The Rise of Rehabilitative Therapy for COPD

1. The Rise of Rehabilitative Therapy for COPD Richard Casaburi, Ph.D.,M.D. Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center Torrance, California

2. Established Therapies for COPD • Smoking Cessation • Bronchodilators • Inhaled Steroids • Lung Volume Reduction Surgery • Lung Transplantation • Supplemental Oxygen • Pulmonary Rehabilitation

3. Components of Pulmonary Rehabilitation • Candidate assessment • Education • Psychologic support • Optimization of medications • Exercise training • Chest physical therapy • Controlled breathing techniques • Nutritional therapy • Continuing care program

4. Components of Pulmonary Rehabilitation • Candidate assessment • Education • Psychologic support • Optimization of medications • Exercise training • Chest physical therapy • Controlled breathing techniques • Nutritional therapy • Continuing care program Delivered by a Multidisciplinary Team

5. Pulmonary Rehabilitationin 2006 The standard of care for COPD patients debilitated by their disease

6. The Dark Ages of Pulmonary Rehabilitation- The 1980s - Exercise programs have only a psychological benefit: Unrealistic fears of exercise are reduced

7. The Dark Ages of Pulmonary Rehabilitation- The 1980s - Exercise programs have only a psychological benefit: Unrealistic fears of exercise are reduced A “touchy-feely” sort of therapy

8. Futility of Exercise Training in Pulmonary Rehabilitation • Exercise tolerance is limited by pulmonary factors • Exercise training doesn’t improve pulmonary function • Critical training intensity can’t be exceeded by most patients

9. Exercise Tolerance is Limited by Pulmonary DefectsExcessive Ventilatory Requirement and Limited Ventilatory Capacity Normal Ventilation COPD COPD Normal Level of exercise

10. Futility of Exercise Training in Pulmonary Rehabilitation • Exercise tolerance is limited by pulmonary factors • Exercise training doesn’t improve pulmonary function • Exercising muscle function can’t be improved because critical training intensity can’t be exceeded

11. The Long March • Adoption of appropriate design principles for training programs • Appreciation that the muscles of ambulation function poorly • Demonstration of physiologic training effects in the muscles of ambulation • Demonstration that improving muscle function relieves ventilatory limitation • Demonstration that exercise tolerance is not only limited by pulmonary factors

12. Characteristics of an Effective Exercise Training Program • Frequency • Duration • Intensity

13. Characteristics of an Effective Exercise Training Program • Frequency • sessions held 3-5 times per week • Duration • sessions of 30-60 minutes length • program 6-8 weeks long

14. Characteristics of an Effective Exercise Training Program • Critical Training Intensity • there is an intensity of training below which no physiologic training effect will be obtained

15. The Long March • Adoption of appropriate design principles for training programs • Appreciation that the muscles of ambulation function poorly • Demonstration of physiologic training effects in the muscles of ambulation • Demonstration that improving muscle function relieves ventilatory limitation • Demonstration that exercise tolerance is not only limited by pulmonary factors

16. Skeletal Muscle Dysfunction in COPD-Evidence- • Early onset of lactic acidosis • Easy fatiguability • Slow oxygen uptake kinetics • Exercise intolerance after lung transplantation

17. Lactate Increase during Exercise in Normal and COPD Subjects 10 9 Healthy COPD 8 7 6 5 Lactic acid (mmol/L) 4 3 2 1 0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Maltais, 1996 VO2 (L/min)

18. Skeletal Muscle Dysfunction in COPD-Evidence- • Early onset of lactic acidosis • Easy fatiguability • Slow oxygen uptake kinetics • Exercise intolerance after lung transplantation

19. Effect of Pulmonary Rehabilitation on Quadriceps Fatiguability in COPD Patients Mador, 2001

20. Skeletal Muscle Dysfunction in COPD-Evidence- • Early onset of lactic acidosis • Easy fatiguability • Slow oxygen uptake kinetics • Exercise intolerance after lung transplantation

21. Kinetics of Oxygen Uptake following Exercise Onset Nery, 1982

22. Skeletal Muscle Dysfunction in COPD-Evidence- • Early onset of lactic acidosis • Easy fatiguability • Slow oxygen uptake kinetics • Exercise intolerance after lung transplantation

23. The Long March • Adoption of appropriate design principles for training programs • Appreciation that the muscles of ambulation function poorly • Demonstration of physiologic training effects in the muscles of ambulation • Demonstration that improving muscle function relieves ventilatory limitation • Demonstration that exercise tolerance is not only limited by pulmonary factors

24. Evidence for a Physiologic Training Effect in COPD • Decreased lactic acidosis for a given level of exercise • Increased levels of aerobic enzymes in muscles undergoing training

25. Effect of Endurance Exercise Training on Blood Lactate During Incremental Exercise in a COPD Patient Casaburi , 1991

26. Evidence for a Physiologic Training Effect in COPD • Decreased lactic acidosis for a given level of exercise • Increased levels of aerobic enzymes in muscles undergoing training

27. Effect of Endurance Training on Aerobic Enzyme Concentrations in Vastus Lateralis Muscle of COPD Patients Maltais et al., 1996

28. The Long March • Adoption of appropriate design principles for training programs • Appreciation that the muscles of ambulation function poorly • Demonstration of physiologic training effects in the muscles of ambulation • Demonstration that improving muscle function relieves ventilatory limitation • Demonstration that exercise tolerance is not only limited by pulmonary factors

29. Changes in Responses to Identical Constant Work Rate Exercise Tasks Resulting from Exercise Training in COPD Patients Casaburi, et al., ARRD, 1991

30. VO2Post VEPost VO2Pre VEPre Work rate Pre 50 40 Work rate Post 30 20 10 0 0 5 10 15 20 25 30 Time (min) Effect of Exercise Training on Oxygen Uptake and Ventilation During Constant-Work Rate Exercise in a Patient with Severe COPD 120 100 1.0 80 60 0.5 40 20 0 0 0 5 10 15 20 25 30 Time (min) Porszasz et al. Chest, 128:2025, 2005

31. The Long March • Adoption of appropriate design principles for training programs • Appreciation that the muscles of ambulation function poorly • Demonstration of physiologic training effects in the muscles of ambulation • Demonstration that improving muscle function relieves ventilatory limitation • Demonstration that exercise tolerance is not only limited by pulmonary factors

32. Exercise Symptom Limitation in COPD Subjectively, a substantial fraction of COPD patients report that leg fatigue, rather than dyspnea is their limiting symptom Killian et al., 1991

33. Limitation to Exercise in COPD:Role of the Exercising Muscles Am J Resp Crit Care Med 168:425,2003

34. Limitation to Exercise in COPD:Role of the Exercising Muscles • Half of COPD patients exercising maximally were found to have evidence of muscle fatigue • Improving lung function (with a bronchodilator) in these patients did not improve exercise tolerance

35. Limitation to Exercise in COPD:Role of the Exercising Muscles • Half of COPD patients exercising maximally were found to have evidence of muscle fatigue • Improving lung function (with a bronchodilator) in these patients did not improve exercise tolerance In these patients, the exercising muscles, not the lungs, limit exercise

36. Rehabilitative Therapy for COPD The Long March Toward Acceptance: Completed The Next Goal: Perfecting Exercise Training Strategies

37. Strategies to Improve the Effectiveness of Pulmonary Rehabilitative Programs in COPD • Bronchodilators • Anabolic drugs • Oxygen breathing • Helium breathing • Pressure support ventilation • Interval training • Electrical muscle stimulation

38. Strategies to Improve the Effectiveness of Pulmonary Rehabilitative Programs in COPD • Bronchodilators • Anabolic drugs  • Oxygen breathing • Helium breathing • Pressure support ventilation • Interval training • Electrical muscle stimulation

39. 42% 32% 16% Effect of Tiotropium on the Improvement in Exercise Tolerance Resulting from Rehabilitation Study drug * * Rehabilitation *P<0.05

40. Strategies to Improve the Effectiveness of Pulmonary Rehabilitative Programs in COPD • Bronchodilators • Anabolic drugs • Oxygen breathing • Helium breathing • Pressure support ventilation • Interval training • Electrical muscle stimulation

41. Changes in Leg Strengthwith 10 Weeks of Testosterone and/or Strength Training in COPD MenBilateral Leg Press 1RM AJRCCM, 2004

42. Strategies to Improve the Effectiveness of Pulmonary Rehabilitative Programs in COPD • Bronchodilators • Anabolic drugs  • Oxygen breathing  • Helium breathing • Pressure support ventilation • Interval training • Electrical muscle stimulation

44. Duration of Constant Work Rate Exercise Tests * * * * * * Before After Before After

45. Increase in Constant Work Rate Test Endurance after Exercise Training *

46. Increase in Constant Work Rate Test Endurance after Exercise Training * 38% greater gain in endurance

47. Strategies to Maximize Exercise Intensity in COPD • Bronchodilators • Anabolic drugs • Oxygen breathing • Helium breathing • Pressure support ventilation • Interval training • Electrical muscle stimulation

48. Rehabilitative Therapy for COPD- Status in 2006 - • Scientific Basis Established! • Training Strategies Perfected! • Benefits Acknowledged!

49. Rehabilitative Therapy for COPD- Status in 2006 - • Scientific Basis Established! • Training Strategies Perfected! • Benefits Acknowledged! ATS/ERS Guidelines for Pulmonary Rehabilitation – in press Pulmonary Rehabilitation State of the Art – AJRCCM, 2005

50. Benefits of Pulmonary Rehabilitation • Increased exercise tolerance • Decreased dyspnea • Improved health-related quality of life