Search

PURPOSE The purpose of this study was to compare functional capacity and daily activity between two exercise rehabilitation interventions in severe chronic obstructive pulmonary disease (COPD) or heart failure with reduced ejection fraction (HFrEF) over 6 months. Secondarily, we compared intervention groups on symptoms, depression, quality of life, and cardiopulmonary function. DESIGN/METHODS Ninety patients with severe COPD (n = 63) or HFrEF (n = 27) were randomized to either an exercise adherence intervention or standard cardiopulmonary rehabilitation. Patients were 65-year-old male veterans who had either severe COPD (FEV1 < 50% predicted) or HFrEF (EF% < 40%). RESULTS There were no statistically significant differences between the intervention groups or COPD or HfrEF groups on functional capacity, daily activity, symptoms, depression, quality of life, or cardiopulmonary function at 6 months. CONCLUSION In late-stage COPD and HFrEF, functional capacity is not improved with rehabilitation interventions. CLINICAL RELEVANCE In severe COPD and heart failure, cardiopulmonary rehabilitation conducted at home or in the outpatient setting was not beneficial.

Cardiopulmonary rehabilitation (CR) improves physical function and quality of life (QoL) in chronic obstructive pulmonary disease (COPD) and heart failure (HF), but it is unknown if CR improves outcomes in very severe disease. This study’s purpose was to describe functional capacity (6-min walk distance [6MWD], steps/day), symptoms (dyspnea, depression), QoL (Short-Form Health Survey–Veterans [SF-36 V]) and cardiopulmonary function ( N-terminal pro-brain natriuretic peptide [NT-proBNP], forced expiratory volume in 1 s [FEV1]), and derive predictors of mortality among patients with severe COPD and HF who participated in CR.Methods and Results:In this secondary analysis of a randomized controlled trial comparing two CR methods in severe COPD and HF, 90 (COPD = 63, HF = 27) male veterans, mean age 66 ± 9.24 years, 79% Caucasian, and body mass index 31 kg/m2, were followed for 12 months after CR. The COPD group had greater functional decline than the HF group (6MWD, p = .006). Dyspnea was lower ( p = .001) and QoL higher ( p = .006) in the HF group. Mean NT-proBNP was higher in the HF group at all time points. FEV1improved over 12 months in both groups ( p = .01). Mortality was 8.9%, 16.7%, and 37.8% at 12, 24, and 60 months, respectively. One-year predictors of mortality were baseline total steps (2,000 mg/pg).Conclusions:In very severe COPD and HF, risks of mortality over 12 months can predict patients unlikely to benefit from CR and should be considered at initial referral.

PURPOSE: The purpose of this study was to determine the impact of chronic obstructive pulmonary disease exacerbation (COPDE) on pulmonary rehabilitation (PR) participation and completion and on PR outcomes of daily activity, self-reported daily exercise, and functional capacity. METHODS: Participants in an 8-week outpatient PR program were studied pre- and post-PR. Variables included COPDE occurrence (computerized patient record system), self-reported exercise (daily activity diary), daily activity (accelerometer), exercise capacity (6-minute walk distance), dyspnea today and over the past 30 days (Lareau's Functional Status and Dyspnea Questionnaire), health status (The Medical Outcomes Study 36-Item Short-Form Health Survey adapted for Veterans), and quality of life (Seattle Obstructive Lung Disease Questionnaire). RESULTS: Outpatients with COPD (N = 146, 140 men) started PR; 112 completed the program and were studied. Of the 30 participants who had at least 1 COPDE during the program, 10 quit the program. Subjects who exacerbated had a lower body mass index than did patients without COPDE (28.4 compared with 30.8, respectively, P < .05), more severe COPD (percent-predicted forced expiratory volume in the first second of expiration, FEV1% predicted, 32%, compared with 40%, respectively, P< .05), and required supplemental oxygen (70% compared with 36%, respectively, P< .05). Exacerbators who completed PR were more likely to be nonsmokers, on oxygen, and have a higher FEV1% predicted than were exacerbators who quit. It was found that postprogram exercise capacity improved overall, with exacerbators performing better than nonexacerbators on the 6-minute walk test (P = .044). There were no significant differences in other outcomes. CONCLUSIONS: Findings suggest that COPD exacerbators who completed PR had similar outcomes as did nonexacerbators and should be encouraged to return to PR after COPDE.

Purpose To determine the feasibility of using an accelerometer to characterize physical activity patterns (PA) surrounding chronic obstructive pulmonary disease (COPD) exacerbations (AECOPD) in patients with COPD for 16 weeks. Methods Patients with COPD (n = 8) wore the RT3®, a triaxial accelerometer (Stayhealthy, Monrovia, CA) during waking hours and kept daily symptom diaries. The mean vector magnitude unit (VMU) per minute was calculated by dividing the total VMU for the day by the number of minutes the device was worn. Descriptive statistics were used and plots were made showing PA for each subject with AECOPD markers based on symptom diaries and health resource utilization. Results Sample characteristics were: age 71 ± 4; 5 Females; forced expiratory volume in one second (FEV1)% predicted: 40% ± 16%; FEV1/forced vital capacity: 45 ± 7; and Medical Research Council dyspnea scale: 2.3 ± 0.9. Overall adherence to the monitoring protocol was 97.6% (Range 92%–100%) while adherence to wearing the device for at least 10 hours per day was 91.5% (Range 75%–99%). Mean vector magnitude units per minute was 117.8 ± 47 (Range 61.4–184.1). Seven exacerbations were captured over a total of 896 person-days of monitoring. There were substantial intra-individual fluctuations in daily PA during both the stable state and with outpatient treated exacerbations. Conclusions Patients with COPD were able to adhere to a 16-week activity monitoring protocol and reported a willingness to wear such a device for an extended period of time if the data yield important and useful information for themselves and their health provider. Future work will need to focus first, on validating other promising devices that produce higher quality PA data and second, replicate this monitoring protocol with a larger sample of COPD patients over a longer period.

Study objective To develop and validate a brief, computer-scannable, self-administered questionnaire to monitor health-related quality of life in patients with COPD. The Seattle Obstructive Lung Disease Questionnaire (SOLQ) consists of 29 items measuring four health dimensions: physical function, emotional function, coping skills, and treatment satisfaction. Methods A series of studies was performed to assess reliability, validity, and responsiveness. Internal consistency was measured using a cross-sectional survey of 203 COPD patients. Reproducibility was tested over a 4-month interval among 97 patients with self-reported stable conditions. To assess construct validity, SOLQ scales were correlated with corresponding Chronic Respiratory Disease Questionnaire (CRDQ) scales, the COPD Self-Efficacy Scale (CSES), percent predicted FEV 1 , and 6-min walk test. Treatment satisfaction scores of 920 subjects were correlated with a general measure of patient satisfaction. Baseline and follow-up scores of subjects were compared to assess treatment responsiveness. Results SOLQ scales were reliable (Cronbach's α 0.79 to 0.93, and intraclass correlation coefficients 0.64 to 0.87). Change in SOLQ scores correlated with corresponding CRDQ scales: dyspnea, r=0.42; emotional burden, r=0.49; mastery, r=0.36. Coping skills correlated highly with CSES, r=0.93. Treatment satisfaction correlation was r=0.54. Significant changes occurred in all three scales postintervention. Conclusion The SOLQ is a reliable, valid, and responsive measure of physical and emotional function, coping skills, and treatment satisfaction. Brief, self-administered, and computer scannable, it is useful in monitoring long-term outcomes among large groups of COPD patients.

The aims of this paper were (1) to describe objectively confirmed physical activity patterns across 3 chronic cardiopulmonary conditions, and (2) to examine the relationship between selected physical activity dimensions with disease severity, self-reported physical and emotional functioning, and exercise performance.Cross-sectional study.Participants' home environment.Patients with cardiopulmonary illnesses: chronic obstructive pulmonary disease (COPD) (n=63), heart failure (n=60), and patients with implantable cardioverter defibrillator (n=60).Not applicable.Seven ambulatory physical activity dimensions (total steps, percent time active, percent time ambulating at low, medium, and high intensity, maximum cadence for 30 continuous minutes, and peak performance) were measured with an accelerometer.Subjects with COPD had the lowest amount of ambulatory physical activity compared with subjects with heart failure and cardiac dysrhythmias (all 7 activity dimensions, P.05); total step counts were: 5319 versus 7464 versus 9570, respectively. Six-minute walk distance was correlated (r=.44-.65, P.01) with all physical activity dimensions in the COPD sample, the strongest correlations being with total steps and peak performance. In subjects with cardiac impairment, maximal oxygen consumption had only small to moderate correlations with 5 of the physical activity dimensions (r=.22-.40, P.05). In contrast, correlations between 6-minute walk test distance and physical activity were higher (r=.48-.61, P.01) albeit in a smaller sample of only patients with heart failure. For all 3 samples, self-reported physical and mental health functioning, age, body mass index, airflow obstruction, and ejection fraction had either relatively small or nonsignificant correlations with physical activity.All 7 dimensions of ambulatory physical activity discriminated between subjects with COPD, heart failure, and cardiac dysrhythmias. Depending on the research or clinical goal, use of 1 dimension, such as total steps, may be sufficient. Although physical activity had high correlations with performance on a 6-minute walk test relative to other variables, accelerometry-based physical activity monitoring provides unique, important information about real-world behavior in patients with cardiopulmonary illness not already captured with existing measures.

The development of a conceptually driven exercise and self-management intervention for improving functional capability and reducing health care costs using social cognitive theory is described. The intervention has 2 components: a 1-month outpatient exercise intervention followed by a home component, lasting 5 months. The intervention is expected to have significant impact on daily function, quality of life, gait/balance, self-efficacy, and health care utilization in persons with advanced heart failure or chronic obstructive pulmonary disease. We report preliminary results related to process-related variables, including feasibility, safety, and intervention adherence. Intervention outcomes are currently under study and will be reported when available.

Dyspnea has been defined as the unpleasant sensation of difficult breathing and the reaction to that sensation. Dyspnea research, however, has largely used a unidimensional, sensory model of dyspnea devoid of the affective and motivational dimensions that uniquely characterize this sensation in clinical populations. Dyspnea might be more comprehensively viewed as a nociceptive phenomenon which, like pain, has affective dimensions expressed as distress in response to aversiveness. A multidimensional, ecologic model of the dyspnea experience is presented that incorporates nociceptive sensation properties and is suggestive of new directions for dyspnea research uniquely relevant to nursing science.

Steele BG, Belza B, Cain KC, Coppersmith J, Lakshminarayan S, Howard J, Haselkorn JK. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease. Objectives To evaluate the effectiveness of an exercise adherence intervention to maintain daily activity, adherence to exercise, and exercise capacity over 1 year after completion of an outpatient pulmonary rehabilitation program. Design A 2-group, experimental design was used with randomization into intervention and usual care groups. Setting Outpatient pulmonary rehabilitation program in a university-affiliated medical center. Participants One hundred six subjects (98 men; 98 with chronic obstructive pulmonary disease) with a mean age of 67 years and chronic lung disease. Intervention Twelve-week adherence intervention (weekly phone calls and home visit) including counseling on establishing, monitoring, and problem-solving in maintaining a home exercise program. Main Outcome Measures Primary outcomes included daily activity (accelerometer), exercise adherence (exercise diary), and exercise capacity (six-minute walk test). All measures were performed at baseline, after the pulmonary rehabilitation program (8wk), after the adherence intervention (20wk), and at 1 year. Results A rank-based analysis of covariance showed less decline at 20 weeks in exercise adherence (intervention mean, +3min; control mean, −13min; P =.015) and exercise capacity (intervention mean, −10.7m; control mean, −35.4m; P =.023). There were no differences in daily activity at 20 weeks or any differences in any primary variable at 1 year. Conclusions The intervention enhanced exercise adherence and exercise capacity in the short term but produced no long-term benefit. These findings are in part attributed to the disappointing measurement characteristics of the accelerometer used to measure daily activity. The intervention was acceptable to participants. Further study is needed to fashion interventions that have more persistent benefit.

Purpose To evaluate the ability of the Seattle Obstructive Lung Disease Questionnaire (SOLDQ) to detect change in health-related quality of life (HRQOL) following a pulmonary rehabilitation program (PRP) and to determine associations with other functional indicators. Methods A prospective pre- and post-test design. A PRP was offered for 60 minutes, 2 times per week for 8 weeks. Measured at entry and exit to the PRP: the SOLDQ (physical, emotional, and coping skills), 6-minute walk, Medical Outcomes Study Short Form Health Survey-36 Veterans (SF-36V) (physical and mental), Lareau Functional Status and Dyspnea Questionnaire, and the Multidimensional Assessment of Fatigue (MAF) scale. Setting was an outpatient PRP in a VA Medical Center. Results Participants included 58 adults who completed the PRP (age mean = 66, SD +/- 9.8; FEV1% predicted mean = 39, SD +/- 15.9). At baseline, significant correlations were found between SOLDQ physical functioning and SF-36V physical, dyspnea, fatigue, 6-minute walk distance, SF-36V mental, and spirometry. SOLDQ emotional functioning significantly correlated with fatigue, dyspnea, and SF-36V mental and physical. SOLDQ coping skills significantly correlated with fatigue, dyspnea, and SF-36V mental and physical. Paired, 2-tailed, t tests comparing the SOLDQ subscales pre- and post-program were significant, with the biggest treatment effect seen with emotional functioning. Other measures showing significant improvement included 6-minute walk, SF-36V physical, dyspnea, and fatigue. Conclusions After participation in a PRP, all 3 SOLDQ subscales improved significantly and were associated with other indicators of function. These findings validate the SOLDQ as a measure sensitive to functional changes associated with participation in pulmonary rehabilitation.

Physical activity is a key dimension of functional status in people with chronic obstructive pulmonary disease (COPD), and the central target of interventions in this group.To determine the relationships among functional performance measured as physical activity, functional capacity, symptom experiences, and health-related quality of life in people with COPD.Cross-sectional, descriptive study. Convenience sample of 63 outpatients with COPD studied prior to entry into a pulmonary rehabilitation program.Daily physical activity, as measured by an accelerometer, was strongly associated with maximal distance walked during a 6-minute walk test (r = .60, p.00), level of airway obstruction (r = .37, p.01), walking self-efficacy (r = .27, p.05), and physical health status (r = .40, p.01). Physical activity was not correlated with self-report of functional status. The only predictor of physical activity was the 6-minute walk test.Accelerometer measurement of functional performance was most significantly related to walking abilities. This methodology represents a novel approach to measuring an important dimension of functional status not previously well quantified.

To determine the reliability, validity, and stability of a triaxial accelerometer for walking and daily activity measurement in a COPD sample.Cross-sectional, correlational, descriptive design.Outpatient pulmonary rehabilitation program in a university-affiliated Veterans Affairs medical center.Forty-seven outpatients (44 men and 3 women) with stable COPD (FEV(1), 37% predicted; SD, 16%) prior to entry into a pulmonary rehabilitation program.Test-retest reliability of a triaxial movement sensor (Tritrac R3D Research Ergometer; Professional Products; Madison, WI) was evaluated in 35 of the 47 subjects during three standardized 6-min walks (intraclass correlation coefficient [rICC] = 0.84). Pearson correlations evaluated accelerometer concurrent validity as a measure of walking (in vector magnitude units), compared to walking distance in all 47 subjects during three sequential 6-min walks (0. 84, 0.85, and 0.95, respectively; p0.001). The validity of the accelerometer as a measure of daily activity over 3 full days at home was evaluated in all subjects using Pearson correlations with other indicators of functional capacity. The accelerometer correlated with exercise capacity (maximal 6-min walk, r = 0.74; p0.001); level of obstructive disease (FEV(1) percent predicted, r = 0.62; p0.001); dyspnea (Functional Status and Dyspnea Questionnaire, dyspnea over the past 30 days, r = - 0.29; p0.05); and activity self-efficacy (Activity Self-Efficacy Questionnaire, r = 0.43; p0.01); but not with self-report of daily activity (Modified Activity Recall Questionnaire, r = 0.14; not significant). Stability of the accelerometer to measure 3 full days of activity at home was determined by an rICC of 0.69.This study provides preliminary data suggesting that a triaxial movement sensor is a reliable, valid, and stable measure of walking and daily physical activity in COPD patients. It has the potential to provide more precise measurement of everyday physical functioning in this population than self-report measures currently in use, and measures an important dimension of functional status not previously well-described.

Transdermal nicotine therapy is widely used to aid smoking cessation, but there is uncertainty about its safety in patients with cardiac disease.In a randomized, double-blind, placebo-controlled trial at 10 Veterans Affairs medical centers, we randomly assigned 584 outpatients (of whom 576 were men) with at least one diagnosis of cardiovascular disease to a 10-week course of transdermal nicotine or placebo as an aid to smoking cessation. The subjects were monitored for a total of 14 weeks for the primary end points of the study (death, myocardial infarction, cardiac arrest, and admission to the hospital due to increased severity of angina, arrhythmia, or congestive heart failure); the secondary end points (admission to the hospital for other reasons and outpatient visits necessitated by increased severity of heart disease); any side effects of therapy; and abstinence from smoking.There were 48 primary and 78 secondary end points noted in a total of 95 subjects. At least one of the primary end points was reached by 5.4 percent of the subjects in the nicotine group and 7.9 percent of the subjects in the placebo group (difference, 2.5 percent; 95 percent confidence interval, -1.6 to 6.5 percent; P=0.23). In the nicotine group, 11.9 percent of the subjects had at least one of the secondary end points, as compared with 9.7 percent in the placebo group (difference, 2.2 percent; 95 percent confidence interval, -2.2 to 7.4 percent; P= 0.37). After 14 weeks the rate of abstinence from smoking was 21 percent in the nicotine group, as compared with 9 percent in the placebo group (P=0.001), but after 24 weeks the abstinence rates were not significantly different (14 percent vs. 11 percent, P= 0.67).Transdermal nicotine does not cause a significant increase in cardiovascular events in high-risk outpatients with cardiac disease. However, the efficacy of transdermal nicotine as an aid to smoking cessation in such patients is limited and may not be sustained over time.

Huong Q Nguyen1, Dawn P Gill1, Seth Wolpin1, BonnieG Steele2, Joshua O Benditt11University of Washington, seattle, WA, USA; 2VA Puget Sound Health Care System, Seattle, WA, USAObjective: To determine the feasibility and efficacy of a six-month, cell phone-based exercise persistence intervention for patients with chronic obstructive pulmonary disease (COPD) following pulmonary rehabilitation.Methods: Participants who completed a two-week run-in were randomly assigned to either MOBILE-Coached (n = 9) or MOBILE-Self-Monitored (n = 8). All participants met with a nurse to develop an individualized exercise plan, were issued a pedometer and exercise booklet, and instructed to continue to log their daily exercise and symptoms. MOBILE-Coached also received weekly reinforcement text messages on their cell phones; reports of worsening symptoms were automatically flagged for follow-up. Usability and satisfaction were assessed. Participants completed incremental cycle and six minute walk (6MW) tests, wore an activity monitor for 14 days, and reported their health-related quality of life (HRQL) at baseline, three, and six months.Results: The sample had a mean age of 68 ± 11 and forced expiratory volume in one second (FEV1) of 40 ± 18% predicted. Participants reported that logging their exercise and symptoms was easy and that keeping track of their exercise helped them remain active. There were no differences between groups over time in maximal workload, 6MW distance, or HRQL (p > 0.05); however, MOBILE-Self-Monitored increased total steps/day whereas MOBILE-Coached logged fewer steps over six months (p = 0.04).Conclusions: We showed that it is feasible to deliver a cell phone-based exercise persistence intervention to patients with COPD post-rehabilitation and that the addition of coaching appeared to be no better than self-monitoring. The latter finding needs to be interpreted with caution since this was a purely exploratory study.Trial registration: ClinicalTrials.gov (NCT00373932).Keywords: chronic obstructive pulmonary disease, physical activity, exercise persistence, pulmonary rehabilitation, cell phones

A primary goal of pulmonary rehabilitation is to improve health and life quality by encouraging participants to engage in exercise and to increase daily physical activity. The recent advent of motion sensors, including digital pedometers and accelerometers that measure motion as a continuous variable, have added precision to the measurement of free-living daily activity. Daily activity and exercise are variables of keen interest to proponents of the national health agenda, epidemiologists, clinical researchers, and rehabilitation interventionists. This paper summarizes issues related to conceptualizing and monitoring activity in the rehabilitation setting; reviews motion sensor methodology; compares motion-sensing devices; presents analysis issues and current and potential applications to the pulmonary rehabilitation setting; and gives practical applications and limitations.