Pulmonary Rehabilitation Assessment Research Articles

The Non-Paced 3-Minute Sit-to-Stand Test: Feasibility and Clinical Relevance for Pulmonary Rehabilitation Assessment.

Pulmonary rehabilitation (PR) improves health-related quality-of-life (HRQoL) in individuals with chronic obstructive pulmonary disease (COPD), notably by increasing exercise tolerance. Easy-to-implement sit-to-stand tests can facilitate the assessment of exercise tolerance in routine practice. This retrospective study conducted in a real-life setting was designed to describe the non-paced 3-min sit-to-stand test (3-STST) and to evaluate its relationship with HRQoL (VQ11 questionnaire) to identify the determinants of 3-STST performance and to analyze the evolution of 3-STST performance and HRQoL over the course of a community-based PR program. Seventy-one COPD patients (age 69 ± 10 years old; 51% with GOLD spirometric stages III-IV) were included. Mean ± SD 3-STST performance at the initial PR assessment was 43 ± 15 repetitions. This performance was significantly associated with HRQoL and other indicators of clinical severity (lung function, dyspnea, and functional capacities). During the multivariate analysis, younger age, exertional dyspnea with mMRC ≤ 1, and better HRQoL were significantly associated with better 3-STST performance. From the initial to second PR assessment, changes in 3-STST performance were significantly associated with changes in HRQoL. This study provides evidence that the non-paced 3-STST is feasible and might be clinically relevant in the assessment of patients with COPD referred for community-based PR. This test deserves to be prospectively validated.

Pulmonary rehabilitation assessment in COPD based on the ICF brief core set: a latent profile analysis

Background Chronic obstructive pulmonary disease (COPD) is the most burdened chronic respiratory disease in the world, resulting in a reduced quality of life and limited physical activity for patients. Pulmonary rehabilitation (PR) is an effective therapy for COPD. Effective PR relies on an accurate pulmonary rehabilitation program. An adequate pre-rehabilitation assessment helps healthcare professionals to develop an accurate pulmonary rehabilitation program. However, pre-rehabilitation assessment strategies lack specific selection criteria and an assessment of the patient’s overall functioning. Methods This study explored the functional characteristics of COPD patients before pulmonary rehabilitation and collected COPD patients from October 2019 to March 2022. A cross-sectional survey of 237 patients was conducted using the ICF brief core set as the study tool. Latent profile analysis identified subgroups of patients with different rehabilitation needs based on body function and activity participation. Results Four subgroups of functional dysfunction were identified: 5.42%, 21.03%, 29.44%, and 34.11% in the high dysfunction group, the moderate dysfunction group, the lower-middle dysfunction but high mobility impairment group, and the low dysfunction group, respectively. Patients in the high dysfunction group were older, had a higher proportion of widowed spouses, and experienced more exacerbation. Most patients in the low-dysfunction group did not use inhaled medication and had a lower participation rate in oxygen therapy. Patients with a more severe disease classification and symptom burden mostly belonged to the high dysfunction group. Conclusions COPD patients require an adequate assessment before implementing a pulmonary rehabilitation program to determine their rehabilitation needs. The four subgroups were heterogeneous in terms of the degree of functional impairment in body function and activity participation. Patients in the high dysfunction group can improve basic cardiorespiratory fitness; patients in the moderate dysfunction group should focus on improving cardiorespiratory endurance and muscle fitness, patients in the lower-middle-dysfunction but high mobility impairment group should focus on improving mobility and patients in the low functional disability group should focus more on preventive measures. Healthcare providers can tailor rehabilitation programs to the functional impairments of patients with different characteristics. Trial registration This study has been registered in the Chinese Clinical Trials Registry (ChiCTR2000040723).

Establishing the Validity of Using the COPD Assessment Test to Screen for Fatigue in People With Chronic Obstructive Pulmonary Disease Referred to Pulmonary Rehabilitation.

Fatigue is the second most prevalent symptom in chronic obstructive pulmonary disease (COPD), yet it is often undetected in pulmonary rehabilitation. The aim of this study was to assess the validity of using a health status questionnaire (COPD Assessment Test [CAT] and CAT-energy score) to detect fatigue in people with COPD referred to a pulmonary rehabilitation program. This study was a retrospective audit of people with COPD referred to pulmonary rehabilitation. The validity of the CAT-total score and CAT-energy score for detecting fatigue was analyzed compared to a validated fatigue questionnaire, the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Cut-off values defining fatigue included a CAT-total score ≥ 10, a CAT-energy score ≥ 2, and a FACIT-F score ≤ 43. Data were analyzed using 2 × 2 tables from which accuracy, sensitivity, specificity, and likelihood ratios were calculated. Data from 97 participants with COPD (age in years mean [SD] = 72 [9]; FEV1% predicted mean [SD] = 46% [18]) were used. The FACIT-F score ≤ 43 classified 84 participants (87%) as fatigued. A CAT-total score ≥ 10 yielded an accuracy of 0.87, sensitivity of 0.95, specificity of 0.31, and positive and negative likelihood ratios of 1.38 and 0.15, respectively. A CAT-energy score ≥ 2 yielded an accuracy of 0.85, sensitivity of 0.93, a specificity of 0.31, and positive and negative likelihood ratios of 1.34 and 0.23, respectively. The CAT-total score is an accurate and sensitive measure for fatigue, and the CAT could be an appropriate tool to screen for fatigue in people with COPD referred to pulmonary rehabilitation. Use of the CAT as a screening tool for fatigue has the potential to improve clinician awareness of fatigue, simplify the pulmonary rehabilitation assessment process by reducing survey burden, and inform fatigue management, which may subsequently reduce the symptomatic burden of fatigue in people with COPD.

Exploring the prevalence and impact of hip and knee pain in pulmonary rehabilitation: a propensity-matched cohort study

BackgroundMusculoskeletal pain is more common in individuals with chronic respiratory diseases than the aged-matched general population. This investigation aimed to understand the prevalence and impact of hip and knee pain on pulmonary rehabilitation outcomes and completion rates.MethodsParticipants who experienced hip/knee pain in the 4 weeks prior to pulmonary rehabilitation completed an Oxford Hip and/or Knee Score alongside a routine pulmonary rehabilitation assessment. Participants engaged in a twice-weekly, 6-week outpatient pulmonary rehabilitation programme. A 1:1 propensity score match for age, sex, BMI, sessions attended and MRC score was completed prior to group comparison for a pulmonary rehabilitation cohort without hip/knee pain.Results6.5% (n = 97) of pulmonary rehabilitation participants reported pain: hip (n = 27), knee (n = 40) or hip and knee pain (n = 30). 75 participants with hip/knee pain provided sufficient data for pre pulmonary rehabilitation matching and were propensity matched with a pulmonary rehabilitation group without hip/knee pain. The average Oxford Score across all reported joints was 28.7 (8.5) indicating moderate/severe pain at baseline. Statistically significant improvements were made in Oxford Scores for the left hip, left knee and right knee (P < 0.01) but not the right hip following pulmonary rehabilitation. There was no statistically significant difference between groups for improvements in quadriceps strength, walking tests or depression scores, both groups achieved within group significance. There were no significant differences in pulmonary rehabilitation completion rates between groups.ConclusionsPrevalence of hip/knee pain in individuals presenting to pulmonary rehabilitation is 6.5%. Pain improved in the majority of joints following pulmonary rehabilitation and pain did not impact the effectiveness or completion of the programme.Trial Registration: This trial was an evaluation of a clinical service and has not been registered in a public domain.

A pulmonary rehabilitation shared decision-making intervention for patients living with COPD: PReSent: protocol for a feasibility study.

BackgroundDespite the variety of pulmonary rehabilitation programmes for patients living with COPD, uptake remains low. To improve this, it is recommended that health professionals engage patients in informed decisions about pulmonary rehabilitation. Shared decision-making (SDM) facilitates informed and value-based decision-making between patients and health professionals. This protocol describes the development and evaluation of a complex SDM intervention for patients living with COPD, who are referred for pulmonary rehabilitation, and their pulmonary rehabilitation health professional.Methods and analysisWe are developing a complex SDM intervention involving a patient decision aid (PtDA) and a decision coaching workshop. Prior to patient recruitment, pulmonary rehabilitation health professionals will attend the workshop. Upon referral to pulmonary rehabilitation, patients will receive the PtDA to support their decision-making prior to and during their pulmonary rehabilitation assessment with a health professional. The intervention will be evaluated in a one-arm exploratory study to investigate its feasibility and acceptability for patients and health professionals, with an integrated fidelity assessment. The primary outcome is recruitment feasibility, data collection feasibility and intervention fidelity. Secondary outcomes include routine pulmonary rehabilitation data, decisional conflict, patient activation, intervention attendance/attrition and patient and pulmonary rehabilitation health professional experience of the intervention. Quantitative outcomes will be evaluated using the most appropriate statistical test, dependent on the sample distribution. Qualitative outcomes will be evaluated using reflexive thematic analysis. Fidelity will be assessed using the Observer OPTION 5 scale.ConclusionThis intervention will provide structure for an informed and values-based decision-making consultation between a patient with COPD and a pulmonary rehabilitation health professional with the potential for optimising pulmonary rehabilitation decision-making.

Community Participation by People with Chronic Obstructive Pulmonary Disease

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV1: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all rs = 0.30, p < 0.05). Older age and more moderate-to-vigorous physical activity independently predicted greater community participation measured by CPI. Higher levels of depression symptoms were associated with less formal and informal community participation on ESS (rs = –0.25). More formal community participation on ESS was weakly (rs = 0.2–0.3) associated with older age, better lung function, exercise capacity and self-efficacy, and less breathlessness. Self-efficacy, exercise capacity, and age independently predicted formal community participation in individuals with COPD. Strategies to optimize self-efficacy and improve exercise capacity may be useful to enhance community participation in people with COPD.

The prevalence of poor sleep quality and its associated factors in patients with interstitial lung disease: a cross-sectional analysis.

BackgroundMany patients with interstitial lung disease (ILD) experience poor sleep quality, which may contribute to decreased quality of life. Sleep disordered breathing is commonly associated with ILD but there is less information on other factors that may contribute to poor sleep quality.MethodsWe conducted a cross-sectional analysis of 101 patients with a diagnosis of ILD at a pulmonary rehabilitation assessment clinic. We assessed the prevalence of poor sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and performed multivariable logistic regression analysis to determine factors independently associated with poor sleep quality.ResultsMedian forced expiratory volume in 1 s was 64% predicted (interquartile range (IQR) 50–77%) and vital capacity was 62% predicted (IQR 48–78%). 67 (66%) out of 101 patients reported poor sleep quality. The median PSQI was 8 units (IQR 4–11 units). There were no significant differences in physical or physiological parameters including age, sex distribution, body mass index or spirometry values between subjects with good sleep quality and those with poor sleep quality (all p>0.1). Multivariable logistic regression showed that depression (p=0.003) and Epworth Sleepiness Scale (p=0.03) were independently associated with poor sleep quality.ConclusionPoor sleep quality is common in patients with ILD and is independently associated with increasing symptoms of depression and sleepiness. Routine assessment of sleep quality should be undertaken and interventions targeting depression and coexisting sleep disorders may be required in symptomatic patients to determine if sleep quality and ultimately, health-related quality of life improves as a result.

Should the 6-Minute Walk Test Be Stopped If Oxyhemoglobin Saturation Falls Below 80%?

ObjectiveTo examine the occurrence of adverse events in patients undergoing assessment for pulmonary rehabilitation when a 6-minute walk test (6MWT) continues despite desaturation below 80%. DesignRetrospective audit following REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. SettingLarge teaching hospital. ParticipantsAll patients (N=549) (55% men, mean age 69±11y) assessed for pulmonary rehabilitation (September 2005 to January 2016). InterventionsThe standardized tests were conducted by experienced cardiorespiratory physiotherapists. Oxyhemoglobin saturation was monitored continuously using a pulse oximeter (lowest value used for analysis). Medical records were reviewed, and adverse events defined as tachycardia, bradycardia, chest pain, or other sign/symptom necessitating cessation. Main Outcome Measure6MWT. ResultsData from 672 walk tests were included with mean distance 369 (124) meters. The main diagnoses were chronic obstructive pulmonary disease (70%), interstitial lung disease (14%), and bronchiectasis (8%). Sixty individuals (11%) recorded desaturation below 80% without adverse events. Two adverse events were recorded during tests without desaturation; in 1 instance, chest pain with no evidence of cardiorespiratory compromise and in another, the patient stopped due to concern regarding blood sugar levels (11.5 mmol/L when tested). Independent predictors of desaturation to less than 80% were resting oxyhemoglobin saturation <95% (odds ratio [OR] 3.82, 95% confidence interval [CI] 2.06-7.08) and a diagnosis of interstitial lung disease or pulmonary arterial hypertension (OR 5.24, 95% CI 2.59-10.58). ConclusionsThis study found that desaturation to less than 80% during a 6MWT was not associated with adverse events in a large cohort of patients referred to pulmonary rehabilitation and assessed by experienced physiotherapists, suggesting that test cessation due to desaturation in stable patients may be unwarranted.

Knowledge, Skill, and Confidence in People Attending Pulmonary Rehabilitation: A Cross-Sectional Analysis of the Effects and Determinants of Patient Activation.

Background:Patient activation is a significant predictor of health behaviors; however, the level of activation in people attending a pulmonary rehabilitation program and the effect of pulmonary rehabilitation on patient activation have not been measured. Furthermore, the potential determinants and relationship between patient activation and characteristics of people attending pulmonary rehabilitation have not previously been reported.Methods:The Patient Activation Measure (PAM) was measured in people with a chronic respiratory disease or congestive cardiac failure at a baseline pulmonary rehabilitation assessment and again at the completion of the 8-week outpatient program.Results:This study included 194 people with chronic respiratory disease or congestive cardiac failure (41% male; mean [standard deviation, SD] age: 73 [11] years; mean [SD] forced expiratory volume in 1 second % predicted: 60% [20%]). The pulmonary rehabilitation program was completed by 61% (n = 118) of participants. The mean (SD) PAM score at baseline was 60.5 (15.7), which improved to 65.4 (15.5) after completion of the pulmonary rehabilitation program (P = .001). In a stepwise forward multiple regression analysis, anxiety, lung information needs, and health-related quality of life impact were found to be significant determinants of baseline PAM. This model explained 12% (P < .001) of the variance.Conclusion:People with a chronic respiratory disease or congestive cardiac failure commencing a pulmonary rehabilitation program demonstrated a moderate level of activation, which improved following an 8-week hospital outpatient pulmonary rehabilitation program. Anxiety, a higher level of lung information needs, and greater health-related quality of life impact were significantly associated with poor patient activation.

Measuring unsupported arm lifts as an outcome in pulmonary rehabilitation of chronic obstructive pulmonary disease patients

Pulmonary rehabilitation includes upper and lower extremity exercise training. While validated tests such as the six-minute walk distance (6MWD) and shuttle walk tests are available to evaluate the effectiveness of lower extremity training, the optimal method of evaluating the effectiveness of upper extremity training has not been determined. This study evaluates the potential utility of unsupported arm lifts (UALs) testing as an outcome measurement for pulmonary rehabilitation. Records of chronic obstructive pulmonary disease (COPD) patients who underwent outpatient pulmonary rehabilitation at our institution were reviewed. Outcomes assessed before and immediately after the intervention included 6MWD, the self-administered Chronic Respiratory Questionnaire (CRQ-SA), and UALs. For the latter, the patient repeatedly raises a wooden dowel from thigh to arm level, with the number of repetitions per minute used as the outcome. Changes in variables from pre- to post-pulmonary rehabilitation were analyzed using paired t test. Pearson correlation coefficients were used to evaluate associations. Of the 241 patients, 51% were male. Mean age was 69 ± 9 years, body mass index was 28 ± 7 kg/m(2), and forced expiratory volume in 1 second was 50 ± 20 percent-predicted. All studied variables increased significantly post-pulmonary rehabilitation: the 6MWD by 45 ± 50 m (effect size 0.49), the CRQ-SA total score by 0.84 ± 0.86 units (effect size 0.89), and UAL by 12 ± 13 lifts/minute (effect size 0.75; p < 0.0001 for all). As a measure of upper extremity exercise capacity, UAL appears to be responsive to the comprehensive pulmonary rehabilitation intervention. Using effect sizes, the degree of improvement appears to be between that of 6MWD and CRQ-SA. UAL may be a useful outcome assessment for pulmonary rehabilitation in COPD patients.

Problematic Activities of Daily Life are Weakly Associated With Clinical Characteristics in COPD

Problematic activities of daily life (ADLs) can be the main reason to refer patients with chronic obstructive pulmonary disease (COPD) for pulmonary rehabilitation. To date, information on problematic ADLs and their clinical correlates in COPD remain scarce. This retrospective chart review aimed to identify the most prevalent self-reported problematic ADLs in COPD patients, determine performance and satisfaction scores of these problematic ADLs, and explore the association between 13 clinical determinants and 4 problematic ADL domains. A total of 820 COPD patients entering pulmonary rehabilitation assessment were included in this retrospective study. Self-reported problematic ADLs were assessed using the Canadian Occupational Performance Measure, administered by occupational therapists in the form of a semistructured interview. COPD patients (59% male, age 63.6 ± 9.3 years, FEV(1) (%pred): 46.4 ± 18.4) reported 2999 problematic ADLs. The most prevalent problematic ADLs were walking (68%), stair climbing (35%), and cycling (30%). Moreover, 30% of the patients reported "not able to do any of the scored problematic ADL" and 44% were "not satisfied at all with the performance of any of the scored problematic ADL." Significant but weak associations were found between clinical determinants (eg, physical and psychosocial) and problematic ADLs. The lack of a strong association between problematic ADLs and clinical determinants emphasizes the need for individualized assessment of these ADLs to allow tailored intervention.

Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation

The purpose of this study was to determine whether a commercially available pedometer could detect changes in home-based walking activity among chronic obstructive pulmonary disease (COPD) patients completing pulmonary rehabilitation (PR). Patients with COPD referred to outpatient PR wore a pedometer to count steps for 1 week at the beginning and 1 week at the end of PR. Patients also completed the 6-min walk test (6MWT), the Medical Research Council (MRC) dyspnea scale and the self-administered chronic respiratory disease questionnaire (CRQ) at the beginning and the end of PR. Paired t tests were used to compare pre- and post-PR changes in outcome variables. 45 patients with severe COPD (forced expiratory volume in 1 second [FEV(1)] 45% +/- 18% of predicted) participated in a total of 17.4 +/- 4.6 PR sessions. Significant improvements in 6MWT (49 +/- 59 m; p < .0001), MRC dyspnea score (-0.64 +/- 0.96 units; p = .003) and CRQ score (10 +/- 18 units; p = .0007) were noted following PR. Patients whose pedometer-measured steps were within 20% of observed counted steps were included in the analysis. Pedometer counts increased by 33 +/- 149 steps per hour worn after, as compared with before PR (p = .14). There was a significant inverse relationship between baseline pedometer counts and change in pedometer counts per hour post-PR (r = -.46; p = .001). Patients with low baseline activity levels had significant increases in pedometer activity (88 +/- 30 counts per hour worn) and a greater reduction in MRC dyspnea score (-0.94 vs -0.29; p = .04) following PR, whereas those with higher baseline activity levels had a decrease in pedometer activity (-19 +/- 29 counts/hour; p = .015). A standard pedometer worn at the waist did not detect changes in lower extremity activity following PR. This negative finding occurred despite demonstrated improvements in dyspnea, exercise tolerance and quality of life measures. Although pedometers are inexpensive and easy to use, they may not be sensitive enough to be used routinely as an outcome measure for PR.

Development of a shortened version of the Breathing Problems Questionnaire suitable for use in a pulmonary rehabilitation clinic: a purpose-specific, disease-specific questionnaire.

One hundred and thirty-eight chronic obstructive pulmonary disease (COPD) patients completed the Breathing Problems Questionnaire (BPQ) before and after a comprehensive programme of rehabilitation. Examination of the changes on individual items showed improvement on 22 items, of which four items were significant at p < 0.05 and deterioration on nine items, of which two were significant at p < 0.01. All deteriorating items were consistent with lifestyle adaptations encouraged as part of the rehabilitation programme. We examined the psychometric properties of a reduced ten item version of the BPQ limited to the items most sensitive to change. We recommend the purpose-specific, disease-specific COPD scale for measuring change in pulmonary rehabilitation assessment in contrast to the longer 33 item questionnaire, which, however, may be more useful for cross-sectional assessment.