Publications by authors named "Claire Nolan"

51 Publications

Gait speed and adverse outcomes following hospitalised exacerbation of COPD.

Eur Respir J 2021 Apr 29. Epub 2021 Apr 29.

Harefield Respiratory Research Group, Royal Brompton & Harefield Hospitals, Guy's and St.Thomas' NHS Foundation Trust, London, UK.

Four-metre gait speed (4MGS) is a simple physical performance measure and surrogate marker of frailty that is associated with adverse outcomes in older adults. We aimed to assess the ability of 4MGS to predict prognosis in patients hospitalised with acute exacerbations of COPD (AECOPD).213 participants hospitalised with AECOPD (52% male, mean age and FEV, 72 years and 35% predicted) were enrolled. 4MGS and baseline demographics were recorded at hospital discharge. All-cause readmission and mortality were collected for 1 y after discharge, and multivariable Cox-proportional hazards regression were performed. Kaplan-Meier and Competing risk analysis was conducted comparing time to all-cause readmission and mortality between 4MGS quartiles.111 participants (52%) were readmitted, and 35 (16%) died during the follow-up period. 4MGS was associated with all-cause readmission, with an adjusted subdistribution hazard ratio of 0.868 (95% CI 0.797-0.945; p=0.001) per 0.1 m·s increase in gait speed, and with all-cause mortality with an adjusted subdistribution hazard ratio of 0.747 (95% CI: 0.622-0.898; p=0.002) per 0.1 m·s increase in gait speed. Readmission and mortality models incorporating 4MGS had higher discrimination than age or FEV% predicted alone, with areas under the receiver operator characteristic curves of 0.73 and 0.80 respectively. Kaplan-Meier and Competing Risk curves demonstrated that those in slower gait speed quartiles had reduced time to readmission and mortality (log rank both p<0.001).4MGS provides a simple means of identifying at-risk patients with COPD at hospital discharge. This provides valuable information to plan post-discharge care and support.
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http://dx.doi.org/10.1183/13993003.04047-2020DOI Listing
April 2021

Integrating Home-Based Exercise Training with a Hospital at Home Service for Patients Hospitalised with Acute Exacerbations of COPD: Developing the Model Using Accelerated Experience-Based Co-Design.

Int J Chron Obstruct Pulmon Dis 2021 19;16:1035-1049. Epub 2021 Apr 19.

School of Health Sciences, University of East Anglia, Norwich, UK.

Background: Hospital at home (HaH) schemes allow early discharge of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Traditional outpatient pulmonary rehabilitation (PR) following an AECOPD has an established evidence-base, but there are issues with low referral, uptake and completion. One commonly cited barrier to PR post-hospitalisation relates to poor accessibility. To address this, the aim of this project was to enrol service users (patients with COPD and informal carers) and healthcare professionals to co-design a model of care that integrates home-based exercise training within a HaH scheme for patients discharged from hospital following AECOPD.

Methods: This accelerated experience-based co-design project included three audio-recorded stakeholder feedback events, using key "touchpoints" from previous qualitative interviews and a recent systematic review. Audio-recordings were inductively analysed using directed content analysis. An integrated model of care was then developed and finalised through two co-design groups, with the decision-making process facilitated by the tables of changes approach.

Results: Seven patients with COPD, two informal carers and nine healthcare professionals (from an existing outpatient PR service and HaH scheme) participated in the stakeholder feedback events. Four key themes were identified: 1) individualisation, 2) progression and transition, 3) continuity between services, and 4) communication between stakeholders. Two patients with COPD, one informal carer and three healthcare professionals participated in the first joint co-design group, with five healthcare professionals attending a second co-design group. These achieved a consensus on the integrated model of care. The agreed model comprised face-to-face supervised, individually tailored home-based exercise training one to three times a week, delivered during HaH scheme visits where possible by a healthcare professional competent to provide both home-based exercise training and usual HaH care.

Conclusion: An integrated model of care has been co-designed by patients with COPD, informal carers and healthcare professionals to address low uptake and completion of PR following AECOPD. The co-designed model of care has now been integrated within a well-established HaH scheme.
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http://dx.doi.org/10.2147/COPD.S293048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064617PMC
April 2021

Integrating Comprehensive Geriatric Assessment for people with COPD and frailty starting pulmonary rehabilitation: the Breathe Plus feasibility trial protocol.

ERJ Open Res 2021 Jan 29;7(1). Epub 2021 Mar 29.

King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.

One in five people with COPD also lives with frailty. People living with both COPD and frailty are at increased risk of poorer health and outcomes, and face challenges to completing pulmonary rehabilitation. Integrated approaches that are adapted to the additional context of frailty are required. The aim of the present study is to determine the feasibility of conducting a randomised controlled trial of an integrated Comprehensive Geriatric Assessment for people with COPD and frailty starting pulmonary rehabilitation. This is a multicentre, mixed-methods, assessor-blinded, randomised, parallel group, controlled feasibility trial ("Breathe Plus"; ISRCTN13051922). We aim to recruit 60 people aged ≥50 with both COPD and frailty referred for pulmonary rehabilitation. Participants will be randomised 1:1 to receive usual pulmonary rehabilitation, or pulmonary rehabilitation with an additional Comprehensive Geriatric Assessment. Outcomes (physical, psycho-social and service use) will be measured at baseline, 90 days and 180 days. We will also collect service and trial process data, and conduct qualitative interviews with a sub-group of participants and staff. We will undertake descriptive analysis of quantitative feasibility outcomes (recruitment, retention, missing data, blinding, contamination, fidelity), and framework analysis of qualitative feasibility outcomes (intervention acceptability and theory, outcome acceptability). Recommendations on progression to a full trial will comprise integration of quantitative and qualitative data, with input from relevant stakeholders. This study has been approved by a UK Research Ethics Committee (ref.: 19/LO/1402). This protocol describes the first study testing the feasibility of integrating a Comprehensive Geriatric Assessment alongside pulmonary rehabilitation, and testing this intervention within a mixed-methods randomised controlled trial.
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http://dx.doi.org/10.1183/23120541.00717-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005693PMC
January 2021

Minimal clinically important difference for daily pedometer step count in COPD.

ERJ Open Res 2021 Jan 22;7(1). Epub 2021 Mar 22.

Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK.

https://bit.ly/3ci97Jh.
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http://dx.doi.org/10.1183/23120541.00823-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983253PMC
January 2021

COPD discharge bundle and pulmonary rehabilitation referral and uptake following hospitalisation for acute exacerbation of COPD.

Thorax 2021 Mar 2. Epub 2021 Mar 2.

Harefield Respiratory Research Group, Royal Brompton & Harefield Hospitals, Guy's and St.Thomas' NHS Foundation Trust, London, UK.

Pulmonary rehabilitation (PR) following hospitalisations for acute exacerbation of COPD (AECOPD) is associated with improved exercise capacity and quality of life, and reduced readmissions. However, referral for, and uptake of, post-hospitalisation PR are low. In this prospective cohort study of 291 consecutive hospitalisations for AECOPD, COPD discharge bundles delivered by PR practitioners compared with non-PR practitioners were associated with increased PR referral (60% vs 12%, p<0.001; adjusted OR: 14.46, 95% CI: 5.28 to 39.57) and uptake (40% vs 32%, p=0.001; adjusted OR: 8.60, 95% CI: 2.51 to 29.50). Closer integration between hospital and PR services may increase post-hospitalisation PR referral and uptake.
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http://dx.doi.org/10.1136/thoraxjnl-2020-215464DOI Listing
March 2021

Supervised pulmonary rehabilitation using minimal or specialist exercise equipment in COPD: a propensity-matched analysis.

Thorax 2021 03 1;76(3):264-271. Epub 2020 Nov 1.

Harefield Respiratory Research Group, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Background: Many trials supporting the benefits of pulmonary rehabilitation (PR) have used specialist exercise equipment, such as treadmills and cycle ergometers. However, access to specialist equipment may not be feasible in some settings. There is growing interest in delivering PR programmes with minimal, low-cost equipment, but uncertainty remains regarding their efficacy compared with programmes using specialist equipment.

Methods: Using propensity score matching, 318 consecutive patients with COPD undergoing supervised PR using minimal equipment (PR-min) were compared 1:1 with a control group of 318 patients with COPD who underwent supervised PR using specialist equipment (PR-gym). A non-inferiority analysis was performed for the primary outcome (incremental shuttle walk (ISW)) and secondary outcomes (Chronic Respiratory Disease Questionnaire (CRQ)-domain and total scores).

Results: Similar improvements in ISW and CRQ-domains were observed in PR-min and PR-gym groups (mean difference ISW: 3 m (95% CI -16 to 9); CRQ-total: 0.9 (95% CI -2.7 to 4.5)). The 95% CI between group differences for ISW and CRQ-total did not cross the predefined non-inferiority margins. However, completion rates were lower in PR-min compared with PR-gym (64% vs 73%; p=0.014).

Conclusions: In patients with COPD, PR delivered using minimal equipment produces clinically significant benefits in exercise capacity and health-related quality of life that are non-inferior to rehabilitation delivered using specialist equipment. This study provides support for the provision of PR using minimal exercise equipment, particularly in areas where access to specialist exercise equipment is limited.
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http://dx.doi.org/10.1136/thoraxjnl-2020-215281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892370PMC
March 2021

Digital habits of PR service-users: Implications for home-based interventions during the COVID-19 pandemic.

Chron Respir Dis 2020 Jan-Dec;17:1479973120936685

Harefield Respiratory Research Group, Royal Brompton & Harefield NHS Foundation Trust, UK.

Remote models of pulmonary rehabilitation (PR) are vital with suspension of face-to-face activity during the COVID-19 pandemic. We surveyed digital access and behaviours and PR delivery preferences of current PR service users. There was significant heterogeneity in access to and confidence in using the Internet with 31% having never previously accessed the Internet, 48% confident using the Internet and 29% reporting no interest in accessing any component of PR through a Web-based app. These data have implications for the remote delivery of PR during the COVID-19 pandemic and raise questions about the current readiness of service users to adopt Web-based delivered models of PR.
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http://dx.doi.org/10.1177/1479973120936685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328358PMC
July 2020

Anxiety and depression in bronchiectasis: Response to pulmonary rehabilitation and minimal clinically important difference of the Hospital Anxiety and Depression Scale.

Chron Respir Dis 2020 Jan-Dec;17:1479973120933292

Harefield Respiratory Research Group, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK.

The aims of the study were to evaluate the responsiveness of Hospital Anxiety and Depression Scale-Anxiety (HADS-A) subscale and HADS-Depression (HADS-D) subscale to pulmonary rehabilitation (PR) in patients with bronchiectasis compared to a matched group of patients with chronic obstructive pulmonary disease (COPD) and provide estimates of the minimal clinically important difference (MCID) of HADS-A and HADS-D in bronchiectasis. Patients with bronchiectasis and at least mild anxiety or depression (HADS-A ≥ 8 or/and HADS-D ≥ 8), as well as a propensity score-matched control group of patients with COPD, underwent an 8-week outpatient PR programme (two supervised sessions per week). Within- and between-group changes were calculated in response to PR. Anchor- and distribution-based methods were used to estimate the MCID. HADS-A and HADS-D improved in response to PR in both patients with bronchiectasis and those with COPD (median (25th, 75th centile)/mean (95% confidence interval) change: HADS-A change: bronchiectasis -2 (-5, 0), COPD -2 (-4, 0); = 0.43 and HADS-D change: bronchiectasis -2 (-2 to -1), COPD -2 (-3 to -2); = 0.16). Using 26 estimates, the MCID for HADS-A and HADS-D was -2 points. HADS-A and HADS-D are responsive to PR in patients with bronchiectasis and symptoms of mood disorder, with an MCID estimate of -2 points.
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http://dx.doi.org/10.1177/1479973120933292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301664PMC
June 2020

Prognostication in COPD using physical function measures: Let's walk before we run away with conclusions.

Respir Med 2020 06 21;167:105942. Epub 2020 Mar 21.

Brunel University London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.rmed.2020.105942DOI Listing
June 2020

The Effects of a Video Intervention on Posthospitalization Pulmonary Rehabilitation Uptake. A Randomized Controlled Trial.

Am J Respir Crit Care Med 2020 06;201(12):1517-1524

Harefield Respiratory Research Group and.

Pulmonary rehabilitation (PR) after hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life and reduces readmissions. However, posthospitalization PR uptake is low. To date, no trials of interventions to increase uptake have been conducted. To study the effect of a codesigned education video as an adjunct to usual care on posthospitalization PR uptake. The present study was an assessor- and statistician-blinded randomized controlled trial with nested, qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including PR information leaflet) or usual care plus the codesigned education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, FEV % predicted, frailty, transport availability, and previous PR experience. The primary outcome was PR uptake within 28 days of hospital discharge. A total of 200 patients were recruited, and 196 were randomized (51% female, median FEV predicted, 36 [interquartile range, 27-48]). PR uptake was 41% and 34% in the usual care and intervention groups, respectively ( = 0.37), with no differences in secondary (PR referral and completion) or safety (readmissions and death) endpoints. A total of 6 of the 15 participants interviewed could not recall receiving the video. A codesigned education video delivered at hospital discharge did not improve posthospitalization PR uptake, referral, or completion.
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http://dx.doi.org/10.1164/rccm.201909-1878OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301747PMC
June 2020

Exercise Training Modalities for People with Chronic Obstructive Pulmonary Disease.

COPD 2019 12 4;16(5-6):378-389. Epub 2019 Nov 4.

Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA.

Exercise training confers health benefits for people with chronic obstructive pulmonary disease (COPD). This article reviews the evidence for several exercise training modalities shown to be beneficial among individuals with COPD. These modalities include aerobic, resistance, nonlinear periodized, upper limb and balance training, as well as yoga, Tai Chi, inspiratory muscle training, whole body vibration training and neuromuscular electrical stimulation. The literature pertaining to each modality was critically reviewed, and information on the rationale, mechanism(s) of action (where known), benefits, and exercise prescription is described to facilitate easy implementation into clinical practice.
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http://dx.doi.org/10.1080/15412555.2019.1637834DOI Listing
December 2019

Home versus outpatient pulmonary rehabilitation in COPD: a propensity-matched cohort study.

Thorax 2019 10 5;74(10):996-998. Epub 2019 Jul 5.

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Home-based exercise has been proposed as an equivalent treatment strategy to supervised outpatient pulmonary rehabilitation (PR), but it is not known whether its implementation into clinical practice produces similar benefits to those observed in trials. We compared the real-world responses of 154 patients with COPD undergoing home-based exercise with a matched group attending supervised PR. We observed smaller improvements in exercise capacity with home-based exercise compared with PR, but similar improvements in quality of life. We propose that supervised PR remains the standard of care, with home-based exercise a less effective alternative for those unable to attend PR.
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http://dx.doi.org/10.1136/thoraxjnl-2018-212765DOI Listing
October 2019

King's Brief Interstitial Lung Disease questionnaire: responsiveness and minimum clinically important difference.

Eur Respir J 2019 09 5;54(3). Epub 2019 Sep 5.

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK.

Health status is increasingly used in clinical practice to quantify symptom burden and as a clinical trial end-point in patients with interstitial lung disease (ILD). The King's Brief Interstitial Lung Disease (KBILD) questionnaire is a brief, validated 15-item, disease-specific, health-related quality of life questionnaire that is increasingly used in clinical trials, but little data exist regarding the minimum clinically important difference (MCID). Using pulmonary rehabilitation as a model, we aimed to determine the responsiveness of KBILD and provide estimates of the MCID.KBILD scores, Chronic Respiratory Questionnaire (CRQ) scores, Medical Research Council (MRC) Dyspnoea score and incremental shuttle walk test (ISWT) distance were measured in 209 patients with ILD (105 with idiopathic pulmonary fibrosis (IPF)) before and after an outpatient pulmonary rehabilitation programme. Changes with intervention and Cohen's effect size were calculated. Anchor-based (linear regression and receiver operating characteristic plots) or distribution-based approaches (0.5 sd and standard error of measurement) were used to estimate the MCID of KBILD domain and total scores.KBILD, CRQ, MRC Dyspnoea and ISWT improved with intervention, and the effect sizes of KBILD domain and total scores ranged from 0.28 to 0.38. Using anchor-based estimates, the MCID estimates for KBILD-Psychological, KBILD-Breathlessness and activities, and KBILD-Total were 5.4, 4.4 and 3.9 points, respectively. Using distribution-based methods, the MCID estimate for KBILD-Chest symptoms was 9.8 points. The MCID estimates for KBILD in IPF patients were similar.In patients with ILD and IPF, KBILD is responsive to intervention with an estimated MCID of 3.9 points for the total score.
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http://dx.doi.org/10.1183/13993003.00281-2019DOI Listing
September 2019

The prognostic significance of weight loss in chronic obstructive pulmonary disease-related cachexia: a prospective cohort study.

J Cachexia Sarcopenia Muscle 2019 12 17;10(6):1330-1338. Epub 2019 Jun 17.

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Background: Cachexia is an important extra-pulmonary manifestation of chronic obstructive pulmonary disease (COPD) presenting as unintentional weight loss and altered body composition. Previous studies have focused on the relative importance of body composition compared with body mass rather than the relative importance of dynamic compared with static measures. We aimed to determine the prevalence of cachexia and pre-cachexia phenotypes in COPD and examine the associations between cachexia and its component features with all-cause mortality.

Methods: We enrolled 1755 consecutive outpatients with stable COPD from two London centres between 2012 and 2017, stratified according to European Respiratory Society Task Force defined cachexia [unintentional weight loss >5% and low fat-free mass index (FFMI)], pre-cachexia (weight loss >5% but preserved FFMI), or no cachexia. The primary outcome was all-cause mortality. We calculated hazard ratios (HRs) using Cox proportional hazards regression for cachexia classifications (cachexia, pre-cachexia, and no cachexia) and component features (weight loss and FFMI) and mortality, adjusting for age, sex, body mass index, and disease-specific prognostic markers.

Results: The prevalence of cachexia was 4.6% [95% confidence interval (CI): 3.6-5.6] and pre-cachexia 1.6% (95% CI: 1.0-2.2). Prevalence was similar across sexes but increased with worsening Global Initiative for Chronic Obstructive Pulmonary Disease spirometric stage and Medical Research Council dyspnoea score (all P < 0.001). There were 313 (17.8%) deaths over a median (interquartile range) follow-up duration 1089 (547-1704) days. Both cachexia [HR 1.98 (95% CI: 1.31-2.99), P = 0.002] and pre-cachexia [HR 2.79 (95% CI: 1.48-5.29), P = 0.001] were associated with increased mortality. In multivariable analysis, the unintentional weight loss feature of cachexia was independently associated with mortality [HR 2.16 (95% CI: 1.31-3.08), P < 0.001], whereas low FFMI was not [HR 0.88 (95% CI: 0.64-1.20), P = 0.402]. Sensitivity analyses using body mass index-specific, age-specific, and gender-specific low FFMI values found consistent findings.

Conclusions: Despite the low prevalence of cachexia and pre-cachexia, both confer increased mortality risk in COPD, driven by the unintentional weight loss component. Our data suggest that low FFMI without concurrent weight loss may not confer the poor prognosis as previously reported for this group. Weight loss should be regularly monitored in practice and may represent an important target in COPD management. We propose the incorporation of weight monitoring into national and international COPD guidance.
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http://dx.doi.org/10.1002/jcsm.12463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903442PMC
December 2019

European Respiratory Society International Congress, Paris, 2018: highlights from the Clinical Assembly.

ERJ Open Res 2019 Feb 11;5(1). Epub 2019 Feb 11.

Dept of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany.

This article contains highlights and a selection of the scientific advances from the European Respiratory Society's Clinical Assembly (Assembly 1 and its five respective groups) that were presented at the 2018 European Respiratory Society International Congress in Paris, France. The most relevant topics from each of the groups will be discussed, covering a wide range of areas including clinical problems, rehabilitation and chronic care, thoracic imaging, interventional pulmonology, and general practice and primary care. The newest research, actual data and highlight sessions will be discussed.
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http://dx.doi.org/10.1183/23120541.00176-2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368995PMC
February 2019

Pulmonary rehabilitation in bronchiectasis: a propensity-matched study.

Eur Respir J 2019 01 17;53(1). Epub 2019 Jan 17.

Harefield Pulmonary Rehabilitation and Muscle Research Group, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK.

International guidelines recommend pulmonary rehabilitation for patients with bronchiectasis, supported by small trials and data extrapolated from chronic obstructive pulmonary disease (COPD). However, it is unknown whether real-life data on completion rates and response to pulmonary rehabilitation are similar between patients with bronchiectasis and COPD.Using propensity score matching, 213 consecutive patients with bronchiectasis referred for a supervised pulmonary rehabilitation programme were matched 1:1 with a control group of 213 patients with COPD. Completion rates, change in incremental shuttle walk (ISW) distance and change in Chronic Respiratory Disease Questionnaire (CRQ) score with pulmonary rehabilitation were compared between groups.Completion rate was the same in both groups (74%). Improvements in ISW distance and most domains of the CRQ with pulmonary rehabilitation were similar between the bronchiectasis and COPD groups (ISW distance: 70 63 m; CRQ-Dyspnoea: 4.8 5.3; CRQ-Emotional Function: 3.5 4.6; CRQ-Mastery: 2.3 2.9; all p>0.20). However, improvements in CRQ-Fatigue with pulmonary rehabilitation were greater in the COPD group (bronchiectasis 2.1 COPD 3.3; p=0.02).In a real-life, propensity-matched control study, patients with bronchiectasis show similar completion rates and improvements in exercise and health status outcomes as patients with COPD. This supports the routine clinical provision of pulmonary rehabilitation to patients with bronchiectasis.
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http://dx.doi.org/10.1183/13993003.01264-2018DOI Listing
January 2019

Gait speed and prognosis in patients with idiopathic pulmonary fibrosis: a prospective cohort study.

Eur Respir J 2019 02 7;53(2). Epub 2019 Feb 7.

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

The 4-m gait speed (4MGS), a simple physical performance measure and surrogate marker of frailty, consistently predicts adverse prognosis in older adults. We hypothesised that 4MGS could predict all-cause mortality and nonelective hospitalisation in patients with idiopathic pulmonary fibrosis (IPF).4MGS and lung function were measured at baseline in 130 outpatients newly diagnosed with IPF. Survival status and nonelective hospital admissions were recorded over 1 year. We assessed the predictive value of 4MGS (as a continuous variable and as a binary variable: slow preserved 4MGS) by calculating hazard ratios using Cox proportional regression, adjusting for potential confounding variables. Receiver operating characteristic curves assessed discrimination between the multivariable regression models and established prognostic indices.Continuous 4MGS and slow 4MGS were independent predictors of all-cause mortality (4MGS: HR 0.03, 95% CI 0.01-0.31; p=0.004; slow 4MGS: 2.63, 95% CI 1.01-6.87; p=0.049) and hospitalisation (4MGS: HR 0.02, 95% CI 0.01-0.14; p<0.001; slow 4MGS: 2.76, 95% CI 1.16-6.58; p=0.02). Multivariable models incorporating 4MGS or slow 4MGS had better discrimination for predicting mortality than either the gender, age and lung physiology index or Composite Physiologic Index.In patients with IPF, 4MGS is an independent predictor of all-cause mortality and nonelective hospitalisation.
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http://dx.doi.org/10.1183/13993003.01186-2018DOI Listing
February 2019

Pulmonary rehabilitation in patients with an acute exacerbation of chronic obstructive pulmonary disease.

J Thorac Dis 2018 May;10(Suppl 12):S1390-S1399

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton and Harefield NHS Foundation Trust, UK.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are one of the most common causes of emergency hospital admission and place great burden upon healthcare systems. Furthermore, AECOPD represent an important life event for patients, and are associated with significant reductions in physical activity, skeletal muscle function, exercise tolerance and health-related quality of life. Pulmonary rehabilitation, an intervention comprising supervised exercise-training and education, may counteract these negative consequences and target modifiable risk factors for hospital readmission. A recent Cochrane systematic review included 20 randomized controlled trials comparing pulmonary rehabilitation after exacerbation of COPD versus conventional care. Overall, the evidence supports moderate to large effects on health-related quality of life and exercise capacity. However, there is substantial heterogeneity across studies, and more recent studies have been more equivocal, including around hospital readmissions, particularly when rehabilitation is started in the inpatient setting. In this narrative review, we examine the rationale for pulmonary rehabilitation following AECOPD with a particular focus on skeletal muscle function, review the current evidence for pulmonary rehabilitation in the AECOPD setting, and identify areas that require future research, including the structure and nature of the intervention, improving uptake and adherence, and the role of alternative rehabilitation strategies for patients with AECOPD.
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http://dx.doi.org/10.21037/jtd.2018.03.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5989101PMC
May 2018

Phenotypic characteristics associated with slow gait speed in idiopathic pulmonary fibrosis.

Respirology 2018 05 14;23(5):498-506. Epub 2017 Nov 14.

Harefield Pulmonary Rehabilitation and Muscle Research Group, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Background And Objective: Usual gait speed over 4 m (4MGS) is an established functional performance measure in older adults that consistently predicts adverse health outcomes, but few data exist in idiopathic pulmonary fibrosis (IPF). We assessed the reliability of 4MGS, its relationship with established outcome measures and its responsiveness to pulmonary rehabilitation.

Methods: In four prospective IPF cohorts, 4MGS inter-observer (n = 46) and test-retest (n = 46) reliability, concurrent validity (n = 65 and n = 62) and responsiveness (n = 60) were determined. The phenotypic characteristics of all patients stratified according to slow 4MGS (<0.8 m/s) were compared, including lung function parameters, HRCT of the chest, 6-min walking distance (6MWD), Medical Respiratory Council (MRC) dyspnoea score, King's Brief Interstitial Lung Disease (KBILD) questionnaire and Gender, Age and lung Physiology (GAP) prognostic index.

Results: Intra-class correlation coefficients for inter-observer and test-retest reliability were 0.996 and 0.983, respectively. There was a strong association between 4MGS and 6MWD (r = 0.76; P < 0.0001) and moderate correlations with MRC (r = -0.56), KBILD (r = 0.44) and GAP index (r = -0.41); all P < 0.005. 4MGS improved significantly with pulmonary rehabilitation (mean (95% CI) change: 0.16 (0.12-0.20) m/s), effect size 0.65. Patients with slow 4MGS had significantly worse exercise performance (6MWD: -167 (-220 to -133) m), dyspnoea, health status and prognosis index than those with preserved 4MGS, despite similar lung function and HRCT parameters.

Conclusion: 4MGS is a simple, reliable, valid and responsive tool that may detect a patient phenotype with worse exercise performance, dyspnoea, health status and prognosis index in stable IPF.
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http://dx.doi.org/10.1111/resp.13213DOI Listing
May 2018

The impact of involvement on researchers: a learning experience.

Res Involv Engagem 2017 18;3:20. Epub 2017 Sep 18.

Parkinson's UK, 215 Vauxhall Bridge Road, London, SW1V 1EJ UK.

Plain English Summary: The impacts of involvement in research are often described in terms of the difference made to the research, the people involved and less frequently the researchers. This paper focuses on the researchers' experiences of involvement, based on an evaluation of a pilot project supporting patient/carer involvement in research at Parkinson's UK. Telephone interviews were conducted with researchers from eight different research projects with involvement. The researchers reported gaining new knowledge from patients and carers. They used this knowledge to change their project designs, interventions and new devices. They also gained new skills in communicating with the public. Meeting patients for the first time had a profound impact on some researchers, causing a change in their professional values. Face-to-face contact seemed particularly important to gain a sense of the 'people behind the data', which suggests such meetings may result in impacts beyond those typically achieved through an exchange of documents. Involvement also influenced one researcher's choices and preferences, in terms of who to ask to take part in their study In summary, researchers often learn something new from talking to patients and carers. Facilitating this conversation seems important to maximise the impact of this learning. In future, it might be helpful for evaluations of involvement to ask researchers in more detail about what they learnt from patients/carers and how they applied their new skills and knowledge. This may help to understand how involvement can influence researchers' thinking to have an impact on research.

Abstract: The impacts of patient/public involvement are often described in terms of the difference made to the research, the researchers and the people involved. Involvement often impacts on by influencing the design, delivery and dissemination. Patients/the public report gaining new skills and knowledge, increased self-confidence, and satisfaction from making a difference. There are fewer reports of the impacts on . This paper discusses the findings from an evaluation of a pilot project supporting patient/carer involvement in research at Parkinson's UK, focusing on the researchers' experiences. Semi-structured telephone interviews were conducted with one researcher from each of the eight research projects which involved patients/carers in the pilot. The findings were analysed using theoretical thematic analysis. Learning can be described as acquiring new knowledge, behaviours, skills, values, or preferences. The researchers' reports reflected these different types of learning. They reported gaining new knowledge from patients and carers, which they recognised as distinct from their textbook knowledge of the condition. They used this learning to change their project designs and their new interventions and devices. They also gained new skills in communicating with patients and carers about the aims and significance of their research. Meeting patients for the first time had a profound impact on some researchers causing them to change their professional values. Face-to-face contact seemed particularly important to gain a sense of the 'people behind the data', which suggests such meetings may result in impacts beyond those typically achieved through an exchange of documents. The involvement also influenced one researchers' priorities and preferences, in terms of what questions to ask and of whom, in their project. Researchers learn from an exchange of knowledge with patients/ carers, which influences their plans and actions. This seems to be one way that involvement subsequently has an impact on research. Facilitating this exchange seems important to support mutual learning and to enhance the impact on researchers. Future evaluations of involvement might benefit from exploring what researchers learnt from patients/carers and how they applied their new skills and knowledge.
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http://dx.doi.org/10.1186/s40900-017-0071-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611580PMC
September 2017

Validity, responsiveness and minimum clinically important difference of the incremental shuttle walk in idiopathic pulmonary fibrosis: a prospective study.

Thorax 2017 Sep 7. Epub 2017 Sep 7.

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK.

The incremental shuttle walk (ISW) is well validated in COPD but limited psychometric data restrict its use in idiopathic pulmonary fibrosis (IPF). Study 1: 50 patients performed the ISW and 6 min walk test (6MWT). Study 2: 72 patients completed the ISW before and after pulmonary rehabilitation (PR). The ISW correlated strongly with 6MWT distance (r=0.81,p<0.0001). Mean (95% confidence interval) improvement in ISW with PR was 54 (38 to 70) m with an effect size of 0.29. Distribution-based and anchor-based minimum clinically important difference (MCID) estimates ranged from 31 to 46 m. The ISW is valid and responsive in IPF, with an anchor-based MCID estimate similar to that observed in chronic obstructive pulmonary disease.

Trial Registration Number: Pre-results; NCT02530736, NCT02436278.
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http://dx.doi.org/10.1136/thoraxjnl-2017-210589DOI Listing
September 2017

Gait speed and pedestrian crossings in COPD.

Thorax 2018 02 5;73(2):191-192. Epub 2017 May 5.

Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Harefield Hospital, Harefield, UK.

The assumed minimum walking speed at pedestrian crossings is 1.2 m/s. In this prospective cohort study, usual walking speed was measured over a 4 m course in 926 community-dwelling, ambulatory patients with stable COPD. Mean (SD) walking speed was 0.91 (0.24) m/s with only 10.7% walking at a speed equal or greater than 1.2 m/s. In order for 95% of this cohort to safely negotiate a pedestrian cross, traffic lights would have to assume a minimum walking speed of 0.50 m/s (2.4 times longer than current times). The current assumed normal walking speed for pedestrian crossings is inappropriate for patients with COPD.The studies were registered on clinicaltrials.gov and these data relate to the pre-results stage: NCT01649193, NCT01515709 and NCT01507415.
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http://dx.doi.org/10.1136/thoraxjnl-2017-210173DOI Listing
February 2018

Simple functional tests in COPD: stand up and be counted!

Eur Respir J 2017 03 2;49(3). Epub 2017 Mar 2.

NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK

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http://dx.doi.org/10.1183/13993003.00104-2017DOI Listing
March 2017

Pedometer Step Count Targets during Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial.

Am J Respir Crit Care Med 2017 05;195(10):1344-1352

1 National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, Harefield, United Kingdom.

Rationale: Increasing physical activity is a key therapeutic aim in chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation (PR) improves exercise capacity, but there is conflicting evidence regarding its ability to improve physical activity levels.

Objectives: To determine whether using pedometers as an adjunct to PR can enhance time spent in at least moderate-intensity physical activity (time expending ≥3 metabolic equivalents [METs]) by people with COPD.

Methods: In this single-blind randomized controlled trial, participants were assigned 1:1 to receive a control intervention (PR comprising 8 wk, two supervised sessions per week) or the trial intervention (PR plus pedometer-directed step targets, reviewed weekly for 8 wk). In the randomization process, we used minimization to balance groups for age, sex, FEV percent predicted, and baseline exercise capacity and physical activity levels. Outcome assessors and PR therapists were blinded to group allocation. The primary analysis was based on the intention-to-treat principle.

Measurements And Main Results: The primary outcome was change from baseline to 8 weeks in accelerometer-measured daily time expending at least 3 METs. A total of 152 participants (72% male; mean [SD] FEV percent predicted, 50.5% [21.2]; median [first quartile, third quartile] time expending ≥3 METs, 46 [21, 92] min) were enrolled and assigned to the intervention (n = 76) or control (n = 76) arm. There was no significant difference in change in time expending at least 3 METs between the intervention and control groups at 8 weeks (median [first quartile, third quartile] difference, 0.5 [-1.0, 31.0] min; P = 0.87) or at the 6-month follow-up (7.0 [-9, 27] min; P = 0.16).

Conclusions: Pedometer-directed step-count targets during an outpatient PR program did not enhance moderate-intensity physical activity levels in people with COPD. Clinical trial registered with www.clinicaltrials.gov (NCT01719822).
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http://dx.doi.org/10.1164/rccm.201607-1372OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443901PMC
May 2017