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Written Disclosure Therapy for Patients With Chronic Lung Disease Undergoing Pulmonary Rehabilitation
Abstract
Chronic lung diseases are typically associated with impaired quality of life, stress, and anxiety. Written disclosure therapy (WDT) reduces stress in patients with a variety of chronic illnesses. We sought to determine whether WDT benefits patients with chronic lung disease.
A prospective, randomized, controlled trial was performed to evaluate the effect of using WDT in patients (N = 66) participating in a pulmonary rehabilitation program. Patients were randomly assigned to write about a particularly traumatic life event (WDT group) or to write about an emotionally neutral subject (control group). Exercise capacity, dyspnea and quality of life, and values of spirometry were recorded at baseline, at the end of the program, and at 6 months.
The 6-minute walk distance (6MWD) significantly improved in both groups at 2 months, from 278 to 327 m in WDT and from 269 to 314 m in control groups (P < .01 in both groups). There was no difference in improvement in 6MWD between groups (P = .88). At 6 months, the gains made in 6MWD were no longer present. Dyspnea severity, as well as most of the other domains of the Chronic Respiratory Disease Questionnaire and the St. George's Respiratory Questionnaire, showed improvement within each group, but not between WDT and control groups.
WDT did not add any additional benefit in patients with chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis when included as a component of pulmonary rehabilitation. These results are in contrast to previously seen benefits in patients with asthma.
... Other arts reported in the studies include 4 rhythm-based, 27,28,30,70 2 singing, 33,34 1 theater, 37 and 1 writing-based intervention. 78 The administrators executing these art interventions included trained and experienced professionals in a branch of the arts, such as music therapists, musicians, and dance instructors. There were also studies administered by rehabilitation specialists, such as physical therapists, physical therapy students, and occupational therapists. ...
Objectives:
The purpose of this scoping review was to analyze the published literature regarding the use of art in the context of rehabilitation for consideration in physical therapy.
Methods:
The CINAHL, PsycArticles, APA PsycInfo, Art Index, Music Index, Cochrane Reviews, and PubMed electronic databases were accessed. Inclusion and exclusion criteria were established and utilized to determine study eligibility. Study details were extracted from each article by researchers using a systematic format. Summation of journal type, participants, dosing and type of intervention, setting and interventionist, outcome domains, and study results were included.
Results:
Out of 1452 studies, 76 were included for extraction. Of these studies, most had outcome measures aligned with the psychomotor and affective domains of learning (n = 66). Very few studies had outcome measures with psychomotor and cognitive domains (n = 2) or psychomotor, affective, and cognitive outcome measures (n = 8). Regarding the arts used, music, dance, or both were used in 77 instances. Fewer studies reported using creative arts therapy, singing, theater, writing, and rhythm (n = 17). Of the 76 studies analyzed, 74 reported a within-group treatment effect.
Conclusions:
The arts effectively enhance physical therapist practice; therefore, it is recommended that physical therapists continue to seek collaboration with art professionals and explore the use of arts in practice.
Impact:
Findings demonstrate that combining the arts with physical therapist practice amplifies not only psychomotor but affective and cognitive outcomes as well. The arts have applicability across broad populations (eg, chronic pain, neurologic dysfunction, respiratory conditions). This study supports that physical therapist education and practice should embrace the arts as a collaborative modality to promote enhanced psychomotor, affective, and cognitive outcomes.
... An earlier trial of EW in adolescents with asthma supports this theory as improvement was only observed among those with symptoms and lung function below the median (27). Interestingly, a recent trial that tested EW in participants with severe dyspnea and nonasthmatic lung disease had a null result (28). This suggests that there is a U-shaped relationship between severity of respiratory illness and responsiveness to EW, which supports our findings. ...
Asthma is a chronic condition affecting 300 million people worldwide. Management involves adherence to pharmacological treatments such as corticosteroids and β-agonists, but residual symptoms persist. As asthma symptoms are exacerbated by stress, one possible adjunct to pharmacological treatment is expressive writing (EW). EW involves the disclosure of traumatic experiences which is thought to facilitate cognitive and emotional processing, helping to reduce physiological stress associated with inhibiting emotions. A previous trial reported short-term improvements in lung function. This study aimed to assess whether EW can improve lung function, quality of life, symptoms, and medication use in patients with asthma.
Adults (18-45 years) diagnosed as having asthma requiring regular inhaled corticosteroids were recruited from 28 general practices in South East England (n = 146). In this double-blind randomized controlled trial, participants were allocated either EW or nonemotional writing instructions and asked to write for 20 minutes for 3 consecutive days. Lung function (forced expired volume in 1 second [FEV1]% predicted), quality of life (Mark's Asthma Quality of Life Questionnaire), asthma symptoms (Wasserfallen Symptom Score Questionnaire), and medication use (inhaled corticosteroids and β-agonist) were recorded at baseline, 1, 3, 6, and 12 months.
Hierarchical linear modeling indicated no significant main effects between time and condition on any outcomes. Post hoc analyses revealed that EW improved lung function by 14% for 12 months for participants with less than 80% FEV1% predicted at baseline (β = 0.93, p = .002) whereas no improvement was observed in the control condition (β = 0.10, p = .667).
EW seems to be beneficial for patients with moderate asthma (<80% FEV1% predicted). Future studies of EW require stratification of patients by asthma severity.
ISRCTN82986307.
... One other RCT from the USA [22] prospectively examined whether adding a psychosocial intervention, that is a written disclosure therapy (WDT), in COPD patients participating in an 8-week outpatient pulmonary rehabilitation program produced additional HRQoL benefits. At the weekly group support session, which was repeated for 3 consecutive weeks, the WDT group (n ¼ 29) wrote for 20 min about their traumatic or upsetting life experiences, compared to a control group (n ¼ 37) who wrote about an emotionally neutral subject. ...
Pulmonary rehabilitation plays a key role in the management of chronic obstructive pulmonary disease (COPD). Although the American Thoracic Society recently provided a grade of 1A for evidence of health-related quality of life (HRQoL) benefits related to pulmonary rehabilitation, knowledge about the psychological and behavioral processes explaining the impact of pulmonary rehabilitation on HRQoL in COPD patients remains limited. This review describes the state of knowledge over the past year concerning HRQoL benefits after pulmonary rehabilitation and suggests avenues for future research.
HRQoL outcomes related to pulmonary rehabilitation explores five themes: optimizing pulmonary rehabilitation components to improve HRQoL; characterization of a responder phenotype; suitability of pulmonary rehabilitation following acute exacerbations; exploration of psychological and behavioral mechanisms explaining pulmonary rehabilitation benefits; and long-term maintenance of HRQoL benefits after pulmonary rehabilitation.
Evidence supports the use of pulmonary rehabilitation to improve HRQoL in patients with moderate-to-severe COPD. However, it is unclear how pulmonary rehabilitation improves HRQoL and which characteristics confer the greatest HRQoL benefits. Moreover, most studies failed to provide a compelling theoretical rationale for the intervention employed. Future research should focus on improving the understanding of the psychological mechanisms implicated in the adoption and maintenance of healthy behavior.
Background:
Anxiety and dyspnea, 2 major symptoms in patients with chronic obstructive pulmonary disease (COPD), are associated with high morbidity and mortality. Thus, critically evaluating and synthesizing the existing literature employing pulmonary rehabilitation (PR) and other behavioral therapies in the treatment of anxiety and dyspnea in patients with COPD may help clinicians determine the most efficacious potential treatments. We aim to examine the efficacy of PR and behavioral therapy [eg, cognitive behavioral therapy (CBT) and counseling] and other adjunct modalities used in patients with COPD.
Methods:
We extracted relevant studies searching the published literature using an electronic database CINAHL, Medline, PubMed, Science Direct, and the Web of Science was conducted (spanning January 1, 2006 to November 15, 2016). Studies were included if they conducted PR and behavioral therapy (CBT, self-management, yoga) to treat anxiety and/or dyspnea in patients with COPD with or without randomized controlled trial.
Results:
The 47 studies selected included 4595 participants (PR = 3756 and behavioral therapy = 839), ranging in age from 58 to 75 years. The total number of participants receiving a treatment was 3928, and 667 participants served in control groups. In the majority of studies, PR and CBT are effective in the treatment of anxiety and dyspnea in the short term, but the long-term benefit is limited. In addition, self-management, yoga therapy, and CBT plus PR were beneficial.
Conclusions:
PR and CBT reduced both anxiety and dyspnea symptoms in patients with COPD in the short term. However, maintenance programs and the long-term benefits of PR and CBT remain inconclusive. Generally, the studies were relatively small and uncontrolled. Thus, prospective and randomized controlled trials with larger sample sizes are needed.
Background:
Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched.
Data sources:
Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015).
Review methods:
Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines.
Objectives:
To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom.
Results:
From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW.
Limitation:
Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.
Conclusions:
Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative.
Study registration:
This study is registered as PROSPERO CRD42012003343.
Funding:
The National Institute for Health Research Health Technology Assessment programme.
The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease (COPD).
Electronic databases were searched, identifying trials comparing exercise training with exercise training plus “add-on” therapy. Outcomes included peak oxygen uptake (V′O2peak), work rate and incremental/endurance cycle and field walking tests. Individual trial effects on exercise capacity were extracted and collated into eight subgroups and pooled for meta-analysis. Sensitivity analyses were conducted to explore the stability of effect estimates across studies employing patient-centred designs and those deemed to be of “high” quality (PEDro score >5 out of 10).
74 studies (2506 subjects) met review inclusion criteria. Interventions spanned a broad scope of clinical practice and were most commonly evaluated via the 6-min walking distance and V′O2peak. Meta-analysis revealed few clinically relevant and statistically significant benefits of “add-on” therapies on exercise performance compared with exercise training. Benefits favouring “add-on” therapies were observed across six different interventions (additional exercise training, noninvasive ventilation, bronchodilator therapy, growth hormone, vitamin D and nutritional supplementation). The sensitivity analyses included considerably fewer studies, but revealed minimal differences to the primary analysis.
The lack of systematic benefits of “add-on” interventions is a probable reflection of methodological limitations, such as “one size fits all” eligibility criteria, that are inherent in many of the included studies of “add-on” therapies. Future clarification regarding the exact value of such therapies may only arise from adequately powered, multicentre clinical trials of tailored interventions for carefully selected COPD patient subgroups defined according to distinct clinical phenotypes.
Background
Psychological stress has been widely implicated in asthma exacerbation. Evidence suggests written emotional disclosure, an intervention that involves writing about traumatic or stressful experiences, helps to reduce stress and promote physical and psychological well-being. There may be a role for written emotional disclosure in the management of asthma.
Objectives
To assess the effectiveness of written emotional disclosure in people with asthma.
Search methods
Trials were identified from the Cochrane Airways Group Specialised Register of trials, MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO. The latest search was conducted in Feb 2013
Selection criteria
Randomised controlled trials published in any language comparing written emotional disclosure intervention to a control writing (emotionally neutral) intervention in asthma patients were included in the review.
Data collection and analysis
Two review authors independently assessed studies against predetermined inclusion criteria and extracted the data. Corresponding authors were contacted where necessary to provide additional information.
Main results
Four studies, involving a total of 414 participants, met the inclusion criteria. The studies were overall of good methodological quality and the interventions based on Pennebaker's method. However, studies were limited by diverse outcome measurements, measurement tools, diverse control group techniques, and number and/or times of follow-up. A pooled result from the four studies, yielding a total of 146 intervention and 135 control patients, indicated no statistically significant difference in FEV1 % predicted between the disclosure group and the control group (WMD 3.43%, CI -0.61% to 7.47%) at short-term follow-up. Similarly, evidence from two studies indicated that written emotional disclosure does not have any beneficial effect on FVC (SMD -0.02, CI -0.30 to 0.26) and asthma symptoms (SMD -0.02, CI -0.52 to 0.09), but may result in improvement in asthma control at short-term follow-up (SMD 0.30, CI 0.01 to 0.58). We were unable to pool the data for other outcomes. Results from individual trials indicated no beneficial effect of written emotional disclosure on quality of life, medication use, healthcare utilisation and psychological well-being. Evidence from one trial suggests a significant reduction in beta-agonist use (WMD -1.62, CI -2.62 to -0.62) at short-term follow-up in the disclosure group compared to controls.
Authors' conclusions
The available evidence from a small number of studies suggests that written emotional disclosure does not improve lung function and symptoms in asthma patients but may have some beneficial effect on asthma control. There is insufficient evidence to draw any conclusion as to the role of disclosure on quality of life, psychological well-being, medication use and healthcare utilisation. More studies, with agreed core outcomes and standardised outcome measurement tools, are required to determine the effectiveness of written emotional disclosure in the management of asthma.
> ‘I hear and I forget, I see and I remember, I write and I understand.’ Chinese Proverb
Disclosure in the form of the spoken word has long been considered beneficial and widely used in counselling and other therapies. Self-inhibition of negative emotions is thought to lead to continuous autonomic arousal and poorer health.1 Writing therapy, otherwise described in the literature as ‘expressive (emotional) disclosure’, ‘expressive writing’, or ’written disclosure therapy’ may have the potential to heal mentally and physically. In early experiments, participants wrote about their most traumatic thoughts and feelings related to a stressful event for up to 20 minutes over three or four writing sessions. To isolate any non-specific beneficial effect from participating in studies, control groups wrote about superficial non-emotive topics. The experimental group observed better physical health, improved immune system functioning, and fewer days off due to illness. This formed the basis of subsequent studies into writing therapy.
How writing potentially brings about health benefits is unknown and the underlying mechanism is likely to be complex and multifactorial. One theory is that of emotional catharsis whereby the mere act of disclosure, essentially ‘getting it off your chest’ is a powerful therapeutic agent in itself.2 Writing may facilitate cognitive processing of traumatic memories, resulting in more adaptive, integrated representations about the writer themselves, their world, and others.3 It is also possible that development of a coherent narrative over time results in ongoing processing and finding meaning in the traumatic experience.4
Writing therapy could potentially be a cheap and easily accessible option that would require minimal input from healthcare professionals. We wondered whether it could be an effective alternative form of therapy in general practice, since access to psychological therapies in primary care can often be slow or limited, much to the frustration of …
In recent years quality of life instruments have been featured as primary outcomes in many randomized trials. One of the challenges facing the investigator using such measures is determining the significance of any differences observed, and communicating that significance to clinicians who will be applying the trial results. We have developed an approach to elucidating the significance of changes in score in quality of life instruments by comparing them to global ratings of change. Using this approach we have established a plausible range within which the minimal clinically important difference (MCID) falls. In three studies in which instruments measuring dyspnea, fatigue, and emotional function in patients with chronic heart and lung disease were applied the MCID was represented by mean change in score of approximately 0.5 per item, when responses were presented on a seven point Likert scale. Furthermore, we have established ranges for changes in questionnaire scores that correspond to moderate and large changes in the domains of interest. This information will be useful in interpreting questionnaire scores, both in individuals and in groups of patients participating in controlled trials, and in the planning of new trials.
Approximately 60 million people in the United States live with one of four chronic conditions: heart disease, diabetes, chronic respiratory disease, and major depression. Anxiety and depression are very common comorbidities in COPD and have significant impact on patients, their families, society, and the course of the disease.
We report the proceedings of a multidisciplinary workshop on anxiety and depression in COPD that aimed to shed light on the current understanding of these comorbidities, and outline unanswered questions and areas of future research needs.
Estimates of prevalence of anxiety and depression in COPD vary widely but are generally higher than those reported in some other advanced chronic diseases. Untreated and undetected anxiety and depressive symptoms may increase physical disability, morbidity, and health-care utilization. Several patient, physician, and system barriers contribute to the underdiagnosis of these disorders in patients with COPD. While few published studies demonstrate that these disorders associated with COPD respond well to appropriate pharmacologic and nonpharmacologic therapy, only a small proportion of COPD patients with these disorders receive effective treatment.
Future research is needed to address the impact, early detection, and management of anxiety and depression in COPD.
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease characterized by a combination of 3 different disorders, namely chronic asthma, chronic bronchitis and pulmonary emphysema, sometimes simultaneously present in the same subject.
The aim of our study was to compare sputum inflammatory markers in patients with different phenotypes of chronic airway obstruction. Methods: Forty-five subjects (forced expiratory volume in 1 s/vital capacity, FEV(1)/VC: 58.8 +/- 12.2%; FEV(1): 49.8 +/- 11.5% of predicted) were classified as chronic asthma (n = 10) or COPD patients (n = 35); the latter were further divided into patients with prevalent chronic bronchitis (n = 24) or prevalent pulmonary emphysema (n = 11) according to clinical history and functional evaluation, and underwent sputum induction and analysis of inflammatory cell and soluble mediators.
Patients with chronic asthma showed higher sputum eosinophil percentages and eosinophilic cationic protein levels, and lower neutrophil percentages and neutrophil elastase levels than COPD patients. Neutrophil chemotactic activity in sputum supernatant was higher than the pool of normal subjects both in chronic asthma and COPD patients. No difference in sputum cell composition and levels of soluble mediators was observed between patients with chronic bronchitis and patients with pulmonary emphysema.
The pattern of airway inflammation in induced sputum of patients with chronic asthma is different from that of COPD patients with a similar FEV(1). Among COPD patients, however, the pattern of airway inflammation shows no difference between chronic bronchitis and patients with pulmonary emphysema, suggesting that these two clinically and functionally distinct phenotypes share a common inflammatory pattern as detected by induced sputum.
Since the relationships between pulmonary function, exercise capacity, and functional state or quality of life are generally weak, a self report questionnaire has been developed to determine the effect of treatment on quality of life in clinical trials. One hundred patients with chronic airflow limitation were asked how their quality of life was affected by their illness, and how important their symptoms and limitations were. The most frequent and important items were used to construct a questionnaire evaluating four dimensions: dyspnoea, fatigue, emotional function, and the patient's feeling of control over the disease (mastery). Reproducibility, tested by repeated administration to patients in a stable condition, was excellent: the coefficient of variation was less than 12% for all four dimensions. Responsiveness (sensitivity to change) was tested by administering the questionnaire to 13 patients before and after optimisation of their drug treatment and to another 28 before and after participation in a respiratory rehabilitation programme. In both cases large, statistically significant improvements in all four dimensions were noted. Changes in questionnaire score were correlated with changes in spirometric values, exercise capacity, and patients' and physicians' global ratings. Thus it has been shown that the questionnaire is precise, valid, and responsive. It can therefore serve as a useful disease specific measure of quality of life for clinical trials.
Examined whether writing about traumatic events would influence long-term measures of health as well as short-term indicators of physiological arousal and reports of negative moods in 46 introductory psychology students. Also examined were aspects of writing about traumatic events (i.e., cognitive, affective, or both) that were most related to physiological and self-report variables. Ss wrote about either personally traumatic life events or trivial topics on 4 consecutive days. In addition to health center records, physiological measures and self-reported moods and physical symptoms were collected throughout the experiment. Findings indicate that, in general, writing about both the emotions and facts surrounding a traumatic event was associated with relatively higher blood pressure and negative moods following the essays, but fewer health center visits in the 6 mo following the experiment. It is concluded that, although findings should be considered preliminary, they bear directly on issues surrounding catharsis, self-disclosure, and a general theory of psychosomatics based on behavioral inhibition. (24 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals.
To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures.
Randomized controlled trial conducted between October 1996 and December 1997.
Outpatient community residents drawn from private and institutional practice.
Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group.
Patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention).
Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition.
Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV1] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001).
Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.
The aim of this study was to explore the effects of guided imagery relaxation in people with chronic obstructive pulmonary disease (COPD) using a randomized controlled design. Half of 26 participants were allocated to the treatment group in which six practice sessions on guided imagery were conducted, while the control group was instructed to take rest quietly during the six sessions. At the seventh session, physiological changes: partial percentage of oxygen saturation; heart rate; upper thoracic surface electromyography; skin conductance; and peripheral skin temperature were recorded during a 30-minute session with a sampling frequency of one minute. Repeated measures analysis of variance was used to explore the changes of the parameters between the groups. Mann-Whitney U test was used to compare the change of perceived dyspnoea between the groups. Results showed there was a statistically significant (p < 0.05) increase in partial percentage of oxygen saturation in the treatment group, but no significant effects on the other physiological parameters. Further study exploring the psychological effects of guided imagery is suggested.
This prospective, randomized controlled trial examined the effect of progressive muscle relaxation (PMR) training on anxiety and depression in patients with chronic breathing disorders receiving pulmonary rehabilitation (PR).
Eighty-three subjects with chronic breathing disorders entering the 8-week PR program were randomly assigned to a standard care or intervention group. The standard program included 2 days per week of exercise, education and psychosocial support delivered by a multidisciplinary team. The intervention group received additional sessions of PMR training using a prerecorded tape for 25 min/week during weeks 2-8. Primary outcome measures were levels of anxiety and depression evaluated by the Hospital Anxiety and Depression Scale.
For anxiety, there was an overall significant improvement within each group over time (p < 0.0001). There was no statistically significant group-time interaction (p = 0.17) and no statistically significant difference between the groups (p = 0.22), despite lower scores for every time point in the PMR group. For depression, there was an overall significant improvement within each group over time (p < 0.0001). Although the difference between the groups (p = 0.09) and group-time interaction (p = 0.07) did not reach statistical significance, the results again favored the PMR group for weeks 5-8. Depression scores were lower for the PMR throughout weeks 1-8.
PR is effective in reducing anxiety and depressive level in chronic lung patients. Our findings suggest that adding structured PMR training to a well-established PR program may not confer additional benefit in the further reduction of anxiety and depression in patients receiving PR.
A need was identified for a fixed-format self-complete questionnaire for measuring health in chronic airflow limitation. A 76-item questionnaire was developed, the St. George's Respiratory Questionnaire (SGRQ). Three component scores were calculated: symptoms, activity, and impacts (on daily life), and a total score. Three studies were performed. (1) Repeatability was tested over 2 wk in 40 stable asthmatic patients and 20 patients with stable COPD. The coefficient of variation for the SGRQ total score was 19%. (2) SGRQ scores were compared with spirometry, 6-min walking distance (6-MWD), MRC respiratory symptoms questionnaire, anxiety, depression, and general health measured using the Sickness Impact Profile score. A total of 141 patients were studied, mean age 63 yr (range 31 to 75) and prebronchodilator FEV1, 47% (range 11 to 114%). SGRQ scores correlated with appropriate comparison measures. For example, symptom score versus frequency of wheeze, r2 = 0.32, p less than 0.0001; activity versus 6-MWD, r2 = 0.50, p less than 0.0001; impact versus anxiety, r2 = 0.38, p less than 0.0001. Multivariate analysis demonstrated that SGRQ scores summed a number of areas of disease activity. (3) Changes in SGRQ scores and other measures were studied over 1 yr in 133 patients. Significant correlations were found between changes in SGRQ scores and the comparison measures (minimum r2 greater than 0.05, p less than 0.01). Multivariate analysis showed that change in total SGRQ score summed changes in a number of aspects of disease activity. We conclude that the SGRQ is a valid measure of impaired health in diseases of chronic airflow limitation that is repeatable and sensitive.
To investigate the hypothesis that clinical methods and psychophysical testing provide different information about breathlessness, we compared dyspnea ratings from a modified Medical Research Council (MRC) scale, the Oxygen-Cost Diagram (OCD), and the Baseline Dyspnea Index (BDI) with the perceived magnitude of added loads in 24 patients with obstructive airway disease (OAD) who experienced dyspnea on exertion. Age of the patients was 55.8 +/- 13.7 yr (mean +/- SD), FEV1 was 1.77 +/- 0.81 L, and FEV1/FVC ratio was 52.6 +/- 10.5%. Dyspnea ratings were obtained for each clinical method by 2 independent observers; estimates of the magnitude of 5 resistive loads (10 to 85 cm H2O/L/s) were obtained using the Borg category scale (0 to 10). For comparative purposes, 12 age-matched (48.9 +/- 13.5 yr) healthy subjects were also studied. Clinical ratings of dyspnea obtained in patients for MRC (range, 0 to 4), OCD (range, 23 to 98), and BDI (range, 0.5 to 12.0) were all highly interrelated (rs = 0.79, -0.83, and -0.71; p less than 0.001 for all comparisons). Exponents of the psychophysical power function for resistive breathing loads were similar for patients with OAD (0.57 +/- 0.27) and control subjects (0.63 +/- 0.18) (p = NS). Clinical dyspnea scores were significantly correlated with both FEV1 and FVC; however, neither dyspnea ratings nor lung function were significantly related to the exponent for added breathing loads in the patient group. These comparisons indicate that in patients with symptomatic OAD, clinical methods for rating dyspnea are interrelated and are correlated with lung function, but are independent of perception of resistive breathing loads.(ABSTRACT TRUNCATED AT 250 WORDS)
The effect of exercise at different intensities as well as the effect of intensive supervised pulmonary rehabilitation on oxidative stress were studied for chronic obstructive pulmonary disease (COPD). Eleven patients with COPD and 11 healthy age-matched control subjects performed a maximal and submaximal exercise cycle ergometry test at 60% of peak workload. Patients with COPD performed these tests before and after 8 wk of pulmonary rehabilitation. Measurements were done before, immediately after, and 4 h after both exercise tests. At rest, increased oxidative stress was observed in patients compared with control subjects, as measured by urinary malondialdehyde (MDA; p < 0.05) and hydrogen peroxide (H2O2) in breath condensate (p < 0.05). In healthy control subjects, a significant increase in urinary MDA was observed 4 h after both exercise tests (p = 0.05), whereas H2O2 significantly increased immediately after maximal exercise (p < 0.05). In patients with COPD, before rehabilitation, reactive oxygen species-induced DNA damage in peripheral blood mononuclear cells, urinary MDA, and plasma uric acid were significantly increased after both exercise tests (p < 0.05), whereas no significant increase was observed in plasma MDA. In contrast, exhaled H2O2 was only significantly increased after maximal exercise (p < 0.02). Although after rehabilitation peak workload was increased by 24%, a similar oxidative stress response was found. Remarkably, a decrease in reactive oxygen species-induced DNA damage was detected after exercise at submaximal intensity despite increased exercise duration of 73%. In summary, patients with COPD had increased pulmonary and systemic oxidative stress both at rest and induced by exercise. In addition, pulmonary rehabilitation increased exercise capacity and was associated with reduced exercise-induced oxidative stress.
This paper reports an investigation of the effects of acupressure therapy on dyspnoea, anxiety and physiological indicators of heart rate and respiratory rate in patients with chronic obstructive pulmonary disease having mechanical ventilation support.
Patients with chronic obstructive pulmonary disease who are using mechanical ventilation often experience dyspnoea and anxiety, which affects successful ventilator use.
The study had an experimental blocking design, using sex, age and length of ventilator use as a blocking factor. Qualified patients in two intermediate respiratory intensive care units were randomly assigned to an acupressure group and a comparison group. A total of 52 patients with chronic obstructive pulmonary disease in northern Taiwan participated. Those in the experimental group received daily acupressure therapy and massage treatment for 10 days. Patients in the comparison group received massage treatment and handholding. The primary outcome measures were the visual analogue scales for dyspnoea and anxiety, and physiological indicators of heart rate and respiratory rate. Data were collected every day from baseline (day 1), during the treatment (days 2-10) and follow-up (days 11-17). Data were analysed using generalized estimation equations. The study was carried out in 2003.
Patients with chronic obstructive pulmonary disease who were using prolonged mechanical ventilatory support experienced high levels of dyspnoea and anxiety. Dyspnoea (P = 0.009), anxiety (P = 0.011) and physiological indicators (P < 0.0001) in the acupressure group improved statistically significantly over time when compared with those of the comparison group.
This results support the suggestion that acupressure therapy could decrease sympathetic stimulation and improve perceived symptoms of dyspnoea and anxiety in patients with chronic obstructive pulmonary disease who are using prolonged mechanical ventilation.
We report the second update of a meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. We wished to determine the impact of rehabilitation (defined as exercise training for at least four weeks with or without education and/or psychological support) on quality of life (QoL) and exercise capacity. We included 31 randomised controlled trials. Statistically significant improvements were found for all the outcomes. In four important domains of QoL (dyspnea, fatigue, emotions and patients' control over disease), the effect was larger than the minimal clinically important difference. These results strongly support respiratory rehabilitation as part of the spectrum of management for patients with COPD.
We tested whether emotional skills and headache management self-efficacy (HMSE) moderated effects of written emotional disclosure (WED) compared with control writing and a different intervention, relaxation training (RT).
Undergraduates with migraine headaches reported emotional approach coping (EAC) and HMSE; were randomized to WED, RT, or control; and assessed on health measures at baseline and 3-month follow-up.
Greater EAC predicted improvement following WED compared with RT and control, whereas low HMSE predicted improvement following both WED and RT, compared with control.
Emotional skill may specifically - and low health management self-efficacy may generally - predict positive responses to WED.