Pulmo Rehab Phase 2

8/3/2019 Pulmo Rehab Phase 2

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MUHAMMAD

FARRUKH

SHAHZAD

ZYRAK



An evidence-based, multi-disciplinary, and

comprehensive intervention for patients with chronic

respiratory diseases who are symptomatic and often have

decreased daily life activities. Integrated into theindividualized treatment of the patient, pulmonary

rehabilitation is designed to reduce symptoms, optimize

functional status, increase participation, and reduce health care

costs through stabilizing or reversing systemic manifestations

of the disease



To provide evidence-based information on current best

practice for the practical management of patients referred for

pulmonary rehabilitation



• To reduce activity limitation and participation restriction

of persons with chronic lung diseases.

• To restore patients to the highest possible level of

independent functioning

PRIMARY AIMS OF

PULMO REHAB



• Increase exercise tolerance in order to reduce impairment..

•

Reduce frequency and severity of symptoms.

• Improve mood and motivation.

• Reduce dependency.

• Improve quality of life.



GOALS OF PULMO REHAB

• Enhance participation in therapy decisions by building

self-management capacity.

• Increase participation in everyday activities.

• Reduce health care burden for patients, families and

communities.

• Improve survival



Include patients who:

• Have chronic obstructive pulmonary disease or other

respiratory conditions.

• Are recovering from an acute exacerbation.

• Are willing to participate (even if they are current

smokers).

ELIGIBILITY CRITERIA



ELIGIBILITY CRITERIA

Exclude patients who:

• Have severe cognitive impairment.

• Have severe psychotic disturbance.

•

Have a relevant infectious disease



• Respiratory specialists including physicians, surgeons,

physiotherapists and nurses.

• General practitioners.

• General physicians.

• Other allied health professionals.

•Community health professionals.

• Potential participants (i.e. self referrals).

Who refers patient



ESSENTIAL COMPONENTS

OF A PULMO REHAB

• Patient assessment.

• Patient exercise training.

• Patient education.

• Program evaluation.

• Maintenance.



• Required to determine whether the patient should participate in

the exercise sessions of a pulmonary rehabilitation program

•

Co-morbidities include cardiac, musculoskeletal andneurological conditions.

• Nutritional status.

• Smoking history.

• Spirometry test results

Medical History



•Body Mass Index (BMI) can provide valuable information

regarding the patient‟s nutritional status.

•Normal BMI values range from 20 to 25

BMI = weight (kg) ÷ height2 (m)

• Referral to a dietician may be required if:

• BMI < 20 = underweight.

• BMI > 30 = obese.



• The high prevalence and negative impact of anxiety and

depression amongst COPD patients

•

disease specific questionnaires (e.g. CRDQ, SGRQ)

• dyspnoea and fatigue

• Another means of screening for anxiety and depression

problems involves case-finding via the use of mental

health instruments (e.g. The Hospital and Anxiety

Depression Scale).



• If the patient is still smoking, refer the patient to a

smoking cessation clinic or equivalent.

Smoking History



SPIROMETRY

Stage Spirometry (post-bronchodilator)

I - Mild COPD FEV1 / FVC < 0.7 and FEV1 60% to 80% predicted

II - Moderate

COPD FEV1 / FVC < 0.7 and FEV1 40% to 59% predicted

III - Severe COPD FEV1 / FVC < 0.7 and FEV1 below 40% predicted



BODE INDEX

•

BODE Index for COPD• The BODE Index is a composite marker of disease taking into consideration the

systemic nature of COPD (Celli et al., 2004).

• Scoring the BODE Index 0 1 2 3

• FEV1% pred ≥65 50-64 36-49 ≤35

• 6MWD (m) ≥350 250-349 150-249 ≤149

• MMRC 0-1 2 3 4

•BMI (kg.m-2) >21 ≤21

Total BODE Index score = 0 to 10 units

(FEV1% pred = predicted amount as a percentage of the forced expiratory lung volume in one second; 6MWD = six minute walkingdistance; MMRC = modified medical research council dyspnea scale; BMI = body mass index)



ASSESSING EXERCISE CAPACITY

• 1. The Six-Minute Walk Test (6MWT)

• 2. The Incremental Shuttle Walk Test (ISWT)

http://www.pulmonaryrehab.com.au/index.asp?page=19






Exercise Test Contraindications and Precautions Unstable angina* or myocardial infarction during the previous

month.

Resting heart rate > 120 beats / min after 10 minutes rest (relative

contraindication).

Systolic blood pressure > 200 mmHg ± diastolic blood pressure > 100

mmHg (relative contraindication).

Resting pulse oximetry (SpO2)% < 88% on room air or while

breathing the prescribed level of supplemental oxygen. The referringdoctor should be notified and exercise assessment should not

proceed.

Physical disability preventing safe performance.



EXERCISE TEST TERMINATION CRITERIA

Onset of angina or angina-like symptoms.

Signs of poor perfusion including lightheadedness, confusion, ataxia,

pallor, central cyanosis, nausea, cold clammy skin, sweating.

Patient requests to terminate test (e.g. intolerable dyspnoea, which is

not relieved by rest and causes patient distress).

Physical or verbal manifestations of severe fatigue.

Development of an abnormal gait pattern (e.g. leg cramps,

staggering).

Tachycardia (i.e. heart rate > 210 – 0.65age). (This should be

considered in conjunction with other signs or symptoms.

SpO < 85%*



ASESSING SHORTNESS OF BREATH

• A reduction in shortness of breath (i.e. dyspnoea) is a

robust finding in pulmonary rehabilitation research

•There are a number of measurement tools available for

assessing dyspnoea, including:

• Modified Medical Research Council (MMRC) Dyspnoea

Scale.

• Modified Borg Dyspnoea Scale (0-10)
















IMPORTANCE OF EXERCISE

• A reduction in exercise tolerance is one of the main

complaints of people with chronic lung disease.

• Exercise training should be an essential component of a

pulmonary rehabilitation program



EXERCISE PRESCRIPTION

An exercise training program requires an individual prescription in terms of:

• Intensity.

• Duration.

• Frequency.

• Type (interval or continuous).

• Mode (e.g. walking, cycling, arm exercise).

• Progression.



EXERCISE TRAINING

A pulmonary rehabilitation program must include, at minimum, lower limb enduranceexercise training.

• Lower limb endurance training.

• Home exercise program

• Optimally, a pulmonary rehabilitation should also include:

• Upper limb endurance training.

• Lower limb strength training.

• Upper limb strength training.

• Other components that may be included are:

• Flexibility and stretching exercises.

• Balance exercises.

• Inspiratory muscle training



















ENDURANCE TRAINING - LOWER LIMB

Lower limb aerobic exercises (uses large muscle mass):

Walking training for all patients.

Stationary cycling training if possible



INTENSITY

Walking training intensity

• walking training a starting intensity should be 80% of theaverage 6MWT speed or

• 75% of the peak speed achieved on the ISWT

Cycle training intensity:

• starting intensity for cycle training should be 60% of peak

cycle work rate.

• In many settings, the peak cycle work rate will not have

been measured and exercise intensity may be titratedbased on achieving a dyspnoea score or rate of perceived

exertion score (RPE) of 3 to 4 on the BORG 0-10 scale



WALKING TRAINING INTENSITY

CALCULATION

• Six-minute walk distance (6MWD) † 6 = Distance in one

minute

• For distance in 30 minutes = one minute distance x 30

• For distance in 20 minutes = one minute distance x 20

Example:

• If the patient walked 324 m in six minutes:

•

One minute distance = 324 † 6 = 54 m.• 30 minute distance = 54 x 30 = 1620 m.

• 80% of 1620 = 1296 m in 30 minutes.



WALKING TRAINING INTENSITY

• Treadmill speed = 80% 6MWT average speed

6MWT average speed = (6MWT distance x 10) † 1000 km

/ hr

Example:

• If the patient walked 324 m in the 6MWT, then:

• 324 x 10 † 1000 = 3.24 km / hr.

• 80% of 3.24 km / hr = 2.59 km / hr.



B. PRESCRIBING INTENSITY BASED ON

DYSPNOEA ASSESSMENTS.

• Encourage their patients to exercise at a dyspnoea score of

about 3 (“moderate”) as this equates to exercising at a

cycle training intensity of approximately 75% VO2 peak.

Therefore, patients could be encouraged to exercise at this

level of dyspnoea.




• Duration

The minimum suggested duration for a lower limbendurance exercise session is 30 minutes (e.g. 30 minutesof walking or cycling).

If a patient is very debilitated, the duration of the initialexercise sessions can be shortened (e.g. to 10 minutes). The duration should be built up to 30 minutesduring the first two weeks of the program.

If a stationary cycle is available, the program can be splitinto 15 minutes of cycling and 15 minutes of walking.




• Frequency

The current recommendation is that frequency of lower

limb endurance exercise training should be:

Supervised exercise training: Three times per week .

Home exercise training: A further one or two times per

week so that exercise is integrated into home life.




Type

• Continuous or Interval Training

• Circuit Training

• Warm-up and Cool-down



ENDURANCE TRAINING - UPPER LIMB

• Mode

The following points should be taken into account whenprescribing unsupported arm exercises with the aim of increasing endurance exercise capacity:

A weight should be chosen that the patient can only lift 15 times.

Each exercise should be repeated 15 times followed byrest.

Try to limit the rest period between each set of 15 repetitions to one minute.

It may help to instruct the patient to move their arms up asthey breathe in and down as they breathe out .



Upper Limb Endurance Exercises

(low weight and high repetition)

Exercise #1Arm Raise

Hold a bar with hands at knee height.

Lift bar above head, then lower.

Breathe in while lifting bar up and out while

lowering bar down.

Exercise #2

Arms Together

Start with arms by your sides.

Lift your arms until they are at shoulder height

(breathe in while you do this).

Move arms forwards to meet in the middle, keeping

elbows straight (breathe out while you do this).

Reverse the movement until the arms are horizontal

at shoulder height (breathe in while you do this).

Return arms to your side again (breathe out while

you do this).




• Intensity

• The intensity for upper limb endurance exercise may be

prescribed based on:

• Weight repetitions.



A. PRESCRIBING INTENSITY BASED ON WEIGHT

REPETITIONS

• Start with a weight that the patient can use to perform at

least 15 repetitions of the chosen arm exercise (for some

patients, the weight of their arms is sufficient as a „starting

weight‟).

• After the patient can perform 15 repetitions of each

exercise (one set) then increase to three sets of each

exercise.

• After the patient can perform three sets of each exercise,

the weight held can be increased by 0.5 kg.

• Tip: For home training, the exercises might begin with ‘no weight’, progressed to a 0.5 kg

weight (eg 0.5 kg bag of rice) and then increased to a 1 kg weight (eg 1 kg bag of rice).




• Duration

• The duration of each upper limb endurance exercise

session will depend on the number of sets the patient is

able to achieve (15 repetitions of each exercise is one set).

• If the patient is able to perform three sets of each exercise,

then the duration will be approximately five minutes.

• Patients should aim to perform at least 10 minutes of

unsupported arm exercise (i.e. three sets of each exercisefor five minutes; repeat).




• Frequency

• Supervised exercise training: Three times per week .

• Home exercise training: A further one or two times per

week so that exercise is integrated into home life.



STRENGTH TRAINING - LOWER LIMB

• Strength training with weights:

o Leg press.

o Quadriceps extension.

•

Strength training without weights:

o Squats.

o Straight leg raise.

o Step-ups or stair climbing

o Sit-to-stand from progressively lower chairs .

Lower Limb Strength Exercises



Lower Limb Strength Exercises

(high weight and low repetition) Exercise #1

Knee extensions in sitting

Sit in a chair.

Straighten your knee.

Hold the knee straight for five seconds, and then relax.

Repeat for other leg.

Progression:

o Add weights to legs. Exercise #2

Squats

Lean your back against a wall.

Squat down until your thighs are parallel with floor.

Slide up the wall to a standing position.

Start with only sliding down a short way.

Progression: Increase depth of slide down. Exercise #3

Climbing stairs

Your instructor can help you with this exercise.

Progression:

o Increase the number of steps.

o Increase the height of the step (or walk up two steps at a time).

o Carry a weight on your back.




• Intensity

The appropriate intensity for lower limb strengtheningexercises can be prescribed based on:

• A. One repetition maximum (1RM)* i.e the maximumweight that can be lifted once by a particular muscle group

• B. Ten repetition maximum (10 RM) i.e the maximumweight that can be lifted 10 times by a particular musclegroup




• Protocol

• Perform one set (10 repetitions) of a particular exercise

(where the weight used is that which can be lifted 10 times

i.e 10RM), then rest.

• Increase the number of sets, at the selected weight to 3

sets.

• Try to limit the rest period between each set of 10

repetitions to less than two minutes.• Once the patient can perform 3 sets of a particular

exercise, the weight can be increased




• Duration

• The duration of a lower limb strengthening training

session will depend on the time it takes to complete the

appropriate number of sets.




• Frequency

• The frequency for lower limb strength exercise sessions

should be two or three times per week.• Patients should ensure they have at least one day of rest

between strength training sessions.



STRENGTH TRAINING - UPPER LIMB

• Strength training for the upper limbs have focused on the accessorymuscles of inspiration and muscle groups used in everyday functionaltasks. These muscles include:

Pectoralis major

Latissimus doris

Trapezius

Biceps

Triceps




• Mode

• Strength training with weights and weight machines:

• Hand weights for biceps and triceps.

• Lat/chest pull down for latissimus dorsi.

• Chest press for pectorals.

• Strength training without weights machine:

•Wall push-ups for pectorals.

• Theraband resistance for pectorals and latissimus dorsi

Upper Limb Strength Exercises



(high weight and low repetition)

Exercise #1

Arm exercise

Hold a weight in each hand at shoulder height.

With one arm, lift the weight straight up and down.

Breathe in while lifting the weight up, and breathe out while loweringthe weight down.

Repeat the exercise with your other arm.

Exercise #2

Biceps

Start with your arms by your sides.

Bend your arm at the elbow to lift your hand towards your shoulder,then lower.

Repeat the exercise with your other arm.

Add hand weights as necessary.

This exercise can also be done in the sitting position.

Exercise #3

Arm exercise

Start with holding a weight in each hand on your lap.

Lift both arms out to the side, but not above your shoulders (move your

arms as if you were “spreading your wings”).

Keep your elbows slightly bent during the exercise.

Breathe in while you move your arms up, and breathe out as you lower




• Intensity

• The appropriate intensity for upper limb strengthening exercises can be prescribed based

on:

A. One repetition maximum.

B. Weight repetitions.

PRESCRIBING INTENSITY BASED ON ONE



PRESCRIBING INTENSITY BASED ON ONE

REPETITION MAXIMUM

• The maximum weight that can be lifted once by a particular musclegroup is known as the one repetition max (1 RM)*.

• Choose an exercise with a weight that can be performed a maximum

of 10 times with correct technique (ie 10 RM).

•

Start with a weight of 50 to 60% of the patient‟s 1 RM weight.• Perform one set (10 repetitions) of a particular exercise.

• Aim to increase the weight up to 80% of the patient‟s 1 RM while

ensuring that the patient performs the exercise with the correct

technique.

• After the patient can perform three sets of an exercise, the weight

may be increased.




Protocol

• Perform one set (10 repetitions) of a particular exercise,then rest.

• Try to limit the rest period between each set of 10repetitions to less than two minutes.

• Once the patient can perform 3 sets of a particularexercise, the weight can be increased by 5% or between

0.5 kg to 5 kg depending on which muscle group is beingtrained. Ask the patient to move their arms up as theybreathe in, and down as they breathe out.

• These exercises can be performed in the sitting position,with the back supported.




Frequency

• The frequency for upper limb strength exercise sessions

should be two or three times per week.

• Patients should ensure they have at least one day of rest

between sessions.



FLEXIBILITY AND STRETCHING

Flexibility

Flexibility Exercises

• Exercise #1

Trunk rotation

• Gently rotate the trunk side to side as far as possible.

Stretching Exercises



g

Exercise #1

Pectoralis stretch

Stand in the corner or in a doorway with your hands at shoulder level

and your feet away from the corner or doorway.

Lean forward until a comfortable stretch is felt across the chest.

Take extra precaution if patient has shoulder pain.

Exercise #2

Triceps stretch

Lift your arm so that your elbow is next to your ear.

Place your hand between your shoulder blades.

Gently push your elbow back with your other hand until you feel a

stretch.

Exercise #3

Hamstring stretch

Sit on the bed.

Lean forward and slowly straighten your knee until you feel a stretch

at the back of your thigh.



BALANCE

• The following exercises can help improve balance:

Lower limb muscle strength training such as

one leg standing,

sideway leg lifting and

stepping up and down on a block (start by holding

the back of a chair to aid balance) Tai Chi



INSPIRATORY MUSCLE TRAINING

• Inspiratory muscle training (IMT), performed in isolation using a threshold loading deviceor target-flow resistive device at loads equal to or greater than 30% of an individual’s

maximum inspiratory pressure generated against an occluded airway (PImax) has been

shown to increase inspiratory muscle strength and endurance and reduce dyspnoea in

patients with COPD.

•

Training may also result in modest improvements in 6 minute walking distance and health-related quality of life.

• However, it remains unclear whether IMT combined with a program of whole -body

exercise training confers additional benefits in dyspnoea, exercise capacity or health-

related quality of life in patients with COPD.

• At present, the evidence does not support the routine use of IMT as an essential

component of pulmonary rehabilitation program.



MAINTAINING THE GAINS

• (To maintain the improvements in exercise capacity and quality of life after the completionof a pulmonary rehabilitation program, patients need to continue to exercise .

• People with severe physical limitations (multiple co morbid conditions and / or frequent

hospital admissions) will benefit from a longer pulmonary rehabilitation program.)

Options for maintenance exercise programs:

• Continue to exercise 3 to 5 days per week by either:

• once a week, supervised exercise program in a health facility, community or hospital

outpatient setting plus unsupervised exercise on 2 to 4 other days per week.

• or

•unsupervised home exercise program with regular review (e.g. every 3 to 6 months) at thepulmonary rehabilitation program

USE OF SUPPLEMENTAL OXYGEN DURING



EXERCISE TRAINING

• Patients who desaturate below an oxygen saturation of

88% during exercise training, despite the use of interval

training, should be assessed to determine the benefit of

supplementary oxygen.

• Assessment for supplementary oxygen is done by

providing oxygen via nasal prongs at a flow rate of 2-4

L/min for during the specific



USE OF BRONCHODILATORS

• Prescribed bronchodilators should be given before

exercise training starts. This medication should only be

given if spirometry results confirm that such use provides

benefits beyond that provided by the long-acting

bronchodilators that the patient may be prescribed.

• Increased lung function after bronchodilator use may

allow the patient to exercise:

• At a greater intensity.

• For a longer duration.

• With less dyspnoea.



CASE STUDY

• Sheikh iftikhar is a 82 year old male with severe copd. He is woriking as…. He has difficultywalking on the flat. Showering and carrying heavy loads. These activities produce

breathlessness. The respiratory medications he uses are ….

• On assessment his spirometry is FEV1/FVC= ?

• FEV1 of %.

• His weight is 90 kg.

• height is ?

• BMI ?

• Resting HR=?

•

Resting Spo2 =?• He is able to walk ?m with two rest in the best of two six minute walk tests but desaturated to

77% on room air and felt very severely breathless (dyspnea score=?) at the end of walk

EXERCISE THAT I WOULD PRESCRIBE



EXERCISE THAT I WOULD PRESCRIBE• Goal

• 20 minutes lower limb endurane exercise, arm endurane exerciese and upper and lower limb

strenghthening exercises I will supervised these exercises in the next 3 visits. Progress theduration to achieve 30 minutes of lower limb endurance exercise as soon as able, then progress

the intensity

• Lower limb endurance exercises.

• Treadmill walking (10 minutes) combined with stationary cycling (10 minutes)

Walking Program

• Convert six minute walk distance into walking speed x 80% intensity.

• i.e. [(324/6 x 60)/1000] x 80% = 2.6 km/hr x 10 minutes duration. The treadmill may need to start

at about 2.1 km/hr to account for Bill being unfamiliar with treadmill walking. Progress the

walking time (eg 15 minutes) as soon as able. Consider interval training or supplemental oxygen

if Bill needs to stop for rests.

Cycling Program

• Use the Borg scale to set intensity level such that Bill feels moderately to somewhat severely

breathless (3 to 4 on Borg Dyspnoea Scale) during the cycle exercise. Cycle at a speed to

maintain this intensity for 10 minutes. Progress the cycle time (eg 15 minutes) as soon as

able. Consider interval training or supplemental oxygen if Bill needs to stop for rests.



CONT”D

Arm Exercises

• Start with low weigh

Strength training

• Start with 1 set of 3 lower limb and 3 upper limb strength training exercise. See examples

in the strengthening exercises tables.

Circuit

• The flexibility and balance exercises and stretches can be included in a group circuit

class.

• t, high repetition arm activities (total duration 5 minutes)



PATIENT EDUCATION

Importance of Education

• Helping patients become active participants in their health

care.

•

Helping patients and their families gain a betterunderstanding of the physical and psychological changes

that occur with chronic illness.

• Helping patients and their families to explore ways to

cope with those changes.



AIMS & OBJECTIVES OF EDUCATION

Improve self-health behaviours.

Encourage physical fitness.

Provide information to help enhance physical fitness.

Improve the patient’s quality of life.

Increase the patient’s ability to cope with the acute and chronic phases of chronic

obstructive pulmonary disease.

Reduce the length of stay in hospital.

Reduce hospital admissions.

Optimise nutritional status.



PROGRAM EVALUATION

• Evaluation of the effectiveness of pulmonary

rehabilitation programs can be based on:

•

Patient outcomes (i.e. what were the effects on the patient‟s exercise capacity and quality of life?).

• Patient feedback (i.e. what did the patient think of the

program?).







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