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 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.

Validity of the Activities-specific Balance Confidence Scale in individuals with chronic obstructive pulmonary disease.

BACKGROUND: Limited research assessed the validity of the Activities-specific Balance Confidence, ABC) Scale in individuals with chronic obstructive pulmonary disease, COPD) at risk of falls. We report on the scale's construct and criterion validity. METHODS: Construct validity was established by assessing known groups, convergent, and divergent validity. A receiver operating characteristic, (ROC) curve and logistic regression examined the criterion validity of the scale. RESULTS: In 223 individuals with COPD, the ABC Scale significantly, (p < 0.001) discriminated between groups, with lower scores for females [Mean difference (MD) = 10%], rollator use [MD = 13%], and fallers [MD = 12%], and had a strong association [r = 0.58, p < 0.001] with Berg Balance Scale. The scale distinguished fallers from non-fallers with a cutoff value of 58% [Area Under the Curve = 0.64, 95% CI = 0.57-0.72, p < 0.001] and significantly identified fall status [B, SE = -0.03, 0.01, p < 0.001] with an odds ratio of 0.97 [95%CI = 0.96-0.99]. The sensitivity, specificity, and test accuracy were: 61, 58, and 60%, respectively. CONCLUSION: The ABC Scale showed evidence for known groups, convergent, and divergent validity and can assist in identifying fall status in individuals with COPD.

Age and Sex Differences in Balance Outcomes among Individuals with Chronic Obstructive Pulmonary Disease (COPD) at Risk of Falls.

No previous research has examined age and sex differences in balance outcomes in individuals with chronic obstructive pulmonary disease (COPD) at risk of falls. A secondary analysis of baseline data from an ongoing trial of fall prevention in COPD was conducted. Age and sex differences were analyzed for the Berg Balance scale (BBS), Balance Evaluation System Test (BEST test) and Activities-specific Balance Confidence Scale (ABC). Overall, 223 individuals with COPD were included. Females had higher balance impairments than males [BBS: mean (SD) = 47 (8) vs. 49 (6) points; BEST test: 73 (16) vs. 80 (16) points], and a lower confidence to perform functional activities [ABC = 66 (21) vs. 77 (19)]. Compared to a younger age (50-65 years) group, age >65 years was moderately associated with poor balance control [BBS (r = - 0.37), BEST test (r = - 0.33)] and weakly with the ABC scale (r = - 0.13). After controlling for the effect of balance risk factors, age, baseline dyspnea index (BDI), and the 6-min walk test (6-MWT) explained 38% of the variability in the BBS; age, sex, BDI, and 6-MWT explained 40% of the variability in the BEST test; And BDI and the 6-MWT explained 44% of the variability in the ABC scale. This study highlights age and sex differences in balance outcomes among individuals with COPD at risk of falls. Recognition of these differences has implications for pulmonary rehabilitation and fall prevention in COPD, particularly among females and older adults.

Implementation of an Acute Care COPD Exacerbation Patient Mobilization Tool. A Mixed-Methods Study.

Background: Improving the mobility of hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a priority of care. AECOPD-Mob is a clinical decision-making tool for physical therapists, especially those who are newly graduated or are new to caring for patients with AECOPDs in acute care settings. Although this tool has been available for several years, dissemination via publication is not sufficient to implement it in clinical practice.Objective: The primary objective of this study was to develop, implement, and evaluate different formats of AECOPD-Mob in an acute care setting.Methods: We used a mixed-methods, convergent parallel design. In addition to the paper format of AECOPD-Mob, we developed a smartphone app, a web-based learner module, and an in-service learning session. Newly graduated physical therapists (PTs) or PTs new to the practice area were recruited from urban acute care hospitals. Participants used the different formats for 3 weeks and then completed the Post-Study System Usability Questionnaire. User data were retrieved for the learning module. Participants participated in focus groups at 3 weeks and 3 months.Results: Eighteen (72% of eligible PTs, 100% female, 94% graduated within 3 yr) PTs participated. Post-Study System Usability Questionnaire scores for the learning module and smartphone indicated that participants were satisfied with these formats (median score 2.0 on 1-7 Likert Scale for both technology formats, lower scores indicating greater satisfaction). However, the participants reported in the focus group that the paper format was preferred over other formats. Concerns with the smartphone app included infection control and the perception of lack of professionalism when using a smartphone during clinical practice. The learning module and in-service were considered helpful as an introduction but not as an ongoing support. The paper format was seen as the most efficient way to access the necessary information and to facilitate communication between other members of the care team about the importance of mobility for hospitalized patients with AECOPDs.Conclusion: Newly graduated PTs strongly preferred the paper format of the AECOPD-Mob tool in the acute care setting. Future research will focus on knowledge translation strategies for other health disciplines.

Appraising the Validity of Tools to Measure Multijoint Leg Power: A Systematic Review.

OBJECTIVE: To critically appraise the validity of tools used to measure maximum multijoint leg extension power in older individuals. DATA SOURCES: A systematic literature search was performed in 5 electronic databases: PUBMED, EMBASE, CINAHL, SPORTDISCUS, and PEDRO from inception and without limits on the year of publication. Secondary searches included hand searching of the reference lists. STUDY SELECTION: One author performed all the searches and identified relevant studies. A second author repeated the search to ensure that no articles were overlooked. Only studies that measured multijoint leg extension power were included. Those that used jump tests on force plates were excluded. Forty-five studies were identified that used 3 different tools. Three of these studies addressed the validity of the instruments and were included in the analyses performed by all the authors. Decisions made by consensus. DATA EXTRACTION: Critical analyses were based on the reference instrument used, reproducibility of methods, appropriateness of the statistical analysis, commercial availability of the tool, and potential conflicts of interests, including financial support. Decisions regarding the data analyses were made by consensus among all authors. DATA SYNTHESIS: We identified 3 tools all of which simulated recumbent bicycles. Two of the 3 identified tools are not commercially available. Each of the 3 included studies used correlational analysis to determine the validity of their tool, which does not describe the accuracy of the measured power in comparison to the reference standard. CONCLUSION: We were unable to identify a validated tool that measured maximum multijoint leg extension power that was appropriate for older individuals. Future research should address this important gap.

Reliability of quadriceps muscle power and explosive force, and relationship to physical function in people with chronic obstructive pulmonary disease: an observational prospective multicenter study.

Background: Muscle power declines with age and is a stronger determinant of physical function than strength. Muscle power using computerized dynamometry has not been investigated in COPD.Objectives: To determine: 1) test-retest reliability of quadriceps power using a standardized protocol with computerized dynamometry; and 2) associations between quadriceps strength and power, and functional capacity.Design/Setting: Prospective observational study in four Canadian research labs.Participants: People with mild to very severe COPD.Methods: Tests were conducted on two days. Quadriceps muscle maximal strength was evaluated during a static maneuver using maximal voluntary isometric contractions (MVIC). Rate of torque development (RTD) during MVIC was used to assess explosive force. Muscle power was measured using a dynamic, isotonic protocol from which peak and average power and peak velocity were derived. Functional capacity was assessed with the Short Physical Performance Battery (SPPB). Reliability was assessed using intraclass correlation coefficients (ICC), standard error of measurements (SEM), and Bland Altman plots. Spearman and Pearson correlation coefficients were used for associations.Results: 65 patients (age 69 ± 8 years; FEV1 48 ± 21% of predicted) were included. ICC was 0.77 for RTD and 0.87-0.98 for isotonic power measures (95%CI 0.63-0.99, p < .001); SEM < 10% for average/peak power and peak velocity, and > 30% for RTD. SPPB had moderate correlation with average power, but not with MVIC or RTD.Conclusion: The standardized isotonic protocol with computerized dynamometry was reliable in assessing quadriceps power in COPD. Our data highlights that average power correlates best with functional capacity, indicating higher relevance than static measures when investigating determinants of function.

Fixed Handheld Dynamometry Provides Reliable and Valid Values for Quadriceps Isometric Strength in People With Chronic Obstructive Pulmonary Disease: A Multicenter Study.

BACKGROUND: Quadriceps weakness is associated with poor clinical outcomes in chronic obstructive pulmonary disease (COPD). However, quadriceps isometric strength assessment has not been routinely adopted in clinical practice because of the lack of homogeneity in the devices and protocols and the lack of reliability studies. OBJECTIVE: The objectives of this study were to determine the test-retest reliability and the criterion validity of a commercially available handheld dynamometer for evaluating the quadriceps isometric maximal voluntary contraction (iMVCquad) using a standardized protocol and to investigate the relationship between iMVCquad and functional capacity in people with COPD. DESIGN: This was a prospective, observational, multicenter trial. METHODS: Participants with mild to severe COPD from 4 Canadian sites were tested on 2 separate days. Five iMVCquad measurements were obtained following a standardized procedure with a fixed handheld dynamometer (iMVCquad-HHD), and then 5 iMVCquad measurements were obtained with a computerized dynamometer (iMVCquad-CD; the gold standard). Functional capacity was assessed with the Short Physical Performance Battery. Intraclass correlation coefficients, standard errors of measurement, Bland-Altman plots, and Spearman correlation coefficients were used for analyses. RESULTS: Sixty-five participants (mean age = 69 years [SD = 8]; forced expiratory volume in 1 second = 48% of predicted value [SD = 21]) completed the study. The mean iMVCquad-HHD values on visits 1 and 2 were 102.7 (SD = 51.6) and 105.6 (SD = 58.8) N·m, respectively; the standard error of measurement was 11.4 N·m. The between-visits intraclass correlation coefficient for iMVCquad-HHD was 0.95 (95% confidence interval  = 0.92-0.97), with a mean bias of 2.0 (Bland-Altman plot). There was a strong correlation between iMVCquad-HHD and iMVCquad-CD (Spearman correlation coefficient = 0.86). There was no correlation between iMVCquad-HHD and Short Physical Performance Battery total score. LIMITATIONS: Participants had stable COPD with few comorbidities and were more physically active than the general population of people with COPD; results might not be applicable to patients with acute exacerbations of the disease or more comorbidities. Assessment order between handheld and computerized dynamometers has not been randomized, but analyses did not highlight any systematic bias or learning effect. CONCLUSIONS: Quadriceps strength assessment can be implemented in a reliable and valid way in people with COPD using a fixed handheld dynamometer and standardized procedure. This protocol should be established in clinical practice to facilitate the assessment of muscle strength in people with COPD.

Intensity of acute aerobic exercise but not aerobic fitness impacts on corticospinal excitability.

Aerobic exercise (AE) modulates cortical excitability. It can alter both corticospinal excitability and intra-cortical networks, which has implications for its use as a tool to facilitate processes such as motor learning, where increased levels of excitability are conducive to the induction of neural plasticity. Little is known about how different intensities of AE modulate cortical excitability or how individual-level characteristics impact on it. Therefore, we investigated whether AE intensities, lower than those previously employed, would be effective in increasing cortical excitability. We also examined whether the aerobic fitness of individual participants was related to the magnitude of change in AE-induced cortical excitability. In both experiments we employed transcranial magnetic stimulation to probe corticospinal excitability before and after AE. We show that 20 min of continuous moderate- (40% and 50% of heart rate reserve, HRR), but not low- (30% HRR) intensity AE was effective at increasing corticospinal excitability. We also found that while we observed increased corticospinal excitability following 20 min of continuous moderate-intensity (50% HRR) AE, aerobic fitness was not related to the magnitude of change. Our results suggest that there is a lower bound intensity of AE that is effective at driving changes in cortical excitability, and that while individual-level characteristics are important predictors of response to AE, aerobic fitness is not. Overall these findings have implication for the way that AE is used to facilitate processes such as motor learning, where increased levels of cortical excitability and plasticity are favourable.

Improvement in upright and supine lung mechanics with bariatric surgery affects bronchodilator responsiveness and sleep quality.

Obesity and weight loss have complex effects on respiratory physiology, but these have been insufficiently studied, particularly at early time points following weight loss surgery and in the supine position. We evaluated 15 female participants with severe obesity before and 5 wk and 6 mo after bariatric surgery using the Pittsburgh Sleep Quality Index (PSQI), spirometry, plethysmography, and oscillometry to measure respiratory system mechanics. Oscillometry and spirometry were conducted in the upright and supine position and before and after bronchodilation with 200 µg of salbutamol. At 5 wk postsurgery, weight loss was 11.9 kg (SD 2.7) with no effect on spirometric outcomes and a slight effect on oscillometric outcomes. However, at 6 mo weight loss was 21.4 kg (SD 7.1) with a 14.1% (SD 6.1) and 17.8 (5.4)% reduction in upright and supine respiratory system resistance (Rrs),6, respectively. Respiratory system elastance also decreased by 25.7% (SD 9.4) and 20.2 (SD 7.2)% in the upright and supine positions. No changes were observed in spirometry, but sleep quality improved from PSQI of 8.4 (SD 3.5) to 4.1 (SD 2.9). Bronchodilator responsiveness was low at baseline but increased significantly after surgery, and this response was comparable to the improvement in Rrs produced by weight loss. Modeling the impedance spectra with a two-compartment model demonstrated that improvements in lung mechanics with weight loss begin in the upper or central compartment of the lungs and progress to include the peripheral compartment. Respiratory mechanics are impaired in individuals with severe obesity and is associated with poor sleep quality, but these improved substantially with weight loss. Our data provide new evidence that individuals with severe obesity may have poor sleep quality because of abnormal respiratory mechanics that weight loss improves.NEW & NOTEWORTHY This is the first study to quantify the degree of weight loss-induced improvements in respiratory system mechanics in both upright and supine positions, and its association with bronchodilator responsiveness and sleep quality at multiple time points. Weight loss induced large improvements in upright and supine respiratory system mechanics with corresponding improvements in bronchodilator responsiveness and sleep quality. Using mathematical modeling, we demonstrate that these improvements begin in the central airways and progress to include the lung periphery.

Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION: Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD. METHODS: A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July-November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80% endorsement for Likert values 5-7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting. RESULTS: Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient's and caregiver's comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme. CONCLUSION: We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle.

The Community Balance and Mobility Scale: A VALID ASSESSMENT TOOL OF BALANCE IN CARDIAC REHABILITATION PATIENTS.

PURPOSE: Many patients participating in cardiac rehabilitation (CR) programs have decreased balance. This is a concern, as it may affect their ability to optimally perform physical exercise in CR and thus decrease CR efficacy. Despite this concern, balance is typically not assessed as part of CR intake. This may be attributable to the fact that a suitable balance assessment tool has not been identified for higher-functioning CR patients. A potential solution to this issue is using the Community Balance and Mobility Scale (CBMS), which has been used to assess balance in higher-functioning clinical populations; however, its use in a CR population has never been investigated. Therefore, the purpose of this study was to determine the reliability and validity of the CBMS for assessing balance in CR patients. METHODS: Fifty-three participants were recruited from local CR programs to perform the CBMS. Dynamic posturography was also measured in a subset of participants (n = 31) using the Limits of Stability (LOS) test. RESULTS: Analysis of CBMS scores revealed that the mean CBMS score was 61.9 ± 16.2 (out of 96) and that no floor or ceiling effects were observed for any participants. CBMS scores were significantly correlated with the LOS results (0.41-0.53). Interrater reliability between novice and expert testers was strong (r = 0.95), with all differences falling within the 95% limits of agreement. CONCLUSION: Overall, these results suggest that the CBMS is a valid tool to measure balance in CR patients and can be reliably administered by health care professionals with minimal training.

Pulmonary Rehabilitation With Balance Training for Fall Reduction in Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Controlled Trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. A growing body of evidence shows that individuals with COPD have important deficits in balance control that may be associated with an increased risk of falls. Pulmonary rehabilitation (PR) is a key therapeutic intervention for individuals with COPD; however, current international guidelines do not include balance training and fall prevention strategies. OBJECTIVE: The primary aim of this trial is to determine the effects of PR with balance training compared to PR with no balance training on the 12-month rate of falls in individuals with COPD. Secondary aims are to determine the effects of the intervention on balance, balance confidence, and functional lower body strength, and to estimate the cost-effectiveness of the program. METHODS: A total of 400 individuals from nine PR centers across Canada, Europe, and Australia will be recruited to participate in a randomized controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last 2 years, or recent near fall will be randomly assigned to an intervention or control group. The intervention group will undergo tailored balance training in addition to PR and will receive a personalized home-based balance program. The control group will receive usual PR and a home program that does not include balance training. All participants will receive monthly phone calls to provide support and collect health care utilization and loss of productivity data. Both groups will receive home visits at 3, 6, and 9 months to ensure proper technique and progression of home exercise programs. The primary outcome will be incidence of falls at 12-month follow-up. Falls will be measured using a standardized definition and recorded using monthly self-report fall diary calendars. Participants will be asked to record falls and time spent performing their home exercise program on the fall diary calendars. Completed calendars will be returned to the research centers in prepaid envelopes each month. Secondary measures collected by a blinded assessor at baseline (pre-PR), post-PR, and 12-month follow-up will include clinical measures of balance, balance confidence, functional lower body strength, and health status. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained. RESULTS: Recruitment for the study began in January 2017 and is anticipated to be complete by December 2019. Results are expected to be available in 2020. CONCLUSIONS: Findings from this study will improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. If effective, the intervention represents an opportunity to inform international guidelines and health policy for PR in individuals with COPD who are at risk of falling. TRIAL REGISTRATION: ClinicalTrials.gov NCT02995681; https://clinicaltrials.gov/ct2/show/NCT02995681 (Archived by WebCite at http://www.webcitation.org/6ukhxgAsg).

The Relationship Between Weather and Objectively Measured Physical Activity Among Individuals With COPD.

PURPOSE: Although daily variation in weather impacts physical activity (PA) levels among relatively healthy individuals, it is largely unknown whether this relationship occurs for those living with chronic obstructive pulmonary disease (COPD). The purpose of this study was to examine how daily variation in temperature, rain, and snow is related to objectively measured PA among patients with COPD, and whether demographic or clinical characteristics moderate these relationships. METHODS: Patients with COPD completed a questionnaire and wore a pedometer for 7 days at baseline, end of pulmonary rehabilitation (PR), and 3 and 9 months after completing PR (28 days in total). RESULTS: Hierarchal linear modeling showed that daily mean temperature and total daily rainfall, but not snowfall, independently predicted steps/day, controlling for demographic and clinical covariates in 189 patients in PR. Specifically, an increase of 10°C translates into 316 more steps (6.6% of mean steps/day) whereas a rainfall of 10 mm translates to 175 less steps (3.6% of mean steps/day). Furthermore, those with higher income had more steps/day on warmer days. CONCLUSIONS: These results add to converging evidence that weather plays an important role in determining PA among individuals with COPD.

Creation of a Tool for Assessing Knowledge in Evidence-Based Decision-Making in Practicing Health Care Providers.

INTRODUCTION: Evidence-based decision-making (EBDM) is the process health care providers (HCPs) use to identify and appraise potential evidence. It supports the integration of best research evidence with clinical expertise and patient values into the decision-making process for patient care. Competence in this process is essential to delivery of optimal care. There is no objective tool that assesses EBDM across HCP groups. This research aimed to develop a content valid tool to assess knowledge of the principles of evidence-based medicine and the EBDM process, for use with all HCPs. METHODS: A Delphi process was used in the creation of the tool. Pilot testing established its content validity with the added benefit of evaluating HCPs' knowledge of EBDM. Descriptive statistics and multivariate mixed models were used to evaluate individual survey responses in total, as well as within each EBDM component. RESULTS: The tool consisted of 26 multiple-choice questions. A total of 12,884 HCPs in Nova Scotia were invited to participate in the web-based validation study, yielding 818 (6.3%) participants, 471 of whom completed all questions. The mean overall score was 68%. Knowledge in one component, integration of evidence with clinical expertise and patient preferences, was identified as needing development across all HCPs surveyed. DISCUSSION: A content valid tool for assessing HCP EBDM knowledge was created and can be used to support the development of continuing education programs to enhance EBDM competency.

Objectively Measured Steps/Day in Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Although individual studies have reported on the number of steps/day taken by individuals with chronic obstructive pulmonary disease (COPD), this evidence has not been systematically reviewed or synthesized. METHODS: MEDLINE and PsycINFO were searched for studies reporting objectively-measured steps/day and percent predicted forced expiratory volume in 1 second (FEV1%) in patients with COPD. Meta-analyses were used to estimate steps/day across studies, while metaregression was used to estimate between-study variance based on clinical and demographic factors (year and location of study, activity monitor brand, number of days wearing the monitor, whether participants were about to enter pulmonary rehabilitation, 6-minute walk distance (6MWD), FEV1%, age, and sex). RESULTS: 38 studies including 2621 participants met inclusion criteria. The pooled mean estimate was 4579 steps/day (95% CI:4310 to 5208) for individuals with COPD. Only 6MWD, FEV1% and whether patients were about to undergo pulmonary rehabilitation explained a significant portion of the variance (P < 0.1) in univariate meta-regression. In a multivariate model including the above risk factors, only FEV1% was associated with steps/day after adjustment for other covariates. CONCLUSIONS: These results indicate that patients with COPD achieve extremely low levels of physical activity as assessed by steps/day, and that severity of airflow obstruction is associated with activity level.

Early detection of changes in lung mechanics with oscillometry following bariatric surgery in severe obesity.

Obesity is associated with respiratory symptoms that are reported to improve with weight loss, but this is poorly reflected in spirometry, and few studies have measured respiratory mechanics with oscillometry. We investigated whether early changes in lung mechanics following weight loss are detectable with oscillometry. Furthermore, we investigated whether the changes in lung mechanics measured in the supine position following weight loss are associated with changes in sleep quality. Nineteen severely obese female subjects (mean body mass index, 47.2 ± 6.6 kg/m(2)) were evaluated using spirometry, oscillometry, plethysmography, and the Pittsburgh Sleep Quality Index before and 5 weeks after bariatric surgery. These tests were conducted in both the upright and the supine position, and pre- and postbronchodilation with 200 µg of salbutamol. Five weeks after surgery, weight loss of 11.5 ± 2.5 kg was not associated with changes in spirometry and plethysmography, with the exception of functional residual capacity. There were also no changes in upright respiratory system resistance (Rrs) or reactance following weight loss. Importantly, however, in the supine position, weight loss caused a substantial reduction in Rrs. In addition, sleep quality improved significantly and was highly correlated with the reduction in supine Rrs. Prior to weight loss, subjects did not respond to the bronchodilator when assessed in the upright position with either spirometry or oscillometry; however, with modest weight loss, bronchodilator responsiveness returned to the normal range. Improvements in lung mechanics occur very early after weight loss, mostly in the supine position, resulting in improved sleep quality. These improvements are detectable with oscillometry but not with spirometry.

A Qualitative Exploration of Exercise Among Pulmonary Rehabilitation Participants: Insight From Multiple Sources of Social Influence.

BACKGROUND: Exercise training within the pulmonary rehabilitation (PR) context is considered the most effective strategy to reduce COPD symptoms. However, participation in PR and continued exercise training following program completion are low. Previous research examined factors related to attendance and adherence, but the knowledge base to date has been limited to quantitative findings that focus solely on participants diagnosed with COPD. In addition to quantitative research, exploring multiple perspectives (eg, PR participants, significant others, staff, and stakeholders) using qualitative research methods opens a window of additional understanding. The goal of this study was to obtain multiple perspectives on PR to gain insight into factors that affect exercise participation among individuals diagnosed with COPD. METHODS: A total of 26 participants were interviewed via telephone, including 8 individuals diagnosed with COPD (4 men and 4 women, mean age of 67 [range of 58-77] y), 4 family members, 11 PR staff, and 3 community stakeholders. RESULTS: Analysis revealed 3 themes: task self-efficacy for exercise, provision of support and encouragement, and perceptions of gender differences. Despite initial concerns, individuals diagnosed with COPD reported becoming more confident during PR and emphasized the importance of being supported by staff. PR staff perceived that men tended to approach exercise in a more eager and aggressive manner compared with women, who were more cautious and hesitant. CONCLUSIONS: In addition to enhancing task self-efficacy, findings suggest that exercise participation and adherence within the PR environment may be improved by adopting a gender-tailored approach.

Pulmonary rehabilitation in Canada: A report from the Canadian Thoracic Society COPD Clinical Assembly.

BACKGROUND: Pulmonary rehabilitation (PR) is a recommended intervention in the management of individuals with chronic lung disease. It is important to study the characteristics and capacity of programs in Canada to confirm best practices and identify future areas of program improvement and research. OBJECTIVE: To identify all Canadian PR programs, regardless of setting, and to comprehensively describe all aspects of PR program delivery. The present article reports the results of the survey related to type of program, capacity and program characteristics. METHODS: All hospitals in Canada were contacted to identify PR programs. A representative from each program completed a 175-item online survey encompassing 16 domains, 10 of which are reported in the present article. RESULTS: A total of 155 facilities in Canada offered PR, of which 129 returned surveys (83% response rate). PR programs were located in all provinces, but none in the three territories. Most (60%) programs were located in hospital settings, 24% were in public health units and 8% in recreation centres. The national capacity of programs was estimated to be 10,280 patients per year, resulting in 0.4% of all Canadians with chronic obstructive pulmonary disease (COPD) and 0.8% of Canadians with moderate to severe COPD having access to PR. COPD, interstitial lung disease, and asthma were the most common diagnoses of patients. The majority of programs had at least four health care professionals involved; 9% had only one health care professional involved. CONCLUSION: The present comprehensive survey of PR in Canada reports an increase in the number of programs and the total number of patients enrolled since the previous survey in 2005. However, PR capacity has not kept pace with demand, with only 0.4% of Canadians with COPD having access.

Distinct Trajectories of Physical Activity Among Patients with COPD During and After Pulmonary Rehabilitation.

Little is known about longitudinal trends in objectively measured physical activity (PA) during and after pulmonary rehabilitation (PR) for individuals with Chronic Obstructive Pulmonary Disease (COPD). The purpose of this study was to examine the PA trajectories of patients with COPD during and after PR and whether demographic, clinical, or program characteristics differed across these trajectories. The study was approved by Research Ethics Boards at all participating institutions, and written informed consent was obtained from each participant prior to study inclusion. COPD patients (N = 190) completed a questionnaire and wore a pedometer for 7 days at baseline, end of PR, and 3 and 9 months after completing PR. Latent class growth analyses showed that two distinct PA trajectories emerged. Active Maintainers averaged 9177 steps/day at baseline, and maintained this level throughout the assessment and post rehabilitation period. In contrast, Inactive Maintainers averaged 3133 steps/day at baseline, which also remained stable during and after PR. Follow-up analyses showed the Inactive Maintainers were more likely to be retired from work and have lower baseline scores for their stress tests and 6-minute walk tests compared to Active Maintainers (all p < 0.05). These results suggest that two distinct steps/day trajectories exist for COPD patients during and after completing PR that are partially explained by specific demographic and clinical characteristics.