5/1/14. Pulmonary Rehabilitation Harmonica Team. Harmonica Therapy for Pulmonary Disease Ventilatory Muscle Training (Respiratory Muscle Training)

Transcription

1 Pulmonary Rehabilitation Harmonica Team Vivian Low MPH, RN-BC, FPCNA Clinical Manager Missy Von Luehrte RN, BSN Pulmonary Rehabilitation Nurse Leslie Rusinak RCP, CRT, AE-C Pulmonary Rehab Therapist Harmonica Therapy for Pulmonary Disease Ventilatory Muscle Training (Respiratory Muscle Training) CSPR Annual Conference May 16 th 2014 Dennis Low MD General Internal Medicine Volunteer Harmonica Instructor DISCLOSURE STATEMENT: There are no conflicts of interest and no disclosures to report. 1

2 5/1/14 San Francisco and South Bay Area Home of Harmonica Greats Not-for-profit community hospital in Mountain View & Los Gatos, California 2 campuses (Enterprise) beds in Mountain View beds in Los Gatos AACVPR Certification Cardiac Rehab 2002 to present Pulmonary Rehab 2003 to present CPWC celebrated our 20th Anniversary in 2014 David Barrett Mark Hummel Blues Harmonica Blowout Charlie Musselwhite At the White House All-Star Celebration Of Memphis Soul 2

3 Why consider harmonica play? Evidence: We lose up to half of our lung function between age 30 and 70. It appears that those who use lungs in extraordinary ways have less loss of lung function with age. (i.e. horn players, opera singers, breath holding divers) Questions: Does their activity mimic inspiratory muscle training (IMT)? Does the pursed-lip and increased volume of breathing during harmonica play result in improved strength of the diaphragm and less loss of lung function? Is improving respiratory muscle strength EFFECTIVE? There are published Meta-analysis and systematic reviews looking at the effect of Inspiratory Muscle Training(IMT) in Chronic Obstructive Pulmonary Disease (COPD). ACCP/AACVPR does not support routine use of IMT. "This therapy may be considered for respiratory patients with documented respiratory muscle weakness or persons who remain symptomatic, with dyspnea and exercise limitation despite peripheral muscle endurance and strength training." ACSM does support IMT also referred to as Ventilatory Muscle Training. (Clinical trials benefits to sports performance) 3

4 Outcome challenges for IMT in pulmonary rehab It is hard to separate the global effect of pulmonary rehab and physical exercise from the local effect on respiratory muscles. Will the benefits of IMT be maintained after pulmonary rehab if patients stop training? It is well documented that muscular strength declines when strength training stops in any muscle training. Choice of IMT devices, including harmonica are very personal and individual. Not everyone enjoys this type of training. IMT using harmonica therapy What s the evidence? No consensus on published scientific studies to date that can quantify improved outcomes. Anecdotal reports and observations conclude that harmonica playing improves RPE, 02 saturation, and exercise capacity. Alexander, J. L. & Wagner, C. L. (2012). Is harmonica playing an effective adjunct therapy to pulmonary rehabilitation? Rehabilitation Nursing, 37(4), No significant improvements between groups in pulmonary rehab. Dr. J. P. Schaman, Medical Director - cardiac rehabilitation and sports medicine, Breslau clinic, Ontario Aerobics Centre. Canada Formation of the Harmonica Exercise for Lung Program (H.E.L.P.) in

5 Research challenges : Patients who are too compromised presented with too many variables and a high drop out rate for research. Older patients had trouble achieving melodic single notes and this type of playing did not provide adequate pulmonary challenge. To achieve a dose-specific study to evaluate a therapeutic response, it is necessary to determine a therapeutic dose. How much drawing/blowing do you need for positive outcomes? Exclusions: Patients at risk for pneumo-thorax or rib fractures. Relative cardiac risk and instability. Dr. Schaman Early Observations: 2007 Used standard harmonica teaching and melody playing in a relatively stable pulmonary population. Participants self reported a rather low RPE with this methodology. Early pulmonary function measurements did not show significant changes. Single note playing for melodies was found to be difficult for older patients and showed no real pulmonary challenge. New techniques and methodology developed: Training technique: Chordal (3+ holes) rhythmic playing. Allows patients to: - achieve a better pulmonary physiological challenge - is easier to play blow and draw chords rather than single notes to accompany soundtracks rhythmic accompaniment. Designed the Diatonic Chord Harmonica, a medical harmonica for this purpose. Plays 8 chords 4 blow/4 draw but still allows single note chords. (Dishwasher safe) 5

6 Dr. Schaman s Goal: To validate and provide proven methods for harmonica therapy. Beginning in the Fall of 2013, participants have been keeping diary charts to record pattern of harmonica play including RPE, time and quantity. Respiratory inductance plethysmography will be used as a pre/post measurement comparing the intensity/duration/frequency of harmonica playing that occurred to determine a dosing correlation. Also plans to quantitate inspiratory and expiratory muscle strength with new equipment. As lung tissue is not trainable, like skeletal and heart muscle, would like to document any changes in the strength of the muscles of breathing. Will explore incorporating quality of life scores. (harmonicamd breathe@harmonicamd.com We know it has motivated people to exercise their lungs! History of Harmonica Programs started to improve lung function. University of Michigan Health Center Ann Arbor, Michigan Seton Medical Center Austin, Texas Sinai Hospital in Baltimore Maryland pediatric patients Bloomington Hospital Bloomington, Indiana Deborah Heart & Lung Center Brown Mills, New Jersey Luther Hospital/Sacred Heart Hospital Eau Claire, Wisconsin Florida Hospital Celebration Health Kissimmee, Florida A.T. Still University, Mesa, Arizona El Camino Hospital Mountain View, California Jacksonville Mayo Clinic, Naples, Florida Advocate Christ Medical Center Oaklawn, Illinois Breslau clinic Ontario, Canada John C. Lincoln North Mountain Hospital, Phoenix Arizona Senior Friendship Center Sarasota, Florida Northside Hospital & Tampa Bay Heart Institute St. Petersburg, Florida 6

7 Harmonica Therapy at El Camino Hospital Patient initiated idea, personal testimony. Curriculum developed by School of the Blues/David Barrett in 2004 and presented at the Better Breather s Club. Exercising the muscles of ventilation - The diaphragm (primary muscle of breathing) - Intercostal muscles Introductory beginners sessions now 1:1 and then onto group classes. Beginner and advanced groups join for performances. Program development Considerations Instruction Space for the program to meet Primary focus/goal Cost Patient participation Managing different skill levels Challenges Reliable, cost effective committed instructor Area large enough that will accommodate music play Clinical based, music based or support group atmosphere Instructor fees, material costs, staff support to facilitate program Intimidation of learning to play, a commitment to continue, drop out rate Keeping all skill levels challenged as new players join. 7

8 Respiratory Muscle Training in Acute Pulmonary Rehab One hour introduction session starting the 8 week program Breathing retraining Pursed lip breathing and diaphragmatic breathing: Inhale 1-2 through the nose, allow the diaphragm to relax, abdomen to expand. Exhale slowly through pursed lips while contracting the diaphragm muscle. Breathing re-training IMT PFLEX PFLEX Harmonica therapy Enhance individualized treatment plans Flow resistive training (breathing through a progressively smaller orifice) Harmonica therapy Mimics pursed lip breathing Playing requires support from the diaphragm for both short and long breath patterns. Inhaling and exhaling through the reeds is a resistive exercise 8

9 Clinical application of IMT Which would you choose? Training Program Use a threshold IMT device. 4-5 days/week, 30 minutes/day or two 15 minute sessions/day Initial Loads > 30% of a person s maximum inspiratory pressure if data is available. Progression Shortness of Breath (SOB) scale of 3-4. (Modified Borg Dyspnea Scale 0-10 scale). Rate of Perceived Exertion (RPE) scale between somewhat hard (The Borg Rating of Perceived Exertion Scale 6-20) Supervision. Monitor initial 02 saturation-respiratory rate. 9

10 Current trends in IMT Renewed interest Inspiratory muscle training protocol study for patients with COPD using the POWERbreathe KH1 Devices readily available to the public: Lung Boost Respiratory Trainer Diatonic Chord Harmonica Development of the Pulmonica Question: Are these respiratory specific training devices more effective than harmonica play or similar? Current Goals Increase long term patient participation Evaluate structure and instruction flexibility to change program based on volume and resources Stabilize funding Determine which patients will benefit most from respiratory muscle training, the best training regime Develop a trial to determine the functional and health benefits of respiratory muscle training and which method is most effective Three groups practicing IMT Measure MIP pre/post rehab 10

11 What patients are saying Linda Mankin (7 years) At the visit to my pulmonologist last week, I was told I didn't t need to return for 6 months! I attribute this success entirely to the fact that I practice deep breathing constantly while having a wonderful experience playing the harmonica. What patients are saying Jack Goldberg (7 years) I believe that as a result of these exercises (harmonica play), my breathing has gotten more controlled and more powerful. Recently during my standard spirometry test the technician remarked that my air volume tested much higher than 4 years ago! 11

12 Enjoying harmonica play at home Learning to make music in a unique way is uplifting for all! Hands on YOUR TURN NOW! Faye Knight with her Practice partner 12

13 C Diatonic Harmonica: Breathing & Chugging (Stand Up!) Diaphragmatic Breathing: hands on abdomen, in and out Articulation: Draw (in) Ta Ta; Blow (out) te te Shuffle rhythm, used in blues, swing, jazz Hold the harp like a corncob, lower notes on the left Embouchure: relaxed lips, mouth slightly open Bring harp tilted down into mouth, cover left three holes 4 beat shuffle, left right left right Ta Ta, te te, Ta Ta, te te Let s play some 12 bar blues! 12 Bar Blues Structure I I I I TaTa tete TaTa tete TaTa tete TaTa tete TaTa tete TaTa tete TaTa tete TaTa tete IV IV I I tete tete tete tete TaTa tete TaTa tete tete tete tete tete TaTa tete TaTa tete V IV I I TaTa TaTa tete tete TaTa tete TaTa tete TaTa TaTa tete tete TaTa tete TaTa tete 13

14 Oh! Susanna Train Whistle by Stephen Foster bonus Thank you for participating in this musical journey with us! 4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4+, 4 4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4, 4+ 4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4+, 4 4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4, 4+ 5, 5, 6, 6, 6, 6+,6+, 5+, 4+, 4, 4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4, 4+ Finish flourish, blow sliding-up harmonica holes 4+thru10+ Vivian Low MPH, RN-BC, FPCNA Leslie Rusinak RCP, CRT, AE-C Clinical Manager Pulmonary Rehab Therapist vivian.low@elcaminohospital.org leslie.rusinak@elcaminohospital.org Missy Von Luehrte RN, BSN Dennis Low MD Pulmonary Rehab Nurse General Internal Medicine missy.vonluehrte@elcaminohospital.org Volunteer Harmonica Instructor dennis.low@hhs.sccgov.org Train Whistle: cover holes 3-4-5, draw while articulating: Keeee youuuu - eeeee 14

15 Acknowledgments Pulmonary Rehab Medical Directors: Dr. Bruce Beck, Dr. Judith Pickersgill David Barrett School of the Blues Dennis Carelli Harmonica Instructor Dr. J. P. Schaman Breslau clinic, Ontario Canada Aerobics Centre El Camino Hospital Foundation El Camino Hospital Marketing & Communications Monica Frankel Graphic Communications Specialist Karen Halverson, Jack Black Health Library Resource Center Mike Ichikawa Multimedia Coordinator Special thanks to harmonica patients and participants for their support: Jack Goldberg, Fay Knight, Linda Mankin, Renee Martinson, Barbara Perkins References American College of Sports Medicine. (2009). ACSM's Guidelines for Exercise Testing and Prescription (8th ed). (pp. 263). Lippincott, Williams & Wilkins. Philadelphia, PA. Alexander, J. L. & Wagner, C. L. (2012). Is harmonica playing an effective adjunct therapy to pulmonary rehabilitation? Rehabilitation Nursing, 37(4), American Association of Cardiovascular and Pulmonary Rehabilitation. (2011). Guidelines for Pulmonary Rehabilitation Programs, Fourth Edition. Champaign, IL: Human Kinetics. Barrett, D. & Bucko, D. (2005). Harmonica for Fun & Health. Pacific, MO: Mel Bay Publications, Inc. Beckerman, M., Magadle, R., Weiner, M. & Weiner, P. (2005). The effects of 1 year of specific inspiratory muscle training in patients with COPD. Chest, 128, Begley, S. (2006). One more reason to play harmonica: it's good for the pipes. Wall Street Journal. Retrieved from Carter, R., Rodriguez, B., Williams, J., & Koh, Y. (2011). Respiratory muscle training in patients with COPD. RT: the Journal for Respiratory Care Practitioners, 24(7), Charususin, N., Gosselink, R., Decramer, M., McConnell, A, Saey, D.,... Langer, D. (2013) Inspiratory muscle training protocol for patients with chronic obstructive pulmonary disease (IMTCO study): a multicentre randomized controlled trial BMJ Open.3(8). doi: /bmjopen Retrieved from Gloeckl, R., Marinov, B. & Pitta, F. (2013) Practical recommendations for exercise training in patients with COPD. European Respiratory Review, 22(128), doi: /

16 References Hill, K., Cecins, N. M., Eastwood, P. R., & Jenkins, S. C. (2010). Inspiratory muscle training for patients with chronic obstructive pulmonary disease: a practical guide for clinicians. Archives of Physical Medicine Rehabilitation, 91(9), doi: /j.apmr Hill, K., Jenkins, S. C., Hillman, D. R., & Eastwood P. R. (2004). Dyspnea in COPD: can inspiratory muscle training help? Australian Journal of Physiotherapy, 50, Holland, A. E., Hill C. J., Jones, A.Y. & McDonald C. F. (2012). Breathing exercises for chronic obstructive pulmonary disease (review). Cochrane Database of Systematic Reviews, Issue 10. CD DOI: / CD pub2 Larson, J. L., Covey, M. K., & Corgridge, S. (2002). Inspiratory muscle strength in chronic obstructive pulmonary disease. AACN Clinical Issues, 13(2), Music for your lungs: pulmonologists treat breath shortness with harmonica classes [video file]. (2006, January 1). Retrieved from Ottenheijm C. A. C., Heunks, L. M. A., Sieck, G. C., Zhan, W., Jansen, S. M., Degens, H., deboo, T., & Dekhuijzen, P. N. R. (2005). Diaphragm dysfunction in chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 172, Reid, W. D., Geddes, L., Brooks, D., O Brien, K., & Crowe, J. (2004).. Inspiratory muscle training in chronic obstructive pulmonary disease. Physiotherapy Canada, 56(3), Schaman, J.P. (2011) HarmonicaMD. Retrieved from Scherer, T. A., Spengler, C. M., Owassapian, D., Imhof, E., & Boutellier, U. (2000). Respiratory muscle endurance training in chronic obstructive pulmonary disease: impact on exercise capacity, dyspnea, and quality of life. American Journal of Respiratory and Critical Care Medicine, 162, References Shoemaker, M. J., Donker, S., & LaPoe, A. (2009). Systematic review: inspiratory muscle training in patients with chronic obstructive pulmonary disease: the state of the evidence. Cardiopulmonary Physical Therapy Journal, 20(3), Simms, A.M., Li, L.C., Geddes, L, Brooks, D., Hoens, A.M., Reid,W.D. (2012). Impact of a behavioral-based intervention on inspiratory muscle training prescription by a multidisciplinary team. Journal of Continuing Education in the Health Professions, 32(2), Simms, A. M., Li, L. C., & Reid,W. D. (2011). Development of a theory-based intervention to increase prescription of inspiratory muscle training by health professionals in the management of people with chronic obstructive pulmonary disease. Physiotherapy Canada, 63(3), doi: /ptc Society for the Preservation and Advancement of the Harmonica. (2013) RX: harmonica therapy for the body and soul: John Schaman, inventor of the harmonicamd diatonic chord. Harmonica Happenings, 47(3), Retrieved from Swift, J. (2013). Harmonicas ease COPD blues: harps' drafted to fight incurable lung disease. Retrieved from Venoy, L. Harmonica helps pulmonary and lung transplant patients breathe easier. [Weblog] Retrieved from Veseley, L. (2011). Harmonicas for health [PDF document] Retrieved from Indiana Society for Respiratory Care website: Weiner, P., Magadle, R., Beckerman, M., Weiner, M., & Berar-Yanay, N. (2003). Comparison of specific expiratory, inspiratory, and combined muscle training programs in COPD. Chest, 124, Ziemba, S. (2003, August 19). Making music like breath of fresh air. Chicago Tribune News. Retrieved from 16