Editorial
Promoting Physical Activity After Hospitalization for Chronic Obstructive Pulmonary Disease Exacerbation
Promoción de la actividad física tras un ingreso hospitalario por exacerbación de la enfermedad pulmonar obstructiva crónica
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"<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Promoting Physical Activity After Hospitalization for Chronic Obstructive Pulmonary Disease Exacerbation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "553" "paginaFinal" => "554" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Maria Antonia Ramon" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Maria Antonia" "apellidos" => "Ramon" "email" => array:1 [ 0 => "maramon@vhebron.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Promoción de la actividad física tras un ingreso hospitalario por exacerbación de la enfermedad pulmonar obstructiva crónica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease (COPD) is a disease that fluctuates between periods of relative stability and episodes during which the patient experiences sustained clinical worsening, known as exacerbations.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Severe exacerbations that require hospital treatment impact negatively on the health of these patients.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2–6</span></a> Their physical activity decreases dramatically during these events and remains significantly lower than that of stable patients 1 month after hospital discharge.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Peripheral muscle strength, particularly in the lower limbs, also declines considerably during a severe COPD exacerbation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Moreover, longitudinal studies have revealed that both physical activity and exercise capacity diminish over time in patients who are hospitalized at least once during follow-up.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,5</span></a> Recently, a validation study of the vicious circle of dyspnea-inactivity associated with COPD, using real data from patients in 2 European cohorts, revealed that both moderate and severe exacerbations play a significant role in this process, and help explain the clinical course of the disease.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Taking into account the importance of physical activity and exercise capacity in COPD prognosis,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> interventions aimed at alleviating the negative effects of hospitalization on these parameters are essential in the early stages, and during and after these events.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent decades, evidence on respiratory rehabilitation (which mainly involves physical training) during or after a COPD exacerbation has been growing, leading to a number of Cochrane reviews, the latest of which was published in 2016.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The results of these reviews suggest that respiratory rehabilitation implemented in the context of an exacerbation increases exercise capacity (62<span class="elsevierStyleHsp" style=""></span>m [95% CI: 38, 86] in the 6-minute walking test) and quality of life (−7.80 points [95% CI: −12.12, −3.47] in the St. George's Respiratory Questionnaire), reduces the risk of readmission (OR: 0.44; 95% CI: 0.21, 91), and is a safe intervention.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">However, the guidelines of the <span class="elsevierStyleItalic">European Respiratory Society</span> (ERS) and the <span class="elsevierStyleItalic">American Thoracic Society</span> (ATS) on the management of COPD exacerbations published in 2017, made a conditional recommendation against starting respiratory rehabilitation during the hospital stay.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> It should be noted that this recommendation is based primarily on the results of a study carried out in the UK (<span class="elsevierStyleItalic">n</span>=389) in which a pulmonary rehabilitation program was initiated randomly (1:1) 48<span class="elsevierStyleHsp" style=""></span>h after hospital admission and continued for a period of 6 weeks after hospital discharge vs conventional care.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> In this study, included in the Cochrane review of 2016, mortality in the intervention group increased significantly after the fifth month of follow-up. However, bearing in mind that the early rehabilitation program was completed 6 weeks after discharge, the observed difference is unlikely to be attributable to the intervention. The authors also found no differences in mortality when a per protocol/effectiveness analysis was performed (taking into account only patients who completed the treatment assigned in the randomization process), suggesting that patients who actually received the intervention were not the ones who died.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore, taking into account the impact of hospital admissions for COPD exacerbation on the functional capacity of these patients,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,6</span></a> and in the light of the currently available results,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> it seems essential that respiratory rehabilitation interventions are implemented during or after these events, although it is clear that such interventions should be carefully adapted to the situation and needs of each patient.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Nevertheless, while physical training undoubtedly increases exercise capacity in COPD patients, it does not always lead to a more active life (increased physical activity).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> This is because, despite the fact that improving exercise tolerance can help patients increase their physical activity,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> other factors, including personal characteristics, physical or psychological barriers, and motivational, cultural, and social factors, determine the physical activity performed by COPD patients.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> As such, physical activity has a strong behavioral component. For this reason, respiratory rehabilitation programs must also include other specific complementary strategies to modify inactive behavior, and to encourage these patients to integrate physical activity into their daily life. This is of particular importance following severe COPD exacerbations, bearing in mind that inactivity increases during and after these events.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Studies have been published that have shown improvements in physical activity in patients with stable COPD when different tools are combined to facilitate behavior change. In this respect, it is important that patients participate actively in setting targets or goals that are personally specific and relevant. Monitoring the progress of physical activity (by using pedometers and diaries, for example) increases patient adherence and the effectiveness of the intervention. We also know that one-off interventions are ineffective, so patients must be guided and accompanied through the process (a method known as coaching), their progress must be assessed, they must receive assistance with barriers and facilitators for performing their physical activity.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the light of these results, it is reasonable to think that the combination of conventional respiratory rehabilitation programs (e.g., physical training during admission) and interventions that promote a change of behavior (e.g., coaching programs using pedometers after hospital discharge) could be a possible solution to increasing exercise capacity and physical activity in COPD patients after a severe disease exacerbation. In this respect, our working group is conducting a study to assess the effectiveness of an early intervention program that combines these 2 strategies. To summarize, patients are recruited during hospitalization for COPD exacerbation, and they all receive physical training with the aim of enhancing their ability to walk, climb stairs, etc., during admission. After hospital discharge, baseline physical activity is monitored with an accelerometer for a week. Patients return to the clinic for the remaining baseline measurements, and are randomly allocated (1:1) to an intervention to progressively increase their physical activity. This intervention consists of a motivational interview (during which barriers and facilitators for performing physical activity are discussed and the patient actively participates in setting objectives), monitoring of physical activity with a pedometer and schedule, and weekly telephone contacts over a period of 3 months to assist patients with any difficulties they may encounter.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> In the near future will we know if interventions of this type can reverse the deleterious effects of severe exacerbations on exercise ability and physical activity in patients with COPD.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">Grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)</span>, Code 126-2015. Grant from the <span class="elsevierStyleGrantSponsor" id="gs2">Catalan Foundation of Pulmonology (FUCAP)</span>, SILVIA 2017.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ramon MA. Promoción de la actividad física tras un ingreso hospitalario por exacerbación de la enfermedad pulmonar obstructiva crónica. Arch Bronconeumol. 2019;55:553–554.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Wedzicha" 1 => "M. Miravitlles" 2 => "J.R. Hurst" 3 => "P.M.A. Calverley" 4 => "R.K. Albert" 5 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 37 | 13 | 50 |
| 2024 September | 36 | 23 | 59 |
| 2024 August | 57 | 46 | 103 |
| 2024 July | 33 | 18 | 51 |
| 2024 June | 56 | 25 | 81 |
| 2024 May | 89 | 23 | 112 |
| 2024 April | 29 | 34 | 63 |
| 2024 March | 40 | 23 | 63 |
| 2024 February | 34 | 21 | 55 |
| 2023 March | 13 | 3 | 16 |
| 2023 February | 39 | 21 | 60 |
| 2023 January | 25 | 38 | 63 |
| 2022 December | 50 | 44 | 94 |
| 2022 November | 53 | 29 | 82 |
| 2022 October | 66 | 36 | 102 |
| 2022 September | 40 | 20 | 60 |
| 2022 August | 41 | 47 | 88 |
| 2022 July | 33 | 43 | 76 |
| 2022 June | 33 | 44 | 77 |
| 2022 May | 31 | 45 | 76 |
| 2022 April | 30 | 35 | 65 |
| 2022 March | 27 | 36 | 63 |
| 2022 February | 25 | 38 | 63 |
| 2022 January | 29 | 23 | 52 |
| 2021 December | 18 | 28 | 46 |
| 2021 November | 25 | 34 | 59 |
| 2020 April | 1 | 0 | 1 |
| 2020 March | 2 | 0 | 2 |
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