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(Chest. 2002;122:948-954.)
© 2002 American College of Chest Physicians

Exercise Maintenance Following Pulmonary Rehabilitation*

Effect of Distractive Stimuli

Gerene S. Bauldoff, RN, PhD; Leslie A. Hoffman, RN, PhD; Thomas G. Zullo, PhD and Frank C. Sciurba, MD, FCCP

* From the University of Pittsburgh School of Nursing (Drs. Bauldoff, Hoffman, and Zullo), and Division of Pulmonary, Allergy and Critical Care Medicine (Dr. Sciurba), University of Pittsburgh School of Medicine, Pittsburgh, PA.

Correspondence to: Gerene S. Bauldoff, RN, PhD, Assistant Professor of Nursing, Ohio State University, College of Nursing, 388 Newton Hall, 1585 Neil Ave, Columbus, OH 43210; e-mail: bauldoff.1{at}osu.edu


   Abstract
TOP
 Abstract
Introduction
 Specific Aims
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
Study objective: To determine if distractive auditory stimuli (DAS) in the form of music would promote adherence to a walking regimen following completion of a pulmonary rehabilitation program (PRP) and, thereby, maintenance of gains achieved during the program.

Design: Experimental, randomized, two-group design with testing at baseline, 4 weeks, and 8 weeks.

Setting: Outpatient.

Patients: Twenty-four patients (4 men and 20 women) with moderate-to-severe COPD (FEV1 41.3 ± 13% predicted [mean ± SD]).

Intervention: Experimental group subjects (n = 12) were instructed to walk at their own pace for 20 to 45 min, two to five times a week, using DAS with a portable audiocassette player. The control group (n = 12) received the same instructions, but no DAS.

Measurements and results: Primary outcome measures were perceived dyspnea during activities of daily living (ADL) and 6-min walk (6MW) distance. Secondary outcome measures were anxiety, depressive symptoms, health-related quality of life (QoL), global QoL, and breathlessness and fatigue at completion of the 6MW. In addition, all subjects recorded the distance and time walked using self-report (pedometers and daily logs). There was a significant decrease in perceived dyspnea during ADL (p = 0.0004) and a significant increase in 6MW distance (p = 0.0004) over time in the DAS group compared to the control group. DAS subjects increased 6MW distance 445 ± 264 feet (mean ± SD) from baseline to 8 weeks, whereas control subjects decreased 6MW distance to 169 ± 154 feet. No significant differences were noted for the remaining variables. The cumulative distance walked by the DAS group was 19.1 ± 16.7 miles compared to 15.4 ± 8.0 miles for the control group, a 24% difference (p = 0.49). Despite this difference, self-report exercise log data were similar for the two groups.

Conclusion: Subjects who used DAS while walking had improved functional performance and decreased perceptions of dyspnea, whereas control subjects could not maintain post-PRP gains. DAS is a simple, cost-effective strategy that may have the potential to augment the effectiveness of post-PRP maintenance training.

Key Words: activities of daily living • dyspnea • lung diseases, obstructive • therapy, exercise • therapy, music


   Introduction
TOP
 Abstract
 Introduction
Specific Aims
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
Pulmonary rehabilitation programs (PRPs) have been shown to increase patient independence by instruction in symptom management and improve activity tolerance through use of exercise training, considered the "cornerstone" of pulmonary rehabilitation. Adherence to an appropriate regimen has repeatedly been shown to improve exercise tolerance, increase strength and endurance, and reduce dyspnea in patients with COPD.1 2 3 4

While such programs have been shown to induce short-term increases in exercise tolerance, these improvements are not sustained.5 The inability to sustain an increase in exercise tolerance may, in part, result from increasing patient age and disease progression. In addition, long-term adherence to an exercise program is known to be poor in patients with COPD. Short-term benefits are quickly lost if exercise intensity and duration are not maintained.6 These observations reinforce the need for home-based programs, which test strategies to sustain gains achieved in PRPs. One approach involves the use of behavioral interventions such as cognitive-behavioral approaches and desensitization including distraction in combination with exercise training.7 Haas and colleagues8 postulate that desensitization to dyspnea can be accomplished by manipulating psychological or physiologic factors so that the perception of a dyspneic stimulus is altered.

Distractive auditory stimuli (DAS) involve the use of auditory stimuli that occupy the attention channels. DAS may reduce the sensation and conscious perception of dyspnea, and thus promote increased exercise tolerance.8 Music has been used as a distractor in multiple populations and settings.9 10 11 12 The varied positive benefits of DAS have included a significant increase in total exercise time and reduction in perceived exertion during exercise in patients with COPD.13 In ambulatory surgical patients, DAS has also been shown to decrease state anxiety, leading to a significant reduction in sedation requirement.9 DAS has also been shown to facilitate a reduction in anxiety following acute myocardial infarction and during mechanical ventilation.10 11


   Specific Aims
TOP
 Abstract
 Introduction
 Specific Aims
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
We sought to determine if DAS in the form of music would facilitate adherence to a walking regimen following completion of a PRP and, thereby, augment the effectiveness of post-PRP maintenance training as indicated by perceptions of dyspnea during activities of daily living (ADL) and 6-min walk (6MW) distance.


   Materials and Methods
TOP
 Abstract
 Introduction
 Specific Aims
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
The sample was a convenience sample of 24 patients (83% female) aged 68.1 ± 8 years (mean ± SD), defined as the first 24 subjects who met the inclusion criteria, consented to participate, and completed 8 weeks of data collection. Of these, 5 patients (16.7%) were African American and 19 patients (83.3%) were white. Six additional patients (all men) were approached but refused to participate because they did not wish to be randomized. Entry criteria were the following: (1) diagnosis of COPD (FEV1/FVC < 60%, FEV1 < 50% predicted); (2) 40 to 85 years of age; (3) ability to read, write, and speak English; (4) ability to hear music without assistive devices (eg, hearing aids); (5) completion of one of four regional PRPs that were clinical or satellite sites for the National Emphysema Treatment Trial (NETT) and used American Association of Cardiovascular and Pulmonary Rehabilitation and NETT guidelines; and (6) time since PRP completion was <= 6 months prior to study entry. Exclusion criteria were: (1) unstable cardiac disease (eg, recent myocardial infarction, uncontrolled hypertension, or severe congestive heart failure); (2) musculoskeletal disability preventing exercise; (3) inability to walk independently as instructed in prior PRPs due to disease advancement; and (4) known diagnosis of deafness or severe hearing loss. Spirometric values to verify eligibility were obtained from the medical records, with all testing performed prior to enrollment in the PRP and within 12 months of study entry. Subjects were enrolled from each of the four PRP sites. There were no significant between-group differences for PRP site location (p = 0.85) or time since PRP completion (p = 0.87).

The study received Institutional Review Board approval, and all subjects signed informed consent. After informed consent was obtained, subjects were randomly assigned to either DAS (music) or control. Sample size was determined by power analysis (PASS 6.0; NCSS Statistical Software; Kaysville, UT) based on 6MW distance and University of California San Diego Shortness of Breath Questionnaire (UCSD-SOB) scores from a pilot study14 that enrolled six subjects. A sample size of 18 subjects (9 subjects per group) was recommended to attain a power > 0.80 with an {alpha} level of 0.05. To adjust for potential attrition, a sample of 24 subjects (12 subjects per group) were enrolled.

Dependent Variables and Instruments
Dependent variables were measured at baseline, 4 weeks, and 8 weeks. Perceived dyspnea was measured using the UCSD-SOB, a 24-item instrument that assesses the occurrence of shortness of breath on a 7-point scale during 21 ADL associated with varying levels of exertion.15 Functional performance was measured using the 6MW, which determines the distance subjects can walk in 6 min.16 Anxiety was measured using Spielberger State-Trait Anxiety Inventory (STAI), which assesses state and trait anxiety using a 4-point Likert-type scale consisting of two subscales of 20 items each.17 Depressive symptoms were measured using Center for Epidemiologic Studies Depression Questionnaire (CES-D). The CES-D is a 20-item instrument measuring the presence and severity of depressive symptoms in the general population.18 Health-related quality of life (HRQoL) was measured using the St. George’s Respiratory Questionnaire (SGRQ). The SGRQ is a 76-item, disease-specific instrument measuring health in COPD.19 Global quality of life (QoL) was measured using a visual analog scale (VAS). The VAS is a self-report device used for measuring subjective phenomena.20 It is comprised of a straight line, usually 100 mm long with word or illustration anchors at each end, which is simple to use.20 Magnitude estimation is provided in determining the VAS score using a standard millimeter ruler, measuring from the left end mark. Breathlessness and fatigue at completion of the 6MW were measured using the modified Borg scale.21 The modified Borg scale is an interval scale in which the symptoms of breathlessness and fatigue are estimated by the patient between zero (nothing at all) and 10 (maximal). Reliability and validity has been previously established for all instruments.22 23 24 25 26 27

Testing to determine 6MW distance was performed using the script developed for the NETT.28 The script includes statements regarding time remaining and encouraging statements. Subjects prescribed oxygen during exercise were instructed to use their prescribed flow rate during the independent exercise program and testing. During the 6MW, an investigator (G.S.B.) carried the subjects’ oxygen. Oxygen saturation was continuously monitored. The protocol required that testing be stopped if the oxygen saturation decreased to < 88%. However, oxygen saturation remained > 88% during testing for all subjects. One investigator (G.S.B.) performed all walks. All subjects performed two 6MWs at each data collection visit, with a 30-min rest period used between walks. The higher of the two values was recorded as the walk distance. Modified Borg scores were obtained at completion of each walk. During the rest period, the subjects completed all questionnaires in the order of their choosing.

Following baseline testing, all subjects were given and instructed in use of an electronic pedometer (Model 342; Sportline; Campbell, CA), which measured walk distance to 1/100 of a mile precision. In addition, all subjects were instructed in completion of a log, which included date, amount of time, and distance walked as measured by the electronic pedometer. Each subject in the DAS group was also given a portable audiocassette player (GPX; High Hill, MO) and two audiocassette tapes with 45-min selections of four types of music (country/western, classical, pop/Motown, big band) for self-selection of music to be used during unsupervised walking programs. The music choices consisted of upbeat selections with a tempo of 90 to 110 beats per minute. For the walking program, subjects were instructed to begin with slow walking without use of the audiotapes for 5 min as warm-up. Subjects were encouraged to pace walking to a subjective sensation of dyspnea equivalent to a modified Borg rating of 2 to 3. The walking program encouraged a minimum duration of 20 min per session with preference of 30- to 45-min duration 2 to 5 days per week. Free walking on a flat area (ie, shopping mall, track, or sidewalk) or treadmill was encouraged. Each subject selected a preferred walking location; however, use of the same location was reinforced. Baseline, 4-week, and 8-week testing were conducted at the site of the previously completed PRP.

Data Analysis
The data were entered into an data file for subsequent analysis (version 10.0; SPSS; Chicago, IL) and were analyzed using a 2 x 3 multivariate analysis of variance for all variables. In addition, 2 x 3 multivariate analysis of variance was used for comparisons of each variable. Subjects’ reports of exercise time, pedometer distance, and symptoms were analyzed using t tests.


   Results
TOP
 Abstract
 Introduction
 Specific Aims
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
There were no significant differences at baseline in any measured variables (Table 1 ). When demographics were examined, control group subjects were older (p = 0.05) than DAS subjects. No between-group differences were found for marital status (p = 0.58), years of education (p = 0.07), ethnicity (p = 0.29), employment (p = 0.89), or oxygen requirement (p = 0.83).


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  		Table 1. Baseline Information*

 
Using multivariate analysis of variance, no significant difference was noted between groups (F = 1.277, degrees of freedom [df] = 11, 12; p = 0.339). However, significant differences were noted over time (F = 1.774, df = 22, 70; p = 0.037) and the interaction of time and group (F = 2.919, df = 22, 70; p = 0.0004). Due to the significant interaction of time and group, the differences for time cannot be interpreted independently.

When change in perceived dyspnea during ADL was analyzed by univariate analysis of variance, subjects in the DAS group reported a decrease and control subjects reported an increase in dyspnea at 8 weeks, compared to baseline, resulting in a significant interaction (F = 15.126, df = 2, 22; p = 0.000; Fig 1 ). Similar changes were seen in 6MW distance. Subjects in the DAS group had an increase and control subjects had a decrease in walk distance, resulting in a significant interaction (F = 33.341, df = 2, 22; p = 0.000). DAS subjects increased their 6MW distance from 1,022.1 ± 233.2 to 1,467.5 ± 363.3 feet from baseline to 8 weeks, whereas control group subjects showed a reduction in 6MW distance from 1,128.9 ± 286.3 feet at baseline to 959.8 ± 245.0 feet at 8 weeks (Fig 2 ).



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  		Figure 1. UCSD-SOB scores. Lower scores indicate less perception of dyspnea during ADL.

 


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  		Figure 2. 6MW distance.

 
Both groups had a reduction in depressive symptoms over time (F = 4.626, df = 2, 22; p = 0.015). Although nonsignificant, the experimental group subjects tended to report less depressive symptoms at 8 weeks (9.3 ± 9.0 vs 6.2 ± 8.2), whereas control group subjects reported little change in depressive symptoms (11.0 ± 6.5 vs 10.5 ± 8.6; Fig 3 ). No significant differences were seen between groups, over time or interaction for anxiety, HRQoL, global QoL, and breathlessness and fatigue at completion of the 6MW (Table 2 ).



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  		Figure 3. CES-D scale. Lower scores indicate less depressive symptoms.

 

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  		Table 2. Dependent Variables for Anxiety, Global QoL and HRQoL, and Breathlessness and Fatigue at End of the 6MW*

 
When trends were examined, several patterns were seen. Both groups increased scores for state anxiety from baseline to 4 weeks but fell below baseline at 8 weeks. The DAS group reported scores reflecting improved HRQoL from baseline to 8 weeks, whereas the control group had a decrement for this period. At completion of the 6MW, the DAS group reported a decrease in breathlessness and fatigue at 8 weeks, whereas the control group demonstrated little difference in scores for breathlessness and fatigue.

According to self-reported log data, 5 of the 24 subjects missed at least 1 week of exercise. Reasons included exacerbation and infection; however, none of the subjects required hospitalization during the study. The subjects reported an average of 2.8 ± 1 sessions per week and reported walking an average distance of 17.3 ± 13.0 miles per subject over the course of the study. The cumulative distance walked by the DAS group was 19.1 ± 16.7 miles compared to 15.4 ± 8.0 miles for the control group, a 24% difference (p = 0.49). Despite this difference, self-report exercise log data were similar for the two groups (Table 3 ).


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  		Table 3. Exercise Log Information*

 

   Discussion
TOP
 Abstract
 Introduction
 Specific Aims
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
The major findings of this study were the following: (1) subjects who used DAS (music) during post-PRP maintenance training improved functional performance reflected in an increase in 6MW distance and a decrease in perceived dyspnea compared to control subjects; and (2) depressive symptoms decreased over time in both groups. No significant differences were noted between groups, over time, or interaction of group and time for anxiety, global QoL, HRQoL (total or subscores), or symptoms during training or for variables of interest from the self-report logs. The mean increase in 6MW for the DAS group was 445.4 feet (136.6 m). Redelmeier and colleagues29 estimated that a 54-m increase or decrease in 6MW distance reflects a significant clinical change that is noticeable to the patient. Using this estimate, the change in the DAS group 6MW distance was both statistically and clinically significant.

This study builds on the conceptual framework of Haas and colleagues,8 who advocate the combination of exercise and desensitization as a behavioral intervention to reduce perception of dyspnea. When desensitization is used, the goal is to decrease anxiety through the use of distraction in the form of DAS. An outpatient setting was chosen for testing because few strategies are currently available to promote exercise continuation following completion of a PRP. The value of the intervention tested is that it is inexpensive and easy to implement as part of a comprehensive program to promote patient independence and to maximize level of functioning.

Two previous studies have tested DAS in the COPD population. Thornby and colleagues13 randomized 36 patients with COPD to exercise while listening to music, gray noise, or silence. In this study, the music served as the DAS and gray noise as a neutral auditory stimulus. Total exercise time was 22% longer with music than with either gray noise or silence (p < 0.001). At every level of exercise, perceived exertion was lower with music than for gray noise of silence (p < 0.01). These findings provide strong support for the short-term efficacy of DAS in improving exercise capacity. However, all testing was performed in a laboratory setting, and long-term benefits were not examined.

Pfister and colleagues30 examined the effects of audiocassette-delivered music (five types, including Big Band, 1960s, country, tropical, or Broadway themes, with tempos set from 119 and 126 beats per minute) on exercise tolerance and perceived symptoms during 6MW in 19 patients with COPD. This study used a cross-over design with treadmill walking on 3 separate days. Findings indicated no statistically significant differences in 6MW distance (p = 0.25), perceived dyspnea, or ratings of perceived exertion (modified Borg scale). However, 60% of the subjects reported enjoyment in listening to music while exercising. Pfister and colleagues30 used a patient-specific maximal treadmill speed during 6MW testing, a factor that may have limited the effect of the intervention, since patients may have focused on the need to maintain a specific walking speed rather than the DAS. A second confounding factor may have been the faster music tempo (119 to 126 beats per minute) vs the slower music tempo (90 to 100 beats per minute) used in this study.

All subjects in the DAS and control groups recorded exercise time and pedometer distance. Little between-group difference was noted for total exercise time, average exercise time, total number of sessions, average number of sessions, total distance walked, or average distance walked. Although between-group differences were small, the cumulative distance walked over the 8-week intervention was 24% greater in the DAS group compared to control subjects. This may indicate a synergistic effect of session time and distance, not seen when these parameters are viewed individually. It is possible that DAS subjects walked at an increased overall velocity due to the music. Increased velocity may have enhanced the training effect and, thereby, led to differences over time. Perhaps our instruction to maintain a given level of dyspnea while walking led to an increased intensity of training, rather than an increased duration.

There are several limitations to this study. Because the intervention was a nonsupervised, independent walking program, it was not possible to determine with certainty that the exercises were performed as advised or that the logs were reliably recorded. However, both groups noted in the logs when they did not exercise. It was also not possible to determine that the DAS was used as instructed, although all patients verbally reported compliance. There also may have been differences in exercise conditioning that favored the DAS subjects at study entry. However, DAS subjects reported more dyspnea at baseline and walked a shorter distance during 6MW testing compared to control subjects. All reported anecdotally that they attempted to continue to exercise as advised following their formal PRP. However, we did not verify this objectively. A final limitation was the relatively short (8-week) follow-up interval. Testing over a longer period is recommended in future studies.


   Conclusion
TOP
 Abstract
 Introduction
 Specific Aims
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 NOTICE OF ANNUAL MEETINGS
 
PRPs significantly increase functional capacity and reduce symptoms in patients with COPD. Unfortunately, the majority of patients experience a significant loss of the training effect within 1 year following completion of a formal program. This study suggests important benefits from the use of distraction as a means to maintain functional performance. The major findings were that subjects who used DAS (music) while walking improved post-PRP 6MW distance and decreased perceptions of dyspnea during ADL relative to control subjects. Findings of this study support the use DAS in the form of music as a simple, cost-effective strategy that has the potential to augment the effectiveness of post-PRP maintenance training.


   Acknowledgements
 
The authors thank Judith Erlen, RN, PhD, and Mildred Jones, RN, PhD, who served as members of the dissertation committee for this study; Andrew Petrini, MS, Lorraine Brock, RN, Todd Pollock, MS, B.J. Veschio, RRT, and Terry Riffer, MS, who served as case finders; and Fred Tasota, RN, MSN, for editorial assistance.


   Footnotes
 
Abbreviations: ADL = activities of daily living; CES-D = Center for Epidemiologic Studies Depression Questionnaire; DAS = distractive auditory stimuli; df = degrees of freedom; HRQoL = health-related quality of life; NETT = National Emphysema Treatment Trial; PRP = pulmonary rehabilitation program; QoL = quality of life; SGRQ = St. George’s Respiratory Questionnaire; 6MW = 6-min walk; STAI = Spielberger State-Trait Anxiety Inventory; UCSD-SOB = University of California San Diego Shortness of Breath Questionnaire; VAS = visual analogue scale

Supported by the National Institute of Nursing Research, National Institutes of Health grant No. 1F31 NR07599.

Received for publication August 30, 2001. Accepted for publication February 28, 2002.


   References
TOP
 Abstract
 Introduction
 Specific Aims
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
NOTICE OF ANNUAL MEETINGS
 

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   NOTICE OF ANNUAL MEETINGS
TOP
 Abstract
 Introduction
 Specific Aims
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 NOTICE OF ANNUAL MEETINGS
 
The Annual Meeting of the current Board of Regents of the American College of Chest Physicians (the "College") will convene at 1:00 p.m. Friday, November 1, 2002, at the Manchester Grand Hyatt San Diego, San Diego, California, to transact such business as shall properly come before the meeting.

The Annual Meeting of the College Fellows will convene at 8:30 a.m. Saturday, November 2, 2002, at the Manchester Grand Hyatt San Diego, to elect Officers, Regents and Governors to hold office for the following year, to vote on the Proposed Bylaw Amendment described below and to transact such other business as shall properly come before the meeting.

The proposed Bylaw Amendment is that Subsection 3.1(D)(1) of Article III of the Bylaws shall be amended by deleting such subsection in its entirety and in lieu and in place thereof adopting the following as Subsection 3.1(D)(1):

The candidate for Member who practices in a country with certifying bodies shall have passed a medical or surgical board examination and shall be licensed to practice medicine.

The effect of the amendment would be that a candidate for Member no longer would be required to be eligible to take an examination for subspecialty certification.




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