Abstracts
OBJECTIVE:
To evaluate the ability of COPD patients to perform activities of daily living (ADL); to identify barriers that prevent these individuals from performing ADL; and to correlate those barriers with dyspnea severity, six-minute walk test (6MWT), and an ADL limitation score.
METHODS:
In COPD patients and healthy, age-matched controls, the number of steps, the distance walked, and walking time were recorded with a triaxial accelerometer, for seven consecutive days. A questionnaire regarding perceived barriers and the London Chest Activity of Daily Living (LCADL) scale were used in order to identify the factors that prevent the performance of ADL. The severity of dyspnea was assessed with two scales, whereas submaximal exercise capacity was determined on the basis of the 6MWT.
RESULTS:
We evaluated 40 COPD patients and 40 controls. In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5 ± 25.8 min/day vs. 105.2 ± 49.4 min/day; p < 0.001), as was the distance walked (3.9 ± 1.9 km/day vs. 6.4 ± 3.2 km/day; p < 0.001). The COPD patients also walked fewer steps/day. The most common self-reported barriers to performing ADL were lack of infrastructure, social influences, and lack of willpower. The 6MWT distance correlated with the results obtained with the accelerometer but not with the LCADL scale results.
CONCLUSIONS:
Patients with COPD are less active than are healthy adults of a comparable age. Physical inactivity and the barriers to performing ADL have immediate implications for clinical practice, calling for early intervention measures.
Pulmonary disease; chronic obstructive; Activities of daily living; Exercise tolerance
OBJETIVO:
Avaliar a capacidade de portadores de DPOC em realizar atividades de vida diária (AVD), identificar barreiras que impedem a sua realização, e correlacionar essas barreiras com gravidade da dispneia, teste de caminhada de seis minutos (TC6) e um escore de limitação de AVD.
MÉTODOS:
Nos pacientes com DPOC e controles saudáveis pareados por idade, o número de passos, a distância percorrida e o tempo de caminhada foram registrados por um acelerômetro tridimensional durante sete dias consecutivos. Um questionário de barreiras percebidas e a escala London Chest Activity of Daily Living (LCADL) foram utilizados para identificar os fatores que impedem a realização de AVD. A dispneia foi medida por duas escalas distintas, e a capacidade física submáxima foi determinada com base no TC6.
RESULTADOS:
Foram avaliados 40 sujeitos com DPOC e 40 controles. Os pacientes com DPOC, comparados aos controles, realizaram menor tempo de caminhada (68,5 ± 25,8 min/dia vs. 105,2 ± 49,4 min/dia; p < 0,001), menor distância caminhada (3,9 ± 1,9 km/dia vs. 6,4 ± 3,2 km/dia; p < 0,001) e menor número de passos/dia. As principais barreiras referidas para realização de AVD foram falta de estrutura, influência social e falta de vontade. A distância caminhada no TC6 correlacionou-se com os resultados do acelerômetro, mas não os resultados da LCADL.
CONCLUSÕES:
Portadores de DPOC são menos ativos quando comparados a adultos saudáveis com idade comparável. O sedentarismo e as barreiras para a realização de AVD têm implicações imediatas na prática clínica, exigindo medidas precoces de intervenção.
Doença pulmonar obstrutiva crônica; Atividades cotidianas; Tolerância ao exercício
Introduction
There are several reasons for physical inactivity among healthy and diseased
individuals. Common factors include technological advances that have influenced daily
life, including the means of urban transportation; lack of time; being overweight;
changes in the weather; lack of social support; and lack of motivation.(
11. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al.
Physical activity and public health. A recommendation from the Centers for Disease
Control and Prevention and the American College of Sports Medicine. JAMA.
1995;273(5):402-7.
=http://dx.doi.org/10.1001/jama.1995.03520290054029
https://doi.org/10.1001/jama.1995.035202...
) Physical activity is recognized to have a beneficial role in the prevention
of chronic diseases, such as systemic arterial hypertension, coronary artery disease,
diabetes, osteoporosis, anxiety, and depression.(
22. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al.
Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med.
2007;176(6):532-55. http://dx.doi.org/10.1164/rccm.200703-456SO
https://doi.org/10.1164/rccm.200703-456S...
)
Physical inactivity in patients with COPD was demonstrated in a study in which physical
activity was objectively assessed by means of an accelerometer.(
33. Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R.
Characteristics of physical activities in daily life in chronic obstructive pulmonary
disease. Am J Respir Crit Care Med. 2005;171(9):972-7.
http://dx.doi.org/10.1164/rccm.200407-855OC
https://doi.org/10.1164/rccm.200407-855O...
) The authors of the study demonstrated that COPD patients spend less time
walking or standing than do sedentary elderly volunteers. In a study of patients with
varying degrees of COPD severity,(
44. Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in
patients with COPD. Eur Respir J. 2009;33(2):262-72
http://dx.doi.org/10.1183/09031936.00024608
https://doi.org/10.1183/09031936.0002460...
) it was shown that physical activity is reduced in those with milder disease
in comparison with smokers without COPD. One group of authors(
55. Pitta F, Breyer MK, Hernandes NA, Teixeira D, Sant'Anna TJ, Fontana
AD, et al. Comparison of daily physical activity between COPD patients from Central
Europe and South America. Respir Med. 2009;103(3):421-6.
http://dx.doi.org/10.1016/j.rmed.2008.09.019
https://doi.org/10.1016/j.rmed.2008.09.0...
) compared COPD patients from Brazil and Austria and showed that 23% of the
Brazilian patients and half of the Austrian patients did not reach an average of 30 min
of walking per day, which is the minimum recommended physical activity
level.(
11. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al.
Physical activity and public health. A recommendation from the Centers for Disease
Control and Prevention and the American College of Sports Medicine. JAMA.
1995;273(5):402-7.
=http://dx.doi.org/10.1001/jama.1995.03520290054029
https://doi.org/10.1001/jama.1995.035202...
) Few studies have investigated physical activity levels in patients with
COPD in Brazil.
Knowledge of the determinants and outcomes of physical activity in COPD patients allows
the development of interventions designed to guide future research and improve the
management of COPD. In a systematic review of the determinants of physical activity in
patients with COPD,(
66. Gimeno-Santos E, Frei A, Steurer-Stey C, Batlle J, Rabinovic RA,
Raste Y, et al. Determinants and outcomes of physical activity in patients with COPD:
a systematic review. Thorax. 2014;69(8):731-9.
http://dx.doi.org/10.1136/thoraxjnl-2013-204763
https://doi.org/10.1136/thoraxjnl-2013-2...
) the authors found studies of clinical, functional, sociodemographic, and
lifestyle factors. In addition, they criticized the quality of the evidence found in
cross-sectional uncontrolled studies, stating that it did not allow them to establish
causal associations and that it led to inconsistent results, the exception being that
physical activity reduces exacerbations and mortality in COPD patients.(
66. Gimeno-Santos E, Frei A, Steurer-Stey C, Batlle J, Rabinovic RA,
Raste Y, et al. Determinants and outcomes of physical activity in patients with COPD:
a systematic review. Thorax. 2014;69(8):731-9.
http://dx.doi.org/10.1136/thoraxjnl-2013-204763
https://doi.org/10.1136/thoraxjnl-2013-2...
)
Comparisons between different populations indicate that the factors that prevent
individuals from performing activities of daily living (ADL) are heterogeneous. In a
study of elderly individuals from a South American country, adherence to a physical
activity intervention was 42.6%. Morbidity, poverty, and urban violence reduced
adherence to the intervention, whereas retirement, a history of physical activity, and
the presence of green areas in the neighborhood increased it.(
77. Garmendia ML, Dangour AD, Albala C, Eguiguren P, Allen E, Uauy R.
Adherence to a physical activity intervention among older adults in a
post-transitional middle income country: a quantitative and qualitative analysis. J
Nutr Health Aging. 2013;17(5):466-71.
http://dx.doi.org/10.1007/s12603-012-0417-1
https://doi.org/10.1007/s12603-012-0417-...
) In a population-based study of individuals in the 40-79 year age bracket,
self-reported inability to perform ADL was twice to four times as high in COPD patients
as it was in individuals without the disease. Advanced age, poor health status, and
anxiety/depression were associated with a higher probability of disability.(
88. Rodríguez-Rodríguez P, Jiménez-García R, Hernández-Barrera V,
Carrasco-Garrido P, Puente-Maestu L, de Miguel-Díez J. Prevalence of physical
disability in patients with chronic obstructive pulmonary disease and associated risk
factors. COPD. 2013;10(5):611-7.
http://dx.doi.org/10.3109/15412555.2013.781150
https://doi.org/10.3109/15412555.2013.78...
) In a sample of 9,415 adults in the USA, 9.6% of whom reported having COPD,
44.3% (vs. 27.5% of those who reported not having COPD) had difficulty in performing at
least one ADL (60% having difficulty in performing practical/instrumental ADL), being
less likely to be engaged in social activities and more likely to die.(
99. Liu Y, Croft JB, Anderson LA, Wheaton AG, Presley-Cantrell LR, Ford
ES. The association of chronic obstructive pulmonary disease, disability, engagement
in social activities, and mortality among US adults aged 70 years or older,
1994-2006. Int J Chron Obstruct Pulmon Dis. 2014;9:75-83.
http://dx.doi.org/10.2147/COPD.S53676
https://doi.org/10.2147/COPD.S53676...
) The aforementioned data suggest that it is necessary to identify the
barriers to performing ADL in each population in order to increase the chance of success
of ADL programs.
In a systematic review aimed at identifying barriers to and facilitators of physical
activity (including pulmonary rehabilitation) in patients with COPD, only a small number
of studies met the inclusion criteria. Most (70%) of the studies included in the review
were qualitative studies and had methodological problems, such as small sample size and
poor description of data collection and analysis.(
1010. Thorpe O, Johnston K, Kumar S. Barriers and enablers to physical
activity participation in patients with COPD: a systematic review. J Cardiopulm
Rehabil Prev. 2012;32(6):359-69.
http://dx.doi.org/10.1097/HCR.0b013e318262d7df
https://doi.org/10.1097/HCR.0b013e318262...
) Barriers identified included changing health status, personal problems,
lack of support, external factors, smoking, and program-specific barriers. In one of the
studies included in the aforementioned systematic review,(
1010. Thorpe O, Johnston K, Kumar S. Barriers and enablers to physical
activity participation in patients with COPD: a systematic review. J Cardiopulm
Rehabil Prev. 2012;32(6):359-69.
http://dx.doi.org/10.1097/HCR.0b013e318262d7df
https://doi.org/10.1097/HCR.0b013e318262...
,
1111. Thorpe O, Kumar S, Johnston K. Barriers to and enablers of physical
activity in patients with COPD following a hospital admission: a qualitative study.
Int J Chron Obstruct Pulmon Dis. 2014;9:115-28.
http://dx.doi.org/10.2147/COPD.S54457
https://doi.org/10.2147/COPD.S54457...
) the authors identified a plethora of barriers to participation in
rehabilitation programs following hospitalization for COPD exacerbation. However, given
that most of the barriers identified were subjective and were derived from interviews,
it is difficult to use those barriers in the comparison of different groups. In fact,
little is known about the barriers that prevent COPD patients from being more physically
active or how to measure such barriers.(
1212. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et
al. An official American Thoracic Society/European Respiratory Society statement: key
concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med.
2013;188(8):e13-64. http://dx.doi.org/10.1164/rccm.201309-1634ST
https://doi.org/10.1164/rccm.201309-1634...
)
Patients with COPD benefit from appropriate physical activity. Some of the benefits
include increased exercise capacity, improvement in dyspnea, improved psychological and
emotional status, improved quality of life, fewer emergency room visits,(
22. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al.
Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med.
2007;176(6):532-55. http://dx.doi.org/10.1164/rccm.200703-456SO
https://doi.org/10.1164/rccm.200703-456S...
) and reduced risk of exacerbation. The 2013 consensus statement on pulmonary
rehabilitation established that patients with COPD should seek to increase their
physical activity levels.(
1212. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et
al. An official American Thoracic Society/European Respiratory Society statement: key
concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med.
2013;188(8):e13-64. http://dx.doi.org/10.1164/rccm.201309-1634ST
https://doi.org/10.1164/rccm.201309-1634...
) Desired outcomes include reduced dyspnea, increased distance walked, and
increased walk time, given that dyspnea, the distance walked, and the time spent walking
are directly related to the level of physical activity. Accelerometers and pedometers
can be used in order to measure and increase physical activity.(
1313. Kovelis D, Zabatiero J, Furlanetto KC, Mantoani LC, Proença M, Pitta
F. Short-term effects of using pedometers to increase daily physical activity in
smokers: a randomized trial. Respir Care. 2012;57(7):1089-97.
http://dx.doi.org/10.4187/respcare.01458
https://doi.org/10.4187/respcare.01458...
)
In the present study, we hypothesized that daily physical activity levels are lower in patients with COPD than in healthy, age-matched controls, and that this is not exclusively due to symptoms or functional limitations, being also due to psychological, social, and cultural barriers. Our objective was to evaluate the ability of COPD patients to perform ADL, as well as to identify barriers that prevent such patients from being more physically active, in order to develop an effective program to encourage physical activity.
Methods
Patients with COPD(
1414. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis
and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur
Respir J. 2004;23(6):932-46.
http://dx.doi.org/10.1183/09031936.04.00014304
https://doi.org/10.1183/09031936.04.0001...
) were recruited from among those treated at the pulmonology outpatient
clinic of our hospital. In parallel, healthy elderly individuals were selected for the
control group, which comprised spouses of the patients with COPD and individuals treated
at the geriatric outpatient clinic of our hospital. The inclusion criteria for COPD
patients were as follows: age ≥ 50 years; FEV1 ≤ 60% of the predicted value
before bronchodilator use; FEV1/FVC < 0.70; and stable medication use in
the past 30 days.
The exclusion criteria were as follows: clinical exacerbation in the past 30 days; long-term home oxygen therapy; musculoskeletal, cognitive, and mental disorders preventing patients from completing questionnaires, undergoing tests, or both; and limited mobility or other major comorbidity. The control group comprised gender- and age-matched volunteers, all of whom reported no lung disease and had normal pulmonary function test results.
The present study was approved by the local research ethics committee, and all of the individuals who agreed to participate gave written informed consent.
The first visit included the following:
-
In order to determine the severity of baseline dyspnea, we used the modified Medical Research Council (mMRC) scale, the score for which ranges from 0 to 4 (a higher score translating to a higher degree of dyspnea),( 1515. Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54(7):581-6. http://dx.doi.org/10.1136/thx.54.7.581
https://doi.org/10.1136/thx.54.7.581... ) and the Baseline Dyspnea Index (BDI),( 1616. Mahler DA, Weinberg DH, Wells CK, Feinstein AR. The measurement of dyspnea. Contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Chest. 1984;85(6):751-8. http://dx.doi.org/10.1378/chest.85.6.751
https://doi.org/10.1378/chest.85.6.751... ) which includes three domains: functional impairment; magnitude of task; and magnitude of effort. Scores for each domain range from 0 to 4, the total score ranging from 0 (maximum dyspnea) to 12 (no dyspnea) ( 1616. Mahler DA, Weinberg DH, Wells CK, Feinstein AR. The measurement of dyspnea. Contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Chest. 1984;85(6):751-8. http://dx.doi.org/10.1378/chest.85.6.751
https://doi.org/10.1378/chest.85.6.751... ) -
For objective measurement of physical activity, the participants were instructed to carry a triaxial accelerometer (PowerWalker; Yamax, Tokyo, Japan) in a trouser or shirt pocket.( 1717. Steele BG, Belza B, Cain K, Warms C, Coppersmith J, Howard J. Bodies in motion: monitoring daily activity and exercise with motion sensors in people with chronic pulmonary disease. J Rehabil Res Dev. 2003;40(5 Suppl 2):45-58. http://dx.doi.org/10.1682/JRRD.2003.10.0045
http://dx.doi.org/10.1682/JRRD.2003.10.0... ) The device records the number of steps, the distance walked (in kilometers) and the time spent walking. The participants were instructed to use it daily for 7 consecutive days, removing it before taking a shower and before going to bed at night -
We administered a questionnaire assessing perceived barriers to performing ADL: lack of time; social influences; lack of energy; lack of willpower; fear of injury; lack of ability; and lack of infrastructure.( 1818. U.S. Department of Health and Human Services. Public Health Service. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Division of Nutrition, Physical Activity and Obesity. Promoting physical activity: a guide for community action. Champaign, IL: Human Kinetics; 1999 ) Three specific questions addressing each of the aforementioned domains are answered, the score for each answer ranging from 0 to 3. The maximum possible score for each domain is 9 points, and a score greater than or equal to 5 indicates a significant barrier
-
We also administered the Brazilian Portuguese version of the London Chest Activity of Daily Living (LCADL) scale, which assesses dyspnea during ADL in patients with COPD. The LCADL scale consists of 15 questions divided into four domains: self-care activities; domestic activities; physical activities; and leisure activities. The total score can range from 0 to 75 points, a higher score translating to greater limitations in ADL.( 1919. Carpes MF, Mayer AF, Simon KM, Jardim JR, Garrod R. The Brazilian Portuguese version of the London Chest Activity of Daily Living scale for use in patients with chronic obstructive pulmonary disease. J Bras Pneumol. 2008;34(3):143-51. http://dx.doi.org/10.1590/S1806-37132008000300004
https://doi.org/10.1590/S1806-3713200800... ) The minimal detectable change for the LCADL scale score to measure the effect of interventions is of less than 3.88 points ( 2020. Bisca GW, Proença M, Salomão A, Hernandes NA, Pitta F. Minimal detectable change of the London chest activity of daily living scale in patients with COPD J Cardiopulm Rehabil Prev. 2014;34(3):213-6. http://dx.doi.org/10.1097/HCR.0000000000000047
https://doi.org/10.1097/HCR.000000000000... ) -
In order to assess submaximal exercise capacity, we used the six-minute walk test (6MWT). The 6MWT is a submaximal test that determines the functional capacity of patients with chronic lung disease, being easy to perform, well tolerated, reproducible, and inexpensive.( 2121. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7. http://dx.doi.org/10.1164/ajrccm.166.1.at1102
https://doi.org/10.1164/ajrccm.166.1.at1... ) The first visit also included SpO2 measurement
In their second visit to the pulmonology outpatient clinic (which occurred 7 days after
the first), the participants returned the accelerometer and underwent spirometry for
pulmonary function testing, performed in accordance with international
guidelines.(
2222. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A,
et al. Standardisation of spirometry. Eur Respir J. 2005;26(2):319-38.
http://dx.doi.org/10.1183/09031936.05.00034805
https://doi.org/10.1183/09031936.05.0003...
) All of the spirometric values analyzed in the present study were obtained
without the use of a bronchodilator.
Statistical analysis
In order to calculate the sample size, we conducted a pilot study involving 5 patients with COPD and 5 controls. We found a 45% difference in the number of steps during three days of monitoring with the accelerometer, the standard deviation being 40%. Considering a power of 0.9 and a type I error of 0.05, we calculated that each group required at least 30 individuals.
We performed a descriptive analysis of the groups. Variables with normal distribution were expressed as mean and standard deviation, whereas those with non-normal distribution were expressed as median, 95% CI, and interquartile range. The self-reported barriers to performing ADL were compared on the basis of the percentage of affirmative answers. The baseline characteristics were compared by the t-test or the chi-square test. Linear correlation analysis was performed with Pearson's and Spearman's correlation coefficients. The level of significance was set at 5%. The SigmaStat statistical package, version 3.5 (Systat Software Inc., San Jose, CA, USA), was used.
Results
A total of 92 individuals (48 COPD patients and 44 controls) were invited to participate in the present study. Of the 48 patients with COPD, 6 declined to participate, 1 had overlapping asthma and COPD, and 1 had borderline SpO2, requiring long-term home oxygen therapy. Of the 44 controls, 2 declined to participate and 1 reported to be receiving treatment for prostate cancer.
A total of 81 individuals were included in the study, and 80 (40 COPD patients and 40
controls) completed it. One of the controls was excluded from the study because of lung
function changes. The sociodemographic and functional characteristics of the COPD
patients and controls are presented in Table 1. As expected, there was a significant
difference between the two groups in terms of the proportion of smokers. Likewise, all
pulmonary function parameters were found to be significantly decreased in the COPD group
(Table 1). The median mMRC scale score in the
COPD group was 2.0 (interquartile range, 1.0-3.0). On the basis of the spirometry
results, 2.8%, 27.8%, 55.5%, and 13.9% of the COPD patients were classified as having
mild COPD, moderate COPD, severe COPD, and very severe COPD, respectively.(
2020. Bisca GW, Proença M, Salomão A, Hernandes NA, Pitta F. Minimal
detectable change of the London chest activity of daily living scale in patients with
COPD J Cardiopulm Rehabil Prev. 2014;34(3):213-6.
http://dx.doi.org/10.1097/HCR.0000000000000047
https://doi.org/10.1097/HCR.000000000000...
) With regard to exercise capacity, the 6MWD was approximately 82 m shorter
in the COPD group than in the control group, the difference being statistically
significant (p < 0.001). The same was true for pre-6MWT SpO2 (94.3% in the
COPD group vs. 97.2% in the control group; p < 0.001).
The level of physical activity was found to be significantly lower in the COPD group than in the control group. The number of steps per day was 6,251.0 ± 2,422.8 vs. 9,854.1 ± 4,736.6 in the control group (p < 0.001). In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5 ± 25.8 min/day vs. 105.2 ± 49.4 min/day; p < 0.001), as was the distance walked (3.9 ± 1.9 km/day vs. 6.4 ± 3.2 km/day; p < 0.001).
Among the COPD patients, lack of infrastructure was the most common self-reported barrier to physical activity. Table 2 shows the scores obtained by the COPD patients and controls on the questionnaire regarding barriers to ADL. There were no significant differences between the COPD and control groups in terms of measures of central tendency. However, when divided by questionnaire values of intrinsic significance (5 points), approximately 80% of the patients with COPD and 35% of the controls (p < 0.001) reported that they did not perform physical activities because they had no access to exercise facilities or because they had no resources to exercise. Lack of willpower was the second most common self-reported barrier to performing ADL, reported by 63% of the patients with COPD and 55% of the controls, followed by social influences, reported by 53% of the patients with COPD and 32.5% of the controls (p < 0.05). The social influence domain includes having no one (e.g., family members or friends) to exercise with (or receiving no encouragement from family members or friends to exercise), as well as feeling embarrassed when performing physical activities. The remaining scores on the questionnaire regarding barriers to ADL are shown in Figure 1. A significant difference was found between the COPD and control groups regarding the lack of ability domain, indicating that patients with COPD feel that they are unable to perform ADL.
Questionnaire regarding perceived barriers to physical activity: proportion of participants with scores = 5 on each domain in the COPD and control groups.
There were significant differences between the patients with COPD and the controls regarding their scores on all LCADL scale domains except domestic activities, with a significant impact on the total score (Table 3). These results are consistent with those obtained with the accelerometer, which showed that the patients with COPD performed less physical activity than did the controls.
The 6MWD was significantly correlated with the time spent walking, the distance walked, and the number of steps as measured by the accelerometer (Figure 2). There was a trend toward a significant negative correlation between the 6MWD and the total LCADL scale score (R = −0.30; p = 0.08). In contrast, there was a trend toward a significant positive correlation between the BDI and the distance walked as measured by the accelerometer (R = 0.31; p = 0.06). There were no correlations of LCADL scale scores, FEV1, SpO2, and mMRC scale scores with the results obtained with the accelerometer.
Correlation of the six-minute walk distance (6MWD) with the distance walked, the time spent walking, and the number of steps as measured by the accelerometer.
Discussion
The results of the present study show that the level of physical activity as measured by an accelerometer is lower in patients with COPD than in healthy controls, as well as showing that the distance walked, the number of steps, and the walk time recorded daily by the accelerometer showed a significant linear correlation with the 6MWD. This difference between the two groups was identified by the LCADL scale as well. The results of the present study also showed that lack of infrastructure, lack of willpower, and social influences were the most common barriers that prevent COPD patients from being more physically active.
With regard to ADL, our results corroborate those of previous studies.(
2323. Vorrink S, Kort H, Troosters T, Lammers J. Level of daily physical
activity in individuals with COPD compared with healthy controls. Respir Res.
2011;12:33 http://dx.doi.org/10.1186/1465-9921-12-33
https://doi.org/10.1186/1465-9921-12-33...
) A literature review of COPD showed a significant reduction in the duration
and intensity of ADL in patients with COPD when compared with healthy controls. The
physical activity level of the controls in the present study was found to be similar to
those of elderly individuals and smokers in other studies.(
1313. Kovelis D, Zabatiero J, Furlanetto KC, Mantoani LC, Proença M, Pitta
F. Short-term effects of using pedometers to increase daily physical activity in
smokers: a randomized trial. Respir Care. 2012;57(7):1089-97.
http://dx.doi.org/10.4187/respcare.01458
https://doi.org/10.4187/respcare.01458...
,
2424. Hernandes NA, Probst VS, Da Silva RA Jr, Januário RS, Pitta F,
Teixeira DC. Physical activity in daily life in physically independent elderly
participating in community-based exercise program. Braz J Phys Ther.
2013;17(1):57-63. http://dx.doi.org/10.1590/S1413-35552012005000055
https://doi.org/10.1590/S1413-3555201200...
) In the aforementioned studies of COPD patients, most of the individuals
were male. In the present study, the 80 participants were well distributed by gender and
age, and most of the controls were spouses of the COPD patients, meaning that they were
in the same social circle. Our findings reinforce the efficiency of accelerometers in
determining the physical activity levels of COPD patients in a simple and easily
repeatable manner.
In the present study, the 6MWT confirmed the findings of other studies, showing in a
sensitive manner that patients with COPD have lower exercise capacity, as well as
confirming the correlation of the 6MWD (in m) with the performance of ADL as measured by
the accelerometer over a greater number of days, better with the distance walked in
kilometers in the present study, previously demonstrated with the use of a multiaxial
accelerometer.(
2525. Hernandes NA, Teixeira Dde C, Probst VS, Brunetto AF, Ramos EM,
Pitta F. Profile of the level of physical activity in the daily lives of patients
with COPD in Brazil. J Bras Pneumol. 2009;35(10):949-56.
) Although the 6MWT is known to reflect the performance of ADL, it is more
widely used in order to measure interventions, especially in research. In contrast,
accelerometers, which are currently widely used, can be used in routine care. It should
be emphasized that a low level of physical activity leads to a higher risk of mortality
and hospitalization.(
2626. Garcia-Rio F, Rojo B, Casitas R, Lores V, Madero R, Romero D, et al.
Prognostic value of the objective measurement of daily physical activity in COPD
patients. Chest. 2012;142(2):338-46.
http://dx.doi.org/10.1378/chest.11-2014
https://doi.org/10.1378/chest.11-2014...
)
The BDI tended to correlate with the distance walked as measured by the accelerometer.
This suggests that the BDI is more sensitive in the evaluation of this relationship.
However, daily dyspnea (as assessed by the LCADL scale) apparently did not affect the
performance of ADL; no correlations were found between LCADL scale scores and the
results obtained with the accelerometer. Nevertheless, although the LCADL is apparently
better for self-assessed changes in COPD patients undergoing training programs than is
the mMRC scale,(
2727. Kovelis D, Zabatiero J, Oldemberg N, Colange AL, Barzon D,
Nascimento CH, et al. Responsiveness of three instruments to assess self-reported
functional status in patients with COPD. COPD. 2011;8(5):334-9.
http://dx.doi.org/10.3109/15412555.2011.594463
https://doi.org/10.3109/15412555.2011.59...
) the difference between the COPD patients and the controls in the present
study was four times greater than the change obtained by such programs.
Studies evaluating the reliability and sensitivity of the LCADL scale showed a weak but
significant correlation between LCADL scores and shuttle walk test results.(
2828. Garrod R, Paul EA, Wedzicha JA. An evolution of the reliability and
sensitivity of the London Chest Activity of Daily Living Scale (LCADL). Respir Med.
2002;96(9):725-30. http://dx.doi.org/10.1053/rmed.2002.1338
https://doi.org/10.1053/rmed.2002.1338...
) In the present study, the 6MWD tended to correlate with the total LCADL
scale score, such a correlation having been demonstrated in a study in which the
Brazilian Portuguese version of the scale was validated.(
2929. Pitta F, Probst VS, Kovelis D, Segretti NO, Mt Leoni A, Garrod R, et
al. Validation of the Portuguese version of the London Chest Activity of Daily Living
Scale (LCADL) in chronic obstructive pulmonary disease patients. Rev Port Pneumol.
2008;14(1):27-47.
) A larger sample might be required in order to confirm these findings.
One current challenge is to determine the external factors that influence the lack of
physical activity. The most common self-reported barriers to physical activity in the
general population are as follows(
3030. Centers for Disease Control and Prevention [homepage on the
Internet]. Atlanta: CDC. [cited 2014 Jan 1]. Overcoming barriers to physical
activity. Available from:
www.cdc.gov/physicalactivity/everyone/getactive/barriers.html
www.cdc.gov/physicalactivity/everyone/ge...
): not having enough time to exercise; not finding exercise enjoyable
(finding it inconvenient to exercise); lack of self-motivation; finding exercise
unpleasant; finding exercise boring; lack of confidence in the ability to be physically
active (low self-efficacy); fear of being injured or having recently been injured; lack
of self-management skills, such as the ability to set personal goals, monitor progress,
or reward progress toward such goals; lack of encouragement, support, or companionship
from family and friends; and lack of parks, sidewalks, bicycle trails, or safe and
pleasant walking paths convenient to homes or offices. The US Centers for Disease
Control and Prevention have sought to measure and encourage physical activity for 20
years. The questionnaire used in the present study in order to assess barriers to
physical activity originated from US Centers for Disease Control and Prevention
recommendations.(
3030. Centers for Disease Control and Prevention [homepage on the
Internet]. Atlanta: CDC. [cited 2014 Jan 1]. Overcoming barriers to physical
activity. Available from:
www.cdc.gov/physicalactivity/everyone/getactive/barriers.html
www.cdc.gov/physicalactivity/everyone/ge...
)
Lack of infrastructure, social influences, and lack of ability were the most common
self-reported barriers to physical activity in the COPD patients in the present study.
However, it is of note that a large proportion of individuals in the control group also
reported lack of infrastructure, lack of willpower, and social influences as barriers to
physical activity. The lack of ability to perform physical activities might be directly
related to insecurity. A study of 28 patients (22 males and 6 females) with COPD sought
to identify, through interviews, the main barriers to and facilitators of physical
activity after hospitalization.(
1111. Thorpe O, Kumar S, Johnston K. Barriers to and enablers of physical
activity in patients with COPD following a hospital admission: a qualitative study.
Int J Chron Obstruct Pulmon Dis. 2014;9:115-28.
http://dx.doi.org/10.2147/COPD.S54457
https://doi.org/10.2147/COPD.S54457...
) After systematization, the barriers were divided into three broad
categories: health-related barriers; environment-related barriers; and self-related
barriers. Health-related barriers included comorbidities, COPD (or COPD severity), and
physical health or status. Environment-related barriers included the weather, (house)
dust, and pollen, as well as transport difficulties (which were considered a major
barrier to pulmonary rehabilitation) and financial difficulties, which were also related
to the cost of transportation, especially for patients receiving home oxygen therapy
(the cost of oxygen having also been reported). Self-related barriers included advanced
age, lack of access to oxygen therapy, and problems related to physical
activity/pulmonary rehabilitation programs. The authors reported the need for actively
recognizing and overcoming barriers to physical activity and pulmonary
rehabilitation.(
1111. Thorpe O, Kumar S, Johnston K. Barriers to and enablers of physical
activity in patients with COPD following a hospital admission: a qualitative study.
Int J Chron Obstruct Pulmon Dis. 2014;9:115-28.
http://dx.doi.org/10.2147/COPD.S54457
https://doi.org/10.2147/COPD.S54457...
)
In addition to the severity of COPD, the small number of pulmonary rehabilitation centers in Brazil represents a real barrier; most of the COPD patients in the present study reported that they would engage in physical activity if they had more resources and more encouragement. However, the mere existence of pulmonary rehabilitation centers does not guarantee higher levels of physical activity. Not being able to perform ADL with someone who does not have COPD-because of the functional differences, this inability leading to a feeling of physical disability-can aggravate depression, which is common in patients with COPD. The fear and lack of knowledge of family members and friends regarding disability in patients with COPD also have a direct influence on perceived barriers to physical activity.
The present study has limitations because it was a cross-sectional study with a small sample size. However, we used an objective instrument in order to assess the barriers to physical activity, and this aids in planning an intervention to change the sedentary lifestyle of COPD patients (and the consequences thereof). Physical inactivity and the barriers to physical activity in COPD patients have immediate implications for clinical practice, calling for early intervention measures. Physical exercise (e.g., walking) is recommended as a form of treatment for patients with COPD, allowing them to maintain a level of independence in ADL and making them more physically active, as well as reducing the impact of COPD and changing the prognosis of the disease.
We conclude that patients with COPD are less active than healthy adults, and that lack of infrastructure, lack of willpower, and social influences are the main barriers to physical activity in patients with COPD. The time spent walking, the distance walked (in km), and the number of steps taken are objective, easily obtained measurements of physical inactivity in patients with COPD, being directly correlated with the 6MWD. Further studies, involving a larger number of patients and the use of more detailed questionnaires assessing limitations in and perceived barriers to ADL, are required for the planning of physical activity programs for patients with COPD.
References
-
1Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402-7. =http://dx.doi.org/10.1001/jama.1995.03520290054029
» https://doi.org/10.1001/jama.1995.03520290054029 -
2Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532-55. http://dx.doi.org/10.1164/rccm.200703-456SO
» https://doi.org/10.1164/rccm.200703-456SO -
3Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;171(9):972-7. http://dx.doi.org/10.1164/rccm.200407-855OC
» https://doi.org/10.1164/rccm.200407-855OC -
4Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in patients with COPD. Eur Respir J. 2009;33(2):262-72 http://dx.doi.org/10.1183/09031936.00024608
» https://doi.org/10.1183/09031936.00024608 -
5Pitta F, Breyer MK, Hernandes NA, Teixeira D, Sant'Anna TJ, Fontana AD, et al. Comparison of daily physical activity between COPD patients from Central Europe and South America. Respir Med. 2009;103(3):421-6. http://dx.doi.org/10.1016/j.rmed.2008.09.019
» https://doi.org/10.1016/j.rmed.2008.09.019 -
6Gimeno-Santos E, Frei A, Steurer-Stey C, Batlle J, Rabinovic RA, Raste Y, et al. Determinants and outcomes of physical activity in patients with COPD: a systematic review. Thorax. 2014;69(8):731-9. http://dx.doi.org/10.1136/thoraxjnl-2013-204763
» https://doi.org/10.1136/thoraxjnl-2013-204763 -
7Garmendia ML, Dangour AD, Albala C, Eguiguren P, Allen E, Uauy R. Adherence to a physical activity intervention among older adults in a post-transitional middle income country: a quantitative and qualitative analysis. J Nutr Health Aging. 2013;17(5):466-71. http://dx.doi.org/10.1007/s12603-012-0417-1
» https://doi.org/10.1007/s12603-012-0417-1 -
8Rodríguez-Rodríguez P, Jiménez-García R, Hernández-Barrera V, Carrasco-Garrido P, Puente-Maestu L, de Miguel-Díez J. Prevalence of physical disability in patients with chronic obstructive pulmonary disease and associated risk factors. COPD. 2013;10(5):611-7. http://dx.doi.org/10.3109/15412555.2013.781150
» https://doi.org/10.3109/15412555.2013.781150 -
9Liu Y, Croft JB, Anderson LA, Wheaton AG, Presley-Cantrell LR, Ford ES. The association of chronic obstructive pulmonary disease, disability, engagement in social activities, and mortality among US adults aged 70 years or older, 1994-2006. Int J Chron Obstruct Pulmon Dis. 2014;9:75-83. http://dx.doi.org/10.2147/COPD.S53676
» https://doi.org/10.2147/COPD.S53676 -
10Thorpe O, Johnston K, Kumar S. Barriers and enablers to physical activity participation in patients with COPD: a systematic review. J Cardiopulm Rehabil Prev. 2012;32(6):359-69. http://dx.doi.org/10.1097/HCR.0b013e318262d7df
» https://doi.org/10.1097/HCR.0b013e318262d7df -
11Thorpe O, Kumar S, Johnston K. Barriers to and enablers of physical activity in patients with COPD following a hospital admission: a qualitative study. Int J Chron Obstruct Pulmon Dis. 2014;9:115-28. http://dx.doi.org/10.2147/COPD.S54457
» https://doi.org/10.2147/COPD.S54457 -
12Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13-64. http://dx.doi.org/10.1164/rccm.201309-1634ST
» https://doi.org/10.1164/rccm.201309-1634ST -
13Kovelis D, Zabatiero J, Furlanetto KC, Mantoani LC, Proença M, Pitta F. Short-term effects of using pedometers to increase daily physical activity in smokers: a randomized trial. Respir Care. 2012;57(7):1089-97. http://dx.doi.org/10.4187/respcare.01458
» https://doi.org/10.4187/respcare.01458 -
14Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23(6):932-46. http://dx.doi.org/10.1183/09031936.04.00014304
» https://doi.org/10.1183/09031936.04.00014304 -
15Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54(7):581-6. http://dx.doi.org/10.1136/thx.54.7.581
» https://doi.org/10.1136/thx.54.7.581 -
16Mahler DA, Weinberg DH, Wells CK, Feinstein AR. The measurement of dyspnea. Contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Chest. 1984;85(6):751-8. http://dx.doi.org/10.1378/chest.85.6.751
» https://doi.org/10.1378/chest.85.6.751 -
17Steele BG, Belza B, Cain K, Warms C, Coppersmith J, Howard J. Bodies in motion: monitoring daily activity and exercise with motion sensors in people with chronic pulmonary disease. J Rehabil Res Dev. 2003;40(5 Suppl 2):45-58. http://dx.doi.org/10.1682/JRRD.2003.10.0045
» http://dx.doi.org/10.1682/JRRD.2003.10.0045 -
18U.S. Department of Health and Human Services. Public Health Service. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Division of Nutrition, Physical Activity and Obesity. Promoting physical activity: a guide for community action. Champaign, IL: Human Kinetics; 1999
-
19Carpes MF, Mayer AF, Simon KM, Jardim JR, Garrod R. The Brazilian Portuguese version of the London Chest Activity of Daily Living scale for use in patients with chronic obstructive pulmonary disease. J Bras Pneumol. 2008;34(3):143-51. http://dx.doi.org/10.1590/S1806-37132008000300004
» https://doi.org/10.1590/S1806-37132008000300004 -
20Bisca GW, Proença M, Salomão A, Hernandes NA, Pitta F. Minimal detectable change of the London chest activity of daily living scale in patients with COPD J Cardiopulm Rehabil Prev. 2014;34(3):213-6. http://dx.doi.org/10.1097/HCR.0000000000000047
» https://doi.org/10.1097/HCR.0000000000000047 -
21ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7. http://dx.doi.org/10.1164/ajrccm.166.1.at1102
» https://doi.org/10.1164/ajrccm.166.1.at1102 -
22Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. Standardisation of spirometry. Eur Respir J. 2005;26(2):319-38. http://dx.doi.org/10.1183/09031936.05.00034805
» https://doi.org/10.1183/09031936.05.00034805 -
23Vorrink S, Kort H, Troosters T, Lammers J. Level of daily physical activity in individuals with COPD compared with healthy controls. Respir Res. 2011;12:33 http://dx.doi.org/10.1186/1465-9921-12-33
» https://doi.org/10.1186/1465-9921-12-33 -
24Hernandes NA, Probst VS, Da Silva RA Jr, Januário RS, Pitta F, Teixeira DC. Physical activity in daily life in physically independent elderly participating in community-based exercise program. Braz J Phys Ther. 2013;17(1):57-63. http://dx.doi.org/10.1590/S1413-35552012005000055
» https://doi.org/10.1590/S1413-35552012005000055 -
25Hernandes NA, Teixeira Dde C, Probst VS, Brunetto AF, Ramos EM, Pitta F. Profile of the level of physical activity in the daily lives of patients with COPD in Brazil. J Bras Pneumol. 2009;35(10):949-56.
-
26Garcia-Rio F, Rojo B, Casitas R, Lores V, Madero R, Romero D, et al. Prognostic value of the objective measurement of daily physical activity in COPD patients. Chest. 2012;142(2):338-46. http://dx.doi.org/10.1378/chest.11-2014
» https://doi.org/10.1378/chest.11-2014 -
27Kovelis D, Zabatiero J, Oldemberg N, Colange AL, Barzon D, Nascimento CH, et al. Responsiveness of three instruments to assess self-reported functional status in patients with COPD. COPD. 2011;8(5):334-9. http://dx.doi.org/10.3109/15412555.2011.594463
» https://doi.org/10.3109/15412555.2011.594463 -
28Garrod R, Paul EA, Wedzicha JA. An evolution of the reliability and sensitivity of the London Chest Activity of Daily Living Scale (LCADL). Respir Med. 2002;96(9):725-30. http://dx.doi.org/10.1053/rmed.2002.1338
» https://doi.org/10.1053/rmed.2002.1338 -
29Pitta F, Probst VS, Kovelis D, Segretti NO, Mt Leoni A, Garrod R, et al. Validation of the Portuguese version of the London Chest Activity of Daily Living Scale (LCADL) in chronic obstructive pulmonary disease patients. Rev Port Pneumol. 2008;14(1):27-47.
-
30Centers for Disease Control and Prevention [homepage on the Internet]. Atlanta: CDC. [cited 2014 Jan 1]. Overcoming barriers to physical activity. Available from: www.cdc.gov/physicalactivity/everyone/getactive/barriers.html
» www.cdc.gov/physicalactivity/everyone/getactive/barriers.html
-
Financial support: None
-
*
Study carried out at the Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazi
Publication Dates
-
Publication in this collection
Sep-Oct 2014
History
-
Received
08 May 2014 -
Accepted
07 Aug 2014