Cystic Fibrosis Clinical Trial
— A-STEPOfficial title:
Development; Feasibility/Safety and Validation of the Alfred Step Test Exercise Protocol (A-STEP) Developed for Adults With Cystic Fibrosis:
Exercise testing has become clinically important in the management and ongoing evaluation of patients with Cystic Fibrosis (CF) with higher rates of exercise tolerance and participation previously linked to lower mortality risk (1). Lower exercise capacity generally correlates with more severe lung disease (2,3) and landmark studies suggest that low exercise capacity as measured by peak oxygen capacity (VO2peak) and rate of decline in lung function (FEV1) are strong predictors of mortality (1,4). However not all studies have found pulmonary function tests (PFTs) to be reliable predictors of maximal exercise capacity (5), especially in relatively well preserved lung function (6,7). The wide distribution in physical capacity between fit individuals and end stage disease adds to complexity of assessment. Independent factors of age, genetics, habitual exercise, nutritional status and musculoskeletal conditions are all known to influence physical capacity in patients with CF (8,9). Maximal exercise testing places additional stress on cardiovascular, respiratory and peripheral systems providing more information around multiple influences on disease progression including degree of limitation in these major systems (10,11) and is useful for assessment of exercise desaturation, more common (but not always present) in advanced lung disease (5,12). With prediction of exercise performance and functional capacity from PFTs unreliable and the understanding that health status correlates better with exercise tolerance there has been an increase in maximal exercise testing for patient management (13). Many international centers now regard exercise testing as highly important with many assessing maximal exercise capacity annually to monitor disease progression, identify physical status and drive changes in medical, physiotherapy or nutritional management (14,15). The main vision is to develop a standardized incremental step test protocol suitable for adults with Cystic Fibrosis (CF), all ages, levels of fitness and disease state that is in line with current exercise testing recommendations (15). To develop a more useful field test to assess exercise tolerance and a more "user friendly" test than the currently available laboratory exercise test to allow for early detection of decline in physical function in the day-to-day clinical setting. To date no studies have been published in adults with CF where an incremental exercise step test has been investigated to assess exercise tolerance or determine maximum oxygen uptake (VO2max).
Status | Recruiting |
Enrollment | 30 |
Est. completion date | October 2024 |
Est. primary completion date | July 2024 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years and older |
Eligibility | INCLUSION - Confirmed Diagnosis of CF (by genotype or positive sweat test) - Aged 18yrs and older - FEV1 =20% (Forced expiration in 1 sec) - Stable baseline state. (Stable baseline state is defined as: clinically stable respiratory status, for at least 30 days, characterized by the absence of hospitalization and no changes in maintenance therapy during this period (Yankaskas et al 2004)). EXCLUSION - Febrile - Haemoptysis - Uncontrolled asthma - Pneumothorax - Cardiac issues - Unreliable readings on pulse oximetry - Pulmonary hypertension - Unstable CF related diabetes (CFRD) - Vascular issues - Renal disease - Pregnancy - Body mass index (BMI) <18.0 - Significant musculoskeletal issues - Unable to safely follow instructions (ATS/ACCP 2003; Hebestreit 2015) |
Country | Name | City | State |
---|---|---|---|
Australia | The Alfred Hospital | Melbourne | Victoria |
Lead Sponsor | Collaborator |
---|---|
The Alfred | Monash University |
Australia,
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Andrade CH, Cianci RG, Malaguti C, Corso SD. The use of step tests for the assessment of exercise capacity in healthy subjects and in patients with chronic lung disease. J Bras Pneumol. 2012 Jan-Feb;38(1):116-24. doi: 10.1590/s1806-37132012000100016. English, Portuguese. — View Citation
Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, Forman D, Franklin B, Guazzi M, Gulati M, Keteyian SJ, Lavie CJ, Macko R, Mancini D, Milani RV; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Interdisciplinary Council on Quality of Care and Outcomes Research. Clinician's Guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association. Circulation. 2010 Jul 13;122(2):191-225. doi: 10.1161/CIR.0b013e3181e52e69. Epub 2010 Jun 28. No abstract available. — View Citation
Balfour-Lynn IM, Prasad SA, Laverty A, Whitehead BF, Dinwiddie R. A step in the right direction: assessing exercise tolerance in cystic fibrosis. Pediatr Pulmonol. 1998 Apr;25(4):278-84. doi: 10.1002/(sici)1099-0496(199804)25:43.0.co;2-g. — View Citation
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Camargo AA, Lanza FC, Tupinamba T, Corso SD. Reproducibility of step tests in patients with bronchiectasis. Braz J Phys Ther. 2013 May-Jun;17(3):255-62. doi: 10.1590/s1413-35552012005000089. — View Citation
de Andrade CH, de Camargo AA, de Castro BP, Malaguti C, Dal Corso S. Comparison of cardiopulmonary responses during 2 incremental step tests in subjects with COPD. Respir Care. 2012 Nov;57(11):1920-6. doi: 10.4187/respcare.01742. Epub 2012 Jun 15. — View Citation
de Camargo AA, Justino T, de Andrade CH, Malaguti C, Dal Corso S. Chester step test in patients with COPD: reliability and correlation with pulmonary function test results. Respir Care. 2011 Jul;56(7):995-1001. doi: 10.4187/respcare.01047. — View Citation
Godfrey S, Mearns M. Pulmonary function and response to exercise in cystic fibrosis. Arch Dis Child. 1971 Apr;46(246):144-51. doi: 10.1136/adc.46.246.144. — View Citation
Hebestreit H, Arets HG, Aurora P, Boas S, Cerny F, Hulzebos EH, Karila C, Lands LC, Lowman JD, Swisher A, Urquhart DS; European Cystic Fibrosis Exercise Working Group. Statement on Exercise Testing in Cystic Fibrosis. Respiration. 2015;90(4):332-51. doi: 10.1159/000439057. Epub 2015 Sep 9. — View Citation
Henke KG, Orenstein DM. Oxygen saturation during exercise in cystic fibrosis. Am Rev Respir Dis. 1984 May;129(5):708-11. doi: 10.1164/arrd.1984.129.5.708. — View Citation
Holland AE, Rasekaba T, Wilson JW, Button BM. Desaturation during the 3-minute step test predicts impaired 12-month outcomes in adult patients with cystic fibrosis. Respir Care. 2011 Aug;56(8):1137-42. doi: 10.4187/respcare.01016. Epub 2011 Apr 15. — View Citation
Lands LC, Heigenhauser GJ, Jones NL. Respiratory and peripheral muscle function in cystic fibrosis. Am Rev Respir Dis. 1993 Apr;147(4):865-9. doi: 10.1164/ajrccm/147.4.865. — View Citation
Marcotte JE, Grisdale RK, Levison H, Coates AL, Canny GJ. Multiple factors limit exercise capacity in cystic fibrosis. Pediatr Pulmonol. 1986 Sep-Oct;2(5):274-81. doi: 10.1002/ppul.1950020505. — View Citation
Moorcroft AJ, Dodd ME, Webb AK. Exercise testing and prognosis in adult cystic fibrosis. Thorax. 1997 Mar;52(3):291-3. doi: 10.1136/thx.52.3.291. — View Citation
Narang I, Pike S, Rosenthal M, Balfour-Lynn IM, Bush A. Three-minute step test to assess exercise capacity in children with cystic fibrosis with mild lung disease. Pediatr Pulmonol. 2003 Feb;35(2):108-13. doi: 10.1002/ppul.10213. — View Citation
Nixon PA, Orenstein DM, Kelsey SF, Doershuk CF. The prognostic value of exercise testing in patients with cystic fibrosis. N Engl J Med. 1992 Dec 17;327(25):1785-8. doi: 10.1056/NEJM199212173272504. — View Citation
Nixon PA, Orenstein DM, Kelsey SF. Habitual physical activity in children and adolescents with cystic fibrosis. Med Sci Sports Exerc. 2001 Jan;33(1):30-5. doi: 10.1097/00005768-200101000-00006. — View Citation
Pianosi P, Leblanc J, Almudevar A. Peak oxygen uptake and mortality in children with cystic fibrosis. Thorax. 2005 Jan;60(1):50-4. doi: 10.1136/thx.2003.008102. — View Citation
Planner, S., Morrison, L., Campbell, J., Bicknell, S., Ross, E. (2007). The Chester Step Test-Is this a Valid Predictor of Disease Severity in Adult CF? . Paper presented at the 2007 Cystic Fibrosis Conference.
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Shah AR, Gozal D, Keens TG. Determinants of aerobic and anaerobic exercise performance in cystic fibrosis. Am J Respir Crit Care Med. 1998 Apr;157(4 Pt 1):1145-50. doi: 10.1164/ajrccm.157.4.9705023. — View Citation
Stevens D, Oades PJ, Armstrong N, Williams CA. A survey of exercise testing and training in UK cystic fibrosis clinics. J Cyst Fibros. 2010 Sep;9(5):302-6. doi: 10.1016/j.jcf.2010.03.004. Epub 2010 Mar 31. — View Citation
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Wilson LM, Ellis MJ, Lane RL, Wilson JW, Keating DT, Jaberzadeh S, Button BM. Development of the A-STEP: A new incremental maximal exercise capacity step test in cystic fibrosis. Pediatr Pulmonol. 2021 Dec;56(12):3777-3784. doi: 10.1002/ppul.25667. Epub 2 — View Citation
* Note: There are 27 references in all — Click here to view all references
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Other | Study A & B) Gender; Age, Height, BMI, fitness level | Demographic baseline descriptive measures. | Recorded on the day of testing maximum 10 mins. | |
Other | Study A & B) Spirometry (Pulmonary Function Tests) | Baseline Pulmonary Function Test measures. | Recorded on the day of testing prior to testing, maximum 10 minutes Study B. Most recent PFTs if day of testing lung function is not available study A. | |
Other | Study A & B) Alfred Wellness Score for CF (AweScore CF) | Alfred specific clinical tools: quality of life measure. | Recorded on the day of testing prior to testing, maximum 2 minutes. | |
Other | Study A) Musculoskeletal Assessment Tool-Quick Screen | Alfred specific clinical tool: to screen for musculoskeletal issues. | Recorded on the day of testing, maximum 20 minutes. | |
Other | Study A & B) Medical history. | Baseline descriptive measures of health status. | Recorded on the day of testing, maximum 10 minutes. | |
Primary | Study B) Maximum oxygen uptake (VO2max) | The highest oxygen uptake achieved during the exercise test taken from inspired gas in a given period of time. Body weight is used to calculate this from oxygen consumption during the test. VO2peak may be used as a surrogate if VO2max is not achieved. Criteria for reaching maximum effort is not included in this document. | Measured during the incremental test for a maximum of 15 minutes. | |
Primary | Study A) Oxygen Saturation | Standard objective outcome measures of field exercise testing. Measured via pulse oximetry. | Measured for 3 min prior to exercise (recorded at baseline sitting and standing), monitored during the test (recorded at minute intervals) and for at least 2 min of recovery up to a maximum of 10 minutes. | |
Primary | Study A) Heart Rate | Standard objective outcome measures of field exercise testing. Measured via pulse oximetry. | Measures for 3 min prior to exercise (recorded at baseline sitting and standing), monitored during the test (recorded at minute intervals) and for at least 2 min of recovery up to a maximum of 10 minutes. | |
Secondary | Study B) Carbon Dioxide Production | Standard secondary outcome measure of maximal exercise testing using breath- by-breath gas analysis with portable metabolic measurement equipment. | Measured during the test incremental tests for a maximum 15 minutes and 5 mins of recovery. | |
Secondary | Study B) Respiratory Exchange Ratio | Standard secondary outcome measure of maximal exercise testing using breath- by-breath gas analysis. The ratio of carbon dioxide production to oxygen consumption. | Measured during the test incremental tests for a maximum 15 minutes and 5 mins of recovery. | |
Secondary | Study B) Minute Ventilation | Standard secondary outcome measure of maximal exercise testing using breath- by-breath gas analysis. The product of tidal volume and respiratory rate. | Measured during the test incremental tests for a maximum 15 minutes and 5 mins of recovery. | |
Secondary | Study B) Oxygen Pulse | Standard secondary outcome measure of maximal exercise testing using breath- by-breath gas analysis. Calculated by dividing the oxygen consumption by heart rate. | Measured during the test incremental tests for a maximum 15 minutes and 5 mins of recovery. | |
Secondary | Study B) Tidal Volume | Standard secondary outcome measure of maximal exercise testing using breath- by-breath gas analysis. The volume of each breath taken. | Measured during the test incremental tests for a maximum 15 minutes and 5 mins of recovery. | |
Secondary | Study B) Oxygen Saturation | Standard objective outcome measures of exercise testing. Measured via pulse oximetry. | easures are taken at baseline (post 5 mins), monitored during the test (recorded at minute intervals) and for min 5 mins of recovery | |
Secondary | Study B) Heart rate | Standard objective outcome measures of exercise testing. Measured via pulse oximetry. | easures are taken at baseline (post 5 mins), monitored during the test (recorded at minute intervals) and for min 5 mins of recovery | |
Secondary | Study B) Measures from Electrocardiogram | Used to monitor the patient's cardiac rhythm (CPET only) | easures are taken at baseline (post 5 mins), monitored during the test (recorded at minute intervals) and for min 5 mins of recovery | |
Secondary | Study A & B) Breathlessness and Leg Fatigue | Standard subjective outcome measures of exercise testing. Modified Borg 0-10. | Measures are taken at baseline (post 5 mins), monitored during the test (recorded at minute intervals) and for min 5 mins of recovery | |
Secondary | Study A & B) Blood pressure | Standard outcome measure of exercise testing. | Measures are takenpre/post A-STEP, pre/every 2 mins during/post CPET | |
Secondary | Study A & B) Duration of test; Highest level (mins and sec)/stage achieved; Reason for test termination. | Parameters of exercise test. | Measured during or on completion of the test. Maximum 15 minutes. |
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