Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials

Figures & data

Figure 1 PRISMA flow diagram for database search and study selection process.

Abbreviations: PA, physical activity; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomized controlled trial.

Table 1 Qualitative synthesis of included studies using PEDro scale for the quality of RCTs

Study name	Eligibility criteriaa	Random allocation	Concealed allocation	Baseline similarity	Blinding (subject)	Blinding (therapist)	Blinding (assessor)	Measure for >85%	ITT	Group comparison	Point measure	Quality score
Studies comparing PA interventions versus usual care (or placebo; n=16)
Berry et al^Citation15	*	*		*			*		*	*	*	6
Borges and Carvalho^Citation16	*	*	*	*			*	*	*	*	*	8
Breyer et al^Citation17	*	*		*				*		*	*	5
Dal Negro et al^Citation46,Citation47	*	*	*	*	*	*	*	*	*	*	*	10
Faulkner et al^Citation19	*	*	*	*						*	*	5
Goris et al^Citation48	*	*		*				*	*	*	*	6
Hornikx et al^Citation31	*	*		*				*	*	*	*	6
Hospes et al^Citation32	*	*		*				*		*	*	5
Jonsdottir et al^Citation39	*	*	*	*		*				*	*	6
Kruis et al^Citation53	*	*	*	*			*	*	*	*	*	8
Larson et al^Citation20	*	*	*	*	*		*	*	*	*	*	9
Sandland et al^Citation51	*	*		*	*		*			*	*	6
Schuz et al^Citation41; Walters et al^Citation42	*	*	*	*	*		*		*	*	*	8
Steele et al^Citation37	*	*		*					*	*	*	5
Watz et al^Citation45	*	*	*	*	*	*		*	*	*	*	9
Wilson et al^Citation24	*	*	*	*					*	*	*	6
Studies comparing PA interventions added to PR versus PR alone (n=8)
Altenburg et al^Citation25	*	*	*						*	*	*	5
Burtin et al^Citation27	*	*	*		*	*	*			*	*	7
Cruz et al^Citation29	*	*	*	*	*				*	*	*	7
de Blok et al^Citation30	*	*		*						*	*	4
Duiverman et al^Citation50	*	*		*						*	*	4
Kawagoshi et al^Citation33	*	*		*					*	*	*	5
Kesten et al^Citation43	*	*		*	*	*	*				*	6
Pleguezuelos et al^Citation52	*	*	*	*				*		*	*	6
Studies comparing PA interventions versus another PA intervention (n=13)
Berry et al^Citation26	*	*	*	*			*			*	*	6
Casaburi et al^Citation49	*	*		*					*	*	*	5
Effing et al^Citation18	*	*		*				*	*	*	*	6
Mendoza et al^Citation34	*	*	*	*			*	*		*	*	7
Moy et al^Citation35	*	*		*				*	*	*	*	6
Nguyen et al^Citation36	*	*	*				*	*	*	*	*	7
Nguyen et al^Citation40	*	*		*			*	*	*	*	*	7
Pomidori et al^Citation21	*	*		*					*	*	*	5
Probst et al^Citation22	*	*		*					*	*	*	5
Sewell et al^Citation23	*	*	*	*					*	*	*	6
Tabak et al^Citation38	*	*	*	*	*			*		*	*	7
Troosters et al^Citation44	*	*	*	*	*	*	*	*	*	*	*	10
Vergeret et al^Citation14	*			*						*	*	3

Notes:

* Yes, score = 1.

a Item does not contribute to total quality score. The higher the given score, the better the quality. Cut points of the scale were excellent (9–10), good (6–8), fair (4–5) and poor (3).

Abbreviations: ITT, intention to treat; PA, physical activity; PEDro, Physiotherapy Evidence Database; PR, pulmonary rehabilitation; RCTs, randomized controlled trials.

Table 2 Characteristics of included studies

Author	Year	Country	n (I/C)	Age, years; mean (SD)	FEV1 % predicted L; mean (SD)	Gender (male/female)	Intervention arm	Control arm	Time points/outcomes
Studies comparing PA interventions versus usual care (or placebo; n=16)
Berry et al^Citation15	2003	USA	70/70	67.7 (5.8)	58.4 (18.1)	78/62	Exercise maintenance (1 h ×3 times/W supervised ET sessions after 3M of ET program pre-randomization – 15M)	UC (PA advice after 3M of ET program pre-randomization – 15M)	15M: subjective activity score, FEV1, FVC and FER. 6M, 12M, 15M: 6MWD
Borges and Carvalho^Citation16	2014	Brazil	15/14	65.9 (10.9)	40.4 (14.3)	18/11	Whole-body ET (≥3 ET sessions starting at day 3 of admission, mean sessions =5.6)	UC (daily chest physiotherapy and O2 therapy)	1M post-discharge: daily walking, standing, sitting and lying time, FEV1 % predicted. 1M post-discharge: 6MWD, SGRQ
Breyer et al^Citation17	2010	Austria	30/30	60.3 (8.5)	46.3 (17.6)	27/33	Nordic walking (3 times/W walking with power poles ET sessions and 1 time/W EDU sessions – 3M)	UC (1 time/W EDU sessions – 3M)	3M, 6M, 9M: movement intensity, 6MWD, SF36
Dal Negro et al^Citation46,Citation47	2012 and 2010	Italy	44/44	74 (6.7)	FEV1 =0.8 (0.3)	61/27	Daily EAA dietetics (4 g ×2 times/day – 12W)	Placebo dietetics (4 g ×2 times/day – 12W)	1M, 3M: daily steps and energy expenditure, FEV1 (l/sec). 3M: SGRQ
Faulkner et al^Citation19	2010	UK	6/8	–	–	–	Health-enhancing PA program (3 times/W supervised ET and EDU sessions with exercise diary – 8W)	UC (8W)	9W: subjective 7-day total PA, ISWT, CRQ, MRC, FEV1 % predicted
Goris et al^Citation48	2003	the Netherlands	11/9	62 (11)	40 (16)	11/9	Respifor^® (Nutricia Advanced Medical Nutrition, Schiphol, The Netherlands) nutritional supplement (375 mL ×3 times/day with nutritional consultation sessions – 3M)	UC (3M)	1M, 3M post-discharge: daily PA levels and energy expenditure
Hornikx et al^Citation31	2009	Belgium	15/15	67 (6.5)	43 (18)	17/12	PA counseling and GS (3 times/W phone calls – 1M)	UC (1M)	1M: daily steps, walking time and movement intensity during walking, 6MWD, MRC
Hospes et al^Citation32	2009	the Netherlands	18/17	62.2 (8.6)	64.7 (16.1)	21/14	Individualized exercise counseling (30 min × 5 sessions using MI – 12W)	UC (12W)	12W: daily steps, 6MWD, SGRQ, CCQ, SF36
Jonsdottir et al^Citation39	2015	Iceland	48/52	59 (4.5)	57.6 (17.7)	46/54	Partnership with families’ self-management (≥30 min ×4 RN/patient/family consultations, 6M of SC treatment and one interdisciplinary team/patient/family meeting – 6M)	UC (6M)	12M: weekly IPAQ subscales: total, vigorous, moderate and walking, SGRQ
Kruis et al^Citation53 (clustered RCT)	2014	the Netherlands	554/532	68.3 (11.2)	67.8 (20.4)	585/501	Primary care practitioners training for integrated disease management: spirometry use, MI, SC and exercise advice (24M)	UC (24M)	12M: daily IPAQ, SGRQ, CCQ, SF36, MRC
Larson et al ^Citation20	2014	USA	15/14	71 (7.8)	58.5 (18.5)	–	Self-efficacy and UBRT (15 min ×4 times/M EDU sessions – 4M)	UC (gentle chair exercise – 4M)	4M: daily MVPA, LPA, and sedentary time
Sandland et al^Citation51	2008	UK	10/10	73.4 (6.8)	43.6 (22.5)	14/6	Ambulatory O2 (3.1 kg cylinder O2 with a backpack – 8W)	Ambulatory air (3.1 kg cylinder placebo with a backpack – 8W)	8W: daily activity counts, ISWT, ESWT, CRQ
Schuz et al^Citation41 (Walters et al^Citation42)	2015 (2013)	Australia	90/92	67.7 (7.8)	55.2 (13.4)	96/86	Health monitoring (16×30 min phone calls by trained community nurses – 12M)	UC (12 times/M social phone calls)	6M, 12M: daily steps, SGRQ, SF36
Steele et al^Citation37	2008	USA	52/54	–	40.4 (17.8)	–	Exercise adherence counseling (12 phone calls, 1 home visit and ≥20 min ×4 times/W maintenance home ET sessions after 8W of PR pre-randomization – 20W)	UC (after 8W of PR pre-randomization – 20W)	20W, 12M: daily PA activity, SR daily exercise time, 6MWD, SOLDQ, SF36, SOB levels, FEV1 % predicted
Watz et al^Citation45 (crossover RCT)	2014	Germany	129	61.4 (8.9)	64.02 (9.38)	87/42	Indacaterol (Onbrez^®; Novartis Pharmaceuticals, Basel, Switzerland) 150 μg (1 time/day – 21 days)	Placebo (1 time/day – 21 days)	3W: daily steps, MVPA time and PA levels, adverse events
Wilson et al^Citation24	2015	UK	73/75	68.3 (12.4)	41 (16)	91/57	PR maintenance (1 h ×3 personalized ET sessions and 1 h ×3 EDU sessions – 12M)	UC (PA advice – 12M)	12M: weekly IPAQ, VAS, ISWT, ESWT, CRQ
Studies comparing PA interventions added to PR versus PR alone (n=8)
Altenburg et al^Citation25	2014	the Netherlands	31/30	54 (9.6)	43 (25.9)	32/25	PA counseling (30 min ×5 sessions using MI – 12W) added to PR (2 h ×3 times/W – 9W)	PR (2 h ×3 times/W – 9W)	3M, 15M: daily steps and steps equivalent*, 6MWD, CRQ, CCQ
Burtin et al^Citation27	2015	Belgium	40/40	66.5 (7.5)	45.5 (16.03)	66/14	Individualized PA counseling (30 min ×8 sessions using MI – 6M) added to multidisciplinary PR (average 1.5 h ×2.5 times/W – 6M)	Multidisciplinary PR (average 1.5 h ×Δ2.5 times/W – 6M)	3M, 6M: daily steps, walking and MVPA time, 6MWD, CRQ
Cruz et al^Citation29	2016	Portugal	16/16	66.5 (8.4)	66.9 (20.1)	27/5	PA-focused behavioral counseling (average 25 min ×8 sessions using SCT: SE, MI and pedometer and diary feedback – 6M) added to PR (1 h ×3 times/W ET and 1.5 h ×1 time/W EDU sessions – 3M)	PR (1 h ×3 times/W ET and 1.5 h ×1 time/W EDU sessions – 3M)	3M, 6M: daily steps and MVPA, PA and sedentary time, 6MWD, SGRQ
de Blok et al^Citation30	2006	the Netherlands	10/11	64.0 (11.3)	47.3 (17.9)	9/12	Lifestyle PA counseling (30 min ×4 sessions using MI – 9W) added to PR (9W)	PR (9W)	9W: daily steps, SGRQ, SF36
Duiverman et al^Citation50	2008	the Netherlands	31/35	62 (8.6)	–	35/31	Nocturnal noninvasive positive pressure ventilation during multidisciplinary PR (1 h ×3 times/W ET sessions – 12W)	Multidisciplinary PR (1 h ×3 times/W ET sessions – 12W)	3M: daily steps, 6MWD, ESWT, FEV1 (l/sec)
Kawagoshi et al^Citation33	2015	Japan	12/15	74.5 (8.4)	59.4 (21.5)	24/3	Pedometer feedback (1 time/M sessions – 12M) added to multidisciplinary home-based PR (1 time/day home ET, 45 min ×1 time/M EDU and 2 h ×2 times/M supervised ET sessions – 12M)	Multidisciplinary home-based PR (1 time/day home ET, 45 min ×1 time/M EDU and 2 h ×2 times/M supervised ET sessions – 12M)	12M: daily walking, standing, sitting and lying down time, 6MWD, CRQ, MRC
Kesten et al^Citation43	2008	USA	25/21	67.4 (7.2)	33.4 (12.4)	20/26	Tiotropium (18 μg ×1 time/day – 25W) added to PR (0.5 h ×3 times/W – 8W)	Placebo (18 μg ×1 time/day – 25W) added to PR (0.5 h ×3 times/W – 8W)	13W, 17W, 21W, 25W: subjective activity time in 2W, endurance time (min)
Pleguezuelos et al^Citation52	2013	Spain	34/37	70.4 (2.5)	53.4 (2.9)	–	Urban walking circuit promotion (leaflets distributed and reviewed 2 times/M – 9M) following PR (1 h ×3 times/W ET sessions – 12W)	UC (generic PA advice reviewed 2 times/M – 9M) following PR (1 h × 3 times/W ET sessions – 12W)	12M: subjective daily walking time, weekly number of days walked, 6MWD
Studies comparing PA interventions versus another PA intervention (n=13)
Berry et al^Citation26	2010	USA	89/87	66 (10)	51.5 (19.3)	95/81	Lifestyle activity program (1 h ×3 times/W ET sessions, group discussions, individualized counseling and 15 min follow-up phone calls – 3M)	ET (1 h ×3 times/W ET sessions – 3M)	3M, 6M, 12M: subjective weekly MVPA levels, 6MWD, SF36, CRQ. 12M: adverse events
Casaburi et al^Citation49	2012	USA	11/11	66.9 (9.2)	31.3 (10)	–	Lightweight ambulatory O2 (1.6 kg aluminum cylinders – 6M)	E-cylinder ambulatory O2 (10 kg towed on a cart cylinders – 6M)	3M, 6M: midday PA time
Effing et al^Citation18 (2×2 factorial RCT)	2011	the Netherlands	77/76	63.4 (7.9)	50 (15.6)	89/64	COPE active (average 2.5 times/W supervised ET and 1 time/W home-based ET sessions – 11M) added to self-management (1 h ×6 individualized SC counseling, 2 h ×4 behavioral change group discussions and 1 EDU session – 3M)	Self-management (1 h ×6 individualized SC counseling, 2 h ×4 behavioral change group discussions and 1 EDU session – 3M)	7M, 12M: daily steps, ISWT, ESWT, CRQ, CCQ
Mendoza et al^Citation34	2015	Chile	52/50	68.7 (8.5)	66.1 (19.4)	62/40	PA counseling (30 min ×1 time/M individualized pedometer and exercise diary feedback sessions – 3M)	Standardized counseling (30 min × 1 time/M individualized exercise diary feedback sessions – 3M)	3M: daily steps, 6MWD, SGRQ, mMRC
Moy et al^Citation35	2015	USA	154/84	67 (9)	–	223/15	Internet-mediated pedometer-based program (1 time/W GS and pedometer feedback and online social support – 4M)	Pedometer reporting (1 time/M pedometer and adverse events outcomes reporting to HCP) – 4M	4M: daily steps, SGRQ
Nguyen et al^Citation36	2009	USA	8/9	68.2 (11)	40.9 (17.7)	6/11	Cell phone-mediated exercise persistence program (individualized PA advice followed by 1 time/W reinforcement, GS and activity feedback – 6M)	Cell phone-mediated self-monitoring program (individualized PA advice followed by 1 time/day activity recording – 6M)	3M, 6M: daily steps and % of sedentary and MVPA time, 6MWD, incremental cycle endurance, SGRQ, SF36
Nguyen et al^Citation40	2013	USA	43/41	68.5 (9.6)	51.6 (20.1)	49/35	Internet-mediated dyspnea self-management program (1.5–2 h dyspnea management face-to-face consultation, 30 min ×4 times/W individualized home ET sessions, 1 time/W in M01 followed by 2 times/M from M2 to M11 exercise GS feedback and structured EDU sessions – 12M)	General EDU (initial home visit, 2 times/M phone calls and 1 time/M EDU sessions – 12M)	3M, 6M, 12M: subjective weekly exercise duration, 6MWD, CRQ, SF36
Pomidori et al^Citation21	2012	Italy	18/18	72 (8.2)	48 (12.4)	27/9	Home-based walking (20–30 min ×4 times/W walking at a fixed speed paced by metronome, 4 times/W supervised sessions in M1 and 2 times/M phone calls support in M2 to M6 – 6M)	Home-based walking (20–30 min × 4 times/W walking a fixed distance, 4 times/W supervised sessions in M1 and 2 times/M phone calls support in M2 to M6 – 6M)	6M, 12M: daily METs, METs peak and MVPA time, SGRQ. 12M: 6MWD
Probst et al^Citation22	2011	Brazil	20/20	66 (8.6)	39.5 (13.3)	21/19	ET (1 h ×3 times/W high-intensity and whole-body ET sessions – 12W)	ET (1 h ×3 times/W light-intensity and breathing ET sessions – 12W)	12W: daily steps, walking, sitting, standing, lying and activities cost >3 METs time. Total and activities cost >3 MET energy expenditure, 6MWD, maximum work load, endurance time, SGRQ, MRC
Sewell et al^Citation23	2005	UK	90/90	68.3 (8.6)	–	99/81	Individually targeted ET (2 h ×2 times/W individualized ET and EDU sessions – 7W)	General ET (2 h ×2 times/W standardized ET and EDU sessions – 7W)	7W: daily activity counts, ISWT, ESWT, CRQ
Tabak et al^Citation38	2014	the Netherlands	14/16	66.6 (7.4)	52.8 (14.1)	19/11	Tele-rehabilitation program (1 time/W internet-mediated pedometer feedback and 90 min ×2 self-management sessions – 4W) added to ET (1 time/W ET sessions – 4W)	ET (1 time/W ET sessions – 4W)	3W: daily steps, CCQ, MRC
Troosters et al^Citation44	2014	Belgium	238/219	61.7 (8.4)	65.7 (8.2)	312/145	Tiotropium HandiHaler 18 μg and salbutamol(1 time/day – 24W) added to individualized activity plan and exercise diary feedback (20 min ×1 time/M sessions using MI – 24W)	Placebo HandiHaler and salbutamol (1 time/day – 24W) added to individualized activity plan and exercise diary feedback (20 min ×1 time/M sessions using MI – 24W)	24W: daily steps and age-appropriate LPA and MVPA time, FEV1 (l/sec)
Vergeret et al^Citation14	1989	France	84/75	61.9 (7.8)	–	139/20	LTOT with portable O2 (>15 h/day O2 concentrators plus gaseous or liquid O2 – 12M)	LTOT with fixed O2 (>15 h/day O2 concentrators – 12M)	12M: subjective daily indoor and outdoor rest and activities time, subjective daily outdoor distance walked

Note:

* steps equivalent=steps + metabolic equivalent.

Abbreviations: C, control arm; CCQ, Clinical COPD Questionnaire; COPE, community based physiotherapeutic exercise; CRQ, Chronic Respiratory Questionnaire; EAA, essential amino acid; EDU, education; ESWT, endurance shuttle walk test; ET, exercise training; FER, forced expiratory ratio; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; GS, goal setting; HCP, health care professionals; I, intervention arm; IPAQ, International PA Questionnaire; ISWT, incremental shuttle walk test; LPA, light PA; LTOT, long-term oxygen therapy; M, month(s); MET, metabolic equivalent task; MI, motivational interviewing; mMRC, Modified Medical Research Council; MRC, Medical Research Council; MVPA, moderate to vigorous PA; 6MWD, 6-minute walk distance; PA, physical activity; PR, pulmonary rehabilitation; RCT, randomized controlled trial; RN, registered nurse; SC, smoking cessation; SCT, social cognitive therapy; SE, self-efficacy; SF36, 36-Item Short Form Survey; SGRQ, Saint George Respiratory Questionnaire; SOB, shortness of breath; SOLDQ, Seattle Obstructive Lung Disease Questionnaire; SR, self-reported; UBRT, upper-body resistance training; UC, usual care; VAS, Visual Activity Scale; W, week(s).

Figure 2 Studies comparing PA interventions versus usual care.

Abbreviations: CI, confidence interval; ET, exercise training; IV, independent variable; PA, physical activity; SMD, standardized mean difference.

Figure 3 Studies comparing PA counseling added to PR versus PR (short-term effect).

Abbreviations: CI, confidence interval; IV, independent variable; PA, physical activity; PR, pulmonary rehabilitation; SMD, standardized mean difference.

Figure 4 Studies comparing PA counseling added to PR versus PR (long-term effect).

Abbreviations: CI, confidence interval; IV, independent variable; PA, physical activity; PR, pulmonary rehabilitation; SMD, standardized mean difference.

Table 3 Studies comparing PA interventions versus another active intervention

Study	Intervention	Control	Outcome (unit)	Time point	Intervention arm		Control arm		ES (95% CI)
					n	Mean (SD)	n	Mean (SD)
Studies that showed effect of ET when compared to another PA intervention (n =3)
Effing et al^Citation18	ET and self-management	Self-management	Daily steps (n)	Δ12M	55	815.6 (2,659.4)	55	−374.8 (2,272.3)	0.48 (0.10–0.86)
Pomidori et al^Citation21	Home-based walking with fixed speed	Home-based walking with fixed distance	Daily METs (3.5 mL/kg⋅min)	Δ12M	18	0.17 (0.14)	18	0.04 (0.13)	0.94 (0.25–1.63)
			Daily METs peak (3.5 mL/kg⋅min)	Δ12M	18	0.16 (0.20)	18	0.06 (0.13)	0.58 (−0.09 to 1.25)
			Daily highest MVPA (>3 METs) time in 7 days (min)	Δ12M	18	35 (32)	18	13 (28)	0.72 (0.04–1.39)
Probst et al^Citation22	High-intensity and whole-body ET	Light-intensity and breathing ET	Daily steps (n)	3M	20	4,179 (646.7)	20	4,278.6 (796)	−0.13 (−0.76 to 0.49)
			Daily walking (min)	3M	20	52.7 (40.4)	20	43.5 (26.7)	0.26 (−0.36 to 0.89)
			Daily activities cost >3 METs (min)	3M	20	74 (18.7)	20	53.1 (16.4)	1.16 (0.49–1.84)
			Daily total EE (kcal)	3M	20	1,312.3 (119.4)	20	1,347 (199)	−0.21 (−0.83 to 0.41)
			Daily activity cost >3 METs EE (kcal)	3M	20	408 (118.3)	20	343.8 (442.4)	0.19 (−0.43 to 0.82)
Studies that showed effects of self-management or counseling models when compared to another PA intervention (n =3)
Mendoza et al^Citation34	Pedometer-based counseling	Standard counseling	Daily steps (n)	Δ3M	50	3,080 (3,254.8)	47	138.3 (1,950.4)	1.08 (0.65–1.51)
Moy et al^Citation35	Internet-mediated pedometer-based program	Pedometer recording only	Daily steps (n)	Δ4M	133	447 (1,817)	68	−346 (1,949)	0.84 (0.59–1.08)
Nguyen et al^Citation40	Internet-mediated dyspnea self-management program	General EDU	SR weekly exercise duration (min)	12M	43	221 (184)	41	115 (186)	0.57 (0.13–1.00)

Note: Δ, change from baseline.

Abbreviations: CI, confidence interval; EDU, education; EE, energy expenditure; ET, exercise training; ES, effect size; M, month(s); METs, metabolic equivalent tasks; min, minutes; MVPA, moderate to vigorous PA; PA, physical activity; SR, self-reported; W, week(s).

Figure 5 Comparison between differences in daily steps achieved by PA interventions according to the MID of daily steps in COPD.

Abbreviations: ET, exercise training; MID, minimal important difference; NNIV, nocturnal noninvasive ventilation; PA, physical activity; PR, pulmonary rehabilitation.

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