Effect of counselling during pulmonary rehabilitation on self-determined motivation towards physical activity in people with chronic obstructive pulmonary disease – protocol of a mixed methods study

Physical inactivity in daily life is a prominent feature in people with Chronic Obstructive Pulmonary Disease (COPD) [1‐5]. The amount of daily physical activity (PA) gradually declines with the severity of COPD [5‐7]. In addition, PA is associated with the number of hospitalizations [8‐10] and recognised as the strongest predictor of all-cause mortality [9, 11] in these patients. A downward circle of dyspnoea induced by PA may lead to a shift in patients’ lifestyle resulting in a vicious circle of decreased exercise tolerance, which in turn further reduces activity levels and increases social isolation and depression [12]. In addition, results from the PERCEIVE study indicated that patients’ perception of their COPD impacted the activities of daily living [13].

Physical inactivity became topic of great interest since both the American Thoracic Society (ATS) and the European Respiratory Society (ERS) stressed the fact that long-term self-management and adherence to exercise at home should be the primary goals of pulmonary rehabilitation programs (PR) [14]. Research has demonstrated sufficiently that PR is beneficial to people with COPD as it improves exercise capacity and locomotor muscle strength [15, 16]. Although the main purpose of PR should be enhancing PA, the impact of PR on PA in people with COPD is still unclear [17, 18]. Mantoani and colleagues [19] showed in a literature review that the intervention of 13 studies demonstrated a positive effect while the strategy of seven studies had no effect. Mantoani and colleagues stressed the fact that objectively assessed improvements were only shown by studies with an intervention phase equal or longer than 12 weeks duration, even though the increments in activity level ranged between 10 and 20%.

Apparently there is an eloquent difference between functional capacity status and daily PA, as the latter may be elicited by the habitual and environmental factors of sedentary patients. However, in order to be meaningful for people with COPD, PR-induced improvements need to be translated into changes in PA and participation in everyday situations. An alternative strategy to improve physical activity levels may be a lifestyle PA counselling program to help the patients to translate PR-induced improvements in exercise capacity during daily living. It may be postulated that implementation of comprehensive counselling program during PR is the strategy of choice [20]. One promising approach is counselling based on motivational interviewing (MI). According to Miller and Rollnik [21] this conversation method is client-centred and directive. It focusses on the exploration and evocation of a person’s intrinsic motivation to change his/her status quo regarding daily physical activity. Hereby MI emphasises the attitude of rather seeing a person ambivalent than unmotivated in regards to behavioural change. Consequently, it is the therapist’s intension to detect a patient’s ambivalence and to further resolve it. This attitude is called “MI spirit” and is based on four principles such as; be empathetic, develop discrepancy, roll with resistance and support self-efficacy [22]. The process to change the problem behaviour can be divided in two phases; first to create motivation to change and second to commit to change. The MI method is self-defined and not tailored. Several authors investigated the effects of PA counselling based on MI added to PR in people with COPD [23‐25]. De Blok and colleagues [23] compared the short-term effects of a lifestyle PA counselling program with feedback of a pedometer during a nine-weeks PR on daily step count to PR alone. Twenty-one individuals with moderate to severe COPD were randomized into two groups. Four counselling sessions a 30 min were performed by physiotherapists following the principles of MI. The experimental group increased the mean daily step count by 69% for continuous 6 days without PR, whereas the control group increased by 19% compared to baseline. Effects were not statistically significant, however the between-group effect size was d > 0.8. This was the first study using a feedback-tool to improve motivation which gave useful information for following trials evaluating long-term effects in a larger patient group living in the region of Groningen [26, 27]. However, PA was quantified by using a pedometer, but objectively measuring PA by using multiaxial accelerometer seems to be the most accurate field based estimate of PA [28, 29]. Burtin and colleagues [24, 25] investigated as well the additional effect of counselling during PR in PA levels in 80 people with moderate to very severe COPD. To measure PA levels objectively an accelerometer was used before and after 3 months and after 6 months of PR. Those individuals randomized to the intervention group participated in eight individual counselling sessions a 20 to 30 min with a physiotherapist based on principles of MI. Controls received a sham attention program. Unfortunately, the study failed to show any improvements regarding PA after 6 months. The authors reflect it could be more effective to put the counselling sessions at the end respectively short after the end of PR. Furthermore, the counselling providers had no prior experience with MI. They have had three 1 h–training sessions and supervision during the first few months of the study. Additionally, adherence to PR was not documented.

Holland and colleagues [30] published a protocol describing a RCT in 166 individuals evaluating the effect of home-base PR using MI compared to outpatient PR. It is an eight-week program and primary outcome will be the immediate change in six-minute walk distance.

Designing the optimal intervention for the promotion of PA in people with COPD is an intensively investigated topic in recent literature [19, 20, 31]. In order to address the recommendations of the ATS and the ERS more accurately, the current study aims to improve long-term self-management and adherence to exercise at home during PR by adding counselling based on MI. This study also aims to gain information about the willingness to actually change habitual behaviour in patients with COPD and evaluates the patients’ perspective on barriers and facilitators towards daily PA. There is no conclusive evidence yet about the best strategy to promote PA and helping people with COPD to change their behaviour. Data from well-designed interventional studies looking at the willingness to actually change habitual behaviour in people with COPD are urgently needed [20]. The results of the study may gain insight into the factors determining physical activity and help leading to novel therapeutic approaches in the care of people with COPD.

The development and implementation of successful strategies to improve PA are in the focus of both, medical research and public health [8‐11]. The minimal important difference regarding a proxy of PA has not been defined yet in people with COPD. PA recommendations for the elderly state that 30 min of moderate intense physical activity on at least 5 days per week in order to improve or maintain their health status [61]. But even these recommendations are not realistic for people with very severe COPD. There seems to be a common agreement that PA promotion in people with COPD has to incorporate the patients’ personal values and goals, symptoms, and motivation status [20, 24, 25, 62, 63]. Donaire-Gonzales and colleagues [64] evaluated the interaction of quantity and intensity of PA in their effects on COPD hospitalisation risk. For people with low average PA intensity the risk for COPD hospitalisation was reduced by 20% for every additional 1000 daily steps. Contrary and a little surprising, adding steps to an anyway high-intensity PA does not produce any risk reduction. Reducing sedentary behaviour is especially beneficial for people with low PA. Currently, it is still on debate which strategy might be the best to improve PA in people with COPD. Recent literature shows a tendency to patient-centred interventions like counselling [19]. This study aims to investigate if a PA counselling program based on the principles of MI, during PR increases PA level in daily life in people with COPD. Using a mixed-method-approach will gain multifaceted knowledge about barriers and facilitators about the acceptance and effect of this strategy.

It might be a disadvantage not to offer direct feedback like a pedometer to every participant [19]. However, if a participant has the idea to use a step counter (pedometer, mobile phone, etc.) as part of his strategy to be more active, we support this purpose.

The accelerometer SenseWear is especially accurate and validated in this patient group [39, 65], but not easy accessible in clinical practice. The device is much more uncomfortable and unattractive than other devices like a smart watch. Furthermore, the SenseWear device production was stopped in 2015. Anyhow, we decided to stick with the SenseWear.

If this strategy is approved to be effective PA counselling might be implemented as an integral part of PR Pneumofit.