Pulmonary

rehabilita0on
Program adapta+on:
the challenge in Chest

clinical prac+ce Physician Researchers

GP Soc
Patient

PT RN
Prof Dr R. Gosselink
Faculty of Kinesiology and Rehabilita+on Sciences Psy
Occ Ther
Katholieke Universiteit Leuven Nutrition

REHABILITATION PROGRAM T H E K N G F G U I D E L I N E F O R
PHYSIOTHERAPY IN COPD
GENERAL PHYSICAL EXERCISE TRAINING
PERIPHERAL AND RESPIRATORY MUSCLE TRAINING
BREATHING EXERCISES
OCCUPATIONAL THERAPY
NUTRITION
PSYCHOSOCIAL SUPPORT
PATIENT-EDUCATION / SELF MANAGEMENT
SUPPLEMENTS
Oxygen

Non-invasive ven0la0on

1
 IMPAIRED EXERCISE PERFORMANCE/DYSPNEA

Peripheral Anxiety
Cardio- Ven0latory Oxygen transport Mo0va0on
muscle
circulatory in the lungs Selfesteem
strength

l Respiratory
muscle weakness
l Hyperina0on

Hypoxemia/Hypercapnia
during exercise?

Dutch
www.fysionet.nl
English
IMT
www.cebp.nl
French Body posi0oning
Endurance Interval- Rollator
Muscle training Counseling
www.bvp-sbp.org training training NIV
Portugese Ac0ve expira0on
NEMS Relaxa0on
ev. suppl O2 Nutri0on Educa0on
PLB

ANXIETY
LUNGS DEPRESSION
AND MOTIVATION
AIRWAYS
HEART AND
CIRCULATION

Casaburi & ZuWallack

NEJM 2009

2
 EXERCISE TRAINING: HOW?

GUIDELINES FOR TRAINING

l INTENSITY: 55 - 90% HRmax or
40 - 85% VO2max
l DURATION: 20 - 60 MIN
l FREQUENCY: 3 - 5 TIMES/WEEK


ACSM Posi*on Stand. Recommended quan*ty and Quality for
developing and maintaining cardiorespiratory and muscular
tness, and exibility in healthy adults, Med.Sci.Sports Med. 1998;
30:975-991

3
 TRAINING INTENSITY
0

-5

-10
% change

-15

-20
High work rate
-25
Low work rate (longer
-30 duration)
-35
Lact VE VE/VO2 HR

Casaburi et al. Am.Rev.Respir.Dis: 143, 9-18, 1991

Endurance training
WEEK DURATION INTENSITY
1 10 min. 30% Wmax
'Longer' periods of loading (10-20 min) 2 10 min. 40% Wmax
3 10 min. 55% Wmax
Large muscle mass 4 15 min. 55% Wmax
5 15 min. 60% Wmax
Applied in healthy subjects and subjects with 6 15 min. 65% Wmax
7 20 min. 65% Wmax
c a r d i o v a s c u l a r l i m i t a 0 o n o f e x e r c i s e
8 20 min. 70% Wmax
performance 9 20 min. 70% Wmax
10 25 min. 70% Wmax
11 25 min. 75% Wmax
12 25 min. 75% Wmax

Example Endurance Cycling Program

4
 HOW TO TARGET TRAINING INTENSITY

TRAINING INTENSITY
HR >60-70% HRmax, pred/a[
HR >70% HRmax, pred HR >50-60% HRmax-HRrest
> Anaerobic threshold u No cardiocirculatory limita+on to exercise in COPD
Work load > 60% Wmax u High variability in heart rate response
u Applies to specic exercise test
> 40 - 85% VO2max
u Medica+on interference
Symptom- limited

TRAINING INTENSITY
VE
(L.min-1)

> Anaerobic threshold

u Non-invasive detec+on AT dicult in COPD
u Early onset lac+c acidosis present in COPD
MVV
u Applies to specic exercise test

VO2 (L.min-1)

5
 TRAINING INTENSITY Incremental exercise test

Work load > 60% Wmax 1.1

u Applies to specic exercise test 20W/min

VO2 (L/min)
0.9 10W/min
5 W/min
u Depending on incremental test protocol
0.7
u No maximal exercise capacity data present
0.5
for each training modality
0 10 20 30 40 50 60 70

Work (Watts)
Debigare et al, Med Sci Sports Exc: 32, 1365-1368; 2000

SYMPTOMS BORG CR10 SCALE

Symptom - limited 0 NOTHING AT ALL

0.5 EXTREMELY WEAK - JUST NOTICEABLE
Individual adjustment of training protocol 1 VERY WEAK
2 WEAK - LIGHT
u Breathing frequency (talk test) 3 MODERATE
u Symptoms 4
5 STRONG - HEAVY
l dyspnea (BORG)
6
l fa+gue (BORG) 7 VERY STRONG
u Careful instruc+on of Borg scale 8
9
u Applies to various training modali+es 10 EXTREMELY STRONG MAXIMAL

*11 ABSOLUTE MAXIMUM HIGHEST POSSIBLE

6
 Symptom scores to target training intensity
Symptom ra0ngs to target training intensity
10

Borg Dyspnea (0-10)

Ra+ngs of perceived exer+on are reliable to es+mate training 8
Session 1
intensity in healthy subjects (ACSM)
A dyspnea score of 4-5 represents a VO2 of 75-80% of the 6
Session 18
VO2peak in COPD pa+ents
Target dyspnea ra+ngs are a useful and reliable tool to target 4
exercise intensity in COPD
2

4 6 8 10 12 14

Mejia et al. Am.J.Respir.Crit.Care Med.: 159, 1485-89, 1999 VO2 peak (ml.min-1.kg-1)
Horowitz et al. Chest: 109, 1169-75, 1996
Mahler et al Med Sci Sports & Exercise 2003

Exercise intensity Supervised vs. Unsupervised

l There is no consensus about the op0mal intensity of
exercise training. However, lower extremity exercise at a 2000
Supervised
high intensity exercise produces greater physiological Unsupervised
1500
W ork (kJ)

eects low intensity exercise (Level 2).

l There are indica0ons that pa0ents with severe airway 1000
obstruc0on (mean GOLD stage III) are frequently not
capable of reaching high training intensi0es during 500

endurance training (Level 3).

0
l Ra0ngs of perceived exer0on (RPE 5-6/10) or dyspnea on a
modied Borg-scale can be used to adjust training intensity week 1 week 4 week 8

during the program (Level 2). TRAINING TIME

Training time

Puente-Maestu, et al. Eur.Respir.J., 15: 517-26, 2000

7
 Supervised vs. Unsupervised Exercise supervision
l Exercise training should be conducted partly or
*
20
90 fully supervised to ensure op+mal physiological
15 80 benets of exercise training (Level 3).
* * 70
10 l Whether it is useful to combine supervised
60
5
50
programs with self-monitored home-based
0 40 interven+ons has to be inves+gated in future
-5
30 studies. This approach might enhance
20 implementa+on of physical ac+vity in daily life
-10
10
-15 0
VO2peak VE isowork CRDQ Endurance

Puente-Maestu, Eur.Respir.J., 15: 517-26, 2000

TRAINING INTENSITY
Not all pa*ents will be able to perform at sucient intensity REDUCED VENTILATORY INCREASED VENTILATORY
CAPACITY REQUIREMENT
100
lAirow obstruc+on l Early onset lactate

80 30 lDynamic accumula+on
Training time (min)
Training intensity

hyperina+on l Increased dead

(% Wmax)

60
lRespiratory muscle space ven+la+on
40 15 weakness

20

0 0

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Training weeks Training weeks

Maltais et al, Am.J.Respir.Crit.Care Med., 155, 555-61, 1997

8
 INCREASE
SOLUTIONS VENTILATORY CAPACITY:

Bronchodilators
Inspiratory muscle High intensity
training PERIPHERAL
INCREASE VENTILATORY CAPACITY Breathing exercises MUSCLE
Ven0latory support TRAINING
REDUCE THE VENTILATORY REQUIREMENT

Exercise training

LIMIT
VENTILATORY
REQUIREMENTS:
High intensity
Small muscle mass
PERIPHERAL
Short intervals
Supplemental oxygen MUSCLE
TRAINING

Resistance training
NMES
Interval training
One-leg exercise ONE LEG CYCLING

9
 One leg exercise: eect on endurance cycling 0me LIMIT
VENTILATORY
25 REQUIREMENTS:
two legs
High intensity
20 Small muscle mass PERIPHERAL
one leg Short intervals
MUSCLE
Time (min)

15 Supplemental oxygen
TRAINING
10
5
Resistance training
0 NMES
Healthy COPD
Interval training
Dolmage et al Chest 2006 One-leg exercise

Interval training

" Shorter exercise bouts Stair climbing

Time for recovery Walking uphill
Arm cranking
" Specicity Cycling
Playing ac0vi0es
More ADL task specic

10
 WEEK DURATION NUMBER of INTENSITY
Interval exercise training
per serie series
1 2 - 2 - 2 min. 3x 60% Wmax
2 2 - 2 - 2 min. 4x 60% Wmax
1.1
3 2 - 2 - 2 min. 5x 60% Wmax
4 2 - 2 - 2 min. 5x 60% Wmax
5 5x 65% Wmax 0.9
2 - 2 - 2 min.

VO2 (L/min)
6 2 - 2 - 2 min. 6x 65% Wmax
7 2 - 2 - 2 min. 6x 65% Wmax 0.7
8 2 - 2 - 2 min. 6x 70% Wmax
9 2 - 2 - 2 min. 6x 70% Wmax
10 6x 75% Wmax 0.5
2 - 2 - 2 min.
11 2 - 2 - 2 min. 6x 75% Wmax
12 6x 80% Wmax 0.0
2 - 2 - 2 min.
0 2 4 6 8 54 56 58 60 62
Time (min)

Example Interval Cycling Program Sabapathy Thorax 2004

160
Interval vs Endurance training in COPD
WR (%peak)

120

80
3 weeks (13 sessions) rehabilitation in
endurance (n=50) or interval (n=48) form.
40
120
Wmax
2
DYS (%peak)

100 45
1,5
80
30
60 1

40 15
0,5
120
FAT (%peak)

100 0
6MWD
0
CRDQ
VO2max
80 Unexpected breaks IT : 2
60 ET : 11
40

0 5 10 15 20 25 30
Session number Vogiatzis Chest 2006 Puhan Ann Int Med 2006 Beauchamp et al. Thorax 2010

11
 Exercise modality (I)
Treadmill or Cycle ergometer ?
l Endurance exercise training is
recommended for COPD pa+ents in all Func0onal " Less func0onal
stages of disease Specic " Less specic
" Larger muscle mass Less muscle mass
l Interval training is equally eec+ve and " Minimal load weight Minimal load external load
be[er tolerated as endurance training dependent ergometer and leg weight
" Expensive Less expensive
" Applicable in ambulatory Applicable in most pa0ent groups
pa0ents
GRADE RECOMMENDATION: Level 2

LIMIT
VENTILATORY
GUIDELINES FOR TRAINING 2

REQUIREMENTS:
Resistance training should be an integral part:
High intensity dynamic exercises, 1 set of 10-15RM, 2-3 days per
Small muscle mass PERIPHERAL week
Short intervals MUSCLE
Supplemental oxygen
TRAINING Flexibility training should stretch (dynamic and
sta0c) major muscle groups, 2-3 days per week


Resistance training ACSM Posi*on Stand. Recommended quan*ty and Quality for
developing and maintaining cardiorespiratory and muscular
NMES tness, and exibility in healthy adults, Med.Sci.Sports Med. 1998;
Interval training 30:975-991
One-leg exercise

12
 Resistance training w-up
cycling cycling
quadriceps
3 x 8 reps.
walking
5.8 km/h
1x8min / 1x5min
steps
cycling 15,5Kg
50 W 40 W
60
55
l Specific training for 50

muscle weakness 45
40

VE (l/min)
l Exercising muscle mass 35
30
low VE and Dyspnea 25
20
150 15
Healthy
COPD 10
100 5
% pred

0
0 400 800 1200 1600 2000 2400 2800 3200 3600 4000 4400 4800
50
Time (sec)

0
PImax PEmax HF QF 6MWD Probst et al, ERJ 2006; 27:1110-1118

Whole body exercise vs resistance training

WEEK INTENSITY SERIES-
REPETITIONS.
1 70% 1 R.M. 3x8
stair arm 2 70% 1 R.M 3x8
8 * * *
115 cycling walking climbing cranking leg press
7
3 76% 1 R.M 3x8
# # 4 82% 1 R.M 3x8
Borg dyspnea

6
VO2 (%VO2m ax)

95
5 5 88% 1 R.M 3x8
4 6 94% 1 R.M 3x8
75
3 7 100% 1 R.M 3x8
55
2 8 106% 1 R.M 3x8
1 9 112% 1 R.M 3x8
35 0
1 6 12
10 115% 1 R.M 3x8
1 6 12 1 6 12 1 6 12 1 6 12 1 6 12
week week
11 118% 1 R.M 3x8
12 121% 1 R.M 3x8
#p<0.05 vs cycling, walking and stair climbing cycling leg press *p<0.05

Example Peripheral Muscle Training Program

Probst et al, ERJ 2006; 27:1110-1118

13
 Resistance training

50
(% initial or points)

STRENGTH
40 ENDURANCE

30

20

10

0
6MWD VO2max CRDQ OShea et al. Chest 2009
Spruit et al. Eur.Respir.J. 2002; 19:1072-1078

OShea et al.
Chest 2009
OShea et al. Chest 2009

14
LIMIT
VENTILATORY Peripheral muscle electrical s+mula+on
REQUIREMENTS:
High intensity
Small muscle mass PERIPHERAL
Short intervals MUSCLE
Supplemental oxygen
TRAINING


Resistance training
NMES
Interval training
One-leg exercise

Improving skeletal muscle strength Improving skeletal muscle strength

" Neuromuscular electrical s0mula0on

l Neuromuscular electrical s0mula0on

60
lSquare wave
MVC (% baseline)

l400s
l50Hz 40

l7s - 25s

20

0
Neder Thorax Bourjeirly Thorax Vivodzef Chest
Picture courtesy Simone Dal Corso

15
 NEUROMUSCULAR ELECTRICAL STIMULATION IN COPD

Muscle strength

Walking distance

Bourjeily-Haber et al. Thorax 2002; 57:1045-1049 Roig et al. Respir Medicine 2009

Exercise modality (II)

l Resistance peripheral muscle training is Exercise frequency
recommended in all pa+ents, and
especially important in pa+ents with l 3-5 +mes a week for general exercise training
peripheral muscle weakness (Level 2) (Level 2)
l Upper limb exercises are recommen- l 2-3 +mes a week for strength training
ded as an additional training modality l When specied treatment goals have been
in upper extremity muscle weakness
perceiving limitations in daily upper achieved maintenance of training eects can be
limb activities (Level 2) accomplished by training at least 1-2 +mes a week
l Neuromuscular electrical stimulation provided that training intensity remains
is recommended in patients with unchanged
severely impaired muscle strength
unable to participate in regular
physical exercises (Level 2)

16
 Exercise dura0on LIMIT
VENTILATORY
l The recommenda+ons of the ACSM include that the REQUIREMENTS:
minimum dura+on of a session is 20 minutes eec+ve
exercise training.
High intensity
Small muscle mass PERIPHERAL
lIt has been suggested that longer las+ng programs
Short intervals MUSCLE
maintained be[er benecial eects (Level 2)
Supplemental oxygen
l Programs of shorter dura+on (4-7 weeks) have also TRAINING

resulted in clinically relevant benets.
It is therefore not possible to recommend an op*mal dura*on for an
exercise training treatment
l The appropriate dura+on of rehabilita+on programs
depends on pa+ent characteris+cs, individual treatment
Exercise training
goals and cost eec+veness should to be taken into
account

OXYGEN SUPPLEMENTATION IN COPD Supplemental oxygen therapy

l Pa+ents who are hypoxemic at rest and are receiving
long-term oxygen therapy should have this con+nued
during exercise training (Level 1).
lIn pa+ents who desaturate only during exercise, it is
ENDURANCE TIME generally recommended not to let oxygen satura+on fall
below 90% during training. Medical subscrip+on is
needed (Level 4).
lBased on available studies and observed eect sizes it
can not be recommended to apply regular oxygen
supplementa+on during exercise in pa8ents without
important desatura8on during exercise to enhance
VO2max
training eects (Level 3).
Nonyama et al. Cochrane Database of Systema+c Reviews 2007

17
 ANXIETY
INCREASE LUNGS DEPRESSION
VENTILATORY CAPACITY: AND MOTIVATION
AIRWAYS
Bronchodilators HEART AND
Inspiratory muscle High intensity CIRCULATION
training PERIPHERAL
Breathing exercises MUSCLE
Ven0latory support TRAINING

Exercise training

IMPAIRED EXERCISE PERFORMANCE AND DYSPNEA

RESPIRATORY MUSCLE
TRAINING
Peripheral Anxiety
Cardio- Ven0latory Oxygen transport Mo0va0on
muscle
circulatory in the lungs Selfesteem
strength

l Respiratory
muscle weakness
l Hyperina0on

Hypoxemia/Hypercapnia
during exercise?

IMT Threshold loading

Body posi0oning Normocapnic Hyperpnea
Endurance Interval- NIV
Muscle training Counseling
training training Ac0ve expira0on
NEMS Relaxa0on
ev. suppl O2 PLB
DB
Nutri0on Educa0on
Tapered Flow Resis+ve loading

18
 Inspiratory muscle func0on in
COPD
200 PImax independent of FEV1 in COPD

PImax (% predicted)
150
Pronounced inspiratory muscle weakness is present in ~40% of COPD
ACCP-AACVPRERS EB Clinical Prac0ce Guidelines on Pulmonary 100 pa0ents
Rehabilita0on Chest 2007
50

0
0 20 40 60 80 100
FEV1 (%predicted)
ATS-ERS Statement on Pulmonary Rehabilita0on AJRCCM Revalis database, UZ Leuven
2013

Expiratory ow limita0on and Opera0ng Lung Volumes and Respiratory Eort

exercise
Flow IC AT REST
6 DURING EXERCISE

4 Hyperina0on
VT expansion is limited COPD
2
BF
0 Normal

PIF -2
(faster contrac0on)
-4
At rest
-6 0 1 2 3 4
During exercise
Volume
Modied from ODonnell DE. AJRCCM ODonnell DE, et al. AJRCCM, 1997
2006;3:180-184

19
Eort to breath and Exer0onal Dyspnea Dyspnea and Pimax

5 10

Borg Dyspnea (0-1 0)

8 1 = P i,max < 4 0 c m H 2 O
4
Borg Score

2 = P i,max 4 0-80 c m H 2 O
6
3 3 = P i,max > 8 0 c m H 2 O
4
2 FEV1 >80% pred
2 FEV1 40-80% pred
1 FEV1 <40% pred
0
Borg Pes/PImax r=0.6,
0 p<0.05

1
2
3

1
2
3

1
2
3
50 % P REDICTED E XERCISE C APACITY
0 10 20 30 40 50 Killian KJ and Jones NL. Respiratory Muscles and Dyspnea. Clinics
in Chest Medicine. 1988;9(2):237-47.
Pes (% PImax)
Modied from ODonnell et al JAP 1998

INSPIRATORY MUSCLE TRAINING

70

COPD
60
ESOPHAGEAL PRESSURE

50
( % PImax )

40

Normals
30
. .

20 . .

10

0

0 10 20 30 40
.
VO 2 (ml/min/kg)
ODonnell et al. Am J Respir Crit Care Med, 155: 109-115, 1997.

20
 PImax Exercise training plus IMT vs Exercise training alone
PImax
Walking distance: +32m*
Dyspnoe Borg: -0.9 point*
Dyspnoe TDI: +2.8 point*
CRDQ: +3.8 point#

*p<0.001
# p<0.01

+13 cm H2O

Gosselink et al. ERJ 2011; 37:416

Exercise training plus IMT vs Exercise training alone

FUNCTIONAL EXERCISE PERFORMANCE IS THERE A FUTURE FOR INSPIRATORY
MUSCLE TRAINING IN COPD?

INDICATION FOR RESPIRATORY MUSCLE

TRAINING:
RESPIRATORY MUSCLE WEAKNESS (< 60cm H2O or
<70%pred)
SYMPTOMS RELATED TO RESPIRATORY MUSCLE

WEAKNESS (dyspnea, hypercapnia)

OPTIMIZATION OF THE MODALITY FOR
p=0.07
INSPIRATORY MUSCLE TRAINING?

21
RESPIRATORY MUSCLE TRAINING:
WHICH DEVICE?

Threshold loading
Normocapnic Hyperpnea

Tapered Flow Resis+ve breathing

Mechanical Threshold Loading Tapered Flow Resis0ve

Loading

22
Tapered Flow Resis0ve Mechanical Threshold
Baseline
8 weeks 8 weeks
2 daily sessions 30 breaths (3 3 daily sessions 2 min (~20
min) breaths)
2 sessions / week supervised 2 sessions / week supervised
Highest tolerable intensity Highest tolerable intensity

Langer et al. Physical Therapy

2015; 95: in press

Training progression Constant load endurance test

TFRL (n=10) MTL (n=10) P
Pi,max (cmH2O) +31.24.3* +18.15.7 * 0.02
Dura0on sec +532204* +187233* 0.02
Breaths n +6427* +2133* 0.03
Avg. Inspiratory Time (ti) sec -1.10.8* -0.20.3 0.02
Avg. Total Time Breath (tTOT) sec +0.9*0.8 +1.0*0.8 0.6
Total Work (J) +407230* +193245* 0.03
ti/ttot (duty cycle) % -166* -55* 0.02

Avg. Peak Inspiratory Flow L/sec +1.40.6* +0.10.3 0.001

Avg. Mean Power / Breath Wa\ +2.31.0* +0.51.2 0.004

Langer et al. Physical Therapy +0.40.2*
Avg. Inspiratory Volume L +0.10.1 0.25
2015; 95
Langer et al. Physical Therapy 2015; 95: in press Avg. Work / Breath J +1.71.0* +0.91.1 0.32

23
 Conclusions I Conclusions II
Respiratory muscle weakness is present in Tapered ow resis+ve IMT as an add-on to
pa+ents with respiratory condi+ons and is exercise training induces favorable changes in
strongly associated with dyspnea breathing pa[ern (slower and deeper breathing)
IMT improves inspiratory muscle strength and at iso-ven+la+on during exercise
endurance, dyspnea, and func+onal exercise Eects of IMT as an add-on to exercise training on
capacity. symptoms of dyspnea and improvements in
Pa+ents with more pronounced inspiratory func+onal exercise capacity need to be studied in
muscle weakness tend to respond with larger selected pa+ents with respiratory muscle
improvements in muscle strength and exercise weakness in a larger, prospec+ve, randomized
performance . controlled trial.
Tapered ow resis+ve loading elicits more The poten+al eec+veness of IMT in other
pronounced improvements in respiratory muscle p a + e n t p o p u l a + o n s s h o u l d b e f u r t h e r
performance inves+gated

IMPAIRED EXERCISE PERFORMANCE/DYSPNEA

Peripheral Anxiety
Cardio- Ventilatory Oxygen transport Motivation
muscle
circulatory in the lungs Selfesteem
strength

Respiratory
l
muscle weakness
SUCCESSFUL REHABILITATION:
Hyperinflation
l

THE CHALLENGE OF ADJUSTING THE SAILS

Hypoxemia/Hypercapnia
during exercise?

IMT
Body positioning
Endurance Interval- Rollator
Muscle training Counseling
training training NIV
NEMS Relaxation
ev. suppl O2 Active expiration
PLB Nutrition Education

24