Background Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit. Methods A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR. Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted. Discussion This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases. Trial registration The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666 ). Electronic supplementary material The online version of this article (10.1186/s12889-019-7045-1) contai...

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Objective To establish normative values and reference equations of the 6-minute walk test (6MWT), incremental shuttle walk test (ISWT) and unsupported upper limb exercise test (UULEX) for Portuguese adults. 2 Design Cross-sectional study. Descriptive statistics and differences between age decades and genders were explored using univariate general linear models to compute reference values. Reference equations were established with a forward stepwise multiple regression. Setting General community. Participants In total, 645 adult volunteers without disabilities [43% male, mean age 55.1 (standard deviation 23.6) years] were recruited from the university campus and surrounding community. Intervention Not applicable. Main outcome measures Data on age, gender, height, weight, body mass index and smoking status were collected using a structured questionnaire. Physical activity was evaluated using the Brief Physical Activity Assessment Tool. Participants performed two repetitions of the 6MWT, ISWT and UULEX, and the best repetition was used for analysis. Results Overall, performance was better in males than in females, and decreased with age. Participants' performance was significantly reduced after the sixth decade of life compared with the other decades (P<0.001). Reference equations were: 6MWT=226.93-(5.00×age)+(360.41×height), R 2 =71%; ISWT=393.81-(17.98×age)+(185.64×gender)+(775.88×height), R 2 =83%; and UULEX=16.71-(0.14×age)+(2.66×gender), R 2 =57%. Conclusion Leg or arm exercise field tests are affected significantly by age and gender. These results will aid health professionals to interpret the results of field tests obtained from healthy or diseased adult populations.

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Quadriceps strength training is a key component of pulmonary rehabilitation (PR). Clinical interpretability of changes in muscle strength following PR is however limited due to the lack of cut-off values to define clinical improvement. This study estimated the minimal clinically important difference (MCID) for the isotonic and isometric quadriceps muscle strength assessed with the one-repetition maximum (1RM) and hand-held dynamometry (HHD) in people with chronic obstructive pulmonary disease (COPD) following PR.A secondary analysis of a real life non-randomised controlled study was conducted in people with COPD enrolled in a 12-week community-based PR programme. Anchor and distributionbased methods were used to compute the MCIDs. The anchors explored were the St. George's respiratory questionnaire (SGRQ) and the six-minute walk test (6MWT) using Pearson's correlations. Pooled MCIDs were computed using the arithmetic weighted mean (2/3 anchor, 1/3 distribution-based methods) and reported as absolute and/or percentage of change values.Eighty-nine people with COPD (84% male, 69.9±7.9 years, FEV1 49.9±18.9% predicted) were included. No correlations were found between changes in 1RM and the SGRQ neither between changes in HHD and the SGRQ and 6MWT (p>0.05). Thus, anchor-based methods were used only in the MCID of the 1RM with the 6MWT as the anchor. The pooled MCIDs were 5.7Kg and 26.9% of change for the isotonic quadriceps muscle strength with 1RM and 5.2KgF for isometric quadriceps muscle strength assessed with HHD.The MCIDs found are estimates to improve interpretability of community-based PR effects on quadriceps muscle strength and may contribute to guide interventions.

Objective The Brief-Balance Evaluation Systems Test (Brief-BESTest) is a comprehensive, reliable, and valid balance test that provides valuable information to guide balance training in people with chronic obstructive pulmonary disease (COPD). Its clinical interpretability is, however, currently limited, as cutoff points to identify clinically relevant changes in people with COPD after pulmonary rehabilitation are still lacking. This study aimed to establish the responsiveness and minimal clinically important difference (MCID) for the Brief-BESTest in people with COPD after pulmonary rehabilitation (PR). Methods A secondary analysis of data from 2 previous studies was conducted. The modified British Medical Research Council (mMRC) dyspnea scale, the 6-Minute Walk Test (6-MWT), and the Brief-BESTest (0–24 points) were collected in people with COPD pre/post a 12-week PR program including balance training. The MCID was computed using anchor- and distribution-based methods. Changes in the 6-MWT and the mMRC were assessed and used as anchors. The pooled MCID was computed using the arithmetic weighted mean (2/3 anchor- and 1/3 distribution-based methods). Results Seventy-one people with COPD [69 years (SD = 8); 76% male; FEV1 = 49.8%predicted (SD = 18%)] were included. There was a significant improvement in the Brief-BESTest after PR [mean difference = 3 points (SD = 3)]. Significant correlations were found between the Brief-BESTest and the mMRC (r = −.31) and the 6-MWT (r = .37). The pooled MCID was 3.3 points. Conclusion An improvement of at least 3 points in the Brief-BESTest in people with COPD will enhance the interpretability of PR effects on balance performance of this population and guide tailored interventions. Impact The Brief-BESTest outcome measure is comprehensive, easily administered, and simple to interpret in clinical practice. This study represents a significant contribution toward the clinical interpretation of changes in balance in people with COPD following PR.

Introduction Low physical activity (PA) levels are associated with poor health‐related outcomes in Chronic Obstructive Pulmonary Disease (COPD). Thus, PA should be routinely assessed in clinical practice. Objectives This study assessed the construct validity of the Brief Physical Activity Assessment Tool (BPAAT) for clinical use in COPD and explored differences in age, sex and COPD grades. Methods After linguistic adaptation of the tool to Portuguese, 110 patients (66.4 ± 9.6yrs, 72.7% male, FEV1 = 59.3 ± 25.5%predicted) completed the BPAAT and received an accelerometer. The BPAAT includes two questions assessing the weekly frequency and duration of vigorous‐ and moderate‐intensity PA/walking, classifying individuals as insufficiently or sufficiently active. The BPAAT was correlated with accelerometry (moderate PA, MPA = 1952‐5724 counts‐per‐min [CPM]); vigorous PA, VPA = 5725‐∞CPM; moderate‐to‐vigorous PA, MVPA = 1952‐∞CPM; daily steps), through: Spearman’s correlations (ρ) for continuous data; %agreement, Kappa, sensitivity and specificity, positive and negative predictive values (PPV, NPV) for categorical data. Results The BPAAT identified 73.6% patients as “insufficiently active” and 26.4% as “sufficiently active”. The BPAAT was weakly to moderately correlated with accelerometry (0.394 ≤ ρ ≤ 0.435, P < 0.05), except for VPA (P = 0.440). This was also observed in age (<65/≥65yrs), COPD grades (GOLD 1–2/3–4) and in male patients (0.363 ≤ ρ ≤ 0.518, P < 0.05 except for VPA). No significant correlations were found in female patients (P > 0.05). Agreement was fair to moderate (0.36 ≤ κ ≤ 0.43; 73.6% ≤ %agreement ≤ 74.5%; 0.50 ≤ sensitivity ≤ 0.52; 0.84 ≤ specificity ≤ 0.91, 0.55 ≤ PPV ≤ 0.79, 0.72 ≤ NPV ≤ 0.82). Conclusion The BPAAT may be useful to screen patients’ PA, independently of age and COPD grade, and identify male patients who are insufficiently active. Care should be taken when using this tool to assess vigorous PA or female patients.