Eccentric Exercise in COPD: Take It or Leave It?

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Pulmonary rehabilitation during acute exacerbations of chronic obstructive pulmonary disease: a mixed-methods approach

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) account for more than 70% of disease-related costs and negatively impact patients’ health status. Pulmonary rehabilitation (PR) is a cornerstone intervention for the management of stable disease with the potential to be equally effective in AECOPD. However, studies assessing PR role during/shortly-after AECOPD have been mainly conducted in inpatient settings, despite most AECOPD being managed in the community, and have been delivering PR with different components, intensities, durations and outcome measures, not considering patients’ needs/expectations. This has led to controversial results across studies. To overcome these drawbacks, adequately powered studies delivering well-designed community-based PR programmes and exploring patients’ perspectives are urgently needed to guide research and clinical practice. This mixed-methods project proposes to design/implement and evaluate a community-based PR programme specifically tailored to patients’ self-reported and clinical needs during AECOPD.publishe

Community-based pulmonary rehabilitation during acute exacerbations of COPD

The role of pulmonary rehabilitation (PR) during acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is controversial. Most studies have been conducted in hospitalised and severe patients, despite more than 80% of AECOPD being managed on an outpatient basis. Thus, this study assessed the effects of a community-based PR program during AECOPD. 23 patients with AECOPD were voluntarilly allocated to intervention (IG: n=12, 69±7yrs, FEV1 52±27pp) or control group (CG: n=11, 66±9yrs, FEV1 55±22pp). The IG received standard medication plus 6 sessions (2*/week) of PR (i.e., breathing control and airway clearance techniques, thoracic mobility and expansion exercises, exercise training and psychoeducational support). The CG received medication only. Respiratory rate (RR), COPD Assessment Test (CAT) and quadriceps muscle strength (QMS) were assessed within 48h of the AECOPD onset (Pre) and after PR (Post). Wilcoxon tests were used for Pre/Post comparisons within groups. The Pre/Post differences per group were pooled and groups were compared with Mann-Whitney tests. Only the EG improved significantly in all outcomes (Fig. 1). The addition of PR in the management of AECOPD seems to be more effective than only usual medication in improving patients’ RR, impact of the disease and QMS, parameters associated with an increased risk of AECOPD and poor prognosis. Randomised studies with larger samples are needed to verify these results.publishe

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

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

The minimal important difference in physical activity in patients with COPD

Background Changes in physical activity (PA) are difficult to interpret because no framework of minimal important difference (MID) exists. We aimed to determine the minimal important difference (MID) in physical activity (PA) in patients with Chronic Obstructive Pulmonary Disease and to clinically validate this MID by evaluating its impact on time to first COPD-related hospitalization. Methods PA was objectively measured for one week in 74 patients before and after three months of rehabilitation (rehabilitation sample). In addition the intraclass correlation coefficient was measured in 30 patients (test-retest sample), by measuring PA for two consecutive weeks. Daily number of steps was chosen as outcome measurement. Different distribution and anchor based methods were chosen to calculate the MID. Time to first hospitalization due to an exacerbation was compared between patients exceeding the MID and those who did not. Results Calculation of the MID resulted in 599 (Standard Error of Measurement), 1029 (empirical rule effect size), 1072 (Cohen's effect size) and 1131 (0.5SD) steps.day(-1). An anchor based estimation could not be obtained because of the lack of a sufficiently related anchor. The time to the first hospital admission was significantly different between patients exceeding the MID and patients who did not, using the Standard Error of Measurement as cutoff. Conclusions The MID after pulmonary rehabilitation lies between 600 and 1100 steps.day(-1). The clinical importance of this change is supported by a reduced risk for hospital admission in those patients with more than 600 steps improvement

Standardizing the analysis of physical activity in patients with COPD following a pulmonary rehabilitation program

BACKGROUND: There is a wide variability in measurement methodology of physical activity. This study investigated the effect of different analysis techniques on the statistical power of physical activity outcomes aft er pulmonary rehabilitation. METHODS: Physical activity was measured with an activity monitor armband in 57 patients with COPD (mean +/- SD age, 66 +/- 7 years; FEV 1, 46 +/- 17% predicted) before and aft er 3 months of pulmonary rehabilitation. The choice of the outcome (daily number of steps [STEPS], time spent in at least moderate physical activity [TMA], mean metabolic equivalents of task level [METS], and activity time [ACT]), impact of weekends, number of days of assessment, post-processing techniques, and influence of duration of daylight time (DT) on the sample size to achieve a power of 0.8 were investigated. RESULTS: The STEPS and ACT (1.6-2.3 metabolic equivalents of task) were the most sensitive outcomes. Excluding weekends decreased the sample size for STEPS (83 vs 56), TMA (160 vs 148), and METS (251 vs 207). Using 4 weekdays (STEPS and TMA) or 5 weekdays (METS) rendered the lowest sample size. Excluding days with, 8 h wearing time reduced the sample size for STEPS (56 vs 51). Differences in DT were an important confounder. CONCLUSIONS: Changes in physical activity following pulmonary rehabilitation are best measured for 4 weekdays, including only days with at least 8 h of wearing time (during waking hours) and considering the difference in DT as a covariate in the analysis

Physical activity counselling during pulmonary rehabilitation in patients with COPD : a randomised controlled trial

Background Pulmonary rehabilitation programs only modestly enhance daily physical activity levels in patients with chronic obstructive pulmonary disease (COPD). This randomised controlled trial investigates the additional effect of an individual activity counselling program during pulmonary rehabilitation on physical activity levels in patients with moderate to very severe COPD. Methods Eighty patients (66 +/- 7 years, 81% male, forced expiratory volume in 1 second 45 +/- 16% of predicted) referred for a six-month multidisciplinary pulmonary rehabilitation program were randomised. The intervention group was offered an additional eight-session activity counselling program. The primary outcomes were daily walking time and time spent in at least moderate intense activities. Results Baseline daily walking time was similar in the intervention and control group (median 33 [interquartile range 16-47] vs 29 [17-44]) whereas daily time spent in at least moderate intensity was somewhat higher in the intervention group (17[4-50] vs 12[2-26] min). No significant intervention*time interaction effects were observed in daily physical activity levels. In the whole group, daily walking time and time spent in at least moderate intense activities did not significantly change over time. Conclusions The present study identified no additional effect of eight individual activity counselling sessions during pulmonary rehabilitation to enhance physical activity levels in patients with COPD

Use of pedometers as a tool to promote daily physical activity levels in patients with COPD: a systematic review and meta-analysis

The aim of this study was to examine the use of pedometers as a tool to promote daily physical activity levels in patients with COPD.A systematic review meta-analysis of pedometer physical activity promotion in patients with COPD was conducted. Medline/PubMed, Cochrane Library, Web of Science and CINAHL were searched from inception to January 2019. The search strategy included the following keywords: physical activity promotion, pulmonary rehabilitation and daily physical activity. The eligibility criteria for selecting studies were randomised controlled trials reporting pedometer physical activity promotion in patients with COPD.Improvements in steps per day were found with pedometer physical activity promotion either standalone (n=12, mean 0.53 (95% CI 0.29textendash0.77); p=0.00001) or alongside pulmonary rehabilitation (n=7, 0.51 (0.13textendash0.88); p=0.006). A subgroup analysis reported significant differences in the promotion of physical activity based on baseline physical activity levels and the type of instrument used to assess levels of physical activity.Future trials should consider the way in which pedometers are used to promote physical activity to inform clinical practice in the setting of pulmonary rehabilitation.Pedometer based physical activity promotion as a standalone intervention or alongside pulmonary rehabilitation induces meaningful improvements in daily physical activity levels (steps per day) in patients with COPD. http://bit.ly/2LnxM2

Design of pulmonary rehabilitation programmes during acute exacerbations of COPD: a systematic review and network meta-analysis

This systematic review aimed to systematise the different designs used to deliver pulmonary rehabilitation during acute exacerbations of COPD (AECOPD) and explore which ones are the most effective. PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Randomised controlled trials comparing pulmonary rehabilitation or at least one of its components with usual care or comparing different components of pulmonary rehabilitation were included. Network meta-analysis was conducted in MetaXL 5.3 using a generalised pairwise modelling framework. Pooled effects compared each treatment to usual care. 42 studies were included. Most studies were conducted in an inpatient setting (57%) and started the intervention 24-48 h after hospital admission (24%). Exercise training (71%), education and psychosocial support (57%) and breathing techniques (55%) were the most used components. Studies combining exercise with breathing techniques presented the larger effects on exercise capacity (weighted mean difference (WMD) -41.06, 95% CI -131.70-49.58) and health-related quality of life (WMD 16.07, 95% CI 10.29-21.84), and breathing techniques presented the larger effects on dyspnoea (WMD 1.90, 95% CI 0.53-3.27) and length of hospitalisation (effect size =0.15, 95% CI -0.28-0.57). A few minor adverse events were found.Pulmonary rehabilitation is a safe intervention during AECOPD. Exercise, breathing techniques, and education and psychosocial support seem to be the core components for implementing pulmonary rehabilitation during AECOPD. Studies may now focus on comparisons of optimal timings to start the intervention, total duration of the intervention, duration and frequency of sessions, and intensity for exercise prescription.publishe

COPD and exercise: does it make a difference?

Physical activity is defined as any bodily movement produced by skeletal muscles which results in energy expenditure. Physical activity in daily life can be categorised into occupational, sports, conditioning, household, or other activities. Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness [1]. According to international guidelines, exercise training, widely regarded as the cornerstone of pulmonary rehabilitation, is the best available means of improving muscle function and exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) [2, 3]. It truly makes a difference in the life of patients with COPD. In this review, an overview is provided on the history of exercise training (as standalone intervention or as part of a comprehensive pulmonary rehabilitation programme), the state-of-the-art exercise training, exercise training in comorbid patients with COPD, and the impact of physical activity counselling in a clean air environment