SKELETAL MUSCLE TRAINING, PERIPHERAL AND
RESPIRATORY MUSCLESProf. Dr. Sema SAVCI
Hacettepe University Faculty of Health Sciences,
Department of Physical Therapy and Rehabilitation.
Chronic Respiratory Diseases
DyspneaDecreased exercise toleranceDecreased quality of life
Chronic Respiratory Diseases
Ventilatory limitationImpaired gas changingCardiac problemsSymptoms seen with effortPeripheral muscle weakness
muscle circulaion Ventilation
CO2
O2O2
CO2
Oxygen transporOxygen transportt
Pathology/ Inflammation/ HypoxemiaPathology/ Inflammation/ HypoxemiaMedicinesMedicines
Inactivity/ Inactivity/ DDeconditioningeconditioning
Wasserman, Principles of Exercise Testing and Interpretation 1994
Peripheral muscle adaptations
Muscle atrophyMuscle weaknessFatigue Morphological changes – Decreased numbers of
type I fibers – Increased numbers of
Type IIx fibers – Atrophy in type I and IIa
fibers – Decreased
capillarisation
Changes in metabolic capacity:
– Intramuscular pH – Concentration of ATP
– Muscle lactate level – Activity of
mitochondrial enzyme
Properties of muscles fiber types
Fibril type
Defination Metabolism
Myoglobulin /Mitochondria
Function
I Slow Fatigue resistant
Oxidative Rich red Standing, Normal breathing
IIa FastFatigue resistant
Oxidative/Glycolytic
Red-white Walking, hyperventilation
IIx FastNot fatigue resistant
Glycolytic Less white Jumping Coughing
Prevalence of muscle atrophy
Vestbo ve ark. AJRCCM 2006;173:79-83..
00
2020
3030
4040
5050
6060
1010
FF: : FFMFFM 14.62 kg/m 14.62 kg/m22
MM: : FFMFFM 17.05 kg/m 17.05 kg/m22
ratio
ratio
(%)
(%)
GOLD GOLD stagestage00 11 22 3 & 43 & 4
Normal Normal BMIBMI
26%womanwoman
manman
Muscle Weakness in Muscle Weakness in COPDCOPD
PePecctoralistoralismajormajor
StrengthStrength (kg) (kg)
00
2020
4040
6060
8080
100100
COPDCOPDControlsControls
LatissimusLatissimusdorsidorsi
QuadricepsQuadriceps
**
**
**
Bernard ve ark. AJRCCM 1998; 158: 629-634.
Peripheral muscle strength and endurance
30 % muscle strength decreased in patients with COPDPeripheral muscle strength is a determinant of exercise capacity (6-MWT and VO2 max) Reduction of peripheral muscle endurance results with reduction of exercise capacityEarly muscle fatigue appears.
Symptoms
26%
43%31%
Dyspnea
Leg Fatique Dyspnea and leg fatique
Killian ve ark. ARRD 1992; 146: 935-940.
Pulmonary Rehabilitation Programs
Exercise training OxygenBreathing training Patient education NutritionPhysicosocial and stress approaches
Exercise training and peripheral muscles
Exercise training
Aerobic/endurance training
Strength/resistive training
Aerobic Exercise Training
Peak VO2 ↑Reduces exercise oxygen consumption Reduces blood lactate levels at given workloadImproves oxidative capacity of peripheral musclesImproves symptoms
Increases neuromuscular coordinationImproves quality of life Decreases using health facilitiesImproves self-esteemImproves motivation
Aerobic Exercise Training
– Aerobic Exercise Training– Lower extremity aerobic exercise
trainingTreadmill, cycling, walking, climbing stairs, swimming.
– Upper extremity exercise trainingarm ergometry
Aerobic Exercise Training
Time: 30 min/dayIntensity: – 60-90% of max HR– 50-80% of VO2max– Dyspnea (Borg Scale 4-6)Frequency: 3-5 day/weekDuration: 4-6, 6-8, 12-24 weeks
Exercise Training –NIMV
Respiratory muscle loadDecreased work of breathingImprovement of ABG Dyspnea Exercise endurance capacity
Troosters et al AJRCCM 2005; 72:19-38
Peripheral muscle training
Intensity: %80-100 of 1 max.Repetitions : 1-3 set 1-8 timesResting : 2-3 minFrequency: 4-6 day/weekImprovement: 2-10%Benefits: muscle mass, strength, bone mineral density improvements.
Kramer WJ ve ark. Med Sci Sport Exerc 2002
Peripheral muscle strength-endurance
trainingIntensity: 70-85% of 1 maxRepetitions: 3 set 8-12 timesResting : 1-2 minFrequency: 2-4 day/weekImprovement: 60-70 %Benefits : improvement in muscle mass, and strength, bone mineral density and muscle endurance
Kramer WJ ve ark. Med Sci Sport Exerc 2002
Peripheral muscle endurance training
Intensity: 30-60% of 1 maxRepetitions: 1-3 set 20-30 timesResting : 1 min Frequency: 2-4 day/weekImprovement: no strength improvementBenefits : improvement in muscle oxidative capacity and capillarization, muscle endurance and exercise capacity.
Kramer WJ ve ark. Med Sci Sport Exerc 2002
Peripheral muscle training
COPD, 8 weeks85% of 1 max. – %16- %40 strength
improvements– Submaximal
exercise capacity ↑ and
– ↑quality of life
Simpson K, Thorax 1992
To investigate the effects of heavy resistance training in the elderly males with COPD (n=18, age range 65-80 years)Cross sectional area of quadriceps asssessed by MRIİsometric isokinetic knee extension, isometric trunk strength, leg extension power, stair climbing time, normal and max gait speed on a 30 m track.RE performed twice a week for 12 weeks.Significant improvements in muscle size, knee extension strength, leg extension power, functional performance in elderly male COPD patients.
Peripheral muscle training
Aerobic training+ muscle strength trainingImproves bone mineral density
Evans WJ. Med Sci Sport Exer 1999
Applicable at homeImproves endurance capacity and quality of life Clark CJ ve ark Eur Respir J 1996
Exercise and peripheral muscle training
Strength training should be started before aerobic training– Less dyspnea– Applicable at high
intensity
Neuromuscular electrical stimulation
Exercise performancePeripheral muscle strenghtQuality of life
It was hypothesised that this novel strategy would be particularly effective in improving functional impairment and the consequent disability which characterises patients with end stage COPD.Advanced COPD patient (n=15) were randomly assigned to either a home based 6 week quadriceps femoris NMES training programme. Group 1, n=9, age: 66.6 (7.7) years FEV1=38.0 (9.6)% or a 6 week control period before receiving NMES. Group 2, n=6, age: 65.0 (5.4) FEV1=39.5 (13.3)%. Knee extensor strength and endurance, whole body exercise capacity, and health related quality of life (Chronic Respiratory Disease Questionnaire, CRDQ) were assessed.
For severely disabled COPD patients short term electricalstimulation of selected lower limb muscles involved in ambulation can improve muscle strength andendurance, whole body exercise tolerance, and breathlessness during activities of daily living.
ES
To evaluate whether ES was a beneficial tecnique in the rehabilitation programs for severely deconditioned COPD patients after acute exacerbation.17 COPD patient participated in this study (FEV1, 30+3% pred, BMI 18+2.5 kg/m2) Group 1(n=8) usual rehab (UR), Group 2(n=9) UR +ES program for 4 weeks QMS, exercise capacity, HRQoL were measured before and after rehabilitation.
Chest 2006; 129:1540-1548.
Exercise training
Illness severityPatient’s first physical activity level Motivation of the patients Self monitarization
fibre type
External intercostalLower extremity muscles
External intercostalLower extremity muscles
1.biyopsy
2. biyopsy
. 40 % MIP
. 30’ / day, 5 d/week, 5 weeks
Ramírez et al. AJRCCM 2002
Respiratory muscle training
Respiratory muscle training
Inspiratory muscle training (MIP % 40)Placebo
50
70
90
MIP
(%
pred
icte
d) **
10
15
20
time
(min
)
**
before after
30
50
70
Tip
I L
ifler
(%
) **
2000
2500
3000
t
ypeI
I fib
res (
µm2 )
**
1500
Önce Sonra
Ramírez et al. AJRCCM 2002
IMT
The long term effects of inspiratory muscle training on inspiratory muscles, exercise capacity, perceived dyspnea, quality of life , and intensity of admission to hospital in patients with COPD
Results
Impairment in peripheral muscle effects exercise capacity and quality of life Exercise training (aerobic and resistance training) improves exercise tolerance and quality of lifeAerobic and resistance training together improves peripheral muscles functional impairments physiologically.High intensity training improves aerobic capacity and muscle strength much more
Thanks