Improving Exercise-Based Interventions for People Living with Both COPD and Frailty: A Realist Review

Abstract

Background

People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from exercise-based interventions, including pulmonary rehabilitation, but face challenges completing them. Research to understand ways to optimise exercise-based interventions in this group is lacking. We aimed to understand how exercise-based interventions might improve outcomes for people living with both COPD and frailty.

Methods

This realist review used database searches and handsearching until October 2019 to identify articles of relevance to exercise-based interventions for people living with COPD and frailty. A scoping search explored what is important about the context of living with COPD and frailty, and what mechanisms might be important in how exercise-based interventions result in their intended outcomes. Through discussion with stakeholders, the review scope was refined to areas deemed pertinent to improving care. We retained articles within this refined scope and identified additional articles through targeted handsearching. Data were extracted and synthesised in a narrative, prioritised by relevance and rigour.

Results

Of 344 records identified, 35 were included in the review and 20 informed the final synthesis. Important contextual factors to consider included: negative beliefs about themselves and exercise-based interventions; heterogenous presentation and comorbidities; decreased reserves and multidimensional loss; and experiencing unpredictable health and disruptions. In these circumstances, mechanisms that may help maximise outcomes from exercise-based interventions included: trusting relationships; creating a shared understanding of needs; having the capacity to address multidimensional concerns; being able to individualise approaches to needs and priorities; and flexible approaches to intervention delivery. Mixed-methods research and explicit theorising were often absent.

Conclusion

Building trusting relationships, understanding priorities, using individualised and multidisciplinary approaches, and flexible service delivery can improve the value of exercise-based interventions for people living with both COPD and frailty. Development and evaluation of new and adapted interventions should consider these principles.

Keywords:

• chronic obstructive pulmonary disease
• frailty
• rehabilitation
• exercise
• review

Acknowledgments

Thank you to all the patient, informal carer, public representatives who contributed to the study design and interpretation of the findings, including members of the BRC Respiratory PPI group, the Cicely Saunders Institute public involvement group, and project team members from the Harefield Breathing Group. Thank you to the professional stakeholders who contributed to discussions in refining the scope of the review, and to Patricia Wilson who provided feedback on the initial review protocol. Thank you also to Simon Etkind for providing constructive feedback on the structure and clarity of the manuscript.

Disclosure

Dr Matthew Maddocks reports grants from NIHR, outside the submitted work. The authors declare that there is no conflict of interest in this work.