Pulmonary rehabilitation is a cornerstone of care for COPD but uptake of traditional centre-based programmes is poor. We assessed whether home-based pulmonary rehabilitation, delivered using minimal ...resources, had equivalent outcomes to centre-based pulmonary rehabilitation.
A randomised controlled equivalence trial with 12 months follow-up. Participants with stable COPD were randomly assigned to receive 8 weeks of pulmonary rehabilitation by either the standard outpatient centre-based model, or a new home-based model including one home visit and seven once-weekly telephone calls from a physiotherapist. The primary outcome was change in 6 min walk distance (6MWD).
We enrolled 166 participants to receive centre-based rehabilitation (n=86) or home-based rehabilitation (n=80). Intention-to-treat analysis confirmed non-inferiority of home-based rehabilitation for 6MWD at end-rehabilitation and the confidence interval (CI) did not rule out superiority (mean difference favouring home group 18.6 m, 95% CI -3.3 to 40.7). At 12 months the CI did not exclude inferiority (-5.1 m, -29.2 to 18.9). Between-group differences for dyspnoea-related quality of life did not rule out superiority of home-based rehabilitation at programme completion (1.6 points, -0.3 to 3.5) and groups were equivalent at 12 months (0.05 points, -2.0 to 2.1). The per-protocol analysis showed the same pattern of findings. Neither group maintained postrehabilitation gains at 12 months.
This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation. Neither model was effective in maintaining gains at 12 months. Home-based pulmonary rehabilitation could be considered for people with COPD who cannot access centre-based pulmonary rehabilitation.
NCT01423227, clinicaltrials.gov.
Uncertainty exists regarding the clinical relevance of exercise training across the range of interstitial lung diseases (ILDs).
To establish the impact of exercise training in patients with ILDs of ...differing aetiology and severity.
142 participants with ILD (61 idiopathic pulmonary fibrosis (IPF), 22 asbestosis, 23 connective tissue disease-related ILD (CTD-ILD) and 36 with other aetiologies) were randomised to either 8 weeks of supervised exercise training or usual care. Six-minute walk distance (6MWD), Chronic Respiratory Disease Questionnaire (CRDQ), St George Respiratory Questionnaire IPF-specific version (SGRQ-I) and modified Medical Research Council dyspnoea score were measured at baseline, 9 weeks and 6 months.
Exercise training significantly increased 6MWD (25 m, 95% CI 2 to 47 m) and health-related quality of life (CRDQ and SGRQ-I) in people with ILD. Larger improvements in 6MWD, CRDQ, SGRQ-I and dyspnoea occurred in asbestosis and IPF compared with CTD-ILD, but with few significant differences between subgroups. Benefits declined at 6 months except in CTD-ILD. Lower baseline 6MWD and worse baseline symptoms were associated with greater benefit in 6MWD and symptoms following training. Greater gains were seen in those whose exercise prescription was successfully progressed according to the protocol. At 6 months, sustained improvements in 6MWD and symptoms were associated with better baseline lung function and less pulmonary hypertension.
Exercise training is effective in patients across the range of ILDs, with clinically meaningful benefits in asbestosis and IPF. Successful exercise progression maximises improvements and sustained treatment effects favour those with milder disease.
Results, ACTRN12611000416998.
Supplemental oxygen is commonly prescribed in patients with idiopathic pulmonary fibrosis (IPF), although its benefits have not been proven. The aims of this study were to investigate the effect of ...oxygen on oxidative stress, cytokine production, skeletal muscle metabolism and physiological response to exercise in IPF.
Eleven participants with IPF received either oxygen, at an FiO
of 0.50, or compressed air for 1 h at rest and during a cycle endurance test at 85% of peak work rate. Blood samples collected at rest and during exercise were analysed for markers of oxidative stress, skeletal muscle metabolism and cytokines. The protocol was repeated a week later with the alternate intervention.
Compared with air, oxygen did not adversely affect biomarker concentrations at rest and significantly improved endurance time (mean difference = 99 ± 81s, P = 0.002), dyspnoea (-1 ± 1 U, P = 0.02), systolic blood pressure (BP; -11 ± 11 mm Hg, P = 0.006), nadir oxyhaemoglobin saturation (SpO
; 8 ± 6%, P = 0.001), SpO
at 2-min (7 ± 6%, P = 0.003) and 5-min isotimes (5 ± 3, P < 0.001) and peak exercise xanthine concentrations (-42 ± 73 µmol/L, P = 0.03). Air significantly increased IL-10 (5 ± 5 pg/mL, P = 0.04) at 2-min isotime. Thiobarbituric acid-reactive substances (TBARs), IL-6, TNF-α, creatine kinase, lactate, heart rate and fatigue did not differ between the two interventions at any time point.
In patients with IPF, breathing oxygen at FiO
of 0.50 at rest seems safe. During exercise, oxygen improves exercise tolerance, alleviates exercise-induced hypoxaemia and reduces dyspnoea. A potential relationship between oxygen administration and improved skeletal muscle metabolism should be explored in future studies.
This study aimed to document the perspective of patients with chronic obstructive pulmonary disease (COPD) who underwent home-based pulmonary rehabilitation (HBPR) in a clinical trial. In this ...qualitative study, open-ended questions explored participants’ views regarding HBPR. Thirteen semi-structured interviews were analysed using a thematic analysis approach. Major themes from interviews included the positive impact of HBPR on physical fitness, breathing and mood. Participants valued the flexibility and convenience of the programme. Participants also highlighted the importance of social support received, both from the physiotherapist over the phone and from family and friends who encouraged their participation. Reported challenges were difficulties in initiating exercise, lack of variety in training and physical incapability. While most participants supported the home setting, one participant would have preferred receiving supervised exercise training at the hospital. Participants also reported that HBPR had helped establish an exercise routine and improved their disease management. This study suggests that people with COPD valued the convenience of HBPR, experienced positive impacts on physical fitness and symptoms and felt supported by their community and programme staff. This highly structured HBPR model may be acceptable to some people with COPD as an alternative to centre-based pulmonary rehabilitation.
The optimal method to collect accurate healthcare utilisation data in people with chronic obstructive pulmonary disease (COPD) is not well established. The aim of this study was to determine ...feasibility and compare self-report and administrative data sources to capture health care resource use in people with COPD for 12 months following pulmonary rehabilitation.
This is a secondary analysis of a randomised controlled equivalence trial comparing centre-based and home-based pulmonary rehabilitation. Healthcare utilisation data were collected for 12 months following pulmonary rehabilitation from self-report (monthly telephone questionnaires and diaries) and administrative sources (Medicare Benefits Schedule, medical records). Feasibility was assessed by the proportion of self-reports completed and accuracy was established using month-by-month and per participant comparison of self-reports with administrative data.
Data were available for 145/163 eligible study participants (89%, mean age 69 (SD 9) years, mean forced expiratory volume in 1 s 51 (SD 19) % predicted; n = 83 male). For 1725 months where data collection was possible, 1160 (67%) telephone questionnaires and 331 (19%) diaries were completed. Accuracy of recall varied according to type of health care encounter and self-report method, being higher for telephone questionnaire report of emergency department presentation (Kappa 0.656, p < 0.001; specificity 99%, sensitivity 59%) and hospital admission (Kappa 0.669, p < 0.001; specificity 97%, sensitivity 68%) and lower for general practitioner (Kappa 0.400, p < 0.001; specificity 62%, sensitivity 78%) and medical specialist appointments (Kappa 0.458, p < 0.001; specificity 88%, sensitivity 58%). A wide variety of non-medical encounters were reported (allied health and nursing) which were not captured in administrative data.
For self-reported methods of healthcare utilisation in people with COPD following pulmonary rehabilitation, monthly telephone questionnaires were more frequently completed and more accurate than diaries. Compared to administrative records, self-reports of emergency department presentations and inpatient admissions were more accurate than for general practitioner and medical specialist appointments.
NCT01423227 at clinicaltrials.gov.
The "contingent valuation" method is used to quantify the value of services not available in traditional markets, by assessing the monetary value an individual ascribes to the benefit provided by an ...intervention. The aim of this study was to determine preferences for home or center-based pulmonary rehabilitation for participants with chronic obstructive pulmonary disease (COPD) using the "willingness to pay" (WTP) approach, the most widely used technique to elicit strengths of individual preferences. This is a secondary analysis of a randomized controlled equivalence trial comparing center-based and home-based pulmonary rehabilitation. At their final session, participants were asked to nominate the maximum that they would be willing to pay to undertake home-based pulmonary rehabilitation in preference to a center-based program. Regression analyses were used to investigate relationships between participant features and WTP values. Data were available for 141/163 eligible study participants (mean age 69 SD 10 years, n = 82 female). In order to undertake home-based pulmonary rehabilitation in preference to a conventional center-based program, participants were willing to pay was mean $AUD176 (SD 255) (median $83 IQR 0 to 244). No significant difference for WTP values was observed between groups (p = 0.98). A WTP value above zero was related to home ownership (odds ratio OR 2.95, p = 0.02) and worse baseline SF-36 physical component score (OR 0.94, p = 0.02). This preliminary evidence for WTP in the context of pulmonary rehabilitation indicated the need for further exploration of preferences for treatment location in people with COPD to inform new models of service delivery.
To examine the predictive validity, minimal important difference (MID) and responsiveness of the PRAISE tool.
Retrospective data analysis from HomeBase trial of home vs centre-based pulmonary ...rehabilitation.
Tertiary health service.
One hundred and sixty-six participants with COPD (100 men) with mean age 69 (SD 9) years, FEV1% predicted 50% (19).
Eight-week pulmonary rehabilitation program, conducted at the hospital or at home.
The 15-item PRAISE tool comprising 10 general and five pulmonary rehabilitation-specific self-efficacy questions. Predictive validity was examined by exploring the relationship between baseline PRAISE score and objective change in physical activity following pulmonary rehabilitation using the SenseWear Armband. The MID was evaluated using anchor-based and distribution-based methods. Responsiveness was assessed with effect sizes.
A higher baseline PRAISE score (indicating better self-efficacy) was an independent predictor of reduced sedentary time following pulmonary rehabilitation (P=0.03). A one point increase in PRAISE was associated with a decrease in sedentary time of 4minutes/day (95% confidence interval −7.8 to −0.4minutes/day). Anchor-based estimates of the MID were 0.5 to 1.5 points; however sensitivity and specificity were modest (area under the curve <0.70). Change in PRAISE score following pulmonary rehabilitation had an effect size of 0.21.
The PRAISE tool has predictive validity and may be useful to identify those with high self-efficacy who are more likely to achieve important health behaviour changes with pulmonary rehabilitation. The small effect size suggests that the PRAISE tool was not responsive to changes following pulmonary rehabilitation.
NCT01423227, clinicaltrials.gov.
To compare levels of physical activity during center and home-based pulmonary rehabilitation (PR) in people with chronic obstructive pulmonary disease.
Forty-five consecutive participants (23 male, n ...= 20, in the home-based group) with mean age of 68 ± 8 yr and forced expiratory volume in the first second of expiration (FEV1) 53 ± 18% predicted undertook physical activity monitoring using the SenseWear Armband during the final week of the interventions of center or home-based PR. Differences in time spent in total physical activity (≥1.5 METs), time spent in moderate to vigorous intensity physical activity (≥3 METs), and steps were compared.
Home participants spent a median and interquartile range of 310 (199-328) min/d engaged in total physical activity (29% moderate to vigorous intensity physical activity) compared with 300 (204-370) min/d for the center group (28% moderate to vigorous intensity physical activity, P = .98). Daily step count did not differ between groups (home-based median 5232 2067-7718 versus center-based median 4049 1983-6040, P = .66). Of note, center-based participants took 38% more steps on days of program attendance compared with nonattendance days (mean difference: 761 steps/d; 95% CI, -56 to 1579, P = .06).
For people with chronic obstructive pulmonary disease undertaking PR, no differences in physical activity levels between center and home-based programs were demonstrated. Understanding the impact of the indirect supervision and motivational interviewing technique utilized during home-based PR on levels of physical activity in people with chronic obstructive pulmonary disease may support clinical implementation of the model as an alternative option to traditional care.
Physical activity levels are low in people with chronic obstructive pulmonary disease, and there is limited knowledge about how pulmonary rehabilitation transforms movement behaviors. This study ...analyzed data from a pulmonary rehabilitation trial and identified determinants of movement behaviors.
Objectively assessed time in daily movement behaviors (sleep, sedentary, light-intensity physical activity, and moderate- to vigorous-intensity physical activity) from a randomized controlled trial (n = 73 participants) comparing home- and center-based pulmonary rehabilitation was analyzed using conventional and compositional analytical approaches. Regression analysis was used to assess relationships between movement behaviors, participant features, and response to the interventions.
Compositional analysis revealed no significant differences in movement profiles between the home- and center-based groups. At end rehabilitation, conventional analyses identified positive relationships between exercise capacity (6-min walk distance), light-intensity physical activity, and moderate- to vigorous-intensity physical activity time. Compositional analyses identified positive relationships between a 6-minute walk distance and moderate- to vigorous-intensity physical activity time, accompanied by negative relationships with sleep and sedentary time (relative to other time components) and novel relationships between body mass index and light-intensity physical activity/sedentary time.
Compositional analyses following pulmonary rehabilitation identified unique associations between movement behaviors that were not evident in conventional analyses.
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