Background: Chronic obstructive pulmonary disease (COPD) is an important common chronic lung condition that is a leading cause of morbidity and mortality worldwide, resulting in a substantial and increasing economic and social burden to health care systems. Physical activity (PA) is the strongest predictor of mortality in this population, playing an important role determining the quality of life in COPD, with better outcomes being reported by those who have higher levels of PA. Therefore, improving PA levels has been considered a key component in the management of patients with COPD. Likewise, it is important to understand the mechanisms that lead to inactivity, as it is to develop accurate methods of measuring PA in this population. Aims of the thesis: 1) To identify and to summarize the interventions able to increase PA levels in patients with COPD; 2) To understand the longitudinal interaction between muscle mass and function and PA levels in COPD; 3) To study the acceptability and the suitability of a new activity monitor (TracMor D - Philips, the Netherlands) for home coaching in daily routine of patients with COPD; and 4) To investigate whether a PA enhancing programme with set targets and feedback would constitute a successful intervention to increase PA levels in patients with COPD attending pulmonary rehabilitation (PR). Methods: To achieve the first aim of the thesis I performed a systematic review summarizing interventional studies that assessed PA as an outcome in patients with COPD. For the second aim, I analysed some multicentric longitudinal data (one year follow-up) on PA and muscle mass/function in COPD. The third aim was achieved with a pilot study I conducted in Edinburgh, where patients with COPD wore three TracMor D in different body places simultaneously with the criterion method (Actigraph GT3x activity monitor) for a week. To accomplish the fourth and main aim of my PhD, I conducted a randomised controlled trial (RCT) where patients with COPD undergoing PR were randomised to either receive PR only or PR plus a PA coaching programme using the TracMor D activity monitor for 12 weeks. Main Results: Study 1: Sixty studies were considered for data extraction in the systematic review. Seven types of intervention with the potential to increase PA levels in patients with COPD were identified. PR programmes with more than 12 weeks of duration and PA coaching programmes with feedback of an activity monitor are promising interventions to increase activity levels in patients with COPD. Overall, the quality of evidence across interventional studies was graded as very low. Study 2: The longitudinal study showed that there were weak correlations between PA levels and muscle strength at baseline (0.19 ≤ r ≤ 0.33 p < 0.001 for all). No correlations were found between changes in PA and muscle strength (-509 [-1295-362] vs -0.4 [-3.5-2.6] - 12 months minus baseline - respectively) and future muscle mass (p > 0.05). Baseline PA levels are related to future muscle strength (0.30 ≤ r ≤ 0.41, p < .0001) but not with muscle mass. Study 3: This study showed that TracMor D had strong correlations with Actigraph GT3x in terms of Kcal consumption in all three positions (necklace, pocket and hip) (0.84 ≥ r < 0.86, p < 0.001 for all). TracMor D was considered comfortable and easy to use at home, receiving a mean usability score of 98 out of 100 maximum points. Study 4: My RCT showed that the proposed PA intervention was effective in changing steps/day (1251 ± 2408 vs control -410 ± 1118, p=0.01), time spent in light activities (21 ± 60 vs -37 ± 55, p=0.004), exercise capacity (99 ± 139 vs 3 ± 83 meters; 85 ± 114 vs 2 ± 62 seconds, p < 0.03 for both) and muscle strength (15 ± 20 vs -5 ± 18, p=0.01) among others when compared to the control group. Conclusions: Strategies focussing specifically on increasing PA and longer PR programmes may have greater impacts on PA levels in COPD. Well-designed clinical trials with objective assessment of PA in patients with COPD are needed. PA levels are not related to one-year changes in muscle mass and muscle strength in patients with COPD. However, higher PA levels at baseline are related to having higher muscle strength at one-year. TracMor D strongly correlated with the criterion method and was highly accepted by patients with COPD in their daily routine, being considered comfortable and easy to use at home. The combination of PR with a physical activity enhancing programme using a PA monitor to set targets and give feedback on activity levels significantly improves PA, exercise capacity, muscle strength, quality of life, and anxiety and depression levels in patients with COPD.

No description available.

Pulmonary rehabilitation is a highly evidenced intervention used in the management of patients with chronic obstructive pulmonary disease. Both patients and healthcare professionals have anecdotally acknowledged motivation as a key element in a programme. It has been suggested by some authors that motivation should be a prerequisite to entry, yet there is no evidence to support this suggestion. The purpose of this study therefore, was to provide some theory about the role of motivation in pulmonary rehabilitation and to produce a measurement instrument to enable further quantitative study. Methods A qualitative, exploratory investigation using focus groups and face-to-face interviews with patients undergoing a pulmonary rehabilitation programme was undertaken to generate data around factors influencing motivation. Results were used to develop a 43 item self-report questionnaire. The questionnaire was administered to 77 patients before and after a pulmonary rehabilitation programme along with other health status measures. The questionnaire was tested for reliability and validity. Item reduction was performed using factor analysis. Results Motivation within the context of a PR programme was shown to consist of a number of psychological, social and circumstantial variables that fell into 3 broad dimensions: Essential motivation, external motivation and functional outcome. A key finding was that attending pulmonary rehabilitation had an enormous positive influence on the patients’ essential motivation. The questionnaire was reduced to 21 items and principal components analysis demonstrated 9 factors within the questionnaire. These were function, self-efficacy, effort, optimism, tenacity, self worth, isolation, ability and achievement. The questionnaire was named the Malvern pulmonary rehabilitation motivation questionnaire (MPMQ) for identification. The MPMQ was shown to be reliable with internal consistency, reproducibility on test-retest and sensitivity to change. Correlations were found between the MPMQ and health related quality of life, anxiety and depression, breathlessness, exercise capacity and hospital admissions during the previous 12 months. Motivation score was significantly lower in patients who dropped out of the programme and was significantly higher at the end than the start of a programme. Conclusion The MPMQ has been shown to be a reliable tool with sound evidence of validity that can be used to objectively assess patients’ motivation within the context of a pulmonary rehabilitation programme. These findings need to be supported with further evidence for the validity and reliability of the questionnaire. Further investigation of the association of MPMQ score and adherence in pulmonary rehabilitation is needed along with further exploration of the determinants of motivation. This would enable specialist staff to identify patients who are likely to have adherence problems and channel efforts into effective cognitive-behavioural interventions in the ongoing effort to establish the optimum pulmonary rehabilitation programme.

Introduction: This dissertation aims to explore, in a clinical setting, the effectiveness of pursed lips breathing (PLB), in the management of dyspnoea in stable COPD. Methodology: A mixed methodology that comprised a randomised controlled trial (RCT), a predominantly qualitative follow-up (FU) study and two measurement studies was used. The RCT intervention group was taught PLB at home over 8 weeks. Primary outcome measures were the Self Report Chronic Respiratory Disease Questionnaire (CRQ-SR) dyspnoea and mastery domains and Endurance Shuttle Walk Test (ESWT). The FU study investigated the long-term experience of PLB in a subset of RCT participants through telephone interview, focus group and observation of PLB technique at home visit. Prior to the RCT a study using limits of agreement (LoA) methodology was conducted to investigate reliability of hand-held spirometric measurement of inspiratory capacity (IC) with a view to using it as an outcome measure. Following the RCT a retrospective analysis of data collected from the ESWT was performed comparing a 1-walk protocol with the published 2-walk protocol. Results: Forty-one patients with COPD were recruited to the RCT (PLB n = 22, control n =19); mean age 68 years (SD 11), mean FEV1% predicted 47% (SD 15.80) and 13 were approached to participate in the FU; 11 of 13 agreed to telephone interview, 5 to attend the focus group and 6 to home visit. The median time since learning PLB was 17 months (6 - 23). The RCT found no statistically significant difference between groups in the primary outcome measures and in retrospect was insufficiently powered. Post hoc analysis found effect sizes for primary outcome measures were: CRQ-SR dyspnoea 0.05, CRQ-SR mastery 0.48 and ESWT 0.44. For secondary outcome measures the PLB group showed a significant (p = 0.02) improvement in oxygen saturation on ESWT. Long-term follow-up found 9 of 11 still used PLB, 8 reported definite benefit. Those using PLB used it for breathlessness with four themes identified: use of PLB with physical activity (8/11), to increase confidence and reduce panic (4/11), as an exercise (3/11), at night (3/11). Discontinuation of PLB (2/11) was due to no benefit. Hand-held spirometric measurement of IC found LoA for same-day IC measurement in healthy volunteers (n = 20) ± 0.630L (95%CI ± 0.255) and over 3 weeks (n = 11) ± 0.560L (95%CI ± 0.326). In COPD, same day LoA (n = 26) were ± 0.582L (95%CI ± 0.169) and over 6 weeks (n = 8) ± 0.486L (95%CI ± 0.302). Retrospective analysis of ESWT data identified that completion rates improved by 17% for the 1-walk protocol but that the ceiling-effect was 12.2% compared to 7.3% for the 2-walk protocol. LoA between protocols when measuring change over time (n = 31) was ±80% (95%CI 25.56); less than the difference described as "somewhat better" (113%) following pulmonary rehabilitation (PR) but greater than the m.c.i.d. of 68%. Conclusions: LoA for IC exceeded the clinically significant reported 0.3L; the protocol tested here was not sufficiently reliable for use as an outcome measure. Analysis of ESWT data showed the 1-walk protocol was adequate for identify change in clinical practice but, for research purposes the 2-walk protocol should be retained. From the RCT learning PLB resulted in reduced physiological stress with respect to oxygen desaturation when performing ESWT compared to the control group. Long-term follow-up showed that, in severe COPD perceived benefits persisted in 62% of patients.

Introduction: This study explored the health behaviour of older adults with COPD. Objectives included: 1) to explore the process of successfully managing COPD; 2) to identify health behaviour strategies utilized; 3) to identify factors influencing health behaviour change; 4) to understand the impact of pulmonary rehabilitation (PR). Methods: Eleven community-dwelling older adults were interviewed following PR. Interviews were coded and analyzed using constant comparative analysis, comparing and contrasting incoming data with emerging theory. Findings: Two distinct models were developed representing participants’ experience with COPD and health behaviour change: Struggling with Living: Life with COPD before Pulmonary Rehabilitation; and Carrying on with Living: Life with COPD following Pulmonary Rehabilitation. Conclusions: Older adults with COPD engaged in a limited repertoire of health behaviour strategies which were relatively ineffectual prior to participation in PR. PR had a major impact on health behaviour strategies, and on the external and personal factors influencing health behaviour.

Introduction: This study explored the health behaviour of older adults with COPD. Objectives included: 1) to explore the process of successfully managing COPD; 2) to identify health behaviour strategies utilized; 3) to identify factors influencing health behaviour change; 4) to understand the impact of pulmonary rehabilitation (PR). Methods: Eleven community-dwelling older adults were interviewed following PR. Interviews were coded and analyzed using constant comparative analysis, comparing and contrasting incoming data with emerging theory. Findings: Two distinct models were developed representing participants’ experience with COPD and health behaviour change: Struggling with Living: Life with COPD before Pulmonary Rehabilitation; and Carrying on with Living: Life with COPD following Pulmonary Rehabilitation. Conclusions: Older adults with COPD engaged in a limited repertoire of health behaviour strategies which were relatively ineffectual prior to participation in PR. PR had a major impact on health behaviour strategies, and on the external and personal factors influencing health behaviour.

BACKGROUND SUMMARY: Pulmonary rehabilitation programs are an important component of the multidisciplinary approach to minimizing the symptomatology of patients with chronic obstructive pulmonary disease. Within the program, patients learn about how to live with their non-curable disease and how to minimize exacerbations. Although patients learn about their disease process, breathing techniques, and exercise, there are no specific components that bridge the mind and body gap to promote mindfulness through the patients’ efforts within the program. LITERATURE REVIEW FINDINGS: This thesis contains a comprehensive literature review composed largely of randomized trials. These trials and studies summarize the framework of pulmonary rehabilitation programs and how yoga is implemented within treatment options for chronic diseases. The literature review highlights that pulmonary rehabilitation programs improve the quality of life in patients with emphysema through patient education on breathing and exercise. However, there is a lack of literature on the use of yoga techniques of breathing and exercise within the framework of pulmonary rehabilitation programs to promote mindfulness when living with a chronic disease. PROPOSED PROJECT: This thesis proposes a randomized controlled study to identify a more mindful approach to a pulmonary rehabilitation program for emphysema patients through the use of timed ujjayi pranayama (mindful breathing) and yoga asanas (poses). CONCLUSIONS: The results will be analyzed to determine if yoga techniques lead to statistically significant improvement in patient outcomes in emphysema patients enrolled in a pulmonary rehabilitation program. SIGNIFICANCE: The compiled data will reveal how yoga breathwork and movement will be beneficial for emphysema patients enrolled within a pulmonary rehabilitation program.

No description available.

The thesis deals with the possibility to influence the values of the lung function in patiens with chronic obstructive pulmonary disease (COPD) after exercise carried out according to the Methodology of sensorimotor training. The thesis contains a summary of theoretical knowledge about the pathophysiologic expresion of COPD, including their consequences not only for the respiratory system, but musculoskeletal system as well. Furthermore the thesis includes the information about the Methodology of sensorimotor training, that was used to influence the posture correction in our research. Methods: The spirometric examination of flow-volume curves monitor the changes prior to and after the exercise according to sensorimotor training in patiens with COPD (mean age 60, 733 ± 11,817). Results: The using of sensorimotor training can provide correction of the position of the whole body, of the chest, and change a chest mobility and in total to set up conditions for more economical muscle activation. This enable the changes in the values of the lung functions in the patiens with COPD, that we measured. Not all changes showed statistically significant change. Conclusion: Using sensorimotor training have an objective effect on the values of the lung function in patiens with COPD.

Previous researchers have identified that participation in a pulmonary rehabilitation program improves health outcomes yet, continuation in a weekly maintenance program yielded mixed results. Self-management programs have had reported use in chronic obstructive pulmonary disease (COPD). A meta analysis has identified that no self-management program had evaluated the effect of this type of intervention on the functional status of the participant with COPD. Reduced functional status is well reported as an indicator of disease progression in COPD. Adjuvant therapies for people with COPD need to demonstrate an effect in this domain. The Stanford model chronic disease self-management program (CDSMP) had been reported as a program that may optimise the health of people with chronic health conditions. However, its utility has not been formally evaluated for people with COPD. There have not been any reports of a comparison of the Stanford model CDSMP with pulmonary rehabilitation via a randomised controlled study in COPD. Aim: To compare and evaluate the health outcomes from participation in nurse ledwellness-promoting interventions conducted in the ambulatory care setting of a metropolitan hospital. Participants were randomised to either a six-week behavioural intervention: the Stanford model CDSMP or, a six-week pulmonary rehabilitation program and results compared to usual care (a historical control group). The efficacy of the interventions was measured at week seven and repeated at week 26 and 52. Following the week seven evaluation, the pulmonary rehabilitation program participants were rerandomised to usual care or, weekly maintenance pulmonary rehabilitation for 18 weeks and, followed up until the study completion at week 52.Little is reported about the costs of care for people with COPD in Australia. This study prospectively evaluated the costs of the interventions and health resource for the 52 weeks and undertook a cost utility analysis. Methods: Walking tests (The Incremental Shuttle Walking Test) and questionnaires asking participants about their health related quality of life, mood status, dyspnoea and self efficacy were assessed prior to randomisation to either six week intervention and repeated at weeks 7, 26 and 52. The implementation of these adjuvant therapies enabled all costs associated with the interventions to be prospectively examined and compared. Results: During the two years of recruitment 252 people (54% males) with a mean age 71 years (SD 11, range 39-93 years) were referred to the study. Student’s ttests identified that there were no statistically significant differences (P=0.16) between all those referred by age and gender as compared to all those admitted to Hospital A with an exacerbation of COPD. Ninety-seven people (51% male) with a mean age of 68 years (SD 9, range 39-87 years) agreed to participate in the study. Follow up in the study continued for 12 months following enrolment with only a modest level of attrition by week seven (3%) and week 52 (25%). Following the six-week interventions, both the pulmonary rehabilitation and CDSMP groups recorded statistically significant increases in functional capacity, self-efficacy and health related quality of life.Functional performance was additionally evaluated in the intervention arms with participants wearing pedometers for the six-week period of the interventions. There were no statistically significant differences between steps per week (P=0.15) and kilometres per week (P=0.17) walked between these two groups in functional performance. The Spearman rho statistic identified no statistically significant relationship between functional performance and the severity of COPD (rs (33) = 0.19, P = 0.26). No significant correlation between functional capacity and functional performance was identified (rs (32) = 0.19, P = 0.29). This suggests that other factors contribute to daily functional performance. The largest cost of care for people with COPD has been reported to be unplanned admissions due to an exacerbation of COPD.In this study there were no statistically significant differences between the three intervention groups in the prospective measurement of ambulatory care visits, Emergency Department presentations and admissions to hospital. The calculation of costs illuminated the costs of care in COPD are greater than the population norm. In addition, maintenance pulmonary rehabilitation generated a greater quality adjusted life year (QALY) than a six-week program. Despite the strength of the participants preferences (as measured by the QALY) for maintenance PRP, there were no significant differences in use of hospital resources throughout the study period by the three intervention groups, which suggests some degree of equivalence.