Stefania Costi

Role of comorbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation

Background: Chronic obstructive pulmonary disease (COPD) is often associated with other chronic diseases. These patients are often admitted to hospital based rehabilitation programmes. Objectives: To determine the prevalence of chronic comorbidities in patients with COPD undergoing pulmonary rehabilitation and to assess their influence on outcome. Design: Observational retrospective cohort study. Setting: A single rehabilitation centre. Patients: 2962 inpatients and outpatients with COPD (73% male, aged 71 (SD 8) years, forced expiratory volume in 1 s (FEV1) 49.3 (SD 14.8)% of predicted), graded 0, 1 or ⩾2 according to the comorbidity categories and included in a pulmonary rehabilitation programme. Measurements: The authors analysed the number of self-reported comorbidities and recorded the Charlson Index. They then calculated the percentage of patients with a predefined positive response to pulmonary rehabilitation (minimum clinically important difference (MCID)), as measured by improvement in exercise tolerance (6 min walking distance test (6MWD)), dyspnoea (Medical Research Council scale) and/or health related quality of life (St George’s Respiratory Questionnaire (SGRQ)). Results: 51% of the patients reported at least one chronic comorbidity added to COPD. Metabolic (systemic hypertension, diabetes and/or dyslipidaemia) and heart diseases (chronic heart failure and/or coronary heart disease) were the most frequently reported comorbid combinations (61% and 24%, respectively) among the overall diseases associated with COPD. The prevalence of patients with MCID was different across the comorbidity categories and outcomes. In a multiple categorical logistic regression model, the Charlson Index (OR 0.72 (96% CI 0.54 to 0.98) and 0.51 (96% CI 0.38 to 0.68) vs 6MWD and SGRQ, respectively), metabolic diseases (OR 0.57 (96% CI 0.49 to 0.67) vs 6MWD) and heart diseases (OR 0.67 (96% CI 0.55 to 0.83) vs SGRQ) reduced the probability to improve outcomes of rehabilitation. Conclusions: Most patients with COPD undergoing pulmonary rehabilitation have one or more comorbidities. Despite the fact that the presence of comorbidities does not preclude access to rehabilitation, the improvement in exercise tolerance and quality of life after rehabilitation may be reduced depending on the comorbidity.

Effectiveness of an ergonomic intervention on work-related posture and low back pain in video display terminal operators: A 3 year cross-over trial

UNLABELLED This study investigated the effectiveness of a workstation ergonomic intervention for work-related posture and low back pain (LBP) in Video Display Terminal (VDT) workers. 100 VDT workers were selected to receive the ergonomic intervention, whereas 100 were assigned to a control group. The two groups were then crossed-over after 30 months from baseline. Follow-ups were repeated at 5, 12, and 30 months from baseline and then at 6 months following crossover. OUTCOMES Work-related posture and LBP point-prevalence using the Rapid Entire Body Assessment method and a Pain Drawing, respectively. The ergonomic intervention at the workstation improved work-related posture and was effective in reducing LBP point-prevalence both in the first study period and after crossover, and these effects persisted for at least 30 months. In conclusion, our findings contribute to the evidence that individualized ergonomic interventions may be able to improve work-related posture and reduce LBP for VDT workers.

Effects of early inpatient rehabilitation after acute exacerbation of COPD

We have undertaken an observational retrospective cohort study to assess feasibility and clinical effectiveness of early rehabilitation in patients recovering from acute exacerbation of COPD (AECOPD). A cohort of 1826 inpatients (73% male, age 70+/-8 yrs, FEV(1) 50+/-16% pred.) admitted to a pulmonary rehabilitation (PR) program and completing at least 15 sessions were divided into categories according to their dyspnoea grade (Medical Research Council--MRC scores 2-5) as assessed before AECOPD. The pre-post changes in 6-minute walking distance (6MWD) test, perceived end-effort dyspnoea (Borg scale), and self-reported quality of life (St. Georges respiratory Questionnaire: SGRQ) were measured throughout. Absolute change in 6MWD (52 [95%CI 45-59], 65 [95%CI 60-70], 63 [95%CI 59-66], and 70 [95%CI 67-74] meters in MRC 2-5 respectively) and the percentage of patients achieving the minimal clinically important difference (MCID) of +54 m (40, 55, 57, and 61%, respectively, p=0.001) differed across MRC grades. Proportion of patients able to reach > or = 350 m at the 6MWD after PR was higher in MRC 4 and 5 (18 and 22%) as compared to MRC 2 and 3 (6 and 15%). Early PR in a cohort of AECOPD patients is feasible and it is associated to clinically meaningful improvement in exercise tolerance independent on the severity of dyspnoea. The proportion of patients reaching the limit of > or = 350 m after this intervention is higher in the most severe patients.

Functional recovery following physical training in tracheotomized and chronically ventilated patients

BACKGROUND: Rehabilitation is a non-pharmacologic therapy that can restore health and reverse the patients disability, but the efficacy of rehabilitation in critically ill patients is not well documented. METHODS: In a prospective cohort study, we assessed whether the degree of change in functional status after comprehensive rehabilitation influenced clinical outcomes in 77 tracheotomized patients (mean ± SD age 75 ± 7 y) admitted for difficult weaning to our regional weaning center. The care plan, including peripheral muscle training, was delivered daily. We recorded admission demographic, anthropometric, and functional characteristics. We measured the change in basic activities of daily living score (ΔBADL), survival, and weaning success rate as clinical outcomes. We performed the Pearson correlation analysis and linear regression, with ΔBADL as the dependent variable, to test the predictive power of the baseline measurements. RESULTS: Sixty-seven patients (87%) survived, and 55 of them (74%) succeeded in weaning during their stay in the weaning center. The mean ± SD ΔBADL improvement was 2.5 ± 2.0 points (median 2 points). Baseline performance of the latissimus dorsi predicted ΔBADL (β = 0.388, 95% CI 0.111–1,664, P = .03). The probability of remaining ventilator-free (P = .043) and survival (P = .001) differed across the 4 ΔBADL categories (0 = no change, 1–2 = least improvement, and > 2 = improvement above median change). CONCLUSIONS: Mortality rate and weaning success differ according to ΔBADL following active rehabilitation/training in tracheotomized, ventilated, difficult-to-wean patients. The performance of the latissimus dorsi was the only significant predictor of change.

Repeated Pulmonary Rehabilitation in Severe and Disabled COPD Patients

Background: The optimal frequency of delivering a pulmonary rehabilitation program (PR) is not yet a well established issue. It is still unclear whether repeated PR at established intervals will result in effective maintenance or further improvement in the patient’s health status. Objectives: To investigate whether more frequently repeated PR in patients with COPD (1) leads to similar short and long-term physiological gains, and (2) decreases the burden due to hospitalization. Methods: Thirty-five disabled COPD patients (FEV1 below 50% predicted, MRC score 3) in a stable state were studied in a randomized controlled trial. After completing an initial inpatient PR program, they were randomly assigned to either group 1 (performing a second and a third PR after 6 and 12 months) or group 2 (performing only a second PR after 12 months). Results: Lung functions, exercise capacity (by means of a timed walk test – 6MWT), peak-effort dyspnea (D) and leg fatigue (F), and health-related quality of life by means of SGRQ were assessed prior to (T1, T3, T5) and after (T2, T4, T6) each PR program: the same measures were taken on an outpatient basis at T3 in group 2. The number of hospital admissions (HA) and days spent in the hospital (DH) were also recorded over the year. The two groups did not differ in any parameter at baseline. 6MWD, D, F and SGRQ improved to the same level (p = 0.05) after each PR in both groups. However, the baseline level of D, F and SGRQ symptoms and impact scores progressively improved over time in group 1 but not in group 2. After 12 months, a larger amount of patients in Group 1, as compared to Group 2, reported H10 DH/year (p < 0.0001). Conclusions: In severe and disabled COPD, a more frequently repeated inpatient PR may lead to some additional physiological and clinical benefits over 1 year.

Short-term Efficacy of Upper-Extremity Exercise Training in Patients With Chronic Airway Obstruction: A Systematic Review

Background, Objectives, and Measurements: Patients with chronic airway obstruction (CAO) frequently experience dyspnea and fatigue during activities performed by accessory muscles of ventilation, which competitively participate in arm elevation. This systematic review of randomized controlled trials (RCTs) concerning patients with CAO addresses the effects of upper-extremity exercise training (UEET), added to lower-extremity training or comprehensive pulmonary rehabilitation, on the following patient-centered outcomes: exercise capacity, symptoms, ability to perform daily activities, and health-related quality of life. Methods: Studies were retrieved using comprehensive database and hand-search strategies. Two independent reviewers determined study eligibility based on inclusion criteria. A detailed description of treatments was mandatory. Reviewers rated study quality and extracted information on study methods, design, intervention, and results. Results: Forty publications were evaluated. Four RCTs met the inclusion criteria but had serious methodological limitations, which introduce possible biases that reduce their internal validity. The outcomes measured were heterogeneous, and the results were inconsistent regarding maximal exercise capacity, dyspnea, and health-related quality of life. No effect of UEET was demonstrated for measures of arm fatigue. Limitations and Conclusions: The limited methodological quality of the studies retrieved prevented us from performing a meta-analysis, the results of which could be misleading. This systematic review shows that there is limited evidence examining UEET and that the evidence available is of poor quality. Therefore, a recommendation for the inclusion or exclusion of UEET in pulmonary rehabilitation programs for individuals with CAO is not possible. Further research is needed to definitively ascertain the effects of this training modality on patient-centered outcomes.

Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence?

Surgical resection appears to be the most effective treatment for early-stage non-small cell lung cancer. Recent studies suggest that perioperative pulmonary rehabilitation improves functional capacity, reduces mortality and postoperative complications and enhances recovery and quality of life in operated patients. Our aim is to analyse and identify the most recent evidence-based physical exercise interventions, performed before or after surgery. We searched in MEDLINE, EMBASE, CINAHL, Cochrane Library and PsycINFO. We included randomised controlled trials aimed at assessing efficacy of exercise-training programmes; physical therapy interventions had to be described in detail in order to be reproducible. Characteristics of studies and programmes, results and outcome data were extracted. Six studies were included, one describing preoperative rehabilitation and three assessing postoperative intervention. It seems that the best preoperative physical therapy training should include aerobic and strength training with a duration of 2–4 weeks. Although results showed improvement in exercise performance after preoperative pulmonary rehabilitation, it was not possible to identify the best preoperative intervention due to paucity of clinical trials in this area. Physical training programmes differed in every postoperative study with conflicting results, so comparison is difficult. Current literature shows inconsistent results regarding preoperative or postoperative physical exercise in patients undergoing lung resection. Even though few randomised trials were retrieved, treatment protocols were difficult to compare due to variability in design and implementation. Further studies with larger samples and better methodological quality are urgently needed to assess efficacy of both preoperative and postoperative exercise programmes.

Effectiveness of standing frame on constipation in children with cerebral palsy: a single-subject study.

Children with cerebral palsy (CP) and quadriplegia or severe diplegia suffer from highly reduced mobility and consequent constipation. Clinicians recommend standing frames to exercise the support reaction in this population, sharing the opinion that the upright position may facilitate intestinal transit, although no evidence supports this assumption. We conducted this study to determine the effects of the standing frame on spontaneous evacuation in children with CP. Moreover, we studied its effects on the frequency of induction of evacuation, the characteristics of the stool and the pain suffered by the child due to constipation and/or evacuation. We implemented a single-subject research design in one chronically constipated child with CP and quadriplegia, Gross Motor Function Classification System Level V. To monitor the effects of the standing frame, we measured the outcome of interest throughout the study using a daily diary and the Bristol Stool Scale. This study was approved by the local Ethics Committee. This study has several limitation; primarily, the use of a single-subject research design only makes possible the visual analysis of data obtained from a unique patient. So, by themselves, data obtained do not allow us any generalization for the target population. Future research should verify our results collecting more data and also investigating the effect of the standing-frame on respiratory functions. Although the standing frame did not affect the frequency of evacuations or the characteristics of the stool, its employment reduced the inductions of evacuation and the related pain suffered by the child. However, this study has several limitations, such as the lack of generalization due to the fact that we studied a unique patient and the overall brevity of the study due to external circumstances. Therefore, we suggest future research to verify our results, also investigating the effect of the standing frame on respiratory functions. Relevance to clinical practice. The standing frame may positively influence the management of constipation of these children, possibly improving their quality of life.

Occupational therapy for complex inpatients with stroke: identification of occupational needs in post-acute rehabilitation setting

Abstract Purpose: Inpatients admitted to rehabilitation express needs not linked to disease causing hospitalization. This observational cross-sectional study identifies features and occupational needs of complex inpatients during rehabilitation, focusing on function and ability, regardless of diagnosis. Method: This study included sixteen adult inpatients with stroke, deemed complex according to Rehabilitation Complexity Scale-Extended, at admission to Rehabilitation ward (from July 2014 to February 2015). Patients with primary psychiatric disorders, language barriers, cognitive or severe communication deficits were excluded. Upon admission, a multidisciplinary team collected data on general health, independence in daily activities (Modified Barthel Index), fatigue (Fatigue Severity Scale), resistance to sitting and ability to perform instrumental activities (Instrumental Activities of Daily Living). The occupational therapist identified occupational needs according to Canadian Occupational Performance Measure. Results: Inpatients enrolled in this study were dependent in basic ADL, limited in instrumental ADL and easily fatigable. Their occupational needs related to self-care (75%) and, to a lesser extent, productivity (15%) and leisure (10%). According to inpatients, rehabilitation process should firstly address self-care needs, followed by productivity and leisure problems. Conclusions: Despite small sample size, this study described patterns of occupational needs in complex inpatients with stroke. These results will be implemented in client-centered rehabilitation programs to be tested in a phase-two trial. [NCT02173197] Implications for Rehabilitation Priority occupational needs of complex inpatients with stroke during rehabilitation are focused on self-care area. Productivity and leisure problems also arise in early post-acute phase. Client-centered rehabilitation programs should firstly address self-care needs and, later on, they should also focus on the recovery of family and social roles.

Anthropometry in Special and Selective Conditions and Circumstances: Anthropometry as Measure of Risk in COPD Patients

In the last decade, Chronic Obstructive Pulmonary Disease (COPD) has been redefined and newly approached not only as an airway-disease condition, but as a multi-component disease including extra-pulmonary manifestations, such as peripheral muscle weakness and malnutrition. The evaluation of body composition (as a part of nutritional assessment) fairly integrates the simple body mass index (BMI) measure by measuring the individual’s active metabolism (fat free mass, FFM). Indeed, BMI and FFM are both parameters correlated with many COPD-strong outcomes. In several epidemiological studies of COPD population admitted to both in- or outpatient rehabilitation programmes, the estimated prevalence of weight loss ranges from 17% to 53%. Nonetheless, weight reduction, together with FFM depletion, is a common feature in emphysema as well as in chronic bronchitis. A nutritionally depleted patient is usually defined by a BMI of ≤ 20 kg/m2. Several studies aimed at evaluating the prognostic value of BMI in COPD patients have documented that BMI ≤ 25 kg/m2 and weight reduction of >3 kg/m2 are strong predictors of mortality. Moreover, other studies confirmed that FFM and measurement of the cross-sectional area of muscle mass (mid-thigh and mid-arm) also correlate to survival rates. In future research, studies looking at other anthropometric, metabolic and functional factors able to predict the long-term survival should be welcomed in patients with other diseases, such as pulmonary fibrosis, similarly leading to chronic respiratory failure.