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Physical activity following pulmonary rehabilitation in COPD

Systematic review of the facilitators and barriers to physical activity after pulmonary rehabilitation

Hayley Robinson, University of Lincoln and Veronika Williams, University of Oxford

Pulmonary rehabilitation improves quality of life and exercise capacity in the short term. However, we are less clear on how to maintain these improvements over time. To understand the patients’ perspective of the barriers and facilitators of physical activity after pulmonary rehabilitation, researchers conducted a systematic review of qualitative studies. The results suggest that the main facilitators and barriers to patients’ maintenance of physical activity were centred around patients’ beliefs, social support and environment. The findings have important implications for future research in this area. 

Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung condition affecting more than 3 million people in the UK. The condition is associated with persistent cough, breathlessness (particularly on exertion), fatigue, worsening mental health and higher unplanned hospital admission rates.

Since there is no cure for COPD, treatment focuses on limiting the impact of symptoms and maintaining functional ability. There is evidence that pulmonary rehabilitation – typically a 6-8 week outpatient course which includes physical activity, education and relaxation techniques – improves quality of life and exercise capacity in the short term. However, we are less clear on how to maintain these improvements over time, and what the barriers and facilitators are to physical activity uptake in the longer term.

In order to answer this, we undertook a qualitative systematic review, published in npj Primary Care Respiratory Medicine.

What did we find?

Our main objective was to identify the main barriers and facilitators to physical activity from the patient’s perspective. We screened 2392 papers and included 14 primary qualitative studies in the synthesis.

We found that the main facilitators to patients’ maintenance of physical activity were centred around patients’ beliefs, social support and environment.

Forming routines and habits were key to continuing physical activity post rehabilitation. Part of this included opportunities to access physical activity maintenance groups. Continued peer interaction, the sense of accomplishment gained through self-monitoring and feedback, also appear crucial.

Other important factors included: the strength of relationships with healthcare professionals; pre-existing exercise regimes (prior to COPD diagnosis); self-efficacy and social support. Although intention to maintain physical activity can be a factor in continuing physical activity regimes, positive intentions did not always translate into behaviour change highlighting an intention-behaviour gap.

What does this mean?

Our findings suggest that physical activity behaviours post pulmonary rehabilitation are complex, and a single ‘one size fits all’ approach to increasing uptake is unlikely to be successful.

Instead, we should consider individually tailored approaches to support long-term behaviour change, taking into account patients’ existing routines and beliefs, as well as external factors, such as access to activity maintenance programmes.

Social support appears to be important for motivating patients to stay active, and findings suggest that support from both peers and health care professionals can play a key role in maintaining patients’ physical activity levels. This may be supplemented by harnessing the potential of digital health apps to monitor and provide feedback on patients’ improvements.

Our findings also have implications for future research in this area. In particular, how we assess long-term behaviour change after pulmonary rehabilitation – highlighting the need for high quality mixed-methods evaluations of complex interventions. Such methodological approaches will allow us to understand, not only if such interventions are effective, but also how they are best implemented into routine patient care.

Robinson, H., Williams, V., Curtis, F., Bridle, C. and Jones, A.W., 2018. Facilitators and barriers to physical activity following pulmonary rehabilitation in COPD: a systematic review of qualitative studies. NPJ primary care respiratory medicine, 28(1), p.19. https://rdcu.be/SFDH