Tania Janaudis-Ferreira

A Randomized Controlled Trial of Balance Training During Pulmonary Rehabilitation for Individuals With COPD

BACKGROUND Deficits in balance are increasingly recognized among the important secondary impairments in COPD. The purpose of this study was to investigate the effect of a balance-training program on measures of balance and physical function in patients with COPD enrolled in pulmonary rehabilitation (PR). METHODS Patients were assigned randomly to an intervention or control group. The intervention group underwent balance training three times a week for 6 weeks concurrently with PR. The control group received only the 6-week PR program. Clinical balance measures included the Berg Balance Scale (BBS), the Balance Evaluation Systems Test (BESTest), and the Activities-Specific Balance Confidence (ABC) scale. The physical function subscale of the 36-Item Short Form Health Survey (PF-10) and the 30-s chair-stand test were used to measure self-reported physical function and lower-extremity muscle strength, respectively. RESULTS Thirty-nine patients with COPD (mean FEV1, 37.5% ± 15.6% predicted) were enrolled in the study. Mean compliance with the balance-training program was 82.5%, and no adverse events were reported. Compared with control subjects, scores on the BBS (P < .01), BESTest (P < .01), PF-10 (P = .01), and 30-s chair-stand (P = .02) were significantly improved in the intervention group. No significant between-group differences were found in change scores on the ABC scale (P = .2). CONCLUSIONS Our results support the feasibility and effectiveness of balance training as part of PR for improving balance performance, muscle strength, and self-reported physical function in patients with moderate to severe COPD.

Measurement Properties of the Incremental Shuttle Walk Test: A Systematic Review

Background: The incremental shuttle walk test (ISWT) was developed > 20 years ago and has been used to assess peak exercise capacity in a variety of chronic diseases. The aim of this systematic review is to describe the measurement properties of the ISWT in a clinical population.Methods: Of 800 articles identified by electronic and hand searches, 35 were included. Twenty-one articles included data on the validity of the ISWT, 18 on the reliability, four on the responsiveness,and four on the interpretability.Results: Most of the studies were conducted in patients with COPD (n = 13) or cardiac disease(n = 8). For criterion validity, comparisons between distance covered during the ISWT and peak oxygen consumption reported correlations ranging from 0.67 to 0.95 ( P <.01). Intraclass correlation coefficients for test-retest reliability ranged from 0.76 to 0.99. The ISWT was shown to be responsive to pulmonary rehabilitation and bronchodilator administration. The minimal clinically important difference (MCID) in patients with COPD was 48 m. Predictive equations for the distance in the ISWT are available for healthy individuals.Conclusions: The ISWT can be considered a valid and reliable test to assess maximal exercise capacity in individuals with chronic respiratory diseases. The ISWT has been shown to be responsive to pulmonary rehabilitation and bronchodilator use in individuals with COPD, cystic fibrosis,and asthma. Further studies examining responsiveness and the MCID of the ISWT in patients with conditions other than lung diseases are required for the interpretation of interventions in other populations.

Measurement of Activities of Daily Living in Patients With COPD: A Systematic Review

BACKGROUND The objectives of this systematic review were to synthesize the literature on measures of activities of daily living (ADLs) that have been used in individuals with COPD and to provide an overview of the psychometric properties of the identified measures and describe the relationship of the disease-specific instruments with other relevant outcome measures for individuals with COPD and health-care use. METHODS Studies that included a measure of ADLs in individuals with COPD were identified using electronic and hand searches. Two investigators performed the literature search. One investigator reviewed the study title, abstract, and full text of the articles to determine study eligibility and performed the data extraction and tabulation. In cases of uncertainty, a second reviewer was consulted. RESULTS A total of 679 articles were identified. Of those, 116 met the inclusion criteria. Twenty-seven ADLs instruments were identified, of which 11 instruments were respiratory disease-specific, whereas 16 were generic. Most instruments combined instrumental ADLs (IADLs) with basic ADLs (BADLs). The majority of the instruments were self-reported; only three instruments were performance based. Twenty-one studies assessed psychometric properties of 16 ADLs instruments in patients with COPD. CONCLUSIONS Although several ADLs instruments were identified, psychometric properties have only been reported in a few. Selection of the most appropriate measure should focus on the target construct (BADLs or IADLs or both), type of test (disease-specific vs generic and self-reported vs performance-based), depth of information obtained, and psychometric properties of the instruments. Given the relevance of ADLs to the lives of patients with COPD, its assessment should be more frequently incorporated as a clinical outcome in their management.

Self-management following an acute exacerbation of COPD: a systematic review.

BACKGROUND Self-management (SM) reduces hospital admissions in patients with stable COPD. However, its role immediately post-acute exacerbation (AE) is unclear. The objectives of this review were to describe SM interventions delivered immediately following an AE of COPD (AECOPD) and to conduct a systematic review with meta-analysis of its impact on health-care utilization and health outcomes. METHODS Randomized controlled trials reporting on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge were included. Seven articles were identified. Data were extracted and assessed for quality by two researchers. RESULTS By definition, all interventions included action plans, education, and at least two SM skills. Nurses were responsible for providing all SM interventions. The delivery and follow-up periods varied widely. At 12 months, there were no significant differences between those who completed the SM intervention and control subjects in the number of patients readmitted to hospital (P = .38), or in health-related quality of life (P = .27). No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health promoting behavior. SM was associated with positive effects on knowledge and management of an AECOPD. CONCLUSIONS SM interventions delivered immediately post-AE vary widely and outcome measures are inconsistent, making it difficult to draw strong recommendations regarding its effectiveness. The evaluation of SM interventions, delivered by trained health-care professionals to selected patients and which offer structured follow-up, appears necessary.

Skeletal muscle atrophy in advanced interstitial lung disease

A limited number of studies examine skeletal muscle dysfunction in individuals with interstitial lung disease (ILD). We compared upper and lower limb muscle size and strength in individuals with advanced ILD with healthy controls. Second, the relationships of muscle size to muscle strength and function were explored.

How Should We Measure Arm Exercise Capacity in Patients With COPD?: A Systematic Review

BACKGROUND There are no recommendations on how to measure arm exercise capacity in individuals with COPD. The objectives of this study were (1) to synthesize the literature on measures of arm exercise capacity in individuals with COPD, (2) to describe the psychometric properties and the target construct of each measure, and (3) to make recommendations for clinical practice and research. METHODS Studies conducted in patients with COPD that included a measure of arm exercise capacity were identified after searches of five electronic databases (PubMed, CINAHL, EMBASE, PEDro, and Cochrane Library) and reference lists of pertinent articles. One reviewer performed data extraction, and two assessed the quality of the studies that described measurement properties, using the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. RESULTS Of 654 reports, 41 met the study criteria. Five types of arm exercise tests were identified: arm ergometry, ring shifts, dowel lifts, proprioceptive neuromuscular facilitation, and activities of daily living. Four studies assessed the measurement properties of the unsupported upper-limb exercise test (UULEX), the 6-min pegboard and ring test (6PBRT), a test involving weight shifts, and the grocery-shelving task (GST). Validity studies were of fair to good quality, whereas reliability studies were of poor quality. CONCLUSIONS Arm ergometry may be the best method for measuring peak supported arm exercise capacity and endurance. The UULEX, 6PBRT, and GST may better reflect activities of daily living and should be the tests of choice to measure peak unsupported arm exercise capacity (UULEX) and arm function (6PBRT and GST).

Mindfulness in people with a respiratory diagnosis: A systematic review

OBJECTIVES To describe how mindfulness is delivered and to examine the effect of mindfulness on health-related quality of life (HRQOL), mindful awareness and stress in adults with a respiratory diagnosis. METHOD Five electronic databases were searched. Data were extracted and assessed for quality by two reviewers. RESULTS Data were extracted from four studies. Interventions were based on Mindfulness-Based Stress Reduction and delivered by trained instructors. Recordings of mindfulness were provided for home-based practice. One study targeted the intervention exclusively to anxious individuals with a respiratory diagnosis. Adherence to mindfulness was poor. No effects were seen on disease-specific HRQOL (standardized mean difference (SMD)=-0.21 95% CI: -0.36 to 0.48, p=0.78), mindful awareness (SMD=0.09 95% CI: -0.34 to 0.52, p=0.68) or stress levels (SMD =-0.11 95% CI: -0.46 to 0.23, p=0.51). CONCLUSION Mindfulness interventions, delivered to individuals with a respiratory diagnosis, varied widely in terms of delivery and the outcomes assessed making it difficult to draw any conclusions regarding its effectiveness.

Factors affecting discharge destination following lung transplantation

Lung transplant (LT) recipients requiring additional care may be referred to inpatient rehabilitation prior to discharge home. This study seeks to describe discharge destinations following LT, compare the characteristics of patients discharged to different destinations, and identify the predictors of discharge destination.

How should we train the upper limbs

The article by McKeough and colleagues in this issue of Chronic Respiratory Disease is the first study to compare different modes of upper extremity training in individuals with chronic obstructive pulmonary disease (COPD). Limitations during exercise and daily activity in individuals with COPD are not limited to lower extremity activities such as walking or stair climbing; most of the patients experience difficulty during activities that involve their arms due to the sensation of dyspnea and/or arm fatigue. Upper extremity training for patients with COPD is an important component of pulmonary rehabilitation (PR), resulting in improvements in arm exercise capacity, arm function and muscle strength. However, there is limited evidence on what type of training should be performed. The study by McKeough and colleagues adds to the growing body of evidence in the area of upper extremity training in COPD and provides support for the inclusion of arm endurance and strength training as a part of PR. The study is a randomized controlled trial (RCT) that aimed to compare the effects of arm endurance training; arm strength training, a combination of arm endurance and strength training; and no arm training (control group) on endurance arm exercise capacity, functional arm exercise capacity and health-related quality of life (HRQL) in individuals with mild-tovery severe COPD. The authors found a significant improvement in arm endurance time (arm endurance capacity) between the endurance group and control group. There were nonsignificant trends in arm endurance time favoring the strength training and combined groups compared with the control group. In terms of symptoms, the authors demonstrated that the combined group had a significantly greater reduction in dyspnea and rate of perceived exertion at the end of the functional arm exercise test compared with the control and with each of the intervention groups. When the combined group was compared with the other two intervention groups, the improvement in HRQL (measured using the St George’s Respiratory Questionnaire) exceeded the minimum clinically important difference of 4 units, although it did not reach statistical significance. Until the beginning of the century, several RCTs had been conducted to examine the effects of upper extremity training in individuals with COPD. However, there were considerable variations in the exercise protocols rendering it impossible to determine the optimal training regimen for these patients. Moreover, the impact of upper extremity training on other clinical outcomes besides arm exercise capacity was unclear as shown consistently by four systematic reviews. More recently, four RCTs examining the effects of arm exercise training in individuals with COPD have been published. Holland and colleagues compared the effects of unsupported upper limb endurance training with lower extremity training alone. The authors found that unsupported upper limb endurance training improved upper limb exercise capacity but had no additional effects on the symptoms or HRQL compared with lower extremity training alone. Costi and colleagues examined the effects of upper extremity resistance training in patients with COPD compared with standard PR. The authors demonstrated improvement in arm functional exercise capacity (measured using the 6-minute pegboard and ring test) and in performance during activities of daily living (ADL) measured by an ADL field test. In addition, the authors found a decrease in arm fatigue at the end of the ADL test in the intervention group. Our

Alternative field exercise tests for people with respiratory conditions

Assessment of exercise capacity and physical function is critical in individuals with respiratory conditions. While field walking tests are well-established measures of exercise capacity, alternative options involving walking of a shorter duration, stair or step climbing, and functional activities are also available. This review outlines these alternative tests and their relevant measurement properties, including comparisons with established field walking tests and their clinical applications. The 4-m gait speed and 30-m walking test are walking tests of shorter duration than traditional tests and may be a surrogate marker for exercise capacity. Stair climbing tests require greater body movement against gravity, often imposing a greater workload compared to field walking tests. Functional tests such as sit-to-stand tests provide information related to strength and general functioning. The current measurement properties established, together with the emerging evidence for responsiveness to interventions suggest potential for broader clinical use of these alternative field tests.