Elizabeth Horton

Physical activity monitoring: addressing the difficulties of accurately detecting slow walking speeds.

OBJECTIVE To test the accuracy of a multi-sensor activity monitor (SWM) in detecting slow walking speeds in patients with chronic obstructive pulmonary disease (COPD). BACKGROUND Concerns have been expressed regarding the use of pedometers in patient populations. Although activity monitors are more sophisticated devices, their accuracy at detecting slow walking speeds common in patients with COPD has yet to be proven. METHODS A prospective observational study design was employed. An incremental shuttle walk test (ISWT) was completed by 57 patients with COPD wearing an SWM. The ISWT was repeated by 20 patients wearing the same SWM. RESULTS Differences were identified between metabolic equivalents (METS) and between step-count across five levels of the ISWT (p < 0.001). Good within monitor reproducibility between two ISWT was identified for total energy expenditure and step-count (p < 0.001). CONCLUSIONS The SWM is able to detect slow (standardized) speeds of walking and is an acceptable method for measuring physical activity in individuals disabled by COPD.

Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: a randomised non-inferiority trial

Background Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD. Methods A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV1% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units. Results There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: −0.24, 95% CI −0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks. Conclusions The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation. Trial registration number ISRCTN81189044.

S24 A self-management programme of activity, coping and education (SPACE) for COPD: A randomised non-inferiority trial in a pulmonary rehabilitation population

Introduction Self-managed programmes for patients with COPD offer an alternative to conventional pulmonary rehabilitation (PR). Previously reported self management (SM) programmes either offer short education sessions or action plans or are long intensive programme with a high level of support which are more comprehensive than tradition UK PR programmes. There is limited data reported on self managed approaches to PR which offer minimal support for education, skills acquisition and exercise in comparison to PR in the UK. We have recently developed a SM programme for patients with COPD (SPACE for COPD) and have completed studies in primary care1. The demand for PR is high but the service is compromised by limited access and drop out rates. Therefore the aim of this study was to determine if SPACE for COPD is noninferior to (as good as) PR for patients with COPD over 7 weeks. Methods 287 patients (187 male: mean (SD) age 67 (9) yrs; FEV1 1.25 (0.55); BMI 27.63 (6.22) kg/m2) with COPD were consented and randomised to either SPACE for COPD or PR. Those who were assigned to the SPACE for COPD group received an introduction to the SPACE for COPD manual and 2 telephone calls at 2 and 4 weeks. Those assigned to PR received 14, 2 hour sessions of education and exercise over 7 weeks. The primary outcome was the Chronic Respiratory Questionnaire (CRQ) dyspnoea, with secondary measure of CRQ fatigue, emotion and mastery, Incremental Shuttle Walk Test (ISWT) and Endurance Shuttle Walk Test (ESWT). Measures were taken at baseline and 7 weeks. Within and between group differences were analysed using paired and unpaired t-tests respectively. Results Please see table 1. Abstract S24 Table 1. SPACE for COPDn=94 Pulmonary Rehabilitationn=84 Between group differences Baseline(SD) 7 weeks(SD) Change(95% CI) Baseline(SD) 7 weeks(SD) Change(95% CI) (95% CI) Dyspnoea 2.58(0.93) 3.11(1.23) 0.55(0.26 to 0.85)p=<0.001 2.42(0.91) 3.38(1.18) 0.87(0.61 to 1.13)p<0.001 -0.32(-0.71 to 0.08)p=0.113 Fatigue 3.42(1.19) 3.71(1.22) 0.13(-0.14 to 0.39)p=0.339 3.36(1.20) 4.09(1.49) 0.54(0.27 to 0.82)p<0.001 -0.41(-0.79 to 0.03)p=0.033 Emotion 4.41(1.24) 4.56(1.20) 0.005(-0.23 to 0.24)p=0.965 4.37(1.24) 4.92(1.03) 0.53(0.26 to 0.79)p<0.001 -0.52(-0.88 to 0.17)p=0.004 Mastery 4.50(1.40) 4.78(1.31) 0.15(-0.11 to 0.40)p=0.259 4.36(1.30) 4.94(1.19) 0.58(0.34 to 0.81)p<0.001 -0.43(-0.77 to 0.09)p=0.014 ISWT (metres) 260.24(147.91) 277.86 (145.59) 17.62(3.26 to 31.98)P=0.17 268.61(149.89) 310.13 (156.46) 41.52(23.91 to 59.12) -23.90(-46.33 to -1.47)p=0.038 ESWT (seconds) 231.42(231.00) 444.33(393.09) 212.91(139.49 to 286.34)P<0.001 189.14(96.25) 534.85 (395.38) 345.70(260.20 to 431.20)p<0.001 -132.78(-244.63 to -20.94)p=0.02 Conclusion SPACE for COPD can improve dyspnoea and endurance capacity over 7 weeks to a similar level to PR, although it remains unclear to its noniferiority to PR. The SPACE for COPD programme does offer a number of health benefits despite it involving limited support and could offer a suitable alternative to patients with COPD who would otherwise not attend conventional rehabilitation. References Mitchell-Wagg K et al. (2012). Thorax 67 (Suppl_2) A25–26.

Pulmonary rehabilitation using the SPACE (A Self-management Programme of Activity, Coping and Education) manual at home: A randomised controlled trial

P53 Table 1 Mean baseline and mean changes for Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire Self-Reported (CRQ-SR) Dyspnoea Domain and MRC for conventional rehabilitation and self-management groups Measure Conventional rehabilitation Self-management Baseline Mean change (95% CI) Baseline Mean change (95% CI) ISWT 277.24 54.43 (88.36 to 20.60)* 253.33 40.30 (65.13 to 15.47)* ESWT 225.00 500.62 (656.90 to 344.32)** 257.02 331.33 (483.86 to 178.81)** CRQ-SR Dyspnoea 2.61 0.64 (1.11 to 1.72)* 2.14 0.77 (1.19 to 0.34)* MRC 3.40 20.80 (20.48 to 1.12)** 3.19 20.71 (20.35 to 0.07)** *.0.01; **.0.001. Poster sessions Thorax 2009;64(Suppl IV):A75–A174 A97 on 3 December 2009 thorax.bmj.com Downloaded from

Hemodynamic Instability during Dialysis: The Potential Role of Intradialytic Exercise

Acute haemodynamic instability is a natural consequence of disordered cardiovascular physiology during haemodialysis (HD). Prevalence of intradialytic hypotension (IDH) can be as high as 20–30%, contributing to subclinical, transient myocardial ischemia. In the long term, this results in progressive, maladaptive cardiac remodeling and impairment of left ventricular function. This is thought to be a major contributor to increased cardiovascular mortality in end stage renal disease (ESRD). Medical strategies to acutely attenuate haemodynamic instability during HD are suboptimal. Whilst a programme of intradialytic exercise training appears to facilitate numerous chronic adaptations, little is known of the acute physiological response to this type of exercise. In particular, the potential for intradialytic exercise to acutely stabilise cardiovascular hemodynamics, thus preventing IDH and myocardial ischemia, has not been explored. This narrative review aims to summarise the characteristics and causes of acute haemodynamic instability during HD, with an overview of current medical therapies to treat IDH. Moreover, we discuss the acute physiological response to intradialytic exercise with a view to determining the potential for this nonmedical intervention to stabilise cardiovascular haemodynamics during HD, improve coronary perfusion, and reduce cardiovascular morbidity and mortality in ESRD.