institutions and written informed consent was obtained from each participant.
Variables and instruments
All patients answered an interviewer-administered questionnaire about dog ownership (question: ‘Do you have a dog at home?’), dog walking (if positive to having a dog, ‘Do you walk the dog? ’), having grandchildren (‘Do you have grandchildren?’) and grandparenting (if positive to having grandchildren, ‘Do you take care of them or collaborate in their care? ’). The ques- tionnaire also included data on education, marital status, working status, occupation, number of people living at home, smoking status, dyspnoea (assessed using the modi ﬁed Medical Research Council scale (mMRC)), health-related quality of life (assessed using the COPD Assessment Test (CAT)), and anxiety and depression symptoms (assessed using the Hospital Anxiety and Depression scale (HAD)). SES was obtained from questions on employment characteristics, and classi ﬁed using the National Statistics Socio-economic Classi ﬁcation into six categories (I, professional; II, managerial and technical; IIIN, skilled non- manual; IIIM, skilled manual; IV, partly skilled; and V, unskilled occupations). Comorbidities were assessed from medical records. Body mass index (BMI) was obtained by physical examination. FEV 1 and FVC before and after bronchodilator
Background: Indacaterol, a once-daily, long-acting β 2 -agonist, may improve not only respiratory function, dyspnea symptoms, and quality of life, but also physicalactivity for patients with chronicobstructivepulmonarydisease (COPD). This study aimed to evaluate the effect of 12-week indacaterol therapy on daytime physicalactivity in patients with untreated COPD. Methods: The subjects were stable and untreated COPD outpatients with a percent predicted forced expiratory volume in 1 second (%FEV 1 ) below 80%. Baseline assessments included clini- cal assessment, respiratory function testing, arterial blood gas analysis, the COPD assessment test (CAT™), and the Medical Outcomes Study 36-Item Short-Form Health Survey, Japanese version 2 (SF-36v2 ® ). Patients underwent monitoring by uniaxial accelerometer before and after
Abstract: Background Evidence from longitudinal studies on the impact of exacerbation symptoms on physicalactivity in chronicobstructivepulmonarydisease (COPD) is lacking. The aim of this first exploratory study was to assess the association between exacerbation symptoms and physicalactivity, and to quantify the relative influence of specific symptoms. Methods We recruited COPD patients at high risk for exacerbations from 2 pulmonary rehabilitation clinics and 1 acute care clinic in Switzerland. For 3 months after discharge, patients completed a daily symptom diary on a smartphone application, the EXAcerbations of Chronicpulmonarydisease Tool (EXACT), and wore a pedometer to measure daily steps. We used mixed-effects models to determine the association of daily steps with exacerbation symptoms. Results A total of 21 patients (Global Initiative for ChronicObstructive Lung Disease grades 2-4) were enrolled for a mean of 94.4 days (standard deviation 4.2). The baseline median number of daily steps was 3,264.6 (interquartile range [IQR]: 1,851.3-4,784.1) and EXACT score was 37.0 (IQR: 30.9-41.4). A 12-point increase in EXACT score (indicating the start of an exacerbation) was statistically significantly associated with a decrease in daily steps of 653.3 (95% CI 969.7-336.9). Chest symptoms (tightness, discomfort and congestion) were more strongly associated with change in steps than breathlessness, and cough and sputum (-value -4.5 vs -2.9 and -3.0). Conclusion This is the first study to show that, in a small cohort of COPD patients, increases in exacerbation symptoms were associated with a statistically and clinically significant reduction in daily physicalactivity. These results underscore the importance for symptom control and exacerbation prevention in COPD patients.
This cross-sectional, observational study included 39 clini- cally stable COPD (34 male and five female) patients between the ages of 41 and 78 years with a mean forced expiratory volume in 1 second (FEV 1 ) of 50.64% ± 23.17%. Diagnosis of disease and classification of disease severity were established in line with the Global initiative for chronicObstructive Lung Disease (GOLD) criteria. Patients who were not able to walk or perform the 6-minute walk test (6MWT), patients who were not able to cooperate in pulmonary function testing, patients with oral corticosteroid use for at least 6 weeks, and patients with heart disease and acute exacerbation were not included in the study. According to arterial blood gas analysis, patients with oxygen partial pressure (PaO 2 ) of 60 mmHg were assigned to the hypoxemic COPD group and patients with PaO 2 60 mmHg were assigned to the non-hypoxemic control group. The hypoxemic group consisted of 18 patients and the non-hypoxemic control group consisted of 21 patients. The study was approved by the Ethics Committee of Hacettepe University, Ankara, Turkey, and signed informed consent forms were obtained from each patient before the study.
Figures 1 and 2 indicate that the strength of the association between exacerbation symptoms and physicalactivity differs among patients. Reasons for these inter-patient differences are currently unclear; however, there may be some influence from the average number of daily steps or overall variability in the number of daily steps, as suggested by the differences between estimated intercepts and slopes (Figure 1). It could be that patients with on average higher steps or with more variation in steps are influenced by exacerbation symptoms in a stronger manner, as their activity levels are able to reduce more than those who have an already low level, or it could be that another factor, such as severity of COPD, is driving the between-patient differences. One previous study found that patients with more daily and weekly variability in symptoms were more affected in their daily activities. 18 However, this would need to be
the association between morning symptoms and phys- ical activity used self-reported questionnaires, while accelerometers are superior in physicalactivity assess- ment than questionnaires [13, 37]. Another strength was the inclusion of patients from an academic med- ical center, a local hospital and patients recruited by flyers in local papers. This resulted in a heteroge- neous population that is generalizable to all patients with moderate to very severe COPD. A limitation of the study was that the accelerometer was not water- proof and patients were not allowed to wear it while taking a shower. For some patients, taking a shower is one of the main physical activities during a day, and this activity was not measured. This means, ac- tive time was underestimated. A second limitation is that morning symptoms were evaluated with a non- validated questionnaire. However, there is no validated morning symptom questionnaire available yet. Patients filled in the questionnaire at the study center and not at home at the time they woke up. This might have result in recall bias that might cause higher (or lower) total morning symptom scores. The mean morning symptom score was slightly higher than in a previous study that used the PRO-Morning COPD Symptoms Questionnaire too . Therefore, it could be possible that the cut-off point to separate high from low morning symptom scores was too high. However, when patients with an AE were removed and the cut- off point dropped to 15.0, the outcomes were nearly the same. Another limitation is the observational design of the study. Therefore, it is not possible to prove whether morning symptoms are fully responsible for the differ- ences in physicalactivity or that physical inactivity itself resulted in more symptoms due to muscle depletion and loss of physical condition.
This study included 23 patients with COPD attending the outpatient department at Matsusaka Municipal Hospital. Table 1 shows the anthropometry, clinical staging, and results of pulmonary function testing in these subjects. All of the patients were ex-smokers and not on active smoking cessation pharmacotherapy, and had stable disease with no exacerba- tions before the beginning or during the study. Patients who were physically unable to move and those receiving home oxygen therapy or pulmonary rehabilitation were excluded. Three patients had comorbid arterial hypertension and three had hyperuricemia. In total, 24 patients were included in the study but one was excluded because of contusions and a sprained ankle following a traffic accident. Among the 23 eligible patients, 14 were receiving tiotropium 18 µ g/day (by Handihaler) while nine were receiving no therapy; thus, during the entire study period, 14 cases received treatment with tiotropium together with indacaterol and nine with
Results: Bronchodilation was obtained by additional medication. The mean values of PA evalu- ated by metabolic equivalents (METs) at $3.0 METs and the duration of PA at $3.0 METs and $3.5 METs were improved by medication. The % change in the duration of PA at $3.5 METs was significantly correlated with the baseline functional residual capacity (FRC), residual volume, and inspiratory capacity/total lung capacity. However, the % change in the duration of PA at any intensity was not correlated with the % changes of any values of the pulmonary function tests or incremental shuttle walking test except the PA at $2.5 METs with FRC. Conclusion: Medication could improve the PA in patients with COPD, especially at a relatively high intensity of activity when medication was administered based on airflow limitation and breathlessness. The improvement was seen in the patients with better baseline lung volume, but was not correlated with the improvements in the pulmonary function tests or exercise capacity.
Our present pilot study suggests that objectively measured SPI is common in patients referred for PR, which only improves daily physicalactivity in a minority of subjects despite wearing an accelerometer in a clinical trial. SPI at baseline was not precluded by being moderately physically active for $150 minutes/week. As SPI is significantly asso- ciated with morbidity and mortality, future studies should address SPI-focused intervention strategies and elucidate factors associated with failure to improve physicalactivity in COPD patients receiving PR.
Prevention and therapy: suggestions for the future:-The prevention of osteoporosis in COPD patients is dependent on an awareness of the magnitude of the problem. There is little impetus for screening and/or preventive therapy because patients are generally asymptomatic until they experience a fracture. However, early recognition and the institution of preventive therapy are essential in avoiding fractures (Biskobing, 2002).In order to assess the efficacy of treatments, more information on the risk factors and the pathogenesis of COPD-induced osteoporosis is needed. Such information could be gathered through prospective studies designed to assess the rate of decline of the BMD and the contributing factors such as the type of corticotherapy, the presence of hypogonadism, ongoing smoking, reduced physicalactivity and the weakness of the skeletal muscles (Ionescu and Schoon, 2003). In view of the relationship between the skeletal muscle mass and the BMD (Sandler, 1989; Henderson et al., 1998; Aniansson et al., 1984; Winett and Carpinelli, 2001), it is likely that training programmes and conditioning will have beneficial effects on the maintenance of BMD in patients with COPD. However, the types of training and the specific programmes of rehabilitation need to be designed. Hormone replacement therapy is likely to be beneficial in patients with COPD and hypogonadism. In view of the age group and exposure to corticosteroid treatment, which are associated with hypogonadism, the assessment of the hormonal status should be part of the general investigation of osteoporosis in patients with COPD (Ionescu and Schoon, 2003). The intake of calcium and vitamin D should be assessed, in view of some reports that supplementation is beneficial for the preservation of the bone mass, mainly in subjects with a reduced intake (Eastell, 1998; Ionescu and Schoon, 2003; Chapuy et al., 1994). According to the current nutritional recommendations the daily intake of calcium (1,200–1,500 mg·day −1 ) and vitamin D (at least 400 IU·day −1 ) should be ensured (Goldstein et al., 1999; Lane and Lukert, 1998; American College of Rheumatology, 1996). More promising in view of the available research in patients with chronic lung disease is the therapy with bisphosphonates. The patients with COPD and osteoporosis treated with long-term systemic corticosteroids should be considered for such treatments. For patients with osteopenia, those on long-term inhaled corticosteroids and/or intermittent courses of oral corticosteroids without florid osteoporosis, regular monitoring of BMD by DEXA scanning should be undertaken (Ionescu and Schoon, 2003).
Causal treatment includes both pharmacological (mostly inhalation medication + vaccination) and nonpharmacological treatment (physicalactivity, pulmonary rehabilitation, education and training of inhalation techniques). In the treatment of COPD the basic medication is made up, according to the stage of the disease and the patient's symptoms, of inhalation ß2agonist with a long term to ultra long term effect (LABA, U-LABA) and inhalation antagonist of muscarinic receptors, also with a long term to ultra long term effect (LAMA, U-LAMA). Treatment must be modified in such a way so that it best responds to the health condition of the patient (Kašák, 2014, p. 406-407). Bronchodilatational and anti- inflammatory therapy is meant to improve the quality of life of the patient, decrease the frequency of COPD exacerbations, and limit the application of so-called rescue medication. In the treatment of COPD medication is gradually increased based on severity and the category of the disease (GOLD 2017). COPD with bronchiectases profits mainly from the administration of mucolytics, antibiotics, and physiotherapy. In patients with COPD who suffer from chronic respiratory insufficiency it is advisable to consider indications of so-called long term home oxygen therapy (Chlumský, 2016).
A strength of this study is the adjustment for multiple confounders in the regression analysis, which was omitted in previous studies.[2, 37] Furthermore, we believe that this study population is representative of the COPD population since patients were recruited from a variety of sources, namely a university medical center, a regional hospital and recruitment via flyers. This resulted in a heterogeneous COPD patient group. However, the exclusion of COPD GOLD I patients can be seen as a limitation. We expect that including COPD GOLD I patients would result in a slightly lower mean morning symptom score since morning symptoms are also present in mild COPD. However, in this study we decided to focus on more symptomatic patients since it was a cross-sectional study that explored factors that were associated with morning symptoms. One other limitation of this study is that there might be selection bias, since nonparticipants were most likely patients who were not able to come to the study center in the morning. This might have resulted in an underestimation of morning symptoms in the overall COPD population. A limitation for the use of a MoveMonitor was the non-water resistance. For some patients, taking a shower is the most intensive physicalactivity of the day, and this has not been measured. This resulted in an underestimation of active time. Furthermore, patients were not blinded for the accelerometer. This could have resulted in increased activity since patients felt they were being watched and would not be categorized as “inactive.” However, patients took a comparable amount or fewer steps than reported in previous studies[41, 42] suggesting that patients in the MODAS did not adapt their lifestyle to the study. Furthermore, with this observational study design it is not possible to prove causality. Therefore, we are not able to state whether physicalactivity limitations is a result of morning symptoms, or if it is the other way around: that physical inactivity causes deconditioning which results in an increase of morning symptoms.
research participation compared with patients attending rehabilitation or admitted to hospital. The comprehensive list of predictors and the use of objectively measured physicalactivity and sedentary time, the high accelerometer compliance and comparison to apparently healthy adults must also be noted. Recruitment bias may have occurred. For example, those patients concerned about their health, more able to complete the range of measures as part of the study or patients who are more physically active may have preferentially responded to the study invitation. The cross-sectional design of the study means causality cannot be inferred. Whilst the present sample was ethnically homogenous due to an insufficient sample of non- White COPD patients recruited, the lower occurrence of smoking (10% for Indian South Asians and 26% for White British) translates into fewer South Asian COPD patients and lower COPD admission rates in Leicestershire (Director of Public Health., 2010). As data from this study relates to mild-moderate COPD patients, stronger associations between physicalactivity and some related variables may have existed had more severe patients from the study been included. Whilst findings were materially unchanged when additional cut- point thresholds for sedentary time (<1853 vmcpm) (Koster et al., 2016), light activity (2000- 8249 vm cpm) and MVPA (≥8250 vmcpm) (Kamada et al., 2016) no cut-points have yet been developed against criterion methods such as indirect calorimetry. Sedentary time was unable to discriminate between sitting and standing. Further advancements in the objective measurement of behaviour will provide richer insights into the role of physicalactivity and sedentary time in COPD.
Physical therapy employs a variety of methods for improving mucus clearance. Patients are taught mucus clearance tech- niques that enable them to effectively clear secretions from the airways themselves. Physicalactivity enhances mucus clear- ance (in addition to other benefi ts). Forced expiration (huff- ing and coughing) is effective and can be used independently by patients. Appropriate self-management seems important to achieve potential long-term benefi ts (fewer exacerbations, slower deterioration of pulmonary function). Patients should be encouraged to practice these techniques independently from care providers. Patients with COPD and mucus retention who are unable to expectorate mucus effectively and independently should be taught an alternative technique. The physical thera- pist should choose the most appropriate technique, or combina- tion of techniques, based on observed problems such as lack of expiratory force and tracheo-bronchial collapse. See Table 6. Figure 4 is a practical guideline to select the appropriate treat- ment modalities for patients with mucus retention.
speed over 30 meters. The 30-meter walk test has been shown to correlate well with the 6MWT . Pitta et al. showed that patients with COPD spent less time walking in daily life than did age-matched controls and also walked at lower walking speeds . Furthermore, the authors concluded that the 6-minute walk distance (6MWD) was the best surrogate marker for inactivity in COPD. Our results are therefore in accordance with the results of previous studies confirming the value of walk- ing performance with regard to daily activity  How- ever, to our knowledge, the finding of walking speed as an independent predictor of daily physicalactivity has been reported in only one previous study . DePew et al. measured walking performance using the 4-meter gait speed test and the 6MWT in a sample of chronic lung disease subjects. In agreement with our present Table 1 Description of sample. Numbers are means ± standard deviations, medians (IQRs) or numbers (%)
If data is collected based on patients recollection of events the method is said to be subjective. To assess physicalactivity (or sedentary) behaviors by sub- jective methods, questionnaires, recall forms or record/log books of activity can be utilized (32). Typically questionnaires are designed to collect data on the four dimensions relating to the activity behavior; frequency, intensity, type and duration. With these data, physiological attributes relating from the reported activity can be estimated using standard tables of energy expendi- ture for various types of activities (38). Advantages of subjective measures compared to objective methods are low costs and ease of administration which makes it a feasible method for large scale, epidemiological studies (39). Drawbacks include uncertainty of subjects to recall activities, and con- cerns regarding the construct validity in many of the questionnaires have been raised (40). Some types of activities, such as eating behaviors are often underreported, whereas physicalactivity is over reported (41).
out in the study where as the present study performed with conventional physiotherapy along with physical training protocol. In one particular study, due to interdisciplinary intervention there was reduced leptin level, in which it indirectly showed improvement in lung function with a duration of one year intervention (Leão da Silva et al. 2012). Similarly a study carried out in the year 2003, suggested that exercise training promoted exercise capacity, reduced dyspnea and health related quality of life (Gigliothi et al. 2003). In the present study, the subjects initially showed increase in blood pressure and later on, it got normalized. The possible reason could be the instruction on, how to perform exercise made the subjects nervous and finally increased the blood pressure to a little extent. The physiological reason behind the reduction in the blood pressure was not well understood, but it has been suggested that the reduction in blood pressure were due to the involvement of increased sympathetic activity which decreased baroreflex function and reduced arterial wall compliance. The nitrous oxide produced as a result of aerobic exercise would have caused relaxation of smooth muscles of the blood vessels . We humbly admit few limitations of the study. Initially in the present study most of the subjects
BACKGROUND AND PURPOSE: Rising numbers of patients are dying at home of chronicobstructivepulmonarydisease. The aim of this study is to determine the wants and needs from the physical therapist of these patients dying at home. SUBJECTS: The participants were 3 adults (2 male, 1 female) METHODS: Semi-structured interviews were conducted with three patients. RESULTS: Four themes were identified: (1) Activity’s of daily living (2) Check-up (3) Psychological meaning (4) Communication between health services. DISCUSSION AND
Results of densitometry of the lumbar spine L2- L4 are represented in Fig. 2 . The average indicators of the T-criterion were within (-1.83±0.17) SD and were significantly lower than in healthy persons (-0.56±0.10) SD (p<0.001). As it is known, in COPD the treatment with GCS has a negative in- fluence not only on ”quantity” (mineral density of bone tissue), but also on ”quality” of bone. This leads to the fact that the ”threshold of fracture” in patients receiving GCS is lower than in those who do not take these medicines. That is why in most cases, steroid osteoporosis is diagnosed according to the T-criterion of osteo-densitometry not at 2.5, but at 1.5 standard deviations (SD) from the peak bone mass of persons of the corresponding gender [ 2 ]. The peculiarity of steroid osteoporosis is a