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Pulmonary rehabilitation in chronic obstructive pulmonary disease : impact on patients' self-efficacy
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Integrated care of chronic lung disease management comprises pulmonary rehabilitation (PR), which is an individually tailored intervention including exercise training and self-management education, purposeful on long-term adherence to health behaviour change. There is high scientific evidence that PR improves dyspnea, health status, exercise tolerance and anxiety and depression levels in people with chronic obstructive pulmonary disease (COPD), one of the most prevalent respiratory conditions worldwide. Self-efficacy (SE), defined as one’s belief of being capable of doing something to accomplish a desired goal, is considered a core outcome of self-management interventions, and a clinical and functional determinant of physical activity (PA) in people with COPD. Telemonitoring (TM) and telerehabilitation are telemedicine subsets of digital health supportive environments, that can be designed to meet high ecological validity of assessments and interventions, with potential impact on healthcare effectiveness. The aim of this thesis was to study the impact of PR on SE of people with COPD, including digitally health supportive environments such as TM and pulmonary telerehabilitation (PTR).
Study I accomplished the Portuguese validation of the Pulmonary Rehabilitation Adapted-Index of Self-Efficacy (PRAISE) tool, translating, and culturally adapting this SE instrument specific to PR into European Portuguese, by means of forward-backward translation, pilot testing and content validity through a multidisciplinary panel of expert judges. Reliability and construct validity was investigated on a cross-sectional study with 150 Portuguese PR outpatients by means of statistical exploratory factorial analysis. Results were a 4-factor solution suggesting discriminative SE qualities that cumulatively explained 52.3% of SE total variance and showed a PRAISE reliability of Cronbach alpha of 0.78.
To refine the accuracy of daily PA assessment methodology, Study II was a cross-sectional study with 100 PR outpatients comparing subjective and objective measures of PA as a vital sign before an exercise-based intervention. Regardless of self-reported PA and International Physical Activity Questionnaire (IPAQ) results, a 4-day continuous combined oximetry-accelerometery TM showed that patients spend at least a mean of 70% of daytime with activities below 2 metabolic equivalent of task (METs) and a mean sedentary time of 5.8 ± 2.7h/day. Moreover, as it was found that 93% of patients had daily episodes of oxygen desaturation, Study III further extended the same research by comparing free-living TM assessments with hospital six-minute walk test (6MWT) results. TM identified 24% more cases of oxygen desaturation compared with the 6MWT, detecting lower 7.2 ± 8.4% peripheral oxygen saturation, higher 9.3 ± 15.5% peak heart rate for more intense 0.3 ± 0.8 METs engaged PA. Also, there were 27% of patients with TM daily oxygen desaturation episodes undetected by the 6MWT, a finding that requires further attention on oximetry-guided interventions, such as telemedicine algorithms, oxygen therapy titration and regular PA assessment in PR.
Study IV was a participatory research on PTR including patients within stakeholders, aiming to develop strategies for setting up a person-centred digitally enabled model of care purposeful to enhance SE. This was a proof-of-concept and proof-of-implementation research, providing tacit knowledge about five types of requirements for PTR implementation and related operational strategies: PR core principles, quality and security standards, technological functionality, home environment appropriateness and telesetting skills. Patient’s mean level of satisfaction about PR goals achievement was of 88.1 ± 8.6% and of 95.4 ± 6.3% regarding experienced PTR.
Upon the arrival of COVID-19 pandemic, Study V included 100 PR hospital outpatients with suspended face-to-face PR in a prospective quasi-experimental design, including patients discharged and those shifted from face-to-face to PTR. PRAISE was applied as a follow-up screening criteria, together with surveys on the beginning of the outbreak and at 4-month follow-up. Results were that in response to the first ever COVID-19 lockdown, highest follow-up priority should be given to sedentary patients with lower SE, focusing on self-management to increase PA. At 4 months follow-up, 66% of patients suspended breathing exercise routines and 47% discontinued PA, with SE preserved on at least 70% of patients. Patient reported experience about shifting to PTR included «no need for time or means of transportation» and «sense of not being forgotten or left behind» as enablers, whereas «self-execution of the exercises» and «lack of equipment for exercise» as barriers. PTR would be recommended to others by 97.9% of these patients. Overall, 40% of patients who experienced PTR would prefer a hybrid model on a pandemic-free future, whereas 49.2% of those who had been discharged have future interest in PTR.
Overall, it can be concluded that PR integrating digital health supportive environments such as TM and telerehabilitation, has potential impact on SE enhancement of people with chronic respiratory disease, including people with COPD.
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Palavras-chave
reabilitação respiratória telemonitorização telerreabilitação actividade física auto-eficácia pulmonary rehabilitation telemonitoring telerehabilitation physical activity self-efficacy