Ingeborg Farver-Vestergaard ^1,2* Eva H. Buksted ³ Dorthe Sørensen ³ Sune Jonstrup ⁴ Henrik Hansen ^5,6 Camilla Christiansen ^1,2 Anders Løkke ^1,2

• ¹ Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
• ² Department of Medicine, Lillebaelt Hospital, Vejle, Denmark
• ³ Research Centre for Health and Welfare Technology, VIA University College, Aarhus, Denmark
• ⁴ Department of Health, Vejle Municipality, Vejle, Denmark
• ⁵ Respiratory Research Unit and Department of Respiratory Medicine, Copenhagen University Hospital, Hvidovre, Denmark
• ⁶ Institute of Rehabilitation Sciences, University of Antwerp, Antwerp, Antwerp, Belgium

Background: Fear-avoidance in COPD can have detrimental effects on pulmonary rehabilitation (PR) outcomes and is therefore important to address. This prospective study examined changes in and management of COPD-related anxiety symptoms over the course of a PR program.Methods: Patients with COPD referred to 9-weeks of PR in the municipality of Vejle, Denmark from January to December 2022 completed a six-minute walk test (6MWT) and the following questionnaires, both before and after PR: COPD Anxiety Questionnaire 20-item version (CAF-R), measuring COPD-related anxiety; COPD Assessment Test (CAT), measuring COPD-related disability; 12-Item Short-Form Health Survey (SF-12), measuring health-related quality of life (HR-QoL); sociodemographic and disease-related information. After PR, a subsample of the patients took part in semi-structured interviews exploring their understanding of how they managed COPD-related anxiety during PR. Pre-and post-assessment of COPD-related anxiety and other PR outcomes were analysed with t-tests and correlation analyses. Qualitative interviews were analysed using a thematic analysis approach.Results: A total of 72 patients with COPD (mean ± SD age 71±8, 53% female) were included in the study, of which 13 took part in qualitative interviews. A significant decrease in COPD-related anxiety was observed from before to after PR, corresponding to a small effect size (Cohen's d=0.32; p=0.018). Reductions in COPD-related anxiety were not associated with improvements in COPDrelated disability, HR-QOL, or functional exercise capacity. The qualitative findings identified four anxiety management strategies, i.e., 'planning', 'problem-solving', 'accepting', and 'confronting', which were influenced by interactions with healthcare professionals and co-patients as well as patients' own perception.Conclusions: COPD-related anxiety was reduced after PR, potentially through the use of various management strategies. The strategies appeared to be influenced by interactional factors during the PR program.