1. Why anxiety associates with non-completion of pulmonary rehabilitation program in patients with COPD?
Dr Abebaw Mengistu Yohannes
Associate Professor in Physiotherapy
Manchester Metropolitan University

2. Anxiety in COPD
The prevalence of anxiety symptoms that interferes in daily activities ranges from 8% to 64 % in patients with COPD.
Anxious patients are most likely to exhibit elevated fear of engaging in exercise program, poor compliance to medical treatment and poorer quality of life compared to non-anxious patients.
(Maurer et al., 2008; Yohannes, et al 2010)

3. Aims of the study
Recently, we have designed a disease-specific anxiety scale that measures anxiety in patients with chronic obstructive pulmonary disease (COPD).
We examined whether the Anxiety Inventory for Respiratory disease (AIR) is a predictor of non-completion of eight-week pulmonary rehabilitation (PR) programme.

4. Ten Items of the AIR scale
Not at all
Occasionally
Frequently
Almost all of the time
Score
I have had worrying thoughts going through my mind
I have felt very frightened or panicky
I have felt worked up and/ or upset
I have had a fear of losing control and/or falling apart
I have worried about experiencing panic
I have found it hard to relax
I have had sudden and intense feelings of fear and/or panic
I have felt generally anxious
I have felt nervous or on-edge
I have had thought that something bad might happen

5. Content of the Pulmonary rehabilitation
192 COPD patients participated in eight weeks pulmonary rehabilitation (PR) programme.
The PR programme is once a week for two hours, which (combined of circuit aerobic exercise therapy and muscle strengthening exercises )
The educational component of the programme consist of nutrition, relaxation therapy, managing inhalers etc.

6. Outcome measures Anxiety Inventory for Respiratory Disease.
St-Georges Respiratory Questionnaire.
Medical Research Council dyspnoea scale.
Incremental Shuttle Walk Test.
Completion defined as attending 75% of the designated PR schedules and completed the eight weeks evaluation.
(Willgoss et al., 2013; Singh et al., 1992; Jones et al., 1991; Fletcher et al., 1959)

7. Data analysis
Descriptive statistics was used where appropriate e.g. mean, median etc.
Relationship between anxiety, exercise capacity, quality of life was examined using the Pearson Correlation test.
Differences between completers and non-completers was assessed using related t-test.
Logistic regression analysis was used to determine factors related to non-completion of PR.
Significance was set at p < 0.05.

8. Baseline difference between completers and non-completers
Table
Baseline differences between completers versus non-completers of PR program in patients with COPD Mean (SD)
Baseline difference between completers and non-completers
Characteristics
Completers
(n= 192)
Non-completers (n- 65)
t-value
p-value
Age (years)
71.1 (8.51)
69.42 (9.86)
1.32
0.18
FEV1(% predicted)
56.91 (15.16)
55.68 (14.48)
0.49
0.62
FEV1/FVC
45.91 (20.16)
44.71 (14.29)
0.48
0.64
SGRQ total score
51.22 (19.06)
41.63 (19.81)
1.78
0.07
AIR score
5.36 (5.37)
8.05 (7.13)
3.19
0.002
ISWT
(127.38)
(117.53)
2.01
0.04
MRC dyspnea
2.79 (1.12)
3.12 (1.24)
1.96
0.05
Characteristics
Completers (n= 192)
Non-completers (n- 65)
t-value
p-value
Age (years)
71.1 (8.51)
69.42 (9.86)
1.32
0.18
FEV1(% predicted)
56.91 (15.16)
55.68 (14.48)
0.49
0.62
FEV1/FVC
45.91 (20.16)
44.71 (14.29)
0.48
0.64
Sex (%)
Male
Female
48.95
51.05
52.31
47.69
χ2= 0.67
0.37
AIR score
5.36 (5.37)
8.05 (7.13)
3.19
< 0.002
ISWT
(127.38)
(117.53)
2.01
0.04
MRC dyspnea
2.79 (1.12)
3.12 (1.24)
1.96
0.05

9. Non-completion rate of Pulmonary Rehabilitation
25% of patients did not complete the eight weeks PR program.
Anxiety was associated with odds ratio (95% CI) 0.93 (0.89 – 0.97), p <

10. The responsiveness of the AIR scale
COPD patients; Mean age 72 years
Variable
Mean Pre versus Post
P-value
AIR
5.13 vs. 3.26
p < 0.001
ISWT
202 vs. 267
SGRQ
52.97 vs
p< 0.001
MRC
2.97 vs 2.78
p = 0.05

11. Conclusion
Pulmonary rehabilitation improves exercise capacity, quality of life and reduce anxiety symptoms.
Patients with COPD with high load of anxiety symptoms are less likely to complete the PR program.
Patients with high load of anxiety symptoms may benefit with additional practical support that may include psychological therapy to complete PR.