Promoting Regular Physical Activity in Pulmonary Rehabilitation

doi:10.1016/j.ccm.2014.02.011

Clinics in Chest Medicine

Volume 35, Issue 2, June 2014, Pages 363-368

https://doi.org/10.1016/j.ccm.2014.02.011 Get rights and content

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Key points

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Physical inactivity is common in individuals with chronic respiratory diseases, and worsens their prognosis.
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Physical activity is an important outcome of pulmonary rehabilitation because it is a potentially modifiable factor that can improve prognosis.
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Current evidence from pulmonary rehabilitation studies shows inconsistent results in modifying physical activity.
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Behavioral components of pulmonary rehabilitation are a target of future research aimed at having an impact on levels of physical

Components of pulmonary rehabilitation addressing physical activity

Pulmonary rehabilitation programs provide an excellent framework to enhance patients’ capabilities and promote physical activity. Rehabilitation aims to address both the pathophysiologic limitations to physical activity and the low levels of self-efficacy for regular exercise (through promoting self-management), thus addressing the 2 pillars of inactivity: physical limitation and maladaptive behavior.

How physical activity is measured as an outcome of pulmonary rehabilitation

Energy-expenditure assessment and the use of questionnaires and motion sensors are means used to quantify physical (in)activity. Assessment of energy expenditure aims at measuring how much energy is spent in physical activity, and not specifically at measuring the amount and intensity of the physical activity performed. Energy expended in physical activity depends on several factors such as age, gender, body mass, movement efficiency, and the energy cost of each activity.30, 31 This complexity,

Effects of pulmonary rehabilitation on physical activity

Physical activity has only been recently included as an outcome of pulmonary rehabilitation, when the independent effects of physical activity on outcomes in chronic respiratory diseases became apparent and direct measures of activity were made available. Again, most of the available evidence comes from studies of patients with COPD. Unfortunately, the results of these studies have been inconsistent: some have demonstrated statistically significant increases in activity level after pulmonary

Challenges of pulmonary rehabilitation in promoting physical activity

The increase (or maintenance) of daily physical activity up to the recommended level of 30 minutes per day of moderate physical activity on most days of the week49, 50 should be a target of pulmonary rehabilitation programs. Ideally this goal should be set irrespective of the underlying disease or baseline levels of physical activity. However, the current organization and content of pulmonary rehabilitation programs impose some limitations and, therefore, future challenges, to achieving this

Summary

Physical activity is a strong and independent risk factor for increased health care utilization and mortality in patients with COPD and, probably, in all patients with chronic respiratory disease. As such, and because of its potential response to exercise capacity and behavioral interventions, it has become a key outcome for pulmonary rehabilitation programs. Research thus far has provided inconsistent results on the potential beneficial effects of pulmonary rehabilitation on levels of physical

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Citation Excerpt :
Despite the high level of evidence for improvement in many clinically important outcomes in COPD, the effects of PR in relation to lifestyle changes are still contradictory [6]. It is well-established that an increase of 600 steps per day after PR can be considered a clinically important improvement in PADL level in patients with COPD [7] and that long-term programs provide greater benefits [8,9]. Recently, a study demonstrate that patients with better baseline exercise capacity (6MWT ≥ 350 m) presented higher chance of achieve the minimal important difference (MID) of PADL after PR [10].
Knowing the patients with chronic obstructive pulmonary disease (COPD) that increase the physical activity of daily living (PADL) after pulmonary rehabilitation (PR) is a challenge. Aims: to compare baseline characteristics between patients who achieved and failed to achieve the minimal important difference (MID) of PADL post-PR; to verify which baseline variables better predict the change and identify a cut-off point to discriminate MID achievers.
Fifty-three patients with COPD (FEV₁: 38.3; 95%CI 34.4–42.2%pred) were evaluated for spirometry, dyspnea, quality of life, functional capacity, mortality risk and PADL level. After 24 sessions of PR had their PADL level revaluated.
The MID achievers presented lower FEV₁, functional capacity, time walking, number of steps, active time, energy expenditure (EE) walking, time on PADL≥3 metabolic equivalent of task (METs) and higher time on PADL<1.5MET. Inactive patients and with severe physical inactivity presented a hazard ratio of 4.27 and 6.90 (95%CI: 1.31–13.9, p = 0.02; 95%CI: 1.99–23.9, p = 0.002; respectively) for achieving the MID. The variables of predictive model for the change in the PADL were EE walking and time on PADL<1.5MET (R²: 0.37; p = 0.002). The cut-off point of 6525 steps [sensitivity = 95%; specificity = 61%; AUC = 0.82 (95%CI: 0.71–0.93), p < 0.001] was able to discriminate patients who achieved and failed to achieve the MID.
Patients with worse lung function, functional capacity and lower PADL level before PR are those that improve the PADL level. EE walking and time on PADL<1.5MET better predict this change. The cut-off point of 6525 steps can help to identify patients with higher chances of improving the PADL level.
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: The authors have no conflicts of interest.

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