Emma Vincent

An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial

Objective To investigate whether an early rehabilitation intervention initiated during acute admission for exacerbations of chronic respiratory disease reduces the risk of readmission over 12 months and ameliorates the negative effects of the episode on physical performance and health status. Design Prospective, randomised controlled trial. Setting An acute cardiorespiratory unit in a teaching hospital and an acute medical unit in an affiliated teaching district general hospital, United Kingdom. Participants 389 patients aged between 45 and 93 who within 48 hours of admission to hospital with an exacerbation of chronic respiratory disease were randomised to an early rehabilitation intervention (n=196) or to usual care (n=193). Main outcome measures The primary outcome was readmission rate at 12 months. Secondary outcomes included number of hospital days, mortality, physical performance, and health status. The primary analysis was by intention to treat, with prespecified per protocol analysis as a secondary outcome. Interventions Participants in the early rehabilitation group received a six week intervention, started within 48 hours of admission. The intervention comprised prescribed, progressive aerobic, resistance, and neuromuscular electrical stimulation training. Patients also received a self management and education package. Results Of the 389 participants, 320 (82%) had a primary diagnosis of chronic obstructive pulmonary disease. 233 (60%) were readmitted at least once in the following year (62% in the intervention group and 58% in the control group). No significant difference between groups was found (hazard ratio 1.1, 95% confidence interval 0.86 to 1.43, P=0.4). An increase in mortality was seen in the intervention group at one year (odds ratio 1.74, 95% confidence interval 1.05 to 2.88, P=0.03). Significant recovery in physical performance and health status was seen after discharge in both groups, with no significant difference between groups at one year. Conclusion Early rehabilitation during hospital admission for chronic respiratory disease did not reduce the risk of subsequent readmission or enhance recovery of physical function following the event over 12 months. Mortality at 12 months was higher in the intervention group. The results suggest that beyond current standard physiotherapy practice, progressive exercise rehabilitation should not be started during the early stages of the acute illness. Trial registration Current Controlled Trials ISRCTN05557928.

Randomized controlled trial of dietary creatine as an adjunct therapy to physical training in chronic obstructive pulmonary disease.

RATIONALE Skeletal muscle strength and bulk are reduced in patients with chronic obstructive pulmonary disease (COPD) and influence quality of life, survival, and utilization of health care resources. Exercise training during pulmonary rehabilitation (PR) can reverse some of these effects. In athletes and healthy elderly individuals, dietary creatine supplementation (CrS) has been shown to augment high-intensity exercise training, thereby increasing muscle mass. OBJECTIVES This article examines the effect of CrS on functional exercise capacity and muscle performance in people with COPD. METHODS One hundred subjects with COPD (mean [SD] age, 68.2 [8.2] yr; FEV(1), 44.0 [19.6] %predicted) were randomized to a double-blind, placebo-controlled, parallel group trial of CrS during 7 weeks of PR encompassing aerobic and resistance exercises. Subjects ingested creatine (22 g/d loading for 5 d; maintenance, 3.76 g/d throughout PR) or placebo. Baseline, postloading, and postrehabilitation measurements included pulmonary function, body composition, peripheral muscle strength, and functional performance (shuttle walking tests). A volunteer subgroup (n = 44) had pre- and postloading quadriceps muscle biopsies. MEASUREMENTS AND MAIN RESULTS Eighty subjects completed the trial (38 creatine, 42 placebo). All outcome measures significantly improved after PR. There were no significant differences between groups post-PR (mean [SD] change in incremental shuttle walk distance, 84 [79] m in the creatine group vs. 83.8 [60] m in the placebo group; P = 1.0; knee extensor work, 19.2 [16] Nm [Newton meters] in the creatine group vs. 19.5 [17] Nm in the placebo group; P = 0.9). Muscle biopsies showed evidence of creatine uptake. CONCLUSIONS This adequately powered, randomized, placebo-controlled trial shows that CrS does not augment the substantial training effect of multidisciplinary PR for patients with COPD. Clinical trial registered with https://portal.nihr.ac.uk/Pages/NRRArchiveSearch.aspx (NO123138126).

Measuring a Change in Self-Efficacy Following Pulmonary Rehabilitation: An Evaluation of the PRAISE Tool

BACKGROUND Self-efficacy explores the emotional functioning and coping skills of an individual and is thought to be a strong predictor of health behaviors, which is particularly important for pulmonary rehabilitation (PR). However, to our knowledge, there is no measure of self-efficacy developed to explore behavior change in the context of PR. METHODS We investigated the reproducibility and sensitivity of Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE): a tool adapted from the General Self-Efficacy Scale (GSES) to measure the dimension of self-efficacy at the time of a course of PR. Twenty-nine clinically stable patients with COPD completed PRAISE on their initial assessment to PR. The tool was then completed 7 days later. An additional 225 patients completed PRAISE prior to, and on completion of a 7-week course of PR. In addition, exercise capacity was measured by the incremental shuttle walk test (ISWT), with the Medical Research Council (MRC) dyspnea scale, Chronic Respiratory Questionnaire-Self Reported (CRQ-SR), and Hospital Anxiety and Depression Scale (HADS) also being collected. This process was repeated postrehabilitation. Data were then analyzed to investigate the possibility that PRAISE could be an indicator of PR response. RESULTS In the reproducibility study, the mean change in score was 0.72 (95% CI, -2.27-0.82), examined with intraclass correlation coefficients, r = 0.99; indicating PRAISE test-retest reproducibility. The mean change of score in the sensitivity study pre- to post-PR was 3.59 (95% CI, 2.24-4.73; P = .015). Change in the ISWT was 83.44 m (95% CI, 54.0-112.8; P < .0001). There were several statistically significant differences between variables, particularly with the mastery and emotion elements of the CRQ-SR at baseline, but this was lost post-PR. This observation was also found with HADS. No significant differences were found between MRC dypsnea scale grades with the change in PRAISE score. PRAISE could not predict a successful outcome of PR. CONCLUSIONS The PRAISE tool is a reliable and sensitive measure of self-efficacy for patients with COPD attending PR.

Original ResearchCOPDMeasuring a Change in Self-Efficacy Following Pulmonary Rehabilitation: An Evaluation of the PRAISE Tool

BACKGROUND Self-efficacy explores the emotional functioning and coping skills of an individual and is thought to be a strong predictor of health behaviors, which is particularly important for pulmonary rehabilitation (PR). However, to our knowledge, there is no measure of self-efficacy developed to explore behavior change in the context of PR. METHODS We investigated the reproducibility and sensitivity of Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE): a tool adapted from the General Self-Efficacy Scale (GSES) to measure the dimension of self-efficacy at the time of a course of PR. Twenty-nine clinically stable patients with COPD completed PRAISE on their initial assessment to PR. The tool was then completed 7 days later. An additional 225 patients completed PRAISE prior to, and on completion of a 7-week course of PR. In addition, exercise capacity was measured by the incremental shuttle walk test (ISWT), with the Medical Research Council (MRC) dyspnea scale, Chronic Respiratory Questionnaire-Self Reported (CRQ-SR), and Hospital Anxiety and Depression Scale (HADS) also being collected. This process was repeated postrehabilitation. Data were then analyzed to investigate the possibility that PRAISE could be an indicator of PR response. RESULTS In the reproducibility study, the mean change in score was 0.72 (95% CI, -2.27-0.82), examined with intraclass correlation coefficients, r = 0.99; indicating PRAISE test-retest reproducibility. The mean change of score in the sensitivity study pre- to post-PR was 3.59 (95% CI, 2.24-4.73; P = .015). Change in the ISWT was 83.44 m (95% CI, 54.0-112.8; P < .0001). There were several statistically significant differences between variables, particularly with the mastery and emotion elements of the CRQ-SR at baseline, but this was lost post-PR. This observation was also found with HADS. No significant differences were found between MRC dypsnea scale grades with the change in PRAISE score. PRAISE could not predict a successful outcome of PR. CONCLUSIONS The PRAISE tool is a reliable and sensitive measure of self-efficacy for patients with COPD attending PR.

Bedside assessment of quadriceps muscle by ultrasound after admission for acute exacerbations of chronic respiratory disease

RATIONALE Hospitalization represents a major event for the patient with chronic respiratory disease. There is a high risk of readmission, which over the longer term may be related more closely to the underlying condition of the patient, such as skeletal muscle dysfunction. OBJECTIVES We assessed the risk of hospital readmission at 1 year, including measures of lower limb muscle as part of a larger clinical trial. METHODS Patients hospitalized with an exacerbation of chronic respiratory disease underwent measures of muscle function including quadriceps ultrasound. Independent factors influencing time to hospital readmission or death were identified. Patients were classified into four quartiles based on quadriceps size and compared. MEASUREMENTS AND MAIN RESULTS One hundred and ninety-one patients (mean age, 71.6 [SD, 9.1] yr) were recruited. One hundred and thirty (68%) were either readmitted or died. Factors associated with readmission or death were age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.08; P = 0.015), Medical Research Council (MRC) dyspnea grade (OR, 4.57; 95% CI, 2.62-7.95; P < 0.001), home oxygen use (OR, 12.4; 95% CI, 4.53-33.77; P < 0.001), quadriceps (rectus femoris) cross-sectional area (Qcsa) (OR, 0.34; 95% CI, 0.17-0.65; P = 0.001), and hospitalization in the previous year (OR, 4.82; 95% CI, 2.42-9.58; P < 0.001). In the multivariate analyses, home oxygen use (OR, 4.80; 95% CI, 1.68-13.69; P = 0.003), MRC dyspnea grade (OR, 2.57; 95% CI, 1.44-4.59; P = 0.001), Qcsa (OR, 0.46; 95% CI, 0.22-0.95; P = 0.035), and previous hospitalization (OR, 3.04; 95% CI, 1.47-6.29; P = 0.003) were independently associated with readmission or death. Patients with the smallest muscle spent more days in hospital than those with largest muscle (28.1 [SD, 33.9] vs. 12.2 [SD, 23.5] d; P = 0.007). CONCLUSIONS Smaller quadriceps muscle size, as measured by ultrasound in the acute care setting, is an independent risk factor for unscheduled readmission or death, which may have value both in clinical practice and for risk stratification.

Review Article: Addressing the sexual health of patients with COPD: the needs of the patient and implications for health care professionals

Sexual expression is an important part of our individual identity and yet, this area is rarely addressed by health professionals. This article will explore the possible reasons for this and will also demonstrate the importance of assessing sexuality in patients with chronic obstructive pulmonary disease (COPD). Chronic Respiratory Disease 2007; 4: 111—115

Erectile dysfunction in COPD: A hidden co-morbidity

COPD is associated with a number of different co-morbid conditions and, unsurprisingly, the frequency of these increases with age and disease severity. Co-morbidities can have a severe impact on the costs of healthcare, provision and resources, they can also increase the intensity of symptoms, increase mortality risk and perhaps most importantly impact on quality of life and health status. Whilst some co-morbidities are well recognized and have established management and treatment, not all receive the same attention. The evidence suggests patients with COPD are at a significantly higher risk of developing erectile dysfunction (ED) compared with the general population, regardless of age and presence of other co-morbidity. However, despite the evidence, the presence of ED is not generally sought or discussed with patients. Rarely does erectile dysfunction come up in respiratory disease discussions and if it does, it is infrequently or inadequately addressed. This may be because of uncertainty around the existence or the cause of ED in COPD. For a working definition, ED is the inability to persistently reach and/or maintain an erection sufficient to have satisfactory sexual activity including intercourse. Whilst this may be often a source of amusement to the non-sufferer, it can have a profound effect on quality of life of the person affected. At a time when many every day activates are becoming limited, the inability to maintain a satisfactory sexual relationship may be the one potentially remediable problem that is of concern to the sufferer. An international study, examining men’s attitudes and behaviours in relation to their ED, emphasized the importance of the couple’s relationship and strengthened the view that ED matters to men because of its significant impact on valued partner relationships. We have known about ED and COPD for some time. Fletcher and Martins work in 1982 reported rates of 30% of people with COPD experiencing ED compared with the controls. Later studies, for example, Koseoglu et al., found rates of 75.5% similar to Collins et al. whose study showed around 74% but all were in relatively small numbers of patients or by passive questionnaire and therefore difficult to extrapolate to the whole population. A more recent study by Kahraman et al. compared erectile function of two groups of men aged between 42 and 81 years. Most (80%) of those with COPD had problems with their erections, whist the rate in those without a COPD diagnosis was 56%. In a later article by Shen et al., over 29,000 males with COPD age and index year matched with the controls found the incidence of ED was 1.88-fold higher in the COPD population, but they had more prevalent morbidities such as diabetes, depression and anxiety, and poor control of COPD was a key factor in ED development so those with more emergency visits and admissions were more likely to have ED. In this issue, Turan et al. remind us that sexual problems, inclusive of ED are not commonly addressed by health professionals. This sensitive discussion is often overshadowed by the prevalence of disturbing symptoms such as breathlessness, infection and respiratory failure. It may be that patients have a lack of understanding of how ED and their lung condition could be related. As health professionals, we recognize how factors such as hypoxemia can be an important factor for ED, therefore both patient education and a thoughtful holistic assessment are required by those with COPD to address this possible ‘hidden need’. So where does this lead us to? ED may be physical or psychological. The relationship with lower oxygen levels is known, and we know that ED is more common at

Experiences of patients undergoing pulmonary rehabilitation during an exacerbation of chronic respiratory disease

Chronic obstructive pulmonary disease (COPD) is characterized in the later stages by acute exacerbations that often require hospitalization. Pulmonary rehabilitation is recommended for patients with COPD to aid symptom control, improve quality of life and increase physical activity. We have previously reported a large intervention trial commenced during a hospital admission. The aim of this sub-study was to evaluate the patients’ experiences of discharge following the hospitalization for an acute exacerbation of COPD. During a programme of early rehabilitation (ER) patient perceptions, experiences and healthcare use were collated during the month that followed their discharge. ER (started during their admission) was comprised of exercise training techniques that were modified to suit the environment of acute illness, together with an education and self-management programme. Each patient was then supported on the programme by telephone contact, following their discharge home, at 48 hours, 2 weeks and 4 weeks. We collected information in relation to the walking and exercise progression; we monitored patient recall of healthcare use, compliance/understanding of medical therapy, as well as their wider perceptions that may have influenced the recovery process. Healthcare use was captured using GP records and data analysis. Of the 100 patients, 47 males, (mean (standard deviation)) 71 (9.3) years, FEV1 1.14 L (0.6), BMI 26.6 (6.9), pack smoked years 45.8 (29.6), ethnicity White British 97%, were discharged home following an acute exacerbation of their respiratory symptoms, to an ER programme. At 48 hours following discharge, a minority (20%) of patients stated their symptoms were ‘feeling better’; 15% highlighted that they found the prescribed ‘exercise difficult’; 44% of patients felt at the end of the month that prescribed exercise programme had a ‘positive effect’ on their recovery from their exacerbation; 38% of patients felt their family had a positive effect on their recovery; 11% felt their family hindered. Patients reported a mean confidence score of 8.21 (2.1) for exercise that did not vary over the three contacts (p = 0.166). A similar mean confidence score of 7.76 (2.6) was reported for walking with a non-statistical change also noted (p = 0.223). When patient recall of primary health care contact was compared with actual use, there was statistical significance shown (p = 0.002); patients underestimated the amount of care they received. The data indicate that patients do recover at home within the support of an early intervention. Patients are positive about the benefit of ER in the process of recovery; however, this is uncontrolled data.

Meaningful patient education: How can pulmonary rehabilitation help to bridge the gap for those with interstitial lung disease?

Interstitial lung disease (ILD) is a heterogeneous group of lung disorders associated with exertional dyspnea, hypoxemia, which is often worse with activity, and deconditioning. There is growing evidence supporting the implementation of pulmonary rehabilitation (PR) as an effective and safe intervention for patients with ILD. 1 However, despite the recommendations from quality standards to support PR, 2 programs devised specifically for patients with ILD are as yet uncommon in the United Kingdom. Nevertheless, the general feeling is for the need for further research to justify PR being available as a standard route of care. One of the common concerns for those patients with ILD attending PR is that the educational program (originally devised for patients with chronic obstructive pulmonary disease (COPD)) may not be relevant to their specific needs. 3 Many patients continue to have a low level of knowledge, manifested by a lack of a clear understanding as to what ILD is, what it means, and how it is managed. Patient education is a crucial element of PR and should be provided to address specific needs through effective, wellevaluated, and thoughtful strategies. In this issue, Holland and colleagues suggest that, although patients with ILD value participation in PR programs, they have specific educational needs which may not be met by current educational content. 4 Moreover, they reason that despite some clinicians expressing significant reservations relating to the inclusion of information regarding prognosis and end-of-life care, these topics were highly valued by the patients. In this study, patients with ILD expressed a strong desire to receive information about disease trajectory during PR educational sessions. However, as well as the reservations expressed by the health professional participants for the need for privacy, it is also important to recognize that specific ILDs vary in their rates of progression. In addition, some patients may attend PR with the total lack of recognition that their ILD diagnosis, such as idiopathic pulmonary fibrosis (IPF) may be life limiting. Once the words ‘‘it is not lung cancer’’ are said, some patients, through relief, ‘‘hear’’ nothing else. This may be despite a health professional informing them that they have a different fatal lung disease. Hence, gaining a greater insight into patients’ understanding allows health professionals to adapt an educational forum that is acceptable to all patients. The educational intervention of PR for patients with ILD therefore needs to sensitively target barriers to patient/carer understanding, to recognize misconceptions, and to provide the truth in an experienced and meaningful manner. PR demonstrates an outwardly positive, rewarding experience for the patients who attend. The classes can, from my experience, offer a valuable source of support, education, and mutual kinship from other patients in the class. Effective educational strategies to improve the patient experience, begin with the assessment of needs, in particular the recognition of anxiety/depression, low self-esteem, a lack of understanding or motivation, and the identification of misconceptions.