Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart
  • Log out

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Subscriptions

An official European Respiratory Society statement on physical activity in COPD

Henrik Watz, Fabio Pitta, Carolyn L. Rochester, Judith Garcia-Aymerich, Richard ZuWallack, Thierry Troosters, Anouk W. Vaes, Milo A. Puhan, Melissa Jehn, Michael I. Polkey, Ioannis Vogiatzis, Enrico M. Clini, Michael Toth, Elena Gimeno-Santos, Benjamin Waschki, Cristobal Esteban, Maurice Hayot, Richard Casaburi, Janos Porszasz, Edward McAuley, Sally J. Singh, Daniel Langer, Emiel F.M. Wouters, Helgo Magnussen, Martijn A. Spruit
European Respiratory Journal 2014 44: 1521-1537; DOI: 10.1183/09031936.00046814
Henrik Watz
1Task Force co-chairs
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: h.watz@pulmoresearch.de
Fabio Pitta
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Carolyn L. Rochester
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Judith Garcia-Aymerich
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Richard ZuWallack
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Thierry Troosters
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Anouk W. Vaes
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Milo A. Puhan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Melissa Jehn
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael I. Polkey
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ioannis Vogiatzis
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Enrico M. Clini
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael Toth
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Elena Gimeno-Santos
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Benjamin Waschki
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Cristobal Esteban
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Maurice Hayot
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Richard Casaburi
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Janos Porszasz
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Edward McAuley
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sally J. Singh
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Daniel Langer
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Emiel F.M. Wouters
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Helgo Magnussen
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Martijn A. Spruit
1Task Force co-chairs
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force of experts representing the ERS Scientific Group 01.02 “Rehabilitation and Chronic Care” determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members.

The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD.

This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity.

The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5–8 years).

Abstract

An official ERS statement providing a comprehensive overview on physical activity in patients with COPD http://ow.ly/C6v78

Introduction

Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic respiratory disease affecting about 10% of the adult population above 40 years of age [1]. In addition to progressive chronic airflow limitation, patients with COPD commonly have multiple extrapulmonary effects and comorbidities, which are associated with physical inactivity [2, 3]. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has recommended regular physical activity for all COPD patients [2]. However, the clinical relevance of regular physical activity has not been addressed in depth. The purpose of this official European Respiratory Society (ERS) statement is to highlight the existing science regarding physical (in)activity in patients with COPD, including, but not limited to, its prevalence, determinants, consequences, measurement, and potential treatment.

Methods

An international group of pulmonologists, physiotherapists, movement scientists, exercise physiologists, health psychologists, social psychologists, and epidemiologists knowledgeable in the area of physical activity and/or COPD research was assembled into a Task Force by the leadership of the ERS Scientific Group 01.02 “Rehabilitation and Chronic Care”. Contributors searched the scientific literature (PubMed and the Cochrane Library) for original studies and systematic reviews relevant to the topic. Selection of relevant studies and reviews was based on the expertise of the contributors. Draft contributions were shared among committee members, reviewed and revised iteratively. Members were vetted for potential conflicts of interest according to the policies and procedures of ERS. This document represents the consensus of these Task Force members.

Definitions

Physical activity can be defined as any bodily movement produced by skeletal muscles that results in energy expenditure [4]. Physical activity is a complex behaviour that can be characterised by type, intensity, duration, patterns and symptom experience. Exercise is a subset of physical activity. Exercise is physical activity that is planned, structured, repetitive and purposeful [4]. Physical activity also includes, but is not limited to, leisure-time, domestic and occupational activities [4, 5]. Activities of daily living are another subset of physical activity and this term refers to a set of basic, everyday tasks required for personal self-care and independent living [6, 7].

While physical inactivity can be defined simply as “an absence of physical activity” [8], it is commonly used to represent a level of physical activity that is below an optimal or specified threshold. This concept rests on the strong evidence that lower levels of physical activity are related to poor health and predict negative health outcomes [9]. In general, a healthy individual can be considered physically inactive if one of the following criteria is not met: 1) 30 min of at least moderate-intensity physical activity on ≥5 days every week; 2) 20 min of vigorous-intensity physical activity on at least 3 days every week; or 3) an equivalent combination, which can also be accumulated in shorter bouts usually lasting 10 min of moderate (three times 10 min) or vigorous (two times 10 min) exercise [10, 11]. This represents a framework on which to base recommendations for physical activity promotion. However, the recommended intensity and duration of physical activity for the elderly may be different [12]. Furthermore, the extent to which these recommendations apply to persons with COPD is currently unknown.

In recent years, attention has been raised regarding the adverse health effects of a sedentary lifestyle [13]. A sedentary lifestyle is characterised by behaviours that do not increase skeletal muscle energy expenditure substantially above the resting level [14]. Sedentary individuals expend less than 10% of their total daily energy expenditure in performing moderate- or high-intensity activities [15].

Consequences of physical inactivity in the general population and in chronic diseases other than COPD

Physical inactivity is a fundamental characteristic of many chronic diseases, both as a cause and as a consequence. Evidence suggests that reduced physical activity predisposes to greater incidence of cardiovascular disease [16, 17], obesity [18], diabetes [19, 20], cancer [21], dementia [22] and physical disability [23]. In addition to its effect on development of chronic disease, physical inactivity may develop or worsen as a result of many diseases, owing to the sequelae of the disease and/or the associated reduction in physiological reserve. These effects of physical inactivity to both potentiate and develop from chronic disease probably explain the fact that reduced physical activity, measured either subjectively or objectively, is associated with higher overall mortality rates in the elderly [24, 25]. The exact mechanisms whereby physical inactivity interacts with anatomical and physiological changes related to ageing and other pathological cofactors to contribute to the evolution of disease or subsequent morbidity or mortality, however, is poorly understood within the human population.

Consequences of physical inactivity on lung function decline and COPD incidence

Several population-based epidemiological studies have assessed the longitudinal effect of regular physical activity on lung function decline or COPD incidence [26–30]; their main characteristics and results are summarised in table 1. Briefly, all studies show an inverse relationship between physical activity levels and the magnitude of lung function decline in at least one of the population subgroups or physical activity variables studied. However, the association between lower physical activity levels and faster lung function decline is not consistent across all population subgroups or physical activity variables. Potential explanations for such inconsistencies include selection bias, lack of adjustment for potential confounders and lack of consideration of changes in physical activity level during follow-up. Only one study overcomes such limitations and, interestingly, shows beneficial effects of regular physical activity on lung function decline and COPD risk in active smokers but not in former or never-smokers [29, 30].

View this table:
  • View inline
  • View popup
Table 1– Studies on physical inactivity and lung function decline or COPD incidence

Physical activity assessment

Questionnaires

The physical activity of patients with COPD can be assessed using questionnaires. These instruments are commonly used in epidemiological studies and large clinical trials because they are inexpensive and easy to use [31]. A variety of questionnaires exist that capture different aspects of physical activity such as amount, type, intensity, symptom experience and limitations in the performance of “activities of daily living” [31]. The selection of a questionnaire to measure physical activity requires that the specific questionnaire fits the study aim, is properly developed and has strong psychometric properties, for example, validation, test-retest reliability and responsiveness to change [32]. In the specific case of COPD studies, additional criteria could be considered to improve validity of the questionnaire, such as the inclusion of information on low-intensity activities [31, 33], or the availability of a version for interviewer-based administration [34]. Other practical issues include the availability of a culturally validated version, the time required for questionnaire administration and the ability to compare outcome levels across studies.

Recent systematic reviews have assessed all questionnaires available to measure physical activity in the elderly or chronically ill patients [35, 36]. From the 104 questionnaires identified in these systematic reviews, 15 were developed for use in patients with COPD. Validity was assessed in 85% of these instruments, test-retest-reliability in 69% and responsiveness in only 19%, and none of the instruments was based on a conceptual framework [37]. A current Innovative Medicines Initiative project is filling this gap by developing a valid patient reported outcome tool (PROactive) capturing physical activity experience in COPD (www.proactivecopd.com).

A common methodological issue is recall bias, which may become a limitation if not addressed in the development and validation process. Garfield et al. [38] assessed four questionnaires against physical activity measured directly by accelerometry and found that while the Stanford 7-Day Physical Activity Recall questionnaire could identify patients at both extremes of physical activity the other three had a poor relationship with directly measured activity. Also, in two other studies the relationship between questionnaire-derived physical activity measures and accelerometer-derived physical activity measures was either not given [39] or did not allow the authors to reliably identify extremely inactive patients [40].

Despite limitations of questionnaires when used on an individual level, some questionnaires might be used to measure physical activity in groups of patients with COPD. However, the choice depends on matching the question to be addressed with the psychometric properties of the instrument.

Step counters

Pedometers are small, lightweight, portable and nonintrusive devices which measure the number of steps performed in a given period of time. From that metric estimates of distance and energy expenditure can be made [31]. Many pedometers are available, and variability exists not only in cost but also in mechanism of step detection, data storage and sensitivity. Pedometers are most accurate at step counting, less accurate in distance estimates, and even less accurate at estimating energy expenditure [41]. Pedometers may underestimate the number of steps and energy expenditure during walking at slow speed, which is typical in patients with COPD [42–44]. This may limit their accuracy in patients with moderate-to-very severe disease. However, pedometers may have positive role as a motivational tool aiming to increase daily activity, especially in addition to other combined interventions [45–47].

Activity monitors

Accelerometers are portable electronic devices that are worn on the body to detect acceleration and thereby reflect bodily movement. They quantify activity counts, and may provide an estimate of time spent above or below a pre-specified activity level, number of steps and energy expenditure [31]. The use of accelerometers has received increasing interest since they add objective data which cannot be obtained from questionnaires or pedometers.

Accelerometers can detect movement along one axis (uni-axial accelerometers), two axes (bi-axial accelerometers) or three axes (tri-axial accelerometers). Uni-axial devices provide information similar to pedometers, but with the advantage of assessing acceleration in addition to simply detecting steps. Bi-axial and tri-axial devices allow for detection of movement in a wider range of physical activities and are, therefore, more sensitive than uni-axial devices [48]. Activity monitors sometimes combine accelerometers with other physiological sensors (e.g. heart rate or skin temperature) or are used in conjunction with positioning systems with the objective of increasing their accuracy to estimate daily physical activity and energy expenditure [49–51].

The validity of activity monitors for assessment of physical activity in patients with COPD has been the subject of many investigations in recent years [31, 39, 42, 43, 49, 52–61]. Two studies in COPD patients recently investigated the validity of six widely used accelerometers in comparison to the “gold standards” of indirect calorimetry and doubly-labelled-water [62, 63]. Among the six devices, the DynaPort MiniMod (McRoberts BV, the Hague, the Netherlands), the Actigraph GT3X (Actigraph, Pensacola, FL, USA) and the SenseWear Armband (BodyMedia, Inc., Pittsburgh, PA, USA) (all employing triaxial accelerometers) were valid and responsive for use in COPD [62, 63]. These devices were demonstrated to be valid in other studies in COPD as well [42, 43, 49, 52, 54–56, 58].

Several factors may influence the outcome of physical activity monitoring. Vibration from vehicle travel can falsely elevate activity counts measured by some devices, although this may be reduced by filtering the accelerometer signal [64]. The number of assessment days and hours of use per day are also important factors that may influence the reliability of the physical activity assessment [65, 66]. Interestingly, compared with the other days of the week Sundays seem to be days of less physical activity in GOLD stage I to III patients [65]. A recent study demonstrates that for cross-sectional analyses 2 to 3 days are sufficient for reliable measurement of physical activity in GOLD stage IV patients, whereas up to 5 days of measurement are required in patients with GOLD stage I [65]. For measurements that aim to assess longitudinal changes 4 days were shown to be sufficient to demonstrate treatment effects following pulmonary rehabilitation in moderate-to-severe COPD, when weekends were excluded from the analysis [67].

The use of accelerometers certainly presents limitations. It should be noted that there is little uniformity in output from the various types of accelerometers, which makes it difficult to compare studies using different devices [68]. Another limitation is that estimates of energy expenditure for individual patients may be inaccurate, especially among those with functional limitations due to chronic diseases that affect walking speed and efficiency of movement [69]. Furthermore, purchase costs vary considerably between devices.

Doubly labelled water

The doubly labelled water (DLW) method provides an indirect assessment of total energy expenditure by the body over a substantial period of time (e.g. 2 weeks). The technique has been described elsewhere [70]. Briefly, known doses of deuterium and 18O are ingested (2H2O and H218O). The deuterium washes out of the body through the urine, whereas the 18O is eliminated as urine water and CO2. The difference between the wash out of the two (typically measured in urine samples) provides an estimate of CO2 production by the body, which can be converted to energy expenditure [71].

The biggest drawback of the technique in the context of physical activity assessment in COPD is that it does not allow separation of energy expenditure linked to physical activity and energy expenditure linked to basal metabolic rate or diet-induced metabolism. Thus, although the DLW technique is used to estimate total energy expenditure in patients with COPD [63, 72, 73] its ability to estimate physical activity is compromised by a number of assumptions that may be correct for healthy subjects but not for patients with COPD. For example, one study used DLW in severe COPD and concluded that active energy expenditure was even higher in COPD compared with controls, which might be related to the increased oxygen cost of breathing and decreased mechanical efficiency in patients with COPD [72]. By contrast, actual physical activity levels are lower in patients with COPD [65]. The DLW technique should probably be restricted to questions about caloric balance in patients with COPD rather than questions concerning the amount and intensity of physical activity. It can be questioned whether the technique should remain the “gold standard” to validate monitors that measure the amount and intensity of movement in COPD, even though DLW will very likely remain a “gold standard” for measuring the caloric cost of physical activity.

Levels of physical activity in patients with COPD

Patients with COPD have significantly lower levels of physical activity as compared with healthy controls [65, 74–81]. Existing data show that time spent walking is significantly lower in COPD patients compared with healthy, age-matched persons [74, 76, 77, 80, 82]. These findings appear to be consistent across settings, cultural background, geographic area and methods used to measure physical activity. In addition, movement intensity of patients with COPD is lower compared with age-matched healthy subjects, which indicates that patients with COPD walk at a slower pace [74]. Current data suggest that patients with COPD reduce their physical activity early in the course of the disease [83–85]. Accordingly, most patients do not meet currently recommended physical activity levels. For example, in one study only 26% of 177 patients with a mean forced expiratory volume in 1 s (FEV1) 52% predicted achieved at least 30 consecutive minutes of moderate intensity activity on at least 5 days; this increased to 50% if the 30 min was accomplished in bouts of at least 10 min each [86]. Corroborating these results, another study reported that only 29% of 73 patients with COPD achieved a mean of at least 30 min of moderate physical activity summed up throughout the day [87]. Compared with controls, COPD patients had a reduction by 50% of their minutes of moderate physical activity per day, which was even more reduced when bouts of at least 10 min were compared between controls and COPD patients [88].

Factors associated with physical activity in COPD

This section addresses associations between physical activity and clinical characteristics of patients with COPD, such as disease severity, comorbidities, exacerbations and behavioural factors. Since most of the studies are cross-sectional it is not possible to draw conclusions regarding the directionality of the established associations [89]. It should be acknowledged that, in general, physical activity is dependent of many factors, which include biological, behavioural, genetic, social, environmental, cultural and policy factors [90]. In this section we will discuss those aspects that are specifically studied in COPD.

Lung function

FEV1 shows a weak-to-moderate positive association with objectively measured physical activity in patients with COPD (table 2) [39, 65, 74, 77, 79, 80, 91, 92]. In general, FEV1 explains only a small proportion of the variation in physical activity in subjects with COPD. Directly measured maximal voluntary ventilation may provide an increased correlation with physical activity in this population [92]. Fewer studies have investigated the relationship between physical activity and other lung function measures. While three studies found weak-to-moderate positive associations between physical activity and diffusion capacity [74, 80, 93], one study showed a strong and independent linear association [94]. A robust inverse association was found between dynamic hyperinflation (measured in the laboratory during cardiopulmonary exercise test on a stationary cycle ergometer) and physical activity [95]. Overall, while increasing severity of lung function impairment is associated with reduced physical activity in subjects with COPD, the relationship is relatively weak. Therefore, levels of physical activity cannot be accurately predicted from resting lung function parameters.

View this table:
  • View inline
  • View popup
Table 2– Relationship between FEV1 and physical activity in some representative cross-sectional studies

Exercise performance

Physical fitness, which can be measured by various exercise tests, comprises a set of attributes that relates to the ability to perform physical activity [4]. Accordingly, most studies in COPD have found moderately positive associations between either 6-min walking distance or peak work rate in an incremental exercise test and objectively measured physical activity (table 3) [40, 65, 74, 79, 96].

View this table:
  • View inline
  • View popup
Table 3– Relationship between exercise tolerance and physical activity in some representative cross sectional studies

Two studies evaluated the predictive power of the 6-min walking distance to identify physically inactive COPD patients with an objectively measured physical activity level lower than 1.4 (i.e. <40% of total daily energy expenditure is related to physical activity). In both studies 6-min walking distance, even though moderately associated with physical activity, was found to be of limited value to reliably identify physically inactive COPD patients [40, 65].

Self-efficacy

Self-efficacy, an individual’s belief in his or her capability of performing a specific task in a specific situation, is influenced by expectations of ability to perform the task and its outcome [97]. Theoretically, higher levels of self-efficacy may be associated with increased physical activity; and higher levels of physical activity may result in enhanced self-efficacy belief. However, self-efficacy for walking, assessed in COPD using the Self-Efficacy Questionnaire – Walking (SEQ-W) instrument, was only weakly associated with objectively measured physical activity [91]. Furthermore, in another study of 165 patients with COPD, general self-efficacy as measured with the General Self-Efficacy Scale (SES6) was not associated with physical activity [98].

Sociodemographic factors and environment

Several sociodemographic and environmental factors, including ethnicity, socioeconomic status, job availability, education level, patient choices about where to live, and seasonal variations in temperature and humidity, have the potential to influence performance of daily physical activity among persons with COPD.

Among healthy adults, lower physical activity levels have been associated with lower socioeconomic status, lower education level and non-Caucasian race [99–101]. However, this may not be the case for patients with COPD, since two studies have demonstrated a relationship between lower physical activity levels and higher socioeconomic status [102, 103]. In these studies, it is difficult to distinguish the impact of socioeconomic status from that of other influences, such as geographical location and ethnic and cultural differences, but it is possible that increased dependence on walking and public transportation among persons of lower socioeconomic status accounts for the findings. Also, both studies focused on persons with severe airflow limitation; hence the findings may not be applicable to patients with less severe lung function impairment.

Weather, climate and altitude conditions can also influence physical activity levels among persons with COPD. Extremes of heat or cold and/or high environmental levels of particulates or other air pollutants can trigger increased symptoms, bronchoconstriction and acute exacerbations [104–106] and may pose a barrier to exercise and activity adherence [107, 108]. Accordingly, seasonal variations in daily physical activity have been reported [93, 109–111], with a tendency for lower activity during periods with lower temperature. High altitude environments may also influence physical activity levels, since elevation in altitude leads to worsening resting and/or exercise hypoxaemia and reduced exercise tolerance among patients with COPD [112]. Geographical location per se may not strongly influence activity levels (e.g. independently of other factors such as climate, altitude or socioeconomic status) as no significant differences in physical activity were observed among patients with varying severity of COPD across diverse geographical locations in Europe and the USA [78, 79]. Finally, physical activity levels may be influenced by the day of the week; total activity and activity intensity were lower on Sundays or during the weekend as compared with other days [63, 65].

Exacerbations of COPD

Physical activity is dramatically reduced during and after hospitalisation due to an exacerbation of COPD [113, 114]. Furthermore, recovery time is prolonged over several weeks and physical activity may not return to pre-exacerbation activity levels [113, 114].

Even patients with milder exacerbations, which do not require hospitalisation, tend to stay indoors during the exacerbation period [115]. Moreover, patients with a history of frequent exacerbations reduce their time spent outdoors at a faster rate compared with those with infrequent exacerbations, and thus are more likely to become housebound [115]. This was confirmed by another study demonstrating that a history of more than one exacerbation was correlated with lower physical activity levels [79].

Comorbidities

Comorbidities are common in COPD [116–118] and may independently impact physical activity levels. A cross-sectional study of 170 patients with COPD demonstrated that left ventricular cardiac dysfunction (assessed by elevated N-terminal pro-brain natriuretic peptide and echocardiographic assessment of diastolic function) was associated with reduced physical activity levels, independent of COPD severity assessed by GOLD stage or the multidimensional BODE (body mass index, airflow obstruction, dyspnoea, exercise capacity) score [119]. In this study, depression, anaemia, systemic arterial blood pressure and nutritional depletion were not associated with reduced physical activity levels [119]. In the same cohort, physical activity levels were significantly lower among patients with metabolic syndrome and COPD across all GOLD stages as compared with the patients without metabolic syndrome [120]. It is not yet clear which of the components of metabolic syndrome contributed to this finding. For instance, obese COPD patients have lower activity levels compared with underweight and normal weight patients [121, 122]. Furthermore, diabetes is strongly associated with inactivity in COPD, independent of other confounders [102]. In a cohort of newly diagnosed COPD patients, physical inactivity was more strongly associated with the presence of comorbidities compared with airflow obstruction [123].

Quadriceps muscle strength and mass, which are commonly reduced in patients with COPD, were positively correlated with physical activity in several studies [74, 79, 85]. In one study quadriceps muscle strength was predictive of physical activity, independent of FEV1 [79]. By contrast, handgrip strength did not correlate with physical activity in patients with COPD [94, 119].

Mood disturbances such as symptoms of anxiety and depression are highly prevalent in patients with COPD [124]. Of the six studies examining the relationship between physical activity and depression in patients with COPD [79, 80, 119, 125–127], only two found significant associations [80, 127]. In one study higher levels of anxiety were associated with higher levels of physical activity, whereas more depressive symptoms were associated with lower physical activity only when anxiety was part of the statistical model [127].

Systemic inflammation

In the general population a growing body of evidence demonstrates that physical activity, inflammation and immunity are tightly linked, with regular moderate physical activity reducing systemic inflammation [128–131]. Potential mechanisms underlying these observations include the release of anti-inflammatory myokines by contracting skeletal muscles [132]. In COPD, four studies have demonstrated that higher levels of low-grade systemic inflammation are associated with lower levels of physical activity even after adjusting for relevant confounders [79, 94, 119, 133]. Whether anti-inflammatory mechanisms of regular physical activity or COPD-specific mechanisms of systemic inflammation underlie the associations between systemic inflammation and physical activity in COPD needs to be elucidated in further longitudinal studies [134].

Health status

Various assessments of health status have been related to physical activity measurements in patients with COPD. Most studies showed that an impaired health status assessed either by generic or disease-specific instruments is weakly to moderately related to a lower amount and intensity of physical activity [79, 91, 102, 135, 136]. Changes in physical activity over time parallel trends in health status [137]. Since most health status questionnaires have items addressing physical activity this could obviously affect these relationships.

Symptoms

Breathlessness on exertion is the primary symptom limiting exercise, which in turn leads to reduced physical activity in patients with COPD [138]. Accordingly, patients’ perception of breathlessness on exertion is reported to be a barrier for participation in exercise and activities of daily living [110, 139]. Indeed, greater levels of dyspnoea as measured by the modified Medical Research Council dyspnoea scale are related to lower levels of physical activity in patients with COPD [65, 79].

Fatigue is also reported to be a frequent symptom in patients with COPD [140]. There is one study that evaluated the association of fatigue assessed by the Functional Assessment of Chronic Illness Therapy – Fatigue questionnaire and physical activity. After adjusting for several confounders physical activity was demonstrated to be associated with fatigue in patients with COPD [79]. Whether, and to what extent, pain symptoms may affect physical activity in patients with COPD remains currently unknown.

Effect of physical inactivity on hospitalisations in patients with COPD

To date, seven prospective longitudinal studies have assessed the association between levels of regular physical activity and hospital admission or readmission due to COPD exacerbations [30, 113, 141–145]. All studies consistently showed a statistically significant association of low physical activity levels with increased risk of hospitalisations. Although all studies reported associations adjusted for confounders, just one study adjusted for previous COPD hospitalisations, which is one of the most important risk factors for readmission [146]. Importantly, the studies have shown that the amount of regular physical activity needed to obtain a significant effect on admissions due to COPD is relatively small, equivalent to walking or cycling for 2 h per week [30, 113, 141–145].

Effects of physical inactivity on survival in COPD

Three longitudinal studies with a follow-up of 3–12 years have demonstrated that low levels of physical activity predict all-cause mortality in patients with COPD after controlling for relevant confounding factors [144, 145, 147]. The relationship was consistent across differing settings, patient characteristics and methods used to measure physical activity. In one study that separated respiratory-related from cardiovascular and all-cause mortality, the greatest effect was on the former [144]. Recently, an assessment of physical activity has also been included as a prognostic factor in a multidimensional prognostic score for stable COPD patients [148].

Whether, and to what extent, improvements in physical activity levels may lower the risk of dying remains unknown in patients with COPD. It seems reasonable to hypothesise that patients who have a decline in physical activity over time have a worse prognosis compared with those patients who remain physically active.

Treatment strategies to improve physical activity

Pharmacological therapy

While it is well-known that bronchodilators improve dyspnoea and exercise tolerance, only a few studies have investigated the impact of bronchodilator therapy on physical activity [149–151]. Two studies had positive results with regard to improvements in physical activity following bronchodilator treatment. Of these, one study (23 patients) was a nonrandomised open-label study of a long-acting β-agonist in a small number of patients [150], while the other study was a retrospective subgroup analysis [151]. By contrast, two randomised, placebo-controlled, multicentre studies could not demonstrate a change in physical activity following therapy with a long-acting bronchodilator [149, 152]. Therefore, it remains currently unknown whether bronchodilator therapies that are known to improve exercise capacity will also either improve physical activity or prevent deterioration of physical activity over time in patients with COPD.

Ambulatory oxygen therapy

Oxygen therapy improves exercise tolerance in hypoxaemic COPD patients, but whether activity levels are also enhanced is unclear. A small, randomised trial of replacing heavier oxygen tanks with lightweight ambulatory oxygen therapy failed to detect improvements in activity monitor assessments of physical activity over a 6-month period [153].

Pulmonary rehabilitation

Pulmonary rehabilitation is a “comprehensive intervention to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours” [154]. Pulmonary rehabilitation has been demonstrated clearly to reduce dyspnoea, increase exercise capacity and improve quality of life in patients with COPD. Increases in exercise capacity in combination with behavioural change may also have the potential to increase physical activity in patients with COPD. Despite this rationale, the 10 studies that evaluated the effect of pulmonary rehabilitation on physical activity [80, 82, 155–162] have yielded inconsistent results; four showed an increase in physical activity [80, 160–162] and six failed to do so [82, 155–159]. In the negative studies, the lack of improvement in physical activity was observed despite a concomitant increase in exercise capacity and quality of life. A systematic review and meta-analysis of single-group and randomised trials of the effect of exercise training (not necessarily pulmonary rehabilitation) on physical activity concluded that this intervention conferred a significant, but small, increase in this outcome [163].

Behaviour changes, feedback, counselling

Solely increasing the exercise capacity of patients with COPD may be insufficient to increase participation in self-directed leisure time activity [47, 80, 82, 155, 157–162, 164]. Widespread acknowledgement of the exercise maintenance problem has led to the identification of behavioural factors related to participation in daily physical activity and to the development of interventions targeting these factors.

Interventions including self-monitoring of activity behaviour using activity monitors in combination with behavioural counselling in patients with COPD might have the potential to change physical activity behaviour [45–47, 165–167]. However, the evidence base is weak since only a few studies have been conducted using small samples [46, 47], often without a control group [45, 165, 166]. Larger studies with long-term follow-up are needed in patients with COPD.

Key components that increase the effectiveness of behavioural interventions have already been summarised in several meta-analyses and international guidelines [168–172], and include mobilising social support, using well-described/established behaviour change and self-regulatory techniques (self-monitoring, stimulus control, problem solving, relapse prevention management, goal setting, self-reinforcement, providing feedback on performance and developing action plans), providing higher contact time or contact frequency, and assessing the readiness/motivation to change [168, 170]. Motivational interviewing techniques have further been recommended as a collaborative communication approach [168].

Summary of treatment strategies to improve physical activity

To date, only a few randomised controlled trials have studied the efficacy of pharmacological or non-pharmacological treatment strategies on daily physical activity in patients with COPD. Therefore, there is an urgent need for additional well-designed trials. Based on the correlates of physical activity, it seems reasonable to focus in future studies on physical, non-physical and environmental factors to improve physical activity in patients with COPD. Moreover, future trials should not only focus on improvements in physical activity but also on the prevention of loss of physical activity.

Moving forward

The scientific foundation regarding the clinical importance of assessing and improving physical activity in patients with COPD has grown considerably in the past decade. Nevertheless, many questions remain unanswered and the methodology of physical activity assessment needs to be further standardised. Therefore, this Task Force identifies the following major areas that need to be further addressed in the coming years.

1) In addition to smoking cessation the disease-modifying potential of increased physical activity in smokers without COPD and in patients with all degrees of airflow limitation should be explored.

2) Further understanding is needed regarding the concepts for optimising the impact of the pharmacological and non-pharmacological interventions that aim to maintain or increase physical activity levels in patients with COPD.

3) Research should be undertaken to understand how improvements in exercise capacity, dyspnoea, and self-efficacy following an intervention (e.g. pulmonary rehabilitation or pharmacological therapy) might translate into increased physical activity.

4) The methodology to measure physical activity needs to be further standardised and formal guidance on this should be provided in the future. Such methodologies could rely on objective and accurate assessment of physical activity, patient reported assessment of physical activity experience, or a combination thereof.

Acknowledgments

The realisation of the Official ERS Statement on Physical Activity in COPD would not have been possible without the support of Guy Brusselle (ERS Guidelines Director), and Sandy Sutter (ERS CME and Guidelines Coordinator). Moreover, the Task Force co-chairs are grateful to the ERS for funding this ERS Statement.

The authors’ affiliations are as follows. Henrik Watz: Pulmonary Research Institute at LungenClinic Grosshandorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany; Fabio Pitta: Laboratory of Research in Respiratory Physiotherapy, Dept of Physiotherapy, Universidade Estadual de Londrina, Brazil; Carolyn L. Rochester: Yale University School of Medicine and VA Connecticut Healthcare System, New Haven, CT, USA; Judith Garcia-Aymerich: Centre for Research in Environmental Epidemiology (CREAL); CIBER Epidemiología y Salud Pública (CIBERESP); and Universitat Pompeu Fabra, Departament de Ciències Experimentals i de la Salut, Barcelona, Spain; Richard ZuWallack: St Francis Hospital Medical Center, Hartford, CT, USA; Thierry Troosters: Dept of Rehabilitation Sciences, KU Leuven, Leuven, Belgium, and Respiratory Division and Pulmonary Rehabilitation, UZ Gasthuisberg, Leuven, Belgium; Anouk W. Vaes: Dept of Research and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands; Milo A. Puhan: Institute of Social and Preventive Medicine, University of Zurich, Switzerland; Melissa Jehn: Dept of Pneumological Onkology and Transplantology, Charite Universitätsmedizin, Berlin, Germany; Michael I. Polkey: NIHR Respiratory Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK; Ioannis Vogiatzis: Medical School, 1st Dept of Respiratory Medicine, Pulmonary Rehabilitation Unit, National and Kapodistrian University of Athens, Athens, Greece; Enrico M. Clini: Dept of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy, and Ospedale Villa Pineta, Pavullo n/F, Modena, Italy; Michael Toth: Dept of Medicine, University of Vermont, College of Medicine, Burlington, VT, USA; Elena Gimeno-Santos: Centre for Research in Environmental Epidemiology (CREAL); CIBER Epidemiología y Salud Pública (CIBERESP); and Universitat Pompeu Fabra, Departament de Ciències Experimentals i de la Salut, Barcelona, Spain; Benjamin Waschki: Pulmonary Research Institute at LungenClinic Grosshandorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany; Cristobal Esteban: Pneumology Dept, Hospital Galdakao-Usansolo, Bizkaia, Spain; Maurice Hayot: INSERM U-1046, University Montpellier I, Université Montpellier II, Montpellier, France, and Dept of Clinical Physiology, CHRU Montpellier, Montpellier, France; Richard Casaburi: Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA; Janos Porszasz: Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA; Edward McAuley: Dept of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA; Sally J. Singh: Centre for Exercise and Rehabilitation Science, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK, and Faculty of Health and Life Sciences, Coventry University, Coventry, UK; Daniel Langer: Dept of Rehabilitation Sciences, KU Leuven, Leuven, Belgium, and Respiratory Division and Pulmonary Rehabilitation, UZ Gasthuisberg, Leuven, Belgium; Emiel F.M. Wouters: Dept of Research and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands, and Dept of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Helgo Magnussen: Pulmonary Research Institute at LungenClinic Grosshandorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany; Martijn A. Spruit: Dept of Research and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands, and REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.

Footnotes

  • Support statement: Michael Polkey’s contribution to this work was part funded by the NIHR Respiratory Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, UK, who part fund his salary. Thierry Trooster’s contribution was partly funded by the Flemish Research Foundation (#G.0871.13). Anouk Vaes’ contribution to this work was partially funded by “Stichting de Weijerhorst” and Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, the Netherlands. Martijn A. Spruit’s contribution to this work was partially funded by Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, the Netherlands. Benjamin Waschki’s contribution to this work was partially funded by the German Center for Lung Research, Germany. The Task Force co-chairs are grateful to the ERS for funding this ERS statement.

  • Conflict of interest: Disclosures can be found alongside the online version of this article at erj.ersjournals.com

  • Received March 11, 2014.
  • Accepted July 29, 2014.
  • ©ERS 2014

References

  1. ↵
    1. Buist AS,
    2. McBurnie MA,
    3. Vollmer WM,
    4. et al
    . International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet 2007; 370: 741–750.
    OpenUrlCrossRefPubMedWeb of Science
  2. ↵
    1. Vestbo J,
    2. Hurd SS,
    3. Agustí AG,
    4. et al
    . Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013; 187: 347–365.
    OpenUrlCrossRefPubMedWeb of Science
  3. ↵
    1. Decramer M,
    2. Janssens W,
    3. Miravitlles M
    . Chronic obstructive pulmonary disease. Lancet 2012; 379: 1341–1351.
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Caspersen CJ,
    2. Powell KE,
    3. Christenson GM
    . Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985; 100: 126–131.
    OpenUrlPubMedWeb of Science
  5. ↵
    1. Howley ET
    . Type of activity: resistance, aerobic and leisure versus occupational physical activity. Med Sci Sports Exerc 2001; 33: Supp. l, S364–S369.
    OpenUrlCrossRefPubMedWeb of Science
  6. ↵
    1. Katz S
    . Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 1983; 31: 721–727.
    OpenUrlPubMedWeb of Science
  7. ↵
    1. Fricke J
    . Activities of Daily Living.. In: Stone J H, Blouin M , eds. International Encyclopedia of Rehabilitation. Center for International Rehabilitation Research Information and Exchange (CIRRIE) 2013 http://cirrie.buffalo.edu/encyclopedia/en/
  8. ↵
    World Health Organization. Global Recommendations on Physical Activity for Health. Geneva, WHO Press 2010.
  9. ↵
    1. Wen CP,
    2. Wai JP,
    3. Tsai MK,
    4. et al
    . Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011; 378: 1244–1253.
    OpenUrlCrossRefPubMedWeb of Science
  10. ↵
    1. Haskell WL,
    2. Lee IM,
    3. Pate RR,
    4. et al
    . Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 2007; 116: 1081–1093.
    OpenUrlCrossRefPubMedWeb of Science
  11. ↵
    1. Hallal PC,
    2. Andersen LB,
    3. Bull FC,
    4. et al
    . Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012; 380: 247–257.
    OpenUrlCrossRefPubMedWeb of Science
  12. ↵
    1. Nelson ME,
    2. Rejeski WJ,
    3. Blair SN,
    4. et al
    . Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007; 39: 1435–1445.
    OpenUrlCrossRefPubMedWeb of Science
  13. ↵
    1. Owen N,
    2. Healy GN,
    3. Matthews CE,
    4. et al
    . Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev 2010; 38: 105–113.
    OpenUrlCrossRefPubMedWeb of Science
  14. ↵
    1. Pate RR,
    2. O’Neill JR,
    3. Lobelo F
    . The evolving definition of “sedentary”. Exerc Sport Sci Rev 2008; 36: 173–178.
    OpenUrlCrossRefPubMedWeb of Science
  15. ↵
    1. Bernstein MS,
    2. Morabia A,
    3. Sloutskis D
    . Definition and prevalence of sedentarism in an urban population. Am J Public Health 1999; 89: 862–867.
    OpenUrlCrossRefPubMedWeb of Science
  16. ↵
    1. Li TY,
    2. Rana JS,
    3. Manson JE,
    4. et al
    . Obesity as compared with physical activity in predicting risk of coronary heart disease in women. Circulation 2006; 113: 499–506.
    OpenUrlAbstract/FREE Full Text
  17. ↵
    1. Mora S,
    2. Cook N,
    3. Buring JE,
    4. et al
    . Physical activity and reduced risk of cardiovascular events: potential mediating mechanisms. Circulation 2007; 116: 2110–2118.
    OpenUrlAbstract/FREE Full Text
  18. ↵
    1. Li S,
    2. Zhao JH,
    3. Luan J,
    4. et al
    . Physical activity attenuates the genetic predisposition to obesity in 20,000 men and women from EPIC-Norfolk prospective population study. PLoS Med 2010; 7: e1000332.
    OpenUrlCrossRefPubMed
  19. ↵
    1. Sieverdes JC,
    2. Sui X,
    3. Lee DC,
    4. et al
    . Physical activity, cardiorespiratory fitness and the incidence of type 2 diabetes in a prospective study of men. Br J Sports Med 2010; 44: 238–244.
    OpenUrlAbstract/FREE Full Text
  20. ↵
    1. Jefferis BJ,
    2. Whincup PH,
    3. Lennon L,
    4. et al
    . Longitudinal associations between changes in physical activity and onset of type 2 diabetes in older British men: the influence of adiposity. Diabetes Care 2012; 35: 1876–1883.
    OpenUrlAbstract/FREE Full Text
  21. ↵
    1. Friedenreich CM,
    2. Neilson HK,
    3. Lynch BM
    . State of the epidemiological evidence on physical activity and cancer prevention. Eur J Cancer 2010; 46: 2593–2604.
    OpenUrlCrossRefPubMedWeb of Science
  22. ↵
    1. Rovio S,
    2. Kåreholt I,
    3. Helkala EL,
    4. et al
    . Leisure-time physical activity at midlife and the risk of dementia and Alzheimer’s disease. Lancet Neurol 2005; 4: 705–711.
    OpenUrlCrossRefPubMedWeb of Science
  23. ↵
    1. Gill TM,
    2. Allore HG,
    3. Gahbauer EA,
    4. et al
    . Change in disability after hospitalization or restricted activity in older persons. JAMA 2010; 304: 1919–1928.
    OpenUrlCrossRefPubMedWeb of Science
  24. ↵
    1. Manini TM,
    2. Everhart JE,
    3. Patel KV,
    4. et al
    . Daily activity energy expenditure and mortality among older adults. JAMA 2006; 296: 171–179.
    OpenUrlCrossRefPubMedWeb of Science
  25. ↵
    1. Matthews CE,
    2. George SM,
    3. Moore SC,
    4. et al
    . Amount of time spent in sedentary behaviors and cause-specific mortality in US adults. Am J Clin Nutr 2012; 95: 437–445.
    OpenUrlAbstract/FREE Full Text
  26. ↵
    1. Jakes RW,
    2. Day NE,
    3. Patel B,
    4. et al
    . Physical inactivity is associated with lower forced expiratory volume in 1 second: European Prospective Investigation into Cancer-Norfolk Prospective Population Study. Am J Epidemiol 2002; 156: 139–147.
    OpenUrlAbstract/FREE Full Text
    1. Pelkonen M,
    2. Notkola IL,
    3. Lakka T,
    4. et al
    . Delaying decline in pulmonary function with physical activity: a 25-year follow-up. Am J Respir Crit Care Med 2003; 168: 494–499.
    OpenUrlCrossRefPubMedWeb of Science
    1. Cheng YJ,
    2. Macera CA,
    3. Addy CL,
    4. et al
    . Effects of physical activity on exercise tests and respiratory function. Br J Sports Med 2003; 37: 521–528.
    OpenUrlAbstract/FREE Full Text
  27. ↵
    1. Garcia-Aymerich J,
    2. Lange P,
    3. Benet M,
    4. et al
    . Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study. Am J Respir Crit Care Med 2007; 175: 458–463.
    OpenUrlCrossRefPubMedWeb of Science
  28. ↵
    1. Garcia-Aymerich J,
    2. Lange P,
    3. Serra I,
    4. et al
    . Time-dependent confounding in the study of the effects of regular physical activity in chronic obstructive pulmonary disease: an application of the marginal structural model. Ann Epidemiol 2008; 18: 775–783.
    OpenUrlCrossRefPubMedWeb of Science
  29. ↵
    1. Pitta F,
    2. Troosters T,
    3. Probst VS,
    4. et al
    . Quantifying physical activity in daily life with questionnaires and motion sensors in COPD. Eur Respir J 2006; 27: 1040–1055.
    OpenUrlAbstract/FREE Full Text
  30. ↵
    1. Terwee CB,
    2. Mokkink LB,
    3. van Poppel MN,
    4. et al
    . Qualitative attributes and measurement properties of physical activity questionnaires: a checklist. Sports Med 2010; 40: 525–537.
    OpenUrlCrossRefPubMedWeb of Science
  31. ↵
    1. Forsén L,
    2. Loland NW,
    3. Vuillemin A,
    4. et al
    . Self-administered physical activity questionnaires for the elderly: a systematic review of measurement properties. Sports Med 2010; 40: 601–623.
    OpenUrlCrossRefPubMedWeb of Science
  32. ↵
    1. Dinger MK,
    2. Oman RF,
    3. Taylor EL,
    4. et al
    . Stability and convergent validity of the Physical Activity Scale for the Elderly (PASE). J Sports Med Phys Fitness 2004; 44: 186–192.
    OpenUrlPubMedWeb of Science
  33. ↵
    1. Frei A,
    2. Williams K,
    3. Vetsch A,
    4. et al
    . A comprehensive systematic review of the development process of 104 patient-reported outcomes (PROs) for physical activity in chronically ill and elderly people. Health Qual Life Outcomes 2011; 9: 116.
    OpenUrlCrossRefPubMed
  34. ↵
    1. Williams K,
    2. Frei A,
    3. Vetsch A,
    4. et al
    . Patient-reported physical activity questionnaires: a systematic review of content and format. Health Qual Life Outcomes 2012; 10: 28.
    OpenUrlCrossRefPubMed
  35. ↵
    1. Gimeno-Santos E,
    2. Frei A,
    3. Dobbels F,
    4. et al
    . Validity of instruments to measure physical activity may be questionable due to a lack of conceptual frameworks: a systematic review. Health Qual Life Outcomes 2011; 9: 86.
    OpenUrlCrossRefPubMed
  36. ↵
    1. Garfield BE,
    2. Canavan JL,
    3. Smith CJ,
    4. et al
    . Stanford Seven-Day Physical Activity Recall questionnaire in COPD. Eur Respir J 2012; 40: 356–362.
    OpenUrlAbstract/FREE Full Text
  37. ↵
    1. Steele BG,
    2. Holt L,
    3. Belza B,
    4. et al
    . Quantitating physical activity in COPD using a triaxial accelerometer. Chest 2000; 117: 1359–1367.
    OpenUrlCrossRefPubMedWeb of Science
  38. ↵
    1. van Gestel AJ,
    2. Clarenbach CF,
    3. Stöwhas AC,
    4. et al
    . Predicting daily physical activity in patients with chronic obstructive pulmonary disease. PLoS One 2012; 7: e48081.
    OpenUrlCrossRefPubMed
  39. ↵
    1. Schneider PL,
    2. Crouter SE,
    3. Lukajic O,
    4. et al
    . Accuracy and reliability of 10 pedometers for measuring steps over a 400-m walk. Med Sci Sports Exerc 2003; 35: 1779–1784.
    OpenUrlCrossRefPubMedWeb of Science
  40. ↵
    1. Cavalheri V,
    2. Donária L,
    3. Ferreira T,
    4. et al
    . Energy expenditure during daily activities as measured by two motion sensors in patients with COPD. Respir Med 2011; 105: 922–929.
    OpenUrlCrossRefPubMed
  41. ↵
    1. Furlanetto KC,
    2. Bisca GW,
    3. Oldemberg N,
    4. et al
    . Step counting and energy expenditure estimation in patients with chronic obstructive pulmonary disease and healthy elderly: accuracy of 2 motion sensors. Arch Phys Med Rehabil 2010; 91: 261–267.
    OpenUrlCrossRefPubMed
  42. ↵
    1. Turner LJ,
    2. Houchen L,
    3. Williams J,
    4. et al
    . Reliability of pedometers to measure step counts in patients with chronic respiratory disease. J Cardiopulm Rehabil Prev 2012; 32: 284–291.
    OpenUrlCrossRefPubMed
  43. ↵
    1. Moy ML,
    2. Weston NA,
    3. Wilson EJ,
    4. et al
    . A pilot study of an Internet walking program and pedometer in COPD. Respir Med 2012; 106: 1342–1350.
    OpenUrlCrossRefPubMed
  44. ↵
    1. Hospes G,
    2. Bossenbroek L,
    3. ten Hacken NH,
    4. et al
    . Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: results of an exercise counseling program. Patient Educ Couns 2009; 75: 274–278.
    OpenUrlCrossRefPubMedWeb of Science
  45. ↵
    1. de Blok BM,
    2. de Greef MH,
    3. ten Hacken NH,
    4. et al
    . The effects of a lifestyle physical activity counseling program with feedback of a pedometer during pulmonary rehabilitation in patients with COPD: a pilot study. Patient Educ Couns 2006; 61: 48–55.
    OpenUrlCrossRefPubMedWeb of Science
  46. ↵
    1. Hikihara Y,
    2. Tanaka S,
    3. Ohkawara K,
    4. et al
    . Validation and comparison of 3 accelerometers for measuring physical activity intensity during nonlocomotive activities and locomotive movements. J Phys Act Health 2012; 9: 935–943.
    OpenUrlPubMed
  47. ↵
    1. Patel SA,
    2. Benzo RP,
    3. Slivka WA,
    4. et al
    . Activity monitoring and energy expenditure in COPD patients: a validation study. COPD 2007; 4: 107–112.
    OpenUrlCrossRef
    1. Theou O,
    2. Jakobi JM,
    3. Vandervoort AA,
    4. et al
    . A comparison of physical activity (PA) assessment tools across levels of frailty. Arch Gerontol Geriatr 2012; 54: e307–e314.
    OpenUrlCrossRefPubMed
  48. ↵
    1. Troped PJ,
    2. Oliveira MS,
    3. Matthews CE,
    4. et al
    . Prediction of activity mode with global positioning system and accelerometer data. Med Sci Sports Exerc 2008; 40: 972–978.
    OpenUrlCrossRefPubMedWeb of Science
  49. ↵
    1. Pitta F,
    2. Troosters T,
    3. Spruit MA,
    4. et al
    . Activity monitoring for assessment of physical activities in daily life in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2005; 86: 1979–1985.
    OpenUrlCrossRefPubMedWeb of Science
    1. Moy ML,
    2. Garshick E,
    3. Matthess KR,
    4. et al
    . Accuracy of uniaxial accelerometer in chronic obstructive pulmonary disease. J Rehabil Res Dev 2008; 45: 611–617.
    OpenUrlCrossRefPubMed
  50. ↵
    1. Langer D,
    2. Gosselink R,
    3. Sena R,
    4. et al
    . Validation of two activity monitors in patients with COPD. Thorax 2009; 64: 641–642.
    OpenUrlFREE Full Text
    1. Hill K,
    2. Dolmage TE,
    3. Woon L,
    4. et al
    . Measurement properties of the SenseWear armband in adults with chronic obstructive pulmonary disease. Thorax 2010; 65: 486–491.
    OpenUrlAbstract/FREE Full Text
  51. ↵
    1. Cohen MD,
    2. Cutaia M
    . A novel approach to measuring activity in chronic obstructive pulmonary disease: using 2 activity monitors to classify daily activity. J Cardiopulm Rehabil Prev 2010; 30: 186–194.
    OpenUrlCrossRefPubMed
    1. Sant’Anna T,
    2. Escobar VC,
    3. Fontana AD,
    4. et al
    . Evaluation of a new motion sensor in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2012; 93: 2319–2325.
    OpenUrlCrossRefPubMed
  52. ↵
    1. Bauldoff GS,
    2. Ryan-Wenger NA,
    3. Diaz PT
    . Wrist actigraphy validation of exercise movement in COPD. West J Nurs Res 2007; 29: 789–802.
    OpenUrlAbstract/FREE Full Text
    1. Sugino A,
    2. Minakata Y,
    3. Kanda M,
    4. et al
    . Validation of a compact motion sensor for the measurement of physical activity in patients with chronic obstructive pulmonary disease. Respiration 2012; 83: 300–307.
    OpenUrlCrossRefPubMedWeb of Science
    1. Annegarn J,
    2. Spruit MA,
    3. Uszko-Lencer NH,
    4. et al
    . Objective physical activity assessment in patients with chronic organ failure: a validation study of a new single-unit activity monitor. Arch Phys Med Rehabil 2011; 92: 1852–1857.
    OpenUrlCrossRefPubMed
  53. ↵
    1. Van Remoortel H,
    2. Giavedoni S,
    3. Raste Y,
    4. et al
    . Validity of activity monitors in health and chronic disease: a systematic review. Int J Behav Nutr Phys Act 2012; 9: 84.
    OpenUrlCrossRefPubMed
  54. ↵
    1. Van Remoortel H,
    2. Raste Y,
    3. Louvaris Z,
    4. et al
    . Validity of six activity monitors in chronic obstructive pulmonary disease: a comparison with indirect calorimetry. PLoS One 2012; 7: e39198.
    OpenUrlCrossRefPubMed
  55. ↵
    1. Rabinovich RA,
    2. Louvaris Z,
    3. Raste Y,
    4. et al
    . Validity of physical activity monitors during daily life in patients with COPD. Eur Respir J 2013; 42: 1205–1215.
    OpenUrlAbstract/FREE Full Text
  56. ↵
    1. Cohen MD,
    2. Cutaia M,
    3. Brehm R,
    4. et al
    . Detecting motor vehicle travel in accelerometer data. COPD 2012; 9: 102–110.
    OpenUrlCrossRefWeb of Science
  57. ↵
    1. Watz H,
    2. Waschki B,
    3. Meyer T,
    4. et al
    . Physical activity in patients with COPD. Eur Respir J 2009; 33: 262–272.
    OpenUrlAbstract/FREE Full Text
  58. ↵
    1. Hecht A,
    2. Ma S,
    3. Porszasz J,
    4. et al
    . Methodology for using long-term accelerometry monitoring to describe daily activity patterns in COPD. COPD 2009; 6: 121–129.
    OpenUrlCrossRefWeb of Science
  59. ↵
    1. Demeyer H,
    2. Burtin C,
    3. Van Remoortel H,
    4. et al
    . Standardizing the analysis of physical activity in patients with COPD following a pulmonary rehabilitation program. Chest 2014; 146: 318–327.
    OpenUrlCrossRefPubMedWeb of Science
  60. ↵
    1. Butte NF,
    2. Ekelund U,
    3. Westerterp KR
    . Assessing physical activity using wearable monitors: measures of physical activity. Med Sci Sports Exerc 2012; 44: Suppl. 1, S5–S12.
    OpenUrlCrossRefPubMedWeb of Science
  61. ↵
    1. Strath SJ,
    2. Pfeiffer KA,
    3. Whitt-Glover MC
    . Accelerometer use with children, older adults, and adults with functional limitations. Med Sci Sports Exerc 2012; 44: Suppl. 1, S77–S85.
    OpenUrlCrossRefPubMedWeb of Science
  62. ↵
    1. Westerterp KR,
    2. Wouters L,
    3. van Marken Lichtenbelt WD
    . The Maastricht protocol for the measurement of body composition and energy expenditure with labeled water. Obes Res 1995; 3: Suppl. 1, 49–57.
    OpenUrlPubMedWeb of Science
  63. ↵
    1. Schoeller DA
    . Recent advances from application of doubly labeled water to measurement of human energy expenditure. J Nutr 1999; 129: 1765–1768.
    OpenUrlAbstract/FREE Full Text
  64. ↵
    1. Baarends EM,
    2. Schols AM,
    3. Pannemans DL,
    4. et al
    . Total free living energy expenditure in patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155: 549–554.
    OpenUrlCrossRefPubMedWeb of Science
  65. ↵
    1. Arvidsson D,
    2. Slinde F,
    3. Nordenson A,
    4. et al
    . Validity of the ActiReg system in assessing energy requirement in chronic obstructive pulmonary disease patients. Clin Nutr 2006; 25: 68–74.
    OpenUrlCrossRefPubMed
  66. ↵
    1. Pitta F,
    2. Troosters T,
    3. Spruit MA,
    4. et al
    . Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005; 171: 972–977.
    OpenUrlCrossRefPubMedWeb of Science
    1. Schönhofer B,
    2. Ardes P,
    3. Geibel M,
    4. et al
    . Evaluation of a movement detector to measure daily activity in patients with chronic lung disease. Eur Respir J 1997; 10: 2814–2819.
    OpenUrlAbstract
  67. ↵
    1. Singh S,
    2. Morgan MD
    . Activity monitors can detect brisk walking in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2001; 21: 143–148.
    OpenUrlCrossRefPubMed
  68. ↵
    1. Hernandes NA,
    2. Teixeira DC,
    3. Probst VS,
    4. et al
    . Profile of the level of physical activity in the daily lives of patients with COPD in Brazil. J Bras Pneumol 2009; 35: 949–956.
    OpenUrlPubMed
  69. ↵
    1. Troosters T,
    2. Sciurba F,
    3. Battaglia S,
    4. et al
    . Physical inactivity in patients with COPD, a controlled multi-center pilot-study. Respir Med 2010; 104: 1005–1011.
    OpenUrlCrossRefPubMedWeb of Science
  70. ↵
    1. Waschki B,
    2. Spruit MA,
    3. Watz H,
    4. et al
    . Physical activity monitoring in COPD: compliance and associations with clinical characteristics in a multicenter study. Respir Med 2012; 106: 522–530.
    OpenUrlCrossRefPubMed
  71. ↵
    1. Walker PP,
    2. Burnett A,
    3. Flavahan PW,
    4. et al
    . Lower limb activity and its determinants in COPD. Thorax 2008; 63: 683–689.
    OpenUrlAbstract/FREE Full Text
  72. ↵
    1. Vorrink SN,
    2. Kort HS,
    3. Troosters T,
    4. et al
    . Level of daily physical activity in individuals with COPD compared with healthy controls. Respir Res 2011; 12: 33.
    OpenUrlCrossRefPubMed
  73. ↵
    1. Coronado M,
    2. Janssens JP,
    3. de Muralt B,
    4. et al
    . Walking activity measured by accelerometry during respiratory rehabilitation. J Cardiopulm Rehabil 2003; 23: 357–364.
    OpenUrlCrossRefPubMed
  74. ↵
    1. Van Remoortel H,
    2. Hornikx M,
    3. Demeyer H,
    4. et al
    . Daily physical activity in subjects with newly diagnosed COPD. Thorax 2013; 68: 962–963.
    OpenUrlAbstract/FREE Full Text
    1. Gouzi F,
    2. Préfaut C,
    3. Abdellaoui A,
    4. et al
    . Evidence of an early physical activity reduction in chronic obstructive pulmonary disease patients. Arch Phys Med Rehabil 2011; 92: 1611–1617.
    OpenUrlCrossRefPubMed
  75. ↵
    1. Shrikrishna D,
    2. Patel M,
    3. Tanner RJ,
    4. et al
    . Quadriceps wasting and physical inactivity in patients with COPD. Eur Respir J 2012; 40: 1115–1122.
    OpenUrlAbstract/FREE Full Text
  76. ↵
    1. Donaire-Gonzalez D,
    2. Gimeno-Santos E,
    3. Balcells E,
    4. et al
    . Physical activity in COPD patients: patterns and bouts. Eur Respir J 2013; 42: 993–1002.
    OpenUrlAbstract/FREE Full Text
  77. ↵
    1. Vitorasso R,
    2. Camillo CA,
    3. Cavalheri V,
    4. et al
    . Is walking in daily life a moderate intensity activity in patients with chronic obstructive pulmonary disease? Eur J Phys Rehabil Med 2012; 48: 587–592.
    OpenUrlPubMed
  78. ↵
    1. van Remoortel H,
    2. Camillo CA,
    3. Langer D,
    4. et al
    . Moderate intense physical activity depends on selected Metabolic Equivalent of Task (MET) cut-off and type of data analysis. PLoS One 2013; 8: e84365.
    OpenUrlCrossRefPubMed
  79. ↵
    1. Gimeno-Santos E,
    2. Frei A,
    3. Steurer-Stey C,
    4. et al
    . Determinants and outcomes of physical activity in patients with COPD: a systematic review. Thorax 2014; 69: 731–739.
    OpenUrlAbstract/FREE Full Text
  80. ↵
    1. Bauman AE,
    2. Reis RS,
    3. Sallis JF,
    4. et al
    . Correlates of physical activity: why are some people physically active and others not? Lancet 2012; 380: 258–271.
    OpenUrlCrossRefPubMedWeb of Science
  81. ↵
    1. Belza B,
    2. Steele BG,
    3. Hunziker J,
    4. et al
    . Correlates of physical activity in chronic obstructive pulmonary disease. Nurs Res 2001; 50: 195–202.
    OpenUrlCrossRefPubMedWeb of Science
  82. ↵
    1. Pitta F,
    2. Takaki MY,
    3. Oliveira NH,
    4. et al
    . Relationship between pulmonary function and physical activity in daily life in patients with COPD. Respir Med 2008; 102: 1203–1207.
    OpenUrlCrossRefPubMedWeb of Science
  83. ↵
    1. Langer D,
    2. Cebrià i Iranzo MA,
    3. Burtin C,
    4. et al
    . Determinants of physical activity in daily life in candidates for lung transplantation. Respir Med 2012; 106: 747–754.
    OpenUrlCrossRefPubMed
  84. ↵
    1. Garcia-Aymerich J,
    2. Serra I,
    3. Gómez FP,
    4. et al
    . Physical activity and clinical and functional status in COPD. Chest 2009; 136: 62–70.
    OpenUrlCrossRefPubMedWeb of Science
  85. ↵
    1. Garcia-Rio F,
    2. Lores V,
    3. Mediano O,
    4. et al
    . Daily physical activity in patients with chronic obstructive pulmonary disease is mainly associated with dynamic hyperinflation. Am J Respir Crit Care Med 2009; 180: 506–512.
    OpenUrlCrossRefPubMedWeb of Science
  86. ↵
    1. Eliason G,
    2. Zakrisson AB,
    3. Piehl-Aulin K,
    4. et al
    . Physical activity patterns in patients in different stages of chronic obstructive pulmonary disease. COPD 2011; 8: 369–374.
    OpenUrlCrossRefWeb of Science
  87. ↵
    1. Strecher VJ,
    2. DeVellis BM,
    3. Becker MH,
    4. et al
    . The role of self-efficacy in achieving health behavior change. Health Educ Q 1986; 13: 73–92.
    OpenUrlCrossRefPubMedWeb of Science
  88. ↵
    1. DePew ZS,
    2. Garofoli AC,
    3. Novotny PJ,
    4. et al
    . Screening for severe physical inactivity in chronic obstructive pulmonary disease: the value of simple measures and the validation of two physical activity questionnaires. Chron Respir Dis 2013; 10: 19–27.
    OpenUrlAbstract/FREE Full Text
  89. ↵
    1. Marshall SJ,
    2. Jones DA,
    3. Ainsworth BE,
    4. et al
    . Race/ethnicity, social class, and leisure-time physical inactivity. Med Sci Sports Exerc 2007; 39: 44–51.
    OpenUrlPubMedWeb of Science
    1. Crespo CJ,
    2. Ainsworth BE,
    3. Keteyian SJ,
    4. et al
    . Prevalence of physical inactivity and its relation to social class in U.S. adults: results from the Third National Health and Nutrition Examination Survey, 1988–1994. Med Sci Sports Exerc 1999; 31: 1821–1827.
    OpenUrlCrossRefPubMedWeb of Science
  90. ↵
    1. Parks SE,
    2. Housemann RA,
    3. Brownson RC
    . Differential correlates of physical activity in urban and rural adults of various socioeconomic backgrounds in the United States. J Epidemiol Community Health 2003; 57: 29–35.
    OpenUrlAbstract/FREE Full Text
  91. ↵
    1. Garcia-Aymerich J,
    2. Félez MA,
    3. Escarrabill J,
    4. et al
    . Physical activity and its determinants in severe chronic obstructive pulmonary disease. Med Sci Sports Exerc 2004; 36: 1667–1673.
    OpenUrlCrossRefPubMedWeb of Science
  92. ↵
    1. Pitta F,
    2. Breyer MK,
    3. Hernandes NA,
    4. et al
    . Comparison of daily physical activity between COPD patients from Central Europe and South America. Respir Med 2009; 103: 421–426.
    OpenUrlCrossRefPubMed
  93. ↵
    1. Koskela HO,
    2. Koskela AK,
    3. Tukiaineu HO
    . Bronchoconstriction due to cold weather in COPD. The roles of direct airway effects and cutaneous reflex mechanisms. Chest 1996; 110: 632–636.
    OpenUrlCrossRefPubMedWeb of Science
    1. Wedzicha JA
    . Mechanisms of exacerbations. Novartis Found Symp 2001; 234: 84–93.
    OpenUrlPubMed
  94. ↵
    1. Atkinson RW,
    2. Anderson HR,
    3. Sunyer J,
    4. et al
    . Acute effects of particulate air pollution on respiratory admissions: results from APHEA 2 project. Air Pollution and Health: a European Approach. Am J Respir Crit Care Med 2001; 164: 1860–1866.
    OpenUrlCrossRefPubMedWeb of Science
  95. ↵
    1. O’Shea SD,
    2. Taylor NF,
    3. Paratz JD
    . But watch out for the weather: factors affecting adherence to progressive resistance exercise for persons with COPD. J Cardiopulm Rehabil Prev 2007; 27: 166–174.
    OpenUrlCrossRefPubMedWeb of Science
  96. ↵
    1. Kosatsky T,
    2. Dufresne J,
    3. Richard L,
    4. et al
    . Heat awareness and response among Montreal residents with chronic cardiac and pulmonary disease. Can J Public Health 2009; 100: 237–240.
    OpenUrlPubMedWeb of Science
  97. ↵
    1. Moy ML,
    2. Danilack VA,
    3. Weston NA,
    4. et al
    . Daily step counts in a US cohort with COPD. Respir Med 2012; 106: 962–969.
    OpenUrlCrossRefPubMed
  98. ↵
    1. Katajisto M,
    2. Kupiainen H,
    3. Rantanen P,
    4. et al
    . Physical inactivity in COPD and increased patient perception of dyspnea. Int J Chron Obstruct Pulmon Dis 2012; 7: 743–755.
    OpenUrlPubMed
  99. ↵
    1. Sewell L,
    2. Singh SJ,
    3. Williams JE,
    4. et al
    . Seasonal variations affect physical activity and pulmonary rehabilitation outcomes. J Cardiopulm Rehabil Prev 2010; 30: 329–333.
    OpenUrlCrossRefPubMed
  100. ↵
    1. Kelly PT,
    2. Swanney MP,
    3. Stanton JD,
    4. et al
    . Resting and exercise response to altitude in patients with chronic obstructive pulmonary disease. Aviat Space Environ Med 2009; 80: 102–107.
    OpenUrlCrossRefPubMedWeb of Science
  101. ↵
    1. Pitta F,
    2. Troosters T,
    3. Probst VS,
    4. et al
    . Physical activity and hospitalization for exacerbation of COPD. Chest 2006; 129: 536–544.
    OpenUrlCrossRefPubMedWeb of Science
  102. ↵
    1. Borges RC,
    2. Carvalho CR
    . Physical activity in daily life in Brazilian COPD patients during and after exacerbation. COPD 2012; 9: 596–602.
    OpenUrlCrossRefWeb of Science
  103. ↵
    1. Donaldson GC,
    2. Wilkinson TM,
    3. Hurst JR,
    4. et al
    . Exacerbations and time spent outdoors in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005; 171: 446–452.
    OpenUrlCrossRefPubMedWeb of Science
  104. ↵
    1. Barnes PJ,
    2. Celli BR
    . Systemic manifestations and comorbidities of COPD. Eur Respir J 2009; 33: 1165–1185.
    OpenUrlAbstract/FREE Full Text
    1. Nussbaumer-Ochsner Y,
    2. Rabe KF
    . Systemic manifestations of COPD. Chest 2011; 139: 165–173.
    OpenUrlCrossRefPubMedWeb of Science
  105. ↵
    1. Vanfleteren LE,
    2. Spruit MA,
    3. Groenen M,
    4. et al
    . Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2013; 187: 728–735.
    OpenUrlCrossRefPubMedWeb of Science
  106. ↵
    1. Watz H,
    2. Waschki B,
    3. Boehme C,
    4. et al
    . Extrapulmonary effects of chronic obstructive pulmonary disease on physical activity: a cross-sectional study. Am J Respir Crit Care Med 2008; 177: 743–751.
    OpenUrlCrossRefPubMedWeb of Science
  107. ↵
    1. Watz H,
    2. Waschki B,
    3. Kirsten A,
    4. et al
    . The metabolic syndrome in patients with chronic bronchitis and COPD: frequency and associated consequences for systemic inflammation and physical inactivity. Chest 2009; 136: 1039–1046.
    OpenUrlCrossRefPubMedWeb of Science
  108. ↵
    1. Monteiro F,
    2. Camillo CA,
    3. Vitorasso R,
    4. et al
    . Obesity and physical activity in the daily life of patients with COPD. Lung 2012; 190: 403–410.
    OpenUrlCrossRefPubMedWeb of Science
  109. ↵
    1. Vozoris NT,
    2. O’Donnell DE
    . Prevalence, risk factors, activity limitation and health care utilization of an obese, population-based sample with chronic obstructive pulmonary disease. Can Respir J 2012; 19: e18–e24.
    OpenUrlPubMed
  110. ↵
    1. Van Remoortel H,
    2. Hornikx M,
    3. Langer D,
    4. et al
    . Risk factors and comorbidities in the preclinical stages of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2014; 189: 30–38.
    OpenUrlPubMedWeb of Science
  111. ↵
    1. von Leupoldt A,
    2. Taube K,
    3. Lehmann K,
    4. et al
    . The impact of anxiety and depression on outcomes of pulmonary rehabilitation in patients with COPD. Chest 2011; 140: 730–736.
    OpenUrlCrossRefPubMedWeb of Science
  112. ↵
    1. Moy ML,
    2. Matthess K,
    3. Stolzmann K,
    4. et al
    . Free-living physical activity in COPD: assessment with accelerometer and activity checklist. J Rehabil Res Dev 2009; 46: 277–286.
    OpenUrlCrossRefPubMed
    1. Venkata A,
    2. DeDios A,
    3. ZuWallack R,
    4. et al
    . Are depressive symptoms related to physical inactivity in chronic obstructive pulmonary disease? J Cardiopulm Rehabil Prev 2012; 32: 405–409.
    OpenUrlCrossRefPubMed
  113. ↵
    1. Nguyen HQ,
    2. Fan VS,
    3. Herting J,
    4. et al
    . Patients with COPD with higher levels of anxiety are more physically active. Chest 2013; 144: 145–151.
    OpenUrlCrossRefPubMedWeb of Science
  114. ↵
    1. Handschin C,
    2. Spiegelman BM
    . The role of exercise and PGC1α in inflammation and chronic disease. Nature 2008; 454: 463–469.
    OpenUrlCrossRefPubMedWeb of Science
    1. Febbraio MA
    . Exercise and inflammation. J Appl Physiol 2007; 103: 376–377.
    OpenUrlFREE Full Text
    1. Gleeson M
    . Immune function in sport and exercise. J Appl Physiol 2007; 103: 693–699.
    OpenUrlAbstract/FREE Full Text
  115. ↵
    1. Pedersen BK,
    2. Febbraio MA
    . Muscles, exercise and obesity: skeletal muscle as a secretory organ. Nat Rev Endocrinol 2012; 8: 457–465.
    OpenUrlCrossRefPubMed
  116. ↵
    1. Pedersen BK
    . Exercise-induced myokines and their role in chronic diseases. Brain Behav Immun 2011; 25: 811–816.
    OpenUrlCrossRefPubMed
  117. ↵
    1. Moy ML,
    2. Teylan M,
    3. Weston NA,
    4. et al
    . Daily step count is associated with plasma C-reactive protein and IL-6 in a US cohort with COPD. Chest 2014; 145: 542–550.
    OpenUrlCrossRefPubMedWeb of Science
  118. ↵
    1. Magnussen H,
    2. Watz H
    . Systemic inflammation in chronic obstructive pulmonary disease and asthma: relation with comorbidities. Proc Am Thorac Soc 2009; 6: 648–651.
    OpenUrlCrossRefPubMed
  119. ↵
    1. McGlone S,
    2. Venn A,
    3. Walters EH,
    4. et al
    . Physical activity, spirometry and quality-of-life in chronic obstructive pulmonary disease. COPD 2006; 3: 83–88.
    OpenUrlCrossRef
  120. ↵
    1. Jehn M,
    2. Schindler C,
    3. Meyer A,
    4. et al
    . Daily walking intensity as a predictor of quality of life in patients with chronic obstructive pulmonary disease. Med Sci Sports Exerc 2012; 44: 1212–1218.
    OpenUrlCrossRefPubMedWeb of Science
  121. ↵
    1. Esteban C,
    2. Quintana JM,
    3. Aburto M,
    4. et al
    . Impact of changes in physical activity on health-related quality of life among patients with COPD. Eur Respir J 2010; 36: 292–300.
    OpenUrlAbstract/FREE Full Text
  122. ↵
    1. O’Donnell DE
    . Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2006; 3: 180–184.
    OpenUrlCrossRefPubMed
  123. ↵
    1. Bestall JC,
    2. Paul EA,
    3. Garrod R,
    4. et al
    . Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999; 54: 581–586.
    OpenUrlAbstract/FREE Full Text
  124. ↵
    1. Todt K,
    2. Skargren E,
    3. Kentson M,
    4. et al
    . Experience of fatigue, and its relationship to physical capacity and disease severity in men and women with COPD. Int J Chron Obstruct Pulmon Dis 2014; 9: 17–25.
    OpenUrlPubMed
  125. ↵
    1. Benzo RP,
    2. Chang CC,
    3. Farrell MH,
    4. et al
    . Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease. Respiration 2010; 80: 10–18.
    OpenUrlCrossRefPubMedWeb of Science
    1. Chen YJ,
    2. Narsavage GL
    . Factors related to chronic obstructive pulmonary disease readmission in Taiwan. West J Nurs Res 2006; 28: 105–124.
    OpenUrlAbstract/FREE Full Text
    1. Garcia-Aymerich J,
    2. Farrero E,
    3. Felez MA,
    4. et al
    . Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax 2003; 58: 100–105.
    OpenUrlAbstract/FREE Full Text
  126. ↵
    1. Garcia-Aymerich J,
    2. Lange P,
    3. Benet M,
    4. et al
    . Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006; 61: 772–778.
    OpenUrlAbstract/FREE Full Text
  127. ↵
    1. Garcia-Rio F,
    2. Rojo B,
    3. Casitas R,
    4. et al
    . Prognostic value of the objective measurement of daily physical activity in patients with COPD. Chest 2012; 142: 338–346.
    OpenUrlCrossRefPubMed
  128. ↵
    1. Garcia-Aymerich J,
    2. Serra Pons I,
    3. Mannino DM,
    4. et al
    . Lung function impairment, COPD hospitalisations and subsequent mortality. Thorax 2011; 66: 585–590.
    OpenUrlAbstract/FREE Full Text
  129. ↵
    1. Waschki B,
    2. Kirsten A,
    3. Holz O,
    4. et al
    . Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest 2011; 140: 331–342.
    OpenUrlCrossRefPubMedWeb of Science
  130. ↵
    1. Esteban C,
    2. Quintana JM,
    3. Aburto M,
    4. et al
    . The health, activity, dyspnea, obstruction, age, and hospitalization: prognostic score for stable COPD patients. Respir Med 2011; 105: 1662–1670.
    OpenUrlCrossRefPubMed
  131. ↵
    1. O’Donnell DE,
    2. Casaburi R,
    3. Vincken W,
    4. et al
    . Effect of indacaterol on exercise endurance and lung hyperinflation in COPD. Respir Med 2011; 105: 1030–1036.
    OpenUrlCrossRefPubMed
  132. ↵
    1. Hataji O,
    2. Naito M,
    3. Ito K,
    4. et al
    . Indacaterol improves daily physical activity in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2013; 8: 1–5.
    OpenUrlPubMed
  133. ↵
    1. Kesten S,
    2. Casaburi R,
    3. Kukafka D,
    4. et al
    . Improvement in self-reported exercise participation with the combination of tiotropium and rehabilitative exercise training in COPD patients. Int J Chron Obstruct Pulmon Dis 2008; 3: 127–136.
    OpenUrlPubMed
  134. ↵
    1. Troosters T,
    2. Sciurba FC,
    3. Decramer M,
    4. et al
    . Tiotropium in patients with moderate COPD naive to maintenance therapy: a randomised placebo-controlled trial. NPJ Prim Care Respir Med 2014; 24: 14003.
    OpenUrlCrossRefPubMed
  135. ↵
    1. Casaburi R,
    2. Porszasz J,
    3. Hecht A,
    4. et al
    . Influence of lightweight ambulatory oxygen on oxygen use and activity patterns of COPD patients receiving long-term oxygen therapy. COPD 2012; 9: 3–11.
    OpenUrl
  136. ↵
    1. Spruit MA,
    2. Singh SJ,
    3. Garvey C,
    4. et al
    . An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188: e13–e64.
    OpenUrlCrossRefPubMedWeb of Science
  137. ↵
    1. Steele BG,
    2. Belza B,
    3. Hunziker J,
    4. et al
    . Monitoring daily activity during pulmonary rehabilitation using a triaxial accelerometer. J Cardiopulm Rehabil 2003; 23: 139–142.
    OpenUrlCrossRefPubMed
    1. Steele BG,
    2. Belza B,
    3. Cain KC,
    4. et al
    . A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease. Arch Phys Med Rehabil 2008; 89: 404–412.
    OpenUrlCrossRefPubMedWeb of Science
  138. ↵
    1. Dallas MI,
    2. McCusker C,
    3. Haggerty MC,
    4. et al
    . Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation. Chron Respir Dis 2009; 6: 217–224.
    OpenUrlAbstract/FREE Full Text
    1. Mador MJ,
    2. Patel AN,
    3. Nadler J
    . Effects of pulmonary rehabilitation on activity levels in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev 2011; 31: 52–59.
    OpenUrlCrossRefPubMed
  139. ↵
    1. Egan C,
    2. Deering BM,
    3. Blake C,
    4. et al
    . Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med 2012; 106: 1671–1679.
    OpenUrlCrossRefPubMed
  140. ↵
    1. Sewell L,
    2. Singh SJ,
    3. Williams JE,
    4. et al
    . Can individualized rehabilitation improve functional independence in elderly patients with COPD? Chest 2005; 128: 1194–1200.
    OpenUrlCrossRefPubMedWeb of Science
    1. Mercken EM,
    2. Hageman GJ,
    3. Schols AM,
    4. et al
    . Rehabilitation decreases exercise-induced oxidative stress in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005; 172: 994–1001.
    OpenUrlCrossRefPubMedWeb of Science
  141. ↵
    1. Pitta F,
    2. Troosters T,
    3. Probst VS,
    4. et al
    . Are patients with COPD more active after pulmonary rehabilitation? Chest 2008; 134: 273–280.
    OpenUrlCrossRefPubMedWeb of Science
  142. ↵
    1. Cindy Ng LW,
    2. Mackney J,
    3. Jenkins S,
    4. et al
    . Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis. Chron Respir Dis 2012; 9: 17–26.
    OpenUrlAbstract/FREE Full Text
  143. ↵
    1. Probst VS,
    2. Kovelis D,
    3. Hernandes NA,
    4. et al
    . Effects of 2 exercise training programs on physical activity in daily life in patients with COPD. Respir Care 2011; 56: 1799–1807.
    OpenUrlAbstract/FREE Full Text
  144. ↵
    1. Nguyen HQ,
    2. Gill DP,
    3. Wolpin S,
    4. et al
    . Pilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD. Int J Chron Obstruct Pulmon Dis 2009; 4: 301–313.
    OpenUrlPubMed
  145. ↵
    1. Wewel AR,
    2. Gellermann I,
    3. Schwertfeger I,
    4. et al
    . Intervention by phone calls raises domiciliary activity and exercise capacity in patients with severe COPD. Respir Med 2008; 102: 20–26.
    OpenUrlCrossRefPubMed
  146. ↵
    1. Vaes AW,
    2. Cheung A,
    3. Atakhorrami M,
    4. et al
    . Effect of “activity monitor-based” counseling on physical activity and health-related outcomes in patients with chronic diseases: a systematic review and meta-analysis. Ann Med 2013; 45: 397–412.
    OpenUrlCrossRefPubMed
  147. ↵
    1. Greaves CJ,
    2. Sheppard KE,
    3. Abraham C,
    4. et al
    . Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011; 11: 119.
    OpenUrlCrossRefPubMed
    1. Conn VS,
    2. Minor MA,
    3. Burks KJ,
    4. et al
    . Integrative review of physical activity intervention research with aging adults. J Am Geriatr Soc 2003; 51: 1159–1168.
    OpenUrlCrossRefPubMedWeb of Science
  148. ↵
    1. Conn VS,
    2. Hafdahl AR,
    3. Brown SA,
    4. et al
    . Meta-analysis of patient education interventions to increase physical activity among chronically ill adults. Patient Educ Couns 2008; 70: 157–172.
    OpenUrlCrossRefPubMedWeb of Science
    1. Estabrooks PA,
    2. Glasgow RE,
    3. Dzewaltowski DA
    . Physical activity promotion through primary care. JAMA 2003; 289: 2913–2916.
    OpenUrlCrossRefPubMed
  149. ↵
    1. Ferrier S,
    2. Blanchard CM,
    3. Vallis M,
    4. et al
    . Behavioural interventions to increase the physical activity of cardiac patients: a review. Eur J Cardiovasc Prev Rehabil 2011; 18: 15–32.
    OpenUrlPubMedWeb of Science
View Abstract
PreviousNext
Back to top
View this article with LENS
Vol 44 Issue 6 Table of Contents
European Respiratory Journal: 44 (6)
  • Table of Contents
  • About the Cover
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
An official European Respiratory Society statement on physical activity in COPD
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
An official European Respiratory Society statement on physical activity in COPD
Henrik Watz, Fabio Pitta, Carolyn L. Rochester, Judith Garcia-Aymerich, Richard ZuWallack, Thierry Troosters, Anouk W. Vaes, Milo A. Puhan, Melissa Jehn, Michael I. Polkey, Ioannis Vogiatzis, Enrico M. Clini, Michael Toth, Elena Gimeno-Santos, Benjamin Waschki, Cristobal Esteban, Maurice Hayot, Richard Casaburi, Janos Porszasz, Edward McAuley, Sally J. Singh, Daniel Langer, Emiel F.M. Wouters, Helgo Magnussen, Martijn A. Spruit
European Respiratory Journal Dec 2014, 44 (6) 1521-1537; DOI: 10.1183/09031936.00046814

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
An official European Respiratory Society statement on physical activity in COPD
Henrik Watz, Fabio Pitta, Carolyn L. Rochester, Judith Garcia-Aymerich, Richard ZuWallack, Thierry Troosters, Anouk W. Vaes, Milo A. Puhan, Melissa Jehn, Michael I. Polkey, Ioannis Vogiatzis, Enrico M. Clini, Michael Toth, Elena Gimeno-Santos, Benjamin Waschki, Cristobal Esteban, Maurice Hayot, Richard Casaburi, Janos Porszasz, Edward McAuley, Sally J. Singh, Daniel Langer, Emiel F.M. Wouters, Helgo Magnussen, Martijn A. Spruit
European Respiratory Journal Dec 2014, 44 (6) 1521-1537; DOI: 10.1183/09031936.00046814
Reddit logo Technorati logo Twitter logo Connotea logo Facebook logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Abstract
    • Introduction
    • Methods
    • Definitions
    • Consequences of physical inactivity in the general population and in chronic diseases other than COPD
    • Consequences of physical inactivity on lung function decline and COPD incidence
    • Physical activity assessment
    • Levels of physical activity in patients with COPD
    • Factors associated with physical activity in COPD
    • Effect of physical inactivity on hospitalisations in patients with COPD
    • Effects of physical inactivity on survival in COPD
    • Treatment strategies to improve physical activity
    • Moving forward
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • COPD and smoking
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Task Force Report

  • Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary
  • Nasal nitric oxide measurement in children for the diagnosis of primary ciliary dyskinesia: European Respiratory Society technical standard
  • Genetic counselling and testing in PAH
Show more Task Force Report

ERS statement

  • ERS statement on familial pulmonary fibrosis
  • ERS statement defining exacerbations in bronchiectasis for clinical trials
  • ERS statement on long COVID follow-up
Show more ERS statement

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society