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Disability in Patients With COPDDisability in COPD FREE TO VIEW

Abebaw M. Yohannes, PhD, FCCP
Author and Funding Information

From the Department of Health Professions, Research Institute for Health and Social Care, Manchester Metropolitan University.

Correspondence to: Abebaw M. Yohannes, PhD, FCCP, Department of Health Professions, Manchester Metropolitan University, Hathersage Road, Manchester, England, M13 0JA; e-mail: A.yohannes@mmu.ac.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(2):200-202. doi:10.1378/chest.13-1703
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Published online

COPD is a major cause of physical disability and impaired quality of life in older people.1 Over the past 2 decades, despite medical advances in the management of COPD, the incidence of COPD-related death has risen exponentially compared with a decline in other chronic diseases (such as cardiovascular diseases).2 Patients with moderate to severe COPD experience excessive dyspnea on exertion disproportionate to activity, reduced exercise tolerance, frequent acute exacerbations, and recurrent hospitalizations.3-5 Progressive decline in physical activity has been associated with reduced social interaction, elevated mortality, and frequency of hospital admission.3,5 Although the factors related to the progressive decline in physical activity in patients with COPD are unclear, the causes are most likely multifactorial, including psychologic, behavioral, and social aspects, which all play an important role in physical activity. In view of the debilitative and unpredictable nature of the course of COPD, it is difficult for physicians to quantify the magnitude of the physical limitations of their patients’ daily activities. Therefore, it is critical to develop well-validated scales to determine the impact of COPD on those activities.

A study identified that more than three-fifths of patients with COPD live with two or more comorbidities that significantly interfere with their daily activities.6 The decline in a patient’s physical condition is progressive and may result in difficulties in taking part in activities such as shopping and carrying out social and household activities, which are a prerequisite to leading an independent life in the community. Knowledge of these limitations may help physicians focus on (design) an individually tailored intervention to alleviate the impact of physical disability for patients with COPD.

If this deterioration is not identified in a timely manner and dealt with promptly, it may eventually lead to an individual requiring assistance to maintain independence at home. Why might it take time to identify the problem? It is possible that not all health-care professionals are fully aware of the extent of the physical abilities of their patients with COPD because they may not routinely incorporate an activities of daily living (ADLs) scale to monitor the efficacy of treatment or deterioration in health status. Patients with COPD often lack a “badge of disability” that would alert physicians to make these associations, which contrasts with such “disability badges” in other disabling conditions (eg, a hemiparesis in a patient with stroke). Nevertheless, patients with moderate to severe COPD are most likely to be housebound and may require an increased level of support from their caregivers to perform routine chores.

These patients may also experience multiple disease-related trajectories that fluctuate during the course of the disease, have an impact on their physical activity, and relate to a wide range of clinical phenotypes, as illustrated in Table 1. Do we have well-validated, disease-specific ADLs tools that measure and determine the magnitude of physical disability in patients with COPD? To answer this important question, in this issue of CHEST (see page 253), Janaudis-Ferreira et al14 have performed a state-of-the-art review that highlights the impact of physical disability and the psychometric properties of the ADLs scale (eg, level of measurement, reliability, validity, and responsiveness) that have been used for patients with COPD. They identified 27 ADLs tools; of these, 11 instruments were respiratory disease specific and 11 were generic tools.

Table Graphic Jump Location
Table 1 —Association of Physical Disability in Patients With COPD

Their findings indicate that only three-fifths of the ADLs instruments were adequately designed to assess disability in patients with COPD. In addition, the responsiveness (the ability of the ADLs scale to capture subtle differences after an intervention) has been examined in only five instruments. Furthermore, there are no data on interpretability (the degree to which it is possible to draw meaningful interpretations from quantitative scores) of the respiratory disease-specific ADLs instruments.

What Can We Learn From This Timely Systematic Review?

First, all the ADLs scales that were identified as either generic or disease specific did not satisfy all the requirements of tool validity. Therefore, it is critical to develop a disease-specific ADLs scale for patients with COPD that is robust, feasible, and “fit-for-purpose” for research and routine clinical practice.

Second, fewer than one-half of the disease-specific ADLs tools have ever had their responsiveness to an intervention reported. Two observational studies, from Canada15 and the United Kingdom,16 showed that most pulmonary rehabilitation (PR) programs in those countries did not use ADLs scales, although there is strong evidence to suggest that a PR program improves exercise capacity and quality of life in patients with COPD.17 Therefore, further work is needed to determine the efficacy of ADLs scales in PR programs and to ascertain the minimal clinical important differences among those scales as they are used in clinical practice.

Third, there are some concerns that self-report ADLs scales are prone to recall bias and that patients may overestimate their physical functions when they are asked to self-complete questionnaires compared with when they are presented with objective ratings.18 Therefore, a rigorous evaluation of the content of the items should be undertaken during the construction and validation process, and clear instructions on how to administer the ADLs scale must be emphasized. Advancements in technology have made possible objective assessment markers that use motion sensors and accelerometers to generate objective data to determine the quantity and intensity of physical activities.19,20 However, further work is required to determine the psychometric properties (eg, the validity and responsiveness of these scales) in patients with COPD.21

Fourth, caution is required in interpreting the findings of this review14 because there were no gold standard criteria against which to test the scales, and those that were reviewed were heterogeneous, including both disease-specific and generic scales. The observation that a decline in physical activity starts early in the disease, even before subjects have been given a diagnosis of COPD, is intriguing.8 This signifies that a decline in physical activity is a dynamic process and that, unless appropriate intervention is undertaken, the transition and progression toward more severe disability increases with the severity of respiratory impairment.12,13 Therefore, further insight into the relationship among inflammatory markers, the course of the disease, and physical activity is worthy of exploration. Cross-sectional studies7,9,10,11,22 have reported associations among physical disability, inactivity, increased smoking, dynamic hyperinflation, social isolation, low self-esteem, elevated health-care use, and premature mortality in patients with COPD. However, the direction of causality is unclear.

Finally, the use of an ADLs scale may help physicians focus on the problems of patients with COPD, which may improve quality of care and monitoring of an individual patient’s progress or deterioration, and which may lead to appropriate social-care service. Future studies aimed at designing an ADLs scale for patients with COPD should address all relevant psychometric properties and practicalities and should include long-term follow-up that explores the efficacy of interventions.

Other contributions: This work was performed at Manchester Metropolitan University, Elizabeth Gaskell Campus, Manchester, England.

Maurer C, Rebbapragada V, Borson S, et al; for the ACCP Workshop Panel on Anxiety and Depression in COPD. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest. 2008;134(4_suppl):43S-56S. [CrossRef] [PubMed]
 
Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 1970-2002. JAMA. 2005;294(10):1255-1259. [CrossRef] [PubMed]
 
Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink R. Physical activity and hospitalization for exacerbation of COPD. Chest. 2006;129(3):536-544. [CrossRef] [PubMed]
 
Yohannes AM, Roomi J, Connolly MJ. Elderly people at home disabled by chronic obstructive pulmonary disease. Age Ageing. 1998;27(4):523-525. [CrossRef] [PubMed]
 
Yohannes AM, Baldwin RC, Connolly MJ. Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire. Int J Geriatr Psychiatry. 2000;15(12):1090-1096. [CrossRef] [PubMed]
 
Thomsen M, Dahl M, Lange P, Vestbo J, Nordestgaard BG. Inflammatory biomarkers and comorbidities in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186(10):982-988. [CrossRef] [PubMed]
 
Watz H, Waschki B, Kirsten A, et al. The metabolic syndrome in patients with chronic bronchitis and COPD: frequency and associated consequences for systemic inflammation and physical inactivity. Chest. 2009;136(4):1039-1046. [CrossRef] [PubMed]
 
Van Remoortel H, Hornikx M, Demeyer H, et al. Daily physical activity in subjects with newly diagnosed COPD. Thorax. 2013;68(10):962-963. [CrossRef] [PubMed]
 
Yohannes AM, Baldwin RC, Connolly MJ. Predictors of 1-year mortality in patients discharged from hospital following acute exacerbation of chronic obstructive pulmonary disease. Age Ageing. 2005;34(5):491-496. [CrossRef] [PubMed]
 
Katz P, Chen H, Omachi TA, et al. The role of physical inactivity in increasing disability among older adults with obstructive airway disease. J Cardiopulm Rehabil Prev. 2011;31(3):193-197. [CrossRef] [PubMed]
 
Garcia-Rio F, Lores V, Mediano O, et al. Daily physical activity in patients with chronic obstructive pulmonary disease is mainly associated with dynamic hyperinflation. Am J Respir Crit Care Med. 2009;180(6):506-512. [CrossRef] [PubMed]
 
Eisner MD, Iribarren C, Blanc PD, et al. Development of disability in chronic obstructive pulmonary disease: beyond lung function. Thorax. 2011;66(2):108-114. [CrossRef] [PubMed]
 
Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katxmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-229. [CrossRef] [PubMed]
 
Janaudis-Ferreira T, Beauchamp MK, Robles PG, Goldstein RS, Brooks D. Measurement of activities of daily living in patients with COPD: a systematic review.Chest. 2014;145(2):253-271.
 
Brooks D, Sottana R, Bell B, et al. Characterization of pulmonary rehabilitation programs in Canada in 2005. Can Respir J. 2007;14(2):87-92. [PubMed]
 
Yohannes AM, Connolly MJ. Pulmonary rehabilitation programmes in the UK: a national representative survey. Clin Rehabil. 2004;18(4):444-449. [CrossRef] [PubMed]
 
Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5_suppl):4S-42S. [CrossRef] [PubMed]
 
Shulman LM, Pretzer-Aboff I, Anderson KE, et al. Subjective report versus objective measurement of activities of daily living in Parkinson’s disease. Mov Disord. 2006;21(6):794-799. [CrossRef] [PubMed]
 
Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in patients with COPD. Eur Respir J. 2009;33(2):262-272. [CrossRef] [PubMed]
 
Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink R. Quantifying physical activity in daily life with questionnaires and motion sensors in COPD. Eur Respir J. 2006;27(5):1040-1055. [CrossRef] [PubMed]
 
Glaab T, Vogelmeier C, Buhl R. Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations. Respir Res. 2010;11:79. [CrossRef] [PubMed]
 
Yohannes AM, Roomi J, Winn S, Connolly MJ. The Manchester Respiratory Activities of Daily Living questionnaire: development, reliability, validity, and responsiveness to pulmonary rehabilitation. J Am Geriatr Soc. 2000;48(11):1496-1500. [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Association of Physical Disability in Patients With COPD

References

Maurer C, Rebbapragada V, Borson S, et al; for the ACCP Workshop Panel on Anxiety and Depression in COPD. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest. 2008;134(4_suppl):43S-56S. [CrossRef] [PubMed]
 
Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 1970-2002. JAMA. 2005;294(10):1255-1259. [CrossRef] [PubMed]
 
Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink R. Physical activity and hospitalization for exacerbation of COPD. Chest. 2006;129(3):536-544. [CrossRef] [PubMed]
 
Yohannes AM, Roomi J, Connolly MJ. Elderly people at home disabled by chronic obstructive pulmonary disease. Age Ageing. 1998;27(4):523-525. [CrossRef] [PubMed]
 
Yohannes AM, Baldwin RC, Connolly MJ. Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire. Int J Geriatr Psychiatry. 2000;15(12):1090-1096. [CrossRef] [PubMed]
 
Thomsen M, Dahl M, Lange P, Vestbo J, Nordestgaard BG. Inflammatory biomarkers and comorbidities in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186(10):982-988. [CrossRef] [PubMed]
 
Watz H, Waschki B, Kirsten A, et al. The metabolic syndrome in patients with chronic bronchitis and COPD: frequency and associated consequences for systemic inflammation and physical inactivity. Chest. 2009;136(4):1039-1046. [CrossRef] [PubMed]
 
Van Remoortel H, Hornikx M, Demeyer H, et al. Daily physical activity in subjects with newly diagnosed COPD. Thorax. 2013;68(10):962-963. [CrossRef] [PubMed]
 
Yohannes AM, Baldwin RC, Connolly MJ. Predictors of 1-year mortality in patients discharged from hospital following acute exacerbation of chronic obstructive pulmonary disease. Age Ageing. 2005;34(5):491-496. [CrossRef] [PubMed]
 
Katz P, Chen H, Omachi TA, et al. The role of physical inactivity in increasing disability among older adults with obstructive airway disease. J Cardiopulm Rehabil Prev. 2011;31(3):193-197. [CrossRef] [PubMed]
 
Garcia-Rio F, Lores V, Mediano O, et al. Daily physical activity in patients with chronic obstructive pulmonary disease is mainly associated with dynamic hyperinflation. Am J Respir Crit Care Med. 2009;180(6):506-512. [CrossRef] [PubMed]
 
Eisner MD, Iribarren C, Blanc PD, et al. Development of disability in chronic obstructive pulmonary disease: beyond lung function. Thorax. 2011;66(2):108-114. [CrossRef] [PubMed]
 
Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katxmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-229. [CrossRef] [PubMed]
 
Janaudis-Ferreira T, Beauchamp MK, Robles PG, Goldstein RS, Brooks D. Measurement of activities of daily living in patients with COPD: a systematic review.Chest. 2014;145(2):253-271.
 
Brooks D, Sottana R, Bell B, et al. Characterization of pulmonary rehabilitation programs in Canada in 2005. Can Respir J. 2007;14(2):87-92. [PubMed]
 
Yohannes AM, Connolly MJ. Pulmonary rehabilitation programmes in the UK: a national representative survey. Clin Rehabil. 2004;18(4):444-449. [CrossRef] [PubMed]
 
Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5_suppl):4S-42S. [CrossRef] [PubMed]
 
Shulman LM, Pretzer-Aboff I, Anderson KE, et al. Subjective report versus objective measurement of activities of daily living in Parkinson’s disease. Mov Disord. 2006;21(6):794-799. [CrossRef] [PubMed]
 
Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in patients with COPD. Eur Respir J. 2009;33(2):262-272. [CrossRef] [PubMed]
 
Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink R. Quantifying physical activity in daily life with questionnaires and motion sensors in COPD. Eur Respir J. 2006;27(5):1040-1055. [CrossRef] [PubMed]
 
Glaab T, Vogelmeier C, Buhl R. Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations. Respir Res. 2010;11:79. [CrossRef] [PubMed]
 
Yohannes AM, Roomi J, Winn S, Connolly MJ. The Manchester Respiratory Activities of Daily Living questionnaire: development, reliability, validity, and responsiveness to pulmonary rehabilitation. J Am Geriatr Soc. 2000;48(11):1496-1500. [PubMed]
 
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