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SKELETAL MUSCLE TRAINING, PERIPHERAL AND RESPIRATORY MUSCLES Prof. Dr. Sema SAVCI Hacettepe University Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation.
Chronic Respiratory Diseases • Dyspnea • Decreased exercise tolerance • Decreased quality of life
Chronic Respiratory Diseases • Ventilatory limitation • Impaired gas changing • Cardiac problems • Symptoms seen with effort • Peripheral muscle weakness
Pathology/ Inflammation/ Hypoxemia Medicines Inactivity/ Deconditioning CO2 CO2 muscle Ventilation circulaion O2 O2 Oxygen transport Wasserman, Principles of Exercise Testing and Interpretation 1994
Muscle atrophy Muscle weakness Fatigue 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 Peripheral muscle adaptations
26% Prevalence of muscle atrophy Normal BMI F: FFM 14.62 kg/m2 M: FFM 17.05 kg/m2 60 50 40 30 ratio (%) woman 20 man 10 0 0 1 2 3 & 4 GOLD stage Vestbo ve ark. AJRCCM 2006;173:79-83.
Muscle Weakness in COPD COPD Strength (kg) Controls * * 100 * 80 60 40 20 0 Pectoralis Latissimus Quadriceps major dorsi Bernard ve ark. AJRCCM 1998; 158: 629-634.
Peripheral muscle strength and endurance • 30 % muscle strength decreased in patients with COPD • Peripheral muscle strength is a determinant of exercise capacity (6-MWT and VO2 max) • Reduction of peripheral muscle endurance results with reduction of exercise capacity • Early muscle fatigue appears.
Symptoms 43% 31% Leg Fatique Dyspnea and leg fatique Dyspnea 26% Killian ve ark. ARRD 1992; 146: 935-940.
Pulmonary Rehabilitation Programs • Exercise training • Oxygen • Breathing training • Patient education • Nutrition • Physicosocial and stress approaches
Peak VO2 ↑ Reduces exercise oxygen consumption Reduces blood lactate levels at given workload Improves oxidative capacity of peripheral muscles Improves symptoms Increases neuromuscular coordination Improves quality of life Decreases using health facilities Improves self-esteem Improves motivation Aerobic Exercise Training
Aerobic Exercise Training • Aerobic Exercise Training • Lower extremity aerobic exercise training Treadmill, cycling, walking, climbing stairs, swimming. • Upper extremity exercise training arm ergometry
Aerobic Exercise Training • Time: 30 min/day • Intensity: • 60-90% of max HR • 50-80% of VO2max • Dyspnea (Borg Scale 4-6) • Frequency: 3-5 day/week • Duration: 4-6, 6-8, 12-24 weeks
Exercise Training –NIMV • Respiratory muscle load • Decreased work of breathing • Improvement 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 times • Resting : 2-3 min • Frequency: 4-6 day/week • Improvement: 2-10% • Benefits: muscle mass, strength, bone mineral density improvements. Kramer WJve ark. Med Sci Sport Exerc 2002
Peripheral muscle strength-endurance training • Intensity: 70-85% of 1 max • Repetitions: 3 set 8-12 times • Resting : 1-2 min • Frequency: 2-4 day/week • Improvement: 60-70 % • Benefits : improvement in muscle mass, and strength, bone mineral density and muscle endurance Kramer WJve ark. Med Sci Sport Exerc 2002
Peripheral muscle endurance training • Intensity: 30-60% of 1 max • Repetitions: 1-3 set 20-30 times • Resting : 1 min • Frequency: 2-4 day/week • Improvement: no strength improvement • Benefits :improvement in muscle oxidative capacity and capillarization, muscle endurance and exercise capacity. Kramer WJve ark. Med Sci Sport Exerc 2002
Peripheral muscle training • COPD, 8 weeks • 85% 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 MRI • İsometric 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 training • Improves bone mineral density Evans WJ. Med Sci Sport Exer 1999 • Applicable at home • Improves 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 performance • Peripheral muscle strenght • Quality of life
It was hypothesised that this novel strategy would beparticularly effective in improving functional impairment and the consequent disability which characterisespatients with end stage COPD. • Advanced COPD patient (n=15) were randomly assigned to either a homebased 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 relatedquality of life (Chronic Respiratory Disease Questionnaire, CRDQ) were assessed.
For severely disabled COPD patients short term electrical stimulation of selected lower limb muscles involved in ambulation can improve muscle strength and endurance, 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 severity • Patient’s first physical activity level • Motivation of the patients • Self monitarization
Respiratory muscle training 1.biyopsy 2. biyopsy . 40 % MIP . 30’ / day, 5 d/week, 5 weeks External intercostal Lower extremity muscles External intercostal Lower extremity muscles fibre type Ramírez et al. AJRCCM 2002
* * 90 20 MIP (%predicted) time (min) 70 15 50 10 * 3000 * 2500 70 typeII fibres (µm2) 2000 50 Tip I Lifler (%) 1500 30 Sonra Önce after before Inspiratory muscle training (MIP % 40) Placebo Ramírez et al. AJRCCM 2002 Respiratory muscle training
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 life • Aerobic and resistance training together improves peripheral muscles functional impairments physiologically. • High intensity training improves aerobic capacity and muscle strength much more