Burge Angela T, Cox Narelle S, Abramson Michael J, Holland Anne E
La Trobe University, Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, Melbourne, Victoria, Australia.
Institute for Breathing and Sleep, Melbourne, Australia.
Cochrane Database Syst Rev. 2020 Apr 16;4(4):CD012626. doi: 10.1002/14651858.CD012626.pub2.
Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far.
In people with COPD, which interventions are effective at improving objectively-assessed physical activity?
We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies.
We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions.
We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data.
We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training.
AUTHORS' CONCLUSIONS: A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.
人们对慢性阻塞性肺疾病（COPD）患者身体活动水平低下所带来挑战的认识不断提高，这凸显了采取干预措施以增加身体活动参与度的必要性。身体活动具有广泛认可的益处，再加上可穿戴监测设备越来越多地用于客观测量参与情况，旨在改善COPD患者身体活动的研究数量和种类急剧增加。然而，对于目前所测试干预措施的相对疗效知之甚少。
在COPD患者中，哪些干预措施能有效改善客观评估的身体活动？
我们从Cochrane气道试验注册库中识别试验，该注册库包含从书目数据库中识别的记录，这些书目数据库包括Cochrane对照试验中心注册库、MEDLINE、Embase、CINAHL、AMED和PsycINFO。我们还检索了PEDro、ClinicalTrials.gov、世界卫生组织国际临床试验注册平台门户以及澳大利亚新西兰临床试验注册库（从创建到2019年6月）。我们检查了所有原始研究和综述文章的参考文献列表以获取其他参考文献，以及呼吸期刊和呼吸会议摘要，以识别相关研究。
我们纳入了使用客观测量方法评估COPD患者身体活动的干预措施的随机对照试验。试验将一种干预措施与无干预措施或假手术/安慰剂干预措施进行比较，一种干预措施与两组共有的另一种标准干预措施相结合，或两种不同的干预措施进行比较。
我们采用Cochrane推荐的标准方法。对于临床稳定的COPD患者，在一系列身体活动结果方面，与无监督的肺康复计划相比，有监督的肺康复计划可进行亚组分析。次要结果包括与健康相关的生活质量、运动能力、不良事件和依从性。由于数据不足，无法按干预持续时间或疾病严重程度进行预先设定的亚组分析。我们通过剔除在盲法和不完整结果数据领域存在高偏倚风险或偏倚风险不明确的研究进行敏感性分析。
我们纳入了76项研究，共8018名参与者。大多数研究由政府机构资助，不过有些研究由设备或药品制造商赞助。只有38项研究将身体活动作为主要结果。已评估了多种干预措施，主要是在单项研究中，但没有任何一种特定干预措施能系统地证明有改善效果。在有改善效果的情况下，结果仅限于单项研究，或者未提供持续改善的数据。步数是最常报告的结果，但通常使用对此变量记录不准确的设备进行评估。与无干预相比，肺康复后中度至剧烈强度身体活动（MVPA）时间的平均差异（MD）为每天4分钟（95%置信区间（CI）-2至9；3项研究，190名参与者；低确定性证据）。高强度间歇运动训练后有改善（每天6分钟，95%CI 4至8；2项研究，275名参与者；中度确定性证据）。一项研究表明，进行六个月的身体活动咨询后有改善（MD为每天11分钟，95%CI 7至15；1项研究，280名参与者；中度确定性证据），但我们发现将身体活动咨询添加到肺康复中结果不一。与安慰剂相比，使用长效毒蕈碱拮抗剂和长效β-激动剂（LAMA/LABA）进行三至四周的药物治疗后有改善（MD为每天10分钟，95%CI 4至15；2项研究，423名参与者；高确定性证据）。这些干预措施在其他身体活动测量指标上也显示出改善。其他干预措施包括自我管理策略、营养补充、补充氧气、支气管内瓣膜手术、无创通气、神经肌肉电刺激和吸气肌训练。
已评估了多种干预措施，主要是在单项研究中。没有任何一种特定干预措施能系统地证明身体活动有改善效果。包括运动训练、身体活动咨询和药物管理等策略在改善身体活动方面的证据有限。干预措施的最佳时机、组成部分、持续时间和模式仍不明确。由于缺乏方法学细节，质量评估受到限制。几乎没有证据表明干预措施完成后随着时间推移会有持续效果，而这可能是对COPD患者产生有意义健康益处的必要条件。
