This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.
Background
Previous research has suggested that most adults improve their asthma control after a short-term behavioral intervention program to increase physical activity in daily life (PADL). However, the characteristics of individuals who respond and do not respond to this intervention and the medium-term response remain unknown.
Objective
This study aims to (1) identify the characteristics of adult responders and nonresponders with asthma to a behavioral intervention to increase physical activity and (2) evaluate the functional and clinical benefits in the medium term.
Methods
This prospective pragmatic study will include adults with moderate to severe asthma who enroll in a behavioral intervention. All individuals will receive an educational program and an 8-week intervention to increase PADL (1 time/wk; up to 90 min/session). The educational program will be conducted in a class setting through group discussions and video presentations. Behavioral interventions will be based on the transtheoretical model using counseling, incentives, and individual feedback aiming to increase participation in physical activity. Motivational interviewing and guidelines for overcoming barriers will be used to stimulate individuals to reach their goals. Pre- and postintervention assessments will include the following: PADL (triaxial accelerometry), body composition (octopolar bioimpedance), barriers to PADL (questionnaire), clinical asthma control (Asthma Control Questionnaire), quality of life (Asthma Quality of Life Questionnaire), anxiety and depression levels (Hospital Anxiety and Depression Scale), and exacerbations. “Responders” to the intervention will be defined as those who demonstrate an increase in the number of daily steps (≥2500).
Results
In December 2021, the clinical trial registration was approved. Recruitment and data collection for the trial is ongoing, and the results of this study are likely to be published in late 2024.
Conclusions
The intervention will likely promote different effects according to the clinical characteristics of the individuals, including asthma control, age, anxiety and depression levels, obesity, and several comorbidities. Identifying individuals who respond or do not respond to behavioral interventions to increase PADL will help clinicians prescribe specific interventions to adults with asthma.
International Registered Report Identifier (IRRID)
DERR1-10.2196/49032
asthmabehavioral interventionphysical activityrespondersext-peer-revThis paper was peer reviewed by the funding agencies São Paulo Research Foundation (FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). See the Multimedia Appendix for the peer-review report; Introduction
According to the Global Initiative for Asthma (GINA), asthma is a heterogeneous disease characterized by chronic airway inflammation [1]. Asthma is defined by the history of respiratory symptoms, such as shortness of breath, wheezing, chest tightness, and cough, which can vary over time and in intensity, together with variable expiratory airflow limitation [1]. Asthma is a global health problem that affects all age groups. For example, in 2019, about 262 million people were diagnosed with asthma, and 461,000 died from this disease [2]. Moreover, its prevalence is increasing, affecting up to 18% of the population in some countries [1].
Several treatments, both pharmacological and nonpharmacological, are involved in the control of asthma. A supervised, structured exercise program is a nonpharmacological treatment known to improve asthma control [3]. However, despite the proven benefits of exercise, several barriers, such as the lack of space, limited access to pulmonary rehabilitation programs, and decreased motivation to remain physically active after the completion of such programs [4], make interventions to increase physical activity in daily life (PADL) an attractive and viable option [5].
Despite the known benefits of being physically active that have already been shown in this population, individuals with asthma are less physically active than control populations [6]. For instance, a previous study demonstrated that physical inactivity and a sedentary lifestyle are the only extrapulmonary factors associated with asthma exacerbation [7]. In addition, higher levels of physical activity positively impacted the clinical outcomes in this group [6]. Consequently, it is important to develop strategies to modify behavior to increase physical activity and reduce sedentary activities in this population.
The World Health Organization (WHO) recommends that adults perform 150 to 300 minutes of moderate-intensity aerobic physical activity weekly to achieve certain health benefits [8]. In addition, international guidelines [9] and GINA [1] classify, with A-level evidence, people with asthma who engage in regular physical activity to reduce cardiovascular risk and improve their quality of life [1]. A previous study found that a behavioral intervention to increase PADL improves clinical asthma control, sleep quality, and anxiety symptoms in adults with moderate to severe asthma [5]. However, 17% of the individuals did not improve their physical activity level, and 25% did not improve their clinical control after the intervention. Individuals with other chronic respiratory [10], cardiac [11], musculoskeletal [12], and neurological diseases [13] have also been classified as better or worse responders to specific interventions.
Thus, despite the benefits obtained by behavioral intervention aimed at increasing PADL in adults with asthma [5], it is necessary to know the characteristics of responders and nonresponders to guide the management in a more personalized approach. Moreover, the effects of this intervention were only assessed in the short term (immediately after the intervention), and the medium-term effects remained unknown. We hypothesize that the intervention might cause different effects according to the clinical characteristics of the individuals, including asthma control, age, anxiety and depression levels, obesity, and several comorbidities. Therefore, the main objective this prospective cohort study will be to identify the characteristics of adult responders and nonresponders with moderate to severe asthma to a behavioral intervention to increase PADL and evaluate the functional and clinical responses in the short and medium terms.
MethodsStudy Design
This prospective cohort study will be conducted at a university hospital that provides specialized asthma treatment. The study protocol was developed following the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) checklist guidelines [14], and the trial was registered at ClinicalTrials.gov (NCT05159076). The study design is illustrated in Figure 1. Individuals with asthma will be enrolled in the trial after a routine medical consultation. Baseline lung function will be checked from the medical records. Eligible participants will undergo an 8-week behavioral intervention protocol to increase PADL and reduce sedentary behavior. First, all included individuals will receive an educational program, followed by an intervention aimed at increasing physical activity. All individuals will be assessed before and after the 8-week intervention and then 16 weeks later. The outcomes assessed will include anthropometric variables, clinical asthma control, health-related quality of life, physical activity levels, anxiety and depression symptoms, exacerbations, body composition, barriers to performing PADL, and physical activity behavioral stages (Figure 1).
Study design. PADL: physical activity in daily life.
Participants
The study will include both male and female adults aged 18 to 65 years with moderate to severe asthma [1] who are not physically active (<150 min of moderate to vigorous physical activity/wk [15] or ≤7500 steps/d) and have partially controlled or uncontrolled asthma (Asthma Control Questionnaire [ACQ] score ≥0.75) [16]. In addition, the following inclusion criteria will be considered: diagnosis of asthma based on the recommendations established by GINA [1], outpatient medical treatment for at least six months, and a stable clinical status for at least 30 days (no hospitalizations, visits to emergency services, or medication changes) [17]. Pharmacotherapy will be maintained throughout the intervention period. After being informed about the possible risks and benefits of the study, participants will be instructed to sign an informed consent form.
Ethics Approval
This study will be performed in accordance with the Declaration of Helsinki. Ethics approval has been granted by the Research Ethics Committee of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (#51929221.7.0000.0068).
Consent to Participate
Written informed consent will be obtained by researchers from all study participants.
Analysis of the Population
Exclusion criteria will include participation in another research study, difficulty understanding any questionnaires, and pregnancy or psychiatric problems that make it difficult to understand the questionnaires and study protocol. If a patient misses any session, they will be contacted by telephone to confirm the reason, and the session will be rescheduled. Attending a total of 6 sessions will be considered the cut-off point to establish patient compliance [18-20]. An intention-to-treat analysis will be performed using the patient’s most recent assessment in the case of withdrawal from the study or the absence of data. The intervention will be conducted by a trained physiotherapist who is not otherwise directly involved in the assessments. In case of possible injuries occurring during the intervention period, the individuals will be referred for appropriate treatment.
ProceduresInterventions
The intervention proposed here has been previously performed for individuals with asthma [5]. All individuals will participate in a brief asthma education program with 2 sessions, each lasting approximately 90 minutes. The educational program will be conducted in a class setting in the form of group discussions and video presentations. Educational topics will include asthma pathophysiology, medication and peak flow meter use, self-monitoring symptoms, environmental hygiene [1,21], and physical activity recommendations and benefits [15].
Behavioral interventions will be based on the transtheoretical model using counseling and incentives to increase the practice of physical activity [22,23]. Motivational interviewing, feedback, and guidelines for overcoming barriers will be used to stimulate individuals to reach their goals. Furthermore, individuals will receive a commercially available smartwatch activity monitor (Mi Band 5; Xiaomi) with an alarm that vibrates when the recommended daily number of steps is achieved and if the individual remains sedentary for 60 minutes. The main objective of the behavioral intervention will be to increase the level of PADL at any intensity, and the secondary objective will be to reduce sedentary time. The program will include 8 weekly face-to-face individual sessions, lasting up to 90 minutes each. At the beginning of the protocol, the motivational interview will identify the behavioral stage for physical activity practice using an appropriate questionnaire [24]. In addition, individuals will be asked to complete a daily physical activity diary and sign a contract with the health professional.
The data referring to the respective weeks of use will be reviewed for each behavioral intervention session. Each individual will receive advice based on their smartwatch data. Each session will address different topics related to physical activity practice and sedentary behavior, and individuals will be motivated and encouraged to make behavioral changes. In the last session, a motivational interview will be conducted to identify the individual’s behavioral stage, goals achieved, benefits gained, strategies used to overcome the most significant barriers, and proposed attitudes to keep themselves physically active in the long term. The schedule and content of each session are detailed in Table 1. The protocol of Freitas et al [25] will be modified by only changing the activity smartwatch monitor used during the intervention (Mi Band instead of Fitbit) [25].
Description of the behavioral change intervention sessions. Reproduced from Freitas et al [25] under CC-BY License [26] . In this study, Mi Band 5 replaces Fitbit Flex 2.
No. Week
Topics covered
Week 1: Lifestyle choices
Motivational interview to establish an educational diagnosis
Identify the behaviour stage regarding physical activity
Raise awareness of physical activity benefits
Provide the Fitbit Flex 2 and ask them to wear it for at least 3 days each week
Week 2: Why become physically active?
Raise awareness of the physical activity international recommendations
Deepen the knowledge about the physical activity benefits for patients with asthma
Review Fitbit Flex 2 data of the past week and set one smart weekly goal (number of steps)
Establish the action planning (goal) and sign a contract
Evaluate the confidence of patients in achieving the goal (self-efficacy)
Explain about the use of the workbook, diary and vibration alert
Week 3: Sedentary behaviour
Raise awareness of the risks of prolonged uninterrupted periods of sitting
Ask them to start monitoring their sitting time (diary in a workbook)
Discuss strategies to stand up/break up the sedentary time, according to the Fitbit Flex 2 vibration function
Review achievement (using the diary and Fitbit Flex 2 data) of the current goal
Discuss progress of the current goal
Set one smart weekly goal (number of steps)
Week 4: Dealing with barriers
Dealing with barriers (as part of action and coping planning)
Brainstorm the main barriers and possible solutions/modifications
Discuss preferred activities
Invite participants to come up with ideas for walking (progression in duration/intensity)
Congratulate patients on any success (positive reinforcement) and ask them to reflect on any difficulties
Review achievement (using the diary and Fitbit Flex 2 data) of the current goal
Progress the current smart goal (number of steps and sedentary behaviour)
Week 5: Self-control
Facilitate self-control (how to self-monitor the negative and positive behaviours regarding PA)
Identify the benefits acquired with the lifestyle change and reinforce the commitment to change
Invite participants to come up with ideas to break up the sedentary time
Review achievement (using the diary and Fitbit Flex 2 data) of the current goal
Progress current goal(s) as able/required
Week 6: Setting additional goal
Review initial goal and discuss the progress of this goal (challenges)
Evaluate the confidence about achieving the new goal (self-efficacy)
Reinforce the health benefits of increased participation in PA and of breaking up sedentary time
Congratulate any success and reflect on any difficulties
Review achievement (using the diary and Fitbit flex 2 data) of the current goal
Set a new smart goal as able/required
Week 7: Being rewarded
Identify the behaviour stage regarding physical activity
Discuss the change (or not) that was achieved, as well as the benefits acquired with the new lifestyle
Discuss positive reinforcement
Review achievement (using the diary and Fitbit flex 2 data) of the current goal
Set a final goal (number to steps)
Week 8: Goal balance
Final motivational interview (goal setting, benefits acquired and strategies to overcome barriers)
Reinforce the importance of following through with these changes
Establish a long-term goal to stay physically active
Participant Timeline
The schedule of enrollment, interventions, and assessments is outlined in Table 2. The recruitment of the study participants began in May 2022.
Content for the schedule of enrollment, interventions, and assessments.
Time point
Enrollment
Allocation
Postallocation
–t1
0
Baseline
8 Weeks
16-Week follow-up
Enrollment
Eligibility screen
✓
Informed consent
✓
Allocation
Interventions:
Behavioral intervention
✓
Assessments:
Lung function
✓
PADLa and sedentary behavior
✓
✓
✓
Asthma Control
✓
✓
✓
Asthma exacerbations
✓
✓
✓
Quality of life
✓
✓
✓
Anxiety and depression
✓
✓
✓
Barriers to perform PADL
✓
✓
✓
Behavioral stage for PADL
✓
✓
✓
Anthropometric data
✓
✓
✓
Body composition
✓
✓
✓
aPADL: physical activity in daily life.
Outcome Measures
The primary outcome will be PADL (the number of steps per day) using an activity monitor (by actigraphy). Secondary outcomes will include clinical asthma control, quality of life, body composition and anthropometric data, anxiety and depression levels, asthma exacerbations, physical activity barriers, and behavioral stages for physical activity. This will be a single-blinded (outcome assessor) study in which assessments will be performed before, immediately after, and 16 weeks later.
Primary Outcome: PADL
PADL will be objectively assessed using an activity monitor (ActiGraph GT9X), a device that monitors frequency, intensity, and duration [27] in real time and is considered a sensitive and reliable method [28,29]. This triaxial monitor provides measurements of the amount and intensity of PADL and the monitoring of posture [27,30] through variations in acceleration. The “counts” obtained in a given period of time are linearly related to the intensity of the patient’s physical activity in this period [29]. Individuals will be instructed to use the accelerometer, attached to the hip using an elastic belt, for 7 consecutive days. All accelerometers will be initialized to collect data in 60 “epochs” on the 3 axes using ActiLife (version 6.9.5; ActiGraph) software. The following data will be later analyzed using the same software: the number of daily steps and the time spent in sedentary, light, moderate, and vigorous states of activity. Moderate to vigorous physical activity will also be evaluated. Sedentary behavior will be assessed using the same activity monitor.
Secondary OutcomesAsthma Clinical Control
Clinical asthma control will be assessed using the ACQ, a reliable and validated tool [16,31] that comprises 7 questions [16]. Five questions are related to asthma symptoms (waking up at night, activity limitation, shortness of breath, and wheezing), 1 question is related to rescue medication (short-acting β2-agonist use), and 1 question is related to lung function (forced expiratory volume prebronchodilator, in percentage of predicted). The questions are scored on a 7-point scale ranging from 0 (no limitation) to 6 (maximum limitation), and the total score is the average of the 7 items, ranging from 0 (totally controlled) to 6 (severely uncontrolled). A cut-off value ≥1.5 indicates poorly controlled asthma, 0.75-1.5 indicates partially controlled asthma, and ≤0.75 indicates fully controlled asthma [16]. A change of at least 0.5 points in the ACQ score is considered clinically significant [32].
Asthma-Related Quality of Life
Health-related quality of life will be evaluated using the Asthma Quality of Life Questionnaire (AQLQ) [33,34]. This questionnaire consists of 4 domains that assess the last 2 weeks: activity limitation, symptoms, emotional function, and environmental stimulation. The AQLQ score ranges from 0 to 7; the higher the score is, the better the quality of life. A difference of 0.5 points is considered clinically significant [35].
Body Composition and Anthropometric Indexes
Octopolar InBody 720 equipment (Biospace) will be used. The weight, fat mass, fat-free mass, visceral adiposity area, and skeletal muscle mass will be calculated. The InBody 720 uses 8 electrodes to assess body composition according to total body water, proteins, minerals, and fat mass. The contact points to connect the electrodes will be cleaned with an electrolytic cloth, according to the manufacturer’s instructions. Data will be electronically imported into Microsoft Excel using Lookin’Body 3.0 software (Biospace). Anthropometric data, including height, body weight (Filizola), abdominal, waist, and hip circumference, and waist-to-hip ratio will be measured according to standardized protocols [36,37]. BMI will be calculated by dividing body weight (in kg) by height (in m2) [38].
Anxiety and Depression
The Hospital Anxiety and Depression Scale (HADS) will be used to assess anxiety and depression symptoms [39]. The HADS is composed of 14 questions divided into 2 subscales, anxiety and depression (7 questions each). Each question ranges from 0 to 3, with a maximum score of 21 points for each subscale. In this study, a cut-off score (≥8) will be used to classify the presence or absence of symptoms of anxiety or depression [40].
Asthma Exacerbations
Asthma exacerbation is defined as an event in which a patient requires urgent action and needs to change the pharmacological treatment [41]. During this study, at least one of the following criteria will be used to define an exacerbation: the use of ≥4 puffs of rescue medication per 24 hours during a 48-hour period, a need for the administration of systemic corticosteroids, an unscheduled medical appointment, and either a visit to the emergency room or hospitalization [21,25,41].
The Behavioral Stage for Physical Activity
The assessment of “readiness to change” will be graded using a questionnaire to evaluate the following behavioral stages for physical activity: Precontemplation, Contemplation, Preparation, Action, and Maintenance [24,42]. The data will be presented in frequencies.
Barriers to Performing Physical Activity
Barriers to PADL practice will be assessed using a questionnaire that contains the most common barriers in adults [43,44]. The options to answer each question included: never, rarely, sometimes, almost always, and always, and each item score varies from 0 to 4. Higher scores indicate higher barriers.
Sample Size Calculation
A minimum number of 17 individuals in at least one of the groups (responder or nonresponder) was established to detect a difference of 2500 (SD 2500) steps [45] in the primary outcome (α=5%, 1 – β=80%). A sample of 100 participants was established, considering the percentage of nonresponders (17%) as previously observed [5]. Clinical improvement in the ACQ score (≥0.5) [3,32] will be considered a secondary outcome.
Statistical Analysis Planning
Individuals will be stratified as “responders” and “nonresponders” based on an increase of ≥2500 steps [45]. The Kolmogorov-Smirnov test will be used to assess data normality. Cluster analysis will be used to characterize the groups according to individual characteristics. Cluster analysis will be carried out in 2 stages: hierarchical analysis using the Ward method to determine the number of clusters and k-means analysis to group the clusters [46]. Comparisons of clinical, anthropometric, and psychosocial data obtained in the responder and nonresponder groups will be conducted using the 2-tailed t test or Mann-Whitney U test for continuous variables and the chi-square test for categorical variables. To determine the independent factors associated with the level of PADL (dependent variable, considering clinical control, smoking, obesity, anxiety, and depression as independent variables), multiple linear regression analysis (stepwise forward) will be used. The intra- and between-group comparison at baseline, short term, and medium term will be assessed using the 2-way ANOVA with repeated measures test. The significance level will be adjusted to 5% (P<.05) for all tests. If necessary, intention-to-treat analysis will be performed, as described earlier. SPSS Statistics (version 22.0; IBM Corp) will be used for statistical analysis. Data integrity will be monitored by regularly scrutinizing data files for omissions and errors. Participants will be given an anonymous study ID to protect confidentiality, and only study investigators will have access to the final trial data set.
Results
In December 2021, the clinical trial registration was approved. Recruitment and data collection for the trial is ongoing, and the results of this study are likely to be published in late 2024.
DiscussionPotential Impact and Significance of the Study
The role of exercise training in individuals with moderate to severe asthma has been widely studied in recent years [47,48]. Aerobic exercise training improves physical fitness, health-related quality of life, asthma control, and lung function in this population [46,49]. However, despite the beneficial effects of exercise training, little is known about the behavioral modifications needed to achieve a more active lifestyle [4], and studies have been conducted to address behavioral interventions. Very recently, it was demonstrated that a behavioral intervention aimed at increasing PADL modified the behavior of patients with asthma, resulting in an increase in PADL and improvement in symptoms of the disease [5]. This protocol was developed to identify the characteristics of individuals who respond and do not respond to this type of intervention, which may help guide clinical practice.
Strengths and Limitations of the Study
In addition to the potential to identify the characteristics of responders and nonresponders, this study will also follow up 4 months after training, considered the medium term. These results will allow us to determine if behavioral changes are maintained in the responders over time. The assessment of PADL using accelerometers as a primary outcome is a study strength because it is an objective outcome measure, thus decreasing the risk of bias. The fact that the study will be performed in only 1 hospital center can be considered a limitation.
Contribution and Clinical Applicability
To our knowledge, this will be the first study to assess the characteristics of responders and nonresponders to a behavioral intervention aimed at increasing PADL in adults with asthma. Therefore, the results obtained in the proposed protocol may provide vital information for health care professionals to refer patients with asthma to more specific intervention approaches (behavioral or otherwise) based on their profile as potential responders or nonresponders. Furthermore, this study may clarify whether the potential gains obtained in the short term after the intervention are maintained in the medium term in individuals with moderate to severe asthma.
Conclusion
The behavioral intervention to increase PADL may promote different effects according to the clinical characteristics of the individuals, including asthma control, age, anxiety and depression levels, obesity, and several comorbidities. Furthermore, identifying individuals who respond or do not respond to behavioral interventions to increase PADL will help clinicians prescribe specific interventions to adults with asthma.
AbbreviationsACQ
Asthma Control Questionnaire
AQLQ
Asthma Quality of Life Questionnaire
GINA
Global Initiative for Asthma
HADS
Hospital Anxiety and Depression Scale
PADL
physical activity in daily life
SPIRIT
Standard Protocol Items: Recommendations for Interventional Trials
WHO
World Health Organization
The Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) sponsored FFdL and CRFC (grants #150845/2021-9 and #312.279/2018-3, respectively). The São Paulo Research Foundation (FAPESP) sponsors FFdL, DHAP, and CRFC (grants #2021/04198-6, #2021/03745-3, and #2018/17788-3).
The study funders (FAPESP and CNPq) are public research foundations and do not have any influence on the study’s results, including data collection; the management, analysis, and interpretation of data; or writing of the manuscript.
Table 1 was reproduced from from Freitas et al [25], which is published under Creative Commons Attribution 4.0 International License [49].
Data Availability
The data obtained in this study will be available from the corresponding author (CRFC) upon reasonable request.
FFdL and CRFC contributed to the writing of this study protocol. FFdL and DHAP are involved in recruiting and collecting data. FFdL, ACL, and CRFC will conduct the analyses. ACL, DHAP, RMCP, RS, PGB, and RCA contributed to the review and commented on all versions of this study protocol. All authors approved the final manuscript.
None declared.
Global Strategy for Asthma Management and PreventionGlobal Initiative for Asthma20212023-07-24https://ginasthma.org/GBD 2019 DiseasesInjuries CollaboratorsGlobal burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019Lancet20201017396102581204122210.1016/S0140-6736(20)30925-933069326S0140-6736(20)30925-9PMC7567026DograSKukJLBakerJJamnikVExercise is associated with improved asthma control in adultsEur Respir J2011023723182310.1183/09031936.001822092053004209031936.00182209Cindy NgLWMackneyJJenkinsSHillKDoes exercise training change physical activity in people with COPD? a systematic review and meta-analysisChron Respir Dis20120291172610.1177/1479972311430335221946291479972311430335FreitasPDPassosNFPCarvalho-PintoRMMartinsMACavalheriVHillKStelmachRCarvalhoCRFA behavior change intervention aimed at increasing physical activity improves clinical control in adults with asthma: a randomized controlled trialChest2021011591465710.1016/j.chest.2020.08.211332931821S0012-3692(20)34492-5Cordova-RiveraLGibsonPGGardinerPAMcDonaldVMA systematic review of associations of physical activity and sedentary time with asthma outcomesJ Allergy Clin Immunol Pract2018116619681981.e210.1016/j.jaip.2018.02.02729510231S2213-2198(18)30127-2FreitasPDXavierRFMcDonaldVMGibsonPGCordova-RiveraLFurlanettoKCde OliveiraJMCarvalho-PintoRMCukierAStelmachRCarvalhoCRFIdentification of asthma phenotypes based on extrapulmonary treatable traitsEur Respir J202101571200024010.1183/13993003.00240-20203273232613993003.00240-2020WHO guidelines on physical activity and sedentary behaviourWorld Health Organization202011252023-07-24https://www.who.int/publications/i/item/9789240015128Carvalho-PintoRMDCançadoJosé Eduardo DelfiniPizzichiniMMMFitermanJRubinASCerci NetoACruzFernandesALGAraujoAMSBlancoDCCordeiro JuniorGCaetanoLSBRabahiMFMenezesMBDOliveiraMADLimaMAPitrezPM2021 Brazilian Thoracic Association recommendations for the management of severe asthmaJ Bras Pneumol20211215476e2021027310.36416/1806-3756/e2021027334932721S1806-37132021000600400PMC8836628SpruitMAAugustinIMLVanfleterenLEJanssenDJAGaffronSPenningsHSmeenkFPietersWvan den BerghJJAMMichelsAGroenenMTJRuttenEPAWoutersEFMFranssenFMECIRO+ Rehabilitation NetworkDifferential response to pulmonary rehabilitation in COPD: multidimensional profilingEur Respir J20151246616253510.1183/13993003.00350-20152645362613993003.00350-2015SchmidJZurekMSanerHChronotropic incompetence predicts impaired response to exercise training in heart failure patients with sinus rhythmEur J Prev Cardiol2013082045859210.1177/2047487312444368224928662047487312444368CecchiFPasquiniGPaperiniABoniRCastagnoliCPistrittoSMacchiCPredictors of response to exercise therapy for chronic low back pain: result of a prospective study with one year follow-upEur J Phys Rehabil Med2014045021435124429917R33Y9999N00A140279BowdenMGBehrmanALNeptuneRRGregoryCMKautzSALocomotor rehabilitation of individuals with chronic stroke: difference between responders and nonrespondersArch Phys Med Rehabil2013059458566210.1016/j.apmr.2012.11.03223220082S0003-9993(12)01196-3ChanAWTetzlaffJMAltmanDGLaupacisAGøtzschePeter CKrleža-JerićKHróbjartssonAsbjørnMannHDickersinKBerlinJADoréCaroline JParulekarWRSummerskillWSMGrovesTSchulzKFSoxHCRockholdFWRennieDMoherDSPIRIT 2013 statement: defining standard protocol items for clinical trialsAnn Intern Med201302051583200710.7326/0003-4819-158-3-201302050-00583232959571556168PMC5114123GarberCEBlissmerBDeschenesMRFranklinBALamonteMJLeeINiemanDCSwainDPAmerican College of Sports MedicineAmerican College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exerciseMed Sci Sports Exerc20110743713345910.1249/MSS.0b013e318213fefb2169455600005768-201107000-00026JuniperEFBousquetJAbetzLBatemanEDGOAL CommitteeIdentifying 'well-controlled' and 'not well-controlled' asthma using the Asthma Control QuestionnaireRespir Med200604100461662110.1016/j.rmed.2005.08.01216226443S0954-6111(05)00335-5França-PintoAndrezzaMendesFARde Carvalho-PintoRMAgondiRCCukierAStelmachRSaraiva-RomanholoBMKalilJMartinsMAGiavina-BianchiPCarvalhoCRFAerobic training decreases bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomised controlled trialThorax20150870873273910.1136/thoraxjnl-2014-20607026063507thoraxjnl-2014-206070HaytonCClarkAOliveSBrownePGaleyPKnightsEStauntonLJonesACoombesEWilsonAMBarriers to pulmonary rehabilitation: characteristics that predict patient attendance and adherenceRespir Med201303107340140710.1016/j.rmed.2012.11.01623261311S0954-6111(12)00427-1National Clinical Guideline Centre (UK)Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary careNICE Clinical Guidelines, No. 10120106London, the United KingdomRoyal College of Physicians (UK)SabitRGriffithsTLWatkinsAJEvansWBoltonCEShaleDJLewisKEPredictors of poor attendance at an outpatient pulmonary rehabilitation programmeRespir Med200806102681982410.1016/j.rmed.2008.01.01918337077S0954-6111(08)00052-8FreitasPDFerreiraPGSilvaAGStelmachRCarvalho-PintoRMFernandesFLAManciniMCSatoMNMartinsMACarvalhoCRFThe role of exercise in a weight-loss program on clinical control in obese adults with asthma. a randomized controlled trialAm J Respir Crit Care Med201701011951324210.1164/rccm.201603-0446OC27744739PatrickKSallisJFLongBCalfasKJWootenWHeathGPrattMA new tool for encouraging activityPhys Sportsmed1994112211455510.1080/00913847.1994.1194770629275663ProchaskaJODiClementeCCStages and processes of self-change of smoking: toward an integrative model of changeJ Consult Clin Psychol19830651339039510.1037//0022-006x.51.3.3906863699RibeiroMAMartinsMDACarvalhoCRFThe role of physician counseling in improving adherence to physical activity among the general populationSao Paulo Med J20070301125211512110.1590/s1516-3180200700020001017625711S1516-31802007000200010FreitasPDXavierRFPassosNFPCarvalho-PintoRMCukierAMartinsMACavalheriVHillKStelmachRCarvalhoCRFEffects of a behaviour change intervention aimed at increasing physical activity on clinical control of adults with asthma: study protocol for a randomised controlled trialBMC Sports Sci Med Rehabil2019814111610.1186/s13102-019-0128-631428433128PMC6694673Attribution 4.0 International (CC BY 4.0)Creative Commons2023-08-15https://creativecommons.org/licenses/by/4.0/CarrLJMaharMTAccuracy of intensity and inclinometer output of three activity monitors for identification of sedentary behavior and light-intensity activityJ Obes20121113201246027110.1155/2012/46027122175006PMC3228344ReillyJJPenprazeVHislopJDaviesGGrantSPatonJYObjective measurement of physical activity and sedentary behaviour: review with new dataArch Dis Child20080793761461910.1136/adc.2007.13327218305072adc.2007.133272TrostSGMcIverKLPateRRConducting accelerometer-based activity assessments in field-based researchMed Sci Sports Exerc2005113711 SupplS53154310.1249/01.mss.0000185657.86065.981629411600005768-200511001-00006García-OrtizLuisRecio-RodríguezJosé IMartín-CanteraCarlosCabrejas-SánchezAlfredoGómez-ArranzAmparoGonzález-ViejoNatividadIturregui-San NicolásEguskiñePatino-AlonsoMCGómez-MarcosManuel AEVIDENT GroupPhysical exercise, fitness and dietary pattern and their relationship with circadian blood pressure pattern, augmentation index and endothelial dysfunction biological markers: EVIDENT study protocolBMC Public Health201005061023310.1186/1471-2458-10-233204596341471-2458-10-233PMC2881095JuniperEFO'ByrnePMGuyattGHFerriePJKingDRDevelopment and validation of a questionnaire to measure asthma controlEur Respir J199910144902710.1034/j.1399-3003.1999.14d29.x10573240JuniperEFSvenssonKMörkAnn-ChristinStåhlElisabethMeasurement properties and interpretation of three shortened versions of the asthma control questionnaireRespir Med200505995553810.1016/j.rmed.2004.10.00815823451S0954-6111(04)00392-0JuniperEFGuyattGHEpsteinRSFerriePJJaeschkeRHillerTKEvaluation of impairment of health related quality of life in asthma: development of a questionnaire for use in clinical trialsThorax199202472768310.1136/thx.47.2.761549827PMC463574de OliveiraMABarbiereASantosLAFaresinSMFernandesALGValidation of a simplified quality-of-life questionnaire for socioeconomically deprived asthma patientsJ Asthma20050242141410.1081/jas-20004477215801327JuniperEFGuyattGHWillanAGriffithLEDetermining a minimal important change in a disease-specific Quality of Life QuestionnaireJ Clin Epidemiol199401471818710.1016/0895-4356(94)90036-182831970895-4356(94)90036-1KeenanNLStrogatzDSJamesSAAmmermanASRiceBLDistribution and correlates of waist-to-hip ratio in black adults: the Pitt County StudyAm J Epidemiol19920315135667868410.1093/oxfordjournals.aje.a1163471580244LohmanTGRocheAFMartorellRAnthropometric Standardization Reference Manual1988Windsor, OntarioHuman Kinetics BooksBrayGAClassification and evaluation of the obesitiesMed Clin North Am19890173116118410.1016/s0025-7125(16)30697-62643002S0025-7125(16)30697-6ZigmondASSnaithRPThe hospital anxiety and depression scaleActa Psychiatr Scand19830667636137010.1111/j.1600-0447.1983.tb09716.x6880820BotegaNJBioMRZomignaniMAGarciaCPereiraWAMood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HAD. Article in PortugeseRev Saude Publica19951029535536310.1590/s0034-891019950005000048731275ReddelHKTaylorDRBatemanEDBouletLBousheyHABusseWWCasaleTBChanezPEnrightPLGibsonPGde JongsteJohan CKerstjensHAMLazarusSCLevyMLO'ByrnePMPartridgeMRPavordIDSearsMRSterkPJStoloffSWSullivanSDSzeflerSJThomasMDWenzelSEAmerican Thoracic Society/European Respiratory Society Task Force on Asthma ControlExacerbationsAn official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practiceAm J Respir Crit Care Med200907011801599910.1164/rccm.200801-060ST19535666180/1/59MarcusBHSimkinLRThe transtheoretical model: applications to exercise behaviorMed Sci Sports Exerc1994112611140014047837962LeslieEOwenNSalmonJBaumanASallisJFLoSKInsufficiently active Australian college students: perceived personal, social, and environmental influencesPrev Med199901281202710.1006/pmed.1998.03759973584S0091-7435(98)90375-9MartinsMdOPetroskiELMensuração da percepção de barreiras para a prática de atividades fisicas: uma proposta de instrumento. Perception of physical activities barriers measurement: an instrument propositionRev Bras Cineantropom Desempenho Hum2000215865Tudor-LockeCBassettDRHow many steps/day are enough? preliminary pedometer indices for public healthSports Med20043411810.2165/00007256-200434010-00001147150353411LopesACXavierRFAc PereiraACStelmachRFernandesFLHarrisonSLCarvalhoCRIdentifying COPD patients at risk for worse symptoms, HRQoL, and self-efficacy: a cluster analysisChronic Illn20190615213814810.1177/174239531775388329343090HansenESHPitzner-FabriciusAToennesenLLRasmusenHKHostrupMHellstenYBackerVHenriksenMEffect of aerobic exercise training on asthma in adults: a systematic review and meta-analysisEur Respir J202007561200014610.1183/13993003.00146-20203235010013993003.00146-2020ShiSHuangHZhengRZhangNDaiWLiangJDaiYCan long-term regular physical activity improve health outcomes among adults with asthma-evidence from a systematic review and Bayesian meta-analysisAnn Transl Med20220310633810.21037/atm-22-117035434043atm-10-06-338PMC9011288CarsonKVChandratillekeMGPicotJBrinnMPEstermanAJSmithBJPhysical training for asthmaCochrane Database Syst Rev201309309CD00111610.1002/14651858.CD001116.pub424085631