Exercise as it relates to Disease/Getting back your stride: How pedometers can increase physical fitness in COPD patients

This is a critique of the journal article: Hospes G, Bossenbroek L, ten Hacken NHT, van Hengel P, de Greef MHG. Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: results of an exercise counseling program. Patient education and counseling. 2009;75(2):274-8.

This critique was written as a university assignment for the University of Canberra for the unit: Health, Disease and Exercise.

Background to Research
Chronic obstructive pulmonary disease (COPD) is known to cause breathlessness, disability, and frequent hospitalisations, which leads to decreased physical activity (PA). International guidelines recommend a minimum of thirty minutes per day of PA in all COPD patients, regardless of their stage of disease. Within this population, daily step counts are significantly reduced compared with healthy individuals. Increasing PA in this population has shown beneficial effects on functional status, decreased hospital admissions and lower mortality. Currently, best practice for increasing PA in COPD patients requires attendance at pulmonary rehabilitation (PR) 2-3 times each week for up to 12 weeks ; as home-based exercise programs have limited ability to monitor the exercise. The solution is the implementation of walking programs as a form of PA as it is generally safe, convenient and inexpensive. A minimum of 30-minutes 5-days a week moderate intensity PA is recommended for elderly adults and adults with a significant chronic condition.

Hospes et al contributes to the large amount of research that looks at increasing PA in COPD patients. This study demonstrates a feasible way to increase PA through the use of pedometers and exercise counselling programs. These findings are corroborated by Altenburg and Colleagues (2015) who found daily steps and PA significantly increased after 3-months in an exercise counselling group. Kawagoshi and colleagues (2015) also found elderly COPD patients who wore a pedometer improved their PA more so than those who attended PR alone. They associated this with the pedometer motivating the patient and therefore improving their walking time. A study conducted in 2009 found pedometers to have a moderate and positive effect on the increase of PA. Studies have found measuring the number of steps is meaningful to patients and is easily monitored by a therapist. Pedometers are sensitive to walking/ambulatory activities ; however, step count may be underestimated when walking speed is slow, which must be considered if used for testing. Pedometers are an inexpensive way to monitor and give feedback to patients about their daily activity as well as being an effective tool to monitor and increase PA in healthy populations.

Research Origin
Hospes et al conducted this research through the Wilhelmina Hospital in Assen, Netherlands.

Research Type
This is a randomised control trial, using numerical data to collect information. The study scored 5/10 on the Physiotherapy Evidence Database (PEDro), indicating the study is of average quality in terms of reliability and validity. Within this study there was: random allocation; baseline comparability; adequate follow-up; between-group comparisons; point estimates and variability. The criteria that were not met in this study were: concealed allocation; blinding to subjects, therapists and assessors; and intention-to-treat analysis.

What the Research Involved
Outpatients from the pulmonary department of Wilhelmina Hospital in Assen were approached to participate in the study. Those who fit the inclusion criteria signed a written informed consent form and were randomly assigned to an exercise counselling group or usual care group.

Results
Hospes et al (2008) found the exercise counselling group increased its average number of steps per day by 11%, whereas the usual care group had a decrease in the average number of steps per day by 18%. Further: 56% of the exercise counselling group and 29% of the usual care group showed an increase in their average number of steps. The exercise counselling group showed a significant increase in leg and arm strength, improved quality of life and increased motivation score when compared to the usual care group. These results suggest that daily PA can be increased in COPD patients through the use of an exercise counselling program.

Conclusions
From this research we can conclude that a pedometer-based exercise counselling program is feasible and can enhance daily PA, physical fitness, health-related quality of life and motivation in COPD patients. The authors hypothesised the distance covered in the 6-minute walk test will increase if patients stick to their new lifestyle habits. The use of pedometers as a motivational tool should be introduced into PR as it gives the patient motivation and incentive to exercise. Further research should be conducted with this population to further improve participants daily step count and assist in maintaining their lifestyle change.

Practical advice
The research suggests pedometers are a simple, inexpensive and effective tool to motivate a patient with COPD to increase their daily PA. COPD patients should be referred to a PR physiotherapist/exercise physiologist to have a tailored exercise program written for them. This will prevent any injuries or adverse effects as patients will be assessed whether a home-based exercise program is right for them or if they need to be attending regular PR. The patient should be encouraged to buy a pedometer and learn how to use it in a controlled environment, ie. doctors office or hospital. If the patient has any questions or concerns when completing their exercise program or using the pedometer they should be encouraged to speak to their PR physiotherapist/exercise physiologist. If the patient experiences any symptoms of dizziness, pain, shortness of breath they are to call 000 immediately.

Further information/resources
For further information regarding the benefits of physical activity on COPD patients click the links below or alternatively contact your GP for additional information.
 * What is COPD?: https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx
 * Living with a lung condition – Education and Exercise: http://lungfoundation.com.au/patient-support/living-with-a-lung-condition/education-and-exercise/
 * Fitness: Using a pedometer or step counter: https://www.cardiosmart.org/Healthwise/za13/91/za1391