Discrepancy between functional exercise capacity and daily physical activity: a cross-sectional study in patients with mild to moderate COPD.

BACKGROUND: In patients with moderate to severe chronic obstructive pulmonary disease (COPD) the six-minute walk distance reflects the functional exercise level for daily physical activity. It is unknown if this also applies to patients with mild to moderate COPD in primary care. AIMS: To assess the relationship between functional exercise capacity and physical activity in patients with mild to moderate COPD. METHODS: A cross-sectional study was performed in 51 patients with mild to moderate COPD in primary care. Functional exercise capacity was assessed by the six-minute walk test and physical activity was measured with an accelerometer-based activity monitor. RESULTS: Functional exercise capacity was close to normal values. However, the daily physical activity of the patients could be classified as 'sedentary' and 'low active'. No significant correlations were observed between six-minute walk distance (% predicted) and any of the physical activity variables (steps per day, movement intensity during walking, total active time, total walking time, physical activity level, and time spent in moderate physical activity). CONCLUSIONS: A discrepancy was found between functional exercise capacity and daily physical activity in patients with mild to moderate COPD recruited and assessed in primary care. We conclude that these variables represent two different concepts. Our results reinforce the importance of measuring daily physical activity in order to fine-tune treatment (i.e. focusing on enhancement of exercise capacity or behavioural change, or both).

The Effect of a Comprehensive, Interdisciplinary Medication Review on Quality of Life and Medication Use in Community Dwelling Older People with Polypharmacy.

Background: We conducted a comprehensive medication review at the patients' home, using data from electronic patient records, and with input from relevant specialists, general practitioners and pharmacists formulated and implemented recommendations to optimize medication use in patients aged 60+ years with polypharmacy. We evaluated the effect of this medication review on quality of life (QoL) and medication use. Methods: Cluster randomized controlled trial (stepped wedge), randomly assigning general practices to one of three consecutive steps. Patients received usual care until the intervention was implemented. Primary outcome was QoL (SF-36 and EQ-5D); secondary outcomes were medication changes, medication adherence and (instrumental) activities of daily living (ADL, iADL) which were measured at baseline, and around 6- and 12-months post intervention. Results: Twenty-four general practices included 360 women and 410 men with an average age of 75 years (SD 7.5). A positive effect on SF-36 mental health (estimated mean was stable in the intervention, but decreased in the control condition with -6.1, p = 0.009,) was found with a reduced number of medications at follow-up compared to the control condition. No significant effects were found on other QoL subscales, ADL, iADL or medication adherence. Conclusion: The medication review prevented decrease of mental health (SF36), with no significant effects on other outcome measures, apart from a reduction in the number of prescribed medications.

Effectiveness of an exercise training programme COPD in primary care: A randomized controlled trial.

BACKGROUND: Pulmonary rehabilitation is very effective in improving exercise capacity, dyspnea and quality of life in the small group of patients with moderate to severe COPD. Given that little is known about exercise training in the large group of patients with mild to moderate COPD, we assessed the effectiveness of an exercise training programme in primary care. METHODS: In this RCT, 90 patients with mild to moderate COPD (FEV1 74.2 ± 13.5%pred) participated in a 4-month exercise training programme or control treatment. Primary outcome was improvement in functional exercise capacity, assessed by the 6-min walking distance (6MWD). Secondary outcomes were breathlessness (MRC dyspnoea score), disease-specific quality of life (CCQ, CRQ), muscle strength and objective daily physical activity. There was a follow-up measurement at 6 months. RESULTS: At 4 months, we found a statistically and clinically relevant between-group difference in 6MWD of +26.6 m (95% CI: 4,3-49.0, p = 0.020). Shoulder strength significantly improved with a between-group difference of 23.9 Nm (p = 0.0350). At 6 months, there was a significant improvement in handgrip force and CRQ sub score mastery of respectively 1.9 KgF (p = 0.028) and 0.5 (p = 0.035). There were no significant between-group differences in breathlessness, quality of life, knee strength and daily physical activity. CONCLUSION: The results indicate that exercise training in primary care is particularly effective in improving physical fitness (exercise capacity and strength), but not in breathlessness, health-related quality of life and daily physical activity. A broader assessment for COPD patients in primary care might be a necessary condition to offer the most effective intervention.

The association between arterial stiffness and the angiotensin II type 1 receptor (A1166C) polymorphism is influenced by the use of cardiovascular medication.

OBJECTIVE: To examine in a population with a high prevalence of hypertension, the association between six cardiovascular polymorphisms, arterial stiffness and medication use. METHODS: In this cross-sectional study (Hypertension: Interaction and Prevalence of POlymorphisms related to Cardiovascular Risk and the Association to Treatment Efficacy Study project), arterial stiffness was assessed by measuring pulse wave velocity (PWV) in 575 patients in one primary care practice. Patients were genotyped for the angiotensin II type 1 receptor [AGTR1 (A1166C)], angiotensinogen (M235T), angiotensin-converting enzyme (4656rpt), endothelial nitric oxide synthase (E298D), G-protein beta3 (C825T), and alpha-adducin (G460W) polymorphisms. Linear regression analyses were performed to assess the association between polymorphisms and PWV. RESULTS: Thirty percent of the patients (273 men, 302 women) had a carotid-femoral pulse wave velocity above 12 m/s and more than 60% of the patients had a carotid-femoral/carotid-radial PWV (CF/CR ratio) above 1. The CF/CR ratio was significantly associated with age, sex, dislipidemia, cardiovascular medication use and pulse pressure. After correction for these covariates, multivariate linear regression analyses showed that the C allele of AGTR1 was associated with a lower CF/CR ratio. This association was significantly influenced by cardiovascular medication use (P = 0.011), and showed a dose-allele effect, the CF/CR ratio decreasing with the number of C alleles (P = 0.04). CONCLUSION: In a primary care population, this study showed an independent protective dose-allele effect for the presence of C alleles of the AGTR1 polymorphism on PWV. This association, which was influenced by the use of cardiovascular medication, needs further investigations to identify the underlying mechanisms.

Pain-related fear and daily functioning in patients with osteoarthritis.

There is growing evidence supporting the relationship between pain-related fear and functional disability in chronic musculoskeletal pain conditions. In osteoarthritis (OA) patients the role of pain-related fear and avoidance has received little research attention so far. The present study investigates the degree to which pain-related fear, measured with the Tampa Scale for Kinesiophobia (TSK), influences daily functioning in OA patients. The purpose of the present paper was twofold: (1) to investigate the factor structure of the TSK in a sample of OA patients by means of confirmatory factor analysis; and (2) to investigate the role of pain-related fear in OA compared to other factors, such as radiological findings and level of pain intensity. The results show that TSK consists of two factors, called 'activity avoidance' and 'somatic focus', which is in line with other studies in low back pain and fibromyalgia. Furthermore, pain-related fear occurred to a considerable extent in this sample of osteoarthritis patients and was negatively associated with daily functioning. Level of pain and level of pain-related fear were significantly associated with functional limitations. Radiological findings were not significant predictors and when compared to pain-related fear they were not significant. These findings underscore the importance of pain-related fear in daily functioning of OA patients. Therefore, treatment strategies aiming at reduction of pain-related fear in OA patients need to be developed and investigated.

The influence of six cardiovascular polymorphisms on a first event of ischemic heart disease is modified by sex and age.

OBJECTIVE: To examine the contribution of six cardiovascular polymorphisms to the occurrence of a first event of ischemic heart disease (IHD) in a primary care population with a high prevalence of hypertension. Furthermore, we specified the data for sex and age. METHODS: In this cross sectional case-control study, patients with a first event of IHD (157) and event-free controls (571) were studied. Both the groups were genotyped for the angiotensin II type 1 receptor (A1166C), angiotensinogen (M235 T), angiotensin converting enzyme (4656rpt), endothelial nitric oxide synthase (E298D), G-protein beta3 subunit (C825 T), and alpha-adducin (G460W) polymorphisms. Univariate and multivariate odds ratios (ORs) were calculated to assess the association between a first ischemic event and these polymorphisms. Sliding mean analyses were performed to show age-specific associations. RESULTS: Multivariate ORs indicated a protective association for the carrier status of the T-allele of AGT, overall [OR = 0.69 (0.34-0.90)] and for males [OR = 0.58 (0.27-0.89)]. Sliding mean analyses showed a continuous protective association with IHD of the T-allele of AGT with increasing age in males, whereas in females an increased risk for IHD was observed with a maximum OR of 1.6 at the age of 56 years. CONCLUSION: In this population the T-allele of the AGT polymorphism is protective for a first event of IHD in males.

Sex-specific effect of the alpha-adducin (G460W) and AGTR1 (A1166C) polymorphism on carotid intima-media thickness.

OBJECTIVE: In a primary care population covering a broad spectrum of cardiovascular risk (HIPPOCRATES project) the relationship between carotid intima-media thickness (CIMT) and six cardiovascular polymorphisms were analyzed in a cross-sectional study. METHODS: CIMT was assessed in 618 participants, who were genotyped for the AGTR1 (A1166C), AGT (M235T), ACE (4656(rpt)), NOS3 (E298D), GNB3 (C825T) and ADD1 (G460W) polymorphisms. Linear regression analyses were performed to assess the relationship between CIMT and the polymorphisms. RESULTS: The study population included 289 men (46.8%) and 329 (53.2%) women of whom 52.3% were treated with cardiovascular medication. CIMT was significantly associated with age, female sex, use of cardiovascular medication, waist circumference and dyslipidemia. After correction for these covariates, multivariate linear regression analyses showed that only in women the C-allele of AGTR1 was associated with a thicker CIMT (P = 0.03). The T-allele of ADD1 was associated with a smaller CIMT in both men and women, but this only reached statistical significance in women (P = 0.03). CONCLUSION: Although the effect of both genetic variants on CIMT was small, this study showed a statistically significant effect of AGTR1 and ADD1 in women. However, our findings should be viewed as hypothesis-generating and require further confirmation in prospective epidemiological primary care studies.

Assessment of readiness to change in patients with osteoarthritis. development and application of a new questionnaire.

OBJECTIVE: To develop a self-report measure for assessment of the stage of change in patients with osteoarthritis, in order to identify patients who would benefit from a self-management programme. METHODS: According to the 'stages of change' model a questionnaire was developed with three groups of items corresponding to the precontemplation stage (Pre), the contemplation (Cont) and the action (Act) stage. Internal consistency and factor structure of this questionnaire were investigated by assessing Cronbach's alphas and by performing factor analysis. SUBJECTS AND SETTING: The questionnaire was offered to 273 patients who entered a randomized clinical trial on self-management in a general health care setting. RESULTS: Factor analysis revealed that most items corresponded to the a priori described groups, while some items were not loading on the presumed factor. In each subgroup some items were deleted, resulting in a 15-item questionnaire. After this item reduction Cronbach's alphas were 0.72 (Pre), 0.76 (Cont) and 0.79 (Act) and all factor loadings were satisfactory (above 0.35). Classification revealed some differences between parts of the total group, for example in the proportion of patients in the preparation stage (recruited by general practitioner = 33.6%; advertisement = 49.2%). CONCLUSIONS: The Stages of Change Questionnaire in Osteoarthritis, a 15-item questionnaire to assess the 'stage of change' of a patient with osteoarthritis showed good internal consistency and adequate factor structure. These findings warrant further studies on validity and applicability in a clinical context.

Self-management in osteoarthritis of hip or knee: a randomized clinical trial in a primary healthcare setting.

OBJECTIVE: To assess in a primary healthcare setting the efficacy of a self-management program in middle-aged patients with osteoarthritis (OA). METHODS: This was a 2-group randomized controlled trial, with 273 patients aged 40 to 60 years with OA of the hip(s) and/or knee(s). The experimental intervention was compared with care-as-usual. Treatments and followup measurements were performed in a general healthcare setting by general practitioners. Duration of followup was 21 months after start of the intervention. Instruction in self-management techniques was given by physiotherapists. The main outcome measures were pain severity in hips and knees, other significant complaints, and functional limitations. RESULTS: To begin, 297 patients were randomized: 149 as self-management and 148 controls; before the intervention 24 withdrew for practical reasons (17 self-management, 7 controls). At 3-month followup the intervention group was significantly improved on a visual analog scale (VAS) for knee pain (score 0.67; SD 2.10) and the WOMAC (score 2.46; SD 9.49), while the control group showed stable VAS knee pain (0.01; SD 2.00) and deterioration on WOMAC (-0.53; SD 9.47). At 21-month followup the differences between the groups increased in favor of the intervention group (VAS pain knee: p values from 0.023 at 3 mo to 0.004 at 21 mo; WOMAC: p values from 0.030 to 0.022). CONCLUSION: The self-management program positively influenced knee pain and self-reported functional level in this sample of patients with OA. Differences between the study groups increased during followup in favor of the intervention group.