2013

http://informahealthcare.com/idsISSN 0963-8288 print/ISSN 1464-5165 online

Disabil Rehabil, Early Online: 1–12! 2012 Informa UK Ltd. DOI: 10.3109/09638288.2012.745625

RESEARCH ARTICLE

Chronic obstructive pulmonary disease and functioning: implications forrehabilitation based on the ICF framework

Cristina Jacome1, Alda Marques1,2, Raquel Gabriel1, and Daniela Figueiredo1,2

1School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal and 2Unidade de Investigacao e Formacao sobre Adultos e Idosos

(UniFAI), Porto, Portugal

Abstract

Purpose: This study aimed to describe the functioning of patients with Chronic ObstructivePulmonary Disease (COPD) according to the International Classification of Functioning,Disability and Health (ICF) framework to inform future rehabilitation interventions. Method: Across-sectional study with a convenience sample of outpatients with COPD was conducted.Data were collected using the Comprehensive ICF Core Set for Obstructive Pulmonary Diseases.Descriptive and inferential statistics were applied. Results: In total, 119 participants (71.43%male) with a mean age of 68.71� 11.61 years old were included. The frequency and extent ofthe majority of the impairments assessed were similar among participants at different COPDgrades. The most relevant (frequency470%) Body functions and structures impairments wererelated to exercise tolerance functions, sensations associated with cardiovascular andrespiratory functions and respiratory system structure. Mobility and domestic life restrictionswere the most frequently reported in the activities and participation component. Products forpersonal consumption, immediate family, health professionals and their attitudes were mostfrequently understood as facilitators whilst climate and air quality were perceived as barriers.Conclusions: Recommendations were drawn from this study in order to improve comprehensiverehabilitation interventions for patients with COPD based on ICF framework.

� Implications for Rehabilitation

� Functioning of patients with Chronic Obstructive Pulmonary Disease can be comprehensivelyassessed in a worldwide common language – the International Classification of Functioning,Disability and Health.

� Rehabilitation interventions for patients with Chronic Obstructive Pulmonary Disease shouldbe designed according to the International Classification of Functioning, Disability and Healthframework, i.e. assessing and monitoring Body functions, Body structures, Activities andparticipation and Environmental factors.

Keywords

COPD, ICF, rehabilitation

History

Received 4 April 2012Revised 2 October 2012Accepted 29 October 2012Published online 7 January 2013

Introduction

The Chronic Obstructive Pulmonary Disease (COPD) currentlyaffects 210 million people around the world [1]. According to theGlobal Initiative for Chronic Obstructive Lung Disease (GOLD),COPD is a progressive condition that can be classified into fourgrades [2]. At earlier grades (GOLD 1 and 2), the condition ismainly characterised by airflow limitation, however, as thedisease progresses (GOLD 3 and 4), exacerbations and comorbid-ities contribute to a high disability [2].

Since COPD can become a highly incapacitating disease, it isimperative to organise and plan health care for patients withCOPD at its different grades. Several international guidelines

have been recommending rehabilitation as a first line interventionfor patients with COPD, since it is the multi and interdisciplinarymanagement of a person’s functioning and health [2–4]. However,the international rehabilitation recommendations have been basedin patients’ problems and needs assessed through condition-specific health-status measures. These measures typically coverselected aspects of the patient’s health experience and do notconsider all factors impacting on health and functioning ofpatients [4]. These guidelines also have failed in providing ameaningful standard language to all agents involved in planningrehabilitation interventions across the world [2,3]. Therefore, acomprehensive specification of symptoms and limitations infunctioning of patients with COPD in a worldwide commonlanguage about health is needed for decision-making purposes.

The International Classification of Functioning, Disability andHealth (ICF), approved by the World Health Organization (WHO)as an official member of the WHO Family of Classifications inMay 2001, reflects the biopsicossocial model in a unified and

Address for correspondence: Alda Marques, School of Health Sciences,University of Aveiro (ESSUA), Campus Universitario de SantiagoEdifıcio III, 3810-193 Aveiro, Portugal. Tel: þ351 234 372 462. Fax:þ351 234 401 597. E-mail: amarques@ua.pt

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coherent view of various dimensions of health (biological,individual and social) [5]. Moreover, ICF allows the establishmentof a standard language for describing health, which is not possibleusing other classifications [5]. Thus, describing the functioning ofpatients through the ICF framework may improve the commu-nication between different users that are needed to be involved inthe design of comprehensive rehabilitation interventions, such ashealth and social professionals, researchers, policy-makers,patients and families [5]. Therefore, ICF provides an appropriateframework to plan and implement guidelines in COPDrehabilitation.

The main aim of this study was to comprehensively assess thefunctioning of patients with COPD according to the ICFframework to inform the development of future rehabilitationinterventions. Specifically, the study aimed (i) to investigate thefrequency and extent of the impairments of participants withCOPD and (ii) to examine the differences among COPD grades.

Methods

Study design and participants

A cross-sectional study with a convenience sample of outpatientswith COPD was conducted in the central region of Portugal. Thestudy received full approval from the Ethics Committees of theCenter Health Regional Administration and of the Sao SebastiaoHospital. Potential participants were identified by clinicians fromthe institutions involved (two primary care centres and onehospital) and the recruitment occurred from December 2010 toOctober 2011. Participants were included in the study if they:(i) were diagnosed with COPD (International StatisticalClassification of Diseases and Related Health Problems (ICD-10) codes J40-J44) according to the GOLD criteria; (ii) were 18years of age or older and (iii) were able to understand the purposeof the study and voluntarily consent to participate. Participantswere excluded from the study if they presented severe psychiatricconditions and/or inability to understand and co-operate.

Instruments

As the ICF classification comprises over 1400 categories, ICFCore Sets have been developed, which represent a selection of ICFcategories describing the prototypical spectrum of impairments inthe functioning of patients with a specific health condition [6]. ForObstructive Pulmonary Diseases (OPD), where COPD is included,two types of ICF Core Sets have been developed: the brief and thecomprehensive. The brief core set is composed by minimum datato be used at any clinical encounter [6]. The comprehensive coreset has the ability to collect more information and it is indicated toguide multidisciplinary assessments in the rehabilitation process[6]. Therefore, in this study, functioning was assessed with theComprehensive ICF Core Set developed for OPD as it wasintended to inform rehabilitation [7]. The current version consistsof 71 categories, 19 of which assess the Body functions, five theBody structures, 24 the Activities and participation and 23 theEnvironmental factors [7]. This instrument follows the ICFcategories which are designated by specific letters, i.e. ‘‘b’’ forBody functions, ‘‘s’’ for Body structures, ‘‘d’’ for Activities andparticipation and ‘‘e’’ for Environmental factors. These categoriesare followed by a numeric code which first digit represents the ICFchapter number. More detailed information is given throughadding a second (two digits), third and fourth levels (one digiteach). For example, in the Body functions, there are these codes:b2 Sensory functions and pain (first-level)b280 Sensation of pain (second-level)b2801 Pain in body part (third-level)b28010 Pain in head and neck (fourth-level).

For the Body functions, Body structures and Activities andparticipation components, the extent of the patients’ impairmentswas quantified on a 0–4 qualifier scale, corresponding to no, mild,moderate, severe and complete impairment, respectively. TheActivities and participation component enables the assessment ofboth participation restrictions and activity limitations. However,to assess activity limitations, a standardised environment isneeded to neutralise the impact of different environments on eachindividual’s ability [5]. As this study was conducted in differentclinical settings, it was only possible to assess the frequency andextent of the participation restrictions. The qualifier scale of theEnvironmental factors component ranged from �4 to 4, since anenvironmental factor can be a barrier (�1 mild, �2 moderate, �3severe and �4 complete), a facilitator (1 mild, 2 moderate, 3substantial and 4 complete), or can have no influence (0) on apatient’s functioning. Additionally, in all four ICF components,‘‘8 – not specified’’ was used when the available information wasnot sufficient to quantify the severity of the problem, and ‘‘9 - notapplicable’’ when a category was not applicable to a specificpatient.

Data collection procedures

Socio-demographic (gender, age and occupation situation),anthropometric (height and weight) and clinical (medication andcomorbidities) data were first recorded. Patients were interviewedby a health professional trained in the application and principlesof the ICF. The Comprehensive ICF Core Set for OPD was filledusing information from participants (interview and observation),from proxies (i.e. a spouse or close relative, who could also havethe role of a carer), from medical records and from a physicalexam. The physical exam included the assessment of: (i) heightand weight, which were measured using a calibrated digital scale;(ii) vital signs, arterial blood pressure and heart rate measuredwith a digital automatic blood pressure monitor (HEM-742 INT,Omron Healthcare Co., Ltd., Kyoto, Japan) and respiratory ratewhich was determined manually; (iii) airflow obstruction, whichwas measured with a portable spirometer (MicroLab 3500,CareFusion, Kent, UK); (iv) mobility, which was determined bythe ‘‘Timed up and go’’ Test as it is a reliable and valid test forquantifying functional mobility [8] and (v) peripheral oxygensaturation before, during and after the ‘‘Timed up and go’’ Test,which was monitored with a portable pulse oximeter (Pulsox-300i, Konica Minolta Sensing, Inc., Osaka, Japan). On average,the Comprehensive ICF Core Set for OPD lasted 55� 17 min tocomplete.

Data analysis

Descriptive statistics were used to describe the sample and toexamine the frequency and extent of participants’ impairments inthe Body functions and structures, Activities and participation andEnvironmental factors components. In order to perform thesedescriptive statistics some qualifiers were recoded. The ICFqualifier ‘‘9 – not applicable’’ was recoded to ‘‘0 – noimpairment’’, whereas the response option ‘‘8 – not specified’’was treated as missing. As considered by previous authors,categories with frequencies below 30% were considered notrelevant, above 30% were considered relevant and above 70% asthe most relevant [9–11].

To investigate the differences in the frequency of theimpairments among participants at different COPD grades, theChi-square test was performed since it is the statistical test used toinvestigate whether distributions of categorical variables differfrom one another [12]. When a statistically significant differencewas found, chi-square multiple comparison tests with Bonferronicorrection were performed to explore which COPD grades differ

2 C. Jacome et al. Disabil Rehabil, Early Online: 1–12

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from each other. To investigate the differences in the extent ofthe impairments among the four COPD grades and since thequalifiers of the ICF are defined in an ordinal scale, the Kruskal–Wallis test was used. When a statistically significant differencewas found, multiple comparison tests were performed. The levelof significance considered was 0.05. Statistical analyses wereperformed using PASW Statistics (Predictive Analytics Software)version 18.0 for Windows (SPSS Inc., Chicago, IL).

Results

Sample characterisation

A total of 128 patients were approached for inclusion in the study,however, seven did not want to participate and two did notcomplete the assessment. Therefore, 119 participants (71.43%male; age, 68.71� 11.61 years old) were included in the study.Most participants were married (n¼ 95; 79.83%) and werecurrently retired (n¼ 96; 80.67%). Their mean FEV1 percentagepredicted was 57.33� 22.22 (ranged from 16 to 99) and meanFVC percentage predicted was 69.82� 20.21 (ranged from 22 to119). Twenty-six (21.80%) participants were current smokers and14 (11.80%) were on long-term oxygen therapy. According to theGOLD criteria, 70 participants had COPD at earlier grades(GOLD 1 and 2) and 49 at advanced grades (GOLD 3 and 4). Itwas verified that participants at advanced COPD were older thanthose at earlier grades. Table 1 describes the socio-demographicand clinical characteristics of the sample.

Body functions

Table 2 presents the frequency and extent of the participants’impairments in the Body functions component. Seventeen(89.47%) of the 19 categories included in the body functionscomponent of the Comprehensive Core Set for OPD were relevantimpairments for the participants studied. The most frequentimpairments (frequency above 70%) were related to the sensationsassociated with cardiovascular and respiratory functions (n¼ 111,93.28%) and to exercise tolerance (n¼ 111; 93.28%), respiratorymuscle (n¼ 97; 81.51%), respiration (n¼ 90; 75.63%) andemotional functions (n¼ 90; 75.63%). On the other hand, thefunctions of voice and of the haematological system were thecategories considered less frequently impaired (frequency below30%). The extent of the impairments is shown in Table 2. Exercisetolerance functions and sensations associated with cardiovascularwere those rated with more severity (median 3).

When the four grades of COPD were compared (Table 2), itwas observed that both frequency and extent of the impairmentswere similar among the different COPD grades. However,exceptions were identified for the sensations associated withcardiovascular and respiratory systems functions and for theexercise tolerance, respiratory muscle and respiration functions,where both frequency and extent increased from GOLD 1 toGOLD 4. Regarding the frequency, it was verified thatimpairments in respiratory muscle functions were significantlyless frequent in participants at GOLD 1 (p¼ 0.001) and thatimpairments in muscle power and muscle endurance werereported significantly more often by participants at advancedgrades (p¼ 0.001 and 0.002). In relation to the extent, impair-ments in sensations associated with cardiovascular and respiratorysystems functions and in exercise tolerance and respiratorymuscle functions were significantly more severe at advancedgrades than at earlier grades (p¼ 0.006, 0.001 and 0.001,respectively).

Body structures

Table 3 presents the frequency and extent of the participants’impairments in the Body structures component. Two categories(40%) of the five included in the Body structures component ofthe Comprehensive Core Set for OPD were relevant impairmentsfor the participants studied. All participants presented impair-ments in the respiratory system structure and more than half(n¼ 66; 55.46%) in the cardiovascular system structure.Impairments in the structures of the trunk (n¼ 26; 21.85%),head/neck (n¼ 22; 18.49%) and shoulder (n¼ 12; 10.08%) wereless frequent in this sample of patients with COPD. There was noobvious difference in the frequency of impairments in this ICFcomponent among the four grades of COPD. However, in relationto the extent of the impairments, participants at GOLD 3 and 4had significantly more severe impairments in the respiratorysystem structure, than participants at GOLD 1 and 2 (p¼ 0.001).

Activities and participation

The frequency and extent of difficulties reported in the Activitiesand participation component are presented in Table 4. Nineteen(79.17%) of the 24 categories included in this ICF component ofthe Comprehensive Core Set for OPD were relevant for theparticipants studied. The most frequent limitations were movingaround (n¼ 106; 89.08%), which was also the difficultyexperienced with more severity (median 3), moving around indifferent locations (n¼ 97; 81.51%) and acquiring goods andservices (n¼ 85; 71.43%). More than half of the participants alsoreported difficulties in recreation and leisure (n¼ 75; 63.03%),doing housework (n¼ 71; 59.66%), dressing (n¼ 68; 57.14%),caring for household objects (n¼ 64; 53.78%) and usingtransportation (n¼ 60; 50.42%).

When the frequency and extent of the difficulties among thedifferent grades of COPD were analysed (Table 4), it wasobserved that both increased from GOLD 1 to GOLD 4 in thedifficulties related to the ICF chapters d2 general tasks anddemands (d230, d240), d4 mobility (d455, d460, d450, d430,d410, d475, d4750), d5 self-care (d540 and d510), d6 domesticlife (d650) and d9 community, social and civic life (d910 andd920). Statistically significant differences in the frequency werefound in all these categories, with the exception of d230, d455and d460. However, in relation to the extent, statisticallysignificant differences were found just in the categories d230and d455.

Difficulties related to assisting others, speaking, remunerativeemployment, moving around using equipment and acquiring,keeping and terminating a job were less frequent in the sample

Table 1. Socio-demographic and clinical characteristics of theparticipants (n¼ 119).

Characteristics

Age, M� SD (range) 68.71� 11.61 (42–93)Male, n (%) 85 (71.43%)Marital status, n (%)

Single 6 (5%)Married 95 (79.80%)Separated/divorced 4 (3.40%)Widowed 14 (11.80%)

Current occupation, n (%)Employed 17 (14.29%)Unemployed 6 (5.04%)Retired 96 (80.67%)

BMI, M� SD (range) 27.23� 4.78 (16.33–39.81)GOLD classification, n (%)

GOLD 1 25 (21%)GOLD 2 45 (37.80%)GOLD 3 30 (25.20%)GOLD 4 19 (16%)

DOI: 10.3109/09638288.2012.745625 COPD functioning: implications for rehabilitation 3

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4 C. Jacome et al. Disabil Rehabil, Early Online: 1–12

Dis

abil

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from

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.com

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193.

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(%)

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QR

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00

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2]

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8

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wit

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uen

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or

over

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%ar

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atis

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ific

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are

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inb

old

and

iden

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*(a¼

0.0

5).

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;IQ

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[p2

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equ

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ces

inth

eex

ten

to

fim

pai

rmen

tsam

on

gC

OP

Dg

rad

es.

DOI: 10.3109/09638288.2012.745625 COPD functioning: implications for rehabilitation 5

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

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care

.com

by

193.

137.

168.

215

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1/08

/13

For

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[0,

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0.5

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Cat

ego

ries

wit

ha

freq

uen

cyeq

ual

or

over

70

%ar

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igh

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dan

dst

atis

tica

lsi

gn

ific

ant

val

ues

are

sig

ned

inb

old

and

iden

tifi

edw

ith

*(a¼

0.0

5).

M–

med

ian

;IQ

R–

inte

rqu

arti

lera

nge

[p2

5,

p7

5].

aD

iffe

ren

ces

inth

efr

equ

ency

of

imp

airm

ents

amo

ng

CO

PD

gra

des

.bD

iffe

ren

ces

inth

eex

ten

to

fim

pai

rmen

tsam

on

gC

OP

Dg

rad

es.

6 C. Jacome et al. Disabil Rehabil, Early Online: 1–12

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

193.

137.

168.

215

on 0

1/08

/13

For

pers

onal

use

onl

y.

studied. Nevertheless, when the frequency of these impairmentsamong COPD grades were analysed, it was observed that bothassisting others and speaking were significantly more frequentdifficulties for participants at GOLD 3 and 4 (p¼ 0.019 and0.003, respectively).

Environmental factors

Table 5 provides an overview of the frequency and extent of theEnvironmental factors perceived as facilitators or barriers. Twelve(52.17%) of the 23 categories of this component of theComprehensive Core Set for OPD were relevant for theparticipants studied. The Environmental factors most frequentlyunderstood as facilitators were immediate family (n¼ 112;94.12%), health professionals (n¼ 115; 96.64%) and theirindividual attitudes (n¼ 108; 90.76%), products or substancesfor personal consumption (n¼ 110; 92.44%) and products andtechnology for personal use in daily living (n¼ 86; 72.27%).These were also considered as the most substantial facilitators.The environmental factors considered more frequently as a barrierand also as the most severe barriers were the climate (n¼ 100;84.03%) and the air quality (n¼ 92; 77.31%). The frequency ofthe Environmental factors considered as facilitators or barrierswere similar among participants at different grades of the disease,with the exception of day/night cycles, that was considered morefrequent as a barrier by patients at GOLD 4 than patients atGOLD 1 (p¼ 0.035). Regarding the differences in the extent ofthe Environmental factors among the grades, it was observed thatpatients at GOLD 4 considered day/night cycles significantlymore severe barriers (p¼ 0.044) and health services, systems andpolicies more important facilitators (p¼ 0.004) than patients atGOLD 1.

Discussion

In this cross-sectional study, the majority of the categories of theComprehensive ICF Core Set for OPD were considered asrelevant impairments for the participants studied. Therefore, thisCore Set allowed the description of the typical spectrum ofimpairments of the participants’ functioning.

Body functions

In general, the impairments in this ICF component were similaramong the four grades of COPD. These results are consistent withrecent literature, which have shown that the airflow limitation hasa weak correlation with the patients’ health status [13].Nevertheless, the impairments of functions, such as exercisetolerance and respiration, were found to increase from GOLD 1 toGOLD 4. Thus, to manage these specific impairments in patientswith COPD, the GOLD classification system should be taken intoaccount.

Exercise tolerance functions and sensations associated withcardiovascular and respiratory functions, often referred in theliterature as fatigue and dyspnoea, were found to be the mostsevere impairments and associated with the grade of COPD.These impairments are extremely common in patients with COPDand recent evidence have shown that patients at advanced gradesreport more dyspnoea than those at earlier grades [14–16]. Theimpairments on respiratory muscle functions and respirationfunctions are well-described in the literature and are oftenassessed in patients with COPD [17,18]. Specifically, impair-ments in respiratory muscle functions were more frequent inparticipants at moderate to very severe COPD. This result is inline with the study by Terzano et al., where it was found thatairway obstruction is associated with decreased respiratorypressures in patients with COPD [18]. Impairments in muscle

power and muscle endurance functions also allowed to distinguishCOPD grades. In a study by Seymour et al., which aimed toquantify the weakness of quadriceps in COPD, it was found thatthe highest weakness was observed in participants at GOLD 4[19]. These data emphasises that pulmonary rehabilitationinterventions, a recommended standard care for patients withCOPD, combining exercise training (endurance and strengthtraining) with respiratory physiotherapy (airway clearance andrespiratory re-education), should be available for patients withCOPD [20]. These interventions should also include respiratorymuscle training, since it seems to be a strategy to manage therespiratory dysfunction observed in this population [21]. Thisreinforces the idea that pulmonary rehabilitation, if followed asrecommended by the European Respiratory Society and AmericanThoracic Society, is organised and structured to address the mainbody functions impairments of patients with COPD [20].

Emotional impairments, often referred as anxiety and depres-sion, were also the most frequent and are highly associated withCOPD [22]. This result showed that it is imperative to investigatethe effect of psycho-education sessions with a greater supportivecomponent, since they may increase patient’s instrumental andemotional coping abilities to manage the disease’s demands. Inother chronic diseases, such as cancer and chronic liver diseases,evidence revealed that these interventions had a significant effecton improving patients’ emotional function [23,24].

Impairments in the voice functions and in the haematologicalsystem functions have been described as a less relevant problemfor patients with COPD [17,25,26]. Therefore, it is important toconsider these functions in the first assessment of the health ofpatients with COPD, however, they may not be a priority in therehabilitation interventions plan for this population [10].

Body structures

The impairments in the Body structures were similar among thefour grades of COPD. These results, together with those found inthe Body functions component, strengthen the findings fromrecent research, which have been advocating that the grade of theairflow limitation is not directly related to the severity of thedisease [13]. In this ICF component, only the impairments of thecardiovascular and respiratory systems structures were consideredrelevant. As expected by the progressive nature of COPD, theextent of the impairment in the respiratory system structure wasdifferent between earlier and advanced grades [2,27]. More thanhalf of the participants had impairments in the cardiovascularsystem structure. This prevalence is above to the one found byEwert et al. [17] (35.6%). However, this result reflects that theairflow obstruction and the systemic inflammation present inCOPD are significant risk factors for cardiovascular diseases[28,29]. From these results, it can be established that the presenceof cardiovascular disease in patients with COPD has to becarefully considered when planning interventions based inexercise training, particularly endurance training. To answer thisconcern, it may be imperative to assess the safety of the exercisetraining in these patients with a maximal cardiopulmonaryexercise test as it has been recommended [20].

Impairments in the trunk, head/neck and shoulder structureshad a low frequency in the participants studied, which is in linewith previous literature [17]. Nevertheless, it is essential to assessthese structures in this population, since they can be associatedwith the respiratory dysfunction [5].

Activities and participation

In contrast with the components discussed above, in the Activitiesand participation component, it was found that the majority of therestrictions assessed were associated with the grade of the

DOI: 10.3109/09638288.2012.745625 COPD functioning: implications for rehabilitation 7

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DOI: 10.3109/09638288.2012.745625 COPD functioning: implications for rehabilitation 9

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patients’ airflow limitation. Participants’ most relevant limitationswere related to the mobility and were at advanced grades thatthese limitations were experienced as more severe [30,31].Acquisition of goods and services was also one of the mostrelevant limitations reported. In the study by Ewert et al., thisproblem was also one of the most prevalent [17].

Other restrictions on mobility and domestic life and related tothe participation in the community, social and civic life, self-careand general tasks and demands were important for the samplestudied, particularly at advanced grades. These results areconsistent with the well-known spectrum of restrictions ofpatients with COPD [17,32,33]. This may be explained by thefact that at advanced grades the symptoms are experienced moreseverely, and therefore, patients’ performance is probablymore affected. Also, difficulties in speaking were significantlymore frequent for participants at advanced grades, which may beexplained by the severity of their symptoms, especially dyspnoea.Therefore, assessing speech difficulties may be important insymptomatic patients. Since the majority of participants wereretired, restrictions on work and employment activities wereexpected to be less relevant. However, these restrictions are ofvaluable interest in patients with COPD at working-ages.

One of the major goals of rehabilitation is to overcomepatients’ participation restrictions. The Activities and participa-tion component of the ICF assesses the experience of patients indifferent life domains. However, this ICF component is notroutinely used as an outcome measure in rehabilitation [4,5].Therefore, assessing the most relevant participation restrictions inpatients with COPD would be undoubtedly relevant to ensure thatrehabilitation interventions effectively improve patients’ involve-ment in their life situations.

Environmental factors

The facilitation role of immediate family has been observed inother studies about COPD [34] and other chronic diseases [35].Hence, these results highlight the relevance of supporting thefamily members of patients with COPD, as they are substantialfacilitators of their lives. Health professionals and their attitudeswere reported as facilitators. However, in other studies involvingpatients with COPD, the relationship with health professionalswas ambivalent, since it was seen as a facilitator but also as abarrier, specifically in sharing information and in surveillance role

[36,37]. Products for personal consumption, where medicationand inhaler devices are included, and technology for personal usein daily living were also perceived as facilitators. Grill et al., in astudy including inpatients with cardiopulmonary conditions alsofound that these environmental factors were considered as themost relevant [10]. These results demonstrated the relevance ofassessing regularly the need and the adaptability of the productsfor personal consumption and of the technology for personal usein daily living in this population.

Climate and air quality were seen as severe barriers. Ewertet al. have also found climate to be the most frequent barrier forpatients with COPD [17]. In relation to air quality, it was expectedsince a number of studies have been shown that there is arelationship between air pollution and respiratory diseasesmorbidity [38].

The perspective about the majority of the Environmentalfactors was similar among participants at different grades of thedisease, which might indicate that contextual factors are perceivedin a similar way. Nevertheless, day/night cycles, were consideredmore often as a severe barrier by participants at GOLD 4.A number of studies demonstrated that early morning is the worsttime of day, particularly in patients with severe COPD [34,39,40].Thus, early morning rehabilitation interventions for patients withCOPD should be considered with caution. Conversely, healthservices, systems and policies were seen as more importantfacilitators to participants at GOLD 4, which might emphasise theimportance of health services, especially for patients who needmore integrated care due the complexity of their symptoms.Therefore, health services, systems and policies should bedesigned to address the needs of patients with COPD. A summaryof the recommendations for the COPD rehabilitation based on theICF are shown in Table 6.

Limitations

Limitations of the present study were (i) the relatively smallconvenience sample used and (ii) the inclusion of mainly olderpatients with COPD. A larger sample size, including a higherproportion of patients with COPD at middle-age, would be morerepresentative of the general population with COPD and wouldallow the establishment of stronger recommendations for theCOPD rehabilitation. Another limitation is that only Portuguesepatients were included. Patients in other countries or cultures may

Table 6. Summary of the recommendations for the COPD rehabilitation based on the ICF.

ICF Components Recommendations

Body functions g Pulmonary rehabilitation interventions, combining exercise training with respiratory physiotherapy, should beavailable for patients with COPD.

g Respiratory muscle training should be offered for patients with respiratory dysfunction.g A greater supportive component should be incorporated in the psycho-education sessions designed for patients

with COPD.

Body structures g The safety of the exercise training in patients with COPD should be assessed through a maximalcardiopulmonary exercise test.

g Impairments in the trunk, head/neck and shoulder structures should be assessed since they are related to therespiratory dysfunction.

Activities and participation g The most relevant participation restrictions in patients with COPD should be used to evaluate the effectivenessof rehabilitation interventions.

g Speech difficulties should be evaluated in symptomatic patients.g Restrictions on work and employment activities should be considered in patients with COPD at working-ages.

Environmental factors g Psycho-education should be offered to family members of patients with COPD.g The need and the adaptability of the products for personal consumption and of the technology for personal use in

daily living should be regularly assessed.g Early morning rehabilitation interventions for patients with COPD should be considered with caution.g Health services, systems and policies should be designed to address the needs of patients with COPD.

10 C. Jacome et al. Disabil Rehabil, Early Online: 1–12

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experience impairments with different frequencies and extents.However, as the ICF framework was used, this study may be usedto compare results among different countries and informrehabilitation recommendations in a common health language ineach country and across countries. Also, the absence of a validoperationalisation of the ICF categories, which introduce asubjective component in the application of the ComprehensiveICF Core Set for OPD, potentially introduced some bias in theresults of the study. However, correspondence intervals withqualifiers and control questions to evaluate the extent of theimpairment were developed before data collection to overcomesome of these difficulties. In addition, during data collection allinterviews were conducted by the same person. It is believed thatthese procedures have reduced the impact of any potential bias ofthe results.

Conclusion

This study comprehensively characterised the functioning andhealth of patients with COPD using the ICF framework. Differentinformation about COPD daily life was therefore, integratedwhich is not considered in other assessment instruments. Ingeneral, functioning of patients at different grades of COPD wasfound to be similar and therefore, recommendations are advisedfor patients at earlier and advanced grades. However, this studyalso confirmed that the grade of airflow limitation is significantlyassociated with the presence/severity of some specific impair-ments, which supports the importance of using the GOLDclassification system. Hence, this study allowed the description ofrecommendations with a worldwide common language to developcomprehensive rehabilitation interventions for patients withCOPD. In the future, it would be of valuable interest to comparethese results with other studies involving different samples, indifferent countries and also to examine the applicability of theICF Core Set for OPD during the rehabilitation process.

Acknowledgements

The authors would like to acknowledge all institutions involved and allpatients for their participation in this research.

Declaration of interest

The authors report no declarations of interest. This work was funded byPortuguese National Funds through FCT – Foundation for Science andTechnology in the context of the project RIPD/CIF/109502/2009.

References

1. World Health Organization. Global surveillance, prevention andcontrol of chronic respiratory diseases: a comprehensive approach.Geneva: World Health Organization; 2007.

2. The Global Initiative for Chronic Obstructive Lung Disease(GOLD). Global Strategy for Diagnosis, Management, andPrevention of Chronic Obstructive Pulmonary Disease. 2011.Available from: http://www.goldcopd.org [last accessed 20 Nov2012].

3. National Clinical Guideline Centre. Chronic obstructive pulmonarydisease: management of chronic obstructive pulmonary disease inadults in primary and secondary care. London: National ClinicalGuideline Centre; 2010.

4. Stucki G, Ewert T, Cieza A. Value and application of the ICF inrehabilitation medicine. Disabil Rehabil 2003;25:628–34.

5. World Health Organization. International classification of function-ing, disability and health: ICF. Geneva: World Health Organization;2001.

6. Cieza A, Ewert T, Ustun TBU, et al. Development of ICFCore Sets for patients with chronic conditions. J Rehabil Med2004;44:9–11.

7. Stucki A, Stoll T, Cieza A, et al. ICF Core Sets for obstructivepulmonary diseases. J Rehabil Med 2004;36:114–20.

8. Podsiadlo D, Richardson S. The timed ‘‘up and go’’: a test of basicfunctional mobility for frail elderly persons. J Am Geriat Soc1991;39:142–8.

9. Stier-Jarmer M, Grill E, Muller M, et al. Validation of thecomprehensive ICF Core Set for patients in geriatric post-acuterehabilitation facilities. J Rehabil Med 2011;43:113–22.

10. Grill E, Huber EO, Stucki G, et al. Identification of relevant ICFcategories by patients in the acute hospital. Disabil Rehabil2005;27:447–58.

11. Bautz-Holter E, Sveen U, Cieza A, et al. Does the InternationalClassification of Functioning, Disability and Health (ICF) core setfor low back pain cover the patients’ problems? A cross-sectionalcontent-validity study with a Norwegian population. Eur J PhysRehabil Med 2008;44:387–97.

12. Katz MH. Study design and statistical analysis – a practical guide forclinicians. New York: Cambridge University Press; 2006.

13. Jones PW. Health status and the spiral of decline. COPD J ChronObstruct Pulmon Dis 2009;6:59–63.

14. Bourbeau J. Activities of life: the COPD patient. COPD J ChronObstruct Pulmon Dis 2009;6:192–200.

15. Theander K, Unosson M. Fatigue in patients with chronicobstructive pulmonary disease. J Adv Nurs 2004;45:172–7.

16. Mahler DA, Ward J, Waterman LA, et al. Patient-reported dyspneain COPD reliability and association with stage of disease. Chest2009;136:1473–9.

17. Ewert T, Fuessl M, Cieza A, et al. Identification of the mostcommon patient problems in patients with chronic conditions usingthe ICF checklist. J Rehabil Med 2004;44:22–9.

18. Terzano C, Ceccarelli D, Conti V, et al. Maximal respiratory staticpressures in patients with different stages of COPD severity. RespirRes 2008;9:1–7.

19. Seymour JM, Spruit MA, Hopkinson NS, et al. The prevalence ofquadriceps weakness in COPD and the relationship with diseaseseverity. Eur Respir J 2010;36:81–8.

20. Nici L, Donner C, Wouters E, et al. American thoracic society/European respiratory society statement on pulmonary rehabilitation.Am J Respir Crit Care Med 2006;173:1390–413.

21. Lotters F, van Tol B, Kwakkel G, Gosselink R. Effects of controlledinspiratory muscle training in patients with COPD: a meta-analysis.Eur Respir J 2002;20:570–7.

22. Maurer J, Rebbapragada V, Borson S, et al. Anxiety and depressionin COPD. Chest 2008;134:43S–56S.

23. Okamura H, Fukui S, Nagasaka Y, et al. Psychoeducationalintervention for patients with primary breast cancer and patientsatisfaction with information: an exploratory analysis. Breast CancerRes Treatment 2003;80:331–8.

24. Sharif F, Mohebbi S, Tabatabaee H-R, et al. Effects of psycho-educational intervention on health-related quality of life (QOL) ofpatients with chronic liver disease referring to Shiraz University ofMedical Sciences. Health Qual Life Outcomes 2005;3:1–6.

25. Lotvall J, Bakke PS, Bjermer L, et al. Efficacy and safety of 4weeks’ treatment with combined fluticasone furoate/vilanterol in asingle inhaler given once daily in COPD: a placebo-controlledrandomised trial. BMJ Open 2012;2:1–11.

26. Man SFP, Sin DD. Inhaled corticosteroids in chronicobstructive pulmonary disease: is there a clinical benefit? Drugs2005;65:579–91.

27. Celli BR, MacNee W, Agusti A, et al. Standards for the diagnosisand treatment of patients with COPD: a summary of the ATS/ERSposition paper. Eur Respir J 2004;23:932–46.

28. Sin DD, Man SFP. Why are patients with chronic obstructivepulmonary disease at increased risk of cardiovascular diseases?: thepotential role of systemic inflammation in chronic obstructivepulmonary disease. Circulation 2003;107:1514–19.

29. Wouters EFM, Celis MPM, Breyer MK, et al. Co-morbidmanifestations in COPD. Respir Med COPD Update 2007;3:135–51.

30. Ergun P, Kaymaz D, Gunay E, et al. Comprehensive out-patientpulmonary rehabilitation: treatment outcomes in early and latestages of chronic obstructive pulmonary disease. Ann Thoracic Med2011;6:70–6.

31. Spruit MA, Watkins ML, Edwards LD, et al. Determinants of poor6-min walking distance in patients with COPD: the ECLIPSEcohort. Respir Med 2010;104:849–57.

32. Lahaije A, van Helvoort HAC, Dekhuijzen PNR, Heijdra YF.Physiologic limitations during daily life activities in COPD patients.Respir Med 2010;104:1152–9.

DOI: 10.3109/09638288.2012.745625 COPD functioning: implications for rehabilitation 11

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

193.

137.

168.

215

on 0

1/08

/13

For

pers

onal

use

onl

y.

33. Gullick J, Stainton MC. Living with chronic obstructive pulmonarydisease: developing conscious body management in a shrinking life-world. J Adv Nurs 2008;64:605–14.

34. Kanervisto M, Kaistila T, Paavilainen E. Severe chronic obstructivepulmonary disease in a family’s everyday life in Finland: perceptionsof people with chronic obstructive pulmonary disease and theirspouses. Nurs Health Sci 2007;9:40–7.

35. Kong E-H. Family caregivers of older people in nursing homes.Asian Nurs Res 2008;2:195–207.

36. Gysels M, Higginson IJ. The experience of breathlessness: the socialcourse of chronic obstructive pulmonary disease. J Pain SymptomManage 2010;39:555–63.

37. Seamark DA, Blake SD, Seamark CJ, Halpin DM. Living withsevere chronic obstructive pulmonary disease (COPD): perceptionsof patients and their carers. Palliat Med 2004;18:619–25.

38. Sauerzapf V, Jones AP, Cross J. Environmental factors andhospitalisation for chronic obstructive pulmonary disease in arural county of England. J Epidemiol Community Health 2009;63:324–8.

39. Partridge MR, Karlsson N, Small IR. Patient insight into the impactof chronic obstructive pulmonary disease in the morning: an internetsurvey. Curr Med Res Opin 2009;25:2043–8.

40. Barnett M. Chronic obstructive pulmonary disease: a phenomen-ological study of patients’ experiences. J Clin Nurs 2005;14:805–12.

12 C. Jacome et al. Disabil Rehabil, Early Online: 1–12

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

193.

137.

168.

215

on 0

1/08

/13

For

pers

onal

use

onl

y.