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Supported by the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (GNT1116371), and by foundation partner, Boehringer Ingelheim, and program partners, Roche and Galapagos. Rationale : The interstitial lung disease (ILD) multidisciplinary meetings (MDM), composed of pulmonologists, radiologists, and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs, and questions regarding their best practices remain unanswered. Objectives : To achieve consensus among ILD experts on essential components of an ILD MDM. Methods : Using a Delphi methodology, semi-structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0. Results : We interviewed 15 ILD experts, and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high-resolution computed tomography, and a standardized template summarizing collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM, such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs. Conclusions : This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represent an important step toward potential collaborative research into future standardization of ILD MDMs. Postprint

Questions: What airway clearance techniques and exercise regimens are used by adults with cystic fibrosis (CF) in Australia when well or unwell? What proportion of these adults believe that exercise can be used as a substitute for traditional airway clearance techniques, and how have they come to this belief? What type of exercise is used as a substitute for traditional airway clearance techniques? Design: Cross-sectional survey at 13 CF centres in Australia, using a purpose-designed questionnaire. Participants: Six hundred and ninety-two adults with CF completed the questionnaire. Outcome measures: The questionnaire included questions about: the participants' current use of traditional airway clearance techniques and exercise, when well and unwell; and beliefs regarding the use of exercise as a substitute for traditional airway clearance techniques. Results: Coughing, huffing and positive expiratory pressure were the most commonly used airway clearance techniques. Walking, jogging and lifting weights were the most commonly used forms of exercise. Overall, 43% of participants believed that exercise could be used as a substitute for traditional airway clearance techniques, with 44% having substituted exercise for traditional airway clearance techniques in the previous 3 months. Personal experience was the most commonly reported factor influencing participants' beliefs about the use of exercise as a substitute for traditional airway clearance techniques. Conclusion: Exercise is commonly used as a substitute for traditional airway clearance techniques. Physiotherapists should advise patients that whilst there is some research suggesting a possible mechanism for exercise as a form of airway clearance, there are currently no medium-term to long-term data supporting exercise as a stand-alone form of airway clearance. These results suggest that future research to investigate the clinical effectiveness of exercise as a substitute for traditional airway clearance techniques should be a priority. Registration: ACTRN12616000994482. Key words: Cystic fibrosis, Exercise, Physical therapy modalities, Respiratory therapy

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that constitutes a major global health burden. A significant proportion of patients experience skeletal muscle wasting and loss of strength as a comorbidity of their COPD, a condition that severely impacts on their quality of life and survival. At present, the lung pathology is considered to be largely irreversible; however, the inherent adaptability of muscle tissue offers therapeutic opportunities to tackle muscle wasting and potentially reverse or delay the progression of this aspect of the disease, to improve patients' quality of life. Muscle wasting in COPD is complex, with contributions from a number of factors including inflammatory cytokines, oxidative stress, growth and anabolic hormones, nutritional status, and physical activity. In this review, we discuss current and emerging therapeutic approaches to treat muscle wasting in COPD, including a number of pharmacological therapies that are in development for muscle atrophy in other pathological states that could be of relevance for treating muscle wasting in COPD patients.

RationalePulmonary rehabilitation is an effective treatment for people with chronic respiratory disease but is delivered to MethodsA multicentre randomised controlled trial with assessor blinding, powered for equivalence was undertaken. Individuals with a chronic respiratory disease referred to pulmonary rehabilitation at four participating sites (one rural) were eligible and randomised using concealed allocation to pulmonary rehabilitation or telerehabilitation. Both programmes were two times per week for 8 weeks. The primary outcome was change in Chronic Respiratory Disease Questionnaire Dyspnoea (CRQ-D) domain at end-rehabilitation, with a prespecified equivalence margin of 2.5 points. Follow-up was at 12 months. Secondary outcomes included exercise capacity, health-related quality of life, symptoms, self-efficacy and psychological well-being.Results142 participants were randomised to pulmonary rehabilitation or telerehabilitation with 96% and 97% included in the intention-to-treat analysis, respectively. There were no significant differences between groups for any outcome at either time point. Both groups achieved meaningful improvement in dyspnoea and exercise capacity at end-rehabilitation. However, we were unable to confirm equivalence of telerehabilitation for the primary outcome ΔCRQ-D at end-rehabilitation (mean difference (MD) (95% CI) −1 point (−3 to 1)), and inferiority of telerehabilitation could not be excluded at either time point (12-month follow-up: MD −1 point (95% CI −4 to 1)). At end-rehabilitation, telerehabilitation demonstrated equivalence for 6-minute walk distance (MD −6 m, 95% CI −26 to 15) with possibly superiority of telerehabilitation at 12 months (MD 14 m, 95% CI −10 to 38).Conclusiontelerehabilitation may not be equivalent to centre-based pulmonary rehabilitation for all outcomes, but is safe and achieves clinically meaningful benefits. When centre-based pulmonary rehabilitation is not available, telerehabilitation may provide an alternative programme model.Trial registration numberACtelerehabilitationN12616000360415.

Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk–benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.

BackgroundThe impact of pulmonary rehabilitation (PR) on survival in patients with fibrotic interstitial lung disease (ILD) is unknown. Given the challenges conducting a large randomised controlled trial, we aimed to determine whether improvement in 6-minute walk distance (6MWD) was associated with better survival.MethodsThis retrospective, international cohort study included patients with fibrotic ILD participating in either inpatient or outpatient PR at 12 sites in 5 countries. Multivariable models were used to estimate the association between change in 6MWD and time to death or lung transplantation accounting for clustering by centre and other confounders.Results701 participants (445 men and 256 women) with fibrotic ILD were included. The mean±SD ages of the 196 inpatients and 505 outpatients were 70±11 and 69±12 years, respectively. Baseline/changes in 6MWD were 262±128/55±83 m for inpatients and 358±125/34±65 m for outpatients. Improvement in 6MWD during PR was associated with lower hazard rates for death or lung transplant on adjusted analysis for both inpatient (HR per 10 m 0.94, 95% CI 0.91 to 0.97, pConclusionsPatients with fibrotic ILD who improved physical performance during PR had better survival compared with those who did not improve performance. Confirmation of these hypothesis-generating findings in a randomised controlled trial would be required to definitely change clinical practice, and would further support efforts to improve availability of PR for patients with fibrotic ILD.

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV1: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all rs = 0.30, p

© 2020 The Authors. Health Expectations published by John Wiley & Sons Ltd Background: Brain injury rehabilitation is an expensive and long-term endeavour. Very little published information or debate has underpinned policy for service delivery in Australia. Within the context of finite health budgets and the challenges associated with providing optimal care to persons with brain injuries, members of the public were asked ‘What considerations are important to include in a model of care of brain injury rehabilitation?’. Methods: Qualitative study using the Citizen Jury method of participatory research. Twelve adult jurors from the community and seven witnesses participated including a health services funding model expert, peak body representative with lived experience of brain injury, carer of a person with a brain injury, and brain injury rehabilitation specialists. Witnesses were cross-examined by jurors over two days. Results: Key themes related to the need for a model of rehabilitation to: be consumer-focused and supporting the retention of hope; be long-term; provide equitable access to services irrespective of funding source; be inclusive of family; provide advocacy; raise public awareness; and be delivered by experts in a suitable environment. A set of eight recommendations were made. Conclusion: Instigating the recommendations made requires careful consideration of the need for new models of care with flexible services; family involvement; recruitment and retention of highly skilled staff; and providing consumer-focused services that prepare individuals and their carers for the long term. Patient and public contribution: As jury members, the public deliberated information provided by expert witnesses (including a person with a head injury) and wrote the key recommendations.

Aim To investigate the short- and long-term effects of home-based pulmonary rehabilitation (HBPR) on functional capacity, quality of life, peripheral muscle strength, dyspnoea and daily physical activity in people with bronchiectasis. Methods Randomised controlled trial with 63 participants with bronchiectasis. The HBPR group performed three sessions per week for 8 weeks (aerobic exercise: step training for 20 min; resistance training: exercises for quadriceps, hamstrings, deltoids and biceps brachii using elastic bands). The control group received a recommendation to walk at moderate intensity, three times per week. A weekly phone call was conducted for all participants, and the HBPR group received a home visit every 15 days. The primary outcome was distance in the incremental shuttle walk test (ISWT). Secondary outcomes were time in the endurance shuttle walk test (ESWT), number of steps in the incremental step test, quality of life, quadriceps muscle strength and daily physical activity. Measures were taken before and after intervention and 6 months later. Results After the intervention, the HBPR group had increased ISWT distance compared with the control group with between-group difference 87.9 m (95% CI 32.4–143.5 m). In addition, between-group differences were found in the ESWT, incremental step test, quality of life and quadriceps muscle strength, favouring the HBPR group. After 6 months, no differences were observed between the groups. Conclusion HBPR is an effective alternative offering of pulmonary rehabilitation for people with bronchiectasis. However, the programme was not effective in maintaining the benefits after 6 months of follow-up., Home-based pulmonary rehabilitation (HBPR) delivers improvements in functional capacity, peripheral muscle strength and QoL in people with bronchiectasis. HBPR is safe, well tolerated and can be considered an alternative rehabilitation programme. https://bit.ly/2Q2Bout

BackgroundExercise and traditional airway clearance techniques (ACTs) are both routinely recommended for people with cystic fibrosis (CF), with some people using exercise as a substitute for traditional ACTs. The effectiveness of this is unclear. We systematically reviewed the evidence for using exercise as a substitute for traditional ACTs in people with CF.MethodsA systematic database and literature search were undertaken of studies comparing exercise to rest or traditional ACTs. Primary outcomes were respiratory function, respiratory exacerbations and health-related quality of life. Secondary outcomes included mucociliary clearance (MCC), sputum weight and ease of expectoration. Data are mean difference (95% CI).ResultsA total of 12 studies (15 reports) were included, all of short duration (single session to 2 weeks). In crossover trials, exercise did not improve forced expiratory volume in one second in comparison to rest, but peak expiratory flow was increased during treadmill exercise (mean difference (MD) range 1.00–1.16 L/s) and cycle ergometry (1.19 (0.96 to 1.42) L/s). Treadmill exercise improved MCC (2.6 (1.6 to 3.6)%) and ease of expectoration (MD range 1.3–1.8 cm) compared with rest. No consistent differences in respiratory function were evident when exercise was compared with traditional ACTs (four crossover studies). There was no significant difference in MCC or sputum weight in studies where forced expirations were included in the exercise intervention.ConclusionsExercise improves ease of expectoration and sputum clearance compared with rest. Exercise, incorporating forced expirations, may have similar effects to traditional ACTs over the short term. There are no data comparing exercise to traditional ACTs over the longer term.PROSPERO registration numberCRD42018102780.

Positive expiratory pressure (PEP) and oscillating positive expiratory pressure (OscPEP) therapies are often used by people with cystic fibrosis (CF) to facilitate airway clearance. However, suboptimal adherence and poor technique may reduce their effectiveness.To develop a device (PEPtrac) to accurately measure and provide preliminary clinical data of adherence and technique characteristics when airway clearance is performed using PEP/OscPEP devices.This study comprised two distinct phases: 1) a benchtop validation study; and 2) clinical study. Benchtop study: Accuracy of PEPtrac was measured by comparing it to video analysis for five different PEP/OscPEP devices. Clinical study: Clinical data were then collected for 18 adults with CF using one of three PEP/OscPEP devices (PariPEP S®, Acapella DH® or Aerobika®) unsupervised.There was 100% agreement between PEPtrac and video analysis data. Clinical data revealed significant variability in expiratory duration and pressure properties between the three PEP/OscPEP devices and between participants. For example, expiratory duration with PariPEP S® (mean [SD] = 4.8 [1.2] sec) was longer (Accurate measurement of PEP/OscPEP adherence and technique using a device such as PEPtrac was possible. Further research is required to investigate the clinical importance of the variability in technique seen in our clinical data.

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement). Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

Purpose To determine if eccentric exercise was effective, safe and feasible in increasing function and quality of life in people with heart failure compared to usual care and a waitlist control group. Methods A prospective, three-armed, parallel-design, assessor-blind, pilot randomised controlled trial with 1:1:1 allocation. Forty-seven participants (16 female; mean age 66 years) with mild to moderate heart failure were randomly allocated to either eccentric exercise, concentric exercise or a waitlist control group. Participants in the exercise groups completed twice-weekly exercise for eight weeks. Primary outcome was walking capacity. Secondary outcomes were quality of life, leg strength and fatigue. Outcomes were assessed at baseline, post intervention and three-month follow-up. Attendance, tolerability and adverse events were used to determine safety and feasibility. Results Intention-to-treat analysis showed no differences between eccentric exercise and either concentric exercise or waitlist for any outcome. Per-protocol analysis found improvements identified by the Minnesota living with heart failure questionnaire were significantly greater post-intervention for eccentric exercise compared to concentric exercise (-17.99 units, 95% confidence interval -35.96 to -0.01). No major adverse events were reported. Conclusion In this small trial, eccentric exercise did not demonstrate superior outcomes to concentric exercise or a waitlist control group. Clinical trial registration The protocol for this trial was registered at clinicaltrials.gov, registration number: NCT02223624, registration date: 22 August 2014. IMPLICATIONS FOR REHABILITATION Regular physical activity and referral to rehabilitation is recommended for people with chronic heart failure, however exercise can be challenging for this group. Eccentric exercise was safe and tolerable for participants with heart failure. Documentation of exercise progression is important to demonstrate a dose-response relationship. In this study there were no differences between groups who received eccentric exercise, concentric exercise or no exercise.

© 2020 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology. Pulmonary complications in CTD are common and can involve the interstitium, airways, pleura and pulmonary vasculature. ILD can occur in all CTD (CTD-ILD), and may vary from limited, non-progressive lung involvement, to fulminant, life-threatening disease. Given the potential for major adverse outcomes in CTD-ILD, accurate diagnosis, assessment and careful consideration of therapeutic intervention are a priority. Limited data are available to guide management decisions in CTD-ILD. Autoimmune-mediated pulmonary inflammation is considered a key pathobiological pathway in these disorders, and immunosuppressive therapy is generally regarded the cornerstone of treatment for severe and/or progressive CTD-ILD. However, the natural history of CTD-ILD in individual patients can be difficult to predict, and deciding who to treat, when and with what agent can be challenging. Establishing realistic therapeutic goals from both the patient and clinician perspective requires considerable expertise. The document aims to provide a framework for clinicians to aid in the assessment and management of ILD in the major CTD. A suggested approach to diagnosis and monitoring of CTD-ILD and, where available, evidence-based, disease-specific approaches to treatment have been provided.

Pulmonary rehabilitation is an effective intervention for people with chronic lung disease, with evidence for improvements in exercise capacity, breathlessness and health-related quality of life [1]. It is strongly recommended in clinical guidelines for the management of people with chronic obstructive pulmonary disease [2] and there is growing evidence for its effectiveness in other respiratory conditions [3–5]. The majority of pulmonary rehabilitation programmes are centre based, requiring participants to attend an outpatient centre for every session of supervised exercise and education related to self-management [6]., Home-based pulmonary rehabilitation is a clinically effective alternative for people who cannot attend centre-based programmes https://bit.ly/33qPx7A

Background Despite a lack of evidence, ambulatory oxygen therapy is frequently prescribed for patients with interstitial lung disease (ILD) and exertional desaturation. Patients often prefer portable oxygen concentrators to oxygen cylinders. This study aimed to examine the feasibility of conducting a clinical trial of ambulatory oxygen delivered via portable concentrators in patients with ILD. Research Question Is it feasible to conduct a clinical trial of ambulatory oxygen delivered via portable concentrators in patients with ILD? Study Design and Methods In this randomized, triple-blinded, sham-controlled trial, 30 participants with ILD and isolated exertional desaturation to Results Study recruitment was completed within 18 months, with six withdrawals. Participant blinding was successful, with the Bang’s Blinding Index being 0 (95% CI, −0.40 to 0.40) for the oxygen group and 0 (95% CI, −0.42 to 0.42) for the sham group. No significant difference in 6MWD was seen between groups at week 12 (mean difference of −34 m [95% CI, −105 to 36], P = .34). For secondary outcomes, compared with the sham group, the oxygen group had a significantly higher Leicester Cough Questionnaire psychological domain score, indicating better cough-related quality of life (mean difference of 0.9 [95% CI, 0.2 to 1.6], P = .01), but a shorter duration of moderate-to-vigorous activities (mean difference of −135 [95% CI, −267 to −3], P = .04) at week 12. Interpretation Based on the results of this pilot study, a definitive randomized controlled trial with a longer intervention duration is warranted to clarify therapeutic impacts of ambulatory oxygen in patients with ILD. Trial Registry Australian New Zealand Clinical Trials Registry; No.: ACTRN12617000054314; URL: www.anzctr.org.au/

To establish the prevalence of obesity in an inpatient rehabilitation setting, examine its impact on hospital outcomes, and explore staff perceptions of caring for patients with obesity.A retrospective audit of inpatients admitted to a sub-acute rehabilitation hospital over 12 months. Hospital outcomes included length of stay (LOS), Functional Independence measure (FIM), and discharge destination. Linear regression models were used to determine whether obesity was associated with hospital outcomes. Staff working on rehabilitation wards were invited to complete a survey exploring their perceptions on caring for those who are obese.Of 1280 episodes of care, 359 (28%) patients were classified as obese with a body mass index ≥30 kg/mOne-third of patients admitted to inpatient subacute rehabilitation were classified as obese. Whilst obesity was not associated with poorer hospital outcomes, staff perceived that obesity negatively impacts on care requirements and LOS.Implications for rehabilitationA third of patients admitted to a public, inpatient rehabilitation setting may be classified as obese based on their body mass index.Although staff perceived that obesity negatively impacts on length of stay and functional gains, there was no evidence that obesity was associated with poorer hospital outcomes.Patients who are classified as obese were able to achieve comparable hospital outcomes including length of stay in the rehabilitation setting to those who are not obese.

Background As our population ages, older adults are increasingly exposed to trauma. Frailty could be a useful measure to identify patients at risk of a poor outcome. This study aimed to determine the impact of frailty in an Australian trauma intensive care unit (ICU) population. Methods A prospective observational study of critically ill trauma patients ≥50 years of age. Frailty was determined on admission to the ICU using the frailty phenotype. Demographic and hospital data were collected, and patients were followed up at 6 and 12 months. The primary outcome was 12-month mortality, and multiple regression was used to determine associated factors. Results One hundred thirty-eight patients were included, whose mean age was 68 years; 78.2% (108/138) were classified as major trauma (Injury Severity Score >12). Twenty-two percent (30/138) of patients were identified as frail. Patients with frailty were significantly older: however, they were less severely injured and required lower rates of surgical interventions and mechanical ventilation. Frailty was independently associated with mortality at 6 and 12 months (odds ratio: 5.9, 95% confidence interval: 1.9–18.1 and odds ratio: 7.3, 95% confidence interval: 2.5–21.9, respectively). Patients with frailty had lower measures of global functioning (Glasgow Outcome Scale-Extended frail 3 [1–5] vs nonfrail 6 [(5–7], p = 0.002) and health status (Euro Qol 5Q-5D-5L utility score 0.6 [0.5–0.7] vs 0.7 [0.6–0.9], p = 0.02) at 12 months than patients without frailty. Conclusion Frailty is a useful predictor of poor outcomes in critically ill trauma patients. Registration of protocol number ACTRN12615000039583.

INTRODUCTION People with mild chronic obstructive pulmonary disease (COPD) experience exercise intolerance, dyspnoea and poor quality of life. However, the role of pulmonary rehabilitation (PR) in this group is unclear. OBJECTIVES This randomised controlled trial aimed to explore the effects of home-based PR in people with mild COPD. METHODS People with mild COPD (FEV1 /FVC 80%predicted) with a smoking history of ≥10 packet years were randomised to either 8 weeks of home-based PR (one home visit and seven once-weekly telephone calls) or standard care (weekly social telephone calls). Six minute walk distance (6MWD), and Modified Medical Research Council Dyspnoea Scale (mMRC) and Chronic Respiratory Disease Questionnaire (CRQ) scores were compared. RESULTS A total of 58 participants (34 males, mean age 68 (SD 9) years, FEV1 %predicted 90 (7), 6MWD 496 (105) m) were included with 31 participants randomised to home-based PR. Participants attended an average of 6.8 of the 8 scheduled sessions, ranging from 3 to 8 sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life (HRQoL) over time, however there was no difference in 6MWD at end-intervention (mean difference -3 m, 95% confidence interval (CI) -64 to 58) or 6 months (7 m, 95% CI -59 to 72). At 6 months home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, P

Purpose Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices. Patients and methods Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George's Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone. Results Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p

BackgroundInterstitial lung disease is a debilitating condition associated with significant dyspnoea, fatigue, and poor exercise tolerance. Pulmonary rehabilitation is an effective and key intervention in people with interstitial lung disease. However, despite the best efforts of patients and clinicians, many of those who participate are not achieving clinically meaningful benefits. This assessor-blinded, multi-centre, randomised controlled trial aims to compare the clinical benefits of high intensity interval exercise training versus the standard pulmonary rehabilitation method of continuous training at moderate intensity in people with fibrotic interstitial lung disease.MethodsEligible participants will be randomised to either a standard pulmonary rehabilitation group using moderate intensity continuous exercise training or high intensity interval exercise training. Participants in both groups will undertake an 8-week pulmonary rehabilitation program of twice-weekly supervised exercise training including aerobic (cycling) and strengthening exercises. In addition, participants in both groups will be prescribed a home exercise program.Outcomes will be assessed at baseline, upon completion of the intervention and at six months following the intervention by a blinded assessor. The primary outcome is endurance time on a constant work rate test. Secondary outcomes are functional capacity (6-min walk distance), health-related quality of life (Chronic Respiratory Disease Questionnaire (CRQ), St George’s Respiratory Questionnaire idiopathic pulmonary fibrosis specific version (SGRQ-I), breathlessness (Dyspnoea 12, Modified Medical Research Council Dyspnoea Scale), fatigue (fatigue severity scale), anxiety (Hospital Anxiety and Depression Scale), physical activity level (GeneActiv), skeletal muscle changes (ultrasonography) and completion and adherence to pulmonary rehabilitation.DiscussionThe standard exercise training strategies used in pulmonary rehabilitation may not provide an optimal exercise training stimulus for people with interstitial lung disease. This study will determine whether high intensity interval training can produce equivalent or even superior changes in exercise performance and symptoms. If high intensity interval training proves effective, it will provide an exercise training strategy that can readily be implemented into clinical practice for people with interstitial lung disease.Trial registrationClinicalTrials.gov Registry (NCT03800914). Registered 11 January 2019,https://clinicaltrials.gov/ct2/show/NCT03800914Australian New Zealand Clinical Trials Registry ACTRN12619000019101. Registered 9 January 2019,https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376050&isReview=true

Objectives: The objectives of this study were to determine the proportion of patients with interstitial lung disease (ILD) referred to pulmonary rehabilitation (PR) and to understand their experiences of participation or non-participation. Methods: Adults (>18 years old) with a diagnosis of ILD were identified from the Alfred Health ILD registry in Melbourne. Information regarding PR referral and attendance were collected from medical records. Semi-structured interviews with open-ended questions were conducted with patients who had been referred to PR. Results: Of 336 patients eligible for inclusion, PR referral was identified in 137 patients (40.7%). Patients referred to PR had worse respiratory function than those not referred (forced vital capacity mean 64 (SD 23) vs 79 (19) % predicted) and more desaturation during a 6-min walk test (86.6 (7.8%) vs 88.5 (7.0%)). Semi-structured interviews identified three major themes: valued components of PR (supervision and individualization, improved confidence with exercise, education and peer support); limited knowledge about PR prior to attendance and barriers to attending PR (lack of perceived benefits, fear of exercise and accessibility). Discussion: Over 40% of patients who attended a specialist ILD clinic were referred to pulmonary rehabilitation, with higher referral rates in those with more severe disease. There are opportunities to improve patient knowledge regarding the role and expected benefits of PR in people with ILD.

IntroductionChronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care.MethodsA multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9–10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up.Ethics and disseminationHuman Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications.Trial registration numberACTRN12619001122145.

Granuloma annulare (GA) is a difficult-to-treat granulomatous skin disorder characterized by multiple annular, raised, and erythematous lesions. While numerous therapies have been proposed, there is currently no clear gold standard of treatment. We present a series of five patients with biopsy-proven generalized GA who were treated with pentoxifylline and oral vitamin E. Each patient in this series had at least a one-year history of GA refractory to other treatments. After three months of treatment, four of the five patients demonstrated objective improvement in their lesions through before and after clinical photographs. No patients suffered any adverse events on this treatment regimen. As our series has demonstrated modest benefits in concurrence with previously published studies, we recommend combination therapy with pentoxifylline and vitamin E as a strong contender for first- or second-line treatment for generalized GA. Pentoxifylline and vitamin E are advantageous for their tolerability, cost-effectiveness, minimal drug interactions, and convenience.

Background Quality of life has improved dramatically over the past two decades in people with cystic fibrosis (CF). Quantification has been enabled by patient-reported outcome measures (PROMs); however, many are lengthy and can be challenging to use in routine clinical practice. We propose a short-form PROM that correlates well with established quality-of-life measures. Methods We evaluated the utility of a 10-item score (AWESCORE) by measuring reliability, validity and responsiveness in adults with CF. The questions were developed by thematic analysis of survey questions to patients in a single adult CF centre. Each question was scored using a numerical rating scale 0 to 10. Total scores ranged from 0 to 100. Test–retest reliability was assessed over 24 h. To determine validity, comparisons were sought between stable subjects and those in pulmonary exacerbation, and between AWESCORE and Cystic Fibrosis Questionnaire – Revised (CFQ-R). Responsiveness to pulmonary exacerbation in individual subjects was evaluated. Results Five domains, each with two questions, were identified for respiratory, physical, nutritional, psychological and general health. A total of 246 consecutive adults attending the outpatient clinic completed the AWESCORE. Scores were higher during clinical stability compared to pulmonary exacerbation (mean± sd): 73±11 versus 48±11 (p, The AWESCORE: a new, short patient-reported outcome measure for adults with cystic fibrosis in clinical settings. It is feasible, valid, reliable and responsive to change, and developed to enhance communication and decision-making in clinical practice. https://bit.ly/2TWDaj3

Background and objective In Australia, little is known about delivery of care for people with idiopathic pulmonary fibrosis (IPF). This study examined the organization of IPF care across Australia, how it aligns with guidance for best practice, and identified barriers and facilitators to best care. Methods Data on the organization of IPF care in Australia were collected from public hospitals using a study-specific questionnaire between February and July 2020. Semi-structured telephone interviews were conducted with respiratory physicians from around Australia between April and December 2020. Interviews were transcribed verbatim and thematic analysis was undertaken. Results Almost all hospitals (n = 38, 97%) held multidisciplinary meetings (MDMs) for diagnosing IPF, with 90% of multidisciplinary teams including expert respiratory physicians and radiologists; however, rheumatologists, interstitial lung disease nurses and a histopathologist were often not available. More than 90% of institutions had access to oxygen therapy, pulmonary rehabilitation and advanced care planning, but access to psychological support and clinical trials was limited (53% and 58%, respectively). Fifteen respiratory physicians (27% regional) were interviewed. Approaches to diagnosis, treatment and access to referral services were generally consistent with best practice guidance; however, regional respondents reported barriers related to inadequate staffing, lack of a nurse coordinator, inadequate access to clinical trials and funding models. Telehealth technologies were perceived as facilitators to best care. Conclusion Clinical management of IPF in Australia generally aligns with best practice guidance, but there may be some inequity of access to specialist services, particularly in regional areas, that should be addressed to ensure optimal care for all.

Background Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging. Objectives To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme. Search methods We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL. Selection criteria We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events. Data collection and analysis Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence. Main results We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported. Authors' conclusions This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear.

Chronic cough is experienced by most patients with idiopathic pulmonary fibrosis (IPF). It is often the first symptom and is associated with reduced quality of life, increased rates of depression and anxiety, more severe physiological impairment, and disease progression. Although not fully understood, recent gains in understanding the pathophysiology of chronic cough in IPF have been made. The pathophysiology is likely multifactorial and includes alterations in mucous production and clearance, architectural distortion, and increased cough reflex sensitivity, suggesting a role for targeted therapies and multidisciplinary treatment. Modifiable comorbidities can also induce cough in patients with IPF. There is a renewed emphasis on measuring cough in IPF, with clinical trials of novel and repurposed therapies for chronic cough emerging in this population. This review provides an update on the clinical characteristics, pathophysiology, and measurement of chronic cough in patients with IPF and summarizes recent developments in non-pharmacological and pharmacological therapies.

Background\ud Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co‐existing long‐term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.\ud \ud Objectives\ud To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all‐cause and respiratory‐related hospital admissions, mortality, pain, and depression and anxiety.\ud \ud To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all‐cause and respiratory‐related hospital admissions, mortality, pain, and depression and anxiety.\ud \ud To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).\ud \ud Search methods\ud We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.\ud \ud Selection criteria\ud Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed‐methods studies to identify themes.\ud \ud Data collection and analysis\ud We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed‐methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.\ud \ud Main results\ud Quantitative studies\ud We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water‐based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land‐based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type.\ud \ud Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates.\ud \ud Intervention versus usual care\ud Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) −10.85, 95% confidence interval (CI) −12.66 to −9.04; 1 study, 70 participants; low‐certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD −8.02, 95% CI −9.44 to −6.60; 1 study, 70 participants, moderate‐certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD −6.90, 95% CI −9.56 to −4.24; moderate‐certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care.\ud \ud There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low‐certainty evidence).\ud \ud For secondary outcomes, six‐minute walk distance (6MWD) may improve with pulmonary rehabilitation, water‐based exercise or multicomponent interventions at 38 to 52 weeks (low‐certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality.\ud \ud Intervention versus active comparator\ud We included one study comparing water‐based and land‐based exercise (30 participants). We found no evidence for quality of life or exacerbations.\ud \ud There may be little to no difference between water‐ and land‐based exercise for 6MWD (MD 5 metres, 95% CI −22 to 32; 38 participants; very low‐certainty evidence).\ud \ud Qualitative studies\ud One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long‐term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment.\ud \ud Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self‐efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self‐management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.\ud \ud Authors' conclusions\ud Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take‐home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities.\ud \ud Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

It is imperative to develop novel therapeutic strategies for Alzheimer’s disease (AD) and related dementia syndromes based on solid mechanistic studies. Maintenance of memory and synaptic plasticity relies on de novo protein synthesis, which is partially regulated by phosphorylation of eukaryotic elongation factor 2 (eEF2) via its kinase eEF2K. Abnormally increased eEF2 phosphorylation and impaired mRNA translation have been linked to AD. We recently reported that prenatal genetic suppression of eEF2K is able to prevent aging-related cognitive deficits in AD model mice, suggesting the therapeutic potential of targeting eEF2K/eEF2 signaling in AD. Here, we tested two structurally distinct small-molecule eEF2K inhibitors in two different lines of AD model mice after onset of cognitive impairments. Our data revealed that treatment with eEF2K inhibitors improved AD-associated synaptic plasticity impairments and cognitive dysfunction, without altering brain amyloid β (Aβ) and tau pathology. Furthermore, eEF2K inhibition alleviated AD-associated defects in dendritic spine morphology, postsynaptic density formation, protein synthesis, and dendritic polyribosome assembly. Our results may offer critical therapeutic implications for AD, and the proof-of-principle study indicates translational implication of inhibiting eEF2K for AD and related dementia syndromes.One Sentence SummaryTreatment with eEF2K inhibitors and genetic eEF2K knockout improved cognitive deficits in Alzheimer’s disease model mice.

Background and objective Patients with idiopathic pulmonary fibrosis (IPF) have reduced levels of daily physical activity (DPA); however, little is known about how DPA changes as disease progresses. We aimed to (i) describe change in DPA over 12 months, (ii) analyse its association with conventional markers of disease severity and quality of life and (iii) assess DPA as a prognostic tool. Methods A total of 54 patients with IPF had DPA monitored at baseline and at 6 and 12 months with a SenseWear armband for 7 consecutive days. Participants completed the Hospital Anxiety and Depression scale, St George's Respiratory Questionnaire and Leicester Cough Questionnaire at each time point and provided clinical data including forced vital capacity (FVC), diffusion capacity of carbon monoxide and 6-min walk distance (6MWD). Results Baseline and 12-month daily step count (DSC) were 3887 (395) and 3326 (419), respectively. A significant reduction in DSC (mean = 645 [260], p = 0.02) and total energy expenditure (mean = 486 kJ [188], p = 0.01) was demonstrated at 12 months. The decline in DSC over 12 months was proportionally larger than decline in lung function. Annual change in DPA had weak to moderate correlation with annual change in FVC % predicted and 6MWD (range r = 0.34-0.45). Change in physical activity was not associated with long-term survival. Conclusion In IPF, decline in DPA over 12 months is significant and disproportionate to decline in pulmonary physiology and may be a useful tool for assessment of disease progression.

Prospective cohort study. To validate a Clinical Prediction Rule (CPR) for ambulation in a non-traumatic spinal cord injury population (NTSCI). Tertiary spinal rehabilitation inpatient service, Melbourne, Australia. Adults with confirmed NTSCI were recruited between April 2013 and July 2017. Data based on the original van Middendorp CPR (age and four neurological variables) were collected from participant’s medical records and by interview. The Spinal Cord Independence Measure item 12 was used to quantify the ability to walk at 6 and 12 months. A receiver operator curve (ROC) was utilised to determine the performance of the CPR. Ambulatory outcomes were compared for AIS A, B, C and D and aetiology groups. The area under the ROC curve (AUC) was 0.94 with 95% confidence interval (CI) 0.86–1.0 (n = 52). Overall accuracy was 75% at 6 months and 82% at 12 months. For the whole cohort the sensitivity at 12 months was 95% and specificity 73%. However, specificity for AIS C and D was only 50%. The CPR correctly predicted those who did not walk at 6 and 12 months following NTSCI, but was less accurate in predicting those who would walk particularly those with an AIS C or D classification. This CPR may be useful to inform planning for future care in individuals with NTSCI, particularly for those who are not expected to walk. Further research with larger sample sizes is required to determine if the trends identified in this study are generalisable.

This study describes physical activity levels and factors associated with physical activity at the end of stroke rehabilitation.Primary stroke survivors were assessed at completion of physical rehabilitation. Outcomes included physical activity (e.g. step count, moderate-vigorous physical activity duration) and sedentary time measured with the Sensewear Armband, gait speed, and cognition. The number of participants meeting physical activity recommendations was calculated. Differences in physical activity were examined between household ambulators (gait speed0.4 m/s), limited community ambulators (0.4-0.8 m/s), and unlimited community ambulators (0.8 m/s). The influence of age, cognition, and gait speed on physical activity was determined by multiple regression.Seventy-nine stroke survivors participated. Twenty-one participants achieved 30 min/day of moderate-vigorous physical activity accumulated in 10 min bouts. Unlimited community ambulators took more steps/day (median 4975 vs. 469 limited, 355 household,Physical activity is low following stroke and should be a target for treatment, particularly in those with gait speeds ≤0.8 m/s.Implications for rehabilitationSeventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day.Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts.Despite relatively good physical ability, daily step count was low in this sample.Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time.

Objective The aim of this study was to determine the duration of physical activity (PA) monitoring required for reliable measurements following stroke. Design Single-center, prospective, observational study. Setting PA was measured in a community setting. Participants Adults (N=70) poststroke. Main Outcome Measures The SenseWear armband was used to monitor PA for 5 days (≥10 hours wear per day). Data Analysis Variance among 2, 3, 4, and 5 days of consecutive measurements for PA variables was examined using intraclass correlation coefficients (ICCs). The minimum number of days to achieve acceptable reliability (ICC ≥0.8) was calculated. Differences between weekdays and weekend days were investigated using paired t tests and Wilcoxon signed rank tests. Results Two days of measurement was sufficient to achieve an ICC ≥0.8 for daily averages of total energy expenditure, step count, and time spent sedentary (≤1.5 metabolic equivalent tasks [METs]) and in light (1.5-3 METs) and moderate- to vigorous-intensity (>3 METs) PA. At least 3 days were required to achieve an ICC ≥0.8 when investigating the number of and time spent in bouts (≥10 minutes) of moderate to vigorous PA and sedentary behavior. Participants took significantly more steps (P=.03) and spent more time in light PA (P=.03) on weekdays than weekends. Conclusion Following stroke, 2 days of measurement appears sufficient to represent habitual PA for many simple variables. Three or more days may be necessary for reliable estimates of bouts of PA and sedentary behavior. Consistent inclusion or exclusion of a weekend day is recommended for measuring step count and light PA. Short periods of monitoring provide reliable PA information and may make PA measurement more feasible in the clinical setting.

The complex multisystem nature of cystic fibrosis (CF) commonly results in reduced exercise tolerance, which is independently associated with poor clinical outcomes. Exercise is routinely recommended as part of the therapeutic regimen in CF to improve both respiratory and non-respiratory impairments. Areas covered: This article summarises the most recent evidence regarding the use of exercise as a therapeutic intervention in CF and discusses some of the practical considerations for exercise prescription in this setting. Clinical trials in progress and future research priorities are outlined. Expert opinion: On the balance of available evidence, exercise is likely to assist in improving physical fitness and health-related quality of life (HRQOL) and may be associated with a slower rate of decline in respiratory function in CF. Limitations to current studies include small sample sizes, study durations insufficient to achieve a training effect and difficulty distinguishing the effects of exercise training from that of other interventions implemented as part of a package of care. Larger, multi-centred trials are required to clarify the role of exercise in CF in improving physical fitness, respiratory function, HRQOL, as a substitute for traditional airway clearance techniques and in the management of common CF-related comorbidities.

Objectives To determine in women with clinically stable chronic lung disease (CLD) and healthy women; (1) prevalence of urinary incontinence; (2) risk factors for urinary incontinence; (3) effects of a standard course of specialised physiotherapy treatment (PT) in women with CLD. Design Prospective prevalence study; PT study in CLD subgroup. Setting Tertiary metropolitan public hospital. Participants Women with cystic fibrosis (CF, n = 38), chronic obstructive pulmonary disease (COPD, n = 27) and 69 healthy women without CLD. PT study — 10 women with CLD. Interventions Five continence PT sessions over 3 months. Main outcome measures Prevalence and impact of incontinence (questionnaire), number of leakage episodes (7-day accident diary), pelvic floor muscle function (ultrasound imaging) and quality of life (King’s Health Questionnaire). Results The majority of women in all three groups reported episodes of incontinence (CF 71%; COPD 70%; healthy women 55%). Compared to age-matched healthy controls, women with CF reported more episodes of incontinence (P = 0.006) and more commonly reported stress incontinence (P = 0.001). A logistic regression model revealed that women with CLD were twice as likely to develop incontinence than healthy women (P = 0.05). Women with COPD reported significantly more ‘bother’ with incontinence than age-matched women with incontinence. There was a significant reduction in incontinence episodes following treatment, which was maintained after three months. Conclusions The presence of CLD is an independent predictor of incontinence in women. In older women this is associated with more distress than in age-matched peers without CLD. Larger treatment studies are indicated for women with CLD and incontinence.

To compare levels of physical activity during center and home-based pulmonary rehabilitation (PR) in people with chronic obstructive pulmonary disease.Forty-five consecutive participants (23 male, n = 20, in the home-based group) with mean age of 68 ± 8 yr and forced expiratory volume in the first second of expiration (FEV1) 53 ± 18% predicted undertook physical activity monitoring using the SenseWear Armband during the final week of the interventions of center or home-based PR. Differences in time spent in total physical activity (≥1.5 METs), time spent in moderate to vigorous intensity physical activity (≥3 METs), and steps were compared.Home participants spent a median and interquartile range of 310 (199-328) min/d engaged in total physical activity (29% moderate to vigorous intensity physical activity) compared with 300 (204-370) min/d for the center group (28% moderate to vigorous intensity physical activity, P = .98). Daily step count did not differ between groups (home-based median 5232 [2067-7718] versus center-based median 4049 [1983-6040], P = .66). Of note, center-based participants took 38% more steps on days of program attendance compared with nonattendance days (mean difference: 761 steps/d; 95% CI, -56 to 1579, P = .06).For people with chronic obstructive pulmonary disease undertaking PR, no differences in physical activity levels between center and home-based programs were demonstrated. Understanding the impact of the indirect supervision and motivational interviewing technique utilized during home-based PR on levels of physical activity in people with chronic obstructive pulmonary disease may support clinical implementation of the model as an alternative option to traditional care.

Acute exacerbations are associated with disease progression, hospital admission and death in people with chronic obstructive pulmonary disease (COPD). The detrimental outcomes associated with acute exacerbations highlights a need to understand the time course of recovery following acute exacerbation of COPD (AECOPD) so that effective and timely interventions can be provided. The aim of this narrative review was to describe the natural recovery in physiology, symptoms and function following AECOPD. Substantial recovery of lung function and airway inflammation occurs in the first week after onset of an AECOPD, whilst systemic inflammatory markers may take up to two weeks to recover. Symptoms generally improve over the first 14 days, however marked variation is evident between studies and individuals. There are limited data regarding the time course of recovery for functional capacity, quality of life and strength. In a small number of patients (

Abnormal sleep duration is associated with poor health. Upwards of 50% of people with chronic obstructive pulmonary disease (COPD) report poor sleep quality. The effect of pulmonary rehabilitation on self-reported sleep quality is variable. The aim of this study was to assess the effect of pulmonary rehabilitation on objectively measured sleep quality (via actigraphy) in people with COPD. Sleep quality was assessed objectively using the SenseWear Armband (SWA, BodyMedia, Pittsburgh, PA), worn for ≥4 days before and immediately after completing an 8-week pulmonary rehabilitation program. Sleep characteristics were derived from accelerometer positional data and registration of sleep state by the SWA, determined from energy expenditure. Forty-eight participants (

Idiopathic pulmonary fibrosis and other forms of fibrosing interstitial lung disease (F-ILD) are life-altering conditions that increasingly deprive patients and their caregivers of their quality of...

Background Sleep quality in people with cystic fibrosis (CF) is known to be poor, whereas participating in regular physical activity is associated with less decline in lung function (forced expiratory volume in 1 sec [FEV1]). The relationship between sleep quality and physical activity in people with CF is unknown. Methods Secondary analysis of sleep and activity data collected via actigraphy. Adults with CF in stable health, participating in a study of physical activity (including assessment of exercise capacity), completed 7 d of activity and sleep assessment (SenseWear Armband [SWA]; BodyMedia). Sleep characteristics were derived from accelerometer positional data and registration of sleep state by the SWA, determined by energy expenditure. Results Sleep and activity data were available for 47 participants [n = 28 male; mean ± standard deviation age = 29 ± 8 yr; median (IQR) FEV1 = 60 (50, 82) % predicted]. More fragmented sleep was associated with poorer exercise capacity (rs = -0.303, P = .04), less time spent in moderate-vigorous physical activity (rs = -0.337, P = .020), and poorer FEV1 (rs = -0.344, P = .018). Regression analysis showed that less fragmented sleep was an independent predictor of more total daily activity time (β = -1.0, standard error [SE] of β = .4, P = .02) and trended toward significance for more moderate-vigorous physical activity (β = -.3, SE of β = -.26, P = .08). Greater total sleep time and sleep efficiency were related to better exercise capacity and lung function (P Conclusion This secondary analysis demonstrated a modest relationship between sleep parameters and physical activity and exercise capacity in adults with CF. Future studies of interventions to promote physical activity participation in this group should consider the relationship between sleep and activity performance.

To establish the feasibility and effectiveness of a 6-week ballistic strength training protocol in people with stroke.Randomized, controlled, assessor-blinded study.Subacute inpatient rehabilitation.Consecutively admitted inpatients with a primary diagnosis of first-ever stroke with lower limb weakness, functional ambulation category score of ≥3, and ability to walk ≥14 m were screened for eligibility to recruit 30 participants for randomization.Participants were randomized to standard therapy or ballistic strength training 3 times per week for 6 weeks.The primary aim was to evaluate feasibility and outcomes included recruitment rate, participant retention and attrition, feasibility of the exercise protocol, therapist burden, and participant safety. Secondary outcomes included measures of mobility, lower limb muscle strength, muscle power, and quality of life.A total of 30 participants (11% of those screened) with mean age of 50 years (SD 18) were randomized. The median number of sessions attended was 15 of 18 and 17 of 18 for the ballistic and control groups, respectively. Earlier than expected discharge to home (n=4) and illness (n=7) were the most common reasons for nonattendance. Participants performed the exercises safely, with no study-related adverse events. There were significant (P.05) between-group changes favoring the ballistic group for comfortable gait velocity (mean difference [MD] 0.31m/s, 95% confidence interval [CI]: 0.08-0.52), muscle power, as measured by peak jump height (MD 8cm, 95% CI: 3-13), and peak propulsive velocity (MD 64cm/s, 95% CI: 17-112).Ballistic training was safe and feasible in select ambulant people with stroke. Similar rates of retention and attrition suggest that ballistic training was acceptable to patients. Secondary outcomes provide promising results that warrant further investigation in a larger trial.

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

BackgroundPhysical inactivity is associated with poor outcomes in patients with many chronic lung diseases, however little is known about physical activity in patients with idiopathic pulmonary fibrosis (IPF). Our aim was to describe daily physical activity (DPA) in patients with a confirmed diagnosis of IPF and analyse its associations with traditional markers of disease severity and quality of life.MethodsFifty-nine patients with IPF had DPA parameters and sedentary time assessed with the Sensewear armband for seven consecutive days. Participants completed the Hospital Anxiety and Depression scale (HADS), St Georges Respiratory Questionnaire (SGRQ) and Leicester Cough Questionnaire (LCQ). Data on current markers of disease severity; forced vital capacity (FVC), carbon monoxide diffusion capacity (DLCO) and 6-minute walk test (6MWT) as well as prognostic markers; composite physiologic index (CPI) and gender age and physiology (GAP) was collected.ResultsPatients had a median daily step count of 3957 (300–7614), mean daily moderate to vigorous (MV) physical activity duration of 8.6 minutes (-13.1 to 30.3) and mean total daily sedentary time of 1234.6 minutes (± 122.8). Patients with early stages of IPF according to GAP stage had significantly higher daily step count than those with more severe disease (p Trial Registration: please note that a request has been made for retrospective registration with the Australian New Zealand Clinical Trial Registry with the request number being 381161. Due to holiday period closure, this is yet to be processed. I will supply this as soon as accepted.

Dyspnoea is a cardinal symptom of fibrotic interstitial lung disease (ILD), with a lack of proven effective therapies. With emerging evidence of the role of facial and nasal airflow for relieving breathlessness, this pilot study was conducted to examine the feasibility of conducting a clinical trial of a handheld fan (HHF) for dyspnoea management in patients with fibrotic ILD. In this mixed-methods, randomised, assessor-blinded, controlled trial, 30 participants with fibrotic ILD who were dyspnoeic with a modified Medical Research Council Dyspnoea grade ≥ 2 were randomised to a HHF for symptom control or no intervention for 2 weeks. Primary outcomes were trial feasibility, change in Dyspnoea-12 scores at Week 2, and participants’ perspectives on using a HHF for dyspnoea management. Study recruitment was completed within nine months at a single site. Successful assessor blinding was achieved in the fan group [Bang’s Blinding Index − 0.08 (95% CI − 0.45, 0.30)] but not the control group [0.47 (0.12, 0.81)]. There were no significant between-group differences for the change in Dyspnoea-12 or secondary efficacy outcomes. During qualitative interviews, participants reported that using the HHF relieved breathlessness and provided relaxation, despite initial scepticism about its therapeutic benefit. Oxygen-experienced participants described the HHF being easier to use, but not as effective for symptomatic relief, compared to oxygen therapy. Our results confirmed the feasibility of a clinical trial of a HHF in fibrotic ILD. There was a high level of patient acceptance of a HHF for managing dyspnoea, with patients reporting both symptomatic benefits and ease of use.

Purpose Early pulmonary rehabilitation (PR) has beneficial impacts on people with chronic obstructive pulmonary disease (COPD) when delivered after an exacerbation; however, program characteristics are diverse. This systematic review aimed to determine the impact of PR program characteristics (mode, length, commencement, frequency, location, and supervision) on clinical outcomes following an exacerbation of COPD. Methods Studies were screened from Medline, Medline in progress, Embase, CINAHL, SCOPUS, CENTRAL, and PEDro. Included studies were randomized controlled trials of early PR after an exacerbation of COPD (commenced during hospital stay or ≤4 wk of hospital discharge). The primary outcomes were hospital readmissions and mortality. Results Thirty studies were included. Exercise training alone was delivered in 43% of studies. Program duration varied from length of inpatient stay to 12 wk. The interventions commenced as early as ≤24 hr of hospitalization for acute exacerbation, and up to 2 wk after discharge. Early PR was compared to usual care, and no studies made a direct comparison of the program characteristics of interest. Program characteristics associated with reduced risk of hospital admission were commencement after hospital discharge, duration longer than 3 wk, and programs that included exercise training and education (relative risk of readmission range 0.6-0.79); however, it was not possible to determine which of these characteristics made the most important contribution. Mortality risk did not vary according to PR program characteristics. Conclusion Programs >3 wk, started after hospital discharge or including an educational component in addition to exercise, were most effective at reducing hospital readmissions.