Title: The Physiotherapy Assessment of Breathing Pattern Dysfunction
Funder: Health Education England

Abstract: The Physiotherapy Assessment of Breathing Pattern Dysfunction BackgroundNon-physiological disorders in breathing patterns are known as Breathing Pattern Disorder (BPD)2. Its pathogenesis comprises a complex interplay between biomechanical/biochemical stimuli and psychopathological, cognitive factors3,4. It is prevalent in up to 8% of the general population5, rising to 29% in those with asthma6 giving an overall prevalence of 10%7. The British Thoracic Society highlights the importance of screening for BPD in survivors of COVID-198. BPD profoundly impacts on overall health and morbidity9,10 but its diagnosis is hampered by the lack of a universally accepted method of assessment2. Without clear diagnosis, patients with BPD are prescribed expensive medications that may not be required, or be effective and may do harm11. In 2016 I developed an assessment tool called the Breathing Pattern Assessment Tool (BPAT)1; helping to evaluate BPD. The BPAT is clinically acceptable and widely used. Further testing is need to determine its reliability and responsiveness to ensure that it is valid for use. Well-designed assessment tools are required to target the right patients for physiotherapy and to evaluate treatment responses to in both clinical practice and trials12. Aims To complete a systematic review to evaluate current methods for the assessment of BPD To investigate the validity, reliability and clinical utility of the BPAT in the characterisation and assessment of BPD and to investigate its responsiveness to a co-designed physiotherapy intervention To qualitatively evaluate the validity and acceptability, to patients and clinicians, of assessments and treatments for BPDMethods & Timelines Study 1: 0-12 months A systematic review of published evidence on tools used to assess BPD Study 2: 12-36 months An observational study of 100 patients referred to physiotherapy for BPD assessment. Test-retest and inter-observer reliability of BPAT at rest will be assessed by calculating single-measure intra-class correlation coefficients (ICCs) of consistency. Validity of the BPAT and other assessments of BPD (NQ, SEBQ, D12, 6MWT) will be determined using Pearson's correlation. BPAT scores following exertion will also be evaluated. The BPAT and other assessment tools will be prospectively measured before and after a co-designed physiotherapy intervention. Paired t-tests will compare pre- and post-measurements, and effect sizes calculated. Linear regression will be used to compare change in BPAT with change in other assessments. Follow-up will occur at 3-months to determine if there are sustained improvements in the BPAT and other measurements. Study 3: 32-43 months A qualitative study will investigate the acceptability of the assessment tools and treatments completed by patients and physiotherapy clinicians. Analysis and stakeholder engagement 40-51 monthsResults will be analysed and submitted to peer reviewed scientific journals. Patients, clinicians and stakeholders will review the data and, where relevant, produce outputs together. Joint dissemination will occur through sharing with networks, PPI groups and presentations at conferences. Anticipated impact and disseminationIncreased knowledge on the clinical utility of a novel assessment tool (BPAT) for the assessment of BPD, and its feasibility for use in future clinical trials or for evaluation of treatment responses, as recommended by previous systematic reviews.

Lay abstract: Background and rationale When the natural rhythm of breathing is disrupted, people can develop an unhelpful way of compensating, for example, by breathing too fast or too deeply when this is unnecessary; the medical term for this is a breathing pattern disorder (BPD). BPD causes people to feel out of breath when they do not 'need' to be, which may be frustrating and depressing. BPD is present in around 10% of the general public and in up to 30% of people with asthma. It has proved to be a significant problem after COVID-19, with up to 30% of patients with 'long Covid' having BPD; national guidelines recommend assessment for BPD in follow-up clinics. BPD often goes undiagnosed bringing additional distress to those patients who do not know what is wrong with them. Often, symptoms are mis-attributed to respiratory disease; this may lead to treatment with medications patients do not need, offering limited symptom relief. Improving access to and timely assessment by a specialist respiratory physiotherapist is essential to confirm the presence of BPD and prescribe the relevant treatment that can improve patients' symptoms. However, we currently have limited tools to identify all types of BPD. In 2016 I developed an instrument called the Breathing Pattern Assessment Tool (BPAT) to evaluate BPD. The BPAT is clinically accepted and widely used Further formal testing to understand how reliable the BPAT is over time is needed. If we can develop better means of assessing BPD, and use these in well-designed studies, we will understand more about the best ways to manage the condition and improve patient care. This project aims to expand our knowledge and understanding of the BPAT. Aims Systematic Review to evaluate different methods of assessing BPD, by a thorough summary of the published literature and an analysis of how well the methods perform. To evaluate if the BPAT is a consistent and accurate method of recognising and assessing BPD and if it can be useful in monitoring the effects of treatment for BPD. To better understand patients' and clinicians' experiences of assessment and treatments of BPD.Methods I propose three studies to achieve these aims; Study 1: A systematic literature review to identify and evaluate all the different methods available to assess BPD Study 2: A observational study to determine the consistency accuracy and responsiveness of the BPAT, and the extent to which it is an improvement on other tools used to assess BPD. Study 3: A qualitative study to explore patients and clinicians experiences of BPAT assessment and the treatments received in study 2. Patient and public involvementPatients with respiratory conditions, including asthma and BPD, attended a PPI day in May 2021. This protocol was shared with them, alongside an evaluation of their experiences with the assessment and treatment of BPD. Many of their comments and thoughts were embedded in the protocol redesign. A number of the patients volunteered to be in a BPD PPI group and will form part of a 'Study Advisory Group' (SAG), to continue helping us during this research, and co-writing subsequent research outputs. The protocol was further shared with the Lay Respiratory Group at the Royal Brompton Hospital for their guidance and experience. DisseminationMy findings will be submitted to high quality peer-reviewed journals for publication and will be shared at relevant (inter)national conferences. Lay summaries of the findings will be sent to participants (if requested) and published on expert patient websites e.g. Asthma UK. At the end of the study a knowledge exchange day will be hosted to bring clinicians, patients and researchers together to discuss and explore findings.

Research activity codes: 6.7 PHYSICAL
Health categories: RESPIRATORY;DISPUTED AETIOLOGY AND OTHER