COPD and Exercise: What's Really Important? A Nursing Perspective

Abstract

Numerous studies demonstrate the importance of exercise training to improve endurance in patients with chronic obstructive pulmonary disease (COPD) and its positive effect on activities of daily living and quality of life. However, successful care of the individual with COPD also relies on recognizing that this person requires individualized care and non-pharmacologic modalities specific to their needs in order to cope with the various aspects of their disease. It is also important to note that improvement in quality of life is not necessarily related to improvement in exercise endurance alone. Comprehensive and effective pulmonary rehabilitation for the COPD patient needs to encompass several components to provide benefit for the spectrum of symptoms of COPD beyond exercise tolerance and dyspnea to ultimately improve quality of life.

Keywords::

• COPD
• Exercise
• Anxiety
• Activities of daily living
• Quality of life

INTRODUCTION

Much has been written about the importance of exercise training in patients with chronic obstructive pulmonary disease (COPD) and its effect on activities of daily living (ADLs) and quality of life. There are numerous studies that demonstrate convincingly that pulmonary rehabilitation in many settings, using various protocols and strategies, increases exercise tolerance and improves functional status and health-related quality of life ([1], [2], [3], [4], [5]). Success in the care of patients with COPD, however, is less dependent on exercise modalities than on the recognition of the patient as a person–one who needs help to cope with the various medical and social stressors that accompany the disease.

It is known that lung function does not improve and that the course of the disease remains progressive despite optimal therapy and pulmonary rehabilitation. What can be altered, however, are the patients' attitudes and adaptability to the disturbances in ADLs and quality of life produced by the symptoms. Indeed, the ability of patients to successfully adapt is a major determinant of their quality of life. The nurse, in partnership with the physician, the patient and other health-care team members, has the unique skills to bring about this adaptation. Going beyond the medical approach of diagnosis and pharmacologic symptom management, nurses provide patients with the tools to adapt and to manage their illness appropriately.

Impact of COPD

Early in the course of the disease, the individual with COPD is unaware of the seriousness of the intermittent symptoms of cough, fatigue and dyspnea, and usually attributes shortness of breath to weight gain or aging. The slow and insidious decline in functional performance eventually results in the need to make significant changes in lifestyle, work, social and family life. Each aspect of coping with the disease presents a new challenge to overcome. Thus, the need to adapt ultimately becomes inevitable. The disease is often perceived by others as self-inflicted and irreversible, conveying a sense of despair and treatment futility. Loss of income, spousal concerns (e.g., grief, anger, resentment, abandonment, pity) often accompanied by role reversal, as well as a sense of impending mortality are among the weighty psychosocial stressors. The manner in which patients adapt to these stressors frequently determines their health-related quality of life. The nurse provides the patient with strategies to improve self-confidence and sense of control.

• Anxiety and depression

  In patients with severe COPD, anxiety and fear of dyspnea become the patient's daily companions ([6]) and the most commonly reported emotional consequence associated with COPD is depression ([7], [8], [9]). The reported prevalence of depression ranges from 7–42% ([9]) with reported levels being much higher (75%) in patients with severe oxygen-dependent disease ([10]). Depression is difficult to recognize in routine clinical practice because symptoms are frequently attributed to the disease and overlooked. It is also woefully under-treated because it is seen as an inherent part of COPD. The reported prevalence of anxiety is also considerable, with 33% of patients suffering from moderate to severe anxiety and 41% having panic disorder ([11], [12]). Depression and anxiety have major significance in that they affect patient functioning at multiple levels. The fatigue, lethargy, mental confusion, difficulty concentrating and following instructions often affect adherence to the medical plan as well as preventing participation in exercise ([4]). When the patient's depression and anxiety are addressed and treated, the many sequaelae listed above are minimized. If not addressed, the ability to adapt is severely limited.

• Other neuro-psychological and emotional sequelae

  Irritability, frustration, aggressive behavior, guilt and hopelessness are other commonly observed sequelae of COPD ([13], [14]). Sexual dysfunction is also well documented in both men and women with COPD, closely linked with cardiopulmonary dysfunction, psychogenic impotence and hypoxemia ([13]). At the same time, cognitive decline secondary to aging and hypoxemia adds to the problems. These emotional and neuro-psychological responses to the disease contribute significantly to the morbidity.

  Activity avoidance because of the depression, anxiety, dyspnea and fatigue lead to muscle weakness and deconditioning which, in turn, make future attempts at activity even more frightening. This cycle of worsening dyspnea and inactivity often result in feelings of anxiety, uselessness and of being out of control. It is not surprising that an anxiety/dyspnea cycle develops and contributes to inactivity and overall disability. In fact, many individuals live in what is described by Dudley as an “emotional straightjacket,” fearful that laughing, crying or an angry outburst will bring on fits of coughing, wheezing or dyspnea.

  As with other chronic illnesses, successful adaptation is characterized by an active, engaging coping style with a positive, yet realistic, outlook. A number of psychosocial assets have been described which help with coping: adequate financial resources and housing, social support, a vital interest in life, congeniality, and the ability to cope with modifications in the environment ([14]). Although adaptation is most successful in patients who present with these positive assets, when significant support is afforded those with fewer assets, positive results can still be achieved. Taking care not to encourage excessive patient dependency, several crisis management strategies listed in Table 1 may provide benefit to these patients.

  Table 1 Crisis management interventions

  • Conveying empathy through active listening

  • Calming exercises (e.g., breathing techniques)

  • Panic control techniques

  • Offering anticipatory guidance re: upcoming stressors

  • Assisting with problem solving

  • Identifying resources and support systems

  • Mental health providers

  • Social service agencies to help with financial concerns

  • Pastoral services

  • Community-based support groups

• Effect of co-morbid conditions and polypharmacy

  In a recent survey, people with COPD were found to also have an average of 4 co-morbid conditions with which they must contend. They consumed at least 5 different prescription medications daily as well as 3 over-the-counter remedies for “non-disease symptoms” (e.g., sleep, pain, allergy) ([15]). Indeed, it is not unusual for many patients to be taking 16 different medications, often from 3 to 5 different prescribers 16). Failure to manage the treatment regimen is reported in 25–60% of all elderly who take care of their own medications ([17]). With each increase in the number or doses of medication, costs increase, adherence decreases, and the risk of adverse drug effects and drug interactions multiplies ([18]).

  The risk of adverse drug effects is reported at 13% for 2 medications, 58% for 5 medications and 82% for 7 or more medications ([18]). Polypharmacy has indeed become a formidable burden on patients and the health-care system. Exercise and ADL training must often be adapted to take into account the various co-morbid conditions. This can be done by incorporating alternative training modalities, energy conservation and work simplification techniques. The nurse is also an advocate for the patient in helping to simplify the medication regimen in collaboration with the PCP, in educating the patient about their medication, and in seeking payment sources for those patients unable to afford them.

  In view of the complexity of issues above, the approach to therapy cannot simply be a biomedical or pharmacologic one alone. The disability (reductions in functional performance and quality of life) resulting from COPD is, indeed, multifaceted (depicted in Figure 1) and requires a multidisciplinary approach to adequately address these multiple problems.

  Figure 1 Impact of chronic respiratory disease on disability. (Originally published by Dr. Mike Morgan; permission obtained.)

  

Improvement in exercise, adls and quality of life: what affects what?

Patients with moderate to severe COPD demonstrate significantly less spontaneous physical activity when compared with healthy controls ([20]). This translates into restrictions affecting personally important activities to patients. In order to improve the patient's activity level and therefore their quality of life, many factors must come into play. It is important to note that improvement in quality of life is not related to improvement in exercise endurance alone. In 1 study, change in 12-minute walking distance was compared with changes in 4 quality-of-life dimensions (as measured by Guyatt's Chronic Respiratory Disease Questionnaire) ([21]). In 44 patients with advanced COPD (FEV₁ 1.01 ± 0.56) completing a 6 week outpatient pulmonary rehabilitation program, there was a 37.6% increase in exercise endurance and a 35.9% increase in quality of life, but there was no significant association between changes in the 12-minute walking distance and change in either the quality-of-life score or any of its 4 dimensions ([22]).

This lack of relationship may seem surprising until one considers the many self-management techniques that are taught during pulmonary rehabilitation programs that improve dyspnea, fatigue, emotional function and the sense of disease mastery, all dimensions in Guyatt's questionnaire. For example, by learning effective secretion clearance techniques, self-confidence in social and work-related activities increases. Incorporating pursed lip breathing and panic control techniques into daily activities can improve self-care, and stress is often reduced. These improvements indirectly stem from improved self-efficacy, coping strategies and task –associated dyspnea–all of which can occur in pulmonary rehabilitation ([19]). Multiple strategies to improve both self-efficacy and exercise adherence have been widely used in managing chronic disease and are listed in Table 2.

Table 2 Strategies to improve self-efficacy and exercise adherence (the more used, the more likely to succeed¡)

• Set personally important, realistic and measurable goals withpatients

• Tailor the exercise to the individual's goals

• Encourage use of logs or diaries to keep tract of improvement

• Review progress on a pre-set, regular basis

• Provide praise for both attempts and accomplishments

• Mutually brainstorm solutions to threats to compliance

• Provide skill training (e.g., using pursed lip breathing while climbing stairs) and monitor patient's ability to do it

• Supply opportunities for vicarious learning

• Help enlist a partner for social support

• Maintain regular telephone contact for questions, support, and problem-solving

• Set up a system of reminders to keep up with daily goals (e.g., keeping exercise clothes/gear in a prominent place)

Among the many factors affecting improvement in exercise, ADLs and quality of life, the trust relationship between the provider and the patient is perhaps among the most important. This relationship entails a mutual giving and receiving of feedback and may enhance or impair adherence. In a climate of shared responsibility, dignity and respect, best adherence is achieved. Motivation is also needed to change behavior. Three components contribute to the patient's motivation to change: (a) perceived severity of the health condition, (b) perceived benefits outweighing the barriers to change and (c) a cue to action (often a severe exacerbation) ([23]). Sparking motivation in the reluctant patient is often best accomplished when the patient to provider trust relationship is strong. For example, when a patient asks how he can possibly participate in an exercise program when he can't even walk to the bathroom, the nurse might (on the spot) show the pacing and breathing techniques to accomplish this and then do it with him¡ This demonstration of belief in the patient and the technique is key to a successful intervention.

Pulmonary rehabilitation (PR): Influence on exercise ability, functional performance and quality of life

Exercise is foreign and frightening to the majority of COPD patients. Dyspnea and fatigue must first be addressed before exercise training can be initiated. Different components of PR appear to modify specific aspects of physiologic and psychologic functioning related to dyspnea and exercise ([24]). Those components of PR that likely alter the central perception of dyspnea include: education, desensitization to exercise stimulus ([25]), optimizing pharmacologic therapy, and cognitive-behavioral strategies. Oxygen therapy, anxiolytics, and pursed lip breathing are thought to decrease central drive.

The use of vibration, fans and inhaled therapies is believed to alter pulmonary afferent information. Improvement in inspiratory muscle function can be achieved by better nutrition, inspiratory muscle training, positioning, and less steroid use. A reduction in airway resistance is achieved via drug therapy, correct use of delivery devices and secretion clearance strategies. Active COPD self-management is a major goal of pulmonary rehabilitation professionals. The therapies and strategies used in a comprehensive program encourage the required behaviors ([26]) listed in Table 3 to promote self-management success.

Table 3 Required behaviors for active self-management

• Adequate coping

• Adherence with medication

• Attention to changes in disease severity

• Effective MDI/DPI technique

• Self-adjustment of medication during exacerbation

Improvement in functional performance is another major focus of PR. An important treatment outcome in PR is an increase in functional reserve, determined by patients having “fewer symptoms and greater tolerance levels for intermittent performance demands” ([27]). Functional performance is impaired by anxiety and depression in COPD patients ([28]).

Pulmonary rehabilitation has been shown to benefit anxiety and depressive symptoms as well as exercise tolerance, dyspnea and health-related quality of life ([29]). In a randomized trial of exercise, education and stress management among patients with COPD, Emery was able to show that the group in the arm that included all three components improved endurance, reduced anxiety and improved cognitive performance better than the education/stress management or waiting list groups ([30]). Guell and colleagues ([4]) showed that pulmonary rehabilitation decreased psycho-social morbidity even when no specific psychological intervention was included in the program. Improvements in aerobic fitness have also been shown to improve gains in cognitive performance after an exercise intervention ([31], [32]). Patients with depression and anxiety at program entry also responded well to PR. The most positive outcomes are reported when patients with difficult psychosocial problems are treated using a multidisciplinary approach ([33], [34], [35]).

It is important to reinforce that PR is not simply a brief program with a beginning and an end, but that it is a commitment to a lifestyle change. If long-term improvement is to be maintained, adherence to exercise must be continued. Ongoing, intermittent reinforcement is needed if exercise gains are to be maintained ([1]).

CONCLUSION

As health-care providers, we frequently underestimate the impact of chronic illness on our patients with COPD. In a society that emphasizes doing and not just being, it is important for our patients to maintain the highest level of functioning. Successful outcomes will most likely occur when the pulmonary rehabilitation team designs a plan with each individual patient, taking into consideration their unique personal goals as well as their life and health-related circumstances ([36]). PR may be a useful strategy for treating depression and anxiety symptoms, as well as cognitive slowing in older patients with COPD. The non-pharmacologic treatment of COPD requires multiple modalities (in addition to exercise) to improve functional capacity and quality of life. Patients who complete PR feel better, know more, cost less, and demand less.