Pulmonary rehabilitation (PR) Introduction • Pulmonary rehabilitation (PR) is a tailored therapies after thorough assessment, that include • Exercise training • Education • Behavior change • It is designed to improve • Physical condition • Psychological condition • It is designed to promote • long-term adherence to programme Pulmonary Rehabilitation team • Pulmonary rehabilitation programs are ideally delivered by an multidisciplinary team • • • • • • Physician Nurse Physiotherapist Clinical psychologist Dietician Patient and family members or care giver Holistic approach • All patients are assessed by physician before entering into exercise training programme • Physician does regular follow up of patient for necessary change in pharmacological therapy • Programme tries to improve • • • • • • • Symptoms Exercise tolerance Nutritional status Quality of life Exacerbation frequency Daily physical activity comorbidities Aims of rehabilitation in COPD • Aims of pulmonary rehabilitation(PR) are to • • • • • • Reduce symptom burden Maximize exercise capacity Promote autonomy Improve participation in ADLs Enhance HR-QoL Promote health behavior change assessment Assessment Strength • Lower limb • Upper limb • Respiratory muscles endurance cardiopulmonary Outcome measures • Field walking tests (6MWT, shuttle walk test)) • Health-related quality of life questionnaires (HR-QoL) • Borg scale for RPE • Physiological testing for VO2max Modified Borg scale Assessment for strength • Use manual muscle testing (MMT) for lower limb strength • Mostly quadriceps femoris is tested • Isokinetic dynamometer or hand-held dynamometer can be used for LL strength • Handgrip dynamometer can be considered as an indicator for UL strength Assessment of endurance • Check contraindications for cardiopulmonary exercise testing Assessment of endurance • Incremental cycle ergometry (ACCP recommendation) • • • • • • • • • History, PFT, ECG Familiarization with borg scale Measure vital signs 3 minutes of rest 3 minutes of unloaded cycling at “0 W” Incremental phase - increase intensity every 3 minutes by 5-25 W Termination when exhaustion / continue for 8-12 minutes 3 minutes unloaded cycling Measure vital signs and borg scale • peak work rate (W) and peak heart rate are used to derive exercise intensity for endurance training protocol for cycle ergometer Assessment of endurance • Indications for termination of cardiopulmonary exercise testing Assessment of endurance • Maximal Incremental treadmill testing • Incremental protocol similar to cycle ergometer may be used • Use 0.6 to 1.0 mph speed for exercise baseline • Work rate can be incremented at regular interval with combination of speed and grade Assessment of endurance • 6 minute walk test (6MWT) • Most popular field walking test used for patients with respiratory disorders • Self-paced 6MWT assesses sub-maximal level of functional capacity • It better reflects function exercise level for ADL • Oxygen desaturation during 6MWT reflects oxygen desaturation during patients’ ADL Assessment of endurance • 6 minute walk test (6MWT) • At the beginning and the end of the test, measure the followings • • • • Oxygen saturation Heart rate Perceived dyspnoea and leg fatigue by borg scale Distance walked (in meters) during the test Assessment of endurance • Incremental shuttle walk test (ISWT) Assessment of endurance • Incremental shuttle walk test (ISWT) • It is field walking test • It uses audio signal from CD player to determine walking pace back and forth on 10 meter course • ISWT has better correlation with VO2peak • VO2peak (ml/kg/min) = 4.19+0.025 x ISWT distance Training programme Exercise prescription • Same principles are applied for both healthy person and chronic respiratory disease patient • But the exercise prescription for patient is symptom limited • Good medical management makes rehabilitation more effective Pulmonary rehabilitation strength endurance additional F I T T protocol F frequency I intensity T time (duration) T type (mode) Frequency • 3 times per week under regular supervision can be done • Programme with twice weekly supervision with home exercise can be done Duration • Minimum 8 weeks are required to get improvement in • Exercise tolerance • HR-QoL • Programme of 6 months or longer may show better longterm effects type & intensity (LL strengthening mode) • Strength training for LL in COPD is required to • Prevent falls • Improve balance and function • Reduce osteoporosis type & intensity (LL strengthening mode) • According to American College of Sports Medicine 2013 • Perform 2-3 times weekly • Keep intensity 60-70% of 1RM • Perform 1-3 sets of 8-12 repetitions • Progression is done over time to ensure progressive overload is achieved type & intensity (UL strengthening mode) • Activities of daily living require upper limb involvement • so strengthening of UL is included in programme • • • • Biceps Triceps Pectoral muscles Arm cycle ergometry Type & intensity (endurance mode) • Most programmes are continuous (endurance) exercise training, incorporating walking and/or cycling for 20-30 minutes per session • For interval training, 20-30 minutes session is divided into short bouts of high-intensity exercise for 30 seconds and 2-3 minutes for rest and lower-intensity exercise • Interval training may be suitable for severe patients so they can exercise for longer with fewer symptoms Type & intensity (continuous endurance mode) • Practical recommendations • Frequency • Mode • Intensity 3-4 days per week continuous 60-70% of peak work rate (PWR) • Duration initially 10-15 min for first 3 to 4 sessions progression to 30-40 min keep between 4-6 point on 10 point borg scale • RPE increase work load by 5-10% as tolerated Progressively try to reach ,80–90% of baseline PWR Type & intensity (interval endurance mode) • Practical recommendations • Frequency • Mode 3-4 days per week 30 s of exercise, 30 s of rest or • Intensity 80-100% of peak work rate (PWR) for first 3 to 4 sessions • Duration • RPE 20 s of exercise, 40 s of rest increase work load by 5-10% as tolerated progression ~150% of baseline PWR Initially 15–20 min for the first 3to 4 sessions progression to 45-60 min keep between 4-6 point on 10 point borg scale Type & intensity (interval endurance mode) • Practical indications for interval training approach • • • • • Severe airflow obstruction (FEV1 <40%) Low exercise capacity (PWR <60%) Total time at a constant work rate test of <10 min Marked oxygen desaturation during exercise (SpO2 <85%) Intolerable dyspnoea during continuous endurance training Type & intensity (cycle vs walking) • Walking is most important activity of ADL in patient with COPD • Supervised progressive walking training gives significant larger increase in endurance walking capacity as compared with cycling training • It is easy to set and control proper walking speed on treadmill Type & intensity (cycle vs walking) • Using metronome or listening to music can help keeping walking speed • If no supportive devices are available to determine walking speed, a perceived exertion on Borg scale from 4 to 6 could be targeted Additional measures water-based training • Only indication for water-based training in COPD is to have comorbidities which restricts their participation in landbased exercise • Post Fracture • Osteoarthritis • Obesity respiratory muscle training • By improving strength or endurance of diaphragm, greater inspiratory loads may be tolerated • Inspiratory muscle training (IMT) might be useful when added to whole-body exercise training respiratory muscle training • Practical recommendations • Frequency • Objective • Mode • Intensity • Duration 5-7 days per week to increase inspiratory muscle strength in patient with inspiratory muscle weakness (Pimax <60cm H2O) most commonly threshold loading initially >30% of Pimax increase load as tolerated 7 x 2 min with 1 min rest between interval neuromuscular electrical stimulation (NMES) • NMES is an adjunct to rehabilitation in severely disabled patient with low body mass index (BMI) • Transcutaneous low-intensity currents can induce muscle contraction and specific muscle groups can be trained neuromuscular electrical stimulation (NMES) • Practical recommendations • Frequency • Objective 3-7 days per week to increase peripheral muscle strength in severely • Mode pulse duration 200-700 microsecond • Intensity • Duration deconditioned or bed-bound patients duty cycle 2-10 s on /4-50 s off increase until visible muscle contraction occurs or to the maximum tolerated level 1 to 2 sessions per day for 20-60 min balance training • Altered postural balance control is secondary impairment in COPD, which can increase the risk of falling • COPD patients have high fear of falling & they reduce their physical activity level • Exercise training with balance re-education programme improves balance in people with COPD whole-body vibration (WBV) • WBV has shown significant benefits in walking distance and these benefits may be greater than conventional exercise training alone whole-body vibration (WBV) • Practical recommendations • Frequency • Objective 3 days per week to increase peripheral muscle strength and neuro- • Mode side-alternating or vertical vibration platform • Intensity • Duration muscular activation, especially of lower limbs peak-to-peak displacement >4mm side-alternating >20 Hz vertical vibration >35 Hz 2 to 4 sets of each 30-120 s per exercise Timing of pulmonary rehabilitation (PR) • Disease stability • PR can be started if patient has been stable (exacerbation free) for 8 weeks • post-exacerbation • Patients discharged from hospital with acute exacerbation of COPD be offered PR within 1 month of discharge Timing of pulmonary rehabilitation (PR) • peri-exacerbation • During hospitalization for acute exacerbation, both peripheral muscle strength and physical activity levels are markedly reduced • So aim is to prevent or minimize this decline • Quadriceps muscle strengthening can be started during hospitalization period Practical aspects of PR training • Location • PR can be started at hospital inpatient department, outpatient, home or community level • for mild to moderate disease, training can be done at home or in community which requires only initial supervision by physiotherapist • For moderate to severe disease and exercise hypoxaemia, assessment and training is done at specialist centre where oxygen and adequate monitoring facilities are available during exercise Practical aspects of PR training • Equipment • • • • • • Mat for floor exercises Dumbbells or hand weights multigym Space for aerobic training Cycle ergometry and treadmill for endurance training Four-wheeled rollator and three-wheeled walker for walking practice Practical aspects of PR training • Supplemental oxygen • For patients having exercise desaturation even without resting daytime hypoxaemia, the saturation level should be monitored throughout training & oxygen is provided • The patients who are on long-term oxygen therapy (LTOT) should exercise with supplemental oxygen Practical aspects of PR training • non-invasive ventilation (NIV) • It is an adjunct to PR • NIV reduces the effort of respiratory muscles during activity, so high intensity exercise can be performed Practical aspects of PR training • Safety issues in PR • Many elderly people perceive exercise to be dangerous for their age • Full exercise testing with ECG monitoring is recommended as routine for patients with COPD • Maximal incremental cycle ergometry test is unrealistic for many patients with severe disease • Even unloaded cycling can be exhausting for these patients & adding incremental loads may cause distressing dyspnoea • Considerable reassurance may be required concerning safety Practical aspects of PR training • Nutrition • Some research showed no significant effects of nutritional supplementation on anthropometric measures • Some patients showed benefits during research • Protein, carbohydrate, vitamin and mineral deficiency can cause adverse effect on body • Diet planning can be helpful for COPD patients Practical aspects of PR training • Education and self-efficacy • Educating the patient is a shared responsibility of family and all health care professionals • Teach the patient about self-management which includes • • • • Goal setting Problem solving Decision-making Utilizing resources Practical aspects of PR training • Education and self-efficacy • Teach disease-specific skills like • • • • Chest clearance Breathing strategies Nutritional control Energy conservation Practical aspects of PR training • Education and self-efficacy • Prevalence of depression and anxiety is very high in COPD patients • Psychological counselling can provide additional benefits Goals and interventions (for practical exam) 1. Gain confidence of patient and family member or caregiver 2. Prevent complications • NMES • IMT 3. Manage chief complaints • Chest physiotherapy 4. Functional independence / cardiopulmonary endurance • Aerobic training to develop endurance for ADL
