Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

The incidence of Chronic Obstructive Pulmonary Disease (COPD) is expected to rise in the coming years. Presently, in health care there has been a shift of the provision of care to the home therefore, the major burden of care falls on informal caregivers. The challenges that these caregivers face may be compounded by residing in a rural area where the provision of health care services has been increasingly compromised. In the literature, there has been an abundance of information looking at the experiences of caregivers of people with other chronic illnesses. However, the information on the lived experience of caregivers of people with severe COPD has been minimal. The purpose of this study was to explore the lived experience and meaning of that experience for spousal caregivers providing care to a person with severe COPD living in rural Saskatchewan. Face-to-face, conversational interviews, along with observations of the caregivers and their spouses interactions and environment, were utilized to collect information from five women caring for their husbands with severe COPD living in rural Saskatchewan. Hermeneutic phenomenological reflection, as guided by the works of van Manen, utilized writing, collaborative discussion, life world existentials, and imaginative variation to illuminate themes and the overall essence of this experience. Five overlapping themes identified stemmed from the essence of unrelenting responsibility: 1) Assuming additional roles; 2) Ongoing vigilance; 3) Unfulfilled expectations; 4) Emotional burden; 5) Intermittent reprieve. This study assists in understanding the challenges faced by COPD caregivers and further aids in our understanding of how COPD patients manage their condition. In addition, it will facilitate the identification of strategies and actions to meet the needs sensitive to this population.

The incidence of Chronic Obstructive Pulmonary Disease (COPD) is expected to rise in the coming years. Presently, in health care there has been a shift of the provision of care to the home therefore, the major burden of care falls on informal caregivers. The challenges that these caregivers face may be compounded by residing in a rural area where the provision of health care services has been increasingly compromised. In the literature, there has been an abundance of information looking at the experiences of caregivers of people with other chronic illnesses. However, the information on the lived experience of caregivers of people with severe COPD has been minimal. The purpose of this study was to explore the lived experience and meaning of that experience for spousal caregivers providing care to a person with severe COPD living in rural Saskatchewan. Face-to-face, conversational interviews, along with observations of the caregivers and their spouses interactions and environment, were utilized to collect information from five women caring for their husbands with severe COPD living in rural Saskatchewan. Hermeneutic phenomenological reflection, as guided by the works of van Manen, utilized writing, collaborative discussion, life world existentials, and imaginative variation to illuminate themes and the overall essence of this experience. Five overlapping themes identified stemmed from the essence of unrelenting responsibility: 1) Assuming additional roles; 2) Ongoing vigilance; 3) Unfulfilled expectations; 4) Emotional burden; 5) Intermittent reprieve. This study assists in understanding the challenges faced by COPD caregivers and further aids in our understanding of how COPD patients manage their condition. In addition, it will facilitate the identification of strategies and actions to meet the needs sensitive to this population.

Despite the efficacy of pulmonary rehabilitation programs which assist patients in managing chronic obstructive pulmonary disease (COPD), the high costs and lack of availability of such programs pose considerable barriers for underserved COPD patients, such as those living in rural communities. Because of this, patients are encouraged to actively self-manage COPD. Unfortunately, COPD patients have reported dissatisfaction with the self-management education they are provided. This mixed methods study assessed the self-management learning needs of COPD patients treated at a Certified Federal Rural Health Clinic through conducting focus group interviews (n = 2) to inform the development a targeted self-management education DVD. The effectiveness of 3 distinct educational treatments (DVD vs. Pamphlet vs. DVD Pamphlet) was evaluated by comparing outcomes related to informational needs, self-management self-efficacy, and generic/lung-specific HRQoL in a randomly-assigned, multiple-group pretestposttest design with a control group (n = 41). Focus group data was analyzed using three qualitative analysis tools. Findings from the interviews indicated that patients viewed self-management as simply taking prescribed medications and reducing activity. Patients reported a lack of knowledge and skill development related to rehabilitative activities such as controlled breathing and stress reduction. A multivariate analysis of covariance was conducted to determine the effect of 3 educational treatments on multiple outcome measures. Three nontrend orthogonal planned contrasts were tested to determine selected contrast effects. The data analysis revealed that participants receiving a DVD reported statistically significantly higher levels of lung-specific physical functioning as compared to those in the Pamphlet group. Additionally, the DVD group revealed clinically significant improvements on the physical ( 19.01) and emotional ( 10.74) functioning dimensions of lung-specific HRQoL; whereas, no such improvement occurred within the Pamphlet and control groups. Results also suggested that providing patients with a Pamphlet alone was more effective than providing participants with both interventions concurrently to increase self-management self-efficacy. The simultaneous provision of both interventions did, however, enhance generic HRQoL more so than the provision of one of the two treatments alone. Finally, any type of self-management education as compared to usual care did not statistically significantly improve outcome variables among this small sample of rural patients.

Σκοπός: Η FEV1 αποτελεί μέτρο του βαθμού της απόφραξης των αεραγωγών και γι’ αυτό το λόγο χρησιμοποιείται για τη σταδιοποίηση της ΧΑΠ και του άσθματος. Οι μηχανισμοί που εμπλέκονται και προσδιορίζουν τη δυνατότητα ανοχής στην κόπωση αυτών των ασθενών είναι πλέον πολύπλοκοι και δεν καθορίζονται μόνο από το βαθμό απόφραξης των αεραγωγών . Σκοπός της μελέτης ήταν η αξιολόγηση 1. Του βαθμού που ο λειτουργικός έλεγχος που προηγείται της κόπωσης σχετίζεται με την ανοχή στην κόπωση 2. Της σχέσης που υπάρχει μεταξύ της ποιότητας ζωής και της ανοχής στην κόπωση σε ασθενείς με αποφρακτική πνευμονοπάθεια Υλικό-Μέθοδος: Μελετήθηκαν 163 ενήλικες (107 άνδρες, 56 γυναίκες), οι οποίοι παρακολουθούνται στο τακτικό Πνευμονολογικό Ιατρείο της Πανεπιστημιακής Παθολογικής Κλινικής του Πανεπιστημίου Πατρών. Στην μελέτη περιλήφθησαν 57 ασθενείς (44 άνδρες, 13 γυναίκες) με ΧΑΠ Επίσης περιλήφθησαν 29 ασθενείς με άσθμα (16 άνδρες, 13 γυναίκες). 77 (47 άνδρες, 30 γυναίκες) είχαν φυσιολογική σπιρομέτρηση και χρησιμοποιήθηκαν ως ομάδα ελέγχου. Όλοι οι ασθενείς πριν την έναρξη του λειτουργικού ελέγχου συμπλήρωσαν την ελληνική μετάφραση του ερωτηματολογίου για τις αναπνευστικές νόσους το St. George’s Respiratory Questionnaire και υπεβλήθησαν σε πλήρη λειτυργικό έλεγχο της αναπνοής. Αποτελέσματα: Οι ασθενείς με ΧΑΠ και βαρύτητα νόσου σταδίου Ι είχαν φυσιολογική ανταπόκριση στην άσκηση με φυσιολογική ικανότητα για άσκηση, οι ασθενείς σταδίου ΙΙ είχαν μειωμένη ικανότητα κόπωσης 70%, ενώ οι ασθενείς σταδίου ΙΙΙ και ΙV είχαν πολλή μεγαλύτερη μείωση της ικανότητας για άσκηση. Όσο αφορα τους ασθματικούς 28 από τους 29 ασθματικούς ασθενείς είχαν φυσιολογική VO2peak (109%) και είχαν επαρκείς αναπνευστικές εφεδρείες (>43%), δείγμα ότι το αναπνευστικό σύστημα γι’ αυτούς τους ασθενείς δεν αποτέλεσε περιοριστικό παράγοντα άσκησης. Η ποιότητα ζωής των ασθενών με ΧΑΠ και ιδιαίτερα οι δραστηριότητες τους εξαρτώνται από τη μέγιστη ικανότητα για άσκηση και επομένως από τον περιορισμό των εκπνευστικών ροών όπως αυτές περιγράφονται από την FEF25-75, από τη βλάβη που υφίστανται οι μηχανικές ιδιότητες του πνεύμονα όπως αυτές περιγράφονται από τον MVV καθώς επίσης και από το δείκτη επιφανείας σώματος. Συμπεράσματα: Με αρκετά σημαντική ακρίβεια είναι δυνατόν να προβλεφθεί η μείωση της ικανότητας για άσκηση των ασθενών με ΧΑΠ από τις τιμές του λειτουργικού ελέγχου που προηγείται της άσκησης, ενώ και η ποιότητα ζωής των ασθενών με ΧΑΠ φαίνεται να επηρεάζεται από λειτουργικές παραμέτρους που συμβάλουν στη μειωμένη αυτή ικανότητα για άσκηση που εμφανίζουν οι ασθενείς με αποφρακτική πνευμονοπάθεια. / Exercise tolerance in patients with airflow limitation (COPD and Asthma) has multiple determinants and is difficult to predict from measurements of resting pulmonary function. Measurements of maximum exercise tolerance have been reported to be useful in disability evaluation and determination of the cause of exertional symptoms. In addition, understanding the factors which predict exercise capacity will provide clues to a better understanding of physical activity limitations in patients with airflow limitation (COPD and asthma). Previous studies in patients with COPD have indicated that ventilatory limitation is a primary determinant of exercise tolerance. However, individual pulmonary function parameters as FEV1 explain only about half of the variance in measured exercise tolerance. For many patients with airflow limitation, psychosocial characteristics may interact with physiologic abnormalities to limit physical work capacity. To date, few published studies have closely examined the role of psychosocial variables in the prediction of peak VO2 in patients with COPD and asthma. The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) statement and GINA statement recommended that chronic obstructive disease and asthma be staged on the basis of the percentage of predicted FEV1. Patients with COPD have restricted respiratory airflow, which predisposes them to dyspnea. To avoid dyspnea, patients develop a sedentary lifestyle that leads to a decreased exercise tolerance, which, in turn, aggravates the dyspnea. The decrease in exercise tolerance is marked by a reduced maximum oxygen consumption (VO2max) and lower ventilatory anaerobic threshold (Vth). This study uses data from a clinical trial of rehabilitation in COPD patient and from outpatient stable asthmatic patient. The purposes of the analysis were the following: to examine how well exercise tolerance, specifically PaO2 after exercise and VO2 peak, can be predicted from a combination of physiologic and psychosocial measurements, and to provide insight into factors determining and limiting exercise capacity in COPD and asthmatic patients. The other purpose of this study was to examine the relation between patients with airway limitation (COPD and Asthma) and health-related quality of life. A total of 57 outpatient stable COPD patients and 29 asthmatic stable patients underwent cardiopulmonary testing and filled in a form of Saint George’s Respiratory Questionnaire (SGRQ). We examined the correlation between GOLD criteria for staging COPD patients and health-related QoL throughout the performance of a cardiopulmonary exercise test. CONCLUSIONS According to our results, maximum exercise tolerance is predicted reasonably well from measurements of resting pulmonary function in COPD patients. The most consistent predictors of VO2 peak were measurements of expiratory airflow limitation (FEF2575) and inspiratory– expiratory strength (MVV); none of the psychosocial variables added significantly to the accuracy of the prediction of peak VO2. In addition, only symptoms (dyspnea) influenced maximum exercise performance and decreased it. The effect of symptoms on VO2max depended on the severity of the disease set by the GOLD guidelines. Our findings indicate that we will have to include additional parameters in GOLD stages, such as the SGRQ and probably ergometry test, when COPD patients are classified. The predicted value and FEV1/FVC <70%) minimally affects health-related QoL, whereas stage II (FEV1, 30% to 80% of the predicted value) and stage III (FEV1< 30% of the predicted value) disease is associated with profound deterioration in health-related QoL. The relation between FEV1 and health-related QoL reported that the QoL was not significantly associated with the percentage of predicted FEV1; Activities are impaired proportionally to GOLD stages in our study. This indicates that COPD patients in early stages do not reduce their activities, but in severe stages (continually diminishing FEV1) their activities are reduced. We found that in COPD patients, activities do not correlate with aximum exercise performance our findings indicate that we will have to include additional parameters in GOLD stages, like SGRQ and probably ergometry test, when COPD patients are classified.

Research on sex and gender in chronic obstructive pulmonary disease (COPD) has primarily focused on differences in pulmonary function. Detailed gender- and sex-based analyses of other aspects of COPD, including epidemiology, risk factors other than cigarette smoke, pathophysiology, and measurement tools are warranted. In Chapter Two we analyzed administrative health services data to compare the prevalence, mortality and use of drugs and spirometry in men and women with COPD. Contrary to recent predictions, we did not detect a dramatic increase in the prevalence or mortality of COPD over time in women compared to men. We discuss how different coding practices in medical billing can impact the results. In Chapter Three we examined sex differences in COPD phenotypes. We hypothesized that male smokers would have more emphysema whereas female smokers would have more airway wall remodeling using data from high resolution computed tomography (HRCT) scans. We did detect more emphysema in male smokers but there was no evidence of increased airway remodeling in women. We discuss the limits of HRCT to detect airway differences in women and men. In Chapter Four we examined the use of HRCT in assessing emphysema. We hypothesized that the computer-derived estimates of emphysema (the fractal value and the % low attenuation area (%LAA)) would differentiate COPD from non-COPD as accurately as the radiologist’s emphysema scores, and would provide similar predictions in both men and women. Instead, we found that the subjective rating of emphysema best differentiated COPD, and the fractal value (a measure of emphysematous lesion size) better differentiated COPD compared with an established objective measurement, the %LAA. These results were generally the same in men and women. In Chapter Five we examined characteristics of COPD in women exposed to biomass smoke. We hypothesized that biomass smoke would induce an airway disease-predominant phenotype. We found that women with biomass smoke-exposed COPD had greater airway remodeling and less emphysema than women with tobacco smoke-exposed COPD. In summary, these findings suggest that sex and gender differences are present in COPD epidemiology and pathophysiology. However, current research measurement tools may limit the ability to accurately measure these differences.

Bakgrund: Kroniskt obstruktiv lungsjukdom (KOL) är en av vår tids vanligaste sjukdomar och förväntas bli den tredje största dödsorsaken i världen inom tio år. Sjukdomen orsakar ofta andnöd, hosta och ökad slembildning. De flesta som drabbas av sjukdomen är personer som är eller har varit rökare. Personer som lever med sjukdomen upplever ofta ett lidande av att inte ha samma ork som tidigare och upplever stigmatiserande fördömanden på grund av sjukdomens troliga orsak. Syfte: Syftet med översikten var att beskriva upplevelsen av att leva med kronisk obstruktiv lungsjukdom. Metod: Detta är en litteraturöversikt som är baserad på elva vetenskapliga artiklar. Artiklarna är analyserade och kvalitetsgranskade av båda författarna i flera steg enligt rekommendationer för analysarbete av Friberg (2012). Alla artiklar är tillgängliga i databaserna CINAHL och PubMed och är utgivna mellan 2008-2013. Resultat: Resultatet visade att det fysiska symtom som var mest påtagligt var andnöden. Andra symtom som togs upp som bes värande var den ökade slem bildningen,hostan och tröttheten. Psykiska symtom som var vanligt förekommande vid KOL var ångest, depression och frustration över förlorad ork och detta framförallt till följd av andnöden. Dömande attityder kring sjukdomens uppkomst med återkommande frågor om tidigare och/eller nuvarande rökvanor skapade känslor av skuld och skam. Många valde att fortsätta att röka trots sin diagnos, och trots dessa skuldkänslor. De såg rökningen som en rutin och en aktivitet i sin vardag som de inte ville vara utan. Diskussion: KOL innebär ett stort lidande för den drabbade. Lidande kunde bland annat upplevas vid förlust av sociala interaktioner. Enligt omvårdnadsteoretikern Katie Eriksson kan livslidande uppstå när energin inte räcker till för att delta i sociala interaktioner. Lidande upplevdes även vid beroende av andra för att få vardagliga sysslor utförda. De fysiska och psykiska symtom som uppkom till följd av sjukdomen upplevdes minska livskvaliteten. Dömande attityder som kunde uppstå gentemot personer med KOL kunde orsaka ett lidande. Orsaken kan vara att personen inte känner sig värdesatt som människa enligt Eriksson. De som valde att fortsätta röka ansåg att rökningen gav livskvalitet och ett minskat lidande. / Background: Chronic obstructive pulmonary disease (COPD) is one of today's most common diseases, and is expected in less than ten years to become the third largest cause of death worldwide. The disease causes breathlessness, cough and increased sputum. Most people who contract the disease are individuals who are or have been smokers. People living with the disease often experience a hard time to not have the same strength as before and experiencing stigmatizing condemnation because the presumable cause of the disease. Aim: The aim with this study was to describe the experience of living with chronic obstructive pulmonary disease. Methods: This is a literature review based on eleven scientific articles. The articles are reviewed and quality analyzed by both the authors in several steps according to the recommendations of the analysis procedure by Friberg (2012). All the articles are available in the databases PubMed and CINAHL and are published 2008-2013. Results: The results proved that the physical symptoms that were most problematic for a person with the disease is to have problem with their breathing. Other symptoms recognized as troublesome was the increased mucous secretion, cough and fatigue, which are common in COPD. The psychological symptoms that were common were anxiety, depression and frustration about the loss of energy and this was mainly due to the breathing. Condemnatory attitudes about the disease's onset with questions about the past and/or current smoking behavior which created feelings of guilt and shame. Many people decided to continue smoking despite their diagnosis and feelings of guilt. They saw the smoking as a routine and an activity in their daily lives that they didn’t want to be without. Discussion: The discussion concluded that COPD involved a life of suffering for those who gets the disease. Suffering was experienced in loss of social interactions. According to the nursing theorist Katie Eriksson life suffering arise when energy is not sufficient to engage in social interactions. Suffering could also be experienced when a person became dependent on others to cope with everyday tasks, when the energy wasn’t enough. The physical and psychological symptoms that emerged because of the disease were experienced as a lower quality of life. Judgmental attitudes that could occur to people with COPD could cause a suffering. According to Eriksson the reason to this can be that the person does not feel valued as a person. Those who chose to continue smoking felt that smoking resulted in a quality of life and reduced suffering.

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic disease that causes illness and death over the whole world. There are a little available data about COPD patients in Vietnam and how the disease affects their health related quality of life (HRQL). Aim: The aim of this study was to examine HRQL among patients with COPD in Ho Chi Minh City, Vietnam, and investigate differences in HRQL between men and women with COPD. Method: This was a descriptive study with a cross-sectional design. The method was quantitative by using a questionnaire. The study was performed at the respiratory department at Cho Ray Hospital in Ho Chi Minh City, Vietnam. The sampling was made through a consecutive sample. The questionnaire was based on Short Form 36 (SF-36) which is a widely used questionnaire to measure HRQL. The answers from the questionnaires were turned into a scale where 0 represent the lowest possible HRQL and 100 represent the highest possible HRQL. Results: The results showed that patients with COPD have a low HRQL. Mean value for HRQL in the total group of respondents was 22.42.The result also showed that women suffering from COPD have a significant lower HRQL than men concerning total HRQL (P-value= 0.04), general health (P-value= 0.02) and pain (P-value= 0.05). Conclusion: Patients suffering from COPD in Ho Chi Minh City have a low score of HRQL. Better routines and knowledge about the symptoms and caring for these patients are needed. Keywords: Chronic Obstructive Pulmonary Disease, Health related quality of life, Vietnam, SF-36

Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

Research on sex and gender in chronic obstructive pulmonary disease (COPD) has primarily focused on differences in pulmonary function. Detailed gender- and sex-based analyses of other aspects of COPD, including epidemiology, risk factors other than cigarette smoke, pathophysiology, and measurement tools are warranted. In Chapter Two we analyzed administrative health services data to compare the prevalence, mortality and use of drugs and spirometry in men and women with COPD. Contrary to recent predictions, we did not detect a dramatic increase in the prevalence or mortality of COPD over time in women compared to men. We discuss how different coding practices in medical billing can impact the results. In Chapter Three we examined sex differences in COPD phenotypes. We hypothesized that male smokers would have more emphysema whereas female smokers would have more airway wall remodeling using data from high resolution computed tomography (HRCT) scans. We did detect more emphysema in male smokers but there was no evidence of increased airway remodeling in women. We discuss the limits of HRCT to detect airway differences in women and men. In Chapter Four we examined the use of HRCT in assessing emphysema. We hypothesized that the computer-derived estimates of emphysema (the fractal value and the % low attenuation area (%LAA)) would differentiate COPD from non-COPD as accurately as the radiologist’s emphysema scores, and would provide similar predictions in both men and women. Instead, we found that the subjective rating of emphysema best differentiated COPD, and the fractal value (a measure of emphysematous lesion size) better differentiated COPD compared with an established objective measurement, the %LAA. These results were generally the same in men and women. In Chapter Five we examined characteristics of COPD in women exposed to biomass smoke. We hypothesized that biomass smoke would induce an airway disease-predominant phenotype. We found that women with biomass smoke-exposed COPD had greater airway remodeling and less emphysema than women with tobacco smoke-exposed COPD. In summary, these findings suggest that sex and gender differences are present in COPD epidemiology and pathophysiology. However, current research measurement tools may limit the ability to accurately measure these differences.