Accepted Manuscript

Title: Effectiveness of a combined exercise training and

home-based walking programme on physical activity
compared with standard medical care in moderate COPD: a
randomised controlled trial

Authors: P. de Roos, C. Lucas, J.H. Strijbos, E. van Trijffel

PII: S0031-9406(17)30060-3
DOI: http://dx.doi.org/doi:10.1016/j.physio.2016.08.005
Reference: PHYST 981

To appear in: Physiotherapy

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Effectiveness of a combined exercise training and home-based

walking programme on physical activity compared with standard

medical care in moderate COPD: a randomised controlled trial

P. de Roosa,*, C. Lucasb, J.H. Strijbosc, E. van Trijffelb,d

a
Physiotherapy Centre De Oppers, Drachten, The Netherlands
b
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Medical

Centre, University of Amsterdam, Amsterdam, The Netherlands

c
Department of Respiratory Medicine, Hospital Nij Smellinghe, Drachten, The Netherlands
d
Educational Centre for Musculoskeletal Therapies, Amersfoort, The Netherlands

*
Corresponding author. Address: De Oppers 3, 9203 GD Drachten, The Netherlands. Tel.: +31 512 515 591.

E-mail address: pieterderoos@chello.nl (P. de Roos).

Abstract

Objective To estimate the effectiveness of a 10-week combined exercise training and home-

based walking programme on daily physical activity (PA) compared with standard medical

care in patients with moderate chronic obstructive pulmonary disease (COPD).

Design Randomised controlled trial.

Setting Primary care physiotherapy.

Participants Consecutive patients with stable COPD at Gold Stage II with a score of 2 or

more on the Medical Research Council Dyspnoea Scale.

1
Intervention Ten-week combined exercise training and home-based walking programme

compared with standard medical care.

Main outcomes At baseline and after 10 weeks, daily PA was evaluated by accelerometry

using three levels of intensity and expressed as metabolic equivalent of task. In addition, daily

activities (Physical Activity Scale for the Elderly), functional exercise capacity (6-minute

Walk Test), health-related quality of life (Chronic Respiratory Questionnaire) and exercise

self-efficacy (Exercise Self-Regulatory Efficacy Scale) were measured.

Results Fifty-two patients {34 females; mean age 70.2 [standard deviation (SD) 9.5] years;

mean forced expiratory volume in 1 second 67% (SD 9.2) of predicted} were randomised.

PA, adjusted for baseline differences, increased significantly in the intervention group

compared with the control group, by 26.1 minutes/day [95% confidence interval (CI) 7.3 to

44.9]. The increase in functional capacity between groups was clinically relevant (34.0 m,

95% CI 2.3 to 65.6) in favour of the intervention group.

Conclusions A combined exercise training and home-based walking programme in primary

care physiotherapy improved PA in patients with moderate COPD.

Clinical trial registration number NL24766.018.08

Keywords: Physical activity; Exercise training; COPD; Home-based; Primary care

<A>Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease of the

airways [1], commonly afflicted by co-morbidity and systemic extrapulmonary manifestations

causing deconditioning and physical inactivity [2,3]. The prevalence of COPD increases

steeply to more than 10% amongst those aged 40 years or over [4]. Direct costs account for

over 3% (48.4 billion Euros) of the total healthcare budget in the European Union [5]. COPD

2
is the third leading cause of death worldwide, and in 2015, it was ranked fifth in terms of

global years lived with disability [6].

Of patients with COPD, those with moderate COPD comprise the largest group in Dutch

general practice. These patients are markedly inactive compared with their healthy age-

matched peers, and also when compared with patients with other diseases [7]. In patients with

moderate COPD, moderate-intensity physical activity (PA) seems to decrease initially as a

strategy to minimise dyspnoea [3]. In the mild to moderate stages, the decrease in PA is more

pronounced in patients with mild symptoms of dyspnoea and those with lower levels of

diffusion capacity, exercise capacity and self-efficacy [3,8]. Additionally, the PA level is

influenced by seasonal factors [9]. Decreased PA appears to lead to systemic co-morbidities

such as muscle weakness, osteoporosis and cardiovascular disease, and is the strongest

predictor of all-cause mortality in patients with COPD [10,11].

In the treatment of COPD, exercise training during pulmonary rehabilitation (PR) is a

cornerstone. Exercise is effective in reducing hospital admissions and mortality, as well as in

establishing benefits in health-related quality of life (HRQoL) and functional exercise

capacity (FEC) [12,13]. The American Thoracic Society/European Respiratory Society

(ATS/ERS) Task Force on Pulmonary Rehabilitation has reported that it is important to

enhance PA during exercise training [14]. Moderate COPD may be the ideal target for

intervention as patients are at the onset of becoming sedentary but only marginally limited in

physical and ventilatory terms [2,3,15]. Studies on enhancing PA by exercise training in the

mild-to-moderate stages have been scarce. A primary care programme of exercise training and

promoting PA in patients with mild-to-moderate COPD reported no effectiveness on PA [16].

3
Furthermore, a meta-analysis of centre-based PR programmes in patients with (very) severe

COPD found only small increases in PA [17].

An important feature in exercise adherence seems to be the use of normal daily life activities,

in which walking has been reviewed as the most successful component in behavioural

intervention in COPD [18]. Home-based programmes using normal life activities, including

walking, may have an additional and more sustainable effect on daily PA. However, to the

authors’ knowledge, no PA-enhancing exercise training programmes combined with normal

life activities have been evaluated in a randomised controlled trial of patients with moderate

COPD.

This study aimed to compare the effectiveness of an exercise training programme with

additional home-based walking exercises with standard medical care on PA in patients with

moderate COPD in a primary care setting.

<A>Methods

<B>Study design

In this randomised controlled trial, eligible participants were allocated to the intervention

group or the control group. The intervention group participated in a 10-week supervised

exercise training programme combined with home-based walking exercises. The control

group received standard medical care (i.e. wait and see). There was no additional optimisation

of medication in either group.

<B>Participants

4
An active search of patients in primary general care practices and the local hospital was

undertaken. Patients were included in the study after referral for physiotherapy by a primary

care physician. Recruitment took place from June 2009 to May 2013 in two medium-sized

towns in the north of The Netherlands, throughout the year to avoid seasonal bias in the

measurements. Clinically stable patients with known COPD, diagnosed as GOLD Stage II

[50% ≤ forced expiratory volume in 1 second (FEV1) < 80%] according to the GOLD criteria

[1], were eligible if they also had a score of 2 or more on the Medical Research Council

Dyspnoea Scale, including dyspnoea on this level as a important prognostic predictor of

decreased PA [8,19]. Patients with exercise-restricting, non-COPD-related complaints (e.g.

severe cardiac or musculoskeletal diseases) were excluded from this study. All individuals

gave written informed consent, and ethical approval was granted by the Medical Ethics

Assessment Board of the Academic Medical Centre, Amsterdam, The Netherlands.

<B>Randomisation

Allocation was randomised and concealed using opaque-sealed envelopes. All possible

sequences in permuted blocks of four with two intervention and two control tickets were

created and placed at random in sequentially numbered order by an individual not affiliated to

the study. At intake and under the supervision of the physiotherapist in the primary care

centre, participants were instructed to open the first envelope. Block randomisation was

necessary as no specific data on PA of patients with moderate COPD were available at the

outset of the trial. Using this procedure, interim analysis on established power was possible

after inclusion of approximately 25 and 50% of the study population (12 and 24 patients,

respectively).

<B>Interventions

5
The intervention programme involved a group-based circuit exercise training programme that

was executed in two primary physiotherapy care centres under the guidance of three

therapists. The intervention took place over 10 consecutive weeks, in which patients

performed exercises two times per week during 1-hour sessions. The centre-based programme

consisted of incremental exercises of 10 minutes of treadmill walking, 10 minutes of cycling

and extremity resistance exercises (further details on onset intensity, frequency duration and

progression of the workload are described in Appendix A, see online supplementary material).

During and between the exercise sessions, patients were instructed weekly about exercise

compliance and the importance of staying active in daily life. These education sessions took

place for 5 minutes each week, and were based on five important elements of educational

intervention: assessing, advising, collaborative agreement, assisting and arranging (Appendix

A, see online supplementary material). The intervention also included an unsupervised home

walking programme, with patients instructed to walk for at least 30 minutes for 1 day per

week on a fixed day of the week (day of patient’s choice) over the 10 weeks. Emphasis was

placed on continuity rather than on increasing training intensity and goal setting. Compliance

was checked verbally during training each week. Patients in the control group received

standard medical care from their general physician, which consisted of standard monitoring

and self-referral consultation in case of worsening symptoms.

<B>Measurements

PA, the primary outcome of this trial, was recorded in minutes per day using a uniaxial

accelerometer personal activity monitor (PAM), quantifying the amount of motion in the

vertical plane with an energy expenditure of 0.8 METs or more. The test–retest reliability of

the PAM is good, and it correlates highly with the Actigraph accelerometer for treadmill

walking and stair walking [20]. In addition, the PAM is capable of measuring three different

6
levels of PA intensity, expressed as metabolic equivalent of task (MET), as recommended by

the ATS/ERS [14]. Energy expenditure during PA is graded as low (1.8 to 3 METs), moderate

(more than 3 METs) or vigorous (more than 7 METs) [21]. The lightweight PAM was worn at

the waist for a full week, except during sleeping hours.

As a secondary outcome measure, daily activities were measured using the Physical Activity

Scale for Elderly (PASE). Concurrent validity compared with accelerometry was variable

(r=0.42 and 0.17) and test–retest reliability (intraclass correlation coefficient) was 0.65 [22].

Functional exercise capacity (FEC) was measured with the 6-minute Walk Test and expressed

as the 6-minute walk distance (6MWD). Assessment was performed by the treating

physiotherapist according to the ATS recommendations with standardised encouragement.

The minimal clinically important difference (MCID) in COPD is 25 m [23]. Health-related

quality of life (HRQoL) was measured by the self-administrated version of the Chronic

Respiratory Questionnaire with a MCID per domain of 0.5 [24]. Exercise self-efficacy was

measured by the Exercise Self-Regulatory Efficacy Scale (Ex-SRES) questionnaire [25].

All measurements were performed after allocation at baseline 1 week before and 1 week after

the 10-week intervention period for both groups. The intervention programme started after

completion of all measurements. Due to the setting of the research, the outcome assessor was

not blinded. Instructions on how to wear the PAM and other information about the PAM was

shared with the patients. The device did not provide feedback. Compliance with wearing the

PAM was checked verbally on a weekly basis.

<B>Statistical analysis

7
Descriptive data were described as mean [standard deviation (SD)] or median (min to max).

Statistical differences were calculated using independent t-tests or Mann–Whitney U-tests for

between-group differences, and paired t-tests or Wilcoxon matched pairs signed rank sum t-

tests for within-group differences. Outcomes were analysed based on an intention-to-treat

principle using all available data. Correlations between changes in PA and secondary

outcomes were expressed using Pearson’s correlation coefficients. To adjust for baseline

inequality in potentially clinically relevant prognostic factors between the two groups,

multivariate linear regression was conducted including all unbalanced predictors as co-

variables [3,9].

Sample size was calculated using an alpha of 0.05 and power of 80%, which gave a sample

size of 52 patients (26 per treatment arm) to allow detection of a mean improvement in

walking time of 21 min (or 50% improvement) in the intervention group [26]. Statistical

analysis was performed using SPSS Statistics Version 24.0 (IBM Corp., Armonk, NY, USA).

<A>Results

Sixty-four patients with COPD were referred. Five patients were GOLD Stage I and were

excluded, and three eligible patients decided not to enter the study. At intake, four patients did

not have an MRC score of 2 or more, and were therefore excluded (Fig. A, see online

supplementary material). In total, 52 patients were enrolled.

Over the 10-week intervention period, seven patients were lost to follow-up. In the

intervention group, two patients dropped out because of a traumatic accident and orthopaedic

complaints during leisure time, and one patient dropped out due to a non-COPD-related

8
internal organ disorder. Four patients, two in each group, had a severe exacerbation and

dropped out on the advice of their physician.

The intervention group (n=26) and the control group (n=26) consisted of 18 (69%) and 16

(62%) females, with mean age of 69.4 (SD 9.7) and 71 (SD 9.4) years, mean FEV1 of 68%

(SD 7.7) and 65 (SD 10.3) of predicted, and mean body mass index 28.2 of (SD 5.5) kg/m2

and 27.2 (SD 4.3), respectively (Table A, see online supplementary material).

The mean time frame of wearing the activity monitor was 6.8 (SD 0.7) days; this was similar

in both groups, with no periods of unrecorded activity of less than 1 minute (SD 0.1) reported.

The mean number of training sessions was 18.2 (SD 1.1) and 8.6 (SD 0.4) for exercise

training and home-based walking, respectively.

<B>Primary outcome

In the intervention group, PA increased from 66.8 to 90.8 minutes/day (mean difference 24.0,

95% CI 9.2 to 38.9), while the control group showed a decrease in PA (mean difference -1.2,

95% CI -12.7 to 10.3), resulting in a significant mean difference between the groups of 25.2

minutes/day (95% CI 7.3 to 43.1). After adjusting for the unbalanced, potentially clinically

relevant prognostic baseline co-variables (PA, 6MWD and exercise self-efficacy), a mean

between-group difference in PA of 26.1 minutes/day (95% CI 7.33 to 44.88) was observed in

favour of the intervention group (Table 1). This difference was divided into 19.2 minutes/day

of low-intensity PA (significant between-group effect; P=0.035) and 6.6 minutes/day of

moderate-intensity PA (P=0.12).

<Insert Table 1 here>

9
<B>Secondary outcomes

The 6MWD increased significantly in the intervention group (P<0.001). After controlling for

baseline differences in PA, 6MWD and exercise self-efficacy, a clinically relevant increase in

6MWD was observed, with a between-group difference of 33.96 m (Table B, see online

supplementary material). The PASE score showed no significant difference between the

groups (P=0.25). Leisure activities, dyspnoea and total HRQoL showed a significant change

in the intervention group, but between-group differences were not significant.

The increase in PA in the intervention group correlated significantly with the change in the

PASE score (r=0.408, P=0.037). PA was weakly and not significantly correlated with changes

in FEC, leisure time, dyspnoea, exercise self-efficacy and HRQoL (Table C, see online

supplementary material).

<A>Discussion

This study showed a significant improvement in PA after a 10-week physiotherapist-guided

exercise training programme combined with home-based walking, compared with standard

medical care, in patients with moderate COPD.

Only a few randomised clinical trials on enhancing PA by exercise training have been

performed, and most have been combined with PR. This study of patients with moderate

COPD showed that exercise training had a significant effect on FEC [14,15]. However, a

comparable primary care programme of exercise training and promoting PA in patients with

mild-to-moderate COPD reported no effect on PA [15]. Furthermore, a meta-analysis of

studies with patients with (very) severe COPD showed an overall small pooled effect size of

0.12, which is equivalent to a slight increase in PA of 4.5 minutes/day [17]. The authors
10
concluded that the increased FEC, shown by the 6MWD, was only weakly correlated with PA

and this is not automatically transmitted into increased PA. Therefore, as well as centre-based

training, it also seems to be necessary to integrate exercise into daily life activities to enhance

PA. Another option is to include a behavioural/psychological intervention with optional

pedometer feedback. These multimodal approaches are generally effective in enhancing PA,

but they are also more comprehensive and expensive, need individualisation, and are more

difficult to generalise to daily practice in primary care physiotherapy [27–30]. Furthermore, a

self-efficacy intervention was effective in increasing light-intensity PA [31].

PA increased significantly in this study, but the authors were not able to determine which

domain of activities was associated with the increase as the change in the PASE score was not

significant. This could be explained by the fact that questionnaires do not always yield a

sufficiently sensitive measure of PA in slow-walking patients with COPD [32].

In the intervention group, the 6MWD increased by 52 m; this was significant and clinically

relevant, and is comparable with the regular mean increase of 44 m induced by PR. Therefore,

FEC seems to have improved compared with the standard exercise programme [33]. HRQoL

also improved significantly in the intervention group, but between-group differences in

6MWD and HRQoL were not significant. This may be due to the power calculation not being

based on 6MWD or HRQoL.

In this trial, the increased FEC was only marginally correlated with the increase in PA. This is

in accordance with recent research, and was expected as the target population is, in general,

only marginally limited in physical and ventilatory terms [16,34]. Whether a behavioural

change contributed to the increase in PA was not shown by higher values in exercise self-
11
efficacy. However, the unknown responsiveness of the Ex-SRES questionnaire is unknown.

This questionnaire was, however, the best option available at the outset of this study.

Despite the fact that triaxial devices tend to have better validity than uniaxial devices [35],

accelerometry is currently accepted as the most accurate method for the assessment of daily

PA in patients with COPD [32]. The PAM is regarded as an unobtrusive instrument with high

reliability and is therefore highly feasible in practice.

The extent to which the improved PA should affect health conditions and disease deterioration

remains unclear as no MCID has been stated. The total amount of moderate-intensity PA in

the intervention group increased to a mean of 17.2 minutes/day, which is still insufficient

according to the American College of Sports Medicine recommendation of 30 minutes of

moderate-intensity PA for 5 days/week [36].

<B>Study limitations

First, the application of this intervention programme is thought to be limited to sedentary

patients with mild-to-moderate COPD, and an MRC score of 2 or more, as these patients have

less advanced symptoms and complaints [15]. The results of the programme are therefore not

interchangeable and not automatically applicable to patients with more severe COPD, or

patients with fewer complaints or exercise training limiting co-morbidity.

Second, the precision of the presented effect on PA may be limited as dropouts were not taken

into account in the sample size calculation. However, the improvement in PA in the

intervention group was clearly higher, and the power may therefore be regarded as sufficient.

Third, there was an inevitable lack of blinding of the physiotherapists and the outcome

assessor. The consequent risk of bias can, however, be expected to be marginal as the primary

outcome (PA) was measured objectively and over a full week.

12
Finally, a weakness of this study may have been the inability to perform a valid assessment of

adherence to the home-based walking programme. The authors attempted to minimise this

risk of bias by checking compliance verbally. However, participants could have given a

socially desirable response, which may have overestimated the effect of the programme on

PA.

<A>Conclusions

It is recommended that home-based walking should be added to a physiotherapist-led exercise

training programme for increasing PA in patients with moderate COPD. Further research

should investigate optimal frequency and intensity of the combined interventions, and also

their effect in patients with more severe COPD.

Ethical approval: The Medical Ethics Assessment Board of the Academic Medical Centre,

Amsterdam, The Netherlands.

Funding: Eight activity monitors were provided without charge by PAM. PAM had no

involvement in the study.

Conflict of interest: None declared.

Acknowledgements

The authors would like to thank all participating patients, general practices and colleagues for

their efforts.

13
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18
Fig. A. CONSORT flow diagram. MRC, Medical Research Council Dyspnoea Scale.

Assessed for eligibility (n=64)

Excluded (n=12)
Did not meet inclusion criteria (n=9)
- n=5: GOLD Stage I
- n=4: MRC score <2
Declined to participate (n=3)

Randomised (n=52)

Allocated to combined therapy programme Allocated to usual care (n=26)

and received intervention (n=26)

Lost to follow-up (n=5):

- n=2: Severe acute exacerbation
Lost to follow-up (n=2):
- n=1:Traumatic
- n=2: Severe acute exacerbation
- n=1: Orthopaedic
- n=1: Internal organ disease

Analysed after 10 weeks (n=21) Analysed after 10 weeks (n=24)

19
Table 1

Physical activity at baseline and after intervention for intervention (n=21) and control (n=24) groups.
Measurements T0 T10 Within-group Within- Between-group Between-
mean (SD) mean (SD) effect group effect group
Mean (95% CI) effect Mean (95% CI)a effect P
P
Total PA 26.1 (7.3 to 44.9) 0.037b
(minutes/day)
- Intervention group 66.8 (30.4) 90.8 (38.6) 24 (9.2 to 38.9) 0.003b
- Control group 66.8 (29.3) 65.6 (38.8) -1.2 (-12.7 to 0.84
10.3)
Low-intensity PA (minutes/day) 19.2 (5.2 to 33.3) 0.035b
b
- Intervention group 55.4 (21.9) 73.6 (27.8) 18.2 (6.4 to 0.004
30.0)
- Control group 55.9 (22.4) 55.5 (27.2) -0.4 (-8.9 to 8.2) 0.93
Moderate-intensity PA (minutes/day) 6.6 (-1.0 to 14.8) 0.12
- Intervention group 11.9 (11.0) 17.2 (15.8) 5.4 (-0.4 to 11.1) 0.06
- Control group 10.9 (10.0) 10.1 (14.2) -0.8 (-5.0 to 3.3) 0.69
PA, physical activity; SD, standard deviation; CI, confidence interval.
P-values within-group effect from paired samples t-test and between-group effect differences from Student’s t-
test.
a
Adjusted for baseline differences in PA, 6-minute walk distance and exercise self-efficacy.
b
Significance level 0.05.

20
Table A

Baseline characteristics of the study population (n=52)

Characteristic Intervention group Control group

(n=26) (n=26)
Age (years) 69.4 (9.7) 71.0 (9.4)
Female (%) 18 (69) 16 (62)
FEV1/FVC ratio 0.59 (0.1) 0.56 (0.1)
FEV1 % predicted 68 (7.7) 65 (10.3)
BMI (kg/m2) 28.2 (5.5) 27.2 (4.3)
6MWD (m) 339.4 (86.1) 338.3 (94.3)
Total PA (minutes/day) 65.1 (29.4) 63.7 (30.3)
Low-intensity PA (minutes/day) 54.7 (21.6) 53.6 (23.1)
Moderate-intensity PA 10.1 (10.0)
10.8 (10.6)
(minutes/day)
Vigorous-intensity PA 0
0
(minutes/day) 11.5 (6 to 16)
11 (7 to 23)
PASE leisure
PASE household 8 (6 to 11) 8 (6 to 12)
PASE work 1 (1 to 5) 1 (1 to 6)
PASE total 22.5 (16 to 34) 21 (16 to 30)
PASE score 115.9 (74.9) 98.2 (56.9)
Exercise self-efficacy 915.7 (294.9) 1041 (295.1)
CRQ dyspnoea 18.3 (5.4) 19.9 (6.2)
CRQ emotion 31.5 (7.2) 31.7 (7.5)
CRQ fatigue 16.6 (4.1) 16.1 (4.4)
CRQ mastery 20.0 (4.5) 19.6 (5.4)
CRQ total 86.4 (13.5) 87.3 (18.1)

BMI, body mass index; CRQ, Chronic Respiratory Questionnaire; FEV1, forced expiratory volume in 1 second;
FEV1/FVC= Tiffeneau index; PA, physical activity; PASE, Physical Activity Scale for Elderly; 6MWD, 6-
minute walk distance.
Note: values are presented as % or mean (standard deviation), except PASE leisure, household, work and total:
median (min to max). Between-group differences from Student’s t-test except PASE household and work:
Mann–Whitney U-test.

21
Table B

Secondary outcome measurements after randomisation and after intervention period for intervention (n=21) and control (n=24) groups
Measurements Measure T0 Measure T10 Within-group Within - Between-group Between-
mean (SD) mean (SD) effect group effect group
Mean (95% CI) effect Mean (95% CI)a effect
P P
6MWD 34.0 (2.3 to 65.6) 0.27
b
- Intervention group 354.3 (77.9) 406.6 (90.9) 52.3 (34.2 to <0.001
70.4)
- Control group 350.4 (85.9) 363.6 (83.2) 13.2 (-12.9 to 0.31
39.3)
PASE leisure 2.9 (0.7 to 5.2) 0.020b
b
- Intervention group 13.6 (4.4) 15.3(4.2) 1.7 (0.1 to 3.4) 0.042
- Control group 11.8 (2.6) 12.7(3) 0 (-3 to 2) 0.15
PASE housework -0.1 (-0.8 to 0.7) 0.79
- Intervention group 8 (6 to 12)c 9 (6 to 11)c 0 (-1 to 3) 0.77
- Control group 8 (6 to 11)c 9 (7 to 11)c 0 (-3 to 2) 0.28
PASE work 0.1 (-0.8 to 0.9) 0.91
- Intervention group 1 (1 to 5)c 1 (1 to 5)c 0 (0 to 0) 0.32
- Control group 1 (1 to 6)c 1 (1 to 6)c 0 (-3 to 0) 1.00
PASE total 2.9 (0.5 to 5.4) 0.10
- Intervention group 23.9 (5.2) 25.7 (5.2) 1.8 (-0.2 to 3.8) 0.07
- Control group 22 (3.1) 23.1 (3.6) 1.13 (-0.9 to 3.2) 0.26
PASE score 16.2 (-13.2 to 45.5) 0.25
- Intervention group 120.2 (77.2) 126.1 (61.2) 5.9 (-21.0 to 32.9) 0.65
- Control group 104.1 (54.9) 106.8 (49.5) 2.7 (-21.1 to 26.4) 0.82
Exercise self-efficacy 18.9 (-129.8 to 0.54
167.7)
- Intervention group 915.2 (278) 943.8 (380.5) 28.6 (-74.9 to 0.57
132.1)
- Control group 1024.1 (300.4) 1004.5 (252.6) -130 (-430 to -80) 0.72

22
CRQ dyspnoea 1.1 (-3.2 to 5.3) 0.70
b
- Intervention group 18.1(5.6) 22.3 (6.64) 4.1 (1.85 to 6.43) 0.001
- Control group 19.8(6.1) 21.5 (7.48) 1.7 (-1.02 to 4.44) 0.21
CRQ emotion 1.4 (-2.8 to 5.7) 0.48
- Intervention group 31.7 (6.9) 34.4 (6.7) 2.7 (-0.3 to 5.8) 0.08
- Control group 32 (7.7) 33 (6.8) 1 (-1.6 to 3.5) 0.45
CRQ fatigue 1.2 (-1.6 to 3.9) 0.46
- Intervention group 16.3 (4.1) 17.9 (4.8) 1.5 (-1.2 to 4.2) 0.25
- Control group 16.2 (4.6) 16.8 (5) 0.6 (-1.7 to 2.5) 0.38
CRQ mastery 0.9 (-1.6 to 3.2) 0.71
- Intervention group 19.9 (4.8) 20.8(3.6) 1 (-0.8 to 2.8) 0.28
- Control group 20 (5.5) 20.3(4.9) 0.4 (-1.7 to 2.5) 0.71
CRQ total 4.4 (-5.4 to 14.2) 0.47
- Intervention group 86 (13.4) 95.3 (16.3) 9.3 (2.55 to 16.1) 0.009b
- Control group 88 (18.5) 91.6 (18) 3.6 (-2.7 to 10) 0.25

CRQ, Chronic Respiratory Questionnaire; PA, physical activity; PASE, Physical Activity Scale for Elderly; 6MWD, 6-minute walk distance.
P-values within-group effect from paired samples t-test except PASE household and work: Wilcoxon matched pairs signed rank sum t-test. Between-group effect from
Student’s t-test and Mann–Whitney U-test.
a
Adjusted for baseline differences in PA, 6MWD and exercise self-efficacy.
b
Significance level 0.05.
c
Median (min to max).

23
Table C

Pearson correlation coefficient (r) between changes in the intervention group (n=21) in physical
activity and other outcomes greater than 0
Correlation PASE score 6MWT PASE leisure CRQ Self-efficacy CRQ total
dyspnoea
PA 0.41a 0.35 0.14b 0.10 0.07 0.02

CRQ, Chronic Respiratory Questionnaire; PA, physical activity (objective); PASE, Physical Activity Scale for
Elderly (subjective); 6MWT, 6-minute Walk Test.
a
Significance level 0.05.
b
Spearman Rho (rs).

24