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

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

Promoting Handwashing and Sanitation Behaviour Change in Low- and Middle-Income Countries: A Mixed-Method Systematic Review

This systematic review shows which promotional approaches are effective in changing handwashing and sanitation behaviour and which implementation factors affect the success or failure of such interventions. The authors find that promotional approaches can be effective in terms of handwashing with soap, latrine use, safe faeces disposal and open defecation. No one specific approach is most effective. However, several promotional elements do induce behaviour change. Different barriers and facilitators that influence implementing promotional approaches should be carefully considered when developing new policy, programming, practice, or research in this area

Health status deterioration in subjects with mild to moderate airflow obstruction, a six years observational study

BackgroundPatients with COPD need to cope with a disabling disease, which leads to health status impairment.AimTo investigate the long term change of health status in subjects with mild to moderate airflow obstruction and to compare this to subjects without airflow obstruction, with and without a smoking history. Second, to investigate the factors potentially associated to rapid health status decline in our total cohort.MethodsTwo hundred and one subjects were included. Generic [Short form 36 health survey (SF36) and EuroQol - 5 dimensions (EQ-5D)] and disease specific [Clinical COPD questionnaire (CCQ) and COPD Assessment Test (CAT)] health status questionnaires were regularly repeated over a six years period. Other functional outcomes comprised measures of lung function, physical fitness, physical activity and emotional state.ResultsOn average, health status decline did not differ between groups with the exception of the EQ-5D index, which deteriorated faster in subjects with airflow obstruction compared to the never smoking control group [-0.018(0.008) versus 0.00006(0.003), p=0.03]. Subjects presenting at least one exacerbation had faster rate of deterioration measured with CAT [0.91(0.21) versus -0.26(0.25), p<0.01]. Characteristics of the fast declining group were older age, worse lung function, physical fitness, physical activity and disease specific baseline health status. Subjects with airflow obstruction had a 2.5 (95% CI 1.36-4.71) higher risk of presenting fast overall health status decline. Fast overall decline was associated with the presence of acute exacerbation(s) (44% of the subjects with exacerbation(s) versus 17% of subjects without exacerbation, p=0.03). Changes in fat free mass, functional exercise capacity and in symptoms of anxiety and depression correlated weakly to changes in health status measured with all questionnaires.ConclusionSubjects with mild airflow obstruction present a significant deterioration of health status, which is generally not much faster compared to smoking and never smoking controls. Subjects with fast decline in overall health status are older and more likely to have airflow obstruction, acute respiratory exacerbation(s), reduced physical fitness, physical activity and impaired COPD specific health status at baseline.Trial registrationNCT01314807 - retrospectively registered on March 2011

Daily physical activity in subjects with newly diagnosed COPD

Background Background Patients undergoing tumour necrosis factor (TNF)-alpha antagonist therapy are at increased risk of latent tuberculosis infection (LTBI) reactivation. The aim of this study was to determine the optimum available screening strategy for identifying patients for tuberculosis (TB) chemoprophylaxis. Methods Methods We conducted a prospective observational study of consecutive adults with chronic rheumatological disease referred for LTBI screening prior to commencement of TNF-alpha antagonist therapy. All patients included had calculation of TB risk according to age, ethnicity and year of UK entry, as described in the 2005 British Thoracic Society (BTS) guidelines and measurement of tuberculin skin test (TST) and T.Spot.TB. Results Results There were 187 patients included in the study, with 157 patients (84%) taking immunosuppressants. 137 patients would require further risk stratification according to the BTS algorithm, with 110 (80.3%) classified as being at low risk of having LTBI. There were 39 patients (35.5%) who were categorised as low risk but were either TST and/or T.Spot positive and would not have received chemoprophylaxis according to the BTS algorithm. Combination of all three methods (risk stratification and/or positive T.Spot and/or positive TST) identified 66 patients out of 137 who would potentially be offered chemoprophylaxis, which was greater than any single test or two-test combination. Conclusion Conclusion Performing both a TST and T.Spot in patients on immunosuppressants prior to commencement of TNF-alpha antagonist therapy gives an additional yield of potential LTBI compared with use of risk stratification tables alone. Our results suggest that use of all three screening modalities gives the highest yield of patients potentially requiring chemoprophylaxis

Validity of Six Activity Monitors in Chronic Obstructive Pulmonary Disease: A Comparison with Indirect Calorimetry

<div><p>Reduced physical activity is an important feature of Chronic Obstructive Pulmonary Disease (COPD). Various activity monitors are available but their validity is poorly established. The aim was to evaluate the validity of six monitors in patients with COPD. We hypothesized triaxial monitors to be more valid compared to uniaxial monitors. Thirty-nine patients (age 68±7years, FEV₁ 54±18%predicted) performed a one-hour standardized activity protocol. Patients wore 6 monitors (Kenz Lifecorder (Kenz), Actiwatch, RT3, Actigraph GT3X (Actigraph), Dynaport MiniMod (MiniMod), and SenseWear Armband (SenseWear)) as well as a portable metabolic system (Oxycon Mobile). Validity was evaluated by correlation analysis between indirect calorimetry (VO₂) and the monitor outputs: Metabolic Equivalent of Task [METs] (SenseWear, MiniMod), activity counts (Actiwatch), vector magnitude units (Actigraph, RT3) and arbitrary units (Kenz) over the whole protocol and slow versus fast walking. Minute-by-minute correlations were highest for the MiniMod (r = 0.82), Actigraph (r = 0.79), SenseWear (r = 0.73) and RT3 (r = 0.73). Over the whole protocol, the mean correlations were best for the SenseWear (r = 0.76), Kenz (r = 0.52), Actigraph (r = 0.49) and MiniMod (r = 0.45). The MiniMod (r = 0.94) and Actigraph (r = 0.88) performed better in detecting different walking speeds. The Dynaport MiniMod, Actigraph GT3X and SenseWear Armband (all triaxial monitors) are the most valid monitors during standardized physical activities. The Dynaport MiniMod and Actigraph GT3X discriminate best between different walking speeds.</p> </div

Determinants and outcomes of physical activity in patients with COPD:a systematic review

BACKGROUND The relationship between physical activity, disease severity, health status and prognosis in patients with COPD has not been systematically assessed. Our aim was to identify and summarise studies assessing associations between physical activity and its determinants and/or outcomes in patients with COPD and to develop a conceptual model for physical activity in COPD. METHODS We conducted a systematic search of four databases (Medline, Embase, CINAHL and Psychinfo) prior to November 2012. Teams of two reviewers independently selected articles, extracted data and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess quality of evidence. RESULTS 86 studies were included: 59 were focused on determinants, 23 on outcomes and 4 on both. Hyperinflation, exercise capacity, dyspnoea, previous exacerbations, gas exchange, systemic inflammation, quality of life and self-efficacy were consistently related to physical activity, but often based on cross-sectional studies and low-quality evidence. Results from studies of pharmacological and non-pharmacological treatments were inconsistent and the quality of evidence was low to very low. As outcomes, COPD exacerbations and mortality were consistently associated with low levels of physical activity based on moderate quality evidence. Physical activity was associated with other outcomes such as dyspnoea, health-related quality of life, exercise capacity and FEV1 but based on cross-sectional studies and low to very low quality evidence. CONCLUSIONS Physical activity level in COPD is consistently associated with mortality and exacerbations, but there is poor evidence about determinants of physical activity, including the impact of treatment

Physical activity and comorbidities in patients with COPD

Over the past two decades, the prevalence of a physically inactive lifestyle has increased markedly in the general population. This reduction in daily physical activity is even more pronounced in chronic disease populations, such as Chronic Obstructive Pulmonary Disease (COPD). In addition, physical inactivity is not only linked with COPD but also can act as a potential risk factor for the presence of co-morbidities. Since physical inactivity and the presence of co-morbidities have a negative impact on several health-related outcomes (hospital admission, health care costs and survival), the objective measurement with a valid and usable activity monitor and the early detection of the inactive COPD patients are two important issues that were focused in the present PhD-project.A systematic literature review looked at 134 papers validating 40 activity monitors. We concluded that triaxial and multisensor devices tend to be the more valid monitors. Most validation studies were performed in healthy adults (88% of the studies), only few looked at patients with chronic diseases (12% of studies). Hence, we selected six activity monitors for prospective validation in COPD in both a laboratory setting and a field setting (not part of the PhD thesis). Based on a set of pre-defined validation and usability criteria, it is concluded that the Dynaport MiniMod, the Actigraph GT3X and the SenseWear Armband were considered as valid and usable activity monitors in COPD. An active lifestyle increases the chances to a healthy life . In order to know whether a subject is active or not, clear physical activity guidelines/targets should be available. We demonstrated that moderate intense physical activities (MVPA) varies depending on the selected physical activity guideline/target with lowest values for age-specific cut-offs. The observation of a reduced exercise capacity may lead to an overestimation of MVPA when selecting a relative METs cut-point (corresponding to 50% of VO2 reserve). Accelerometry measured MVPA (non-bouts) of 80 min*day-1 corresponds to the current recommendation of 30 minutes of MVPA*day-1 (in bouts of at least 10 minutes) and is valid to discriminate active from inactive subjects. This finding indicates that caution is needed when MVPA data are analyzed and interpreted in bouts or not.In the cross-sectional studies on activity profiles of patients in the preclinical stages of COPD, we found that the reduction in physical activity starts early in the disease, even when subjects are just diagnosed as having COPD, especially in those with mild symptoms of dyspnea, lower levels of diffusion capacity and lower levels of exercise capacity. The prevalence of pre-morbid risk factors and co-morbid diseases in this population was significantly higher compared to age- and gender-matched never-smokers, but similar to smoking controls not suffering from COPD. Finally, we showed that co-morbidities pool together (especially cardiovascular and musculoskeletal disease) and that physical inactivity was independently associated with thepresence of co-morbidities. Therefore, symptomatic COPD patients, those with reduced diffusion capacity and those with reduced exercise capacity should be targeted for physical activity enhancing interventions.status: publishe