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Papers by Roger Goldstein

Swiss Medical Weekly

Pulmonary rehabilitation comprises a variety of interventions grouped into three main categories:... more Pulmonary rehabilitation comprises a variety of interventions grouped into three main categories: exercise training, education, and psychological support. Typically, patients participate in a programme of exercise rehabilitation 2-3 times a week for 6-12 weeks, at the same time being encouraged to incorporate breathing and stretching exercises as part of their daily routine. The physiological rationale for pulmonary rehabilitation in COPD is primarily based on its effect on peripheral muscle dysfunction. A recent meta-analysis demonstrated that pulmonary rehabilitation is effective in reducing dyspnoea and fatigue as well as improving patients' sense of control (mastery) over their condition. Without compliance with a maintenance programme these improvements will diminish with time. The value of various components of rehabilitation, programme length, the required degree of supervision, the intensity of training and the best approach to maintaining programme adherence represent issues that remain to be explored.

Differences in content and organisational aspects of pulmonary rehabilitation programmes

Chronic respiratory disease, 2017

We described physical activity measures and hourly patterns in patients with chronic obstructive ... more We described physical activity measures and hourly patterns in patients with chronic obstructive pulmonary disease (COPD) after stratification for generic and COPD-specific characteristics and, based on multiple physical activity measures, we identified clusters of patients. In total, 1001 patients with COPD (65% men; age, 67 years; forced expiratory volume in the first second [FEV1], 49% predicted) were studied cross-sectionally. Demographics, anthropometrics, lung function and clinical data were assessed. Daily physical activity measures and hourly patterns were analysed based on data from a multisensor armband. Principal component analysis (PCA) and cluster analysis were applied to physical activity measures to identify clusters. Age, body mass index (BMI), dyspnoea grade and ADO index (including age, dyspnoea and airflow obstruction) were associated with physical activity measures and hourly patterns. Five clusters were identified based on three PCA components, which accounted f...

Respiratory medicine, Jul 1, 2017

Increasing symptoms and activity restriction associated with COPD progression greatly impact on t... more Increasing symptoms and activity restriction associated with COPD progression greatly impact on the lives of their informal caregivers, who play a vital role in maintaining their health. An understanding of this impact is important for clinicians to support caregivers and maintain a viable patient environment at home. This systematic review aimed to identify the instruments commonly used to assess informal caregiving in COPD and describe their measurement properties in this population. Searches were conducted in PubMed, Scopus, Web of Science, CINAHL and PsycINFO and in references of key articles, until November 2016 (PROSPERO: CRD42016041401). Instruments used to assess the impact of COPD on caregivers were identified and their properties described. Quality of studies was rated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Quality of the measurement properties of instruments was rated as 'positive', 'negative...

Multidisciplinary Respiratory Medicine, 2015

This article is related to meeting report part 2 [8th International Conference on Management and ... more This article is related to meeting report part 2 [8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure: the Long Summaries-Part 2], available here dx.

Respiratory Medicine, 2005

Objectives: To determine the efficacy of oral theophylline compared with placebo in people with s... more Objectives: To determine the efficacy of oral theophylline compared with placebo in people with stable chronic obstructive pulmonary disease (COPD). Methods: Systematic review of randomized-controlled trials comparing oral theophylline with placebo for a minimum of 7 days in people with stable COPD. Results: Twenty randomized-controlled trials were included in this review. The following outcomes showed significant improvement with theophylline compared with placebo: FEV 1 and FVC both improved with theophylline (weighted mean difference [WMD] 0.10 L; 95% confidence interval [95% CI] 0.04-0.16 and WMD 0.21 L; 95% CI 0.10-0.32, respectively). VO 2 max also improved with theophylline (WMD 195.27 mL/ min; 95% CI 112.71-277.83), as did PaO 2 and PaCO 2 (WMD 3.18 mmHg; 95% CI 1.23-5.13 and WMD À2.36 mmHg; 95% CI À3.52 to À1.21, respectively). Patients preferred theophylline over placebo (relative risk 2.27; 95% CI 1.26-4.11). Theophylline increased the risk of nausea compared with placebo (RR 7.67; 95% CI 1.47-39.94).

COPD, 2007

Patients with chronic obstructive pulmonary disease (COPD) frequently describe limitations in fun... more Patients with chronic obstructive pulmonary disease (COPD) frequently describe limitations in functional performance. These limitations predict mortality, adversely affect health-care burden and impair health-related quality of life. The optimal method for quantifying the functional performance in COPD subjects has not been established. This paper discusses the (i) nature of limited functional performance reported by individuals with COPD, (ii) mechanisms that contribute to these limitations, (iii) assessment techniques available to provide markers of functional performance and (iv) areas for further research in measuring functional performance of COPD subjects.

Chronic respiratory disease, 2011

The purpose of this review was to determine the impact of duration of pulmonary rehabilitation on... more The purpose of this review was to determine the impact of duration of pulmonary rehabilitation on measures of health-related quality of life and exercise tolerance in individuals with chronic obstructive pulmonary disease (COPD). Randomized controlled trials (RCTs) comparing different lengths of pulmonary rehabilitation in patients with COPD were identified after searches of six electronic databases (MEDLINE, PubMed, CINAHL, EMBASE, Physiotherapy Evidence Database [PEDro] and the Cochrane Library of clinical trials) and reference lists of pertinent articles. Two reviewers performed the searches and assessed trial quality using PEDro and Jadad scales. Five RCTs met inclusion criteria. The mean PEDro score was 6 (range 3-8) and mean Jadad was 2 (range 1-3). Three trials reported a difference in health-related quality of life in favour of the longer duration program; two trials reported a benefit in exercise capacity in favour of longer programs. A meta-analysis of results was not poss...

Thorax, 2010

Rationale The SenseWear armband (SAB) is designed to measure energy expenditure (EE). In people w... more Rationale The SenseWear armband (SAB) is designed to measure energy expenditure (EE). In people with chronic obstructive pulmonary disease (COPD), EE estimated using the SAB (EE SAB) is a popular outcome measure. However, a detailed analysis of the measurement properties of the SAB in COPD is lacking. Objective To examine the sensitivity of EE SAB , agreement between EE SAB and EE measured via indirect calorimetry (EE IC), and its repeatability in COPD. Methods 26 people with COPD (forced expiratory volume in 1 s (FEV 1)¼49618% predicted; 15 males) spent 6 min in five standardised tasks that comprised supine, sitting, standing and two walking speeds. A subgroup (n¼12) walked using a rollator. Throughout each task, measurements of EE SAB and EE IC were collected. The protocol was repeated on a second day. Results EE SAB increased between standing and slow walking (2.4, metabolic equivalents (METs) 95% CI 2.2 to 2.7) as well as slow and fast walking (0.5 METs, 95% CI 0.3 to 0.7). Considering all tasks together, the difference between EE SAB and EE IC was À0.2 METs (p¼0.21) with a limit of agreement of 1.3 METs. The difference between days in EE SAB was 0.0 METs with a coefficient of repeatability of 0.4 METs. Rollator use increased the variability in EE SAB , compromising its repeatability and agreement with EE IC. Conclusions EE SAB was sensitive to small but important changes. There was fair agreement between EE SAB and EE IC , and measurements of EE SAB were repeatable. These observations suggest that the SAB is useful for the evaluation of EE in patients with COPD who walk without a rollator.

Respiratory Medicine, 2007

Background: Selection of heath-related quality of life (HRQL) instruments that are most responsiv... more Background: Selection of heath-related quality of life (HRQL) instruments that are most responsive to changes in HRQL prevents investigators from drawing falsenegative conclusions about the effectiveness of an intervention. The objective of this study was to compare the responsiveness of the Chronic Respiratory Questionnaire (CRQ), the St. Georges Respiratory Questionnaire (SGRQ) and four other HRQL instruments.

Respiratory Medicine, 2009

Background: Preliminary evidence suggests individuals with COPD exhibit deficits in balance. Furt... more Background: Preliminary evidence suggests individuals with COPD exhibit deficits in balance. Further investigation of balance and risk of falls is warranted in these patients. The objective of this study was to determine the clinical measures that discriminate fallers from non-fallers among patients with COPD. Methods: A cross-sectional study design was used. Subjects > 60 years with COPD attended a single assessment session. A one-year incidence of falls was collected via self-report questionnaire. Risk of falls and balance were determined using the Berg Balance Scale (BBS), Timed Up and Go Test (TUG) and the Activity-Specific Balance Confidence (ABC) Scale. Exercise tolerance was determined from the Six-Minute Walk Test and functional limitation attributable to dyspnea from the Medical Research Council (MRC) dyspnea scale. Results: Of the 39 COPD subjects (FEV 1 Z 41.5 AE 17.0% predicted; age: 71.1 AE 6.8 years) who completed the study, 46% (n Z 18) reported at least one fall in the preceding year. Significant differences between fallers and non-fallers were found for the ABC (65.8 AE 18.2 vs. 81.7 AE 11.1; p Z 0.002), TUG (17.0 AE 4.9 vs. 14.0 AE 3.1 s; p Z 0.024), BBS (45.2 AE 5.4 vs. 48.8 AE 5.0; p Z 0.042), use of supplemental oxygen (72% vs. 24%; p Z 0.002), and MRC dyspnea scale (median 4, range 3 vs. median 3, range 4; p Z 0.046). Conclusions: Patients with COPD fall frequently. Standard clinical balance measures discriminate self-reported fallers from non-fallers. These observations draw attention to an important secondary impairment in COPD.

Physiotherapy Canada, 2007

Purpose: The purposes of this article are (1) to list key messages from the 2003 chronic obstruct... more Purpose: The purposes of this article are (1) to list key messages from the 2003 chronic obstructive pulmonary disease (COPD) guidelines of the Canadian Thoracic Society (CTS) and associated implications and responsibilities for physiotherapists and (2) to compare these guidelines with other published reports or statements describing pulmonary rehabilitation. Summary of Key Points: The main responsibilities that physiotherapists should assume to optimize prevention of COPD and management of persons with COPD are to (1) recommend and support smoking cessation for all patients who are smokers; (2) prescribe exercise programmes for patients with COPD; (3) ensure that people with COPD resume activity after an acute exacerbation; (4) refer patients to physicians for appropriate evaluation and care if not yet diagnosed with COPD or if the management of the patient's symptoms is not optimal or consistent with the COPD guidelines developed by the CTS; (5) facilitate adherence to pharmac...

Physiotherapy Canada, 2013

Purpose: To determine (1) the relationship among three common upper-limb tests for patients with ... more Purpose: To determine (1) the relationship among three common upper-limb tests for patients with chronic obstructive pulmonary disease (COPD): unsupported upper limb exercise test (UULEX), 6-minute pegboard and ring test (6PBRT), and a muscle-strength test using a hand-held dynamometer; and (2) the responsiveness of these three tests to changes after pulmonary rehabilitation that included a resistance arm-training programme. Methods: The study was a secondary analysis of a randomized controlled trial (RCT). The UULEX and the 6PBRT were used to measure peak arm exercise capacity and arm function, respectively. A handheld dynamometer was used to measure elbow and shoulder flexion force. We analyzed baseline data for all participants in the RCT, as well as baseline and post-PR data for those who completed 6-week follow-up testing. Results: 36 patients with COPD (mean forced expiratory volume in 1 second [FEV1]=35% [SD 15%] predicted; age 66 [9] y) participated, of whom 13 completed an ...

Although feelings of anxiety and depression are common in patients with chronic obstructive pulmo... more Although feelings of anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), estimates of their prevalence vary considerably. This probably reflects the variety of scales and methods used to measure such symptoms. Regardless of whether anxiety and depression are considered separately or as a single construct, their impact on COPD patients is important. A heightened experience of dyspnoea is likely to be a contributing factor to anxiety. Feelings of depression may be precipitated by the loss and grief associated with the disability of COPD. Smoking has been associated with nicotine addiction, and the factors that contribute to smoking may also predispose to anxiety and depressive disorders. Randomised controlled trials indicate that exercise training and carefully selected pharma- cological therapy are often effective in ameliorating anxiety and depression. Most medical illnesses are influenced by the psychological responses and coping mechani...

European Respiratory Journal, 2013

The aim was to study the overall content and organisational aspects of pulmonary rehabilitation p... more The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice. @ERSpublications Differences in aspects of pulmonary rehabilitation programmes suggest caution in generalisation of research findings http://ow.ly/qOJhl

European Respiratory Journal, 2002

The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary ... more The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. D.

European Respiratory Journal, 2008

Although feelings of anxiety and depression are common in patients with chronic obstructive pulmo... more Although feelings of anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), estimates of their prevalence vary considerably. This probably reflects the variety of scales and methods used to measure such symptoms. Regardless of whether anxiety and depression are considered separately or as a single construct, their impact on COPD patients is important. A heightened experience of dyspnoea is likely to be a contributing factor to anxiety. Feelings of depression may be precipitated by the loss and grief associated with the disability of COPD. Smoking has been associated with nicotine addiction, and the factors that contribute to smoking may also predispose to anxiety and depressive disorders. Randomised controlled trials indicate that exercise training and carefully selected pharmacological therapy are often effective in ameliorating anxiety and depression. Most medical illnesses are influenced by the psychological responses and coping mechanisms that patients use. However, anxiety and depression are associated with dyspnoea, fatigue and altered sleep, all of which also occur in COPD. An understanding of the psychological history and coping mechanisms of patients and the role of anxiety and depressive reactions to illness may enable clinicians to reduce these symptoms and improve quality of life among patients with chronic obstructive pulmonary disease.

Canadian Medical Association Journal, 2010

C hronic obstructive pulmonary disease (COPD) is a common and costly condition worldwide. 1,2 A r... more C hronic obstructive pulmonary disease (COPD) is a common and costly condition worldwide. 1,2 A recent global population-based study estimated the prevalence of the disease to be about 10% among people 40 years of age and older. 3 People with known risk factors for COPD, such as increased age and a history of smoking, are likely to have a substanially higher prevalence 4-6 and to have progressive manifestations of COPD if they continue to smoke. 7 They are thus appropriate targets for intervention early in the course of their disease. People with early or undiagnosed COPD are most likely to encounter the health care system in the primary care setting. Consequently, accurate knowledge of the prevalence of COPD in this setting is critical to planning and implementing strategies for the detection and management of the disease. However, valid estimates are lacking of the prevalence of COPD among at-risk individuals in primary care practices. Access by family doctors to spirometric data confirming irreversible airway obstruction has been shown to influence patient management 8 and to enable implementation of a targeted self-management plan that may include smoking cessation, pharmacotherapy and increased exercise. 9-11 We sought to measure the prevalence of spirometrically confirmed COPD in an at-risk population of adults aged 40 years or more with a smoking history of at least 20 pack-years who visited a primary care practitioner (physician or nurse practitioner) for any reason and to describe their characteristics. We also evaluated the accuracy of prior diagnosis or nondiagnosis of COPD and to identify associated clinical characteristics. Methods The research ethics committees of the University of Toronto and the Sault Saint Marie Group Health Centre approved this study.

Chest, 2011

The study aimed to evaluate the effect of upper extremity resistance training for patients with C... more The study aimed to evaluate the effect of upper extremity resistance training for patients with COPD on dyspnea during activity of daily living (ADL), arm function, arm exercise capacity, muscle strength, and health-related quality of life (HRQL). Patients were randomly assigned to an intervention or control group. The intervention group underwent arm resistance training. The control group performed a sham. Both groups exercised three times a week for 6 weeks. Dyspnea during ADL and HRQL were measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Arm function and exercise capacity were measured using the 6-min pegboard and ring test (6PBRT) and the unsupported upper limb exercise test (UULEX), respectively. Muscle strength for the biceps, triceps, and anterior and middle deltoids was obtained using an isometric dynamometer. Thirty-six patients with COPD (66 ± 9 years) participated in the study. Compared with the control group, the magnitude of change in the intervention group was greater for the 6PBRT (P = .03), UULEX (P = .01), elbow flexion force (P = .01), elbow extension force (P = .02), shoulder flexion force (P = .029), and shoulder abduction force (P = .01). There was no between-group difference in dyspnea during ADL, HRQL, or symptoms during the 6PBRT or UULEX (all P values > .08). Resistance-based arm training improved arm function, arm exercise capacity, and muscle strength in patients with COPD. No improvement in dyspnea during ADL, HRQL, or symptoms was demonstrated.

Swiss Medical Weekly

Pulmonary rehabilitation comprises a variety of interventions grouped into three main categories:... more Pulmonary rehabilitation comprises a variety of interventions grouped into three main categories: exercise training, education, and psychological support. Typically, patients participate in a programme of exercise rehabilitation 2-3 times a week for 6-12 weeks, at the same time being encouraged to incorporate breathing and stretching exercises as part of their daily routine. The physiological rationale for pulmonary rehabilitation in COPD is primarily based on its effect on peripheral muscle dysfunction. A recent meta-analysis demonstrated that pulmonary rehabilitation is effective in reducing dyspnoea and fatigue as well as improving patients' sense of control (mastery) over their condition. Without compliance with a maintenance programme these improvements will diminish with time. The value of various components of rehabilitation, programme length, the required degree of supervision, the intensity of training and the best approach to maintaining programme adherence represent issues that remain to be explored.

Differences in content and organisational aspects of pulmonary rehabilitation programmes

Chronic respiratory disease, 2017

We described physical activity measures and hourly patterns in patients with chronic obstructive ... more We described physical activity measures and hourly patterns in patients with chronic obstructive pulmonary disease (COPD) after stratification for generic and COPD-specific characteristics and, based on multiple physical activity measures, we identified clusters of patients. In total, 1001 patients with COPD (65% men; age, 67 years; forced expiratory volume in the first second [FEV1], 49% predicted) were studied cross-sectionally. Demographics, anthropometrics, lung function and clinical data were assessed. Daily physical activity measures and hourly patterns were analysed based on data from a multisensor armband. Principal component analysis (PCA) and cluster analysis were applied to physical activity measures to identify clusters. Age, body mass index (BMI), dyspnoea grade and ADO index (including age, dyspnoea and airflow obstruction) were associated with physical activity measures and hourly patterns. Five clusters were identified based on three PCA components, which accounted f...

Respiratory medicine, Jul 1, 2017

Increasing symptoms and activity restriction associated with COPD progression greatly impact on t... more Increasing symptoms and activity restriction associated with COPD progression greatly impact on the lives of their informal caregivers, who play a vital role in maintaining their health. An understanding of this impact is important for clinicians to support caregivers and maintain a viable patient environment at home. This systematic review aimed to identify the instruments commonly used to assess informal caregiving in COPD and describe their measurement properties in this population. Searches were conducted in PubMed, Scopus, Web of Science, CINAHL and PsycINFO and in references of key articles, until November 2016 (PROSPERO: CRD42016041401). Instruments used to assess the impact of COPD on caregivers were identified and their properties described. Quality of studies was rated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Quality of the measurement properties of instruments was rated as 'positive', 'negative...

Multidisciplinary Respiratory Medicine, 2015

This article is related to meeting report part 2 [8th International Conference on Management and ... more This article is related to meeting report part 2 [8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure: the Long Summaries-Part 2], available here dx.

Respiratory Medicine, 2005

Objectives: To determine the efficacy of oral theophylline compared with placebo in people with s... more Objectives: To determine the efficacy of oral theophylline compared with placebo in people with stable chronic obstructive pulmonary disease (COPD). Methods: Systematic review of randomized-controlled trials comparing oral theophylline with placebo for a minimum of 7 days in people with stable COPD. Results: Twenty randomized-controlled trials were included in this review. The following outcomes showed significant improvement with theophylline compared with placebo: FEV 1 and FVC both improved with theophylline (weighted mean difference [WMD] 0.10 L; 95% confidence interval [95% CI] 0.04-0.16 and WMD 0.21 L; 95% CI 0.10-0.32, respectively). VO 2 max also improved with theophylline (WMD 195.27 mL/ min; 95% CI 112.71-277.83), as did PaO 2 and PaCO 2 (WMD 3.18 mmHg; 95% CI 1.23-5.13 and WMD À2.36 mmHg; 95% CI À3.52 to À1.21, respectively). Patients preferred theophylline over placebo (relative risk 2.27; 95% CI 1.26-4.11). Theophylline increased the risk of nausea compared with placebo (RR 7.67; 95% CI 1.47-39.94).

COPD, 2007

Patients with chronic obstructive pulmonary disease (COPD) frequently describe limitations in fun... more Patients with chronic obstructive pulmonary disease (COPD) frequently describe limitations in functional performance. These limitations predict mortality, adversely affect health-care burden and impair health-related quality of life. The optimal method for quantifying the functional performance in COPD subjects has not been established. This paper discusses the (i) nature of limited functional performance reported by individuals with COPD, (ii) mechanisms that contribute to these limitations, (iii) assessment techniques available to provide markers of functional performance and (iv) areas for further research in measuring functional performance of COPD subjects.

Chronic respiratory disease, 2011

The purpose of this review was to determine the impact of duration of pulmonary rehabilitation on... more The purpose of this review was to determine the impact of duration of pulmonary rehabilitation on measures of health-related quality of life and exercise tolerance in individuals with chronic obstructive pulmonary disease (COPD). Randomized controlled trials (RCTs) comparing different lengths of pulmonary rehabilitation in patients with COPD were identified after searches of six electronic databases (MEDLINE, PubMed, CINAHL, EMBASE, Physiotherapy Evidence Database [PEDro] and the Cochrane Library of clinical trials) and reference lists of pertinent articles. Two reviewers performed the searches and assessed trial quality using PEDro and Jadad scales. Five RCTs met inclusion criteria. The mean PEDro score was 6 (range 3-8) and mean Jadad was 2 (range 1-3). Three trials reported a difference in health-related quality of life in favour of the longer duration program; two trials reported a benefit in exercise capacity in favour of longer programs. A meta-analysis of results was not poss...

Thorax, 2010

Rationale The SenseWear armband (SAB) is designed to measure energy expenditure (EE). In people w... more Rationale The SenseWear armband (SAB) is designed to measure energy expenditure (EE). In people with chronic obstructive pulmonary disease (COPD), EE estimated using the SAB (EE SAB) is a popular outcome measure. However, a detailed analysis of the measurement properties of the SAB in COPD is lacking. Objective To examine the sensitivity of EE SAB , agreement between EE SAB and EE measured via indirect calorimetry (EE IC), and its repeatability in COPD. Methods 26 people with COPD (forced expiratory volume in 1 s (FEV 1)¼49618% predicted; 15 males) spent 6 min in five standardised tasks that comprised supine, sitting, standing and two walking speeds. A subgroup (n¼12) walked using a rollator. Throughout each task, measurements of EE SAB and EE IC were collected. The protocol was repeated on a second day. Results EE SAB increased between standing and slow walking (2.4, metabolic equivalents (METs) 95% CI 2.2 to 2.7) as well as slow and fast walking (0.5 METs, 95% CI 0.3 to 0.7). Considering all tasks together, the difference between EE SAB and EE IC was À0.2 METs (p¼0.21) with a limit of agreement of 1.3 METs. The difference between days in EE SAB was 0.0 METs with a coefficient of repeatability of 0.4 METs. Rollator use increased the variability in EE SAB , compromising its repeatability and agreement with EE IC. Conclusions EE SAB was sensitive to small but important changes. There was fair agreement between EE SAB and EE IC , and measurements of EE SAB were repeatable. These observations suggest that the SAB is useful for the evaluation of EE in patients with COPD who walk without a rollator.

Respiratory Medicine, 2007

Background: Selection of heath-related quality of life (HRQL) instruments that are most responsiv... more Background: Selection of heath-related quality of life (HRQL) instruments that are most responsive to changes in HRQL prevents investigators from drawing falsenegative conclusions about the effectiveness of an intervention. The objective of this study was to compare the responsiveness of the Chronic Respiratory Questionnaire (CRQ), the St. Georges Respiratory Questionnaire (SGRQ) and four other HRQL instruments.

Respiratory Medicine, 2009

Background: Preliminary evidence suggests individuals with COPD exhibit deficits in balance. Furt... more Background: Preliminary evidence suggests individuals with COPD exhibit deficits in balance. Further investigation of balance and risk of falls is warranted in these patients. The objective of this study was to determine the clinical measures that discriminate fallers from non-fallers among patients with COPD. Methods: A cross-sectional study design was used. Subjects > 60 years with COPD attended a single assessment session. A one-year incidence of falls was collected via self-report questionnaire. Risk of falls and balance were determined using the Berg Balance Scale (BBS), Timed Up and Go Test (TUG) and the Activity-Specific Balance Confidence (ABC) Scale. Exercise tolerance was determined from the Six-Minute Walk Test and functional limitation attributable to dyspnea from the Medical Research Council (MRC) dyspnea scale. Results: Of the 39 COPD subjects (FEV 1 Z 41.5 AE 17.0% predicted; age: 71.1 AE 6.8 years) who completed the study, 46% (n Z 18) reported at least one fall in the preceding year. Significant differences between fallers and non-fallers were found for the ABC (65.8 AE 18.2 vs. 81.7 AE 11.1; p Z 0.002), TUG (17.0 AE 4.9 vs. 14.0 AE 3.1 s; p Z 0.024), BBS (45.2 AE 5.4 vs. 48.8 AE 5.0; p Z 0.042), use of supplemental oxygen (72% vs. 24%; p Z 0.002), and MRC dyspnea scale (median 4, range 3 vs. median 3, range 4; p Z 0.046). Conclusions: Patients with COPD fall frequently. Standard clinical balance measures discriminate self-reported fallers from non-fallers. These observations draw attention to an important secondary impairment in COPD.

Physiotherapy Canada, 2007

Purpose: The purposes of this article are (1) to list key messages from the 2003 chronic obstruct... more Purpose: The purposes of this article are (1) to list key messages from the 2003 chronic obstructive pulmonary disease (COPD) guidelines of the Canadian Thoracic Society (CTS) and associated implications and responsibilities for physiotherapists and (2) to compare these guidelines with other published reports or statements describing pulmonary rehabilitation. Summary of Key Points: The main responsibilities that physiotherapists should assume to optimize prevention of COPD and management of persons with COPD are to (1) recommend and support smoking cessation for all patients who are smokers; (2) prescribe exercise programmes for patients with COPD; (3) ensure that people with COPD resume activity after an acute exacerbation; (4) refer patients to physicians for appropriate evaluation and care if not yet diagnosed with COPD or if the management of the patient's symptoms is not optimal or consistent with the COPD guidelines developed by the CTS; (5) facilitate adherence to pharmac...

Physiotherapy Canada, 2013

Purpose: To determine (1) the relationship among three common upper-limb tests for patients with ... more Purpose: To determine (1) the relationship among three common upper-limb tests for patients with chronic obstructive pulmonary disease (COPD): unsupported upper limb exercise test (UULEX), 6-minute pegboard and ring test (6PBRT), and a muscle-strength test using a hand-held dynamometer; and (2) the responsiveness of these three tests to changes after pulmonary rehabilitation that included a resistance arm-training programme. Methods: The study was a secondary analysis of a randomized controlled trial (RCT). The UULEX and the 6PBRT were used to measure peak arm exercise capacity and arm function, respectively. A handheld dynamometer was used to measure elbow and shoulder flexion force. We analyzed baseline data for all participants in the RCT, as well as baseline and post-PR data for those who completed 6-week follow-up testing. Results: 36 patients with COPD (mean forced expiratory volume in 1 second [FEV1]=35% [SD 15%] predicted; age 66 [9] y) participated, of whom 13 completed an ...

Although feelings of anxiety and depression are common in patients with chronic obstructive pulmo... more Although feelings of anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), estimates of their prevalence vary considerably. This probably reflects the variety of scales and methods used to measure such symptoms. Regardless of whether anxiety and depression are considered separately or as a single construct, their impact on COPD patients is important. A heightened experience of dyspnoea is likely to be a contributing factor to anxiety. Feelings of depression may be precipitated by the loss and grief associated with the disability of COPD. Smoking has been associated with nicotine addiction, and the factors that contribute to smoking may also predispose to anxiety and depressive disorders. Randomised controlled trials indicate that exercise training and carefully selected pharma- cological therapy are often effective in ameliorating anxiety and depression. Most medical illnesses are influenced by the psychological responses and coping mechani...

European Respiratory Journal, 2013

The aim was to study the overall content and organisational aspects of pulmonary rehabilitation p... more The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice. @ERSpublications Differences in aspects of pulmonary rehabilitation programmes suggest caution in generalisation of research findings http://ow.ly/qOJhl

European Respiratory Journal, 2002

The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary ... more The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. D.

European Respiratory Journal, 2008

Although feelings of anxiety and depression are common in patients with chronic obstructive pulmo... more Although feelings of anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), estimates of their prevalence vary considerably. This probably reflects the variety of scales and methods used to measure such symptoms. Regardless of whether anxiety and depression are considered separately or as a single construct, their impact on COPD patients is important. A heightened experience of dyspnoea is likely to be a contributing factor to anxiety. Feelings of depression may be precipitated by the loss and grief associated with the disability of COPD. Smoking has been associated with nicotine addiction, and the factors that contribute to smoking may also predispose to anxiety and depressive disorders. Randomised controlled trials indicate that exercise training and carefully selected pharmacological therapy are often effective in ameliorating anxiety and depression. Most medical illnesses are influenced by the psychological responses and coping mechanisms that patients use. However, anxiety and depression are associated with dyspnoea, fatigue and altered sleep, all of which also occur in COPD. An understanding of the psychological history and coping mechanisms of patients and the role of anxiety and depressive reactions to illness may enable clinicians to reduce these symptoms and improve quality of life among patients with chronic obstructive pulmonary disease.

Canadian Medical Association Journal, 2010

C hronic obstructive pulmonary disease (COPD) is a common and costly condition worldwide. 1,2 A r... more C hronic obstructive pulmonary disease (COPD) is a common and costly condition worldwide. 1,2 A recent global population-based study estimated the prevalence of the disease to be about 10% among people 40 years of age and older. 3 People with known risk factors for COPD, such as increased age and a history of smoking, are likely to have a substanially higher prevalence 4-6 and to have progressive manifestations of COPD if they continue to smoke. 7 They are thus appropriate targets for intervention early in the course of their disease. People with early or undiagnosed COPD are most likely to encounter the health care system in the primary care setting. Consequently, accurate knowledge of the prevalence of COPD in this setting is critical to planning and implementing strategies for the detection and management of the disease. However, valid estimates are lacking of the prevalence of COPD among at-risk individuals in primary care practices. Access by family doctors to spirometric data confirming irreversible airway obstruction has been shown to influence patient management 8 and to enable implementation of a targeted self-management plan that may include smoking cessation, pharmacotherapy and increased exercise. 9-11 We sought to measure the prevalence of spirometrically confirmed COPD in an at-risk population of adults aged 40 years or more with a smoking history of at least 20 pack-years who visited a primary care practitioner (physician or nurse practitioner) for any reason and to describe their characteristics. We also evaluated the accuracy of prior diagnosis or nondiagnosis of COPD and to identify associated clinical characteristics. Methods The research ethics committees of the University of Toronto and the Sault Saint Marie Group Health Centre approved this study.

Chest, 2011

The study aimed to evaluate the effect of upper extremity resistance training for patients with C... more The study aimed to evaluate the effect of upper extremity resistance training for patients with COPD on dyspnea during activity of daily living (ADL), arm function, arm exercise capacity, muscle strength, and health-related quality of life (HRQL). Patients were randomly assigned to an intervention or control group. The intervention group underwent arm resistance training. The control group performed a sham. Both groups exercised three times a week for 6 weeks. Dyspnea during ADL and HRQL were measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Arm function and exercise capacity were measured using the 6-min pegboard and ring test (6PBRT) and the unsupported upper limb exercise test (UULEX), respectively. Muscle strength for the biceps, triceps, and anterior and middle deltoids was obtained using an isometric dynamometer. Thirty-six patients with COPD (66 ± 9 years) participated in the study. Compared with the control group, the magnitude of change in the intervention group was greater for the 6PBRT (P = .03), UULEX (P = .01), elbow flexion force (P = .01), elbow extension force (P = .02), shoulder flexion force (P = .029), and shoulder abduction force (P = .01). There was no between-group difference in dyspnea during ADL, HRQL, or symptoms during the 6PBRT or UULEX (all P values > .08). Resistance-based arm training improved arm function, arm exercise capacity, and muscle strength in patients with COPD. No improvement in dyspnea during ADL, HRQL, or symptoms was demonstrated.