PULMONARY REHABILITATION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: PROGRAMS

1

• PULMONARY REHABILITATION IN CHRONIC OBSTRUCTIVE
  PULMONARY DISEASE PROGRAMS DIFFICULTIES

Assoc. Prof. Alev GÜRGÜN Ege University Medical
School Department of Chest Diseases IZMIR
2
Benefits of Pulmonary Rehabilitation

• Reduce dyspnoea (level 1a)
• Increase muscle strength and endurance (1b)
• Improve HRQOL (1a)
• Increase independence in daily functioning (11b)
• Improve knowledge of lung condition
• Promote self management
• Promote long term commitment to exercise
• Reduce hospital length of stay / admissions (1b).

3
Pulmonary rehabilitation programme
Stages Selection Assessment Rehabilitation Re-ass
essment Maintenance
Multi disciplinary team
Lifestyle change
Outcomes Functional performance Health
status Dyspnoea Cost reduction Programme audit
Disabled patient
Content Exercise training Disease
education Psychological Social support
Family
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Rehabilitation setting

• PR is most frequently provided in a hospital
  setting.
• PR performed in a community ? preferable in terms
  of access
• There is little evidence regarding a community
  setting for PR
• Home-based pulmonary rehabilitation programs have
  achieved similar benefits to hospital-based
  programs.
• Greatest convenience for patients
• Prolong benefit
• In severely disabled patients home rehab may not
  be as effective

Elliott et al, Respirology, 2004 Aug 9(3)
345-51)
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Rehabilitation setting
6
Rehabilitation setting

• Hospital versus community
• Similar benefits are reported in exercise
  performance and health status
• The content of a rehab program is more important
  than setting
• Essentially does not matter where provided if it
  is done properly
• Access /travel /parking
• Staffing expertise
• Quality control

(CoHoRT Study, Waterhouse JA ERS 2006)
7
Exercise

• Intensity
• Duration
• Frequency
• Components
• New strategies

8

• INTENSITY

9
Challenge of finding optimal exercise protocol

• Balance of effectiveness and tolerance
• Standard High-intensity continuous exercise
• ? effective, but often not sustainable
• High target continuous training intensity can be
  difficult to reach in COPD
• Alternative Interval exercise
• ? sustainable, but as effective?

Nici AJRCCM 20061731390
10
High Intensity Continuous Training

• In healty subjects, high-intensity training is
  defined as
• Increased blood lactate levels
• In PR population
• A training intensity that exceeds 60 of the peak
  exercise capacity
• A Borg score of 4 to 6 dyspnea or fatigue

11
Interval Training

• Interval Training
• Is characterized by repeated bouts of
  high-intensity exercise interspersed with
  recovery periods (light exercise or rest)
• In healty subjects, interval training with rest
  shows better results than continuous training
• Interval training induces physiologic training
  effects

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Low intensity
High intensity
VE/VO2
VCO2
Lactate
Heart Rate
Heart Rate
.
.
Lactate
VCO2
VE/VO2
VE
VO2
VE
VO2
.
Change
.
.
.
.
.
.
.
0
0
-10
-10
-20
-20
-30
-30
Casaburi et al. ARRD 19911439-18.
13
Interval training
(Coppoolse et als ERJ 199914258)
14
Interval Training
(Vogiatzis et als ERJ 20022012)
15
Interval Training in COPD

• The most common interval training is moderate to
  high intensity exercise alternated with
  low-intensity exercise.
• High intensity interval exercise is equally
  effective as moderately intense
• It is better tolerated in severe COPD
• Interval training has been found promising in
  COPD

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• Interval and high intensity continuous exercise
  for three weeks followed by home exercise
• Setting Inpatient rehabilitation centre
• Primary outcome Chronic Respiratory
  Questionnaire
• Additional outcomes Protocol adherence,
  exercise tests

BMC Pulmonary Medicine, 2004
17
Primary outcome CRQ
Favours
Favours
Favours
Favours
Interval exercise
continuous exercise
Interval exercise
continuous exercise
(n44)
(n41)
(n44)
(n41)
CRQ Domain
Difference
CRQ Domain
Difference
-
0.07 (
-
0.53
-
0.38)
-
0.07 (
-
0.53
-
0.38)
Dyspnea
Dyspnea
-
0.02 (
-
0.
41
-
0.
37
)
-
0.02 (
-
0.
41
-
0.
37
)
Fatigue
Fatigue
Emotional
Emotional
-
0.08 (
-
0.48
-
0.32)
-
0.08 (
-
0.48
-
0.32)
function
function
-
0.01 (
-
0.46
-
0.45)
-
0.01 (
-
0.46
-
0.45)
Mastery
Mastery
-
0.05 (
-
0.42
-
0.32)
-
0.05 (
-
0.42
-
0.32)
Total score
Total score
-
1
-
.75
-
.5
-
.25
0
.25
.5
.75
1
-
1
-
.75
-
.5
-
.25
0
.25
.5
.75
1
Adjusted

differences
between
Adjusted

differences
between
change
scores
change
scores
Adjusted for gender, six
-
minute walk distance, HADS depression score, long
-
term oxygen,
Adjusted for gender, six
-
minute walk distance, HADS depression score, long
-
term oxygen,
recent exacerbation, cardiovascular and endocrine
co
-
morbidities
recent exacerbation, cardiovascular and endocrine
co
-
morbidities
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• Controversy exists regarding whether different
  modalities of supervised exercise training
  continuous (C), interval (I) or self-paced (S)
  programs are equally beneficial
• 71 COPD patients
• 8 weeks C,I or S training
• 45 min., 3 /week
• C ? 80 of pre-training peak work rate in
  incremental cycle ergometer
• I? 2 min. 90 followed 1 min. 50 cycling 30
  min.
• S? Cycle, climb stairs and walk at home with same
  periodicity and time intervals
• Improvement in C and I group but not in S group
• Peak oxygen uptake and lactic acidosis treshold
  improved in supervised group
• C and I training is superior to S

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Conclusions

• Interval exercise as effective as continuous
  exercise
• Exercise tolerance significantly better with
  interval exercise
• Interval training is an effective option
  appropriate for patients unable to tolerate high
  intensity training for long-enough intervals.

• ERS/ATS may strengthen recommendations for
  interval
• exercise in advanced COPD

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• DURATION

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Duration of training (COPD)
Adaptation /control ratio
Training duration ( months)
(Puente L. et al Eur J Appl Physiol 2002)
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Duration of pulmonary rehabilitation

• Reported (short term) successful outpatient
  programmes 4-78 weeks
• Inpatient 2 weeks (physical performance)
• Generally 8-12 weeks
• 4 weeks showed less benefit than similar training
  for 7 weeks
• 20 sessions show considerably more improvement in
  multiple outcomes than 10 sessions
• Short term intensive programmes (20 sessions
  condensed in 3-4 weeks) are also effective
• Longer programs yield larger, more endurable
  training effects

23
Pulmonary rehabilitation for COPD Cochrane
reviewLacasse et al 2003Duration of programme
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Duration

• The optimum length ??
• The length depends on the resources available and
  usually ranges from 4 to 12 weeks
• Longer programs resulting in larger effects
• The different physiological adaptations to
  training may follow a different time course along
  the training period.
• GOLD, The longer the better
• Severe patients need gt 6 months rehabilitation?

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• FREQUENCY

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Frequency

• In healthy at least 30 min per day 3-5 days/wk
  are needed
• Twice weekly is not enough in COPD

ACSM position paper Med Sci Sports Exerc.
199830975-91 Ringbaek TJ et al Respir Med.
200094150-4).
27
Frequency

• COPD patients should perform at least three times
  per week and regular supervision of exercise
  sessions is necessary for optimal benefits.
• Any alternative for supervised exercise?

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Unsupervised Programs

• Because of program constraints, twice weekly
  supervised exercise training at home may be an
  acceptable alternative although it is unclear
  whether effective
• Once-weekly supervised sessions appear to be
  insufficient

ATS/ERS Statement on pulmonary rehabilitation,2006
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• 41 COPD patients
• Supervised training on a treadmill, 4 dys/week
• Walking 3 or 4 km. selfmonitored with a
  pedometer, weekly visits 4 dys/week
• Both types of training improved exercise
  tolerance but the magnitude and extend of
  physiological improvements were larger in
  supervised

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Supervised (S) (n21) Supervised (S) (n21) Self-monitored (SM) (n20) Self-monitored (SM) (n20)
Units Pretrain. Postraining Pretrain. Postraining
Time Min 9.4 (4.7) 17.4 (4.3) 8.5 (3.9) 12.4 (5.1)
VO2p m1 min-1 1243 (243) 1353 (298) 1250 (291) 1255 (278)
HR E min-1 132 (12) 125 (13) 130 (13) 128 (9)
VE E 1 min-1 39 (7) 34 (7) 39 (6.4) 38 (7)
SBP E mm Hg 179 (29) 174 (23) 172 (15) 165 (17)
DBP E mm Hg 95 (11) 91 (8) 92 (8) 89 (9)
DLa mmol l-1 3.2 (1.8) 1.6 (0.8) 2.7 (1.8) 2.6 (1.0)
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• Following 8 wk PR program
• Supervised weekly, hospital based maintenance
  exercise group
• Control unsupervised home exercise group
• Supervised program maintains functional capacity
  and quality of life longer than unsupervised

32

• COMPONENTS

33
Exercise, an essential component of rehabilitation
26
24
Exercise training education
22
20
18
Endurance time (minutes)
16
14
Education
12
10
6
12
0
2
Months
Ries et al. Ann Int Med 1995 122 823-832.
34
Exercise, an essential component of rehabilitation
6
Education
5
Dyspnea
4
Exercise training education
3
0
2
6
12
Months
Ries et al. Ann Int Med 1995 122 823-832.
35
THE WAY TO EXERCISE COPD

• LOWER LIMB EXERCISE
• (cyclo, treadmill, walking)
• UPPER LIMB EXERCISE
• (arm-ergometer)
• RESPIRATORY MUSCLES

Protocols Endurance training Strength
training Combined
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Endurance, Strength or Both?

• Compare the effects of endurance and
  endurancestrength (combined) training
• Muscle strength
• Quality of life
• Exercise performance
• Muscle fatigue
• Combined training led significant improvements in
  major muscles strength
• This improvement in muscle strength did not cause
  any improvement in exercise performance, quality
  of life or muscle fatigability.

M. Jeffrey Mador et al. Chest 2004 1252036-2045
37
Endurance, Strength or Both?

• Strength training ? Muscle growth
• Strength may be associated with less dyspnea than
  aerobic exercise.
• The combination of strength and aerobic training
  ? Physiologically complete approach

38
Muscle adaptation to exercise
Endurance
15
30
Endurance strength

25

10
20

change with training
15
5
10
5
0
0
Mid-thigh CSA
Quadriceps
Pectoralis
Latissimus
major
dorsi
Bernard et al. AJRCCM 1999159 896-901.
39

• There is contoversy regarding the components of
  the optimal exercise protocol
• Strength exercise ? Larger improvements of HRQL
  than endurance training
• Interval exercise ? Similar effectiveness as
  continuous exercise (Few data)
• Larger physiologic training effects in high
  intensity exercise (few data)
• Strength exercise should be routinely
  incorporated in rehab.

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Specific expiratory, inspiratory or combined?

• Specfic expiratory muscle training (SEMT)
• Specific inspiratory muscle training (SIMT)
• SEMTSIMT
• Control? Very low load
• 6 times/week,3 months
• The inspiratory and expiratory muscles can be
  specifically trained with strength and endurance
  training
• Increase in 6 min. Walk test and dyspnea.

Paltiel Weiner et al. Chest 20031241357-1364
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Exercise prescription guidelines

• Supervised group exercise program
• Adequate program duration, session frequency and
  session duration
• Individualized exercise intensity prescription
  based on exercise test
• High intensity target based on target work rate
  or heart rate

42
Training a COPDOther strategies
In order to enhance intensity in the most
disabled individuals other strategies could be
followed
EXERCISE WITH OXYGEN SUPPLEMENT Snider, G.L.
Chest 2002, 122 1830-6 EXERCISE WITH
VENTILATORY SUPPORT Ambrosino, N. Eur Respir J
2004, 24 313-22 ADOPT AN INTERVAL TRAINING
MODALITY Vogiatzis, GL. Eur Respir J 2002, 20
12-9 PASSIVE MUSCLE STIMULATION Ambrosino N.
Eur Respir J 2004, 24 313-22 BIOFEEDBACK Ambrosi
no, N. Eur Respir J 2004, 24 313-22
43
Exercise with oxygen supplement

• The mechanisms of oxygens benefit
• Carotid body inhibition
• Vasodilation in pulmonary circulation
• Arterial oxygen content increases
• Supplemental oxygen
• Reduce ventilatory requirement, hyperinflation
• Improve exercise tolerance
• Allow higher training intensities
• Results are not enough for generalise such
  intervention

ATS/ERS Statement on pulmonary rehabilitation,2006
44
Exercise with ventilatory support

• Improves respiration in COPD by unloading
  inspiratory muscles.
• Reduces inspiratory muscle effort in COPD.
• Reduces the work of breathing and increase
  tolerance

Ambrosino N, Strambi S. New strategies to improve
exercise tolerance in COPD ERJ 200424313-322.
45
PS reduces inspiratory effort during exercise
Maltais, Am J Respir Crit Care Med
46
Effects of PNMES in COPD patients with severe
peripheral muscle dysfunction

• Cellular function
• Fibre type transition in the fast to slow
  direction
• Enzymology change from anaerobic to aerobic
  direction
• Exercise tolerance
• Very significant clinical improvement in muscle
  strength
• transfer from bed to chair, walking tests
• Quality of life
• Improvement in quality of life

.
47
Neuromuscular electrical stimulation
Eligible patients

• All patients unable to perform the regular basic
  programme of exercise training.
• Patients with extreme atrophy with extreme
  dyspnea.
• This training programme would be appropriate for
  patients hospitalised in an ICU in order to
  decrease the risk of readmission and mortality.

48
Biofeedback

• Involves direct visual or aural feedback
  regarding physiological states.
• Target to regulate muscle tension
• People might be thaught to increase or decrease
  the internal bodily fuctions
• Stress management by major muscle group relaxation

Ambrosino N, Strambi S. New strategies to improve
exercise tolerance in COPD ERJ 200424313-322.
49
Pulmonary Rehabilitation

• Negative Aspects
• Disruption of routine
• Tiredness
• Transportation difficulties
• Limited privacy
• Confrontation with severely ill patients
• Reasons for drop-out
• Transporation problems
• Sudden illness
• Other duties, resposibilities
• Lack of improvement
• Social factors

• Treatment Goals
• Increase in functional functional performance
• Weight regulation
• Reduction of dyspnea
• Improvement in psychosocial well-being
• Positive Aspects
• Opportunity for improvement
• A safe and multidisciplinary setting
• Presence of motivating and supporting patients

Fischer MJ. Clinical Rehabilitation
200721212-221
50
Difficulties in Pulmonary RehabilitationPatient
Perspectives

• Patients treatment beliefs have been found to
  play a role in uptake and adherence

First time referral Mildly limited in daily
functioning Concrete treatment goals, low
salience Unsure about benefits Few concerns
regarding participation
Highly limited in daily functioning Concrete
treatment goals Many anticipated benefits of
participation (physical, social) Many concerns
regarding participation
Wait Sea
Optimistic
Participation in Pulmonary Rehabilitation
Sceptic
Pessimistic
No involvement in referral decision Highly
limited in daily functioning Few treatment
goals Few anticipated benefits Many concerns
regarding participation
Highly limited in daily functioning Few
anticipated benefits Many concerns regarding
participation Insufficient confidence in own
capabilities
Refere edilirken fikri alinmayangili birçok
endiseö
DROP-OUT
DECLINE
Fischer MJ. Clinical Rehabilitation
200721212-221
51
CONCLUSION

• A minimum of 20 sessions at least 3/week (to
  achieve physiologic benefits)
• 2/week1 unsupervised ? Acceptable
• High-intensity produces greater benefit,
  low-intensity is also effective
• Interval training is useful ( more symptomatic
  patients)
• Both upperlower ext. exercise
• Comination of strengthaerobic ?
• Multiple beneficial effects
• Well tolerated
• Strength ? Sigificant muscle atrophy