Original Article
Patients admitted with an acute exacerbation of chronic obstructive pulmonary disease had positive experiences exercising from the beginning of their hospital stay: A qualitative analysis
Chronic Respiratory Disease 10(4) 197–205 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972313504941 crd.sagepub.com
Clarice Y Tang1,2, Nicholas F Taylor2,3 and Felicity C Blackstock2
Abstract The aim of the study is to explore the experiences of inpatients with an acute exacerbation of chronic obstructive pulmonary disease, who participated in a very early exercise programme while acutely unwell. This qualitative study analysed responses from participant interviews as part of a mixed method trial whereby participants were randomly allocated into three groups: low intensity, moderate to high intensity aerobic and resistance exercises or a control group who received routine physiotherapy. Everyone allocated to the exercise groups were invited to participate in the qualitative study. Interviews were within a week post discharge and the results were analysed thematically. A total of 19 participants were interviewed and described their experience as positive and beneficial and reported an increased motivation towards exercising. These findings converged with the high levels of exercise adherence (83%) and withingroup improvements in walking capacity observed in both exercise groups. Participants also reported commencement of a home exercise programme after discharge but intention to participate in community pulmonary rehabilitation remained low. Participation in a very early exercise programme while acutely unwell can lead to positive attitude towards exercise. The results converge with the quantitative results that provided preliminary evidence of programme feasibility and within-group improvement in exercise tolerance. Keywords Pulmonary disease, chronic obstructive, acute, exercise therapy, motivation, perception, pulmonary rehabilitation
Introduction Exercise is a primary and integral non-pharmacological approach in the management of patients with stable chronic obstructive pulmonary disease (COPD).1–3 Implementing an exercise programme for people with COPD while their condition is stable has been demonstrated to improve exercise tolerance, quality of life and reduce hospital readmissions.1–4 However, an acute exacerbation of COPD requiring hospitalisation has been shown to have detrimental effects on exercise capacity, muscle strength and physical activity levels for people with COPD.5–7 Declines in these parameters have also been associated with increase in mortality risk and morbidity among people with COPD.8,9
However, getting people with COPD to exercise can be challenging. Patients are often hesitant to participate in pulmonary rehabilitation, being concerned
1
Physiotherapy Department, Eastern Health, Maroondah Hospital, Victoria, Australia 2 Department of Physiotherapy, La Trobe University, Victoria, Australia 3 Allied Health Clinical Research Office, Eastern Health, Victoria, Australia Corresponding author: Clarice Y Tang, Department of Physiotherapy, La Trobe University, Bundoora, Victoria 3086, Australia. Email: [email protected]
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that the exercise component of pulmonary rehabilitation would increase their shortness of breath.10 A recent survey conducted among people with COPD revealed that 26% of people associated participation in strenuous activity with exacerbation of their COPD condition and were reluctant to exercise.11 Perhaps related to these concerns, the adherence rate to exercise classes for people with COPD remains low,12,13 despite the known positive effects of exercise for this population. In a recent phase one randomised controlled trial, an exercise programme based on the principles of pulmonary rehabilitation was implemented with people requiring hospitalisation for an acute exacerbation of COPD and was found to be safe and feasible14 Another trial demonstrated that implementation of a quadriceps strengthening exercise programme for patients requiring hospitalisation for an acute exacerbation of COPD was effective in preventing quadriceps muscle deterioration.15 These programmes were conducted while patients were medically unwell and symptomatic from their acute exacerbation. The quantitative results of these trials were promising and suggested that very early exercise during an exacerbation of COPD may be safe and feasible and therefore have the potential to address the detrimental effects of hospitalisation in this population.14,15 However, they did not report participants’ perceptions of the programme nor their attitudes towards exercising when unwell. In light of the challenges of adherence and negative perceptions of pulmonary rehabilitation during stable COPD, an exercise programme implemented when acutely unwell with significant increases in dyspnoea may reinforce any negative perceptions of exercise. This may in turn negatively impact on uptake and adherence to community pulmonary rehabilitation, especially if patients perceived exercising not to be beneficial for their COPD condition. Therefore, the aims of this study were to use a qualitative research design to explore people’s attitudes and experiences towards participation in an exercise programme when acutely unwell and whether this early exercise programme experiences changed perceptions about ongoing exercise and attendance to pulmonary rehabilitation following discharge.
The findings were briefly discussed in relation to those coming from the randomised controlled trial14,16 The lack of previous studies investigating experiences and perceptions of people with COPD exercising while acutely unwell meant that we did not have preconceived judgements thereby allowing us to appropriately adopt the phenomenology approach to explore the lived experience of exercising while unwell.17
Participants Participants were recruited from a sample of people involved in the randomised controlled trial.14 Purposive sampling strategies were used to obtain rich and meaningful information from the interviews.17 Participants were included if they had been admitted to hospital with an acute exacerbation of COPD, recruited in the randomised controlled trial and allocated to the exercise groups and were able to attend an interview session following hospital discharge. Patients allocated to the control group in the randomised controlled trial were not invited to participate. Written informed consent to participate in the interview was obtained from each participant prior to commencement of the trial. The study received approval from the ethics committees of Eastern Health – Maroondah Hospital (E59-0809) and La Trobe University (FHEC 08/191).
Procedure Semi-structured interviews were used to obtain rich thick descriptions of the participants’ perception, experience and attitude towards the exercise programme.18 Participants were given an interview time prior discharge from hospital and a choice between face-to-face and phone interview, as each mode of interview has its merits.19 All interviews were completed within a week of discharge from hospital to increase the likelihood of participants having a clear recollection of the programme. Each interview was conducted by a clinician who had previous experience in conducting semi-structured interviews and did not have any previous contact with the participants. This allowed participants to be comfortable to express their unbiased opinions.
Methods
Intervention
This article reported on the findings of a qualitative study completed as part of a mixed-methods trial.
The exercise rehabilitation programme involved supervised twice-daily 15 minutes physiotherapy sessions
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Table 1. Interview guide. Topic area
Sample questions
Effects of exercise programme Aim to get participants to discuss any positive and negative outcomes of the programme Programme design Aim to get participants to discuss aspects of programme design that facilitated or hindered performance
‘‘Could you comment on whether you noticed any changes from your participation in the programme?’’
‘‘Could you discuss what you like or disliked about the programme? ‘‘Could you discuss how feasible the exercise programme was during your hospital stay?’’
Exercise performance Aim to get participants to discuss factors affecting their adherence
‘‘Could you describe anything that may have hindered your performance of the exercise programme?’’
Exercise maintenance Aim to get participants on factors affecting ongoing exercise performance
‘‘Has your involvement in this exercise programme changed your perception about exercising?
that included both resistance and aerobic training from the second day of admission to hospital till the day of discharge in addition to standard physiotherapy treatment. Full details of the programme are described elsewhere.14 Depending on allocation, participants were either required to exercise at a low intensity (40% maximal intensity) or at a moderate to high intensity (70% maximal intensity). Aerobic intensity was based on the results of 3-minute walk test at baseline, while strengthening intensity was based on repetitions maximum. All participants were given a copy of the exercise programme and a resistance band at time of discharge and were encouraged to continue their exercise programme at home.
Data analysis All interviews were audiotaped and transcribed verbatim. Credibility of the study was addressed by the use of member checking for all transcripts to maximise the accuracy of the responses. Once the transcribed transcript had been checked, all identifiable information was removed from the transcript and the participants were assigned a participant identity number to ensure anonymity. Qualitative software, NVIVO (QSR, Melbourne, Australia) was used to assist with the management of data. The process of assigning open codes was completed on all transcribed transcripts by two researchers independently (CYT and FCB). The codes provided an insightful meaning to the data and to establish any
new relationships within the common exercise experience.17 Codes were then analysed and compared, creating links between a category and subcategories. Finally, an analysis on all categories and subcategories was completed to find the main theme that linked all other categories together. The thematic analysis allowed us to formulate any possible themes from the interview transcripts without being influenced by any preconceived judgements. These themes were compared with the findings of the randomised controlled trial to explore for any convergence of the themes. Effort was made to improve rigor by establishing credibility, transferability, dependability and conformability of the data.17 For this study, the first author (CYT) had 7 years of clinical experience as a physiotherapist with patients admitted for acute exacerbation of COPD and supervised the physiotherapy sessions. The second author (NFT) had a physiotherapy background, worked at the affiliated university and had experience in qualitative research. The third author (FCB) had over 10 years of cardiorespiratory physiotherapy experience and worked at the affiliated university. The first and third authors completed coding. By having no direct contact with the participants, the third author was able to remain neutral to the coding process, thus reducing the potential of subjective prejudices from the first author. In addition, transferability and dependability of the study was ensured through the use of standard interview guides that had been agreed upon by the research team prior to interviews so as to ensure the same set of questions were asked of each participants (Table 1).
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Results Of the 21 participants invited for the study, 19 (90%) took part. Two participants declined to participate, as they felt too unwell to participate in the interview. The sample comprised 12 women and 7 men, who averaged 70 years of age. Based on the GOLD guidelines,20 participants were of a moderate severity (50–79% predicted forced expiratory volume in one second) in their COPD condition (Table 2). The average 3-minute walk test distance covered by participants who completed the exercise programme was 108 m (SD, 62 m) at base line (Table 2). This is approximately two-thirds of the average 3-minute walk test distance achieved by people with stable COPD status.21 All participants completed the exercise rehabilitation programme during their hospital admission. Fourteen (74%) participants had previously attended pulmonary rehabilitation or a community based exercise class (Table 2). Eighteen interviews were conducted via the phone. The median length of stay in hospital was 6.0 days (range 3–16 days), while the median length of time in the exercise programme was 5.0 days (range 2–15 days). The randomised controlled trial examining implementation of the exercise programme for patients (n ¼ 32) admitted with an acute exacerbation of COPD found the programme to be safe and feasible.14 Adherence to exercise was 83%, and from 174 exercise sessions, there was only one event classified as serious and in that case, symptoms had resolved within an hour and the person continued with their exercise at the next session. The exercise groups improved significantly in walking distance in the 3minute walk test; however, no significant betweengroup differences were observed.14 From analysis of the 19 transcribed interviews, one main theme (positive experience with exercise programme) and two sub-themes (increased motivation towards exercise at home and reluctance towards formal ongoing exercise programmes) emerged.
Main theme: positive experience with the exercise programme There was an overwhelming response from the participants, irrespective of the intensity of the exercise programme allocated, expressing that their experience with the exercise programme was positive and enjoyable: I thoroughly enjoyed the programme and I think I did quite well. You had people there with you showing
you what you do and it was great company at the same time. It was not a chore but a fun thing to do. (P11)
When participants were asked to explain why they had enjoyed the programme, participants expressed that the exercise programme kept them active while in hospital compared to their previous inpatient physiotherapy experiences. The presence of someone supervising and explaining the purpose of their exercises gave them a deeper understanding as to the importance of exercising and motivation to keep exercising. Participants also commented that they enjoyed the wider variety of exercises from what they had from previous admissions. In addition, participants also expressed that they liked having some control over the exercises, being given an option to stop exercising if they felt that they could no longer continue: The fact that I was actively exercising while in hospital made the difference. (P2) The fact that I can do them to the point that I cannot do anymore was good. The flexibility of knowing that I can sit down if I cannot do it anymore and just take a few minutes to catch my breath back was good. (P15) I was just so grateful that someone encouraged me throughout my hospital stay to exercise even though it might be hard at that time. (P15)
Participants overwhelmingly perceived the programme to be beneficial and motivational to continue to exercise: I think it was extremely useful to do the exercises while in hospital. (P2) It was very helpful. The exercises that were conducted improved my breathing quite substantially. (P5)
Participants also felt that the exercises were more relevant to them while they are acutely unwell as compared to their previous pulmonary rehabilitation experiences whereby they were exercising when they felt well. Participants did not report a negative experience with the programme or felt that the programme was ineffective. This finding converged with the quantitative data that indicated that it was safe to exercise, and a high percentage of physiotherapy sessions (83%) were completed among participants in the exercise groups with no significant differences between the two intensities of exercise, nor the control group and the exercise groups (Table 3).14
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68 59 78
84 82
58
87 81 78 55 68
83
69 78 67
60
63
3 4 5
6 7
8
9 10 11 12 13
14
15 16 17
18
19
F
F
F F F
F
M F F F F
M
F M
M M M
F M
54
20
45 34 40
76
52 67 40 58 Not available
15
36 23
69 67 54
37 65
FEV1% predicted
Yes
Yes
Yes Yes Yes
Yes No Yes Yes Yes (fail to complete) Yes
Yes
Yes Yes
No No No
No Yes
Low
Low
Low Low Mod
Mod
Low Mod Mod Low Mod
Low
Mod Mod
Low Low Low
Mod Mod
(67) (50) (100) (100) (75)
2/3 (67)
6/8 (75)
4/8 (50) 4/6 (67) 2/2 (100)
1/2 (50)
4/6 3/6 3/3 5/5 3/4
4/6 (67)
5/8 (63) 8/13 (63)
3/4 (75) 4/4 (100) 10/17 (59)
13/15 (87) 8/12 (67)
Completed/ total physiotherapy sessions (%)
155
140
110 45 165
93
100 81 88 125 15
40
77 52
157 270 180
155 158
Home
Home
Home Home Home
Home
Home Home Home Home Home
Home Inpatient rehabilitation Home
Home Home Home
Home Home
3-MWT at base Discharge line (m) destination
4
8
9 8 3
3
3 6 3 4 4
8
4 10
4 5 14
10 9
Length of stay in hospital (days)
Phone
Phone
Phone Phone Phone
Phone
Phone Phone Phone Phone Phone
Phone
Phone Face
Phone Phone Phone
Phone Phone
Mode of interview (phone/ face-toface)
No strict exercise programme but does increase walking distances Half hour every day No home exercises 6 hours intermittently a day including housework Not doing any programme until health is good again 20 minutes a day
Participating in pulmonary rehab, ad hoc exercises at home Doing squats everyday 10-15 minutes once a day Exercises 3 times a week Exercise twice a day No exercises
20 minutes per day Walking programme and once a day strengthening exercises Exercise once a day Exercises half hour a day 10 Minutes of bike, walking daily and 3 times a week of strengthening exercises Exercises whenever she remembers Daily exercises
Self reported home exercise programme
F: female; M: male; Low: 40% maximal intensity; Mod: 70% maximal intensity; 3-MWT: 3-minute walk test distance; FEV1: forced expiratory volume in one second.
75 54
1 2
Gender ID Age (F/M)
Intensity of Previous exercise pulmonary programme rehabilitation (Low/Mod)
Table 2. Demographic characteristics of participants.
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Table 3. Triangulation of qualitative and quantitative findings. Theme
Qualitative findings
Quantitative findings14
Triangulation
Positive experience with the exercise programme
Participants reported that the exercise programme was enjoyable and beneficial
Only one serious adverse event occurred out of the possible 218 physiotherapy sessions despite participants being required to exercise while acutely unwell.83% of the physiotherapy sessions completed by participants in the exercise groups.No significant between-group differences in percentages of completed physiotherapy sessions. Control vs. mod/high ¼ 19% (95%CI: 1–40%) Control vs low ¼ 12% (95%CI: 7–32%)
Convergent
Increased motivation towards ongoing exercise
Most participants reported commencement of home exercise programme post discharge for at least 30 minutes daily
Significant within-group improvements in 3-MWT distances in the low intensity (21 m; 95%CI: 11–30 m) and moderate to high intensity exercise groups (31 m; 95%CI: 10–52 m). Within-group improvements in 3-MWT in the control group (18 m; 95%CI: 7–44m)
Convergent
Reluctance towards ongoing formal exercise programme
Most participants reported that they were not interested to participate in community pulmonary rehabilitation
Significant within-group improvements in 3-MWT distance in both exercise groups
Divergent
3-MWT: 3-minute walk test.
However, perceptions from participants that symptoms and co-morbidities had hindered their ability to participate in the programme had emerged during the interviews: My muscles tend to really ache and cramp up quite a bit after the exercise programme and it took me a while after discharge to get rid of the muscle ache. (P18)
In the context of a positive experience, there were comments on challenges within the programme. An increase in provision of information regarding the benefits of exercise was felt to have enhanced the effectiveness of the programme. Comments about the frequency of exercising were also made whereby exercising twice a day was too often. It was also suggested that the duration of the exercise programme can be increased as participants felt that the short hospital stay had not allowed them to see the physical effects of the programme: I felt that two days were really short and if I had more time doing the exercises over a period of time, I believe that the exercises will improve my general mobility and also clear my lungs. (P3)
Sub-theme: increased motivation towards ongoing exercise Related to the overall positive feedback regarding the exercise programme, a sub-theme emerged, that participant’s attitudes towards ongoing exercise had changed because of their experience with the inpatient programme. Convergent with the significant within-group improvements in 3-minute walk test distances in both the exercise groups (Table 3), participants reported a positive change in attitude towards exercise after participation in the exercise programme: It had changed my attitude to keep going even if I am a little short of breathe or a little tired. (P15)
Participants also reported that they had commenced a home exercise programme, doing the exercises that they had learnt in hospital during their acute exacerbation at least once a day for approximately 30 minutes (Table 2).
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Sub-theme: reluctance towards ongoing formal exercise programmes From the quantitative data, the exercise programme seemed to have motivated participants towards ongoing exercising. However, when participants were asked whether they were interested in attending ongoing formal community exercise programmes such as pulmonary rehabilitation, few expressed an intention to attend. It emerged that participants preferred exercising at home: Basically I prefer not to work in a group. I prefer to do my own exercises and I have a pretty full schedule at the moment and may not have the time to attend an exercise programme. (P3)
Consistent with this sub-theme of preferring to exercise at home by themselves, participants expressed reasons such as lack of accessibility to community exercise programme in terms of parking access and distance from car to centre and the fear of travelling for not wanting to participate in community exercise programmes: It is not my thing to do community exercise programme. I am worried about the travelling time and how far is it for me to walk to the facility. (P12)
In addition, participants expressed that they felt that they knew the exercises from previous participation in pulmonary rehabilitation and this knowledge reduced their likelihood of participating in future pulmonary rehabilitation. Participants also felt that the exercises they had experienced in pulmonary rehabilitation were not challenging enough and did not like the burden of having to travel to the programme.
Discussion An overall positive experience among participants who had completed a very early exercise programme during their admission to hospital with an acute exacerbation of COPD was the main theme that emerged from this qualitative study. Participants who completed this exercise programme enjoyed the experience, despite being acutely unwell with potentially increased symptoms of dyspnoea. The programme appeared to reinforce the benefits of exercise to participants and motivated the majority of them to continue with an ongoing exercise programme after discharge. Most participants did not cite feeling unwell during their acute exacerbation as a barrier towards their
participation in the programme. Importantly, participants did express that participating in the exercise programme made them realise that they were able to exercise even when symptomatic. The above findings of the interviews converge with the reported adherence rates of 83%,14 indicating that the exercise programme was indeed feasible (Table 3). Participants reporting that the exercise programme was enjoyable and that their acutely unwell status was not a barrier to participating may help counter concerns that getting people with COPD to exercise is challenging, especially when they are unwell.10,12 Motivation to exercise at home on discharge appeared to be high in participants following the implementation of a very early exercise programme. The majority of the participants reported commencing a home exercise programme meeting the American Thoracic Society and the European Respiratory Society’s guideline of at least 30 minutes of moderate physical activity, 3–5 times a week following discharged from hospital (Table 2).22 The positive health behaviour with reported independent home exercise might be related to the participants’ perception of benefits from undergoing the exercise programme as inpatients. The perceived benefits of the programme reported by participants converge with the results of the quantitative trial, where significant within-group improvements in 3-minute walk test distance in the both exercise groups were observed.14 Considering that it has been demonstrated that physical activity levels for people with COPD decline to below population mean with a hospitalisation and remain below this mean 7 days after admission,6 reported increases in motivation to exercise once home is a significant positive effect of commencing a supervised exercise programme when acutely unwell. Personal and environmental factors can affect adherence to exercise in people with COPD.23 The main personal factors included lack of perceived benefits, negative experience towards exercises and more importantly, a perception of poor health status that leads to a perception of an inability to exercise.12,13,23–25 It seems that implementation of this early exercise programme may have addressed the personal factors affecting the level of adherence to exercise among COPD patients.14 It might be expected that the reported improvement in motivation towards exercise may increase uptake of community pulmonary rehabilitation post discharge. However, willingness to take up pulmonary rehabilitation post discharge remained low among our participants.
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A lack of transport and accessibility emerged from this study as the main deterrent for patients considering commencing community pulmonary rehabilitation. These results are consistent with literature finding accessibility issues as a consistent environmental factor affecting adherence to pulmonary rehabilitation.12,13,23 It is possible that environmental factors may have a larger influence than personal factors in influencing the willingness of people with COPD to participate in community pulmonary rehabilitation. No further follow-up was conducted in this study to find out whether participants did eventually attend pulmonary rehabilitation as the aim of the study was only to determine perceptions of exercise when acutely unwell. Further research into whether changed perceptions affects uptake of community pulmonary rehabilitation is warranted. Another theme that emerged as a reason for not intending to participate in pulmonary rehabilitation programme was the preference for independent home exercise over formalised exercise groups. Even though participants had expressed that they enjoyed the support that staff had given them during the exercise programme and felt that some supervision would benefit them with maintenance of their exercise programme, most participants reported preferring to exercise on their own either due to personal preference or being too ‘‘busy’’ to participate in a formal exercise programme. Utilising telecommunications to engage people with COPD with exercises at home while being supervised by a physiotherapist may eliminate issues such as transport and accessibility, addressing individual preference of exercising on their own.26,27
Strengths and limitations The short time between discharge and interview was both a strength and limitation of this study. The short time allowed participants to provide greater insights on their opinions about the programme. However, this also meant that we did not find out whether participants continued their exercise programme at home or whether they did change their mind regarding participation in community pulmonary rehabilitation. We were also unable to establish whether participants were completing the reported home exercise programme regimen. Also, interviewing those in the control group would have allowed us to describe differences in the perceptions about ongoing exercise and participation in community pulmonary rehabilitation programs and provided a clearer understanding of the impact the programme had on these perceptions.
Implications for future research or clinical practice This qualitative study in combination with the results from the randomised controlled trial has indicated that implementation of a very early exercise programme for people with an acute exacerbation of COPD requiring hospitalisation may not only be feasible and safe but also enjoyable, beneficial and improve attitudes towards independent exercise at home among people with COPD.14 However, despite these positive results, intention to participate in community pulmonary rehabilitation after discharge remained low. Exploration of long-term effects of exercise training for people with COPD who are acutely unwell is warranted, since changes in attitudes towards physical activity may be evident when a very early exercise programme is commenced. Conflict of Interest The authors declared no conflicts of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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7. Garcia-Aymerich J, Lange P, Benet M, Schnohr P and Anto J. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006; 61: 772–778. 8. Cassanova C, Cote C, Marin JM, Pinto-Piata V, de Torres JP, Aguirre-Jaime A, et al. Distance and oxygen desaturation during the 6-min walk test as predictors of long-term mortality in patients with COPD. Chest 2008; 134(4): 746–752. 9. Pinto-Plata V, Cote C, Cabral H, Taylor J and Celli B. The 6-min walk distance: change over time and value as a predictor of survival in severe COPD. Eur Respir J 2004; 23(1): 28–33. 10. Harris D, Hayter M and Allender S. Improving the uptake of pulmonary rehabilitation in patients with COPD: qualitative study of experiences and attitudes. Br J Gen Pract 2008; 58(555): 703–710. 11. Hernandez P, Balter M, Bourbeau J and Hodder R. Living with chronic obstructive pulmonary disease: a survey of patient’s knowledge and attitudes. Resp Med 2009; 103: 1004–1012. 12. Arnold E, Bruton A and Ellis-Hill C. Adherence to pulmonary rehabilitation: a qualitative study. Resp Med 2006; 100: 1716–1723. 13. Keating A, Lee A and Holland A. Lack of perceived benefit and inadequate transport influence uptake and completion of pulmonary rehabilitation in people with chronic obstructive pulmonary disease: a qualitative study. J Physiother 2011; 57: 183–190. 14. Tang C, Blackstock F, Clarence M and Taylor N. Early rehabilitation exercise program for inpatients during an acute exacerbation of chronic obstructive pulmonary disease (COPD): a randomized controlled trial. J Cardiopulm Rehabil 2012; 32(3): 163–169. 15. Troosters T, Probst V, Crul T, Pitta F, Gayan-Ramirez G, Decramer M, et al. Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 181(10): 1072–1077.
16. Cresswell J. Qualitative inquiry and research design: choosing among five approaches. 2nd ed. Thousand Oaks, CA: Sage Publications, 2007. 17. Liamputtong P. Qualitative research methods. 3rd ed. Melbourne, Australia: Oxford University Press, 2009. 18. Kvale S. Doing interviews. 1st ed. Flick U (ed). London, UK: Sage Publications, 2007. 19. Sturges J and Hanrahan K. Comparing telephone and face to face qualitative interviewing: a research note. Qual Res 2004; 4: 107–108. 20. Rodriguez-Roisin R, Anzueto A, Bourbeau J, deGuia T, Hui D and Martinez F, et al. Global strategy for the diagnosis, management and the prevention of chronic obstructive pulmonary disease http://www.goldcopd. org/ (2011, accessed 3 May 2013). 21. Iriberri M, Galdiz J, Gorostiza A, Ansola P and Jaca C. Comparison of the distances covered during 3 and 6 min walking test. Resp Med 2002; 96: 812–816. 22. Nici L, Donner C, Wouters E, Zuwallack R, Nicolino A, Bourbeau J, et al. American thoracic society/European respiratory society statement on pulmonary rehabiitation. Am J Respir Crit Care Med 2006; 173: 1390–1413. 23. O’Shea S, Taylor N and Paratz J. But watch out for the weather: factors affecting adherence to progressive resistance exercise for persons with COPD. J Cardiopulm Rehabil 2007; 27: 166–174. 24. Fischer MJ, Scharloo M, Abbink JJ, Hul AJvt, Ranst Dv, Rudolphus A, et al. Drop-out and attendance in pulmonary rehabilitation: the role of clinical and psychosocial variables. Respir Med 2009; 103: 1564–1571. 25. Taylor R, Dawson S, Roberts N, Sridhar M and Partridge MR. Why do patients decline to take part in a research project involving pulmonary rehabilitation. Respir Med 2007; 101: 1942–1946. 26. McKinstry B, Pinnock H and Sheikh A. Telemedicine for management of patients with COPD. Lancet 2009; 274: 672–673. 27. Ekeland A, Bowes A and Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform 2010; 9(11): 736–771.
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Patients admitted with an acute exacerbation of chronic obstructive pulmonary disease had positive experiences exercising from the beginning of their hospital stay: A qualitative analysis
Chronic Respiratory Disease 10(4) 197–205 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972313504941 crd.sagepub.com
Clarice Y Tang1,2, Nicholas F Taylor2,3 and Felicity C Blackstock2
Abstract The aim of the study is to explore the experiences of inpatients with an acute exacerbation of chronic obstructive pulmonary disease, who participated in a very early exercise programme while acutely unwell. This qualitative study analysed responses from participant interviews as part of a mixed method trial whereby participants were randomly allocated into three groups: low intensity, moderate to high intensity aerobic and resistance exercises or a control group who received routine physiotherapy. Everyone allocated to the exercise groups were invited to participate in the qualitative study. Interviews were within a week post discharge and the results were analysed thematically. A total of 19 participants were interviewed and described their experience as positive and beneficial and reported an increased motivation towards exercising. These findings converged with the high levels of exercise adherence (83%) and withingroup improvements in walking capacity observed in both exercise groups. Participants also reported commencement of a home exercise programme after discharge but intention to participate in community pulmonary rehabilitation remained low. Participation in a very early exercise programme while acutely unwell can lead to positive attitude towards exercise. The results converge with the quantitative results that provided preliminary evidence of programme feasibility and within-group improvement in exercise tolerance. Keywords Pulmonary disease, chronic obstructive, acute, exercise therapy, motivation, perception, pulmonary rehabilitation
Introduction Exercise is a primary and integral non-pharmacological approach in the management of patients with stable chronic obstructive pulmonary disease (COPD).1–3 Implementing an exercise programme for people with COPD while their condition is stable has been demonstrated to improve exercise tolerance, quality of life and reduce hospital readmissions.1–4 However, an acute exacerbation of COPD requiring hospitalisation has been shown to have detrimental effects on exercise capacity, muscle strength and physical activity levels for people with COPD.5–7 Declines in these parameters have also been associated with increase in mortality risk and morbidity among people with COPD.8,9
However, getting people with COPD to exercise can be challenging. Patients are often hesitant to participate in pulmonary rehabilitation, being concerned
1
Physiotherapy Department, Eastern Health, Maroondah Hospital, Victoria, Australia 2 Department of Physiotherapy, La Trobe University, Victoria, Australia 3 Allied Health Clinical Research Office, Eastern Health, Victoria, Australia Corresponding author: Clarice Y Tang, Department of Physiotherapy, La Trobe University, Bundoora, Victoria 3086, Australia. Email: [email protected]
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that the exercise component of pulmonary rehabilitation would increase their shortness of breath.10 A recent survey conducted among people with COPD revealed that 26% of people associated participation in strenuous activity with exacerbation of their COPD condition and were reluctant to exercise.11 Perhaps related to these concerns, the adherence rate to exercise classes for people with COPD remains low,12,13 despite the known positive effects of exercise for this population. In a recent phase one randomised controlled trial, an exercise programme based on the principles of pulmonary rehabilitation was implemented with people requiring hospitalisation for an acute exacerbation of COPD and was found to be safe and feasible14 Another trial demonstrated that implementation of a quadriceps strengthening exercise programme for patients requiring hospitalisation for an acute exacerbation of COPD was effective in preventing quadriceps muscle deterioration.15 These programmes were conducted while patients were medically unwell and symptomatic from their acute exacerbation. The quantitative results of these trials were promising and suggested that very early exercise during an exacerbation of COPD may be safe and feasible and therefore have the potential to address the detrimental effects of hospitalisation in this population.14,15 However, they did not report participants’ perceptions of the programme nor their attitudes towards exercising when unwell. In light of the challenges of adherence and negative perceptions of pulmonary rehabilitation during stable COPD, an exercise programme implemented when acutely unwell with significant increases in dyspnoea may reinforce any negative perceptions of exercise. This may in turn negatively impact on uptake and adherence to community pulmonary rehabilitation, especially if patients perceived exercising not to be beneficial for their COPD condition. Therefore, the aims of this study were to use a qualitative research design to explore people’s attitudes and experiences towards participation in an exercise programme when acutely unwell and whether this early exercise programme experiences changed perceptions about ongoing exercise and attendance to pulmonary rehabilitation following discharge.
The findings were briefly discussed in relation to those coming from the randomised controlled trial14,16 The lack of previous studies investigating experiences and perceptions of people with COPD exercising while acutely unwell meant that we did not have preconceived judgements thereby allowing us to appropriately adopt the phenomenology approach to explore the lived experience of exercising while unwell.17
Participants Participants were recruited from a sample of people involved in the randomised controlled trial.14 Purposive sampling strategies were used to obtain rich and meaningful information from the interviews.17 Participants were included if they had been admitted to hospital with an acute exacerbation of COPD, recruited in the randomised controlled trial and allocated to the exercise groups and were able to attend an interview session following hospital discharge. Patients allocated to the control group in the randomised controlled trial were not invited to participate. Written informed consent to participate in the interview was obtained from each participant prior to commencement of the trial. The study received approval from the ethics committees of Eastern Health – Maroondah Hospital (E59-0809) and La Trobe University (FHEC 08/191).
Procedure Semi-structured interviews were used to obtain rich thick descriptions of the participants’ perception, experience and attitude towards the exercise programme.18 Participants were given an interview time prior discharge from hospital and a choice between face-to-face and phone interview, as each mode of interview has its merits.19 All interviews were completed within a week of discharge from hospital to increase the likelihood of participants having a clear recollection of the programme. Each interview was conducted by a clinician who had previous experience in conducting semi-structured interviews and did not have any previous contact with the participants. This allowed participants to be comfortable to express their unbiased opinions.
Methods
Intervention
This article reported on the findings of a qualitative study completed as part of a mixed-methods trial.
The exercise rehabilitation programme involved supervised twice-daily 15 minutes physiotherapy sessions
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Table 1. Interview guide. Topic area
Sample questions
Effects of exercise programme Aim to get participants to discuss any positive and negative outcomes of the programme Programme design Aim to get participants to discuss aspects of programme design that facilitated or hindered performance
‘‘Could you comment on whether you noticed any changes from your participation in the programme?’’
‘‘Could you discuss what you like or disliked about the programme? ‘‘Could you discuss how feasible the exercise programme was during your hospital stay?’’
Exercise performance Aim to get participants to discuss factors affecting their adherence
‘‘Could you describe anything that may have hindered your performance of the exercise programme?’’
Exercise maintenance Aim to get participants on factors affecting ongoing exercise performance
‘‘Has your involvement in this exercise programme changed your perception about exercising?
that included both resistance and aerobic training from the second day of admission to hospital till the day of discharge in addition to standard physiotherapy treatment. Full details of the programme are described elsewhere.14 Depending on allocation, participants were either required to exercise at a low intensity (40% maximal intensity) or at a moderate to high intensity (70% maximal intensity). Aerobic intensity was based on the results of 3-minute walk test at baseline, while strengthening intensity was based on repetitions maximum. All participants were given a copy of the exercise programme and a resistance band at time of discharge and were encouraged to continue their exercise programme at home.
Data analysis All interviews were audiotaped and transcribed verbatim. Credibility of the study was addressed by the use of member checking for all transcripts to maximise the accuracy of the responses. Once the transcribed transcript had been checked, all identifiable information was removed from the transcript and the participants were assigned a participant identity number to ensure anonymity. Qualitative software, NVIVO (QSR, Melbourne, Australia) was used to assist with the management of data. The process of assigning open codes was completed on all transcribed transcripts by two researchers independently (CYT and FCB). The codes provided an insightful meaning to the data and to establish any
new relationships within the common exercise experience.17 Codes were then analysed and compared, creating links between a category and subcategories. Finally, an analysis on all categories and subcategories was completed to find the main theme that linked all other categories together. The thematic analysis allowed us to formulate any possible themes from the interview transcripts without being influenced by any preconceived judgements. These themes were compared with the findings of the randomised controlled trial to explore for any convergence of the themes. Effort was made to improve rigor by establishing credibility, transferability, dependability and conformability of the data.17 For this study, the first author (CYT) had 7 years of clinical experience as a physiotherapist with patients admitted for acute exacerbation of COPD and supervised the physiotherapy sessions. The second author (NFT) had a physiotherapy background, worked at the affiliated university and had experience in qualitative research. The third author (FCB) had over 10 years of cardiorespiratory physiotherapy experience and worked at the affiliated university. The first and third authors completed coding. By having no direct contact with the participants, the third author was able to remain neutral to the coding process, thus reducing the potential of subjective prejudices from the first author. In addition, transferability and dependability of the study was ensured through the use of standard interview guides that had been agreed upon by the research team prior to interviews so as to ensure the same set of questions were asked of each participants (Table 1).
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Results Of the 21 participants invited for the study, 19 (90%) took part. Two participants declined to participate, as they felt too unwell to participate in the interview. The sample comprised 12 women and 7 men, who averaged 70 years of age. Based on the GOLD guidelines,20 participants were of a moderate severity (50–79% predicted forced expiratory volume in one second) in their COPD condition (Table 2). The average 3-minute walk test distance covered by participants who completed the exercise programme was 108 m (SD, 62 m) at base line (Table 2). This is approximately two-thirds of the average 3-minute walk test distance achieved by people with stable COPD status.21 All participants completed the exercise rehabilitation programme during their hospital admission. Fourteen (74%) participants had previously attended pulmonary rehabilitation or a community based exercise class (Table 2). Eighteen interviews were conducted via the phone. The median length of stay in hospital was 6.0 days (range 3–16 days), while the median length of time in the exercise programme was 5.0 days (range 2–15 days). The randomised controlled trial examining implementation of the exercise programme for patients (n ¼ 32) admitted with an acute exacerbation of COPD found the programme to be safe and feasible.14 Adherence to exercise was 83%, and from 174 exercise sessions, there was only one event classified as serious and in that case, symptoms had resolved within an hour and the person continued with their exercise at the next session. The exercise groups improved significantly in walking distance in the 3minute walk test; however, no significant betweengroup differences were observed.14 From analysis of the 19 transcribed interviews, one main theme (positive experience with exercise programme) and two sub-themes (increased motivation towards exercise at home and reluctance towards formal ongoing exercise programmes) emerged.
Main theme: positive experience with the exercise programme There was an overwhelming response from the participants, irrespective of the intensity of the exercise programme allocated, expressing that their experience with the exercise programme was positive and enjoyable: I thoroughly enjoyed the programme and I think I did quite well. You had people there with you showing
you what you do and it was great company at the same time. It was not a chore but a fun thing to do. (P11)
When participants were asked to explain why they had enjoyed the programme, participants expressed that the exercise programme kept them active while in hospital compared to their previous inpatient physiotherapy experiences. The presence of someone supervising and explaining the purpose of their exercises gave them a deeper understanding as to the importance of exercising and motivation to keep exercising. Participants also commented that they enjoyed the wider variety of exercises from what they had from previous admissions. In addition, participants also expressed that they liked having some control over the exercises, being given an option to stop exercising if they felt that they could no longer continue: The fact that I was actively exercising while in hospital made the difference. (P2) The fact that I can do them to the point that I cannot do anymore was good. The flexibility of knowing that I can sit down if I cannot do it anymore and just take a few minutes to catch my breath back was good. (P15) I was just so grateful that someone encouraged me throughout my hospital stay to exercise even though it might be hard at that time. (P15)
Participants overwhelmingly perceived the programme to be beneficial and motivational to continue to exercise: I think it was extremely useful to do the exercises while in hospital. (P2) It was very helpful. The exercises that were conducted improved my breathing quite substantially. (P5)
Participants also felt that the exercises were more relevant to them while they are acutely unwell as compared to their previous pulmonary rehabilitation experiences whereby they were exercising when they felt well. Participants did not report a negative experience with the programme or felt that the programme was ineffective. This finding converged with the quantitative data that indicated that it was safe to exercise, and a high percentage of physiotherapy sessions (83%) were completed among participants in the exercise groups with no significant differences between the two intensities of exercise, nor the control group and the exercise groups (Table 3).14
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68 59 78
84 82
58
87 81 78 55 68
83
69 78 67
60
63
3 4 5
6 7
8
9 10 11 12 13
14
15 16 17
18
19
F
F
F F F
F
M F F F F
M
F M
M M M
F M
54
20
45 34 40
76
52 67 40 58 Not available
15
36 23
69 67 54
37 65
FEV1% predicted
Yes
Yes
Yes Yes Yes
Yes No Yes Yes Yes (fail to complete) Yes
Yes
Yes Yes
No No No
No Yes
Low
Low
Low Low Mod
Mod
Low Mod Mod Low Mod
Low
Mod Mod
Low Low Low
Mod Mod
(67) (50) (100) (100) (75)
2/3 (67)
6/8 (75)
4/8 (50) 4/6 (67) 2/2 (100)
1/2 (50)
4/6 3/6 3/3 5/5 3/4
4/6 (67)
5/8 (63) 8/13 (63)
3/4 (75) 4/4 (100) 10/17 (59)
13/15 (87) 8/12 (67)
Completed/ total physiotherapy sessions (%)
155
140
110 45 165
93
100 81 88 125 15
40
77 52
157 270 180
155 158
Home
Home
Home Home Home
Home
Home Home Home Home Home
Home Inpatient rehabilitation Home
Home Home Home
Home Home
3-MWT at base Discharge line (m) destination
4
8
9 8 3
3
3 6 3 4 4
8
4 10
4 5 14
10 9
Length of stay in hospital (days)
Phone
Phone
Phone Phone Phone
Phone
Phone Phone Phone Phone Phone
Phone
Phone Face
Phone Phone Phone
Phone Phone
Mode of interview (phone/ face-toface)
No strict exercise programme but does increase walking distances Half hour every day No home exercises 6 hours intermittently a day including housework Not doing any programme until health is good again 20 minutes a day
Participating in pulmonary rehab, ad hoc exercises at home Doing squats everyday 10-15 minutes once a day Exercises 3 times a week Exercise twice a day No exercises
20 minutes per day Walking programme and once a day strengthening exercises Exercise once a day Exercises half hour a day 10 Minutes of bike, walking daily and 3 times a week of strengthening exercises Exercises whenever she remembers Daily exercises
Self reported home exercise programme
F: female; M: male; Low: 40% maximal intensity; Mod: 70% maximal intensity; 3-MWT: 3-minute walk test distance; FEV1: forced expiratory volume in one second.
75 54
1 2
Gender ID Age (F/M)
Intensity of Previous exercise pulmonary programme rehabilitation (Low/Mod)
Table 2. Demographic characteristics of participants.
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Table 3. Triangulation of qualitative and quantitative findings. Theme
Qualitative findings
Quantitative findings14
Triangulation
Positive experience with the exercise programme
Participants reported that the exercise programme was enjoyable and beneficial
Only one serious adverse event occurred out of the possible 218 physiotherapy sessions despite participants being required to exercise while acutely unwell.83% of the physiotherapy sessions completed by participants in the exercise groups.No significant between-group differences in percentages of completed physiotherapy sessions. Control vs. mod/high ¼ 19% (95%CI: 1–40%) Control vs low ¼ 12% (95%CI: 7–32%)
Convergent
Increased motivation towards ongoing exercise
Most participants reported commencement of home exercise programme post discharge for at least 30 minutes daily
Significant within-group improvements in 3-MWT distances in the low intensity (21 m; 95%CI: 11–30 m) and moderate to high intensity exercise groups (31 m; 95%CI: 10–52 m). Within-group improvements in 3-MWT in the control group (18 m; 95%CI: 7–44m)
Convergent
Reluctance towards ongoing formal exercise programme
Most participants reported that they were not interested to participate in community pulmonary rehabilitation
Significant within-group improvements in 3-MWT distance in both exercise groups
Divergent
3-MWT: 3-minute walk test.
However, perceptions from participants that symptoms and co-morbidities had hindered their ability to participate in the programme had emerged during the interviews: My muscles tend to really ache and cramp up quite a bit after the exercise programme and it took me a while after discharge to get rid of the muscle ache. (P18)
In the context of a positive experience, there were comments on challenges within the programme. An increase in provision of information regarding the benefits of exercise was felt to have enhanced the effectiveness of the programme. Comments about the frequency of exercising were also made whereby exercising twice a day was too often. It was also suggested that the duration of the exercise programme can be increased as participants felt that the short hospital stay had not allowed them to see the physical effects of the programme: I felt that two days were really short and if I had more time doing the exercises over a period of time, I believe that the exercises will improve my general mobility and also clear my lungs. (P3)
Sub-theme: increased motivation towards ongoing exercise Related to the overall positive feedback regarding the exercise programme, a sub-theme emerged, that participant’s attitudes towards ongoing exercise had changed because of their experience with the inpatient programme. Convergent with the significant within-group improvements in 3-minute walk test distances in both the exercise groups (Table 3), participants reported a positive change in attitude towards exercise after participation in the exercise programme: It had changed my attitude to keep going even if I am a little short of breathe or a little tired. (P15)
Participants also reported that they had commenced a home exercise programme, doing the exercises that they had learnt in hospital during their acute exacerbation at least once a day for approximately 30 minutes (Table 2).
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Sub-theme: reluctance towards ongoing formal exercise programmes From the quantitative data, the exercise programme seemed to have motivated participants towards ongoing exercising. However, when participants were asked whether they were interested in attending ongoing formal community exercise programmes such as pulmonary rehabilitation, few expressed an intention to attend. It emerged that participants preferred exercising at home: Basically I prefer not to work in a group. I prefer to do my own exercises and I have a pretty full schedule at the moment and may not have the time to attend an exercise programme. (P3)
Consistent with this sub-theme of preferring to exercise at home by themselves, participants expressed reasons such as lack of accessibility to community exercise programme in terms of parking access and distance from car to centre and the fear of travelling for not wanting to participate in community exercise programmes: It is not my thing to do community exercise programme. I am worried about the travelling time and how far is it for me to walk to the facility. (P12)
In addition, participants expressed that they felt that they knew the exercises from previous participation in pulmonary rehabilitation and this knowledge reduced their likelihood of participating in future pulmonary rehabilitation. Participants also felt that the exercises they had experienced in pulmonary rehabilitation were not challenging enough and did not like the burden of having to travel to the programme.
Discussion An overall positive experience among participants who had completed a very early exercise programme during their admission to hospital with an acute exacerbation of COPD was the main theme that emerged from this qualitative study. Participants who completed this exercise programme enjoyed the experience, despite being acutely unwell with potentially increased symptoms of dyspnoea. The programme appeared to reinforce the benefits of exercise to participants and motivated the majority of them to continue with an ongoing exercise programme after discharge. Most participants did not cite feeling unwell during their acute exacerbation as a barrier towards their
participation in the programme. Importantly, participants did express that participating in the exercise programme made them realise that they were able to exercise even when symptomatic. The above findings of the interviews converge with the reported adherence rates of 83%,14 indicating that the exercise programme was indeed feasible (Table 3). Participants reporting that the exercise programme was enjoyable and that their acutely unwell status was not a barrier to participating may help counter concerns that getting people with COPD to exercise is challenging, especially when they are unwell.10,12 Motivation to exercise at home on discharge appeared to be high in participants following the implementation of a very early exercise programme. The majority of the participants reported commencing a home exercise programme meeting the American Thoracic Society and the European Respiratory Society’s guideline of at least 30 minutes of moderate physical activity, 3–5 times a week following discharged from hospital (Table 2).22 The positive health behaviour with reported independent home exercise might be related to the participants’ perception of benefits from undergoing the exercise programme as inpatients. The perceived benefits of the programme reported by participants converge with the results of the quantitative trial, where significant within-group improvements in 3-minute walk test distance in the both exercise groups were observed.14 Considering that it has been demonstrated that physical activity levels for people with COPD decline to below population mean with a hospitalisation and remain below this mean 7 days after admission,6 reported increases in motivation to exercise once home is a significant positive effect of commencing a supervised exercise programme when acutely unwell. Personal and environmental factors can affect adherence to exercise in people with COPD.23 The main personal factors included lack of perceived benefits, negative experience towards exercises and more importantly, a perception of poor health status that leads to a perception of an inability to exercise.12,13,23–25 It seems that implementation of this early exercise programme may have addressed the personal factors affecting the level of adherence to exercise among COPD patients.14 It might be expected that the reported improvement in motivation towards exercise may increase uptake of community pulmonary rehabilitation post discharge. However, willingness to take up pulmonary rehabilitation post discharge remained low among our participants.
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A lack of transport and accessibility emerged from this study as the main deterrent for patients considering commencing community pulmonary rehabilitation. These results are consistent with literature finding accessibility issues as a consistent environmental factor affecting adherence to pulmonary rehabilitation.12,13,23 It is possible that environmental factors may have a larger influence than personal factors in influencing the willingness of people with COPD to participate in community pulmonary rehabilitation. No further follow-up was conducted in this study to find out whether participants did eventually attend pulmonary rehabilitation as the aim of the study was only to determine perceptions of exercise when acutely unwell. Further research into whether changed perceptions affects uptake of community pulmonary rehabilitation is warranted. Another theme that emerged as a reason for not intending to participate in pulmonary rehabilitation programme was the preference for independent home exercise over formalised exercise groups. Even though participants had expressed that they enjoyed the support that staff had given them during the exercise programme and felt that some supervision would benefit them with maintenance of their exercise programme, most participants reported preferring to exercise on their own either due to personal preference or being too ‘‘busy’’ to participate in a formal exercise programme. Utilising telecommunications to engage people with COPD with exercises at home while being supervised by a physiotherapist may eliminate issues such as transport and accessibility, addressing individual preference of exercising on their own.26,27
Strengths and limitations The short time between discharge and interview was both a strength and limitation of this study. The short time allowed participants to provide greater insights on their opinions about the programme. However, this also meant that we did not find out whether participants continued their exercise programme at home or whether they did change their mind regarding participation in community pulmonary rehabilitation. We were also unable to establish whether participants were completing the reported home exercise programme regimen. Also, interviewing those in the control group would have allowed us to describe differences in the perceptions about ongoing exercise and participation in community pulmonary rehabilitation programs and provided a clearer understanding of the impact the programme had on these perceptions.
Implications for future research or clinical practice This qualitative study in combination with the results from the randomised controlled trial has indicated that implementation of a very early exercise programme for people with an acute exacerbation of COPD requiring hospitalisation may not only be feasible and safe but also enjoyable, beneficial and improve attitudes towards independent exercise at home among people with COPD.14 However, despite these positive results, intention to participate in community pulmonary rehabilitation after discharge remained low. Exploration of long-term effects of exercise training for people with COPD who are acutely unwell is warranted, since changes in attitudes towards physical activity may be evident when a very early exercise programme is commenced. Conflict of Interest The authors declared no conflicts of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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