Management of Dyspnoea and Anxiety in Chronic Obstructive Pulmonary Disease: A Systematic Review

Abebaw M Yohannes1, Maira Junkes-Cunha1, Jacky Smith2, Jørgen Vestbo2

1- Department of Health Professions, Manchester Metropolitan University, Manchester, UK

2- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Science Centre, University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester, U.K

Correspondence

Prof Abebaw Mengistu Yohannes

Department of Health Professions

Brooks Building

Faculty of Health, Psychology and Social Care

Manchester Metropolitan University

Bonsall Street,

Manchester

M15 6GX

United Kingdom

Phone 44-161-247-2943

Fax 44-161- 247-5671

A.Yohannes@mmu.ac.uk

Keywords: Chronic obstructive pulmonary disease, dyspnoea, anxiety, management, pulmonary rehabilitation, cognitive behavioural therapy, self-management, yoga

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Abstract

Introduction:

Anxiety and dyspnea, two major symptoms in patients with chronic obstructive pulmonary

disease (COPD), are associated with high morbidity, impaired quality of life, and decrease in

physical functioning.

Areas covered:

This article reviews the most recent publications addressing the management of dyspnea and

anxiety in patients with COPD, focused on pulmonary rehabilitation (PR) and behavioral

therapy including cognitive behavioral therapy (CBT), self-management intervention,

counseling, and yoga therapy. The publications discussed in this systematic review were

extracted from an electronic database search of CINAHL, Medline, Pub Med, Science Direct

and the Web of Science spanning 1st January 2006 to 15th November 2016.

Expert commentary:

In the majority of studies, PR reduced both anxiety and dyspnea symptoms in patients with

COPD in the short-term. However, maintenance programs and the long-term benefits of PR

remain inconclusive. CBT is also effective in the treatment of anxiety and dyspnea in the

short-term, but again the long-term benefit is limited. In addition, self-management, yoga

therapy, and CBT plus PR were beneficial. Generally, the studies were relatively small in

sample sizes and uncontrolled. Thus, prospective and randomized control trials with larger

sample sizes are needed.

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Introduction

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and

disability in old age. The World Health Organization estimates over 200 million people

worldwide live with COPD [1]. The primary cause of COPD is cigarette smoking, and other

potentially contributing factors include excessive fumes exposure (especially wood and

charcoal use for domestic cooking in developing countries), atmospheric pollution, passive

smoking, alpha antitrypsin deficiency and childhood acute respiratory infection [2].

Inadequately treated COPD may lead to increased disease burden and healthcare utilization,

impaired quality of life, and premature mortality [2,3]. Both the direct (e.g. inpatient care and

prescription of drugs) and indirect (e.g. loss of earnings to individual, sick leave and

impaired work performance) economic cost of COPD is estimated over $50 billion per

annum in the US [4].

More than one in three COPD patients suffers from anxiety symptoms of clinical

importance that interfere in their daily activities [5]. An international survey primarily in

Europe and North America identified that over 36% of patients who describe their symptoms

as being mild to moderate are in fact too breathless to leave their home [6]. The presence of

anxiety and dyspnoea often relates to worse outcomes including higher rates of

exacerbations, hospitalization, re-admission, length of hospital stay and reduced survival

rates even after inpatient rehabilitation [7,8]. Moreover, anxiety has been linked to worse

physical functioning [8] and a recent prospective cohort study [9] found that anxiety was

associated with more than a thirteen fold (hazard ratio = 13.7; 95% confidence interval, 2.13

– 88.63) increased risk of death in female patients with COPD. Strong evidence suggests that

pulmonary rehabilitation (PR) consisting of exercise training and education improves

exercise capacity and quality of life in patients with COPD [10]. To date, there is very little

understanding of how PR and behavioural therapy work to relieve dyspnoea and anxiety

symptoms in patients with COPD.

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Thus, critically evaluating and synthesizing the existing literature employing PR and

other behavioural therapies in the treatment of anxiety and dyspnoea in patients with COPD

may help clinicians determine the most efficacious potential treatments. In this systematic

review, we examine the efficacy of PR and behavioural therapy (e.g. cognitive behavioural

therapy [CBT] and counselling) and other adjunct modalities utilized in patients with COPD.

Causes of dyspnoea and anxiety

Dyspnoea is a hallmark of COPD and often caused by dynamic hyperinflation of the

lungs. Dyspnoea is one of the most important factors limiting older COPD patients from

actively engaging in daily activities. Furthermore, in patients with COPD, anxiety can trigger

hyperventilation. Once triggered, hyperventilation may worsen breathlessness, which

provokes further anxiety. To date, the exact mechanisms behind how anxiety provokes

dyspnoea or vice versa are unclear, although there is a complex inter-relationship between the

patient’s breathlessness and anxiety states. Most likely, a combination of physical,

physiological and behavioural factors contribute to increased anxiety and dyspnoea in

patients with COPD (Table 1). One potential pathway through which dyspnoea causes

anxiety could be inappropriately aligned cognitive perception of the increased work of

breathing. These interactions may cause worsening of COPD patients’ health status,

impaired quality of life, and withdrawal of engagement from social activities and being

housebound due to fear of anxiety and excessive dyspnoea on exertion, all highlighting the

importance of developing evidence-based therapies to treat anxiety and dyspnoea for patients

with COPD (Figure 1).

2. Material and methods

Identification and selection criteria

An electronic database search of CINAHL, Medline, Pub Med, Science Direct and the

Web of Science was conducted (spanning 1st January 2006 to 15th November 2016). Two

searches were made with different combinations according to the type of intervention (PR

and CBT). The following Medical Subject Headings (MeSH) and free text words were

used:

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1st search: ("chronic obstructive pulmonary disease" OR COPD) AND (dyspnea

OR dyspnoea) AND (anxi* OR stress) AND (management or treatment or control

or intervention or therapy) AND ("pulmonary rehabilitation" or exercise or

training)

2nd search: ("chronic obstructive pulmonary disease" OR COPD) AND (dyspnea

OR dyspnoea) AND (anxi* OR stress) AND (management or treatment or control

or intervention or therapy) AND (“cognitive behavioral therapy” OR education

OR CBT or behavioral)

Inclusion and exclusion criteria for considering studies for this review

The following criteria were used to identify relevant studies:

Patients: Diagnosis of COPD;

Intervention: PR, CBT and other therapies (self-management, yoga, and music

therapy);

Type of study: randomized controlled trials (RCTs), pre and post intervention

studies;

Outcome measures: anxiety and dyspnoea;

Articles were excluded if they:

had insufficient information available (abstract only);

did not involve an intervention (eg. observational cross-sectional descriptive

study, protocol study, guidelines);

included participants without COPD;

had a small sample size (n<10);

were not written in English;

did not present the findings of their studies.

Data collection and analysis

Two investigators evaluated each article fulfilling the inclusion and exclusion criteria.

Data extraction

The two investigators (M.J.C. and A.M.Y.) independently extracted data using a

standardized form regarding: the author(s), date of publication, study design, sample size,

age, duration and frequency of intervention, content (type of intervention), domains (outcome

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measures), and their results in relation to anxiety and dyspnoea. Disagreements were resolved

through discussion.

3. Results

A total of 135 studies were identified (PR=91; BT=44) based on the search

descriptors of bibliography references: CINAHL (PR=14/BT=4); Medline

(PR=17/BT=17); Pubmed (PR=13/BT=11); Web of Science (PR=45/BT=10); Science

Direct (PR=2;BT=2). After the initial screening of the titles and abstracts, 47 studies

satisfied the inclusion criteria and were selected for the present systematic review. The 47

studies were separated according to the type of intervention (Figure 2).

Participants

The 47 studies selected included 4,595 participants (PR=3,756 and behavioural

therapy=839), ranging in age from 58 to 75 years. The total number of participants

receiving a treatment was 3.928, and 667participants served in control groups.

Outcome measures

COPD affects physical, social and psychological aspects of patients’ health status or

exercise capacity. The outcome measures used in the present review relate to these aspects,

especially anxiety and dyspnoea as primary outcome measures.

Anxiety: The Hospital Anxiety and Depression Scale (HADS) was the most

commonly used instrument, and significant improvement after intervention was found in

most studies [11–33]. Four studies used the Beck Anxiety Inventory (BAI) [34–37]. Other

instruments that were used include the Anxiety Inventory for Respiratory disease (AIR) scale

[38], the Emotional State (DASS) [39] the Revised Symptom Checklist 90 (SCL-90-R) [40]

and the Spielberger State-Trait Anxiety Inventory (SSTAI) [35,41].

Dyspnoea: The dyspnoea scale most used in the studies was the Modified Medical

Research Council Scale (MMRC) [11-13,–15-17,–,22,24,26,29,35,38, 39, 42-45 ]. Other

instruments used to measure dyspnoea were the Chronic Respiratory Questionnaire (CRQ) –

Dyspnoea [14,18,20,21,30,31,34,36,46–52]; the BORG scale [19,23,53,54]; the Dyspnoea

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Visual Analog Scale [32,48]; the Modified Pulmonary Functional Status and Dyspnea

Questionnaire (PFSDQ-M) [55] and Anxiety Sensitivity revised (ASI-3) [49].

Pulmonary rehabilitation

PR is a well-recognised intervention in the treatment of patients with COPD.

Guidelines [10] recommend PR as an integral part of medical management of patients with

COPD. Indeed, PR improves exercise capacity and quality of life in patients with COPD.

The majority of studies report that PR reduces anxiety and dyspnoea in patients with COPD

during short-term follow-up (Table 2).

Eight week PR program on anxiety and dyspnoea

Ten studies completed measurements before and after eight weeks of PR

[13,20,22,23,34,35,38,42,53,54]. Five studies showed improvement both in anxiety and

dyspnoea in patients with COPD [20,22,23,35,38,]. Yohannes and colleagues [38] [n= 192,

49% men and 51% women, mean age 71 years] in a community based, eight week PR

program (2 hours, once weekly) showed significant improvement both in dyspnoea and

level of anxiety measured by the newly developed AIR scale. The change in anxiety score

was correlated with both health status (using the St. George’s Respiratory Questionnaire) and

in dyspnoea score. However, there was no significant correlation between change in anxiety

and exercise capacity. Likewise, Dodd et al. [42] [n = 294] demonstrated that change in

health status following PR significantly correlated with changes in anxiety, depression, and

dyspnoea scores (all p < 0.01) but not with change in exercise capacity using the incremental

shuttle walk test (p = 0.35). The male predominance (almost two-thirds of the COPD

population) may compromise the generalisability to a wider population.

Ergun and colleagues [13] examined the efficacy of eight weeks PR on early stage

COPD patients (Global Obstructive Lung Disease [GOLD] stages I and II, n= 28, mean age

63.2 years) versus late stage of COPD (defined as GOLD stages III and IV, n= 27, mean age

62.8 years). After, PR both groups showed significant, similar reductions in anxiety and

dyspnoea scores, and significant, similar improvements in walking distance and endurance

time. Therefore, PR is appropriate for patients with all stages of COPD. However, caution is

required in interpreting the findings as the sample sizes were relatively small, and changes in

anxiety and dyspnoea scores in response to PR were not correlated with changes in other

clinical measures. In a separate study from Luk and co-workers [20] [n= 129], patients who

completed 8 weeks PR showed significant improvement on dyspnoea, anxiety and exercise

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capacity. Out of these, 88 patients completed the 22 months follow-up observational

interview and measurements. Their findings indicate there were no significant improvements

in anxiety, dyspnoea, exercise capacity and physiological parameters of COPD after the

observational follow-up period.

Efficacy on dyspnoea

An eight week, supervised twice weekly, before and after study design in a Veterans

Administration Medical Centre in US [34] and in Brazil [35] showed PR was effective in

ameliorating dyspnoea and improving quality of life without changing the level of anxiety.

These studies highlight the need to address anxiety symptoms. Interestingly, the change in

depression score after PR correlated with change in the mastery, emotion and fatigue score.

These results signify that alleviating the depressive symptom burden plays an important role

in improving quality of life [34]. Furthermore, a seven week, twice weekly PR program [8]

significantly reduced dyspnoea, without significantly changing anxiety scores.

A randomised controlled trial [23] examined the efficacy of PR on three aspects

dyspnoea domains: sensory-perceptual (i.e, exertional dyspnoea intensity), affective (i.e.,

intensity of breathing-related anxiety during exercise) and impact (i.e., activity –related

dyspnoea measured e.g. by CRQ dyspnoea component) domains of dyspnoea, compared to

usual care in 48 COPD patients. The PR comprised three supervised 2.5 hours sessions per

week over an 8-week period. Compared to usual care, PR significantly improved the affective

and impact domains but not the sensory perceptual domain. In contrast, there were no group

differences in the intensity and quality of breathlessness during cycle exercise. This lack of

difference might be due to a variation in ventilation, breathing pattern and operating lung

volumes. The authors raised the important question whether ‘closer attention should be paid

to the achievement of improved respiratory physiology as a primary goal of exercise training

in COPD’ [23]. Further studies are needed to examine the effective way in achieving

sustained improvements in activity-related dyspnoea across all three major domains.

12 weeks pulmonary rehabilitation program

Cheng et al [53] examined the efficacy of a 12 week (n= 64, before and after design),

2 sessions per week supervised outpatient PR program on dyspnoea (measured by Borg

Scale), exercise capacity, quality of life and heart rate variability (HRV). The findings

indicate a moderate effect size on improvement on dyspnoea, exercise capacity and HRV. In

addition, Lan and colleagues [54] and Elçi et al. [12] showed significant improvement in

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dyspnoea, depression health status, exercise capacity and respiratory muscle strength and

improvement in sleep quality. Kavoura [40] and co-workers also showed significant

improvement in anxiety and dyspnoea, exercise capacity and quality of life following 12

weeks PR. Likewise, Tselebis et al. [41] found 12 weeks PR was effective in improving

anxiety and depression, not in dyspnoea. In this study, four fifths of the participants were

male COPD patients. These five studies were uncontrolled [12,41,53,54], with relatively

small sample size and without follow-up. Thus, the efficacy of 12 weeks PR in improving

dyspnoea and anxiety and maintaining any significant benefits in long-term follow-up

remains unknown.

Completion of PR twice weekly versus once weekly

Currently, it is unclear whether once or twice weekly PR is equally effective for

patients with COPD. Hogg and co-workers [18] in a large cohort [n= 812] examined the

effectiveness of attendance and completion of twice weekly rolling recruitment and once

weekly cohort recruitment PR programmes in community settings. Their findings showed

that both once and twice weekly PR sessions for eight weeks were comparable and

statistically significant in reducing dyspnoea, anxiety and depression in patients with COPD.

However, participants with twice-weekly rolling programmes group did not achieve the

minimal clinical important difference (MCID) of the HADS anxiety. In addition, over 45% of

the patients did not complete the PR program; and non-completion of the PR programme was

associated with an elevated level (HAD > 11) of anxiety and depression, severe dyspnoea

(MRC> 4), and lower socio-economic status (4th quintile of deprivation), limiting the

interpretation of these findings. Boutou et al. [11] reported similar findings in that non-

completers had baseline severe dyspnoea score, elevated anxiety and depression, worse

quality of life and reduced exercise capacity, and younger in age than COPD patients

completing the PR programme. Interestingly, less than a third of completers achieved an

improvement above MCID in HAD anxiety (about 1.5 points, corresponding to a change of

baseline about 20%) [56].

A prospective, parallel group design comparing 6 weeks of supervised PR twice

versus once weekly did not show significant differences between the two groups in the

primary outcome measures of exercise capacity and quality of life [21]. There was no

significant reduction in the HAD anxiety score in both groups. In contrast, Duruturk et al.

[24] examined in a parallel group study the efficacy of 6 weeks, three times per week

calisthenics versus cycle exercise training compared to a control group receiving no

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intervention. Both modalities improved quality of life and reduced anxiety and dyspnea

symptoms compared to the control group, with no difference between the two interventions.

Sixty COPD patients were randomized to either interval [n= 28] or continuous

training [n = 32] twice weekly for 16 weeks employing structured ergometer cycling. After

cycling, the session continued once a week with calisthenics (using stretching and flexibility

exercises for trunk, upper and lower limbs), Jacobson method of relaxation technique, and

once a week resistance training [14]. The investigators showed significant reductions in

dyspnea, anxiety and depression scores and improvement in exercise capacity and quality of

life in both groups, with no difference between the groups. Over 85% of the participants

were women. Thus, further studies are needed with both genders equally in numbers to

generalize these findings to men.

An intensive, three week PR program (6 hours per day for 5 days per week) showed

significant improvement in reducing dyspnea and anxiety symptoms and improving exercise

capacity and quality of life [19]. The improvement observed after rehabilitation on anxiety

symptoms related to the magnitude of patients’ perceived dyspnea at rest. However, caution

is required as this type of intense PR program may not be applicable to moderate-to-severe

COPD patients.

Home-based program versus standardized outpatient program

Holland and co-workers [57] conducted a randomized, controlled equivalence trial of

home-based rehabilitation [n = 80]: either one session supervised at home by a

physiotherapist and seven once weekly structured telephone contacts, using a motivational

interviewing approach; or a standardized outpatient center based model [n = 86], twice

weekly for eight weeks with a group based supervised program. In the short term both home-

based and outpatient PR showed significant improvement in exercise capacity, dyspnea and

quality of life. However, both models did not maintain the improvement at 12 months,

without significant difference between the two groups. Fifty-one COPD patients were

randomized [58] to a structured outpatient PR program [n = 28] or home-based rehabilitation

[n = 23] for eight weeks. The outpatient group PR program consisted of respiratory muscle

training and strengthening exercises for both upper and lower limb muscle groups using a

cycle ergometer. The home group was advised to perform respiratory and arm muscle

strengthening exercises and unsupervised daily walking exercises. Subjects were followed

for six months. Both groups showed similar improvement in exercise tolerance at the end of

the program. However, the hospital based program showed significant improvement on the

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health status compared to home based program. There were no significant group differences.

These two studies demonstrate that a home based rehabilitation program can be effective for

COPD patients who cannot access outpatient pulmonary rehabilitation.

Maintenance PR program

Wilson et al. [47] randomized COPD patients to receive either maintenance or

standard care, following an eight week PR program. The maintenance program comprised 2

hours (1 hour individually tailored exercise training and 1-hour education) every three

months for one year. The maintenance program did not improve dyspnea, anxiety, exercise

capacity or quality of life compared to the usual care group at the end of the program. In

contrast, a single arm longitudinal study following PR [n = 29] examined the efficacy of

supervised maintenance program [59] in a community setting. A fitness consultant

conducted maintenance sessions once weekly for a year, showing further improvement from

the results achieved at the end of PR in dyspnea, exercise capacity, and health related quality

of life in patients with COPD. A case manager supported participants and provided

appropriate encouragement, liaised with the fitness consultant, and highlighted any specific

needs or concerns. Thus, it is important to include innovative approaches in supporting

patients during the maintenance program. Prospective, randomized controlled trials are

needed to examine the efficacy of maintenance PR.

Emerging therapies for managing patients with COPD

Kaymaz and co-workers [15] examined the efficacy of adding neuromuscular

electrical stimulation (NEMS) to PR [n= 14] compared to sham NEMS plus PR [n= 13] in

severe COPD patients with forced expiratory volume in one second < 30% predicted. The

NEMS intervention was carried out 2 days a week, for 10 weeks on quadriceps and deltoid

muscles. The eight week PR consisted of exercise training twice weekly in a hospital setting

and one day per week in the presence of a therapist at home. Both interventions improved

dyspnoea, anxiety and exercise capacity. However, these improvements were equivalent

between the sham and NEMS groups. The small sample size and absence of follow-up

warrant further studies of NEMS.

Only one randomised controlled study examined the efficacy of non-invasive

intermittent positive pressure ventilation (NIPPV) plus PR [n= 26] compared with the PR

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alone [n = 32] in a two year, home-based exercise program in severe COPD patients with

chronic respiratory failure [16]. Patients were recruited to the program after completing a 12-

week, multidisciplinary PR. A physiotherapist provided the home-based program in a

community care setting once or twice weekly during the study period with or without NIPPV.

Both interventions improved health status, depression, anxiety, dyspnoea, and exercise

tolerance in patients with chronic respiratory failure. NIPPV plus PR was more effective in

improving dyspnoea and anxiety compared to PR alone. The relatively small sample size

merits replication of this study in other clinical settings.

Gurgun and co-workers [17] in a pilot, randomised controlled trial investigated in

undernourished COPD patients the benefits of eight weeks of nutritional supplementation

plus conventional PR, compared to PR alone and to a control group. They showed similar

improvement in dyspnoea, anxiety and health status in the two groups receiving PR. The

nutritional supplementation group showed improvement in lean mass and mid-thigh

quadriceps cross-sectional area [27]. This promising finding warrants a definitive prospective

RCT with a larger sample size.

A randomised controlled study [48] examined the efficacy of adding once per week

music therapy for six weeks to PR, compared to PR alone in patients with COPD and other

chronic lung diseases. The music therapy session included live musical visualizations, wind

instrument playing of clinical improvisation, and singing, which provided direct methods of

working with breathing control. Music therapy plus PR was superior in ameliorating

perceived dyspnoea, fatigue and improving quality of life compared with PR alone (p <

0.007). Future studies should consider the potential additional benefits of music therapy for

PR programs.

A pilot study examined the efficacy of a 12 week yoga program specifically designed

for patients with COPD compared with the usual care group. The twice weekly program

included asanos (body posture) and visama vritti pranayama (timed breathing), implemented

for about an hour. Trained yoga instructors conducted the sessions. In addition, patients

were given a video tape of one yoga class and were strongly encouraged to practice the

exercise daily at home. Yoga safely and effectively reduced dyspnoea related distress and

improved exercise capacity compared to the usual care group [29], warranting replicating this

finding in other clinical settings.

Behavioural therapy

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Behavioural therapy is an umbrella term for different therapies to treat mental health

disorders (e.g. depression, anxiety, panic disorders) of patients suffering with or without

chronic diseases. Behavioural therapy comprises CBT, counselling, meditation and yoga,

relaxation and self-management exercises.

CBT is a popular non-pharmacological therapy that combines behavioural with

cognitive therapy. CBT disentangles patients’ patterns of thoughts and beliefs that may

induce excessive worry, anxiety and depressed mood. Delivered either in a one-to-one or in a

group format session, CBT deals with current problems that the patients are experiencing and

works collaboratively with the therapist and patients. CBT has been used in the treatment of

depression, anxiety and dyspnoea in patients with COPD

[28,60]. Most studies report that compared to usual care, CBT reduces anxiety and dyspnoea

in patients with COPD (Table 3).

Eight weeks CBT on anxiety and dyspnoea

Four studies utilized a before and after design of eight weeks behavioural

interventions [28,36,44,49]. One study offered each CBT alone [28], CBT compared with

education [36], meditation [49], or CBT plus PR compared with CBT alone [44].

Livermore et al. (2015) [28] investigated the effects 4 individually administered, 1-hr

sessions of CBT [n=18] in each of 8 weeks, upon dyspnoea ratings when breathing through

inspiratory resistive loads compared to routine care group [n=13] in patients with COPD with

mean age 72 years. The CBT group showed a significant decrease in the intensity of

dyspnoea after 8 weeks and 24 weeks of follow-up (p < 0.001), compared to no change or

worsening anxiety in the control group.

In a randomised parallel group trial in 238 elderly patients with COPD, Kunik et al.

(2008) [36] reported improvements in quality of life, anxiety and depression in groups

receiving either eight sessions of group CBT [n=118, mean age 66 years] or COPD education

[n=120, mean age 66 years]. The eight weeks 1 hour group CBT session followed a format

focusing on anxiety and depression and enhancing coping skills such as relaxation,

decreasing anxiety-related avoidance, thought modification, problem solving, sleep

management and skills review. The eight weeks group education session comprised 45

minutes lecture and 15 minutes discussion. The education topics covered included breathing

strategies and airways management, pathophysiology of lung disease, medications, use of

oxygen, avoidance of environmental irritants, nutrition, exercise, smoking cessation and end-

of-life planning. Both modalities similarly reduced anxiety and depression at 8 weeks and 12

13

months follow up. However, over one third of the participants did not complete the eight

weeks course of either CBT or educational group, compromising the power of the study.

A weekly, one-hour meditation intervention for eight weeks reduced anxiety in 41

participants with mean age 69 years. Interviews after completing the program revealed that

half of the participants had ‘difficulties in practicing helpful meditation or mind/body

activities, personal disbelief and complexities associated with meditations and mind/body

practices’. Furthermore, high levels of social anxiety combined with impaired emotional

function and resilience diminished participation in the program [49]. Thus, further studies

are needed prior to routine incorporation of meditation into clinical practice.

A recent pilot [n =11] study compared an 8-week PR program plus CBT program to

PR alone, using retrospective controls [n= 58]. No significant difference in the level of

dyspnoea occurred between the two groups. Both groups showed similar improvement in

six-minute walk distance. However, the CBT plus PR group demonstrated greater gains in

exercise capacity [44], possibly due to the individualized attention and interactive sessions

involving the sharing and addressing of significant fears of dyspnoea in daily activities [61].

Table 4 shows other therapies investigated for the treatment of dyspnoea anxiety in patients

with COPD.

Short-term BT programs on anxiety and dyspnoea

Howard & Dupont [27] compared the efficacy of a cognitive-behavioural manual

(CM) to information booklets (IB) on anxiety and dyspnoea over five weeks. They found the

CM significantly improved anxiety (p=0.004) and dyspnoea (p⩽0.001) compared to IB.

Furthermore, in 6 and 12 months follow-up, the CM group required fewer accident and

emergency visits and hospital readmissions, thereby reducing costs, compared to the IB

group. The data suggest that providing information is important, but in itself does not lead to

a significant behavioural change in IB group. These encouraging results are worthy of,

replication in other clinical settings.

In a separate, previous study, Howard et al. [26] investigated the efficacy of a non-

exercise-based program of a weekly, two hour session, for four weeks, of a breathlessness

CBT intervention in 48 elderly patients. They showed improvement in depression and health

status, but not in anxiety (p>0.05). The lack of improvement in anxiety might be due to the

severity of COPD (average of FEV1< 33% predicted) and the short duration of CBT.

Hynnien and co-workers [37], in a randomised controlled trial compared CBT to

usual care in COPD patients with high anxiety and depressive symptoms. Seven weekly 2-

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hour group CBT sessions reduced anxiety and depression compared to the control group.

The CBT group maintained these improvements at follow-up eight months later.

Long-term behavioural programs on anxiety and dyspnoea

Effing et al. [50] demonstrated a significant reduction in dyspnoea (p<0.05) among

patients receiving a one-year community-based physiotherapeutic exercise programme

incorporating a self-management programme, compared to self-management alone. They

attributed the results to the ‘desensitisation to dyspnoea’ (reducing fear of breathlessness by

repetitive performance of exercise tasks in a safe and supervised environment by healthcare

professionals), which seems to be an important strategy in improving exercise tolerance in

COPD patients and a positive behaviour change in their daily activities e.g. walking [62].

Self-Management Efficacy on dyspnoea and anxiety

Use of a Self-Management Programme of Activity, Coping and Education (SPACE),

which included a structured exercise program, showed statistically significant reduction in

dyspnoea at 6 weeks (p=0.04) compared to usual care. However, the improved dyspnoea was

not maintained at 6 months (p=0.17). This underlines the importance of maintenance PR and

continued contacts by healthcare professionals to provide patients with appropriate support

and encouragement, whether by telephone contacts or face-to-face appointments. In addition,

fostering a peer group support network is worthy of consideration [30].

In COPD patients after hospital discharge, Johnson-Warington et al. [31] investigated

the efficacy of a SPACE program on readmission rates at 12 weeks compared with usual

care. This SPACE program consisted of written educational information and a home based

exercise program (a daily walking-based aerobic program and thrice-weekly resistance

training using free weights of the upper and lower limbs). There were no significant

differences in readmission rates or mortality between groups, but a trend was observed in

reduction of dyspnoea in favour of the SPACE group (p=0.06). In contrast, Lou et al. [45]

showed significant improvement in dyspnoea, anxiety, depression, exercise capacity and

reduction in healthcare utilization (p < 0.001) in COPD patients (n = 8,217) that attended a 4-

year health management program compared to usual care in rural communities in China. The

health management program, delivered every two weeks, comprised an hour lecture of

general information about COPD, direct observation of inhaler techniques, information about

medications, smoking cessation, counselling, encouragement for regular exercise, instruction

on rehabilitation, and psychological counselling. In addition, healthcare professionals visited

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patients at home every 2 weeks to improve compliance with advice and instruction from the

general practitioners. It is worth replicating this study to demonstrate feasibility in Western

countries with different healthcare care settings.

Donesky et al. [63] showed the benefits of a dyspnoea self-management program on

the affective dimension of dyspnoea measured by dyspnoea related anxiety (DA) and

dyspnoea-related distress (DD) in COPD patients. The participants were randomly allocated

into three groups, for duration of 12 month with varying doses of a supervised exercise

program (24 nurse-coached exercise sessions, 4 exercise sessions, or unsupervised home

walking). After 8 and 24 weeks, patients completing the nurse-coached exercise sessions had

less anxiety than the other two groups. At 12 months, there were no differences between the

three groups. Since the ‘nurse coached exercise sessions were only beneficial during the

intervention period, further investigation of the intensity and frequency of the exercise

program is warranted to achieve prolonged amelioration of dyspnoea.

An innovative study by Nguyen et al. [51] investigated the efficacy of an internet-

based compared to a face-to-face dyspnoea self-management programs. Both 6-month

programs focused on education, skills training, and ongoing support for dyspnoea self-

management, including exercise program engagement. Both programs reduced dyspnoea

from the activities of daily life after 3 months and sustained these improvements up to 6

months (p<.001), despite early stopping of the internet-based intervention due to multiple

technical challenges. These findings should be confirmed in a larger randomized trial with

personal digital assistant tools, a control group, and longer duration follow-up.

A Chinese mind-body intervention called Liuzijue qigong (LQG), comprising 6

months of four 45-minute sessions per week and daily 30 minutes walking exercises, was

compared with a control group (pursed-lip, coordinated breathing, and daily 30 minute

walking exercises). The LQG group had greater improvement in CRQ-dyspnoea (p=0.05), 6-

minute walk distance (p=0.02), and Medical Outcomes Study 36-item Short-Form Health

Survey (SF-36; general health (p<0.001), mental health (p=0.03)) at 6-month follow-up. The

control group did not show these improvements, except for the SF-36 mental health (p=0.02)

[52]. Thus, this type of therapy may be onsidered an alternative to home-based exercise for

those patients unable to attend an outpatient PR program.

Alexopoulos et al. (2014) [55] investigated the effects of a Personalized Intervention

for Depressed Patients (PID-C) on dyspnoea-related disability using the PFSDQ-M and on

depression assessed by the Hamilton Depression Rating Scale, compared to usual care over

28 weeks. Trained social workers carried out the PID-C intervention of a clinical state

16

review and reinforcement of plans to address treatment engagement. The first PID-C session

was carried out occurred prior to discharge and eight 30 minute sessions were provided at

home at 3, 4, 8, 12, 16, 20, 24, and 26 weeks after discharge. The PID-C group showed

greater reductions both in depression (p=0.02) and in dyspnoea-related disability (p=0.04),

compared to usual care. The inter-relationship of the course of depression and dyspnoea-

related disability highlights the need to target adherence to both antidepressants and COPD

rehabilitation.

A randomised trial by Pala Özdemir et al [33] has reported that a 4 week water based

therapy improved dyspnoea and anxiety compared to a control group. The water-based

exercise program involved movements of the arms and strengthening of the shoulder girdle

upper extermity muscles. However, scarcity of hydrotherapy in many healthcare setttings

limits the feasability of this intervention.

The efficacy of a controlled breathing exercise program plus 10 days of counselling

[n= 23] was compared to usual care [n=23] in older patients admitted with an acute

exacerbation of COPD and moderate to severe dyspnoea and anxiey symptoms [29]. At

discharge, the intervention group showed significant improvement in anxiety and dyspnoea

symptoms compared to the control group. This study provides some evidence of the potential

role of counselling in allevating these symptoms during hospital admission, but whether the

improvement gained is sustainable requires further investigation.

Expert commentary

Dyspnoea on exertion increases as COPD progresses from mild to severe, and frightens

patients and caregivers (families). Uncontrolled dyspnoea is often associated with increased

stress, depression, anxiety and hospital admission [7,8]. Acute exacerbations frequently cause

hospital admission, dislocate patient confidence, disrupt social interaction, and increase

feelings of losing mastery and an inability to cope with managing the disease. These factors

contribute to excessive worry, panic, fatigue and dependency on others for basic activities of

daily living. It is important to break the vicious cycle of fear of dyspnoea on exertion, which

may lead to physical inactivity and perceived high level of anxiety or vice versa. Thus, a

17

multi-modal approach of intervention is necessary to increase patients’ confidence and

alleviate the daily burden of dyspnoea and anxiety.

In this systematic review, most PR studies reduced anxiety and/or dyspnoea in COPD

patients during the short term (Table 2). A number of studies have shown the efficacy of PR

in reaching the MCID using the HAD anxiety or the AIR scale. In addition, the long-term

benefits of PR in reducing anxiety or dyspnoea remain inconclusive, with relatively little

evidence of a carryover effect into the follow up period. COPD patients’ lacks of

engagement with continuing exercise after PR have not systematically studied, and potential

explanations include:

1) Patients may lack confidante (friends) to exercise on a regular basis or during poor

weather conditions.

2) Patients may lack support and encouragement from peers, family members and healthcare

professionals after completion of PR.

3) Maintenance PR programs are not readily available in most healthcare settings, and may

hamper patients’ confidence to continue the exercise program on their own.

4) Most community gymnasiums do not meet the requirements of COPD patients, lack skilled

healthcare exercise instructors, and may be unaffordable.

5) Most studies did not use outcome measures to assess anxiety that were disease-specific for

COPD. The nonspecific anxiety measures used may be insensitive to subtle changes in the

longer-term follow-up. Disease-specific anxiety measures such as the AIR scale [64] might

be useful to investigate in longer-term follow-up studies.

Likewise, CBT (employed with or without PR) reduced anxiety and dyspnoea by

challenging COPD patients’ attitudes and beliefs regarding their illness in the short-term

18

(Table 3). Self-management, counselling and yoga interventions also showed promising

results in reducing anxiety and dyspnoea (Table 4), but these studies were relatively small in

sizes, largely uncontrolled, and with short duration interventions. It is critical to examine the

frequency, intensity of these interventions to identify clinical benefits for patients and

potentially reduce healthcare utilization with longer-term follow-up. Furthermore, a recent

study by Yohannes [65] showed inadequate availability and provision of psychological

services for COPD patients in primary care settings in the UK, with long waiting times for

psychological treatment.

Five-year view

Strong evidence suggests that PR ameliorates dyspnoea and reduces anxiety and dyspnoea in

patients with COPD in the short-term. In the next five years, well-controlled clinical trials

are needed to demonstrate the efficacy of PR and CBT programs in the management of

anxiety and dyspnoea with long term follow-up.

The high dropout rate of COPD patients from PR programs is an important concern for

healthcare professionals, as it limits the effectiveness of PR and raises the costs of healthcare.

Ironically, COPD patients with high-level anxiety symptoms who are most likely to benefit

often do not complete the PR program. Thus, it is paramount to develop and incorporate

from the outset treatment adherence strategies that encourage patient engagement in PR

programs, using the latest technology such as texting reminder messages to continue with

home exercise and PR sessions. Some evidence shows that CBT plus PR better reduces

anxiety and depression than PR alone. PR programs should have a trained counsellor,

preferably a psychologist, to support patients with high levels of depression, anxiety

symptoms and excessive fear of dyspnoea.

19

Very little literature examines the efficacy of PR and CBT on addressing the different

components of affective and sensory dyspnoea in patients with COPD. Likewise, anxiety

syndromes such as panic and social phobias were scarcely addressed in this population.

These challenging and emerging areas require future research to address the mechanism

behind and the efficacy of PR.

In summary, this review demonstrates the efficacy of PR and behavioural therapy

programs (including CBT) in improving dyspnoea and anxiety symptoms in patients with

COPD in the short term. In addition, a paucity of studies investigated the effectiveness of PR

and CBT programs with long-term follow-up. Thus, well-controlled, randomised controlled

trials are needed to examine the efficacy of a maintenance program for both CBT and PR.

Key issues

PR improves dyspnoea and anxiety in patients with COPD short-term follow-up

studies.

The long-term benefits of PR in managing anxiety and dyspnoea are inconclusive.

CBT also decreases dyspnoea intensity and anxiety symptoms compared to usual care.

No clear consensus exists from this systematic review about the duration or intensity

of CBT for the management of dyspnoea and anxiety in patients with COPD.

Twenty five to forty percent of COPD patients enrolled in PR do not complete the

program.

COPD patients with high anxiety are less likely to complete a PR program.

The long-term benefits of CBT, self-management, counselling and yoga in alleviating

anxiety and dyspnoea remain uncertain.

20

Both 8 and 12 weeks of PR are similarly effective in reducing dyspnoea and anxiety

in patients with COPD.

21

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28

Table 1

Factors that contribute to elevated anxiety and dyspnoea in patients with COPD

Physiological

Severity of lung function impairment

Ineffective medication and including poor technique of using inhalers

Severity of dyspnoea

Increased CO 2 retention

Hypoxia

Behavioural factors

Active cigarette smoking

Obesity

Physical inactivity

Cachexia

Poor self-esteem

Physical and psychosocial factors

Decrease exercise tolerance

Poor balance

Fear of falling

Physical inactivity

Sedentary lifestyle

Lower social class status

Dwindling social network

29

Table 2. Summary of studies meeting the selection criteria for inclusion in the systematic review for PR program.

Authors Year Study design Sample n Mean age (SD) in years

Duration Frequency Content

Donesky-Cuenco et al. 2009

Randomized pilot study

Yoga (n=14); Usual care (n=15)

Yoga (72.2±6.5); Usual care (67.7±11.5) 12 weeks

24 sessions, 1h per week

Yoga asanas (poses) interspersedwith visama vritti pranayama (timed breathing)

Ja´come & Marques 2014

Quasi-experimental study 26 67.8 ±10.3 12 weeks

Exercise training (3 sessions perweek, 60 min each), psychoeducation (one session perweek, 90 min)

Exercise training, psychoeducation

Yohannes et al. 2016Prospective study 192 patients 71.4 years 8 weeks Once a week

1h of strength andendurance aerobic exercises; 1h of educational program

Botou et al. 2014Prospective study 787 patients

68.1±10.5 years 8–12 weeks

Two supervised sessions, one or more unsupervisedhome exercise sessions per week

Combination of aerobic andstrength training

Dodd et al. 2011 Multicentre, prospective

261 patients 69±9 years 8 weeks Two supervised and

Aerobic and strength

30

study

one or more home sessions per week

training, supervised and unsupervised home exercise sessions

Elçi et al. 2008

Prospective randomized, controlled trial

78 patients. Intervention (n=39); control (n=39)

Intervention group (59.67±8.60); Control group (58.08±11.45) 12 weeks

Twicea week (90 min per session)

Endurance training and muscle strengthening; nutritional advise and psychosocial counselling

Ergun et al. 2011Prospective study

55 patients. Early disease stage (n=28); late disease stage (n=27)

Early stage (63.25 ± 10.10); late stage (62.81 ± 7.18) 8 weeks Twice a week

Comprehensive PR (educational support; exercise training; nutritional intervention; psychological counselling)

Arnardo´ttir et al. 2007

Comparative parallel group study

60 patients. Interval group (n=28); Continuous (n=32)

Interval training (65±7); Continuous training (64±8) 16 weeks

Twice a week (90 min per session)

Ergometer cycling; callisthenics and relaxation; resistance training

Pirraglia et al. 2011

Retrospective observational cohort study 81 patients 69.8±9.1 years 8 weeks

Twice a week; 2hrs duration per session

Aerobic exercises, strengthtraining exercises and education.

Kaymaz et al. 2014 Non-randomized controlled observationalstudy

50 patients. NMES (n=23); Endurance training - ET (n=27)

NMES group (63.25±10.10); ET group (62.81±7.18)

NMES=10 weeks; ET=8 weeks

NMES: 2 days at hospital; ET: 2 days at hospital and 1 day at home

Neuromuscular electrical stimulation versus aerobic exercises and active strengthening

31

exercises

Wilson et al. 2015

Randomised, controlled, parallel, investigator blindstudy

148 patients with COPD

Intervention (67.3±15.1), Control (69.3±8.9) 48 weeks

1 session every 3 months; 2hrs duration

Education,exercise training

Paz-Dı´az et al. 2007

Randomized prospectively study

24 patients. Intervention group (n=10); Control group (n=14)

Intervention (67±5), Control (62±7) 8 weeks

Three times per week

PR program (disease

education, energy conservation techniques, relaxation, and aerobic exercise)

Canga et al. 2015Randomized control study 98 patients 70.1 years 24 weeks 6 times a week

Live music visualizations, wind instrument playing inclusiveof clinical improvisation, and singing plus the PR versus only PR

Cheng et al. 2014

Randomized controlled study 64 patients 70.1±8.7 12 weeks Twice a week

Formal education (breathing retraining, proper use of medications and self-management skills) and lower limb cycle ergometer exercise

Duiverman et 2011 Randomized 66 patients NIPPV group Two-year 1-2 times a NIPPV

32

al.

controlled with parallel-groups

+ PR group (63±10); PR group (61±8)

home-based follow-up period after 12 weeks of PR week

(nocturnal bilevel) + PR group (30-minute periods of cyclingexercises, walking, and inspiratory muscle training)and only PR group

Gurgun et al. 2013

Randomized, controlledstudy

46 patients. PRNS (n= 15); PR (n=15); control group (n=16)

PRNS (64±10.8); PR (66.8±9.6); Control (67.8±6.6) 8 weeks Twice a week

PR (education and exercise training); nutritional supplementation

Hogg et al. 2012

Prospective observational study 441 patients

68.1±11.0 years 8 weeks

Twice weekly/ once weekly

Exercise training

Kavoura et al. 2016Prospective study 95 patients 65±3 years 12 weeks Not reported

Exercise training, psychosocial andnutrition support, and education

Lan et al. 2014Prospective study 34 patients 70.2±9.4 years 12 weeks Twice a week

Formal education (breathing training, proper use of medications,and self-management skills); exercise training with a lower limbcycle ergometer

Von Leupoldt 2011 Prospective 238 patients 62.0±9.9 years 3 weeks 5 days per Exercise,

33

et al. studyweek (6 hrs per day)

patient education, nutrition counselling,breathing therapy, relaxation therapy, psychosocial education, and smoking cessation support

Luk et al. 2015prospective cohort study 129 patients 70.7±7 years

8 weeks and long-term (>1 year) Twice a week

Exercise and education sessions

O’Neill et al. 2007

Prospective, randomized, parallel-group study

91 patients. Group 1: 1 supervised exercisesession a week and 2 unsupervised sessions (n=46); Group 2: 2 supervised exercise sessions a week and 1 unsupervised session (n=45)

Group 1 (69.3±8.4); Group 2 (67.7±7.3) 6 weeks

3 times per week

Exercise and education sessions

Tselebis et al. 2013 Prospective study

101 patients 64.1 ± 8.1 years

12 weeks 3 times per week

Respiratory physiotherapy, respiratory muscletraining, aerobic exercise on a bicycle ergometer and on

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a treadmill and strengthening of muscle groups

Vincent et al. 2011

Prospective, observational, uncontrolled study 225 patients 69 ± 8.8 years 7 weeks Not reported

Training exercises

Wadell et al. 2013

randomized, controlled study

41 patients. PR (n = 17) and CTRL (n = 24) groups

PR (68 ± 6) and CTRL (66 ± 7) 8 weeks

3 times a week (2.5 hrs sessions)

Intervention (exercise training and education) vs Usual care

Duruturk et al. 2016

Randomized prospectively study

47 patients. Cycle Exercise

Calisthenic Exercise (61.2 ± 5.1); Cycle Exercise (61.2 ± 5.0); Control (63.8 ± 5.7) 6 weeks 3 times a week

Calisthenic: 16 different, rhythmical exercises strengthening and stretching; Cycle: cycle ergometer training

Zoeckler et al. 2014Prospective study 96 patients

61.2 ± 8.8 years Not reported Not reported

Pulmonary rehabilitation

Sharifabad et al.

2010  Prospective, randomized, controlled trial

Intervention group (n=29); Control group (n=37)

Intervention group (71.25±9.8); Control group (71.7±7.3)

8-week pulmonary rehabilitationprogram; Intervention: 3 consecutive weeks.

3 sessions per week; 2hrs duration. Intervention (20 minutes)

Pulmonary rehabilitation

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NMES: Neuromuscular electrical stimulation; MMRC: Modified Medical Research Council; HADS: Hospital Anxiety Depression Scale; NIPPV: Non-invasive intermittent positive pressure ventilation; PRNS: PR and nutritional support; SSTAI: Spielberger State-Trait Anxiety Inventory; CTRL: control; CRQ: Chronic Respiratory Disease Questionnaire

Table 3. Summary of studies meeting the selection criteria for inclusion in the systematic review for behavioural therapy.

Authors Year Study design Sample n Mean age (SD) in years

Duration Frequency Content

Howard & Dupont 2014

Prospective, randomised, single-blind, parallel-group trial

Allocated COPD manual (n =112); Allocated to information booklets (n =110)

Cognitive-behavioural manual (CM) group (71.2±10.4); Information booklets group (73.2±11.4) 5 weeks 1h per day

Cognitive-behavioural manual (CM) versus information booklets (IB)

Alexopoulos et al.

2014 Randomized controlled trial

138 patients PIDC (70.9±8.5); Usual care (71.0±7.7)

28 weeks 10 individual sessions

PIDC (Education) versus usual care

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Chan et al. 2016

Randomized controlled study

41 participants 69.5±7.9 8 weeks

One hour per week Meditation

Howard et al. 2010

Retrospective between subjects design

48 patients (29 males, 19 females) 71 years 4 weeks

Twice a week

Cognitive-behavioural model ofanxiety and breathlessness

Livermore et al. 2015

Randomised controlled trial study

31 patients. Cognitive behavioural therapy - CBT (n=18); Routine care (n=13) 72±6 years

8 weeks (24 weeks follow-up)

4 individuallyadministered, 1h per week

CBT (Strategieseffective for the prevention and treatment of panic disorder; training in “pursed lipbreathing”)

Kunik et al. 2008

Randomized controlled trial

238 COPD patients. Education (n=120); CBT (n=118)

Education (66.5±10.4); CBT (66.1±10.1) 8 weeks 8 sessions

Education (breathing strategies and airwaymanagement, pathophysiology of lung disease); CBT (relaxation training, cognitivetherapy)

Hynninen et al.

2010 Randomized, controlled trial

CBT (n=25); standard care (n=26)

CBT (59.3); control (62.6)

Follow up at 8 and 32 weeks

7 sessions CBT (Psychoeducation/awareness; Relaxation; Cognitive therapy;

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Behavioural activation; Fear-based exposure; Sleep management skills)

Williams et al. 2015

Pilot study with a retrospective control

Intervention group (n=12; 11 males), Control group (n=58; 36 males)

Pilot (75±6) and control (71±9) 8 weeks

Twice a week, 2h of knowledge-based groupeducation

PR program (Exercisetraining) and CBT program (education)

MRC: Medical Research Council; MMRC: Modified Medical Research Council; HADS: Hospital Anxiety Depression Scale; PIDC: Personalized Intervention for Depressed Patients with COPD; CRQ: Chronic Respiratory Disease Questionnaire; PFSDQ-M: Modified Pulmonary Functional Status and Dyspnoea Questionnaire

Table 4. Summary of studies meeting the selection criteria for inclusion in the systematic review for other therapies.

Authors Year Type of therapy

Study design

Sample n Mean age (SD) in years

Duration Frequency

Valenza et al. 2014 Counselling

Randomized controlled pilot study

Intervention group (n=23); Control group (n=23)

Intervention group (76±5.5); Control group (74.43±6.7) 10 days

Twice a day; 30 min per session

Lou et al. 2015 Self-management

Randomized controlled trial

Health Management (n=3,418); Usual care (n=2,803)

Health Management (61.6±13.5); Usual care (61.4±13.2)

2 days of health management training; 4 years follow-up; lecture for 40–60 min

Every 2 weeks

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Donesky et al. 2014

Self-management

Longitudinal randomized controlledtrial

115 patients. DM (n=36),DM-E (n=33), DM-T (n=34)

DM=65.7±8.8, DM-E=67.2±7.6, DM-T=66.2±6.4

Follow-up at 8 weeks, 24 weeks and 48 weeks

DM group individualizededucational sessions and reinforcement sessions; DM-E: 4 exercise sessions; DM-T: 24 nurse-coaching

Mitchell et al.

2014 Self-management

Single-blind RCT

184 patients. SPACE (n=89); Usual care (n=95)

SPACE (69±8.0, Usual care (69±10.1)

24 weeks 1 consultation, 30-45 min, telephone calls from the physiotherapist at 2 and 4 weeks into the programme

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Effing et al. 2011Self-management

Two-by-two factorial design

153 patients. Intervention (n=74); control (n=68)

Intervention group (62.9±8.1); Control group (63.9±7.8) 48 weeks

3 sessions per week (2hrs duration)

Johnson-Warrington et al. 2016

Self-management

Prospective, two-center, single-blinded randomized controlledtrial

78 patients. Usual care (n=39); SPACE (n=39)

Self-management Program of Activity, Coping, and Education - SPACE (67.64±8.54); Usual care (68.33±7.73) 12 weeks

One session lasting 30–45 minutes and phone calls within 72 hours and at 2 weeks, 4 weeks, 6 weeks, 8 weeks, and 10 weeks

Reychler et al.

2015 Musical therapy

Randomized crossover

41 COPD 70.5±8.4 The interval between the

2 sessions per week; 1h

40

controlled study subjects years

sessions varied from 1 to 6 days

15min of duration each

Pala Özdemir et al. 2010

 Water-based exercise

Prospective study

50 patients. WE group (n= 25) or to control group (n= 25).

Intervention: 60.9 ± 8.8; Control: 64.1 ±8.9 4 weeks

3 times per week

Nguyen et al.

2008  Self-management internet based

Randomized pilot study

50 COPD participants. eDSMP (n=19); fDSMP (n=20)

eDSMP (68.0 ± 8.3); fDSMP (70.9 ± 8.6)

24 weeks Consultation (1-1.5 hrs); Endurance (4 times per week, 30 min per session); Unsupervised independent exercise

(3 times per week); self-

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monitoring of exercise and respiratory

symptoms

(weekly in month 1; biweekly in months 2-6); education of dyspnoea management (six sessions of 1h duration)

Xiao et al. 2015Liuzijue qigong

Randomized prospective study

126 patients. Liuzijue qigong - LQG (n = 63); control (n = 63)

71.1 ± 2.7 years 24 weeks

Four 45-minute sessions each week and dailywalking exercise for 30 minutes

MMRC: Modified Medical Research Council; HADS: Hospital Anxiety Depression Scale; CRQ: Chronic Respiratory Disease Questionnaire; SPACE: Self-Management Programme of Activity, Coping and Education; DM: Dyspnoea self-management; DM-E: Dyspnoea self-management Exposure; DM-T: Dyspnoea self-management Training; 6-MWT: 6- minute walk test; WE: Water-based exercise; eDSMP: Dyspnoea self-management programs Internet-based; fDSMP: Dyspnoea self-management programs face-to-face; ADL: Activities of daily living; PDA: Personal digital assistant.

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Dyspnoea Increase sedentary

HyperventilationSuffocating sensation of breathlessness

Air hunger Panic Poor sleeping pattern

43

Potentially relevant article:s

Abstracts identified and screened for

review n=135

Pulmonary Rehabilitation n=91

Behavioural Therapy n=44

Article excluded:sBased on abstract and title

review

Pulmonary Rehabilitation n=63

Behavioural Therapy n=33

Reasons:

Systematic reviews

Explorative studies

Unrelated issues to dyspnoea and anxiety as

outcome measures

Protocol studies

Guidelines

Participants sample size <10

Relevant citations for inclusion in systematic

review Pulmonary rehabilitation n=28;

Behavioural therapy n=18.

Increase sedentary

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Figure . Flow chart of the literature search2

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