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REVIEW
Exercise training combined with psychological interventions for people with chronic obstructive pulmonary disease LOUISE WILES,1 PAUL CAFARELLA2 AND MARIE T. WILLIAMS3 1
School of Health Sciences, Division of Health Sciences, 3School of Population Health and Centre for Nutritional Physiology, Sansom Institute for Health Research, School of Health Sciences, University of South Australia, and 2Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, South Australia, Australia
ABSTRACT Previous systematic reviews have confirmed the benefits of both exercise training and psychological interventions in people with chronic obstructive pulmonary disease (COPD). The objective of this systematic review was to examine the effect of interventions which combine exercise training and psychological interventions for a range of health outcomes in people with COPD. Database searches identified randomized controlled trials of people with COPD participating in interventions that combined exercise training with a psychological strategy compared with control (usual care, waiting list) or active comparators (education, exercise, psychological interventions alone). Health outcomes included dyspnoea, anxiety, depression, quality of life or functional exercise capacity. Standardized mean differences (SMD) were calculated for each intervention arm/control comparison. Across the 12 included studies (738 participants), compared with control conditions, SMD consistently favoured interventions which included both exercise + psychological components (SMD range dyspnoea −1.63 to −0.25; anxiety −0.50 to −0.20; depression −0.46 to −0.18; quality of life 0.09 to 1.16; functional exercise capacity 0.22 to 1.23).When compared with active comparators, SMD consistently favoured interventions that included exercise training + psychological component for dyspnoea (SMD range −0.35 to −0.97), anxiety (SMD range −0.13 to −1.00) and exercise capacity (SMD range 0.64 to 0.71) but were inconsistent for depression (−0.11 to 1.27) and quality of life (0.02 to −2.00). The magnitude of effect for most interventions was greater than the minimum required for clinical significance (i.e. > 0.32) in behavioural medicine. While interventions, outcomes and effect sizes differed substantially between studies, combining exercise training with a psychological intervention may provide a means of optimizing rehabilitation in people with COPD. Correspondence: Louise Wiles, School of Health Sciences, Division of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide, SA 5000, Australia. Email: [email protected] Received 1 April 2014; invited to revise 23 May 2014; revised 31 July 2014; accepted 19 August 2014 (Associate Editor: Melissa Benton). © 2014 Asian Pacific Society of Respirology
Key words: chronic obstructive pulmonary disease, exercise training, psychological intervention, pulmonary rehabilitation, systematic review. Abbreviations: 6MWT, 6-min walk test; BDI, Beck Depression Inventory; COPD, chronic obstructive pulmonary disease; CPR, comprehensive pulmonary rehabilitation; CRQ, Chronic Respiratory Questionnaire; CRQ-D, Chronic Respiratory Questionnaire dyspnoea subscore; FEV1, forced expiratory volume in 1 s; PEDro, Physiotherapy Evidence Database; QOL, quality of life; RCT, randomized controlled trials; SD, standard deviation; SMD, standardized mean difference.
INTRODUCTION Exercise training with or without education has been shown to improve psychological well-being (e.g. anxiety and depression), health-related quality of life (QOL) and functional exercise capacity in people with chronic obstructive pulmonary disease (COPD).1–4 Psychologically based interventions (e.g. cognitive behaviour therapy) have also been used in this same population to manage anxiety, depression, QOL,5–11 dyspnoea12 and exercise tolerance.13 Over the last decade, four systematic reviews (with and without meta-analysis) have examined the evidence base for psychologically based interventions to alleviate anxiety and depression in people with COPD14–17 with one systematic review for adults with asthma.18 These reviews variously concluded that there was insufficient,17,18 limited14,16 and sufficient evidence15 to support the use of psychological interventions. Each of these reviews included studies where psychological interventions may have been provided in combination with exercise training, and (with the exception of Coventry et al.15) did not undertake subgroup analyses to compare different forms of interventions. The magnitude of effect also varied substantially among these reviews, ranging from small,14,15,17 moderate,15,18 large,16 to very large17 for common measures of anxiety. However, the ability to pool data and/or draw meaningful conclusions from these reviews was limited by the considerable heterogeneity (i.e. interventions, outcomes) among included studies. Respirology (2015) 20, 46–55 doi: 10.1111/resp.12419
Exercise and psychological interventions
Given that high-level evidence exists to support both exercise training and psychological interventions in the management of people with COPD, it is currently unclear if combining psychologically based interventions and exercise training results in greater improvements in health outcomes. In addition, the effects on outcomes such as dyspnoea, QOL and functional exercise capacity are also unknown.15 The aim of this systematic review was to examine whether, in people with COPD, combining psychologically based interventions with exercise training resulted in greater improvements in dyspnoea, anxiety, depression, QOL and functional exercise capacity compared with control conditions or other interventions.
METHODS The protocol for this review was developed a priori and published on the International Prospective Register of Systematic Reviews (PROSPERO, registration number CRD42013003584).
Review question In adults with COPD, do psychological interventions combined with exercise training provide greater benefit in dyspnoea, anxiety, depression, QOL and functional exercise outcomes compared with a range of comparators? Information sources and search strategy Electronic databases (searched 1 August 2013) included: OVID Medline (1946 to present), AMED (Allied and Complementary Medicine) (1985 to present), EMBASE (1974 to present), PsycINFO (1840 to present), CINAHL (1982 to present), Scopus, Web of Science (1983 to present), Cochrane Library and CENTRAL, World Health Organisation International Clinical Trials Registry Platform and PROSPERO. The search strategy was based on previous existing systematic reviews of psychological interventions in COPD14–17 and developed using Cochrane reviews as a guide.18 Search terms and MeSH/keyword terms (e.g. COPD, exercise*, psychotherap*) were collated for psychological intervention(s), exercise training or pulmonary rehabilitation, and adults with COPD. A psychologist (P.C.) and an academic librarian (University of South Australia) reviewed the search strategy.19 The search terms and strategy were adapted for use in all trials registers and databases searched (Supplementary Table S1 presents the OVID Medline database). No search limits for publication type, year or language were set. The search was conducted simultaneously by two independent researchers (L.W., H.L.) within the same 24 h to moderate daily updating of databases with consistency confirmed through crosschecking (100% consistency). Eligibility Studies were eligible for inclusion in this review if they met the following criteria: © 2014 Asian Pacific Society of Respirology
47 Study design Randomized controlled trials (RCTs) published in any language and year in peer-reviewed journals. Participants Adults (aged over 18 years) with a physician or spirometric diagnosis of COPD or COPD/asthma overlap (using diagnostic criteria of the American Thoracic Society 2004, British Thoracic Society 2010, European Respiratory Society or Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011),20–23 irrespective of their gender, disease severity or medical comorbidities (e.g. diagnosis of anxiety/ depression). Populations with non-reversible asthma were excluded. Interventions All forms of psychological interventions delivered to individuals or groups in conjunction with exercise training or standard comprehensive pulmonary rehabilitation (CPR), of greater than 2 weeks duration in any setting (e.g. hospital, outpatient, community, home). Psychological interventions were defined as any procedure by which therapists (i.e. the professional charged with delivering or facilitating the therapy such as psychologists, psychiatrists, counsellors) purposively and systematically attempted to influence patients by psychological means leading to a reduction in symptoms or a positive change in behaviour.18 Consistent with other reviews,14–17 CPR programmes which included educational or psychological based strategies/sessions were required to include more than a single exposure (e.g. education session). Comparator(s)/control All comparators which did not include a combination of exercise training and psychological intervention (e.g. true control conditions, usual care, psychological interventions alone, exercise training alone, pulmonary rehabilitation, waiting lists for the active intervention, other therapies). Outcomes All outcomes for dyspnoea, anxiety, depression, QOL and/or functional exercise capacity. Study selection Titles and abstracts of trials identified from the searches were independently screened by two reviewers and where eligible, full-text copies were assessed against the eligibility criteria. Additional studies were sought by reviewing the reference lists of all eligible studies and contacting an expert in the field of selfmanagement programmes for COPD (Dr Tanja Effing, Department of Respiratory Medicine, Repatriation General Hospital). Data extraction A data extraction template was prospectively developed based on the Cochrane Consumers and Respirology (2015) 20, 46–55
48 Communication Review Group’s data extraction template.24 Data extraction was pilot-tested on 10 randomly selected included studies and refined according to reviewers’ feedback. Two reviewers (L.W. and H.L.) independently extracted data, with any disagreements in data collection resolved by discussion (9 of 996 data entries, 0.90%). The following information was extracted verbatim from each included study: • Publication demographics: year of publication, country of study location, study design • Participants: group mean and standard deviation (SD) for participants’ age and pulmonary function (e.g. forced expiratory volume in 1 s (FEV1)% predicted, FEV1/forced vital capacity), method of diagnosis (physician diagnosis, spirometry), comorbidities (psychological and others) • Intervention: details of exercise and psychological intervention(s), e.g. format (individual versus group sessions, study setting, duration) and content/type. The content/type of psychological intervention was categorized according to a taxonomy of behaviour change techniques (Supplementary Table S2), including the theoretical base18 and function.25 • Comparator: details of ‘control’ condition or comparator (e.g. true control conditions, usual care, psychological interventions alone, exercise training/pulmonary rehabilitation alone, other therapies) • Outcomes: For both primary (dyspnoea, anxiety, depression, QOL) and secondary outcomes (functional exercise), instrument(s) used to report outcome measures, pre and post and change score(s)/between group differences.
Risk of bias assessment Risks of bias assessments were either obtained from pre-existing information on the Physiotherapy Evidence Database (PEDro) website26 or undertaken using the PEDro scoring criteria independently by two reviewers.
Data analysis and synthesis Descriptive summaries of data were created. For each study that included continuous data for any primary or secondary outcomes, a standardized mean difference (SMD) was calculated by subtracting the mean of the control group from the mean of the intervention group, divided by the pooled SD.15 SMD are a useful expression of effect sizes when comparing the effects of an intervention across studies when different measures (and measurement scales) are used.15 If there were several follow-up measures made, outcome data closest to post-intervention were extracted. SMD were categorized as large (SMD of 0.56 to 1.2), moderate (0.33 to 0.55) and small (less than or equal to 0.32).15,27 Where trials reported two intervention groups and a single control group, or multiple measures for outcomes, separate SMD were calculated for each eligible intervention group and outcome measurement.15 Respirology (2015) 20, 46–55
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RESULTS Twelve RCT met the inclusion criteria for this systematic review (Fig. 1). The diagnosis of COPD was established by spirometry, with the majority of studies (n = 9, 75%) including participants with moderate or severe airflow obstruction (Table 1). A summary of studies and interventions detailed are presented in Supplementary Table S3a,b. Supervised exercise and relaxation training were the most commonly employed interventions (n = 6 studies)5,29–33 within CPR programmes. Comparators included usual care, wait listing, psychological interventions or exercise or education alone. Risk of bias information (PEDro scores) was publically available for 10 included studies, with the remaining two studies independently scored by each of the reviewers using the PEDro criteria (mean score 5, SD 1 (Supplementary Table S4)). Outcome measures for both primary and secondary outcomes differed substantially across studies (Figs 2a,b;3a,b) with less than half of the studies using the same outcome measures for dyspnoea (Chronic Respiratory Questionnaire dyspnoea subscore (CRQD): n = 5), anxiety (Beck Anxiety Inventory: n = 2), depression (Beck Depression Inventory (BDI): n = 3), QOL (Chronic Respiratory Questionnaire (CRQ) total score: n = 5) and functional exercise capacity (6-min walk test (6MWT): n = 6). Lindsay et al.35 reported insufficient data with which to calculate effect size/ SMD. Berry et al.38 reported estimated means for repeated measures analysis (adjusted for age and gender) for QOL measures and physical function. Due to the heterogeneity of intervention/control conditions and outcome measures, meta-analysis was not performed. Separate forest plots were created for interventions (exercise and psychological components) versus control conditions (e.g. wait listing list for active intervention, usual care, Fig. 2a,b) or active comparators (e.g. education/lecture series, exercise/ psychotherapy alone, Fig. 3a,b). Compared with control conditions, SMD consistently favoured interventions which included both exercise + psychological components (SMD range dyspnoea −1.63 to −0.25; anxiety −0.50 to −0.20; depression −0.46 to −0.18; QOL 0.09 to 1.16; functional exercise capacity 0.22 to 1.23 ) (Fig. 2a,b). When compared with active comparators, SMD consistently favoured interventions that included exercise training and a psychological component for dyspnoea (SMD range −0.35 to −0.97), anxiety (SMD range −0.13 to −1.00) and exercise capacity (SMD range 0.64 to 0.71), but were inconsistent for depression (−0.11 to 1.27) and QOL (0.02 to −2.00) (Fig 3a,b).
DISCUSSION The majority of randomized trials included within this review consistently favoured interventions that combined exercise training with a psychological intervention for dyspnoea, anxiety, depression, QOL and exercise performance when compared with control or active comparator conditions. With the exception of two outcomes in two studies (depression © 2014 Asian Pacific Society of Respirology
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Exercise and psychological interventions 975 records identified through database searching
807 records after duplicates removed
604 records excluded
807 records screened
(after review of title and abstract)
203 full-text articles assessed for eligibility
171 full-text articles excluded on the basis of:
research design no psych intervention no exercise / CPR non-COPD participants single session psych only
111 36 14 7 3
contacted PROSPERO and
10 full-text articles
screened reference lists of
WHO protocol authors
11 systematic reviews
systematic reviews
(n=10)
8 PROSPERO systematic review protocols
(n=11)
2 WHO International Trial Registry protocols
no additional studies
12 full-text articles
identified
2 additional studies identified
no additional studies identified
list of 12 studies submitted to
for inclusion
independent expert for review
12 studies included in final analysis
Figure 1
Modified PRISMA flow chart outlining the search results (Moher et al. 2009).28
and QOL37,38), this pattern was consistent irrespective of the specific nature of the psychological intervention, the intervention prescription or setting. The magnitude of effect for most interventions was greater than the minimum required for clinical significance (i.e. > 0.32) in behavioural medicine.15,27 Previous authors of systematic reviews concerning psychological interventions for people with COPD15 have pooled data between studies and completed meta-analysis; we opted to use a more conservative approach by reporting SMD for each outcome. Our decision was based on the considerable heterogeneity in outcomes measures, interventions and comparators. The diversity of interventions/comparators and outcome measures is reflected in Table 1 and Figures 2a,b and 3a,b. Interventions differed in numerous ways including their focus (e.g. relaxation, © 2014 Asian Pacific Society of Respirology
psychosocial support, cognitive behavioral therapy), length (range 8 to 16 weeks), maximum number of supervised sessions (range 4 to 63), duration of sessions (range 15 to 240 minutes) and setting (outpatient versus home). In theory, the nature of the comparator was also likely to influence the effect sizes with control comparators (usual care, waiting list) likely to have larger effects than active intervention comparators which may have variable, associated impacts on psycho-cognitive processes (Supplementary Table S3a,b). There were two pairs of studies—Wijkstra et al.29,30 and de Godoy et al.5,6—that appeared to report on similar datasets. The first pair of studies29,30 differed in the outcomes reported for dyspnoea (CRQ-D, Borg) and functional exercise capacity (W max/cycle ergometry, 6MWT) (Supplementary Table S3a). The Respirology (2015) 20, 46–55
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Key COPD diagnosis: S P
Control/comparator
Exercise training + psychological intervention
Spirometry Physician
Sample size Mean age COPD diagnosis GOLD stage Exercise training Inspiratory muscle training Breathing retraining Education Tiotropium Dietary intervention Relaxation training Stress management Cognitive behavioral therapy Psychotherapy Psychosocial support Activity training/counselling Dyspnoea strategies Motivational interviewing Usual care Waiting list Education Exercise training Psychotherapy Tiotropium
43 63 S 3
Wijkstra et al.30
GOLD stages: GOLD stage 1 GOLD stage 2
43 63 S 3
Wijkstra et al.29 40 67 S 3
Guell et al.31 45 66 S 2
Kayahan et al.32
Mild Moderate
79 67 S 3
Emery et al.33 119 63 S/P 3
Ries et al.34
Table 1 Summary of participants’ characteristics and intervention and control/comparator components
49 >50 S/P 4
de Godoy et al.6 30 61 S/P 3
GOLD Stage 3 GOLD stage 4
50 70 S 1
Lindsay et al.35
de Godoy and de Godoy5 43 77 S/P 2
Norweg et al.36
21 64 S 2/3
176 66 S 2
Berry et al.38
Severe Very severe
de Blok et al.37
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(a) Wijkstra et al.29 Wijkstra et al.30 Guell et al.31 Kayahan et al.32
Emery et al. 199833(A) Guell et al.31 Kayahan et al.32
Emery et al. 199833(A)
Guell et al.31 Kayahan et al.32 (b) Wijkstra et al.29
Emery et al. 199833(A)
Guell et al.31
Kayahan et al.32
Wijkstra et al.29 Wijkstra et al.30 Emery et al. 199833(A)
Guell et al.31 Kayahan et al.32
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Figure 2 Effects of interventions compared with control for the outcomes of dyspnoea, anxiety, depression, quality of life and functional exercise capacity. (a) Negative standardized mean difference (SMD) values favoured the intervention for the outcomes of dyspnoea, anxiety and depression. (b) Positive SMD values favoured the intervention for the outcomes of quality of life and functional exercise capacity. 6MWT, 6-min walk test; ABS, Affect Balance Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiologic Studies Depression Scale; CRQ, Chronic Respiratory Questionnaire; CRQ-D, Chronic Respiratory Questionnaire dyspnoea domain; CRQ-E, Chronic Respiratory Questionnaire emotional function domain; CRQ-F, Chronic Respiratory Questionnaire fatigue domain; CRQ-M, Chronic Respiratory Questionnaire mastery domain; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Rating Scale for Depression; HR, heart rate; MHLOC-C, Multidimensional Health Locus of Control (chance health); MHLOC-I, Multidimensional Health Locus of Control (internal health); MHLOC-PO, Multidimensional Health Locus of Control (powerful others health); RAND-36, 36-Item Short Form Survey from the RAND Medical Outcomes Study; SCL-90-R-A, Symptom Checklist-90-Revised-Anxiety subscale; SCL-90-R-D, Symptom Checklist-90-Revised-Depression subscale; SF-36, Short Form Health Survey; SGRQ, St George’s Respiratory Questionnaire; SIP, Sickness Impact Profile; SOB-Q, Shortness of Breath Questionnaire; STAI, State-Trait Anxiety Inventory; VAS, visual analogue scale; VO2 max, maximal oxygen uptake; VVAS, vertical visual analogue scale; W max, maximal workload of the cycle ergometer test. Emery et al.33(A) compared exercise, education and stress management (intervention arm) with wait-listed control.
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second pair of studies5,6 differed with respect to different GOLD stages for COPD severity (Supplementary Table S3a), and interventions that were categorized differently by type and the personnel who delivered them (Supplementary Table S3b). Hence, we have treated these two studies as separate studies. While this systematic review did not aim to explore the mechanisms underpinning the efficacy of exercise training combined with psychological interventions, the consistent pattern presented for the positive effects of exercise training combined with a psychological intervention suggests a number of possible mechanisms. In people with COPD, exercise is often limited due to cardiovascular and musculoskeletal deconditioning resulting in dyspnoea with minimum physical exertion. Dyspnoea is a distressing and often anxiety-provoking perceptual experience that may lead to early cessation or avoidance of physical activity. Providing people with strategies to manage anxiety (relaxation exercises, psychotherapy or cognitive restructuring) and the opportunity to practice these strategies during repeated safe exposures to dyspnoea-inducing situations (supervised exercise training) may result in a positive synergistic relationship between anxiety, dyspnoea and exercise behaviours with subsequent positive effects on depression and QOL.15,39 That is, as participants become more confident or proficient with strategies for reducing anxiety and/or managing dyspnoea, the duration/ intensity of exercise might be extended as the experience becomes less aversive. Repeated exposure to exercise training affords increased opportunities and potential for desensitization to dyspnoea as well as an expectation and acceptance of breathlessness as a component of exercise. The subsequent improvement in anxiety and dyspnoea management may promote higher levels of exercise performance, potentially contributing to reduced depression and improved QOL.39 Alternatively, by their nature, psychological interventions require the time and attention of a ‘therapist’ in order to purposively and systematically educate individuals or groups in cognitive or other psychological strategies which target specific symptoms or patterns of behaviour.25 Therapeutic attention may also be provided by staff supervising exercise sessions in order to educate, motivate and encourage participants to achieve their exercise goals. The psychosocial benefits (e.g. support) of regular education and training (exercise and/or Respirology (2015) 20, 46–55
psychological strategies) in a group environment that includes participants with similar chronic health conditions may also contribute to improved health outcomes.15,39 Both de Blok et al.37 and Berry et al.38 included similar comparators (pulmonary rehabilitation, exercise training and education) and interventions (exercise training with activity counseling), with de Blok et al.’s37 psychological intervention including feedback from a pedometer. The most likely explanation for SMD favouring the comparator in Berry et al.’s38 trial is the disparity in durations of the intervention arms. At the 3-month assessment point, 25% (17 contact hours) of the lifestyle activity programme versus 100% (36 contact hours) traditional exercise and education intervention was complete. As a result of attrition, de Blok et al.’s37 study was limited by small sample size (n = 8 in each intervention arm) and while the SMD for depression and QOL outcomes favoured the comparator, the effect sizes were generally small and there was no significant difference between the intervention or comparator (depression BDI: P = 0.79, effect size =0.19; St George’s Respiratory Questionnaire total score: P = 0.55, effect size = 0.36).37 One of the issues associated with reviewing nonpharmacological interventions for people with COPD is the difficulty with defining and categorizing interventions. There is no clear definition for psychological interventions and little consistency in the terms authors use to describe such interventions.40 Similarly, there are also a variety of terms used to describe different rehabilitative approaches for people with COPD encompassing exercise and pulmonary rehabilitation: self-management,41 holistic42 and complex interventions.15 Hybrid interventions including psychological, exercise and/or comprehensive rehabilitation components are increasingly being used in the management of COPD and other chronic health conditions.43 Future consistency in the terms used to describe interventions and their function may help standardize the reporting of research studies in this area, and enable more direct comparisons to be made for outcomes across studies. The results of this review indicated that interventions combining exercise training with psychological strategies were associated with consistent benefits in terms of dyspnoea, anxiety, depression, QOL and functional exercise capacity, particularly when © 2014 Asian Pacific Society of Respirology
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Figure 3 Effects of interventions compared with other active comparators for the outcomes of dyspnoea, anxiety, depression, quality of life and functional exercise capacity. (a) Negative SMD values favoured the intervention for the outcomes of dyspnoea, anxiety and depression. (b) Positive SMD values favoured the intervention for the outcomes of quality of life and functional exercise capacity. 6MWT, 6-min walk test; ABS, Affect Balance Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiologic Studies Depression Scale; CRQ, Chronic Respiratory Questionnaire; CRQ-D, Chronic Respiratory Questionnaire dyspnoea domain; CRQ-E, Chronic Respiratory Questionnaire emotional function domain; CRQ-F, Chronic Respiratory Questionnaire fatigue domain; CRQ-M, Chronic Respiratory Questionnaire mastery domain; Dxw, Distance walked weight; endur, endurance; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Rating Scale for Depression; HR, heart rate; MHLOC-C, Multidimensional Health Locus of Control (chance health); MHLOC-I, Multidimensional Health Locus of Control (internal health); MHLOC-PO, Multidimensional Health Locus of Control (powerful others health); QWB, Quality of Well-being Scale; RAND-36 BP, 36-Item Short Form Survey from the RAND Medical Outcomes Study (bodily pain); RAND-36 GH, 36-Item Short Form Survey from the RAND Medical Outcomes Study (general health perception); RAND-36 HC, 36-Item Short Form Survey from the RAND Medical Outcomes Study (health change); RAND-36 PF, 36-Item Short Form Survey from the RAND Medical Outcomes Study (physical functioning); RAND-36 V, 36-Item Short Form Survey from the RAND Medical Outcomes Study (vitality);SCL-90-R-A, Symptom Checklist-90-Revised-Anxiety subscale; SCL-90-R-D, Symptom Checklist-90-Revised-Depression subscale; SF-36, Short Form Health Survey; SGRQ, St George’s Respiratory Questionnaire; SIP, Sickness Impact Profile; SOB-Q, Shortness of Breath Questionnaire; STAI, State-Trait Anxiety Inventory; VAS, visual analogue scale; VO2 max, maximal oxygen uptake; VVAS, vertical visual analogue scale; W, workload; W max, maximal workload of the cycle ergometer test. Emery et al.33(B) compared exercise, education and stress management (intervention) and education and stress management (no exercise, other comparator). de Godoy et al.6(A) compared exercise and psychotherapy (intervention) and exercise (other comparator). de Godoy et al.6(B) compared exercise and psychotherapy (intervention) and psychotherapy (other comparator). Norweg et al.36(A) compared exercise and activity training (intervention) and exercise (other comparator). Norweg et al.36(B) compared exercise and activity training (intervention) and exercise and lecture series (other comparator). ◀
compared with control conditions. These benefits were evident irrespective of the type of psychological intervention employed by individual studies. While there may be a number of inter-related mechanisms underpinning these improvements in health outcomes, determining the nature and type of psychological processes inherent within exercise training, group dynamics and specific psychological interventions may assist in optimizing rehabilitation for people with COPD.
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Acknowledgements This study was supported by the National Health and Medical Research Council (NHMRC) Australia (NHMRC Project Grant 1010309). The study team would like to thank Ms Halyey Lewthwaite for her assistance in independently undertaking the search strategy, data extraction and appraisal of methodological bias and Dr Tanja Effing for her expertise and valuable critique of the manuscript.
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treatments to reduce anxiety and panic in patients with chronic obstructive pulmonary disease. Patient Educ. Couns. 2002; 47: 311–18. Yorke J, Fleming SL, Shuldham C. Psychological interventions for adults with asthma (review). Cochrane Database Syst. Rev. 2009; 1: CD002982. Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C. An evidence-based practice guideline for the peer review of electronic search strategies. J. Clin. Epidemiol. 2009; 62: 944–52. American Thoracic Society, ATS; 2004, Standards for the diagnosis and management of patients with COPD, [Accessed 22 Sept 2014.] Available from URL: http://www.thoracic.org/clinical/ copd-guidelines/resources/copddoc.pdf British Thoracic Society, BTS; 2010, Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care, [Accessed 22 Sept 2014.] Available from URL: http://www.nice.org.uk/ nicemedia/live/13029/49425/49425.pdf European Respiratory Society, ERS; 2011, Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease, [Accessed 22 Sept 2014.] Available from URL: http://www.goldcopd.org/uploads/users/files/GOLD_Report _2011_Feb21.pdf Global Initiative for Chronic Obstructive Lung Disease 2011, Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease, [Accessed 14 October 2012.], Available from URL: http://www.goldcopd.com Cochrane 2012, Cochrane Consumers and Communication Review Group data extraction template, Accessed 19 November 2012, Available from URL: http://www.latrobe.edu.au/chcp/ cochrane/resources.html Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement. Sci. 2011; 6: 42. PEDro 1999, The PEDro scale. [Accessed 23 Oct 2013.] Available from URL: http://www.pedro.org.au/wp-content/uploads/ PEDro_scale.pdf Lipsey MW, Wilson DB. The efficacy of psychological, educational and behavioural treatment: confirmation from metaanalysis. Am. Psychol. 1993; 48: 1181–209. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. PLoS Med. 2009; 6: e1000097. doi: 10.1371/journal.pmed1000097. Wijkstra PJ, Van Altena R, Kraan J, Otten V, Postma DS, Koëter GH. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. Eur. Respir. J. 1994; 7: 269–73. Wijkstra PJ, van der Mark TW, Kraan J, van Altena R, Koëter GH, Postma DS. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease. Eur. Respir. J. 1996; 9: 104–10. Guell R, Resqueti V, Sangenis M, Morante F, Martorell B, Casan P, Guyatt GH. Impact of pulmonary rehabilitation on psychosocial morbidity in patients with severe COPD. Chest 2006; 129: 899– 904. Kayahan B, Karapolat H, Atýntoprak E, Ataseverc A, Oztürk O. Psychological outcomes of an outpatient pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease. Respir. Med. 2006; 100: 1050–7. Emery CF, Schein RL, Hauck ER, MacIntyre NR. Psychological and cognitive outcomes of a randomized trial of exercise among
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patient with chronic obstructive pulmonary disease. Health Psychol. 1998; 17: 232–40. Ries A, Kaplan R, Limberg T, Prewitt L. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann. Intern. Med. 1995; 122: 823–32. Lindsay M, Lee A, Chan K, Poon P, Hasn LK, Wong WCW, Wong S. Does pulmonary rehabilitation give additional benefit over tiotropium therapy in primary care management of chronic obstructive pulmonary disease? Randomized controlled clinical trial in Hong Kong Chinese. J. Clin. Pharm. Ther. 2005; 30: 567–73. Norweg A, Whiteson J, Malgady R, Mola A, Rey M. The effectiveness of different combinations of pulmonary rehabilitation program components: a randomized controlled trial. Chest 2005; 128: 663–72. de Blok B, De Greef M, ten Hacken N, Sprenger SR, Postema K, Wempe JB. The effects of a lifestyle physical activity counselling program with feedback of a pedometer during pulmonary rehabilitation in patients with COPD: a pilot study. Patient Educ. Couns. 2006; 61: 48–55. Berry MJ, Rejeski J, Miller ME, Adair NE, Lang W, Foy CG, Katula JA. A lifestyle activity intervention in patients with chronic obstructive pulmonary disease. Respir. Med. 2010; 104: 829–39. Norweg A, Collins EG. Evidence for cognitive-behavioral strategies Improving dyspnoea and related distress in COPD. Int. J. Chron. Obstruct. Pulmon. Dis. 2013; 8: 439–51. Hodges LJ, Walker J, Kleiboer AM, Ramirez AJ, Richardson A, Velikova G, Sharpe M. What is a psychological intervention? A metareview and practical proposal. Psychooncology 2011; 20: 470–8. Effing TW, Bourbeau J, Vercoulen J, Apter AJ, Coultas D, Meek P, van der Valk P, Partridge MR, van der Palen J. Self management programmes for COPD: moving forward. Chron. Respir. Dis. 2012; 9: 27–35. Nurmatov UB, Buckingham S, Kendall M, Sheikh A, Pinnock S. Can holistic interventions improve the care of people with severe chronic obstructive pulmonary disease (COPD)? A systematic review. Thorax 2012; 67: A154. doi: 10.1136/thoraxjnl-2012202678.268. Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst. Rev. 2012; (4): Art. No.: CD006560. doi: 10.1002/ 14651858.CD006560.pub2.
Supplementary Information Additional Supplementary Information can be accessed via the html version of this article at the publisher’s web-site: Supplementary Table S1 Search terms and strategy for OVID Medline database. Supplementary Table S2 The categorizations used for each interventions’ theoretical base and function. Supplementary Table S3 (a) Characteristics of the study populations; (b) Characteristics of the interventions. Supplementary Table S4 Risk of bias assessment (PEDro scale) for included articles.
Respirology (2015) 20, 46–55
REVIEW
Exercise training combined with psychological interventions for people with chronic obstructive pulmonary disease LOUISE WILES,1 PAUL CAFARELLA2 AND MARIE T. WILLIAMS3 1
School of Health Sciences, Division of Health Sciences, 3School of Population Health and Centre for Nutritional Physiology, Sansom Institute for Health Research, School of Health Sciences, University of South Australia, and 2Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, South Australia, Australia
ABSTRACT Previous systematic reviews have confirmed the benefits of both exercise training and psychological interventions in people with chronic obstructive pulmonary disease (COPD). The objective of this systematic review was to examine the effect of interventions which combine exercise training and psychological interventions for a range of health outcomes in people with COPD. Database searches identified randomized controlled trials of people with COPD participating in interventions that combined exercise training with a psychological strategy compared with control (usual care, waiting list) or active comparators (education, exercise, psychological interventions alone). Health outcomes included dyspnoea, anxiety, depression, quality of life or functional exercise capacity. Standardized mean differences (SMD) were calculated for each intervention arm/control comparison. Across the 12 included studies (738 participants), compared with control conditions, SMD consistently favoured interventions which included both exercise + psychological components (SMD range dyspnoea −1.63 to −0.25; anxiety −0.50 to −0.20; depression −0.46 to −0.18; quality of life 0.09 to 1.16; functional exercise capacity 0.22 to 1.23).When compared with active comparators, SMD consistently favoured interventions that included exercise training + psychological component for dyspnoea (SMD range −0.35 to −0.97), anxiety (SMD range −0.13 to −1.00) and exercise capacity (SMD range 0.64 to 0.71) but were inconsistent for depression (−0.11 to 1.27) and quality of life (0.02 to −2.00). The magnitude of effect for most interventions was greater than the minimum required for clinical significance (i.e. > 0.32) in behavioural medicine. While interventions, outcomes and effect sizes differed substantially between studies, combining exercise training with a psychological intervention may provide a means of optimizing rehabilitation in people with COPD. Correspondence: Louise Wiles, School of Health Sciences, Division of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide, SA 5000, Australia. Email: [email protected] Received 1 April 2014; invited to revise 23 May 2014; revised 31 July 2014; accepted 19 August 2014 (Associate Editor: Melissa Benton). © 2014 Asian Pacific Society of Respirology
Key words: chronic obstructive pulmonary disease, exercise training, psychological intervention, pulmonary rehabilitation, systematic review. Abbreviations: 6MWT, 6-min walk test; BDI, Beck Depression Inventory; COPD, chronic obstructive pulmonary disease; CPR, comprehensive pulmonary rehabilitation; CRQ, Chronic Respiratory Questionnaire; CRQ-D, Chronic Respiratory Questionnaire dyspnoea subscore; FEV1, forced expiratory volume in 1 s; PEDro, Physiotherapy Evidence Database; QOL, quality of life; RCT, randomized controlled trials; SD, standard deviation; SMD, standardized mean difference.
INTRODUCTION Exercise training with or without education has been shown to improve psychological well-being (e.g. anxiety and depression), health-related quality of life (QOL) and functional exercise capacity in people with chronic obstructive pulmonary disease (COPD).1–4 Psychologically based interventions (e.g. cognitive behaviour therapy) have also been used in this same population to manage anxiety, depression, QOL,5–11 dyspnoea12 and exercise tolerance.13 Over the last decade, four systematic reviews (with and without meta-analysis) have examined the evidence base for psychologically based interventions to alleviate anxiety and depression in people with COPD14–17 with one systematic review for adults with asthma.18 These reviews variously concluded that there was insufficient,17,18 limited14,16 and sufficient evidence15 to support the use of psychological interventions. Each of these reviews included studies where psychological interventions may have been provided in combination with exercise training, and (with the exception of Coventry et al.15) did not undertake subgroup analyses to compare different forms of interventions. The magnitude of effect also varied substantially among these reviews, ranging from small,14,15,17 moderate,15,18 large,16 to very large17 for common measures of anxiety. However, the ability to pool data and/or draw meaningful conclusions from these reviews was limited by the considerable heterogeneity (i.e. interventions, outcomes) among included studies. Respirology (2015) 20, 46–55 doi: 10.1111/resp.12419
Exercise and psychological interventions
Given that high-level evidence exists to support both exercise training and psychological interventions in the management of people with COPD, it is currently unclear if combining psychologically based interventions and exercise training results in greater improvements in health outcomes. In addition, the effects on outcomes such as dyspnoea, QOL and functional exercise capacity are also unknown.15 The aim of this systematic review was to examine whether, in people with COPD, combining psychologically based interventions with exercise training resulted in greater improvements in dyspnoea, anxiety, depression, QOL and functional exercise capacity compared with control conditions or other interventions.
METHODS The protocol for this review was developed a priori and published on the International Prospective Register of Systematic Reviews (PROSPERO, registration number CRD42013003584).
Review question In adults with COPD, do psychological interventions combined with exercise training provide greater benefit in dyspnoea, anxiety, depression, QOL and functional exercise outcomes compared with a range of comparators? Information sources and search strategy Electronic databases (searched 1 August 2013) included: OVID Medline (1946 to present), AMED (Allied and Complementary Medicine) (1985 to present), EMBASE (1974 to present), PsycINFO (1840 to present), CINAHL (1982 to present), Scopus, Web of Science (1983 to present), Cochrane Library and CENTRAL, World Health Organisation International Clinical Trials Registry Platform and PROSPERO. The search strategy was based on previous existing systematic reviews of psychological interventions in COPD14–17 and developed using Cochrane reviews as a guide.18 Search terms and MeSH/keyword terms (e.g. COPD, exercise*, psychotherap*) were collated for psychological intervention(s), exercise training or pulmonary rehabilitation, and adults with COPD. A psychologist (P.C.) and an academic librarian (University of South Australia) reviewed the search strategy.19 The search terms and strategy were adapted for use in all trials registers and databases searched (Supplementary Table S1 presents the OVID Medline database). No search limits for publication type, year or language were set. The search was conducted simultaneously by two independent researchers (L.W., H.L.) within the same 24 h to moderate daily updating of databases with consistency confirmed through crosschecking (100% consistency). Eligibility Studies were eligible for inclusion in this review if they met the following criteria: © 2014 Asian Pacific Society of Respirology
47 Study design Randomized controlled trials (RCTs) published in any language and year in peer-reviewed journals. Participants Adults (aged over 18 years) with a physician or spirometric diagnosis of COPD or COPD/asthma overlap (using diagnostic criteria of the American Thoracic Society 2004, British Thoracic Society 2010, European Respiratory Society or Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011),20–23 irrespective of their gender, disease severity or medical comorbidities (e.g. diagnosis of anxiety/ depression). Populations with non-reversible asthma were excluded. Interventions All forms of psychological interventions delivered to individuals or groups in conjunction with exercise training or standard comprehensive pulmonary rehabilitation (CPR), of greater than 2 weeks duration in any setting (e.g. hospital, outpatient, community, home). Psychological interventions were defined as any procedure by which therapists (i.e. the professional charged with delivering or facilitating the therapy such as psychologists, psychiatrists, counsellors) purposively and systematically attempted to influence patients by psychological means leading to a reduction in symptoms or a positive change in behaviour.18 Consistent with other reviews,14–17 CPR programmes which included educational or psychological based strategies/sessions were required to include more than a single exposure (e.g. education session). Comparator(s)/control All comparators which did not include a combination of exercise training and psychological intervention (e.g. true control conditions, usual care, psychological interventions alone, exercise training alone, pulmonary rehabilitation, waiting lists for the active intervention, other therapies). Outcomes All outcomes for dyspnoea, anxiety, depression, QOL and/or functional exercise capacity. Study selection Titles and abstracts of trials identified from the searches were independently screened by two reviewers and where eligible, full-text copies were assessed against the eligibility criteria. Additional studies were sought by reviewing the reference lists of all eligible studies and contacting an expert in the field of selfmanagement programmes for COPD (Dr Tanja Effing, Department of Respiratory Medicine, Repatriation General Hospital). Data extraction A data extraction template was prospectively developed based on the Cochrane Consumers and Respirology (2015) 20, 46–55
48 Communication Review Group’s data extraction template.24 Data extraction was pilot-tested on 10 randomly selected included studies and refined according to reviewers’ feedback. Two reviewers (L.W. and H.L.) independently extracted data, with any disagreements in data collection resolved by discussion (9 of 996 data entries, 0.90%). The following information was extracted verbatim from each included study: • Publication demographics: year of publication, country of study location, study design • Participants: group mean and standard deviation (SD) for participants’ age and pulmonary function (e.g. forced expiratory volume in 1 s (FEV1)% predicted, FEV1/forced vital capacity), method of diagnosis (physician diagnosis, spirometry), comorbidities (psychological and others) • Intervention: details of exercise and psychological intervention(s), e.g. format (individual versus group sessions, study setting, duration) and content/type. The content/type of psychological intervention was categorized according to a taxonomy of behaviour change techniques (Supplementary Table S2), including the theoretical base18 and function.25 • Comparator: details of ‘control’ condition or comparator (e.g. true control conditions, usual care, psychological interventions alone, exercise training/pulmonary rehabilitation alone, other therapies) • Outcomes: For both primary (dyspnoea, anxiety, depression, QOL) and secondary outcomes (functional exercise), instrument(s) used to report outcome measures, pre and post and change score(s)/between group differences.
Risk of bias assessment Risks of bias assessments were either obtained from pre-existing information on the Physiotherapy Evidence Database (PEDro) website26 or undertaken using the PEDro scoring criteria independently by two reviewers.
Data analysis and synthesis Descriptive summaries of data were created. For each study that included continuous data for any primary or secondary outcomes, a standardized mean difference (SMD) was calculated by subtracting the mean of the control group from the mean of the intervention group, divided by the pooled SD.15 SMD are a useful expression of effect sizes when comparing the effects of an intervention across studies when different measures (and measurement scales) are used.15 If there were several follow-up measures made, outcome data closest to post-intervention were extracted. SMD were categorized as large (SMD of 0.56 to 1.2), moderate (0.33 to 0.55) and small (less than or equal to 0.32).15,27 Where trials reported two intervention groups and a single control group, or multiple measures for outcomes, separate SMD were calculated for each eligible intervention group and outcome measurement.15 Respirology (2015) 20, 46–55
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RESULTS Twelve RCT met the inclusion criteria for this systematic review (Fig. 1). The diagnosis of COPD was established by spirometry, with the majority of studies (n = 9, 75%) including participants with moderate or severe airflow obstruction (Table 1). A summary of studies and interventions detailed are presented in Supplementary Table S3a,b. Supervised exercise and relaxation training were the most commonly employed interventions (n = 6 studies)5,29–33 within CPR programmes. Comparators included usual care, wait listing, psychological interventions or exercise or education alone. Risk of bias information (PEDro scores) was publically available for 10 included studies, with the remaining two studies independently scored by each of the reviewers using the PEDro criteria (mean score 5, SD 1 (Supplementary Table S4)). Outcome measures for both primary and secondary outcomes differed substantially across studies (Figs 2a,b;3a,b) with less than half of the studies using the same outcome measures for dyspnoea (Chronic Respiratory Questionnaire dyspnoea subscore (CRQD): n = 5), anxiety (Beck Anxiety Inventory: n = 2), depression (Beck Depression Inventory (BDI): n = 3), QOL (Chronic Respiratory Questionnaire (CRQ) total score: n = 5) and functional exercise capacity (6-min walk test (6MWT): n = 6). Lindsay et al.35 reported insufficient data with which to calculate effect size/ SMD. Berry et al.38 reported estimated means for repeated measures analysis (adjusted for age and gender) for QOL measures and physical function. Due to the heterogeneity of intervention/control conditions and outcome measures, meta-analysis was not performed. Separate forest plots were created for interventions (exercise and psychological components) versus control conditions (e.g. wait listing list for active intervention, usual care, Fig. 2a,b) or active comparators (e.g. education/lecture series, exercise/ psychotherapy alone, Fig. 3a,b). Compared with control conditions, SMD consistently favoured interventions which included both exercise + psychological components (SMD range dyspnoea −1.63 to −0.25; anxiety −0.50 to −0.20; depression −0.46 to −0.18; QOL 0.09 to 1.16; functional exercise capacity 0.22 to 1.23 ) (Fig. 2a,b). When compared with active comparators, SMD consistently favoured interventions that included exercise training and a psychological component for dyspnoea (SMD range −0.35 to −0.97), anxiety (SMD range −0.13 to −1.00) and exercise capacity (SMD range 0.64 to 0.71), but were inconsistent for depression (−0.11 to 1.27) and QOL (0.02 to −2.00) (Fig 3a,b).
DISCUSSION The majority of randomized trials included within this review consistently favoured interventions that combined exercise training with a psychological intervention for dyspnoea, anxiety, depression, QOL and exercise performance when compared with control or active comparator conditions. With the exception of two outcomes in two studies (depression © 2014 Asian Pacific Society of Respirology
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Exercise and psychological interventions 975 records identified through database searching
807 records after duplicates removed
604 records excluded
807 records screened
(after review of title and abstract)
203 full-text articles assessed for eligibility
171 full-text articles excluded on the basis of:
research design no psych intervention no exercise / CPR non-COPD participants single session psych only
111 36 14 7 3
contacted PROSPERO and
10 full-text articles
screened reference lists of
WHO protocol authors
11 systematic reviews
systematic reviews
(n=10)
8 PROSPERO systematic review protocols
(n=11)
2 WHO International Trial Registry protocols
no additional studies
12 full-text articles
identified
2 additional studies identified
no additional studies identified
list of 12 studies submitted to
for inclusion
independent expert for review
12 studies included in final analysis
Figure 1
Modified PRISMA flow chart outlining the search results (Moher et al. 2009).28
and QOL37,38), this pattern was consistent irrespective of the specific nature of the psychological intervention, the intervention prescription or setting. The magnitude of effect for most interventions was greater than the minimum required for clinical significance (i.e. > 0.32) in behavioural medicine.15,27 Previous authors of systematic reviews concerning psychological interventions for people with COPD15 have pooled data between studies and completed meta-analysis; we opted to use a more conservative approach by reporting SMD for each outcome. Our decision was based on the considerable heterogeneity in outcomes measures, interventions and comparators. The diversity of interventions/comparators and outcome measures is reflected in Table 1 and Figures 2a,b and 3a,b. Interventions differed in numerous ways including their focus (e.g. relaxation, © 2014 Asian Pacific Society of Respirology
psychosocial support, cognitive behavioral therapy), length (range 8 to 16 weeks), maximum number of supervised sessions (range 4 to 63), duration of sessions (range 15 to 240 minutes) and setting (outpatient versus home). In theory, the nature of the comparator was also likely to influence the effect sizes with control comparators (usual care, waiting list) likely to have larger effects than active intervention comparators which may have variable, associated impacts on psycho-cognitive processes (Supplementary Table S3a,b). There were two pairs of studies—Wijkstra et al.29,30 and de Godoy et al.5,6—that appeared to report on similar datasets. The first pair of studies29,30 differed in the outcomes reported for dyspnoea (CRQ-D, Borg) and functional exercise capacity (W max/cycle ergometry, 6MWT) (Supplementary Table S3a). The Respirology (2015) 20, 46–55
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Key COPD diagnosis: S P
Control/comparator
Exercise training + psychological intervention
Spirometry Physician
Sample size Mean age COPD diagnosis GOLD stage Exercise training Inspiratory muscle training Breathing retraining Education Tiotropium Dietary intervention Relaxation training Stress management Cognitive behavioral therapy Psychotherapy Psychosocial support Activity training/counselling Dyspnoea strategies Motivational interviewing Usual care Waiting list Education Exercise training Psychotherapy Tiotropium
43 63 S 3
Wijkstra et al.30
GOLD stages: GOLD stage 1 GOLD stage 2
43 63 S 3
Wijkstra et al.29 40 67 S 3
Guell et al.31 45 66 S 2
Kayahan et al.32
Mild Moderate
79 67 S 3
Emery et al.33 119 63 S/P 3
Ries et al.34
Table 1 Summary of participants’ characteristics and intervention and control/comparator components
49 >50 S/P 4
de Godoy et al.6 30 61 S/P 3
GOLD Stage 3 GOLD stage 4
50 70 S 1
Lindsay et al.35
de Godoy and de Godoy5 43 77 S/P 2
Norweg et al.36
21 64 S 2/3
176 66 S 2
Berry et al.38
Severe Very severe
de Blok et al.37
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(a) Wijkstra et al.29 Wijkstra et al.30 Guell et al.31 Kayahan et al.32
Emery et al. 199833(A) Guell et al.31 Kayahan et al.32
Emery et al. 199833(A)
Guell et al.31 Kayahan et al.32 (b) Wijkstra et al.29
Emery et al. 199833(A)
Guell et al.31
Kayahan et al.32
Wijkstra et al.29 Wijkstra et al.30 Emery et al. 199833(A)
Guell et al.31 Kayahan et al.32
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Figure 2 Effects of interventions compared with control for the outcomes of dyspnoea, anxiety, depression, quality of life and functional exercise capacity. (a) Negative standardized mean difference (SMD) values favoured the intervention for the outcomes of dyspnoea, anxiety and depression. (b) Positive SMD values favoured the intervention for the outcomes of quality of life and functional exercise capacity. 6MWT, 6-min walk test; ABS, Affect Balance Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiologic Studies Depression Scale; CRQ, Chronic Respiratory Questionnaire; CRQ-D, Chronic Respiratory Questionnaire dyspnoea domain; CRQ-E, Chronic Respiratory Questionnaire emotional function domain; CRQ-F, Chronic Respiratory Questionnaire fatigue domain; CRQ-M, Chronic Respiratory Questionnaire mastery domain; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Rating Scale for Depression; HR, heart rate; MHLOC-C, Multidimensional Health Locus of Control (chance health); MHLOC-I, Multidimensional Health Locus of Control (internal health); MHLOC-PO, Multidimensional Health Locus of Control (powerful others health); RAND-36, 36-Item Short Form Survey from the RAND Medical Outcomes Study; SCL-90-R-A, Symptom Checklist-90-Revised-Anxiety subscale; SCL-90-R-D, Symptom Checklist-90-Revised-Depression subscale; SF-36, Short Form Health Survey; SGRQ, St George’s Respiratory Questionnaire; SIP, Sickness Impact Profile; SOB-Q, Shortness of Breath Questionnaire; STAI, State-Trait Anxiety Inventory; VAS, visual analogue scale; VO2 max, maximal oxygen uptake; VVAS, vertical visual analogue scale; W max, maximal workload of the cycle ergometer test. Emery et al.33(A) compared exercise, education and stress management (intervention arm) with wait-listed control.
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second pair of studies5,6 differed with respect to different GOLD stages for COPD severity (Supplementary Table S3a), and interventions that were categorized differently by type and the personnel who delivered them (Supplementary Table S3b). Hence, we have treated these two studies as separate studies. While this systematic review did not aim to explore the mechanisms underpinning the efficacy of exercise training combined with psychological interventions, the consistent pattern presented for the positive effects of exercise training combined with a psychological intervention suggests a number of possible mechanisms. In people with COPD, exercise is often limited due to cardiovascular and musculoskeletal deconditioning resulting in dyspnoea with minimum physical exertion. Dyspnoea is a distressing and often anxiety-provoking perceptual experience that may lead to early cessation or avoidance of physical activity. Providing people with strategies to manage anxiety (relaxation exercises, psychotherapy or cognitive restructuring) and the opportunity to practice these strategies during repeated safe exposures to dyspnoea-inducing situations (supervised exercise training) may result in a positive synergistic relationship between anxiety, dyspnoea and exercise behaviours with subsequent positive effects on depression and QOL.15,39 That is, as participants become more confident or proficient with strategies for reducing anxiety and/or managing dyspnoea, the duration/ intensity of exercise might be extended as the experience becomes less aversive. Repeated exposure to exercise training affords increased opportunities and potential for desensitization to dyspnoea as well as an expectation and acceptance of breathlessness as a component of exercise. The subsequent improvement in anxiety and dyspnoea management may promote higher levels of exercise performance, potentially contributing to reduced depression and improved QOL.39 Alternatively, by their nature, psychological interventions require the time and attention of a ‘therapist’ in order to purposively and systematically educate individuals or groups in cognitive or other psychological strategies which target specific symptoms or patterns of behaviour.25 Therapeutic attention may also be provided by staff supervising exercise sessions in order to educate, motivate and encourage participants to achieve their exercise goals. The psychosocial benefits (e.g. support) of regular education and training (exercise and/or Respirology (2015) 20, 46–55
psychological strategies) in a group environment that includes participants with similar chronic health conditions may also contribute to improved health outcomes.15,39 Both de Blok et al.37 and Berry et al.38 included similar comparators (pulmonary rehabilitation, exercise training and education) and interventions (exercise training with activity counseling), with de Blok et al.’s37 psychological intervention including feedback from a pedometer. The most likely explanation for SMD favouring the comparator in Berry et al.’s38 trial is the disparity in durations of the intervention arms. At the 3-month assessment point, 25% (17 contact hours) of the lifestyle activity programme versus 100% (36 contact hours) traditional exercise and education intervention was complete. As a result of attrition, de Blok et al.’s37 study was limited by small sample size (n = 8 in each intervention arm) and while the SMD for depression and QOL outcomes favoured the comparator, the effect sizes were generally small and there was no significant difference between the intervention or comparator (depression BDI: P = 0.79, effect size =0.19; St George’s Respiratory Questionnaire total score: P = 0.55, effect size = 0.36).37 One of the issues associated with reviewing nonpharmacological interventions for people with COPD is the difficulty with defining and categorizing interventions. There is no clear definition for psychological interventions and little consistency in the terms authors use to describe such interventions.40 Similarly, there are also a variety of terms used to describe different rehabilitative approaches for people with COPD encompassing exercise and pulmonary rehabilitation: self-management,41 holistic42 and complex interventions.15 Hybrid interventions including psychological, exercise and/or comprehensive rehabilitation components are increasingly being used in the management of COPD and other chronic health conditions.43 Future consistency in the terms used to describe interventions and their function may help standardize the reporting of research studies in this area, and enable more direct comparisons to be made for outcomes across studies. The results of this review indicated that interventions combining exercise training with psychological strategies were associated with consistent benefits in terms of dyspnoea, anxiety, depression, QOL and functional exercise capacity, particularly when © 2014 Asian Pacific Society of Respirology
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Figure 3 Effects of interventions compared with other active comparators for the outcomes of dyspnoea, anxiety, depression, quality of life and functional exercise capacity. (a) Negative SMD values favoured the intervention for the outcomes of dyspnoea, anxiety and depression. (b) Positive SMD values favoured the intervention for the outcomes of quality of life and functional exercise capacity. 6MWT, 6-min walk test; ABS, Affect Balance Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiologic Studies Depression Scale; CRQ, Chronic Respiratory Questionnaire; CRQ-D, Chronic Respiratory Questionnaire dyspnoea domain; CRQ-E, Chronic Respiratory Questionnaire emotional function domain; CRQ-F, Chronic Respiratory Questionnaire fatigue domain; CRQ-M, Chronic Respiratory Questionnaire mastery domain; Dxw, Distance walked weight; endur, endurance; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Rating Scale for Depression; HR, heart rate; MHLOC-C, Multidimensional Health Locus of Control (chance health); MHLOC-I, Multidimensional Health Locus of Control (internal health); MHLOC-PO, Multidimensional Health Locus of Control (powerful others health); QWB, Quality of Well-being Scale; RAND-36 BP, 36-Item Short Form Survey from the RAND Medical Outcomes Study (bodily pain); RAND-36 GH, 36-Item Short Form Survey from the RAND Medical Outcomes Study (general health perception); RAND-36 HC, 36-Item Short Form Survey from the RAND Medical Outcomes Study (health change); RAND-36 PF, 36-Item Short Form Survey from the RAND Medical Outcomes Study (physical functioning); RAND-36 V, 36-Item Short Form Survey from the RAND Medical Outcomes Study (vitality);SCL-90-R-A, Symptom Checklist-90-Revised-Anxiety subscale; SCL-90-R-D, Symptom Checklist-90-Revised-Depression subscale; SF-36, Short Form Health Survey; SGRQ, St George’s Respiratory Questionnaire; SIP, Sickness Impact Profile; SOB-Q, Shortness of Breath Questionnaire; STAI, State-Trait Anxiety Inventory; VAS, visual analogue scale; VO2 max, maximal oxygen uptake; VVAS, vertical visual analogue scale; W, workload; W max, maximal workload of the cycle ergometer test. Emery et al.33(B) compared exercise, education and stress management (intervention) and education and stress management (no exercise, other comparator). de Godoy et al.6(A) compared exercise and psychotherapy (intervention) and exercise (other comparator). de Godoy et al.6(B) compared exercise and psychotherapy (intervention) and psychotherapy (other comparator). Norweg et al.36(A) compared exercise and activity training (intervention) and exercise (other comparator). Norweg et al.36(B) compared exercise and activity training (intervention) and exercise and lecture series (other comparator). ◀
compared with control conditions. These benefits were evident irrespective of the type of psychological intervention employed by individual studies. While there may be a number of inter-related mechanisms underpinning these improvements in health outcomes, determining the nature and type of psychological processes inherent within exercise training, group dynamics and specific psychological interventions may assist in optimizing rehabilitation for people with COPD.
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Acknowledgements This study was supported by the National Health and Medical Research Council (NHMRC) Australia (NHMRC Project Grant 1010309). The study team would like to thank Ms Halyey Lewthwaite for her assistance in independently undertaking the search strategy, data extraction and appraisal of methodological bias and Dr Tanja Effing for her expertise and valuable critique of the manuscript.
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Supplementary Information Additional Supplementary Information can be accessed via the html version of this article at the publisher’s web-site: Supplementary Table S1 Search terms and strategy for OVID Medline database. Supplementary Table S2 The categorizations used for each interventions’ theoretical base and function. Supplementary Table S3 (a) Characteristics of the study populations; (b) Characteristics of the interventions. Supplementary Table S4 Risk of bias assessment (PEDro scale) for included articles.
Respirology (2015) 20, 46–55
