Pulmonary rehabilitation with balance training for fall reduction in chronic obstructive pulmonary disease: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Available evidence suggests that adults with chronic obstructive pulmonary disease (COPD) performed substantially worse than healthy controls on many balance measures and balance training can improve the balance measures in this population. We conducted this study to determine the effects of incorporating balance training into pulmonary rehabilitation (PR) on the incidence of falls at 12 months follow-up in high fall risk adults with COPD. METHODS: We conducted a prospective international multi-center randomized controlled trial. Eligible participants were adults with COPD at a high risk of future falls and were randomly assigned (1:1) to the intervention or control group. The intervention included personalized balance training for a targeted total of 90 min per week. Both the intervention and control groups received usual PR (2-3 times per week for 8-12 weeks). The primary outcome was the incidence of falls at 12-month follow-up using monthly fall diary calendars. Negative binomial regression or recurrent events models were used to examine the effects of the intervention on fall events. Multiple imputations were performed to deal with missing values. RESULTS: Of 258 participants who were enrolled in the trial, 178 provided falls information (intervention group = 91, control group = 87) and were included in the main analysis. Forty-one participants (45%) experienced at least one fall event in the intervention group and 33 (38%) in the control group (p = 0.34). The mean incidence of falls at 12 months was similar between the two groups (128 versus 128 per 100 person-years; mean difference: 0.30, 95% CI: -0.76 to 1.36 per 100 person-years). The results are robust after multiple imputations for missing data (n = 67). CONCLUSIONS: PR incorporating balance training compared to PR alone did not reduce the incidence of falls over the 12-month period in high fall risk adults with COPD. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov (NCT02995681) on 14/12/2016.

Reflections on the challenges of conducting an international multicentre randomized controlled trial of balance training in addition to pulmonary rehabilitation and its impact on fall incidence in people with COPD.

BACKGROUND: Pulmonary rehabilitation (PR) is accepted as standard care for individuals with COPD. We conducted an international, multi-centred randomized controlled trial (RCT) to determine if adding balance training to PR would reduce the incidence of falls in people with COPD. While there have been many trials investigating the effectiveness of PR, few have involved international collaboration. Successful execution of rehabilitation trials requires a significant investment of time, staffing, and resources. With the recent completion of the Balance Training for Fall Reduction in COPD RCT, we report on the design, implementation, and execution of our trial using project management phases. We also highlight our lessons learned for consideration in future multi-centre rehabilitation trials. METHODS: This was a retrospective review of the planning, preparation, timelines, and personnel training involved in the execution of this study using four of the five project management phases described by Farrell et al. in 2010: (1) initiation, (2) planning, (3) execution, and (4) monitoring and controlling. We report descriptive statistics as percentages and counts and summarize our lessons learned. RESULTS: Ten outpatient PR programs in three continents participated. Thirty-one personnel worked on the trial across all sites. Enrolment began in January 2017 and was suspended in March 2020 due to the COVID-19 pandemic. Approximately 1275 patients were screened, 455 (36%) were eligible, 258 (57%) consented, 243 (53%) participated, and 130 (61%) completed the 12-month follow-up assessment. Lessons learned through our experience included (1) ensuring awareness of funder policies and considering the impact on collaborating sites; (2) preparing for the possibility of human resource and program disruptions; (3) anticipating site dropout and having a contingency plan in place; (4) planning and monitoring process measure data before, during, and after trial initiation; (5) ensuring frequent and consistent communication with and between collaborating sites; (6) maximizing features of database platform to ensure data set completeness and controlled data access; and (7) identifying strategies for increasing patient engagement in a high-demand study. CONCLUSIONS: We identify seven lessons learned through our experience conducting an international, multicentre rehabilitation-based RCT. These lessons can provide guidance to other trialists conducting studies with similar logistics and may assist with future trial planning and implementation.

Factors related to the implementation of pulmonary rehabilitation in Jordan: Perspective of healthcare professionals.

BACKGROUND: Although the benefits of pulmonary rehabilitation (PR) in the management of chronic respiratory disease conditions (CRC) are well-documented, it remains underutilized. In Jordan, the scarcity of PR services denies those with CRC the opportunity to improve their functional capacity, mental health, and quality of life. OBJECTIVE: To explore the factors related to the implementation of PR in Jordan from the perspective of the healthcare professionals (HCPs). METHODS: This was a qualitative study that utilized semi-structured interviews informed by the Theoretical Domains Framework (TDF). Twenty-one HCPs were interviewed. Interview transcripts were coded against the relevant TDF domain(s) and then domains' summaries were generated. RESULTS: A total of 997 quotes were coded against the TDF domains. Knowledge, environmental context and resources, social influences, and skills domains were the ones most coded. The study identified several barriers to PR implementation such as: limited knowledge and skills pertaining to PR among HCPs, limited public awareness of PR, financial costs, limited legislation related to establishment of PR and role confusion of HCPs in PR. The main facilitators include: HCPs willingness to be involved in new programs such as PR, the perception of the importance and need for PR and HCPs beliefs about capabilities to overcome barriers for a successful implementation of PR. CONCLUSION: The current study provided information that will inform stakeholders and policymakers about the factors affecting PR implementation in Jordan. Improvements in HCPs skills and knowledge about PR, financial support, improvements in undergraduate syllabi and policies to control PR service provision are considered to be key to a successful implementation of PR.

The importance of addressing physical activity and exercise intolerance in our patients with COPD.

Both increased physical activity and increased exercise capacity are desired outcomes in the treatment of individuals with COPD https://bit.ly/4apLYzm.

Translating the Interplay of Cognition and Physical Performance in COPD and Interstitial Lung Disease: Meeting Report and Literature Review.

TOPIC IMPORTANCE: Cognitive and physical limitations are common in individuals with chronic lung diseases, but their interactions with physical function and activities of daily living are not well characterized. Understanding these interactions and potential contributors may provide insights on disability and enable more tailored rehabilitation strategies. REVIEW FINDINGS: This review summarizes a 2-day meeting of patient partners, clinicians, researchers, and lung associations to discuss the interplay between cognitive and physical function in people with chronic lung diseases. This report covers four areas: (1) cognitive-physical limitations in patients with chronic lung diseases; (2) cognitive assessments; (3) strategies to optimize cognition and motor control; and (4) future research directions. Cognitive and physical impairments have multiple effects on quality of life and daily function. Meeting participants acknowledged the need for a standardized cognitive assessment to complement physical assessments in patients with chronic lung diseases. Dyspnea, fatigue, and age were recognized as important contributors to cognition that can affect motor control and daily physical function. Pulmonary rehabilitation was highlighted as a multidisciplinary strategy that may improve respiratory and limb motor control through neuroplasticity and has the potential to improve physical function and quality of life. SUMMARY: There was consensus that cognitive function and the cognitive interference of dyspnea in people with chronic lung diseases contribute to motor control impairments that can negatively affect daily function, which may be improved with pulmonary rehabilitation. The meeting generated several key research questions related to cognitive-physical interactions in individuals with chronic lung diseases.

Balance measures for fall risk screening in community-dwelling older adults with COPD: A longitudinal analysis.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) increases fall risk, but consensus is lacking on suitable balance measures for fall risk screening in this group. We aimed to evaluate the reliability and validity of balance measures for fall risk screening in community-dwelling older adults with COPD. METHODS: In a secondary analysis of two studies, participants, aged ≥60 years with COPD and 12-month fall history or balance issues were tracked for 12-month prospective falls. Baseline balance measures - Brief Balance Evaluation Systems Test (Brief BESTest), single leg stance (SLS), Timed Up and Go (TUG), and TUG Dual-Task (TUG-DT) test - were assessed using intra-class correlation (ICC2,1) for reliability, Pearson/Spearman correlation with balance-related factors for convergent validity, t-tests/Wilcoxon rank-sum tests with fall-related and disease-related factors for known-groups validity, and area under the receiver operator characteristic curve (AUC) for predictive validity. RESULTS: Among 174 participants (73 ± 8 years; 86 females) with COPD, all balance measures showed excellent inter-rater and test-retest reliability (ICC2,1 = 0.88-0.97) and moderate convergent validity (r = 0.34-0.77) with related measures. Brief BESTest and SLS test had acceptable known-groups validity (p < 0.05) for 12-month fall history, self-reported balance problems, and gait aid use. TUG test and TUG-DT test discriminated between groups based on COPD severity, supplemental oxygen use, and gait aid use. All measures displayed insufficient predictive validity (AUC<0.70) for 12-month prospective falls. CONCLUSION: Though all four balance measures demonstrated excellent reliability, they lack accuracy in prospectively predicting falls in community-dwelling older adults with COPD. These measures are best utilized within multi-factorial fall risk assessments for this population.

Validation of Constant Work Rate Cycling Endurance Time for Use in Chronic Obstructive Pulmonary Disease Clinical Trials.

Rationale: A COPD Foundation working group sought to identify measures of exercise endurance, a meaningful aspect of physical functioning in everyday life among patients with chronic obstructive pulmonary disease (COPD) that is not fully accepted in regulatory decision making, hampering drug development. Objectives: To demonstrate, as we previously asserted (Casaburi COPD 2022;9:252), that constant work rate cycling endurance time is an appropriate exercise endurance measure in patients with COPD. Methods: To validate this assertion, we assembled an integrated database of endurance time responses, including 8 bronchodilator (2,166 subjects) and 15 exercise training (3,488 subjects) studies (Casaburi COPD 2022;9:520). Results: Construct validity was demonstrated: 1) peak physiologic and perceptual responses were similar for constant work rate and incremental cycling; 2) after bronchodilator therapy, there were greater increases in endurance time in patients with more severe airflow limitation; 3) after exercise training, endurance time increases were similar across airflow limitation severities; and 4) there were correlations between changes in endurance time and changes in mechanistically related physiologic and perceptual variables. Test-retest reliability was demonstrated, with consistency of changes in endurance time at two time points after the intervention. Responsiveness was confirmed, with significant increases in endurance time after active (but not placebo) bronchodilator therapy, with greater increases seen with more severe airflow limitation and after exercise training. On the basis of regression analysis using multiple anchor variables, the minimum important difference for endurance time increase is estimated to be approximately 1 minute. Conclusions: Constant work rate cycling endurance time is a valid exercise endurance measure in COPD, suitable for contributing to the evaluation of treatment benefit supporting regulatory decision making and evidence-based therapeutic recommendations.

A Non-Pharmacological Cough Therapy for People with Interstitial Lung Diseases: A Case Report.

Purpose: To explore the feasibility of a non-pharmacological cough control therapy (CCT) customized for a client with interstitial lung disease (ILD). Client Description: An 83-year-old female with hypersensitivity pneumonitis, and chronic cough for 18 years treated previously with pharmacological treatment for the underlying lung disease and gastroesophageal reflux disease, as well as lozenges and breathing and relaxation strategies. Intervention: Four cough education and self-management sessions (45-60 minutes each) facilitated by a physiotherapist and speech-language pathologist via videoconference were conducted. Session topics included mechanisms of cough in ILD, breathing and larynx role in cough control, trigger identification, cough suppression and control strategies, and psychosocial support towards behaviour change using motivational interviewing. Measures and Outcome: The following assessments were conducted prior to and one week after the intervention: semi-structured interviews, Leicester Cough Questionnaire, King's Brief Interstitial Lung Disease questionnaire, Functional Assessment of Chronic Illness Therapy Fatigue Scale, modified Borg Scale for severity and intensity of cough, and the Global Rating of Change Questionnaire. Implications: Implementing the CCT was feasible. The client reported increased perceived cough control, a reduction in exhaustion from coughing bouts, and a better understanding of the mechanisms behind cough management and suppression. Improvements were also observed in cough-related quality of life, severity, and intensity.

Objectif: explorer la faisabilité d'un traitement non pharmacologique de contrôle de la toux adapté à une cliente atteinte de Pneumopathie interstitielle (PPD). Description de la cliente: une femme de 83 ans atteinte d'une Pneumopathie d'hypersensibilité et d'une toux chronique depuis 18 ans, soignée auparavant par un traitement pharmacologique de la Pneumopathie sous-jacente et du reflux gastro-œsophagien pathologique, de même que par des pastilles et des stratégies de respiration et de relaxation. Intervention: un physiothérapeute et un orthophoniste ont facilité quatre séances d'éducation et d'autogestion de la toux (de 45 à 60 minutes chacune) par visioconférence. Les séances ont porté sur les mécanismes de la toux en cas de PPD, le rôle de la respiration et du larynx pour le contrôle de la toux, la détermination des déclencheurs, des stratégies de suppression et de contrôle de la toux et le soutien psychosocial pour un changement de comportement au moyen d'entrevues motivationnelles. Mesures et résultats cliniques: les évaluations suivantes ont été effectuées avant l'intervention, puis une semaine après: entrevues semi-structurées, questionnaire de Leicester sur la toux, court questionnaire de King sur la Pneumopathie interstitielle, échelle d'évaluation de la fatigue fonctionnelle découlant d'une maladie chronique, l'échelle de Borg modifiée pour la gravité et l'intensité de la toux et le questionnaire d'évaluation globale du changement. Conséquences: la mise en œuvre du traitement de contrôle de la toux était faisable. La cliente avait la perception de mieux contrôler sa toux, d'être moins épuisée à cause des crises de toux et de mieux comprendre les mécanismes de gestion et de suppression de la toux. Elle a également observé des améliorations à sa qualité de vie liée à la toux ainsi qu'une diminution de la gravité et de l'intensité de la toux.

Exploring factors affecting the timely transition of ventilator assisted individuals in Ontario from acute to long-term care: Perspectives of healthcare professionals.

Rationale: Ventilator Assisted Individuals (VAIs) frequently remain in intensive care units (ICUs) for a prolonged period once clinically stable due to a lack of transition options. These VAIs occupy ICU beds and resources that patients with more acute needs could better utilize. Moreover, VAIs experience improved outcomes and quality of life in long-term and community-based environments. Objective: To better understand the perspectives of healthcare providers (HCPs) working in an Ontario ICU regarding barriers and facilitators to referral and transition of VAIs from the ICU to a long-term setting. Methods: We conducted semi-structured interviews with ten healthcare providers involved in VAI transitions. Main Results: Perceived barriers included long wait times for long-term care settings, insufficient bed availability at discharge locations, medical complexity of patients, long waitlists, and a lack of transparency of waitlists. Facilitators included strong partnerships and trusting relationships between referring and discharge locations, a centralized referral system, and utilization of community partnerships across care sectors. Conclusions: Insufficient resourcing of long-term care is a key barrier to transitioning VAIs from ICU to long-term settings; strong partnerships across care sectors are a facilitator. System-level approaches, such as a single-streamlined referral system, are needed to address key barriers to timely transition.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline.

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

Mobile heath applications for self-management in chronic lung disease: a systematic review.

Integration of mobile health (mHealth) applications (apps) into chronic lung disease management is becoming increasingly popular. MHealth apps may support adoption of self-management behaviors to assist people in symptoms control and quality of life enhancement. However, mHealth apps' designs, features, and content are inconsistently reported, making it difficult to determine which were the effective components. Therefore, this review aims to summarize the characteristics and features of published mHealth apps for chronic lung diseases. A structured search strategy across five databases (CINAHL, Medline, Embase, Scopus and Cochrane) was performed. Randomized controlled trials investigating interactive mHealth apps in adults with chronic lung disease were included. Screening and full-text reviews were completed by three reviewers using Research Screener and Covidence. Data extraction followed the mHealth Index and Navigation Database (MIND) Evaluation Framework (https://mindapps.org/), a tool designed to help clinicians determine the best mHealth apps to address patients' needs. Over 90,000 articles were screened, with 16 papers included. Fifteen distinct apps were identified, 8 for chronic obstructive pulmonary disease (53%) and 7 for asthma (46%) self-management. Different resources informed app design approaches, accompanied with varying qualities and features across studies. Common reported features included symptom tracking, medication reminders, education, and clinical support. There was insufficient information to answer MIND questions regarding security and privacy, and only five apps had additional publications to support their clinical foundation. Current studies reported designs and features of self-management apps differently. These app design variations create challenges in determining their effectiveness and suitability for chronic lung disease self-management. Registration: PROSPERO (CRD42021260205). Supplementary Information: The online version contains supplementary material available at 10.1007/s13721-023-00419-0.

The effects of pulmonary rehabilitation on inflammatory biomarkers in patients with chronic obstructive pulmonary disease: Protocol for a systematic review and meta-analysis.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common, preventable lung disease which affects more than 300 million people worldwide. People with COPD have elevated levels of inflammatory biomarkers, which are linked to physiological alterations in the respiratory system and extrapulmonary manifestations. Pulmonary rehabilitation (PR) is one of the strategies used in the management of individuals with COPD irrespective of severity, however its effect on systemic inflammation is poorly understood. We report the protocol of a systematic review on the effects of PR on systemic inflammation in patients with COPD. MATERIALS AND METHODS: Using the search terms "chronic obstructive pulmonary disease", "pulmonary rehabilitation", and "inflammatory biomarkers" and their synonyms, five databases (AMED, CINAHL, Ovid MEDLINE, MEDLINE (Pubmed), EMBASE) will be searched from their inception to identify primary literature evaluating the effects of PR on systemic inflammation. Two reviewers will independently screen titles, abstracts, and full texts for eligibility using the Covidence web-based software. Eligible studies must be published in a peer-reviewed journal and include: (1) participants with COPD undergoing PR with an exercise component of at least 4 weeks in length and (2) a measure of systemic inflammation (e.g., bloodwork or sputum sample) as an outcome of interest. We will use the Cochrane Risk of Bias Tools (ROB2 and ROBINS-I) and will rate the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. This protocol has followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines and is registered with the International Prospective Register of Systematic Reviews (PROSPERO). CONCLUSION: The results of this systematic review will summarize the status of the evidence highlighting the effect of PR on systemic inflammation. A manuscript will be drafted and submitted to a peer-reviewed journal and shared at conferences.

The Relationship between Physical Activity, Depression and Anxiety in People with COPD: A Systematic Review and Meta-analyses.

Depression and anxiety are related to physical activity among people with chronic obstructive pulmonary disease (COPD), although the strength and direction of the reported relationships are inconsistent. This study systematically synthesized the relationships between physical activity and i) depression and ii) anxiety in people with COPD. Physical activity measurement type (objective, self-report) was examined as a moderator of these relationships. A systematic search of physical activity and COPD was conducted from inception to February 2022 across 8 databases. Studies were included if they provided correlation coefficients for the relationship between measures of physical activity and depression or anxiety in people with COPD and were published in English. Two reviewers independently screened, reviewed and extracted data, with discrepancies resolved by a third reviewer. Across 13 studies, a small relationship was found between physical activity and depression, weighted r = -0.15, 95%CI [-0.21, -0.10], which was not moderated by physical activity measurement type. Across 8 studies, a negligible relationship was found between physical activity and anxiety, weighted r = -0.03, 95%CI [-0.11, 0.04], although this was moderated by physical activity measurement type, such that self-reported physical activity had a small negative relationship with anxiety (weighted r = -0.09, 95% CI [-0.15, -0.03]) and objectively measured physical activity had a small positive relationship (weighted r = 0.07, 95% CI [-0.13, 0.26]). In COPD, the bivariate association between physical activity and anxiety and depression are small.

Features and characteristics of publicly available mHealth apps for self-management in chronic obstructive pulmonary disease.

Mobile health applications (mHealth apps) may be able to support people living with chronic obstructive pulmonary disease (COPD) to develop the appropriate skills and routines for adequate self-management. Given the wide variety of publicly available mHealth apps, it is important to be aware of their characteristics to optimize their use and mitigate potential harms. Objective: To report the characteristics and features of publicly available apps for COPD self-management. Methods: MHealth apps designed for patients' COPD self-management were searched in the Google Play and Apple app stores. Two reviewers trialed and assessed the eligible apps using the MHealth Index and Navigation Database framework to describe the characteristics, qualities, and features of mHealth apps across five domains. Results: From the Google Play and Apple stores, thirteen apps were identified and eligible for further evaluation. All thirteen apps were available for Android devices, but only seven were available for Apple devices. Most apps were developed by for-profit organizations (8/13), non-profit organizations (2/13), and unknown developers (3/13). Many apps had privacy policies (9/13), but only three apps described their security systems and two mentioned compliance with local health information and data usage laws. Education was the common app feature; additional features were medication reminders, symptom tracking, journaling, and action planning. None provided clinical evidence to support their use. Conclusions: Publicly available COPD apps vary in their designs, features, and overall quality. These apps lack evidence to support their clinical use and cannot be recommended at this time.

Cough Assessment and Management in Pulmonary Rehabilitation- A Canadian Survey.

Pulmonary rehabilitation is a cornerstone intervention for controlling respiratory symptoms in people with chronic respiratory diseases. Chronic cough affects up to 90% of people with chronic respiratory diseases, however, it is currently unknown whether chronic cough is assessed and/or managed in pulmonary rehabilitation. This study aimed to determine if and how chronic cough is assessed and managed in pulmonary rehabilitation. This was a cross-sectional study. Pulmonary rehabilitation programs in Canada were identified via online websites. A representative from each program was invited to complete an online survey including the following topics: program demographics, assessment and management practices, and barriers and facilitators. Of 133 programs contacted, 31 returned a completed survey (23% response rate). Approximately half (52%) of respondents reported enrolling patients with chronic cough. Of those, 45% reported assessing and 62% reported intervening in chronic cough. Inadequate knowledge of assessment and management techniques was commonly identified to be a barrier and increased education was suggested as a possible facilitator. Based on pulmonary rehabilitation programs that responded to our survey, chronic cough is a prevalent symptom; however, it is scarcely assessed and managed. A need for structured education and the use of standardised strategies were reported as facilitators to the assessment and management of chronic cough in pulmonary rehabilitation.

Responsiveness of the late life disability instrument to pulmonary rehabilitation in people with COPD.

PURPOSE: To establish the responsiveness of the disability component of the Late Life Function and Disability Instrument (LLDI) and its Computer Adaptive Test (LLDI-CAT) in people with chronic obstructive pulmonary disease (COPD). METHOD: Participants completed the LLDI, LLDI-CAT and measures of physical function, health-related quality of life (HRQOL) and symptom severity before and after pulmonary rehabilitation (PR), and global rating of change (GRC) scales at the end of PR. Responsiveness was explored by calculating correlations between LLDI and LLDI-CAT change scores and change scores on the other measures, and calculating the area under the receiver operating characteristic curve (AUC) for the ability of the LLDI and LLDI-CAT to discriminate between participants who were improved versus unchanged. We hypothesized fair correlations (-0.3 to -0.5 or 0.3 to 0.5) with other measures and considered an AUC≥0.7 acceptable. Minimal important differences (MIDs) were estimated using anchor- and distribution-based approaches. RESULTS: Fifty participants (mean (SD) age 69.8 (7.9) years) completed the study. Only the limitation dimension of the LLDI showed improvement at follow-up (z = 2.4, p = 0.018) and was able to discriminate between participants who were improved versus unchanged (AUC 0.7 (95% CI 0.6-0.9)). Correlations between change scores were as hypothesized between the participation measures and measures of at least two other constructs. CONCLUSION: This study provides MID values for the LLDI and LLDI-CAT to support their clinical application. The limitation dimension of the LLDI appears to be particularly responsive to PR in people with COPD.

COPD: Providing the right treatment for the right patient at the right time.

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Assessing caregiving experience in COPD: content validity of the Zarit Burden Interview in Canadian and Portuguese caregivers.

PURPOSE: Informal caregivers play an important role in chronic disease management but their experience is often neglected. The objective of this study was to explore the content validity of the Zarit Burden Interview (ZBI) in caregivers of individuals with COPD in Canada and Portugal. MATERIALS AND METHODS: Cognitive debriefing interviews were conducted with informal caregivers of individuals with moderate to very severe COPD. Participants completed the ZBI and verbalised their thinking process to assess the adequacy of the questionnaire's content and instructions. Content validity was assessed using deductive content analysis of interviews and descriptive statistics of questionnaire responses. RESULTS: Nine caregivers from Canada (age = 67 ± 8 years) and 13 from Portugal (age = 69 ± 7 years) participated. For Canadian caregivers, 3/22 items were not understood, and 8/22 items were not relevant to at least 1/3 of them. For Portuguese caregivers, 1/22 items were not understood, and 20/22 items were not relevant to at least 1/3 of them. The distribution of response choices was approximately symmetrical for 17/22 items in the Canadian sample. The response option "no/never" was selected by at least 75% of Portuguese participants for 18/22 items. CONCLUSIONS: The instrument was well understood by caregivers of people with COPD, but its relevance is uncertain.IMPLICATIONS FOR REHABILITATIONInformal caregivers provide essential care for people living with disability and chronic disease, but their experience is often neglected.The Zarit Burden Interview assesses caregiver burden but has not been validated in caregivers of people with chronic obstructive pulmonary disease.In its current form, the Zarit Burden Interview does not adequately represent the experience of COPD caregivers.We recommend selecting tools that assess caregiver burden that have been validated in the caregiver population of interest.

Interstitial lung diseases specific measures in exercise interventions: A systematic review of measurement properties.

BACKGROUND: Effects of exercise-based interventions (EBIs) on people with interstitial lung disease (ILD) are not yet fully understood. Reasons may include the limited use of ILD-specific measures and/or the lack of adequate information regarding their measurement properties. The purpose of this review was to summarize the ILD-specific outcome measures used in EBI studies and their measurement properties. METHODS: This was a two-phase systematic review: phase 1 identified ILD-specific measures used in EBI studies; phase 2 reviewed their measurement properties. PubMed, Web of Science, Scopus, EBSCO and EMBASE were searched up to March 2021. One reviewer extracted data, and 2 reviewers independently assessed studies risk of bias as well as the quality of measurement properties using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations. RESULTS: Phase 1 identified 18 records. The St George's Respiratory Questionnaire for Interstitial Pulmonary Fibrosis (SGRQ-IPF) was the only ILD-specific outcome measure used (n = 2 trials). Phase 2 resulted in 31 eligible records; measurement properties were reported for 12 measures. Measures presented sufficient content validity, internal consistency (Cronbach's alpha 0.61-0.96), test-retest reliability (intraclass correlation coefficient 0.39; 0.96), hypothesis testing and responsiveness but were insufficient for measurement error and indeterminate for cross-cultural and structural validity. The outcome measures King's Brief Interstitial Lung Disease and SGRQ-IPF had higher evidence of adequate measurement properties than other measures. Quality of the evidence was mostly very low to moderate. CONCLUSIONS: ILD-specific outcome measures are used infrequently in EBI trials, and there is scarce information regarding their measurement properties. DATABASE REGISTRATION: CRD42018112466.

Evaluation of a New Performance-Based Health Literacy Measurement Tool for Individuals With Chronic Airways Disease.

BACKGROUND: Low health literacy is a global challenge. Health literacy is positively correlated with chronic airways disease desirable outcomes. Despite the importance of health literacy in disease management, current health literacy measurement tools are suboptimal. As part of a multi-stage project to develop a performance-based, disease-specific Vancouver Airways Health Literacy Tool (VAHLT) for individuals with chronic airways disease, this study assessed the relationships between the VAHLT scores and characteristics of patients with chronic airways disease. The primary aim of the study was to provide preliminary evidence of construct validity of the VAHLT. METHODS: A cross-sectional study design was applied. Study subjects were recruited from 6 specialty care clinics to complete the VAHLT measurement tool. Demographic and clinical data, including quality of life and disease control, were collected via validated questionnaires. The study subjects also completed a spirometry test. Inferential analysis was conducted by using mean difference testing and correlational methods. RESULTS: A total of 320 subjects were recruited, and, after imputing missing data, 315 were ultimately analyzed. The subjects were predominantly women (61%), white (83%), had a post-high-school education (74%), and a mean ± SD age of 65.2 ± 13.2 y. Age was significantly negatively correlated with the VAHLT scores (P = .004); the subjects with a post-high school education had significantly higher VAHLT scores than those with a high school education or less (P < .001). No significant sex or ethnicity related differences in VAHLT scores were observed. For clinical outcomes, no significant differences were found between the VAHLT scores and disease severity or measures of quality of life and asthma control. CONCLUSIONS: We report a chronic airways disease-specific health literacy measurement tool developed with the involvement of patients and professionals. Age and education were highly correlated with health literacy, which emphasizes the importance of addressing these factors in health literacy interventions among patients with chronic airways disease.