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Morning symptoms and physical activity

Association between Morning Symptoms and Physical Activity in COPD: a systematic review.

van Buul et al. - Eur Respir Rev. 2017

  • Morning symptoms are common in COPD. Many COPD patients consider the morning as the most troublesome part of the day, in which they experience more symptoms and physical activity limitations.
  • Despite the large impact of morning symptoms on activities and quality of life, morning symptoms are not a focus of current treatment guidelines and have not been mentioned in the official European Respiratory Society Statement on physical activity in COPD.
  • This literature review aims to further investigate the impact of morning symptoms on COPD patients and especially on physical activity.
  • This publication is the result of an electronic literature search in PubMed, Embase, Web of Science, Cochrane, CINAHL and PsycINFO. The search was performed on October 27th, 2015. There was no limitation on the date of publication.
  • All types of COPD studies were included, except meeting abstracts, reviews and articles from non-peer-reviewed journals. Studies were excluded when the predefined outcomes did not comprise either morning symptoms or physical activity. The quality of the studies was evaluated using the STROBE and CONSORT checklist.
  • The search identified 390 articles. After removing duplicates, 195 individual articles remained. After screening titles, 117 articles were considered relevant. After reading abstracts, 32 articles remained. After full read, 24 articles were excluded. 8 remaining studies were included in the systematic review.

Morning symptoms

  • When analysing all COPD patients, the percentage of morning symptoms varied between 39.8 and 94.4%. The most common morning symptoms were cough, sputum production and shortness of breath. In symptomatic severe and very severe COPD patients, it was found that the morning was the worst time of the day for the symptom sputum production (in 70.9-87.2%), for cough (in 60.1-72.6%) and for shortness of breath (in 45.4-85.1%).
  • Morning symptoms could be detected across all stages of disease. Mostly, patients do not experience solely morning symptoms, but might experience daytime and night-time problems as well.

Association between morning symptoms and physical activity

  • All studies showed that COPD patients who experience morning symptoms also report a negative impact on physical activity. When analysing all COPD patients, 37-90.6% of patients experienced physical activity limitations that were associated with morning symptoms.
  • Most mentioned limited activities were getting up, taking a shower and dressing. Half of the patients reported to have made changes to their morning routines because of morning symptoms. Patients’ core coping strategies were doing things slowly and taking more breaks.

Treatment to improve activity limitations that are associated with morning symptoms

  • It was found that improvement in the ability to perform morning activities is one of the patient’s expectations of treatment. Nevertheless, patients reported that physicians were unlikely to ask about morning symptoms and the ability to perform morning activities.
  • In a pooled analysis study, there was a significant improvement of early morning symptom severity after treatment with the fixed combination aclidinium/formoterol versus mono-components. In the same study, the fixed combination of aclidinium and formoterol significantly improved limitation of early-morning activities due to morning symptoms when compared with aclidinium and formoterol alone (p<0.05).
  • Across all disease stages, COPD patients experience morning symptoms that are negatively associated with physical activity.
  • This suggests that physicians should include the evaluation of morning symptoms in their clinical assessment and they should include the control of morning symptoms as a goal of treatment.

van Buul et al., Eur Respir Rev. 2017; 26: 160033. Doi: 10.1183/16000617.0033-2016

NS Approval ID XL-1013-RD05/2017-WEB