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Title: RETRAINING OBSTRUCTIVE PULMONARY DISEASE SUBJECTS: From theory to practice


1
RETRAINING OBSTRUCTIVE PULMONARY DISEASE
SUBJECTSFrom theory to practice
Alain VARRAY Diplôme Européen Universitaire en
Activités Physiques Adaptées
2
From
To
3
COPDChronic Obstructive Pulmonary Disease
  • Permanent and irreversible bronchial obstruction
    ? chronic hypoxemia
  • In 2020 probably 3rd cause of mortality in the
    world
  • From a clinical point of view
  • Main symptom dyspnea
  • Very poor respiratory function (permanent)
  • obvious and high exercise intolerance

4
Physical Activity and COPD not evident at all !
  • 2 main hurdles
  • PA ? increased breathlessness
  • to be avoided in dyspneic individuals
  • PA does not change respiratory function so,

PA considered difficult and useless or even non
relevant
5
Major changes
  • In ten years, many works have improved our
    understanding of the COPD/exercise interface
  • Exercise tolerance is not only linked to COPD
    severity
  • COPD muscle shows important abnormalities
  • Quantitative aspect (low muscle mass)
  • Qualitative aspect (muscle structure)
  • Functional consequences
  • Metabolic aspect the muscle impairments are not
    linked with insufficient O2 delivery

6
WHAT IS THE CONSEQUENCE ?
?
  • Reminder of reasons in favor of PA avoidance
  • Poor exercise tolerance due to pulmonary
    function
  • impossible to improve it (chronic disease)
  • exercise induces dyspnea worsening

New evidences in favor of APA Alteration of
muscle function ? early dyspnea PA can be used
to improve muscle function for the same disease
severity improve exercise tolerance is possible,
so better quality of life
7
The main key
  • To prove that muscle impairment is responsible
    for early dyspnea

8
COPD MUSCLE STRUCTURE
  • Less fat free mass
  • Loss of maximal force
  • Predictive of peak V'O2

________________ Baarends et al. Eur Respir J,
1997, 10  2807-13.
9
Localized muscle endurance
  • Interest of localized exercise
  • Muscle evaluation without cardiorespiratory
    limitation
  • Exercise with adequate O2 supply
  • Despite this
  • Endurance time (Tlim) ?

______ Serres, Gauthier, Varray, Préfaut. Chest,
1998, 113 900-05.
10
Muscle structure abnormalities typology
Whittom, Jobin, Simard, Leblanc, Simard, Bernard,
Belleau, Maltais. Med Sci Sports Exerc, 1998 30
1467-74.
11
Muscle structure abnormalities
  • Decreased activity of oxidative enzymes in
    COPD Maltais et al, Am J Respir Crit Care Med,
    1996.
  • Citrate synthase, HADH
  • Normal activity of glycolytic enzymes
  • LDH, HK, PFK
  • Explains excessive anaerobic contribution during
    exercise (localized or general)

12
Excessive anaerobic contribution localized
exercise
_______________________ Wuyam, Payen, Levy, et
al. Eur Respir J, 1992, 5 157-62.
13
Excessive anaerobic contribution localized
exercise
_______________________ Wuyam, Payen, Levy, et
al. Eur Respir J, 1992, 5 157-62.
14
Excessive anaerobic contribution general
exercise
Maltais, Jobin, Sullivan, Bernard, Whittom,
Killian, Desmeules, Belanger, LeBlanc. J Appl
Physiol 1998, 84 1573-80.
15
Excessive anaerobic contribution general
exercise
Maltais, Jobin, Sullivan, Bernard, Whittom,
Killian, Desmeules, Belanger, LeBlanc. J Appl
Physiol 1998, 84 1573-80
16
Muscle oxidative stress evidence
  • COPD tested in local muscle exercise conditions
    (quadriceps)
  • Assessment of oxidative stress (TBARs)
  • Consequences on
  • Muscle membrane integrity
  • Impairment of oxidative pathways

Couillard, Koechlin, Cristol, Varray, Prefaut.
Eur Respir J, 2002, 20 1123-9.
17
Muscle impairment occurs before any problem in O2
supply
Gosselin, Poulain, Ramonatxo, Ceugniet, Préfaut,
Varray. Muscle Nerve, 2003, 27 170-9.
18
Muscle impairment occurs before any problem in O2
supply
Gosselin, Poulain, Ramonatxo, Ceugniet, Préfaut,
Varray. Muscle Nerve, 2003, 27 170-9.
19
Muscle impairment occurs before any problem in O2
supply
Gosselin, Poulain, Ramonatxo, Ceugniet, Préfaut,
Varray. Muscle Nerve, 2003, 27 170-9.
20
Consequences for exercise adaptations
  • Decreased aerobic pathway for a given exercise
    intensity
  • Abnormal, excessive anaerobic contribution

X
  • H ?

21
Dyspnea spiral
RESPIRATORY IMPAIRMENT
DYSPNEA
INTENSE EXERCISE
MODERATE EXERCISE
DAILY ACTIVITIES
DECREASED
STOPPED
SEVERE
MODERATE
ACTIVITY
DECONDITIONING
.even if stable disease severity
22
INITIAL OR PRIME PATHOLOGY
RESPIRATORY IMPAIRMENT
DYSPNEA
SECONDARY PATHOLOGY Deconditioning Muscle
dysfunction
ACTIVITY
DECONDITIONING
23
SYNTHESIS
  • PRIME PATHOLOGY
  • DYSPNEA due to respiratory impairment
  • SECONDARY PATHOLOGY
  • dyspnea due to respiratory center hyper
    activation
  • Deconditioning consequence
  • Muscle dysfunction
  • DYSPNEA MANAGEMENT
  • Fight against prime pathology (medical treatment)
  • Subject RECONDITIONING fight against secondary
    pathology

24
AIMS OF EXERCISE TRAINING
  • Fight against Deconditioning and muscle
    dysfunction
  • cardio respiratory
  • peripheral
  • To solve problems due to prime and secondary
    pathology

25
A.P.A. JUSTIFICATION
  • PRIME PATHOLOGY
  • Medical and paramedical management
  • Treatment stabilisation and optimization
  • SECONDARY PATHOLOGY
  • EPSA teacher directly concerned
  • Work on relationship between
  • Metabolic effects physical practice and
  • Health increase
  • Decreased dyspnea so increased quality of life

26
BASIC KNOWLEDGE NEEDED TO OPTIMIZE A.P.A.
  • Good adaptation of exercise testing
  • Methodological basis of individualization
  • Exercise tests too often done incorrectly
  • dyspnea measurement (diagnosis and evaluation)
  • Optimal training intensity
  • Field test development
  • Retraining follow-up

27
ADAPTED EXERCISE TESTING
  • Basic principle
  • Individualize on standardized basis
  • Main principles
  • Continuous test
  • Progressively increased
  • Step duration 1 min
  • Total test duration about 10 min after warm-up
  • so imperative individualization of load increment

28
WHY INDIVIDUALIZATION ?
  • Initially, exercise inadaptation are
    proportional to pathology severity
  • Most of the time exercise testing too short
  • impossible ventilatory threshold assessment
  • No maximal exercise test (RERlt1.10)
  • Bad interpretation of subject ability to perform
    exercise and training programing

29
HOW INDIVIDUALIZE ?
  • STEPS
  • Calculation of theoretical max. O2 uptake
  • Correction according FEV1 ( theoretical)
  • Calculation of expected maximal power output by
    converting in watts (remove 250 ml/min and divide
    by 10.3)
  • Warm-up 20 of expected Pmax during 3 min
  • Step 8 of expected Pmax (every minute)

30
CALCULATION OF THEORETICAL VO2max
height in cm weight in kg age in years
Predicted maximal O2 uptake (ml.min-1)
MEN a) if weightlt0.79 x height - 60.7 b) if
weightgt0.79 x height - 60.7
weight x (50.72 - 0.372 x age) (0.79 x height
- 60.7) x (50.72 - 0.372 x age)
(42.8 weight) x (22.78 - 0.17 x age) height
x (14.81 - 0.11 x age)
WOMEN c) if weightlt0.65 x height - 42.8 d) if
weightgt0.65 x height - 42.8
Wasserman et al., Principles of exercise testing
and interpretation. Lea Febiger, Philadelphia,
1986 pp.72.
31
EXAMPLE
  • Man 38 years, 80 kg, 1.76 m and FEV1 65 of
    theoretical value
  • V'O2max théor. (formula b)2865 ml.min-1
  • Corrected V'O2max 2865 x 0,65 1862 ml.min-1
  • Expected Pmax (1862-250)/10,3 156 watts
  • SO
  • Warm-up 156 x 0,2 31 watts
  • Increment 156 x 0,08 12,5 watts per minute

32
EXAMPLE FOR EXPECTED Pmax 156 WATTS
33
MEASUREMENT OF VENTILATORY THRESHOLD
  • DURING INCREMENTAL EXERCISE/
  • Recording VO2 and VCO2 (breath-by-breath)
  • Averaging every 10 seconds
  • Computation of VO2 / VCO2 relationship

34
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35
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36
Interest of individualization at ventilatory
threshold
  • directly function of aerobic physical fitness
  • Individualization / real capacities
  • Before excessive hyperventilation
  • Very well tolerated (no or few dyspnea)
  • Efficient to induce training effects
  • Easy learning of individualized practice
  • Usable in current life
  • If impossible to measure ? dyspnea threshold

37
DYSPNEA by Visual Analog Scale (VAS)
At each work load (every min) dyspnea
evaluation Delete mark after measurement from
zero point
38
DYSPNEA THRESHOLD(Visual Analog Scale VAS)
39
OPTIMIZATION... RETRAINING DEVELOPMENT USEFULNES
S OF FIELD TESTS
40
RATIONALE
  • Disadvantage of individualized training
  • Regular cardio respiratory evaluation gt cost ?
  • Solution
  • Adapted field test
  • One of the most popular
  • 6 or 12 min walking test

41
6 MINUTE WALKING TEST
  • From Cooper test (12 min)
  • shortened until 6 min
  • Linearity of walking pace (12 2 x 6)
  • highly simple
  • Excellent reproducibility
  • If correct learning
  • Without verbal encouragement
  • alone
  • Very well correlated with V'O2sl

42
ADAPTED TO ASSESS TRAINING EFFECTS ?
  • NOT YET STUDIED
  • Relationship with physical fitness
  • Not sufficient (correlation ? cause to effect
    relationship)
  • QUESTION
  • 6 min walking test is it able to identify
    physiological modifications due to retraining ?
  • Protocol study of relationships
  • Aerobic physical fitness and 6 min WT
  • Before and after retraining

43
6MWT and training effects

44
RELATIONSHIP 6MWT AND VENTILATORY THRESHOLD
45
RELATIONSHIP 6MWT AND VO2sl
46
PHYSICAL FITNESS PREDICTION
  • For VO2 sl (r0.95)
  • For ventilatory threshold (r0.91)
  • In addition
  • After training measured and calculated values non
    different (diff. Mean 0.06 l.min-1)

47
6 MIN WALKING TEST
  • Sensitive to physical fitness variation
  • ventilatory threshold
  • Max O2 uptake /-
  • Possible aerobic physical fitness prediction
  • Stables relationships throughout training
  • Valid equations even after training

48
Enright and Sherrill, Am Rev Resp Crit Care Med,
1998, 158 1384-87.
49
Enright and Sherrill, Am Rev Resp Crit Care Med,
1998, 158 1384-87.
50
OPTIMIZATION WHICH INTENSITIES ?
51
STATE OF THE ART
  • Works of literature
  • No consensus
  • Most of the time
  • Training intensities based on reserve heart
    rate HRrest (HRmax - HRrest)
  • Interest
  • Simplicity of realization

52
PROBLEM NEED TO CERTIFY EFFECTIVENESS OF RESULTS
  • Relevance ???
  • No consideration of cardio respiratory fitness
  • standardization is in opposition to
    individualization
  • QUESTION
  • Which method lead to best results ?

53
-- INTEREST --
  • Stays in specialized centers
  • More and more shortened
  • SO
  • High need to be as efficient as possible
  • That is
  • Obtain best results every time
  • In a minimum amount of time

54
PROTOCOL
  • 2 groups studied
  • Trained at the same absolute HR, but
  • 1 gpe at ventilatory threshold (individualization)
  • 1 gpe at 50 of reserve HR (standardtion
    )training at the same frequency and duration
  • Blind final evaluation

55
RESULT 1 RESERVE HR NO RELEVENT INTENSITY
56
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57
CONCLUSION
  • Reserve HR
  • Random results
  • Under- or over-estimation of efficient intensities

Another reserve HR choice cannot be a solution
to improve this technique
58
GENERAL RESULTS
  • Exercise adaptations
  • Better exercise tolerance dyspnea decrease
  • Restoration on self confidence
  • Enhancement of quality of life
  • General well-being, emotional state (Ojanen et
    al, 1993)
  • durable effect (Dekhuijzen et al., 1990)
  • Improvement of psychological state
  • Never linked with resting pulmonary function
  • Always related to possible physical activity
    amount linked to functional state

59
Main results
  • Validated in international literature
  • Original studies and meta-analysis
  • Evidence-based medicine rating the strength of
    evidence

60
Respiratory rehabilitation based on
A.P.AFromJoint ACCP/AACVPR Evidence-Based
Guidelines. Chest, 1997, 112136396.Fabbri and
Hurd GOLD Scientific Committee. Eur Respir J,
2003, 22 1-2.
  • Unique technique assessed with grade A for
  • ? breathlessness
  • ? health-related quality of life
  • ? depression and anxiety associated with COPD
  • ? hospitalization number and duration
  • Amazingly better exercise tolerance
  • ? exercise capacity
  • ? dyspnea for a given exercise intensity
  • Grade B for
  • Improved survival

61
AEROBIC PHYSICAL FITNESS
Ventilatory Threshold (l.min-1)
Trained Untrained
Trained Untrained
___________________________ Vallet et al., Rev.
Mal. Resp., 1993
62
Effects on ventilatory requirement
  • ______ Varray, Mercier, Préfaut. Int. J. Rehab.
    Res., 1995, 18 297-312.

63
VENTILATORY REQUIREMENT
  • Ventilation decrease for a given exercise
    intensity
  • Increased ventilatory comfort for any exercise
    intensity
  • Decreased respiratory cost (dyspnea ?)
  • SO more O2 for exercising muscles
  • Exercise capacity increased
  • Better exercise efficiency

64
respiratory muscles
respiratory muscles
o
exercising muscles
exercising muscles
65
BREATHING PATTERN
of pre-training ventilation
_________________ Varray et al., Int. J. Rehab.
Res., 1995
66
BREATHING PATTERN MODIFICATION
  • VT always higher for a given ventilation
  • Better alveolar ventilation
  • Airways turbulences decrease for a given
    obstruction level
  • Explanation of the effects on dynamic
    hyperinflation
  • Dyspnea decrease during exercise (lower fb)
  • Reduced ventilatory cost

67
Individualization versus standardization
Standard training
Individualised training
pre-training pic VO2
pre-training pic VO2
68
Individualization versus standardization
(breathing pattern)
INDIVIDUALIZED GROUP
STANDARDIZED GROUP
Before training
Before training
After training
After training
pre-training VE max
pre-training VE max
_____________________ Vallet et al., Eur. Resp.
J., 1997
69
Effects on muscle dysfunction localized exercise
Localized exercise No cardiorespiratory
limitation Assessment of muscle function per se
Delay in fatigue threshold
__________ Serres, Varray, Vallet, Micallef,
Préfaut. J Cardiopulm Rehab, 1997, 17 232-8.
70
Effects on muscle dysfunction localized exercise
Local endurance 250
__________ Serres, Varray, Vallet, Micallef,
Préfaut. J Cardiopulm Rehab, 1997, 17 232-8.
71
Effects on muscle dysfunction general exercise
Gosselin, Lambert, Poulain, Martin, Prefaut,
Varray. Muscle Nerve, 2003, 28 744-53.
72
Muscle efficiency
Before training After training
_________________________ Gosselin et al.,
Muscle Nerve, 2003.
73
COST/EFFECTIVENESS RELATIONSHIPS
GROUP 1 GROUPE 2 GROUPE 3 Treatment
Treatment Respiratory medical
Médical Education Rehabilitation
n 50 n 50 n 50
Sneider, J. Cardio-pulm. Rehab., 1988
5 years PRE-R.R. 4.24 / 1069 2.34 / 586
3.2 / 801 5 years POST-R.R. 6.28 /
1570 3.78 / 946 1.67 /
417 EVOLUTION COST / 5 years (1193/day) 600
000 430 000 - 458 000
hospitalization days /patient/year
total hospitalization days during 5 years
  • work of Trautner (Eur. Resp. J., 1993) - asthma
    and health management
  • For 1 DM (cost), 5 DM saved for public health
    economy
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