An action plan for increasing physical activity in patients with COPD

Primary care physicians can do much to improve the quality and length of life for patients with chronic obstructive pulmonary disease (COPD), and a key objective is increasing patients’ levels of physical activity. Physical activity spans from planned, structured exercise training to simple activities of daily living, such as walking and household chores.¹ Patients with COPD have considerably lower levels of physical activity than sedentary, healthy, age-matched individuals.² Furthermore, in a 20-year follow-up of patients with COPD, exercising for more than
2 hours per week was linked to a 30% to 40% reduced risk of COPD-related hospitalization or respiratory mortality.³

Primary care physicians regularly interact with patients with COPD and have a real opportunity to substantially reduce their disease burden. This goal can be achieved by emphasizing the importance of physical activity to patients, treating symptoms that impair patients’ ability to be active, and encouraging patients to increase their physical activity levels and intensity through tailored goal setting as well as addressing their personal barriers to physical activity.

The American College of Sports Medicine and the American Heart Association guidelines on physical activity recommend that adults undertake a minimum of 30 minutes of moderate exercise a day, 5 days a week. Patients with COPD become less physically active significantly earlier in their lives than sedentary, healthy, age-matched controls (median age of 45 years vs 55 years, respectively).⁴ In one study, only 29% of 73 patients with COPD achieved the recommended 30 minutes of moderate exercise when physical activity throughout the day was reviewed.⁵ Activity levels are often reduced during the early stages of COPD.⁶ Inactivity in patients with COPD results from a combination of factors: symptoms of COPD and its comorbidities, lung function impairment, and fatigue of the peripheral muscles.¹

One of the most common and distressing symptoms that patients with COPD report is breathlessness or labored breathing.⁷ Breathlessness substantially limits physical activity as the disease progresses, and patients with COPD often subconsciously avoid physical activity in order to avoid breathlessness.⁷ In addition, nearly 80% of patients with COPD have one or more comorbid conditions, such as coronary artery disease or arterial hypertension.⁸

Patients with mild-to-moderate COPD report general reasons for limited physical activity, such as a change in the season, whereas patients with severe COPD find that physical disease-specific factors (such as breathlessness and lung hyperinflation) are the main reasons for their physical inactivity.⁹

Increasing breathlessness, indicated by an increase in modified Medical Research Council Dyspnea Scale grade (TABLE 1),¹⁰ can lead to further reductions in the already low physical activity levels of patients with COPD.⁶ Patients who experience physical activity–related breathing discomfort will often begin to avoid exercising, which, in turn, leads to muscle deconditioning.⁷ Patients with COPD may enter a downward spiral of inactivity as breathlessness worsens (FIGURE 1),¹¹ leading to disease progression as breathing problems are experienced at increasingly lower levels of exertion.¹¹ Patients with severe COPD often struggle with even basic tasks (eg, activities of daily living, such as getting dressed in the morning).¹

Figure 1. The downward spiral of breathlessness

Psychological symptoms of COPD can alter patients’ perceptions of breathing discomfort, so that they are no longer in proportion with their objective level of lung function impairment.¹¹ Limited physical activity levels may also lead to feelings of anxiety and depression, further reducing activity levels and quality of life.^1,12 If patients with COPD become isolated, they may lose the motivation to remain active, and experience intensified symptoms of depression.¹²

Patients with COPD are often unable or unwilling to undertake physical activity after an exacerbation.¹³ The greater the decrease in activity (measured by a change in daily step count), the longer it takes patients to regain their normal activity levels.¹³ Patients with frequent COPD exacerbations also experience more rapid declines in exercise capacity over time than patients who experience fewer exacerbations.¹³

Reduced physical activity is closely associated with diminished health-related quality of life. A lower step count increases the risk of acute exacerbations and COPD-related hospitalizations, independent of forced expiratory volume in 1 second (FEV₁) levels and previous exacerbation history.¹⁴ Physical activity is the strongest predictor of all-cause mortality in patients with COPD when compared with other established predictors of mortality, such as FEV₁, dyspnea, cardiovascular health, and systemic inflammation.¹⁵

Primary care physicians can take a pragmatic approach to increasing physical activity levels in patients with COPD by asking patients appropriate questions about their physical activity levels at initial and follow-up consultations, discussing the pharmacologic and nonpharmacologic treatments available, and motivating patients to undertake more exercise/daily activity (FIGURE 2).

Figure 2. A patient-centered action plan for increasing physical activity in COPD

Initially, COPD should be confirmed using the latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.¹⁶ A possible diagnosis should be confirmed using spirometric measurement of airflow obstruction (postbronchodilator FEV₁/forced vital capacity ratio of 0.7).¹⁶ Published COPD clinical practice guidelines highlight that patients should be questioned directly about their activity levels, rather than their symptoms alone, to identify which patients are limiting their activities to avoid experiencing symptoms.¹⁷ In support of this recommendation, a study found that age and lung-function-matched patients with COPD who were concerned about experiencing breathlessness walked significantly fewer steps per day than those with COPD who were not concerned (difference: 1329 steps).¹⁸

To assess physical activity limitation, begin by discussing key questions with patients to gather information (TABLE 2). Establishing baseline physical activity levels enables further discussion to determine activity goals (eg, improving walking times or re-engaging in a valued activity). You and your patients must come to an understanding of which goals are achievable, and should evaluate these goals at follow-up appointments.¹⁹

GOLD and the COPD Foundation recommend that all patients with COPD increase their physical activity levels.^16,20 Physical activity for patients with COPD is still underappreciated by many primary care physicians and by many of their patients, as well. A number of therapeutic options are available to reduce symptom severity and improve exercise capacity in patients with COPD.^21-23

Bronchodilators are recommended for maintenance treatment of patients with COPD, with the primary focus on improving airflow limitation (as measured by FEV₁).¹⁶ Depending on an individual’s symptom burden and risk of exacerbation, a patient with COPD may be prescribed a single bronchodilator (short-acting muscarinic antagonists or long-acting muscarinic antagonists [LAMAs], or short acting β2-agonists or long-acting β2-agonists [LABAs]), a dual bronchodilator (LAMA/LABA), or even triple combination therapy (LAMA/LABA/inhaled corticosteroids [ICS]). Clinical evidence suggests that treatment with fixed-dose LAMA/LABA combinations is more efficacious for improving lung function than monotherapy with LAMAs or LABAs.²⁴

A network meta-analysis of 8 studies showed that LAMAs were more effective than LABAs for improving both hyperinflation and exercise tolerance in patients with COPD, and that LAMA/LABA combinations were superior to monotherapy with either component.²⁵ However, it is important to distinguish that exercise tolerance is a clinical measure of what patients can do, but this value may not be a true measure of their actual levels of activity. Encouraging patients to keep up their daily activities can have a substantial positive impact on their lives.

ICS have been shown to reduce exacerbation risk.²⁶ However, patients with COPD show variable responses to ICS,²⁷ and the GOLD 2019 guidelines recommend selecting bronchodilators over ICS for maintenance treatment of patients with frequent exacerbations, except for patients who may have asthma–COPD overlap.¹⁶ Nonetheless, in the TRIBUTE and IMPACT studies, which recruited patients with symptomatic COPD, ICS/LAMA/LABA treatment significantly decreased the moderate-to-severe exacerbation rate compared with LAMA/LABA treatment.^28,29 Triple therapies are commonly prescribed for frequent exacerbations.²⁷

Pulmonary rehabilitation is a therapeutic regimen that is tailored to each individual patient.²² Pulmonary rehabilitation programs may include exercise training, self-management education, psychosocial support, advice on smoking cessation, and advice on appropriate diet.^16,22 American Thoracic Society/European Respiratory Society guidelines recommend that pulmonary rehabilitation should be combined with other treatments (pharmacotherapy, noninvasive ventilation, or oxygen therapy) as the standard of care for patients with COPD.³⁰

Formal hospital-based pulmonary rehabilitation programs that include an exercise component provide clinically significant improvements in patients’ outcomes, such as health-related quality of life, symptom severity, and physical activity capacity.²² Furthermore, completion of pulmonary rehabilitation and a clinically significant improvement in the ability to exercise after participating in a pulmonary rehabilitation program are both associated with significantly improved survival (exponential for B 1.56 [95% CI, 1.238–1.967, P <.001] and 0.996 [95% CI, 0.994–0.998, P =.018], respectively).³¹ The improved outcomes observed after pulmonary rehabilitation are likely to result from changes in patients’ perceptions of activities associated with breathlessness, rather than improvements in lung function.³² In the United States, Medicare Part B covers pulmonary rehabilitation for patients with moderate-to-very severe COPD who are referred by their doctor.³³

However, a referral for pulmonary rehabilitation may not be effective for some patients for several reasons. For example, a patient’s physician may choose not to prescribe pulmonary rehabilitation, or a facility offering pulmonary rehabilitation may not be available in the patient’s community.^30,34 Even when patients are referred for pulmonary rehabilitation, 32% of patients do not initiate treatment and 29% abandon the program before completion.³⁵ The benefits of pulmonary rehabilitation are lost if patients who complete the program return to their former levels of inactivity.³⁴ Programs that encourage increased physical activity in the patient’s own setting, including walking and home exercise programs, are often sustainable and therefore may yield long-term benefits.^36,37 For example, a patient may be encouraged to complete a daily walking diary and slowly increase the time spent exercising each day.³⁸ Strengthening exercises may also be adapted for use in a home environment by using household objects, such as milk containers, for hand weights.³⁸ All patients diagnosed with COPD should be offered some form of pulmonary rehabilitation or home exercise program, regardless of their disease severity.

A physical therapist who has experience working with patients with COPD can help to establish a sensible home-based exercise program in the absence of any formal pulmonary rehabilitation program. It is important to identify what forms of exercise would be most beneficial for patients who cannot access formal pulmonary rehabilitation programs. Activities that these patients could perform once a day or several times a week should be selected, such as gardening, swimming, or playing golf. In addition, it is advisable to encourage patients to choose activities they find most enjoyable to motivate sustained exercise for the long term. For patients who are unable to engage in a formal pulmonary rehabilitation program, walking is likely to be the most useful exercise. Patients with COPD should be given the goal of walking at least 5000 steps per day to avoid the negative outcomes associated with physical inactivity.³⁹ Community recreational facilities often provide access to exercise programs or equipment at a reduced cost or free to older people, regardless of whether they have a chronic health condition.

In a clinical study combining 8 weeks of pulmonary rehabilitation with pharmacologic treatment (tiotropium) or placebo, the tiotropium combination reduced breathlessness severity and increased exercise tolerance both at program completion and during the 3 months after program completion, compared with placebo plus pulmonary rehabilitation.⁴⁰ The authors concluded that the addition of a bronchodilator prolonged the benefits of the pulmonary rehabilitation program.⁴⁰

The most challenging aspect of managing COPD for primary care physicians is knowing what to say to patients to encourage them to be physically active: Simply providing medications and advising the patient to do more exercise is not enough. Patients with COPD are often exercise avoidant, and recommendations to increase physical activity can fail because patients are not sufficiently motivated.³⁴ Furthermore, patients may initially benefit from pulmonary rehabilitation programs, but lose motivation to remain physically active once they have completed these programs.³⁴ If you are able to fully engage with patients, you will be more successful at motivating these patients to commit to a program of sustained pulmonary rehabilitation, and therefore, increase their physical activity. Even within the time limitations of primary care practice, motivational interviewing, goal setting, and feedback can be powerful tools when used strategically to help motivate patients (FIGURE 2). For example, patients who like and trust their physicians and are involved in treatment decision-making are more likely to feel able to adhere to treatment.⁴¹ Developing an individualized approach to patient motivation is best captured by the concept of patient-centered care. This concept embraces the trust established between the physician and patient, in which the physician demonstrates genuine interest in and concern about the patient.⁴¹

The principles of motivational interviewing can be applied to a number of scenarios in which primary care physicians are looking to elicit behavioral change in their patients.^42,43 Motivational enhancement draws from, but is not the same as, motivational interviewing; it incorporates a feedback element, in which a patient and their physician engage in an outcome evaluation over the course of a treatment period.⁴⁴ Both motivational interviewing and motivational enhancement follow 4 important strategies: open-ended questions, affirmations, reflective listening, and summary statements.⁴⁴ These strategies can be applied in clinical practice for COPD management (FIGURE 3), and have been successfully applied to dyspnea management.⁴⁵

Figure 3. Practical suggestions for patient motivation and encouragement

It is imperative that primary care physicians help their patients who have COPD with goal setting, regardless of whether these patients have been enrolled in pulmonary rehabilitation or a less formal exercise training program. For many, goal setting is an effective way to personalize programs and reinforce successes, making the benefits of pulmonary rehabilitation or exercise training more salient and relevant to the patient. An example of personalizing programs is by encouraging patients to select the activities they most enjoy, thereby motivating sustained exercise. In a study investigating a patient-centered walking program for patients with COPD, patients were randomized to a goal-setting group or a control group.³⁴ Patients in the goal-setting group received the same level of contact and support from study staff, but also interacted with a wellness coach to discuss goal setting.³⁴ In the goal-setting group, the wellness coach used a motivational interviewing strategy to support patients to set their own personally meaningful goals relating to physical activity.³⁴ In each of the biweekly telephone calls, the wellness coach and patient discussed the patient’s perception of his or her progress toward achieving their goal, and determined any barriers that the patient thought could prevent them from accomplishing it. If required, the wellness coach also helped the patients to modify their goal or set a new goal. Over the 12-week study period, patients in the goal-setting group significantly increased the number of steps per day compared with patients in the control group. Furthermore, patients who achieved one of their goals in the patient-centered walking program walked more often than patients who did not achieve any of their goals.³⁴ Physicians can engage in similar wellness coaching in primary care practice, helping their patients by encouraging them to set their own goals.

Providing regular feedback improves treatment adherence. In the COPD walking study, feedback in the goal-setting group included use of results from individual pedometers to foster an encouraging discussion with each patient.³⁴ Feedback and positive reinforcement are powerful elements of a behavior-change program, and can lead to improvement in patients’ confidence in their ability to change.^34,46 Activity monitors, such as pedometers or other commercially available fitness trackers, can help increase positive health behavior,⁴⁶ but are most effective when combined with in-person coaching.³⁴

Conclusions

Improving physical activity levels is critical to increasing the quality and length of life for patients with COPD. As a primary care physician, you can be instrumental in decreasing the burden of disease by assessing physical activity levels, treating symptoms that can impair patients’ ability to be physically active, and encouraging patients to exercise. Pharmacologic therapies show promise in reducing activity-limiting symptoms, thereby improving patients’ capacity to exercise. Pulmonary rehabilitation and less formal exercise programs can also be effective in increasing exercise capacity, but many patients lose motivation once completing these programs. Even within the time limitations of primary care practice, motivational interviewing, goal setting, and feedback can be powerful tools when used strategically to encourage these patients.

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