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Revitt O, Sewell L, Morgan MDL, Steiner M, Singh S. Short outpatient pulmonary rehabilitation programme reduces readmission following a hospitalization for an exacerbation of chronic obstructive pulmonary disease. Respirology 2014; 18:1063-8. [PMID: 23734624 DOI: 10.1111/resp.12141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 11/17/2012] [Accepted: 03/15/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE The benefits of pulmonary rehabilitation (PR) are now firmly established. However, less is known about the provision and efficacy of PR immediately after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The study aimed to explore the effectiveness of a short outpatient PR programme and the impact upon readmission rates. METHODS One hundred sixty (87 males) patients, mean (SD) age 70.35 (8.59) years, forced expiratory volume in 1 s 0.99 (0.44) litres were assessed for a 7-week PR programme following a hospital admission for an acute exacerbation of COPD. Patients were assessed and commenced PR within 4 weeks of discharge from hospital. Outcome measures included: Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire Self-Reported (CRQ-SR). Patients were assessed at baseline and at 7 weeks (after the 4-week supervised and 3-week unsupervised components). Readmission data were collected retrospectively for the 12 months pre and post admission (n = 155). RESULTS Statistically significant improvements were found in the ISWT, ESWT and CRQ-SR at discharge (P < 0.05). The number of admission was significantly less in the 12-month post-pulmonary rehabilitation compared to the previous 12 months. CONCLUSIONS A short course of PR showed improvements in exercise capacity and health status in patients who have had an acute exacerbation of COPD. The number of readmissions was also significantly lower in the year following PR.
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Affiliation(s)
- Olivia Revitt
- Pulmonary Rehabilitation Research Group, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
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Abstract
The systemic effects and comorbidities of chronic respiratory disease such as COPD contribute substantially to its burden. Symptoms in COPD do not solely arise from the degree of airflow obstruction as exercise limitation is compounded by the specific secondary manifestations of the disease including skeletal muscle impairment, osteoporosis, mood disturbance, anemia, and hormonal imbalance. Pulmonary rehabilitation targets the systemic manifestations of COPD, the causes of which include inactivity, systemic inflammation, hypoxia and corticosteroid treatment. Comorbidities are common, including cardiac disease, obesity, and metabolic syndrome and should not preclude pulmonary rehabilitation as they may also benefit from similar approaches.
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Affiliation(s)
- Rachael A Evans
- Department of Respiratory Medicine, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Michael D L Morgan
- Department of Respiratory Medicine, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
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Harvey-Dunstan TC, Singh SJ, Steiner MC, Morgan MDL, Evans RA. P39 A comparison of the repeatability and responsiveness of field and laboratory incremental exercise tests between COPD and Chronic Heart Failure. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Bafadhel M, Greening NJ, Harvey-Dunston T, Williams J, Morgan MDL, Hussain F, Pavord L, Singh SJ, Steiner MC. S26 Severe hospitalised exacerbations of COPD with an eosinophilic phenotype have favourable outcomes with prednisolone therapy: sub-analysis from a prospective multi-centre randomised control trial. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Morgan MDL. Inferring the quality of hospital treatment for COPD by mortality; caution is needed. Thorax 2013; 68:897-8. [DOI: 10.1136/thoraxjnl-2013-203717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Morgan MDL. Book Review: Functional Respiratory Disorders. Chron Respir Dis 2013. [DOI: 10.1177/1479972313485459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Evans RA, Singh SJ, Collier R, Loke I, Steiner MC, Morgan MDL. Generic, symptom based, exercise rehabilitation; integrating patients with COPD and heart failure. Respir Med 2010; 104:1473-81. [PMID: 20650624 DOI: 10.1016/j.rmed.2010.04.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 04/23/2010] [Accepted: 04/26/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with Chronic Heart Failure (CHF) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD. Although pulmonary (exercise based) rehabilitation (PR) is an integral part of the management of COPD, the potential for exercise rehabilitation (ER) to assist patients with CHF may not be as readily appreciated. We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR. METHODS 57 patients with CHF were randomized 2:1 to 7 weeks ER (CHF-ER) or 7 weeks of usual care (CHF-UC). As a comparator 55 patients with COPD were simultaneously recruited to the same ER program (COPD-ER). The primary outcome measure was the Incremental Shuttle Walk Test (ISWT) and the secondary outcome measures were the Endurance Shuttle Walk Test (ESWT), isometric quadriceps strength and health status. RESULTS 27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC. The CHF-ER group made significant improvements, compared to CHF-UC, in the mean (95%CI) ISWT distance; 62(35-89)m vs -6(-11 to 33)m p < 0.001. The CHF-ER group also made statistically significant improvements in health status. The improvements in exercise performance and health status were similar between patients with CHF and COPD, treated with ER. CONCLUSION Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD. Combined training programs for COPD and CHF are effective and feasible, such that service provision could be targeted around common disability rather than the primary organ disease.
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Affiliation(s)
- R A Evans
- Dept. of Respiratory Medicine, Allergy and Thoracic Surgery, University Hospitals of Leicester NHS trust, Glenfield Hospital, Leicester, United Kingdom.
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Oey IF, Morgan MDL, Spyt TJ, Waller DA. Staged bilateral lung volume reduction surgery - the benefits of a patient-led strategy. Eur J Cardiothorac Surg 2009; 37:846-52. [PMID: 19955000 DOI: 10.1016/j.ejcts.2009.10.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 10/12/2009] [Accepted: 10/19/2009] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Lung volume reduction surgery (LVRS) is conventionally a one-staged bilateral operation. We hypothesised that a more conservative staged bilateral approach determined by the patient not the surgeon would reduce operative risk and prolong the overall benefit. METHODS In a population of 114 consecutive patients who were identified as suitable for bilateral LVRS an initial cohort of 26 patients (15 male; 11 female, median age: 58 years) underwent one-staged bilateral surgery: 18 by median sternotomy and eight by video-assisted thoracoscopic surgery (VATS) (group OB). A subsequent cohort of 88 patients had unilateral VATS LVRS with the contralateral operation not scheduled until the patient requested this. Longitudinal follow-up included analysis of lung function, health status (SF 36) and survival. RESULTS At a median follow-up of 2.8 (range: 0-9.9) years, staged bilateral LVRS was performed in 16 patients (10 male; 6 female, median age: 59 years) (group SB) at a median interval of 3.9 (range: 0.7-5.9) years after the first operation. Unilateral LVRS has been performed in 73 patients (43 male; 30 female, median age: 60 years) (group U). There were significant improvements in forced expiratory volume in 1s (FEV1) for 6 months in groups OB and U; in group SB there was a second improvement at 4 years (p<0.05). There were significant reductions in residual volume (RV) and total lung capacity (TLC) in groups OB and U for 2 years; in group SB there was a further significant reduction lasting up to 6 years in TLC (p<0.05) and RV (p<0.01). There were significant improvements in health status lasting up to 1 year in groups OB and U. However, in group SB these improvements lasted for 4 years in the domain of physical functioning and 6 years in the domains of social functioning and energy/vitality. There was no significant difference (p=0.07) in 30-day mortality among groups OB (7.7%), SB (13%) and U (4.1%). Similarly, there was no difference between groups OB and SB/U in 3-year survival (81% vs 77%) or 5-year survival (54% vs 66%). CONCLUSION A staged bilateral approach to LVRS dictated by patients' perception of their condition appears to lead to a more prolonged overall benefit than one-staged LVRS without compromising survival.
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Affiliation(s)
- Inger F Oey
- Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester, LE3 9QP, UK.
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Affiliation(s)
- MDL Morgan
- Department of Respiratory Medicine University Hospitals of Leicester Glenfield Hospital Leicester
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Abstract
BACKGROUND The incremental shuttle walking test (ISWT) is used to assess exercise capacity in patients with chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. This study was designed to establish the minimum clinically important difference for the ISWT. METHODS 372 patients (205 men) performed an ISWT before and after a 7-week outpatient pulmonary rehabilitation programme. After completing the course, subjects were asked to identify, from a 5-point Likert scale, the perceived change in their exercise performance immediately upon completion of the ISWT. The scale ranged from "better" to "worse". RESULTS The mean (SD) age was 69.4 (8.4) years, forced expiratory volume in 1 s (FEV(1)) 1.06 (0.53) l and FEV(1)/forced vital capacity (FVC) ratio 50.8 (18.1)%. The baseline shuttle walking test distance was 168.5 (114.6) m which increased to 234.7 (125.3) m after rehabilitation (mean difference 65.9 m (95% CI 58.9 to 72.9)). In subjects who felt their exercise tolerance was "slightly better" the mean improvement was 47.5 m (95% CI 38.6 to 56.5) compared with 78.7 m (95% CI 70.5 to 86.9) in those who reported that their exercise tolerance was "better" and 18.0 m (95% CI 4.5 to 31.5) in those who felt their exercise tolerance was "about the same". CONCLUSION Two levels of improvement were identified. The minimum clinically important improvement for the ISWT is 47.5 m. In addition, patients were able to distinguish an additional benefit at 78.7 m.
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Affiliation(s)
- S J Singh
- Pulmonary Rehabilitation Research Group, Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester LE3 9QP, UK.
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Sewell L, Singh SJ, Williams JEA, Collier R, Morgan MDL. How long should outpatient pulmonary rehabilitation be? A randomised controlled trial of 4 weeks versus 7 weeks. Thorax 2006; 61:767-71. [PMID: 16449270 PMCID: PMC2117104 DOI: 10.1136/thx.2005.048173] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The evidence of benefit for pulmonary rehabilitation (PR) programmes is established. However, the optimal duration of a PR programme is not known. A randomised controlled trial was undertaken in patients with chronic obstructive pulmonary disease (COPD) to assess whether a 4 week PR programme was equivalent to our conventional 7 week PR programme at equivalent time points of 7 weeks and 6 months. METHODS One hundred patients (56 men) with stable COPD of mean (SD) age 70 (8) years and forced expiratory volume in 1 second (FEV1) 1.13 (0.50) litres were randomised to either a 7 week (n = 50) or 4 week (n = 50) supervised PR programme. Patients were assessed at baseline, at completion of the supervised PR programme, and 6 months later. Patients randomised to the 4 week group were also assessed at the 7 week time point. Outcome measures were the Incremental Shuttle Walk Test, Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire-Self Reported, and the Breathing Problems Questionnaire. RESULTS Forty one patients in each group completed the PR programme. Patients made significant within group improvements after supervised rehabilitation. There were no statistically significant differences between the groups for any other measure at the 7 week or 6 month time points, except that patients in the 4 week group attained higher ESWT times (mean difference 124 seconds (95% CI 17.00 to 232.16), p = 0.024) at the 7 week time point. CONCLUSIONS A shortened 4 week supervised PR programme is equivalent to a 7 week supervised PR programme at the comparable time points of 7 weeks and 6 months.
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Affiliation(s)
- L Sewell
- Pulmonary Rehabilitation Research Group, Institute for Lung Health, Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK.
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Abstract
BACKGROUND Little information exists about the pattern of daily activity in patients with chronic obstructive pulmonary disease (COPD), especially in those who are on long-term oxygen therapy (LTOT). The aim of this study was to explore the regular level of domestic physical activity in patients with COPD and to explore differences in activity in those on LTOT. METHODS Daily activity was recorded using an activity monitor for 7 consecutive days in 4 groups. Group 1 had severe COPD (FEV1 0.66 [0.42] L) receiving LTOT (n = 9). Group 2 had severe COPD (FEV1 1.07 [0.43] L) and had full knowledge of the activity monitor and the purpose of the study (n = 10). Group 3 had severe COPD (FEV1 1.16 [0.27] L) but were unaware of the precise nature of the study (n = 10). Group 4 (n = 10) were the healthy control group. Participants also completed health status questionnaires. RESULTS There were statistically significant differences in the level of daily activity between all groups (P < .001) except between groups 2 and 3. There were no significant differences between days within groups. The activity counts compared to the healthy groups were reduced by 49% in groups 2 and 3 and by 79% in those on LTOT. CONCLUSION Patients with COPD demonstrate reduced levels of spontaneous physical activity compared with healthy controls. Furthermore, patients receiving LTOT have an even lower level of domestic activity compared with that of those not on LTOT but with COPD of similar severity.
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Affiliation(s)
- C J Sandland
- Institute for Lung Health, Department of Pulmonary Rehabilitation, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK.
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Sewell L, Singh SJ, Williams JEA, Collier R, Morgan MDL. [Can individualized rehabilitation improve functional independence in elderly patients with COPD?]. Rev Port Pneumol 2005; 11:593-6. [PMID: 16514719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
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Sewell L, Singh SJ, Williams JEA, Collier R, Morgan MDL. Can Individualized Rehabilitation Improve Functional Independence in Elderly Patients With COPD? Chest 2005; 128:1194-200. [PMID: 16162706 DOI: 10.1378/chest.128.3.1194] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The aims of this study were to establish whether pulmonary rehabilitation (PR) improves domestic function and daily activity levels in COPD and whether individually targeted exercise is more effective than general exercise. DESIGN Prospective randomized, controlled trial. SETTING Outpatient PR program in secondary care. PARTICIPANTS One-hundred eighty patients (mean [+/-SD] age, 68.3 +/- 8.6 years; FEV1, 0.95 +/- 0.4 L; FEV1/FVC ratio, 0.51 +/- 0.15; 111 male patients; 69 female patients) with stable COPD. One hundred twenty-one patients completed the study. INTERVENTIONS Patients were randomized to a conventional 7-week general exercise program ([GEP] n = 90) or an individually targeted exercise program ([ITEP] n = 90). MEASUREMENT AND RESULTS Daily activity was measured using ambulatory activity monitors (Z80 -32k V1 Int; Gaehwiler Electronics; Hombrechtikon, Switzerland). These were lightweight devices, which contained a uniaxial accelerometer. Domestic function was assessed by the Canadian Occupational Performance Measure (COPM). Exercise performance was assessed by the incremental shuttle walk test (ISWT) and the endurance shuttle walk test and health status by the chronic respiratory questionnaire-self-reported. Activity monitor counts increased by 29.18% (95% confidence interval [CI], 3.19 to 55.17; p = 0.03) for the GEP and 40.63% (95% CI, 7.42 to 73.83; p = 0.02) for the ITEP. Mean COPM performance scores increased by 1.71 (95% CI, 1.37 to 2.05; p = 0.0001) for the GEP and 1.46 (95% CI, 1.05 to 1.87; p = 0.0001) for the ITEP. Mean COPM satisfaction scores increased by 2.27 (95% CI, 1.74 to 2.81; p = 0.0001) for the GEP and 2.04 (95% CI, 1.56 to 2.52; p = 0.0001) for the ITEP. ISWT scores increased by 81.72 m (range, 63.83 to 99.62) for the GEP and by 85.52 m (range, 67.62 to 103.42) for the ITEP. No statistically significant difference was found between the general exercise group and the individually targeted exercise group for any outcome measure. CONCLUSIONS Pulmonary rehabilitation improves domestic function and physical activity. This study also demonstrates that general exercise training is as effective as individually targeted training.
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Affiliation(s)
- Louise Sewell
- Institute for Lung Health, Department of Respiratory Medicine and Thoracic Surgery, Occupational Therapist Pulmonary Rehabilitation Research Group, Glenfield Hospital, Leicester, United Kingdom.
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Steiner MC, Evans R, Deacon SJ, Singh SJ, Patel P, Fox J, Greenhaff PL, Morgan MDL. Adenine nucleotide loss in the skeletal muscles during exercise in chronic obstructive pulmonary disease. Thorax 2005; 60:932-6. [PMID: 16055624 PMCID: PMC1747228 DOI: 10.1136/thx.2004.038802] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Skeletal muscle adenine nucleotide loss has been associated with fatigue during high intensity exercise in healthy subjects but has not been studied in patients with chronic obstructive pulmonary disease (COPD). Changes in adenine nucleotides and other metabolites in the skeletal muscles were measured in patients with COPD and age matched healthy volunteers by obtaining biopsy samples from the quadriceps muscle at rest and following a standardised exercise challenge. METHODS Eighteen patients with COPD (mean (SD) forced expiratory volume in 1 second 38.1 (16.8)%) and eight age matched healthy controls were studied. Biopsy samples were taken from the vastus lateralis muscle at rest and immediately after a 5 minute constant workload cycle test performed at 80% peak work achieved during a maximal incremental cycle test performed previously. RESULTS The absolute workload at which exercise was performed was substantially lower in the COPD group than in the controls (56.7 (15.9) W v 143.2 (26.3) W, p<0.01). Despite this, there was a significant loss of adenosine triphosphate (mean change 4.3 (95% CI -7.0 to -1.6), p<0.01) and accumulation of inosine monophosphate (2.03 (95% CI 0.64 to 3.42), p<0.01) during exercise in the COPD group that was similar to the control group (-4.8 (95% CI -9.7 to 0.08), p = 0.053 and 1.6 (95% CI 0.42 to 2.79), p<0.01, respectively). CONCLUSIONS These findings indicate that the ATP demands of exercise were not met by resynthesis from oxidative and non-oxidative sources. This suggests that significant metabolic stress occurs in the skeletal muscles of COPD patients during whole body exercise at low absolute workloads similar to those required for activities of daily living.
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Affiliation(s)
- M C Steiner
- Institute for Lung Health, Department of Respiratory Medicine, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
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Steiner MC, Singh SJ, Morgan MDL. The Contribution of Peripheral Muscle Function to Shuttle Walking Performance in Patients With Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2005; 25:43-9. [PMID: 15714112 DOI: 10.1097/00008483-200501000-00010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The contribution of muscle strength and mass to incremental and endurance walking performance in chronic obstructive pulmonary disease (COPD) is unknown. This study analyzes the relationship between field incremental and endurance walking performance and indices of peripheral muscle mass and strength. METHODS Eighty-five stable COPD patients (53 males; mean [SD] age = 67 [9] years; mean [SD] forced expiratory volume in 1 second [FEV1] = 35 [14] [% predicted]) were studied prior to participation in pulmonary rehabilitation. Isometric quadriceps and handgrip strength were measured. Total body and lower limb lean muscle mass were estimated using dual energy x-ray absorptiometry. Exercise performance was measured using the incremental shuttle walk test (ISWT) and the endurance (ESWT) shuttle walk test. RESULTS ISWT was related to muscle strength (r = 0.467, P </= .001) but not to whole body or lower limb lean mass. There was no association between muscle strength or mass and ESWT. In a multivariate linear regression analysis, the only variables significantly contributing to ISWT were age (P < .001), FEV1 (% predicted) (P < .001) and quadriceps strength (P < .001). Variables contributing to ESWT were FEV1 (% predicted) (P < .001) and ISWT performance (P < .001). CONCLUSIONS We conclude that muscle strength is related to incremental but not endurance shuttle walking performance. Muscle mass and strength are not synonymous in their effects on exercise performance in patients with COPD.
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Affiliation(s)
- Michael C Steiner
- Institute for Lung Health, Department of Respiratory Medicine, Glenfield Hospital, Leicester, UK.
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Oey IF, Bal S, Spyt TJ, Morgan MDL, Waller DA. The increase in body mass index observed after lung volume reduction may act as surrogate marker of improved health status. Respir Med 2004; 98:247-53. [PMID: 15002761 DOI: 10.1016/j.rmed.2003.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the effects of lung volume reduction surgery (LVRS) on body mass index (BMI). METHODS Prospective data was collected on a series of 63 patients undergoing LVRS (bilateral in 22 patients, unilateral in 41 patients). Median age was 58 (41-70) years. The peri-operative effects of LVRS on BMI, lung function and health status (assessed by SF 36 questionnaire) were recorded at 3, 6, 12 and 24 months. RESULTS We found an overall increase in BMI after LVRS, which was significant up to 2 years. These changes correlated with the changes in FEV1 (R = 0.3, P < 0.01 6 months after LVRS) and diffusing capacity for carbon monoxide (DLCO) (R = 0.5, P < 0.01 6 months after LVRS). At 6 months, when the best results in health status were found, the patients were divided in a responders group (improved SF 36 score) and a non-responders group (same or worse SF 36 score) for each of the 8 domains of the SF 36. In 6 domains the non-responders showed no increase in BMI. In 6 domains the responders showed a significant increase in BMI. CONCLUSION LVRS significantly improves postoperative BMI, which correlates with improvements in DLCO and reflects changes in health status.
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Affiliation(s)
- Inger F Oey
- Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester LE3 9QP, UK.
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Abstract
OBJECTIVES To correlate the long-term changes in respiratory physiology, body mass index (BMI) and health status after lung volume reduction surgery (LVRS). PATIENTS/METHODS From 1995 to 2002 77 patients; 48 male: 29 female, median age 59 (41-72) years, have undergone LVRS (simultaneous bilateral in 27; staged bilateral in 3; unilateral in 47). FEV(1), total lung capacity (TLC), residual volume (RV) and RV/TLC ratio were measured preoperatively and at 3 months, 6 months, 1 year, 2 years, 3 years and 4 years post surgery. At the same time interval health status was assessed by Euroquol and Short Form 36 (SF 36) questionnaires. Seventeen patients have died within 4 years of their operation (30 day mortality 5%). RESULTS The changes in FEV(1) are only significantly improved for 1 year post LVRS, while the improvements in TLC and RV remain significant up to 3 years postoperatively. The improvements in BMI also persist for 3 years. The best scores in Euroquol and SF 36 are obtained 6 months after LVRS but are only significantly improved up to 1 year. CONCLUSION The physiological effects of volume LVRS are lasting but initial improvements in health status decline more rapidly.
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Affiliation(s)
- Inger F Oey
- Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
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Oey IF, Morgan MDL, Waller DA. Postoperative pain detracts from early health status improvement seen after video-assisted thoracoscopic lung volume reduction surgery☆. Eur J Cardiothorac Surg 2003; 24:588-93. [PMID: 14500079 DOI: 10.1016/s1010-7940(03)00433-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess the impact of lung volume reduction surgery (LVRS) on postoperative pain. METHODS Fifty-two patients, 34 male/18 female, median age 59 (46-70) years, underwent unilateral video-assisted thoracoscopic (VAT) LVRS. FEV(1), TLC, RV and RV/TLC ratio were assessed preoperatively and at 3, 6, 12 and 24 months post surgery. At the same time interval health status was assessed by Euroquol and SF 36 questionnaires. RESULTS Significant improvements in health status, as assessed by SF 36, persisted from 3 months to 1 year. However, in the pain domain there was a worsening of the mean score from 74 preoperatively to 64 at 3 months, 68 at 6 months, 73 at 12 months and 65 at 24 months. The improvements in Euroquol score were not statistically significant. However, they became significant for at least 2 years postoperatively, when those patients who had a worsening pain score postoperatively were excluded. While the percentage of patients with a worsening of pain scores measured with SF 36 remained between 40 and 45% even 2 years after LVRS, when using Euroquol this percentage did decrease from 30% at 3 months to 14% at 2 years. There was no significant correlation between the change of scores and length of operation, hospital stay or air leak. It was also not statistically significant whether these patients had an extra procedure (redo thoracotomy or insertion of extra drain postoperatively). There were some significant correlations between changes in hyperinflation and changes in pain scores but this was not consistent for Euroquol and SF 36. CONCLUSION Postoperative pain detracts from global improvement in health status after LVRS even after unilateral VATS. There may be an influence of alterations in chest mechanics after surgery on the development of pain.
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Affiliation(s)
- I F Oey
- Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester LE3 9QP, UK
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Steiner MC, Barton RL, Singh SJ, Morgan MDL. Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial. Thorax 2003; 58:745-51. [PMID: 12947128 PMCID: PMC1746806 DOI: 10.1136/thorax.58.9.745] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Pulmonary rehabilitation is effective in improving exercise performance and health status in chronic obstructive pulmonary disease (COPD). However, the role of nutritional support in the enhancement of the benefits of exercise training has not been explored. A double blind, randomised, controlled trial of carbohydrate supplementation was undertaken in patients attending outpatient pulmonary rehabilitation. METHODS 85 patients with COPD were randomised to receive a 570 kcal carbohydrate rich supplement or a non-nutritive placebo daily for the duration of a 7 week outpatient pulmonary rehabilitation programme. Primary outcome measures were peak and submaximal exercise performance using the shuttle walk tests. Changes in health status, body composition, muscle strength, and dietary macronutrient intake were also measured. RESULTS Patients in both the supplement and placebo groups increased shuttle walking performance and health status significantly. There was no statistically significant difference between treatment groups in these outcomes. Patients receiving placebo lost weight whereas supplemented patients gained weight. In well nourished patients (BMI >19 kg/m(2)) improvement in incremental shuttle performance was significantly greater in the supplemented group (mean difference between groups: 27 (95% CI 1 to 53) m, p<0.05). Increases in incremental shuttle performance correlated with increases in total carbohydrate intake. CONCLUSIONS When universally prescribed, carbohydrate supplementation does not enhance the rehabilitation of patients with COPD. This study suggests that exercise training results in negative energy balance that can be overcome by supplementation and that, in selected patients, this may improve the outcome of training. The finding of benefit in well nourished patients may suggest a role for nutritional supplementation beyond the treatment of weight loss in COPD.
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Affiliation(s)
- M C Steiner
- Institute for Lung Health, Department of Respiratory Medicine, Glenfield Hospital, Leicester LE3 9QP, UK.
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Williams JEA, Singh SJ, Sewell L, Morgan MDL. Health status measurement: sensitivity of the self-reported Chronic Respiratory Questionnaire (CRQ-SR) in pulmonary rehabilitation. Thorax 2003; 58:515-8. [PMID: 12775865 PMCID: PMC1746719 DOI: 10.1136/thorax.58.6.515] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND A self-reported CRQ (CRQ-SR) has recently been developed and found to be a reproducible and reliable measure of health status. This study explores both the sensitivity of the CRQ-SR and relative sensitivity compared with the conventional interviewer led CRQ (CRQ-IL) in patients undergoing pulmonary rehabilitation. METHODS Eighty patients with stable chronic obstructive pulmonary disease who had been referred for pulmonary rehabilitation completed the CRQ-SR at initial assessment and at the end of the 7 week programme. A further 35 patients completed both the CRQ-SR and the CRQ-IL, administered 1 week apart, before starting rehabilitation and again at the end of the programme. RESULTS There were large statistically and clinically significant changes in mean score per dimension following rehabilitation in all dimensions of the CRQ-SR (dyspnoea mean difference 0.87 (95% CI 0.61 to 1.14); fatigue 0.76 (0.53 to 1.0); emotion 0.60 (0.35 to 0.86); mastery 0.76 (0.52 to 1.0); p<0.001). Similar results were found in the comparison of the sensitivity of the CRQ-SR and the CRQ-IL, with large changes in mean score per dimension following rehabilitation for both versions of the questionnaire (p<0.005). No significant differences were seen in the magnitude of change between the two formats of the questionnaire (p>0.05). CONCLUSION The self-reported CRQ is as sensitive to change as the interviewer led CRQ in patients undergoing pulmonary rehabilitation but has the advantage of being less time consuming to administer.
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Affiliation(s)
- J E A Williams
- Institute for Lung Health, Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
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Abstract
The role of smoking cessation and the use of measures to reduce the disability associated with COPD are reviewed. The political profile of patients with COPD is increasing as patient support groups develop the confidence to campaign for better services.
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Affiliation(s)
- M D L Morgan
- Institute for Lung Health, Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester LE3 9QP, UK.
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Birring SS, Prudon B, Carr AJ, Singh SJ, Morgan MDL, Pavord ID. Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ). Thorax 2003; 58:339-43. [PMID: 12668799 PMCID: PMC1746649 DOI: 10.1136/thorax.58.4.339] [Citation(s) in RCA: 640] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Chronic cough is a common condition which has a significant impact on quality of life. Assessment and management are hampered by the absence of well validated outcome measures. The development and validation of the Leicester Cough Questionnaire (LCQ), a self-completed health related quality of life measure of chronic cough, is presented. METHODS Patients with chronic cough were recruited from outpatient clinics. The development of the LCQ consisted of three phases: phase 1 (item generation); phase 2 (item reduction, allocation of items to domains and validation of questionnaire); phase 3 (repeatability and responsiveness testing of final version of questionnaire). RESULTS Phase 1: Literature review, multidisciplinary team meeting and 15 structured interviews with chronic cough patients generated 44 items (LCQ1) with a 7 point Likert response scale. Phase 2: 104 chronic cough outpatients completed the LCQ1 along with an importance rating for each item. The clinical impact factor method was used for item reduction to 19 items (LCQ2: final version). These items were divided into three domains (physical, psychological and social) following expert opinion. Internal reliability, as assessed using Cronbach's alpha coefficients, varied between 0.79 and 0.89. Concurrent validity was high when the LCQ2 (n=56) was compared with a cough visual analogue score (r=-0.72). There was a moderate relationship with response to the St George's Respiratory Questionnaire (r=-0.54) and SF36 total score (r=0.46). Phase 3: Two week repeatability (n=24) was high with intraclass correlation coefficients for domains varying between 0.88 and 0.96. Responsiveness in nine patients whose cough was successfully treated varied within domains from an effect size of 0.84 to 1.75. CONCLUSION The LCQ is a valid, repeatable 19 item self-completed quality of life measure of chronic cough which is responsive to change. It should be a useful tool in clinical trials and longitudinal studies.
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Affiliation(s)
- S S Birring
- Institute for Lung Health, Department of Respiratory Medicine, Glenfield Hospital, Leicester, UK.
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Morgan MDL. Clinical Management of Chronic Obstructive Pulmonary Disease: T Similowski, W A Whitelaw, J-P Derenne, Editors. Lung Biology in Health and Disease, Volume 165. New York: Marcel Dekker, 2002. $250.00. ISBN 0 8247 0610 2. Thorax 2003. [DOI: 10.1136/thorax.58.3.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Morgan MDL. Dysfunctional breathing in asthma: is it common, identifiable and correctable? Thorax 2002; 57 Suppl 2:II31-II35. [PMID: 12364708 PMCID: PMC1765996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- M D L Morgan
- Institute for Lung Health, Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
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Oey IF, Waller DA, Bal S, Singh SJ, Spyt TJ, Morgan MDL. Lung volume reduction surgery – a comparison of the long term outcome of unilateral vs. bilateral approaches. Eur J Cardiothorac Surg 2002; 22:610-4. [PMID: 12297181 DOI: 10.1016/s1010-7940(02)00385-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs. METHODS Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months. RESULTS The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval. CONCLUSION We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.
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Affiliation(s)
- I F Oey
- Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester, UK
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Abstract
The measurement of body composition is of value in the nutritional assessment of patients with chronic obstructive pulmonary disease (COPD). The purpose of the present study was to compare two bedside methods for the measurement of body composition using dual energy X-ray absorptiometry (DEXA) as a reference method. Fat-free mass (FFM) was measured using DEXA, bioelectric impedance analysis (BIA) and skinfold anthropometry (SFA) in a cohort of 85 COPD patients accepted for pulmonary rehabilitation. Patients whose body mass index was >30 were excluded. Relative to DEXA, BIA underestimated FFM, whereas it was overestimated by SFA. There was a systematic increase in bias with mean FFM for both DEXA versus BIA and DEXA versus SFA, but this was almost eliminated when results were expressed as FFM index. Significant sex differences in the bias of BIA and SFA measurements of FFM were found. Forty-two (49.4%) patients were identified as nutritionally depleted using DEXA. Compared to DEXA, the sensitivity for detecting nutritional depletion was 86 and 74% for BIA and SFA, respectively, and the specificity 88 and 98%, respectively. There are significant intermethod differences in the measurement of body composition in chronic obstructive pulmonary disease patients. The choice of measurement method will have implications for nutritional assessment in chronic obstructive pulmonary disease.
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Affiliation(s)
- M C Steiner
- Institute for Lung Health, Dept of Respiratory Medicine, Glenfield Hospital, Leicester, UK.
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Pavord ID, Morgan MDL, Wardlaw AJ. Duplicate publication. Clin Med (Lond) 2002; 2:167. [PMID: 11991105 PMCID: PMC4952385 DOI: 10.7861/clinmedicine.2-2-167a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Morgan MDL. Second International Conference on Advances in Pulmonary Rehabilitation and Management of Chronic Respiratory Failure, Venice, 4-7 November 1992. Thorax 1993. [DOI: 10.1136/thx.48.3.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Morgan MDL, Bush A. Doctors and the drug industry. West J Med 1986. [DOI: 10.1136/bmj.293.6559.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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