Functional Status Following Pulmonary Rehabilitation: Responders and Non-Responders

[Effects of gender on pulmonary rehabilitation outcomes in patients with COPD]

INTRODUCTION

COPD has become more prevalent among women, revealing a specific feminine phenotype. Women experience greater dyspnea and a more impaired quality of life. The main objective of this study was to assess the effect of gender on dyspnea during a pulmonary rehabilitation program (PRP).

METHODS

Retrospective study including COPD patients having participated in PRPs. The following data were analyzed according to gender before and after a PRP: dyspnea, quality of life, anxiety and depression, exercise capacity, muscle function (quadriceps and inspiratory muscles).

RESULTS

More than 500 patients (252 men and 252 women) were included. We did not find a significant effect of gender on the evolution of dyspnea, anxiety or depressive disorders, exercise capacity, inspiratory muscle strength, or overall quality of life score. That said, we found a possible effect on the sub-scores of the quality of life questionnaire, and regarding quadriceps strength. All criteria improved during the program in both groups.

CONCLUSIONS

During a PRP, gender does not impact the evolution of dyspnea. While women may nonetheless benefit to a greater extent in terms of quality of life sub-scores (impact, activities, symptoms) and quadriceps strength, these results still require confirmation.

Functional capacity using sit-to-stand tests in people with chronic obstructive pulmonary disease and its relationship with disease severity-a cross-sectional study with matched controls

BACKGROUND

Functional capacity impairment is a crucial consequence of chronic obstructive pulmonary disease (COPD). Although it can be identified with simple tests, such as the sit-to-stand tests, its prevalence, relation with disease severity, and the characteristics of people presenting this impairment remain unknown.

OBJECTIVE

To explore the functional capacity of people with COPD.

METHODS

A cross-sectional study with people with COPD and age-/sex-matched healthy controls was conducted. Functional capacity was assessed with the 5-repetitions (5-STS) and the 1-minute (1-minSTS) sit-to-stand tests. People with COPD were grouped according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifications. Comparisons between people with COPD and healthy controls, and among GOLD groups were established. Associations between symptoms, muscle strength, quality of life, and measures of functional capacity were explored.

RESULTS

302 people with COPD [79% male; mean (SD) 68 (10) years old] and 304 healthy controls [75% male; 66 (9) years old] were included. 23% of people with COPD presented impairment in the 5-STS and 33% in the 1-minSTS. People with COPD from all GOLD classifications presented significantly lower functional capacity than healthy controls (5-STS: COPD median [1st quartile; 3rd quartile] 8.4 [6.7; 10.6] versus healthy 7.4 [6.2; 9.3] s; 1-minSTS: COPD 27 [21; 35] vs healthy 35 [29; 43] reps). Correlations with symptoms, muscle strength, and quality of life were mostly weak (5-STS: rs [-0.34; 0.33]; 1-minSTS: rs [-0.47; 0.40]).

CONCLUSION

People with COPD have decreased functional capacity independently of their GOLD classifications. The prevalence of functional impairment is 23-33%. Because impaired functional capacity is a treatable trait not accurately reflected by other outcomes, comprehensive assessment and management is needed.

Effects of Combined Endurance and Resistance Eccentric Training on Muscle Function and Functional Performance in Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

OBJECTIVE

To evaluate the adherence to treatment and efficacy of an eccentric-based training (ECC) program on peripheral muscle function and functional exercise capacity in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Prospective, assessor-blinded, randomized controlled trial.

SETTING

The cardiopulmonary rehabilitation unit of a tertiary subacute referral center.

PARTICIPANTS

Thirty (N=30) stable inpatients (mean age 68±8 years; FEV1 44±18% of predicted) with COPD were included in the study.

INTERVENTIONS

Inpatients were randomly assigned to 4 weeks of a combined endurance and resistance ECC (n=15) or conventional training (CON; n=15).

MAIN OUTCOME MEASURES

Quadriceps peak torque (PT) was the primary outcome measure for muscle function. Rate of force development (RFD), muscle activation and quality (quadriceps PT/leg lean mass), 6-min walk distance (6MWD), 4-meter gait speed (4mGS), 10-meter gait speed, 5-repetition sit-to-stand (5STS), dyspnea rate, and mortality risk were the secondary outcomes. Evaluations were performed at baseline and repeated after 4 weeks and 3 months of follow-up.

RESULTS

Quadriceps PT, RFD, and muscle quality improved by 17±23% (P<.001), 19±24%, and 16±20% (both P<.05) within the ECC group. Besides, a significant between-group difference for RFD (56±94 Nm/s, P=.038) was found after training. Both groups showed clinically relevant improvements in 6MWD, 4mGS, dyspnea rate, and mortality risk, with no significant differences between groups.

CONCLUSION

Combined endurance and resistance ECC improved lower limbs muscle function compared with CON in inpatients with COPD. In contrast, ECC did not further improve functional performance, dyspnea, and mortality risk. ECC may be of particular benefit to effect on skeletal muscle function in patients with COPD.

The intersection of HIF-1α, O-GlcNAc, and skeletal muscle loss in chronic obstructive pulmonary disease

Sarcopenia, defined as the loss of muscle mass and strength, is a major cause of morbidity and mortality in COPD (chronic obstructive pulmonary disease) patients. However, the molecular mechanisms that cause sarcopenia remain to be determined. In this review, we will highlight the unique molecular and metabolic perturbations that occur in the skeletal muscle of COPD patients in response to hypoxia, and emphasize important areas of future research. In particular, the mechanisms related to the glycolytic shift that occurs in skeletal muscle in response to hypoxia may occur via a hypoxia-inducible factor 1-alpha (HIF-1α)-mediated mechanism. Upregulated glycolysis in skeletal muscle promotes a unique post-translational glycosylation of proteins known as O-GlcNAcylation, which further shifts metabolism toward glycolysis. Molecular changes in the skeletal muscle of COPD patients are associated with fiber-type shifting from Type I (oxidative) muscle fibers to Type II (glycolytic) muscle fibers. The metabolic shift toward glycolysis caused by HIF-1α and O-GlcNAc modified proteins suggests a potential cause for sarcopenia in COPD, which is an emerging area of future research.

Predictors of Success of Inpatient Pulmonary Rehabilitation Program in COPD Patients

Purpose

Pulmonary rehabilitation programs (PR) are an important part of the comprehensive treatment of patients with chronic pulmonary diseases. Patients respond individually to PR. The aim of this study is to identify potential predictors of success of PR to recognise patients who benefit most and to uncover possible reasons for poor response to PR.

Patients and Methods

We included 121 patients with chronic obstructive pulmonary disease (COPD) who completed our 4-week inpatient PR without any exacerbations of disease during PR that could potentially affect PR outcomes. Improvement in distance of ≥30 m on the 6-minute walk test (6MWT) after PR was chosen as a primary marker of physical success. Ninety-one patients achieved improvement of ≥30 m on the 6MWT and were thus considered good responders, and 30 patients were poor responders with improvement in the distance of <30 m on the 6MWT.

Results

We compared baseline clinical characteristics, medication, lung function, physical capacity, body composition, and laboratory blood tests between groups of good and poor responders. The most prominent differences between groups were associated with differences in baseline body composition and erythrocyte-related parameters. Good responders had significantly lower body water content (p = 0.042) and higher body weight (p = 0.036), body fat content (p = 0.049), dry lean mass (p = 0.021), haemoglobin levels (p = 0.040), erythrocyte count (p = 0.017), haematocrit (p = 0.030) and iron level (p = 0.028).

Conclusion

A more muscular body composition and a higher ability to transport oxygen from the blood to the muscles could be beneficial for the outcome of PR.

Pulmonary telerehabilitation vs. conventional pulmonary rehabilitation - a secondary responder analysis

Home-based pulmonary telerehabilitation (PTR) has been proposed to be equivalent to supervised outpatient pulmonary rehabilitation (PR) but available randomised trials have failed to reach the minimal important changes (MIC). The purpose of this study was to analyse the proportion of MIC responders and non-responders on short-term (10 weeks from baseline) and long-term (62 weeks from baseline) in total and between groups in 134 patients with COPD randomised (1:1) to either home-based PTR or traditional hospital-based outpatient PR. Difference between PTR and PR on 6MWD response proportion could not be shown at 10 (OR=0.72, CI=0.34 to 1.51, p=0.381) or 62 weeks (OR=1.12, CI=0.40 to 3.14, p=0.834). While the evidence and knowledge of PTR accumulate, outpatient supervised PR for now remains the standard of care, with home-based PTR as a strong secondary option for those unable to attend out-patient programmes.

Airflow grades, outcome measures and response to pulmonary rehabilitation in individuals after an exacerbation of severe chronic obstructive pulmonary disease

BACKGROUND

Individuals with COPD may be staged according to symptoms and exacerbation history (GOLD groups: A-D) and on airflow obstruction (GOLD grades: 1-4). Guidelines recommend pulmonary rehabilitation (PR) for these individuals, including those recovering from an exacerbation (ECOPD) OBJECTIVE: To evaluate whether in individuals with clinically severe COPD, recovering from an ECOPD, the effect size of an in-hospital PR program would be affected by airflow severity grades and assessed outcome measures.

METHODS

Retrospective, multicentre study. Participants were compared according to different GOLD airflow grades. In addition to the MRC dyspnoea scale, six-minute walking distance test and COPD assessment test (CAT), Barthel dyspnoea index (Bid), and Short Physical Performance Battery (SPPB) were assessed, evaluating the proportion of individuals reaching the minimum clinically important difference (MCID) (responders).

RESULTS

Data of 479 individuals, completing the program were evaluated. Most of the participants were allocated in GOLD grades 4, (57.6%) and 3 (22.1%). All outcome measures significantly improved after PR (p < 0.05), without any significant difference in the proportion of responders in any measure.

CONCLUSIONS

in individuals with severe COPD, recovering from ECOPD the success rate of PR does not depend on airflow severity, or outcome measure assessed. In addition to the most used outcome measures, also Bid and SPPB are sensitive to PR.

The presence of extra-pulmonary treatable traits increases the likelihood of responding to pulmonary rehabilitation

INTRODUCTION

Studies suggest that people with chronic obstructive pulmonary disease (COPD) who are worse at baseline respond better to pulmonary rehabilitation (PR). Identifying treatable traits (TTs) may help to distinguish responders from non-responders. We explored the impact of PR on extra-pulmonary traits of people with COPD and whether the presence of TT influences the type of response to PR.

METHODS

A comprehensive assessment of 9 TT including symptoms (dyspnoea, fatigue, anxiety and depression), functional capacity, deconditioning, balance, impact of the disease and health-related quality of life was conducted before and after a 12-week community-based PR programme. Pre-post differences between people with or without each TT at baseline were compared with independent samples t-tests or Mann-Whitney U tests. Proportion of responders between groups were explored with chi-square tests and odds ratio.

RESULTS

102 people with COPD were included (70 [65; 75] years old, 78% male, FEV₁ 47 [36; 60] %predicted). They had a median of 3 (out of 9) TTs per person and each patient responded on average to 5 (out of 9) outcomes of PR. People with TT were more responsive than those without them in all outcomes (p < 0.05) except for the 1-min sit-to-stand test. The presence of TT increased 4 to 20 times the likelihood of being a good responder.

CONCLUSIONS

Identification of baseline extra-pulmonary TT in people with COPD showed the potential to inform on PR responsiveness and might therefore be an important strategy for patient prioritization, treatment personalisation (i.e., activation of the most suitable components) and optimisation.

International perspectives on outcome measurement in pulmonary rehabilitation of people with COPD: A qualitative study

BACKGROUND

There is high heterogeneity of outcomes and measures reported in the literature for pulmonary rehabilitation (PR), which might limit benchmarking and an effective evidence synthesis. A core outcome set (COS) can minimise this problem. It is however unclear which outcomes and measures are most important and suitable for different stakeholders.

METHODS

A multicentre qualitative study with one-to-one semi-structured interviews with people with chronic obstructive pulmonary disease (COPD), healthcare professionals (HCPs), researchers and policy makers was conducted. Manifest content analysis was conducted to explore the frequency of outcomes viewed as crucial or not. Thematic analysis was performed to better understand stakeholders' views.

RESULTS

37 participants (17 people with COPD and 20 HCPs/researchers/policy makers) from 14 countries and 4 continents were included. Participants expressed that i) core outcomes need to be meaningful to people with COPD and show PR benefits; ii) there should be comprehensive assessment and similar outcomes across settings; iii) a balance between optimal and practical measures is needed; iv) the COS is needed to benchmark PR and advance knowledge; and v) reluctance to change outcomes/measures used by HCPs and using the COS as a maximum set of outcomes might be the pitfalls. 28 outcomes were identified as crucial, and 12 as not crucial.

CONCLUSIONS

This study provided important insights into outcome measurement in PR from the perspectives of different key international stakeholders and a list of outcomes that will inform a future consensus study.

Monthly Follow-Ups of Functional Status in People with COPD: A Longitudinal Study

Functional status is an important and meaningful outcome in people with chronic obstructive pulmonary disease (COPD), although its measurement is not embedded in routine clinical assessments. This study described the functional status of people with COPD using the 1-min sit-to-stand test (1minSTS) over a 6-month period and the examined sociodemographic and clinical characteristics associated with this outcome. Data from a prospective study including people with COPD were analyzed. Functional status was assessed monthly with the 1minSTS over 6 months. Linear-mixed effect models assessed the 1minSTS number of repetitions mean change. One-hundred and eight participants (82.4% men; 66.9 ± 9.5 years) were included. A significantly lower number of repetitions in the 1minSTS over the 6-month period was associated with being female (estimate: −4.69, 95%CI: −8.20; −1.18), being older (estimate: −0.56, 95%CI: −0.77; −0.34), having higher BMI (estimate: −0.55, 95%CI: −0.81; −0.28) and having higher activity-related dyspnea (estimate: −2.04, 95%CI: −3.25; −0.83). Half of the participants showed improvements above three repetitions in the 1minSTS over the 6-month period, independently of their baseline impairment (1minSTS < 70% predicted: 52.5%; ≥70% predicted: 54.4%). To conclude, monthly follow-up assessments were associated with clinically relevant benefits in the functional status of people with COPD. Age, body composition, and activity-related dyspnea were the main predictors of functional status over time. Further research is needed to corroborate our findings and to support the beneficial effects of regular COPD monitoring.

Efficacy of Acupuncture on Quality of Life, Functional Performance, Dyspnea, and Pulmonary Function in Patients with Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial

Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterized by the presence of chronic airflow obstruction. Previous studies have evaluated the effect of acupuncture treatment (AT) in patients with COPD. Nevertheless, these studies show a great deal of heterogeneity in treatment protocols, having sample sizes that are too small to estimate and clarify effect size and heterogeneity in patients’ baseline. The aim of this study is to evaluate the effectiveness of acupuncture on quality of life, functional performance, dyspnea, and pulmonary function in patients with COPD. As such, patients will go through the following three phases: Phase I–pretreatment: period of subject selection and inclusion in the protocol, with an interview and performance of exams and tests as follows: Mini-Cog, dual-energy X-ray absorptiometry, spirometry, the Patient-Generated Index, Saint George’s Respiratory Questionnaire, the six-minute walk test, the London Chest Activity of Daily Living, and the COPD Assessment Test. Phase II–8 weeks of treatment, with AT 3 times a week, with two parallel groups: Group I–with 50 subjects–AT according to the recommended technical standards; Group II–with 50 subjects–Control, without acupuncture. Phase III–Continuation of AT for 8 weeks, maintaining the subjects in the previously allocated groups and following the same methodology.