Resistance Training as an Intervention to Increase Activity - - PowerPoint PPT Presentation

Resistance Training as an Intervention to Increase Activity Tolerance in Patients With COPD

Seth Nooe

Chronic Obstructive Pulmonary Disease (Devine, 2008)

• 4th leading cause of death in United States
• Group of clinical syndromes that share common

feature of limited expiratory airflow

• Poorly reversible
• Physical rehabilitation is traditionally focused
• n endurance exercise to increase work and

exercise capacity

Patient Details

• 89 y.o. African American female
• Lives alone in split level house
• Independent at baseline and does not use any

assistive device

• Daughter noticed patient was short of breath

with cyanotic hands

• Admitted to hospital with O2 saturation in the

50’s

• Admitted to skilled nursing facility with

COPD diagnosis

Patient Details Cont...

• Past medical history:

○ COPD requiring 8 liters of O2 at rest and 10 liters of O2 with activity ○ Glaucoma ○ Bilateral hearing loss ○ Hypertension ○ Chronic Kidney Disease

Initial Examination

• Pain: 0/10
• Passive/Active Range of Motion: Bilateral lower extremities within functional

limits

• Lower extremity strength: Bilateral lower extremities 3+/5
• Oxygen saturation at rest: 96%
• Bed Mobility: Independent
• Transfers: Contact Guard for sit-to-stand and stand-pivot transfer, O2

saturation dropped to 76%

• Gait: Dependent
• Stairs: Dependent

ICF Model

Evaluative Findings

• Impairments

○ Decreased strength ○ Decreased activity tolerance ○ Altered respiratory volumes

• Activity Limitations

○ Decreased transfers ○ Decreased standing balance ○ Decreased gait ○ Decreased ability to negotiate stairs

• Participation Restrictions

○ Decreased Community Ambulation ○ Gardening ○ Shopping

• Environmental Factors

○ Multiple-story home ○ Supportive daughter lives nearby

• Personal Factors

○ Discouraged by inability to move ○ Motivated to return home

PT Diagnosis:

Patient presents with impairments consistent with chronic obstructive pulmonary disease with decreased expiratory airflow and difficulty maintaining oxygen saturation leading to decreased strength, activity tolerance, ability to perform transfers, ambulation in household or community, negotiation of stairs, and ability to work in garden or go shopping.

Prognosis:

Fair prognosis due to advanced stage of condition and extremely low activity tolerance. Patient education essential and discharge home with support from daughter anticipated

Treatment Goals

• Patient will…

○ Perform functional transfers with supervision and O2 saturation >90% within 2 weeks ○ Ambulate 25 feet without an assistive device with contact guard assist and O2 saturation >90% within 2 weeks ○ Perform functional transfers independently with O2 saturation >90% within 4 weeks ○ Ambulate 75 feet without an assistive device independently with 02 saturation >90% within 4 weeks ○ Ascend/descend 6 stairs with supervision and O2 saturation >90% within 4 weeks

Treatment Sessions

• Unable to tolerate any endurance training due

to drop in O2 saturation with any sustained activity

• Focused on resistance/strength training
• Performed exercises for 3 sets of 15 while O2

saturation was closely monitored

• Outcomes:

○ Transfers improved from contact guard to supervision ○ Ambulation goals were removed ○ Stair negotiation goals removed ○ Bilateral lower extremity strength increased from 3+/5 to 4+/5

Purpose: To determine if resistance training as a treatment approach was appropriate for our patient Question: Is resistance training an effective alternate intervention compared to endurance training to increase activity tolerance in an 89-year

• ld female with COPD?

Article 1

A Systematic Review of Resistance Training Versus Endurance Training in COPD

Iepsen et al.

Background

• Journal of Cardiopulmonary Rehabilitation

and Prevention

• Impact Factor: 1.568
• Published in 2015
• Sought to formulate evidence-based

recommendations on the use of resistance training as part of pulmonary rehabilitation for patients with COPD

Methods

• Articles comparing effect resistance training to endurance training
• Resistance training broadly defined
• Endurance training of moderate- to high-intensity continuous walking or cycle ergometer
• 8 primary randomized control trials with 328 randomized participants
• Quality of evidence and risk of bias assessed

Outcome Measures

Primary:

• Health Related Quality of Life
• Activities of Daily Living
• Dyspnea
• Adverse Events
• Total Mortality

Secondary:

• Walking Distance
• Lean Body Mass
• Muscle Strength
• Exercise Capacity

Results

• Outpatient setting (5 studies)
• Admission to rehabilitation center (2 studies)
• Home-based (1 study)
• Program durations ranged from 3-12 weeks
• Program frequencies ranged from 2-3 sessions/week
• Resistance training - machines, free weights, bodyweight, progressively increased

workload

• Endurance training - Treadmill, cycle ergometer, combination, differing intensity levels

Results - Primary Outcomes

• Health Related Quality of Life - 3 studies (279 patients) used St. George’s Respiratory

Questionnaire, found no significant difference

• Activities of Daily Living: - 3 studies (107 patients) using different scales found no significant

difference

• Dyspnea - None of the studies included dyspnea
• Adverse Events - 2 studies included and reported that none occurred
• Total Mortality - 1 study with 1-year follow-up reported 2 deaths in resistance training group

and 1 death in endurance training group

Results - Secondary Outcomes

• Walking Distance - 6 studies (250 patients) found no significant difference
• Muscle Strength - 4 studies (121 patients) using pooled leg press and leg extension test

results found statistically nonsignificant trend favoring resistance training

• Exercise Capacity - 5 studies (167 participants) using maximal oxygen uptake found no

significant difference

• Lean Body Mass - Not reported

Conclusion Application

• No significant differences between resistance

training and endurance training

• Resistance training may be used as alternative
• Limitations

○ Low quality evidence ○ No double blinding ○ High drop-out rates ○ Array of outcome measures used

• Resistance training was an appropriate

choice for patient

• Adherence may be more important than

type of intervention

• Patient should see similar outcomes as

participation in endurance training

Article 2

Comparison of Effects of Endurance and Strength Training Programs in Patients with COPD

Berry et al.

Background

• COPD: Journal of Chronic Obstructive

Pulmonary Disease

• Impact factor: 2.576
• Published in 2018
• Sought to compare changes in physical

function and health related quality of life in a group of patients that completed an endurance training program and later completed a strength training program

Methods

• Patients were part of previous 3-month center-based endurance training trial
• 11 male patients volunteered for 3-month strength training trial 5 years later
• Inclusion criteria:

○ Expiratory airflow limitation (FEV1/FVC<70%) ○ Reported dyspnea during daily activities

• Exclusion Criteria

○ Severe cardiovascular or peripheral vascular disease ○ Active treatment for cancer ○ Uncontrolled hypertension or diabetes

Endurance Training

• 1-hour session 3x per week
• 12 weeks
• Brief warm-up
• 30-35 minutes walking at rating of

perceived dyspnea of 3-5

• 10-15 minutes upper extremity endurance

training with light resistance bands

• Brief cooldown

Strength Training

• 1-hour session 3x per week
• 12 weeks
• Brief warm-up
• Exercises for all major muscle groups
• 3 x 8 at 80% 1 rep max
• Increased weight by 10% when 3 x 8

achieved

Outcome Measures

• Physical Function

○ 6-minute walk test ○ 5 times sit-to-stand ○ Self-reported physical function (physical function scale of SF-36)

• Health Related Quality of Life

○ Generic Instrument - SF-36 Mental Component ○ Disease specific instrument - Chronic Respiratory Disease Questionnaire

Results

Endurance Strength Black = Baseline Grey = 3-month follow-up

• No significant

difference in improvement when comparing interventions (p = 0.473)

Endurance Strength

• No significant

difference in improvement when comparing interventions (p = 0.238)

Endurance Strength

• No significant

difference in improvement when comparing interventions (p = 0.223)

Conclusion Application

• Both programs can increase physical function,

although endurance training may be more beneficial

• Endurance training may lead to more

improvement in health-related quality of life

• Limitations:

○ Only 11 male patients ○ No randomization ○ Time between interventions ○ Volunteer bias

• Endurance may be slightly better,

resistance training still appropriate

• Patient capabilities and preference

need to be taken into account when choosing intervention

A Practical Prescription

Practical recommendations for exercise training in patients with COPD.

• Gloeckl et al.
• Journal: European Respiratory Review
• June 2013

Looking Back

Q: Is resistance training an effective alternate intervention compared to endurance training to increase activity tolerance in an 89-year old female with COPD? A: Given patient characteristics and inability to perform any sustained endurance

exercise due to drops in O2 saturation and dyspnea, resistance training may be an appropriate alternative. Resistance training may offer similar beneficial effects as endurance training in terms of physical function and health related quality of life.

Future Research

• Further research on best

protocol/exercise selection

• Studies with larger number of subjects
• Studies for patients with differing

severity levels

• Other forms of exercise

References

• Berry MJ, Sheilds KL, Adair NE. Comparison of Effects of Endurance and Strength Training Programs in

Patients with COPD. COPD. 2018;15(2):192–199.

• Devine JF. Chronic obstructive pulmonary disease: an overview. Am Health Drug Benefits.

2008;1:34–42.

• Gloeckl R., Marinov B., Pitta F. Practical recommendations for exercise training in patients with COPD.
• Eur. Respir. Rev. 2013;22:178–186.
• Iepsen UW, Jørgensen KJ, Ringbaek T, Hansen H, Skrubbeltrang C, Lange P. A systematic review of

resistance training versus endurance training in COPD. Journal of cardiopulmonary rehabilitation and

• prevention. 2015;35(3):163–172.

Questions?

***Not my patient