A Comparison of the BODE Index and the GOLD Stage Classification of COPD Patients in the Evaluation of Physical Ability

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1 A Comparison of the BODE Index and the GOLD Stage Classification of COPD Patients in the Evaluation of Physical Ability J.Phys. Ther. Sci 23: , 2011 KUNIHIKO ANAMI MS, PT 1), JUN HORIE MS, PT 2,3), SYUICHI SHIRANITA PT 1), YUJIRO IMAIZUMI PT 4), KATSUAKI ICHIMARU PT 5), HIROYUKI NAOTSUKA PT 6), HOZUMI YAMADA PhD, MD 7), YOSHIYUKI KOGA PhD, MD 8), ETSUO HORIKAWA PhD 3) 1) Department of Rehabilitation, Keitendo Koga Hospital: Kamioda 1150, Kouhoku-cho, Kishima, Saga , Japan. TEL: , FAX: , 2) Department of Rehabilitation science, Nishikyushu University 3) Graduate School of Medicine, Saga University 4) Department of Rehabilitation, Saga Social Insurance Hospital 5) Department of Rehabilitation, Saga Prefectural Hospital Koseikan 6) Department of Rehabilitation, Saga University Hospital 7) Department of Respiratory Medicine, Keitendo Koga Hospital 8) Department of Surgical Medicine, Keitendo Koga Hospital Abstract. [Purpose] The aim of this cross-sectional study was to test whether the body mass index (BMI), airway obstruction, dyspnea, and exercise capacity (BODE) index is superior to the global initiative for chronic obstructive lung disease (GOLD) classification for physical ability, and to ascertain the usefulness of the BODE index in chronic obstructive pulmonary disease (COPD) patients. [Methods] We studied 48 patients with stable COPD (mean [±SD] age: 76.2±7.0 years). We measured BMI, modified medical research council (mmrc) dyspnea score, pulmonary function, muscle strength, timed up-and-go test (TUG), 6 minute walk distance (6MWD), and St. George s respiratory questionnaire (SGRQ). Comparisons of each measurement item in the BODE index quartile groups 1 2 and 3 4 were conducted for patients in GOLD Stages II and III. [Results] The mean total score for the BODE index was 3.9±2.9. The characteristics that showed a significant difference between the two groups were mmrc, %FVC, muscle strength, TUG and 6MWD. [Conclusions] This study showed that the GOLD classification assesses milder symptoms than the BODE index. The BODE index is as useful as the GOLD classification for physical ability, and also indicates comprehensive measures for COPD patients. Key words: BODE index, GOLD classification, Physical ability (This article was submitted Oct. 20, 2010, and was accepted Dec. 16, 2010) INTRODUCTION The need for pulmonary rehabilitation after chronic respiratory failure is increasing because of the increased number of patients with chronic obstructive pulmonary disease (COPD). According to the World Health Organization, COPD is currently ranked as the fourth cause of death and is predicted to be the third in 2010, after heart disease and cerebrovascular disorders 1). According to WHO guidelines, the GOLD stage, which enables classification of the severity based upon the forced vital capacity in 1.0 second (FEV 1.0 ) % of predicted measured by spirometry, has frequently been used. While it is known that there is a correlation between FEV 1.0 and prognosis 2), FEV 1.0 is simply one of many indices. It has also been reported that the inspiratory capacity (IC), exercise capacity, dyspnea score and body mass index (BMI) exhibit stronger correlations with prognosis 3 8). Recently, the BMI, airway obstruction, dyspnea score, and exercise capacity (BODE) index, which is an evaluation method considering the multidimensional symptoms of COPD, have been used 9). It has been reported that COPD can be evaluated as a multidimensional disease using the BODE index. Thus, the BODE index is more useful than an evaluation method that is only based on severity of ventilatory disorder in the prognostic evaluation of COPD patients 9 13). Previous studies have reported that the BODE index exhibits correlations with muscle strength, health-related QOL (HRQOL), and anxious and depressive symptoms 11,14 16). However, few studies have investigated physical ability using both the BODE index and the GOLD stage. The evaluation of physical ability is necessary for the

2 438 J. Phys. Ther. Sci. Vol. 23, No. 3, 2011 performance of safe and effective rehabilitation. The objective of this study was to compare the BODE index and the GOLD stage in the evaluation of physical ability of COPD patients. SUBJECTS AND METHODS Subjects The subjects were 48 stable COPD patients who were undergoing pulmonary rehabilitation. Patients with cerebrovascular disease, heart disease, orthopedic diseases, a medical history of severe complications, systemic symptoms, fever, dementia or patients from whom informed consent could not be obtained were excluded from this study. Methods Age, BMI, mmrc dyspnea score, pulmonary function (forced vital capacity (FVC), FEV 1.0 and FEV 1.0 / FVC (measured with Autospiro AS-507, Minato Science Co., Ltd.)) 17), quadriceps force (measured with μ-tus, Anima Corporation) 18), respiratory muscle strength (measured with Autospiro AS-507, Minato Science Co., Ltd.) 19), timed upand-go test (TUG) 20) and the 6 minute walking test (6MWT) 21), were measured and the HRQOL test was conducted using St. George s respiratory questionnaire (SGRQ) 22). Correlation analyses between the BODE index and the GOLD stage and the characteristics of each subject were conducted using Pearson s correlation coefficient. Cross tabulation of the subjects was conducted using the BODE index quartile and GOLD stage to compare each measurement item in the BODE index quartile groups 1 2 and 3 4 and in patients GOLD stages II and III using the t-test. The statistical significance level was chosen as 5% and the data are expressed as the mean±sd. SPSS Ver.17.0 was used for statistical analysis. This study was approved by the Ethical Committee of the Saga Medical School, Faculty of Medicine, Saga University. All of the subjects were informed of the purpose of the research and the therapeutic evaluation, and consent was secured on the provision that there were no conditions of treatment, i.e., no forcible execution of participation, freedom to withdraw consent, consideration of human rights based on the Declaration of Helsinki, and discontinuation of the study when acute dyspnea and physiological abnormalities were evident. RESULTS The subjects were 48 COPD patients including 45 males with a mean age of 76.2±7.0 years. The %FEV 1.0 was 67.4±22.9% and the BODE index was 3.9±2.9. The mean (SD) of each of the characteristics are shown in Table 1. The mmrc, %FVC, %FEV 1.0, quadriceps force, MEP, TUG, 6MWD and SGRQ were found to have significant Table 1. Characteristics of patients with COPD included in the study (n = 48) Characteristics mean±sd Age, years 76.2±7.0 Male/female gender, n 45 / 3 Body-mass index, kg/m ±2.8 mmrc dyspnea score 0, 1, 2, 3, 4, (%) 6 (13%), 14 (29%), 16 (33%), 6 (13%), 6 (13%) GOLD Stage 1, 2, 3, 4, (%) 7(15%), 13(27%), 20(42%), 8(17%) BODE index 3.9±2.9 quartile 1, 2, 3, 4, (%) 17 (35%), 12 (25%), 10 (21%), 9 (19%) %FVC, % 67.4±22.9 %FEV 1.0, % 50.3±23.3 FEV 1.0 /FVC, % 54.1±17.6 Quadriceps force, % 50.5±17.1 MIP, cmh 2 O 55.0±30.4 MEP, cmh 2 O 77.1±38.8 TUG, sec 8.0±4.6 6MWD, m 333.4±147.1 SGRQ 44.0±16.7

3 439 Table 2. Variables Correlation Coefficients for BODE index quartile and GOLD Stage to Selected Characteristics Indices BODE index quartile r Value GOLD stage r Value Age, years 0.329* Body-mass index, kg/m ** mmrc dyspnea score 0.879*** 0.610*** BODE index 0.957*** 0.424** %FVC, % 0.642*** 0.604*** %FEV 1.0, % 0.593*** 0.931*** FEV 1.0 /FVC, % 0.327* 0.651*** Quadriceps force, % 0.483*** MIP, cmh 2 O MEP, cmh 2 O 0.487** TUG, sec 0.606*** MWD, m 0.825*** SGRQ 0.468** *: p<0.05, **: p<0.01, ***: p<0.001 Table 3. Cross tabulation of the subjects in the BODE index quartile and GOLD Stage GOLD Stage I II III IV BODE index quartile Total GOLD, Global Initiative for Chronic Obstructive Lung Disease Total correlations with the BODE index quartile and the mmrc, %FVC, %FEV 1.0 and FEV 1.0 /FVC exhibited significant correlations with the GOLD stage. The results are shown in Table 2. Twenty-one patients were categorized in the BODE index quartile group 1 2 and 12 patients in the BODE index quartile group 3 4 who were classified as GOLD stages II and III (Table 3). Significant differences were found between the two BODE groups in age, mmrc, %FVC, quadriceps force, MIP, MEP, TUG and 6MWD. The results are shown in Table 4. DISCUSSION Each physical ability was cross-sectionally analyzed with the BODE index of COPD patients. There were strong correlations between the BODE index quartile and the dyspnea score, %FVC, muscle strength, TUG, exercise capacity and SGRQ. However, there were no correlations between each physical ability and the GOLD stage.

4 440 J. Phys. Ther. Sci. Vol. 23, No. 3, 2011 Table 4. Comparison between each of the measurement items in BODE index quartile groups 1 2 and 3 4 and patients classified in GOLD Stages II and III. Characteristics BODE 1-2 (n=21) BODE 3-4 (n=12) Age, years 74.1± ±4.6* Male/female gender, n 20 / 1 11 / 1 Body-mass index, kg/m ± ±2.2 mmrc dyspnea score 1.2± ±0.9** %FVC, % 74.0± ±18.9* %FEV 1.0, % 51.2± ±12.0 FEV 1.0 /FVC, % 52.1± ±18.5 Quadriceps force, % 57.0± ±17.9* MIP, cmh 2 O 67.3± ±25.9* MEP, cmh 2 O 93.9± ±30.6* TUG, sec 5.9± ±5.6* 6MWD, m 422.1± ±109.2** SGRQ 39.8± ±15.0 *: p<0.05, **: p<0.001 Furthermore, 21 patients were categorized in the BODE index quartile groups 1 2 and 12 patients in the BODE index quartile groups 3 4 who were classified as GOLD stages II and III. Although no significant differences were found between the two BOD groups in %FEV 1.0, which indicates the stage of pulmonary disease, a significant difference was observed in mmrc, %FVC, quadriceps force, MIP, MEP, TUG and 6MWD, with low scores in the BODE index quartile group 3 4. In particular, the mean 6MWD, an evaluation of exercise capacity, was 422 m in patients in the BODE index quartile groups 1 2 and 230 m in patients in the BODE index quartile groups 3 4, showing a large difference. Miyamoto et al. 23) reported that the survival rate was lower when 6MWD was less than 332 m while Cote et al. 24) reported that the survival rate was low when 6MWD was less than 350 m. The TUG was 10.6 sec. in patients in BODE index quartile groups 3 4. Shimada et al. 25) reported that the mean TUG of men aged 80 to 84 years living in Japan was 7.9 sec. Based on this, we suggest the balance and alertness of patients in BODE index quartile group 3 4 are likely inferior to those of the elderly living in Japan. In addition, it was reported that the frequency of falling increased in accordance with decreased walking function in patients with TUG of 8.5 sec or longer, showing that the risk of falling was increased for patients in the BODE index quartile groups 3 4. Dyspnea score and muscle strength were also significantly decreased for patients in the BODE index quartile groups 3 4. Thus, we consider the GOLD stage is an unclear criteria for physical ability, which is similar the reports above 3 8). According to Fabbri et al. 26), 14% of patients who were clinically diagnosed with COPD were actually categorized in GOLD stage 0 in which FEV 1.0 / FVC is 70% or higher and more and %FEV 1.0 is 80% or higher. In other words, their report indicates that in addition to FEV 1.0 / FVC, a more comprehensive index is needed to clinically determine COPD. In this respect, we consider the BODE index is a more comprehensive evaluation method of COPD than the GOLD stage. The clinical features of COPD of chronic cough, sputum and dyspnea in motion, are accompanied with decreased exercise capacity, skeletal muscle function disorder and nutritional disorder, as well as pulmonary functional disorder. These disorders secondarily limit activities, e.g. decreasing ADL, leading to the development of tertiary restrictions on work and social participation etc. resulting in patients following an inactive lifestyle 27). Therefore, disuse syndrome is likely to develop in patients with respiratory diseases as well as cerebrovascular disease and bone fracture. Thus, the need and importance of pulmonary rehabilitation are increasing, and the BODE index will be useful for the evaluation of the effects of COPD on patients. For further investigations, more detailed investigations with a larger number of subjects should be conducted. Furthermore, the validity of the BODE index in Japan and minimal clinically important difference should be investigated, and therapeutic strategies and pulmonary rehabilitation programs should be reviewed from the

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