Physical activity and sedentary behaviour across the spectrum of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) patients are generally more sedentary and less physically active than healthy adults; putting them at increased risk of hospitalisation and death. For patients with mild-moderate COPD, physical activity appears to be reduced compared with apparently healthy adults but differences in time spent sedentary are less well established. Additionally, there is a need for a greater understanding of the correlates of behaviour in mild-moderate patients with much of the existing literature focusing on more severe or mixed stage patient samples and with many studies lacking objective behavioural monitoring, not adjusting for confounders and a paucity of data on correlates of sedentary time. Despite having mild-moderate airflow obstruction, these patients also report a range of symptom burdens with some individuals reporting severe symptoms. Subsequently, these patients represent a sub-set of individuals who may require lifestyle interventions. Therefore, factors associated with patients reporting more severe symptoms need to be identified to help understand how this phenomenon may manifest and be intervened upon. For patients with more advanced COPD who are admitted to hospital for an acute exacerbation behavioural intervention focussing on less intense movement may be a more suitable approach for reducing the risk of readmissions than more intense physical activity or exercise. To date no studies have specifically targeted reductions in sedentary behaviour in COPD. In addition, wearable self-monitoring technology may facilitate the provision of such interventions, removing important participation barriers such as travel and cost, but this has not been sufficiently examined in COPD. This thesis investigated: (i) objectively measured physical activity and sedentary time and the correlates of these behaviours for mild-moderate COPD patients and apparently healthy adults (Study One); (ii) factors associated with self-reported symptom severity and exacerbation history in mild-moderate COPD patients (Study Two) and (iii) the feasibility and acceptability of a home-based sedentary behaviour intervention using wearable self-monitoring technology for COPD patients following an acute exacerbation (Study Three). Methods: Study One: COPD patients were recruited from general practitioners and apparently healthy adults from community advertisements. Objectively measured moderate-to-vigorous physical activity (MVPA), light activity and sedentary time for 109 mild-moderate COPD patients and 135 apparently healthy adults were obtained by wrist-worn accelerometry. Patients with at least four valid days (≥10 waking hours) out of a possible seven were included in analysis. A range of demographic, social, symptom-based, general health and physical factors were examined in relation to physical activity and sedentary time using correlations and linear regressions controlling for confounders (age, gender, smoking status, employment status and accelerometer waking wear time). Study Two: In 107 patients recruited from general practitioners, symptoms were assessed using the COPD Assessment Test (CAT) and Modified Medical Research Council (mMRC) questionnaires. Twelve-month exacerbation history was self-reported. Exercise capacity was assessed via incremental shuttle walk test (ISWT) and self-reported usual walking speed. Physical activity and sedentary time were obtained from a wrist-worn accelerometer. Study Three: Patients were randomised in-hospital into a usual care (Control), Education or Education + Feedback group with the intervention lasting 14 days following discharge. The intervention groups received information about reducing prolonged sitting. The Education + Feedback group also received real-time feedback on their sitting time, number of stand-ups and step count at home through an inclinometer linked to a smart device app. The inclinometer also provided vibration prompts to encourage movement when the wearer had been sedentary for too long. Feasibility of recruitment (e.g. uptake and retention) and intervention delivery (e.g. fidelity) were assessed. Acceptability of the intervention technology (e.g. wear compliance, app usage and response to vibration prompts) was also examined. Results: Study One: COPD patients were more sedentary (592±90 versus 514±93 minutes per day, p20 or an mMRC score of ≥2 had lower VMCPM, were more sedentary and took part in less light activity than patients reporting a CAT score of 0-10 or mMRC of 0, respectively. Patients reporting ≥2 exacerbations took part in less MVPA than patients reporting zero exacerbations. Study Three: Study uptake was 31.5% providing a final sample of 33 COPD patients. Retention of patients at two-week follow-up was 51.5% (n=17). Reasons for drop-out were mostly related to being unable to cope with their COPD. Patients wore the inclinometer for 11.8±2.3 days (and charged it 8.4±3.9 times) with at least one vibration prompt occurring on 9.0±3.4 days over the 14 day study period. Overall, 325 vibration prompts occurred with patients responding 106 times (32.6%). 40.6% of responses occurred within 5 minutes of the prompt with patients spending 1.4±0.8 minutes standing and 0.4±0.3 minutes walking, taking 21.2±11.0 steps. Discussion: Study One: COPD patients were less active and more sedentary than apparently healthy adults; however, factors predicting behaviour were similar between groups. Correlates differed between sedentary time, light activity and MVPA for both groups. Interventions to boost physical activity levels and reduce sedentary time should be offered to patients with mild-moderate COPD, particularly those reporting more severe breathlessness. Study Two: Worse exercise capacity, low levels of physical activity and more time spent sedentary are some of the factors associated with patients of the same severity of airflow limitation reporting differing symptom severities. These patients may benefit from both lifestyle and exercise interventions. Study Three: Recruitment and retention rates suggest a trial targeting sedentary behaviour in hospitalised COPD patients is feasible. A revised intervention, building on the successful components of the present feasibility study is justified. Conclusion: The findings from this thesis have contributed a greater understanding of physical activity and sedentary behaviour in COPD and can inform the development of tailored physical activity and sedentary behaviour interventions for patients across the grades of COPD severity

Chronic obstructive pulmonary disease (COPD), illness narratives and Elias's sociology of knowledge

This paper draws on Elias’s sociology of knowledge to provide a critical assessment of illness narratives. Focusing on a cohort of chronic obstructive pulmonary disease (COPD) patients (n=26), the paper employs a comparative analysis of mixed method data derived from qualitative interviews, quantitative questionnaires, and physiological and accelerometer testing. The article firstly compares four narratives conveyed in interviews with the broader paradigmatic approach to illness narratives and existing COPD-specific studies. It then explores the relationship between these ‘stories’ and COPD patients’ biographical contingencies (e.g. age, wealth, context of diagnosis) and embodied condition (e.g. co-morbidities, lung function), demonstrating how illness narratives are shaped by both broader social structural factors and embodied experience. Invoking Elias we further find that different narrative subthemes are varyingly affected by patients’ emotional engagement and ontological security and thus that people are differently enabled or constrained to present illness narratives that are consistent with their broader social and physical condition. Consequently, while narratives, social structure and embodied experience are interdependent, our reading of ‘truth’ must be sensitive to the social positioning of the ‘teller’ and the specific content being relayed. The paper therefore presents a more systematic, comparative, bio-psycho-social analysis than has hitherto been produced

Sensing interstitial glucose to nudge active lifestyles (SIGNAL): Feasibility of combining novel self-monitoring technologies for persuasive behaviour change

© Article author(s) 2017. Introduction Increasing physical activity (PA) reduces the risk of developing diabetes, highlighting the role of preventive medicine approaches. Changing lifestyle behaviours is difficult and is often predicated on the assumption that individuals are willing to change their lifestyles today to reduce the risk of developing disease years or even decades later. The self-monitoring technologies tested in this study will present PA feedback in real time, parallel with acute physiological data. Presenting the immediate health benefits of being more physically active may help enact change by observing the immediate consequences of that behaviour. The present study aims to assess user engagement with the self-monitoring technologies in individuals at moderate-to-high risk of developing type 2 diabetes. Methods and analysis 45 individuals with a moderate-to-high risk, aged ≥40 years old and using a compatible smartphone, will be invited to take part in a 7-week protocol. Following 1 week of baseline measurements, participants will be randomised into one of three groups: group 1 -glucose feedback followed by biobehavioural feedback (glucose plus PA); group 2 - PA feedback followed by biobehavioural feedback; group 3 - biobehavioural feedback. A PA monitor and a flash glucose monitor will be deployed during the intervention. Participants will wear both devices throughout the intervention but blinded to feedback depending on group allocation. The primary outcome is the level of participant engagement and will be assessed by device use and smartphone usage. Feasibility will be assessed by the practicality of the technology and screening for diabetes risk. Semistructured interviews will be conducted to explore participant experiences using the technologies. Trial registration number ISRCTN17545949. Registered on 15/05/2017

Physical activity and respiratory health (PhARaoH): Data from a cross-sectional study

The dataset consists of a densely phenotyped sample of adults collected from March to August 2014. The dataset captures behavioural, physical, physiological and psychosocial characteristics of individuals with and without a General Practitioner diagnosis of chronic obstructive pulmonary disease (COPD). Data were collected at Glenfield Hospital on 436 individuals (139 COPD patients and 297 apparently healthy adults) aged 40–75 years, residing in Leicestershire and Rutland, United Kingdom. The dataset includes seven days of raw wrist-worn accelerometry, venous blood biomarkers, non-invasive point-of-care cardio-metabolic risk profiles, physical measures and questionnaire data

Findings of the Chronic Obstructive Pulmonary Disease-Sitting and Exacerbations Trial (COPD-SEAT) in reducing sedentary time using wearable and mobile technologies with educational support: Randomized controlled feasibility trial

Background: Targeting sedentary time post exacerbation may be more relevant than targeting structured exercise for individuals with chronic obstructive pulmonary disease. Focusing interventions on sitting less and moving more after an exacerbation may act as a stepping stone to increase uptake to pulmonary rehabilitation. Objective: The aim of this paper was to conduct a randomized trial examining trial feasibility and the acceptability of an education and self-monitoring intervention using wearable technology to reduce sedentary behavior for individuals with chronic obstructive pulmonary disease admitted to hospital for an acute exacerbation. Methods: Participants were recruited and randomized in hospital into 3 groups, with the intervention lasting 2 weeks post discharge. The Education group received verbal and written information about reducing their time in sedentary behavior, sitting face-to-face with a study researcher. The Education+Feedback group received the same education component along with real-time feedback on their sitting time, stand-ups, and steps at home through a waist-worn inclinometer linked to an app. Patients were shown how to use the technology by the same study researcher. The inclinometer also provided vibration prompts to encourage movement at patient-defined intervals of time. Patients and health care professionals involved in chronic obstructive pulmonary disease exacerbation care were interviewed to investigate trial feasibility and acceptability of trial design and methods. Main quantitative outcomes of trial feasibility were eligibility, uptake, and retention, and for acceptability, were behavioral responses to the vibration prompts. Results: In total, 111 patients were approached with 33 patients recruited (11 Control, 10 Education, and 12 Education+Feedback). Retention at 2-week follow-up was 52% (17/33; n=6 for Control, n=3 for Education, and n=8 for Education+Feedback). No study-related adverse events occurred. Collectively, patients responded to 106 out of 325 vibration prompts from the waist-worn inclinometer (32.62%). Within 5 min of the prompt, 41% of responses occurred, with patients standing for a mean 1.4 (SD 0.8) min and walking for 0.4 (SD 0.3) min (21, SD 11, steps). Interviews indicated that being unwell and overwhelmed after an exacerbation was the main reason for not engaging with the intervention. Health care staff considered reducing sedentary behavior potentially attractive for patients but suggested starting the intervention as an inpatient. Conclusions: Although the data support that it was feasible to conduct the trial, modifications are needed to improve participant retention. The intervention was acceptable to most patients and health care professionals

Influence of muscle mass in the assessment of lower limb strength in COPD: validation of the prediction equation

Absence of established reference values limits application of quadriceps maximal voluntary contraction (QMVC) measurement. The impact of muscle mass inclusion in predictions is unclear. Prediction equations encompassing gender, age and size with (FFM+) and without (FFM−), derived in healthy adults (n=175), are presented and compared in two COPD cohorts recruited from primary care (COPD-PC, n=112) and a complex care COPD clinic (COPD-CC, n=189). Explained variance was comparable between the prediction models (R2: FFM+: 0.59, FFM−: 0.60) as were per cent predictions in COPD-PC (88.8%, 88.3%). However, fat-free mass inclusion reduced the prevalence of weakness in COPD, particularly in COPD-CC where 11.9% fewer were deemed weak

The influence of muscle mass in the assessment of lower limb strength in COPD [Abstract]

The influence of muscle mass in the assessment of lower limb strength in COPD [Abstract

Meanings of sitting in the context of chronic disease: Critical reflection on sedentary behaviour, health, choice and enjoyment

Reducing sedentary behaviour or sitting is a new public health focus. Emerging research has, however, found that sedentary activities may be associated with health and mental health benefits for older adults. This article reports findings of the qualitative arm of a feasibility trial to reduce sedentary behaviour among patients with Chronic Obstructive Pulmonary Disease (COPD). From interviews (n=21) conducted prior to the intervention we identified three themes: (i) participants sat to enable them to perform activities, such as housework, (ii) sitting, such as watching TV or fishing, was experienced as enjoyable, and (iii) the most ill participants experienced sitting in terms of sadness, as the only thing they could do. Our observations draw attention to three issues. First, our participants did not always sit out of choice, they had to rest between activities and sat due to breathlessness and mournfulness. Second, the intrinsic value of enjoyment associated with sedentary activities comes into sharp relief in the context of progressive chronic disease, which makes it increasingly difficult to enjoy any activity or life. Third, trials, predicated on trying out a pre-defined solution, are particularly challenging for mixed methods qualitative research seeking to trouble categories, such as choice, health and enjoyment. In conclusion we concur with research that has highlighted that sedentary activities may also have benefits, however, we would make a stronger case for appreciating alternative values, such as enjoyment of life, rather than just health, when appropriate, in research and in practice.