EHR519 202430 Week 12b exercise testing and prescription for COPD.pdf

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Warning This material has been produced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the copyright act (Act). The material in this communication may by subject to copyright under the act. Any further reproduction or communication of this material by you may be the subject of copyright protection under this act. Do not remove this notice  Exercise testing and prescription for COPD EHR519 Week 12 Part b Chapter 19 Ehrman text Learning Outcomes be able to outline the risk factors, complications and co-morbidities that must be accounted for when applying exercise interventions to individuals with pulmonary conditions; be able to explain the diagnostic techniques and treatment procedures used in the treatment of pulmonary conditions; be able to demonstrate the ability to conduct exercise/fitness/functional tests on individuals with pulmonary conditions; be able to prescribe exercise as a therapeutic modality for individuals with pulmonary conditions. Lecture Overview 1. Considerations 2. Exercise testing COPD 3. Exercise prescription American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins  COPD Figure 19.1. A normal airway that has little inflammation or mucus Figure 19.2. An obstructed airway that has significant inflammation and plugging and is being held open by parenchymal lung tissue. mucus plugging. Also shown is the loss of alveolar attachments, making airway collapse more likely. 7 American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins Considerations for clients with COPD Signs and Symptoms Dyspnoea Cough Sputum production Wheezing Chest tightness Occasional fever 9  History and Physical Examination Diagnosis is based on history, completion of physical exam by doctor and laboratory results (CT scan and x-ray) GOLD recommendations include Comprehensive medical history e.g. medical history, family history of COPD, other chronic lung disease, pattern of symptom development, exacerbation history, hospitalisations, co-morbidities, impact on QoL, social and family support and potential risk factors – Absence of signs should rule out a diagnosis; often not seen at rest until the disease is quite advance Initial Diagnosis is established through spirometry, with a post-bronchodilator forced expiratory volume in one second (FEV1) and forced vital capacity ratio of less than 0.7 confirming the presence of persistent airflow obstruction. Laboratory and radiographic results are often used to confirm COPD 10  Exercise Testing Important for clients with COPD, even mild-to-moderate as symptoms often do not present until increased demand is placed on the respiratory system Mild COPD (GOLD grade 1) (normal spirometry) show small airway dysfunction at rest & abnormal respiratory mechanical and gas exchange responses to exercise = impaired exercise tolerance and increased dyspnea More severe disease = FC is further reduced & simple ADL’s may impose a challenge to the respiratory system. Moderate to severe COPD have Reduced exercise capacity because of reduced ventilatory capacity compared to demand Exercise testing is a important to: Track the progression of disease Detect exercise hypoxemia Determine the need for supplemental oxygen during exercise training Evaluate the response to treatment and prescribe exercise 11 Mode Protocol Design Duration Clinical Measures Clinical implications Treadmill 1 to 2 METS per stage 8 to 10 min HR Serious dysrhythmias, Constant work rate protocols (5 to 9 min in 12-lead ECG >2 mm ST-segment Small incremental increases in workload severe and very BP depression or and slow progression individualized severe COPD) RPE elevation, ischemic Dyspnea scale threshold, T-wave O2 saturation inversion with Blood lactate significant ST change Ventilation and gas exchange SBP >250 mmHg or DBP >115 mmHg Cycle ergometer Unloaded cycling for 3min, followed by Power output ramped protocol 5, 10, 15 or 20 W/min Maximum ventilations, Constant work rate protocols VO2peak, lactate/ventilatory 6min walk test Field walking tests can be either self Walking Distance threshold paced or externally paced and conducted over a predetermined time or Note rest stop distance distance or time, dyspnoea index, vitals Incremental and Field walking tests can be either self Distance/Duration endurance paced or externally paced and shuttle walk conducted over a predetermined time or distance 12  Special Considerations Arm ergometer testing results in increased dyspnea, which may limit the intensity and duration of exercise. Clients with COPD often have coexisting CAD. Breathing pattern and inspiratory capacity maneuvers may help identify COPD patients with dynamic hyperinflation. Lactic acidosis may contribute to exercise limitation in some patients. Exercise should be terminated in the event of severe arterial oxyhemoglobin desaturation ≤80%. Exercise testing in mid to late afternoon is desirable. Constant work rate cycle ergometer testing is useful for measuring improvements in physiological and exercise performance responses following therapeutic interventions. Constant work rate treadmill testing is useful for evaluating the effects of inhaled bronchodilators on exercise endurance. 13 Mode Protocol Design Clinical Measures Special considerations Muscular strength Isokinetic, isotonic or both Peak force development or maximum Clients may become more dyspneic and endurance voluntary contraction when lifting objects (teach Sit-to-stand appropriate breathing strategies for Maximum number of reps without rest lifting). Stair climb-descent Time to 10 reps Specific evaluation and training may Lifting be needed. Absolute 1 or multiple RM Push-up 10 to 15RM within the appropriate Duration of static contraction before training recommendations may be Curl-up fatigue more appropriate in COPD. Flexibility Sit-and-reach ROM Body mechanics Coordination Goniomtery Work efficiency often impaired Gait analysis Balance 14 Exercise Prescription HR is not a reliable indicators for exercise tolerance Rating of perceived exertion (4-6 on the 0-10 modified Borg scale) Aerobic exercise >3d/wk Resistance and flexibility training >2d/wk Inspiratory muscle training 4d/wk 15  Aerobic Mode Intensity Frequency Duration Progression Goals Large muscle Light: 30 - 40% 3-5d/wk 20-60 min Emphasise duration Increase activities peak work progression more VO2peak walking Duration than intensity, cycling Vigorous: 60 - 80% based on Increase LT swimming peak COPD 2-3 months to and VT seated severity and ensure compliance, aerobics Alternative: RPE 4 may be just a titrate to symptoms, Less sensitive arm to 6 on 10 point few minutes dyspnea scale rates, to dyspnea ergometry scale (comfortable long at initial or selected RPE or water pace and endur- training MET level; More efficient exercises ance) stages breathing step exercises Increase 5-10 patterns Monitor dyspnea min/wk during first 4- 6 wk Improve ADLs 16  Aerobic Training Goal to improve aerobic capacity, function of ambulatory muscles, reduce dyspnoea and fatigue Cycling elicits less O2 desaturation responses compared to walking exercise Interval training is particularly useful for severely deconditioned or co- morbidities are present (similar improvements to continuous) Interval at same absolute intensity as continuous (i.e. not HIIT) = greater amounts of work, demonstrate less dynamic hyperinflation, desaturate less and are less breathless. One-leg cycling can have as many benefits as conventional cycling 17 American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins  Resistance Mode Intensity Frequency Duration Progression Goals Free Light: 40 - 50% 2-3 d/wk 1-4 sets Gradual; resistance and Respiratory weights 1RM reps should be increased muscle weakness 8-10 as strength increases is common in Machines Moderate: 60 - exercises pulmonary 70% 1RM Monitor RPE, fatigue, and patients Emphasize pain functional Or 100% of 8- Upper body activities 12RM exercise contributes to Low resistance, dyspnoea high reps (fatigue by 8 to Inspiratory 15 reps) muscles may require training 19 Resistance Training Dyspnoea and reduced exercise capacity are two of the most common complaints Diaphragm + accessory muscles of inspiration (scalene, sternocleidomastoid, and serratus anterior) are activated during exercise. Even at low work rates, unsupported arm exercise = greater levels of dyspnoea compared with lower extremity exercise Arm exercise use of the accessory muscles of inspiration (decreasing participation in ventilation/ increasing diaphragm work). Skeletal muscle dysfunction contributes to the reduced exercise tolerance Contributor to symptom-limited intensity 20  No clear evidence of recommendations Some evidence to suggest upper-body RT prescribed to help reduce dyspnoea Examples of exercises targeting a range of exercise (that incorporate inspiratory muscles): Upper extremity muscles (e.g., biceps, triceps, deltoids, trapezius, pectorals, and latissimus dorsi) include free weights and bands, machines, functional tasks, suspension training with pulleys, and pushing off and throwing a ball against a wall Typically a combination of upper and lower body exercises 2d/wk 1-4 sets 10-15 reps 40-50% 1RM (60-70% for those who can tolerate moderate initial intensity) 21 American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins  Flexibility Mode Intensity Frequency Duration Progression Goals Balance Stretch to the >2d/wk 10-60s 2-4 reps per exercise Increase ROM point of static Stretching tightness, not stretch Improved gait, pain balance Tai Chi Improved breathing Modified efficiency yoga 23  Ventilatory muscle training Recommended for COPD patients to increase ventilatory muscle strength and endurance. Goal is to improve exercise capacity, alleviate dyspnea, and improve health-related QoL. 1. Voluntary isocapnic hyperpnea: Breathe at highest sustainable level of minute ventilation for 10 to 15 min. With this technique, the patient is hyperventilating, and therefore a rebreathing circuit must be used to maintain isocapnia. 2. Inspiratory Resistive Loading: Breathes through inspiratory orifices of smaller and smaller diameter while attempting to maintain a normal breathing pattern. 3. Inspiratory threshold loading: Breathes through a device that permits air to flow through it only after a critical inspiratory pressure has been reached. These devices are small, do not require supervision, and avoid the problems associated with changing breathing patterns during inspiratory resistive loading. Currently the benefits of these types of training are equivocal 24  Ventilatory Muscle Training ACSM: minimal recommendations other than an intensity of the training load of ≥30% MIP Guidelines for inspiratory muscle training have been provided by the AACVPR (1) and include the following: Frequency: 4–5 d/ wk Intensity: 30% maximal inspiratory pressure measured at the mouth (Pimax) Time: Two 15 min sessions per day or one 30 min session per day Type: Three types of inspiratory muscle training are used: Inspiratory resistance training Threshold loading Normocapnic hyperventilation There is no demonstrated superiority of one method over another to suggest its preferred ESSA position statement (exercise and COPD) suggest the clinical efficacy of IMT in terms of exercise capacity, dyspnoea and HRQoL, over and above the benefits achieved with therapeutic exercise alone, remains contradictory 25 American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins Benefits of Training for COPD clients American College of Sports Medicine. (2014). ACSM's resource manual for guidelines for exercise testing and prescription. D. P. Swain, & C. A. Brawner (7th Ed.). Lippincott Williams & Wilkins 27 Watch ✓ Week 12 Lecture ENGAGE ✓ Week 12 Tutorial READ ✓ ESSA statement on COPD ✓ Ehrman Chapters 19 (COPD) 28