Angela T. Burge

Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial

Background Pulmonary rehabilitation is a cornerstone of care for COPD but uptake of traditional centre-based programmes is poor. We assessed whether home-based pulmonary rehabilitation, delivered using minimal resources, had equivalent outcomes to centre-based pulmonary rehabilitation. Methods A randomised controlled equivalence trial with 12 months follow-up. Participants with stable COPD were randomly assigned to receive 8 weeks of pulmonary rehabilitation by either the standard outpatient centre-based model, or a new home-based model including one home visit and seven once-weekly telephone calls from a physiotherapist. The primary outcome was change in 6 min walk distance (6MWD). Results We enrolled 166 participants to receive centre-based rehabilitation (n=86) or home-based rehabilitation (n=80). Intention-to-treat analysis confirmed non-inferiority of home-based rehabilitation for 6MWD at end-rehabilitation and the confidence interval (CI) did not rule out superiority (mean difference favouring home group 18.6 m, 95% CI −3.3 to 40.7). At 12 months the CI did not exclude inferiority (−5.1 m, −29.2 to 18.9). Between-group differences for dyspnoea-related quality of life did not rule out superiority of home-based rehabilitation at programme completion (1.6 points, −0.3 to 3.5) and groups were equivalent at 12 months (0.05 points, −2.0 to 2.1). The per-protocol analysis showed the same pattern of findings. Neither group maintained postrehabilitation gains at 12 months. Conclusions This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation. Neither model was effective in maintaining gains at 12 months. Home-based pulmonary rehabilitation could be considered for people with COPD who cannot access centre-based pulmonary rehabilitation. Trial registration number NCT01423227, clinicaltrials.gov.

Benefits and costs of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease - a multi-centre randomised controlled equivalence trial

BackgroundPulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease (COPD) to improve exercise capacity, symptoms and quality of life, however only a minority of individuals with COPD are able to participate. Travel and transport are frequently cited as barriers to uptake of centre-based programs. Other models of pulmonary rehabilitation, including home-based programs, have been proposed in order to improve access to this important treatment. Previous studies of home-based pulmonary rehabilitation in COPD have demonstrated improvement in exercise capacity and quality of life, but not all elements of the program were conducted in the home environment. It is uncertain whether a pulmonary rehabilitation program delivered in its entirety at home is cost effective and equally capable of producing benefits in exercise capacity, symptoms and quality of life as a hospital-based program. The aim of this study is to compare the costs and benefits of home-based and hospital-based pulmonary rehabilitation for people with COPD.Methods/DesignThis randomised, controlled, equivalence trial conducted at two centres will recruit 166 individuals with spirometrically confirmed COPD. Participants will be randomly allocated to hospital-based or home-based pulmonary rehabilitation. Hospital programs will follow the traditional outpatient model consisting of twice weekly supervised exercise training and education for eight weeks. Home-based programs will involve one home visit followed by seven weekly telephone calls, using a motivational interviewing approach to enhance exercise participation and facilitate self management. The primary outcome is change in 6-minute walk distance immediately following intervention. Measurements of exercise capacity, physical activity, symptoms and quality of life will be taken at baseline, immediately following the intervention and at 12 months, by a blinded assessor. Completion rates will be compared between programs. Direct healthcare costs and indirect (patient-related) costs will be measured to compare the cost-effectiveness of each program.DiscussionThis trial will identify whether home-based pulmonary rehabilitation can deliver equivalent benefits to centre-based pulmonary rehabilitation in a cost effective manner. The results of this study will contribute new knowledge regarding alternative models of pulmonary rehabilitation and will inform pulmonary rehabilitation guidelines for COPD.Trial registrationClinicalTrials.gov: NCT01423227.

The evidence of benefits of exercise training in interstitial lung disease: a randomised controlled trial

Background Uncertainty exists regarding the clinical relevance of exercise training across the range of interstitial lung diseases (ILDs). Objective To establish the impact of exercise training in patients with ILDs of differing aetiology and severity. Methods 142 participants with ILD (61 idiopathic pulmonary fibrosis (IPF), 22 asbestosis, 23 connective tissue disease-related ILD (CTD-ILD) and 36 with other aetiologies) were randomised to either 8 weeks of supervised exercise training or usual care. Six-minute walk distance (6MWD), Chronic Respiratory Disease Questionnaire (CRDQ), St George Respiratory Questionnaire IPF-specific version (SGRQ-I) and modified Medical Research Council dyspnoea score were measured at baseline, 9 weeks and 6 months. Measurements and main results Exercise training significantly increased 6MWD (25 m, 95% CI 2 to 47 m) and health-related quality of life (CRDQ and SGRQ-I) in people with ILD. Larger improvements in 6MWD, CRDQ, SGRQ-I and dyspnoea occurred in asbestosis and IPF compared with CTD-ILD, but with few significant differences between subgroups. Benefits declined at 6 months except in CTD-ILD. Lower baseline 6MWD and worse baseline symptoms were associated with greater benefit in 6MWD and symptoms following training. Greater gains were seen in those whose exercise prescription was successfully progressed according to the protocol. At 6 months, sustained improvements in 6MWD and symptoms were associated with better baseline lung function and less pulmonary hypertension. Conclusions Exercise training is effective in patients across the range of ILDs, with clinically meaningful benefits in asbestosis and IPF. Successful exercise progression maximises improvements and sustained treatment effects favour those with milder disease. Trial registration number Results, ACTRN12611000416998.

A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome

Background Obesity hypoventilation syndrome (OHS) is the most common indication for home ventilation, although the optimal therapy remains unclear, particularly for severe disease. We compared Bi-level and continuous positive airways pressure (Bi-level positive airway pressure (PAP); CPAP) for treatment of severe OHS. Methods We conducted a multicentre, parallel, double-blind trial for initial treatment of OHS, with participants randomised to nocturnal Bi-level PAP or CPAP for 3 months. The primary outcome was frequency of treatment failure (hospital admission, persistent ventilatory failure or non-adherence); secondary outcomes included health-related quality of life (HRQoL) and sleepiness. Results Sixty participants were randomised; 57 completed follow-up and were included in analysis (mean age 53 years, body mass index 55 kg/m2, PaCO2 60 mm Hg). There was no difference in treatment failure between groups (Bi-level PAP, 14.8% vs CPAP, 13.3%, p=0.87). Treatment adherence and wake PaCO2 were similar after 3 months (5.3 hours/night Bi-level PAP, 5.0 hours/night CPAP, p=0.62; PaCO2 44.2 and 45.9 mm Hg, respectively, p=0.60). Between-group differences in improvement in sleepiness (Epworth Sleepiness Scale 0.3 (95% CI -2.8, 3.4), p=0.86) and HRQoL (Short Form (SF)36-SF6d 0.025 (95% CI -0.039, 0.088), p=0.45) were not significant. Baseline severity of ventilatory failure (PaCO2) was the only significant predictor of persistent ventilatory failure at 3 months (OR 2.3, p=0.03). Conclusions In newly diagnosed severe OHS, Bi-level PAP and CPAP resulted in similar improvements in ventilatory failure, HRQoL and adherence. Baseline PaCO2 predicted persistent ventilatory failure on treatment. Long-term studies are required to determine whether these treatments have different cost-effectiveness or impact on mortality. Trial registration number ACTRN12611000874910, results.

Advance care planning education in pulmonary rehabilitation: A qualitative study exploring participant perspectives

Background: Advance care planning is considered to have an important role in the management of people with chronic lung disease; however, uptake in clinical practice remains limited. Participant acceptance of the inclusion of an advance care planning information session in pulmonary rehabilitation and maintenance programmes could support a practical solution. Aim: To evaluate the introduction of a structured group advance care planning information session from the perspective of participants in pulmonary rehabilitation and maintenance programmes. Design: Prospective qualitative study with semi-structured interview transcripts analysed using iterative thematic analysis. Setting/participants: Participants in pulmonary rehabilitation and maintenance programmes at a tertiary metropolitan hospital and two affiliated community sites. Results: Sixty-seven participants with a range of chronic lung diseases were interviewed with ages ranging from 39 to 88 years, forced expiratory volume in 1 s (FEV1) ranging from 18% to 130% predicted and 6-min walk distance ranging from 105 to 619 m. Sixteen participants (24%) had previously heard of advance care planning. Major themes were that participants valued the advance care planning information and thought pulmonary rehabilitation was an appropriate setting. The group education format was well accepted and perceived to have advantages over individual sessions. Participants were happy to receive the information from a non-medical facilitator. Non-attendees had usually missed the session for reasons unrelated to content. A small number of participants felt advance care planning was not appropriate for them, but all recognised its value for other participants. Conclusions: Participants in our pulmonary rehabilitation and maintenance programmes value the opportunity to participate in a structured, group-based advance care planning session. Consideration should be given to broader inclusion of advance care planning education into existing pulmonary rehabilitation and maintenance programmes for people with chronic respiratory disease.

The benefits of exercise training in interstitial lung disease: protocol for a multicentre randomised controlled trial

BackgroundInterstitial lung disease encompasses a diverse group of chronic lung conditions characterised by distressing dyspnoea, fatigue, reduced exercise tolerance and poor health-related quality of life. Exercise training is one of the few treatments to induce positive changes in exercise tolerance and symptoms, however there is marked variability in response. The aetiology and severity of interstitial lung disease may influence the response to treatment. The aims of this project are to establish the impact of exercise training across the range of disease severity and to identify whether there is an optimal time for patients with interstitial lung disease to receive exercise training.Methods/DesignOne hundred and sixteen participants with interstitial lung disease recruited from three tertiary institutions will be randomised to either an exercise training group (supervised exercise training twice weekly for eight weeks) or a usual care group (weekly telephone support). The 6-minute walk distance, peripheral muscle strength, health-related quality of life, dyspnoea, anxiety and depression will be measured by a blinded assessor at baseline, immediately following the intervention and at six months following the intervention. The primary outcome will be change in 6-minute walk distance following the intervention, with planned subgroup analyses for participants with idiopathic pulmonary fibrosis, dust-related interstitial lung disease and connective-tissue related interstitial lung disease. The effects of disease severity on outcomes will be evaluated using important markers of disease severity and survival, such as forced vital capacity, carbon monoxide transfer factor and pulmonary hypertension.DiscussionThis trial will provide certainty regarding the role of exercise training in interstitial lung disease and will identify at what time point within the disease process this treatment is most effective. The results from this study will inform and optimise the clinical management of people with interstitial lung disease.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12611000416998

The 6-minute walk distance cannot be accurately assessed at home in people with COPD

Abstract Purpose: The 6-minute walk test (6MWT) is commonly used to measure exercise capacity in COPD, but it is unclear if this test is accurate when performed at home. This study aimed to determine whether exercise capacity can be accurately assessed at home using the 6MWT in COPD. Methods: A total of 19 participants with stable COPD (mean [SD] FEV1/FVC 52[13]) undertook the 6MWT at home and at the hospital, in random order, with two tests performed on each occasion. Hospital tests were conducted on a 30-metre walking track whilst home tests (indoor or outdoor) were conducted using the longest available track. Agreement for 6-minute walk distance (6MWD) was examined using the Bland and Altman method. Results: The track length at home was mean [SD] of 17[9] m. The home 6MWD was shorter than the hospital 6MWD (mean 30 m shorter, limits of agreement −167 to 102 m). For the home tests, a shorter track length was associated with a greater reduction in 6MWD (rs = 0.59, p = 0.01), but not an increased number of turns (rs = −0.41, p = 0.08). Conclusions: The 6MWD underestimates exercise capacity when conducted at home in COPD. Alternative tests suitable for the home environment should be considered if a comprehensive assessment is to be performed at home. Implications for Rehabilitation The 6-minute walk test is commonly used to assess change in exercise capacity following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease, and may be conducted on varying track lengths, indoors or outdoors. When conducted at home, the 6-minute walk test underestimates exercise capacity in chronic obstructive pulmonary disease, due to a shorter track length available in the home environment. This suggests that results from 6-minute walk tests performed at home environment cannot be directly compared to results from centre-based tests

Patient experience of expanded-scope-of-practice musculoskeletal physiotherapy in the emergency department: a qualitative study.

OBJECTIVE The increasing number of people presenting to hospital with musculoskeletal conditions places pressure on existing services, and has resulted in expanding the scope of practice of musculoskeletal physiotherapists working in emergency departments (ED). The aim of the present study was to qualitatively explore the perspectives of patients presenting with an isolated musculoskeletal condition seen by a musculoskeletal physiotherapist in the ED of two Australian hospitals situated in contrasting geographical locations. METHODS Semistructured interviews were conducted with nine participants from a major metropolitan hospital and 16 participants from a remote hospital. Interviews were transcribed, coded and analysed using a thematic approach. RESULTS. The emerging themes from the two datasets were remarkably similar, so the final themes were merged. The major themes were: (1) participants were satisfied with the process and service provided by the physiotherapist; (2) the personal attributes of the physiotherapists were important to participants; (3) participant confidence in the skills and attributes of the physiotherapist made them a suitable alternative to a doctor in these situations; and (4) the timing and efficiency of the physiotherapy service was better than expected and valued. CONCLUSIONS Participants from both settings described their experience in positive terms, reflecting satisfaction with their management by an expanded scope of practice musculoskeletal physiotherapist.

Field Walking Tests Are Reliable and Responsive to Exercise Training in People With Non–Cystic Fibrosis Bronchiectasis

PURPOSE: The 6-Minute Walk Test (6MWT) and Incremental Shuttle Walk Test (ISWT) are used to assess exercise capacity, but the reliability and responsiveness of these tests in individuals with non–cystic fibrosis (CF) bronchiectasis have not been determined. This study aimed to determine the reliability and responsiveness of both tests in adults with non-CF bronchiectasis. METHODS: Eighty-five participants completed 2 6MWTs and 2 ISWTs in random order. Testing was repeated at the conclusion of an 8-week intervention period of exercise training. Reliability was assessed using intraclass correlation coefficients (ICC) and Bland-Altman analysis. Responsiveness was measured by effect size (ES) and standardized response mean (SRM). RESULTS: At baseline, test-retest reliability was high for both tests (ICC ≥ 0.95). The mean (95% CI) increase in the 6MWT from test 1 to test 2 was 20 m (13-26 m): 3% (0-5%) change. The mean (95% CI) increase in the ISWT was 15 m (4-25m): 4% (2-6%) change. A significant learning effect persisted after 8 weeks for the 6MWT (P = .04), but not the ISWT (P = .61). The 6MWT ES was 0.32 and SRM was 0.68; for the ISWT, ES was 0.42 with SRM of 0.71. CONCLUSION: The 6MWT and ISWT are reliable measures of exercise capacity in non-CF bronchiectasis and responsive to exercise training. The small learning effect in both measures at baseline suggests that 2 of each test are necessary to correctly assess exercise capacity. Completion of 2 6MWTs at followup may minimize the risk of underestimating a treatment effect.

Home-based pulmonary rehabilitation for people with COPD: A qualitative study reporting the patient perspective:

This study aimed to document the perspective of patients with chronic obstructive pulmonary disease (COPD) who underwent home-based pulmonary rehabilitation (HBPR) in a clinical trial. In this qualitative study, open-ended questions explored participants’ views regarding HBPR. Thirteen semi-structured interviews were analysed using a thematic analysis approach. Major themes from interviews included the positive impact of HBPR on physical fitness, breathing and mood. Participants valued the flexibility and convenience of the programme. Participants also highlighted the importance of social support received, both from the physiotherapist over the phone and from family and friends who encouraged their participation. Reported challenges were difficulties in initiating exercise, lack of variety in training and physical incapability. While most participants supported the home setting, one participant would have preferred receiving supervised exercise training at the hospital. Participants also reported that HBPR had helped establish an exercise routine and improved their disease management. This study suggests that people with COPD valued the convenience of HBPR, experienced positive impacts on physical fitness and symptoms and felt supported by their community and programme staff. This highly structured HBPR model may be acceptable to some people with COPD as an alternative to centre-based pulmonary rehabilitation.