HOW TO TRAIN A COPD PATIENT.ppt

HOWTOTRAINACOPDPATIENT EnricoM CliniProfessorinRespiratoryMedicineUniversityofModena Dept OfRehabilitationOspedaleVillaPineta Pavullo MO ItalyCorrespondence OspedaleVillaPinetaViaGaiato 127 41026Pavullo MO Phone Fax 39 053642039E mail clini enrico unimore it NOTE Thefollowingslidesaretobeusedformedicaleducationpurposesonly CopyrightbelongstoProusScienceandProusScienceisnotresponsibleforanymodificationorchangemadebytheuserstotheseslides ContentsImpairedexerciseinCOPDMeasuresofexercisecapacityPulmonaryrehabilitationandtraininginCOPDTrainingaCOPDpatient modalities sites programs HOWTOTRAINACOPDPATIENT ImpairedexerciseinCOPDCauses VENTILATIONReducedventilatorycapacityLUNGMECHANICSExpiratoryflowlimitationDynamichyperinflationRespiratorymusclesinefficiencyBLOODGASESHypoxemiaImpairedperipheraloxygendeliveryPERIPHERALMUSCLESStructuralchangesanddysfunctionLowerlactatethreshold ENHANCEDSYMPTOMS ImpairedexerciseinCOPDVentilatorylimitation Twomainfactorslimitexerciseperformance thereducedtotalventilatorycapacity left andtheincreasedhyperinflation right duringeffort fromPellegrinoRetal JAP1999 87 1697 1704 ImpairedexerciseinCOPDThe so called viciouscircle ImpairedexerciseinCOPDPeripheralmuscledysfunction BUT muscleschangetheirstructure thediseaseprogressionleadstoasignificantreductioninmassandstrength especiallyatthelowerlimblevel fromBernardS etal AJRCCM1998 158 629 634 ImpairedexerciseinCOPDPeripheralmuscledysfunction And additionally musclemetabolismchanges reductioninmuscleaerobicenzymesandinoxygenuptakekineticslowlacticacidosisthresholdrapidfallinintramuscularpH Measuresofphysicalexercise Thereforeexercisecapacityshouldbeindependentlymeasured Withprogressiveloadincrementaltests bycycloergometry arm ergometryortreadmill Maxload VO2 heart respiratoryrate MV symptomsWithconstantloadtests bycycloergometry arm ergometryortreadmill Maxexercisetime iso timeVO2 andMV symptomsWithfieldwalkingtests by6 minwalkorshuttletest Maxdistance symptoms Principalmeasuresofmusclestrength andmusclestrengthalsoshouldbeassessed PeaktorqueforceMaximalonerepetitionatthehighestsustainableweight Measuresaretakenatdifferentmusclegroups generallyquadriceps armbiceps handgrip PulmonaryRehabilitation PR andtraininginCOPDWhatPRis anevidence based multidisciplinary andcomprehensiveinterventionforpatientswithchronicrespiratorydiseaseswhoaresymptomaticandoftenhavedecreaseddailylifeactivities isdesignedtoreducesymptoms optimizefunctionalstatus increaseparticipationandreducehealthcarecoststhroughstabilizingorreversingsystemicmanifestationsofthedisease ATS ERSStatement AJRCCM2006 173 1390 1413 PulmonaryRehabilitation PR andtraininginCOPDFocaloutcomesinPRprograms PulmonaryRehabilitation PR andtraininginCOPDComponentsandlevelofefficacyinPR MuscletrainingBodycompositionabnormalitiesandinterventionsEducationandself managementPsychosocialissuesChestphysiotherapy ScientificLevelofefficacy ABBCC accordingtotheSackettrulesofevidence PulmonaryRehabilitation PR andtraininginCOPDComponentsandlevelofefficacyinPR Therefore TRAININGmustbeincludedinanyrehabilitationprogramtomaximizetheindividual sfunctionThemechanismofimprovementisthereductionintheventilatoryandmetabolicdemands PulmonaryRehabilitation PR andtraininginCOPDEffectsizeoftraining fromSalmanGF etal JGIM2003 18 213 221 Severalstudieshaveclearlyindicatedthatapositiveeffectoftraininghasbeenobtainedbothinmoderateandseveredegreeoftheillness TrainingaCOPDPatientPrinciple Onemajorprincipleforsuccessfultrainingisthe overloadprinciple sothatmuscularadaptationswillonlyappearifthemuscleissufficientlystressed TrainingaCOPDPatientModalities ENDURANCE ET Theaimistocarryonexerciseaslongaspossible Itinvolvesalargemusclemassatthehighestintensityforalongperiodoftime TrainingaCOPDPatientModalities STRENGTH ST Theaimistopreventorcounterbalancethemuscleatrophy Itinvolvesasmallmusclemassathighintensityforashortperiodoftime TrainingaCOPDPatientSites UPPERLIMBSMeansforET cycloergometry treadmillMeansforST weights multigymstationLOWERLIMBSMeansforET cycloergometer treadmillMeansforST weights multigymstationRESPIRATORYMUSCLESMeansforST thresholdloaddevices TrainingaCOPDPatient INTENSITYUpto70 80 ofthemaximalsustainableloadatbaselineDURATION eachsession Upto30 40minutes orupto3seriesof10repetitions LENGTHNotlessthan15 20sessionsFREQUENCYOnadailyorweeklybasis Eachtrainingprogrammustbeindividuallytailoredandgraduallymaximizedaccordingtothefollowingparameters TrainingaCOPDPatient Exampleonhowtograduallyincreasebothintensityanddurationofsessions Tosummarize Legend HR Heartrate VO2 Oxygenuptake ADL Activityofdailyliving MIP Maximalinspiratorypressure MIP Maximalexpiratorypressure TrainingaCOPDPatientOtherstrategies EXERCISEWITHOXYGENSUPPLEMENTSnider G L Chest2002 122 1830 6EXERCISEWITHVENTILATORYSUPPORTAmbrosino N EurRespirJ2004 24 313 22ADOPTANINTERVALTRAININGMODALITYVogiatzis GL EurRespirJ2002 20 12 9PASSIVEMUSCLESTIMULATIONAmbrosinoN EurRespirJ2004 24 313 22 Inordertoenhanceintensityinthemostdisabledindividualsotherstrategiescouldbefollowed TrainingaCOPDPatientEnduranceorstrength SomestudiesshowthatenduranceandstrengthtraininginCOPDmaybenefitCOPDpatientsinasimilarway Inarecentmeta analysisitwasshownthattheoveralleffectofthesemodalitiesonboththeindividual sexerciseperformanceandthespecificqualityoflifeissimilar PuhanM A etal Thorax2005 60 367 375 Inconclusion 1 TrainingpreventsphysicaldeteriorationinpatientswithsymptomaticanddisablingCOPD 3 Thecombinationofenduranceandstrengthtrainingisprobablythebeststrategytotreatperipheralmuscledysfunction 2 EnduranceandStrengthtrainingaretwospecificmodalitiesfortreatingmuscledisfunctioninthesepatients Strengthtrainingcanbeusedasanadditionalmodalitytowholebodytrainingtofurtherimprovebenefits Suggestedbibliography 1 Ambrosino N Strambi S NewstrategiestoimproveexercisetoleranceinCOPD EurRespiJ2004 24 313 322 AmericanThoracicSociety EuropeanRespiratorySociety StatementonPulmonaryRehabilitation AmJRespirCritCareMed2006 173 1390 1413 ATSandERS Skeletalmuscledysfunctioninchronicobstructivepulmonaarydisease AstatementoftheAmericanThoracicSocietyandEuropeanRespiratorySociety AmJRespirCritCareMed1999 159 S1 S40 Clini E Costi S Lodi S Rossi G Non pharmacologicaltreatmentforchronicobstructivepulmonarydisease MedSciMonit2003 9 RA300 05 Clini E Costi S Romagnoli M Florini F RehabilitationofCOPDpatients whichtrainingmodality MonaldiArchChestDis2004 61 167 73 Gosselink R Decramer M Muscletraininginpulmonaryrehabilitation In PulmonaryRehabilitation C F Donner M Decramer Eds EurRespirMon2000 13 99 11