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Association between morning symptoms and physical activity in COPD: a systematic review

Amanda R. van Buul, Marise J. Kasteleyn, Niels H. Chavannes, Christian Taube
European Respiratory Review 2017 26: 160033; DOI: 10.1183/16000617.0033-2016
Amanda R. van Buul
Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
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  • For correspondence: a.r.van_buul@lumc.nl
Marise J. Kasteleyn
Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
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Niels H. Chavannes
Dept of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Christian Taube
Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
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  • Figure 1
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    Figure 1

    Study flow diagram with the use of the official PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart.

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    Figure 2

    Occurrence of morning symptoms. a) In all studied chronic obstructive pulmonary disease (COPD) patients. b) Occurrence of different morning symptoms in COPD patients experiencing symptoms. c) Symptomatic COPD patients who report the morning as worst time of the day for that symptom (results for at waking and the rest of the morning are combined). #: Classification of airflow limitation according to Global initiative for Chronic Obstructive Lung Disease (GOLD); ¶: “severe” was defined in this study as regular use of COPD medication plus a third level of breathlessness or above using the Medical Research Council dyspnoea scale and one or more exacerbations in the preceding 12 months +: in all included COPD patients.

Tables

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  • Table 1

    Overall conclusion and quality of included studies

    First author [ref.]Study designParticipants' characteristics at baselineOverall conclusionQuality
    Bateman [15]Pooled analysis from two phase III double-blind, randomised, parallel-group active- and placebo-controlled studiesn=3394; age ≥40 years; stable moderate-to-severe COPDAclidinium/formoterol 400/12 μg significantly improves 24-h symptom control compared with placebo or aclidinium or formoterol alone. The frequency of exacerbations was also reduced compared with placebo17/25#,¶
    Stephenson [20]Cross-sectional survey studyn=752; 60.5% female; age ≥40 years; COPD plus at least one pharmacy claim for maintenance COPD medicationThe majority of the patients with night time or morning symptoms experience at least three distinct types of symptoms a week. Approximately half of them consider their symptoms to be moderate to severe. They felt that their symptoms had impact on their sleep and morning activities, and they were anxious18/22+
    Miravitlles [16]Observational studyn=727; 34.2% female; age ≥40 years; current of former smokers; stable mild-to-very-severe COPDMore than half of COPD patients experience symptoms throughout the whole day. There was a significant association between night time, early morning and daytime symptoms. In each period, symptoms were associated with worse patient-reported outcomes18/22+
    O’Hagan [19]Observational studyn=811; 44% female; age 30–70 years; COPD diagnosed by a physician; at least one morning symptomMorning symptoms can severely interfere with COPD patients’ ability to perform tasks throughout the day. Half of the patients had made changes in their morning routines15/22+
    Roche [17]Cross-sectional observational studyn=1489; 34.3% female; age ≥40 years; with a history of smoking, airflow obstruction and the diagnosis of COPD39.8% of the COPD patients experience morning symptoms. Morning symptoms are associated with poorer health status, impaired daily activities and increased risk of exacerbations16/22+
    Kim [18]Prospective non-interventional and observational studyn=133; 5.3% female; age >45 years; with a history of smoking; stable severe-to-very severe COPD57% of COPD patients experience limitation in their activities due to morning symptoms. These patients also have more prevalent and severe COPD symptoms14/22+
    Kessler [22]Cross-sectional observational studyn=2441; 21.5% female; age >45 years; with a history of smoking; stable severe-to-very severe COPDPatient-perceived COPD symptoms vary over the day and the week, and have impact on activities. The morning was considered the worst time of the day16/22+
    Partridge [21]Quantitative internet interviewsn=803; 44% female; age ≥40 years; with a history of smoking; all stages of COPDCOPD are worst during the morning. Many patients consider the impact of COPD on morning activities to be extensive17/22+
    • COPD: chronic obstructive pulmonary disease; #: CONSORT (Consolidated Standards of Reporting Trials) was used as a tool to assess quality; ¶: pooled analysis from two studies; +: STROBE (Strengthening the Reporting of Observational studies in Epidemiology) was used as a tool used to assess quality.

  • Table 2

    Influence of morning symptoms on physical activity

    First author [ref.]Stage of COPDDefinition of the morningMethod to evaluate morning symptoms and activity limitationsPhysical activity limitation associated with morning symptomsSelf-reported limitationsConclusion
    Bateman [15]Moderate to severeAs described in the EMSCI and NiSCIQuestionnaires (EMSCI and NiSCI) for the patients90.6% of all patients with COPDNAMost COPD patients with morning symptoms considered that their symptoms affect their morning activities
    Stephenson [20]All stagesTime of getting out of bed and approximately 11:00 hA 30-min questionnaire for patients about morning symptoms and the impact on morning activities60.4%#Work§More than half of patients considered that their symptoms affect their morning activities
    Miravitlles [16]All stagesTime of getting out of bed and approximately 11:00 hPatients filled out a Night-time, Morning and Daytime Symptoms of COPD questionnaire, developed by the sponsorPatients who are sedentary experience more symptoms in any part of the day (also in the morning); p<0.05NAIn each part of the day (morning, daytime, night time) there was an significant association between symptoms and a low physical activity level
    O’Hagan [19]All stagesNot definedOnline questionnaire consisting predefined questions for patients34–79%# have problems with common morning activities; 56–70%# with more physically demanding activitiesSelf-care, domestic activities and work§Morning symptoms can severely compromise patients’ ability to perform, even simple tasks. Half of the patients had made changes to their morning routines
    Roche [17]All stagesSymptoms that are present when getting up in the morning, thus those symptoms present on waking, rather than those persisting through the morningQuestionnaires with predefined questions. Physicians gave information about severity grade of the symptoms; patients about the impact on daily lifeImpact on normal activities was higher in those with morning symptoms (3.96 versus 3.29+; p=0.007)Self-care and work§Impact on daily activities was significantly higher in patients with morning symptoms than without
    Kim [18]Severe to very severeNot definedPatients filled out the CSQ. Those who reported morning symptoms, subsequently completed the MAQ57% of all patients with COPDSelf-care and domestic activities§57% of COPD patients had considerable impact on their morning activities
    Kessler [22]Severe to very severeIn the morning, after waking up and later in the morningInterview over the telephone. Predefined questions developed by the sponsor35.4–41.0% of patients that experience any symptom felt that morning symptoms affect morning activitiesSelf-care§There was an association between morning symptoms and the impact on activities
    Partridge [21]All stagesFrom the time they woke up until they were dressed, had breakfast and were ready to start the dayPredefined questions were answered by the patient by an internet interview37% of all COPD patients and 73% of the severe¶ COPD patients regarded problems associated with morning routines as bothersome. 74% of all COPD patients and 96% of the severe¶ patients reported that they took longer to complete their morning routinesSelf-care and domestic activities§Many patients considered the impact of COPD on morning activities to be extensive
    • COPD: chronic obstructive pulmonary disease; CSQ: clinical symptom questionnaire; EMSCI: early-morning symptoms of COPD instrument; MAQ: morning activity questionnaire; NiSCI: night-time symptoms of COPD instrument. #: in patients with morning symptoms; ¶: “severe” was defined in this study as regular use of COPD medication plus a third level of breathlessness or above using the Medical Research Council dyspnoea scale and one or more exacerbations in the preceding 12 months; +: measured on a 7-point Likert scale of 0=no impact to 7=constant impact; §: more detailed information in supplementary table S3.

  • Table 3

    Impact of medication on morning symptoms and physical activity

    First author [ref.]MedicationMorning symptomsPhysical activity limitation associated with morning symptomsEffect medication on morning symptomsEffect intervention/medication on physical activity limitation due to morning symptoms
    Bateman [15]Aclidinium bromide/formoterol94.4% of all patients90.6% of all patientsFDC 400/12 µg on severity scores: −0.23 units (−17.0%); aclidinium 400 µg: −0.14 units (−10.7%); formoterol 12 µg: −0.17 units (−13.6%) p<0.0001 versus aclidinium and p<0.01  versus formoterol#. Individual morning symptoms: p<0.05  versus aclidinium for cough and difficulty bringing up phlegm, and  versus both monotherapies for wheezing and shortness of breathImprovements in limitation of early morning activities: p<0.05  versus aclidinium and p<0.05 versus formoterol
    O’Hagan [19]Patients were allowed to select any of their applied medicationMorning symptoms was an inclusion criterion in this studyImpact on normal activities was higher in those with morning symptoms compared to those without (3.96 versus 3.29; p<0.007)79% of COPD patients who feel medications provides relief from symptoms in the morning enough33% of patients considered “improvement of ability to carry out morning activities” a key treatment goal. 21% of patients feel medication provides improvement in the ability to carry out morning activities
    Kim [18]No standard treatment for COPD was defined by the study protocol57% of all patients57% of all patientsLAMA and ICS plus LABA were used significantly less frequent in patients with morning symptoms. LAMA was a preventive factor for the presence of morning symptomsSeverity of all morning activities were significantly reduced after 2 months follow-up
    • COPD: chronic obstructive pulmonary disease; FDC: fixed-dose combination; LAMA: long-acting muscarinic antagonists; ICS: inhaled corticosteroids; LABA: long-acting β2-agonist. #: symptom severity measured on a score from 0 (no symptoms) to 4 (very severe symptoms).

Supplementary Materials

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    Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

    Supplementary material ERR-0033-2016_Supplement

    Supplementary table S2 ERR-0033-2016_Supplementary_table_S2

    Supplementary table S3 ERR-0033-2016_Supplementary_table_S3

  • Supplementary Material

    N.H. Chavannes ERR-0033-2016_Chavannes

    C. Taube ERR-0033-2016_Taube

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Association between morning symptoms and physical activity in COPD: a systematic review
Amanda R. van Buul, Marise J. Kasteleyn, Niels H. Chavannes, Christian Taube
European Respiratory Review Mar 2017, 26 (143) 160033; DOI: 10.1183/16000617.0033-2016

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Association between morning symptoms and physical activity in COPD: a systematic review
Amanda R. van Buul, Marise J. Kasteleyn, Niels H. Chavannes, Christian Taube
European Respiratory Review Mar 2017, 26 (143) 160033; DOI: 10.1183/16000617.0033-2016
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