Pulmo Rehab Phase 2
-
Upload
farrukh-shahzad -
Category
Documents
-
view
220 -
download
0
Transcript of Pulmo Rehab Phase 2
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 2/65
MUHAMMAD
FARRUKH
SHAHZAD
ZYRAK
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 3/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 4/65
To provide evidence-based information on current best
practice for the practical management of patients referred for
pulmonary rehabilitation
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 5/65
• 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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 6/65
• Increase exercise tolerance in order to reduce impairment..
•
Reduce frequency and severity of symptoms.
• Improve mood and motivation.
• Reduce dependency.
• Improve quality of life.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 7/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 8/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 9/65
ELIGIBILITY CRITERIA
Exclude patients who:
• Have severe cognitive impairment.
• Have severe psychotic disturbance.
•
Have a relevant infectious disease
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 10/65
• 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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 11/65
ESSENTIAL COMPONENTS
OF A PULMO REHAB
• Patient assessment.
• Patient exercise training.
• Patient education.
• Program evaluation.
• Maintenance.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 12/65
• 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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 13/65
•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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 14/65
• 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).
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 15/65
• If the patient is still smoking, refer the patient to a
smoking cessation clinic or equivalent.
Smoking History
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 16/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 17/65
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)
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 18/65
ASSESSING EXERCISE CAPACITY
• 1. The Six-Minute Walk Test (6MWT)
• 2. The Incremental Shuttle Walk Test (ISWT)
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 19/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 20/65
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%*
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 21/65
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)
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 22/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 23/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 24/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 25/65
ENDURANCE TRAINING - LOWER LIMB
Lower limb aerobic exercises (uses large muscle mass):
Walking training for all patients.
Stationary cycling training if possible
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 26/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 27/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 28/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 29/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 30/65
ENDURANCE TRAINING - LOWER LIMB
• 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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 31/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 32/65
ENDURANCE TRAINING - LOWER LIMB
Type
• Continuous or Interval Training
• Circuit Training
• Warm-up and Cool-down
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 33/65
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 .
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 34/65
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).
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 35/65
ENDURANCE TRAINING - UPPER LIMB
• Intensity
• The intensity for upper limb endurance exercise may be
prescribed based on:
• Weight repetitions.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 36/65
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).
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 37/65
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 exercisefor five minutes; repeat).
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 38/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 39/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 40/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 41/65
STRENGTH TRAINING - LOWER LIMB
• 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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 42/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 43/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 44/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 45/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 46/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 47/65
(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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 48/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 49/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 50/65
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 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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 51/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 52/65
FLEXIBILITY AND STRETCHING
Flexibility
Flexibility Exercises
• Exercise #1
Trunk rotation
• Gently rotate the trunk side to side as far as possible.
Stretching Exercises
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 53/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 54/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 55/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 56/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 57/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 58/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 59/65
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
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 60/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 61/65
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)
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 62/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 63/65
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.
8/3/2019 Pulmo Rehab Phase 2
http://slidepdf.com/reader/full/pulmo-rehab-phase-2 64/65
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?).