Revalidatie bij patiënten met COPD: wat is het optimale programma?

Transcription

1 Revalidatie bij patiënten met COPD: wat is het optimale programma? Dr. Maurice Sillen Fysiotherapeut / Coördinator CIRO netwerk CIRO+, expertisecentrum voor chronisch orgaanfalen Horn, Nederland 27 februari 2016

2 Contents Peripheral muscle dysfunction in COPD Decreased exercise tolerance in patients with COPD Physical inactivity Exercise training Summary

3 Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. COPD GOLD 2015

4 Peripheral muscle dysfunction in patients with COPD Maltais et al AJRCCM 2014

5 Decreased exercise tolerance in patients with COPD Spruit et al Respir Med 2011

6 Airflow limitation and exercise capacity in COPD 6MWD (meters) n= FEV1 1 (l) (l) Preliminary data Ciro

7 Negative spiral Chronic lung disease Dyspnoea during moderate exertion Loss of physical condition (PC) PC LPE Dyspnoea during daily activities Dyspnoea during little effort Less physical exercise (LPE)

8 Inactivity and mortality in COPD Waschki et al Chest 2011

9 Pulmonary rehabilitation definition Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors." Spruit et al AJRCCM 2013

10 Rehabilitation in COPD 3822 patients 65 RCTs Rehabilitation Control Maximal exercise capacity Functional exercise capacity Health status (SGRQ) 7 Watts (MCID 4 Watts) 44 mtr (MCID 30 mtr) -7 p (MCID -4 p) McCarthy et al Cochrane database of Systematic Reviews 2015

11 Pulmonary rehabilitation definition Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors." Spruit et al AJRCCM 2013

12 Exercise training ENDURANCE TRAINING NON-LINEAR EXERCISE TRAINING STRENGTH TRAINING INSPIRATORY MUSCLE TRAINING NORDIC WALKING TAI CHI HIGH-INTENSITY INTERVAL TRAINING NMES Spruit et al AJRCCM 2013

13 Exercise training ENDURANCE TRAINING NON-LINEAR EXERCISE TRAINING STRENGTH TRAINING INSPIRATORY MUSCLE TRAINING NORDIC WALKING TAI CHI HIGH-INTENSITY INTERVAL TRAINING NMES Spruit et al AJRCCM 2013

14 Endurance vs. Intervaltraining 98 patients (FEV1: 34% pred, Wpeak: 52Wat ts) Endurance (n=50) 70% Wpeak 20 min. Interval (n=48) Alternating 20 sec % Wmax, 40 sec. 20% Wmax 20 min. Puhan et al Ann Intern Med 2006

15 Endurance vs. Intervaltraining Adjusted differences between Change scores Puhan et al Ann Intern Med 2006

16 Endurance vs. Intervaltraining Niet-geplande pauzes (aantal) Therapietrouw aan het trainingsprotocol (procent) Duur Interval Puhan et al Ann Intern Med 2006

17 Exercise training ENDURANCE TRAINING NON-LINEAR EXERCISE TRAINING STRENGTH TRAINING INSPIRATORY MUSCLE TRAINING NORDIC WALKING TAI CHI HIGH-INTENSITY INTERVAL TRAINING NMES Spruit et al AJRCCM 2013

18 Strength training in patients with COPD O'Shea et al Chest 2009

19 Spruit et al Eur Respir J 2002 Strength vs. endurance training Strength training (n=24) 48 COPD patients FEV1: 40% pred QF: 57% pred 6MWD: 290 meters Endurance training (n=24) 12 weeks - outpatient - 36 sessions

20 MWD (m) Peak cycling load (watts) CRDQ total score (points) Strength vs. endurance training * * * * 30 * * ET RT ET RT ET RT * p<0.05 versus baseline Spruit et al Eur Respir J 2002

21 VE (l/min) w-up fietsen fietsen 50 W fietsen 40 W Quadriceps 3 x 8 herh. 15,5Kg steps Tijd (sec) wandelen 5.8 km/u 1x8min/1x5min Probst et al ERJ 2006

22 Exercise training ENDURANCE TRAINING NON-LINEAR EXERCISE TRAINING STRENGTH TRAINING INSPIRATORY MUSCLE TRAINING NORDIC WALKING TAI CHI HIGH-INTENSITY INTERVAL TRAINING NMES Spruit et al AJRCCM 2013

23 NMES NMES involves the application of an electrical current through electrodes placed on the skin over the targeted muscles, thereby depolarizing motor neurons and, in turn, inducing skeletal muscle contractions. Vanderthommen et al Exerc Sport Sci Rev 2007

24 Neuromuscular electrical stimulation 15 patients FEV1: 38% predicted MRC grade 5 NMES (n=9) 15 tot 30 min bilateral CONTROL (n=6) usual care 6 weeks - home-based - 30 sessions Neder et al Thorax 2002

25 Neuromuscular electrical stimulation Quadriceps (Newton-meter) Fatigue Exercise capacity Peak oxygen uptake Baseline 6 weeks 12 weeks Neder et al Thorax 2002

26 DICES trial To compare the efficacy of high-frequency NMES, low-frequency NMES and strength training.

27 Peak muscle strength # p<0.05 with-in group * p<0.05 between-group Sillen et al Thorax 2014

28 Exercise capacity 6MWD # p<0.05 with-in group Sillen et al Thorax 2014

29 VE (L/min) Metabolic load during NMES 40 * * * * * * HF-NMES LF-NMES Strength training * p< Time (weeks) Sillen et al BMC Pulm Med 2014

30 Summary 1) Patients with COPD are characterized by peripheral muscle dysfunction, decreased exercise tolerance and physical inactivity. 2) Exercise training should be individualized to the unique needs of the patient, based on initial and ongoing assessments, including disease severity, complexity, and comorbidities.. 3) Resistance training and NMES are to be considered during an acute exacerbation.

31 Thank you!