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Background: Downhill walking (DW) enhances quadriceps contractile muscle fatigue (CMF) with less symptoms than level walking (LW) in patients with COPD. Its use in clinical practice is limited by a lack of data regarding efficacy, acceptability and safety. Aim: To determine the feasibility, acceptability and safety of DW as part of pulmonary rehabilitation (PR) in patients with COPD. Methods: 39 COPD patients (62±9yrs; FEV 1 49±17%pred) were randomised to PR with DW or LW. CMF was assessed via magnetic femoral nerve stimulation at week 2 & 12. Feasibility was defined as protocol completion >75% DW patients. Acceptability was assessed via surveys, and safety via incidence of adverse events and serum creatine kinase (CK) levels at weeks 0, 2, 6 & 12. Training progression was analysed weekly. Results: The table shows development of CMF was maintained in DW more than LW. In DW, protocol completion rate was high (attrition unrelated to training) and adverse events rare (mild tendinopathy). CK levels were lower in DW compared to LW (p Conclusion: DW as part of PR is feasible, acceptable, safe and enhances training progression more than LW. These data support the use of DW in exercise training programs for COPD.

Background: It has been suggested that body balance is impaired in COPD patients. It is unknown to what extent ET impacts on balance status in this patient population. Aim: Investigate the effects of an ET program on balance status and falls in COPD patients. Methods: We evaluated 44 COPD patients (FEV1:47±19%pred) before and after 3 months and 6 months of ET (N=32). Patients performed balance tests: Timed up & go test (TUG), Berg Balance Scale (BBS), Mini-Balance Evaluation Systems Test (mini-BESTest) and routine assessments (lung function, exercise capacity and peripheral muscle force). Falls Efficacy Scale-International (FES-I) was applied. Falls history in the previous year was recorded. Fall or stumble incidence were prospectively monitored using a fall calendar. Results: Twenty % of patients reported a fall in the previous year. Five falls were reported by 3 patients in 7567 patient-days follow-up. 5 patients reported 24 stumbles in the same period. Balance tests had relatively good baseline values and improved slightly with ET (Table 1). Conclusion: ET has a small, statistically significant effect on balance in patients with COPD. Funding: Competence center physiotherapy, UZ-Leuven-KULeuven and FWO #G087113N.

Rationale A 3 month tele-coaching (TC) program is effective to increase physical activity (PA) in patients with COPD, but the impact of contact time between patient and coach has never been assessed. Methods 140 patients with COPD, allocated to TC as part of a multicenter RCT (NCT02158065), were analysed. The TC consisted of patients interacting with a stepcounter and a smartphone application. Telephone contact was initiated if patients did not increase their PA goal or in case of health/technical issues. PA was measured by Actigraph GT3x at baseline and week 12. Results Total median[IQR] contact time per patient was 50[30-100] minutes in 6[4-9] contacts with the coach. These contacts were mainly related to not increasing PA goal (39.5%) and to technical issues (58.3%). In a tertile analysis, patients with a low/medium contact time had more PA improvement (steps) compared to those with high contact time (p=0.01). High contact time patients were older and had a worse baseline FEV 1 and functional exercise capacity. Conclusion Older and more severe patients need more interaction with their coach and have less improvement in PA compared to patients with a lower contact time. Such patients may not be ideal candidates for telecoaching only. Funding:IMU-JU#115011.

Background: Development of contractile muscle fatigue (CMF) directly relates to training response in COPD. Downhill walking (DW) induces CMF with less symptoms of dyspnoea and fatigue than conventional level walking (LW). Aim: To compare the effects of LW and DW as part of a 12-week high-intensity pulmonary rehabilitation program in COPD patients. Methods: 34 patients (62±8years; FEV1 50±17%pred) were randomised to complete training with LW or DW. Exercise capacity (6-minute walk test, 6MWT [primary outcome]; cycle endurance test, CET), muscle function and quality of life were assessed before and after program completion. Absolute training change and the proportion of subjects exceeding the 30m minimally important difference (MID) for 6MWT were compared between the two groups. Results: Similar improvements were observed across all outcomes in both groups(Table 1). 94% of patients in DW(n=16) exceeded the 6MWT MID compared to 65%(n=11) in LW(χ 2 test p=0.03). Conclusion: The magnitude of improvement with DW was similar to that of LW across most outcomes in patients with COPD, however a significantly greater proportion of patients exceeded the MID for 6MWT. These results support the use of downhill walking as a useful adjunct in pulmonary rehabilitation programs for patients with COPD. Funding: CAC- CNPq/Brazil (202425/2011–8); CO- ERS (LTRF 2014); HD- ERS/SEPAR (LTRF 2015); TT- FWO/Belgium (G.0871.13).

The Daily and Clinical visit “PROactive physical activity in COPD” instruments (D- and C-PPAC) are new valid and reliable hybrid tools combining a short patient-reported outcome questionnaire and 2 activity monitor variables to assess patient experience with physical activity (PA) in the domains of 9amount9 and 9difficulty9. We aimed to test the responsiveness of both domain scores from both instruments. We enrolled 330 COPD patients (63% male, age 66(8)y and FEV 1 57(22)%pred) from 6 European centres randomly allocated to a 3 months telecoaching intervention or to usual care. Both at baseline and follow-up, patients completed the D- and C-PPAC questionnaire, wore an accelerometer 1 week preceding each visit, and answered 2 questions on global rating of changes in PA (used as anchor). We defined a priori values>|0.5| in standardized response means (SRMs) to represent responsiveness in those reporting changes in PA and patients in the intervention group. D-PPAC difficulty score was responsive to decreasing the global rating of difficulty, and D-PPAC amount score responsive to both increases and decreases in global rating of amount and difficulty (Table). The scores were not responsive to the intervention, but the amount score increased in the intervention and decreased in the usual care (p Conclusion: both domains of both PROactive instruments are responsive to changes in experienced PA.

Rationale: Exercise training improves exercise capacity, dyspnea and quality of life in ILD. Some patients, however, benefit less than others. Aim: To investigate which patients do not experience significant benefits of a training program embedded in a multidisciplinary outpatient rehabilitation program. Methods: Patients with ILD who attended pulmonary rehabilitation between 2003 and 2014 were recruited. 65 patients (54% men) were evaluated before and after 12 weeks of training. Patients who did not complete the program or showed an improvement in 6MWD ≤30m and improved dyspnea (Chronic Respiratory Disease Questionnaire (CRDQdys) ≤2.5 points were defined as non-responders. Results: Baseline characteristics are presented in Table 1. Conclusion: Patients with ILD, not responding to exercise training are those with a poorer lung function, peak exercise performance and somewhat better preserved quadriceps force. These results suggest that exercise training is more effective when offered earlier in the disease course, particularly in patients with muscle weakness.

Background: Pulmonary rehabilitation (PR) enhances exercise tolerance in COPD. Improvements in physical activity (PA) are less guaranteed. We speculate some patients are less likely to improve PA with PR. Aim: To explore the relationship between changes in PA levels and exercise tolerance before and after PR in COPD patients. Methods: 74 COPD patients (mean FEV 1 48%, age 66y, baseline six-minute walk distance [6MWD] 409±120m) wore PA monitors (Actigraph or Sensewear) for one week before and after a 12-week PR program. Change in PA relative to baseline 6MWD was inspected via XY coordinate scatter plot (figure 1). The proportion of patients who improved PA levels (>1000 steps/day) after PR completion was compared across three groups, defined according to baseline 6MWD 450m (n=29), via Chi square test. Results: Median [IQR] improvement in 6MWD and PA was 49 [19 to 84.5] meters and 476 [-449 to 1455] steps/day, respectively. The proportion of patients who improved PA after PR increased with increasing baseline 6MWD (18.2%, 26.5%, 51.7% across the 3 groups, p=0.05). Conclusion: The likelihood of improved PA following PR increases with increasing functional exercise tolerance. Patients with poor exercise tolerance appear less likely to improve PA levels. It is therefore questionable whether increasing PA is a realistic goal of 12 weeks PR in this frail patient sub-group.

Rationale: Tele-coaching programs are potentially an effective strategy to increase physical activity in patients with COPD. Whether such complex interventions are feasible and well received by patients is unknown. Methods: From a larger RCT investigating the effectiveness of a tele-coaching program to increase physical activity levels in patients with COPD, 80 patients were included in the present analysis. These patients finished the 3 month complex coaching intervention including a step counter (SC), an exercise booklet (EX), an application (APP) installed on a smartphone device, text messages (SMS) and telephone contact with investigators (TEL) if problems occurred. After 3 months patient satisfaction was assessed using a tailored questionnaire. Results: Main results are expressed as median [P 25 -P 75 ] or frequency (%). When rating the usefulness of the different components on a 0 (not at all) to 10 (a lot) scale, patients rated the SC (10[8-10]) and TEL (9[8-10]) as the most important aspects. Display of an (educational) activity tip in the evening by the APP (7[5-9]) and EX (7[5-9]) were rated as somewhat less useful. SC was rated as the most important part of the intervention by 70% of patients and 10% of patients reported working with the smartphone as being difficult. Respectively 41% and 90% of patients were willing to use the APP and the SC in the future. Conclusion: Based on this preliminary data a coaching intervention including a smartphone intervention seems well received by patients with COPD. The step counter and contact with investigators in case of problems were rated as crucial parts of the intervention by the majority of participants.

Background: It has been suggested that body balance is impaired in people with COPD, however, balance and falls are not routinely investigated in pulmonary rehabilitation (PR) programs. Aim: To investigate balance status and falls of patients with COPD referred to PR. Methods: All patients referred to PR since December 2014 performed balance tests (Timed up & go test (TUG), Berg Balance Scale (BBS), Mini-Balance Evaluation Systems Test (mini-BESTest)) and routine assessments (lung function, exercise capacity, physical activity (PA), respiratory and peripheral muscle force). Chronic Respiratory Disease Questionnaire and Falls Efficacy Scale-International (FES-I) were applied. History of falls in the previous year was checked and subsequent falls will be recorded. Results: 15 patients (7 male, 63±8 years, FEV 1 49±19 %pred, BMI: 29±7 Kg/m 2 ) completed the assessments. BBS score was 52±3, mini-BESTest score was 24[15-25], FES-I score was 25[19-33] and TUG time was 9.5±2 sec. One patient was at risk of falling according to the BBS (score≤46), 1 patient mentioned a fall in the previous year and 1 patient fell after inclusion. The mini-BESTest correlated with exercise capacity, respiratory and peripheral muscle force (0.52≤r≤0.61). TUG correlated with exercise capacity and PA (-0.55≤r≤-0.79). FES-I correlated with exercise capacity (r=-0.58) and time spent in vigorous PA (r=-0.27). BBS correlated with PA (r=0.56); p Conclusion: Outpatients referred for PR generally presented a satisfying performance in functional balance tests. When confirmed in a larger dataset, these data do not support the inclusion of a falls prevention program in standard outpatient rehabilitation.

Background: Contractile quadriceps fatigue is associated with acute reductions in exercise capacity in COPD (Gagnon, 2009). We hypothesized patients with fatigable quadriceps would present with reduced physical activity (PA). Aim: To compare PA between COPD patients who develop quadriceps fatigue (F) after exercise training and those who are less fatigable (NF). Methods: 19 patients with COPD (65±8years; FEV1 51±17%pred) referred to pulmonary rehabilitation performed PA monitoring (McRoberts; NL) for 7 days before starting exercise training. Potentiated quadriceps twitch force (Twqpot) was measured via magnetic stimulation before and after 1 exercise session in the 2nd training week to determine muscle fatigability. A >15% decrease in Twqpot from initial value defined F. PA levels were compared between F and NF. Results: Test-day training loads were similar for F and NF (64±9% vs 66±10%Wmax for cycling; 77±4% vs 79±7%6MWD speed for walking, p>0.05). F had on average 32% lower daily step count and spent 37% less energy during active time compared to NF, however these differences were not statistically significant (table 1). Conclusion: These preliminary data suggest individuals who develop contractile quadriceps fatigue after an exercise session have lower PA levels. When confirmed in a larger sample, our data suggest quadriceps fatigability could be an (as yet) undiscovered mechanism explaining physical inactivity in COPD.