Chronic disease self-management and exercise in COPD as pulmonary rehabilitation: a randomized controlled trial

Figures & data

Table 1 Comparison of program content

CDSMP program content	PR program content (Team member delivering the lecture)
Condition-specific information in the companion book	Heart and lungs: structure and function in relation to chronic heart and lung conditions (physiotherapist)
Symptom management: shortness of breath, breathing exercises	Monitoring and responding to symptoms: relaxation, breathing exercises, managing breathlessness
Muscle relaxation
Endurance exercise (discussion)	Beginning an exercise program (physiotherapist)
Cognitive symptom management
Symptom management: anger, fear, frustration, depression, fatigue, pain	Living with heart and lung conditions: emotional and social impact, communication (social worker)
Communication skills
Advance directives for health care
Working with and informing the health care team
Medication usage: generic advice, specific information in companion book	Medications and delivery devices: condition-specific (pharmacist)
Healthy eating	Nutrition (dietician)
Specific suggestions in the companion book	Activity modification (occupational therapist)
How to set action plans and problem solve	Not formally addressed

Notes: 1) The CDSMP course content is presented in comparison with PR and not as the content of the six individual CDSMP sessions. PR is shown as presented in the six sessions with the presenting health professional at our center. 2) Supervised exercise preceded the educational component of PR. The CDSMP has no supervised exercise component.

Abbreviations: CDSMP, Chronic Disease Self-Management Program; PR, pulmonary rehabilitation.

Table 2 Outcomes and measures

Primary outcome and measure
Physical capacity, measured by the 6MWD, a field walking test^Citation31
Secondary outcomes and measures
Outcome	Measure
Self-reported exercise	CHAMPS Activities Questionnaire for Older Adults^Citation39*
Self-efficacy for exercise	Exercise: Self-Efficacy measure^Citation37*
Exercise participation criteria (achieving recommended level of daily exercise)minimum	Achieving weekly exercise^Citation35,Citation36 “Regular Exercise is any planned physical activity (eg, brisk walking, aerobics, bicycling, swimming, line-dancing, tennis, doing formal exercises etc.) performed to increase or maintain health and physical fitness. Such exercise should be performed on all or at least 5 days of the week to accumulate 30 minutes or more per day. Exercise does not have to be painful to be effective but should be done at a moderate level that increases your breathing rate and makes you feel warmer Do you exercise regularly according to the definition above? Yes/No”
Stage of change for exercise	Exercise: Stages of Change – Short Form questionnaire^Citation36*
SOB	10 cm VAS^Citation38
Self-management behaviors	Flinders University PIH Scale^Citation40*
HRQoL	SF-36v2 Generic Health Survey^Citation41*

Note:

* Permission obtained for instrument use.

Abbreviations: 6MWD, 6-minute walk test distance; CHAMPS, Community Healthy Activities Model Program for Seniors; HRQoL, health-related quality of life; PIH, Partners in Health; SF-36v2, Short Form 36 version 2; SOB, shortness of breath; VAS, visual analog scale.

Figure 1 Flowchart showing participant’s progress through the study.

Abbreviation: 6MWD, 6-minute walk test distance.

Table 3 Participant characteristics

Variable	Participants (n=84)	I: CDSMP + exercise (n=43)	C: CDSMP-only (n=41)	P-value I versus C
Female	39 (46%)	20 (47%)	19 (46%)	0.99
Age, years	65.8±9.35	64.5±9.13	67.1±9.41	0.19
Married	50 (60%)	25 (58%)	25 (61%)	0.97
Education: to year 8	21 (26%)	12 (29%)	9 (23%)	0.53
to year 10	37 (45%)	20 (48%)	17 (43%)
to year 12	24 (29%)	10 (24%)	14 (35%)
Self-reported comorbidities: present	22 (26%)	9 (21%)	13 (33%)	0.35
Referral source: primary health or private practice	37 (44%)	18 (42%)	19 (46%)	0.80
Public hospital wards	19 (23%)	11 (26%)	8 (20%)
Public outpatient clinics	28 (33%)	14 (32%)	14 (34%)
Socioeconomic status: below State median	43 (54%)	21 (53%)	22 (55%)	1.00
Body mass index, kg/m^2	29.0±7.07	28.4±7.63	29.7±6.50	0.44
COPD severity:
Mild (60%–80%)	20 (29%)	8 (22%)	12 (38%)	0.23
Moderate (40%–59%)	16 (23%)	11 (30%)	5 (15.6%)
Severe (<40%)	33 (48%)	18 (49%)	15 (47%)

Notes: Data are reported as either raw number (percent) within study group status and as means ± standard deviations. The P-values are from Student’s t-tests or chi-squared analyses. Level of significance was set at P<0.05. COPD severity classified according to COPD-X Plan Australian and New Zealand management guidelines for COPD.⁵⁰

Abbreviations: C, control; CDSMP, Chronic Disease Self-Management Program; COPD, chronic obstructive pulmonary disease; I, intervention.

Table 4 Intervention versus control group: baseline outcome variables

Variable	Intervention (CDSMP + exercise)	Control (CDSMP-only)	P-value
Primary outcome	(n=42)	(n=40)
6MWD, m	351.6±122.9	353.0±97.4	0.953
Secondary outcomes	(n=41)	(n=40)
All exercise: duration, hours per week	5.250 (0.00–26.00)	9.250 (0.00–52.25)	0.011
All exercise: frequency, times per week	9.0 (0.0–49.0)	13.5 (0.0–59.0)	0.126
Moderate exercise: duration, hours	0.500 (0.00–19.50)	1.500 (0.00–10.25)	0.171
Moderate exercise: frequency, times per week	2.0 (0.0–20.0)	2.0 (0.0–23.0)	0.491
Exercise self-efficacy, scale 0–5	2.7±1.1	2.8±1.0	0.763
Self-management behaviors, scale 0–8	6.1±1.1	6.2±1.0	0.492
Shortness of breath: severity, cm	7.1±2.3	6.8±2.4	0.592
Shortness of breath: frequency, cm	6.9±2.6	6.4±2.6	0.330
SF-36v2 Physical Function	29.26±8.99	28.99±8.04	0.886
SF-36v2 Role Physical	31.95±10.37	32.12±9.42	0.938
SF-36v2 Bodily Pain	45.64±11.68	45.09±11.49	0.832
SF-36v2 General Health	30.30±9.88	32.41±8.96	0.317
SF-36v2 Vitality	41.74±9.19	40.77±9.69	0.648
SF-36v2 Social Function	42.75±13.19	39.94±11.37	0.309
SF-36v2 Role Emotional	36.25±16.10	37.22±15.28	0.782
SF-36v2 Mental Health	47.67±11.66	46.21±10.68	0.557
SF-36v2 Physical Component Summary	31.53±8.19	31.97±7.247	0.796
SF-36v2 Mental Health Component Summary	46.74±12.85	45.53±12.17	0.664
Achieving exercise criteria: Yes	11 (26.8%)	6 (15.0%)	0.301
No	30 (73.2%)	34 (85.0%)
Stage of change for exercise: Precontemplation	4 (9.8%)	6 (15.0%)	0.789
Contemplation	14 (34.1%)	17 (42.5%)
Preparation	9 (22.0%)	7 (17.5%)
Action	6 (14.6%)	5 (12.5%)
Maintenance	8 (19.5%)	5 (12.5%)

Notes: Data are reported as either raw number (percent) within study group, as mean ± standard deviation, or as median with range. The P-values are from Student’s t-tests, Mann–Whitney U tests or chi-squared analyses, with level of significance P<0.05 for 6MWT and P<0.003 for secondary outcomes, following a Bonferroni correction.

Abbreviations: 6MWD, 6-minute walk test distance; CDSMP, Chronic Disease Self-Management Program; SF-36v2, Short Form 36 version 2.

Table 5 Change in outcomes: CDSMP + exercise versus CDSMP-only

Variable	CDSMP + exercise (intervention)			CDSMP-only (control)			Change
	Baseline	Post	P-value	Baseline	Post	P-value	CDSMP + exercise	CDSMP-only	P-value
6MWD, m	351.6±122.9	370.2±128.2	0.013	353.0±97.4	373.0±97.7	0.017	18.6±46.2	20.0±50.6	0.90
Moderate exercise duration, hours (pw)	0.50 (0.0–19.5)	1.75 (0.0–30.8)	0.002	1.50 (0.0–10.3)	1.38 (0.0–15.8)	0.350	1.00 (−5.8–14.0)	0.000 (−9.8–10.3)	0.230
Moderate exercise frequency, times (pw)	2.0 (0.0–20.0)	3.0 (0.0–22.0)	0.007	2.0 (0.0–23.0)	3.0 (0.0–22.0)	0.290	1.0 (−8.0–11.0)	0.5 (−23.0–16.0)	0.766
Exercise self-efficacy, scale 0–5	2.7±1.1	2.9±1.1	0.354	2.8±1.0	3.0±1.0	0.290	0.2±1.1	0.2±1.1	0.892
Self-management behaviors, scale 0–8	6.1±1.1	6.3±0.8	0.037	6.2±1.0	6.4±1.0	0.076	0.3±0.8	0.2±0.7	0.698
Shortness of breath severity, cm	7.1±2.3	6.3±2.5	0.032	6.8±2.4	6.8±2.3	0.989	−0.8±2.4	0.0±2.3	0.118
Stage of change
Precontemplation	4 (10%)	3 (7%)	NS	6 (15%)	4 (10%)	NS	NS	NS	NS
Contemplation	14 (34%)	10 (24%)		17 (43%)	13 (33%)
Preparation	9 (22%)	4 (10%)		7 (18%)	6 (15%)
Action	6 (15%)	15 (36%)		5 (12%)	9 (22%)
Maintenance	8 (19%)	9 (23%)		5 (12%)	8 (20.0%)
Achieving weekly exercise criteria: Yes SF-36v2 domains below	11 (27%)	22 (54%)	0.066	6 (15%)	18 (45%)	0.013	19 (47%)	22 (55%)	NS
Physical function	29.3±9.0	30.7±9.0	0.076	29.0±8.0	30.4±8.2	0.254	1.5±5.2	1.4±7.8	0.963
Role physical	32.0±10.4	34.3±10.3	0.033	32.1±9.4	35.1±9.8	0.038	2.4±6.9	2.9±8.0	0.752
Bodily pain	45.6±11.7	47.7±11.0	0.206	45.1±11.5	44.7±11.5	0.621	2.1±10.3	−0.6±7.9	0.191
General health	30.3±9.9	31.2±8.6	0.467	32.4±9.0	31.8±10.1	0.580	0.9±8.2	−0.6±6.8	0.361
Vitality	41.7±9.2	43.0±9.0	0.382	40.8±9.7	43.7±8.1	0.032	1.2±8.8	3.0±8.5	0.366
Social function	42.8±13.2	43.3±10.9	0.777	40.0±11.4	43.2±11.1	0.050	0.5±11.9	3.8±10.2	0.271
Role emotional	36.3±16.1	38.0±15.8	0.282	37.2±15.3	39.1±13.7	0.358	1.7±10.0	2.9±12.5	0.956
Mental health	47.7±11.7	47.9±10.0	0.849	46.2±10.7	47.7±10.1	0.428	0.2±6.4	1.3±10.0	0.567
Physical component summary	31.5±8.2	33.5±7.3	0.026	32.0±7.2	32.7±8.4	0.506	2.0±5.6	0.7±6.6	0.340
Mental component summary	46.7±12.9	47.2±11.3	0.707	45.5±12.2	47.9±10.4	0.205	0.4±7.1	2.9±11.7	0.362

Notes: Data are reported as either raw number (percentage) within study group status, or as mean ± standard deviation or median with range. The P-values are from Student’s t-tests, Mann–Whitney U-tests or chi-squared analyses, with level of significance P<0.05 for the primary outcome and P<0.003 for the secondary outcomes, following a Bonferroni adjustment. P-values in bold are those which were below or approximated a P-value of 0.05.

Abbreviations: 6MWD, 6-minute walk test distance; CDSMP, Chronic Disease Self-Management Program; NS, not significant as there were insufficient data to report significance; SF-36v2, Short Form 36 version 2; pw, per week.

GuyattGThompsonPJBermanBMHow should we measure function in patients with chronic heart and lung disease?J Chron Dis1985385175244008592

 PubMedGoogle Scholar

StewartAMillsKMKingACHaskellWLGillisDRitterPLCHAMPS physical activity questionnaire for older adultsMed Sci Sports Exerc20013371126114111445760

 PubMed Web of Science ®Google Scholar

Cancer Prevention Research CenterExercise: self-efficacy measure1991 Available from: http://www.uri.edu/research/cprc/Measures/Exercise04.htmAccessed September 20, 2004

 Google Scholar

Australian Institute of Health and WelfareThe Active Australia Survey: a guide and manual for implementation, analysis and reporting2003 Available from: http://www.aihw.gov.au/publications/cvd/aas/aas.pdfAccessed 20 April, 2004

 Google Scholar

Cancer Prevention Research Center [homepage on the Internet]Exercise: stages of change – short form1991 Available from: http://www.uri.edu/research/cprc/Measures/Exercise02.htmAccessed September 20, 2004

 Google Scholar

GiftAGValidation of a vertical visual analogue scale as a measure of clinical dyspneaRehabil Nurs19891463233252813949

 PubMedGoogle Scholar

BattersbyMAskAReeceMMarwickMThe Partners in Health scale: the development and psychometric properties of a generic assessment scale for chronic condition self-managementAust J Prim Health200392/34149

 Google Scholar

WareJEKosinskiMDeweyJEHow to Score Version 2 of the SF-36 Health SurveyLincoln, RIQuality Metric Incorporated2000

 Google Scholar

AbramsonMCrockettAJDabscheckELung Foundation Australia and the Thoracic Society of Australia and New ZealandThe COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease2352013 Available from: http://www.copdx.org.au/Accessed August 19, 2013

 Google Scholar