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Cited by 15Chronic Obstructive Pulmonary Disease (COPD) ResearchCardiac Health and Mental HealthAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Cognitive behavioral therapy for management of dyspnea: A pilot study

Open access
Williams, Marie T, Cafarella, Paul, Paquet, Catherine, Frith, Peter·2015·Respiratory Care
DOI 10.4187/respcare.03764
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Abstract

BACKGROUND: In patients with COPD, psychological interventions usually target generalized anxiety and depression rather than the sensation of breathlessness. The objectives of this pilot study were to develop and implement a cognitive behavioral therapy (CBT) program specific to the perceptual experience of breathlessness, identify practical issues in the study protocol, and estimate beneficial effects of combining the CBT program with comprehensive pulmonary rehabilitation. METHODS: The CBT program for the sensation of breathlessness (Breathing: Recognize sensations, Explore thoughts and beliefs, Validate thoughts as useful or harmful, Evolve and change behavior [BREVE]) was developed as a sequential series of 8 modules enabling it to be embedded within an 8-week comprehensive pulmonary rehabilitation program. When appropriate, outcomes from the pilot group (comprehensive pulmonary rehabilitation program + BREVE) were compared with those from a retrospective control group (comprehensive pulmonary rehabilitation program only). Outcomes included feedback provided by pilot study subjects, sensation of breathlessness (volunteered and endorsed descriptors of breathlessness), 6-min walk distance (6MWD), and St George Respiratory Questionnaire (SGRQ) total score. Within-group analyses were undertaken for descriptors of breathlessness (the McNemar test), whereas between-group analyses (repeated- measures analysis of variance, effect-size comparison) were conducted for the 6MWD and SGRQ total score. RESULTS: Pilot (n = 11) and control (n = 58) groups were not significantly different at baseline. Feedback indicated that the program structure and content were positively received. No significant changes were evident for the sensation of breathlessness or the SGRQ score (< 4 points). The 6MWD improved significantly in both groups, with the pilot group demonstrating greater gains compared with the control group (mean change of 57 m and effect size of 0.73 vs mean change of 27 m and effect size of 0.23; between groups, P =.03, effect size of 0.69). CONCLUSION: The CBT program for the perceptual experience of breathlessness was feasible and well accepted by subjects, although the protocol raised a number of methodological limitations warranting modification. A larger randomized controlled trial is needed to determine the effectiveness and longerterm outcomes. © 2015 Daedalus Enterprises.

AI snapshot

Written from the paper’s full text.

TL;DR

This pilot study developed and tested an eight-module cognitive behavioral therapy program (BREVE) focused on the sensation of breathlessness, embedded within standard pulmonary rehabilitation for people with chronic respiratory conditions. The intervention was feasible and positively received, and the pilot group showed greater improvement in 6-min walk distance than a retrospective control group, but breathlessness descriptors and respiratory-related quality of life did not improve significantly.

Key findings

  • The BREVE program was successfully implemented and well accepted: 11 of 12 recruited subjects completed it, and feedback from 6 subjects was largely positive, though homework tasks were identified for revision.
  • No significant within-group changes were found for volunteered or endorsed breathlessness descriptors in the pilot group; in the control group, two volunteered descriptor categories decreased significantly (air hunger, P = .03; depressed/regret/helpless, P = .04).
  • 6-min walk distance improved in both groups, with a larger mean gain in the pilot group than the control group (57 m vs 27 m; between-group P = .03, effect size 0.69).
  • St George Respiratory Questionnaire total scores showed small, non-significant changes in both groups (mean change about 2 points; between-group P = .93, effect size 0.03), below the 4-point threshold used.

Methods

  • Design: pilot study with a retrospective control group; pilot participants received an 8-week comprehensive pulmonary rehabilitation program plus BREVE, while controls had previously completed the same rehabilitation program without BREVE.
  • Sample: consecutive patients with chronic respiratory conditions and breathing difficulty at Repatriation General Hospital, Adelaide; exclusions included cognitive impairment, unstable disease, or current listing for lung-volume-reduction surgery or transplantation. The pilot group had 11 completers, and the retrospective control group had 58 subjects with COPD.
  • Outcomes and analysis: feedback form, volunteered and endorsed breathlessness descriptors, 6-min walk distance, and SGRQ total score; McNemar tests for descriptor changes within groups, repeated-measures ANOVA and effect-size comparisons for 6MWD and SGRQ, with missing post-intervention data imputed by linear regression.

Limitations

  • The paper states that the pilot had a small, underpowered sample, used a retrospective control group, had unequal group sizes, and had substantial missing post-intervention data (6MWD n = 6, SGRQ n = 3), partly due to reduced staff and staff changes.
  • The authors note potential group contamination, the lack of a social group control, possible inflation of the 6MWD mean change from imputation, and no assessment of longer-term maintenance of benefits.
  • Evident from the text: only 6 of 11 pilot subjects provided feedback, the pilot group was almost entirely male (11/1), and anxiety and depression were not formally assessed, which the authors say should be included in a future randomized controlled trial.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.4187/respcare.03764

Cites

44 of 44 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

19 of 46 cited sources checked · 9 supported · 0 flagged · accuracy not yet measured

  • Interpretationreasoning

    The findings of this pilot study appear consistent with the model of Lansing et al if feedback reflects a change in affective awareness facilitating increased exercise capacity.

    “The findings of this pilot study appear to be consistent with this model if the feedback provided by BREVE program subjects (increased endurance, better breathlessness management, and reduced anxiety associated with exercise-related breathlessness) reflects a change in affective awareness facilitating an ability to increase their exercise capacity.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [21] 21. Lansing RW, Gracely RH, Banzett RB. The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol 2009; 167(1):53-60. source
  • Findingcitation

    Within the control group, a significant proportion of subjects reduced their use of volunteered descriptors in two categories: air hunger (P=.03) and depressed, regret, helpless (P=.04).

    “whereas within the control group, a significant proportion of subjects reduced their use of volunteered descriptors in 2 volunteered language categories (air hunger [P ϭ .03]and depressed, regret, helpless [P ϭ .04];detailed tables are provided by Williams et al 7 ).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [7] 7. Williams MT, Petkov J, Olds TS, Cafarella P, Frith P. A reduction in the use of volunteered descriptors of air hunger is associated with increased walking distance in people with COPD. Respir Care 2012; 57(9):1431-1441. source

      The Changes in Language of Breathlessness section reports significant reductions in volunteered air-hunger (P=.03) and depressed/regret/helpless (P=.04) descriptors after pulmonary rehabilitation. But the Study Design section describes a pre-post study, not a control group; the cited results concern participants after rehabilitation. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
  • Premisecitation

    Both stages of the dyspnea perception model may be modulated by cognitive processes (memory, learning, schemata) and personality (affectivity).

    “Both stages may be modulated by cognitive processes (memory, learning, and schemata) and personality (affectivity). 3”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [3] 3. von Leupoldt A, Dahme B. Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases. Respir Med 2007; 101(3):411-422. source

      The Learning processes and dyspnea section says learning can affect breathlessness perception, and the Emotions and dyspnea section links negative affectivity to less accurate perception. The paper does not establish that memory, learning, schemata, and affectivity modulate both stages of a dyspnea-perception model; the two pathways it describes assign learning and emotions to the secondary pathway. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
  • Findingcitation

    Neither group achieved the minimum clinically important difference of 4 points on the SGRQ.

    “Although neither group achieved the minimum clinically important difference of 4 points”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [33] 33. Glaab T, Vogelmeier C, Buhl R. Outcome measures in chronic ob- structive pulmonary disease (COPD): strengths and limitations. Re- spir Res 2010;11:79. source

      The St. George's Respiratory Questionnaire (SGRQ) section says that 4 points is the most commonly applied threshold for a clinically meaningful change. The paper does not report results for the two groups, so it cannot support the assertion that neither achieved that change. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Exacerbations of chronic disease, lack of time, transport issues, motivation, and lack of perceived benefit of pulmonary rehabilitation are well documented as reasons for withdrawal or dropout in studies of pulmonary rehabilitation.

    “Exacerbations of chronic disease, lack of time, transport issues, motivation, and lack of perceived benefit of pulmonary rehabilitation are well documented as reasons for withdrawal or dropout in studies of pulmonary rehabilitation.26,27”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [26] 26. Bjoernshave B, Korsgaard J, Nielsen CV. Does pulmonary rehabil- itation work in clinical practice? A review on selection and dropout in randomized controlled trials on pulmonary rehabilitation. Clin Epidemiol 2010;2:73-83. source
    • cites [27] 27. Keating A, Lee AL, Holland AE. Lack of perceived benefit and inadequate transport influence uptake and completion of pulmonary rehabilitation in people with chronic obstructive pulmonary disease: a qualitative study. J Physiother 2011;57(3):183-190. source

      The Abstract and the section ‘Minor themes associated with non-completion’ report illness, transport difficulties, competing demands on time, and lack of perceived benefit as barriers; four participants withdrew after feeling no benefit. But the paper does not identify lack of motivation as a reason, says COPD exacerbations were uncommon among non-completers (Discussion), and describes barriers to participation as ‘not well documented’ (Introduction). (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 28
  • May combine two claims. 14

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The sensation of dyspnea was assessed at rest using a standardized protocol that records descriptors volunteered by subjects in their own words and selected from a preexisting list of breathlessness descriptors.

    “The sensation of dyspnea was assessed at rest using a standardized protocol that records descriptors volunteered by subjects in their own words and selected from a preexisting list of breathlessness descriptors.1,14,15”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [1] 1. Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, et al. An official American Thoracic Society state- ment: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012;185(4):435-452. source

      The Qualities of Dyspnea section discusses descriptors people use spontaneously and descriptors they endorse when given a list; the Dyspnea Measurement section also recognizes descriptors as measures of sensory experience. Neither passage describes a standardized protocol that records both kinds of responses while subjects are at rest. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites [14] 14. Mahler DA, Harver A, Lentine T, Scott JA, Beck K, Schwartzstein RM. Descriptors of breathlessness in cardiorespiratory diseases. Am J Respir Crit Care Med 1996;154(5):1357-1363. source
    • cites [15] 15. Williams M, Cafarella P, Olds T, Petkov J, Frith P. Affective de- scriptors of the sensation of breathlessness are more highly associ- ated with severity of impairment than physical descriptors in people with COPD. Chest 2010;138(2):315-322. source

  • Classified as probably not a substantial claim.

    Premisecitation

    Changes in the perceptual experience of dyspnea after repeated exposure to exercise training may result from improvements in system efficiency and/or familiarity.

    “Changes in the perceptual experience of dyspnea after repeated exposure to exercise training may result from improvements in system efficiency (less ventilatory effort for the same work load) and/or familiarity (reduced sensitivity to the sensation of breathlessness).7”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [7] 7. Williams MT, Petkov J, Olds TS, Cafarella P, Frith P. A reduction in the use of volunteered descriptors of air hunger is associated with increased walking distance in people with COPD. Respir Care 2012; 57(9):1431-1441. source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Dyspnea is a multidimensional perceptual experience that reflects an individual's awareness of breathlessness intensity, sensory quality, and unpleasantness.

    “Dyspnea is a multidimensional perceptual experience that reflects an individual's awareness of breathlessness intensity, sensory quality, and unpleasantness.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [1] 1. Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, et al. An official American Thoracic Society state- ment: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012;185(4):435-452. source

  • May combine two claims.

    Premisecitation

    The model of Lansing et al for the perception of dyspnea proposes a sequence in which initially somatosensory areas assess intensity and sensory quality, with a subsequent stage managed by the insula, dorsal anterior cingulate cortex, amygdala, and medial thalamus assessing unpleasantness/threat, and where threatening unpleasantness leads to learned behavioral responses.

    “The model of Lansing et al 21 for the perception of dyspnea proposed a sequence in which initially somatosensory areas assess the intensity and sensory quality (descriptors) of the breathlessness (somatic awareness), with a subsequent stage managed by the insula, dorsal anterior cingulate cortex, amygdala, and medial thalamus assessing the degree of unpleasantness/threat (affective awareness).22”
    • Also stated in: § Discussion · plain
      “Where the degree of unpleasantness is perceived to be threatening, immediate and longerterm behavioral responses are learned (such as early cessation of activity or avoidance).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [21] 21. Lansing RW, Gracely RH, Banzett RB. The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol 2009; 167(1):53-60. source

      Split into 3 atoms — 1 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [22] 22. von Leupoldt A, Sommer T, Kegat S, Baumann HJ, Klose H, Dahme B, Bu ¨chel C. Dyspnea and pain share emotion-related brain network. Neuroimage 2009;48(1):200-206. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    More recent instruments, such as Dyspnea-12 and the Multidimensional Dyspnea Profile, permit the assessment of both the presence and intensity of the descriptor.

    “More recent instruments, such as Dyspnea-12 24 and the Multidimensional Dyspnea Profile, 25 permit the assessment of both the presence and intensity of the descriptor.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [24] 24. Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12. Thorax 2010;65(1):21-26. source
    • cites [25] 25. Meek PM, Banzett R, Parshall MB, Gracely RH, Schwartzstein RM, Lansing R. Reliability and validity of the multidimensional dyspnea profile. Chest 2012;141(6):1546-1553. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A review of the SGRQ undertaken to create a more appropriate instrument for use in patients with COPD identified 26 items that required modification.

    “A review of the SGRQ undertaken to create a more appropriate instrument for use in patients with COPD identified 26 items that required modification.34”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [34] 34. Meguro M, Barley EA, Spencer S, Jones PW. Development and validation of an improved, COPD-specific version of the St. George respiratory questionnaire. Chest 2007;132(2):456-463. source

      The available indexed passages contain the paper’s title and bibliographic metadata, but no account of the questionnaire review or its findings. Searches for “26 items,” item modification, and the review found no passage establishing how many items required modification. (LLM, conf=0.72)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Social support has been linked with improved health outcomes, including better adherence and increased exercise tolerance among the elderly and cardiac rehabilitation populations.

    “Additionally, social support has been linked with improved health outcomes, including better adherence and increased exercise tolerance among the elderly and cardiac rehabilitation populations.36,37”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [36] 36. Fraser SN, Rodgers WM, Murray TC, Daub B. The enduring impact of social factors on exercise tolerance in men attending cardiac re- habilitation. J Cardiopulm Rehabil Prev 2007;27(2):92-96. source
    • cites [37] 37. Karelina K, DeVries AC. Modeling social influences on human health. Psychosom Med 2011;73(1):67-74. source

      In “Social influences on health” (page unavailable), the paper links social support with better medical compliance, increased physical exercise, and improved recovery from cardiovascular disease. It does not report increased exercise tolerance or establish those specific outcomes in elderly and cardiac rehabilitation populations; physical exercise is not the same as exercise tolerance. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A number of authors recommend against the use of inferential statistics, or at least a reduced emphasis on statistical significance, in pilot studies that include small samples.

    “A number of authors recommend against the use of inferential statistics, or at least a reduced emphasis on statistical significance, in pilot studies that include small samples.9,29”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [9] 9. Fain JA. Should we publish pilot/feasibility studies? Diabetes Educ 2010;36(4):521-521. source
    • cites [29] 29. Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, et al. A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol 2010;10:1. source

  • Classified as probably not a substantial claim.

    Premisecitation

    The SGRQ total score minimum clinically important difference is 4 units.

    “SGRQ total score (minimum clinically important difference of 4 units).17”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [17] 17. Jones P. Interpreting thresholds for a clinically significant change in health status in asthma and COPD. Eur Respir J 2002;19(3):398-404. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The main practical issues identified included choice of outcome measures.

    “The main practical issues identified throughout the pilot study included difficulty attaining a complete set of post-intervention data, potential for group contamination, and choice of outcome measures.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    On average, 3 subjects (27%) changed their choice of descriptors within each of the volunteered or endorsed descriptor categories, with the largest change in the frightening and uncomfortable categories (both n=4, 36%).

    “On average, 3 subjects (27%) changed their choice of descriptors within each of the volunteered or endorsed descriptor categories, with the largest change in the frightening and uncomfortable categories (both n ϭ 4, 36%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The main practical issues identified included potential for group contamination.

    “The main practical issues identified throughout the pilot study included difficulty attaining a complete set of post-intervention data, potential for group contamination, and choice of outcome measures.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Mean differences for the SGRQ total score were small and did not reach statistical or clinical importance (mean change of 2 points) in either the pilot or control group.

    “Mean differences for the SGRQ (total score) were small and did not reach statistical or clinical importance (mean change in points of 2) in either the pilot or control group.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Subjects' feedback was positive for the BREVE program.

    “Although subjects' feedback was positive for the BREVE program”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The first 12 consecutive subjects agreed to participate in this pilot study.

    “The first 12 consecutive subjects agreed to participate in this pilot study”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The majority of subjects agreed that the program was useful in helping them understand and manage their breathlessness and confirmed the layout and language style of the BREVE manual.

    “The majority of subjects agreed that the program was useful in helping them understand and manage their breathlessness and confirmed the layout and language style of the BREVE manual.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Areas of revision/improvement included reducing and altering the homework tasks.

    “Areas of revision/improvement included reducing and altering the homework tasks.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    One unanticipated issue that arose midway during the program was the request from a subject undertaking the standard comprehensive pulmonary rehabilitation program to attend the BREVE group sessions (which was accepted).

    “One unanticipated issue that arose midway during the program was the request from a subject undertaking the standard comprehensive pulmonary rehabilitation program to attend the BREVE group sessions (which was accepted).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Six of the 11 subjects provided written feedback: 5 used the feedback form, one provided handwritten feedback without the form.

    “Six of the 11 subjects provided written feedback: 5 used the feedback form, although not all respondents completed each item, and one provided handwritten feedback without the feedback form (Table 3).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Subjects unanimously supported the need for a group session and the role of a facilitator in both the group session and the supervised exercise sessions.

    “Subjects unanimously sup-ported the need for a group session and the role of a facilitator in both the group session and the supervised exercise sessions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Neither the pilot nor control group achieved statistically significant improvements in quality of life at follow-up.

    “neither the pilot nor control group achieved statistically significant improvements in quality of life at follow-up”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The psychologist employed during the pilot study was experienced in CBT for chronic pain, had no prior experience of management of breathlessness, was naive to all outcome measures, and played no part in recruitment, outcome assessment, data management, or analysis.

    “The psychologist employed during the pilot study was experienced in CBT for the management of chronic pain, but had no prior experience of management of breathlessness, was naive to all outcome measures, and played no part in recruitment, outcome assessment, data management, or analysis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Combining exercise training with strategies that target the cognitive processes underlying the perceptual experience of dyspnea may lead to greater improvements in health outcomes.

    “Combining exercise training with strategies that target the cognitive processes underlying the perceptual experience of dyspnea may lead to greater improvements in health outcomes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Disease-specific health-related quality of life was assessed with the St George Respiratory Questionnaire (SGRQ).

    “Disease-specific health-related quality of life was assessed with the St George Respiratory Questionnaire (SGRQ).13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] 13. Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-com- plete measure of health status for chronic airflow limitation: the St. George's Respiratory Questionnaire. Am Rev Respir Dis 1992;145(6): 1321-1327. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Exercise capacity was assessed using the better of duplicate 6-min walk tests as recommended in the American Thoracic Society guidelines.

    “Exercise capacity was assessed using the better of duplicate 6-min walk tests as recommended in the American Thoracic Society guidelines.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] 12. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166(1):111-117. source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Pilot studies can be used to determine whether planning and resources for a larger trial are warranted.

    “Pilot studies can be used to determine whether planning and resources a larger trial are warranted.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] 8. Kraemer HC, Mintz J, Noda A, Tinklenberg J, Yesavage JA. Caution regarding the use of pilot studies to guide power calculations for study proposals. Arch Gen Psychiat 2006;63(5):484-489. source
    • cites [9] 9. Fain JA. Should we publish pilot/feasibility studies? Diabetes Educ 2010;36(4):521-521. source

  • Classified as probably not a substantial claim.

    Interpretationnone given

    The protocol raised a number of methodological limitations warranting modification.

    “although the protocol raised a number of methodological limitations warranting modification.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Anxiety and/or anxiety sensitivity may have been moderated with the BREVE intervention, with reduced anxiety associated with exercise-induced breathlessness reported by BREVE subjects.

    “Anxiety and/or anxiety sensitivity may have been moderated with the BREVE intervention, with reduced anxiety associated with exercise-induced breathlessness reported by BREVE subjects.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The CBT program for the perceptual experience of breathlessness was feasible and well accepted by subjects.

    “The CBT program for the perceptual experience of breathlessness was feasible and well accepted by subjects, although the protocol raised a number of methodological limitations warranting modification.”
    • Also stated in: § Discussion · plain
      “The CBT program was successfully implemented and positively received by the majority of subjects.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The 6-min walk distance minimum clinically important difference is 25 m.

    “the 6-min walk distance (6MWD; minimum clinically important difference of 25 m) 16”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [16] 16. Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2010;91(2):221-225. source

  • May combine two claims.

    Interpretationown data

    This pilot study developed a CBT intervention specific to the sensation of breathlessness that appears feasible and acceptable to subjects undertaking pulmonary rehabilitation.

    “This pilot study developed a CBT intervention specific to the sensation of breathlessness that appears feasible and acceptable to subjects undertaking pulmonary rehabilitation.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Estimating sample sizes for larger trials from pilot study results, although common practice, is contentious.

    “For these reasons, estimating sample sizes for larger trials from pilot study results, although common practice, is contentious.8”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] 8. Kraemer HC, Mintz J, Noda A, Tinklenberg J, Yesavage JA. Caution regarding the use of pilot studies to guide power calculations for study proposals. Arch Gen Psychiat 2006;63(5):484-489. source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisereasoning

    In theory, altering the way the sensation of dyspnea is perceived, especially reducing the fear/threat response, should alter behavioral outcomes.

    “In theory, altering the way the sensation of dyspnea is perceived, especially reducing the fear/threat response, should alter behavioral outcomes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Improving the experience of breathlessness without a subsequent improvement in functional exercise capacity or respiratory-related quality of life is unlikely to reduce health service usage.

    “However, improving the experience of breathlessness without a subsequent improvement in functional exercise capacity or respiratory-related quality of life is unlikely to reduce health service usage.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Pilot group subjects completed the standard program with the entire cohort scheduled within that rehabilitation cycle, which permitted discussion and conversation concerning the nature of the extra group BREVE session and the presence of the facilitator during the supervised exercise sessions.

    “Pilot group subjects completed the standard program with the entire cohort scheduled within that rehabilitation cycle, which permitted discussion and conversation concerning the nature of the extra group BREVE session and the presence of the facilitator during the supervised exercise sessions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The amount of missing data for primary outcomes post-intervention was 6 for 6MWD and 3 for SGRQ score.

    “the amount of missing data for primary outcomes post-intervention (6MWD n ϭ 6, SGRQ score n ϭ 3)”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    The imputation process may have inflated the mean change for the 6MWD.

    “Although the imputation process may have inflated the mean change for the 6MWD”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    There were a number of confounding issues within the pilot study, including disparity between group sizes and use of a retrospective control group.

    “there were a number of confounding issues within the pilot study (eg, disparity between group sizes, use of a retrospective control group)”
    Quote in the paperSubstantial claim
38 of 38

  • The paper relies on this without support.

    The retrospective control group is comparable to the pilot group in all relevant respects except for the BREVE intervention, so between-group differences can be attributed to BREVE.

    “This was a pilot study with a retrospective control.”

  • The paper relies on this without support.

    The extra psychologist contact and group attention in the BREVE arm did not by itself produce the greater 6MWD gains.

    “The psychologist also attended the supervised exercise sessions to coach individuals while breathless, in key tasks and techniques relevant to each module.”
    “The mean increase in the 6MWD was greater for the pilot group compared with the control group (P ϭ .03,effect size of 0.69).”

  • The paper relies on this without support.

    The six pilot subjects who provided feedback are representative of all pilot subjects, so the program's acceptability can be generalized to the pilot group.

    “Six of the 11 subjects provided written feedback: 5 used the feedback form, although not all respondents completed each item, and one provided handwritten feedback without the feedback form (Table 3).”
    “The CBT program was successfully implemented and positively received by the majority of subjects.”

  • The paper relies on this without support.

    The 6-min walk test and SGRQ have been previously used to assess responsiveness to pulmonary rehabilitation.

    “The 6-min walk test and SGRQ have been previously used to assess responsiveness to pulmonary rehabilitation.”

  • The paper relies on this without support.

    The SGRQ was originally developed for asthma and COPD, but, in the clinical research environment, is used predominantly in COPD populations.

    “The SGRQ was originally developed for asthma and COPD, but, in the clinical research environment, is used predominantly in COPD populations.”

  • The paper relies on this without support.

    At the time of this pilot study, the SGRQ was the recommended instrument for assessing quality of life for patients undertaking pulmonary rehabilitation within the Australian context.

    “At the time of this pilot study, the SGRQ was the recommended instrument for assessing quality of life for patients undertaking pulmonary rehabilitation within the Australian context”

  • The paper relies on this without support.

    The revised version of the SGRQ was not yet available at the time of this pilot study.

    “the revised version of the SGRQ was not yet available.”

  • The paper relies on this without support.

    Pilot studies commonly include small sample sizes (underpowered) and a variety of known and unforeseen methodological limitations.

    “By their nature, pilot studies commonly include small sample sizes (underpowered) and a variety of known and unforeseen methodological limitations.”
8 of 8

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Reported descriptor-change average omits the endorsed-category result

    Minor

    The discussion assigns an average change of 27% to volunteered or endorsed descriptor categories, but Table 5 reports 27% for volunteered categories and 20% for endorsed categories.

  • Pilot baseline SGRQ standard deviations conflict

    Minor

    Table 2 gives a pilot-group baseline SGRQ standard deviation of 6, while Table 6 gives 14.76. Even though the tables list 12 and 11 pilot subjects respectively, removing one subject cannot increase a standard deviation by this much.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. American Thoracic Society. Surveillance for respiratory hazards in the occupational setting. Am Rev Respir Dis, 1982; 126(5):952–956.
  2. Coe R. It's the effect size stupid. What effect size is and why it is important. Paper presented at the British Educational Research Association annual conference Exeter 12-14 September 2002. http://www.cem.org/attachments/ebe/ESguide.pdf. Accessed April 4 2015.

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Related

Authors
Williams, M. T., Cafarella, P., Paquet, C., & Frith, P.
Affiliations
  • University of South Australia (AU)
  • Department of Respiratory Medicine
  • Repatriation General Hospital (AU)
ORCID
Venue
Respiratory Care
Publisher
SAGE Publications
Published
2015-09
Volume
60
Issue
9
Pages
1303-1313
ISSN
0020-1324 (ISSN-L)
DOI
10.4187/respcare.03764
OpenAlex
W2167181578
Cited by
15
References
42
Citations by year
2025: 1 · 2023: 4 · 2022: 1 · 2021: 1 · 2020: 2 · 2019: 2 · 2018: 1 · 2017: 3
FWCI
1.05
Type
journal article
Language
en
Open access
Licence
journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations
  • Respiratory Care (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Australian Physiotherapy Association
  • University of South Australia
  • Lung Foundation Australia
Topics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
cognitive behavioral therapy, dyspnea, chronic obstructive pulmonary disease, pulmonary rehabilitation, 6-minute walk distance, St George's Respiratory Questionnaire, psychological intervention, feasibility
MeSH terms
Aged, Aged, 80 and over, Analysis of Variance, Dyspnea, Exercise Test, Feasibility Studies, Female, Humans, Male, Patient Acceptance of Health Care, Pilot Projects, Surveys and Questionnaires, Pulmonary Ventilation, Severity of Illness Index, Program Evaluation, Cognitive Behavioral Therapy, Walking, Exercise Tolerance, Disease Management, Pulmonary Disease, Chronic Obstructive

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-11.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-11.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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