In two cohorts, participants were randomly assigned to a web-based, pedometer-mediated PA intervention which has previously been demonstrated to improve PA. RESULTS Three-hundred and seventy-three (373) unique study participants were included in this analysis. Eighty-three percent (n = 311) of the population reported at least mild pain and/or at least a little bit of interference due to pain at baseline. Cross-sectionally, greater bodily pain was associated with lower 6MWT distance (β = 0.51; 95% CI 0.20, 0.82; p = 0.0013). Longitudinally, worsening bodily pain was associated with a decline in 6MWT distance (β = 0.30; 95% CI 0.03, 0.58; p = 0.0312). There was no association between baseline bodily pain and baseline daily step counts, baseline bodily pain and change in PA, or change in bodily pain and change in PA. Compared to usual care, our PA intervention improved bodily pain scores (β = 6.17; 95% CI 1.84, 10.45; p = 0.0054). Bodily pain scores did not affect the impact of the intervention on daily step counts. CONCLUSION Pain is highly prevalent and significantly associated with lower exercise capacity among Veterans with COPD. Worsening pain co-occurred with decline in exercise capacity but not PA. Our intervention reduced pain, although pain did not affect the impact of the intervention on PA.
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Affiliation(s)
- Rebecca A Raphaely
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
- Department of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
- Department of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maria A Mongiardo
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
| | - Rebekah L Goldstein
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
| | - Stephanie A Robinson
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
- VA Bedford Healthcare Systems, Bldg 70, 200 Springs Rd, Bedford, MA, 01732, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Emily S Wan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
- Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA.
- Harvard Medical School, Boston, MA, USA.
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Robinson SA, Shimada SL, Quigley KS, Moy ML. A web-based physical activity intervention benefits persons with low self-efficacy in COPD: results from a randomized controlled trial. J Behav Med 2019; 42:1082-1090. [PMID: 30980223 DOI: 10.1007/s10865-019-00042-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/04/2019] [Indexed: 01/23/2023]
Abstract
Promoting physical activity (PA) is of top priority in chronic obstructive pulmonary disease (COPD). This study examines the influence of an internet-delivered intervention on the relationship between exercise self-efficacy and changes in PA, physical health, and exercise capacity in COPD. 112 U.S. Veterans with COPD were randomized to either a comparison (pedometer alone) or an intervention group (pedometer plus access to an internet-mediated PA intervention). There was a significant interaction between baseline exercise self-efficacy and randomization group on change in PA. In the comparison group, there was a significant relationship between higher baseline exercise self-efficacy and greater change in PA, whereas in the intervention group, improvements in PA were independent of level of baseline self-efficacy. Similar patterns were found with physical health and exercise capacity as outcomes. The use of an internet-mediated intervention significantly benefited persons with COPD who had low baseline self-efficacy to increase PA and physical health.Clinical trial registration The randomized clinical trial was registered on ClinicalTrials.gov (NCT01772082).
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Affiliation(s)
| | - Stephanie L Shimada
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,School of Public Health, Boston University, Boston, MA, USA
| | - Karen S Quigley
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Northeastern University, Boston, MA, USA
| | - Marilyn L Moy
- VA Boston Healthcare System, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Kadir MA, Kubacki K, Rundle-Thiele S. Perceived benefits and barriers of walking among overweight and obese adults. Health Mark Q 2019; 36:54-70. [PMID: 30784375 DOI: 10.1080/07359683.2019.1567004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The current study aimed to explore perceived barriers and benefits of walking of overweight and obese adults. Fifteen face-to-face, semistructured interviews were conducted. Content and thematic analyses were used. Findings revealed that informants were aware of more benefits from walking than barriers. Gaining health and fitness, losing weight, the opportunity to walk in a group, and setting goals and sharing achievements were more sited benefits of walking. Confusion about walking guidelines and walking location perceived as barriers to walking. The findings of this study would be applied to develop walking intervention.
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Affiliation(s)
- Mohammad A Kadir
- a Department of Marketing , Griffith University , Nathan , Queensland , Australia
| | - Krzysztof Kubacki
- a Department of Marketing , Griffith University , Nathan , Queensland , Australia
| | - Sharyn Rundle-Thiele
- a Department of Marketing , Griffith University , Nathan , Queensland , Australia
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Nguyen BJ, Kim Y, Park K, Chen AJ, Chen S, Van Fossan D, Chao DL. Improvement in Patient-Reported Quality of Life Outcomes in Severely Visually Impaired Individuals Using the Aira Assistive Technology System. Transl Vis Sci Technol 2018; 7:30. [PMID: 30386682 PMCID: PMC6205681 DOI: 10.1167/tvst.7.5.30] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/18/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose We evaluate patient-reported quality of life outcomes in severely visually impaired (SVI) individuals using the Aira system, an on demand assistive wearable technology. Methods Aira is an on-demand assistive wearable technology designed for the severely visually impaired (visual acuity of better eye <20/200). The user wears glasses with a video camera mounted that, when activated, livestreams to a human agent who assists the user in the specified task. Aira subscribers were recruited consecutively and administered the 28-item Impact of Vision Impairment-Very Low Vision (IVI-VLV) Questionnaire, a previously validated survey for vision-related quality of life specifically for low vision individuals. The questionnaire was administered by phone before starting Aira and at 3-month follow-up. Total score as well as validated subset scores of activities of daily living, mobility and safety (ADLMS) and emotional wellbeing (EWB) were assessed. Results A total of 69 participants (mean age, 52.1; 35 female, 34 male) were recruited with a mean of 108 (SD = 19.7) days to follow-up. Mean total minutes used over the interval were 334.1 (SD = 318.5). Initial total score (mean 51.7 ± 18.6) significantly improved at follow-up (mean 62.2 ± 15.0; P < 0.0001) with mean change +10.4 ± 12.5. ADLMS subset score (mean 30.4 ± 10.8) significantly improved at follow-up (mean 36.6 ± 8.8; P < 0.0001) with mean change +6.5 ± 8.7. EWB subset score (mean 21.6 ± 8.8) significantly improved at follow-up (mean 25.6 ± 7.9 respectively; P < 0.0001) with mean change +4.0 ± 5.2. There was no correlation between minutes used and improvement in total (r = −0.205, P = 0.098), ADLMS (r = −0.237, P = 0.055), and EWB (r = −0.242, P = 0.051) scores. Conclusions In this exploratory study, regardless of minutes used, the use of Aira significantly improves IVI-VLV total score and ADLMS and EWB subscores for SVI individuals. This improvement is not correlated with total minutes used. Translational Relevance The Aira assistive technology system may provide improvement in quality of life for low vision patients and is worthy of further study to assess the use of this technology to assist SVI patients.
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Affiliation(s)
- Brian J Nguyen
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Yeji Kim
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Kathryn Park
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Allison J Chen
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Scarlett Chen
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Donald Van Fossan
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Daniel L Chao
- Shiley Eye Institute, Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
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Kantorowski A, Wan ES, Homsy D, Kadri R, Richardson CR, Moy ML. Determinants and outcomes of change in physical activity in COPD. ERJ Open Res 2018; 4:00054-2018. [PMID: 30083551 PMCID: PMC6073048 DOI: 10.1183/23120541.00054-2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/05/2018] [Indexed: 12/18/2022] Open
Abstract
Determinants of change in physical activity and outcomes of physical activity promotion are unclear. In this secondary analysis of a randomised controlled trial of a physical activity intervention, we assess predictors of change in physical activity and the effects of increasing physical activity on chronic obstructive pulmonary disease (COPD) measures. Physical activity was promoted in 94 subjects with COPD using the Omron HJ-720ITC pedometer alone or the pedometer plus a website that provides goal setting, feedback, motivational and educational messages, and social support for 3 months. We assessed forced expiratory volume in 1 s (FEV1), 6-min walk test (6MWT) distance, depression, social support and markers of systemic inflammation (C-reactive protein (CRP) and interleukin (IL)-6). Data from both groups were combined and subjects categorised as responders (increased steps per day) or nonresponders (decreased steps per day). Linear regression models explored predictors of change in physical activity and assessed the effect of response on changes in COPD measures. The cohort of responders (n=62) and nonresponders (n=32) had mean FEV1 1.89±0.64 L (63±22% predicted). Baseline steps per day, diagnosis of depression, social support, oxygen use and season significantly predicted change in daily step count. Responders had increases in physical activity (2038 steps per day), FEV1 (308 mL) and 6MWT distance (43.6 m), and decreases in CRP (7.84 mg·L−1) and IL-6 (2.73 ng·mL−1) compared with nonresponders (p<0.0001–0.009). History of depression, social support, oxygen use and season predict change in physical activity, and should be routinely assessed in exercise counselling. Increases in physical activity are associated with improvements in lung function, exercise capacity and systemic inflammation. History of depression, social support, oxygen use and season predict change in physical activity in COPD. Response to physical activity promotion is associated with improvements in lung function, exercise capacity and systemic inflammation.http://ow.ly/oOMA30kPGCE
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Affiliation(s)
- Ana Kantorowski
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA
| | - Emily S Wan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA.,Dept of Veterans Affairs, Rehabilitation Research and Development Service, Washington, DC, USA.,Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Diana Homsy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA
| | - Reema Kadri
- Dept of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA.,Dept of Veterans Affairs, Rehabilitation Research and Development Service, Washington, DC, USA.,Harvard Medical School, Boston, MA, USA
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A Lifestyle Physical Activity Intervention for Patients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial. Ann Am Thorac Soc 2017; 13:617-26. [PMID: 26785249 DOI: 10.1513/annalsats.201508-508oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
RATIONALE Physical inactivity is associated with poor outcomes among patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine effectiveness of a behavioral intervention intended to increase daily physical activity with the goal of improving health-related quality of life and functional performance. METHODS We conducted a randomized trial among patients with COPD cared for in primary care and pulmonary clinics. The patients were at least 45 years of age and eligible for pulmonary rehabilitation. All patients received self-management education during a 6-week run-in period. Subsequently, patients were randomized to usual care or the intervention delivered over 20 weeks. MEASUREMENTS AND MAIN RESULTS Co-primary outcomes were change from baseline in Chronic Respiratory Questionnaire dyspnea domain score and 6-minute-walk distance measured at 6, 12, and 18 months after randomization. A total of 325 patients were enrolled, with 156 randomized to receive usual care and 149 to receive the intervention. At 18 months, there was no overall statistical or clinically significant change in the dyspnea domain in either group. However, for 6-minute-walk distance, there were statistically significant declines in both groups. In contrast, 6-minute-walk distance remained stable (5.3 m; P = 0.54) among patients in the intervention group with moderate spirometric impairment, but it was associated with clinically and statistically significant declines (-28.7 m; P = 0.0001) among usual care patients with moderate spirometric impairment. Overall, there was no increase in adverse events associated with the intervention, which was associated with a lower prevalence of hospitalization for COPD exacerbations (28.3%) compared with usual care (49.5%). CONCLUSIONS During this 18-month trial among outpatients with COPD, a health coach-based behavioral intervention did not improve scores in the dyspnea domain of the Chronic Respiratory Questionnaire or 6-minute-walk test distance. However, subgroup analyses suggested that there may be differential effects for specific outcomes that vary with severity of COPD. Specifically, benefits of this low-intensity intervention may be limited to 6-minute walk distance among patients with moderate spirometric impairment. Clinical trial registered with www.clinicaltrials.gov (NCT1108991).
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Wan ES, Kantorowski A, Homsy D, Teylan M, Kadri R, Richardson CR, Gagnon DR, Garshick E, Moy ML. Promoting physical activity in COPD: Insights from a randomized trial of a web-based intervention and pedometer use. Respir Med 2017; 130:102-110. [PMID: 29206627 DOI: 10.1016/j.rmed.2017.07.057] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/22/2017] [Accepted: 07/24/2017] [Indexed: 11/26/2022]
Abstract
RATIONALE Low physical activity is highly prevalent among COPD patients and is associated with increased healthcare utilization and mortality and reduced HRQL. The addition of a website to pedometer use is effective at increasing physical activity; however, the timeline of change and impact of environmental factors on efficacy is unknown. METHODS U.S. Veterans with COPD were randomized (1:1) to receive either (1) a pedometer and website which provided goal-setting, feedback, disease-specific education, and an online community forum or (2) pedometer alone for 3 months. Primary outcome was change in daily step count. Secondary outcomes included 6MWT distance, HRQL, dyspnea, depression, COPD knowledge, exercise self-efficacy, social support, motivation, and confidence to exercise. Generalized linear mixed-effects models evaluated the effect of the pedometer plus website compared to pedometer alone. RESULTS Data from 109 subjects (98.5% male, mean age 68.6 ± 8.3 years) were analyzed. At 13 weeks, subjects in the pedometer plus website group had significant increases daily step count from baseline relative to the pedometer alone group (804 ± 356.5 steps per day, p = 0.02). The pedometer plus website group had significant improvements in daily step count from baseline beginning in week 3 which were sustained until week 13. In subgroup analyses, the pedometer plus website attenuated declines in daily step count during the transition from summer to fall. No significant differences in secondary outcomes were noted between groups. CONCLUSIONS A website added to pedometer use improves daily step counts, sustains walking over 3 months, and attenuates declines in physical activity due to season.
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Affiliation(s)
- Emily S Wan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ana Kantorowski
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Diana Homsy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Merilee Teylan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Reema Kadri
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - David R Gagnon
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA; Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Eric Garshick
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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11
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Ramon MA, Esquinas C, Barrecheguren M, Pleguezuelos E, Molina J, Quintano JA, Roman-Rodríguez M, Naberan K, Llor C, Roncero C, Miravitlles M. Self-reported daily walking time in COPD: relationship with relevant clinical and functional characteristics. Int J Chron Obstruct Pulmon Dis 2017; 12:1173-1181. [PMID: 28458527 PMCID: PMC5402919 DOI: 10.2147/copd.s128234] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Quantifying physical activity in chronic obstructive pulmonary disease (COPD) is important as physical inactivity is related to poor health outcomes. This study analyzed the relationship between patients’ self-reported daily walking time and relevant characteristics related to COPD severity. Methods Pooled analysis was performed on data from four observational studies on which daily walking time was gathered from a personal interview. Patients were classified as physically inactive if walking time was <30 min/day. Walking times were described and compared according to several markers of disease severity. Results The mean daily walking time of 5,969 patients was 66 (standard deviation [SD] 47) min/day; 893 (15%) patients were inactive. A linear dose–response relationship was observed between walking time and the modified Medical Research Council (mMRC) dyspnea score, admissions, COPD assessment test (CAT), body mass index, airway obstruction, dyspnea, exacerbation (BODEx) index, and Charlson index (P<0.001). Daily walking times were lower in patients classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) B and D (P<0.001). Often, inactive patients had mMRC or Charlson index >3, post-bronchodilator forced expiratory volume in the first second <30% predicted, at least one hospitalization for COPD, classified as GOLD B or D, BODEx >4, and CAT score >30. Conclusion Lower self-reported walking times are related to worse markers of disease severity in COPD.
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Affiliation(s)
- Maria A Ramon
- Department of Pneumology, Vall d'Hebron University Hospital.,Faculty of Medicine, Autonomous University of Barcelona.,Biomedical Research Networking Center Consortium of Respiratory Diseases (CIBERES)
| | | | | | - Eulogio Pleguezuelos
- Physical Medicine and Rehabilitation Department, Mataró Hospital.,TecnoCampus, College of Health Sciences, University of Pompeu Fabra, Mataró-Maresme, Barcelona
| | - Jesús Molina
- Francia Health Center, Dirección Asistencial Oeste, Madrid
| | | | | | | | | | - Carlos Roncero
- Addiction and Dual Diagnosis Unit, Psychiatry Service, Vall d'Hebron University Hospital.,Barcelona Public Health Agency (ASPB), Barcelona.,Biomedical Research Networking Center Consortium of Mental Health (CIBERSAM), Madrid.,Department of Psychiatry, Autonomous University of Barcelona, Barcelona, Spain
| | - Marc Miravitlles
- Department of Pneumology, Vall d'Hebron University Hospital.,Biomedical Research Networking Center Consortium of Respiratory Diseases (CIBERES)
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12
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Bender BG, Depew A, Emmett A, Goelz K, Make B, Sharma S, Underwood J, Stempel D. A Patient-Centered Walking Program for COPD. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:769-777. [PMID: 28848902 DOI: 10.15326/jcopdf.3.4.2016.0142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Pulmonary rehabilitation programs improve dyspnea and health status associated with chronic obstructive pulmonary disease (COPD), but benefits wane when patients return to a sedentary lifestyle. This study tested a simple, low-resource, low-cost home walking program. Methods: In this single center, 3-month study, 115 COPD patients were randomized to a control cohort or a goal setting cohort. Each patient met with study staff and received 5 telephone calls at 2-week intervals. During these contacts, the Goal group was assisted by a wellness coach who helped them set personal activity goals. All patients wore a pedometer to record daily steps, the primary study outcome. Results: Over the 12-week interval, the average step-per-days was 36% higher for the Goal cohort patients (Week 12 mean = 4390) than for Control patients (mean = 3790). No group differences emerged on the modified Medical Research Council (mMRC) dyspnea scale, the COPD Assessment Test, or the St. George's Respiratory Questionnaire. Secondary analyses indicated that even patients with greater disease severity, including those with an mMRC score >2 or forced expiratory volume in 1 second (FEV1) % predicted below 50%, increased their walking relative to Control patients. Almost half (48%) of Goal patients successfully reached at least one personal goal such as increasing stamina and activity, or decreasing shortness of breath or weight. Conclusions: A relatively low-resource wellness coaching, goal-setting intervention resulted in a small improvement in the activity level of COPD patients over a 12-week period including those with marked pulmonary impairment. Further investigation should be directed at understanding the optimal blend of in person and remote coaching needed to produce the greatest cost-to-benefit ratio.
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Affiliation(s)
- Bruce G Bender
- Departments of Pediatrics, National Jewish Health, Denver, Colorado
| | - Ann Depew
- Department of Medicine, National Jewish Health, Denver, Colorado
| | | | - Kelly Goelz
- Department of Medicine, National Jewish Health, Denver, Colorado
| | - Barry Make
- Department of Medicine, National Jewish Health, Denver, Colorado
| | | | | | - David Stempel
- GlaxoSmithKline, Research Triangle Park, North Carolina
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13
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Moy ML, Martinez CH, Kadri R, Roman P, Holleman RG, Kim HM, Nguyen HQ, Cohen MD, Goodrich DE, Giardino ND, Richardson CR. Long-Term Effects of an Internet-Mediated Pedometer-Based Walking Program for Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial. J Med Internet Res 2016; 18:e215. [PMID: 27502583 PMCID: PMC4993862 DOI: 10.2196/jmir.5622] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/21/2016] [Accepted: 05/24/2016] [Indexed: 11/29/2022] Open
Abstract
Background Regular physical activity (PA) is recommended for persons with chronic obstructive pulmonary disease (COPD). Interventions that promote PA and sustain long-term adherence to PA are needed. Objective We examined the effects of an Internet-mediated, pedometer-based walking intervention, called Taking Healthy Steps, at 12 months. Methods Veterans with COPD (N=239) were randomized in a 2:1 ratio to the intervention or wait-list control. During the first 4 months, participants in the intervention group were instructed to wear the pedometer every day, upload daily step counts at least once a week, and were provided access to a website with four key components: individualized goal setting, iterative feedback, educational and motivational content, and an online community forum. The subsequent 8-month maintenance phase was the same except that participants no longer received new educational content. Participants randomized to the wait-list control group were instructed to wear the pedometer, but they did not receive step-count goals or instructions to increase PA. The primary outcome was health-related quality of life (HRQL) assessed by the St George’s Respiratory Questionnaire Total Score (SGRQ-TS); the secondary outcome was daily step count. Linear mixed-effect models assessed the effect of intervention over time. One participant was excluded from the analysis because he was an outlier. Within the intervention group, we assessed pedometer adherence and website engagement by examining percent of days with valid step-count data, number of log-ins to the website each month, use of the online community forum, and responses to a structured survey. Results Participants were 93.7% male (223/238) with a mean age of 67 (SD 9) years. At 12 months, there were no significant between-group differences in SGRQ-TS or daily step count. Between-group difference in daily step count was maximal and statistically significant at month 4 (P<.001), but approached zero in months 8-12. Within the intervention group, mean 76.7% (SD 29.5) of 366 days had valid step-count data, which decreased over the months of study (P<.001). Mean number of log-ins to the website each month also significantly decreased over the months of study (P<.001). The online community forum was used at least once during the study by 83.8% (129/154) of participants. Responses to questions assessing participants’ goal commitment and intervention engagement were not significantly different at 12 months compared to 4 months. Conclusions An Internet-mediated, pedometer-based PA intervention, although efficacious at 4 months, does not maintain improvements in HRQL and daily step counts at 12 months. Waning pedometer adherence and website engagement by the intervention group were observed. Future efforts should focus on improving features of PA interventions to promote long-term behavior change and sustain engagement in PA. ClinicalTrial Clinicaltrials.gov NCT01102777; https://clinicaltrials.gov/ct2/show/NCT01102777 (Archived by WebCite at http://www.webcitation.org/6iyNP9KUC)
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Affiliation(s)
- Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, United States
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14
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Moy ML, Collins RJ, Martinez CH, Kadri R, Roman P, Holleman RG, Kim HM, Nguyen HQ, Cohen MD, Goodrich DE, Giardino ND, Richardson CR. An Internet-Mediated Pedometer-Based Program Improves Health-Related Quality-of-Life Domains and Daily Step Counts in COPD: A Randomized Controlled Trial. Chest 2015; 148:128-137. [PMID: 25811395 DOI: 10.1378/chest.14-1466] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Low levels of physical activity (PA) are associated with poor outcomes in people with COPD. Interventions to increase PA could improve outcomes. METHODS We tested the efficacy of a novel Internet-mediated, pedometer-based exercise intervention. Veterans with COPD (N = 239) were randomized in a 2:1 ratio to the (1) intervention group (Omron HJ-720 ITC pedometer and Internet-mediated program) or (2) wait-list control group (pedometer). The primary outcome was health-related quality of life (HRQL), assessed by the St. George's Respiratory Questionnaire (SGRQ), at 4 months. We examined the SGRQ total score (SGRQ-TS) and three domain scores: Symptoms, Activities, and Impact. The secondary outcome was daily step counts. Linear regression models assessed the effect of intervention on outcomes. RESULTS Participants had a mean age of 67 ± 9 years, and 94% were men. There was no significant between-group difference in mean 4-month SGRQ-TS (2.3 units, P = .14). Nevertheless, a significantly greater proportion of intervention participants than control subjects had at least a 4-unit improvement in SGRQ-TS, the minimum clinically important difference (53% vs 39%, respectively, P = .05). For domain scores, the intervention group had a lower (reflecting better HRQL) mean than the control group by 4.6 units for Symptoms (P = .046) and by 3.3 units for Impact (P = .049). There was no significant difference in Activities score between the two groups. Compared with the control subjects, intervention participants walked 779 more steps per day at 4 months (P = .005). CONCLUSIONS An Internet-mediated, pedometer-based walking program can improve domains of HRQL and daily step counts at 4 months in people with COPD. TRIAL REGISTRY Clinical Trials.gov; No.: NCT01102777; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Marilyn L Moy
- Department of Veterans Affairs, Rehabilitation Research and Development Service, and the Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Harvard Medical School, Boston, MA
| | | | - Carlos H Martinez
- Pulmonary and Critical Care Division, University of Michigan Health System, Ann Arbor, MI
| | - Reema Kadri
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Pia Roman
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Robert G Holleman
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Hyungjin Myra Kim
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, VA Ann Arbor Healthcare System, Ann Arbor, MI; University of Michigan School of Public Health, Ann Arbor, MI
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - David E Goodrich
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Caroline R Richardson
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Family Medicine, University of Michigan, Ann Arbor, MI.
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15
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Martinez CH, Moy ML, Nguyen HQ, Cohen M, Kadri R, Roman P, Holleman RG, Kim HM, Goodrich DE, Giardino ND, Richardson CR. Taking Healthy Steps: rationale, design and baseline characteristics of a randomized trial of a pedometer-based Internet-mediated walking program in veterans with chronic obstructive pulmonary disease. BMC Pulm Med 2014; 14:12. [PMID: 24491137 PMCID: PMC3946238 DOI: 10.1186/1471-2466-14-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/29/2014] [Indexed: 01/24/2023] Open
Abstract
Background Low levels of physical activity are common in patients with chronic obstructive pulmonary disease (COPD), and a sedentary lifestyle is associated with poor outcomes including increased mortality, frequent hospitalizations, and poor health-related quality of life. Internet-mediated physical activity interventions may increase physical activity and improve health outcomes in persons with COPD. Methods/Design This manuscript describes the design and rationale of a randomized controlled trial that tests the effectiveness of Taking Healthy Steps, an Internet-mediated walking program for Veterans with COPD. Taking Healthy Steps includes an uploading pedometer, a website, and an online community. Eligible and consented patients wear a pedometer to obtain one week of baseline data and then are randomized on a 2:1 ratio to Taking Healthy Steps or to a wait list control. The intervention arm receives iterative step-count feedback; individualized step-count goals, motivational and informational messages, and access to an online community. Wait list controls are notified that they are enrolled, but that their intervention will start in one year; however, they keep the pedometer and have access to a static webpage. Discussion Participants include 239 Veterans (mean age 66.7 years, 93.7% male) with 155 randomized to Taking Healthy Steps and 84 to the wait list control arm; rural-living (45.2%); ever-smokers (93.3%); and current smokers (25.1%). Baseline mean St. George’s Respiratory Questionnaire Total Score was 46.0; 30.5% reported severe dyspnea; and the average number of comorbid conditions was 4.9. Mean baseline daily step counts was 3497 (+/- 2220). Veterans with COPD can be recruited to participate in an online walking program. We successfully recruited a cohort of older Veterans with a significant level of disability including Veterans who live in rural areas using a remote national recruitment strategy. Trial registration Clinical Trials.gov NCT01102777
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Caroline R Richardson
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, 48105 Ann Arbor, MI, USA.
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