Activities of Life: The COPD Patient

Abstract

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive and debilitating disease. With worsening disease, a COPD patient will progressively become less physically active, will have reduced social contacts, and this will create a downward vicious circle. This review discusses the significant sequelae of physical inactivity in the COPD patient, approaches to assessment and management, and the impact of COPD exacerbations on the activities of daily life. Patients with COPD are markedly inactive in daily life. Referral to pulmonary rehabilitation and self-management education to promote increase physical activities should be an important part of the management of COPD. Acute exacerbations in COPD patients are severely distressing events that impact greatly on health status, loss of symptom control and functional state with limitation on activities of daily living. If we are to progress in the treatment of acute exacerbation of COPD, it is evident that the effects of interventions on activities of daily living should be considered as an essential component of our goal of treatment.

Keywords:

• COPD
• Chronic Obstructive Pulmonary Disease
• daily activity
• respiratory
• exercise

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness ([1]) that is both preventable and treatable ([2], [3], [4], [5]). Clinical symptoms such as cough, sputum production and dyspnea are used to guide the diagnosis of COPD that needs to be confirmed by spirometry ([2], [3], [4], [5]). Dyspnea is the most important symptom that COPD patients experience and this can have a major impact on their daily lives ([6], [7], [8]). As patients with COPD progress on the continuum of decline, dyspnea with exercise intolerance eventually result in physical deconditioning, activity limitations and reduced social contacts, creating a vicious downward spiral ([9]). COPD treatment goals include to alleviate symptoms, to improve exercise tolerance, physical activity of daily living and quality of life ([2], [3], [5], [10]).

The classic definition of “physical activity” is the execution of a task or action by an individual; activity limitations are the difficulties an individual may have in executing activities ([11]). Common categories include occupational, household, leisure time or transportation. Leisure time activity can further be subdivided into categories such as recreational activities, sport and exercise training. Exercise is a subcategory of physical activity, and is defined as planned, structured and repetitive bodily movement with the purpose of improving or maintaining one or more components of physical fitness.

Physical inactivity in daily life plays an important role in terms of disability and mortality. It is also established that regular physical activities can protect against several diseases ([12]). There is an increasing interest in assessing physical activity in COPD as inactivity has been found to be an important predictor of risk of hospitalization and mortality ([13]). There is also increased interest in this area because physical activity is recognized as an important health behavior in terms of benefits in quality of life and survival in patients with COPD ([14]). Recently, regular exercise has also been reported to modify smoking related lung function decline and to reduce the risks of developing COPD ([15]). Therefore, assessing time spent in physical activity during daily life should be considered important for the clinical management of patients with COPD and for assessment of overall disability.

This article provides a review of activity limitations in COPD including the impact of acute exacerbations, measurements of physical activity, and interventions that improve daily activities. This overview will put in perspective the need for assessment of physical activity and intervention research on physical activity in COPD.

COMPONENTS OF THE DISABILITY EXPERIENCE

The hallmark of COPD is exercise intolerance that often develops in a slow and subtle manner. Reduced exercise tolerance has been studied and it is ascribed to a complex interaction between ventilatory, cardiovascular and peripheral muscle abnormalities ([16]). This links disease only to the classic associations of functional impairments and structural abnormalities, but not to activity limitations and participation in varied aspects of life. According to the World Health Organization's International Classification of Functioning, disabilities and health ([11]), disablement should be seen as a complex interrelationship between the health condition and contextual factors, such as environmental and personal circumstances. There is a dynamic interaction among these factors: interventions at one element level have the potential to modify other related elements.

Figure 1 demonstrates the contextual factors, such as environmental and personal circumstances, that form the framework for the disability and determine the extent of the person's participation in his or her surroundings. Environmental factors are extrinsic to (outside of) the individual (e.g., the attitudes of the society, architectural characteristics, the legal system). In contrast, personal factors have an impact on how disablement is experienced. They include gender, age, other health conditions, fitness, lifestyle, habits, upbringing, coping styles, social background, education, profession, past and current experience (past life events and concurrent events), overall behavior pattern and character style, individual psychological assets and other characteristics which may play a role in the experience of disablement. Thus it is necessary to move beyond the narrow perspective of disease that is based largely on the physiological components of functional impairments and structural abnormalities. Rather, the WHO model suggests a broader, more complex assessment of the individual's specific life circumstances, which will profoundly influence activity limitations and participation in many aspects of life.

Figure 1 The biopsychosocial model proposed by the World Health Organization International Classification of Functioning, Disability and Health. Source: World Health Organization, International classification of functioning, disabilities, and health: ICF. 2001: Geneva ([11]).

ASSESSING ACTIVITY LIMITATIONS

There are a number of available tools for assessing activity limitation. Choice of measurement instrument depends upon the intended use for the data. When an evaluation is carried out in a supervised setting, the environment is standardized to such an extent that it will neutralize the impact of the immediate environment diversity on the individual's ability to perform specific tasks. Assessment of an individual's capacity, as measured by various testing procedures such as field and laboratory exercise tests, will reflect the environmentally adjusted ability of the individual in a specific domain.

Examples of such tests commonly used to measure outcomes within the context of clinical trials include the 6-minute walking test, shuttle test, and cardiopulmonary exercise testing. Such tests, tell us what an individual is capable of doing. However, these tests do not provide any measure of what an individual is doing in his or her daily living environment, where he or she may engage in structured exercise, occupational, recreational and household activities. A study subject may have the capacity to do an exercise test but within the uncontrolled environment of daily life, a multitude of factors can impinge upon patient performance.

Recently, it has been demonstrated that the intensity and amount of activity a COPD patient undertakes at home gives rather different results from those predicted by more conventional measurements such as walking distance, muscle strength and health status questionnaires ([17]). Thus, clinical trials of COPD are not necessarily measuring patient-centered outcomes because the tests used to activity limitation cannot bridge the gap between patient capacity to exercise and living environments, nor can they assess the impact of environmental and psychological changes on activity performance. For example, a patient who experiences an exacerbation may lose confidence in his ability to perform physical activity, and therefore become unnecessarily restricted.

Activity measurements in daily life are mostly investigated with questionnaires or direct measurement with motion sensors. A careful overview of the strengths and limitations of all available techniques is essential before making the choice of an appropriate assessment method. Table 1 shows an overview of the methods used to measure physical activity.

Table 1 Methods of measuring physical activity

	Self-report instruments		Motion sensors
	PA record (diaries & logs)	Questionnaires	Pedometer	Accelerometer	Heart rate monitor
Advantages	-Easy to use and cheap for large scale epidemiological studies		-Direct measuring human movement		-Small unit -Low cost -Easy to use -Storage capacity (days)
	-Provide details PA in everyday life -Bouts of PA can be quantified -Recalling on a short period (days, weeks)	-Most comprehensive -Reflect the volume of PA (freq., intensity, duration) and type (occupational, recreational, etc) -Can estimate EE	-Small device -Low cost	-Large memory capacity (weeks) -Temporal information -Assess the volume of PA (freq., intensity, duration) -Can estimate EE -Reliability and validity fairly good
Constraints	-Prone to misrepresentation: • socially desirable responding • difficulty recalling the time and intensity of PA -Procedure of PA record may influence subjects to change their PA habits		-Only walking related activities are recorded -No distinction can be made between walking, running and climbing stairs -Can't assess effort or EE -No temporal information (don'tstore data) -Low level of accuracy at very low or high walking speed	-High cost -May cause discomfort over long period of time -May need frequent quality control -Under prediction EE for upper body movements	-Other factors than PE can cause change in the HR -Calibration curve based on simultaneous measurement HR and VO2
	-Intensive effort -High level of resource to data entry -Not provide accurate estimate of EE	-Implementing cost -quality control -Processing data -Burden imposed on subjects

*Methods of direct and indirect calorimetry, and direct observation are not presented.

PA = physical activity; EE = energy expenditure.

Questionnaires

Most of the questionnaires that have been used in clinical trials and program evaluation are health-related quality of life questionnaires (PFSDQ-M, SGRQ, SF-36). They have been validated in populations of patients with chronic lung disease such as asthma and COPD. These questionnaires primarily focus is to assess health status according to important domains, including information on patients' physical function. These questionnaires are not providing view of physical activities in the patient's daily life neither they are assessing the amount and intensity of physical activity. This is a significant gap in the current medical literature.

Questionnaires measuring specifically physical activities are available ([18], [19]). Many of these physical activity questionnaires measure sporting and/or occupational physical activity, and are not appropriate for the target population of the general elderly or chronic disease such as COPD. There are questionnaires that have been developed or adapted to be used in the elderly such as the Baecke Physical Activity Questionnaire) ([20]), the Physical Activity Scale for the Elderly (PASE) ([21]) the Zutphen Physical Activity questionnaire (ZPAC) ([22]), and the Community Healthy Activities Model Program for Seniors (CHAMPS) ([11], [12]). Except with the CHAMPS for which there has been a preliminary cross-sectional study in COPD patients that has provided preliminary evidence of the questionnaire's validity ([12]), none of these questionnaires have been validated specifically in the chronically disabled population of COPD patients. Therefore, it is not possible to judge of the comprehensiveness and the applicability of these questionnaires in the specific population of COPD.

Care must also be taken when using these questionnaires (Table 1) ([19]). Patients tend to overestimate the extent of their daily activity and report fewer physical limitations than they actually experience. In a recent European study, outcomes from video recordings were compared with patient estimation of time spent walking, cycling, standing, sitting, and lying ([23]). The study demonstrated large disagreement between video recordings and patients' estimations ([23]). Although population studies about physical activity is likely to contain errors of overreporting, there is no other feasible way to estimate physical activity pattern of a population.

Motion sensors

Great attention has recently been given to the direct measure of daily activities using motion sensors. There are several types of motion sensors that range in complexity and cost, from pedometers (step counters) to uniaxial and triaxial accelerometers (accelerometer detectors) (Table 1). For additional information, the reader is referred to the review by Pitta et al ([19]).

THE BURDEN OF COPD ON ACTIVITIES OF DAILY LIFE

The Confronting COPD International Survey was an international survey of nearly 205,000 international households whose objective was to quantify morbidity and burden in COPD subjects. Survey components included the American Thoracic Society respiratory symptoms questionnaire, plus additional questions on health care use and activity limitation. From a total of 201,921 households screened by random-digit dialing in the USA, Canada, France, Italy, Germany, the Netherlands, Spain and the UK, 3,265 subjects with a diagnosis of COPD, chronic bronchitis or emphysema, or with symptoms of chronic bronchitis were identified ([24]). This international survey confirmed the great burden to society, high individual morbidity and activity limitations associated with COPD in subjects in Europe and North America ([24]). Respiratory conditions limited daily life activities in respondents' of all ages. One-fifth of patients reported that they were breathless even when just sitting or lying still, and 24% when talking. One-third said they were breathless when doing light housework or while getting washed or dressed, and nearly 70% were short of breath when walking up a flight of stairs ([24]). The potential impact of COPD on patients' lifestyle and quality of life was illustrated even more graphically by this survey when respondents were asked which aspects of their daily lives were limited by their condition (Figure 2).

Figure 2 Impact of COPD on lifestyle and quality of life. Source: Rennard S, Decramer M, Calverley PM, et al., Impact of COPD in North America and Europe in 2000: subjects' perspective of Confronting COPD International Survey. Eur Respir J 2002; 20:799–805 ([24]).

It is clear from these data that COPD is associated with a considerable burden of disease, affecting many things that are fundamental to everyday life, such as the ability to breath, talk, sleep, work, and socialize. This has been confirmed in an objective analysis of the impact of COPD on activities of daily living using the multiaxial accelerometer, Pitta and colleagues found that patients with COPD are markedly inactive in daily life (Figure 3) ([25]). COPD also has significant extrapulmonary effects that may contribute to its severity in individual patients ([26]). Reduction in physical activity may be explained by the extrapulmonary effects of COPD and its comorbidities. It has recently been demonstrated that reduced physical activity in patients with COPD is associated not only with clinical stages of COPD severity but also with left heart dysfunction and systemic inflammation ([27]).

Figure 3 COPD patients are markedly inactive in daily life. Source: Pitta F, et al. Am J Respir Crit Care Med 2005; 171:972–977 ([25]).

Patients with COPD don't have limitation in their activities only in household and leisure but also in occupational time. Many patients with COPD are of working age, so even in the early stages of the disease, the breathlessness and fatigue caused by COPD reduce the ability of the patient to go to work or carry out their normal work activities. Patients with COPD included in the 1987 US National Medical Expenditure Survey reported an average of one day of absence from work and 16 restricted activity days due to COPD ([28]). In a survey of adults in California, those with COPD were less likely to be in current employment than those with asthma, other chronic conditions or no chronic conditions ([29]).

Qualitative research has taken a different but complementary approach to quantitative research, exploring what really matter to patients living with COPD. The qualitative studies are also important because they provide insight into the importance of engagement with activity on a physical and social level. Patients with COPD have been reported to experience difficulties with many activities such as walking ([8], [30]), meal-related situations ([31]) and body care activities ([32]). Activities such as walking and household maintenance were found to be most important to patients not just as activities, but because of what they attribute to the activities. These activities are perceived as an important component of their lives, allowing them to participate in life, maintain a sense of their former roles and keep their independence ([8]). Feelings of social isolation also emerged from all patients studied. Finally, early retirement due to COPD contributes to perceptions of feeling isolated and alone.

COPD EXACERBATIONS AND ACTIVITIES OF DAILY LIFE

Exacerbations of COPD are a major cause of morbidity, mortality and hospital admission ([33], [34]). Some patients are particularly susceptible to developing frequent exacerbations, an important determinant in health-related quality of life ([33], [34], [35]). Studies have demonstrated that exacerbations are associated with short- and long-term consequences on health status ([36], [37]). The downward spiral of more frequent exacerbations can lead to decline in lung function; greater anxiety; worsening quality of life; social withdrawal; more exacerbations; and increased risk of hospitalization and mortality ([2], [33], [34], [35], [38], [39], [40], [41], [42]). As frequent exacerbations are associated with a faster long-term decline in lung function, it has also been suggested that prevention of exacerbations might slow disease progression ([38]). In addition, a reduction in the frequency or severity of exacerbations offers an obvious means of reducing demand on the healthcare system.

Of particular note in the existing medical literature, however, is the lack of reports identifying the impact of exacerbations on activities of daily living and physical activities. A recent study has demonstrated that exacerbation clearly impacts on the functional state of patients, and markedly restricts physical activities ([43]). Based on a linear regression extrapolation, most of the variables of health status and symptoms returned to baseline after 14 days except for activities of daily living (18 days) and mental state (39 days) that took longer ([43]). Preventing exacerbation and improving the prognosis should represent a key treatment goal in COPD.

Guidelines ([2], [3], [10]) have emphasized the importance of regular therapies such as long-acting anticholinergics, inhaled corticosteroids, and combination therapy to prevent an acute exacerbation. However, intervention studies should not only focus on preventing exacerbations as it may help to slow down the progression of the disease but also to consider other issues that are of concern to the patient. Interventions such as self-management with an action plan should also focus on helping patients resume activities following exacerbations by and on maintaining an ongoing exercise program, with an emphasis on ongoing support and promotion of self-efficacy. This has to be part of a continuum of care that incorporates not only teaching various disease contents but also implementing strategies to change and maintaining specific behavior in patients.

MANAGING COPD TO IMPROVE DAILY ACTIVITIES

The benefits of pharmacological and non pharmacological treatments in COPD have been established based on measurement of traditional outcomes such as improvements in lung function, exercise capacity, exacerbations, health resource utilization and mortality. In the last decades, there has been an interest in assessing the benefits of treatment on patient centered outcomes with the main focus on health status.

The long-acting anticholinergic tiotropium bromide has been shown to have more sustained effects on pulmonary function, activity-related dyspnea and quality of life compared with regular dose ipratropium bromide (40 μ g 4 times daily) or placebo in patients with moderate to very severe COPD ([44]). The TORCH study ([45]) also demonstrated that the treatment with SALM/FP significantly improved exacerbation reduction, lung function and health status in comparison with the placebo group as well as with the SALM and FP groups alone. The Optimal Therapy study ([46]) did not show that the addition of SALM/FP to tiotropium significantly improved overall exacerbation rates, but significant benefits were demonstrated on secondary outcomes lung function, quality of life and hospitalization rates.

Recently, the UPLIFT study showed that long-acting anticholinergic tiotropium bromide had lung function benefits, positive effects on health-related quality of life and reduced risk of exacerbation in patients who were receiving other classes of respiratory medications ([47]). None of the studies have assessed treatment benefit with respect to improve daily activities. However, more recent COPD Guidelines ([3], [4]) recommend a more intensive comprehensive management strategy in patients who are more disabled.

Pulmonary rehabilitation is now recognized as an essential intervention in managing patients with COPD. The efficacy and scientific foundation are both firmly established ([48]). Results consistently show improvement in dyspnea, functional capacity, and quality of life in patients with COPD. The increase in functional capacity following training of large muscle groups has been related to peripheral muscle physiological adaptations; the degree of improvement being proportional to the training intensity. However, exercise-induced improvements in dyspnea, quality of life, functional capacity and mobility have also been reported following low to moderate intensity exercise training that did not result in changes in cardio respiratory function or peripheral muscle adaptations ([49]).

The model that defines disability simply in terms of biologic and physiologic components of overall health status is both simplistic and unrealistic. The biopsychosocial model proposed by the WHO to describe changes in a standard environment in terms of a patient's level of capacity and level of performance provides a coherent, multifactorial view of different perspectives of health: biologic, individual and social. Little is known about how internal personal factors, such as sex, age, disease severity, coping styles, social background, education, past experience, etc, impact disability. The impact on disability of environmental factors, such as social attitudes, legal and social structures, physical characteristics of the environment, climate, etc., is equally unclear.

Moreover, interventions should be aimed at structural behaviour change so that treatment effects do not ebb away after programs have been completed ([21]). Therefore, interventions should provide the patient with tools to deal with future problems, such as problem solving techniques.

The gap between what a patient is capable of doing and what he is doing in the daily life can be significant; this can possibly be addressed through self-management education. Not only should interventions on a physiological level be incorporated, but also interventions that are effective in achieving behaviour change. Self-management program provides the patient with tools to deal with future problems, such as problem solving techniques. It aimed at teaching skills needed to carry out specific medical regimens specific to the disease and guide health behavior change for patients to control their disease and improve their well-being ([50]).

However, to be effective (improvement of patients' well being and reduction of healthcare utilization such as hospitalizations), self-management has to be supported by a delivery system designed to provide planned chronic care (5[1]). As part of a multicenter randomized clinical trial evaluating the effect of self-management with a team including a skilled health professional “case-manager” on health status and the use of hospital services in COPD ([52]), a qualitative study was completed. Lifestyle modifications were assessed to determine which changes were beneficial ([50]). Patients reported increases in their daily living activity following self-management education (Table 2). Patients also reported that they felt more confident, secure, and better able to accept their disease following self-management education ([50]). Additional research is needed to provide further insight into health behavior change interventions in COPD that can be incorporated into the COPD treatment plan.

Table 2 Lifestyle modifications experienced by COPD patients who received a disease-specific self-management program

Lifestyle modification	COPD patients (%)
Physical condition
Learn to breathe	85
Maintain exercise	74
Walk	59
Use bicycle	44
Increase activities of daily living	74
Use relaxation techniques	63
Improve diet habits	52
Improve sleep habits	48
Psychosocial condition
Feel more self-confident	59
Feel more secure	52
Accept better their disease	52
Feel more support	48
Feel less panic	37
Feel less anxious	26

*Bourbeau J, Nault D, Dang-Tan T. Self-management and behavior modification in COPD. Patient Educ Couns 2004; 52:271–277 (50).

Some studies suggest that patient adherence to the medication treatment plan correlates with continuity of care and follow-up supervision. Explanations of the rationale underlying treatment, and the provision of positive reinforcement emphasizing the importance of therapy all favorably impacted patient adherence, as did the provision of written instruction, a stable family life, and supportive caregivers ([53], [54]). Adherence to prescribed exercise over time is another problematic area not only in COPD, but in the population at large. One study revealed that self-efficacy—a patient's perception of his or her abilities—significantly predicted exercise behavior 4 months after the termination of a formal exercise program ([55]). These findings suggest that behavioral interventions based on self-efficacy cognitions show enormous potential.

“By structuring the exercise environment in such a way that the provision of efficacy information is maximized,” the authors concluded, “exercise and fitness leaders can cultivate in participants a robust belief in exercise capabilities. Rather than a blanket reliance on exercise prescriptions as sources of exercise information, participants need to be provided with information that will boost their efficacy beliefs.” The effect of these approaches on physical activity behavior in the setting of COPD is an area of fertile research.

CONCLUSIONS

All patients should be encouraged to maintain an active lifestyle and cautioned about the negative consequences of prolonged inactivity in this disease. Patients with COPD are markedly inactive in their daily lives. Although there is no single magic bullet to address the problem, physical activity in daily life is an outcome that requires further study. While patient-centered outcomes such as quality of life and survival are important, equally important are outcomes measuring physical activity of daily living. This is a significant gap in the current medical literature. Although multiple instruments are available for measuring daily activity levels, it is important to remember that choice of assessment tool depends upon the clinician's specific question and objective in the clinical management plan.

The multifactorial issues surrounding physical inactivity should be carefully considered, and appropriate interventions incorporated into the management plan. With the availability of new inhaled medication that have been shown to improve exercise endurance by reducing hyperinflation, and with the proven efficacy of pulmonary rehabilitation, clinicians now have resources for helping patients overcome the sedentary lifestyles that contribute to the spiral of decline in COPD. These resources should be part of a global approach to patient care as recommended by the World Health Organization, with an emphasis on long term maintenance of physical activity following pulmonary rehabilitation. Furthermore, this approach has to take into account the complexity of exercise behavior. The self-management model may assist patients in acquiring skills necessary to adjust their behavior to manage their own illness and, more importantly, to gain the confidence to apply these skills on a daily basis. This should affect future research and therapeutic management practices.

Acute exacerbation can make patients severely distressed. Additional study is needed to determine the effects of exacerbations on short- and long-term health status, as well on activities of daily living. If we are to progress in the management of exacerbation of COPD, interventions that speed recovery of symptoms and return to regular activity of daily living should become criteria in the treatment of the disease.

COMPETING INTERESTS

Jean Bourbeau, MD, reports serving on the advisory board for AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Pfizer Inc. and Topigen; receiving lecture fees from AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, and Pfizer Inc.; and receiving grants/research support from AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, and Pfizer Inc.

Genevieve Belfiglio reports independently contracting with medical education, publishing, and communication agencies in the writing and development of a variety of media.

Declaration of interest

The authors report no other conflicts of interest than the preceding information. The authors alone are responsible for the content and writing of the paper.

ACKNOWLEDGMENTS

The author acknowledges the editorial assistance of Genevieve Belfiglio, MA, from Advanced Studies in Medicine, whose services were provided by Boehringer Ingelheim and Pfizer. Responsibility for the content rests with the author, who originated and developed the intellectual content and performed substantive scientific revisions. The manuscript was developed from presentations and discussions at the “Influencing the Spiral of Decline in COPD” task force, which took place in Atlanta, Georgia, on May 2–4, 2007. The meeting, authors' participation, and manuscript preparation were supported by Boehringer Ingelheim and Pfizer. Boehringer Ingelheim and Pfizer did not review or edit the manuscript except to check it for medical misrepresentation.

This article was funded by Boehringer-Ingelheim Pharmaceuticals, Inc and Pfizer Inc. The funding companies did not have any involvement in the development or writing of this article.