Understanding the lived experience of idiopathic pulmonary fibrosis and how this shapes views on home-based pulmonary rehabilitation in Delhi, India.

OBJECTIVES: Pulmonary Rehabilitation (PR) is a high-impact intervention for individuals with idiopathic pulmonary fibrosis (IPF) but access is limited in India. PR barriers include distance to travel, lack of service provision and lack of healthcare professionals to deliver PR, thus it is disproportionate to the immense burden of IPF in India. We explored the lived experiences of people living with IPF, family caregivers (CGs) and healthcare workers (HCWs) as well as their views towards home-based PR (HBPR) in Delhi, India. METHODS: A qualitative study using semi-structured interviews with individuals with IPF (n = 20), CGs (n = 10) and HCWs (n = 10) was conducted. Data were analysed using codebook thematic analysis. RESULTS: Three major themes were generated: (i) Health impact, which included pathophysiological changes, range of symptoms experienced, disease consequences and impact of comorbidities; (ii) Disease management, which described strategies to control the progression and overall management of IPF, such as medications and exercises; (iii) Mode of Pulmonary Rehabilitation, which described perceptions regarding HBPR, comparisons with centre-based programmes, and how HBPR may fit as part of a menu of PR delivery options. CONCLUSION: People living with IPF, family caregivers and healthcare workers were positive about the potential implementation of HBPR and suggested the development of a paper-based manual to facilitate HBPR over digital/online approaches. The content of HBPR should be sensitive to the additional impact of non-IPF health issues and challenges of reduced interactions with healthcare professionals.

Can quantifying the relative intensity of a person's free-living physical activity predict how they respond to a physical activity intervention? Findings from the PACES RCT.

OBJECTIVES: To determine whether quantifying both the absolute and relative intensity of accelerometer-assessed physical activity (PA) can inform PA interventions. We hypothesised that individuals whose free-living PA is at a low relative intensity are more likely to increase PA in response to an intervention, as they have spare physical capacity. METHOD: We conducted a secondary data analysis of a 12-month randomised controlled trial, Physical Activity after Cardiac EventS, which was designed to increase PA but showed no improvement. Participants (N=239, 86% male; age 66.4 (9.7); control N=126, intervention N=113) wore accelerometers for 7 days and performed the incremental shuttle walk test (ISWT) at baseline and 12 months. PA intensity was expressed in absolute terms (intensity gradient) and relative to acceleration at maximal physical capacity (predicted from an individual's maximal ISWT walking speed). PA outcomes were volume and absolute intensity gradient. RESULTS: At baseline, ISWT performance was positively correlated with PA volume (r=0.50, p<0.001) and absolute intensity (r=0.50, p<0.001), but negatively correlated with relative intensity (r=-0.13, p=0.025). Relative intensity of PA at baseline moderated the change in absolute intensity (p=0.017), but not volume, of PA postintervention. Low relative intensity at baseline was associated with increased absolute intensity gradient (+0.5 SD), while high relative intensity at baseline was associated with decreased absolute intensity gradient (-0.5 SD). CONCLUSION: Those with low relative intensity of PA were more likely to increase their absolute PA intensity gradient in response to an intervention. Quantifying absolute and relative PA intensity of PA could improve enables personalisation of interventions.

A proof of concept for continuous, non-invasive, free-living vital signs monitoring to predict readmission following an acute exacerbation of COPD: a prospective cohort study.

BACKGROUND: The use of vital signs monitoring in the early recognition of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) post-hospital discharge is limited. This study investigated whether continuous vital signs monitoring could predict an AECOPD and readmission. METHODS: 35 people were recruited at discharge following hospitalisation for an AECOPD. Participants were asked to wear an Equivital LifeMonitor during waking hours for 6 weeks and to complete the Exacerbations of Chronic Pulmonary Disease Tool (EXACT), a 14-item symptom diary, daily. The Equivital LifeMonitor recorded respiratory rate (RR), heart rate (HR), skin temperature (ST) and physical activity (PA) every 15-s. An AECOPD was classified as mild (by EXACT score), moderate (prescribed oral steroids/antibiotics) or severe (hospitalisation). RESULTS: Over the 6-week period, 31 participants provided vital signs and symptom data and 14 participants experienced an exacerbation, of which, 11 had sufficient data to predict an AECOPD. HR and PA were associated with EXACT score (p < 0.001). Three days prior to an exacerbation, RR increased by mean ± SD 2.0 ± 0.2 breaths/min for seven out of 11 exacerbations and HR increased by 8.1 ± 0.7 bpm for nine of these 11 exacerbations. CONCLUSIONS: Increased heart rate and reduced physical activity were associated with worsening symptoms. Even with high-resolution data, the variation in vital signs data remains a challenge for predicting AECOPDs. Respiratory rate and heart rate should be further explored as potential predictors of an impending AECOPD. TRIAL REGISTRATION: ISRCTN registry; ISRCTN12855961. Registered 07 November 2018-Retrospectively registered, https://www.isrctn.com/ISRCTN12855961.

A feasibility trial of pulmonary rehabilitation for patients with COPD in a low resource setting: Jaffna, Sri Lanka.

BACKGROUND: Pulmonary rehabilitation is recommended for most patients with chronic obstructive pulmonary disease (COPD). Accordingly, the aim of this study was to explore the feasibility of devising a pulmonary rehabilitation program for patients with COPD in a low resource setting (Jaffna, Sri Lanka) and to observe its effects. METHODS: Non-randomized controlled feasibility trial of ambulatory patients with COPD attending the pulmonary outpatient clinic of the Jaffna Teaching Hospital, Northern Province, Sri Lanka. Age-matched patients were allocated alternatively to an intervention group or to a control group. Twice weekly, for six weeks, patients in the intervention group attended pulmonary rehabilitation sessions consisting of supervised stretching, aerobic and strengthening exercises, and patient-education. Before and at the conclusion of the study, all patients performed incremental shuttle walking test (ISWT), 6-min walk test (6MWT) and completed the Medical Research Council (MRC) dyspnea scale, COPD assessment test (CAT), chronic COPD questionnaire (CCQ), and hospital anxiety depression scale (HADS). RESULTS: 204 patients with COPD (94% males) were identified at screening; 136 (66.7%) were eligible for pulmonary rehabilitation and 96 patients (47%) consented to participate. Of these, 54 patients (53 males) eventually participated in the study (42 patients were discouraged to participate by family members or friends); 40 patients (20 in the rehabilitation group and 20 patients in the control group) completed the study. Baseline characteristics of the intervention group and the control group were similar. 95% of patients in the intervention group adhered to regular home training exercises (self-reported diary). At post assessment, only the intervention group experienced clinically-meaningful improvements in symptoms and exercise capacity. CONCLUSION: A simple and clinically beneficial pulmonary rehabilitation program for patients with COPD can be effectively implemented in a low resource setting. However, there is a need for educating patients and the local community on the benefits of pulmonary rehabilitation to enhance uptake. Retrospective Trial Registration date and number: 16/04/2021, ISRCTN10069208.

The untapped potential of physical activity monitoring for quality assurance of field-based walking tests in clinical respiratory trials.

Field-based walking tests are well-established outcome measures in clinical research trials and in the evaluation of routine clinical services, including pulmonary rehabilitation. Despite widespread use, there has been little attention to, or reporting of, the quality assurance of these tests. Physical activity monitoring has become increasingly popular and data from activity monitors could be used for quality assurance of field-based walking tests. We provide examples in this article of data-driven insights possible with this approach, using data from waist-worn accelerometry, for the incremental shuttle walking test (ISWT), endurance shuttle walk test (ESWT) and six-minute walk test (6MWT). Given the multitude of devices to measure physical activity and the range metrics to describe physical activity, we also comment on some of the technical considerations to using activity monitors for walking test quality assurance. Data-driven approaches to quality assurance are already commonplace for other outcome measures in clinical respiratory trials, but little is known about this approach for field-based walking tests. The application of physical activity monitoring may be extended to other field-based exercise tests and additional rehabilitation services. This may be more challenging for self-paced walking tests such as the 6MWT. Future work should apply this approach to research trials and service evaluations to explore the impact of field-based walking test quality on performance (e.g. distance on the ISWT or time achieved for the ESWT), responsiveness to interventions (e.g. pulmonary rehabilitation) and effectiveness of training procedures (e.g. remote training for multi-site trials).

Deriving personalised physical activity intensity thresholds by merging accelerometry with field-based walking tests: Implications for pulmonary rehabilitation.

During pulmonary rehabilitation (PR), patients receive individually tailored walking exercise training. The personalised nature of exercise prescription is a fundamental component of PR. Despite this, the measurement of physical activity (PA) has been limited to a 'one size fits all' approach and can be challenging to translate into clinically meaningful or real-world units, such as cadence. This discrepancy may partly explain the inconsistent evidence for the impact of PR on PA. It may also provide an opportunity to standardise PA assessment in the context of chronic respiratory disease (CRD) and PR, where field-based walking tests are routine measures. This technical note provides an example of how to develop personalised PA intensity thresholds, calibrated against an individual's performance on the Incremental Shuttle Walking Test (ISWT; maximal) and Endurance Shuttle Walk Test (ESWT; sub-maximal). These are externally paced tests, with each level (speed) of the tests denoting a specific speed (intensity); ranging 1.8 km/h (ISWT Level 1) to 8.5 km/h (ISWT Level 12). From the ESWT, it becomes possible to evaluate adherence to each individual's walking exercise prescription. Future research should explore this approach and its responsiveness to PR. It may be possible to extend this methodology with the inclusion of physiological parameters (e.g., heart rate, calorimetry, and oxygen consumption) to derive relative intensity markers (e.g. moderate-to-vigorous), accounting for individual differences in exercise capacity, under the same paradigm as PR exercise prescription.

Adherence to walking exercise prescription during pulmonary rehabilitation in COPD with a commercial activity monitor: a feasibility trial.

BACKGROUND: Regular exercise is important in the management of COPD. Pulmonary rehabilitation (PR) facilitates a more physically active lifestyle through exercise participation, ideally without compromising non-exercise physical activity (PA). During PR patients are advised to perform exercise defined by duration and intensity. The extent to which PR attendees participate in unsupervised exercise bouts and their adherence to the exercise prescription provided during PR is unclear. Commercially available devices have the potential to support patients to exercise at their individually prescribed intensity. Study aims were to (1) assess how adherent patients are to their prescribed walking intensity; (2) examine the pattern of overall PA and walking exercise during the course of PR; (3) determine the feasibility of prescribing exercise to PR attendees using an activity monitor; and (4) explore the relationship between exercise and non-exercise PA with routine PR outcome measures. METHODS: 19 patients wore an activity monitor during routine walking tests and 6 weeks of PR, recording in a diary when they exercised. Exercise intensity (cadence) was prescribed from the Endurance Shuttle Walk Test. Patients completed questionnaires, walking tests and a lower limb strength test before and after PR. Repeated ANOVA compared changes in outcomes between weeks 1-6. RESULTS: Patients wore the monitor every day during PR (median 42 days). Exercise steps increased by 56% (Δ332 [95% CI 54-611] steps/day, p = 0.009) between weeks 1 and 6, with no significant change in non-exercise steps (Δ79 [95% CI - 22 to - 179] steps/day, p = 0.13). Patients reported exercising on 70% of days. Adherence to prescribed cadence was achieved 55% of time spent exercising, and did not change across the 6 weeks (p = 0.907). Change in total daily steps was associated with improved dyspnea (p = 0.027), Chronic Respiratory Questionnaire (CRQ) Dyspnea domain (p = 0.019), CRQ Emotional Functioning domain (p = 0.001) and CRQ Mastery domain scores (p = 0.001) but not with exercise capacity or lower limb muscle strength. CONCLUSIONS: Improvements in exercise participation, not at the expense of non-exercise PA, throughout a PR course was observed in attendees provided with a commercially available activity monitor. Wearable technology may be able to support effective remote walking exercise prescription and participation during PR. Trial registration (retrospectively registered): http://www.isrctn.com/ISRCTN15892972 .

A digital lifestyle behaviour change intervention for the prevention of type 2 diabetes: a qualitative study exploring intuitive engagement with real-time glucose and physical activity feedback.

BACKGROUND: Mobile health technologies have advanced to now allow monitoring of the acute physiological responses to lifestyle behaviours. Our aim was to explore how people engaged with real-time feedback on their physical activity and glucose levels over several weeks. METHODS: Semi-structured interviews with 26 participants (61.5% female, 56.6 years) at moderate-to-high risk of developing type 2 diabetes were conducted. Interviews were completed after participants took part in an intervention comprising a flash glucose monitor (Freestyle Libre) and a physical activity monitor (Fitbit Charge 2). Purposive sampling ensured representation of ages, genders and group allocations. RESULTS: Inductive thematic analysis revealed how individuals intuitively used, interpreted and acted on feedback from wearable technologies. Six key themes emerged: triggers of engagement with the technologies, links between behaviour and health, lack of confidence, changes to movement behaviours, changes to diet and barriers to lifestyle behaviour change. CONCLUSIONS: Our findings demonstrate that accessing behavioural and physiological feedback can increase self-awareness of how lifestyle impacts short-term health. Some participants noticed a link between the feedback presented by the two devices and changed their behaviour but many did not. Training and educational support, as well as efforts to optimize how feedback is presented to users, are needed to sustain engagement and behaviour change. Extensions of this work to involve people with diabetes are also warranted to explore whether behavioural and physiological feedback in parallel can encourage better diabetes self-management. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN17545949 , 12/05/2017, prospectively registered.

Comparison of Inhibitor and Substrate Selectivity between Rodent and Human Vascular Adhesion Protein-1.

Vascular adhesion protein-1 (VAP-1) is an ectoenzyme that functions as a copper-containing amine oxidase and is involved in leukocyte adhesion at sites of inflammation. Inhibition of VAP-1 oxidative deamination has become an attractive target for anti-inflammatory therapy with demonstrated efficacy in rodent models of inflammation. A previous comparison of purified recombinant VAP-1 from mouse, rat, monkey, and human gene sequences predicted that rodent VAP-1 would have higher affinity for smaller hydrophilic substrates/inhibitors because of its narrower and more hydrophilic active site channel. An optimized in vitro oxidative deamination fluorescence assay with benzylamine (BA) was used to compare inhibition of five known inhibitors in recombinant mouse, rat, and human VAP-1. Human VAP-1 was more sensitive compared to rat or mouse VAP-1 (lowest IC50 concentration) to semicarbazide but was least sensitive to hydralazine and LJP-1207. Hydralazine had a lower IC50 in rats compared to humans, although not significant. However, the IC50 of hydralazine was significantly higher in the rat compared to mouse VAP-1. The larger hydrophobic compounds from Astellas (compound 35c) and Boehringer Ingelheim (PXS-4728A) were hypothesized to have higher binding affinity for human VAP-1 compared to rodent VAP-1 since the channel in human VAP-1 is larger and more hydrophobic than that in rodent VAP-1. Although the sensitivity of these two inhibitors was the lowest in the mouse enzyme, we found no significant differences between mouse, rat, and human VAP-1. Michaelis-Menten kinetics of the small primary amines phenylethylamine and tyramine were also compared to the common marker substrate BA demonstrating that BA had the highest affinity among the substrates. Rat VAP-1 had the highest affinity for all three substrates and mouse VAP-1 had intermediate affinity for BA and phenylethylamine, but tyramine was not a substrate for mouse VAP-1 under these assay conditions. These results suggest that comparing oxidative deamination in mouse and rat VAP-1 may be important if using these species for preclinical efficacy models.

Changes in physical activity during hospital admission for chronic respiratory disease.

BACKGROUND AND OBJECTIVE: Establishing the amount of inpatient physical activity (PA) undertaken by individuals hospitalized for chronic respiratory disease is needed to inform interventions. This observational study investigated whether PA changes when a person is an inpatient, how long is required to obtain representative PA measures and whether PA varies within a day and between patients of differing lengths of stay. METHODS: A total of 389 participants were recruited as early as possible into their hospitalization. Patients wore a PA monitor from recruitment until discharge. Step count was extracted for a range of wear time criteria. Single-day intraclass correlation coefficients (ICC) were calculated, with an ICC ≥ 0.80 deemed acceptable. RESULTS: PA data were available for 259 participants. No changes in daily step count were observed during the inpatient stay (586 (95% CI: 427-744) vs 652 (95% CI: 493-812) steps/day for day 2 and 7, respectively). ICC across all wear time criteria were > 0.80. The most stringent wear time criterion, retaining 80% of the sample, was ≥11 h on ≥1 day. More steps were taken during the morning and afternoon than overnight and evening. After controlling for the Medical Research Council (MRC) grade or oxygen use, there was no difference in step count between patients admitted for 2-3 days (short stay) and those admitted for 7-14 days (long stay). CONCLUSION: Patients move little during their hospitalization, and inpatient PA did not increase during their stay. A wear time criterion of 11 waking hours on any single day was representative of the entire admission whilst retaining an acceptable proportion of the initial sample size. Patients may need encouragement to move more during their hospital stay.

Standardising the measurement of physical activity in people receiving haemodialysis: considerations for research and practice.

BACKGROUND: Physical activity (PA) is exceptionally low amongst the haemodialysis (HD) population, and physical inactivity is a powerful predictor of mortality, making it a prime focus for intervention. Objective measurement of PA using accelerometers is increasing, but standard reporting guidelines essential to effectively evaluate, compare and synthesise the effects of PA interventions are lacking. This study aims to (i) determine the measurement and processing guidance required to ensure representative PA data amongst a diverse HD population, and; (ii) to assess adherence to PA monitor wear amongst HD patients. METHODS: Clinically stable HD patients from the UK and China wore a SenseWear Armband accelerometer for 7 days. Step count between days (HD, Weekday, Weekend) were compared using repeated measures ANCOVA. Intraclass correlation coefficients (ICCs) determined reliability (≥0.80 acceptable). Spearman-Brown prophecy formula, in conjunction with a priori ≥  80% sample size retention, identified the minimum number of days required for representative PA data. RESULTS: Seventy-seven patients (64% men, mean ± SD age 56 ± 14 years, median (interquartile range) time on HD 40 (19-72) months, 40% Chinese, 60% British) participated. Participants took fewer steps on HD days compared with non-HD weekdays and weekend days (3402 [95% CI 2665-4140], 4914 [95% CI 3940-5887], 4633 [95% CI 3558-5707] steps/day, respectively, p < 0.001). PA on HD days were less variable than non-HD days, (ICC 0.723-0.839 versus 0.559-0.611) with ≥ 1 HD day and ≥  3 non-HD days required to provide representative data. Using these criteria, the most stringent wear-time retaining ≥ 80% of the sample was ≥7 h. CONCLUSIONS: At group level, a wear-time of ≥7 h on ≥1HD day and ≥ 3 non-HD days is required to provide reliable PA data whilst retaining an acceptable sample size. PA is low across both HD and non- HD days and future research should focus on interventions designed to increase physical activity in both the intra and interdialytic period.

Influence of muscle mass in the assessment of lower limb strength in COPD: validation of the prediction equation.

Absence of established reference values limits application of quadriceps maximal voluntary contraction (QMVC) measurement. The impact of muscle mass inclusion in predictions is unclear. Prediction equations encompassing gender, age and size with (FFM+) and without (FFM-), derived in healthy adults (n=175), are presented and compared in two COPD cohorts recruited from primary care (COPD-PC, n=112) and a complex care COPD clinic (COPD-CC, n=189). Explained variance was comparable between the prediction models (R2: FFM+: 0.59, FFM-: 0.60) as were per cent predictions in COPD-PC (88.8%, 88.3%). However, fat-free mass inclusion reduced the prevalence of weakness in COPD, particularly in COPD-CC where 11.9% fewer were deemed weak.

The influence of South Asian ethnicity on the incremental shuttle walk test in UK adults.

The objective of this study was to compare incremental shuttle walking test (ISWT) performance between South Asian and Caucasian British adults, identify predictors of ISWT distance and produce ethnicity-specific reference equations. Data from a mixed gender sample aged 40-75 years from Leicestershire, United Kingdom, were selected for analyses. Analysis of covariance determined differences in ISWT performance between South Asian and Caucasian British ethnic groups. Linear regressions identified predictors of ISWT distance, which determined the reference equations. In total, 144 participants took part in the study (79 South Asian (54 ± 8 years, 71% female) and 65 Caucasian British (58 ± 9 years, 74% female)). Distance walked for the ISWT was shorter for South Asian individuals compared with Caucasian British (451 ± 143 vs. 575 ± 180 m, p < 0.001). The ethnicity-specific reference equations for ISWT distance explained 33-50% of the variance (standard error of the estimate (SEE): 107-119 m) for South Asians and explained 14-58% of the variance (SEE: 121-169 m) for Caucasian British. Ethnicity univariately explained 12.9% of the variance in ISWT distance and was significantly associated with ISWT distance after controlling for age, gender, height, weight, dyspnoea and lung function ( B = -70.37; 1 = Caucasian British, 2 = South Asian), uniquely explaining 3.7% of the variance. Predicted values for ISWT performance were lower in South Asian people than in Caucasian British. Ethnicity-specific reference equations should account for this.

Can functional magnetic resonance imaging studies help with the optimization of health messaging for lifestyle behavior change? A systematic review.

Unhealthy behaviors, including smoking, poor nutrition, excessive alcohol consumption, physical inactivity and sedentary lifestyles, are global risk factors for non-communicable diseases and premature death. Functional magnetic resonance imaging (fMRI) offers a unique approach to optimize health messages by examining how the brain responds to information relating to health. Our aim was to systematically review fMRI studies that have investigated variations in brain activation in response to health messages relating to (i) smoking; (ii) alcohol consumption; (iii) physical activity; (iv) diet; and (v) sedentary behavior. The electronic databases used were Medline/PubMed, Web of Science (Core Collection), PsychINFO, SPORTDiscuss, Cochrane Library and Open Grey. Studies were included if they investigated subjects aged ≥10years and were published before January 2017. Of the 13,836 studies identified in the database search, 18 studies (smoking k=15; diet k=2; physical activity/sedentary behavior k=1) were included in the review. The prefrontal cortex was activated in seven (47%) of the smoking-related studies and the physical activity study. Results suggest that activation of the ventromedial, dorsolateral and medial prefrontal cortex regions were predictive of subsequent behavior change following exposure to aversive anti-smoking stimuli. Studies investigating the neurological responses to anti-smoking material were most abundant. Of note, the prefrontal cortex and amygdala were most commonly activated in response to health messages across lifestyle behaviors. The review highlights an important disparity between research focusing on different lifestyle behaviors. Insights from smoking literature suggest fMRI may help to optimize health messaging in relation to other lifestyle behaviors.

Combined influence of epoch length, cut-point and bout duration on accelerometry-derived physical activity.

BACKGROUND: It is difficult to compare accelerometer-derived estimates of moderate-to-vigorous physical activity (MVPA) between studies due to differences in data processing procedures. We aimed to evaluate the effects of accelerometer processing options on total and bout-accumulated time spent in MVPA in adults. METHODS: 267 participants from the ProActive Trial provided 1236 days of valid physical activity (PA) data, collected using a 5-s epoch with ActiGraph GT1M accelerometers. We integrated data over 5-s to 60-s epoch lengths (EL) and applied two-level mixed effects regression models to MVPA time, defined using 1500 to 2500 counts/minute (cpm) cut-points (CP) and bout durations (BD) from 1 to 15 min. RESULTS: Total MVPA time was lower on longer EL and higher CP (47 vs 26 min/day and 26 vs 5 min/day on 1500 vs 2500 cpm on 5-s and 60-s epoch, respectively); this could be approximated as MVPA=exp[2.197+0.279*log(CP)+6.120*log(EL) - 0.869*log(CP)*log(EL)] with an 800 min/day wear-time. In contrast, EL was positively associated with time spent in bout-accumulated MVPA; the approximating equation being MVPA=exp[54.679 - 6.268*log(CP)+6.387*log(EL) - 10.000*log(BD) - 0.162*log(EL)*log(BD) - 0.626*log(CP)*log(EL)+1.033*log(CP)*log(BD)]. BD and CP were inversely associated with MVPA, with higher values attenuating the influence of EL. CONCLUSIONS: EL, CP and BD interact to influence estimates of accelerometer-determined MVPA. In general, higher CP and longer BD result in lower MVPA but the direction of association for EL depends on BD. Reporting scaling coefficients for these key parameters across their frequently used ranges would facilitate comparisons of population-level accelerometry estimates of MVPA.

Changes in physical activity, sedentary behaviour and sleep following pulmonary rehabilitation: a systematic review and network meta-analysis.

BACKGROUND: The variety of innovations to traditional centre-based pulmonary rehabilitation (CBPR), including different modes of delivery and adjuncts, are likely to lead to differential responses in physical activity, sedentary behaviour and sleep. OBJECTIVES: To examine the relative effectiveness of different pulmonary rehabilitation-based interventions on physical activity, sedentary behaviour and sleep. METHODS: Randomised trials in chronic respiratory disease involving pulmonary rehabilitation-based interventions were systematically searched for. Network meta-analyses compared interventions for changes in physical activity, sedentary behaviour and sleep in COPD. RESULTS: 46 studies were included, and analyses were performed on most common outcomes: steps per day (k=24), time spent in moderate-to-vigorous physical activity (MVPA; k=12) and sedentary time (k=8). There were insufficient data on sleep outcomes (k=3). CBPR resulted in greater steps per day and MVPA and reduced sedentary time compared to usual care. CBPR+physical activity promotion resulted in greater increases in steps per day compared to both usual care and CBPR, with greater increases in MVPA and reductions in sedentary time compared to usual care, but not CBPR. Home-based pulmonary rehabilitation resulted in greater increases in steps per day and decreases in sedentary time compared to usual care. Compared to usual care, CBPR+physical activity promotion was the only intervention where the lower 95% confidence interval for steps per day surpassed the minimal important difference. No pulmonary rehabilitation-related intervention resulted in greater increases in MVPA or reductions in sedentary time compared to CBPR. CONCLUSION: The addition of physical activity promotion to pulmonary rehabilitation improves volume of physical activity, but not intensity, compared to CBPR. High risk of bias and low certainty of evidence suggests that these results should be viewed with caution.

A Case for Unifying Accelerometry-Derived Movement Behaviors and Tests of Exercise Capacity for the Assessment of Relative Physical Activity Intensity.

Albert Einstein taught us that "everything is relative." People's experience of physical activity (PA) is no different, with "relativism" particularly pertinent to the perception of intensity. Markers of absolute and relative intensities of PA have different but complimentary utilities, with absolute intensity considered best for PA guideline adherence and relative intensity for personalized exercise prescription. Under the paradigm of exercise and PA as medicine, our Technical Note proposes a method of synchronizing accelerometry with the incremental shuttle walking test to facilitate description of the intensity of the free-living PA profile in absolute and relative terms. Our approach is able to generate and distinguish "can do" or "cannot do" (based on exercise capacity) and "does do" or "does not do" (based on relative intensity PA) classifications in a chronic respiratory disease population, facilitating the selection of potential appropriate individually tailored interventions. By synchronizing direct assessments of exercise capacity and PA, clearer insights into the intensity of PA performed during everyday life can be gleaned. We believe the next steps are as follows: (1) to determine the feasibility and effectiveness of using relative and absolute intensities in combination to personalize the approach, (2) to determine its sensitivity to change following interventions (eg, exercise-based rehabilitation), and (3) to explore the use of this approach in healthier populations and in other long-term conditions.

Perspectives of Patients With Chronic Respiratory Diseases and Medical Professionals on Pulmonary Rehabilitation in Pune, India: Qualitative Analysis.

BACKGROUND: Chronic respiratory diseases (CRDs) contribute significantly to morbidity and mortality worldwide and in India. Access to nonpharmacological options, such as pulmonary rehabilitation (PR), are, however, limited. Given the difference between need and availability, exploring PR, specifically remotely delivered PR, in a resource-poor setting, will help inform future work. OBJECTIVE: This study explored the perceptions, experiences, needs, and challenges of patients with CRDs and the potential of and the need for PR from the perspective of patients as well as medical professionals involved in the referral (doctors) and delivery (physiotherapists) of PR. METHODS: In-depth qualitative semistructured interviews were conducted among 20 individuals diagnosed with CRDs and 9 medical professionals. An inductive thematic analysis approach was used as we sought to identify the meanings shared both within and across the 2 participant groups. RESULTS: The 20 patients considered lifestyle choices (smoking and drinking), a lack of physical activity, mental stress, and heredity as the triggering factors for their CRDs. All of them equated the disease with breathlessness and a lack of physical strength, consulting multiple doctors about their physical symptoms. The most commonly cited treatment choice was an inhaler. Most of them believed that yoga and exercise are good self-management strategies, and some were performing yoga postures and breathing exercises, as advised by friends or family members or learned from a televised program or YouTube videos. None of them identified with the term "pulmonary rehabilitation," but many were aware of the exercise component and its benefits. Despite being naive to smartphone technology or having difficulty in reading, most of them were enthusiastic about enrolling in an application-based remotely delivered digital PR program. The 9 medical professionals were, however, reluctant to depend on a PR program delivered entirely online. They recommended that patients with CRDs be supported by their family to use technology, with some time spent with a medical professional during the program. CONCLUSIONS: Patients with CRDs in India currently manage their disease with nonguided strategies but are eager to improve and would benefit from a guided PR program to feel better. A home-based PR program, with delivery facilitated by digital solutions, would be welcomed by patients and health care professionals involved in their care, as it would reduce the need for travel, specialist equipment, and setup. However, low digital literacy, low resource availability, and a lack of expertise are of concern to health care professionals. For India, including yoga could be a way of making PR "culturally congruent" and more successful. The digital PR intervention should be flexible to individual patient needs and should be complemented with physical sessions and a feedback mechanism for both practitioners as well as patients for better uptake and adherence.