Effectiveness of Behavioral and Pharmacologic Interventions for Depressive Symptoms After Spinal Cord Injury: Findings From a Systematic Review.

OBJECTIVE: To summarize and evaluate evidence regarding the efficacy of interventions for depressive symptoms in adults living with spinal cord injury (SCI) and comorbid major depressive disorder or significant depressive symptoms to inform the development of clinical practice guidelines. DATA SOURCES: Articles published since 2013 and available in Medline, The Cochrane Library, Embase, Scopus, CINAHL, or PsycINFO. Databases were searched in June 2022 and updated November 2023. STUDY SELECTION: Inclusion criteria: age 18 years or older, traumatic SCI, and clinically significant depression (Population), mental health interventions including behavioral, pharmacologic, and complementary and alternative medicine (Intervention), inclusion of a control group (Comparator), with a primary outcome of depression symptom reduction (Outcome). Criteria were applied by multiple reviewers and disagreements were reconciled via unanimous decision among the entire research team. Eight articles of 2780 screened met the selection criteria. DATA EXTRACTION: Data were extracted independently by multiple reviewers. Two reviewers independently assigned a quality score using the guidelines described by Hawker and associates and independently evaluated the risk of bias of each article using version 2 of the Cochrane risk-of-bias tool. DATA SYNTHESIS: All studies assessed depressive symptoms during participant recruitment, screening, and/or at a baseline assessment stage. Pharmacotherapy with venlafaxine XR and several behavioral interventions appear promising, including an online mindfulness course and eye movement desensitization and reprocessing therapy. Remote interventions may be effective in reaching individuals who are unable to travel to in-person therapy sessions. CONCLUSIONS: This systematic review provides valuable information for clinicians who treat individuals with SCI and comorbid major depressive disorder or significant depressive symptoms. It highlights the importance of considering a variety of interventions and individualizing treatment to meet individuals' needs and preferences. Future research should aim to identify effective interventions for treating depressive symptoms in individuals with SCI and optimal delivery methods for these interventions.

Informal Caregivers' Perceptions of Facilitators of Successful Weight Management for People With Spinal Cord Injury.

IMPORTANCE: Informal caregivers have valuable insights that occupational therapists can use to prevent and manage problems that may arise in people with spinal cord injury (SCI) because of a lack of physical activity and poor nutrition. OBJECTIVE: To assess caregiver-identified facilitators of weight management in people with SCI. DESIGN: Descriptive qualitative design using semistructured interviews and thematic analysis. SETTING: Regional SCI Care Model System and Veterans Health Administration. PARTICIPANTS: Informal caregivers (n = 24) of people with SCI. OUTCOMES AND MEASURES: Facilitators of successful weight management in care recipients with SCI. RESULTS: Four themes were identified as weight management facilitators: healthy eating (subthemes: food content, self-control, self-management, and healthy preinjury lifestyle), exercise and therapy (subthemes: occupational and physical therapy, receiving assistance, and resources for exercise), accessibility, and leisure activity or activities of daily living, the latter described as a source of activity (because of required energy expenditure) to facilitate weight management for people with more severe injuries. CONCLUSIONS AND RELEVANCE: These findings can inform the development of successful weight management plans by occupational therapists by incorporating feedback from informal caregivers. Because caregivers are involved in many of the facilitators identified, occupational therapists should communicate with the dyad about sourcing accessible places to increase physical activity and assessing in-person assistance and assistive technology needs to promote healthy eating and physical activity. Occupational therapists can use informal caregiver-identified facilitators of weight management to help prevent and manage problems for people with SCI secondary to limited activity and poor nutrition. What This Article Adds: Occupational therapy practitioners provide therapeutic intervention to people with SCI; this includes attention to weight management from the time of initial injury throughout their lives. This article is novel in the presentation of informal caregivers' perceptions about successful facilitators of weight management among people with SCI, which is important because caregivers are intimately involved in the daily activities of people with SCI and can be a liaison for occupational therapists and other health care providers about ways to facilitate healthy eating and physical activity.

Implementing Patient-Reported Outcome Measures in Inpatient Rehabilitation: Challenges and Solutions.

A project with the goal of implementing electronic health record (EHR)-based patient-reported outcome measures (PROMs) into a large inpatient spinal cord injury (SCI) rehabilitation program took twice as long as expected. This report details the lessons learned from the barriers, successes, and unexpected issues that arose during this prolonged, but now successful, project. The goals of this implementation project were to (1) identify barriers and supports to the use of PROMs; (2) develop an implementation strategy to incorporate the use of PROMs into inpatient rehabilitation; and (3) implement the strategy and evaluate its effects on team communication. In brief, we conducted an initial pilot phase outside of the EHR and used our findings to guide procedural and EHR incorporation during a demonstration phase. We encountered multiple barriers. Procedural issues were significant; although grant funding covered the cost of writing the code for integration of the PROMs into the EHR, our institution's competing priorities slowed progress. Institutional inertia was reflected in the reluctance of some clinical staff members to assume new duties that would take away from direct patient care responsibilities. Therefore, we needed to obtain additional staffing. Detailed planning upfront, guided by changes when necessary; cooperation and interaction with our institution's Information Systems department; and identification of key players and Implementation Champions proved essential to our success. We now have an up-and-running system and are sharing our experience, observations, and recommendations to assist other health care organizations incorporate PROMs into their EHRs.

Reporting Guideline for RULER: Rasch Reporting Guideline for Rehabilitation Research: Explanation and Elaboration.

The Rasch Reporting Guideline for Rehabilitation Research (RULER) provides peer-reviewed, evidence-based, transparent, and consistent recommendations for reporting studies that apply Rasch Measurement (RM) Theory in a rehabilitation context. The purpose of the guideline is to ensure that authors, reviewers, and editors have uniform guidance about how to write and evaluate research on rehabilitation outcome assessments. The RULER statement includes an organizing framework and a checklist of 59 recommendations. This companion article supports the RULER statement by providing details about the framework, rationale for the domains and recommendations in the checklist and explaining why these considerations are important for improving consistency and transparency in reporting the results of RM studies. This article is not intended to describe how to conduct RM studies but provides rationale for the essential elements that authors should address in each domain. Consistency and transparency in reporting RM studies will advance rehabilitation research if authors consider these issues when planning their study and include the checklist when they submit their manuscript for peer review. A copy of the checklist can be found at [table 2 in https://doi.org/10.1016/j.apmr.2022.03.013].

Rasch Reporting Guideline for Rehabilitation Research (RULER): the RULER Statement.

The application of Rasch Measurement (RM) Theory to rehabilitation assessments has proliferated in recent years. RM Theory helps design and refine assessments so that items reflect a unidimensional construct in an equal interval metric that distinguishes among persons of different abilities in a manner that is consistent with the underlying trait. Rapid growth of RM in rehabilitation assessment studies has led to inconsistent results reporting. Clear, consistent, transparent reporting of RM Theory results is important for advancing rehabilitation science and practice based on precise measures. Precise measures, in turn, provide researchers, practitioners, patients, and other stakeholders with tools for effective decision making. The goal of this Rasch Reporting Guideline for Rehabilitation Research (RULER: Rasch Reporting Guideline for Rehabilitation Research) is to provide peer-reviewed, evidence-based, transparent, and consistent recommendations for reporting studies that apply RM Theory in a rehabilitation context. The purpose of the guideline is to ensure that authors, reviewers, and editors have uniform expectations about how to write and evaluate research on rehabilitation outcome assessments. A task force of rehabilitation researchers, clinicians, and editors met regularly between November 2018 and August 2020 to identify the need for the guideline, develop an organizing framework, identify content areas, and develop the recommendations. This RULER: Rasch Reporting Guideline for Rehabilitation Research statement includes the organizing framework and a checklist of 59 recommendations. The guideline is supported by an Explanation and Elaboration article that provides more detail about the framework and recommendations in the checklist. A glossary of key terms and a recommended iterations table are provided in supplemental online only materials.

Clinician Perceptions of Robotic Exoskeletons for Locomotor Training After Spinal Cord Injury: A Qualitative Approach.

OBJECTIVE: To describe the experiences of clinicians who have used robotic exoskeletons in their practice and acquire information that can guide clinical decisions and training strategies related to robotic exoskeletons. DESIGN: Qualitative, online survey study, and 4 single-session focus groups followed by thematic analysis to define themes. SETTING: Focus groups were conducted at 3 regional rehabilitation hospitals and 1 Veteran's Administration (VA) Medical Center. PARTICIPANTS: Clinicians (N=40) reported their demographic characteristics and clinical experience using robotic exoskeletons. Twenty-nine clinicians participated in focus groups at regional hospitals that use robotic exoskeletons, as well as 1 VA Medical Center. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Clinicians' preferences, experiences, training strategies, and clinical decisions on how robotic exoskeleton devices are used with Veterans and civilians with spinal cord injury. RESULTS: Clinicians had an average of 3 years of experience using exoskeletons in clinical and research settings. Major themes emerging from focus group discussions included appropriateness of patient goals, patient selection criteria, realistic patient expectations, patient and caregiver training for use of exoskeletons, perceived benefits, preferences regarding specific exoskeletons, and device limitations and therapy recommendations. CONCLUSIONS: Clinicians identified benefits of exoskeleton use including decreased physical burden and fatigue while maximizing patient mobility, increased safety of clinicians and patients, and expanded device awareness and preferences. Suitability of exoskeletons for patients with various characteristics and managing expectations were concerns. Clinicians identified research opportunities as technology continues to advance toward safer, lighter, and hands-free devices.

Sleep Disturbance Trajectories in Osteoarthritis.

BACKGROUND/OBJECTIVE: Sleep disturbance is common among adults with osteoarthritis (OA), but little is known about patterns over time. In this cohort study, we identified restless sleep trajectories and associated factors in adults with or at high risk for knee OA. METHODS: Longitudinal (2004-2014) restless sleep (≥3 nights/week) annual reports over 8 years from 4359 Osteoarthritis Initiative participants were analyzed. Group-based trajectory modeling identified heterogeneous temporal patterns. Logistic regression identified baseline health and behavioral predictors of trajectory membership. RESULTS: Four restless sleep trajectory groups were identified: good (69.7%, persistently low restless sleep probabilities), worsening (9.1%), improving (11.7%), and poor (9.5%, persistently high). Among 2 groups initially having low restless sleep prevalence, the worsening trajectory group had an increased likelihood of baseline cardiovascular disease (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.01-2.33), pulmonary disease (OR, 1.48; 95% CI, 1.07-2.05), lower physical activity (OR, 1.29; 95% CI, 1.03-1.61), knee pain (OR, 1.04; 95% CI, 1.00-1.07), depressive symptoms (OR, 1.03; 95% CI, 1.01-1.06), and a decreased likelihood of better mental health (OR, 0.97; 95% CI, 0.95-0.98) at baseline. Among 2 groups initially having high restless sleep prevalence, the poor group had an increased likelihood of baseline depressive symptoms (OR, 1.03; 95% CI, 1.00-1.05). CONCLUSIONS: Four trajectories of restless sleep over 8 years were identified using data collected from over 4000 older adults aged 45 to 79 years with or at higher risk for knee OA. The presence of depressive symptoms, less physical activity, knee pain, poor mental health, cardiovascular disease, or pulmonary disease was each associated with unfavorable trajectories.

Users with spinal cord injury experience of robotic Locomotor exoskeletons: a qualitative study of the benefits, limitations, and recommendations.

BACKGROUND: Persons with spinal cord injury (SCI) may experience both psychological and physiological benefits from robotic locomotor exoskeleton use, and knowledgeable users may have valuable perspectives to inform future development. The objective of this study is to gain insight into the experiences, perspectives, concerns, and suggestions on the use of robotic locomotor exoskeletons by civilians and veterans living with SCI. METHODS: Participants reported their demographic characteristics and the extent of robotic exoskeleton use in an online survey. Then, 28 experienced robotic locomotor exoskeleton users participated in focus groups held at three regional hospitals that specialize in rehabilitation for persons with SCI. We used a qualitative description approach analysis to analyze the data, and included thematic analysis. RESULTS: Participants expressed that robotic exoskeletons were useful in therapy settings but, in their current form, were not practical for activities of daily living due to device limitations. Participants detailed the psychological benefits of being eye-level with their non-disabled peers and family members, and some reported physiologic improvements in areas such as bowel and bladder function. Participants detailed barriers of increased fatigue, spasticity, and spasms and expressed dissatisfaction with the devices due to an inability to use them independently and safely. Participants provided suggestions to manufacturers for technology improvements. CONCLUSIONS: The varied opinions and insights of robotic locomotor exoskeletons users with SCI add to our knowledge of device benefits and limitations.

Understanding children with cerebral palsy and bullying: A mixed methods approach.

AIM: The study aims to explore the views of children with cerebral palsy (CP) regarding their experiences being bullied and their perceptions of their primary bully. METHOD: Forty-three children aged 10-18 with CP were given the California Bullying Victimization Scale. Fourteen of the children shared a bullying experience orally or written after the survey. Using a mixed methods analysis, the survey answers were tabulated with descriptive statistics and analysed by Gross Motor Function Classification System (GMFCS) level. The comments were coded to determine qualitative responses. RESULTS: Most bullied children viewed the bully as less than or at least equal to them regarding popularity (73%), performance in schoolwork (85%), and physical strength (56%). Bullied children preferentially told an adult at home. Code words and common categories of bullying were determined from their experiences. INTERPRETATION: Children with CP experience bullying but do not view themselves as inferior to their bully in popularity, intelligence, or physical strength. Most bullied participants confided in an adult at home. Children with GMFCS Levels 1, 2, and 3 seem to be at greater risk for bullying than children with GMFCS Levels 4 and 5. Children with CP demonstrate individualized strategies for resilience with reliance on adults for resources.

Use of Physical Activity Monitors in Rheumatic Populations.

PURPOSE OF REVIEW: The purpose of this review paper is to provide an overview of the recent research using physical activity monitors in rheumatic populations including those with osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, and fibromyalgia. RECENT FINDINGS: Recent research demonstrates increased use of physical activity monitors in these populations, especially in those with osteoarthritis. Results from cross-sectional, longitudinal, and intervention studies highlight that physical activity levels are below recommended guidelines, yet evidence suggests benefits such as improving pain, fatigue, function, and overall well-being. While the use of physical activity monitors in rheumatic populations is increasing, more research is needed to better understand physical activity levels in these populations, the effects of activity on relevant clinical outcomes, and how monitors can be used to help more individuals reach physical activity guidelines.

Association Between Sedentary Time and Quality of Life From the Osteoarthritis Initiative: Who Might Benefit Most From Treatment?

OBJECTIVE: To investigate the relationship between sedentary behavior and quality-adjusted life years (QALYs) among participants in the Osteoarthritis Initiative. DESIGN: Longitudinal, observational design. SETTING: Osteoarthritis Initiative cohort. PARTICIPANTS: Individuals (N=1794) from a prospective, multicenter longitudinal cohort were classified into quantile groups based on average daily sedentary time (most sedentary, quartile 1 [Q1] ≥11.6h; 10.7h≤ Q2 <11.6h; 9.7h≤ Q3 <10.7h; least sedentary, Q4 <9.7h). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Individual QALYs were estimated over 2 years from the area under the curve of health-related utility scores derived from the Medical Outcomes Study 12-Item Short-Form Health Survey versus time. The relationship between baseline sedentary behavior and median 2-year QALYs was estimated using quantile regression adjusted for socioeconomic factors and body mass index. RESULTS: Lower QALYs over 2 years were more frequently found among the most sedentary (Q1, median 1.59), and QALYs increased as time spent in baseline sedentary behavior decreased (median QALYs for Q2, 1.64; Q3, 1.65; Q4, 1.65). The relationship of sedentary time and median QALY change was only significant for the most sedentary Q1 group, where an additional hour of sedentary behavior significantly reduced QALYs by -.072 (95% confidence interval, -.121 to -.020). CONCLUSIONS: Our findings suggest that individuals with the most extreme sedentary profiles may be vulnerable to additional losses of quality of life if they become more sedentary. Targeting these individuals to decrease sedentary behavior has the potential to be cost-effective.

Patients Less Likely to Lose Weight Following a Knee Replacement: Results From the Osteoarthritis Initiative.

BACKGROUND: Knee replacement typically results in reduced pain and improved function, but it is unclear if these improvements lead to weight loss. OBJECTIVE: The purpose of this study was to examine weight change patterns preoperatively and postoperatively among overweight/obese knee replacement patients. METHODS: The study evaluated 210 overweight/obese patients from the Osteoarthritis Initiative who underwent a knee replacement during an 8-year longitudinal study. Average annual weight changes during 1- to 2-year intervals prior to, including, and subsequent to knee replacement were categorized as loss (≥-2.5%), maintain (>-2.5% to <2.5%), and gain (≥2.5%). Weight changes across time intervals were compared using logistic regression with generalized estimating equations, adjusting for demographic, health, and knee factors. RESULTS: On average, patients lost -0.6 kg/y during the interval when the surgery was performed, but weight gain (0.9 kg/y) in the initial postoperative interval represented an overall net weight gain (0.3 kg/y) compared with presurgery. Continued weight gain (0.3 kg/y) was also seen among patients with additional follow-ups. Patients were significantly less likely to have a meaningful weight loss in the time interval immediately following the surgery compared with the interval in which the surgery took place (odds ratio, 0.37; 95% confidence interval, 0.18-0.79). CONCLUSIONS: Overweight and obese patients initially lost weight during the interval including knee replacement; however, they were less likely to lose more than 2.5% of their weight in the 1 to 2 years immediately after the surgery. Knee replacement patients may benefit from weight management interventions both preoperatively and postoperatively.

Rehabilitation Research at the National Institutes of Health: Moving the Field Forward (Executive Summary).

Approximately 53 million Americans live with a disability. For decades, the National Institutes of Health (NIH) has been conducting and supporting research to discover new ways to minimize disability and enhance the quality of life of people with disabilities. After the passage of the Americans With Disabilities Act, NIH established the National Center for Medical Rehabilitation Research, with the goal of developing and implementing a rehabilitation research agenda. Currently, 17 institutes and centers at NIH invest more than $500 million per year in rehabilitation research. Recently, the director of NIH, Francis Collins, appointed a Blue Ribbon Panel to evaluate the status of rehabilitation research across institutes and centers. As a follow-up to the work of that panel, NIH recently organized a conference, "Rehabilitation Research at NIH: Moving the Field Forward." This report is a summary of the discussions and proposals that will help guide rehabilitation research at NIH in the near future.

Do Inactive Older Adults Who Increase Physical Activity Experience Less Disability: Evidence From the Osteoarthritis Initiative.

BACKGROUND: Physical inactivity is a leading risk factor for developing disability. Although randomized clinical trials have demonstrated improving physical activity can reduce this risk in older adults with arthritis, these studies did not specifically evaluate inactive adults. OBJECTIVES: The aim of this study was to evaluate the relationship of changes in physical activity with disability changes among initially inactive adults with or at high risk of knee osteoarthritis from Osteoarthritis Initiative. METHODS: Inactive persons were identified at baseline based on the US Department of Health and Human Services classification (no [zero] 10-minute session of moderate-to-vigorous [MV] activity over 1 week) from objective accelerometer monitoring. Two years later, physical activity change status was classified as follows: (1) met Federal physical activity guidelines (≥150 MV minutes/week acquired in bouts ≥10 minutes), (2) insufficiently increased activity (some but <150 MV bout minutes/week), or (3) remained inactive. Disability at baseline and 2 years was assessed by Late Life Disability Instrument limitation and frequency scores. Multiple regression evaluated the relationship of physical activity change status with baseline-to-2-year changes in disability scores adjusting for socioeconomics, health factors, and baseline disability score. RESULTS: Increased physical activity showed a graded relationship with improved disability scores in Late Life Disability Instrument limitation (P < 0.001) and frequency scores (P = 0.027). While increasing MV activity to guideline levels showed the greatest reduction, even insufficiently increased physical activity was related to reduced disability. CONCLUSIONS: Findings support advice to increase MV physical activity to reduce disability among inactive adults with or at high risk of knee osteoarthritis, even when guidelines are not met.

Sedentary Behavior as a Risk Factor for Physical Frailty Independent of Moderate Activity: Results From the Osteoarthritis Initiative.

OBJECTIVES: This prospective longitudinal study investigated the association between baseline objectively measured sedentary time and 2-year onset of physical frailty. METHODS: We studied 1333 Osteoarthritis Initiative participants 55 to 83 years of age who were at risk for physical frailty, as assessed via low gait speed (< 0.6 m per second) or inability to perform a single chair stand. Baseline sedentary time was assessed through accelerometer monitoring. Hazard ratios (HRs) for physical frailty onset were estimated with discrete survival methods that controlled for moderate physical activity, sociodemographic characteristics, baseline gait and chair stand functioning, and health factors. RESULTS: The incidence of physical frailty in this high-risk group was 20.7 per 1000 person-years. Greater baseline sedentary time (adjusted HR = 1.36 per sedentary hour; 95% confidence interval [CI] = 1.02, 1.79) was significantly related to incident physical frailty after control for time spent in moderate-intensity activities and other covariates. CONCLUSIONS: Our prospective data demonstrated a strong relationship between daily sedentary time and development of physical frailty distinct from insufficient moderate activity. Interventions that promote reductions in sedentary behaviors in addition to increases in physical activity may help decrease physical frailty onset.

Accelerometer-monitored sedentary behavior and observed physical function loss.

OBJECTIVES: We examined whether objectively measured sedentary behavior is related to subsequent functional loss among community-dwelling adults with or at high risk for knee osteoarthritis. METHODS: We analyzed longitudinal data (2008-2012) from 1659 Osteoarthritis Initiative participants aged 49 to 83 years in 4 cities. Baseline sedentary time was assessed by accelerometer monitoring. Functional loss (gait speed and chair stand testing) was regressed on baseline sedentary time and covariates (baseline function; socioeconomics [age, gender, race/ethnicity, income, education], health factors [obesity, depression, comorbidities, knee symptoms, knee osteoarthritis severity, prior knee injury, other lower extremity pain, smoking], and moderate-to-vigorous activity). RESULTS: This cohort spent almost two thirds of their waking hours (average=9.8 h) in sedentary behaviors. Sedentary time was significantly positively associated with subsequent functional loss in both gait speed (-1.66 ft/min decrease per 10% increment sedentary percentage waking hours) and chair stand rate (-0.75 repetitions/min decrease), controlling for covariates. CONCLUSIONS: Being less sedentary was related to less future decline in function, independent of time spent in moderate-to-vigorous activity. Both limiting sedentary activities and promoting physical activity in adults with knee osteoarthritis may be important in maintaining function.

Development and use of a knowledge translation tool: the rehabilitation measures database.

Clinical translation of research evidence is a challenge for rehabilitation clinicians. Publicly accessible and free, online educational resources that summarize research evidence can support implementation of research evidence into practice. Several online resources have been developed recently to overcome common knowledge translation barriers. The Rehabilitation Measures Database (RMD) is a free, web-based searchable database of standardized instruments that was designed to support knowledge translation. It helps clinicians select valid and sensitive instruments for screening patients, monitoring progress, and assessing rehabilitation outcomes. The RMD was developed using feedback from focus groups and beta-test participants. Since its launch in 2011, RMD use has grown to an average of 1851 hits per day from 168 countries. As of September 2013, 202 instrument summaries are viewable in the RMD. Most summaries are linked to copies of the instrument or to purchase instructions. A challenge in updating and expanding the RMD is securing the resources to ensure its future. Collaborative relationships with professional associations and graduate programs in the health sciences are critical in sustaining this resource.

Development of additional tasks for the executive function performance test.

OBJECTIVE. The Executive Function Performance Test (EFPT) is a reliable and valid performance-based assessment of executive function for people with stroke. The objective of this study was to enhance the clinical utility of the EFPT by developing and testing additional tasks for the EFPT in the Alternate EFPT (aEFPT). METHOD. We performed a cross-sectional study with poststroke participants (n = 25) and healthy control participants (n = 25). All participants completed a neuropsychological assessment battery and both the EFPT and the aEFPT. RESULTS. No statistically significant differences were found between the EFPT and the aEFPT when examining total scores, construct scores, and two overall task scores. Correlations between the aEFPT and the neuropsychological measures were adequate to strong (r2s = .59-.83). CONCLUSION. The aEFPT tasks are comparable to the original EFPT tasks, providing occupational therapy practitioners with additional tasks that can be used clinically to identify performance-based executive function deficits in people with stroke.

Mind-Body Intervention for Dysfunctional Breathing in Chronic Obstructive Pulmonary Disease: Feasibility Study and Lessons Learned.

Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).