Does a Personalised Behavioural Intervention Enhance Physical Activity in Home-Based vs Centre-Based Pulmonary Rehabilitation: A Retrospective Analysis

Does a Personalised Behavioural Intervention Enhance Physical Activity in Home-Based vs Centre-Based Pulmonary Rehabilitation: A Retrospective Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Does a Personalised Behavioural Intervention Enhance Physical Activity in Home-Based vs Centre-Based Pulmonary Rehabilitation: A Retrospective Analysis Matthew Armstrong, Liliana Silva This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7263357/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Physical activity is a critical outcome for individuals with COPD, but improvements following Pulmonary Rehabilitation (PR) completion are inconsistent. Centre-based PR is the gold standard for COPD, but high drop-out rates and low adherence drive demand for alternative options. This retrospective analysis aimed to compare the impact of home-based PR in Portugal and centre-based PR in the UK on physical activity levels. Methods 75 patients with COPD were included: 27 completed an 8-week home-based PR programme, and 48 completed an 8-week centre-based PR programme. Within the centre-based PR programme, 24 patients underwent PR with physical activity promotion (PR + PA), which included motivational interviews, pedometer monitoring and feedback, and goal setting, while the remaining 24 completed PR alone. Physical activity was measured using a pedometer (Yamax EX 510) for the home-based programme and an accelerometer (Actigraph GT3X) for the centre-based programmes. Results Both home-based PR and centre-based PR + PA achieved clinically meaningful improvements in physical activity (> 600 steps/day). Home-based PR was significantly superior to centre-based PR + PA (p < 0.048) and centre-based PR (p < 0.001) for physical activity. Centre-based PR + PA was also significantly more effective than centre-based PR (p < 0.001) for physical activity. Both centre-based PR + PA and centre-based PR achieved significant and clinically meaningful improvements in functional capacity compared to home-based PR (p < 0.013). No significant differences in quality of life, anxiety and depression, and breathlessness were reported between home-based and centre-based PR. Conclusion Home-based PR demonstrates superior improvements in physical activity compared to centre-based PR. However, only centre-based PR programmes provide superior improvements in functional capacity. These critical distinctions in key findings promote the need for more personalised, patient-centred approaches to PR, which align delivery methods with individual goals, baseline characteristics, and availability to services. Trial registration: NCT03749655 & NCT05315505. COPD Pulmonary Rehabilitation Physical Activity Functional Capacity Figures Figure 1 INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is a prevalent, progressive, and debilitating respiratory condition that significantly impacts patients’ physical activity levels ( 1 , 2 ). A hallmark feature of COPD is dyspnoea, often accompanied by fatigue and muscle deconditioning, which contributes to a downward spiral of reduced physical activity and worsening symptoms ( 3 – 5 ). This cycle leads to decreased exercise tolerance, increased morbidity, higher healthcare utilisation and greater disease-specific mortality ( 6 ). Consequently, a key objective in COPD management is to interrupt this cycle by promoting sustained improvements in physical activity and related health outcomes. Pulmonary rehabilitation (PR) is considered the gold standard non-pharmacological intervention for COPD, offering improvements in exercise capacity, symptom control, and enhanced health-related quality of life ( 7 , 8 ). PR programmes typically include exercise training, patient education, and behaviour change strategies, aiming to equip patients with the tools to maintain an active lifestyle beyond the rehabilitation period ( 7 , 8 ). However, despite its proven efficacy, the uptake, adherence, and completion of PR remains suboptimal- particularly for outpatient and centre-based programmes ( 9 ). In the United States, less than 4% of eligible COPD patients access PR, while in Canada, this figure is less than 1% ( 10 ). Similar trends are observed across Europe, with 2% and 9% of eligible patients accessing PR in Portugal and the UK, respectively ( 11 ). Barriers such as travel distance, programme duration, and disease severity are frequently cited as contributing factors ( 9 ). In response, alternative models of PR delivery- such as community-based PR, home-based PR (HBPR), and telerehabilitation- have gained increasing attention ( 12 ). These approaches offer greater flexibility and accessibility, particularly for patients who face logistical or physical barriers to attending centre-based programmes ( 13 ). However, evidence regarding their effectiveness remains mixed ( 14 ). A subgroup analysis from a Cochrane review favoured centre-based PR (CBPR) ( 15 ), while a recent systematic review concluded that HBPR can be as effective as CBPR in improving outcomes in COPD. Notably, the evidence supporting HBPR remains of low certainty, suggesting it should be considered a supportive tool rather than a direct replacement for CBPR at present ( 14 ). While improvements in exercise capacity and health-related quality of life following PR are well established, these do not necessarily translate into increased physical activity- a critical component of COPD management ( 16 ). Physical activity interventions embedded within PR have shown promise in addressing this gap but are not sufficient to replace PR alone ( 16 ). A recent network meta-analysis demonstrated that the addition of physical activity interventions to PR significantly improves steps/day compared to PR alone ( 17 ). Despite these advances, there is limited evidence on whether HBPR can achieve physical activity improvements comparable to CBPR, particularly when behavioural strategies such as pedometer feedback are included ( 17 ). The optimal strategy for implementing such tools within PR remains an active area of research. Given the central role of physical activity in COPD management and the ongoing challenges in PR delivery, this study aims to compare the outcomes of a HBPR programme, a CBPR programme, and a CBPR programme alongside physical activity behavioural modification (CBPR + PA). Specifically, it will evaluate changes in physical activity levels, functional capacity, and the effectiveness of pedometer-based behavioural interventions. By examining these outcomes, this study seeks to inform more effective and accessible strategies for promoting sustained physical activity in patients with COPD. Aim: To evaluate the effectiveness of different PR models- HBPR, CBPR, and CBPR + PA- in improving physical activity levels and functional capacity in patients with COPD. Objectives : To assess changes in physical activity (steps/day) following participation in HBPR, CBPR, and CBPR + PA programmes. To evaluate improvements in functional capacity, as measured by the six-minute walk test (6MWT), across the three PR models. To identify which PR model offers the most balanced benefit in terms of physical activity enhancement, and functional improvement. METHODS Study design This study is a retrospective analysis of two single centre, parallel group randomised controlled trials (RCTs), both of which were prospectively registered at clinicaltrials.gov (NCT03749655 & NCT05315505) on 20/11/2018 and 09/05/2022 respectively. The UK-based study complied with the National Institute for Health and Care Research and Health Research Authority requirements (reference 18/YH/0376), while the Portuguese study was approved by the Local Health Unit of Matosinhos local ethics committee (136/CES/JAS). In this retrospective analysis, we focused on data from patients with COPD who completed either CBPR in the UK or HBPR in Portugal. The full study design of both trials is provided elsewhere ( 18 , 19 ). In the UK trial, patients were randomised to receive either CBPR (usual care) or CBPR + PA. In the Portuguese trial, patients first completed a HBPR programme and were subsequently randomised to either a maintenance PR programme or usual care (maintenance data not included in this retrospective analysis). Participants Detailed participant information is provided elsewhere ( 18 , 19 ). In the UK, patients with COPD were recruited from the Chest Clinic and PR waiting lists at Newcastle upon Tyne Foundation Health Care Trust. In Portugal, recruitment was conducted through community care units in an urban area. The inclusion and exclusion criteria for both groups are provided in Table 1 . Eligible patients who agreed to participate were contacted by the respective research teams. Comprehensive information about the study was provided, and written informed consent was obtained from all patients prior to enrolment. Table 1 Patient inclusion and exclusion criteria. Inclusion Criteria Exclusion Criteria United Kingdom • COPD confirmed by obstructive spirometry (post-bronchodilator forced expiratory volume in the first second [FEV 1 ] to forced vital capacity [FVC] ratio < 0.70. • Clinically stable male or female COPD patients aged 40 years or older. • Optimised medical therapy • Able to provide informed consent Portugal • Patients classified as B or E, according to GOLD criteria and residents living in the area covered by the institution where the study was carried out. United Kingdom • Orthopaedic, neurological or other concomitant disease that significant impaired normal biomechanical movement patterns, as judged by the investigator • Moderate or severe COPD exacerbation (ECOPD) within 4 weeks prior to study enrolment • Unstable ischaemic heart disease, including myocardial infarction within 6 weeks prior to study enrolment • Moderate or severe aortic stenosis or hypertrophic obstructive cardiomyopathy • Uncontrolled hypertension and another condition likely to limit life expectancy to less than one year (principally metastatic malignancy). Portugal • History of a PR programme in the previous six months • Patients with a COPD exacerbation within the last week • Presence of unstable comorbidities such as those limiting exercise training • Score of the Clinical Frailty Scale 2.0 above six or above five in case of not having a responsible caregiver and living alone • Oxygen saturation level (SpO2) below 85% in the 6-minute walk test. Centre-based PR (CBPR) CBPR in the UK was delivered by a specialised team of respiratory physiotherapists over an 8-week period in accordance with the British Thoracic Society (BTS) guidelines on PR ( 8 ), with specific details provided elsewhere ( 18 ). CBPR comprised 60 minutes of supervised exercise training, delivered twice per week. All supervised sessions involved progressive, individualised aerobic and resistance training, delivered by a respiratory physiotherapist in accordance with the BTS guidelines on PR ( 8 ). Alongside exercise training, 30 minutes of education was delivered by a multidisciplinary team of healthcare professionals once per week. Education included dyspnoea and symptom management, breathing techniques and chest clearance, nutritional advice, and advice on improving physical activity. Patients with a baseline hospital anxiety and/or depression score (HADS) ≥ 8 received up to three sessions of Cognitive Behavioural Therapy (CBT) by a qualified respiratory nurse ( 20 ). Home-based PR (HBPR) HBPR in Portugal was delivered by trained rehabilitation nurses who provided two home visits per week for 8 weeks, with specific details provided elsewhere ( 19 ). Briefly, every home visit included a personalised educational intervention, supervised exercise training, self-management and self-efficacy strategies. The exercise training consisted of a variety of endurance (walking/cycling/stairs) and muscle strengthening exercises (squats/shoulder press/wall push ups), progressed using the 1–10 Borg scale. Behavioural modification of physical activity was encouraged through active participation, self-reflection, and goal setting, with an accelerometer (Yamax EX 510) given to all patients. Physical activity behavioural modification intervention (CBPR + PA) Specific details regarding the physical activity behavioural modification intervention are provided elsewhere ( 18 ). Prior to initiation, patients received a 15 minute one-to-one semi-structured motivational interview with a member of the research team. The interview consisted of motivational issues towards activity, favourite activities, facilitators and barriers to physical activity and strategies to become more physically active. Patients followed this by creating three action plans, used throughout to stimulate self-motivation towards improved physical activity. Following this, patients randomised to this group received a pedometer (Fitbug, London UK), an individualised daily step-count target (reviewed weekly), and a step-count diary that was reviewed at each PR session. Outcome measures All outcome measures were assessed 1 week prior to and 1 week following completion of all PR programmes. Objective physical activity (steps per day) was measured by either a triaxial accelerometer (Actigraph GT3X) or pedometer (Yamax EX 510) in the UK and Portugal respectively. Both tools were previously validated in patients with COPD ( 21 ). All patients wore their respective device during waking hours for seven consecutive days, prior to the onset of PR and following completion of PR. A valid assessment of patient’s physical activity was considered if patients recorded more than 8 hours of wear time on at least 4 weekdays within the 7-day period ( 22 ). Other outcome measures included: six-minute walk distance (6MWD) ( 23 ), health related quality of life (COPD assessment test [CAT] ( 24 ), dyspnoea (MRC) ( 25 ), and anxiety and depression (Hospital Anxiety and Depression Scale [HADS] ( 26 ). Statistical analysis All statistical analyses were performed using IBM SPSS Statistics (version 28). Descriptive statistics were used to summarise patient characteristics and outcome measures. As the data were not normally distributed, results are reported as median and interquartile range (IQR), with non-normality confirmed via visual inspection and the Shapiro-Wilk test. To assess differences in change scores across the three groups (CBPR, CBPR + PA, and HBPR), the Kruskal-Wallis test was used for each outcome variable. A significance level of p < 0.05 was considered statistically significant. For outcomes with significant group differences, effect size was calculated using eta squared (η²) to estimate the magnitude of the differences. Values were interpreted according to conventional thresholds: small (≈ 0.01), moderate (≈ 0.06), and large (≥ 0.14). Pairwise post hoc comparisons were not conducted, as the primary aim was to explore overall differences in outcomes between the three models of PR. RESULTS Participants Baseline characteristics of the study patients are summarised in Table 2 . The study included 75 patients with varying levels of physical activity, lung function, and symptom burden. These characteristics provide an overview of the study population and serve as a reference for interpreting intervention outcomes. There were no statistically significant differences among the groups in terms of age (p = 0.355), BMI (p = 0.241), FEV 1 % predicted (p = 0.255), baseline physical activity (p = 0.259), and 6-minute walk test (6mWT) distance (p = 0.859), indicating comparable distributions across intervention types. However, sex distribution differed significantly between groups (p = 0.05), with a higher proportion of male participants in the HBPR group (66.7%) compared to 37.5% in both CBPR groups. Similarly, smoking status also differed significantly between groups (p = 0.05), with a greater proportion of current smokers in the CBPR + PA group (29.6%) compared to the CBPR (25.0%) and HBPR (25.3%) groups. Table 2 Baseline Characteristics of Study Participants (N = 75). Variable CBPR (n = 24) CBPR + PA (n = 24) HBPR (n = 27) Total p-value Age, med(IQR) 74.0(33.0) 70.5(34.0) 74.0(33.0) 74.0(36.0) 0.355** Sex, n(%) Male 9(37.5) 9(37.5) 18(66.7) 36(48.0) 0.05* Smoking status, n(%) Former smoker Current smoker Non-smoker 19(79.2) 5(20.8) -- 18(75.0) 6(25.0) -- 17(63.0) 8(29.6) 1(3.7) 54(72.0) 19(25.3) 1(1.3) 0.05* BMI, med(IQR) 23.8(16.8) 25.7(27.2) 28.3(19.7) 25.5(28.5) 0.241** FEV 1 (% predicted), med(IQR) 41.5(75.0) 51.5(68.0) 46.0(80.0) 45.0(83.0) 0.255** Physical activity (Steps/day), med(IQR) 2599.0(6957.0) 2687.5(8177.0) 2577.0(8466.0) 2581.0(9137.0) 0.259** Functional capacity (6mWT), med(IQR) 280.0(320.0) 277.5(322.0) 266.0(390.0) 275.0(390.0) 0.859** CAT, med(IQR) 26.5(21.0) 26.5(22.0) 17.0(27.0) 23.0(33.0) < 0.001** HADS - A, med(IQR) 7.5(15.0) 5.5(19.0) 6.0(12.0) 6.0(19.0) 0.824** HADS - D, med(IQR) 7.0(12.0) 5.0(21.0) 8.0(17.0) 6.0(21.0) 0.278** mMRC, med(IQR) 3.0(2.0) 3.0(2.0) 3.0(4.0) 3.0(4.0) 0.091** CBPR: Centre-based; CBPR + PA: Centre-based with physical activity promotion; HB: Home-based; 6mWT: 6 minute Walking Test; Data are reported as median (inter-quartil range) or frequences (percentages), as appropriate; *Qui-square test or Fisher exact test; **Kruskal-Wallis test. Physical activity The Kruskal-Wallis test revealed a significant difference in physical activity across groups (H( 2 ) = 23.789, p < 0.001, η² = 0.30), indicating a large effect size. Differences in median daily step count improvements are illustrated in Table 3 . The HBPR group showed the greatest increase in daily steps (+ 1,709 steps/day), which was significantly higher than both the CBPR + PA group (+ 911 steps/day, p < 0.048), and the CBPR group (+ 26 steps/day, p < 0.001). The CBPR + PA group also demonstrated a significantly greater increase in daily steps compared to the CBPR group (p < 0.001). Functional capacity For functional capacity, measured by the 6MWT, the Kruskal-Wallis test indicted a moderate effect size (H( 2 ) = 8.692, p = 0.013, η² = 0.09). The CBPR + PA group showed the highest median improvement in walking distance (+ 48.5 metres, IQR = 205 metres), followed by the CBPR group (+ 40 metres, IQR = 220 metres). These were both significantly greater than the HBPR group (H = 8.692, p = 0.013), indicating a moderate effect of PR modality on walking distance improvement. Anxiety and depression Minimal changes in HADS anxiety and depression were reported across the groups (H( 2 ) = 1.348 & 0.193, p = 0.510 & 0.908, η² = 0, respectively). The median reduction in anxiety and depression was similar in the CBPR group (-0.5 points, IQR = 15.0 & -0.5 points, IQR = 8.0), CBPR + PA group (-0.5 points, IQR = 9.0 & -1.5 points, IQR = 9.0), and HBPR group (0 points, IQR = 18 & -1.0, IQR 16) respectively. Health-related quality of life For health related quality of life (CAT), minimal changes were reported across the groups (H( 2 ) = 4.106, p = 0.128, η² = 0.03). The median reduction in health-related quality of life was similar in the CBPR group (-2.0 points, IQR = 16.0), CBPR + PA group (-4.0 points, IQR = 12.0), and HBPR group (-3.0 points, IQR = 21.0). Breathlessness No changes in mMRC dyspnoea scale were reported across the groups (H( 2 ) = 0.615, p = 0.735, η² = 0). Table 3 Change in physical activity, functional capacity, quality of life, anxiety and depression, and breathlessness in the centre based (CBPR), centre-based + physical activity promotion (CBPR + PA), and home-based (HBPR) pulmonary rehabilitation groups. Median change CBPR (n = 24) CBPR + PA (n = 24) HBPR (n = 27) H p-value η 2 Physical activity (steps/day) 25.5(2769.0) 911.0(3587.0) 1709.0(1046.0) 23.789 < 0.001 * 0.30 Functional capacity (6mWT) 40.0(220) 48.5(205) 0.0(446) 8.692 0.013 * 0.09 CAT -2.0(16.0) -4.0(12.0) -3.0(21.0) 4.106 0.128* 0.03 HADS-A -0.5(15.0) -0.5(9.0) 0.0(18.0) 1.348 0.510* 0 HADS-D -0.5/8.0) -1.5(9.0) -1.0(16.0) 0.193 0.908* 0 mMRC 0.0(1.0) 0.0(1.0) 0.0(4.0) 0.615 0.735* 0 n 2 : eta squared; CB: Centre-Based; HB: Home-Based; PA: Physical Activity; CAT: COPD Assessment Test; HADS-A: Hospital Anxiety and Depression Scale – Anxiety; HADS-D: Hospital Anxiety and Depression Scale - Depression DISCUSSION Summary of Key Findings This retrospective analysis offers compelling evidence that HBPR may outperform traditional centre-based models of PR in promoting physical activity among patients with COPD. Compared to both CBPR + PA and CBPR alone, HBPR was associated with significantly greater improvements in physical activity levels. These findings highlight the potential of a person-centred, home-based approach to drive meaningful behaviour change in a real-world setting- an insight that could reshape current rehabilitation guidelines ( 16 , 17 ). Interestingly, increased physical activity did not translate into gains in functional capacity. While CBPR + PA and CBPR demonstrated significant improvements in the 6MWT, HBPR did not yield comparable results. This discrepancy highlights a critical nuance where the optimal PR strategy may hinge on individual patient goals – whether prioritising exercise capacity, physical activity or quality of life. Moreover, these findings add to a growing body of evidence questioning the efficacy of CBPR alone in enhancing physical activity outcomes in patients with COPD. Interpretation of Findings These findings highlight important distinctions in physical activity between different models of PR for patients with COPD. The observation that HBPR led to greater improvements in physical activity suggests that delivering PR in a familiar, flexible environment may better support patients’ ability to implement behaviour change ( 27 ). When rehabilitation is embedded in the home context, patients may feel more empowered to integrate physical activity into their daily routines, potentially enhancing autonomy and adherence with interventions ( 28 ). Given the well-established link between low baseline physical activity and increased risk of hospital admissions and premature mortality in COPD, it is imperative to understand why HBPR and CBPR + PA interventions appear more effective in promoting physical activity than CBPR alone. In terms of the HBPR group, both the current analysis and data from the full programme have reported that patients’ engagement and awareness regarding the need for behaviour change were critical to achieving positive outcomes. In fact, previous findings from the full programme suggest that those who reached this awareness more quickly showed greater functional gains, highlighting the relevance of the transition experience and motivational readiness in PR ( 29 ). These findings support the view that PR programmes should not only be structured around clinical parameters but also tailored to the psychological and behavioural stage of the individual. When rehabilitation strategies incorporate person-centred approaches, such as goal setting, shared decision-making, and self-reflection, they are more likely to foster adherence and long-term change ( 30 ). The HBPR model, as implemented here, effectively leveraged these elements within the patient’s home environment, which may explain its superiority in promoting physical activity. Several systematic review and meta-analyses have synthesised existing literature on the impact of adjunct interventions designed to support PR’s ability to improve physical activity ( 16 , 17 , 31 , 32 ). Collectively, these studies report a consistent pattern: significant improvements in steps/day are observed when behavioural interventions targeting physical activity are incorporated into PR programmes. Specifically, the earlier reviews by Lahham et al. and Qiu et al. found that providing persistent and individualised feedback on physical activity levels, often using step counters, alongside PR achieved significant effects that exceeded those of standalone interventions in improving physical activity ( 31 , 32 ). Armstrong et al. further explored how these interventions are applied in practice, finding that patients with baseline physical activity ≤ 4000 steps/day typically demonstrated minimal improvements following completion of an intervention ( 16 ). This aligns closely with the work of Osadnik et al, who proposed that patients with COPD exhibiting greater exercise capacity (≥ 350m in the 6mWT) prior to PR were more likely to achieve meaningful improvements in daily physical activity ( 33 ). Applying these insights to the current findings, all three groups in this study demonstrated very low baseline levels of both physical activity and functional capacity. This may help explain why both CBPR + PA and HBPR, which incorporated persistent and individualised feedback on activity levels, along with the use of step counters, produced superior improvements in physical activity compared to CBPR alone. These findings reinforce the importance of integrating behavioural strategies and personalised feedback into PR models to optimise outcomes. Despite growing interest, current research on the impact of HBPR on physical activity remains limited, with much of the focus historically placed on exercise capacity, health related quality of life and adherence. A recent review by Manifield et al. conducted the first network meta-analysis specifically examining physical activity outcomes across PR models. This analysis reported clinically meaningful improvements in steps/day following all approaches to PR compared to usual care: CBPR (680 [12-1348] steps/day), CBPR + PA (1376 [608–2144] steps/day), and HBPR (1252 [332–2172] steps/day) ( 17 ). While improvements over usual care were expected, the comparable gains between CBPR + PA and HBPR provide further evidence supporting the feasibility and effectiveness of both models in enhancing physical activity. The superior improvements in steps/day observed following HBPA compared to CBPR + PA warrants further discussion. Specifically, the Portuguese HBPR programme offered two weekly home visits which incorporated self-management education, goal-setting, and motivational strategies tailored to each patient’s profile. Although similar components were incorporated in the CBPR + PA, having a personalised intervention delivered in a family setting at home, may have promoted stronger patient engagement, empowerment, and adherence ( 27 ). Other potential factors that may have influenced physical activity across both sites may include climate conditions (e.g. rainfall, daylight hours and temperature), as well as socio-cultural, socio-economic and environments factors at both the micro and macro levels ( 34 ). Several findings have consistently shown that rainfall is a key climate variable negatively associated with physical activity. Specifically, daily rainfall exceeding 10 mm/day has been linked to a significant reduction in average daily steps count ( 34 , 35 ). In contrast, higher ambient temperatures have been positively associated with increased physical activity levels, as demonstrated in multiple single-centre studies ( 35 – 37 ). When comparing climate data between the UK and Portugal, these findings appear consistent with the literature. For example, the average annual rainfall is approximately 920 mm in the UK compared to 694 mm in Portugal, while the average annual temperature is around 10°C in the UK versus 17°C in Portugal ( 38 ). These differences suggest that patients in the UK may be more frequently exposed to environmental conditions that discourage outdoor physical activity. Therefore, it is plausible that such climatic and environmental factors may have contributed to the observed differences in physical activity levels among participants in this study. Importantly, the findings of this study also revealed that improvements in functional capacity were more pronounced in the CBPR + PA and CBPR alone groups, compared to the HBPR group. These findings suggest that structured, supervised exercise training, a core component of CBPR, continues to play a critical role in enhancing functional capacity in patients with COPD. Previous literature has widely evidenced that CBPR leads to significant gains in exercise tolerance, largely due to the well-designed intensity, progression and supervision of exercise sessions ( 39 ). The superior performance of patients following CBPR + PA may also reflect the additive effect of behavioural strategies that promote physical activity outside of structured sessions, potentially reinforcing the physiological adaptations gained through centre-based training ( 18 ). The lack of improvement in the HBPR group, despite notable increases in daily step count, highlights an important distinction between physical activity and functional capacity. While HBPR may effectively promote general movement and lifestyle activity, it may not provide the exercise intensity or specificity required to elicit measurable improvements in cardiorespiratory fitness or walking endurance. This aligns with the principle of training specificity, which suggests that improvements in functional outcomes require targeted, progressive overload-something that may be difficult to achieve in supervised home settings ( 40 ). Clinical Implications for Practice The findings of this study have several important implications for the delivery of PR in patients with COPD. Firstly, the superior improvements in physical activity observed in both the HBPR and CBPR + PA groups underscore the value of integrating behavioural support strategies. Therefore, PR programmes should evolve to include more personalised and behaviourally informed strategies, regardless of the delivery setting. Elements such as goal setting, self-monitoring with pedometers or accelerometers, motivational interviewing, and flexible delivery (including home-based visits) may play a critical role in facilitating sustained behaviour change, particularly in patients with low baseline physical activity levels. Second, the comparable gains in physical activity between HBPR and CBPR + PA suggest that home-based models of PR may offer a viable and effective alternative to traditional centre-based programmes, especially for patients who face barriers to attending in-person sessions. This has significant implications for improving access to PR, particularly in rural or underserved areas, and my help reduce health inequalities. However, the lack of improvement in functional capacity following HBPR highlights the continued importance of structured, supervised exercise training for enhancing exercise capacity. Therefore, a hybrid or tailored approach-combining the flexibility of home-based delivery with targeted centre-based sessions- may offer the most comprehensive benefits for patients with varying needs and capabilities. These findings support a shift towards patient-centred PR models, where the choice of delivery model is guided by individual goals, preferences, and baseline characteristics. Incorporating behavioural interventions into all PR formats may enhance their effectiveness and help address the persistent challenges of low physical activity in COPD populations. Finally, the cost-effectiveness and scalability of such models must be considered. The literature, supports the idea that supervised, home-based programmes can be both clinically effective and economically viable, provided they are adapted to local health system capabilities and workforce structures (41). Tailoring interventions to each country’s context, including professional roles, reimbursement systems, and care pathways, is essential for sustainable implementation. Strengths and Limitations This study offers several strengths that contribute meaningfully to the current understanding of PR in COPD. Firstly, the comparative analysis of three distinct PR models across 2 different countries. This provided valuable insights into how different delivery methods influence physical activity and functional outcomes. Secondly, the inclusion of both home-based and centre-based programmes, with and without behavioural support, allows for a nuanced evaluation of their relative effectiveness. Thirdly, although the patient populations originated from different healthcare systems and cultural contexts, baseline characteristics across the three groups were not statistically different, supporting the validity of outcome comparisons. This strengthens the interpretation that the observed differences are likely due to the structure and delivery of the PR programmes rather than differences in population. However, several limitations must be acknowledged. First, the retrospective analysis limits the ability to establish causal relationships between the interventions and observed outcomes. In addition, being two separate trials conducted in different countries, introduces potential variability due to differences in healthcare delivery, cultural norms, and environmental factors. Second, the tools used to measure physical activity (accelerometers vs. pedometers) differed between groups, potentially affecting comparability, despite both being validated in COPD populations. Third, although baseline characteristics were statistically similar, unmeasured confounding variables such as socioeconomic status, motivation, or caregiver support may have influenced engagement and outcomes. Despite these limitations, the study provides important evidence supporting the integration of behavioural strategies into PR and highlights the potential of home-based models to improve accessibility and engagement in physical activity. Future studies should explore these differences further through prospective, controlled trials conducted within a unified healthcare setting using standardised tools. Additionally, qualitative research is warranted to understand patient experiences, preferences, and perceptions of personalised and home-based interventions. Exploring which behavioural components are most impactful could guide the development of next-generation PR programmes. CONCLUSION This study provides valuable insights into the comparative effectiveness of PR models for patients with COPD, revealing critical distinctions in how different approaches influence physical activity and functional capacity. Both HBPR and CBPR + PA were more effective than CBPR alone in increasing physical activity, likely driven by the integration of behavioural support strategies such as personalised feedback and step counters. However, only CBPR and CBPR + PA led to meaningful improvements in functional capacity, reaffirming the critical role of structured, supervised exercise training in enhancing key outcomes in COPD management. These differences suggest that while home-based behavioural modification can successfully promote activity, it might not fully substitute for the physiological benefits of supervised training. Our findings promote the need for a more personalised, patient-centred approach to PR, one that aligns delivery methods with individual goals, baseline characteristics, and availability to services. Embedding behavioural modification across all formats of PR may be key to addressing the persistent challenge of physical inactivity in patients with COPD. Looking ahead, future research should focus on optimising hybrid models of PR and assess the long-term sustainability of physical activity gains across diverse rehabilitation settings. Abbreviations COPD Chronic Obstructive Pulmonary Disease PR Pulmonary Rehabilitation HBPR Home-based Pulmonary Rehabilitation CBPR Centre-based Pulmonary Rehabilitation CBPR + PA Centre-based Pulmonary Rehabilitation + Physical Activity Behavioural Modification 6MWT Six-Minute Walk Test RCTs Randomised Controlled Trials BTS British Thoracic Society HADS Hospital Anxiety and Depression Scale CBT Cognitive Behavioural Therapy CAT COPD Assessment Test MRC Medical Research Council. Declarations Ethics approval and consent to participate This is a retrospective analysis of two single centre RCT’s, both prospectively registered at clinicaltrials.gov (NCT03749655 & NCT05315505) and both receiving local ethical approval (reference 18/YH/0376 & 136/CES/JAS). Written informed consent was obtained from all patients prior to inclusion in the studies. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare no competing interests. Funding Not applicable. Author’s Contributions M.A and L.S were responsible for the idea and initial manuscript of the article. M.A and L.S collected and analysed data. All authors approved the final version of the manuscript. Acknowledgements Not applicable. References Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in patients with COPD. Eur Respir J. 2009;33(2):262–72. Troosters T, Blondeel A, Rodrigues FM, Janssens W, Demeyer H. Strategies to increase physical activity in chronic respiratory diseases. Clin Chest Med. 2019;40(2):397–404. Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;171(9):972–7. Shrikrishna D, Patel M, Tanner RJ, Seymour JM, Connolly BA, Puthucheary ZA, et al. Quadriceps wasting and physical inactivity in patients with COPD. Eur Respir J. 2012;40(5):1115–22. Troosters T, Sciurba F, Battaglia S, Langer D, Valluri SR, Martino L, et al. Physical inactivity in patients with COPD, a controlled multi-center pilot-study. Respir Med. 2010;104(7):1005–11. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006;61(9):772–8. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–64. Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax. 2013;68(Suppl 2):ii1–30. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, Puhan MA, et al. An official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373–86. Holland AE, Cox NS, Houchen-Wolloff L, Rochester CL, Garvey C, ZuWallack R, et al. Defining modern pulmonary rehabilitation. An official American Thoracic Society workshop report. Annals Am Thorac Soc. 2021;18(5):e12–29. Desveaux L, Janaudis-Ferreira T, Goldstein R, Brooks D. An international comparison of pulmonary rehabilitation: a systematic review. COPD: J Chronic Obstr Pulmonary Disease. 2015;12(2):144–53. Pimenta S, Hansen H, Demeyer H, Slevin P, Cruz J. Role of digital health in pulmonary rehabilitation and beyond: shaping the future. ERJ open Res. 2023;9(2). Slevin P, Kessie T, Cullen J, Butler MW, Donnelly SC, Caulfield B. Exploring the potential benefits of digital health technology for the management of COPD: a qualitative study of patient perceptions. ERJ open Res. 2019;5(2). Uzzaman MN, Agarwal D, Chan SC, Engkasan JP, Habib GM, Hanafi NS et al. Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis. Eur Respiratory Rev. 2022;31(165). Cox NS, Dal Corso S, Hansen H, McDonald CF, Hill CJ, Zanaboni P et al. Telerehabilitation for chronic respiratory disease. Cochrane Database Syst Reviews. 2021(1). Armstrong M, Winnard A, Chynkiamis N, Boyle S, Burtin C, Vogiatzis I. Use of pedometers as a tool to promote daily physical activity levels in patients with COPD: a systematic review and meta-analysis. Eur Respir Rev. 2019;28(154). Manifield J, Chaudhry Y, Singh SJ, Ward TJ, Whelan ME, Orme MW. Changes in physical activity, sedentary behaviour and sleep following pulmonary rehabilitation: a systematic review and network meta-analysis. Eur Respiratory Rev. 2024;33:172. Armstrong M, Hume E, McNeillie L, Chambers F, Wakenshaw L, Burns G, et al. Behavioural modification interventions alongside pulmonary rehabilitation improve COPD patients' experiences of physical activity. Respir Med. 2021;180:106353. Silva L, Maricoto T, Mota Â, Lemos L, Santos M, Cunha H, et al. Effectiveness of a home-based pulmonary rehabilitation maintenance programme: the Rehab2Life study protocol. BMC Nurs. 2024;23(1):338. Heslop-Marshall K, Baker C, Carrick-Sen D, Newton J, Echevarria C, Stenton C et al. Randomised controlled trial of cognitive behavioural therapy in COPD. ERJ open Res. 2018;4(4). Rabinovich RA, Louvaris Z, Raste Y, Langer D, Van Remoortel H, Giavedoni S, et al. Validity of physical activity monitors during daily life in patients with COPD. Eur Respir J. 2013;42(5):1205–15. Swartz AM, Strath SJ, BASSETT DR, O’BRIEN WL, King GA, Ainsworth BE. Estimation of energy expenditure using CSA accelerometers at hip and wrist sites. Med Sci Sports Exerc. 2000;32(9):S450–6. Holland AE, Spruit MA, Troosters T, Puhan MA, Pepin V, Saey D, et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J. 2014;44(6):1428–46. Jones P, Harding G, Berry P, Wiklund I, Chen W, Leidy NK. Development and first validation of the COPD Assessment Test. Eur Respir J. 2009;34(3):648–54. Bestall J, Paul E, Garrod R, Garnham R, Jones P, Wedzicha J. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54(7):581–6. Snaith RP. The hospital anxiety and depression scale. Health Qual Life Outcomes. 2003;1(1):29. Bourbeau J, Sedeno M, Li PZ, Troosters T, Hamilton A, De Sousa D et al. Mechanisms associated with increased physical activity in patients undergoing self-management behaviour modification in the randomised PHYSACTO trial. ERJ Open Res. 2021;7(1). Lahham A, McDonald CF, Mahal A, Lee AL, Hill CJ, Burge AT, et al. Home-based pulmonary rehabilitation for people with COPD: a qualitative study reporting the patient perspective. Chronic Resp Dis. 2018;15(2):123–30. Silva L, Maricoto T, Mota A, Lemos L, Santos M, Cunha H, et al. Understanding Adherence in Pulmonary Rehabilitation: A Multi-Group Analysis. European Respiratory Society; 2024. Silva L, Maricoto T, Costa P, Berger-Estilita J, Padilha JM. A meta-analysis on the structure of pulmonary rehabilitation maintenance programmes on COPD patients’ functional capacity. NPJ Prim care respiratory Med. 2022;32(1):38. Lahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials. Int J Chronic Obstr Pulm Dis. 2016:3121–36. Qiu S, Cai X, Wang X, He C, Zuegel M, Steinacker JM, et al. Using step counters to promote physical activity and exercise capacity in patients with chronic obstructive pulmonary disease: a meta-analysis. Ther Adv Respir Dis. 2018;12:1753466618787386. Osadnik CR, Loeckx M, Louvaris Z, Demeyer H, Langer D, Rodrigues FM et al. The likelihood of improving physical activity after pulmonary rehabilitation is increased in patients with COPD who have better exercise tolerance. Int J Chronic Obstr Pulm Dis. 2018:3515–27. Boutou AK, Raste Y, Demeyer H, Troosters T, Polkey MI, Vogiatzis I et al. Progression of physical inactivity in COPD patients: the effect of time and climate conditions–a multicenter prospective cohort study. Int J Chronic Obstr Pulm Dis. 2019:1979–92. Balish SM, Dechman G, Hernandez P, Spence JC, Rhodes RE, McGannon K, et al. The relationship between weather and objectively measured physical activity among individuals with COPD. J Cardiopulm Rehabil Prev. 2017;37(6):445–9. Alahmari AD, Mackay AJ, Patel AR, Kowlessar BS, Singh R, Brill SE, et al. Influence of weather and atmospheric pollution on physical activity in patients with COPD. Respir Res. 2015;16(1):1–9. Moy ML, Danilack VA, Weston NA, Garshick E. Daily step counts in a US cohort with COPD. Respir Med. 2012;106(7):962–9. Worlddata.info. Climate comparison: Portugal / United Kingdom 2022 [cited 2025 30 July]. Available from: https://www.worlddata.info/climate-comparison.php?r1=portugal&r2=united-kingdom Man W, Chaplin E, Daynes E, Drummond A, Evans RA, Greening NJ, et al. British thoracic society clinical statement on pulmonary rehabilitation. Thorax. 2023;78(Suppl 5):s2–15. Toigo M. Specificity of Adaptation to Training. Muscle Revolution: Concepts and Recipes for Building Muscle Mass and Force. Springer; 2024. pp. 251–4. Burge AT, Holland AE, McDonald CF, Abramson MJ, Hill CJ, Lee AL, et al. Home-based pulmonary rehabilitation for COPD using minimal resources: An economic analysis. Respirology. 2020;25(2):183–90. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7263357","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503585186,"identity":"ff65d80a-5a39-42ba-9d3d-398bced2cd34","order_by":0,"name":"Matthew Armstrong","email":"data:image/png;base64,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","orcid":"","institution":"Durham University","correspondingAuthor":true,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Armstrong","suffix":""},{"id":503585189,"identity":"057ff22a-2648-47d0-9042-eaadd12ce18f","order_by":1,"name":"Liliana Silva","email":"","orcid":"","institution":"Unidade de Saúde Pública de Matosinhos","correspondingAuthor":false,"prefix":"","firstName":"Liliana","middleName":"","lastName":"Silva","suffix":""}],"badges":[],"createdAt":"2025-07-31 14:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7263357/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7263357/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89979337,"identity":"a889adfc-ae86-49f2-8fdb-8dbbf97ce9e8","added_by":"auto","created_at":"2025-08-27 06:17:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":14506,"visible":true,"origin":"","legend":"\u003cp\u003eConsolidation standards of reporting trials diagram of the study. n: Number; PA: Physical activity; PR: Pulmonary Rehabilitation.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7263357/v1/bb8bac14074f2a8e4663430e.png"},{"id":89983566,"identity":"8f8a49f3-7ff5-46c8-a14b-05ec8481d063","added_by":"auto","created_at":"2025-08-27 06:33:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":771918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7263357/v1/ff4309ab-6cdf-4b2d-9d79-d0f46a8cc1b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does a Personalised Behavioural Intervention Enhance Physical Activity in Home-Based vs Centre-Based Pulmonary Rehabilitation: A Retrospective Analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eChronic Obstructive Pulmonary Disease (COPD) is a prevalent, progressive, and debilitating respiratory condition that significantly impacts patients\u0026rsquo; physical activity levels (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A hallmark feature of COPD is dyspnoea, often accompanied by fatigue and muscle deconditioning, which contributes to a downward spiral of reduced physical activity and worsening symptoms (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This cycle leads to decreased exercise tolerance, increased morbidity, higher healthcare utilisation and greater disease-specific mortality (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Consequently, a key objective in COPD management is to interrupt this cycle by promoting sustained improvements in physical activity and related health outcomes.\u003c/p\u003e\u003cp\u003ePulmonary rehabilitation (PR) is considered the gold standard non-pharmacological intervention for COPD, offering improvements in exercise capacity, symptom control, and enhanced health-related quality of life (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). PR programmes typically include exercise training, patient education, and behaviour change strategies, aiming to equip patients with the tools to maintain an active lifestyle beyond the rehabilitation period (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, despite its proven efficacy, the uptake, adherence, and completion of PR remains suboptimal- particularly for outpatient and centre-based programmes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In the United States, less than 4% of eligible COPD patients access PR, while in Canada, this figure is less than 1% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similar trends are observed across Europe, with 2% and 9% of eligible patients accessing PR in Portugal and the UK, respectively (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Barriers such as travel distance, programme duration, and disease severity are frequently cited as contributing factors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn response, alternative models of PR delivery- such as community-based PR, home-based PR (HBPR), and telerehabilitation- have gained increasing attention (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These approaches offer greater flexibility and accessibility, particularly for patients who face logistical or physical barriers to attending centre-based programmes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, evidence regarding their effectiveness remains mixed (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A subgroup analysis from a Cochrane review favoured centre-based PR (CBPR) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), while a recent systematic review concluded that HBPR can be as effective as CBPR in improving outcomes in COPD. Notably, the evidence supporting HBPR remains of low certainty, suggesting it should be considered a supportive tool rather than a direct replacement for CBPR at present (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile improvements in exercise capacity and health-related quality of life following PR are well established, these do not necessarily translate into increased physical activity- a critical component of COPD management (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Physical activity interventions embedded within PR have shown promise in addressing this gap but are not sufficient to replace PR alone (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A recent network meta-analysis demonstrated that the addition of physical activity interventions to PR significantly improves steps/day compared to PR alone (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Despite these advances, there is limited evidence on whether HBPR can achieve physical activity improvements comparable to CBPR, particularly when behavioural strategies such as pedometer feedback are included (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The optimal strategy for implementing such tools within PR remains an active area of research.\u003c/p\u003e\u003cp\u003eGiven the central role of physical activity in COPD management and the ongoing challenges in PR delivery, this study aims to compare the outcomes of a HBPR programme, a CBPR programme, and a CBPR programme alongside physical activity behavioural modification (CBPR\u0026thinsp;+\u0026thinsp;PA). Specifically, it will evaluate changes in physical activity levels, functional capacity, and the effectiveness of pedometer-based behavioural interventions. By examining these outcomes, this study seeks to inform more effective and accessible strategies for promoting sustained physical activity in patients with COPD.\u003c/p\u003e\n\u003ch3\u003eAim:\u003c/h3\u003e\n\u003cp\u003eTo evaluate the effectiveness of different PR models- HBPR, CBPR, and CBPR\u0026thinsp;+\u0026thinsp;PA- in improving physical activity levels and functional capacity in patients with COPD.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjectives\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo assess changes in physical activity (steps/day) following participation in HBPR, CBPR, and CBPR\u0026thinsp;+\u0026thinsp;PA programmes.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo evaluate improvements in functional capacity, as measured by the six-minute walk test (6MWT), across the three PR models.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo identify which PR model offers the most balanced benefit in terms of physical activity enhancement, and functional improvement.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis study is a retrospective analysis of two single centre, parallel group randomised controlled trials (RCTs), both of which were prospectively registered at clinicaltrials.gov (NCT03749655 \u0026amp; NCT05315505) on 20/11/2018 and 09/05/2022 respectively. The UK-based study complied with the National Institute for Health and Care Research and Health Research Authority requirements (reference 18/YH/0376), while the Portuguese study was approved by the Local Health Unit of Matosinhos local ethics committee (136/CES/JAS).\u003c/p\u003e\u003cp\u003eIn this retrospective analysis, we focused on data from patients with COPD who completed either CBPR in the UK or HBPR in Portugal. The full study design of both trials is provided elsewhere (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the UK trial, patients were randomised to receive either CBPR (usual care) or CBPR\u0026thinsp;+\u0026thinsp;PA. In the Portuguese trial, patients first completed a HBPR programme and were subsequently randomised to either a maintenance PR programme or usual care (maintenance data not included in this retrospective analysis).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eDetailed participant information is provided elsewhere (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the UK, patients with COPD were recruited from the Chest Clinic and PR waiting lists at Newcastle upon Tyne Foundation Health Care Trust. In Portugal, recruitment was conducted through community care units in an urban area.\u003c/p\u003e\u003cp\u003eThe inclusion and exclusion criteria for both groups are provided in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Eligible patients who agreed to participate were contacted by the respective research teams. Comprehensive information about the study was provided, and written informed consent was obtained from all patients prior to enrolment.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient inclusion and exclusion criteria.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInclusion Criteria\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExclusion Criteria\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUnited Kingdom\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026bull; COPD confirmed by obstructive spirometry (post-bronchodilator forced expiratory volume in the first second [FEV\u003csub\u003e1\u003c/sub\u003e] to forced vital capacity [FVC] ratio\u0026thinsp;\u0026lt;\u0026thinsp;0.70.\u003c/p\u003e\u003cp\u003e\u0026bull; Clinically stable male or female COPD patients aged 40 years or older.\u003c/p\u003e\u003cp\u003e\u0026bull; Optimised medical therapy\u003c/p\u003e\u003cp\u003e\u0026bull; Able to provide informed consent\u003c/p\u003e\u003cp\u003e\u003cb\u003ePortugal\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026bull; Patients classified as B or E, according to GOLD criteria and residents living in the area covered by the institution where the study was carried out.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnited Kingdom\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026bull; Orthopaedic, neurological or other concomitant disease that significant impaired normal biomechanical movement patterns, as judged by the investigator\u003c/p\u003e\u003cp\u003e\u0026bull; Moderate or severe COPD exacerbation (ECOPD) within 4 weeks prior to study enrolment\u003c/p\u003e\u003cp\u003e\u0026bull; Unstable ischaemic heart disease, including myocardial infarction within 6 weeks prior to study enrolment\u003c/p\u003e\u003cp\u003e\u0026bull; Moderate or severe aortic stenosis or hypertrophic obstructive cardiomyopathy\u003c/p\u003e\u003cp\u003e\u0026bull; Uncontrolled hypertension and another condition likely to limit life expectancy to less than one year (principally metastatic malignancy).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePortugal\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026bull; History of a PR programme in the previous six months\u003c/p\u003e\u003cp\u003e\u0026bull; Patients with a COPD exacerbation within the last week\u003c/p\u003e\u003cp\u003e\u0026bull; Presence of unstable comorbidities such as those limiting exercise training\u003c/p\u003e\u003cp\u003e\u0026bull; Score of the Clinical Frailty Scale 2.0 above six or above five in case of not having a responsible caregiver and living alone\u003c/p\u003e\u003cp\u003e\u0026bull; Oxygen saturation level (SpO2) below 85% in the 6-minute walk test.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eCentre-based PR (CBPR)\u003c/h3\u003e\n\u003cp\u003eCBPR in the UK was delivered by a specialised team of respiratory physiotherapists over an 8-week period in accordance with the British Thoracic Society (BTS) guidelines on PR (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), with specific details provided elsewhere (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). CBPR comprised 60 minutes of supervised exercise training, delivered twice per week. All supervised sessions involved progressive, individualised aerobic and resistance training, delivered by a respiratory physiotherapist in accordance with the BTS guidelines on PR (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Alongside exercise training, 30 minutes of education was delivered by a multidisciplinary team of healthcare professionals once per week. Education included dyspnoea and symptom management, breathing techniques and chest clearance, nutritional advice, and advice on improving physical activity. Patients with a baseline hospital anxiety and/or depression score (HADS)\u0026thinsp;\u0026ge;\u0026thinsp;8 received up to three sessions of Cognitive Behavioural Therapy (CBT) by a qualified respiratory nurse (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eHome-based PR (HBPR)\u003c/h3\u003e\n\u003cp\u003eHBPR in Portugal was delivered by trained rehabilitation nurses who provided two home visits per week for 8 weeks, with specific details provided elsewhere (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Briefly, every home visit included a personalised educational intervention, supervised exercise training, self-management and self-efficacy strategies. The exercise training consisted of a variety of endurance (walking/cycling/stairs) and muscle strengthening exercises (squats/shoulder press/wall push ups), progressed using the 1\u0026ndash;10 Borg scale. Behavioural modification of physical activity was encouraged through active participation, self-reflection, and goal setting, with an accelerometer (Yamax EX 510) given to all patients.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePhysical activity behavioural modification intervention (CBPR\u0026thinsp;+\u0026thinsp;PA)\u003c/h2\u003e\u003cp\u003eSpecific details regarding the physical activity behavioural modification intervention are provided elsewhere (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Prior to initiation, patients received a 15 minute one-to-one semi-structured motivational interview with a member of the research team. The interview consisted of motivational issues towards activity, favourite activities, facilitators and barriers to physical activity and strategies to become more physically active. Patients followed this by creating three action plans, used throughout to stimulate self-motivation towards improved physical activity. Following this, patients randomised to this group received a pedometer (Fitbug, London UK), an individualised daily step-count target (reviewed weekly), and a step-count diary that was reviewed at each PR session.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eAll outcome measures were assessed 1 week prior to and 1 week following completion of all PR programmes. Objective physical activity (steps per day) was measured by either a triaxial accelerometer (Actigraph GT3X) or pedometer (Yamax EX 510) in the UK and Portugal respectively. Both tools were previously validated in patients with COPD (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). All patients wore their respective device during waking hours for seven consecutive days, prior to the onset of PR and following completion of PR. A valid assessment of patient\u0026rsquo;s physical activity was considered if patients recorded more than 8 hours of wear time on at least 4 weekdays within the 7-day period (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther outcome measures included: six-minute walk distance (6MWD) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), health related quality of life (COPD assessment test [CAT] (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), dyspnoea (MRC) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and anxiety and depression (Hospital Anxiety and Depression Scale [HADS] (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics (version 28). Descriptive statistics were used to summarise patient characteristics and outcome measures. As the data were not normally distributed, results are reported as median and interquartile range (IQR), with non-normality confirmed via visual inspection and the Shapiro-Wilk test. To assess differences in change scores across the three groups (CBPR, CBPR\u0026thinsp;+\u0026thinsp;PA, and HBPR), the Kruskal-Wallis test was used for each outcome variable. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. For outcomes with significant group differences, effect size was calculated using eta squared (η\u0026sup2;) to estimate the magnitude of the differences. Values were interpreted according to conventional thresholds: small (\u0026asymp;\u0026thinsp;0.01), moderate (\u0026asymp;\u0026thinsp;0.06), and large (\u0026ge;\u0026thinsp;0.14). Pairwise post hoc comparisons were not conducted, as the primary aim was to explore overall differences in outcomes between the three models of PR.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eBaseline characteristics of the study patients are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The study included 75 patients with varying levels of physical activity, lung function, and symptom burden. These characteristics provide an overview of the study population and serve as a reference for interpreting intervention outcomes.\u003c/p\u003e\u003cp\u003eThere were no statistically significant differences among the groups in terms of age (p\u0026thinsp;=\u0026thinsp;0.355), BMI (p\u0026thinsp;=\u0026thinsp;0.241), FEV\u003csub\u003e1\u003c/sub\u003e% predicted (p\u0026thinsp;=\u0026thinsp;0.255), baseline physical activity (p\u0026thinsp;=\u0026thinsp;0.259), and 6-minute walk test (6mWT) distance (p\u0026thinsp;=\u0026thinsp;0.859), indicating comparable distributions across intervention types.\u003c/p\u003e\u003cp\u003eHowever, sex distribution differed significantly between groups (p\u0026thinsp;=\u0026thinsp;0.05), with a higher proportion of male participants in the HBPR group (66.7%) compared to 37.5% in both CBPR groups. Similarly, smoking status also differed significantly between groups (p\u0026thinsp;=\u0026thinsp;0.05), with a greater proportion of current smokers in the CBPR\u0026thinsp;+\u0026thinsp;PA group (29.6%) compared to the CBPR (25.0%) and HBPR (25.3%) groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics of Study Participants (N\u0026thinsp;=\u0026thinsp;75).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCBPR (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCBPR\u0026thinsp;+\u0026thinsp;PA (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHBPR (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.0(33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.5(34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74.0(33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74.0(36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.355**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, n(%)\u003c/p\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36(48.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking status, n(%)\u003c/p\u003e\u003cp\u003eFormer smoker\u003c/p\u003e\u003cp\u003eCurrent smoker\u003c/p\u003e\u003cp\u003eNon-smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(79.2)\u003c/p\u003e\u003cp\u003e5(20.8)\u003c/p\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18(75.0)\u003c/p\u003e\u003cp\u003e6(25.0)\u003c/p\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17(63.0)\u003c/p\u003e\u003cp\u003e8(29.6)\u003c/p\u003e\u003cp\u003e1(3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54(72.0)\u003c/p\u003e\u003cp\u003e19(25.3)\u003c/p\u003e\u003cp\u003e1(1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI, med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.8(16.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.7(27.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.3(19.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25.5(28.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.241**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e (% predicted), med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.5(75.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.5(68.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.0(80.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.0(83.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.255**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical activity (Steps/day), med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2599.0(6957.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2687.5(8177.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2577.0(8466.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2581.0(9137.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.259**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFunctional capacity (6mWT), med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e280.0(320.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e277.5(322.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e266.0(390.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e275.0(390.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.859**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCAT, med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.5(21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.5(22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.0(27.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.0(33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHADS - A, med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.5(15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.5(19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.0(12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.0(19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.824**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHADS - D, med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.0(12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0(21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.0(17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.0(21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.278**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emMRC, med(IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0(2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.0(2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.0(4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.0(4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.091**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eCBPR: Centre-based; CBPR\u0026thinsp;+\u0026thinsp;PA: Centre-based with physical activity promotion; HB: Home-based; 6mWT: 6 minute Walking Test; Data are reported as median (inter-quartil range) or frequences (percentages), as appropriate; *Qui-square test or Fisher exact test; **Kruskal-Wallis test.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePhysical activity\u003c/h2\u003e\u003cp\u003eThe Kruskal-Wallis test revealed a significant difference in physical activity across groups (H(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;23.789, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.30), indicating a large effect size. Differences in median daily step count improvements are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The HBPR group showed the greatest increase in daily steps (+\u0026thinsp;1,709 steps/day), which was significantly higher than both the CBPR\u0026thinsp;+\u0026thinsp;PA group (+\u0026thinsp;911 steps/day, p\u0026thinsp;\u0026lt;\u0026thinsp;0.048), and the CBPR group (+\u0026thinsp;26 steps/day, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The CBPR\u0026thinsp;+\u0026thinsp;PA group also demonstrated a significantly greater increase in daily steps compared to the CBPR group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eFunctional capacity\u003c/h2\u003e\u003cp\u003eFor functional capacity, measured by the 6MWT, the Kruskal-Wallis test indicted a moderate effect size (H(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;8.692, p\u0026thinsp;=\u0026thinsp;0.013, η\u0026sup2; = 0.09). The CBPR\u0026thinsp;+\u0026thinsp;PA group showed the highest median improvement in walking distance (+\u0026thinsp;48.5 metres, IQR\u0026thinsp;=\u0026thinsp;205 metres), followed by the CBPR group (+\u0026thinsp;40 metres, IQR\u0026thinsp;=\u0026thinsp;220 metres). These were both significantly greater than the HBPR group (H\u0026thinsp;=\u0026thinsp;8.692, p\u0026thinsp;=\u0026thinsp;0.013), indicating a moderate effect of PR modality on walking distance improvement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAnxiety and depression\u003c/h2\u003e\u003cp\u003eMinimal changes in HADS anxiety and depression were reported across the groups (H(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;1.348 \u0026amp; 0.193, p\u0026thinsp;=\u0026thinsp;0.510 \u0026amp; 0.908, η\u0026sup2; = 0, respectively). The median reduction in anxiety and depression was similar in the CBPR group (-0.5 points, IQR\u0026thinsp;=\u0026thinsp;15.0 \u0026amp; -0.5 points, IQR\u0026thinsp;=\u0026thinsp;8.0), CBPR\u0026thinsp;+\u0026thinsp;PA group (-0.5 points, IQR\u0026thinsp;=\u0026thinsp;9.0 \u0026amp; -1.5 points, IQR\u0026thinsp;=\u0026thinsp;9.0), and HBPR group (0 points, IQR\u0026thinsp;=\u0026thinsp;18 \u0026amp; -1.0, IQR 16) respectively.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eHealth-related quality of life\u003c/h2\u003e\u003cp\u003eFor health related quality of life (CAT), minimal changes were reported across the groups (H(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;4.106, p\u0026thinsp;=\u0026thinsp;0.128, η\u0026sup2; = 0.03). The median reduction in health-related quality of life was similar in the CBPR group (-2.0 points, IQR\u0026thinsp;=\u0026thinsp;16.0), CBPR\u0026thinsp;+\u0026thinsp;PA group (-4.0 points, IQR\u0026thinsp;=\u0026thinsp;12.0), and HBPR group (-3.0 points, IQR\u0026thinsp;=\u0026thinsp;21.0).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eBreathlessness\u003c/h2\u003e\u003cp\u003eNo changes in mMRC dyspnoea scale were reported across the groups (H(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.615, p\u0026thinsp;=\u0026thinsp;0.735, η\u0026sup2; = 0).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChange in physical activity, functional capacity, quality of life, anxiety and depression, and breathlessness in the centre based (CBPR), centre-based\u0026thinsp;+\u0026thinsp;physical activity promotion (CBPR\u0026thinsp;+\u0026thinsp;PA), and home-based (HBPR) pulmonary rehabilitation groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian change\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCBPR (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCBPR\u0026thinsp;+\u0026thinsp;PA\u003c/p\u003e\u003cp\u003e (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHBPR (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eH\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eη\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical activity (steps/day)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.5(2769.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e911.0(3587.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1709.0(1046.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.789\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFunctional capacity (6mWT)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.0(220)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.5(205)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0(446)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.692\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCAT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-2.0(16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-4.0(12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-3.0(21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.128*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHADS-A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.5(15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.5(9.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0(18.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.348\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.510*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHADS-D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.5/8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.5(9.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.0(16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.193\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.908*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emMRC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0(4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.735*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e: eta squared; CB: Centre-Based; HB: Home-Based; PA: Physical Activity; CAT: COPD Assessment Test; HADS-A: Hospital Anxiety and Depression Scale \u0026ndash; Anxiety; HADS-D: Hospital Anxiety and Depression Scale - Depression\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eSummary of Key Findings\u003c/h2\u003e\u003cp\u003eThis retrospective analysis offers compelling evidence that HBPR may outperform traditional centre-based models of PR in promoting physical activity among patients with COPD. Compared to both CBPR\u0026thinsp;+\u0026thinsp;PA and CBPR alone, HBPR was associated with significantly greater improvements in physical activity levels. These findings highlight the potential of a person-centred, home-based approach to drive meaningful behaviour change in a real-world setting- an insight that could reshape current rehabilitation guidelines (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInterestingly, increased physical activity did not translate into gains in functional capacity. While CBPR\u0026thinsp;+\u0026thinsp;PA and CBPR demonstrated significant improvements in the 6MWT, HBPR did not yield comparable results. This discrepancy highlights a critical nuance where the optimal PR strategy may hinge on individual patient goals \u0026ndash; whether prioritising exercise capacity, physical activity or quality of life. Moreover, these findings add to a growing body of evidence questioning the efficacy of CBPR alone in enhancing physical activity outcomes in patients with COPD.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eInterpretation of Findings\u003c/h2\u003e\u003cp\u003eThese findings highlight important distinctions in physical activity between different models of PR for patients with COPD. The observation that HBPR led to greater improvements in physical activity suggests that delivering PR in a familiar, flexible environment may better support patients\u0026rsquo; ability to implement behaviour change (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). When rehabilitation is embedded in the home context, patients may feel more empowered to integrate physical activity into their daily routines, potentially enhancing autonomy and adherence with interventions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGiven the well-established link between low baseline physical activity and increased risk of hospital admissions and premature mortality in COPD, it is imperative to understand why HBPR and CBPR\u0026thinsp;+\u0026thinsp;PA interventions appear more effective in promoting physical activity than CBPR alone.\u003c/p\u003e\u003cp\u003eIn terms of the HBPR group, both the current analysis and data from the full programme have reported that patients\u0026rsquo; engagement and awareness regarding the need for behaviour change were critical to achieving positive outcomes. In fact, previous findings from the full programme suggest that those who reached this awareness more quickly showed greater functional gains, highlighting the relevance of the transition experience and motivational readiness in PR (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese findings support the view that PR programmes should not only be structured around clinical parameters but also tailored to the psychological and behavioural stage of the individual. When rehabilitation strategies incorporate person-centred approaches, such as goal setting, shared decision-making, and self-reflection, they are more likely to foster adherence and long-term change (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The HBPR model, as implemented here, effectively leveraged these elements within the patient\u0026rsquo;s home environment, which may explain its superiority in promoting physical activity.\u003c/p\u003e\u003cp\u003eSeveral systematic review and meta-analyses have synthesised existing literature on the impact of adjunct interventions designed to support PR\u0026rsquo;s ability to improve physical activity (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Collectively, these studies report a consistent pattern: significant improvements in steps/day are observed when behavioural interventions targeting physical activity are incorporated into PR programmes.\u003c/p\u003e\u003cp\u003eSpecifically, the earlier reviews by Lahham et al. and Qiu et al. found that providing persistent and individualised feedback on physical activity levels, often using step counters, alongside PR achieved significant effects that exceeded those of standalone interventions in improving physical activity (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Armstrong et al. further explored how these interventions are applied in practice, finding that patients with baseline physical activity\u0026thinsp;\u0026le;\u0026thinsp;4000 steps/day typically demonstrated minimal improvements following completion of an intervention (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This aligns closely with the work of Osadnik et al, who proposed that patients with COPD exhibiting greater exercise capacity (\u0026ge;\u0026thinsp;350m in the 6mWT) prior to PR were more likely to achieve meaningful improvements in daily physical activity (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eApplying these insights to the current findings, all three groups in this study demonstrated very low baseline levels of both physical activity and functional capacity. This may help explain why both CBPR\u0026thinsp;+\u0026thinsp;PA and HBPR, which incorporated persistent and individualised feedback on activity levels, along with the use of step counters, produced superior improvements in physical activity compared to CBPR alone. These findings reinforce the importance of integrating behavioural strategies and personalised feedback into PR models to optimise outcomes.\u003c/p\u003e\u003cp\u003eDespite growing interest, current research on the impact of HBPR on physical activity remains limited, with much of the focus historically placed on exercise capacity, health related quality of life and adherence. A recent review by Manifield et al. conducted the first network meta-analysis specifically examining physical activity outcomes across PR models. This analysis reported clinically meaningful improvements in steps/day following all approaches to PR compared to usual care: CBPR (680 [12-1348] steps/day), CBPR\u0026thinsp;+\u0026thinsp;PA (1376 [608\u0026ndash;2144] steps/day), and HBPR (1252 [332\u0026ndash;2172] steps/day) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). While improvements over usual care were expected, the comparable gains between CBPR\u0026thinsp;+\u0026thinsp;PA and HBPR provide further evidence supporting the feasibility and effectiveness of both models in enhancing physical activity.\u003c/p\u003e\u003cp\u003eThe superior improvements in steps/day observed following HBPA compared to CBPR\u0026thinsp;+\u0026thinsp;PA warrants further discussion. Specifically, the Portuguese HBPR programme offered two weekly home visits which incorporated self-management education, goal-setting, and motivational strategies tailored to each patient\u0026rsquo;s profile. Although similar components were incorporated in the CBPR\u0026thinsp;+\u0026thinsp;PA, having a personalised intervention delivered in a family setting at home, may have promoted stronger patient engagement, empowerment, and adherence (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther potential factors that may have influenced physical activity across both sites may include climate conditions (e.g. rainfall, daylight hours and temperature), as well as socio-cultural, socio-economic and environments factors at both the micro and macro levels (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Several findings have consistently shown that rainfall is a key climate variable negatively associated with physical activity. Specifically, daily rainfall exceeding 10 mm/day has been linked to a significant reduction in average daily steps count (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In contrast, higher ambient temperatures have been positively associated with increased physical activity levels, as demonstrated in multiple single-centre studies (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhen comparing climate data between the UK and Portugal, these findings appear consistent with the literature. For example, the average annual rainfall is approximately 920 mm in the UK compared to 694 mm in Portugal, while the average annual temperature is around 10\u0026deg;C in the UK versus 17\u0026deg;C in Portugal (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). These differences suggest that patients in the UK may be more frequently exposed to environmental conditions that discourage outdoor physical activity. Therefore, it is plausible that such climatic and environmental factors may have contributed to the observed differences in physical activity levels among participants in this study.\u003c/p\u003e\u003cp\u003eImportantly, the findings of this study also revealed that improvements in functional capacity were more pronounced in the CBPR\u0026thinsp;+\u0026thinsp;PA and CBPR alone groups, compared to the HBPR group. These findings suggest that structured, supervised exercise training, a core component of CBPR, continues to play a critical role in enhancing functional capacity in patients with COPD.\u003c/p\u003e\u003cp\u003ePrevious literature has widely evidenced that CBPR leads to significant gains in exercise tolerance, largely due to the well-designed intensity, progression and supervision of exercise sessions (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The superior performance of patients following CBPR\u0026thinsp;+\u0026thinsp;PA may also reflect the additive effect of behavioural strategies that promote physical activity outside of structured sessions, potentially reinforcing the physiological adaptations gained through centre-based training (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe lack of improvement in the HBPR group, despite notable increases in daily step count, highlights an important distinction between physical activity and functional capacity. While HBPR may effectively promote general movement and lifestyle activity, it may not provide the exercise intensity or specificity required to elicit measurable improvements in cardiorespiratory fitness or walking endurance. This aligns with the principle of training specificity, which suggests that improvements in functional outcomes require targeted, progressive overload-something that may be difficult to achieve in supervised home settings (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eClinical Implications for Practice\u003c/h2\u003e\u003cp\u003eThe findings of this study have several important implications for the delivery of PR in patients with COPD. Firstly, the superior improvements in physical activity observed in both the HBPR and CBPR\u0026thinsp;+\u0026thinsp;PA groups underscore the value of integrating behavioural support strategies. Therefore, PR programmes should evolve to include more personalised and behaviourally informed strategies, regardless of the delivery setting. Elements such as goal setting, self-monitoring with pedometers or accelerometers, motivational interviewing, and flexible delivery (including home-based visits) may play a critical role in facilitating sustained behaviour change, particularly in patients with low baseline physical activity levels.\u003c/p\u003e\u003cp\u003eSecond, the comparable gains in physical activity between HBPR and CBPR\u0026thinsp;+\u0026thinsp;PA suggest that home-based models of PR may offer a viable and effective alternative to traditional centre-based programmes, especially for patients who face barriers to attending in-person sessions. This has significant implications for improving access to PR, particularly in rural or underserved areas, and my help reduce health inequalities.\u003c/p\u003e\u003cp\u003eHowever, the lack of improvement in functional capacity following HBPR highlights the continued importance of structured, supervised exercise training for enhancing exercise capacity. Therefore, a hybrid or tailored approach-combining the flexibility of home-based delivery with targeted centre-based sessions- may offer the most comprehensive benefits for patients with varying needs and capabilities.\u003c/p\u003e\u003cp\u003eThese findings support a shift towards patient-centred PR models, where the choice of delivery model is guided by individual goals, preferences, and baseline characteristics. Incorporating behavioural interventions into all PR formats may enhance their effectiveness and help address the persistent challenges of low physical activity in COPD populations.\u003c/p\u003e\u003cp\u003eFinally, the cost-effectiveness and scalability of such models must be considered. The literature, supports the idea that supervised, home-based programmes can be both clinically effective and economically viable, provided they are adapted to local health system capabilities and workforce structures (41). Tailoring interventions to each country\u0026rsquo;s context, including professional roles, reimbursement systems, and care pathways, is essential for sustainable implementation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study offers several strengths that contribute meaningfully to the current understanding of PR in COPD. Firstly, the comparative analysis of three distinct PR models across 2 different countries. This provided valuable insights into how different delivery methods influence physical activity and functional outcomes. Secondly, the inclusion of both home-based and centre-based programmes, with and without behavioural support, allows for a nuanced evaluation of their relative effectiveness. Thirdly, although the patient populations originated from different healthcare systems and cultural contexts, baseline characteristics across the three groups were not statistically different, supporting the validity of outcome comparisons. This strengthens the interpretation that the observed differences are likely due to the structure and delivery of the PR programmes rather than differences in population.\u003c/p\u003e\u003cp\u003eHowever, several limitations must be acknowledged. First, the retrospective analysis limits the ability to establish causal relationships between the interventions and observed outcomes. In addition, being two separate trials conducted in different countries, introduces potential variability due to differences in healthcare delivery, cultural norms, and environmental factors. Second, the tools used to measure physical activity (accelerometers vs. pedometers) differed between groups, potentially affecting comparability, despite both being validated in COPD populations. Third, although baseline characteristics were statistically similar, unmeasured confounding variables such as socioeconomic status, motivation, or caregiver support may have influenced engagement and outcomes.\u003c/p\u003e\u003cp\u003eDespite these limitations, the study provides important evidence supporting the integration of behavioural strategies into PR and highlights the potential of home-based models to improve accessibility and engagement in physical activity. Future studies should explore these differences further through prospective, controlled trials conducted within a unified healthcare setting using standardised tools. Additionally, qualitative research is warranted to understand patient experiences, preferences, and perceptions of personalised and home-based interventions. Exploring which behavioural components are most impactful could guide the development of next-generation PR programmes.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study provides valuable insights into the comparative effectiveness of PR models for patients with COPD, revealing critical distinctions in how different approaches influence physical activity and functional capacity. Both HBPR and CBPR\u0026thinsp;+\u0026thinsp;PA were more effective than CBPR alone in increasing physical activity, likely driven by the integration of behavioural support strategies such as personalised feedback and step counters.\u003c/p\u003e\u003cp\u003eHowever, only CBPR and CBPR\u0026thinsp;+\u0026thinsp;PA led to meaningful improvements in functional capacity, reaffirming the critical role of structured, supervised exercise training in enhancing key outcomes in COPD management. These differences suggest that while home-based behavioural modification can successfully promote activity, it might not fully substitute for the physiological benefits of supervised training.\u003c/p\u003e\u003cp\u003eOur findings promote the need for a more personalised, patient-centred approach to PR, one that aligns delivery methods with individual goals, baseline characteristics, and availability to services. Embedding behavioural modification across all formats of PR may be key to addressing the persistent challenge of physical inactivity in patients with COPD. Looking ahead, future research should focus on optimising hybrid models of PR and assess the long-term sustainability of physical activity gains across diverse rehabilitation settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Obstructive Pulmonary Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePulmonary Rehabilitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHBPR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHome-based Pulmonary Rehabilitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBPR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentre-based Pulmonary Rehabilitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBPR\u0026thinsp;+\u0026thinsp;PA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentre-based Pulmonary Rehabilitation\u0026thinsp;+\u0026thinsp;Physical Activity Behavioural Modification\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e6MWT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSix-Minute Walk Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCTs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRandomised Controlled Trials\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBTS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBritish Thoracic Society\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHADS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHospital Anxiety and Depression Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCognitive Behavioural Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCAT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCOPD Assessment Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Research Council.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis is a retrospective analysis of two single centre RCT\u0026rsquo;s, both prospectively registered at clinicaltrials.gov (NCT03749655 \u0026amp; NCT05315505) and both receiving local ethical approval (reference 18/YH/0376 \u0026amp; 136/CES/JAS). Written informed consent was obtained from all patients prior to inclusion in the studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor\u0026rsquo;s Contributions\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eM.A and L.S were responsible for the idea and initial manuscript of the article. M.A and L.S collected and analysed data. All authors approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWatz H, Waschki B, Meyer T, Magnussen H. Physical activity in patients with COPD. Eur Respir J. 2009;33(2):262\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTroosters T, Blondeel A, Rodrigues FM, Janssens W, Demeyer H. Strategies to increase physical activity in chronic respiratory diseases. Clin Chest Med. 2019;40(2):397\u0026ndash;404.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. 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A meta-analysis on the structure of pulmonary rehabilitation maintenance programmes on COPD patients\u0026rsquo; functional capacity. NPJ Prim care respiratory Med. 2022;32(1):38.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials. Int J Chronic Obstr Pulm Dis. 2016:3121\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQiu S, Cai X, Wang X, He C, Zuegel M, Steinacker JM, et al. Using step counters to promote physical activity and exercise capacity in patients with chronic obstructive pulmonary disease: a meta-analysis. Ther Adv Respir Dis. 2018;12:1753466618787386.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsadnik CR, Loeckx M, Louvaris Z, Demeyer H, Langer D, Rodrigues FM et al. 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British thoracic society clinical statement on pulmonary rehabilitation. Thorax. 2023;78(Suppl 5):s2\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eToigo M. Specificity of Adaptation to Training. Muscle Revolution: Concepts and Recipes for Building Muscle Mass and Force. Springer; 2024. pp. 251\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBurge AT, Holland AE, McDonald CF, Abramson MJ, Hill CJ, Lee AL, et al. Home-based pulmonary rehabilitation for COPD using minimal resources: An economic analysis. Respirology. 2020;25(2):183\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COPD, Pulmonary Rehabilitation, Physical Activity, Functional Capacity","lastPublishedDoi":"10.21203/rs.3.rs-7263357/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7263357/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePhysical activity is a critical outcome for individuals with COPD, but improvements following Pulmonary Rehabilitation (PR) completion are inconsistent. Centre-based PR is the gold standard for COPD, but high drop-out rates and low adherence drive demand for alternative options. This retrospective analysis aimed to compare the impact of home-based PR in Portugal and centre-based PR in the UK on physical activity levels.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e75 patients with COPD were included: 27 completed an 8-week home-based PR programme, and 48 completed an 8-week centre-based PR programme. Within the centre-based PR programme, 24 patients underwent PR with physical activity promotion (PR\u0026thinsp;+\u0026thinsp;PA), which included motivational interviews, pedometer monitoring and feedback, and goal setting, while the remaining 24 completed PR alone. Physical activity was measured using a pedometer (Yamax EX 510) for the home-based programme and an accelerometer (Actigraph GT3X) for the centre-based programmes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBoth home-based PR and centre-based PR\u0026thinsp;+\u0026thinsp;PA achieved clinically meaningful improvements in physical activity (\u0026gt;\u0026thinsp;600 steps/day). Home-based PR was significantly superior to centre-based PR\u0026thinsp;+\u0026thinsp;PA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.048) and centre-based PR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for physical activity. Centre-based PR\u0026thinsp;+\u0026thinsp;PA was also significantly more effective than centre-based PR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for physical activity. Both centre-based PR\u0026thinsp;+\u0026thinsp;PA and centre-based PR achieved significant and clinically meaningful improvements in functional capacity compared to home-based PR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.013). No significant differences in quality of life, anxiety and depression, and breathlessness were reported between home-based and centre-based PR.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eHome-based PR demonstrates superior improvements in physical activity compared to centre-based PR. However, only centre-based PR programmes provide superior improvements in functional capacity. These critical distinctions in key findings promote the need for more personalised, patient-centred approaches to PR, which align delivery methods with individual goals, baseline characteristics, and availability to services.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eNCT03749655 \u0026amp; NCT05315505.\u003c/p\u003e","manuscriptTitle":"Does a Personalised Behavioural Intervention Enhance Physical Activity in Home-Based vs Centre-Based Pulmonary Rehabilitation: A Retrospective Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:17:54","doi":"10.21203/rs.3.rs-7263357/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-10T13:40:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T10:27:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T03:15:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35952553977592222249000237948631983352","date":"2025-08-21T09:41:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154853045232826641341869400673912920184","date":"2025-08-19T00:28:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148738256641810180164436308195730041110","date":"2025-08-18T00:32:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-16T21:40:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-11T11:20:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-11T11:20:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-07-31T14:27:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cbfd577-ef0d-4598-ae82-78e437898d57","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-19T15:45:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:17:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7263357","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7263357","identity":"rs-7263357","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}