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Physical activity measurement strategies in advanced chronic lung disease Dhillon, Satvir Singh 2014

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PHYSICAL ACTIVITY MEASUREMENT STRATEGIES IN  ADVANCED CHRONIC LUNG DISEASE by Satvir Singh Dhillon B.Sc., Simon Fraser University, 2011 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate and Postdoctoral Studies  (Rehabilitation Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2014 © Satvir Singh Dhillon, 2014  ii  Abstract Background: Physical activity may reduce mortality risk in advanced chronic lung disease by optimizing functional capacity, which is a major prognostic indicator in lung transplantation candidates. There is uncertainty as to the optimal method to measure physical activity in this patient population. We assessed different commercially-available physical activity measurement techniques (flex heart rate monitoring (FHR); pedometry; tri-axial accelerometry; and multi-sensor technology) by investigating their agreement with indirect calorimetry (IC) in adult lung disease patients (chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and cystic fibrosis (CF)) with advanced pulmonary impairment.  Methods: This is a cross-sectional method comparison study conducted on two separate days. We recruited consecutive COPD, ILD, and CF patients with physician diagnosis of advanced pulmonary impairment. On day one, participants performed cardiopulmonary exercise testing until exhaustion with measurements of oxygen uptake (VO2) and heart rate (HR) collected. On day two, subjects had their VO2 and HR measured during standardized resting and sub-maximal activity. SimultaneousVO2 and HR measures from both days were used to develop individual regressions for FHR-derived energy expenditure (EE). We then simultaneously measured each subject‘s EE using a variety of index measures of physical activity and IC during standardized ―free-living‖ type activities and varying intensities of sub-maximal cycle exercise.  Results: In a sample of eight participants (CF, n=5; COPD, n=2; ILD, n=1), Flex HR methods using submaximal (FMSUB) and CPET-derived (FMCPX) calibrations showed the best agreement and interchangeability with IC during free-living and cycling activities compared to the SenseWear (SW) and ActiCal (AC) devices as evidenced by lower mean differences with IC iii  and widths of limit of agreement (LOA) + 95% confidence interval (CI). For the secondary index methods assessed, the Tractivity and DigiWalker devices significantly over and underestimated IC EE respectively (p<0.05), whereas the Dynaport device did not differ from IC (p>0.05) over the entire protocol.   Conclusion: Our study found that the Flex HR method for EE estimation had the lowest bias and variability during free-living activities and exercise. EE estimation using Flex HR methods may be potentially useful clinical tools to ensure metabolic energy balance and activity monitoring in advanced lung disease groups.      iv  Preface This thesis is original work by the author, S. Dhillon. The UBC Pulmonary Rehabilitation Research Laboratory and Pacific Lung Health Centre assisted with data collection. Provision of patients for study recruitment; analysis and interpretation of data; critical revisions of the article for important intellectual content was done by the members of the author‘s supervisory committee, P. Camp, R. Levy, and P. Wilcox.  Providence Health Research Institute Ethics Boards approval was obtained for this research. The certificate number of the ethics certificate of approval to conduct research is H13-01117.  v  Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iv Table of Contents .......................................................................................................................... v List of Tables ............................................................................................................................... vii List of Figures ............................................................................................................................. viii List of Abbreviations .................................................................................................................... x Acknowledgments ...................................................................................................................... xiii Chapter 1: Introduction ............................................................................................................... 1 1.1 Lung transplantation in advanced lung disease ..................................................................... 1 1.2 Epidemiology, etiology, symptoms, and severity of the highest indications for adult lung transplantation ............................................................................................................................. 1 1.2.1 Chronic obstructive pulmonary disease .......................................................................... 1 1.2.2 Interstitial lung disease ................................................................................................... 3 1.2.3 Cystic fibrosis ................................................................................................................. 4 1.3 Growing healthcare burden of advanced lung disease .......................................................... 6 1.3.1 Increasing population of adults living with advanced lung disease ............................... 6 1.3.2 Lung transplantation waiting list trends showing increasing mortality .......................... 7 1.3.3 Mortality risk factors advanced lung disease ................................................................. 8 1.3.4 How can mortality risk be reduced in advanced lung disease? ...................................... 9 1.4 Improving physical activity through pulmonary rehabilitation........................................... 10 1.5 Daily physical activity—how can we measure this outcome? ............................................ 11 1.5.1 Physical activity conceptual framework ....................................................................... 11 1.5.2 Physical activity quantification methodologies ............................................................ 12 1.6 Physical activity measurement validity in chronic lung disease ......................................... 16 1.6.1 Inefficiencies of movement .......................................................................................... 16 1.6.2 Elevated resting metabolism ......................................................................................... 16 1.6.3 Interpretations of the literature ..................................................................................... 17 1.7 Rationale for this study ....................................................................................................... 18 1.8 Study objectives and hypothesis ......................................................................................... 20 vi  Chapter 2: Methods .................................................................................................................... 22 2.1 Statement of ethical adherence ............................................................................................ 22 2.2 Study design ........................................................................................................................ 22 2.3 Participants .......................................................................................................................... 22 2.4 Experimental procedures ..................................................................................................... 25 2.5 Measurements...................................................................................................................... 27 2.6 Data management and statistical analysis ........................................................................... 35 2.6.1 Analyses........................................................................................................................ 35 2.6.2 Prospective sample size calculation ............................................................................. 37 Chapter 3: Results....................................................................................................................... 40 3.1 Study enrollment ................................................................................................................. 40 3.2 Participant characteristics .................................................................................................... 40 3.3 Trends in Bland-Altman agreement plots ........................................................................... 41 3.3.1 Bias estimates and limits of agreement during flat walking (Figure 12) ...................... 41 3.3.2 Bias estimates and limits of agreement during incline walking (Figure 13) ................ 42 3.3.3 Bias estimates and limits of agreement during sit-to-stand activity (Figure 14) .......... 42 3.3.4 Bias estimates and limits of agreement during lift-bend activity (Figure 15) .............. 42 3.3.5 Bias estimates and limits of agreement during cycling (Figure 16 to 19) .................... 43 3.3.6 Interchangeability between primary index and IC methods ......................................... 43 3.4 Nonparametric significance testing ..................................................................................... 44 3.5 Graphical representations of validity .................................................................................. 45 Chapter 4: Discussion ................................................................................................................. 46 4.1 Key findings ........................................................................................................................ 46 4.2 Clinical implications ........................................................................................................... 48 4.3 Study limitations and future research .................................................................................. 50 4.4 Conclusion ........................................................................................................................... 52 References .................................................................................................................................... 84 Appendices ................................................................................................................................. 105 Appendix A. Step-by-step cardiopulmonary exercise testing protocol................................... 105 Appendix B. Calculations of standard deviation of difference from previous validation literature .................................................................................................................................. 106 vii  List of Tables Table 1. Participant Selection Criteria. ......................................................................................... 53 Table 2. Features of the Physical Activity Monitors Including Type, Location of Attachment, Units of Energy Expenditure Estimation, and Cost. ..................................................................... 54 Table 3. Participant Characteristics for All Participants. .............................................................. 55 Table 4. Exacerbation History and Comorbidities. ....................................................................... 56 Table 5. Cardiopulmonary Exercise Test Performance. ............................................................... 57 Table 6. Assessment of Interchangeability for Primary Index Methods using Limits of Agreement with Precision Estimates. ........................................................................................... 58 Table 7. Comparison of Average Energy Expenditure (kcal/min) Measured by Each Index Method During Free-Living Activities, Cycling, and the Entire Protocol. .................................. 60    viii  List of Figures Figure 1. Lung Transplantation Waiting List Trends in Canada. ................................................. 61 Figure 2. Theoretical Model of Physical Fitness and Mortality Risk. .......................................... 62 Figure 3. Conceptual Framework of Physical Activity Measurement. ......................................... 63 Figure 4. Conceptual Framework of Indirect Calorimetry. .......................................................... 64 Figure 5. Conceptual Framework of Doubly Labeled Water Technique...................................... 65 Figure 6. Step-By-Step Flow Diagram of Study Procedures. ....................................................... 66 Figure 7. Flex Heart Rate Calibration Protocol. ........................................................................... 67 Figure 8. Location of Attachment of the Activity Monitors and Indirect Calorimeter................. 68 Figure 9. Low Intensity Free-Living Activities Protocol. ............................................................. 69 Figure 10. Submaximal Steady-State Cycling Protocol ............................................................... 70 Figure 11. Participant Enrollment Flow Diagram. ........................................................................ 71 Figure 12. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Flat Walk. .......................................................................................................... 72 Figure 13. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Incline Walk. ..................................................................................................... 73 Figure 14. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Sit-to-Stand Activity. ......................................................................................... 74 ix  Figure 15. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Lift-Bend Activity. ............................................................................................ 75 Figure 16. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 10% Peak Workload......................................................................... 76 Figure 17. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 25% Peak Workload......................................................................... 77 Figure 18. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 50% Peak Workload......................................................................... 78 Figure 19. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 60% Peak Workload......................................................................... 79 Figure 20. Scatter Plots of Energy Expenditure During Free-Living Activities. .......................... 80 Figure 21. Scatter Plots of Energy Expenditure During Cycling Activities. ................................ 81 Figure 22. Scatter Plots of Overall Energy Expenditure for Primary Index Methods. ................. 82 Figure 23. Scatter Plots of Overall Energy Expenditure for Secondary Index Methods. ............. 83   x  List of Abbreviations 6MWT Six minute walk test AC ActiCalTM ATS American Thoracic Society BCC Burkholderia cepacia complex BMD Bone mineral density BMI Body mass index CF Cystic fibrosis CI Confidence interval COPD Chronic obstructive pulmonary disease CPDR Canadian Cystic Fibrosis Patient Data Registry CPET Cardiopulmonary exercise testing DLCO Diffusing capacity of the lungs for carbon monoxide DLW Doubly labeled water DP DynaportTM DW DigiWalkerTM ECA Energy cost of activities xi  EE Energy expenditure ERS European Respiratory Society FEV1 Forced expiratory volume in one second FMCPX Flex heart rate method with peak exercise calibration profile FMSUB Flex heart rate method using submaximal exercise calibration profile FVC Forced vital capacity HR Heart rate IC Indirect calorimetry Icap Inspiratory capacity ILD Interstitial lung disease LAS Lung allocation score LOA Limit of agreement LTx Lung transplantation REE Resting energy expenditure SD Standard deviation SE Standard error SW SenseWearTM xii  TR TractivityTM VC Vital capacity VCO2 Carbon dioxide production VO2 Oxygen uptake    xiii  Acknowledgments  I would first like to express my deepest appreciation to my supervisor Dr. Pat Camp for her mentorship, friendship, and encouragement, and patience with me throughout this graduate experience. I would also like to express my gratitude to the members of my supervisory committee, Dr. Robert Levy for your advice and guidance, and Dr. Pearce Wilcox for your support during data collection, advice, and guidance. I am grateful to have had the opportunity to work with such exceptional and influential mentors.   Thank you to my lab mates in the UBC Pulmonary Rehabilitation Research Laboratory and the UBC Cardiopulmonary Exercise Physiology Laboratory who have worked with me on this project for your contributions.   Last, but certainly not the least, thank you to my amazing family and friends for supporting me in so many ways throughout my studies. I feel so blessed to have been surrounding by such wonderful people who encouraged me to pursue my goals.     1  Chapter 1: Introduction 1.1 Lung transplantation in advanced lung disease  In the face of advanced lung disease, lung transplantation (LTx) may be the ultimate treatment option for those patients at a high risk of mortality who have exhausted all other conventional medical treatment options. The main goals of this procedure are to confer a survival benefit in patients as well as to improve health related quality of life1, 2.   The annual number of all single and bilateral lung transplants performed in Canada has steadily risen from 116 in 2003 to 188 in 2012, with an overwhelming majority over 90% of first graft patients in Canada being of adult age3. The three most common indications for all single and bilateral adult LTx procedures performed worldwide between 1995 and 2012 (n=37,581) were chronic obstructive pulmonary disease (COPD, 39%), interstitial lung disease (ILD, 24%), and cystic fibrosis (CF, 17%)4.  1.2 Epidemiology, etiology, symptoms, and severity of the highest indications for adult lung transplantation 1.2.1 Chronic obstructive pulmonary disease  COPD is a progressive pulmonary disorder mainly caused by smoking, and primarily characterized by irreversible airflow limitation5, 6. According to data from the Canadian Health Measures Survey, approximately 13% of Canadians aged 35-79 had spirometric evidence consistent with a diagnosis of COPD between 2009 and 20117. Prevalence estimates of COPD have been quite variable in the literature8, possibly due to different methods used to establish a COPD diagnosis.  2  The hallmark of COPD is chronic airflow limitation, which is due to a combination of obstructive bronchiolitis and emphysema9. The chronic inflammatory state of the respiratory tract results in airway remodeling and parenchymal destruction due to exposure to cigarette smoke6. These pathological changes characteristic of COPD also lead to a reduction in lung elastic recoil, thereby furthering airflow limitation5. In addition to the airflow limitation, COPD patients may also suffer from lung hyperinflation, systemic complications, and exacerbations5.  The diagnosis and severity of COPD may be determined by assessing lung function using spirometry testing10. The ratio of the forced expiratory volume in one second and forced vital capacity (FEV1/FVC) less than 0.7 is recommended to establish a diagnosis of COPD6. Further to confirming COPD diagnosis based on FEV1/FVC, measurement of FEV1 % predicted is used to grade the severity of pulmonary impairment according to guidelines developed by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease6: mild (FEV1≥80% predicted), moderate (50%≤FEV1<80% predicted), severe (30%≤FEV1<50%), and very severe (FEV1<30% predicted or FEV1<50% with chronic respiratory failure).   COPD patients suffer from skeletal muscle dysfunction in the peripheral locomotor muscles as a result of the disease progression5. Peripheral muscle wasting occurs in approximately 30% of patients and increases as disease severity advances11. In advanced stages of COPD, peripheral muscle force has been shown to be reduced to 60±15, 85±25, and 81±18 % of predicted values in the quadriceps, triceps, and biceps respectively12. These muscular abnormalities, which result from a combination of impaired mobility, poor nutrition, chronic hypoxia, and inflammatory state13, 14, lead to a reduction in exercise capacity15. Abnormal 3  breathing mechanics, impaired ventilation, and dynamic hyperinflation of the lungs are other factors limiting exercise capacity in COPD16, 17.  1.2.2 Interstitial lung disease ILD is an umbrella term referring to a large number of distinct acute and chronic disorders known as diffuse parenchymal lung diseases which may be of known or unknown (idiopathic) etiologies18. Although heterogeneous in etiology and clinical manifestations, these conditions are characterized by the development of pulmonary fibrosis and diffuse pulmonary inflammation affecting the lung parenchyma19. Epidemiological data in ILD has been scarcely reported in Canada and globally. Registry data out of New Mexico, USA has been frequently cited in the literature to highlight ILD annual prevalence rates of 80.9 per 100,000 population in males and 67.2 per 100,000 population in females20. From the same registry study, ILD incidence is estimated at approximately 30 per 100,000 population annually with higher incidence estimates for males compared to females20.  ILD primarily affects the interstitium of the lung parenchyma in the regions between capillary endothelial cells and alveolar epithelial cells21. Derangement of the alveolar walls is caused by the development of pulmonary fibrosis resulting from long-term pneumonitis, or diffuse pulmonary inflammation22. For the ILD subsets with known causes intrinsic or extrinsic to the body, environmental/occupational toxins, immunological factors, drugs, and radiation may be responsible for the pathogenesis23. Advanced fibrosis of the lung parenchyma is characterized by ‗honeycombing‘ observed through high resolution CT scanning of the lungs22. Clinicians may suspect ILD by the presence of inspiratory crackles on auscultation, which result from the opening of alveolar airspaces encapsulated by a fibrotic interstitial wall21. Respiratory 4  manifestations common to all forms of ILD include shortness of breath and shadowing on chest imaging investigations18. Dyspnea and dry cough that worsens over time regardless of smoking history may also indicate ILD21. In advanced stages of the disease, ILD patients may also have resting tachypnoea, cyanosis, and cor pulmonale18.  ILD patients commonly present a restrictive pattern of pulmonary dysfunction, characterized by abnormally reduced lung volumes despite preserved or elevated FEV1/FVC ratios in addition to reduced diffusing capacity of the lungs for carbon monoxide (DLCO)18. Standard criteria for stratifying the severity of lung disease abnormality in ILD are nonexistent. Restrictive lung abnormality may be graded as followed based on % predicted vital capacity (VC) measurements24: mild severity (70% predicted ≤VC< Lower limit of normal), moderate severity (60%≤VC<70% predicted), moderate severe severity (50%≤VC<60%), severe severity (34%≤VC<50%), and very severe severity (VC<34% predicted). A DLCO ≤ 40% predicted may also indicate severe impairment25. Activity limitation and maximal oxygen uptake impairment is frequently seen in patients with restrictive lung diseases26. Gas exchange abnormality and circulatory limitations are the main factors reducing exercise capacity in ILD27. During exercise, venous return is reduced in ILD patients due to an increased pulmonary vascular resistance caused by a reduction in lung compliance and elevated work of breathing27. As a result, cardiac output increase is insufficient to meet the oxygen requirement of the muscles during exercise27.     1.2.3 Cystic fibrosis  CF is a lethal autosomal recessively inherited disease most commonly seen in Caucasian populations22. The birth prevalence of CF is 1 in 3600 live births in Canada28, with a total of 5  3849 individuals registered in one of the 42 CF clinics nationwide in 201029, up from 2191 registered CF patients in 198430. With therapeutic advances, the prognosis for people born with CF has changed dramatically over the past few decades. The median survival age in Canada has steadily increased from 25 years in 198430 to nearly 50 years in 201029.  The hallmark of CF lung disease is the development of massive airway infection and inflammation31 and airway obstruction by viscous mucus accumulation and aggregation of degraded cellular components, which is related to the failure of the epithelial ion transport system32. Chronic pulmonary dysfunction will eventually lead to respiratory failure and on occasion pulmonary hypertension as the disease severity worsens33. Although CF affects the epithelial cells of many systems in the body, pulmonary and gastrointestinal manifestations of the disease are the main concern. Multiple complications beyond the respiratory and GI systems associated with the disease process have been documented in CF patients including reduced bone mineral density (BMD)34-37, malabsorption and undernutrition34, 35, 37-39, pancreatic disease40, and CF-related bone disease, diabetes, arthropathy, and liver disease41. Pulmonary dysfunction is the most common cause of death in people with CF40.  The degree of CF lung disease impairment may be stratified using FEV1 % predicted according to recently published recommendations42: normal lung function (FEV1≥90 % predicted), mild severity (70%≤FEV1<89% predicted), moderate severity (40%≤FEV1<69% predicted), and severe severity (FEV1<40 % predicted).     Muscle weakness is a comorbidity commonly reported in CF43-45. In advanced stages of CF, peripheral muscle force has been shown to be reduced to 49±18, 60±20, and 71±22 % predicted in the quadriceps, triceps, and biceps respectively12. Despite controlling for lean body 6  mass there is reduced peripheral skeletal muscle mass in CF, suggesting the occurrence of muscle wasting with disease progression46. In addition to peripheral skeletal muscle abnormalities, increased work of breathing, respiratory muscle inefficiency and weakness, and arterial hypoxemia also contribute to exercise limitation in CF47. In advanced stages, the prolonged hypoxemic state can contribute to cardiac limitations to exercise as well such as the development of right ventricular dysfunction47.        1.3 Growing healthcare burden of advanced lung disease 1.3.1 Increasing population of adults living with advanced lung disease Population ageing is a global phenomenon, with projections of the population over 60 years of age expected to increase from 841 million people in the year 2013 to 3 billion in the year 210048. The population of advanced COPD increases with age49. As the population ages and smoking frequencies increase, COPD prevalence is projected to increase in most countries around the world49, 50. Similarly to the COPD population, ILD incidence rises with advancing age51. Idiopathic pulmonary fibrosis is the most common and lethal form of ILD52, comprising the majority of advanced ILD subgroups indicated for LTx4. Estimates of the prevalence of idiopathic pulmonary fibrosis have shown to drastically increase in older age, ranging from 4 per 100, 000 population in those aged 18-34 years to approximately 230 per 100, 000 population in those aged 75 years and older53.   In addition, the proportion of CF patients reaching adulthood is continuing to rise. Of the 3849 patients with CF in the Canadian Cystic Fibrosis Patient Data Registry (CPDR) 2010 Report, 2201 (57.2%) were adults29. This represents a dramatic rise in the number of adults with CF over almost three decades, up from approximately 646 (29.5% of all CF patients) in 198430. 7  These changes may be largely attributed to significant improvements in survival as a result of advances in CF therapy. Although these successes have transformed the prognosis of CF for patients, this demographic shift into the adult CF population presents a growing healthcare burden as the longterm complications of the disease process associated with the increased patient lifespan are now more prevalent54. Adults have a higher risk for serious CF-related complications related to the longterm effects of ion transport abnormality, including more advanced lung function impairment as assessed by % predicted forced expiratory volume in 1 second (FEV1)29, CF-related diabetes29, and low BMD with increased fracture risk36, 54. Additional CF-related complications seen more frequently in adults than children have been described in detail elsewhere55. 1.3.2 Lung transplantation waiting list trends showing increasing mortality As the population of advanced lung disease grows we can expect the number of lung transplant candidates to continue to increase as well. Recent registry data indicates a trend towards a concordant rise in the number of candidates and deaths on the lung transplant waiting list3. Figure 1 shows that the number of deaths in all patients waiting for LTx has risen steadily in Canada, from 29 (17% of 172 total LTx candidates) in 2003 to 69 (21% of 329 total LTx candidates) in 20123. The rise in number of deaths on the waiting list may be attributed to the growing disparity between the increasing number of transplant candidates and the available organ donor pool, which has remained constant56. As a result, more patients will die in the pre-transplant stage while on the waiting list than from transplantation-related mortality56. Mortality of advanced lung disease patients awaiting lung transplantation represents an important public health concern and therefore there is a need to reduce mortality risk in lung transplant candidates. 8  1.3.3 Mortality risk factors advanced lung disease With the recent adoption of the Lung Allocation (LAS) Score system in the United States57, determination of waiting list survival probability has become an important allocation criterion in stratifying patients based on medical urgency. The LAS score is determined by waitlist urgency during pre-transplant stage and predicted survival post-transplant. The International Society for Heart and Lung Transplantation candidate selection guidelines suggest that patients be referred for LTx assessment if they have a less than 50% predicted chance of survival within the next 2 to 3 years or have a III or IV level of function according to the New York Heart Association classification, or both58. The decision to refer a patient for LTx is dependent on a thorough physiological and psychological evaluation of specific baseline prognostic indicators to determine the pulmonary disease severity and suitability of the patient for LTx.  Several models have been developed to assess mortality risk in advanced lung disease groups59-61. FEV1 has been suggested as the best prognostic indicator in people with COPD62 and CF63. FEV1 % predicted measures of less than 20% in COPD and 30% for CF are suggested thresholds for listing advanced patients for LTx58. Other risk factors associated with poor prognosis in COPD which must be taken into consideration include arterial hypoxemia, hypercapnia, emaciation indicated by low BMI, and elevated dyspnea64. In ILD, measurement of DLCO and radiographic evidence of fibrosis are often used predictors of survival60. DLCO % predicted of less than 40% is a suggested threshold for listing ILD patients for LTx58. Exacerbation history is also a factor which must be considered when determining the optimal timing for listing58.     9  Poor performance on physical fitness assessments such as the 6 minute walk test (6MWT) has been shown to be a significant mortality risk factor in LTx candidates65-68. The 6MWT is a submaximal field test of functional capacity that measures the distance walked by the subject on a hard flat surface in a 6 minute time period69. In a sample of 163 lung transplant candidates (46.6% COPD; 29.4% CF; 23.9% ILD) distance walked during 6MWT was a significant predictor of mortality (p<0.001) showing a relative risk of 0.994 (95% confidence interval, 0.990 to 0.997) with each meter increase in 6MWT performance68. Prognosis may also be ascertained by measures of peak aerobic fitness, or peak oxygen uptake (VO2), during maximal exercise testing. Peak VO2 is not associated with mortality in COPD (Hazard Ratio, 0.971; 95% confidence interval, 0.959 to 1.000; p = 0.050); however, non-survivors have a significantly lower mean peak VO2 (p<0.0001) than survivors70. Peak VO2 is significantly associated with mortality in ILD (Hazard Ratio, 0.88; 95% confidence interval, 0.79 to 0.99; p = 0.039)71, and in CF showing a relative risk of 3.2 (95% confidence interval, 1.2 to 8.6; p = 0.024) with lower aerobic fitness72.   1.3.4 How can mortality risk be reduced in advanced lung disease? Unlike the other mortality risk factors discussed previously, physical fitness represents a modifiable risk factor which may be improved or maintained by exercise training, or physical activity conducted in a structured and repetitive manner designed to optimize fitness73.  An individual‘s physical fitness level may be assessed by evaluating the health-related components of functional status, which include musculoskeletal fitness, cardiovascular fitness, body composition, and metabolism74, 75. In fact, physical activity has been reported as the strongest prognostic indicator for mortality in COPD76. Reputable guidelines have recognised physical activity as a non-pharmacological treatment option in COPD9. In candidates for LTx, exercise 10  training has been shown to lead to improvements in physical fitness as measured by 6MWT distance77. LTx candidates with higher exercise capacity have also been shown to have a shorter length of hospital stay post-transplant78. Therefore, optimization of the patient‘s physical fitness with tailored exercise intervention and overall maintenance of physical activity could theoretically improve the patient‘s chances of surviving while waiting for an organ to become available for LTx and improve post-transplant outcomes. Figure 2 presents a theoretical model linking physical fitness to mortality in advanced lung disease. 1.4 Improving physical activity through pulmonary rehabilitation Exercise is a component of pulmonary rehabilitation, ―...a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy...‖79, which is considered an integral part of the clinical management of people with chronic lung disease80, 81. Pulmonary rehabilitation is implemented by lung transplant programs to improve the health of patients during both the pre- and post- transplant stage82, 83. It is comprised of exercise training, education, and nutritional and psychosocial support80. According to the American Thoracic Society, pulmonary rehabilitation is designed to ―…(1) reduce symptoms, (2) optimize functional status, (3) increase participation, (4) and reduce healthcare costs through stabilizing or reversing systemic manifestations of the disease…‖80. An additional goal of rehabilitation specifically for advanced lung disease patients awaiting surgery is to ―...optimize physical and emotional health [prior to surgical intervention]...‖84 The primary purpose of a rehabilitation program is to improve the ability of the patients to perform their activities of daily living and improve habitual physical activity levels85. 11  Physical activity level is an important outcome to consider in advanced lung disease patients in or close to the pre-transplant stage of their disease progression to determine whether or not patients are maintaining the effects of rehabilitation by continuing to be physically active in their home, or ―free-living‖ environment. Langer and colleagues concluded that COPD and ILD LTx candidates are largely inactive (69% of waking hours measured as sedentary)86. Accurate and objective measurement of physical activity level would enable the monitoring of habitual physical activity levels and in the appropriate titration of exercise training prescriptions for these advanced lung disease patients. There are no evidence-based exercise training guidelines designed specifically for advanced lung disease patients87. 1.5 Daily physical activity—how can we measure this outcome?  1.5.1 Physical activity conceptual framework  Physical activity is a bioenergetic process involving the conversion of the chemical energy obtained from dietary intake to the mechanical energy used to perform body movements. It has been defined as ―any bodily movement produced by skeletal muscles that results in energy expenditure [above resting metabolism].‖73Additionally, it has been defined as ―… the totality of voluntary movement produced by skeletal muscles during everyday functioning…‖88. Therefore, the measurement of physical activity may be assessed conceptually in relation to either energy expenditure or bodily movement dimensions. Metabolic energy expenditure (EE), has three components: resting energy expenditure (REE) for maintaining homeostasis at rest, dietary thermogenesis for the acquisition and storage of energy from caloric intake, and energy cost of activity (ECA)89, 90. ECA is the mechanical energy used by skeletal muscles to perform body movements, or physical activity. ECA may be exercise-related or incidental non-exercise activity 12  thermogenesis. Additionally, the dimensions of physical activity may be characterized by their frequency, intensity, duration, and mode of activity components91, 92. Figure 3 presents a conceptual framework of physical activity based on our understanding from the literature.    1.5.2 Physical activity quantification methodologies     Measurement of daily habitual or ―free-living‖ EE or movement patterns throughout the day may be used to evaluate a patient‘s physical activity behavior at home or in a rehabilitation setting. The globally accepted ―gold-standards‖ or criterion methods for quantifying EE are indirect calorimetry (IC) and doubly labeled water (DLW)92. Movement dimensions of physical activity can be measured by direct observation4. Other approaches for estimating daily physical activity are questionnaires and motion and/or physiological sensor devices. Although questionnaires are affordable and simple to use, they are subjective93 and may be inaccurate due to recall bias94 and unreliable due to memory limitations95. In general, there are three main types of field devices used most often in chronic disease populations: pedometry, accelerometry, and integrated multi-sensor technology96. Heart rate monitoring devices may also be utilized in the field setting to estimate physical activity levels97. An overview of the aforementioned objective methodologies, including their specific strengths and drawbacks, is presented in the proceeding sections. 1.5.2.1 Indirect calorimetry (Figure 4)  IC involves the measurement of oxygen consumption (VO2) and carbon dioxide production (VCO2) to calculate EE. The assumption underlying this methodology is that all consumed oxygen is utilized to metabolize chemical fuels from food intake and all carbon dioxide output is recovered98. Using known standard formulae89, EE can be calculated from 13  measured VO2 and VCO2. Portable IC systems have been developed which have been shown to provide accurate and reliable pulmonary gas exchange measurements during rest and activity99, 100. Although IC techniques are highly valid, the instrumentation is prohibitively expensive, cumbersome for the patients to wear, and requires specialized expertise to interpret the recordings and set up the equipment. As a result, IC techniques are not appropriate for regular clinical use and are often used to validate other, more practical methods of physical activity measurement in controlled lab settings101.   1.5.2.2 Doubly labeled water (Figure 5) DLW involves the measurement of the differential clearance rates of previously ingested amounts of oxygen and hydrogen isotopes from the body over multiple days to calculate carbon dioxide production102. VCO2 is then used in conjunction with measurements or estimations of the respiratory quotient to determine VO2 and ultimately EE103.  Although DLW provides valid measure of overall free-living EE during the measurement period (usually 4 to 21 days)104, it does not describe day-to-day EE levels and the isotopes are prohibitively expensive103. Specialized expertise is also required to analyze the recordings and to operate the required equipment. As a result, DLW techniques are not appropriate for regular clinical use and are often used to validate other, more practical methods of physical activity measurement in free-living field settings101.   1.5.2.3 Behavioural observation  Behavioural (direct) observation involves a designated observer, or group of observers, to meticulously quantify movements of subjects by watching their activities in real-time or videotaped recordings from previous activities105. This technique of physical activity assessment 14  requires a large time-commitment, is intrusive for the subjects being evaluated, and would be inappropriate for studying larger populations93. Similar to IC and DLW, it would be inappropriate for regular clinical use; however, may be employed to validate other more practical methods of physical activity measurement106.     1.5.2.4 Pedometry  Pedometers are affordable, lightweight, small-sized monitors worn attached to the waist that provide motion counts, or steps, when its internal spring lever is deflected with each vertical deflection at the hip93. In addition to steps, pedometers may also be able to detect the vertical motions encountered when getting up from a seated position107. Given its ease of use for the general population, large-scale public health campaigns have suggested pedometer output thresholds (10 000 steps per day) to achieve health benefits108. Although simple and inexpensive, studies have shown a tendency for pedometers to underestimate steps during slower speeds of walking109. Additionally, improper positioning may also result in an underestimation of activity output from the pedometer110. Moreover, pedometers are incapable of providing information regarding the duration and intensity of physical activities93, 110.      1.5.2.5 Accelerometry Accelerometers, which may be uni-, bi-, or tri-axial, measure accelerations of body segments in one, two, or three dimensions respectively96. Accelerometers are capable of capturing the quantity and intensities of body movements111. These devices may be more expensive than pedometers and require additional software and expertise to analyze the recordings93. Additionally, waist and lower limb worn accelerometers are limited in their ability 15  to distinguish arm movements93. Some accelerometers may also be unable to measure activity during static exercises112 or may underestimate activity during incline walking113.  1.5.2.6 Multisensor Technology   Devices that integrate accelerometry data with physiological sensor data that records body responses (ie skin temperature or heart rate) have been shown to improve validity compared to accelerometry-only devices114. Multisensors have also been show to be valid in quantifying cycling exercise115, compared to standard accelerometers which have largely underestimated activity level during cycling116. One of the major drawbacks of multisensors is their high costs relative to accelerometers and pedometers, which may increase depending on the type of additional software required for the data analysis93.     1.5.2.7 Heart rate monitoring Heart rate (HR) measurement has been widely used to assess physical activity. Flex-heart rate (HR) techniques assume a relationship between HR and physical activity, and that HR is closely associated with VO2 above resting levels117. This technique involves recording minute-by-minute HR in the field and extrapolating EE data from individual HR-VO2 regressions developed in the lab during invasive exercise testing118. After the invasive exercise testing required to construct the individual calibrations is complete, physical activity measurement by HR monitoring is relatively convenient, cheap, and noninvasive. Another strength of this technique is the individualized, subject-specific nature underlying the measurement of physical activity. One of the limitations of this technique is the requirement of IC instrumentation in developing their HR-VO2 regression profiles in a lab setting which can be costly and time-consuming as discussed previously.  16  1.6 Physical activity measurement validity in chronic lung disease  1.6.1 Inefficiencies of movement  Skeletal muscles utilize a small portion of available EE output to perform external work, with the remaining EE lost to the environment as heat. Higher ratio of external work to EE indicates better muscular efficiency119. Evidence suggests that there may be reduced mechanical efficiency in COPD and CF, resulting in elevated costs of activity. Studies have reported up to 10% increases in energetic costs in COPD patients relative to healthy people when performing strenuous activities120. The energy cost of performing physical activities has been shown to be higher than normal in CF patients as well during walking and cycling121. As a result, patients may be expending greater amounts of energy than normal to carry out a given movement of activity and tiring sooner. In theory, movements or durations of certain activities suggested in the guidelines as of moderate or light intensities122 may actually approach vigorous intensity levels in advanced lung disease patients. Therefore, devices used to monitor movements or durations in particular postures and compared to standard guidelines of the quantity of required activities required to elicit health benefits in healthy people may actually not be appropriate for advanced lung disease patients and require titrations of guidelines to accommodate their elevated energy demands.   1.6.2 Elevated resting metabolism  An elevated REE relative to healthy controls or predicted values has been shown in COPD patients (>10% above predicted)123, ILD patients (>20% above predicted)124, and CF patients (10% above predicted)125. REE 10% above predicted indicates a hypermetabolic state90. The elevated oxygen cost of breathing or oxygen consumption by the respiratory muscles, in 17  chronic lung disease patients with their abnormal pulmonary mechanics and structure may contribute to the increased REE126-128. A phenomenon reported in COPD and CF which may be the largest contributor to the hypermetabolic characteristics of advanced lung disease is dynamic hyperinflation. Lung hyperinflation is defined as the elevation of end expiratory lung volume above normal levels during rest and/or exercise129. Dynamic hyperinflation has been shown to occur in COPD16 and CF130. As a result, using activity measurement techniques calibrated from healthy populations with normal metabolism may not accurately reflect the daily EE of hypermetabolic patient who require increased energy demands from breathing during rest and exercise.  Typically, field devices such as pedometers and accelerometry-based devices estimate energy expenditure using equations developed in relatively healthy populations131. Therefore, the elevated resting and activity EE resulting from abnormal body functioning may not be accurately measured by these physical activity monitors relying on EE estimations from standard equations developed in other non-disease populations.  1.6.3 Interpretations of the literature In summary, many of the field devices discussed previously measure different components of physical activity (i.e. steps, acceleration, position changes, duration of movements, heart rate, etc).  In addition, many of these devices provide an estimation of EE. Therefore, EE measurement is an outcome that can be compared across physical activity monitors. Most of these devices have been validated in young, healthy populations96 and their applicability to a chronic lung disease population is not well established. Specifically, differences in efficiency of movement and resting metabolism, and the use of algorithms for estimating EE 18  derived likely from relatively healthy populations may result in an inaccurate measure of physical activity in chronic lung disease populations.   Our review of the literature identified a small number of validity studies of physical activity measures conducted in COPD132-136 and CF patients137, 138. No validation studies in ILD were found. In general, the mean differences (standard deviation of differences) between estimated EE from actual EE measured by IC or DLW have been quite variable across validated monitors and disease. Pedometers underestimated EE in COPD by 2.4 ± 3.4 kcal/min difference with IC132. Multisensor accuracies ranged from underestimation in COPD of 1.3 ± 4.1 kcal/min difference with IC132 to overestimation in CF of 1.8 ± 1.3 kcal/min difference with IC137. Flex HR was found to underestimate EE measured by DLW by 454.1 ± 406.3 kcal/day in CF138. Although all of these studies concluded the devices were valid for measuring EE, they did not provide any information on whether or not the magnitude of the EE differences was clinically acceptable. As a result, the accuracy and precision of the monitors still remains questionable. These studies were also conducted in samples with wide ranges of disease severity. No study was found that validated the monitors specifically in advanced lung disease patients or in a sample combining multiple disease groups.   1.7 Rationale for this study  It is challenging for clinicians and researchers to determine the appropriate tool for objectively measuring physical activity due to the vast selection of currently available measurement techniques. Although issues of practicality and feasibility come into play when judging which tool would be appropriate for a given patient population, the accuracy of the tool in measurement of a physical activity parameter is an important consideration as well.   19  Since participation in physical activity has the potential to reduce waiting list mortality in advanced chronic lung disease patients during the pre-transplant stage, valid physical activity monitors are needed to accurately monitor physical activity in this patient population. Tudor-Locke and colleagues suggest that motion sensing monitors (pedometers or accelerometers) are ‗good enough‘ for monitoring activities in sedentary individuals139. To our knowledge, these devices would be unable to capture the true activity level of advanced lung disease patients who are prescribed activities more strenuous and complex than walking to maintain training effects of pulmonary rehabilitation programs at home. Accurate measurement of EE would provide a more appropriate evaluation of their activity level, assuming that the EE estimation of the particular monitor is accurate. Whether the standard EE estimation equations developed in commercially available monitors are superior to the EE estimation from an individually calibrated equation such as one developed using the Flex HR method remains to be determined.  Therefore, we undertook this study to investigate and compare the accuracy of a variety of physical activity monitoring techniques (pedometry, accelerometry, multi-sensor technology, HR monitoring techniques) simultaneously against a gold standard of indirect calorimetry-derived measurements from a portable metabolic system in a population of adults with advanced lung disease in a controlled lab setting. We also investigated how their accuracy changed with varying types and intensity levels of activity during standardized ―lifestyle‖ activities and cycling exercise.  All of these techniques have been validated previously in chronic lung disease populations132-136; however, this is the first study to compare the validity of these objective energy expenditure measurement tools specifically in advanced lung disease populations. To our knowledge, no previous study has attempted to compare the validity of all of these specific 20  physical activity monitoring techniques simultaneously in their ability to estimate EE in any chronic lung disease population.  1.8 Study objectives and hypothesis The objective of this study is to investigate and compare the accuracy of various commercially-available energy expenditure (EE) measurement techniques (index test methods) including flex heart rate (HR) technique, multi-sensor activity monitoring, 3 accelerometry devices, and pedometry against indirect calorimetry (gold standard method) during a battery of standardized free-living (lifestyle) - type activities and exercise of varying intensity in patients with advanced lung diseases. In addition, we will explore how the accuracy of the devices differs across different types of activities. To achieve our objective, we addressed the following aims: (1) To develop individualized HR-oxygen uptake (VO2) regression profiles for each subject during standardized resting and submaximal cycling exercise of varying intensities for estimating EE using the Flex HR technique.  (2) To obtain simultaneous EE estimations from each of the index test methodologies using a HR monitor, a multi-sensor activity monitor, a pedometer, and three tri-axial accelerometers concurrently with a gold standard derived measurement of EE from a portable indirect calorimeter during a battery of standardized activities and during a standardized exercise protocol.  (3) To explore the criterion-related and concurrent validity of each index test method for EE estimation against indirect calorimetry-derived measurements of EE across monitors.  21  We proposed the following primary hypothesis based on our understanding of the literature:  Unlike pedometers, accelerometers, and multi-sensor methods, which estimate EE by transforming signals using proprietary prediction equations or equations calibrated in healthy people, an individually calibrated technique such as the Flex HR method may be more accurate for assessing EE in advanced lung disease patients as it takes their REE into account. Therefore, we hypothesized that the Flex HR methods would be more accurate than the other index measurements of EE evaluated in this study due to it being a more individualized approach compared to the other methods, which may not be as capable of quantifying the metabolic abnormalities associated with the disease.    22  Chapter 2: Methods 2.1 Statement of ethical adherence All participants provided written informed consent and were given medical clearance to participate from the study physician prior to commencing any exercise testing conducted as part of this study. Our study protocol was approved by the Providence Health Research Institute Ethics Board (H13-01117).  2.2 Study design This was a cross-sectional method comparison study to investigate and compare the accuracy of various measures of EE (index methods) against indirect calorimetry-derived criterion measures of EE during standardized activities and exercise in patients with COPD, ILD, and CF with advanced pulmonary impairment. We recruited consecutive patients meeting our selection criteria (Table 1) from the outpatient clinics (Pulmonary Rehabilitation Clinic, ILD Clinic, COPD Clinic, and Adult CF Clinic) at St. Paul‘s Hospital (Vancouver, BC, Canada). Additionally, CF inpatients staying at St. Paul‘s Hospital were also invited to participate in the study.   2.3 Participants Inclusion criteria: Table 1 lists the participant selection criteria for this study. The criteria were chosen to be representative of patients who had ―advanced lung disease‖ and may warrant referral for lung transplantation assessment to our provincial lung transplantation program (Solid Organ Transplant Clinic, Vancouver, BC, Canada) at BC Transplant Society. All selection criteria were unanimously agreed upon by our study physicians, one of whom is the Medical 23  Director of our provincial lung transplant program. We recruited adult patients (between 35 and 65 years of age) with a primary diagnosis of COPD or ILD and CF patients aged 19 years and older, as adults comprise the overwhelming majority of first graft LTx procedures in Canada and COPD and ILD are much rarer in younger populations. Participants had previous clinical diagnosis of advanced lung disease as judged by the study physician. COPD patients had a FEV1/FVC ratio < 0.7 and FEV1 less than 50% of predicted. CF patients had a FEV1 less than 50% of predicted. ILD patients had a FVC less than 60% predicted or DLCO less than 40% predicted. These patients were identified from clinic chart data using pulmonary function tests performed within 6 months prior to recruitment. Pulmonary function inclusion criteria were based on routine clinical post-bronchodilator test results. All patients were nonsmokers. All patients were clinically stable at recruitment and maintained clinical stability on and between study days. For COPD and ILD outpatients recruited, clinical stability was defined as no increase in respiratory symptoms requiring hospital stay and no change in usual medications. Additionally for COPD and ILD patients, they had not been on antibiotic therapy or prednisone for 4 weeks prior to recruitment. For CF inpatients recruited, patients within the last week of a hospital stay were considered clinically stable. CF patients (inpatient or outpatient) were considered eligible for study participation even if they were on antibiotic therapy or prednisone because these medications are considered ―usual medications‖ in advanced CF42. Patients also had to be able to speak English to be eligible so that they would have been able to understand the testing instructions given to them by the research staff. If an English-speaking translator was available for the patient, he or she was still eligible for inclusion. Exclusion criteria: We excluded patients referred for LTx assessment who had any previously transplanted organs as metabolic imbalance in this group may have been largely attributed to 24  factors other than impaired pulmonary function, such as post-transplant medications required to prevent organ rejection140. Additionally, we excluded patients referred for heart+lung (combined) transplantation assessment as they may have been at a higher risk for cardiac events during exercise testing. Additionally, patients with any significant right or left heart disease absolutely contraindicated for cardiopulmonary exercise testing (CPET) according to the American Thoracic Society (ATS) guidelines141 were also excluded. Patients with any non-cardiac related contraindications and other relative contraindications for exercise testing according to the ATS guidelines141 were only included after approval from the study physician. Patients using any type of walker, cane, or wheelchair mobility aids were excluded from this study as these assistive devices would have interfered with the exercise testing and standardized activities protocol. Following the recommendations of recent infection control guidelines142, CF patients with Burkholderia cepacia complex (BCC), Myobacterium abscessus, and/or Burkholderia dolosa (non-BCC) and closely related organisms (Apista, Ralstonia) were excluded from participation in this study as these organisms are easily transmissible between patients. Patients requiring supplemental oxygen during activity were also excluded because the face masks used on the subjects are not designed to fit the nasal prongs. Finally, those patients judged by the study physicians as having poor adherence to medications, uncontrolled diabetes, profound emaciation (body mass index<16), or indices of pulmonary hypertension (mean pulmonary artery pressure > 25 mmHg from right heart catheterization test; systolic pulmonary artery pressure > 35 mmHg from echocardiography test) were excluded.    Subject recruitment: Staff from the Adult CF clinic, ILD clinic, COPD clinic, and Pulmonary Rehabilitation clinic at St. Paul‘s Hospital identified outpatients eligible for study participation based on the data collected during their most recent clinical assessment. CF inpatients were 25  identified by additional methods including scanning daily admission rosters. On Day Zero of the study, eligible subjects were hand delivered a letter of initial contact which explained the purpose of the study, contained the informed consent form, and invited patients to participate in the study by contacting the research staff. Subjects agreed to perform a CPET on study Day One, followed by submaximal exercise testing on Day Two, preferably within a one month period. Patients who did not routinely attend the clinics were recruited by letter of initial contact sent by the clinic staff. The study nurse contacted any eligible patients in approximately 10 days after the letter of initial contact had been mailed out or hand delivered to the patient.   2.4 Experimental procedures The following procedures were conducted in the University of British Columbia Pulmonary Rehabilitation Research Laboratory and Pacific Lung Health Centre at St. Paul‘s Hospital (Figure 6): Day Zero: Patients regularly visiting the clinic who were eligible for participation in the study were given a letter of initial contact along with a consent form by the clinic staff. Patients who did not regularly attend the clinic were recruited by letter of initial contact sent by mail. The study nurse contacted the patient eligible for participation in approximately 10 days after the letter of initial contact had been mailed out or hand delivered to the patient to determine interest in study participation. Eligible subjects and patients interested in participating were asked to contact the research staff by phone or email and be scheduled for two study days conducted within a one month period. All eligible patients consented to allow us to review the clinic charts from their most recent clinical assessment to be enrolled in the study.  26  Day One: Demographic and anthropometric data were collected for each subject on entry. Subjects then performed a standardized research pulmonary function test (forced vital capacity manoeuvre only) on entry following standard testing guidelines143. Following pulmonary function testing, subjects performed a standardized symptom-limited CPET. A physician was in the proximity of the testing environment to respond immediately in case of an emergency as required according to ATS guidelines141.  Day Two: Each subject performed a standardized calibration protocol comprised of resting and a submaximal cycle exercise protocol at two different relative work rates (25% and 50% of the peak VO2) to develop their individual Flex HR physical activity measurement profile. Development of the Flex HR profile involved a multi-stage process where the subject‘s VO2 and HR were measured simultaneously at rest and at increasing intensity levels of exercise. Following the calibration protocol, subjects rested in a quiet sitting position until he or she was ready to perform a battery of standardized ―free-living‖ type physical activities and submaximal exercise. During these standardized physical activities and exercise, EE was simultaneously measured using each index method (Table 2) and a portable indirect calorimeter gold standard method.           Testing was conducted in the same controlled lab setting on both study days to minimize or eliminate the impact of differential temperature and humidity in multiple environments on our data. All measurement equipment used in this study were thoroughly cleaned and sanitized in accordance with the Providence Health Infection Control policies at St. Paul‘s Hospital. Disposable equipment were immediately discarded in appropriate containers after usage. Each subject was instructed to avoid strenuous activity for at least 24 hours and food or caffeine drinks for 2 hours prior to Day One CPET testing. They were also instructed to take all of their usual 27  medications including β2-agonist inhalers for at least 2 hours prior to testing on both days. If applicable, patients were also instructed to perform airway clearance therapy at home prior to commencing testing on both study days. The purpose of the aforementioned pre-test instruction was to ensure that subjects were able to perform to their optimal ability on both study days.  2.5 Measurements Basic Subject Information: Information abstracted from the patient‘s medical chart by the research staff included previously available pulmonary function test results (FEV1 % predicted, FVC % predicted, FEV1/FVC ratio, and DLCO % predicted if it was reported), exacerbation frequency within the last year, list of comorbidities, and list of current medications. Age, gender, city of residence, and ethnicity information were obtained by asking the subject. Height in meters (m) and weight in kilograms (kg) were measured with standard stadiometer and weight scale respectively. Body Mass Index (BMI) for each subject was calculated by dividing their weight in kilograms (kg) by height in meters (m) squared. Stride length was determined by asking the patient to walk 10 steps on a flat surface and measuring the distance walked (distance walked in meters divided by 10 equals stride length). Spirometry on Entry: FVC manoeuvres were performed according to guidelines developed by the American Thoracic Society/European Respiratory Society (ATS/ERS) Task Force143. Participants performed the pulmonary function test until three acceptable blows (largest and next largest FVC and FEV1 within 0.150 litres) were made or until participant was no longer able to continue as required according to the ATS/ERS guidlines143. Testing was performed using the ―Pulmonary Function‖ spirometry mode of the SensorMedics Vmax EncoreTM metabolic system (Viasys; Loma Linda, CA, USA). Absolute FEV1 (liters) and Forced Vital Capacity (FVC) 28  (liters) as well as % predicted values were calculated from the highest values of the three acceptable trials. Predicted normal reference values were taken from Hankinson and colleagues 144. The mass flow sensor of the SensorMedics Vmax EncoreTM was calibrated prior to each pulmonary function test. .   Cardiopulmonary Exercise Testing: Prior to the commencement of exercise, participants were instructed to perform three inspiratory capacity (Icap) maneuvers following the ATS/ERS guidelines143. The average of the three Icap maneuvers was recorded as the resting Icap143. Each subject then performed a standardized symptom-limited CPET on an electronically-braked cycle ergometer (Ergoline; Bitz, Germany) using a stepwise protocol (Appendix A). Starting at 0 watts (W), the workload was increased by either 10 or 15 W every 2 minutes. The 2 minute protocol was chosen to ensure a physiological steady state at each incremental stage of exercise. Subject exercised until exhaustion. All gas exchange values (VO2, VCO2) and ventilations were measured using the SensorMedics VmaxTM metabolic system while the subject breathed room air. Cardiac rhythms and HR were continuously recorded by standard 12-lead electrocardiogram.  Blood pressure, HR, oxygen saturation, and perceived dyspnea and muscular leg discomfort using scales based on standard 10-point schemes145, 146 were continuously monitored during CPET for safety purposes. VO2 and HR data were averaged into 30 second bins where the 60-90 second segment of each incremental exercise stage was sampled. Research staff recorded the VO2, HR, and workload at peak exercise as well the peak VO2 % predicted using reference values taken from Jones and colleagues147. The internal gas analyzers of the SensorMedics Vmax EncoreTM and the workload of the cycle ergometer were calibrated prior to each test.  Portable Indirect Calorimetry: The K4b2TM breath by breath metabolic system (Cosmed; Rome, Italy) has been previously tested and well validated to provide accurate and reliable 29  measurements of respiratory gas exchange during resting and exercise100. The system provides measurements of EE (in units of kcal/min) by indirect calorimetry, using the formula by Elia and Livesey (EE  = 3.781 * VO2 + 1.237 * VCO2  ) 89. The lightweight (0.8kg) system consists of a battery pack-operated (1 to 5 hour data collection time before recharge is required) portable unit connected to a Hans RudolphTM facemask (Hans Rudolph Inc, Kansas City, MO, USA). In addition to gas exchange measures, the K4b2TM stores simultaneous breath-by-breath measurements of HR collected from the PolarTM heart rate monitor belt (Polar Electro; Kempele, Finland) The internal gas analyzers and turbine were calibrated prior to each test.  Individual HR-VO2 Calibration Protocol for Flex HR Measurement Technique: Subjects underwent a multi-step procedure to determine their individual HR-VO2 regression equations for use in estimating physical activity from the Flex HR method. This method relies on the assumption that above a critical heart rate threshold known as the flex HR, VO2 (and subsequently energy expenditure) and HR levels are linearly related97, 117, 148. Although there have is no standard Flex HR procedure, a variety of calibration protocols for deriving Flex HR and individual HR-VO2 regression equations have been discussed in the literature148-151. In general, calibration testing involves simultaneous measurement of VO2 and HR while the subject rests in various positions (lying, sitting, and/or standing) and exercises at different intensities. Measurements of HR and VO2 are then taken over a given time period during steady state following an equilibration period. Flex HR is calculated as the average of the lowest HR during exercise and the highest HR during resting positions obtained during calibration testing conducted in a laboratory setting97, 149. Resting metabolic rate is calculated as the mean energy expenditure during the resting stages of the calibration test150. We conducted a resting and exercise Flex HR calibration procedure adapted from protocols used recently in CF patients138, 30  152; however instead of using treadmill exercise at absolute workloads as done in these previous protocols, we chose to conduct cycling exercise at relative workloads for the exercise stages of the calibration protocol to allow for precise workload selections (Figure 7).    Step 1 - After arriving in the lab on Day Two, participants rested for 10-15 minutes. Each participant was then fitted with the K4b2TM portable indirect calorimeter and PolarTM heart rate monitor belt. Step 2 – Gas exchange (VO2 and VCO2) measured by the K4b2TM and HR measured by the PolarTM were simultaneously sampled on a breath-by-breath basis during resting and cycling activities: (1) sitting quietly in a sitting position for 6 minutes, (2) standing quietly for 6 minutes, (3) cycling at 25% of their previously determined peak workload for 6 minutes (following a 1 minute warm-up period), (4) cycling at 50% of their peak workload for 6 minutes (followed by a self-selected cool-down period). Blood pressure, HR, and perceived dyspnea and leg discomfort were continuously monitored during exercise stages for safety purposes.  Step 3 – Using Microsoft Excel (2007) we constructed each subject‘s HR-VO2 regression equation and calculated their Flex HR. Breath-by-breath HR and VO2 levels were averaged into 1 minute bins where we sampled the last three minutes of each stage. We calculated the average HR and VO2 values over the last 3 minutes of each of the 6 minute stages discussed in step 2. We then determined a regression profile using these averaged ―calibration points‖ with the sum of least squares method153.  Flex HR was determined as the mean of the lowest HR attained during the 3 minute sampling period of the cycle exercise and the highest HR attained during the 3 minute sampling period in sitting or standing obtained during calibration testing. We also calculated the subject‘s 31  resting metabolic rate, or ―sedentary EE‖ as it has been referred to in previous flex HR studies, as the average EE attained by IC during the 3 minute measurement periods of the sitting and standing positions.  Additionally, we constructed separate HR-VO2 regression profiles for each subject using the 30 second averaged HR and VO2 measurements during the exercise stages from the CPET conducted on Day One. As a result, each participant had two separate flex HR calibration profiles: (1) flex HR curve calibrated during a submaximal exercise protocol and (2) flex HR curve calibrated during a peak exercise protocol. The flex HR and sedentary EE calculated on Day Two was assumed to be the same as on Day One.      Physical activity monitoring instruments: Following the flex HR calibration protocol patients were fitted with several physical activity monitors, all of which simultaneously measured EE in different ways (Figure 8):  The Digi-Walker CW 701TM pedometer (Yamax; Tokyo, Japan) was attached to each subject‘s waist at the front on the right side. It uses weight and step length data input as well as vertical hip movement counts (steps) detected by an internal spring levered mechanism to estimate EE (in units of kcals) accumulated over a given period of time. Although the algorithm for calculating EE is not commercially available, we assume it is most likely developed using the motion counts and wearer characteristics in a non-disease standard population. Although the device does not come equipped with a timestamp or ―marking‖ feature, it does allow the wearer to reset the display EE. We reset the display before the start of each activity.  The SenseWear ArmbandTM multisensor (BodyMedia; Pittsburgh, PA, USA) was worn by each participant on the upper left arm (triceps). This device uses demographic, triaxial 32  accelerometry, and various other physiological sensor data input (galvanic skin receptor, skin temperature, and heat flux) to estimate minute-by-minute EE through proprietary manufacturer algorithms. The computer software (SenseWear Professional 7.0) used to analyze the data provided minute-by-minute EE in units of kilojoules. We converted the kilojoules per minute into units of kcal per minute using standard conversion factors.  The ActiCalTM triaxial accelerometer (Philips; Eindhoven, Netherlands) was worn on the wrist of each participant on the dominant side. EE was estimated using proprietary manufacturer algorithms incorporating age, height, and weight input from the wearer as well as triaxial accelerometry signals during physical activities. EE was collected in units of METs, which we converted to kcal/min using standard conversion factors. The monitors also had timestamp features allowing us the mark the start and end of each activity.       The DynaPort MiniModTM triaxial accelerometer (McRoberts BV; The Hague, Netherlands) was worn by each participant on their waist at the lower back. This device consists of a piezoelectric triaxial accelerometer to measure the body‘s accelerations in three axes. It measures the amount of time spent in various activities and positions (walking, cycling, sitting, standing, and lying down) as well as walking intensity. EE in units of absolute kcals is accumulated from the start of data collection until the end of data collection. As a result, it provided us with EE accumulated over the entire activity protocol.     The Tractivity SensorTM (Kineteks Corporation; Vancouver, BC, Canada), was worn on the right ankle of each participant. The sensor uses measures motion intensity from the triaxial accelerometer during walking or running along with height and weight input from the wearer to calculate EE using proprietary manufacturer algorithms. The online Tractivity web application 33  provided measurements of EE in absolute kcals in one hour bins throughout the day. Using recorded start and end times we calculated the total EE in kcals measured over the entire activity protocol.  The PolarTM heart rate monitor belt (Polar Electro; Kempele, Finland) was attached around the subject‘s chest. This device transmits minute-by-minute HR recordings through telemetry to a computer software program for data storage and analysis. As discussed earlier, each subject‘s Flex HR was determined as the average of the highest HR during resting activities (during sitting and standing) and lowest HR during steady state submaximal cycle exercising at the two relative workloads during the calibration period. Also, sedentary EE for each participants was calculated as the average EE attained by IC during the 3 minute measurement periods of the sitting and standing positions. We also constructed two separate HR-VO2 regression equations for each participant using: (1) HR-VO2 calibration points collected during a submaximal exercise protocol and (2) HR-VO2 calibration points collected during a peak exercise protocol. During activities, if minute-by-minute HR was below Flex HR, EE was recorded as sedentary EE for that minute. If HR was above or equal to Flex HR, EE were determined by applying HR-VO2 regression equations developed earlier to first calculate the VO2 estimated then converting to EE in kcals by multiplying it by a standard conversion factor of 4.9154.   After being fitted with the aforementioned activity monitors and the portable indirect calorimeter, subjects were instructed to perform a sequence of free-living type activities followed by submaximal steady state cycle exercising at four separate relative workloads.  Free-living activities: Subjects perform a sequence of activities adapted and modified from the Glittre ADL-test of functional status in COPD patients155 (Figure 9). Similar activity protocols 34  were used to validate activity monitors during standardized tasks in chronic lung disease patients136. Subjects were asked to perform the following activities in sequence at a normal pace: walking on flat treadmill, walking on incline treadmill, rising from a chair and sitting in another chair space 1 meter apart (Sit-to-stand), and moving a 1kg object in and out of two shelves positioned at shoulder level and waist level and the ground (Lifting-bending). Participants self-selected their treadmill walking speed such that they walked at a speed that elicited a perceived dyspnea of ‗mild‘ to ‗moderate‘ intensity146. Selected incline grade was between 2 to 4 % depending on the perceived dyspnea response. Participants rested in a quiet sitting position between each of the aforementioned tasks until their HR returned to with 10 beats per min of baseline levels. Each task was performed for 2 minute durations. The start and end times of each activity were synchronized on the SenseWear and ActiCal monitors as well as the portable unit of the indirect calorimeter and Polar HR monitor. The DigiWalker EE counter was reset to zero before the start of each activity. Blood pressure and perceived dyspnea and leg discomfort were measured at rest stages between free-living activities and at the first minute of each cycling stage for safety purposes. Additionally HR was continuously monitored during free-living activities and cycling to ensure that the HR did not exceed 80% HR max determined on Day One during CPET.        Submaximal cycling exercise:  Following the free-living activities protocol, participants performed exercise on a cycle ergometer. Each subject performed cycle exercise at four relative intensities (at 10%, 25%, 50%, and 60% of peak workload) (Figure 10). Participants cycled for a period of 2 minutes at each workload. The start and end times of each exercise intensity stage were synchronized on the SenseWear and Actical monitors as well as the portable unit of the indirect calorimeter and Polar HR monitor. The DigiWalker EE counter was reset to zero before 35  the start of cycling, but not reset between intensity stages as it would have required to participant to stop cycling. During the cool-down stage we removed all measurement equipment from the participant. Blood pressure, HR, and perceived dyspnea and leg discomfort were continuously monitored during exercise stages for safety purposes.      2.6 Data management and statistical analysis    Analyses were performed using R 3.1.0156 and SAS version 9.2 (SAS Institute; Cary, NC, USA). Our significance level was set as p<0.05. Data are presented as mean ± SD unless otherwise stated.  2.6.1 Analyses      Since only the SenseWear multisensor, ActiCal accelerometer, and Flex HR method had the capability for precisely marking the start and end times of activities, we chose these measurements techniques as our primary index methods for comparison. The DigiWalker pedometer, Dynaport, and Tractivity monitors had no marking feature, thus they were considered secondary index methods for comparison as we could not be confident in the exact synchronization of EE measured from these methods with concurrent IC EE values. Minute-by-minute EE in kcal/min from each primary index method had simultaneous minute-by-minute IC EE measurements in kcal/min data collected for comparison with the criterion method. Markers were used to synchronize the time (start and stop) on each primary index method and IC. Since actual EE is best approximated by IC during physiological steady state conditions115, we sampled the last minute of each 2 minute activity for analysis of our primary index methods measuring in units of kcal/min. EE values were analyzed separately for each activity (free-living and cycling stages) as well as averaged over free-living (flat walking, incline walking, sit-to-stand, and lift-36  bend), cycling (all stages; 10% peak, 25% peak, 50% peak, and 60% peak workloads), and overall (free-living and cycling combined). EE in units of absolute kcal from each secondary index method accumulated overall (free-living and cycling combined) were recorded for comparison with breath-by-breath IC EE in units of absolute kcal accumulated overall (start of free-living activities to end of cycling).  Descriptive analyses: Means and standard deviations were reported to describe continuous variables including age, height, weight, pulmonary function test results, clinical chart audit data, and cardiopulmonary exercise test results. Frequency data were reported for categorical variables including, primary diagnosis, sex, and comorbidities.    Primary analyses: Bland-Altman analyses were performed to investigate the agreement between EE estimated by the primary index methods and EE calculated by IC from the K4b2TM portable indirect calorimeter. According to Bland and Altman157, the analysis involves plotting the difference between the index method and criterion method against their average value for each participant. The mean of the differences represents the bias, which is assumed to be zero. The limit of agreement (LOA) between the index method and criterion method is calculated using the variability of the mean difference, or standard deviation (SD) of the differences (LOA = 1.96*SD). Additionally, Wilcoxon signed rank tests were used to assess significant differences between primary index method estimates of EE and IC EE.  Secondary analyses: Spearman correlational analyses were performed on data sampled during free-living activities, cycling (all stages), and overall to measure degree of association between the primary index methods and IC. Additional analyses performed strictly for descriptive purposes include construction of (1) scatter plots between each primary index method 37  measurement of EE and concurrent IC EE measurement with respect to the line of identity, and (2) scatter plot between each secondary index method measurement of EE and concurrent IC EE measurement with respect to the line of identity.                   2.6.2 Prospective sample size calculation  We were interested in the interchangeability of the primary index methods with the criterion method of EE measurement (i.e. the appropriateness of using the index method in place of IC). Accurate measures of EE were deemed to be those that would measure EE (in kcal/min) within a clinically acceptable difference from IC. To our knowledge, there is no standard for an acceptable difference in EE measurement with gold standard techniques in chronic lung disease or healthy people. We stated a priori that the EE difference cannot be greater than the estimated energy required to maintain equilibrium between total daily EE and dietary intake. Differences greater than this threshold may inaccurately show the patient in an imbalanced metabolic state, which may be interpreted as a wasting or weight gaining condition depending on the direction of inaccuracy. Recent guidelines by Health Canada show that approximately 2000 kcal/day is the estimated energy requirement for sedentary Canadian adults, which ranges from 1550 to 2500 kcal/day for sedentary adults158. The actual estimated energy requirement will depend on age, gender, weight, height, and physical activity level159. The 2000 kcal/day estimated requirement equates to 1.39 kcal/min, which we assumed to be a clinically meaningful threshold for our primary index methods.       Step-by-step calculation of required sample size: Limits of agreement (LOA) have confidence intervals (CI) that can be wide or narrow depending on the required precision. Precision of the LOA required will impact the sample size. For an index method and criterion method to be 38  deemed interchangeable, LOA including the CI should not exceed a predetermined clinically meaningful threshold. Therefore, if the LOA is closer to the mean difference (assumed to be zero) relative to the chosen threshold, it may have a lower precision (width of the 95% CI of LOA) and require a lower sample size. To determine the sample size necessary for the 95% LOA of the mean difference including the 95% CI of the LOA not to exceed our predetermined clinically meaningful threshold, we referred to the equation described by Bland and Altman157. To use this equation we assumed a standard deviation (SD) of differences for each index method measuring EE in units of kcal/min (SenseWear, ActiCal, and Flex HR method) based on the EE measurement validation literature in chronic lung disease populations. A previous study validating SenseWear multisensor against IC in COPD patients found a SD of difference of 0.3 kcal/min133. Unfortunately, there was no study which had validated the ActiCal method for measuring EE in lung disease patients. Since the SenseWear method and Actical methods are both accelerometry based approaches, we assumed the same SD of differences for both of these measurement methods. Another previous study validating the Flex HR method against DLW in CF patients found a SD of differences of 0.3 kcal/min138. Our calculations of the aforementioned SDs are described in Appendix B. In interpreting the results from this study, we made the apriori assumption that the measurements from DLW method and IC may be interchangeable as they are both accepted gold standards for measuring energy expenditure.      Using our assumed SD of differences (=0.3 kcal/min for both SenseWear, ActiCal, and Flex HR method) and clinically important threshold (=1.39 kcal/min), we calculated our required sample size as follows: LOA = 0.3 *1.96 = 0.588 (equation 1) 39  95%CI of LOA = 1.96*Standard Error (SE) of difference (equation 2) SE of difference = 1.96 * √(3/n) * SD of difference (equation 3) Since the threshold is 1.39 and the LOA is 0.588, the LOA can have a 95%CI of ± 0.802 that will not exceed the threshold; this scenario required a sample size of at least 6 for minimal precision required to determine interchangeability of the index methods.    40  Chapter 3: Results 3.1 Study enrollment  Participants were recruited from September 2013 to July 2014. A total of 108 patients identified by clinic staff were screened for potential inclusion (60% COPD; 20% CF; 20% ILD). After more thorough screening and initial contact with potentially eligible participants, a total of 13 participants were enrolled in the study. Primary reasons for excluding potentially eligible participants included supplemental O2 use, currently smoking, non-compliant with medications, required mobility aids, cardiac contraindications, missing recent pulmonary function test, upper age limit exceeded, upper lung function criteria exceeded, agreed to participate in future. Due to various reasons, data from 5 participants were disqualified following enrolment (unable to return for Day Two within one month, n=2; unable to complete Day Two activity protocols, n=2; technical difficulty with IC, n=1). A total of 8 participants had complete datasets that qualified for analysis. Figure 11 describes the enrolment process and reasons for exclusion/disqualification at each stage of the study.   3.2 Participant characteristics  The characteristics of 8 participants with complete datasets are summarized in Table 3. The sample was equally distributed in sex (male to female ratio=50/50). CF participants composed a majority of the sample (n=5; 63%). The mean age of the participants was 42.1±17.1 years. On entry, participants ranged from moderate to severe obstruction as assessed by FEV1% predicted (26 to 65% predicted) and severe to non-existent restriction as assessed by FVC% predicted (45 to 117% predicted). There was a wide range in both age and BMI, from 23 years to 65 years and 18 to 31 kg/m2, respectively. Table 4 presents the exacerbation history and 41  comorbidity information obtained from most recent clinical chart data. Approximately 63% of the participants had a known history of exacerbations that required hospital stay. Half of the participants were pancreatic insufficient, all with CF. Bone disease and asthma were other common comorbidities (approximately in 38% of the participants for both conditions). Other less common comorbidities seen in the participants included distal intestinal obstructive syndrome (n=1), arthropathy (n=2), dermatitis (n=1), impaired glucose tolerance (n=1), MRSA infection (n=1), liver disease (n=2), IgA deficiency (n=1), kidney disease (n=1), iron deficiency anemia (n=1), Barrett‘s esophagus (n=1), hiatus hernia (n=1), and splenomegaly (n=1). Heterogeneity in physical fitness levels was evidenced by the wide range in peak CPET parameters including VO2 (52.29 to 93.96% predicted), HR (70 to 104 % predicted), and workload (33 to 136 W) (Table 5). On average, perceived muscular leg fatigue (7.25±2.82 rating on Borg scale) was slightly higher than perceived dyspnea (6.63±2.56 rating on Borg scale) at peak exercise. Participants also had a tendency towards dynamic hyperinflation showing a reduced Icap at peak exercise compared to rest (mean ∆Icap = -0.32±0.54). 3.3 Trends in Bland-Altman agreement plots   We present our findings of the agreement between each primary index and IC methods in the proceeding sections. The bias estimates and limits of agreement are represented as the mean difference (EE measured by primary index method – EE measured by IC) ± LOA.  3.3.1 Bias estimates and limits of agreement during flat walking (Figure 12)    The Flex HR methods (FM), both submaximal exercise- (SUB) and CPET- (CPX) derived methods underestimated by 0.48±1.13 and 0.25±1.60 kcal/min respectively. ActiCal had the highest underestimation at 1.26±1.40 kcal/min. SenseWear (SW) overestimated by 0.36±2.72 42  kcal/min. Therefore, FMCPX provided the closest approximation of EE (lowest bias) during flat walking.    3.3.2 Bias estimates and limits of agreement during incline walking (Figure 13)          FMSUB and FMCPX underestimated by 0.37±1.29 and 0.17±1.79 kcal/min respectively; however, the magnitude of the bias was lower than it was during flat walking. The magnitude of the bias for AC and SW increased with the increased walking intensity resulting from increased grade, with an underestimation of 1.80±2.36 and overestimation of 0.56±2.24 kcal/min respectively. Therefore, FMCPX provided the closest approximation of EE during incline walking.  3.3.3 Bias estimates and limits of agreement during sit-to-stand activity (Figure 14)        AC and SW underestimated to a higher degree than FM methods at 1.05±1.67 and 0.38±1.54 kcal/min respectively. FMSUB underestimated by just 0.06±0.91 kcal/min and FMCPX overestimated by 0.29±1.41 kcal/min. Therefore, FMSUB provided the closest approximation of EE during sit-to-stand activity.     3.3.4 Bias estimates and limits of agreement during lift-bend activity (Figure 15)    The same trend was seen during lift-bend activity as in sit-stand where AC and SW underestimated to a higher degree than FM methods at 0.78±0.82 and 0.39±2.86 kcal/min respectively. FMSUB underestimated by just 0.01±0.90 kcal/min and FMCPX overestimated by 0.28±1.57 kcal/min. Therefore, FMSUB provided the closest approximation of EE during lift-bend activity.       43  3.3.5 Bias estimates and limits of agreement during cycling (Figure 16 to 19)    As cycling intensity increased from 10 to 60% peak workload the magnitude of underestimation by AC also increased from 1.01±1.26 kcal/min (10% peak workload) to 3.36±3.00 kcal/min (60% peak workload). SW underestimated to a lower degree than AC at a given cycling intensity, ranging from 0.86±1.30 kcal/min (10% peak workload) to 1.26±3.45 kcal/min (60% peak workload). The Flex HR methods both provided closer approximations of EE than AC and SW. Both FMSUB and FMCPX underestimated during 10% peak workload, by 0.11±1.46 and 0.03±1.49 kcal/min respectively. Both FMSUB and FMCPX overestimated during higher intensity cycling (25 to 60% peak workload), with FMSUB providing closer approximations of EE than FMCPX (0.21±1.08 to 0.42±0.74 kcal/min by FMSUB; 0.36±1.09 to 0.59±1.46 kcal/min by FMCPX).   3.3.6 Interchangeability between primary index and IC methods  For the primary index method to be deemed interchangeable at a clinically acceptable level, the limit of agreement combined with its 95% CI (LOA + 95%CI) must be within the meaningful threshold fixed a priori. We considered that a reasonable threshold could be within 1.39 kcal/min of an assumed mean difference of zero between the primary index method and IC. Table 6 presents the limits of agreement and associated precision (95% CI) between each primary index method and IC during free-living activities and cycling stages. During free-living activities, the most interchangeable index method (lowest sum of LOA + 95%CI) was FMSUB during flat walk, incline walk, sit-to-stand, and lift-bend activities with interchangeability factors of 2.48, 2.83, 2.01, and 1.99 respectively. During cycling, AC was the most interchangeable during cycling at 10% peak with an interchangeability factor of 2.77; however, FMSUB was 44  most interchangeable during increasing cycling intensities with interchangeability factors of 2.38, 1.61, and 1.62 during cycling at 25%, 50%, and 60% peak respectively. Since none of the limits (including 95% CI) were within the clinically meaningful threshold of 1.39kcal/min, none of the primary index methods were sufficiently interchangeable at a clinically acceptable level; however, due to the small sample size, these results must be interpreted with caution. Indeed, a larger sample size is required for better precision of the limits as our assumed SD of 0.3 prior to the start of this study may have been too small. Our study found SD of differences higher than our a prior assumption, ranging from 0.46 to 0.92 for the Flex methods, 0.79 to 1.76 for SW, and 0.63 to 1.53 for AC. As a result, the aforementioned interchangeability assessment is intended to show the trend rather than actual level of interchangeability, which will require a larger sample size for better precision around the limits.  3.4 Nonparametric significance testing  Table 7 presents the EE measurements (expressed as median and inter-quartile range) by each primary index method and IC averaged over free-living activities, cycling (all stages), and overall (free-living and cycling). We observed significant differences between EE measured by AC and by IC during free-living activities, cycling, and overall as well as between EE measured by FMCPX and by IC during cycling only (p<0.05). The EE measurements from SW and FMSUB were not found to be different from IC. For the secondary index methods (Dynaport, Tractivity, and Digiwalker), the Dynaport estimation of accumulated EE (median = 82.5 kcals) was not significantly different from the accumulated EE measured by IC (median =85.8 kcals) over the entire protocol (p>0.05). Whereas accumulated EE was significantly overestimated by Tractivity (median = 144 kcals) and significantly underestimated by DigiWalker (median = 12.7 kcals) (p<0.05).  45  3.5 Graphical representations of validity X-Y scatter plots with line of identity: To visually observe whether or not there may be a fixed bias, we compared the index methods (ordinates) to the criterion method (abscissa) for the primary index methods (Figure 20, 21, and 22) and secondary index methods (Figure 23). The line of identity was shown on each plot, representing the ideal scenario where both methods give the same EE measurements. According to Figure 20, we noticed FMSUB to most closely approximate EE and suspected a negative bias to exist by nature for AC during free-living activities. From Figure 21, we noticed FMSUB and FMCPX to most closely approximate EE and suspected a negative bias to exist by nature for AC during cycling activities. Overall, the correlations between the EE measured by SW, AC, and FMSUB and by IC were very high (r= 0.90, 0.79, 0.90 respectively; p<0.05) (Figure 22). The mean correlation between FMCPX EE and IC EE only reached significance during cycling (r=0.90; p,0.05). According to Figure 23, we suspected a positive bias to exist by nature for Tractivity monitor, and negative bias to exist by nature for both the Dynaport monitor and to a greater magnitude for the DigiWalker pedometer during the entire protocol. The Dynaport most closely approximated EE over the entire protocol. The mean correlations between the secondary index methods and IC were low and non significant.                             46  Chapter 4: Discussion 4.1 Key findings  This cross-sectional study investigated the validity of three primary index methods and three secondary index methods commonly used to estimate energy expenditure (EE) by comparing their outputs with simultaneous gold standard EE measurements from indirect calorimetry (IC) in a population of advanced lung disease groups. We found that the Flex HR methods (FM) provided a closer approximation of measured EE (lower bias magnitude) than the multisensor and accelerometry methods over the entire free-living and cycling activities. During walking of increasing intensity (flat to incline), the bias was reduced for the Flex HR methods, but increased for the SenseWear and Actical. During cycling of increasing intensity (10% peak workload to 60% peak workload), the bias was increased for all devices; however, the magnitude of bias was lower for the Flex HR methods.  Few studies have validated several physical activity monitors head-to-head with gold standard EE in chronic lung disease populations160, 161. No previous studies have included an individually calibrated approach, such as the Flex HR method, in these head-to-head comparisons. Only one other study validated the Flex HR method by itself in a chronic lung disease population138 In CF patients with moderately severe lung function (FEV1 %predicted mean±SD = 52±12%), the mean % difference ± SD between Flex HR estimation of EE and DLW gold standard EE measurements was 8.8± 7.9% (Flex method underestimated)138. Our findings were in agreement with the aforementioned study, showing a trend towards underestimation of EE compared to the gold standard measurement of EE from IC. Additionally, validation studies of physical activity monitoring devices specifically in advanced lung disease 47  populations are scarce. To our knowledge, only one other study has validated a commercially available physical activity monitor for estimating EE against an accepted gold standard method specifically in an advanced lung disease population135. Another interesting finding of our study was that the accuracy of the Actical declined with increasing intensities of activities (walking from flat to incline; cycling from lower to higher workloads). Overall, the Actical significantly underestimated EE. As a result, motion counts alone were insufficient in being able to accurately estimate the elevated metabolism in participants due to increased activity intensity. The additional physiological sensory input incorporated into the EE estimation algorithms of the SenseWear allowed this instrument to capture the additional EE required during increasing intensities resulting in a lower bias during a given activity or intensity relative to the Actical; however, it still had a higher bias relative to the Flex HR methods. As a result, the individually calibrated nature of the models used to estimate EE in the Flex HR methods may provide a more accurate representation of true EE in advanced lung disease groups. A physical activity monitoring technique known as the ActiRegTM that uses individually measured resting EE, and incorporates body positioning as well as motion (with an option to use additional HR measurement) has been validated by Arvidsson and colleagues in severe COPD patients (FEV1% predicted between 20 and 49%)135. The ActiRegTM estimation of EE and DLW gold standard EE measurements were not found to be significantly different135. As a result, EE estimation based on an individually calibrated approach to physical activity measurement may be superior to devices using manufacturer-developed algorithms relying mainly of body motion and subject demographic input. Additionally, out of the secondary index methods evaluated in this study, the Dynaport monitor which was not significantly different from accumulated EE measured by IC, was shown to be more valid than the Tractivity (significantly 48  overestimated EE) and Digiwalker (significantly underestimated EE). In agreement with our findings, the Digiwalker has been previously shown to significantly underestimate EE compared to EE measured by IC136. In accordance with our findings, Dynaport monitor has been shown to be valid for estimating EE as evidenced by mean correlation coefficient of 0.45 (p<0.05) during a standard 59 minute activity protocol reported by Van Remoortel and colleagues160. The Tractivity has not been previously validated for estimating EE in chronic lung disease. 4.2 Clinical implications Although previous validation studies of EE estimation in chronic lung disease have employed Bland-Altman plots to evaluate validity132, 133, 135, 137, 162, 163, none of these studies defined a threshold for how far apart the EE estimation can be from measured EE without causing difficulties in clinical interpretation. The interchangeability factor, or appropriateness of replacing the gold standard with index method depends on how much the method is likely to differ from the gold standard. According to Bland and Altman, this difference is calculated as the width of the combined LOA and 95% CI for the LOA157. If the width of the LOA and 95%CI is within an acceptable threshold determined a priori, the index method may replace the gold standard.  Wasting diseases are conditions that results in an imbalance in the metabolic energy expenditure/intake dynamics in humans. The main reason for this imbalance may be hypermetabolism resulting from an elevated REE164. Evidence suggests that COPD, ILD, and CF patients are in this hypermetabolic state125, 165, 166, hence may be prone to having a mismatch between their energy expenditure and intake leading a catabolic or wasting state. Knowledge of the true EE of the patient at home would be important for clinicians to help optimize this 49  metabolic balance by appropriately titrating exercise prescriptions in addition to monitoring their physical activity level outside of the rehabilitation setting. Although there are no standard cutoffs for determining whether or not a physical activity monitor may be considered to have acceptable validity for estimating EE at home, previous investigators have set a priori thresholds of greater than 0.7 correlation with gold standard measurements as constituting acceptable validity161. Based on this correlation threshold, we found that all primary index methods were valid over the entire protocol, except for FMCPX which was only valid during cycling activities. According to Bland and Altman, correlation alone is not sufficient to determine device validity157. Acceptable correlations may actually conceal poor agreement. Index methods require a certain level of agreement before they can be deemed interchangeable with the gold standard method for routine clinical practice. Based on our a prior selected threshold for determining interchangeability, FMSUB was the most interchangeable, having the lowest LOA+95%CI interval width; however, since it was higher than our chosen clinically meaningful threshold of 1.39 kcal/min, it may not be interchangeable with IC at a clinically acceptable level. Evidence suggests that patients with chronic lung disease may require a higher dietary intake to maintain body mass relative to standard norms167, 168. As a result, our arbitrarily selected threshold based on available standard dietary intake data from the general population158 may be too low for advanced chronic lung disease populations. Therefore, consensus on an acceptable clinically important threshold of difference for EE estimation is still needed. Although further study is required to determine clinical acceptance, our findings show that the Flex method has great potential as a useful physical activity measurement technique. The development of the individual Flex HR calibration equations for each patient may be constructed during a clinically routine CPET or submaximal exercise test in patients unable to perform a maximal exercise test and have comparable EE 50  estimation validity as implicated by our findings. Due to time commitments and portable metabolic instrumentation required to calibrate submaximal Flex HR profiles, it may be more feasible for some clinical programs to calibrate Flex HR profiles during routine clinical CPET.      4.3 Study limitations and future research  One of the major limitations of this study is our sample size. Our proposed sample size calculation was based on assumed SD of mean differences and arbitrary cutoffs for acceptable interchangeability based on the literature. The results of our study show that a slightly higher SD than the assumed SD would have been more appropriate. Future studies may use our calculated SDs of the differences as pilot data to determine the appropriate sample size required to ensure adequate precisions around the LOAs of the index method estimations of EE relative to IC EE. Additionally, future research may focus on determining an appropriate daily caloric intake requirement for advanced lung disease groups rather than relying on an arbitrarily chosen value based on healthy norms. If a higher threshold is shown to be more applicable for our patient population, more of the index methods evaluated in this study could possibly deemed to have acceptable interchangeability at a clinically meaningful level.     Although the primary index methods were synchronously time-stamped to the best of our ability, it is unrealistic to be able to mark the start and stop of each activity at exactly the same time on each device. The marking of the HR data was more in sync with the marking of the IC measurements than the SenseWear and Actical markings as the Polar monitor signals were incorporated into the Cosmed K4b2 software to allow for HR data to be assigned to each breath of the participant. As a result, this may have introduced potential bias towards the HR input for the Flex methods being more accurate and precise than the SenseWear and Actical estimates of 51  EE. A future study validating a third party HR monitor with data storage capability which is not linked to the breath-by-breath acquisition software of the IC may be required to confirm our findings.     When measuring energy expenditure (EE), determination of whether the subject has reached a physiological ‗steady state‘ is important. Steady state is the stage during physical activity when oxygen consumption matches oxygen requirement. If steady state is not attained, the measured energy expenditure will be less than the actual energy expenditure in the body. Since the approximate time required to reach this steady in patients with severe lung disease is unknown, we assumed a 1 minute equilibration period to allow ventilations to stabilize before all measurements of gas exchange during the standardized activities and exercise (including calibration during CPET). This a prior selected length of time for reaching a steady or stable ventilatory state has been used by previous investigators16. More research needs to be conducted to determine appropriate conditions and approximate time to reach physiological steady state in advanced lung disease conditions.   Due to issues of practicality, we were also limited in the number of activity monitors we were able to simultaneously compare in this study. For each type of activity monitoring device (ie pedometry, accelerometry, multisensor technology, and HR monitoring), a variety of device manufacturers are available. The objective of our study was to evaluate the validity of the most commonly used methods to estimate EE. Based on the results of a systematic review of the literature, we chose to validate these particular activity monitor manufactures as they have been used extensively in chronic lung disease patients. We excluded surveys and questionnaires for assessing EE as these methods were deemed too subjective to include in our study. 52  Finally, in order to evaluate the true ―accuracy‖ of a measurement tool, all clinimetric properties of the tool (ie reliability, responsiveness, and validity) should be evaluated. However, due to the burden that would have been placed on these severely debilitated advanced lung disease patients from measuring all these components of accuracy, we chose not to investigate the reliability or responsiveness. Future studies may look to elucidate these understudied, yet important requirements for measurement accuracy.   4.4 Conclusion    Physical inactivity is common in lung transplant candidates and can worsen their prognosis.  As a result, physical activity is a key outcome for pulmonary rehabilitation programs in advanced chronic lung disease. Future interventions aimed at modifying behaviour and exercise training to improve physical activity may use Flex HR methods to accurately evaluate responses in energy expenditure. For pulmonary rehabilitation programs with access to indirect calorimetry instrumentation or routine cardiopulmonary exercise testing, FMSUB or FMCPX may be more feasible physical activity monitoring techniques to employ compared to the costly SenseWear and Actical devices.             53  Tables Table 1. Participant Selection Criteria. Inclusion Criteria Exclusion Criteria Adult patients (between 35 and 65 years) with a primary diagnosis of COPD or ILD  Require mobility aids to ambulate Adult patients (19 years and older) with a primary diagnosis of CF Qualified for supplemental oxygen during exercise Ability to speak English or availability of English-speaking translator Referred for Heart+Lung (combined) transplant assessment Clinically stable at time of recruitment and maintained clinical stability during testing Poor adherence to medication, uncontrolled diabetes, profound emaciation (BMI(16), or indices of pulmonary hypertension Previous clinical diagnosis of advanced pulmonary impairment:  For COPD: FEV1/FVC ratio < 0.7 and FEV1 % predicted < 50   For ILD: FVC % predicted < 60 or DLCO % predicted < 40  For CF: FEV1 % predicted < 50 For CF only: Colonized with Burkholderia cepacia complex (BCC), Myobacterium abscessus, and/or Burkholderia dolosa (non BCC) and closely related organisms (Apista, Ralstonia) Medically cleared for exercise by study physician Significant right or left heart disease contraindicated for exercise testing    54  Table 2. Features of the Physical Activity Monitors Including Type, Location of Attachment, Units of Energy Expenditure Estimation, and Cost. Activity Monitor Features Name (Manufacturer) Type Location EE Units Approx. Cost (Cdn)  Digi-Walker CW 701TM pedometer (Yamax; Tokyo, Japan) Pedometry Waist (Right) kcal $51.99 (no additional software costs) ActiCalTM triaxial accelerometer (Philips; Eindhoven, Netherlands) Triaxial Accelerometry Wrist (Right) Kcal/min/kg $968.30 (Incl. Software) DynaPort MiniModTM triaxial accelerometer (McRoberts BV; The Hague, Netherlands) Triaxial Accelerometry Waist (Lower Back) kcal $2142.30 (+Software and yearly subscription) Tractivity SensorTM (Kineteks Corporation; Vancouver, BC, Canada) Triaxial Accelerometry Ankle (Right) kcal $39.95  PolarTM heart rate monitor belt (Polar Electro; Kempele, Finland) Flex Heart Rate Chest  kcal/min $50 for HR belt (+ data storage device approx. $100 to $150  SenseWear ArmbandTM multisensor (BodyMedia; Pittsburgh, PA, USA) Multisensor Technology (in combination with accelerometry) Upper Left Arm (Triceps) kJ/min $700 (+ Software)    55  Table 3. Participant Characteristics for All Participants. Participant Characteristics  n total=8; %female=50; COPD (n=2), ILD (n=1), and CF (n=5) Variable Mean SD Minimum Maximum Age (years) 42.10 17.10 23.00 65.00 Height (cm) 164.6 6.20 157.0 174.50 BMI (kg/m2) 23.40 4.10 18.20 30.80 FVC (L) 2.68 0.90 1.79 4.13 FVC % predicted 67.38 22.39 45.00 117.00 FEV1 (L) 1.28 0.32 0.83 1.61 FEV1 % predicted 41.25 14.02 26.00 65.00 FEV1/FVC % 49.89 12.09 37.77 76.65 SD = standard deviation; FVC = forced vital capacity; FEV1 = forced expiratory volume in 1 second  56  Table 4. Exacerbation History and Comorbidities. Comorbidities Diagnosis N %  Participants with known recent exacerbation history 5 62.50 Diabetes 2 25.00 Pancreatic Insufficiency  4 50.00 Bone Disease 3 37.50 Asthma 3 37.50 Gastro Esophageal Reflux Disease 2 25.00 Mental Illness 1 12.50 Chronic Sinusitis 3 37.50           57  Table 5. Cardiopulmonary Exercise Test Performance. Cardiopulmonary Exercise Test Performance Variable Mean SD Minimum Maximum VO2 peak (L/min) 1.43 0.50 0.87 2.40 VO2 peak (mL/kg/min) 23.15 8.20 13.40 36.50 VO2 peak % predicted 76.47 18.01 52.29 93.96 Workload peak (watts) 71.63 34.02 33.00 136.00 Inspiratory Capacity (L) at Rest 2.03 0.82 1.12 3.23 Inspiratory Capacity (L) at Peak 1.71 0.46 1.06 2.39 ∆ Inspiratory Capacity (L) -0.32 0.54 -1.39 0.34 HR peak (Beats/min) 145.50 22.54 109.00 181.00 HR peak % predicted  84.63 10.91 70.23 103.64 Borg Dyspnea score at peak 6.63 2.56 2.00 10.00 Borg Leg Fatigue score at peak 7.25 2.82 2.00 10.00 VO2 = oxygen consumption; HR = heart rate; ∆ = change between peak and rest (peak-rest)    58  Table 6. Assessment of Interchangeability for Primary Index Methods using Limits of Agreement with Precision Estimates. Activity Device Bias LOA SD 95%CI of LOA Interchangeability Flat Walking FMSUB -0.48 1.13 0.58 1.35 2.48 FMCPX -0.25 1.59 0.81 1.91 3.51 SW 0.36 2.72 1.39 3.26 5.98 AC -1.26 1.40 0.72 1.69 3.09 Incline Walking FMSUB -0.37 1.29 0.66 1.54 2.83 FMCPX -0.17 1.79 0.92 2.15 3.95 SW 0.56 2.24 1.14 2.68 4.92 AC -1.80 2.36 1.20 2.83 5.19 Sit-to-Stand FMSUB -0.06 0.91 0.47 1.10 2.01 FMCPX 0.29 1.41 0.72 1.70 3.11 SW -0.38 1.54 0.79 1.85 3.40 AC -1.05 1.67 0.85 2.00 3.67 Lift-Bend FMSUB -0.01 0.90 0.46 1.08 1.99 FMCPX 0.28 1.57 0.80 1.88 3.45 SW -0.39 2.86 1.46 3.43 6.29 AC -0.78 1.26 0.64 1.51 2.77   59  Activity Device Bias LOA SD 95%CI of LOA Interchangeability Cycling at 10% peak work rate FMSUB -0.11 1.46 0.74 1.75 3.21 FMCPX -0.03 1.49 0.76 1.79 3.29 SW -0.86 1.30 0.66 1.56 2.86 AC -1.01 1.26 0.64 1.51 2.77 Cycling at 25% peak work rate FMSUB 0.21 1.08 0.55 1.30 2.38 FMCPX 0.36 1.09 0.56 1.31 2.40 SW -0.70 2.05 1.04 2.46 4.50 AC -1.59 1.24 0.63 1.49 2.73 Cycling at 50% peak work rate FMSUB 0.39 0.73 0.37 0.88 1.61 FMCPX 0.67 1.40 0.71 1.68 3.08 SW -0.69 3.32 1.70 3.99 7.31 AC -2.51 2.03 1.03 2.42 4.45 Cycling at 60% peak work rate FMSUB 0.42 0.74 0.38 0.89 1.62 FMCPX 0.59 1.46 0.74 1.75 3.20 SW -1.26 3.45 1.76 4.14 7.58 AC -3.36 3.00 1.53 3.60 6.60 SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; Interchangeability is the sum of the limit of agreement (LOA) and the 95% confidence interval (CI) of LOA associated with the mean difference (bias) between index method and indirect calorimetry. Lower interchangeability value suggests the device is more interchangeable.  60  Table 7. Comparison of Average Energy Expenditure (kcal/min) Measured by Each Index Method During Free-Living Activities, Cycling, and the Entire Protocol.  IC SW AC FMSUB FMCPX Free-Living   3.43 [0.85] 3.76 [2.33] *2.24 [1.07] 3.61 [0.96] 3.52 [1.03] Cycling (All Stages) 3.35 [1.33] 2.51 [3.27] *1.30 [0.41] 3.63 [1.56] *3.69 [1.33] Averaged Overall 3.43 [1.04] 2.82 [2.21] *1.83 [0.69] 3.62 [1.36] 3.61 [0.94]  All values are expressed as median [inter-quartile range] as data were not normally distributed *Significantly different vs IC at p<0.05 level of acceptance according to Wilcoxon Signed Rank Test  61  Figures Figure 1. Lung Transplantation Waiting List Trends in Canada.    Adapted from the Canadian Organ Replacement Register at the Canadian Institute for Health Information3.62  Figure 2. Theoretical Model of Physical Fitness and Mortality Risk.  High Exercise CapacityLow Exercise CapacityMusculoskeletal Fitness + Cardiovascular Fitness + Body Composition + MetabolismReduced Mortality RiskHigh Mortality RiskPhysically ActiveSedentary Lifestyle63  Figure 3. Conceptual Framework of Physical Activity Measurement.  64  Figure 4. Conceptual Framework of Indirect Calorimetry.      Metabolism   =   FOOD +    Oxygen        Carbon Dioxide + Water             +                 Energy ExpenditureExpired air volume and composition are analyzedIndirect CalorimeterVO2VCO265  Figure 5. Conceptual Framework of Doubly Labeled Water Technique.   66  Figure 6. Step-By-Step Flow Diagram of Study Procedures.    • HR-VO2 measured during rest and steady state exercises• Simultaneous index and criterion measurements of EE during free-living and exercise activitiesFlex HR calibration, and submaximalactivities• Information on age, height, weight, stride length obtained• Standard PFT performed • CPET using symptom-limited incremental protocol performedEntry information, PFT, and CPETDAY ZERO DAY ONE DAY TWOONE MONTH STUDY PERIOD• Patient screened for eligibility• Letter of initial contact provided• Informed consent obtained• Chart data abstractionRecruitment 67  Figure 7. Flex Heart Rate Calibration Protocol.   • Take the highest HR achieved during resting (again, only over last 3 minute sampling period)• Take the lowest HR achieved during exercise• Calculate the average of these two measures = Flex HRFlex Heart Rate Threshold• Average HR and VO2data from last 3 minutes of each 6 minute stage (first 3 minutes is the equilibration period)• Average EE during resting tasks = sedentary EE • Calculate HR-VO2regression Individual Calibration EquationStep 3: Individual HR-VO2curve calibration and Flex Heart Rate calculationResting QuietlyStage 1:Sitting (6 minutes) Stage 2:Standing (6 minutes) Cycling activity60 RPMStage 3:1 minute unloaded warm-up periodStage 4:Cycling at 25% peak workload (6 minutes)Stage 5:Cycling at 50% peak workload (6 minutes)Stage 6:Individually determined cool-down periodStep 2: Conduct resting and submaximal activity protocolStep 1: Fit subject with portable metabolic system and heart rate monitor68  Figure 8. Location of Attachment of the Activity Monitors and Indirect Calorimeter.    Cosmed K4B2TM (facemask andportable unit at front and battery at back)DigiWalkerTMPedometerDynaportTMAccelerometer (around back at waist level)TractivityTMAccelerometerSenseWear Arm BandTM(triceps muscle of the dominant arm)PolarTMHeart Rate Monitor(around chest in contact with skin)ActicalTMAccelerometer69  Figure 9. Low Intensity Free-Living Activities Protocol.     Normal Daily ActivitiesWalk on flatWalk on incline (2-5% grade)Sit/Stand Lift/Bend70  Figure 10. Submaximal Steady-State Cycling Protocol Cycling10% peak workload25% peak workload50% peak workload60% peak workload71  Figure 11. Participant Enrollment Flow DiagramPotentially eligible patients screened for inclusion (n = 108)Completed Day 1 testing (n=13)Completed Day 2 testing(n=11)Data available for analysis (n = 8)Excluded (n = 2)Unable to return for Day 2 within 1 month period, Excluded (n = 3)Technical difficulty with IC recording, unable to perform the entire testing protocolExcluded (n = 95)Supplemental O2, currently smoking, non-compliant with medications, mobility aid, cardiac contraindications, missing recent pulmonary function test, upper age limit exceeded, upper lung function criteria exceeded,agreed to participate in future, declined invite to participate 72  Figure 12. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Flat Walk.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.  73  Figure 13. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Incline Walk.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.  74  Figure 14. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Sit-to-Stand Activity.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.  75  Figure 15. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Lift-Bend Activity.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.  76  Figure 16. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 10% Peak Workload.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.   77  Figure 17. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 25% Peak Workload.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.  78  Figure 18. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 50% Peak Workload.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.   79  Figure 19. Bland-Altman Plot of Agreement Between Indirect Calorimetry and Primary Index Methods During Cycling at 60% Peak Workload.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; Solid horizontal line is the mean difference (index-IC). Dotted lines are the limits of agreement.  80  Figure 20. Scatter Plots of Energy Expenditure During Free-Living Activities.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; r = Spearman correlation coefficient; *significant at p<0.05; Solid diagonal line across from XY intersect represents the line of identity. 0.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00FMSUB EE (kcal/min)IC EE (kcal/min)FMSUB vs IC During Free-Living Activitiesr=*0.786p=0.0210.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00FMCPX EE (kcal/min)IC EE (kcal/min)FMCPX vs IC During Free-Living Activitiesr=0.357p=0.3850.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00SW EE (kcal/min)IC EE (kcal/min)SW vs IC During Free-Living Activitiesr=*0.714p=0.0470.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00AC EE (kcal/min)IC EE (kcal/min)AC vs IC During Free-Living Activitiesr=*0.738p=0.03781  Figure 21. Scatter Plots of Energy Expenditure During Cycling Activities.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; r = Spearman correlation coefficient; *significant at p<0.05; Solid diagonal line across from XY intersect represents the line of identity 0.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00FMSUB EE (kcal/min)IC EE (kcal/min)FMSUB vs IC During Cycling (All Stages)r=*0.833p=0.0100.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00FMCPX EE (kcal/min)IC EE (kcal/min)FMCPX vs IC During Cycling (All Stages)r=*0.905p=0.0020.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00SW EE (kcal/min)IC EE (kcal/min)SW vs IC During Cycling (All Stages)r=*0.976p<0.00010.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00AC EE (kcal/min)IC EE (kcal/min)AC vs IC During Cycling (All Stages)r=0.571p=0.13982  Figure 22. Scatter Plots of Overall Energy Expenditure for Primary Index Methods.  SW = SenseWear; AC = ActiCal; FMSUB = Flex heart rate method using submaximal exercise protocol calibration; FMCPX = Flex heart rate method using peak exercise protocol calibration; IC = indirect calorimetry; EE = energy expenditure; r = Spearman correlation coefficient; *significant at p<0.05; Solid diagonal line across from XY intersect represents the line of identity 0.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00FMSUB EE (kcal/min)IC EE (kcal/min)FMSUB vs IC During Entire Protocolr=*0.905p=0.0020.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00FMCPX EE (kcal/min)IC EE (kcal/min)FMCPX vs IC During Entire Protocolr=0.690p=0.0580.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00SW EE (kcal/min)IC EE (kcal/min)SW vs IC During Entire Protocolr=*0.905p=0.0020.001.002.003.004.005.006.000.00 1.00 2.00 3.00 4.00 5.00 6.00AC EE (kcal/min)IC EE (kcal/min)AC vs IC During Entire Protocolr=*0.786p=0.02183  Figure 23. Scatter Plots of Overall Energy Expenditure for Secondary Index Methods.   DW = DigiWalker pedometer; DP = Dynaport monitor; TR = Tractivity monitor; IC = indirect calorimetry; EE = energy expenditure; r = Spearman correlation coefficient; *significant at p<0.05; Solid diagonal line across from XY intersect represents the line of identity0501001502002503003504000 50 100 150 200TR EE (kcal)IC EE (kcal)TR vs IC Accumulated Overall r=0.323p=0.4350501001502002503003504000 50 100 150 200DP EE (kcal)IC EE (kcal)DP vs IC Accumulated Overall r=0.071p=0.8670501001502002503003504000 50 100 150 200DW EE (kcal)IC EE (kcal)DW vs IC Accumulated Overall r=0.455p=0.25784  References 1. Studer SM, Levy RD, McNeil K, Orens JB. Lung transplant outcomes: a review of survival, graft function, physiology, health-related quality of life and cost-effectiveness. Eur Respir J. 2004;24:674-685.  2. Gross CR, Savik K, Bolman RM, Hertz MI. 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Step-by-step cardiopulmonary exercise testing protocol Step 1(No Stage) – Patients were fitted with a headset, nose clip, mouthpiece attached to an antibacterial filter, automated blood pressure monitor, pulse oximeter, and a multi-lead ECG monitor and then seated on an electronically braked SensorMedics cycle ergometer properly adjusted for each patient. All required patient demographic and anthropometric data were input into the Vmax metabolic computer program which controls the intensity stages of the exercise.    Step 2(Baseline) – After at least 3 minutes of resting comfortably on the cycle, we measured and recorded the subject‘s resting HR, blood pressure, oxygen saturation, and sense of dyspnea and perceived leg discomfort using the modified 10-point Borg scales at baseline. These Borg scores were recorded at each incremental stage of the CPET exercise stage (step 4) as well.   Subjects were also instructed to perform three resting inspiratory capacity (IC) maneuvers.   Step 3(Warmup) – To acclimatize patients to the cycling exercise they were instructed to warm-up for 1 minute by pedaling between 60-70 revolutions per minute (rpm) at a 0 watt (W) workload.      Step 4(Exercise) – Following the brief 1 minute warm-up period patients continued pedaling at the same cadence as we conducted a progressive incremental exercise (every 2 minutes) protocol for each subject where the power  increased electro-magnetically by 15 W every 2 minutes in a stepwise fashion for CF, COPD and ILD patients. If needed, an adapted protocol were implemented where the intensity increased by 10 W every 2 minutes instead of 15 W.. Appropriate protocol selection was determined by communication with treating physician and/or physical therapist. During this step, we continuously monitored the patient‘s blood pressure, HR, VO2, RQ, and Borg scores at each incremental stage. Inspiratory capacity was measured during the last 30 seconds of each incremental stage. Exercise was terminated when the patient requested to stop.  Step 5(Recovery) – Following exercise termination patients continued cycling at a self-selected comfortable work rate for a self-determined time period and continue resting until HR returned to baseline levels. The duration of this cool-down stage varied from subject to subject. During this time, all measurement equipment except for ECG monitoring equipment was removed from the patients.     106  Appendix B. Calculations of standard deviation of difference from previous validation literature Study 1: Flex Method versus gold standard Lead Author: McCloskey, M Study Title: Total energy expenditure in stable patients with cystic fibrosis  Journal Name:  Clinical Nutrition Year: 2001 Study ID (j) Calculations for imputing missing parameters 1 Given in article: Polar Sports Tester (Flex Heart Rate Method) vs Doubly Labeled Water   For free-living activities averaged over a 14 day time period**: o Xi = 9.14 o Si = 1.62 o Xr = 11.07 o Sr =2.44 o Xd = Not reported: 9.14-11.07 = -1.93 MJ/day o Sd = Not reported –calculated below using calculated Rir o Rir = 0.73  **recalculated all data from individual patient data reported in this study for patients with complete flex heart rate and doubly labeled water data.   Sd2j = var(Xrj - Xij) = var(Xrj) + var(Xij) – 2Rirj * Sij * Srj  Sd2 = 2.442 + 1.622 – 2* 0.73 * 1.62 * 2.44        = 2.81 MJ/day Sd = 1.68MJ/day   Units in Kcal/day:  1kcal = 0.004184 MJ  Xd = -1.9MJ/day / 0.004184MJ/Kcal = -454.1 kcal/day Sd = (1/0.004184) * 1.7 = 406.3 kcal/day Sd = 406.3kcal/day /1440min/day = 0.3 kcal/min      107  Study 2 : SenseWear versus gold standard Lead Author: Patel, SA Study Title: Activity monitoring and energy expenditure in COPD patients: A validation study Journal Name:  COPD: Journal of chronic obstructive pulmonary disease Year: 2007 Study ID (j) Calculations for imputing missing parameters 2 Given in article: SenseWear Pro Armband (Multi Sensor Activity Monitor) vs Indirect Calorimetry (Vmax ST, Sensormedics)  For 2 walk tests (six minute walk and incremental shuttle walk), cumulated over both tests (will need to confirm with author that the total time of these two walks was 14 minutes [6 plus 8 minutes]): o Xi = NOT GIVEN (request from author) o Si = NOT GIVEN (request from author) o Xr = NOT GIVEN (request from author) o Sr = NOT GIVEN (request from author) o Xd = -2.8 kcal***  o Sd = 4.3 kcal o Rir =0.93 (P<0.001)*** reported as the correlation between the devices during cumulative kcals from both of the 2nd walks.    Units in Kcal/min: Assuming 14 minutes of sampling time over which the energy expenditure was accumulated:  Xd = 2.8 kcal / 14 min = 0.2 kcal/min  Sd =sqroot( (1/14)2 * (4.3kcals)2) Sd = 0.31 = 0.3 kcal/min      

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