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      Evidence for cognitive–behavioral strategies improving dyspnea and related distress in COPD

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          Dyspnea is a complex, prevalent, and distressing symptom of chronic obstructive pulmonary disease (COPD) associated with decreased quality of life, significant disability, and increased mortality. It is a major reason for referral to pulmonary rehabilitation.


          We reviewed 23 COPD studies to examine the evidence for the effectiveness of cognitive–behavioral strategies for relieving dyspnea in COPD.


          Preliminary evidence from randomized controlled trials exists to support cognitive– behavioral strategies, used with or without exercise, for relieving sensory and affective components of dyspnea in COPD. Small to moderate treatment effects for relieving dyspnea were noted for psychotherapy (effect size [ES] = 0.08–0.25 for intensity; 0.26–0.65 for mastery) and distractive auditory stimuli (ES = 0.08–0.33 for intensity; 0.09 to −0.61 for functional burden). Small to large dyspnea improvements resulted from yoga (ES = 0.2–1.21 for intensity; 0.67 for distress; 0.07 for mastery; and −8.37 for functional burden); dyspnea self-management education with exercise (ES = −0.14 to −1.15 for intensity; −0.62 to −0.69 for distress; 1.04 for mastery; 0.14–0.35 for self-efficacy); and slow-breathing exercises (ES = −0.34 to −0.83 for intensity; −0.61 to −0.80 for distress; and 0.62 for self-efficacy). Cognitive–behavioral interventions may relieve dyspnea in COPD by (1) decreasing sympathetic nerve activity, dynamic hyperinflation, and comorbid anxiety, and (2) promoting arterial oxygen saturation, myelinated vagus nerve activity, a greater exercise training effect, and neuroplasticity.


          While evidence is increasing, additional randomized controlled trials are needed to evaluate the effectiveness of psychosocial and self-management interventions in relieving dyspnea, in order to make them more available to patients and to endorse them in official COPD, dyspnea, and pulmonary rehabilitation practice guidelines. By relieving dyspnea and related anxiety, such interventions may promote adherence to exercise programs and adaptive lifestyle change.

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          Most cited references 65

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          Measurement of health status. Ascertaining the minimal clinically important difference.

          In recent years quality of life instruments have been featured as primary outcomes in many randomized trials. One of the challenges facing the investigator using such measures is determining the significance of any differences observed, and communicating that significance to clinicians who will be applying the trial results. We have developed an approach to elucidating the significance of changes in score in quality of life instruments by comparing them to global ratings of change. Using this approach we have established a plausible range within which the minimal clinically important difference (MCID) falls. In three studies in which instruments measuring dyspnea, fatigue, and emotional function in patients with chronic heart and lung disease were applied the MCID was represented by mean change in score of approximately 0.5 per item, when responses were presented on a seven point Likert scale. Furthermore, we have established ranges for changes in questionnaire scores that correspond to moderate and large changes in the domains of interest. This information will be useful in interpreting questionnaire scores, both in individuals and in groups of patients participating in controlled trials, and in the planning of new trials.
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              Chronic disease self-management program: 2-year health status and health care utilization outcomes.

              To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization. Longitudinal design as follow-up to a randomized trial. Community. Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data. Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured. Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes. A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                25 September 2013
                : 8
                : 439-451
                [1 ]Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago (UIC), Chicago, IL, USA
                [2 ]Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago (UIC), Chicago, IL, USA
                [3 ]Rehabilitation Research and Development (RR&D), Edward Hines Jr. VA Hospital, Hines, IL, USA
                Author notes
                Correspondence: Anna Norweg, University of Illinois at Chicago (UIC), College of Applied Health Sciences, Department of Occupational Therapy, 1919 W Taylor Street, (329 AHSB), Chicago, IL 60612, USA, Email anorweg@
                © 2013 Norweg and Collins,, publisher and licensee Dove Medical Press Ltd

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.



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