Alternatives to Gym-Based Pulmonary Rehabilitation

Transcription

1 4/4/24 Alternatives to Gym-Based Pulmonary Rehabilitation Prof Jennifer Alison Discipline of Physiotherapy Faculty of Health Sciences The University of Sydney Sydney Pulmonary Rehabilitation Department of Physiotherapy Royal Prince Alfred Hospital Sydney Isthispulmonaryrehabilitation? Photos courtesy Dr Peter Bowman, Tiwi Islands Do we need gym equipment? Doweneedgymequipment? Pulmonary Rehabilitation, Leuven, Belgium Prof Rik Gosselink & Prof Thierry Troosters Overview Whatarethemainproblemsrelatedtoexercise forpeoplewithcopd? Whatoutcomesarewetryingtoachievewitha pulmonaryrehabilitationprogram? rehabilitation program? Cantheseoutcomesbeachievedwithout gymbasedpulmonaryrehabilitation? Evidence? Whatarethemainproblemsrelatedto exerciseforpeoplewithcopd?

2 4/4/24 COPD + EXERCISE DisabilitySpiral COPD Ventilatory Cardiac Constraints to exercise: Constraints to exercise: Flow limitation Decreased cardiac output Altered mechanicsof pulmonary vascular breathing - DHI resistance Abnormal gas exchange venous return Skeletal Muscle Constraints to exercise: Deconditioning Malnutrition Systemic inflammation Corticosteroid use Ageing Fatigue Deconditioning Breathlessness Inactivity Dyspnoea Fatigue Exercise Tolerance Reduced Muscle Endurance & Strength Health-Related Quality of Life Alison & McKeough, 28 Whatoutcomescanbeachieved withpulmonaryrehabilitation? Pulmonaryrehabilitation Evidenceofeffectiveness: Reductionindyspnoea and/orfatigue Improvedexercisecapacity Improvedqualityoflife Reducedhospitaladmissions Guidelines/PositionStatementson PulmonaryRehabilitation SymptomsReductionafterPR Ries AL et al (27). Joint AACVPR/ACCP Pulmonary Rehabilitation. Evidence-based Clinical Practice Guidelines (27). Pulmonary Rehabilitation. Chest 3:4S-42S Lacasse YR et al (29). "Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. Issue 3 Puhan M et al. (2) Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, Issue Bolton CE et al (23) British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 68:ii-ii3 Spruit MA et al (23). An official ATS/ERS statement: Key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 88:e3-e64 Muchoftheevidencefromequipmentbasedstudies Dyspnoea Leg Fatigue * 6 * pre post pre post Cycle training and Peak Cycle Test O Donnell DE et al, 995 2

3 4/4/24 % improvement in endurance time Increasedexercisecapacity 99% Ortega et al 22 AJRCCM 36% Mador et al 24 Chest Doweneedequipment toachievethesechanges? Are there any RCTs of exercise training that did not use gym-based equipment? NordicWalking outdoor hour@75%initialhrmax 3x/week 3months ModsevereCOPD WalkingTraining Results: NordicWalkingincreased 6MWD(79m)comparedwith Control(6m) Increaseddailyphysicalactivity IncreasedSF36PCS GroundWalkingTraininginChronicObstructive PulmonaryDisease:ARandomisedControlledTrial Supervisedwalkingtraining Intensity:8%average6MWTspeed Duration:3mins Frequency:23days/week Lengthofprogram:8 8wks Progression Intensity: - symptoms34(scale) - weightbelts Duration:5minsevery6 th sessiontomax45mins Woottonetal(PosteratATS24) nds) Time (seco Error bars = SE Change in ESWT time n=95 IG n=48 UCG Group Mean difference (95%CI): 26 seconds (2 to 3) p <. IG UCG Results Score Change in SGRQ Total Score p <.2 IG UCG Mean difference (95%CI): -6 points(- to -) Prescriptionofwalkingexerciseintensityfrom thesixminutewalktestinpeoplewith chronicobstructivepulmonarydisease ZainuldinR,MackeyM,AlisonJA.JCardiopul Rehab&Prevent(InPress) n=39;fev =58(9)%pred;FEV /FVCratio=.5(.3) 8% 6MWT speed Variables ICT 6MWT minwalk Walkspeed,km/hr 4.5(.7) 3.6(.6) VO 2,ml/min.4(.29).9(.27).86(.22) VO 2 /VO 2peak,% 77(3) VO 2 Reserve,% 69(7) V Epeak,L/min 46.9(2.8) 42.2(.7) 32.8(9.) SpO 2,% 93(7) 9(6) 92(5) Dyspnoea 5(2) 3(2) 2(2) RPE 6(2) 3(3) 2(2) 3

4 4/4/24 Walktraining Walktrainingprescription Intensity =75%peakISWTspeed Duration =3minutes(week) Frequency =3x/week,supervised Length =8weeksprogram(approx24sessions) sessions) JPhysio256:5 2 VS Progression: Intensity=Weightbeltsaddediflimitedbystridelength Duration =Increasedby5mins/wkto45mins(week6) Frequency =Remained3days/week Leung et al, 2 Walktraining HealthRelatedQualityofLife time (seconds) Endurance walk Week 8 *:p<., **:p<. within group #:p<. between groups Mean difference 279 seconds (95%CI: 7 to 483) Walk cycle (n= 7) (n= 5) Leung R et al, 2 CRQ WalkGroup Week8 Week Mean(SD) Leung R et al, 2 MID* Dyspnoea 4(4) 2.5 Fatigue 3(2) 2. EmotionalFunction 4(3) 3.5 Mastery 2(2) 2. TotalScore 4 (9) *Jaeschke et al 989 Whatintensitywaswalking? 7%ISWTpeakspeed n=34;fev =6(7)%pred;FEV /FVCratio=.52(.3) 7% ISWT speed Variables ICT ISWT minwalk WalkSpeed,km/hr 5.2(.7) 3.6(.5) VO 2,L/min.9(.27).22(.3).92(.23) VO 2 /VO 2peak,% 76() V Epeak,L/min 48.3(2.5) 45.4(2.5) 34.6(9.8) V E /V Epeak (%) 78(3) V E /MVV(%) 99(29) 94(3) 73(28) SpO 2,% 94(6) 92(6) 93(6) Dyspnoea 5(2) 3(2) 2(2) RPE 6(2) 2(2) 2(2) Zainuldin R et al, Am J Phys Med Rehabil 22 4

5 4/4/24 Calisthenics Calisthenics dynamicrhythmicalmovements vs Highintensitywholebodyenduranceandstrengthtraining hour,3x/week,2weeks Results: Wmax andmuscleforcesignificanthigherinendurance+strength group Bothgroupsincreased6MWD(32mvs 4m)butNSbetween groups BothgroupssignificantreductioninSGRQ(vs 5)butNS betweengroups ProbstVSetal(2)RespiratoryCare56:79987 Generalhomeexerciseprogram ModeratetoSevereCOPD:FEV 4%predicted Supervisedhomeexercisetrainingvs Control Intensity =Dyspnoea35(BorgScale) 34minutes,2x/week,6weeksprogram Mode =Sittostand,stepping,theraband to stepping theraband (upperlimb) pperlimb) Results (nobetweengroupcomparisonsreported) Withingroup(n=3)Homeexercisetraining Exercisecapacity: 6mincreaseISWT(p<.) QualityofLife: 8pointimprovementinSGRQ(p<.5) (activityandimpacts) Murphy N et al, Resp Med 25 TaiChi Enduranceexercisecapacity(ESWT) Mean difference = 348 seconds SupervisedTaiChitrainingvs vs Control Taichigroup: 2x/week,3minutes(plusminwarmup&mincool down),dyspnoeaorrpescore3 Unsupervised hometaichitrainingsupportedbydvdandmusiccd 5x/week, 3minutes,DyspnoeaorRPEscore3 Change in endurance walk time (seconds) (95%CI: 86 to 5) * Change in walking distance (metres) Tai Chi Group Control Group Mean difference = 55 metres (95%CI: 3 to 8) * Tai Chi Group 8 Control Group OtherOutcomes IntensityofTaiChiexercise Comparedtocontrolgroup,significantimprovements inbalance,lowerlimbstrengthandhrqol n=5 Body Sway -3 mm (95% CI -2 to -7) Forward reach 5 cm (95%cI 3 to 8) Quads strength 24 Newtons (95%CI 5 to 34) Quality of Life-CRQ points (95%CI 4 to 8) VO 2 =64(3)%VO 2 peakoniswt HeartRate=87()%HRpeak oniswt Leung R et al, 23 5

6 4/4/24 Waterbasedtraining StudyDesign Inclusion:Presenceoformorephysicalcomorbidconditions Controlgroup 8weeks Usualmedicalcare Landgroup 8weeks Supervisedtraining 6minutes 3xweek n=5 n=5 n=5 ModerateCOPDFEV =6%predicted Watergroup 8weeks Supervisedtraining 6minutes 3xweek 32 FunctionalWalkingCapacity(6MWT) PeakWalkingCapacity(ISWT) minute e (metres) Change in 6 walk distance Baseline * # 8 weeks MCID = 25m Control Land Water ental shuttle walk (metres) Change in increme distance ( Baseline 8 weeks * # MCID = 47m Control Land Water * control vs water: mean difference (95% CI) = 63m (38 to 87) # control vs land: mean difference (95% CI) = 5m (26 to 76) * control vs water: mean difference (95% CI) = 49m (6 to 82) # land vs water: mean difference (95% CI) = 39m (5 to 72) = SE bars = SE bars EnduranceWalkingCapacity(ESWT) HealthRelatedQualityofLife(SGRQ) ce shuttle metres) Change in enduranc walk distance (m Baseline 8 weeks * # Control Land Water * control vs water: mean difference (95% CI) = 39m (96 to 522) # land vs water: mean difference (95% CI) = 228m (9 to 438) Mean change in SGRQ (Total Score) Control Land Water MCID = - 4 units 6

7 4/4/24 StrengthTraining Evidencefor noequipment? Do we need equipment? Sit-to-stand to Lunges Seated row Chest press Hip abduction in standing Simulated lifting Resistance bands 3 sets 8-2 reps Results: 34% drop-out; 85% compliance in exercise group Knee extensor strength: mean between groups difference 7% No between groups difference in 6MWD, strength, HRQoL, TUG AustJPhysio2753: x wk supervised 2x wk home 2 weeks Theraband RamosEMCet RamosEMCetal(24)ClinicalRehabilitation(OnlineMarch24) al Clinical Rehabilitation (Online March24) Theraband (n=7)vs conventionalresistancetrainingwithequipment(n=7) 6mins,3x/week,8weeks Ramosetal(24) Results Theraband Conventional BetweenGroups Shoulderflexion x Shoulderabduction x Elbowflexion x Kneeextensionextension x Kneeflexion x CRQdyspnoea x CRQfatigue x x x CRQemotionalfunct x x CRQmastery x x 6MWD Diff(95%CI),metres 73(389) 42(273) 24%dropout HospitalreadmissionsafterexacerbationRCTs: Hospitaladmissions Walk Home Pulmonaryrehabilitation Hospitaladmissions NonRCTs: CecinsNetal28: Hospitaladmissionsbeforeandaftersimple(noequipment)pulmonary rehabilitation:(n=256) 27admission2monthsbeforePRvs 62in2monthsafter(p<.) RasekabaTMetal29(n=53)29PR+educationvs 24optedout Pul Rehab=x/wk,hrsupervisedexercise(7stationaerobicandresistance), 45minseducation,8weeks PR+Education n=29 Optout n=22* pvalue EDpresentations(%) 7 68 <. Admissions(%) 7 68 <. LOS,meandays(SD).(.) 9.8(.24) <. *2losttofollowup 7

8 4/4/24 Summary MinimalEquipment but Growingevidencethatminimalequipmentcanachieve improvementsinexercisecapacity,qualityoflifeand reducehospitaladmissions Needclinicianshighlyskilledinexerciseprescriptionfor skilled exercise COPD MorewelldesignedRCTsneeded Physiologicalstudiesstillrequired Acknowledgements PhDstudents: RahizanZainuldin ReginaLeung RenaeMcNamara Collaborators: ZoeMcKeough MartinMackey 8