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 the

individualized 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

PRIMARY AIMS OF PULMO REHAB

To reduce activity limitation and participation restriction of persons with chronic lung diseases. To restore patients to the highest possible level of independent functioning

 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

ELIGIBILITY CRITERIA
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
Exclude patients who: Have severe cognitive impairment.

Have severe psychotic disturbance.

Have a relevant infectious disease

Who refers patient

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).

ESSENTIAL COMPONENTS
OF A PULMO REHAB
Patient assessment.
Patient exercise training. Patient education. Program evaluation. Maintenance.

Medical History
Required to determine whether the patient should participate in the exercise sessions of a pulmonary rehabilitation program Co-morbidities include cardiac, musculoskeletal and neurological conditions.

Nutritional status.

Smoking history. Spirometry test results

 Body Mass Index (BMI) can provide valuable information regarding the patients 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).

Smoking History
If the patient is still smoking, refer the patient to a smoking cessation clinic or equivalent .

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 FEV1% pred 6MWD (m) MMRC BMI (kg.m-2)

0 65 350 0-1 >21

1 50-64 250-349 2 21

2 36-49 150-249 3

3 35 149 4

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 walking distance; 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)

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 referring doctor 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 endurance exercise 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 the average 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 titrated based 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% VO 2 peak. Therefore, patients could be encouraged to exercise at this level of dyspnoea.

ENDURANCE TRAINING - LOWER LIMB

Duration

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

If a patient is very debilitated, the duration of the initial exercise sessions can be shortened (e.g. to 10 minutes). The duration should be built up to 30 minutes during the first two weeks of the program. If a stationary cycle is available, the program can be split into 15 minutes of cycling and 15 minutes of walking.

ENDURANCE TRAINING - LOWER LIMB

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.

ENDURANCE TRAINING - LOWER LIMB

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 when prescribing 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 by rest.

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 as they breathe in and down as they breathe out .

Upper Limb Endurance Exercises (low weight and high repetition)

Exercise #1 Arm 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. 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).

Exercise #2 Arms Together

ENDURANCE TRAINING - UPPER LIMB

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).

ENDURANCE TRAINING - UPPER LIMB

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 exercise for five minutes; repeat).

ENDURANCE TRAINING - UPPER LIMB

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:

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 (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. Your instructor can help you with this exercise. Progression:
o o o

Exercise #3 Climbing stairs

Increase the number of steps. Increase the height of the step (or walk up two steps at a time). Carry a weight on your back.

STRENGTH TRAINING - LOWER LIMB

Intensity

The appropriate intensity for lower limb strengthening exercises can be prescribed based on: A. One repetition maximum (1RM)* i.e the maximum weight that can be lifted once by a particular muscle group
B. Ten repetition maximum (10 RM) i.e the maximum weight that can be lifted 10 times by a particular muscle group

STRENGTH TRAINING - LOWER LIMB

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

STRENGTH TRAINING - LOWER LIMB

Duration

The duration of a lower limb strengthening training

session will depend on the time it takes to complete the

appropriate number of sets .

STRENGTH TRAINING - LOWER LIMB

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 accessory muscles of inspiration and muscle groups used in everyday functional tasks. These muscles include:

Pectoralis major Latissimus doris Trapezius Biceps

Triceps

STRENGTH TRAINING - UPPER LIMB

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 lowering the weight down. Repeat the exercise with your other arm. 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. 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

Exercise #2 Biceps

Exercise #3 Arm exercise

STRENGTH TRAINING - UPPER LIMB

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 REPETITION MAXIMUM

The maximum weight that can be lifted once by a particular muscle group 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 patients 1 RM weight.

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

Aim to increase the weight up to 80% of the patients 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 .

STRENGTH TRAINING - UPPER LIMB

Protocol

Perform one set (10 repetitions) of a particular exercise, then rest. 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 by 5% or between 0.5 kg to 5 kg depending on which muscle group is being trained. Ask the patient to move their arms up as they breathe in, and down as they breathe out. These exercises can be performed in the sitting position, with the back supported.

STRENGTH TRAINING - UPPER LIMB

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 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.
Sit on the bed. Lean forward and slowly straighten your knee until you feel a stretch at the back of your thigh.

Exercise #3 Hamstring stretch

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 device or target-flow resistive device at loads equal to or greater than 30% of an individuals 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 healthrelated 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 healthrelated 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 completion of 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.) 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 the pulmonary rehabilitation program

Options for maintenance exercise programs:

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 difficulty walking 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

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 the duration 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. 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.

Cycling Program

CONTD
Arm Exercises

Start with low weigh

Start with 1 set of 3 lower limb and 3 upper limb strength training exercise. See examples in the strengthening exercises tables. The flexibility and balance exercises and stretches can be included in a group circuit class. t, high repetition arm activities (total duration 5 minutes)

Strength training

Circuit

PATIENT EDUCATION
Importance of Education

Helping patients become active participants in their health care.

Helping patients and their families gain a better understanding 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 patients quality of life. Increase the patients 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

patients exercise capacity and quality of life?).

Patient feedback (i.e. what did the patient think of the program?).