Exercise induced skeletal muscle metabolic stress is reduced after pulmonary rehabilitation in COPD

SummaryIn COPD, skeletal muscle ATP resynthesis may be insufficient to meet demand during exercise due to excessive anaerobic and reduced oxidative (mitochondrial) energy production, leading to metabolic stress. We investigated the effect of outpatient pulmonary rehabilitation (PR) on the metabolic response (measured by exercise-induced accumulation of plasma ammonia) and determined whether this response predicted functional improvement following PR.25 subjects with stable COPD [mean (SD) age 67 (8)years and FEV1 47 (18)% predicted] performed maximal cycling ergometry before and after PR. Plasma ammonia was measured at rest, during exercise and 2 min post-exercise.Following PR, there were significant increases in peak cycle WR and ISWT performance (Mean (SEM) changes 13.1 (2.0) W and 93 (15) m respectively, p < 0.001). Mean (SEM) rise in plasma ammonia was reduced at peak (Pre vs Post-PR: 29.0 (4.5) vs 20.2 (2.5) μmol/l, p < 0.05) and isotime (Pre vs Post-PR: 29.0 (4.5) vs 10.6 (1.7) μmol/l, p < 0.001) exercise. Improvements in exercise performance after PR were similar among subgroups who did versus those who did not show a rise in ammonia at baseline.The results suggest that muscle cellular energy production was better matched to the demands of exercise following PR. We conclude that a pragmatic outpatient PR programme involving high intensity walking exercise results in significant adaptation of the skeletal muscle metabolic response with a reduction in exercise-related metabolic stress. However, the outcome of PR could not be predicted from baseline metabolic response

Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial

Introduction: Patients with COPD experience exacerbations that may require hospitalization. Patients do not always feel supported upon discharge and frequently get readmitted. A Self-management Program of Activity, Coping, and Education for COPD (SPACE for COPD), a brief self-management program, may help address this issue. Objective: To investigate if SPACE for COPD employed upon hospital discharge would reduce readmission rates at 3 months, compared with usual care. Methods: This is a prospective, single-blinded, two-center trial (ISRCTN84599369) with participants admitted for an exacerbation, randomized to usual care or SPACE for COPD. Measures, including health-related quality of life and exercise capacity, were taken at baseline (hospital discharge) and at 3 months. The primary outcome measure was respiratory readmission at 3 months. Results: Seventy-eight patients were recruited (n=39 to both groups). No differences were found in readmission rates or mortality at 3 months between the groups. Ten control patients were readmitted within 30 days compared to five patients in the intervention group (P>0.05). Both groups significantly improved their exercise tolerance and Chronic Respiratory Questionnaire (CRQ-SR) results, with between-group differences approaching statistical significance for CRQ-dyspnea and CRQ-emotion, in favor of the intervention. The “Ready for Home” survey revealed that patients receiving the intervention reported feeling better able to arrange their life to cope with COPD, knew when to seek help about feeling unwell, and more often took their medications as prescribed, compared to usual care (P<0.05). Conclusion: SPACE for COPD did not reduce readmission rates at 3 months above that of usual care. However, encouraging results were seen in secondary outcomes for those receiving the intervention. Importantly, SPACE for COPD appears to be safe and may help prevent readmission with 30 days

The Importance of Self-Management in the Context of Personalized Care in COPD

Despite current guidelines and decades of evidence on the benefits of a self-management approach, self-management of COPD remains relatively under-utilized in clinical care compared with other chronic diseases. However, self-management interventions can play a valuable role in supporting people with COPD to respond to changing symptoms, and thereby make appropriate decisions regarding the management of their own chronic condition. In this review, we discuss the history and evolution of the concept of self-management, assess current multidisciplinary support programs and clinical interactions designed to optimize self-management, and reflect on how effective these are in terms of clinical and humanistic outcomes. We also evaluate the mechanisms for encouraging change from protocol-based care towards a more personalized care approach, and discuss the role of digital self-management interventions and the importance of addressing health inequalities in COPD treatment, which have been accelerated by the COVID-19 pandemic. Reflecting on the importance of self-management in the context of symptom monitoring and provision of educational support, including information from patient organizations and charities, we discuss the ideal components of a self-management plan for COPD and provide six key recommendations for its implementation: 1) better education for healthcare professionals on disease management and consultation skills; 2) new targets and priorities for patient-focused outcomes; 3) skills gap audits to identify barriers to self-management; 4) best practice sharing within primary care networks and ongoing professional development; 5) enhanced initial consultations to establish optimal self-management from the outset; and 6) negotiation and sharing of self-management plans at the point of diagnosis

A Comparison of Physical Activity Between Home-Based and Centre-Based Pulmonary Rehabilitation:A Randomised Controlled Secondary Analysis

Background: Pulmonary rehabilitation (PR) is a highly effective intervention for individuals with chronic obstructive pulmonary disease (COPD). Physical activity (PA) has been shown to increase after a centre-based programme, yet it is not clear if a home-based programme can offer the same benefit. This study aimed to evaluate the effect of home-based PR compared with the centre-based PR on the PA levels post 7 weeks of PR and 6 months follow-up.Method: In this study, 51 participants with COPD, of them, 36 (71%) men completed physical activity monitoring with a SenseWear Armband, at three time points (baseline, 7 weeks, and 6 months). The participants were randomly assigned to either centre-based supervised PR (n = 25; 69 ± 6 years; FEV1 55 ± 20% predicted) or home-based PR (n = 26; 68 ± 7 years; FEV1 42 ± 19% predicted) programmes lasting 7 weeks. The home-based programme includes one hospital visit, a self-management manual, and two telephone calls. The PA was measured as step count, time in moderate PA (3–6 metabolic equivalent of tasks [METs]) in bouts of more than 10 min and sedentary time (&lt;2 METs).Results: Home-based PR increased step count significantly more than the centre-based PR after 7 weeks (mean difference 1,463 steps: 95% CI 280–2,645, p = 0.02). There was no difference in time spent in moderate PA was observed (mean difference 62 min: 95% CI −56 to 248, p = 0.24). Sedentary behaviour was also significantly different between the centre and home-based groups. The home group spent 52 min less time sedentary compared with the centre-based (CI −106 to 2, p = 0.039). However, after 6 months, the step count and time spent in moderate PA returned to baseline in both the groups.Conclusion: This study provides an important insight into the role of home-based PR which has the potential to be offered as an alternative to the centre-based PR. Understanding who may best respond from the centre or home-based PR warrants further exploration and how to maintain these initial benefits for the long-term.Trial Registry: ISRCTN: No.: ISRCTN81189044; URL: isrctn.com

Ultrasound assessment of lower limb muscle mass in response to resistance training in COPD

<p>Abstract</p> <p>Background</p> <p>Quantifying the improvements in lower limb or quadriceps muscle mass following resistance training (RT), is an important outcome measure in COPD. Ultrasound is a portable, radiation free imaging technique that can measure the size of superficial muscles belonging to the quadriceps group such as the rectus femoris, but has not been previously used in COPD patients following RT. We compared the responsiveness of ultrasound derived measures of quadriceps mass against dual energy x-ray absorptiometry (DEXA), in patients with COPD and healthy controls following a programme of high intensity knee extensor RT.</p> <p>Methods</p> <p>Portable ultrasound was used to assess the size of the dominant quadriceps in 45 COPD patients and 19 healthy controls-before, during, and after 8 weeks of bilateral high intensity isokinetic knee extensor RT. Scanning was performed at the mid-thigh region, and 2 indices of quadriceps mass were measured-rectus femoris cross-sectional area (RF_csa) and quadriceps muscle thickness (Q_t). Thigh lean mass (T_dexa) was determined by DEXA.</p> <p>Results</p> <p>Training resulted in a significant increase in T_dexa, RF_csa and Q_t in COPD patients [5.7%, 21.8%, 12.1% respectively] and healthy controls [5.4%, 19.5%, 10.9 respectively]. The effect size for the changes in RF_csa (COPD= 0.77; Healthy=0.83) and Q_t (COPD=0.36; Healthy=0.78) were greater than the changes in T_dexa (COPD=0.19; Healthy=0.26) following RT.</p> <p>Conclusions</p> <p>Serial ultrasound measurements of the quadriceps can detect changes in muscle mass in response to RT in COPD. The technique has good reproducibility, and may be more sensitive to changes in muscle mass when compared to DEXA.</p> <p>Trial registration</p> <p><url>http://www.controlled-trials.com</url> (Identifier: ISRCTN22764439)</p

The use of the practice walk test in pulmonary rehabilitation program: National COPD Audit Pulmonary Rehabilitation Workstream

Our aim was to evaluate the use and impact of the practice walk test on enrolment, completion, and clinical functional response to pulmonary rehabilitation (PR) using the 2015 UK National Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Rehabilitation audit data. Patients were assessed according to whether a baseline practice walk test was performed or not. Study outcomes included use of the practice walk test, baseline and change in incremental shuttle walk test distance (ISWD) or 6-minute walk test distance (6MWD), and enrolment to and completion of PR program. Of 7,355 patients, only 1,666 (22.6%) had a baseline practice test. At baseline, the practice walk test group walked further as compared to the no practice walk test group: ISWD, 17.9 m [95% confidence interval (CI) 8.2–27.5 m] and 6MWD, 34.8 m (95% CI 24.7–44.9 m). The practice walk test group were 2.2 times (95% CI 1.8–2.6) more likely to enroll and 17% (95% CI 1.03–1.34) more likely to complete PR. Although the change in ISWD and 6MWD with PR was lower in the practice walk test group, they walked further at discharge assessment. Only 22.6% of the patients in the 2015 National PR audit had a practice walk test at assessment. Those who did had better enrolment, completion, and better baseline walking distance, from which the prescription is set

Important, misunderstood, and challenging: a qualitative study of nurses' and allied health professionals' perceptions of implementing self-management for patients with COPD.

Hannah ML Young,1 Lindsay D Apps,1 Samantha L Harrison,1 Vicki L Johnson-Warrington,1 Nicky Hudson,2 Sally J Singh1,3 1National Institute of Health Research CLAHRC-LNR Pulmonary Rehabilitation Research Group, University Hospitals of Leicester NHS Trust, 2School of Applied Social Sciences, De Montfort University, Leicester, 3Applied Research Centre in Health and Lifestyle Interventions, Coventry University, Coventry, UK Background: In light of the growing burden of COPD, there is increasing focus on the role of self-management for this population. Currently, self-management varies widely. Little is known either about nurses&rsquo; and allied health professionals&rsquo; (AHPs&rsquo;) understanding and provision of self-management in clinical practice. This study explores nurses&rsquo; and AHPs&rsquo; understanding and implementation of supported COPD self-management within routine clinical practice. Materials and methods: Nurses and AHPs participated in face-to-face semistructured interviews to explore their understanding and provision of COPD self-management, as well as their perceptions of the challenges to providing such care. Purposive sampling was used to select participants from a range of professions working within primary, community, and secondary care settings. Three researchers independently analyzed each transcript using a thematic approach. Results: A total of 14 participants were interviewed. Nurses and AHPs viewed self-management as an important aspect of COPD care, but often misunderstood what it involved, leading to variation in practice. A number of challenges to supporting self-management were identified, which related to lack of time, lack of insight regarding training needs, and assumptions regarding patients&rsquo; perceived self-management abilities. Conclusion: Nurses and AHPs delivering self-management require clear guidance, training in the use of effective self-management skills, and education that challenges their preconceptions regarding patients. The design of health care services also needs to consider the practical barriers to COPD self-management support for the implementation of such interventions to be successful. Keywords: self-management, COPD, qualitative, interviews, nurses, allied health professional

How do informal self-care strategies evolve among patients with chronic obstructive pulmonary disease managed in primary care? A qualitative study

Background: There is much description in the literature of how patients with chronic obstructive pulmonary disease (COPD) manage their breathlessness and engage in self-care activities; however, little of this is from the perspective of those with less severe disease, who are primarily managed in primary care. This study aimed to understand the self-care experiences of patients with COPD who are primarily managed in primary care, and to examine the challenges of engaging in such behaviors. Methods: Semistructured interviews were carried out with 15 patients with COPD as part of a larger project evaluating a self-management intervention. Thematic analysis was supported by NVivo software (version 8, QSR International, Melbourne, Australia). Results: Three main themes are described, ie, experiencing and understanding symptoms of COPD, current self-care activities, and the importance of family perceptions in managing COPD. Conclusion: Self-care activities evolved spontaneously as participants experienced symptoms of COPD. However, there was a lack of awareness about whether these strategies would impact upon symptoms. Perceptions of COPD by family members posed a challenge to self-care for some participants. Health care professionals should elicit patients' prior disease experiences and utilize spontaneous attempts at disease management in future self-management. These findings have implications for promoting self-management and enhancing quality of life