Mike Morgan

Minimum clinically important improvement for the incremental shuttle walking test

Background: The incremental shuttle walking test (ISWT) is used to assess exercise capacity in patients with chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. This study was designed to establish the minimum clinically important difference for the ISWT. Methods: 372 patients (205 men) performed an ISWT before and after a 7-week outpatient pulmonary rehabilitation programme. After completing the course, subjects were asked to identify, from a 5-point Likert scale, the perceived change in their exercise performance immediately upon completion of the ISWT. The scale ranged from “better” to “worse”. Results: The mean (SD) age was 69.4 (8.4) years, forced expiratory volume in 1 s (FEV1) 1.06 (0.53) l and FEV1/forced vital capacity (FVC) ratio 50.8 (18.1)%. The baseline shuttle walking test distance was 168.5 (114.6) m which increased to 234.7 (125.3) m after rehabilitation (mean difference 65.9 m (95% CI 58.9 to72.9)). In subjects who felt their exercise tolerance was “slightly better” the mean improvement was 47.5 m (95% CI 38.6 to 56.5) compared with 78.7 m (95% CI 70.5 to 86.9) in those who reported that their exercise tolerance was “better” and 18.0 m (95% CI 4.5 to 31.5) in those who felt their exercise tolerance was “about the same”. Conclusion: Two levels of improvement were identified. The minimum clinically important improvement for the ISWT is 47.5 m. In addition, patients were able to distinguish an additional benefit at 78.7 m.

How long should outpatient pulmonary rehabilitation be? A randomised controlled trial of 4 weeks versus 7 weeks

Background: The evidence of benefit for pulmonary rehabilitation (PR) programmes is established. However, the optimal duration of a PR programme is not known. A randomised controlled trial was undertaken in patients with chronic obstructive pulmonary disease (COPD) to assess whether a 4 week PR programme was equivalent to our conventional 7 week PR programme at equivalent time points of 7 weeks and 6 months. Methods: One hundred patients (56 men) with stable COPD of mean (SD) age 70 (8) years and forced expiratory volume in 1 second (FEV1) 1.13 (0.50) litres were randomised to either a 7 week (n = 50) or 4 week (n = 50) supervised PR programme. Patients were assessed at baseline, at completion of the supervised PR programme, and 6 months later. Patients randomised to the 4 week group were also assessed at the 7 week time point. Outcome measures were the Incremental Shuttle Walk Test, Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire-Self Reported, and the Breathing Problems Questionnaire. Results: Forty one patients in each group completed the PR programme. Patients made significant within group improvements after supervised rehabilitation. There were no statistically significant differences between the groups for any other measure at the 7 week or 6 month time points, except that patients in the 4 week group attained higher ESWT times (mean difference 124 seconds (95% CI 17.00 to 232.16), p = 0.024) at the 7 week time point. Conclusions: A shortened 4 week supervised PR programme is equivalent to a 7 week supervised PR programme at the comparable time points of 7 weeks and 6 months.

Ultrasound assessment of lower limb muscle mass in response to resistance training in COPD

BackgroundQuantifying the improvements in lower limb or quadriceps muscle mass following resistance training (RT), is an important outcome measure in COPD. Ultrasound is a portable, radiation free imaging technique that can measure the size of superficial muscles belonging to the quadriceps group such as the rectus femoris, but has not been previously used in COPD patients following RT. We compared the responsiveness of ultrasound derived measures of quadriceps mass against dual energy x-ray absorptiometry (DEXA), in patients with COPD and healthy controls following a programme of high intensity knee extensor RT.MethodsPortable ultrasound was used to assess the size of the dominant quadriceps in 45 COPD patients and 19 healthy controls-before, during, and after 8 weeks of bilateral high intensity isokinetic knee extensor RT. Scanning was performed at the mid-thigh region, and 2 indices of quadriceps mass were measured-rectus femoris cross-sectional area (RFcsa) and quadriceps muscle thickness (Qt). Thigh lean mass (Tdexa) was determined by DEXA.ResultsTraining resulted in a significant increase in Tdexa, RFcsa and Qt in COPD patients [5.7%, 21.8%, 12.1% respectively] and healthy controls [5.4%, 19.5%, 10.9 respectively]. The effect size for the changes in RFcsa (COPD= 0.77; Healthy=0.83) and Qt (COPD=0.36; Healthy=0.78) were greater than the changes in Tdexa (COPD=0.19; Healthy=0.26) following RT.ConclusionsSerial ultrasound measurements of the quadriceps can detect changes in muscle mass in response to RT in COPD. The technique has good reproducibility, and may be more sensitive to changes in muscle mass when compared to DEXA.Trial registrationhttp://www.controlled-trials.com (Identifier: ISRCTN22764439)

Short outpatient pulmonary rehabilitation programme reduces readmission following a hospitalization for an exacerbation of chronic obstructive pulmonary disease.

The benefits of pulmonary rehabilitation (PR) are now firmly established. However, less is known about the provision and efficacy of PR immediately after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The study aimed to explore the effectiveness of a short outpatient PR programme and the impact upon readmission rates.

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.

Spirometry and impulse oscillometry (IOS) for detection of respiratory abnormalities in metropolitan firefighters

Background and objective:  As firefighters are at increased risk of adverse health effects, periodic examination of their respiratory health is important. The objective of this study was to establish whether the use of impulse oscillometry (IOS) reveals respiratory abnormalities in metropolitan firefighters that go undetected during routine respiratory health screening by spirometry and assessment of respiratory symptoms.

Study protocol for Chronic Obstructive Pulmonary Disease-Sitting and ExacerbAtions Trial (COPD-SEAT): a randomised controlled feasibility trial of a home-based self-monitoring sedentary behaviour intervention

Introduction An acute exacerbation of chronic obstructive pulmonary disease (COPD) marks a critical life event, which can lower patient quality of life and ability to perform daily activities. Patients with COPD tend to lead inactive and highly sedentary lifestyles, which may contribute to reductions in functional capacity. Targeting sedentary behaviour (SB) may be more attainable than exercise (at a moderate-to-vigorous intensity) for behaviour change in patients following an exacerbation. This study aims to evaluate the feasibility and acceptability of a 2-week at-home intervention providing education and self-monitoring to reduce prolonged periods of SB in patients with COPD discharged following an acute exacerbation. Methods and analysis Patients will be randomised into 1 of 3 conditions: usual care (control), education or education+feedback. The education group will receive information and suggestions about reducing long periods of sitting. The education+feedback group will receive real-time feedback on their sitting time, stand-ups and step count at home through an inclinometer linked to a smart device app. The inclinometer will also provide vibration prompts to encourage movement when the wearer has been sedentary for too long. Data will be collected during hospital admission and 2 weeks after discharge. Qualitative interviews will be conducted with patients in the intervention groups to explore patient experiences. Interviews with healthcare staff will also be conducted. All data will be collected January to August 2016. The primary outcomes are feasibility and acceptability, which will be assessed by qualitative interviews, uptake and drop-out rates, reasons for refusing the intervention, compliance, app usage and response to vibration prompts. Ethics and dissemination The research ethics committee East Midlands Leicester-Central has provided ethical approval for the conduct of this study. The results of the study will be disseminated through appropriate conference proceedings and peer-reviewed journals. Trial registration number ISRCTN13790881; Pre-results.

Preservation of lower limb strength after a short course of pulmonary rehabilitation with no maintenance: a 6-month follow-up study

There is an established body of evidence to confirm he presence of skeletal muscle dysfunction in patients ith chronic obstructive pulmonary disease (COPD) [1], pecifically the loss of skeletal muscle mass and strength, articularly in the muscles of ambulation [1–3]. With this in ind, resistance training is attractive as it is the optimum orm of exercise to increase muscle mass and strength in all ndividuals [4–6]. The short-term benefits of resistance training have been tudied extensively [7,8], but very little is known about hether resistance training is preserved in the long term or COPD patients. Much more is known about the longerm preservation of endurance training in this group, where mprovements in exercise tolerance are maintained for up to 2 months without any formal maintenance [9–11]. Despite trength training being a key component of pulmonary ehabilitation, to the authors’ knowledge [12], only three ublished studies have evaluated the long-term preservation f strength following 12 weeks [13,14] and 6 months [15] f pulmonary rehabilitation. These studies suggested that lthough strength gains decrease, they may remain signifiantly higher than baseline for between 3 [13] and 12 months fter resistance training [15]. The preservation of strength after a short course of resisance training (i.e. a 7-week programme) is unknown.

Do we need a practice incremental shuttle walk test for patients with interstitial lung disease referred for pulmonary rehabilitation

Patients with interstitial lung disease (ILD) are increasingly being referred to pulmonary rehabilitation (PR) where exercise capacity is measured, often by an incremental shuttle walk test (ISWT). These patients are frequently limited by severe dyspnoea and exertional desaturation. Available guidelines suggest two ISWT are needed; however, this is time consuming and it has not been reported whether a practice ISWT is necessary in ILD. We aimed to investigate if a practice ISWT is needed for patients with ILD referred to PR.

One step beyond, does rehabilitation influence physical activity?

The measurement of physical activity has become a ‘hot topic’ in the field of pulmonary rehabilitation, as reflected in the systematic review in this issue. The assessment of physical activity is not new however, and there is an accumulating literature in chronic obstructive pulmonary disease (COPD). The level of activity in COPD seems particularly low in comparison with other significant long-term condition, a comparative review of physical activity revealed that activity for individuals was almost half that of individuals with coronary heart disease or arthritis. More recently Watz et al. described the falling levels of activity associated with increasing disease severity. This interest in physical activity was consolidated by the data obtained from the interaction between physical activity and hospital admissions reported from the Copenhagen Heart Study, although at this time the physical activity was described with data from a questionnaire. More specifically high levels of physical activity seem to protect against subsequent readmissions for COPD, the authors of this article suggested that individuals needed to accumulate 60 min of walking a day to reduce the risk of readmission. Pulmonary rehabilitation would seem the ideal intervention to improve physical activity; supporting behaviour change to enhance physical activity is an implicit aim of the service. It has often been assumed that a meaningful change in exercise tolerance after completing a course of rehabilitation will translate into a significant improvement in physical activity. Until fairly recently it has been difficult to objectively test this assumption, but with the commercial development of activity monitors and increased availability of pedometers some authors have tested this hypothesis. The systematic review aimed to evaluate the impact of exercise training upon physical activity. There were no randomised controlled trials (RCTs), this is perhaps not surprising as the monitors are a fairly recent addition to the repertoire of outcome measures and to conduct an RCT where the control group is no intervention would now be considered unethical. Two RCTs were identified; one study explored the relative value of two different exercise regimes delivered within a rehabilitation programme, one arm being conventional rehabilitation. The second, again used conventional rehabilitation as the control arm, but this time compared the standard programme with the addition of a physical activity counselling programme. There were an additional five observational studies included, all were reasonably small sample sizes, with the exception of the recent study by Steele et al. Overall there was a favourable increase in physical activity observed after a course of rehabilitation but this was felt to be small. There are probably a number of reasons to account for this, most obviously that rehabilitation genuinely failed to provoke a significant increase in physical activity. Changes in domestic activity require a supported and structured approach to supervised and home-based exercise and behaviour techniques should be employed to support increased activity during and after a course of rehabilitation. Rehabilitation practitioners have probably been guilty of not pursuing this aspect of rehabilitation as rigorously as might be required to support behaviour change. The authors of this review suggest that a longer course of rehabilitation might be needed to develop these strategies and reinforce behaviour change.