Physical activity counselling alongside pulmonary rehabilitation in patients with COPD

Armstrong, Matthew George (2021) Physical activity counselling alongside pulmonary rehabilitation in patients with COPD. Doctoral thesis, Northumbria University.

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Abstract

Background: In patients with Chronic Obstructive Pulmonary Disease (COPD) daily physical activity (PA) levels are significantly lower than in healthy age-matched individuals. PA counselling has been employed to address the complex behaviour of PA and was shown via a systematic review and meta-analysis to be effective in improving daily PA levels (steps/day) both as a standalone intervention and alongside pulmonary rehabilitation (PR). However, in patients reporting low baseline levels of PA (≤4000 steps/day), PA counselling alongside PR did not induce clinically important improvements in daily PA levels. A plausible reason involves the concept of a “low functional reserve”, indicating that these patients are less likely to become more physically active within their functional limits.

Objectives: 1) to perform a systematic review and meta-analysis on PA counselling as a standalone intervention and alongside PR in COPD, 2) to determine the criterion validity and test-retest reliability of a commercially available pedometer used by COPD patients to self-monitor and report daily PA levels, 3) to evaluate daily PA levels, muscle function, anxiety and depression in patients with COPD living in the North East of England in comparison to healthy age-matched individuals from the same region in a cross sectional study design, and 4) to investigate the feasibility, acceptability and efficacy of combining PR, designed to improve exercise capacity, with comprehensive PA behavioural modification interventions, designed to translate PR-induced improvements in exercise capacity into improved daily PA, in COPD patients with low baseline PA levels.

Methods: To accomplish the latter objective a prospective, single centre, two parallel-group, RCT, compared the efficacy of a PR programme combined with PA behavioural modification interventions (PR+PA: incorporating motivational interviewing, face-to-face twice weekly goal setting, step count monitoring and feedback) to a PR programme alone in 48 patients with COPD (FEV1: 49±19 % predicted) exhibiting low baseline exercise capacity (6MWT: 289±85m) and daily PA levels (3293±2000 steps/day). In both groups (PR+PA and PA alone) patients with profound anxiety and depression (≥8 HADS score) received sessions of Cognitive Behavioural Therapy (CBT) by a specialist respiratory nurse.

Results: Compared to PR alone, PR+PA induced clinically important improvements in both PA levels (by 1016 steps/day; 95% CI 556 to 1474 steps/day, p = 0.001) and patients’ PA experiences (by 7 points; 95% CI 4 to 11 points, p= 0.001) that were assessed by the European Medicines Agency qualified Clinical PROactive Physical Activity in COPD instrument (C-PPAC). Importantly, both groups reported clinically important improvements in the 6MWT (≥ 30 m) and CAT questionnaire (≥ -2 points), however improvements in upper and lower muscle strength were significantly greater in the PR+PA compared to PR group.
These findings were supported by evidence of adequate PR completion rates (80%) and high patient acceptability of the PA behavioural modification interventions, with 75% of patients indicating that they “liked taking part in the intervention a lot”, and 58% of patients claiming that the intervention “helped them a lot” regarding completing more PA outside of PR. Furthermore, patient adherence to the components of the behavioural modification interventions was high, including the weekly use of the pedometer (6.6±0.2 days) and interaction with the PA diary (93±17%) to self-monitor and report daily step counts.

Conclusions: The findings suggest that in COPD patients with low baseline exercise capacity and daily PA levels, improvements in exercise capacity following completion of a standard PR programme may translate into clinically important improvements in daily PA levels only when tailored PA behavioural modification interventions are added to PR. In addition, PA behavioural modification interventions were proven to be feasible to incorporate into a standard PR programme and were well accepted by patients with COPD.

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