PICk-UP: PersonalIsed CommUnity-based Physical Activities for Patients With Chronic Obstructive Pulmonary Disease (PICk UP)

PICk-UP: PersonalIsed CommUnity-based Physical Activities for Patients With Chronic Obstructive Pulmonary Disease

PICk-UP: PersonalIsed CommUnity-based Physical Activities for Patients With Chronic Obstructive Pulmonary Disease

Fundação para a Ciência e a Tecnologia, Câmara Municipal de Aveiro, Câmara Municipal de Estarreja, Centro Hospitalar do Baixo Vouga, Administração Regional de Saúde do Centro, Escola Superior de Saúde da Universidade de Aveiro, Instituto de Biomedicina da Universidade de Aveiro

Chronic Obstructive Pulmonary Disease (COPD) is a major individual, social and economic burden worldwide. Pulmonary rehabilitation is a fundamental evidence-based intervention to manage COPD. However, pulmonary rehabilitation benefits tend to decline over time and sustaining a long-term physical activity lifestyle is challenging, leading to worse health-related quality of life. Personalised post-pulmonary rehabilitation programmes, combining different physical activities modalities with social interaction, are warranted to enable a shift from a disease-based to a patient-centred model and encourage a sustainable behavioural change. Although such programmes have the potential to sustain pulmonary rehabilitation benefits and promote patients' long-term adherence to physical activity, their availability within the community is scarce. Hence, the investigators will implement a personalised community-based physical activity programme (PICk UP), using the available resources, adapted to patient's needs/preferences. PICk UP will be a sustainable response to support healthy lifestyles and enhance pulmonary rehabilitation benefits of respiratory patients, by integrating them within the community and embracing urban facilities. The aim of this study is to assess the effectiveness of PICk UP, a personalised community-based physical activity programme, tailored to patients' needs and preferences, on their physical activity levels. It is expected that PICk UP will empower patients to remain physically active and foster the maintenance of pulmonary rehabilitation benefits.

COPD-related morbidity and mortality has been increasing, making COPD already the third leading cause of death and a growing global health concern. Pulmonary rehabilitation (PR) is a comprehensive intervention, with known cost-effectiveness in managing patients with COPD. One of the PR goals is to improve physical activity (PA), since it has shown to reduce exacerbations and mortality. Nevertheless, adopting/sustaining a physically active behaviour is highly challenging and benefits of PR are usually lost 6 months after its completion. Therefore, PA programmes capable to maintain the PR effects are urgently needed Community can provide different PA modalities in various settings, which can be personalised to patients' needs and preferences. By filling the gaps between healthcare systems and patients' daily environment, these programmes have the potential to improve patients' HRQoL and self-efficacy, enhancing their ability to overcome exercise barriers and their motivation to sustain a physically active behaviour. PICk UP will offer patients different PA modalities tailored to their preferences and needs, thus personalising the community programmes, and aiming at sustaining a physically active behaviour and enhancing their HRQoL. This study aims at assessing the effectiveness of PICk UP, a personalised community-based physical activity programme tailored to patients' needs and preferences, on their physical activity levels and on the maintenance of pulmonary rehabilitation benefits. To accomplish these aims a randomised controlled trial will be conducted. PICk UP randomised controlled trial The primary aim of this study is to assess the effectiveness of PICk UP, a personalised community-based PA programme, tailored to patients' needs and preferences, on their PA levels. The secondary aims is to determine the short- and mid-term effects of PICk UP on HRQoL symptoms, number of exacerbations, healthcare use, exercise capacity, functionality, motivation to exercise, peripheral muscle strength and emotional status. Recruitment Primary healthcare providers of Aveiro and Estarreja or pulmonologists of the Centro Hospitalar do Baixo Vouga will inform eligible patients about the study. Additional information will be provided to those interested to participate in a meeting with the researcher and written informed consent will be acquired. Patients with COPD will be eligible if they are clinically stable, as determined by their referred doctor, and completed a PR programme in the previous month. Patients will be excluded if they present signs of cognitive impairment or have significant cardiovascular, neurological or musculoskeletal diseases, which may limit their participation. Study design Patients will be randomised into experimental group (EG) or control group (CG). The EG will receive the PICk UP programme. The CG will receive no additional interventions and will only proceed with the physical activity recommendations delivered during the pulmonary rehabilitation programme. Assessments will be conducted by a second researcher blinded to the intervention. Data collection: Data will be collected at baseline, after 3 months and after the intervention (6 months). The researcher will collect: Sociodemographic, anthropometric, general clinical data (e.g., number of exacerbations or healthcare utilisation); Physical activity levels (time in sedentary, moderate and vigorous physical activities; steps/day): accelerometry. Health related quality of life: St. George's Respiratory Questionnaire. Disease impact: COPD Assessment Test. Exercise tolerance: six-minute walk test. Motivations to exercise: Behavioural Regulation and Exercise Questionnaire-3. Quadriceps muscle strength: Handheld dynamometry. Fatigue: Checklist of Individual Strength-8 and the Functional assessment of chronic illness therapy fatigue subscale; Handgrip strength: dynamometry. Emotional status: Hospital Anxiety and Depression Scale. Occurrence of adverse events and adherence to the interventions Intervention: Participants in the EG will enrol a 6-months personalised community-based physical activity programme, which will include 2 sessions/week, with the aerobic training being the cornerstone. Patients will receive the PICk UP manual and a diary to register their physical activities. During the 1st month the physiotherapist will guide patients through 4 types of outdoors (e.g., walking, cycling trails) and indoors (e.g., dance, pilates) physical activities. Patients will then be asked to choose and commit to 1 or 2 activities, according to their preferences, which they shall integrate for another 5 months. During this period, the support provided by physiotherapist will decrease over time 2nd and 3rd months: support every 2-weeks (face-to-face physical activity sessions alternated with phone-calls) to reassure safety, clarify doubts, monitor patients' evolution and enhance their motivation to physical activity; 4th month: 1 face-to-face physical activity session; 5th month: 1 phone-call; 6th month: no support. The sport-related professionals will register patients' attendance to the programme. Sample size estimation: The sample size was estimated using G*Power 3.1.9.6, with an effect size specification "as in G*Power 3.0", for the within-between interaction of a repeated measures ANOVA with two groups (control and experimental) and 3 measurements (immediately after, 3 and 6 months post-PR) of the defined primary outcome (time in moderate to vigorous PA). The investigators considered an α of 0.05, a power of 0.80, a repeated measures correlation of 0.5, a nonsphericity correction of 1 and an expected effect size f of 0.30. The effect size f was derived from the partial η2 of 0.21 (f=0.516) obtained from a study which aimed to assess the impact of a PA-focused behavioural intervention during and after PR on PA levels in patients with COPD. A smaller f value of 0.30 was chosen to account for a longer follow-up period (up to 6 months after PR, instead of 3) and differences in selected time-points. The calculated sample size was 20 (i.e., 10 in each group) COPD patients and considering a possible 50% dropout rate, the final sample size was determined to be 40.

After pulmonary rehabilitation, the experimental group will integrate a community-based physical activity programme.

The control group will only receive pulmonary rehabilitation, which integrates physical activity recommendations.

After completing a pulmonary rehabilitation programme, participants will enrol a 6-months personalised community-based physical activity programme, which will include 2 sessions/week, with the aerobic training being the cornerstone. Patients will receive the PICk UP manual and a diary to register their physical activities. During the 1st month the physiotherapist will guide patients through 4 types of outdoors and indoors physical activities. Patients will then be asked to choose and commit to 1 or 2 activities, according to their preferences, which they shall integrate for another 5 months. During this period, the support provided by physiotherapist will decrease over time.

Patients will receive the same pulmonary rehabilitation programme as the experimental group, i.e., exercise training twice a week and education and psychosocial support once every other week, which integrates physical activity recommendations.

Accelerometer-based activity monitors. Time spent in moderate and vigorous physical activities during the day, will be collected with the activity monitors GT3X+ (ActiGraph) during one week.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Accelerometer-based activity monitors. Time spent in sedentary physical activities during the day, will be collected with the activity monitors GT3X+ (ActiGraph) during one week.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Accelerometer-based activity monitors. Number of steps/day will be collected with the activity monitors GT3X+ (ActiGraph) during one week.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

St. George Respiratory Questionnaire (SGRQ) will be used to assess Health Related quality-of-life. The SGRQ is a comprehensive well-established 50-item questionnaire to measure health status in patients with COPD. Scores can be provided for each domain (symptoms, activities and impact) and as a total score, ranging from 0 (no impairment) to 100 (worst possible health status).

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Exercise capacity will be tested in a 6-minute walk test, since it allows exercise prescription. The test results will be presented as the walked distance (meters).

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Functionality will be tested with the physical performance test (PPT), which assesses multiple domains of physical function using tasks that simulate activities of daily living. This measure has 9-items with a total score of 36 points, with higher scores indicating better performance.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

The Behavioural Regulation Exercise Scale-3 (BREQ-3) will be used to assess behavioural regulation under the self-determination theory in the exercise domain. The BREQ-3 has 24 itens with a 5-point Likert scale grouped into 6 factors (ammotivation, external regulation, introjected regulation, identified regulation, integrated regulation and intrinsic motivation). Those represent different forms of regulation, going from non-self determined to completely self-determined regulation. Scores per subscale range from 0 (not true to the participant) to 4 (very true to the participant), with higher scores indicating a better result.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

The Brief Physical Activity questionnaire will be used to assess physical activity. It a 2 items questionnaire, with scores ranging from 0 to 8 and higher scores representing better results. If the sum of the two items score is above or equal 4 the subject will be considered physically active.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

COPD Assessment Test (CAT) will be used to assess burdensome symptoms in patients' life with 8 items (cough, sputum, dyspnoea, chest tightness, capacity of exercise and home daily activities, confidence leaving home, sleep and energy levels). The scores range from 0-40, organised in 4 categories, namely <10 low impact, 10-20 medium, 21-30 high and >30 very high impact, with 5 representing the upper limit of normal in healthy non-smokers

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Hospital Anxiety and Depression Scale will be used to assess symptoms of anxiety and depression. It is a 14 item questionnaire that can be subdivided in two subscales: anxiety and depression. Scores are provided for each subscale and range from 0 to 21, with higher scores meaning more symptoms of anxiety and depression.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

The fatigue subscale of the Checklist of Individual Strength (CIS-FS) will be used to assess fatigue. The subscale is an 8-item questionnaire, with higher scores indicating higher levels of fatigue. The total scores range from 8 to 56.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

The Functional assessment of cancer therapy - fatigue subscale will be used to assess fatigue levels. It is multi-dimensional 13-item questionnaire assessing tiredness, weakness and difficulty in handling daily activities due to fatigue. Scores range from 0 to 52, with higher scores indicating less fatigue.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Healthcare utilization will be assessed through the number of participants that visit emergency department.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Healthcare utilization will be assessed through the number of visits of each participant to the emergency department in the previous year.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Healthcare utilization will be assessed through the number of hospital admissions each participant had in the previous year.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Healthcare utilization will be assessed through the duration (in days) of hospital admissions each participant had in the previous year.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Participants' from the EG adherence to the physical activity programme will be registered by the sports professional responsible for each physical activity and also by participants' using a diary.

The occurrence of adverse events in participants from the EG during the PICk UP programme will be registered by the sports professional responsible for each physical activity and also by participants' in their diaries.

Occurrence of an adverse event will be collected in each session of physical activity throughout the 6 months.

Multiple time points through study completion - immediately after pulmonary rehabilitation and up to 3 and 6 months after pulmonary rehabilitation.

Inclusion Criteria: clinical diagnosis of a chronic obstructive pulmonary disease clinically stable in the previous month (no changes in medication or occurrence of acute exacerbations) ≥ 18 years old able to provide their own informed consent patients classified as a GOLD C or D (according to the global initiative for chronic obstructive pulmonary disease criteria), or classified as GOLD B and present a FEV1%predicted<30%, or present peripheral oxygen saturation ≤90% at rest or <85 during the 6MWT must be previously assessed by pneumologist or physiatrist. Exclusion Criteria: Signs of cognitive impairment; Neoplasic /immunologic disease or an unstable/significant cardiac, musculoskeletal, neuromuscular or psychiatric condition limiting the ability to exercise or co-operate.

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