A systematic review of exercise studies for individuals hospitalized with an acute exacerbation of chronic obstructive pulmonary disease: Focus on the principles of exercise training.

BACKGROUND: For exercise interventions to be effectively reproduced or applied in a "real world" clinical setting, clinical trials must thoroughly document all components of the exercise prescription and ensure that participants adhere to each component. However, previous reviews have not critically examined the quality of exercise prescription of inpatient Pulmonary Rehabilitation (PR) programs. OBJECTIVE: The objectives of this review were to evaluate the (a) application of the principles of exercise training, (b) reporting of the frequency, intensity, time and type (FITT) components of exercise prescription, and (c) reporting of patient's adherence to the FITT components in intervention studies for patients admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: Relevant scientific databases were searched for randomized controlled trials (RCTs) that compared in-hospital PR with usual care for people hospitalized with AECOPD. Title and abstract followed by full-text screening were conducted independently by two reviewers. Data were extracted and synthesized to evaluate the application of the principles of exercise training and the reporting/adherence of the FITT components. RESULTS: Twenty-seven RCTs were included. Only two applied all principles of exercise training. Specificity was applied by 70%, progression by 48%, overload by 37%, initial values by 89% and diminishing returns and reversibility by 37% of trials. Ten trials adequately reported all FITT components. Frequency and type were the components most reported (85% and 81%, respectively), while intensity was less frequently reported (52%). Only three trials reported on the patient's adherence to all four components. CONCLUSIONS: Studies have not adequately reported the exercise prescription in accordance with the principles of exercise training nor reported all the FITT components of the exercise prescription and patient's adherence to them. Therefore, interpretation of the current literature is limited and information for developing exercise prescriptions to individuals hospitalized with an AECOPD is lacking.

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States.

INTRODUCTION: Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships. METHODS: A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively. RESULTS: A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue. CONCLUSION: This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.

Safety and Efficacy of Inpatient Pulmonary Rehabilitation for Patients Hospitalized with an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-analyses.

Rationale: Pulmonary rehabilitation (PR) during hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) occurs during a period of disease instability for the patient, and the safety and efficacy of PR, specifically during the hospitalization period, have not been established. Objective: The purpose of this review is to determine the safety and efficacy of PR during the hospitalization phase for individuals with AECOPD. Methods: Scientific databases were searched up to August 2022 for randomized controlled trials that compared in-hospital PR with usual care. PR programs commenced during the hospitalization and included a minimum of two sessions. Titles and abstracts followed by full-text screening and data extraction were conducted independently by two reviewers. The intervention effect estimates were calculated through meta-analysis using a random-effect model. Results: A total of 27 studies were included (n = 1,317). The meta-analysis showed that inpatient PR improved the 6-minute-walk distance by 105 m (P < 0.001). Inpatient PR improved the performance on the five-repetition sit-to-stand test by -7.02 seconds (P = 0.03). Quality of life (QOL), as measured by the 5-level EuroQoL Group-5 dimension version (EQ-ED-5L) and the St. George's Respiratory Questionnaire, was significantly improved by the intervention. Inpatient PR increased lower limb muscle strength by 33.35 N (P < 0.001). There was no change in the length of stay. Only one serious adverse event related to the intervention was reported. Conclusions: This review suggests that it is safe and effective to provide PR during hospitalization for individuals with AECOPD. In-hospital PR improves functional exercise capacity, QOL, and lower limb strength without prolonging the hospital length of stay.

Implementation of an Acute Care COPD Exacerbation Patient Mobilization Tool. A Mixed-Methods Study.

Background: Improving the mobility of hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a priority of care. AECOPD-Mob is a clinical decision-making tool for physical therapists, especially those who are newly graduated or are new to caring for patients with AECOPDs in acute care settings. Although this tool has been available for several years, dissemination via publication is not sufficient to implement it in clinical practice.Objective: The primary objective of this study was to develop, implement, and evaluate different formats of AECOPD-Mob in an acute care setting.Methods: We used a mixed-methods, convergent parallel design. In addition to the paper format of AECOPD-Mob, we developed a smartphone app, a web-based learner module, and an in-service learning session. Newly graduated physical therapists (PTs) or PTs new to the practice area were recruited from urban acute care hospitals. Participants used the different formats for 3 weeks and then completed the Post-Study System Usability Questionnaire. User data were retrieved for the learning module. Participants participated in focus groups at 3 weeks and 3 months.Results: Eighteen (72% of eligible PTs, 100% female, 94% graduated within 3 yr) PTs participated. Post-Study System Usability Questionnaire scores for the learning module and smartphone indicated that participants were satisfied with these formats (median score 2.0 on 1-7 Likert Scale for both technology formats, lower scores indicating greater satisfaction). However, the participants reported in the focus group that the paper format was preferred over other formats. Concerns with the smartphone app included infection control and the perception of lack of professionalism when using a smartphone during clinical practice. The learning module and in-service were considered helpful as an introduction but not as an ongoing support. The paper format was seen as the most efficient way to access the necessary information and to facilitate communication between other members of the care team about the importance of mobility for hospitalized patients with AECOPDs.Conclusion: Newly graduated PTs strongly preferred the paper format of the AECOPD-Mob tool in the acute care setting. Future research will focus on knowledge translation strategies for other health disciplines.

Safety and efficacy of inpatient pulmonary rehabilitation for patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease: a systematic review protocol.

INTRODUCTION: Pulmonary rehabilitation (PR) following an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) reduces the risk of hospital admissions, and improves physical function and health-related quality of life. However, the safety and efficacy of in-hospital PR during the most acute phase of an AECOPD is not well established. This paper describes the protocol for a systematic review with meta-analysis to determine the safety and efficacy of inpatient acute care PR during the hospitalisation phase. METHODS AND ANALYSIS: Medical literature databases and registries MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Canadian Agency for Drugs and Technologies in Health, CENTRAL, Allied and Complementary Medicine Database, WHO trials portal and ClinicalTrials.gov will be searched for articles from inception to June 2021 using a prespecified search strategy. We will identify randomised controlled trials that have a comparison of in-hospital PR with usual care. PR programmes had to commence during the hospitalisation and include a minimum of two sessions. Title and abstract followed by full-text screening will be conducted independently by two reviewers. A meta-analysis will be performed if there is sufficient homogeneity across selected studies or groups of studies. The Population, Intervention, Comparator, Outcomes and Study characteristics framework will be used to standardise the data collection process. The quality of the cumulative evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework. ETHICS AND DISSEMINATION: AECOPD results in physical limitations which are amenable to PR. This review will assess the safety and efficacy of in-hospital PR for AECOPD. The results will be presented in a peer-reviewed publication and at research conferences. Ethical review is not required for this study.

The de Morton mobility index is a feasible and valid mobility assessment tool in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease.

There is no accepted standard for measuring mobility in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The objective of this study was to assess convergent, discriminant, and known-group validity and floor/ceiling effects of the de Morton Mobility Index (DEMMI) in hospitalized patients with AECOPD. Individuals with AECOPD (n = 22) admitted to an acute care hospital medical ward were recruited. Data on the DEMMI, gait speed, daytime energy expenditure, step counts, 6-minute walk distance (6MWD), dyspnea, respiratory and heart rates, quality of life, and oxygen supplementation were collected on day 3 of admission. The DEMMI demonstrated convergent validity with the 6MWD and gait velocity measures (Spearman's ρ 0.69 and 0.61, respectively; p < 0.003) but not with measures of physical activity or respiratory impairment. Discriminant validity was present, with no correlation between the DEMMI and quality of life and resting heart rate. Known-group validity (gait aids vs. no gait aids) was demonstrated (p = 0.009). There was no floor effect but there was evidence of a possible ceiling effect (14% of participants received a perfect score). The DEMMI is feasible and showed moderate to strong validity with measures of observed physical function in hospitalized patients with AECOPD.

Myocardial Infarction Injury in Patients with Chronic Lung Disease Entering Pulmonary Rehabilitation: Frequency and Association with Heart Rate Parameters.

BACKGROUND: Myocardial infarction (MI) remains under-recognized in chronic lung disease (CLD) patients. Rehabilitation health professionals need accessible clinical measurements to identify the presence of prior MI in order to determine appropriate training prescription. OBJECTIVES: To estimate prior MI in CLD patients entering a pulmonary rehabilitation program, as well as its association with heart rate parameters such as resting heart rate and chronotropic response index. DESIGN: Retrospective cohort design. SETTING: Pulmonary rehabilitation outpatient clinic in a tertiary care university-affiliated hospital. PATIENTS: Eighty-five CLD patients were studied. METHODS: Electrocardiograms at rest and peak cardiopulmonary exercise testing, performed before pulmonary rehabilitation, were analyzed. Electrocardiographic evidence of prior MI, quantified by the Cardiac Infarction Injury Score (CIIS), was contrasted with reported myocardial events and then correlated with resting heart rate and chronotropic response index parameters. MAIN OUTCOME MEASUREMENTS: CIIS, resting heart rate, and chronotropic response index. RESULTS: Sixteen CLD patients (19%) demonstrated electrocardiographic evidence of prior MI, but less than half (8%) had a reported MI history (P < .05). The Cohen's kappa test revealed poor level of agreement between CIIS and medical records (kappa = 0.165), indicating that prior MI diagnosis was under-reported in the medical records. Simple and multiple regression analyses showed that resting heart rate but not chronotropic response index was positively associated with CIIS in our population (R2 = 0.29, P < .001). CLD patients with a resting heart rate higher than 80 beats/min had approximately 5 times higher odds of having prior MI, as evidenced by a CIIS ≥ 20. CONCLUSIONS: CLD patients entering pulmonary rehabilitation are at risk of unreported prior MI. Elevated resting heart rate appears to be an indicator of prior MI in CLD patients; therefore, careful adjustment of training intensity is recommended under these circumstances. LEVEL OF EVIDENCE: III.

Exercise Telemonitoring and Telerehabilitation Compared with Traditional Cardiac and Pulmonary Rehabilitation: A Systematic Review and Meta-Analysis.

Background: Despite exercise capacity and quality-of-life benefits, pulmonary rehabilitation (PR) and cardiac rehabilitation (CR) programmes are not easily accessed because of several barriers. A solution may be telerehabilitation (TR), in which patients exercise in their communities while they are monitored via teletechnology. However, the benefits of TR for the purposes of PR and CR have not been systematically reviewed. Objective: To determine whether the benefits of the exercise component of PR and CR using TR are comparable to usual-care (UC) programmes. Methods: A comprehensive literature search was performed of the Medline, Embase, and CINAHL databases up to July 13, 2015. Meta-analyses were performed for peak oxygen consumption, peak workload, exercise test duration, and 6-minute walk test (6MWT) distance using the I2 statistic and forest plots displaying standardized mean difference (SMD). Results: Of 1,431 citations found, 8 CR studies met the inclusion criteria. No differences were found in exercise outcomes between UC and TR groups for CR studies, except in exercise test duration, which slightly favoured UC (SMD 0.268, 95% CI: 0.002, 0.534, p<0.05). Only 1 PR study was included, and it showed similar improvements on the 6MWT between the UC and TR groups. Conclusion: TR for patients with cardiac conditions provided benefits similar to UC with no adverse effects reported. Similar studies of TR for patients with pulmonary conditions need to be conducted.

Contexte : malgré leurs effets positifs sur la capacité d'effort et la qualité de vie, les programmes de réadaptation pulmonaire (PR) et de réadaptation cardiaque (CR) ne sont pas faciles d'accès en raison de divers obstacles. La téléréadaptation permet aux patients de faire de l'exercice dans leur communauté tout en étant suivis grâce aux télétechnologies. Or, les bienfaits de la téléréadaptation pulmonaire et cardiaque n'ont pas encore été recensés de façon systématique. Objectif : déterminer si les effets du volet exercice de la réadaptation pulmonaire et cardiaque par téléréadaptation se comparent à ceux que l'on observe chez les patients recevant des soins habituels. Méthodes : une recherche exhaustive a été effectuée sur les banques de données Medline, Embase et CINAHL en amont du 13 juillet 2015. Des méta-analyses ont été effectuées pour la consommation maximale d'oxygène, la charge de travail maximale, la durée du test d'effort et la distance marchée lors du test de 6 minutes de marche au moyen de la statistique I2 et de graphiques en forêt affichant la différence moyenne normalisée (DMN). Résultats : parmi les 1431 articles relevés, huit études en réadaptation cardiaque satisfaisaient aux critères. Aucune différence notable n'a été observée dans les effets de l'exercice entre les groupes recevant des soins traditionnels et les groupes en téléréadaptation dans les études de réadaptation cardiaque, sauf pour la durée du test d'effort, où les résultats des soins traditionnels étaient légèrement meilleurs (DMN: 0,268, intervalle de confiance de 95%, 0,002 à 0,534; p<0,05). Une seule étude sur la réadaptation pulmonaire a été retenue; les améliorations observées au test de marche de 6 minutes étaient semblables pour les groupes en soins traditionnels et en téléréadaptation. Conclusion : la téléréadaptation procure aux patients souffrant de problèmes cardiaques des bienfaits semblables aux soins traditionnels sans effets indésirables signalés. Il faudra réaliser des études similaires sur des patients atteints de problèmes pulmonaires.

Does a Nintendo Wii exercise program provide similar exercise demands as a traditional pulmonary rehabilitation program in adults with COPD?

BACKGROUND AND AIMS: The chronic obstructive pulmonary disease (COPD) population can experience lower activity and fitness levels than the non-COPD population. The Nintendo Wii may be an appropriate at-home training device for the COPD population, which could be used as a supplement for a pulmonary rehabilitation program. This study was a randomized, within-subject, cross-over study involving 10 adults with COPD previously enrolled in St Paul's Hospital's pulmonary rehabilitation program. This study attempted to determine if specific Wii activities resulted in similar energy expenditures to that of a more traditional pulmonary rehabilitation activity. METHODS: Participants completed two 15-min exercise interventions in a single session, with a washout period of 30 min in-between. The interventions were an experimental Wii intervention and a traditional treadmill intervention. RESULTS: There was no significant difference in total energy expenditure between the two 15-min exercise interventions [mean difference 36.3 joules; 95% confidence interval (CI): 31.4, 104]. There was no significant difference in heart rate (mean difference -0.167 beats per minute; 95% CI: -4.83, 4.50), rating of perceived exertion (mean difference 0.100; 95% CI: -0.416, 0.616) and Borg dyspnea scale (mean difference 0.267; 95% CI: -0.004, 0.537) between the two 15-min exercise interventions. There was a significant difference in SpO2 between the two 15-min exercise interventions (Wii intervention mean difference 2.33% > treadmill intervention; 95% CI: 1.52, 3.15). CONCLUSION: Gaming technology can provide an exercise program that has similar cardiovascular demands to traditional pulmonary rehabilitation programs for patients with COPD. Further research is necessary to address feasibility and long-term adherence.

Physical Activity Measurement Accuracy in Individuals With Chronic Lung Disease: A Systematic Review With Meta-Analysis of Method Comparison Studies.

OBJECTIVE: To investigate the accuracy of physical activity measurement strategies in adults with chronic lung disease. DATA SOURCES: MEDLINE, Embase, and CINAHL databases were searched from inception to September 30, 2014. STUDY SELECTION: Studies reporting validity data for devices measuring energy expenditure in comparison with indirect calorimetry or doubly labeled water measurements in chronic lung disease were included. Nine publications in chronic obstructive pulmonary disease (COPD) or cystic fibrosis (CF) from 2294 studies were identified. DATA EXTRACTION: Two reviewers evaluated studies for quality using a modified version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist and extracted data relating to population, setting, devices, activity protocols, and energy expenditure. Disagreements were resolved by consensus. DATA SYNTHESIS: Studies were of high quality, with 8 studies scoring at least 9 out of 11 on the QUADAS checklist. In laboratory-based settings, the SenseWear multisensor accurately estimated energy expenditure during walking compared with indirect calorimetry (pooled mean difference, -0.7 kcal/min; 95% confidence interval [CI], -2.5 to 1.1) in COPD, but overestimated it in CF. However, 2 studies in COPD and CF showed the SenseWear multisensor accurately estimated energy expenditure during lifestyle tasks compared with indirect calorimetry (pooled mean difference, .18 kcal/min; 95% CI, -.13 to .49). The Digi-Walker pedometer underestimated energy expenditure compared with indirect calorimetry in COPD (mean difference walking, -2.4 kcal/min; 95% CI -3.4 to -1.1; mean difference lifestyle tasks, -2.3 kcal/min; 95% CI, -2.8 to -1.8). In free-living settings, the ActiReg multisensor accurately measured energy expenditure in COPD (mean difference, -21 kcal/d; 95% CI, -133.9 to 91.9), whereas the Flex Heart Rate Method underestimated energy expenditure in CF (mean difference, -454.1 kcal/d; 95% CI, -727 to -181.2). CONCLUSIONS: Energy expenditure estimation was accurate from the SenseWear and ActiReg multisensors during laboratory-based and free-living testing. Future studies warrant investigation of activity measures in other lung diseases and in specific ranges of lung disease severity.

Pulmonary rehabilitation in Canada: A report from the Canadian Thoracic Society COPD Clinical Assembly.

BACKGROUND: Pulmonary rehabilitation (PR) is a recommended intervention in the management of individuals with chronic lung disease. It is important to study the characteristics and capacity of programs in Canada to confirm best practices and identify future areas of program improvement and research. OBJECTIVE: To identify all Canadian PR programs, regardless of setting, and to comprehensively describe all aspects of PR program delivery. The present article reports the results of the survey related to type of program, capacity and program characteristics. METHODS: All hospitals in Canada were contacted to identify PR programs. A representative from each program completed a 175-item online survey encompassing 16 domains, 10 of which are reported in the present article. RESULTS: A total of 155 facilities in Canada offered PR, of which 129 returned surveys (83% response rate). PR programs were located in all provinces, but none in the three territories. Most (60%) programs were located in hospital settings, 24% were in public health units and 8% in recreation centres. The national capacity of programs was estimated to be 10,280 patients per year, resulting in 0.4% of all Canadians with chronic obstructive pulmonary disease (COPD) and 0.8% of Canadians with moderate to severe COPD having access to PR. COPD, interstitial lung disease, and asthma were the most common diagnoses of patients. The majority of programs had at least four health care professionals involved; 9% had only one health care professional involved. CONCLUSION: The present comprehensive survey of PR in Canada reports an increase in the number of programs and the total number of patients enrolled since the previous survey in 2005. However, PR capacity has not kept pace with demand, with only 0.4% of Canadians with COPD having access.

Clinical Decision-Making Tool for Safe and Effective Prescription of Exercise in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Results From an Interdisciplinary Delphi Survey and Focus Groups.

BACKGROUND: Exercise is recommended for people with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), yet there is little information to guide safe and effective mobilization and exercise for these patients. OBJECTIVES: The purpose of this study was to develop a clinical decision-making tool to guide health care professionals in the assessment, prescription, monitoring, and progression of mobilization and therapeutic exercise for patients with AECOPD. DESIGN AND METHODS: A 3-round interdisciplinary Delphi panel identified and selected items based on a preselected consensus of 80%. These items were summarized in a paper-based tool titled Mobilization in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD-Mob). Focus groups and questionnaires were subsequently used to conduct a sensibility evaluation of the tool. RESULTS: Nine researchers, 13 clinicians, and 7 individuals with COPD identified and approved 110 parameters for safe and effective exercise in AECOPD. These parameters were grouped into 5 categories: (1) "What to Assess Prior to Mobilization," (2) "When to Consider Not Mobilizing or to Discontinue Mobilization," (3) "What to Monitor During Mobilization for Patient Safety," (4) "How to Progress Mobilization to Enhance Effectiveness," and (5) "What to Confirm Prior to Discharge." The tool was evaluated in 4 focus groups of 18 health care professionals, 90% of whom reported the tool was easy to use, was concise, and would guide a health care professional who is new to the acute care setting and working with patients with AECOPD. LIMITATIONS: The tool was developed based on published evidence and expert opinion, so the applicability of the items to patients in all settings cannot be guaranteed. The Delphi panel consisted of health care professionals from Canada, so items may not be generalizable to other jurisdictions. CONCLUSIONS: The AECOPD-Mob provides practical and concise information on safe and effective exercise for the AECOPD population for use by the new graduate or novice acute care practitioner.