Pulmonary Rehabilitation and Physical Activity in Patients with Chronic Obstructive Pulmonary Disease.

AJRCCM Articles in Press. Published on 10-July-2015 as 10.1164/rccm.201505-0929CI

Page 1 of 35

Concise Clinical Review

Pulmonary rehabilitation and physical activity in patients with COPD Martijn A. Spruit, 1, 2 Fabio Pitta, 3 Edward McAuley,4 Richard L. ZuWallack,5 and Linda Nici 6

1

Dept. Research & Education, CIRO+, center of expertise for chronic organ failure, Horn, the Netherlands

2

REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium

3

Laboratory of Research in Respiratory Physiotherapy (LFIP), Departament of Physiotherapy, Universidade Estadual de Londrina, Londrina, Brazil

4

Dept. of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA

5

Department of Pulmonary/Critical Care medicine, Saint Francis Hospital, Hartford, USA.

6

Pulmonary/Critical Care Section, Providence VA Medical Center, Providence, USA

Correspondence and requests for reprints should be addressed to: Martijn A. Spruit, PhD PT. Dept. Research & Education, CIRO, Hornerheide 1, 6085 NM Horn, The Netherlands. Email: [email protected]

Author Contributions: M.A.S., F.P., E.M., R.L.Z., and L.N. all contributed to the conception and design of this work; participated in writing, revising, and approving the manuscript; and are in agreement as to the integrity of the work and the contributions of all the authors.

Number of words main manuscript: 4745

Page 1 Copyright © 2015 by the American Thoracic Society


Abstract

Physical inactivity is common in COPD patients compared to age-matched healthy individuals or patients with other chronic diseases. Physical inactivity independently predicts poor outcome across several aspects of this disease, but it is (at least in principle) treatable in the COPD patient. Pulmonary rehabilitation has arguably the greatest positive effect of any current therapy on exercise capacity in COPD; as such, gains in this area should facilitate increases in physical activity. Furthermore, since pulmonary rehabilitation also emphasizes behavior change through collaborative selfmanagement, it may aid in the translation of increased exercise capacity to greater participation in activities involving physical activity. Indeed, both increased exercise capacity and adaptive behavior change are necessary to achieve significant and lasting increases in physical activity in the COPD patient. Unfortunately, it is readily assumed that this translation occurs naturally. This clinical concise review will focus on the effects of a comprehensive pulmonary rehabilitation program on physical activity in patients with COPD. Changing physical activity behavior in patients with COPD needs an interdisciplinary approach, bringing together respiratory medicine, rehabilitation sciences, social sciences and behavioral sciences.


Page 2 of 35

Page 3 of 35


1. Introduction “Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.” This frequently quoted phrase, [1-3] attributed to Plato, tells us that the association between physical inactivity and poor outcome - including the beneficial effects of its treatment - has been known since antiquity. More recently, the World Health Organization noted that physical inactivity, which is unfortunately present in 1 of 3 adults, [4] is among the 10 leading risk factors for death worldwide. [5] The importance of a focus on the problem of physical inactivity in COPD is based on several factors: 1) COPD is a major public health problem, being highly prevalent [6] and currently the third leading cause of death worldwide; [7] 2) Physical inactivity appears to be more common in COPD patients compared to age-matched healthy individuals [8] or even patients with other chronic diseases such as coronary artery disease or rheumatoid arthritis; [9] 3) Physical inactivity independently predicts poor outcomes across several aspects of this disease; [10, 11] 4) Physical inactivity (at least in principle) is treatable in the COPD patient, [12] although a causal link between increases in physical activity and improvements in health outcome has not been established; [13] 5) Physical activity substantially decreases over time in patients with COPD, and to a greater extent than in non-COPD subjects; [11] 6) A sustained low level of physical activity over time is associated with an accelerated progression of exercise intolerance and muscle depletion; [14] and 7) Clinicians may under-appreciate the importance of physical inactivity in their respiratory patients.

This concise clinical review will first cover the definition of physical activity (which is a different construct than exercise capacity), its prevalence and significance in COPD, its objective measurement, risk factors for physical inactivity, and potential ways to improve or maintain one or more components of physical fitness. Pulmonary rehabilitation has arguably the greatest positive effect of any current therapy on exercise Page 3 Copyright © 2015 by the American Thoracic Society


capacity in COPD; [15] as such, gains in this area should facilitate increases in physical activity. Furthermore, since pulmonary rehabilitation also emphasizes behavior change through collaborative self-management, it may aid in the translation of increased exercise capacity to greater participation in activities involving physical activity. Accordingly, the second part of this review will focus on the effects of this comprehensive intervention on this important outcome.

2. Pulmonary Rehabilitation

The 2013 Statement on Pulmonary Rehabilitation from the American Thoracic Society (ATS) and European Respiratory Society (ERS) defines it as “… a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.” [16] This definition clearly states that optimization of functional status and increased participation are prominent goals for this intervention. Physical activity is a prominent component of functional status. Participation, which is an important aspect of quality of life, indicates the abandonment of a sedentary, home-bound lifestyle for a more active involvement in activities of daily living. Exercise training and collaborative self-management education, integral components of comprehensive pulmonary rehabilitation, [17] both directly and indirectly promote physical activity and participation. Exercise training increases physical exercise tolerance, [18] allowing patients to have the capacity to do more things, while self-efficacy teaching encourages patients to go out and do more. [19]


Page 4 of 35

Page 5 of 35


Although pulmonary rehabilitation has no direct effect on the physiologic derangements in lung function, it provides the greatest improvements in dyspnea, exercise tolerance, and health-related quality of life of any intervention available for patients with chronic respiratory disease. [16] It also decreases subsequent health care utilization, especially when provided following an exacerbation of COPD. [20] The benefits from pulmonary rehabilitation result from a decrease in the negative effects of co-morbidity (such as physical deconditioning resulting from sedentary behavior and reductions in anxiety and depression) and from enhanced self-efficacy (such as the early recognition and appropriate treatment of the COPD exacerbation). [21]

3. Physical Activity

Physical activity can be defined as "any bodily movement produced by skeletal muscles that results in energy expenditure.” [22, 23] Therefore, physical activity in daily life can be considered as ‘‘the totality of voluntary movement produced by skeletal muscles during every day functioning,” [24, 25] and is assessed by the quantification of this totality of movements during daily life. In distinction, exercise is "a subset of physical activity that is planned, structured, repetitive and purposeful,” [22] and has its own assessment methods (such as maximal and submaximal exercise tests). [26, 27] Physical activity is a complex behavior influenced by a combination of individual, socio-cultural, and environmental factors. [23] It can be characterized by type, intensity, duration, patterns, routines, and activity-related symptoms. [28] Types of physical activity include, but are not limited to, leisure-time, domestic and occupational activities. [29] Activities of daily living refers to a subset of physical activity that encompasses basic, everyday tasks required for personal self-care and independent living. [29, 30] Performance of activities



of daily living has its own assessment methods such as specific activities of daily living questionnaires and functional tests. [31-35] Questionnaires and motion sensors are the more commonly used assessment methods to quantify physical activity in patients with COPD. [36] Despite their widely recognized usefulness, questionnaires are prone to inaccuracy when used on an individual level. [23] Motion sensors, small devices worn on the body to detect movement and therefore quantify physical activity over a period of time, are becoming increasingly available. These devices include pedometers (step counters) and accelerometers (detection of body acceleration). Pedometers quantify steps in a given period (despite a considerable misdetection in slow-walking subjects), [37-40] provide a rough estimate of energy expenditure, and can also be successfully used as a motivational tool to increase physical activity. [41-43] Accelerometers have the advantage of being more sensitive to detection of physical activity differences in inactive and slowly-moving individuals, and are more accurate and sensitive to light activities. [25] Different devices provide a variety of outcomes such as time spent above a certain intensity threshold (e.g., moderate or vigorous physical activity), time spent in sedentary behavior, average metabolic equivalent of task, physical activity level index, vector magnitude units, and/or energy expenditure estimation. Output from the various types of accelerometers varies considerably, making it difficult to compare devices. [44]

4. Physical activity in COPD

Patients with COPD have significantly lower levels of daily physical activity compared to healthy controls: they spend significantly less time walking, walk at a lower intensity than their healthy counterparts, and most do not meet current recommendations for levels of physical activity. [8, 45-52] Physical inactivity is not just a


Page 6 of 35


Page 7 of 35

feature of advanced COPD: it is already reduced in subjects with a new spirometry-based diagnosis of mild or moderate COPD, [53] even preceding the onset of breathlessness. [54]

Physical activity in patients with COPD is dependent on many factors, including physiologic, behavioral, social, environmental, and cultural factors. Please, see Watz and colleagues for all details about factors associated with physical activity in patients with COPD. [23] In brief, daily physical activity is only weakly associated with postbronchodilator FEV1. [23] There is, however, a strong inverse association between daily physical activity and dynamic hyperinflation, [55] which correlates strongly with exertional dyspnea in COPD. [56] In contrast to resting lung function testing, performance on lower-limb muscle function tests and (field) exercise tests correlates better with physical activity in COPD. [27, 50, 57, 58] Daily symptoms (i.e., dyspnea and fatigue) are associated with lower physical activity levels in patients with COPD. [45, 50, 59] Impaired health status is weakly-to-moderately related to physical activity in patients with COPD. [50, 60-63] Interestingly, this association was confirmed in a 5-year longitudinal observational study, showing that a decline physical activity is associated with a decline in health status in patients with COPD. [64] Self-efficacy (i.e., an individual's belief in his or her capacity to execute behaviors necessary to produce specific outcomes [65]) is only weakly associated with daily physical activity in patients with COPD. [60, 66, 67] In addition, socio-demographic and environmental factors all have the potential to influence daily physical activity among patients with COPD. [68-75] Physical activity levels may also be influenced by the day of the week - with activity lower on weekends as compared to other days. [28, 45, 76] Exacerbations clearly reduce physical activity levels in patients with COPD, [77, 78] in particular in very severe exacerbations which necessitate hospitalization. [79, 80] Medical comorbidities may also independently or synergistically impact physical activity levels. [50, 51, 59, 61, 81-88] Page 7 Copyright © 2015 by the American Thoracic Society


Physical activity levels predict important outcomes in COPD. Lower physical activity levels are associated with a higher risk of an exacerbation-related hospitalization. [79, 89-94] In addition to baseline levels of physical activity predicting COPD-related hospitalization, a decline in physical activity over time also predicts this outcome, also after adjustment for age, FEV1, and prior hospitalizations. [95] Lower physical activity levels also increase the risk of all-cause mortality in patients with COPD after controlling for relevant confounding factors. [10, 93, 94] Decline in physical activity over time also predicts mortality. [11] Reflecting these strong associations, physical activity has been included as a factor in multidimensional prognostic scores for all-cause and respiratory mortality [96] or exacerbations and COPD-related hospitalization in stable COPD patients. [97] These outcome studies underscore the importance of promoting physical activity in the earliest stages of COPD, with a goal of more than 2 hours per week.

5. The effects of pulmonary rehabilitation on physical activity in COPD The cornerstones of pulmonary rehabilitation are exercise training and education, aimed at behavior change through promoting self-efficacy. [21] For pulmonary rehabilitation to have its greatest long-term impact, the increases in exercise capacity demonstrated in the rehabilitation center would ideally translate into increases in physical activity in the home and community settings. [16] Both exercise capacity increase and adaptive behavior change are necessary to achieve significant and lasting increases in daily physical activity in the COPD patient (Figure). Unfortunately, it is readily assumed that this translation occurs naturally. Twelve studies have evaluated the effects of pulmonary rehabilitation on physical activity and have had inconsistent results:


Page 8 of 35

Page 9 of 35


The positive studies In a randomized controlled trial, Sewell and colleagues [98] compared the effects of two approaches to exercise training on physical activity in 180 patients with COPD. Physical activity was measured over two consecutive days using an activity monitor (Z8032k V1 Int; Gaewiler Electronics; Hombrechtikon, Switzerland). The pulmonary rehabilitation (7 weeks, 2 sessions per week) consisted of a weekly 1-hour session of supervised aerobic training and a weekly 1-hour supervised circuit training exercises, and twice weekly educational sessions. The circuit training differed between groups: a conventional program of general strengthening exercises or goal-directed exercise based on problematic daily activities. Exercise performance, performance of problematic daily activities, and health status all improved significantly compared to baseline. Physical activity expressed as total activity counts increased significantly after both interventions, without any difference between groups. This study was the first to demonstrate that directly-measured physical activity improves following pulmonary rehabilitation. In a secondary analysis, however, the authors reported that the response in physical activity may be susceptible to seasonal variation, with the best results in the winter. [75] Mercken and colleagues [99] evaluated the effects of an 8-week, inpatient pulmonary rehabilitation program on physical activity in 11 patients with moderate-to-very severe COPD. Physical activity was measured over nine consecutive days using an uniaxial accelerometer (Physical Activity Monitor AM 100; Pam BV, The Netherlands). The pulmonary rehabilitation (8 weeks, 5 sessions per week) consisted of exercise training of the upper and lower extremities (aerobic and strengthening exercises exercise training, education, and when appropriate psychosocial and behavioral intervention. Exercise performance and exercise-induced oxidative improved significantly compared to baseline. Physical activity (measurement unit was not reported) increased significantly compared to baseline.



Walker and colleagues [51] evaluated the effects of an 8-week, outpatient pulmonary rehabilitation program on physical activity in 24 patients with moderate-tovery severe COPD. Physical activity was measured over seven consecutive days using an accelerometer (Dynaport Activity Monitor, McRoberts BV; The Hague, the Netherlands). The pulmonary rehabilitation (8 weeks, 2 supervised sessions per week, 1 unsupervised session per week) consisted of exercise training of the upper and lower extremities (aerobic and strengthening exercises exercise training), and educational sessions. Lowerlimb muscle function, exercise performance, performance of problematic daily activities, symptoms of anxiety and depression, and health status all improved significantly compared to baseline. Physical activity expressed as % of time spent mobile, mean activity score (x103 counts/hour) or as mean intensity of activity score (x103 counts/hour) also increased significantly compared to baseline. Improvement in leg activity counts was positively correlated with baseline lung function: those with better pulmonary function had greater increases in activity following rehabilitation. Interestingly, changes in physical activity were not significantly related to changes in muscle strength or walking distance, even though these variables improved with pulmonary rehabilitation. This discord in outcomes points to the influence of other components of pulmonary rehabilitation, such as promoting self-efficacy, in achieving positive outcome in physical activity.

The negative studies Steele and colleagues [100] assessed the effects of an 8-week hospital-based, outpatient pulmonary rehabilitation program in 41 patients with mild-to-very severe COPD. Physical activity was measured five days before entry into the pulmonary rehabilitation program and during the final week of the program using a triaxial accelerometer (RT3, Stay healthy Inc. Monrovia, California). The pulmonary rehabilitation Page 10 Copyright © 2015 by the American Thoracic Society

Page 10 of 35

Page 11 of 35


(8 weeks, 2 sessions per week) was not described in detail. Changes in exercise performance have not been reported. Physical activity expressed as vector magnitude units per minute differed between a pre-program non-exercise day and a supervised exercise day in the last week of the pulmonary rehabilitation program. Nevertheless, physical activity did not change significantly comparing pre-program and post-program non-exercising days, or for the full 5 days of activity assessment. Coronado and colleagues [52] assessed the effects of 3-week inpatient pulmonary rehabilitation program in 15 patients with mild-to-very severe COPD. Physical activity was measured on the first and last day of the pulmonary rehabilitation program using an uniaxial accelerometer (The Self-Contained Activity Monitor, ADXL05; Analog Devices, Norwood, Mass, USA). The pulmonary rehabilitation (3 weeks, 6 to 7 sessions per week) consisted of exercise training (aerobic and strengthening exercises), and outdoor walking. Lower-limb muscle function, exercise performance, mood status and health status increased significantly. The % of total time spent in medium-intensity activity had increased significantly compared to baseline, but did not remain after exclusion of training periods. Dallas and colleagues [101] evaluated the effects of a 6-to-12-week, hospitalbased, outpatient pulmonary rehabilitation program on physical activity in 54 patients with on average severe COPD. Physical activity was measured over seven consecutive days using a pedometer (NL-2000 Activity Monitor, New Lifestyles Inc., www.newlifestyles.com) during the first and last week of the pulmonary rehabilitation program. The pulmonary rehabilitation (6 to 12 weeks, 2 to 3 sessions per week) consisted of exercise training of the upper and lower extremities (aerobic and strengthening exercises), educational sessions, and psychosocial support. Symptoms, exercise performance and health status all improved significantly compared to baseline. Physical activity level expressed in pedometer counts per hour did not change. Page 11 Copyright © 2015 by the American Thoracic Society


Saunders and colleagues [102] assessed the effects of a seven pulmonary rehabilitation programs (community-based or hospital-based) on physical activity in 294 patients with moderate-to-severe COPD. Physical activity was measured over seven consecutive days using a step counter (Yamax DIGI WALKER). The pulmonary rehabilitation (6 to 12 weeks, 2 to 3 sessions per week) consisted of exercise training (aerobic and strengthening exercises), and educational sessions. Changes in exercise performance have not been reported. Physical activity level expressed in steps per day did not change. Mador and colleagues [103] evaluated the effects of an 8-week pulmonary rehabilitation program on physical activity in 24 patients with moderate-to-severe COPD. Physical activity was measured over seven consecutive days using a triaxial accelerometer (RT3, Stay healthy Inc. Monrovia, California). The pulmonary rehabilitation (8 weeks, 3 sessions per week) consisted of calisthenics (with and without weights) ergometry cycling and treadmill walking, and multidisciplinary educational sessions. Lower-limb muscle function, exercise performance and health status all improved significantly compared to baseline. Physical activity level expressed in vector magnitude units per minute did not change.

The mixed result studies Pitta and colleagues [104] studied the impact of a 12 to 24-week, hospital-based, outpatient pulmonary rehabilitation program on physical activity in 41 patients with severe COPD. Physical activity was measured over five consecutive weekdays using an accelerometer (Dynaport Activity Monitor, McRoberts BV; The Hague, the Netherlands). The pulmonary rehabilitation (12 weeks, 3 sessions per week, followed by 12 weeks, 2 sessions per week) consisted of supervised exercise training (endurance/strengthening exercises), educational sessions, and visits for support and/or counseling with a Page 12 Copyright © 2015 by the American Thoracic Society

Page 12 of 35

Page 13 of 35


pulmonary physician, a nutritionist, a psychologist, an occupational therapist, a respiratory nurse and a social assistant. Symptoms, lower-limb muscle function, exercise performance, performance of problematic daily activities, and health status were significantly better at 12 and 24 weeks compared to baseline. Mean walking time was only significantly better after 24 weeks, not at 12 weeks. Mean movement intensity during walking was significantly better at 12 and 24 weeks after compared to baseline. The time spent standing, sitting and lying down, and the number of blocks of continuous walking done per day did not change. Demeyer and colleagues [105] evaluated the effects of a similar pulmonary rehabilitation program as Pitta and colleagues [104] on physical activity in 57 patients with moderate-to-severe COPD. Physical activity was measured over seven consecutive days using a bi-axial accelerometer (Sensewear Pro Armbands; BodyMedia, Inc Pittsburgh, PA). The possible change in exercise performance was not described. The number of steps per day increased significantly 12 weeks after baseline (with four to seven days of measurement), while time spent in at least moderate physical activity or the mean metabolic equivalents of task level did not change. Egan and colleagues [106] studied the short term improvements in physical activity in 47 patients with severe COPD following a 7-week, hospital-based, outpatient pulmonary rehabilitation program. Physical activity was measured over five consecutive days using a bi-axial accelerometer (Sensewear Pro Armbands; BodyMedia, Inc Pittsburgh, PA). The pulmonary rehabilitation (7 weeks, 2 sessions per week, with a recommended three further days of 30 min of moderate intensity exercise) consisted of a progressive exercise circuit (strength/flexibility/endurance), multidisciplinary interactive educational sessions, and home inspiratory muscle training program. Symptoms, exercise performance and health status all improved significantly compared to baseline. Total energy expenditure decreased significantly compared to baseline, while there was no Page 13 Copyright © 2015 by the American Thoracic Society


change in the average number of daily steps, time spent sedentary, or time spent in active exercise. In summary, a randomized controlled trial comparing the effects of a pulmonary rehabilitation program on daily physical activity with ‘usual care’ in patients with COPD is lacking. Indeed, most studies were non-controlled, small-sized, and observational. All pulmonary rehabilitation programs consisted of a supervised exercise training program and (multidisciplinary) educational sessions. Only a few also contained psychological counseling, occupational therapy and dietary counselling. Interestingly, exercise performance improved significantly following pulmonary rehabilitation in all studies (if reported), while physical activity did not. This suggests a differing trajectory in exercise and activity outcomes. An editorial writer, commenting on the differing trajectories, quipped insightfully, “…one needs 3 months to train the muscle, but 6 months to train the brain.” [107]

6. Which pieces of the puzzle are missing? Even though pulmonary rehabilitation improves exercise performance in patients with COPD, [108] this is not always accompanied by an increase in physical activity in daily life. [109] The reasons for this are not clear, as a comprehensive pulmonary rehabilitation program arguably contains the necessary ingredients to improve physical activity in patients with COPD (Figure). Since self-reported physical activity is unreliable, [110] attention has focused on using physical activity monitors in patients with COPD. [76, 111-113] Pedometers, which are insensitive to detecting activity in slowly-moving individuals with COPD have had negative results; [39] more sensitive motion detectors, such as tri-axial accelerometers, are more likely to detect changes in activity. [104]


Page 14 of 35


Page 15 of 35

The choice of physical activity outcome assessment may determine the success or failure of the pulmonary rehabilitation program’s demonstrable effect on the physical activity. Most COPD trials have focused on the impact of pulmonary rehabilitation on the total number of steps per day, walking time, and/or the time spent in moderate to vigorous intensity. [109] Demeyer and colleagues reported a significant increase in steps per day following a 3-month outpatient pulmonary rehabilitation program, which was not accompanied by increases in metabolic equivalents or time spent in moderate or high intensity physical activity. [105] In some of the observational studies, physical activity has been measured while patients were already/still participating in the pulmonary rehabilitation program . [52, 100, 101] Preferably, physical activity is measured in free-living conditions before and after a pulmonary rehabilitation program (not during). This will increase the validity of the findings. Patients with COPD do not appear to increase the amount of time in moderate-tovigorous intense activities following pulmonary rehabilitation, [105] but they can still adopt a more active lifestyle, through engaging in leisure activities or doing more domestic household activities. [98] Therefore, we may need to transition our thinking from ‘physical activity’ to ‘active living’. This concept includes leisure, occupational, and household activities, as well as active transportation (walking and bicycling), [114] most of which many may not be detected by the currently available physical activity measurement. In addition, it is important to better understand physical activity patterns. Which is more important: more time spent in higher intensity physical activity or less time spent in a sedentary state? This latter approach is in line with the philosophy of Sparling and colleagues, who argue that a reduction in sedentary time and an increase in light activities may prove more realistic and pave the way to more intense exercise in older adults than just focusing on moderate to vigorous intense physical activities. [115]



Indeed, even a slight increase in physical activity in the most sedentary subjects may have significant health benefits (Figure). [116] The duration and content of pulmonary rehabilitation services, which vary widely among pulmonary rehabilitation trials, may explain some of the variance in change in physical activity. [17] This is brought out in the results of the previously described study by Pitta and colleagues. [104] Moreover, the differences in behavior change strategies among centers may also explain some of this variance. [117] For example, a pulmonary rehabilitation program with a lifestyle physical activity counselling program incorporating feedback from a pedometer, increased the number of patients’ steps per day to a greater extent than did pulmonary rehabilitation without this counseling. [42] Also, specificity of the exercise training modality seems to play an important role. Indeed, 12 weeks of Nordic walking increased walking time and walking intensity in patients with COPD, still present 6 months after the intervention. [118] Changing a complex health behavior such as physical activity is very difficult, so interventions should be guided by sound theoretical models. This seems lacking in the current pulmonary rehabilitation construct. One of the most commonly applied theories is Social Cognitive Theory (SCT). [119] The “active agent” in SCT is self-efficacy which is theorized to have both direct and indirect effects on behavior. Although there is evidence of pulmonary rehabilitation programs increasing self-efficacy, [120] this is not always the case. It has been empirically demonstrated that the time point at which self-efficacy is measured influences the extent to which it increases or decreases across the intervention period. [121] Efficacy expectations assessed at baseline are likely over-estimations which are re-calibrated in the early stages of the exercise program. Thus, generally weak but consistent relationships with physical activity may be a function of poor temporal measurement or self-efficacy measures which do not accurately reflect the actual behavior. As interventions do not appear to be able to change moderate-to vigorous


Page 16 of 35

Page 17 of 35


physical activities in patients with COPD, measures reflecting moderate-to vigorous physical activities are likely to be weakly related to behavior. A recent self-efficacy enhancing intervention improved light physical activity by ~21 minutes per day, as measured by accelerometry. This was substantially greater than two exercise interventions without the efficacy enhancement component. [122, 123] Targeting the primary sources of efficacy as integral parts of pulmonary rehabilitation for COPD may bring about important changes in light physical activity that, if maintained, could lead to more intense ‘active living ‘. Other self-regulatory approaches to increasing adherence behavior in older adults hold promise for COPD. For example, higher levels of executive function and use of self-regulatory strategies were associated with greater self-efficacy which led to greater exercise adherence. [124] However, reliance on individual level approaches to behavior change is unlikely to have potent effects on physical activity. Consideration of how individual factors interact within the social and environmental milieu in which individuals exist is warranted. [125] Indeed, socio-ecological variables may also modulate the effect of pulmonary rehabilitation on physical activity. [126] These include intrapersonal, interpersonal/cultural, organizational, physical environment, and policy variables. [127, 128] For example, walking is related to pedestrian infrastructure and concerns for safety in older adults. [129] Moreover, neighbors’ social support and positive neighborhood satisfaction will increase the likelihood of walking, [130] while a lower socioeconomic status will lower walking activity in older adults. [131] Also outdoor air quality needs to be taken into consideration, as physical activity in clean air has larger health benefits compared to physical activity in traffic-related polluted areas. [132, 133] To date, neighborhood walkability, and the influence of interpersonal relationships, formal community engagement, and outdoor air quality on physical activity have not been studied in patients with COPD. Several studies do report that COPD patient’s surroundings and transport/finance were identified as barriers to participation in physical



activity. [134-136] In contrast, health benefits (65%), enjoyment (44%), continuation of an active lifestyle in the past (28%), and functional reasons (i.e., daily activities, transportation, etc.) (26%) have been identified as reasons for patients with COPD to stay/become physically active. [135]

7. Future approaches Changing physical activity behavior in patients with COPD needs an interdisciplinary approach, bringing together respiratory medicine, rehabilitation sciences, social sciences and behavioral sciences. This concise clinical review has presented data that COPD patients are generally very inactive, and that this physical inactivity is detrimental to both quality and quantity of life. Therefore, increased efforts to better understand the determinants of physical activity, as well as effective strategies to improve this variable, must be a prominent goal in pulmonary rehabilitation. Indeed, physical activity is now listed as one of the main outcome measures of pulmonary rehabilitation programs by the ATS/ERS Official Statement on Pulmonary Rehabilitation. [108] Despite this, only a minority of the healthcare professionals identifies physical activity as one of the main outcomes of pulmonary rehabilitation (33.5% in Europe; and 21.9% in North America). [17] Future research in this area should include both advancing the science and optimizing patients’ treatment. The following are suggested areas to focus on. The science 1.

The potential disease-modifying effects of increased physical activity (light/moderate/vigorous intensity) in patients with COPD.

2. The determinants of physical activity (light/moderate/vigorous intensity) in patients with COPD.


Page 18 of 35


Page 19 of 35

3. Self-management strategies that best promote physical activity (light/moderate/vigorous intensity), including long-term increases in activity. 4. The interaction of pharmacological and non-pharmacological interventions on physical activity (light/moderate/vigorous intensity). 5. The relationship between changes in the traditional outcomes of pulmonary rehabilitation (exercise capacity, dyspnea, functional and health status) and changes in physical activity (light/moderate/vigorous intensity). 6. The best instruments to measure physical activity in clinical practice (light/moderate/vigorous intensity). 7. The minimal important difference for physical activity measures, as they relate to health status, health care utilization and mortality (light/moderate/vigorous intensity). 8. Randomized, adequately- powered, controlled trials that evaluate whether increases in physical activity resulting from the therapeutic intervention lead to improvements in health outcome, including health care utilization and mortality. This would establish the needed causality link.

The patient: 1.

Introduce physical activity early on in the pulmonary rehabilitation curriculum and incorporate it as a standard outcome measure.

2. Tailor physical activity to the individual patient, taking into account exercise capacity, morbidities and/or disabilities, home and community environment, and behavioral and cultural factors. 3. Focus on resumption of exercise and physical activity after an exacerbation of COPD, including establishing realistic goals and maintaining support by the professional team.



4. Maintain and foster ongoing lines of communication among the patient and the health care team in order to detect changes in the patient’s condition that interfere with ongoing exercise and activity, thereby allowing for an early intervention.

Acknowledgements

The authors like to thank the anonymous reviewers for their excellent suggestions.


Page 20 of 35


Page 21 of 35

References

1.

Fox, S.M., 3rd and W.L. Haskell, Physical activity and the prevention of coronary heart disease. Bull N Y Acad Med, 1968. 44(8): p. 950-67.

2.

Das, P. and R. Horton, Rethinking our approach to physical activity. Lancet, 2012. 380(9838): p. 189-90.

3.

Wen, C.P., et al., Minimal amount of exercise to prolong life: to walk, to run, or just mix it up? J Am Coll Cardiol, 2014. 64(5): p. 482-4.

4.

Hallal, P.C., et al., Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet, 2012. 380(9838): p. 247-57.

5.

Organization, W.H. Health Topics: Physical Activity. 2015; Available from: http://www.who.int/topics/physical_activity/en/.

6.

Burney, P., et al., Chronic obstructive pulmonary disease mortality and prevalence: the associations with smoking and poverty--a BOLD analysis. Thorax, 2014. 69(5): p. 465-73.

7.

Lozano, R., et al., Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012. 380(9859): p. 2095-128.

8.

Pitta, F., et al., Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2005. 171(9): p. 972-7.

9.

Tudor-Locke, C., T.L. Washington, and T.L. Hart, Expected values for steps/day in special populations. Prev Med, 2009. 49(1): p. 3-11.

10.

Waschki, B., et al., Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest, 2011. 140(2): p. 331-42.

11.

Vaes, A.W., et al., Changes in physical activity and all-cause mortality in COPD. Eur Respir J, 2014. 44(5): p. 1199-209.



12.

Watz, H., et al., Indacaterol improves lung hyperinflation and physical activity in patients with moderate chronic obstructive pulmonary disease--a randomized, multicenter, double-blind, placebo-controlled study. BMC Pulm Med, 2014. 14: p. 158.

13.

ZuWallack, R. and C. Esteban, Understanding the impact of physical activity in COPD outcomes: moving forward. Eur Respir J, 2014. 44(5): p. 1107-9.

14.

Waschki, B., et al., Disease Progression and Changes in Physical Activity in Patients with COPD. Am J Respir Crit Care Med, 2015.

15.

Troosters, T., et al., Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2005. 172(1): p. 19-38.

16.

Spruit, M.A., et al., An official american thoracic society/european respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med, 2013. 188(8): p. e13-64.

17.

Spruit, M.A., et al., Differences in content and organisational aspects of pulmonary rehabilitation programmes. Eur Respir J, 2014. 43(5): p. 1326-37.

18.

McCarthy, B., et al., Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2015. 2: p. CD003793.

19.

Vincent, E., et al., Measuring a change in self-efficacy following pulmonary rehabilitation: an evaluation of the PRAISE tool. Chest, 2011. 140(6): p. 1534-9.

20.

Puhan, M.A., et al., Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2011(10): p. CD005305.

21.

Bourbeau, J., D. Nault, and T. Dang-Tan, Self-management and behaviour modification in COPD. Patient Educ Couns, 2004. 52(3): p. 271-7.


Page 22 of 35


Page 23 of 35

22.

Caspersen, C.J., K.E. Powell, and G.M. Christenson, Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep, 1985. 100(2): p. 126-31.

23.

Watz, H., et al., An official European Respiratory Society statement on physical activity in COPD. Eur Respir J, 2014. 44(6): p. 1521-37.

24.

Steele, B.G., et al., Bodies in motion: monitoring daily activity and exercise with motion sensors in people with chronic pulmonary disease. J Rehabil Res Dev, 2003. 40(5 Suppl 2): p. 45-58.

25.

Pitta, F., et al., Quantifying physical activity in daily life with questionnaires and motion sensors in COPD. Eur Respir J, 2006. 27(5): p. 1040-55.

26.

Holland, A.E., et al., An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J, 2014. 44(6): p. 1428-46.

27.

Singh, S.J., et al., An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disease. Eur Respir J, 2014. 44(6): p. 1447-78.

28.

Spina, G., et al., Identifying Physical Activity Profiles in COPD Patients Using Topic Models. IEEE J Biomed Health Inform, 2015.

29.

Howley, E.T., Type of activity: resistance, aerobic and leisure versus occupational physical activity. Med Sci Sports Exerc, 2001. 33(6 Suppl): p. S364-9; discussion S419-20.

30.

Katz, S., Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc, 1983. 31(12): p. 721-7.

31.

Annegarn, J., et al., Problematic activities of daily life are weakly associated with clinical characteristics in COPD. J Am Med Dir Assoc, 2012. 13(3): p. 284-90.



32.

Vaes, A.W., et al., Task-related oxygen uptake during domestic activities of daily life in patients with COPD and healthy elderly subjects. Chest, 2011. 140(4): p. 970-9.

33.

Skumlien, S., et al., A field test of functional status as performance of activities of daily living in COPD patients. Respir Med, 2006. 100(2): p. 316-23.

34.

Lareau, S.C., P.M. Meek, and P.J. Roos, Development and testing of the modified version of the pulmonary functional status and dyspnea questionnaire (PFSDQ-M). Heart Lung, 1998. 27(3): p. 159-68.

35.

Garrod, R., et al., Development and validation of a standardized measure of activity of daily living in patients with severe COPD: the London Chest Activity of Daily Living scale (LCADL). Respir Med, 2000. 94(6): p. 589-96.

36.

Dhillon, S.S., et al., Physical Activity Measurement Accuracy in Individuals with Chronic Lung Disease: A Systematic Review with Meta-Analysis of Method Comparison Studies. Arch Phys Med Rehabil, 2015.

37.

Furlanetto, K.C., et al., Step counting and energy expenditure estimation in patients with chronic obstructive pulmonary disease and healthy elderly: accuracy of 2 motion sensors. Arch Phys Med Rehabil, 2010. 91(2): p. 261-7.

38.

Cavalheri, V., et al., Energy expenditure during daily activities as measured by two motion sensors in patients with COPD. Respir Med, 2011. 105(6): p. 922-9.

39.

Dallas, M.I., et al., Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation. Chron Respir Dis, 2009. 6(4): p. 217-24.

40.

Turner, L.J., et al., Reliability of pedometers to measure step counts in patients with chronic respiratory disease. J Cardiopulm Rehabil Prev, 2012. 32(5): p. 284-91.

41.

Moy, M.L., et al., A pilot study of an Internet walking program and pedometer in COPD. Respir Med, 2012. 106(9): p. 1342-50.


Page 24 of 35


Page 25 of 35

42.

de Blok, B.M., et al., The effects of a lifestyle physical activity counseling program with feedback of a pedometer during pulmonary rehabilitation in patients with COPD: a pilot study. Patient Educ Couns, 2006. 61(1): p. 48-55.

43.

Mendoza, L., et al., Pedometers to enhance physical activity in COPD: a randomised controlled trial. Eur Respir J, 2015. 45(2): p. 347-54.

44.

Butte, N.F., U. Ekelund, and K.R. Westerterp, Assessing physical activity using wearable monitors: measures of physical activity. Med Sci Sports Exerc, 2012. 44(1 Suppl 1): p. S5-12.

45.

Watz, H., et al., Physical activity in patients with COPD. Eur Respir J, 2009. 33(2): p. 262-72.

46.

Schonhofer, B., et al., Evaluation of a movement detector to measure daily activity in patients with chronic lung disease. Eur Respir J, 1997. 10(12): p. 2814-9.

47.

Singh, S. and M.D. Morgan, Activity monitors can detect brisk walking in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil, 2001. 21(3): p. 143-8.

48.

Hernandes, N.A., et al., Profile of the level of physical activity in the daily lives of patients with COPD in Brazil. J Bras Pneumol, 2009. 35(10): p. 949-56.

49.

Troosters, T., et al., Physical inactivity in patients with COPD, a controlled multicenter pilot-study. Respir Med, 2010. 104(7): p. 1005-11.

50.

Waschki, B., et al., Physical activity monitoring in COPD: compliance and associations with clinical characteristics in a multicenter study. Respir Med, 2012. 106(4): p. 522-30.

51.

Walker, P.P., et al., Lower limb activity and its determinants in COPD. Thorax, 2008. 63(8): p. 683-9.

52.

Coronado, M., et al., Walking activity measured by accelerometry during respiratory rehabilitation. J Cardiopulm Rehabil, 2003. 23(5): p. 357-64.



53.

Van Remoortel, H., et al., Daily physical activity in subjects with newly diagnosed COPD. Thorax, 2013. 68(10): p. 962-3.

54.

Gouzi, F., et al., Evidence of an early physical activity reduction in chronic obstructive pulmonary disease patients. Arch Phys Med Rehabil, 2011. 92(10): p. 1611-1617 e2.

55.

Garcia-Rio, F., et al., Daily physical activity in patients with chronic obstructive pulmonary disease is mainly associated with dynamic hyperinflation. Am J Respir Crit Care Med, 2009. 180(6): p. 506-12.

56.

O'Donnell, D.E., S.M. Revill, and K.A. Webb, Dynamic hyperinflation and exercise intolerance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2001. 164(5): p. 770-7.

57.

Maltais, F., et al., An official American Thoracic Society/European Respiratory Society statement: update on limb muscle dysfunction in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2014. 189(9): p. e15-62.

58.

Osthoff, A.K., et al., Association between peripheral muscle strength and daily physical activity in patients with COPD: a systematic literature review and metaanalysis. J Cardiopulm Rehabil Prev, 2013. 33(6): p. 351-9.

59.

Andersson, M., et al., Physical activity and fatigue in chronic obstructive pulmonary disease - A population based study. Respir Med, 2015.

60.

Belza, B., et al., Correlates of physical activity in chronic obstructive pulmonary disease. Nurs Res, 2001. 50(4): p. 195-202.

61.

Garcia-Aymerich, J., et al., Physical activity and its determinants in severe chronic obstructive pulmonary disease. Med Sci Sports Exerc, 2004. 36(10): p. 1667-73.

62.

McGlone, S., et al., Physical activity, spirometry and quality-of-life in chronic obstructive pulmonary disease. COPD, 2006. 3(2): p. 83-8.


Page 26 of 35


Page 27 of 35

63.

Jehn, M., et al., Daily walking intensity as a predictor of quality of life in patients with chronic obstructive pulmonary disease. Med Sci Sports Exerc, 2012. 44(7): p. 1212-8.

64.

Esteban, C., et al., Impact of changes in physical activity on health-related quality of life among patients with COPD. Eur Respir J, 2010. 36(2): p. 292-300.

65.

Strecher, V.J., et al., The role of self-efficacy in achieving health behavior change. Health Educ Q, 1986. 13(1): p. 73-92.

66.

DePew, Z.S., et al., Screening for severe physical inactivity in chronic obstructive pulmonary disease: the value of simple measures and the validation of two physical activity questionnaires. Chron Respir Dis, 2013. 10(1): p. 19-27.

67.

Hartman, J.E., et al., Physical and Psychosocial Factors Associated With Physical Activity in Patients With Chronic Obstructive Pulmonary Disease. Arch Phys Med Rehabil, 2013.

68.

Alahmari, A.D., et al., Influence of weather and atmospheric pollution on physical activity in patients with COPD. Respir Res, 2015. 16(1): p. 71.

69.

Marshall, S.J., et al., Race/ethnicity, social class, and leisure-time physical inactivity. Med Sci Sports Exerc, 2007. 39(1): p. 44-51.

70.

Crespo, C.J., et al., Prevalence of physical inactivity and its relation to social class in U.S. adults: results from the Third National Health and Nutrition Examination Survey, 1988-1994. Med Sci Sports Exerc, 1999. 31(12): p. 1821-7.

71.

Parks, S.E., R.A. Housemann, and R.C. Brownson, Differential correlates of physical activity in urban and rural adults of various socioeconomic backgrounds in the United States. J Epidemiol Community Health, 2003. 57(1): p. 29-35.

72.

Kosatsky, T., et al., Heat awareness and response among Montreal residents with chronic cardiac and pulmonary disease. Can J Public Health, 2009. 100(3): p. 237-40.



73.

Moy, M.L., et al., Daily step counts in a US cohort with COPD. Respir Med, 2012. 106(7): p. 962-9.

74.

Katajisto, M., et al., Physical inactivity in COPD and increased patient perception of dyspnea. Int J Chron Obstruct Pulmon Dis, 2012. 7: p. 743-55.

75.

Sewell, L., et al., Seasonal variations affect physical activity and pulmonary rehabilitation outcomes. J Cardiopulm Rehabil Prev, 2010. 30(5): p. 329-33.

76.

Rabinovich, R.A., et al., Validity of physical activity monitors during daily life in patients with COPD. Eur Respir J, 2013. 42(5): p. 1205-15.

77.

Donaldson, G.C., et al., Exacerbations and time spent outdoors in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2005. 171(5): p. 446-52.

78.

Alahmari, A.D., et al., Daily activity during stability and exacerbation of chronic obstructive pulmonary disease. BMC Pulm Med, 2014. 14: p. 98.

79.

Pitta, F., et al., Physical activity and hospitalization for exacerbation of COPD. Chest, 2006. 129(3): p. 536-44.

80.

Borges, R.C. and C.R. Carvalho, Physical activity in daily life in Brazilian COPD patients during and after exacerbation. Copd, 2012. 9(6): p. 596-602.

81.

Barnes, P.J. and B.R. Celli, Systemic manifestations and comorbidities of COPD. Eur Respir J, 2009. 33(5): p. 1165-85.

82.

Nussbaumer-Ochsner, Y. and K.F. Rabe, Systemic manifestations of COPD. Chest, 2011. 139(1): p. 165-73.

83.

Vanfleteren, L.E., et al., Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2013. 187(7): p. 728-35.

84.

Watz, H., et al., Extrapulmonary effects of chronic obstructive pulmonary disease on physical activity: a cross-sectional study. Am J Respir Crit Care Med, 2008. 177(7): p. 743-51.


Page 28 of 35


Page 29 of 35

85.

von Leupoldt, A., et al., The impact of anxiety and depression on outcomes of pulmonary rehabilitation in patients with COPD. Chest, 2011. 140(3): p. 730-6.

86.

Moy, M.L., et al., Free-living physical activity in COPD: assessment with accelerometer and activity checklist. J Rehabil Res Dev, 2009. 46(2): p. 277-86.

87.

Venkata, A., et al., Are depressive symptoms related to physical inactivity in chronic obstructive pulmonary disease? J Cardiopulm Rehabil Prev, 2012. 32(6): p. 405-9.

88.

Miravitlles, M., J. Cantoni, and K. Naberan, Factors associated with a low level of physical activity in patients with chronic obstructive pulmonary disease. Lung, 2014. 192(2): p. 259-65.

89.

Garcia-Aymerich, J., et al., Time-dependent confounding in the study of the effects of regular physical activity in chronic obstructive pulmonary disease: an application of the marginal structural model. Ann Epidemiol, 2008. 18(10): p. 775-83.

90.

Benzo, R.P., et al., Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease. Respiration, 2010. 80(1): p. 10-8.

91.

Chen, Y.J. and G.L. Narsavage, Factors related to chronic obstructive pulmonary disease readmission in Taiwan. West J Nurs Res, 2006. 28(1): p. 105-24.

92.

Garcia-Aymerich, J., et al., Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax, 2003. 58(2): p. 100-5.

93.

Garcia-Aymerich, J., et al., Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax, 2006. 61(9): p. 772-8.

94.

Garcia-Rio, F., et al., Prognostic value of the objective measurement of daily physical activity in patients with COPD. Chest, 2012. 142(2): p. 338-46.



95.

Esteban, C., et al., Influence of changes in physical activity on frequency of hospitalization in chronic obstructive pulmonary disease. Respirology, 2014. 19(3): p. 330-8.

96.

Esteban, C., et al., The health, activity, dyspnea, obstruction, age, and hospitalization: prognostic score for stable COPD patients. Respir Med, 2011. 105(11): p. 1662-70.

97.

Moy, M.L., et al., An index of daily step count and systemic inflammation predicts clinical outcomes in chronic obstructive pulmonary disease. Ann Am Thorac Soc, 2014. 11(2): p. 149-57.

98.

Sewell, L., et al., Can individualized rehabilitation improve functional independence in elderly patients with COPD? Chest, 2005. 128(3): p. 1194-200.

99.

Mercken, E.M., et al., Rehabilitation Decreases Exercise-induced Oxidative Stress in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med, 2005.

100.

Steele, B.G., et al., Monitoring daily activity during pulmonary rehabilitation using a triaxial accelerometer. J Cardiopulm Rehabil, 2003. 23(2): p. 139-42.

101.

Dallas, M.I., et al., Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation. Chron Respir Dis, 2009. 6(4): p. 217-24.

102.

Saunders, T.J., et al., Distinct Trajectories of Physical Activity Among Patients with COPD During and After Pulmonary Rehabilitation. Copd, 2015.

103.

Mador, M.J., A.N. Patel, and J. Nadler, Effects of pulmonary rehabilitation on activity levels in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev, 2011. 31(1): p. 52-9.

104.

Pitta, F., et al., Are patients with COPD more active after pulmonary rehabilitation? Chest, 2008. 134(2): p. 273-80.

105.

Demeyer, H., et al., Standardizing the analysis of physical activity in patients with COPD following a pulmonary rehabilitation program. Chest, 2014. 146(2): p. 318-27.


Page 30 of 35


Page 31 of 35

106.

Egan, C., et al., Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med, 2012. 106(12): p. 1671-9.

107.

Polkey, M.I. and K.F. Rabe, Chicken or egg: physical activity in COPD revisited. Eur Respir J, 2009. 33(2): p. 227-9.

108.

Spruit, M.A., et al., An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med, 2013. 188(8): p. e13-64.

109.

Ng, L.W., et al., Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis. Chron Respir Dis, 2011.

110.

Pitta, F., et al., Activity monitoring for assessment of physical activities in daily life in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil, 2005. 86(10): p. 1979-85.

111.

Annegarn, J., et al., Objective physical activity assessment in patients with chronic organ failure: a validation study of a new single-unit activity monitor. Arch Phys Med Rehabil, 2011. 92(11): p. 1852-1857 e1.

112.

Van Remoortel, H., et al., Validity of activity monitors in health and chronic disease: a systematic review. Int J Behav Nutr Phys Act, 2012. 9: p. 84.

113.

Van Remoortel, H., et al., Validity of six activity monitors in chronic obstructive pulmonary disease: a comparison with indirect calorimetry. PLoS One, 2012. 7(6): p. e39198.

114.

Sallis, J.F., et al., The Active Living Research program: six years of grantmaking. Am J Prev Med, 2009. 36(2 Suppl): p. S10-21.

115.

Sparling, P.B., et al., Recommendations for physical activity in older adults. BMJ, 2015. 350: p. h100.



116.

Minton, J., et al., Exploring the relationship between baseline physical activity levels and mortality reduction associated with increases in physical activity: a modelling study. BMJ Open, 2013. 3(10): p. e003509.

117.

Garcia-Aymerich, J. and F. Pitta, Promoting regular physical activity in pulmonary rehabilitation. Clin Chest Med, 2014. 35(2): p. 363-8.

118.

Breyer, M.K., et al., Nordic Walking improves daily physical activities in COPD: a randomised controlled trial. Respir Res, 2010. 11: p. 112.

119.

Bandura, A., Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev, 1977. 84(2): p. 191-215.

120.

Vincent, E., et al., Measuring a change in self-efficacy following Pulmonary Rehabilitation: An evaluation of the PRAISE tool. Chest, 2011.

121.

McAuley, E., et al., Growth trajectories of exercise self-efficacy in older adults: influence of measures and initial status. Health Psychol, 2011. 30(1): p. 75-83.

122.

Larson, J.L., et al., Self-efficacy enhancing intervention increases light physical activity in people with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis, 2014. 9: p. 1081-90.

123.

Covey, M.K., et al., Upper-Body Resistance Training and Self-Efficacy Enhancement in COPD. J Pulm Respir Med, 2012. Suppl 9: p. 001.

124.

McAuley, E., et al., Self-regulatory processes and exercise adherence in older adults: executive function and self-efficacy effects. Am J Prev Med, 2011. 41(3): p. 284-90.

125.

Mermelstein, R.J. and T.A. Revenson, Applying theory across settings, behaviors, and populations: translational challenges and opportunities. Health Psychol, 2013. 32(5): p. 592-6.

126.

Stokols, D., Establishing and maintaining healthy environments. Toward a social ecology of health promotion. Am Psychol, 1992. 47(1): p. 6-22.


Page 32 of 35


Page 33 of 35

127.

Sallis, J.F., et al., An ecological approach to creating active living communities. Annu Rev Public Health, 2006. 27: p. 297-322.

128.

Bauman, A.E., et al., Correlates of physical activity: why are some people physically active and others not? Lancet, 2012. 380(9838): p. 258-71.

129.

Van Cauwenberg, J., et al., Physical environmental factors related to walking and cycling in older adults: the Belgian aging studies. BMC Public Health, 2012. 12: p. 142.

130.

Van Cauwenberg, J., et al., Relationships between the perceived neighborhood social environment and walking for transportation among older adults. Soc Sci Med, 2014. 104: p. 23-30.

131.

Kamphuis, C.B., et al., Socioeconomic differences in lack of recreational walking among older adults: the role of neighbourhood and individual factors. Int J Behav Nutr Phys Act, 2009. 6: p. 1.

132.

Bos, I., et al., Physical activity, air pollution and the brain. Sports Med, 2014. 44(11): p. 1505-18.

133.

Bos, I., et al., Subclinical effects of aerobic training in urban environment. Med Sci Sports Exerc, 2013. 45(3): p. 439-47.

134.

Thorpe, O., S. Kumar, and K. Johnston, Barriers to and enablers of physical activity in patients with COPD following a hospital admission: a qualitative study. Int J Chron Obstruct Pulmon Dis, 2014. 9: p. 115-28.

135.

Hartman, J.E., et al., Self-efficacy for physical activity and insight into its benefits are modifiable factors associated with physical activity in people with COPD: a mixed-methods study. J Physiother, 2013. 59(2): p. 117-24.

136.

Williams, V., et al., The importance of movement for people living with chronic obstructive pulmonary disease. Qual Health Res, 2011. 21(9): p. 1239-48.



Legend Figure. Components of a comprehensive pulmonary rehabilitation program (blue rectangles) have a direct positive effect on disease-specific knowledge, disease-management skills, self-efficacy, or via improvements in the physical and psychological extra-pulmonary features of patients with chronic obstructive pulmonary disease (orange rectangles). These positive effects also translate into a higher self-efficacy. The increase in selfefficacy will induce a behavior change and, in turn, an increase in time in light intensity physical activities and active living. The active living will reduce the risk of exacerbations and/or hospitalizations. The improvements in the physical and psychological extrapulmonary features, the smoking cessation, and the optimization of the pharmacological therapy will also have a direct impact on outcomes.


Page 34 of 35

Page 35 of 35


Copyright © 2015 by the American Thoracic Society

Physical Activity Monitoring in Patients with Chronic Obstructive Pulmonary Disease.

Physical activity recommendations in patients with chronic obstructive pulmonary disease.

Exercise limitation and pulmonary rehabilitation in chronic obstructive pulmonary disease.

Assessment of pulmonary rehabilitation efficacy in chronic obstructive pulmonary disease patients using the chronic obstructive pulmonary disease assessment test.

Disease Progression and Changes in Physical Activity in Patients with Chronic Obstructive Pulmonary Disease.

[Body composition and heart rate variability in patients with chronic obstructive pulmonary disease pulmonary rehabilitation candidates].

Comorbidities and medication burden in patients with chronic obstructive pulmonary disease attending pulmonary rehabilitation.

Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease.

Combined pulmonary fibrosis and emphysema: effect of pulmonary rehabilitation in comparison with chronic obstructive pulmonary disease.

The impact of social support in pulmonary rehabilitation of patients with chronic obstructive pulmonary disease.

Does pulmonary rehabilitation reduce peripheral blood pressure in patients with chronic obstructive pulmonary disease?

Does pulmonary rehabilitation alleviate depression in older patients with chronic obstructive pulmonary disease.

Paraoxonase 1 activity in patients with chronic obstructive pulmonary disease.

Clinical benefits of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

About the effect of pulmonary rehabilitation on lung function in patients with chronic obstructive pulmonary disease.

Home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized clinical trial.

Validity and Usability of Physical Activity Monitoring in Patients with Chronic Obstructive Pulmonary Disease (COPD).

Functional capacity, physical activity, and quality of life in hypoxemic patients with chronic obstructive pulmonary disease.

Pulmonary rehabilitation: the reference therapy for undernourished patients with chronic obstructive pulmonary disease.

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease.

[Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease].

Directly measured physical activity as a predictor of hospitalizations in patients with chronic obstructive pulmonary disease.

Reduced level of physical activity in Japanese patients with chronic obstructive pulmonary disease.

Influence of indacaterol on daily physical activity in patients with untreated chronic obstructive pulmonary disease.