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OPTIMIZING ASSESSMENTOPTIMIZING ASSESSMENTAND OUTCOME FOLLOWINGAND OUTCOME FOLLOWING

AECOPDAECOPD

PhD candidate: Fatim Tahirah

Supervisors: A/Prof Sue JenkinsDr. Kylie Hill

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Chronic bronchitis

the presence of a chronic productive

cough for 3 months during each of 2

consecutive years.

Emphysema

abnormal, permanent enlargement of

the air spaces distal to the terminal

bronchioles, accompanied by destruction

of walls.

Chronic Obstructive Pulmonary Disease

(COPD)

preventable and treatable disease with

some significant extra pulmonary effects(airflow limitation and abnormal

inflammatory response to noxious

particles or gases) that may contribute

to the severity in individual patients.

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Acute Exacerbation: worsening of the patients condition, from the stable state and beyond normal

day-to-day variations, that is acute in onset and necessitates a change in regular medication

Admission rate 2005-2009 60529 hospital stays for COPD

and 7832 (12.9%) are AECOPD

Ozkaya et al. (2011) : Turkey

2008 822500 hospital stays for COPD

and 514000 (62.5%) are AECOPD

Wier et al. (2011): USA

Length of

hospital stay

(days)

Median 8 Roberts et al. (2002): UK

9 (range 5-15) Connors et al. (1996): USA

14.89.5 Ozkaya et al. (2011) : Turkey

mean 4.7 Wier et al. (2011): USA

Strict protocol 10 Troosters et al. (2010): Belgium

Cost per

exacerbation

mean US$ 718364 Ozkaya et al. (2011) : Turkey

$7500 Wier et al. (2011): USA

median $7100 (ranging from $4100-16000)

Rodriguez-Roisin et al. (2000):USA + Europe

SEK 940 (SEK 224-SEK 13708) =

$142.2 ($34-$2074)

Andersson et al. (2002): Sweden

Mortality rate Died in the

hospital

2.3% Ozkaya et al. (2011) : Turkey

1.8% Wier et al. (2011): USA

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1. Gosker et al. (2007), 2. Spruit et al. (2003), 3. Pitta et al.(2006), 4. Decramer et al. (1996), 5. Donalson et al. (2004), 6. Hurst et al. (2008), 7. Roberts et al. (2002), 8. Rodriguez-roisin et al. (2000)

Statement of Problem

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In clinical practice physiotherapy role at exacerbation is limited

only to chest and there are very limited studies looking atexercise training and functional outcome during exacerbation.

Recently, Troosters et al. (2010) found that strength training

are feasible (85% complete the rehabilitation course)and safeto begin as early as day 2 hospitalization. (Limitation: biased

between group intervention & inappropriate OM)

Thus, this study aim to optimize the recovery and proposed aspecific outcome measure during AECOPD.

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AIMS

To proposed 2MWT as the main outcome measure during

hospitalized Acute Exacerbation of COPD by;i.comparing the cardiorespiratory and symptom responsesduring 2MWT with 6MWT in patients with stable COPD

ii.exploring the measurement properties of 2MWT; concerningon test-retest repeatability and test learning effects.

iii.developing a reference value for 2MWD among healthysample of Malaysian population

To proposed a combined treatment of resistance and endurancetraining as the best practice during a hospital admission for an

acute exacerbation of COPD by;i.undertaking a randomised controlled trial (RCT) to compare theeffects of a comprehensive exercise training program (resistance+ walking training) on quadriceps muscle force, functionalexercise capacity, functional activities and daily physical activity.

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OPTIMIZING ASSESSMENTOPTIMIZING ASSESSMENTAND OUTCOME FOLLOWINGAND OUTCOME FOLLOWING

AECOPD :Part 1aAECOPD :Part 1a

Comparison of theComparison of theCardiorespiratory and SymptomCardiorespiratory and Symptom

Responses of 2MWT and 6MWT inResponses of 2MWT and 6MWT in

Patients with COPDPatients with COPD

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VE during 6MWT

Clear VE plateau after the 3rd minute of

6MWT

indicating that a high intensity

constant-load exercise was performed

in the first 3 min

2MWT: an alternative to 6MWT

during AECOPD

Troosters et al. (2002)

1.Cardiorespiratory responses to 6MWT

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Patients walked further during the 2MW than during any 2M segment

of the 6MW

Distance decreased during the latter two intervals of the longer test

2MWT: an alternative to 6MWT

during AECOPD

2.Pacing in 2MWT

Guyatt et al. (1984)

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3. Uptake of timed walking tests by clinicians during AECOPD

2MWT: an alternative to 6MWT

during AECOPD

Harth et al. (2009)

A prospective cross-sectional postal

survey across Canada between Jan

and June 2007 (n=109)

completed by the PT predominantly

involved in managing patients

hospitalized with an AECOPD

Measures of functional exercise

capacity were used always or

frequently by 16% for 6MWT

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MethodologyComparison of the Cardiorespiratory and Symptom Responses of2MWT and 6MWT in

Patients with COPD

Study design Single group observational study

: Patients will attend two testing sessions of 2hours duration each

Setting Stable COPD attending Pulmonary Rehabilitation Programs conducted in

metropolitan Perth that are under the jurisdiction of the Human Research

Ethics Committee (HREC) of Sir Charles Gairdner Hospital (SCGH).

Procedures

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Measures Heart rate will be continuously monitored using a Polar Heart Rate monitor (Polar a1, Polar

Electro Oy, Kempele, Finland). A finger sensor attached to a pulse oximeter will be used to

measure SpO2 (Masimo Rad-5v, Masimo Corporation, California, USA). Both dyspnoea and leg

fatigue will be measured using the modified Borg category ratio scale4.

Ethicalissues

Approval will be sought from the Human Research Ethics Committees (HRECs) at Sir CharlesGairdner Hospital and Curtin University. All subjects will be required to give written, informed

consent prior to data collection

Data

analysis

Statistical analyses will be performed using SPSS software (Version 19, SPSS Inc., Chicago, IL,

USA). P-values 0.05 will be regarded as statistically significant. The distribution of data will be

explored using frequency histograms and Shapiro-Wilks test. Data that are not normally

distributed will be either transformed or analysed using non-parametric statistics. Data will be

expressed as mean standard deviation (SD) or median and interquartile range.

cardiorespiratory and symptoms response will be expressed as mean SD or median and

interquartile range. Where possible, the 95% confidence intervals will be report.

cardiorespiratory and symptom responses measured both within tests and between tests will

be compared using either paired t-tests (for normally distributed data) or Wilcoxon tests (for

data that is not normally distributed).

measures of 2MWD over the three tests will be compared using a repeated measures analysis

of variance.

the bias and coefficient of repeatability will be determined using the best 2MWD measured

during the first testing session and the 2MWD measured during the second testing session.

Specifically, the bias will be defined as the average difference between the 2MWDs measured

across the two days and the coefficient of repeatability will be defined as twice the standard

deviation of the difference in 2MWDs measured across the two days.

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References1 Butland RJ, Pang J, Gross ER, et al. Two-, six-, and 12-minute walking tests in respiratory disease. Br Med J (Clin Res Ed)

1982; 284:1607-1608

2 Guyatt GH, Pugsley SO, Sullivan MJ, et al. Effect of encouragement on walking test performance. Thorax, 1984; 818-822

3 Bernstein ML, Despars JA, Singh NP, et al. Reanalysis of the 12-minute walk in patients with chronic obstructivepulmonary disease. Chest 1994; 105:163-167

4 Eiser N, Willsher D, Dore CJ. Reliability, repeatability and sensitivity to change of externally and self-paced walking

tests in COPD patients. Respir Med 2003; 97:407-414

5 Leung AS, Chan KK, Sykes K, et al. Reliability, validity, and responsiveness of a 2-min walk test to assess exercisecapacity ofCOPD patients. Chest 2006; 130:119-125

6 Jenkins S, Cecins NM. Six-minute walk test in pulmonary rehabilitation: do all patients need a practice test?Respirology 2010; 15:1192-1196

7 Troosters T, Vilaro J, Rabinovich R, et al. Physiological responses to the 6-min walk test in patients with chronic

obstructive pulmonary disease.Eur Respir J 2002; 20:56

4-56

9

8 Casas A, Vilaro J, Rabinovich R, et al. Encouraged 6-min walking test indicates maximum sustainable exercise in COPDpatients. Chest 2005; 128:55-61

9 Harth L, Stuart J, Montgomery C, et al. Physical therapy practice patterns in acute exacerbations of chronic obstructivepulmonary disease. Can Respir J 2009; 16:86-92

10 Demers C, McKelvie RS, Negassa A, et al. Reliability, validity, and responsiveness of the six-minute walk test in

patients with heart failure.

Am Heart J2

001; 142

:698

-703

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BORG Scale Patient particulars form

Appendices

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2MWT Test Protocol6MWT Test Protocol

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Ethics approval

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Thank you

To be continue