Publications by authors named "Anne E Holland"

270 Publications

Pulmonary rehabilitation for interstitial lung disease.

Cochrane Database Syst Rev 2021 Feb 1;2:CD006322. Epub 2021 Feb 1.

Institute for Breathing and Sleep, Melbourne, Australia.

Background: Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise-induced hypoxia. Pulmonary rehabilitation is often used to improve symptoms, health-related quality of life and functional status in other chronic lung conditions. There is accumulating evidence for comparable effects of pulmonary rehabilitation in people with ILD. However, further information is needed to clarify the long-term benefit and to strengthen the rationale for pulmonary rehabilitation to be incorporated into standard clinical management of people with ILD. This review updates the results reported in 2014.

Objectives: To determine whether pulmonary rehabilitation in people with ILD has beneficial effects on exercise capacity, symptoms, quality of life and survival compared with no pulmonary rehabilitation in people with ILD. To assess the safety of pulmonary rehabilitation in people with ILD.

Search Methods: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO) and PEDro from inception to April 2020. We searched the reference lists of relevant studies, international clinical trial registries and respiratory conference abstracts to look for qualifying studies.

Selection Criteria: We included randomised controlled trials and quasi-randomised controlled trials in which pulmonary rehabilitation was compared with no pulmonary rehabilitation or with other therapy in people with ILD of any origin.

Data Collection And Analysis: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We contacted study authors to request missing data and information regarding adverse effects. We specified a priori subgroup analyses for participants with idiopathic pulmonary fibrosis (IPF) and participants with severe lung disease (low diffusing capacity or desaturation during exercise). There were insufficient data to perform the prespecified subgroup analysis for type of exercise training modality.

Main Results: For this update, we included an additional 12 studies resulting in a total of 21 studies. We included 16 studies in the meta-analysis (356 participants undertook pulmonary rehabilitation and 319 were control participants). The mean age of participants ranged from 36 to 72 years and included people with ILD of varying aetiology, sarcoidosis or IPF (with mean transfer factor of carbon dioxide (TLCO) % predicted ranging from 37% to 63%). Most pulmonary rehabilitation programmes were conducted in an outpatient setting, with a small number conducted in home-based, inpatient or tele-rehabilitation settings. The duration of pulmonary rehabilitation ranged from three to 48 weeks. There was a moderate risk of bias due to the absence of outcome assessor blinding and intention-to-treat analyses and the inadequate reporting of randomisation and allocation procedures in 60% of the studies. Pulmonary rehabilitation probably improves the six-minute walk distance (6MWD) with mean difference (MD) of 40.07 metres, 95% confidence interval (CI) 32.70 to 47.44; 585 participants; moderate-certainty evidence). There may be improvements in peak workload (MD 9.04 watts, 95% CI 6.07 to 12.0; 159 participants; low-certainty evidence), peak oxygen consumption (MD 1.28 mL/kg/minute, 95% CI 0.51 to 2.05; 94 participants; low-certainty evidence) and maximum ventilation (MD 7.21 L/minute, 95% CI 4.10 to 10.32; 94 participants; low-certainty evidence). In the subgroup of participants with IPF, there were comparable improvements in 6MWD (MD 37.25 metres, 95% CI 26.16 to 48.33; 278 participants; moderate-certainty evidence), peak workload (MD 9.94 watts, 95% CI 6.39 to 13.49; low-certainty evidence), VO (oxygen uptake) peak (MD 1.45 mL/kg/minute, 95% CI 0.51 to 2.40; low-certainty evidence) and maximum ventilation (MD 9.80 L/minute, 95% CI 6.06 to 13.53; 62 participants; low-certainty evidence). The effect of pulmonary rehabilitation on maximum heart rate was uncertain. Pulmonary rehabilitation may reduce dyspnoea in participants with ILD (standardised mean difference (SMD) -0.36, 95% CI -0.58 to -0.14; 348 participants; low-certainty evidence) and in the IPF subgroup (SMD -0.41, 95% CI -0.74 to -0.09; 155 participants; low-certainty evidence). Pulmonary rehabilitation probably improves health-related quality of life: there were improvements in all four domains of the Chronic Respiratory Disease Questionnaire (CRQ) and the St George's Respiratory Questionnaire (SGRQ) for participants with ILD and for the subgroup of people with IPF. The improvement in SGRQ Total score was -9.29 for participants with ILD (95% CI -11.06 to -7.52; 478 participants; moderate-certainty evidence) and -7.91 for participants with IPF (95% CI -10.55 to -5.26; 194 participants; moderate-certainty evidence). Five studies reported longer-term outcomes, with improvements in exercise capacity, dyspnoea and health-related quality of life still evident six to 12 months following the intervention period (6MWD: MD 32.43, 95% CI 15.58 to 49.28; 297 participants; moderate-certainty evidence; dyspnoea: MD -0.29, 95% CI -0.49 to -0.10; 335 participants; SGRQ Total score: MD -4.93, 95% CI -7.81 to -2.06; 240 participants; low-certainty evidence). In the subgroup of participants with IPF, there were improvements at six to 12 months following the intervention for dyspnoea and SGRQ Impact score. The effect of pulmonary rehabilitation on survival at long-term follow-up is uncertain. There were insufficient data to allow examination of the impact of disease severity or exercise training modality. Ten studies provided information on adverse events; however, there were no adverse events reported during rehabilitation. Four studies reported the death of one pulmonary rehabilitation participant; however, all four studies indicated this death was unrelated to the intervention received.

Authors' Conclusions: Pulmonary rehabilitation can be performed safely in people with ILD. Pulmonary rehabilitation probably improves functional exercise capacity, dyspnoea and quality of life in the short term, with benefits also probable in IPF. Improvements in functional exercise capacity, dyspnoea and quality of life were sustained longer term. Dyspnoea and quality of life may be sustained in people with IPF. The certainty of evidence was low to moderate, due to inadequate reporting of methods, the lack of outcome assessment blinding and heterogeneity in some results. Further well-designed randomised trials are needed to determine the optimal exercise prescription, and to investigate ways to promote longer-lasting improvements, particularly for people with IPF.
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http://dx.doi.org/10.1002/14651858.CD006322.pub4DOI Listing
February 2021

Rocktape provides no benefit over sham taping in people with knee osteoarthritis who are completing an exercise program: a randomised trial.

Physiotherapy 2021 May 17;113:29-36. Epub 2021 May 17.

Physiotherapy Department, The Alfred Hospital, PO Box 315, Prahran, VIC, 3181, Australia; Allied Health, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora, VIC, 3086, Australia. Electronic address:

Objectives: To investigate if Rocktape combined with exercise is more effective than exercise and sham taping in patients with knee osteoarthritis.

Design: Single institution, prospective, participant and assessor blinded, randomised study.

Setting: Outpatient physiotherapy department of a tertiary hospital.

Participants: Thirty-six patients with knee osteoarthritis.

Intervention: Participants were randomised to either; 1) Rocktape plus exercise or 2) sham taping plus exercise.

Main Outcome Measures: A linear mixed-effect model was used to assess differences between groups over time for the primary outcome measure (VAS at rest and movement) as well as the secondary outcome measures. Secondary measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS), 30second sit to stand, 40m walk and stair climb tests. Exercise adherence and analgesia use were recorded via a diary. Outcomes were assessed at baseline, immediately prior to the first tape application and immediately following first taping (both at one week after baseline), then two and five weeks after first tape application.

Results: There were no between group differences over time in pain at rest [median Rocktape group 0.035 (IQR -0.1 to 3.0) vs median sham 0 (IQR 0 to 1.6) mean adj diff (0.053, 95% CI -0.17 to 0.27)] or with movement [median tape group 2.45 (IQR -0.5 to 4.8) vs median sham 2.0 (IQR 0.8 to 4.1) mean adj diff 0.072, 95% CI -0.20 to 0.35]. There were no significant differences between groups in any of the KOOS subscales or performance-based tests administered over time. Pain on movement significantly improved over time in both groups, whilst pain at rest only improved at the final time point.

Conclusion: There was no additional benefit of Rocktape over sham tape in patients with knee osteoarthritis who were completing a home exercise program over five weeks.

Trial Registration: Clinical Trials Registry (#NCT02049216).
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http://dx.doi.org/10.1016/j.physio.2021.05.005DOI Listing
May 2021

The AWESCORE, a patient-reported outcome measure: development, feasibility, reliability, validity and responsiveness for adults with cystic fibrosis.

ERJ Open Res 2021 Jul 20;7(3). Epub 2021 Sep 20.

Monash University, School of Medicine, Prahran, Melbourne, Australia.

Background: Quality of life has improved dramatically over the past two decades in people with cystic fibrosis (CF). Quantification has been enabled by patient-reported outcome measures (PROMs); however, many are lengthy and can be challenging to use in routine clinical practice. We propose a short-form PROM that correlates well with established quality-of-life measures.

Methods: We evaluated the utility of a 10-item score (AWESCORE) by measuring reliability, validity and responsiveness in adults with CF. The questions were developed by thematic analysis of survey questions to patients in a single adult CF centre. Each question was scored using a numerical rating scale 0 to 10. Total scores ranged from 0 to 100. Test-retest reliability was assessed over 24 h. To determine validity, comparisons were sought between stable subjects and those in pulmonary exacerbation, and between AWESCORE and Cystic Fibrosis Questionnaire - Revised (CFQ-R). Responsiveness to pulmonary exacerbation in individual subjects was evaluated.

Results: Five domains, each with two questions, were identified for respiratory, physical, nutritional, psychological and general health. A total of 246 consecutive adults attending the outpatient clinic completed the AWESCORE. Scores were higher during clinical stability compared to pulmonary exacerbation (mean± sd): 73±11 48±11 (p<0.001). Each domain scored worse during an acute exacerbation (p<0.001). No differences in reliability were observed in scores on retesting using Bland-Altman comparison. The CFQ-R scores (mean±sd: 813±125) and AWESCORE (81±13) were moderately correlated (Pearson's r=0.649; p=0.002).

Conclusions: The AWESCORE is valid, reliable and responsive to altered health status in CF.
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http://dx.doi.org/10.1183/23120541.00120-2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8450462PMC
July 2021

Pulmonary Rehabilitation in 2021.

JAMA 2021 Sep;326(10):969-970

Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1001/jama.2021.6560DOI Listing
September 2021

Survival after inpatient or outpatient pulmonary rehabilitation in patients with fibrotic interstitial lung disease: a multicentre retrospective cohort study.

Thorax 2021 Aug 30. Epub 2021 Aug 30.

Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Background: The impact of pulmonary rehabilitation (PR) on survival in patients with fibrotic interstitial lung disease (ILD) is unknown. Given the challenges conducting a large randomised controlled trial, we aimed to determine whether improvement in 6-minute walk distance (6MWD) was associated with better survival.

Methods: This retrospective, international cohort study included patients with fibrotic ILD participating in either inpatient or outpatient PR at 12 sites in 5 countries. Multivariable models were used to estimate the association between change in 6MWD and time to death or lung transplantation accounting for clustering by centre and other confounders.

Results: 701 participants (445 men and 256 women) with fibrotic ILD were included. The mean±SD ages of the 196 inpatients and 505 outpatients were 70±11 and 69±12 years, respectively. Baseline/changes in 6MWD were 262±128/55±83 m for inpatients and 358±125/34±65 m for outpatients. Improvement in 6MWD during PR was associated with lower hazard rates for death or lung transplant on adjusted analysis for both inpatient (HR per 10 m 0.94, 95% CI 0.91 to 0.97, p<0.001) and outpatient PR (HR 0.97, 95% CI 0.95 to 1.00, p=0.042). Participation in ≥80% of planned outpatient PR sessions was associated with a 33% lower risk of death (95% CI 0.49% to 0.92%).

Conclusions: Patients with fibrotic ILD who improved physical performance during PR had better survival compared with those who did not improve performance. Confirmation of these hypothesis-generating findings in a randomised controlled trial would be required to definitely change clinical practice, and would further support efforts to improve availability of PR for patients with fibrotic ILD.
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http://dx.doi.org/10.1136/thoraxjnl-2021-217361DOI Listing
August 2021

Physical activity decline is disproportionate to decline in pulmonary physiology in IPF.

Respirology 2021 Aug 26. Epub 2021 Aug 26.

Lung Fibrosis Service, Department of General Respiratory Medicine and Lung Transplantation, Alfred Hospital, Melbourne, Victoria, Australia.

Background And Objective: Patients with idiopathic pulmonary fibrosis (IPF) have reduced levels of daily physical activity (DPA); however, little is known about how DPA changes as disease progresses. We aimed to (i) describe change in DPA over 12 months, (ii) analyse its association with conventional markers of disease severity and quality of life and (iii) assess DPA as a prognostic tool.

Methods: A total of 54 patients with IPF had DPA monitored at baseline and at 6 and 12 months with a SenseWear armband for 7 consecutive days. Participants completed the Hospital Anxiety and Depression scale, St George's Respiratory Questionnaire and Leicester Cough Questionnaire at each time point and provided clinical data including forced vital capacity (FVC), diffusion capacity of carbon monoxide and 6-min walk distance (6MWD).

Results: Baseline and 12-month daily step count (DSC) were 3887 (395) and 3326 (419), respectively. A significant reduction in DSC (mean = 645 [260], p = 0.02) and total energy expenditure (mean = 486 kJ [188], p = 0.01) was demonstrated at 12 months. The decline in DSC over 12 months was proportionally larger than decline in lung function. Annual change in DPA had weak to moderate correlation with annual change in FVC % predicted and 6MWD (range r = 0.34-0.45). Change in physical activity was not associated with long-term survival.

Conclusion: In IPF, decline in DPA over 12 months is significant and disproportionate to decline in pulmonary physiology and may be a useful tool for assessment of disease progression.
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http://dx.doi.org/10.1111/resp.14137DOI Listing
August 2021

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COPD 2021 Aug 23:1-8. Epub 2021 Aug 23.

Allergy, Clinical Immunology, and Respiratory Medicine, Monash University, Melbourne, Australia.

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all = 0.30,  < 0.05). Older age and more moderate-to-vigorous physical activity independently predicted greater community participation measured by CPI. Higher levels of depression symptoms were associated with less formal and informal community participation on ESS ( = -0.25). More formal community participation on ESS was weakly ( = 0.2-0.3) associated with older age, better lung function, exercise capacity and self-efficacy, and less breathlessness. Self-efficacy, exercise capacity, and age independently predicted formal community participation in individuals with COPD. Strategies to optimize self-efficacy and improve exercise capacity may be useful to enhance community participation in people with COPD.
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http://dx.doi.org/10.1080/15412555.2021.1966761DOI Listing
August 2021

Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease.

Cochrane Database Syst Rev 2021 08 17;8:CD013569. Epub 2021 Aug 17.

Physiotherapy, Alfred Health, Melbourne, Australia.

Background: Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging.

Objectives: To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme.

Search Methods: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL.

Selection Criteria: We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events.

Data Collection And Analysis: Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence.

Main Results: We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported.

Authors' Conclusions: This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear.
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http://dx.doi.org/10.1002/14651858.CD013569.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407510PMC
August 2021

Reliability, Validity, Clinical Utility, and Responsiveness of Measures for Assessing Mobility and Physical Function in Patients with Traumatic Injury in the Acute Care Hospital Setting: A Prospective Study.

Phys Ther 2021 Jul 29. Epub 2021 Jul 29.

Department of Physiotherapy, The Alfred Hospital, Prahran, Melbourne, VIC 3181.

Objective: The longer-term impact of injury is increasingly recognized, but the early phases of recovery are less well understood. The best tools to measure early recovery of mobility and physical function following traumatic injury are unclear. The purpose of this study was to assess the clinical utility, validity, reliability, and responsiveness of 4 mobility and physical function measures in patients following traumatic injury.

Methods: In this cohort, measurement-focused study (n = 100), the modified Iowa Level of Assistance Score, Acute Care Index of Function, Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" short forms, and Functional Independence Measure were completed during first and last physical therapy sessions. Clinical utility and floor and ceiling effects were documented. Known-groups validity (early versus late in admission and by discharge destination), predictive validity (using 6-month postinjury outcomes data), and responsiveness were established. Interrater reliability was assessed in 30 patients with stable mobility and function.

Results: Participants had a median age of 52 years (interquartile range = 33-68 y), and 68% were male. The modified Iowa Level of Assistance Score, Acute Care Index of Function, and "6 Clicks" short forms were quick to administer (an extra median time of 30 seconds to 1 minute), but the Functional Independence Measure took much longer (extra median time of 5 minutes). At the last physical therapy session, ceiling effects were present for all measures except the Functional Independence Measure (18-33% of participants). All had strong known-groups validity (early versus late in admission and by discharge destination). All were responsive (effect sizes >1.0) and had excellent interrater reliability (intraclass correlation coefficients = 0.79-0.94).

Conclusion: All 4 measures were reliable, valid, and responsive; however, their clinical utility varied, and ceiling effects were common at physical therapy discharge.

Impact: This study is a critical building block toward evidence-based measurement in acute trauma physical therapy care. It provides critical information to guide assessment of mobility and physical function in acute trauma physical therapy, which may facilitate benchmarking across different hospitals and trauma centers and further progress the science and practice of physical therapy following traumatic injury.
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http://dx.doi.org/10.1093/ptj/pzab183DOI Listing
July 2021

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review.

Cochrane Database Syst Rev 2021 07 26;7:CD013384. Epub 2021 Jul 26.

Physiotherapy, Alfred Health, Melbourne, Australia.

Background: Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

Objectives: To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

Search Methods: We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

Selection Criteria: Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

Data Collection And Analysis: We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

Main Results: Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

Authors' Conclusions: Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.
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http://dx.doi.org/10.1002/14651858.CD013384.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407330PMC
July 2021

Clinimetrics: Core Outcome Set for trials with Coronavirus disease 2019 (COVID-19-COS).

J Physiother 2021 Jul 14. Epub 2021 Jul 14.

Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Australia; Department of Physiotherapy, Alfred Health, Melbourne, Australia; Institute for Breathing and Sleep, Melbourne, Australia.

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http://dx.doi.org/10.1016/j.jphys.2021.06.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278377PMC
July 2021

Self-management for pulmonary fibrosis: Insights from people living with the disease and healthcare professionals.

Patient Educ Couns 2021 Jul 6. Epub 2021 Jul 6.

Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Victoria, Australia; Department of Respiratory and Sleep Medicine, Alfred Health, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Melbourne, Victoria, Australia; Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia. Electronic address:

Objective: People with pulmonary fibrosis (PF) consider self-management essential for maintaining health. This study aims to explore the needs and expectations of PF self-management from the patient and healthcare professionals (HCPs) perspectives.

Methods: Semi-structured interviews were conducted with people with PF and HCPs. Purposive sampling was used to recruit participants. Thematic analysis was performed using the principles of grounded theory.

Results: 18 individuals with PF and 15 HCPs were interviewed. Common self-management components reported included exercise, nutrition, maintaining healthy mind, avoiding infections, recognising deterioration and seeking help, managing symptoms and treatments, social support, and end-of-life planning. Both groups felt that effective self-management required individualised strategies, supports, and reliable information. People with PF identified access to personal health data and self-acceptance as part of self-management. HCPs highlighted the importance of accessible supports and managing patient expectations of disease course and treatments. Some HCPs concerned about missed detection of deterioration and suggested that self-management strategies for PF may differ to other lung diseases.

Conclusion: This study identified components important for self-management in PF and provides a basis for designing a PF self-management package.

Practice Implications: Self-management of PF can be facilitated with individualised support from HCPs and reliable information that is accessible.
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http://dx.doi.org/10.1016/j.pec.2021.07.005DOI Listing
July 2021

Essential Features of an Interstitial Lung Disease Multidisciplinary Meeting: An International Delphi Survey.

Ann Am Thorac Soc 2021 Jun 30. Epub 2021 Jun 30.

Royal Prince Alfred Hospital, 2205, Department of Respiratory and Sleep Medicine, Camperdown, New South Wales, Australia.

Rationale: The interstitial lung disease (ILD) multidisciplinary meetings (MDM) composing of pulmonologists, radiologists and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs and questions regarding its best practice remain unanswered.

Objective: To achieve consensus among ILD experts on essential components of an ILD MDM.

Methods: Using a Delphi methodology, semi structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0.

Results: We interviewed 15 ILD experts and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high resolution computed tomography and a standardized template summarising collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs.

Conclusion: This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represents a first step toward potential collaborative research into future standardisation of ILD MDMs.
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June 2021

Home-based pulmonary rehabilitation in people with bronchiectasis: a randomised controlled trial.

ERJ Open Res 2021 Apr 31;7(2). Epub 2021 May 31.

Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho, Sao Paulo-SP, Brazil.

Aim: To investigate the short- and long-term effects of home-based pulmonary rehabilitation (HBPR) on functional capacity, quality of life, peripheral muscle strength, dyspnoea and daily physical activity in people with bronchiectasis.

Methods: Randomised controlled trial with 63 participants with bronchiectasis. The HBPR group performed three sessions per week for 8 weeks (aerobic exercise: step training for 20 min; resistance training: exercises for quadriceps, hamstrings, deltoids and biceps brachii using elastic bands). The control group received a recommendation to walk at moderate intensity, three times per week. A weekly phone call was conducted for all participants, and the HBPR group received a home visit every 15 days. The primary outcome was distance in the incremental shuttle walk test (ISWT). Secondary outcomes were time in the endurance shuttle walk test (ESWT), number of steps in the incremental step test, quality of life, quadriceps muscle strength and daily physical activity. Measures were taken before and after intervention and 6 months later.

Results: After the intervention, the HBPR group had increased ISWT distance compared with the control group with between-group difference 87.9 m (95% CI 32.4-143.5 m). In addition, between-group differences were found in the ESWT, incremental step test, quality of life and quadriceps muscle strength, favouring the HBPR group. After 6 months, no differences were observed between the groups.

Conclusion: HBPR is an effective alternative offering of pulmonary rehabilitation for people with bronchiectasis. However, the programme was not effective in maintaining the benefits after 6 months of follow-up.
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http://dx.doi.org/10.1183/23120541.00021-2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165366PMC
April 2021

"Willingness to Pay": The Value Attributed to Program Location by Pulmonary Rehabilitation Participants.

COPD 2021 06 1;18(3):281-287. Epub 2021 Jun 1.

The Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia.

The "contingent valuation" method is used to quantify the value of services not available in traditional markets, by assessing the monetary value an individual ascribes to the benefit provided by an intervention. The aim of this study was to determine preferences for home or center-based pulmonary rehabilitation for participants with chronic obstructive pulmonary disease (COPD) using the "willingness to pay" (WTP) approach, the most widely used technique to elicit strengths of individual preferences. This is a secondary analysis of a randomized controlled equivalence trial comparing center-based and home-based pulmonary rehabilitation. At their final session, participants were asked to nominate the maximum that they would be willing to pay to undertake home-based pulmonary rehabilitation in preference to a center-based program. Regression analyses were used to investigate relationships between participant features and WTP values. Data were available for 141/163 eligible study participants (mean age 69 [SD 10] years,  = 82 female). In order to undertake home-based pulmonary rehabilitation in preference to a conventional center-based program, participants were willing to pay was mean $AUD176 (SD 255) (median $83 [IQR 0 to 244]). No significant difference for WTP values was observed between groups ( = 0.98). A WTP value above zero was related to home ownership (odds ratio [OR] 2.95,  = 0.02) and worse baseline SF-36 physical component score (OR 0.94,  = 0.02). This preliminary evidence for WTP in the context of pulmonary rehabilitation indicated the need for further exploration of preferences for treatment location in people with COPD to inform new models of service delivery.
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http://dx.doi.org/10.1080/15412555.2021.1924127DOI Listing
June 2021

Over-oxygenation in the acute hospital setting: an implementation failure in need of an implementation science solution.

Intern Med J 2021 05;51(5):633-635

Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/imj.15326DOI Listing
May 2021

Community Response to the Impact of Thunderstorm Asthma Using Smart Technology.

Allergy Rhinol (Providence) 2021 Jan-Dec;12:21526567211010728. Epub 2021 Apr 26.

School of BioSciences, University of Melbourne, Parkville, Australia.

Background: The most severe thunderstorm asthma (TA) event occurred in Melbourne on the 21st November 2016 and during this period, daily pollen information was available and accessible on smart devices via an App. An integrated survey within the App allows users to self-report symptoms.

Objective: To explore patterns of symptom survey results during the period when the TA event occurred.

Methods: Symptom data from the Melbourne Pollen Count and Forecast App related to asthma history, hay fever symptoms, and medication use was explored. A one-week control period before and after the event was considered. Chi-square tests and logistic regression were used to assess associations between sex, age, symptoms, and medication use.

Results: Of the 28,655 responses, during the 2016 pollen season, younger (18 to 40 years) males, with no hay fever and no asthma were the most single and regular responders. During the TA event for new users, sex was only significantly associated with hay fever ( = 0.008) of which 60.2% of females' responses reported having hay fever, while 43% of males' responses did not. Those with mild symptoms peaked during the TA event.

Conclusions: Many individuals completed the survey on the app for the first time during the TA event indicating the potential of digital technologies to be used as indicators of health risk among populations at risk of TA events.
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http://dx.doi.org/10.1177/21526567211010728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083005PMC
April 2021

Home-based pulmonary rehabilitation: an implementation study using the RE-AIM framework.

ERJ Open Res 2021 Apr 10;7(2). Epub 2021 May 10.

Dept of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia.

https://bit.ly/33qPx7A.
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http://dx.doi.org/10.1183/23120541.00469-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107349PMC
April 2021

Smoking cessation intervention in Australian general practice: a secondary analysis of a cluster randomised controlled trial.

Br J Gen Pract 2021 06 27;71(707):e458-e464. Epub 2021 May 27.

Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences.

Background: GPs have limited capacity to routinely provide smoking cessation support. New strategies are needed to reach all smokers within this setting.

Aim: To evaluate the effect of a pharmacist-coordinated interdisciplinary smoking cessation intervention delivered in Australian general practice.

Design And Setting: Secondary analysis of a cluster randomised controlled trial (RCT) conducted in 41 Australian general practices.

Method: In all, 690 current smokers were included in this study: 373 from intervention clinics ( = 21) and 317 from control clinics ( = 18). A total of 166 current smokers had spirometry-confirmed chronic obstructive pulmonary disease (COPD). In the intervention clinics, trained pharmacists provided smoking cessation support plus Quitline referral. Control clinics provided usual care plus Quitline referral. Those with COPD in the intervention group ( = 84) were referred for home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase), which included further smoking cessation support. Outcomes included carbon monoxide (CO)-validated smoking abstinence, self-reported use of smoking cessation aids, and differences between groups in readiness-to-quit score at 6 months.

Results: Intention-to-treat analysis showed similar CO-validated abstinence rates at 6 months in the intervention (4.0%) and control clinics (3.5%). No differences were observed in readiness-to-quit scores between groups at 6 months. CO-validated abstinence rates were similar in those who completed HMR and at least six sessions of HomeBase to those with COPD in usual care.

Conclusion: A pharmacist-coordinated interdisciplinary smoking cessation intervention when integrated in a general practice setting had no advantages over usual care. Further research is needed to evaluate the effect of HMR and home-based pulmonary rehabilitation on smoking abstinence in smokers with COPD.
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http://dx.doi.org/10.3399/BJGP.2020.0906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103929PMC
June 2021

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report.

Ann Am Thorac Soc 2021 05;18(5):e12-e29

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.
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http://dx.doi.org/10.1513/AnnalsATS.202102-146STDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086532PMC
May 2021

A mixed-methods pilot study of handheld fan for breathlessness in interstitial lung disease.

Sci Rep 2021 03 25;11(1):6874. Epub 2021 Mar 25.

Department of Respiratory and Sleep Medicine, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.

Dyspnoea is a cardinal symptom of fibrotic interstitial lung disease (ILD), with a lack of proven effective therapies. With emerging evidence of the role of facial and nasal airflow for relieving breathlessness, this pilot study was conducted to examine the feasibility of conducting a clinical trial of a handheld fan (HHF) for dyspnoea management in patients with fibrotic ILD. In this mixed-methods, randomised, assessor-blinded, controlled trial, 30 participants with fibrotic ILD who were dyspnoeic with a modified Medical Research Council Dyspnoea grade ≥ 2 were randomised to a HHF for symptom control or no intervention for 2 weeks. Primary outcomes were trial feasibility, change in Dyspnoea-12 scores at Week 2, and participants' perspectives on using a HHF for dyspnoea management. Study recruitment was completed within nine months at a single site. Successful assessor blinding was achieved in the fan group [Bang's Blinding Index - 0.08 (95% CI - 0.45, 0.30)] but not the control group [0.47 (0.12, 0.81)]. There were no significant between-group differences for the change in Dyspnoea-12 or secondary efficacy outcomes. During qualitative interviews, participants reported that using the HHF relieved breathlessness and provided relaxation, despite initial scepticism about its therapeutic benefit. Oxygen-experienced participants described the HHF being easier to use, but not as effective for symptomatic relief, compared to oxygen therapy. Our results confirmed the feasibility of a clinical trial of a HHF in fibrotic ILD. There was a high level of patient acceptance of a HHF for managing dyspnoea, with patients reporting both symptomatic benefits and ease of use.
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http://dx.doi.org/10.1038/s41598-021-86326-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994303PMC
March 2021

Give a Little or Give a Lot?: The Question of Long-term Maintenance After Pulmonary Rehabilitation.

Chest 2021 03;159(3):893-894

Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Australia.

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http://dx.doi.org/10.1016/j.chest.2020.11.034DOI Listing
March 2021

Reliability of the breathing pattern assessment tool for in-person or remote assessment in people with asthma.

Clin Exp Allergy 2021 Sep 8;51(9):1218-1220. Epub 2021 Mar 8.

Department of Physiotherapy, Alfred Health, Melbourne, Vic., Australia.

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http://dx.doi.org/10.1111/cea.13856DOI Listing
September 2021

Challenges of evaluating the effect of exercise training on salivary IgA in people with COPD.

Clin Respir J 2021 06 17;15(6):699-701. Epub 2021 Feb 17.

Faculty Medicine Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.

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http://dx.doi.org/10.1111/crj.13337DOI Listing
June 2021

Application of the Modified Incremental Step Test for Pulmonary Rehabilitation.

Phys Ther 2021 05;101(5)

Physiotherapy, Alfred Health, Melbourne, Australia.

Objective: A Modified Incremental Step Test (MIST) performed in the home may facilitate entirely home-based pulmonary rehabilitation programs. The aims of this study were to investigate the reliability and responsiveness, and the utility of the MIST for exercise prescription in people with stable chronic lung disease.

Methods: The MIST was undertaken at the center and home in random order, before and after pulmonary rehabilitation, with 2 tests at each time point. Reliability was assessed using intraclass correlation coefficient. Responsiveness was evaluated as effect size. The minimal important difference was appraised using distribution and anchor-based methods. In a substudy, physiological responses to MIST were measured by a portable metabolic system, followed by a constant step rate test at 60% of peak oxygen uptake (VO2peak), to evaluate utility for exercise prescription.

Results: Forty-six participants were recruited (29% of eligible candidates). There was excellent reliability for number of steps recorded in home- and center-based settings (intraclass correlation coefficient = 0.954, 95% CI = 0.915-0.976). A small-moderate effect size was demonstrated following pulmonary rehabilitation (0.34), and the minimal detectable change was 7 steps. All participants in the substudy achieved 60% of VO2peak and achieved steady state by the fourth minute, with 60% of VO2peak corresponding to a mean 37% (95% CI = 29-44) of the MIST final level.

Conclusions: The MIST is reliable and responsive to pulmonary rehabilitation in people with stable chronic respiratory disease. It provides new opportunities to assess exercise capacity, prescribe exercise training, and reassess exercise program outcomes in environments where established field walking tests are not feasible.

Impact: Pulmonary rehabilitation is a highly effective treatment that is underutilized worldwide. Home-based pulmonary rehabilitation may improve access for patients and deliver equivalent clinical outcomes but is limited by the availability of a robust exercise test that can be used at home to assess exercise capacity and prescribe training intensity. This study tested the clinimetric properties of the MIST and demonstrated a new way to assess exercise capacity, prescribe exercise training of an appropriate intensity, and reassess exercise capacity in environments where established field walking tests are not feasible.
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May 2021

Characteristics of Pulmonary Rehabilitation Programs Following an Exacerbation of Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW.

J Cardiopulm Rehabil Prev 2021 03;41(2):78-87

Discipline of Physiotherapy, La Trobe University, Melbourne, Australia (Drs Wageck, Cox, and Holland); Institute for Breathing and Sleep, Melbourne, Australia (Drs Cox and Holland); Central Clinical School, Monash University, Melbourne Australia (Drs Cox and Holland and Ms Lee); The Ian Potter Library, Alfred Health, Melbourne, Australia (Ms Romero); and Department of Physiotherapy, Alfred Health, Melbourne, Australia (Dr Holland).

Purpose: Early pulmonary rehabilitation (PR) has beneficial impacts on people with chronic obstructive pulmonary disease (COPD) when delivered after an exacerbation; however, program characteristics are diverse. This systematic review aimed to determine the impact of PR program characteristics (mode, length, commencement, frequency, location, and supervision) on clinical outcomes following an exacerbation of COPD.

Methods: Studies were screened from Medline, Medline in progress, Embase, CINAHL, SCOPUS, CENTRAL, and PEDro. Included studies were randomized controlled trials of early PR after an exacerbation of COPD (commenced during hospital stay or ≤4 wk of hospital discharge). The primary outcomes were hospital readmissions and mortality.

Results: Thirty studies were included. Exercise training alone was delivered in 43% of studies. Program duration varied from length of inpatient stay to 12 wk. The interventions commenced as early as ≤24 hr of hospitalization for acute exacerbation, and up to 2 wk after discharge. Early PR was compared to usual care, and no studies made a direct comparison of the program characteristics of interest. Program characteristics associated with reduced risk of hospital admission were commencement after hospital discharge, duration longer than 3 wk, and programs that included exercise training and education (relative risk of readmission range 0.6-0.79); however, it was not possible to determine which of these characteristics made the most important contribution. Mortality risk did not vary according to PR program characteristics.

Conclusion: Programs >3 wk, started after hospital discharge or including an educational component in addition to exercise, were most effective at reducing hospital readmissions.
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March 2021

Telerehabilitation for chronic respiratory disease.

Cochrane Database Syst Rev 2021 01 29;1:CD013040. Epub 2021 Jan 29.

Institute for Breathing and Sleep, Melbourne, Australia.

Background: Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

Objectives: To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

Search Methods: We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

Selection Criteria: All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

Data Collection And Analysis: We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

Main Results: We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

Authors' Conclusions: This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.
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http://dx.doi.org/10.1002/14651858.CD013040.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8095032PMC
January 2021

Exercise as a substitute for traditional airway clearance in cystic fibrosis: a systematic review.

Thorax 2020 Dec 22. Epub 2020 Dec 22.

Department of Physiotherapy, Podiatry, and Prosthetics and Orthotics, La Trobe University, Melbourne, Victoria, Australia.

Background: Exercise and traditional airway clearance techniques (ACTs) are both routinely recommended for people with cystic fibrosis (CF), with some people using exercise as a substitute for traditional ACTs. The effectiveness of this is unclear. We systematically reviewed the evidence for using exercise as a substitute for traditional ACTs in people with CF.

Methods: A systematic database and literature search were undertaken of studies comparing exercise to rest or traditional ACTs. Primary outcomes were respiratory function, respiratory exacerbations and health-related quality of life. Secondary outcomes included mucociliary clearance (MCC), sputum weight and ease of expectoration. Data are mean difference (95% CI).

Results: A total of 12 studies (15 reports) were included, all of short duration (single session to 2 weeks). In crossover trials, exercise did not improve forced expiratory volume in one second in comparison to rest, but peak expiratory flow was increased during treadmill exercise (mean difference (MD) range 1.00-1.16 L/s) and cycle ergometry (1.19 (0.96 to 1.42) L/s). Treadmill exercise improved MCC (2.6 (1.6 to 3.6)%) and ease of expectoration (MD range 1.3-1.8 cm) compared with rest. No consistent differences in respiratory function were evident when exercise was compared with traditional ACTs (four crossover studies). There was no significant difference in MCC or sputum weight in studies where forced expirations were included in the exercise intervention.

Conclusions: Exercise improves ease of expectoration and sputum clearance compared with rest. Exercise, incorporating forced expirations, may have similar effects to traditional ACTs over the short term. There are no data comparing exercise to traditional ACTs over the longer term.

Prospero Registration Number: CRD42018102780.
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http://dx.doi.org/10.1136/thoraxjnl-2020-215836DOI Listing
December 2020

More Movement for Better Control: The Importance of Physical Activity Promotion in Uncontrolled Asthma.

Chest 2021 01;159(1):1-2

Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Australia.

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January 2021
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