Abstract and Introduction
Background: Reduced physical activity (PA) was the strongest predictor of all-cause mortality in patients with chronic obstructive pulmonary disease (COPD). This scoping review aimed to map the evidence on the current landscape of physical activity, barriers and facilitators, and assessment tools across COPD patients.
Methods: Arksey and O'Malley's scoping review methodology framework guided the conduct of this review. An electronic search was conducted on five English databases (PubMed, Cochrane Library, PsycINFO, CINAHL and Web of Science) and three Chinese databases (CNKI, CQVIP and WAN-FANG) in January 2022. Two authors independently screened the literature, extracted the studies characteristics.
Results: The initial search yielded 4389 results, of which 1954 were duplicates. Of the remaining 135 articles, 42 studies met the inclusion criteria. Among the reviewed articles, there were 14 (33.3%) cross-sectional study, 9 (21.4%) cohort study, 4 (9.5%) longitudinal study, 3 qualitative study, 12 (28.7%) randomized control trials. The main barriers identified were older age, women, lung function, comorbidities, COPD symptoms (fear of breathlessness and injury, severe fatigue, anxiety and depression), GOLD stage, frequency of exacerbation, oxygen use, lack of motivation and environment-related (e.g., season and weather). Twelve studies have evaluated the effects of physical exercise (e.g., walking training, pulmonary rehabilitation (PR), pedometer, self-efficacy enhancing intervention and behavioral modification intervention) on PA and showed significant positive effects on the prognosis of patients. However, in real life it is difficult to maintain PA in people with COPD.
Conclusions: Changing PA behavior in patients with COPD requires multidisciplinary collaboration. Future studies need to identify the best instruments to measure physical activity in clinical practice. Future studies should focus on the effects of different types, time and intensity of PA in people with COPD and conduct randomized, adequately-powered, controlled trials to evaluate the long-term effectiveness of behavioral change interventions in PA.
Chronic obstructive pulmonary disease (COPD) is a common inflammatory lung disease characterized by persistent respiratory symptoms and airflow limitation.[1,2] According to the World Health Organization (WHO), COPD is the third leading cause of mortality in the world. The China Pulmonary Health (CPH) study showed that the overall prevalence of COPD was 8.6%, accounting for 99.9 million people with COPD in China. For now, COPD has been a worldwide public health challenge to be paid attention to urgently.
Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend pharmacologic therapy, primarily inhaled corticosteroids and bronchodilators, as the preferred treatment for patients with stable COPD. However, these therapies do not effectively halt disease progression. Due to the complexity of its pathophysiology, non-pharmacologic interventions (e.g., physical activity) can have significant effects in improving the quality of life and prognosis, with favorable socioeconomic benefits.
Physical activity (PA) is defined as any bodily movement produced by skeletal muscles that results in energy expenditure. Types of PA in daily life can be categorized into occupational sports, transportation (e.g., cycling and walking), household (e.g., yard work cleaning and home maintenance) or other activities. Strong evidence demonstrates regular PA is beneficial to reducing the risk of many chronic diseases. Conversely, physical inactivity is a major risk factor for poor outcomes in people with COPD and also leads to early mortality death in patients harboring chronic diseases.[7–9] Due to activity-related breathlessness and decreased exercise tolerance, the majority of COPD patients are usually forced to reduce PA and adopt a sedentary lifestyle.[10–12] Specifically, the duration, intensity and counts of activity in people with COPD were reduced significantly. In addition, PA levels in people with COPD began to decrease in the early stage of the disease and substantially declined over time.[14–16] As a result, the risk of readmission and mortality increased, and the patients' quality of life fell.[8,17]
Fortunately, PA in people with COPD has gradually attracted the attention of scholars in recent years. The GOLD guidelines recommend regular physical activity for all patients with COPD, which significantly improves dyspnea, health status, and exercise tolerance. Equally, both the American Thoracic Society (ATS)/the European Respiratory Society (ERS) note that PA can significantly improve health outcomes in people with COPD. For example, a study found that COPD patients with high levels of physical activity had a 34% lower risk of 30-day readmission and a 47% lower risk of death within 12 months of discharge compared to inactive patients.
As for the barriers and facilitators of PA in people with COPD, a previous review found that the factors influencing the facilitators and barriers to PA following pulmonary rehabilitation included three themes, which were beliefs, social support, and the environment. These findings also provide new insights into PA interventions for COPD patients in clinical practice, whereas it did not contain any quantitative findings. For PA interventions, a series of strategies currently implemented to treat low levels of PA in people with COPD, includes pulmonary rehabilitation, various types of exercise training, self-management, and behavior change strategies, reflect the complexity of this issue.[22–25] Another systematic review indicated that exercise training coupled with behavior change interventions (such as goal setting, motivational interviewing, and self-feedback) may be the optimal strategies to increase PA in people with COPD, but the specific type, time and intensity of PA are still unclear and need further research. In addition, assessment of intensity of PA is important to ensure safety and the effectiveness of PA interventions in COPD. At present, two main PA assessment tools commonly utilized contain subjective assessment (questionnaire, diary, self-reported) and objective measurement (pedometer, accelerometer, activity monitor).[27–29] However, the heterogeneity of measurement and reporting methods among different studies makes the results neither comparable nor easily synthesized.
For these reasons, a scoping review could be a better choice. It can quickly describe the research progress of a certain field, showing the scope, depth, breadth and deficiency, finally providing more information for the future. We consider incorporating qualitative and quantitative studies on this specific area from different perspectives, which may increase our understanding of complex physical activity behaviors. Therefore, this scoping review aimed: (1) to synthesize the evidence of barriers to PA in people with COPD; (2) to evaluate effectiveness of PA intervention in people with COPD; (3) to summarize the assessment methods of PA in people with COPD.
BMC Pulm Med. 2022;22(301) © 2022 BioMed Central, Ltd.