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Objective Pulmonary rehabilitation programs that use minimal equipment for exercise training, rather than gymnasium equipment, would enable delivery of pulmonary rehabilitation to a greater number of people with chronic obstructive pulmonary disease (COPD). The effectiveness of minimal equipment programs in people with COPD is unclear. This systematic review and meta-analysis aimed to determine the effects of pulmonary rehabilitation using minimal equipment for aerobic and/or resistance training in people with COPD. Methods Literature databases were searched up to September 2022 for randomized controlled trials (RCTs) comparing the effect of minimal equipment programs with usual care or with exercise equipment-based programs for exercise capacity, health-related quality of life (HRQoL), and strength. Results Nineteen RCTs were included in the review and 14 RCTs were included in the meta-analyses, which reported low to moderate certainty of evidence. Compared with usual care, minimal equipment programs increased 6-minute walk distance (6MWD) by 85 m (95% CI = 37 to 132 m). No difference in 6MWD was observed between minimal equipment and exercise equipment-based programs (14 m, 95% CI = −27 to 56 m). Minimal equipment programs were more effective than usual care for improving HRQoL (standardized mean difference = 0.99, 95% CI = 0.31 to 1.67) and were not different from exercise equipment-based programs for improving upper limb strength (6 N, 95% CI = −2 to 13 N) or lower limb strength (20 N, 95% CI = −30 to 71 N). Conclusion In people with COPD, pulmonary rehabilitation programs using minimal equipment elicit clinically significant improvements in 6MWD and HRQoL and are comparable with exercise equipment–based programs for improving 6MWD and strength. Impact Pulmonary rehabilitation programs using minimal equipment may be a suitable alternative in settings where access to gymnasium equipment is limited. Delivery of pulmonary rehabilitation programs using minimal equipment may improve access to pulmonary rehabilitation worldwide, particularly in rural and remote areas and in developing countries.

Background: COVID-19 pandemic lockdowns led to the closure of most in-person pulmonary rehabilitation programs in Australia. Text message programs are effective for delivering health support to aid the self-management of people with chronic diseases. This study aimed to evaluate the implementation of a six-month pre-post text message support program (Texting for Wellness: Lung Support Service), and the enablers and barriers to its adoption and implementation. Methods: This mixed-methods pre-post study used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate the Texting for Wellness: Lung Support Service, which is an automated six-month text message support program that included evidence-based lifestyle, disease-self management and COVID-19-related information. Reach was measured by the proportion of participant enrolments and demographic characteristics. Adoption enablers and barriers were measured using text message response data and a user feedback survey (five-point Likert scale questions and free-text responses). Implementation was evaluated to determine fidelity including text message delivery data, opt-outs, and intervention costs to promote and deliver the program. Results: In total, 707/1940 (36.4%) participants enrolled and provided e-consent, with a mean age (±standard deviation) of 67.9 (±9.2) years old (range: 23–87 years). Of participants who provided feedback, (326/707) most ‘agreed’ or ‘strongly agreed’ that the text messages were easy to understand (98.5%), helpful them to feel supported (92.3%) and helped them to manage their health (88.0%). Factors influencing engagement included a feeling of support and reducing loneliness, and its usefulness for health self-management. Messages were delivered as planned (93.7% successfully delivered) with minimal participant dropouts (92.2% retention rate) and low cost ($AUD24.48/participant for six months). A total of 2263 text message replies were received from 496 unique participants. There were no reported adverse events. Conclusion: Texting for Wellness: Lung Support Service was implemented quickly, had a broad reach, with high retention and acceptability among participants. The program was low cost and required minimal staff oversight, which may facilitate future implementation. Further research is needed to evaluate the efficacy of text messaging for the improvement of lung health outcomes and strategies for long-term pulmonary rehabilitation program maintenance.

The most common symptoms of post-COVID-19 condition in children are fatigue, shortness of breath, exercise intolerance, and weakness. The post-COVID-19 condition in children can be very debilitating and lead to prolonged school absences, high morbidity, and limitations in daily functioning. The aim of this research project is to determine the effectiveness of land-based and water-based exercise interventions on exercise capacity, fatigue, health-related quality of life, and pulmonary function in children with post-COVID-19 condition. This study is a prospective randomized controlled study with pre- and post-intervention assessment. Participants will be recruited from Warsaw’s primary schools and primary healthcare units according to the inclusion criteria: (i) symptoms of post-COVID-19 condition lasting more than one month following initial COVID-19 infection confirmed by the diagnosis by general practitioner (including obligatory fatigue and shortness of breath/respiratory problems); (ii) age 10–12 years old. Participants meeting the inclusion criteria will be randomized to one of three groups: water-based exercise, land-based exercise, or control (no exercise). We hope this study will provide guidance for long-COVID-19 rehabilitation in children.

Background Few studies have examined sedentary behaviour in chronic respiratory disease. The limited evidence suggests that increased levels of sedentary behaviour are associated with increased mortality. Objectives This study aimed to compare the level of self-reported sedentary behaviour in people with chronic obstructive pulmonary disease (COPD) and bronchiectasis as well as to identify associations between sedentary time with functional performance measures and health-related quality of life in the chronic respiratory disease group. Methods An observational study design was used. Participants completed the Sedentary Behaviour Questionnaire from which average sedentary time (hours/day) was determined. Functional performance was measured using the six-minute walk test, the four-metre gait speed test and the five sit-to-stand test. Health-related quality of life was measured using the St George's Respiratory Questionnaire. Sedentary time was compared between groups using an unpaired t-test. Univariate analysis explored relationships amongst variables. Results The convenience sample consisted of 103 people with COPD [52% male; mean ± SD age: 73 ± 9 years, FEV1% predicted: 56 ± 23] and 33 people with bronchiectasis [52% male; 74 ± 8 years, FEV1% predicted: 69 ± 25]. Average self-reported sedentary time in COPD was 7.6 ± 2.7 hours/day and in bronchiectasis was 8.0 ± 4.1 hours/day, with no between-group difference (−0.4, 95% CI −1.7, 0.8). No associations were found between sedentary time and any functional performance outcome or with health-related quality of life. Conclusion There was no difference in the high sedentary time between people with COPD and bronchiectasis. Sedentary behaviour was not associated with functional performance or disease-related health-related quality of life in people with chronic respiratory disease.

IntroductionChronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care.MethodsA multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9–10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up.Ethics and disseminationHuman Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications.Trial registration numberACTRN12619001122145.

IntroductionThis study aimed to determine whether a 6-week behaviour change intervention was more effective than a sham intervention for reducing sedentary behaviour (SB) in people with chronic obstructive pulmonary disease (COPD).MethodsPeople with stable COPD on the waitlist for entry into pulmonary rehabilitation were recruited to this multicentre trial with randomisation (independent, concealed allocation) to either an intervention group or sham group, assessor blinding and intention-to-treat (ITT) analysis. The behaviour change intervention consisted of once weekly sessions for 6 weeks with a physiotherapist to reduce SB through education, guided goals setting and real-time feedback on SB. The sham intervention consisted of once weekly phone calls for 6 weeks to monitor health status. SB was measured continuously over 7 days using thigh-worn accelerometry (activPAL3 micro). The primary outcome was time spent in SB. Participants with at least 4 days of ≥10 hours waking wear time were included in the ITT analysis and those who reported achieving ≥70% of goals to reduce SB or who completed all sham calls were included in a per-protocol analysis.Results70 participants were recruited and 65 completed the study (mean±SD age 74±9 years, mean FEV1 55%±19% predicted, 49% male). At 6 weeks, no between-group differences in time spent in SB were observed in the ITT analysis (mean difference 5 min/day, 95% CI −38 to 48) or per-protocol analysis (−16 min/day, 95% CI −80 to 48).DiscussionA 6-week behaviour change intervention did not reduce time in SB compared with a sham intervention in people with stable moderate-to-severe COPD prior to pulmonary rehabilitation.

Interventions such as exercise training and breathing strategies are components of pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD); however, the conventional mode of gym-based exercise training may not be optimal for all individuals with COPD, and adaptive breathing strategies may be beneficial in reducing dyspnoea, but the current evidence is limited. Uptake and completion rates of pulmonary rehabilitation are suboptimal, so alternative interventions need to be considered. This review examines the current scientific evidence on alternative exercise and breathing interventions from systematic reviews, experimental and observational studies, clinical trial registries, and grey literature. Alternative interventions are assessed for the effect on exercise capacity and quality of life with the aim of guiding the development of strategies to increase training uptake and completion. Systematic reviews of tai chi, yoga, minimal or no equipment exercise, water-based exercise, inspiratory muscle training, and singing demonstrated positive effects on exercise capacity and/or quality of life compared to no training, with some interventions demonstrating comparable outcomes to conventional training. Some positive outcomes have been demonstrated for whole-body vibration, single-limb partitioning, and Nordic and downhill walking; however, further research is required to compare these interventions to conventional training. The most recent interventions examined include exer-gaming, virtual reality, dancing, and laughing; controlled studies are still required to determine the effect on patient outcomes. Although further research is needed to compare alternative exercise and breathing interventions with conventional exercise training, results to date are promising, suggesting that people with COPD will have more options that may help to improve training uptake and adherence.

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality. Advances in remote technologies and telemedicine provide new ways to monitor respiratory function and improve chronic disease management. However, telemedicine does not always include remote respiratory assessments, and the current state of knowledge for people with COPD has not been evaluated.Systematically review the use of remote respiratory assessments in people with COPD, including the following questions: What devices have been used? Can acute exacerbations of chronic obstructive pulmonary disease (AECOPD) be predicted by using remote devices? Do remote respiratory assessments improve health-related outcomes?The review protocol was registered (PROSPERO 2016:CRD42016049333). MEDLINE, EMBASE, and COMPENDEX databases were searched for studies that included remote respiratory assessments in people with COPD. A narrative synthesis was then conducted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Fifteen studies met the inclusion criteria. Forced expiratory volume assessed daily by using a spirometer was the most common modality. Other measurements included resting respiratory rate, respiratory sounds, and end-tidal carbon dioxide level. Remote assessments had high user satisfaction. Benefits included early detection of AECOPD, improved health-related outcomes, and the ability to replace hospital care with a virtual ward.Remote respiratory assessments are feasible and when combined with sufficient organizational backup can improve health-related outcomes in some but not all cohorts. Future research should focus on the early detection, intervention, and rehabilitation for AECOPD in high-risk people who have limited access to best care and investigate continuous as well as intermittent monitoring.

Background and objective The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts. Methods The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts. Results The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary. Conclusion The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Evidence of personal and health-system benefits of pulmonary rehabilitation are undeniable. However, the capacity of traditional centre-based models to both reach and appeal to the intended population of people living with chronic obstructive pulmonary disease (COPD) remains difficult. It is well established that issues with access, suitability, referral, uptake, and attrition exist. Consequently, considerable energy has been invested into exploring innovative alternative modes of rehabilitation in an effort to increase the awareness and appeal, and expand the availability of pulmonary rehabilitation. The process of 'thinking differently' and 'pushing the boundaries' of clinical practice is underway, particularly in the United Kingdom and Australia, where new models of pulmonary rehabilitation are being evaluated. The number one priority is reaching the population of people with COPD and ensuring they are referred to rehabilitation services. Active case-finding in primary care, inviting health professionals and health consumers to pulmonary rehabilitation programs to increase understanding and awareness, and utilizing peer support via patient success stories, are just a few suggestions for increasing awareness of pulmonary rehabilitation. Once referred, engaging the population to complete a program is the next challenge. Marketing, patient co-design, alternative rehabilitation settings and modes of exercise training, use of technology, and focusing on modes which provide patient enjoyment and choice are all potential strategies to target in an effort to broaden the appeal and reduce the high attrition rate of traditional centre-based pulmonary rehabilitation programs. Reaching and engaging the target population in pulmonary rehabilitation is an important first step in people with COPD achieving successful outcomes from rehabilitation.

Background: Patient activation is a significant predictor of health behaviors; however, the level of activation in people attending a pulmonary rehabilitation program and the effect of pulmonary rehabilitation on patient activation have not been measured. Furthermore, the potential determinants and relationship between patient activation and characteristics of people attending pulmonary rehabilitation have not previously been reported. Methods: The Patient Activation Measure (PAM) was measured in people with a chronic respiratory disease or congestive cardiac failure at a baseline pulmonary rehabilitation assessment and again at the completion of the 8-week outpatient program. Results: This study included 194 people with chronic respiratory disease or congestive cardiac failure (41% male; mean [standard deviation, SD] age: 73 [11] years; mean [SD] forced expiratory volume in 1 second % predicted: 60% [20%]). The pulmonary rehabilitation program was completed by 61% (n = 118) of participants. The mean (SD) PAM score at baseline was 60.5 (15.7), which improved to 65.4 (15.5) after completion of the pulmonary rehabilitation program ( P = .001). In a stepwise forward multiple regression analysis, anxiety, lung information needs, and health-related quality of life impact were found to be significant determinants of baseline PAM. This model explained 12% ( P < .001) of the variance. Conclusion: People with a chronic respiratory disease or congestive cardiac failure commencing a pulmonary rehabilitation program demonstrated a moderate level of activation, which improved following an 8-week hospital outpatient pulmonary rehabilitation program. Anxiety, a higher level of lung information needs, and greater health-related quality of life impact were significantly associated with poor patient activation.

Background and objective Telerehabilitation has the potential to increase access to pulmonary rehabilitation (PR) for patients with COPD who have difficulty accessing centre-based PR due to poor mobility, lack of transport and cost of travel. We aimed to determine the effect of supervised, home-based, real-time videoconferencing telerehabilitation on exercise capacity, self-efficacy, health-related quality of life (HRQoL) and physical activity in patients with COPD compared with usual care without exercise training. Methods Patients with COPD were randomized to either a supervised home-based telerehabilitation group (TG) that received exercise training three times a week for 8 weeks or a control group (CG) that received usual care without exercise training. Outcomes were measured at baseline and following the intervention. Results Thirty-six out of 37 participants (mean ± SD age = 74 ± 8 years, forced expiratory volume in 1 s (FEV1 ) = 64 ± 21% predicted) completed the study. Compared with the CG, the TG showed a statistically significant increase in endurance shuttle walk test time (mean difference = 340 s (95% CI: 153–526, P

Telerehabilitation, consisting of supervised home-based exercise training via real-time videoconferencing, is an alternative method to deliver pulmonary rehabilitation with potential to improve access. The aims were to determine the level of satisfaction and experience of an eight-week supervised home-based telerehabilitation exercise program using real-time videoconferencing in people with COPD. Quantitative measures were the Client Satisfaction Questionnaire-8 (CSQ-8) and a purpose-designed satisfaction survey. A qualitative component was conducted using semi-structured interviews. Nineteen participants (mean (SD) age 73 (8) years, forced expiratory volume in 1 second (FEV1) 60 (23) % predicted) showed a high level of satisfaction in the CSQ-8 score and 100% of participants reported a high level of satisfaction with the quality of exercise sessions delivered using real-time videoconferencing in participant satisfaction survey. Eleven participants undertook semi-structured interviews. Key themes in four areas relating to the telerehabilitation service emerged: positive virtual interaction through technology; health benefits; and satisfaction with the convenience and use of equipment. Participants were highly satisfied with the telerehabilitation exercise program delivered via videoconferencing.

Renae J McNamara,1,2 Zoe J McKeough,3 Laura R Mo,3 Jamie T Dallimore,4 Sarah M Dennis3 1Physiotherapy Department, 2Respiratory and Sleep Medicine Department, Prince of Wales Hospital, Randwick, 3Discipline of Physiotherapy, The University of Sydney, Lidcombe, 4Eastern Sydney Medicare Local, Rosebery, NSW, Australia Background: Poor uptake and adherence are problematic for hospital-based pulmonary and heart failure rehabilitation programs, often because of access difficulties. The aims of this mixed-methods study were to determine the feasibility of a supervised exercise training program in a community gymnasium in people with chronic respiratory and chronic cardiac disease, to explore the experiences of participants and physiotherapists and to determine if a community venue improved access and adherence to rehabilitation. Methods: Adults with chronic respiratory and/or chronic cardiac disease referred to a hospital-based pulmonary and heart failure rehabilitation program were screened to determine their suitability to exercise in a community venue. Eligible patients were offered the opportunity to attend supervised exercise training for 8weeks in a community gymnasium. Semi-structured interviews were conducted with participants and physiotherapists at the completion of the program. Results: Thirty-one people with chronic respiratory and chronic cardiac disease (34% males, mean [standard deviation] age 72 [10] years) commenced the community-based exercise training program. Twenty-two (71%) completed the program. All participants who completed the program, and the physiotherapists delivering the program, were highly satisfied, with reports of the community venue being well-equipped, convenient, and easily accessible. Using a community gymnasium promoted a sense of normality and instilled confidence in some to continue exercising at a similar venue post rehabilitation. However, factors such as cost and lack of motivation continue to be barriers. Conclusion: The convenience and accessibility of a community venue for rehabilitation contributed to high levels of satisfaction and a positive experience for people with chronic respiratory and chronic cardiac disease and physiotherapists. Keywords: pulmonary rehabilitation, exercise, qualitative, COPD

Background Singing is a complex physical activity dependent on the use of the lungs for air supply to regulate airflow and create large lung volumes. In singing, exhalation is active and requires active diaphragm contraction and good posture. Chronic obstructive pulmonary disease (COPD) is a progressive, chronic lung disease characterised by airflow obstruction. Singing is an activity with potential to improve health outcomes in people with COPD. Objectives To determine the effect of singing on health-related quality of life and dyspnoea in people with COPD. Search methods We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, the World Health Organization trials portal and PEDro, from their inception to August 2017. We also reviewed reference lists of all primary studies and review articles for additional references. Selection criteria We included randomised controlled trials in people with stable COPD, in which structured supervised singing training of at least four sessions over four weeks' total duration was performed. The singing could be performed individually or as part of a group (choir) facilitated by a singing leader. Studies were included if they compared: 1) singing versus no intervention (usual care) or another control intervention; or 2) singing plus pulmonary rehabilitation versus pulmonary rehabilitation alone. Data collection and analysis Two review authors independently screened and selected trials for inclusion, extracted outcome data and assessed risk of bias. We contacted authors of trials for missing data. We calculated mean differences (MDs) using a random-effects model. We were only able to analyse data for the comparison of singing versus no intervention or a control group. Main results Three studies (a total of 112 participants) were included. All studies randomised participants to a singing group or a control group. The comparison groups included a film workshop, handcraft work, and no intervention. The frequency of the singing intervention in the studies ranged from 1 to 2 times a week over a 6 to 24 week period. The duration of each singing session was 60 minutes.All studies included participants diagnosed with COPD with a mean age ranging from 67 to 72 years and a mean forced expiratory volume in one second (FEV1) ranging from 37% to 64% of predicted values. The sample size of included studies was small (33 to 43 participants) and overall study quality was low to very low. Blinding of personnel and participants was not possible due to the physical nature of the intervention, and selection and reporting bias was present in two studies.For the primary outcome of health-related quality of life, there was no statistically significant improvement in the St George's Respiratory Questionnaire total score (mean difference (MD) -0.82, 95% confidence interval (CI) -4.67 to 3.02, 2 studies, n = 58, low-quality evidence). However, there was a statistically significant improvement in the SF-36 Physical Component Summary (PCS) score favouring the singing group (MD 12.64, 95% CI 5.50 to 19.77, 2 studies, n = 52, low-quality evidence). Only one study reported results for the other primary outcome of dyspnoea, in which the mean improvement in Baseline Dyspnoea Index (BDI) score favouring the singing group was not statistically significant (MD 0.40, 95% CI -0.65 to 1.45, 1 study, n = 30, very low-quality evidence).No studies examined any long-term outcomes and no adverse events or side effects were reported. Authors' conclusions There is low to very low-quality evidence that singing is safe for people with COPD and improves physical health (as measured by the SF-36 physical component score), but not dyspnoea or respiratory-specific quality of life. The evidence is limited due to the low number of studies and the small sample size of each study. No evidence exists examining the long-term effect of singing for people with COPD. The absence of studies examining singing performed in conjunction with pulmonary rehabilitation precludes the formulation of conclusions about the effects of singing in this context. More randomised controlled trials with larger sample sizes and long-term follow-up, and trials examining the effect of singing in addition to pulmonary rehabilitation, are required to determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

Background: Exercise limitation in COPD is multi-factorial. The contribution of cardiac function to exercise capacity is not clear.Methods: Potential determinants of the different constructs of exercise capacity (functional, peak and endurance exercise capacity using the 6-minute walk distance (6MWD), peak oxygen uptake (VO(2)peak) and peak work load, and sub-maximal constant work rate test (CWRT) cycle time, respectively) were analysed.Results: Data were collected in 516 people with COPD (56% male, age (mean +/- SD) 64 +/- 9 years, FEV1% predicted 49 +/- 20%). Participants had reduced exercise capacity (6MWD 424 +/- 124 m, 67 +/- 18% predicted; VO(2)peak 1090 +/- 414 ml/min, 66 +/- 30% predicted; peak work load 70 +/- 34 watts, 56 +/- 27% predicted; CWRT cycle time (median (IQR)) 225 (169-328) seconds). Cardiac function measures, including echocardiography and N-terminal pro-brain natriuretic peptide level, were independently significantly correlated with exercise capacity. In multiple regression analyses adjusted for age and gender, 72% (p Conclusions: Cardiac function is related to exercise capacity, however is not a primary determinant. Determinants of the different constructs of exercise capacity vary, but there is a strong relationship between quadriceps force and functional and endurance exercise performance, and between lung function and peak exercise capacity.

Background and objective The prevalence of physical comorbidities such as obesity, musculoskeletal or neurological conditions in people with chronic obstructive pulmonary disease (COPD) is high, yet little is known about the impact of these physical comorbidities on physical activity. The primary aim of the study was to compare the physical activity levels of people with COPD with physical comorbidities (COPD + PC) to people with COPD without physical comorbidities (COPD) and healthy age-matched volunteers (control group). Methods Twenty-five people with COPD + PC (mean (standard deviation (SD)) age 73 (11) years, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II–IV), 25 people with COPD (70 (8) years, GOLD stage II–IV) and 25 controls (70 (7) years) wore the SenseWear Pro3 Armband for 7 days. Results Engagement in light intensity physical activity (1.5–3.0 metabolic equivalents (MET)) (140 (76) minutes per day (min/day)) and moderate intensity physical activity (3.0–6.0 MET) (25 (35) min/day) in the COPD + PC group was significantly reduced compared with the COPD (231 (76) and 104 (106), respectively) and control group (259 (75) and 114 (57), respectively). In the 16 daytime hours between 6 am and 10 pm, people with COPD + PC spent a mean (SD) of 771 (98) min/day engaged in sedentary behaviour (

While recommendations for the duration, frequency, mode and intensity of exercise programmes for people with chronic obstructive pulmonary disease (COPD) are specified in consensus statements,criteria for exercise session attendance are less clear.The review questions were: (i) how commonly are a priori criteria and attendance rates reported for people with COPD participating in exercise programmes and (ii) what is the strength of association between attendance and improvements in functional exercise capacity. Database searches identified primary studies of people with COPD participating in exercise or pulmonary rehabilitation programmes of at least 2 weeks duration. Primary outcomes were a priori criteria for attendance, reports of attendance at supervised exercise sessions and mean improvements in functional exercise assessments. Data extraction processes were confirmed prospectively (>80% agreement). Variants of exercise attendance data were described. Linear associations between attendance and improvements in exercise outcomes were explored (Pearson r, P < 0.05). Of the 234 included studies, 86 (37%) reported attendance and 29 (12%) provided a priori criteria for attendance. In the small sample of studies which reported attendance and functional exercise data before and after the intervention, there was little to no relationship between improvements in functional exercise capacity and training volume (prescribed r = 0.03, P = 0.88; attended r = 0.24, P = 0.18). Reporting of exercise programme attendance rates is low and of variable quality for people with COPD. Consistent and explicit reporting of exercise attendance in people with

The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts.The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts.The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary.The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Background: Home-based telerehabilitation (delivery of rehabilitation via desktop videoconferencing) has the potential to overcome the barriers that exist in accessing centre-based pulmonary rehabilitation programs. Aim: To determine the effectiveness of telerehabilitation on exercise capacity, self-efficacy and quality of life in people with COPD compared to no pulmonary rehabilitation. Methods: People with COPD were randomised to either a supervised home-based telerehabilitation group that received exercise training including cycling, walking and lower limb strengthening exercises, three times a week for eight weeks, or a control group that received usual medical care and did not participate in pulmonary rehabilitation. Exercise capacity was measured by the endurance shuttle walk test (ESWT), self-efficacy by the Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) tool and quality of life by the Chronic Respiratory Disease Questionnaire (CRDQ) at baseline and immediately post-intervention. Results: Thirty-six out of 37 participants (mean ± SD age 74 ± 8 years, FEV 1 64 ± 21% predicted) completed the study. Compared to the control group, the telerehabilitation group significantly increased in the ESWT time (mean difference 340 seconds (95% CI 153 to 526, p Conclusion: Telerehabilitation is an effective therapy to improve endurance exercise capacity and self-efficacy in people with COPD.

Background: Water-based exercise has long been used as a therapeutic modality for the treatment of a wide variety of health conditions. However, head out of water immersion (HOWI) was previously thought to be detrimental to the respiratory system and was not recommended for people with chronic obstructive pulmonary disease (COPD). Recent research has provided evidence to the contrary. In fact, HOWI and physical exercise training in water may improve exercise capacity and health-related quality of life in people with COPD.Objective: To review the physiological effects of HOWI and the safety and efficacy of water-based exercise for people with COPD.Major findings: HOWI and exercise in water can be performed safely without any adverse events and with maintenance of oxygen saturation even in those with severe COPD. Evidence is beginning to emerge on the beneficial effects of water-based exercise training on exercise capacity and quality of life in COPD although further high quality research is require...

Visual recognition of cyanosis is an important clinical activity. While pulse oximetry is almost universal in the hospital environment, there are circumstances where it is not available or may be unreliable. Cyanosis recognition is affected by lighting colour. In addition, there is, mainly anecdotal, evidence that people with greater colour vision deficiencies (CVDs) have particular difficulty and there is no effective lighting strategy to assist in the observation. The change of blood colour with oxygenation has been shown to lie close to the direction of colour confusions made by congenital red-green dichromats. The important sites of observation are lips, nail beds and palm creases. 10 subjects who were known to be chronically hypoxaemic were recruited from the chronic respiratory program. Their blood oxygen saturation (SpO 2 ) varied from 84% to 96% pre-exercise, and 61―84% post-exercise. Ten normal subjects were recruited whose SpO 2 was 99% or 100%. The spectral radiances of lips, nail beds and palm creases were measured using a telespectroradiometer and compared with the spectral radiances of a white tile of known spectral reflectances measured in the same location. This is a non-contact method of measurement, avoiding the blanching caused by pressure of contact methods. The spectral reflectances were calculated, and the chromaticities calculated for a Planckian radiator T = 4000K. Measurements on lips yielded the most consistent results. The colour changes pre- and post-exercise and compared with normal colour lie generally along a deutan confusion line. These results show the direction of the colour change and confirm the, previously anecdotal, difficulties in detecting cyanosis by observers with CVDs.

Little is known about the acceptability of wearing physical activity-monitoring devices. This study aimed to examine the compliance, comfort, incidence of adverse side effects, and usability when wearing the SenseWear Armband (SWA) for daily physical activity assessment. In a prospective study, 314 participants (252 people with COPD, 36 people with a dust-related respiratory disease and 26 healthy age-matched people) completed a purpose-designed questionnaire following a 7-day period of wearing the SWA. Compliance, comfort levels during the day and night, adverse side effects and ease of using the device were recorded. Non-compliance with wearing the SWA over 7 days was 8%. The main reasons for removing the device were adverse side effects and discomfort. The SWA comfort level during the day was rated by 11% of participants as uncomfortable/very uncomfortable, with higher levels of discomfort reported during the night (16%). Nearly half of the participants (46%) experienced at least one adverse skin irritation side effect from wearing the SWA including itchiness, skin irritation and rashes, and/or bruising. Compliance with wearing the SWA for measurement of daily physical activity was found to be good, despite reports of discomfort and a high incidence of adverse side effects.

To the Editor: Rutten et al. [1] recently summarised the literature regarding obesity as a comorbidity in chronic obstructive pulmonary disease (COPD). Obesity in COPD has been associated with increased symptoms of dyspnoea [2], poorer health-related quality of life [2], increased levels of fatigue [3] and exercise performance limitations, including a decreased tolerance to weight-bearing exercise such as walking [4]. We have previously reported the results of a randomised controlled trial examining the effect of water-based exercise in 53 individuals with COPD with physical comorbidities, including obesity [5]. In order to contribute to the discussion on the impact of obesity in COPD we present additional data from the subgroup of 24 obese (defined as body mass index ≥32 kg·m−2) individuals with COPD in our trial. These 24 participants were randomised to either 8 weeks water-based exercise (n=8), land-based exercise (n=8) or control (no exercise) (n=8). Participant characteristics and body composition results are presented in table 1. Within-group comparisons using a paired t-test demonstrated that participants in the water-based exercise group lost the greatest amount of weight over the eight-week period (p=0.02) (table 1). Between-group comparisons using independent group t-tests found a significant difference in change in weight between the water-based exercise group and the control …

Introduction Replacing sedentary behaviour with light intensity physical activity (ie, activities classified as less than three metabolic equivalents, such as slow-paced walking) may be a more realistic strategy for reducing cardiometabolic risk in people with chronic obstructive pulmonary disease than only aiming to increase levels of moderate-vigorous intensity physical activity. Behaviour change interventions to reduce sedentary behaviour in people with chronic obstructive pulmonary disease have not yet been developed or tested. Research questions Is a 6-week behaviour change intervention effective and feasible in reducing sedentary time in people with chronic obstructive pulmonary disease? Design This study will be a multi-centre, randomised, controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis, comparing a 6-week behaviour change intervention aimed at reducing sedentary time with a sham intervention in people with chronic obstructive pulmonary disease. Participants and setting Seventy participants will be recruited from the waiting lists for pulmonary rehabilitation programs at Royal Prince Alfred Hospital and Prince of Wales Hospital, Sydney, Australia. Intervention The behaviour change intervention aims to reduce sedentary time through a process of guided goal setting with participants to achieve two target behaviours: (1) replace sitting and lying down with light-intensity physical activity where possible, and (2) stand up and move for 2minutes after 30minutes of continuous sedentary time. Three face-to-face sessions and three phone sessions will be held with a physiotherapist over the 6-week intervention period. The ‘capability', ‘opportunity', ‘motivation' and ‘behaviour' (COM-B) model will be applied to each participant to determine which components of behaviour (capability, opportunity or motivation) need to change in order to reduce sedentary time. Based on this ‘behavioural diagnosis', the Behaviour Change Wheel will be used to systematically select appropriate behaviour change techniques to assist participants in achieving their weekly goals. Behaviour change techniques will include providing information about the health consequences of sedentary behaviour, self-monitoring and review of weekly goals, problem-solving of barriers to achieving weekly goals, and providing feedback on sedentary time using the Jawbone UP3 activity monitor. Control The sham intervention will consist of weekly phone calls for 6 weeks, to enquire whether the participants' health status has changed over the intervention period (eg, hospitalised for an acute exacerbation). No instructions regarding physical activity or exercise will be given. Measurements Outcomes will be assessed at baseline, at the end of the 6-week intervention period, and at the 3-month follow-up. Primary outcome measures will be: (1) total sedentary time, including the pattern of accumulation of sedentary time, assessed by the activPAL3 activity monitor, and (2) feasibility of the intervention assessed by uptake and retention of participants, participant compliance, self-reported achievement of weekly goals, and adverse events. Secondary outcome measures will include functional exercise capacity, health-related quality of life, domain-specific and behaviour-specific sedentary time, patient activation, and anxiety and depression. Semi-structured interviews will be conducted with participants who receive the behaviour change intervention to explore acceptability and satisfaction with the different components of the intervention. Analysis Analysis of covariance (ANCOVA) will be used to calculate between-group comparisons of total sedentary time and the number of bouts of sedentary time>30minutes after adjusting baseline values. Uncertainty about the size of the mean between-group differences will be quantified with 95% CI. Within-group comparisons will be examined using paired t-tests and described as mean differences with 95% CIs. Secondary outcome measures will be analysed similarly. The feasibility measures will be analysed descriptively. Semi-structured interviews will be conducted until data saturation is achieved and there are no new emerging themes. De-identified interview transcripts will be coded independently by two researchers and analysed alongside data collection using the COM-B model as a thematic framework. Discussion/significance If behaviour change interventions are found to be an effective and feasible method for reducing sedentary time, such interventions may be used to reduce cardiometabolic risk in people with chronic obstructive pulmonary disease. An approach that emphasises participation in light-intensity physical activity may increase the confidence and willingness of people with chronic obstructive pulmonary disease to engage in more intense physical activity, and may serve as an intermediate goal to increase uptake of pulmonary rehabilitation.

Background Land-based exercise training improves exercise capacity and quality of life in people with chronic obstructive pulmonary disease (COPD). Water-based exercise training is an alternative mode of physical exercise training that may appeal to the older population attending pulmonary rehabilitation programmes, those who are unable to complete land-based exercise programmes and people with COPD with comorbid physical and medical conditions. Objectives To assess the effects of water-based exercise training in people with COPD. Search methods A search of the Cochrane Airways Group Specialised Register of trials, which is derived from systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, was conducted (from inception to August 2013). Handsearching was done to identify further qualifying studies from reference lists of relevant studies. Selection criteria Review authors included randomised or quasi-randomised controlled trials in which water-based exercise training of at least four weeks' duration was compared with no exercise training or any other form of exercise training in people with COPD. Swimming was excluded. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Main results Five studies were included with a total of 176 participants (71 people participated in water-based exercise training and 54 in land-based exercise training; 51 completed no exercise training). All studies compared supervised water-based exercise training versus land-based exercise training and/or no exercise training in people with COPD (with average forced expiratory volume in one second (FEV1) %predicted ranging from 39% to 62%). Sample sizes ranged from 11 to 53 participants. The exercise training programmes lasted from four to 12 weeks, and the mean age of participants ranged from 57 to 73 years. A moderate risk of bias was due to lack of reporting of randomisation, allocation and blinding procedures in some studies, as well as small sample sizes. Compared with no exercise, water-based exercise training improved the six-minute walk distance (mean difference (MD) 62 metres; 95% confidence interval (CI) 44 to 80 metres; three studies; 99 participants; moderate quality evidence), the incremental shuttle walk distance (MD 50 metres; 95% CI 20 to 80 metres; one study; 30 participants; high quality evidence) and the endurance shuttle walk distance (MD 371 metres; 95% CI 121 to 621 metres; one study; 30 participants; high quality evidence). Quality of life was also improved after water-based exercise training compared with no exercise (standardised mean difference (SMD) -0.97, 95% CI -0.37 to -1.57; two studies; 49 participants; low quality evidence). Compared with land-based exercise training, water-based exercise training did not significantly change the six-minute walk distance (MD 11 metres; 95% CI -11 to 33 metres; three studies; 62 participants; moderate quality evidence) or the incremental shuttle walk distance (MD 9 metres; 95% CI -15 to 34 metres; two studies; 59 participants; low quality evidence). However, the endurance shuttle walk distance improved following water-based exercise training compared with land-based exercise training (MD 313 metres; 95% CI 232 to 394 metres; two studies; 59 participants; moderate quality evidence). No significant differences were found between water-based exercise training and land-based exercise training for quality of life, as measured by the St George's Respiratory Questionnaire or by three of four domains of the Chronic Respiratory Disease Questionnaire (CRDQ); however, the fatigue domain of the CRDQ showed a statistically significant difference in favour of water-based exercise (MD -3.00; 95% CI -5.26 to -0.74; one study; 30 participants). Only one study reported long-term outcomes after water-based exercise training for quality of life and body composition, and no significant change was observed between baseline results and six-month follow-up results. One minor adverse event was reported for water-based exercise training (based on reporting from two studies; 20 participants). Impact of disease severity could not be examined because data were insufficient. Authors' conclusions There is limited quality evidence that water-based exercise training is safe and improves exercise capacity and quality of life in people with COPD immediately after training. There is limited quality evidence that water-based exercise training offers advantages over land-based exercise training in improving endurance exercise capacity, but we remain uncertain as to whether it leads to better quality of life. Little evidence exists examining the long-term effect of water-based exercise training.

Objectives Water-based exercise training is a relatively new concept in the management of people with COPD. This study aimed to examine the acceptability of the aquatic environment as a medium for exercise training in people with COPD with physical comorbidities. Design Following a supervised eight week, three times a week, water-based exercise training programme conducted in a hospital hydrotherapy pool as part of a randomised controlled trial, participants completed a questionnaire about their experience with exercise training in the pool including adverse events, barriers and factors enabling exercise programme completion, satisfaction with the aquatic environment and their preference for an exercise training environment. Results All 18 participants (mean (SD) age 72 (10) years; FEV 1 % predicted 60 (10) %) who commenced the water-based exercise training programme completed the questionnaire. Three participants withdrew from training. High acceptability of the water and air temperature, shower and change-room facilities, staff assistance and modes of pool entry was reported (94% to 100%). Six factors were highly rated as enabling exercise programme adherence and completion: staff support (chosen by 93% of participants), enjoyment (80%), sense of achievement (80%), noticeable improvements (73%), personal motivation (73%) and participant support (53%). Eighty-nine percent of the participants indicated they would continue with water-based exercise. Conclusions This study provides the first insight into the acceptability of the aquatic environment for exercise training in people with COPD and indicates water-based exercise and the aquatic environment is well accepted.

The prevalence of physical comorbidities such as obesity, musculoskeletal or neurological conditions in people with chronic obstructive pulmonary disease (COPD) is high, yet little is known about the impact of these physical comorbidities on physical activity. The primary aim of the study was to compare the physical activity levels of people with COPD with physical comorbidities (COPD + PC) to people with COPD without physical comorbidities (COPD) and healthy age-matched volunteers (control group).Twenty-five people with COPD + PC (mean (standard deviation (SD)) age 73 (11) years, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II-IV), 25 people with COPD (70 (8) years, GOLD stage II-IV) and 25 controls (70 (7) years) wore the SenseWear Pro3 Armband for 7 days.Engagement in light intensity physical activity (1.5-3.0 metabolic equivalents (MET)) (140 (76) minutes per day (min/day)) and moderate intensity physical activity (3.0-6.0 MET) (25 (35) min/day) in the COPD + PC group was significantly reduced compared with the COPD (231 (76) and 104 (106), respectively) and control group (259 (75) and 114 (57), respectively). In the 16 daytime hours between 6 am and 10 pm, people with COPD + PC spent a mean (SD) of 771 (98) min/day engaged in sedentary behaviour (1.5 MET). This was significantly greater than the group with COPD (603 (148) min/day) and the control group (567 (76) min/day) (P0.001).People with COPD + PC had significantly lower daily physical activity levels compared with people with COPD without physical comorbidities and healthy people.