Interventions to Increase Physical Activity in Patients with COPD: A Comprehensive Review

Figures & data

Table 1a.  PEDro quality scores for the 16 RCT and RT studies

Reference	1. Eligibility criteria	2. Random allocation	3. Allocation concealed	4. Similar at baseline	5. Participants blinded	6. Therapists blinded	7. Assessors blinded	8. Outcome obtained from 85% of participants	9. Treatment allocated or intention-to-treat	10. Between group comparisons	11. Point measures and measures of variability	PEDro Score (range 0–10)
Nguyen (20) 2013	Y	Y(1)	N	Y(1)	N	N	Y(1)	Y(1)	Y(1)	Y(1)	Y(1)	7
Pleguezuelos (21) 2013	Y	Y(1)	N	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	6
Tabak (22) 2013	Y	Y(1)	Y(1)	Y(1)	N	N	N	N	Y(1)	Y(1)	Y(1)	6
Pomidori (23) 2012	Y	Y(1)	N	Y(1)	N	N	N	N	Y(1)	Y(1)	Y(1)	5
Effing (24) 2011	Y	Y(1)	N	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	6
Probst (25) 2011	Y	Y(1)	N	Y(1)	N	N	N	N	Y(1)	Y(1)	Y(1)	5
Berry (26) 2010	Y	Y(1)	Y(1)	Y(1)	N	N	Y(1)	N	Y(1)	Y(1)	Y(1)	7
Breyer (27) 2010	Y	Y(1)	N	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	6
Hospes (28) 2009	Y	Y(1)	N	Y(1)	N	N	N	Y(1)	N	Y(1)	Y(1)	5
Nguyen (29) 2009	Y	Y(1)	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	Y(1)	7
Nguyen (30) 2008	Y	Y(1)	Y(1)	Y(1)	N	N	Y(1)	N	Y(1)	Y(1)	Y(1)	7
Steele (31) 2008	Y	Y(1)	N	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	6
Varga (32) 2007	N	Y(1)	N	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	6
De Blok (33) 2006	Y	Y(1)	N	Y(1)	N	N	Y(1)	N	Y(1)	Y(1)	Y(1)	6
Behnke (34) 2005	N	N	N	Y(1)	N	N	N	Y(1)	Y(1)	Y(1)	Y(1)	5
Berry (35) 2003	Y	Y(1)	N	Y(1)	N	N	Y(1)	N	Y(1)	Y(1)	Y(1)	6

N = No; Y = Yes; Y(1) = Yes with 1 point.

* = not included in PEDro score.

Low = ≤3/10; Medium = 4–5/10; High = ≥6/10 (Ref. 15,16).

Table 1b.  CASP quality scores for the four cohort studies

Reference	1. Clearly focused issue	2. Appropriate method	3. Acceptable recruitment	4. Minimise bias-exposure	5. Minimise bias-outcome	6A. Confounders identified	6B. Confounders accounted for	7A. Follow-up – complete enough	7B. Follow-up – long enough	8–10. Results – precise and believable	11. Results – applicable to others	12. Results – fit with available evidence	CASP Score (range 0–10)
Moy (36) 2012	Y	Y	N	CT	Y(1)	N	Y(1)	CT	Y(1)	Y(1)	N	Y(1)	5
Moy (37) 2010	Y	Y	N	CT	N	Y(1)	Y(1)	CT	Y(1)	Y(1)	CT	Y(1)	5
Wewel (38) 2008	Y	Y	Y(1)	CT	CT	CT	Y(1)	CT	N	Y(1)	Y(1)	Y(1)	5
Nguyen (39) 2005	Y	Y	Y(1)	Y(1)	CT	CT	N	CT	Y(1)	Y(1)	CT	Y(1)	5

N = No; CT = Can't tell; Y = Yes; Y(1) = Yes with 1 point.

* = Not included in CASP score.

short-legendFigure 1.

Table 2.  Details of the 20 studies including recruitment, demographics, study design, quality, intervention groups, assessment times, attrition and PA instruments/parameters

Study	Recruitment and Demographics	Design and Quality	Intervention groups	Assessment times	Attrition rate	PA Instrument/Parameters
Randomised Controlled Trials/Randomised Trials
Nguyen (20) 2013	Recruitment: Internet, referrals, letter mailings, support groups, PR sites and advertising I1; n = 43; age 68.5 (11.0) yrs; 25M/18F; FEV1 53.3 (20.4)% I2; n = 41; age 68.2 (9.9) yrs; 19M/22F; FEV1 50.6 (18.2)% I3; n = 41; age 69.3 (8.0) yrs; 24M/17F; FEV1 49.4 (19.8)%	RCT PEDro: 7	I1 – Internet-based DSMP I2 – Face-to-face DSMP I3 – General health education	Baseline (T0), Mth 3, Mth 6, Mth 12 (T1)	I1–12% (n = 38/43); I2–15% (n = 35/41); I3–10% (n = 37/41)	Exercise self-report survey. Frequency and duration of endurance and strengthening exercises for a typical week during the last 4 weeks.
Pleguezuelos (21) 2013	Recruitment: Hospital I; n = 34; age 70.2 (2.5) yrs; 34M/0F; FEV1 32.0 (1.2)% C; n = 54; age 70.5 (2.5) yrs; 54M/0F; FEV1 31.8 (1.0)%	RCT PEDro: 6	I – Urban walking circuits C – Non-urban walking circuits	Baseline (T0), Mth 9 (T1)	15% (n = 6/40)	Activity diary. Frequency and duration of daily walking
Tabak (22) 2013	Recruitment: Hospital I; n = 14; age 65.2 (9.0) yrs; 8M/6F; FEV1 48.7 (16.7)% C; n = 16; age 67.9 (5.7) yrs; 11M/5F; FEV1 56.4 (10.6)%	RCT PEDro: 6	I – Telerehabilitation programme C – Usual care	Baseline (T0), Week 1, Week 2, Week 3 (T1)	22% (n = 4/18)	Yamax DigiWalker SW-200 pedometer. Step counts
Pomidori (23) 2012	Recruitment: Hospital I1; n = 18; age 70 (9) yrs; 13M/5F; FEV1 48 (13)% I2; n = 18; age 74 (7) yrs; 14M/4F; FEV1 49 (12)%	RT PEDro: 5	I1 – Speed walking paced by a metronome I2 – Walking a known distance in a given period of time	Baseline (T0), Mth 6, Mth 12 (T1)	I1–22% (n = 5/23); I2–25% (n = 6/24)	SenseWear armband. Daily and peak EE; time spent > 3 METs
Effing (24) 2011	Recruitment: Hospital I1; n = 77; age; 62.9 (8.1) yrs; 45M/32F; FEV1 49.6 (14.2)% I2; n = 76; age; 63.9 (7.8) yrs; 44M/32F; FEV1 50.5 (17.0)%	RCT PEDro: 6	I1 – Self-management programme including COPE-active I2 – Self-management programme only	Baseline (T0), Mth 7, Mth 12 (I1–T1; I2–T2)	I1–4% (n = 3/77); I2–11% (n = 8/76)	Yamax DigiWalker SW-200 pedometer. Step counts
Probst (25) 2011	Recruitment: Referral I1; n = 20; age 65 (10) yrs; 11M/9F; FEV1 39 (14)% I2; n = 20; age 67 (7) yrs; 10M/10F; FEV1 40 (13)%	RT PEDro: 5	I1 – Calisthenics and breathing exercises I2 – Endurance and strength training	Baseline (T0), Week 12 (T1)	I1–35% (n = 11/31); I2–38% (n = 12/32)	DynaPort activity monitor and SenseWear Armband. Time spent lying, sitting, standing, walking and > 3 METs; EE; step counts
Berry (26) 2010	Recruitment: Advertising and referral I1; n = 87; age 66 (10) yrs; 47M/40F; FEV1 50.5 (20.2)% I2; n = 89; age 66 (10) yrs; 48M/41F; FEV1 53.0 (18.5)%	RCT PEDro: 7	I1 – Lifestyle activity programme I2 – Traditional exercise therapy	Baseline (T0), Mth 3 (I2–T1), Mth 6, Mth 12 (I1–T1; I2–T2)	I1–28% (n = 24/87); I2–22% (n = 20/89)	CHAMPS questionnaire. Weekly moderate PA EE
Breyer (27) 2010	Recruitment: Hospital, local clinics and advertising I; n = 30; age 61.9 (8.87) yrs; 14M/16F; FEV1 48.1 (19.1)% C; n = 30; age 59.0 (8.02) yrs; 13M/17F; FEV1 47.1 (16.3)%	RCT PEDro: 6	I – Nordic Walking C – No intervention	Baseline (T0), Mth 3 (T1), Mth 6, Mth 9 (T2)	6% (n = 2/32)	DynaPort activity monitor. Daily movement intensity (m/s2); time spent walking, standing, sitting and lying
Hospes (28) 2009	Recruitment: Hospital I; n = 18; age 63.1 (8.3) yrs; 10M/8F; FEV1 67.4 (17.5)% C; n = 17; age 61.2 (9.1) yrs; 11M/6F; FEV1 61.8 (14.4)%	RCT PEDro: 5	I – Pedometer-based exercise counselling C – Usual care	Baseline (T0), Week 12 (T1)	10% (n = 2/20)	Yamax DigiWalker SW-200 pedometer. Step counts
Nguyen (29) 2009	Recruitment: PR sites I1; n = 9; age 72 (9) yrs; 3M/6F; FEV1 46.7 (18.7)% I2; n = 8; age 64 (12) yrs; 3M/5F; FEV1 34.4 (15.0)%	RCT PEDro: 7	I1 – MOBILE-Coached intervention I2 – MOBILE-Self-Monitored intervention	Baseline (T0), Mth 3, Mth 6 (T1)	I1–0%; I2–0%	Stepwatch® 3 activity monitor. Step counts,% inactive time (no steps),% active time in moderate (31–80 steps/min) & vigorous activity (>80 steps/min) and peak performance (average steps/min of the best 30 min of the day).
Nguyen (30) 2008	Recruitment: Internet, referrals, letter mailings, support groups, PR sites and advertising I1; n = 19; age 68.0 (8.3) yrs; 11M/8F; FEV1 49.0 (16.8)% I2; n = 20; age 70.9 (8.6) yrs; 11M/9F; FEV1 50.3 (17.6)%	RCT PEDro: 7	I1 – Internet-based DSMP I2 – Face-to-face DSMP	Baseline (T0), Mth 3, Mth 6 (T1)	I1–27% (n = 7/26); I2–17% (n = 4/24)	Stage of motivational readiness for exercise questionnaire and exercise self-report survey. Stage of change (action or maintenance); frequency and duration of endurance, strengthening and stretching exercises for a typical week during the last 4 weeks.
Steele (31) 2008	Recruitment: Hospital and advertising I – n = 54; C – n = 57; age (I & C) 67 yrs; Gender (I & C): 98M/8F; FEV1 I – 45 (17)%; C – 41 (17)%	RCT PEDro: 6	I – Exercise adherence intervention C – Usual care	Baseline (T0), Week 12 (T1), Week 44 (T2)	22% (n = 12/54)	RT3 accelerometer and activity diary. Daily VMU; daily self-reported exercise time
Varga (32) 2007	Recruitment: NR I1; n = 22; age 61 (12) yrs; 19M/3F; FEV1 51 (16)% I2; n = 17; age 67 (10) yrs; 11M/6F; FEV1 64 (29)% I3; n = 32; age 60 (12) yrs; 25M/7F; FEV1 52 (16)%	RT PEDro: 6	I1 – Continuous training I2 – Interval training I3 – Self-paced training	Baseline (T0), Week 8 (T1)	I1–0%; I2–0%; I3–0%	Laboratory activity questionnaire. Activity level score
De Blok (33) 2006	Recruitment: PR site I; n = 10; age 65.7 (10.4) yrs; 5M/5F; FEV1 52 (22)% C; n = 11; age 62.5 (12.3) yrs; 4M/7F; FEV1 43 (13)%	RCT PEDro: 6	I – PR + lifestyle PA programme C – PR only	Baseline (T0), Week 9 (T1)	20% (n = 2/10)	Yamax DigiWalker SW-200 pedometer. Step counts
Behnke (34) 2005	Recruitment: Hospital I; n = 66; age 61.2 (8.6) yrs; 51M/15F; FEV1 41.9 (13.9)% C; n = 22; age 58.4 (6.7) yrs; 20M/2F; FEV1 46.9 (15.1)%	RCT PEDro: 5	I – Hospital-based supervised exercise training C – No intervention	Baseline (T0), Day 8 + Day 10 (T1)	0%	TriTrac-R3D accelerometer. Activity counts
Berry (35) 2003	Recruitment: Mass mailings, advertising and referral I1; n = 70; age 68.4 yrs (95% CI = 67.0-69.8); 39M/31F; FEV1 57.6% (95% CI = 53.2-62.0) I2; n = 70; age 66.9 yrs (95% CI = 65.5-68.3); 39M/31F; FEV1 59.1% (95% CI = 55.0-63.2)	RCT PEDro: 6	I1 – Long-term exercise programme I2 – Short-term exercise programme	Baseline (T0), Mth 3 (I2–T1), Mth 9, Mth 15, Mth 18 (I1–T1; I2–T2)	I1–11% (n = 8/70); I2–20% (n = 14/70)	PASE questionnaire. PASE scores outside of centre-based training only
Cohort Studies
Moy (36) 2012	Recruitment: Hospital n = 27; age 72 (8) yrs; 27M; FEV1 55 (16)%	Cohort study CASP: 5	Internet & pedometer walking programme	Baseline (T0), Mth 1, Mth 2, Mth 3 (T1)	11% (n = 3/27)	Omron HJ-720ITC pedometer. Step counts
Moy (37) 2010	Recruitment: Hospital n = 24; age 56 (7) yrs; 13M/11F; FEV1 NR	Cohort study CASP: 5	Internet and pedometer walking programme	Baseline (T0), Week 16 (T1)	33% (n = 8/24)	Omron HJ-720ITC Enhanced pedometer. Step counts
Wewel (38) 2008	Recruitment: Hospital n = 21; age 65 (9) yrs; 17M/4F; FEV1 32.3 (9.4)%	Cohort study CASP: 5	Telephone-controlled home-based training	P1 (T0), P2 (T1)	19% (n = 4/21)	ActiTrac activity monitor and Kasper & Richter GmbH & Co. pedometer. Activity counts; pedometer readings
Nguyen (39) 2005	Recruitment: I1a – Pulmonary practices, support groups, PR site, internet; I1b – Previous programme participants n = 16; age 69.1 (7.0) yrs; 8M/8F; FEV1 36 (NR)%	Cohort study CASP: 5	Internet DSMP intervention	Baseline (T0), Week 12 (T1)	30% (n = 7/23)	Exercise self-report survey. Frequency and duration of endurance, strengthening and stretching exercises for a typical week during the last 4 weeks.

Abbreviations – 95% CI: 95% Confidence interval; CHAMPS: Community Health Activities Model Program for Seniors physical activity questionnaire; C: Control; DSMP: Dyspnoea Self-Management Programme; EE: Energy Expenditure; F: Female; M: Male; FEV1: Forced expiratory volume in one second; I: Intervention; METs: Metabolic Equivalents; Min: Minutes; Mth: Month: MOBILE; Mobilising Support for Long-term Exercise programme; m/s²: Metres per second squared; n: number; NR: Not reported; P1: 2-week baseline period; P2: 2-week intervention period; PA: Physical activity; PASE: Physical Activity Scale for the Elderly; PR: Pulmonary rehabilitation; RCT: Randomised controlled trial; RT: Randomised trial (no control); T0: Baseline assessment; T1: Post-intervention follow-up period (short-term); T2: Last follow-up period after T1 (long-term); VMU: Vector Magnitude Units; yrs: Years of age

*Baseline characteristics of all randomised participants.

**Baseline characteristics of completed participants only.

Table 3.  Number of behaviour change techniques used across the 31 interventions

Behaviour Change Technique	Number	Behaviour Change Technique	Number
Information on where and when to perform the behaviour (20–27,29–32,34–38)	26	Prompt rewards contingent on effort/progress towards behaviour (22)	1
Instruction on how to perform the behaviour (20–27,29,31,32,34–38)	22	Demonstrate the behaviour (36)	1
Prompt self-monitoring of behaviour (20,22,23,24,26,28,29,30,31,32,33,36,37,39)	18	Environmental restructuring (31)	1
Goal setting (behaviour) (20,22,26,27,28,29,30,31,33,36,37,39)	15	Information about others’ approval	0
Set graded tasks (24–26,28,31–33,36,37)	12	Normative information about others behaviour	0
Facilitate social comparison (24–27,32,35,37)	11	Goal setting (outcome)	0
Prompt practice (20–22,24,26,30,31,38)	11	Action planning	0
Use of follow-up prompts (20,23,24,26,30,31,39)	10	Prompt review of outcome goals	0
Plan social support/social change (20,26,29–31,36,37,39)	10	Provide rewards contingent on successful behaviour	0
Provide feedback on performance (20,22,29,30,35–37,39)	10	Shaping	0
Prompt self-monitoring of behavioural outcome (20,29,30,39)	7	Prompting focus on past success	0
Prompt review of behavioural goals (22,24,26,28,33,36,39)	7	Agree behavioural contract	0
Motivational interviewing (20,28,30,33)	6	Prompt identification as a role model	0
Barrier identification/problem solving (29,31,36,37,39)	5	Prompt anticipated regret	0
Prompting generalisation of a target behaviour (21,26,31,33,38)	5	Fear arousal	0
Stress management/emotional control training (20,30,39)	5	Prompt self-talk	0
Information on individual consequences of behaviour (24,31,36)	4	Prompt imagery	0
Teach to use prompts/cues (22,26)	2	Time management	0
Relapse prevention/coping planning (28,31)	2	General communication skills training	0
Information on general consequences of behaviour (20)	1	Stimulate anticipation of future rewards	0

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