Table 2

Influence of morning symptoms on physical activity

First author [ref.]	Stage of COPD	Definition of the morning	Method to evaluate morning symptoms and activity limitations	Physical activity limitation associated with morning symptoms	Self-reported limitations	Conclusion
Bateman [15]	Moderate to severe	As described in the EMSCI and NiSCI	Questionnaires (EMSCI and NiSCI) for the patients	90.6% of all patients with COPD	NA	Most COPD patients with morning symptoms considered that their symptoms affect their morning activities
Stephenson [20]	All stages	Time of getting out of bed and approximately 11:00 h	A 30-min questionnaire for patients about morning symptoms and the impact on morning activities	60.4%^#	Work^§	More than half of patients considered that their symptoms affect their morning activities
Miravitlles [16]	All stages	Time of getting out of bed and approximately 11:00 h	Patients filled out a Night-time, Morning and Daytime Symptoms of COPD questionnaire, developed by the sponsor	Patients who are sedentary experience more symptoms in any part of the day (also in the morning); p<0.05	NA	In 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 stages	Not defined	Online questionnaire consisting predefined questions for patients	34–79%^# have problems with common morning activities; 56–70%^# with more physically demanding activities	Self-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 stages	Symptoms that are present when getting up in the morning, thus those symptoms present on waking, rather than those persisting through the morning	Questionnaires with predefined questions. Physicians gave information about severity grade of the symptoms; patients about the impact on daily life	Impact 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 severe	Not defined	Patients filled out the CSQ. Those who reported morning symptoms, subsequently completed the MAQ	57% of all patients with COPD	Self-care and domestic activities^§	57% of COPD patients had considerable impact on their morning activities
Kessler [22]	Severe to very severe	In the morning, after waking up and later in the morning	Interview over the telephone. Predefined questions developed by the sponsor	35.4–41.0% of patients that experience any symptom felt that morning symptoms affect morning activities	Self-care^§	There was an association between morning symptoms and the impact on activities
Partridge [21]	All stages	From the time they woke up until they were dressed, had breakfast and were ready to start the day	Predefined questions were answered by the patient by an internet interview	37% 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 routines	Self-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.