Exercise as it relates to Disease/A behavioural intervention to increase physical activity amongst chronic obstructive pulmonary disease patients

This research study 'A Lifestyle Physical Activity Intervention for Patients with Chronic Obstructive Pulmonary Disease' by Coultas, Jacskon, Russo, Peoples, Sloan, Singh, Ashmore, Blair, Uhm and Bae (2016), is a randomised control study that will be further critiqued in this Wiki.

What is the background to this research?
Chronic Obstructive Pulmonary Disease (COPD) is a complex syndrome characterised by irreversible progressive airflow limitation, with the main and most common symptoms of COPD being dyspnoea and fatigue. These symptoms are almost always experienced during physical activity, making it an unpleasant experience for COPD patients, resulting in them avoiding physical activity. This is proven by physical inactivity appearing to be more common in patients with COPD compared with age-matched healthy individuals. It is associated with poor health outcomes, with mortality and hospitalisation predicting and contributing to disease progression. Participating in regular physical activity is important in determining a high level of general health and health related quality of life.

The 2013 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy recommends that all patients with COPD should participate in daily physical activity, although recommended levels have not been defined. Currently there a few and inconsistent studies focusing on specified interventions to increase physical activity rather than supervised exercise training among patients with COPD. Hence, this study has addressed this gap in research by combining the use of self-management education with a lifestyle behavioural intervention among COPD patients; to increase their physical activity levels on a daily basis.

Where is the research from?
The sample of COPD patients from this study were recruited using a registry of patients cared for in primary and specialty care clinics of the University of Texas Health Science Center-Tyler (UTHSCT). Written informed consent was obtained before patient enrolment and data collection.

The findings of this study are relevant in Australia, however it is vital that before any exercise, such as this, is undertaken by patients with COPD in Australia, that they consult a health professional, and adhere with Australian exercise guidelines for COPD.

What kind of research was this?
This study conducted a pragmatic randomised control trial combining self-management education with a lifestyle behavioural intervention, in hope of increasing physical activity among COPD patients.

Inclusion Criteria of Patients:
 * 45 years of age
 * Eligible for pulmonary rehabilitation

Exclusion Criteria of Patients:
 * Uncontrolled medical conditions
 * Participated in a pulmonary rehabilitation program within 12 months
 * Nursing home residents

What did the research involve?
To begin patients of the study were provided with self-management education delivered via a manual and health coach during the first 6 weeks. Following this, patients were randomly assigned to either usual care or the physical activity intervention for COPD; delivered over a 20 week period.

Physical Activity Intervention:
 * At least 30 minutes of accumulated moderate intensity physical activity per day.
 * Program was delivered through workbooks, telephone support from a health coach and automated telephone calls.

Usual Care:
 * A health coach was trained by the principal investigator of the COPD self-management education and by a health psychologist in health behaviour change theory and practical counselling skills i.e. rapport building. active listening and problem solving.

Strengths of the Study's Methodology:
 * A randomised control trial including a control group gave the study a good foundation.
 * Duration of the study for 20 weeks, with follow ups every 6 months for a total of 18 months.
 * Weekly follow ups calls by the health coach for the physical activity intervention i.e. supportive messages.

More face to face contact for follow ups in the physical activity intervention would have been useful, particularly as they involved patients understanding of key concepts, self-efficacy, readiness to change, problem solving, goal setting, adherence and identification of barriers. Having more face to face contact would have allowed a more comfortable setting and closer rapport between the health coach and patient to communicate.

Results
It was concluded and found by the authors of this study, that at the end of the 18 month trial:


 * Dyspnea: No significant change was found in either group.
 * 6 Minute Walk Test: Distance remained stable for the intervention group, but, significant declines were among the usual care group.
 * Adverse Events of COPD Exacerbation's: No increase for the intervention group in comparison to the usual care group, hence no increase in hospitalisations.
 * Lifestyle physical activity intervention combined with the self-management education, only provided functional maintenance of health rather than health related quality of life for COPD.

The researchers of this study did acknowledge the implications and limitations of this research which had an impact on the intervention of the study hence its results. This included a lack of and no opportunity for peer/social support for physical activity participation, uncontrolled symptoms including low self-efficacy, motivation, comorbidities of COPD such as fear of dyspnea occurring whilst exercising etc. Furthermore, the physician's gave limited engagement and support for the patients, from this a lack of advice, encouragement as well as supervision was seen in the physical activity intervention.

What conclusions can we take from this research?
This research has proven there to be improvements from physical activity among COPD patients in a behavioural intervention group. However, specific guidelines, more support, monitoring and supervision that are accustomed to different levels of COPD patients is really needed. This will help further achieve and maintain real improvements, which is vital as many patients with COPD find it difficult to exercise or have a fear in doing so, due to adverse events they may experience. Further research is needed to focus on and understand the determinants and outcomes of physical activity in patients with COPD, to gain greater improvements of both functional performance and health related quality of life aspects, and to maintain them long term.

Accumulation of results from current research on physical activity and COPD, has proven that the more frequent training there is the more significant improvement is seen in physical activity levels, with at least three times a week or more of training to be ideal. However, as this intervention has been implemented by a research team and has shown the improvements it has, it is still up to patients in the end to choose to maintain an active lifestyle for their COPD.

Practical advice
Partaking in any form of physical activity does have implications on a day to day life, particularly when a disease or health issue is also faced. Real world implications that this research holds is the lack of effectiveness of peer support, and support from physicians on the engagement of physical activity for the patients of the study. A lack of understanding of the psychological determinants that have an influence on motivation and maintenance of physical activity is also seen in this study. Patients with COPD who are participating in prescribed exercise require supervision by a health professional, particularly if they are at high risk of adverse events. If the practical advice of this studies intervention were to be taken upon, it is highly recommended and advised that supervision by a health professional is undertaken, to ensure the health and safety of COPD patients, particularly due to the common symptoms experienced in COPD patients.

The following websites provide useful information and fact sheets for information and support to patients with COPD, with regards to exercising too:


 * Lung Foundation Australia
 * A Patient Guide: Better Living with Chronic Obstructive Pulmonary Disease by the Australian Lung Foundation
 * Patient Support: Lung Foundation Australia
 * Chronic respiratory conditions - including asthma and chronic obstructive pulmonary disease (COPD): The Department of Health
 * Exercise is Medicine: Exercising with Chronic Obstructive Pulmonary Disease (COPD)

The following links are to further readings on COPD and physical activity:


 * Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: Results of an exercise counseling program
 * Pulmonary Rehabilitation for Management of Chronic Obstructive Pulmonary Disease