Narelle S. Cox

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.

Telehealth in cystic fibrosis: a systematic review

We conducted a systematic review of the use of telehealth in people with Cystic Fibrosis (CF). The studies reviewed were of adults and children with CF, and incorporated telehealth for monitoring symptoms, assessing adherence to prescribed therapies or providing a therapeutic intervention. Searches of four electronic databases returned 293 references. Eight studies met the inclusion criteria. Variability in study design and outcome measures precluded meta-analysis. Seven studies assessed telemonitoring feasibility for patient usability and acceptance, or for physiological monitoring. Two studies were randomised controlled trials, although only one showed differences in outcome between the intervention and usual care with improved spirometry stability and significantly increased antibiotic use in the intervention group. In four studies participants were asked to transmit data on spirometry (FEV1) or symptoms. Participant non-compliance with data reporting ranged from 43–63%. Generally, participants reported being able to use the required technology. There is insufficient evidence to reach a firm conclusion about the benefits of telehealth in people with CF, but it remains a promising area for future investigation.

Oxygen therapy for interstitial lung disease: a systematic review.

This review aims to establish the impact of oxygen therapy on dyspnoea, health-related quality of life (HRQoL), exercise capacity and mortality in interstitial lung disease (ILD). We included studies that compared oxygen therapy to no oxygen therapy in adults with ILD. No limitations were placed on study design or intervention type. Two reviewers independently evaluated studies for inclusion, assessed risk of bias and extracted data. The primary outcome was dyspnoea. Eight studies evaluated the acute effects of oxygen (n=1509). There was no effect of oxygen therapy on modified Borg dyspnoea score at end exercise (mean difference (MD) −0.06 units, 95% CI −0.24–0.13; two studies, n=27). However, effects on exercise outcomes consistently favoured oxygen therapy. One study showed reduction in dyspnoea at rest with oxygen in patients who were acutely unwell (MD visual analogue scale 30 mm versus 48 mm, p<0.05; n=10). Four studies of long-term oxygen therapy (n=2670) had high risk of bias and no inferences could be drawn. This systematic review showed no effects of oxygen therapy on dyspnoea during exercise in ILD, although exercise capacity was increased. Future trials should evaluate whether acute improvements in exercise capacity with oxygen can be translated into improved physical activity and HRQoL. Oxygen did not improve dyspnoea during exercise in ILD, but exercise capacity was increased http://ow.ly/wu8c307iGaC

Assessing Exercise Capacity Using Telehealth: A Feasibility Study in Adults With Cystic Fibrosis

BACKGROUND: Provision of healthcare from a remote site may assist patients to access important services. We aimed to establish the feasibility of monitoring an assessment of exercise capacity using telehealth technology. METHODS: Adults with CF completed two 3-min step tests, monitored in-person or remotely via videoconferencing, in randomized order. Measurements were physiological responses to exercise, system usability, ease of clinician interaction, metronome acoustics, and participant comfort. RESULTS: Ten adults (5 male), mean ± SD age 32 ± 7 years, and FEV1 55.4% of predicted (range 38–90% of predicted), completed both tests. Participants reported good system usability, with a mean (95% CI) System Usability Scale score of 85.63 out of 100 (79.8–91.5). Metronome acoustics were rated as significantly poorer remotely (P = .006). There were no differences in measurements of oxyhemoglobin saturation or heart rate between assessment settings. CONCLUSION: Exercise capacity assessment using the 3-min step test is feasible and accurate via remote videoconferencing in adults with CF.

Physical activity participation by adults with cystic fibrosis: An observational study.

Studies in children with cystic fibrosis (CF) suggest greater physical activity (PA) is associated with a slower rate of decline in respiratory function. In adults with CF, objectively measured PA time and its relationship to long‐term clinical outcomes of respiratory function and need for hospitalization are unknown.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non‐invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence‐based physiotherapy care to people with CF in Australia and New Zealand.

Validation of a multi-sensor armband during free-living activity in adults with cystic fibrosis ☆

BACKGROUND The SenseWear Armband (SWA) provides simple and non-invasive measures of energy expenditure (EE) during physical activity, however its accuracy in adults with cystic fibrosis (CF) during free living physical activities has not been established. METHODS 26 CF adults (mean FEV1 63% predicted; 11 males) completed a series of standardised static and active tasks with simultaneous analysis of EE via the SWA and indirect calorimetry (IC). RESULTS Mean difference and limits of agreement between EE values from the SWA and IC across all activities were -0.02METs (95% CI -1.1 to 1.1). There was moderate agreement between the two measures (ICC 0.4; 95% CI: 0 to 0.7; p=0.03). For individual activity tasks ICC ranged from 0.1 to 0.6. CONCLUSION Overall, the SWA demonstrated good agreement with IC for EE estimates in CF adults during a series of free-living activities, however accuracy was variable when assessing EE for specific activities of shorter duration.

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.

Feasibility and acceptability of an internet-based program to promote physical activity in adults with cystic fibrosis.

BACKGROUND: Lifelong physical activity is an important component of the therapeutic management of patients with cystic fibrosis (CF). Use of the internet to monitor and encourage participation in physical activity has not been assessed in adults with CF. We aimed to establish the feasibility and acceptability of a specifically developed internet-based program to monitor and encourage physical activity participation in adults with CF. METHODS: Subjects were recruited at hospital discharge to trial an internet-based physical activity program (ActivOnline) for 8 weeks, which incorporated fortnightly telephone consultation to support physical activity behavior change. Acceptability of the program was assessed by semistructured interview, as well as subject-rated system usability and perceived benefit using Likert scales. Feasibility was assessed by frequency of access of the online site and number of physical activity sessions recorded. RESULTS: Ten subjects were recruited who rated system usability and perceived benefit favorably (median score usability of 89% [interquartile range of 84–95%]; median score of perceived benefit (maximum of 5) of 4 [interquartile range of 3–4.8]). During interviews, subjects described a positive reaction to receiving graphical representation of their activity participation; however, 80% would have preferred a more mobile interface such as an app. Subjects accessed ActivOnline on a mean ± SD of 13 ± 11 occasions over 8 weeks and recorded a mean of 35 (range of 15–57) physical activity sessions. CONCLUSIONS: Use of an internet-based program to encourage participation in physical activity was both feasible and acceptable to adults with CF. Feasibility may be further improved with the ability to access the program through a mobile application.