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 ● on 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 Participation Restrictions ● ○ Decreased Community Impairments ● Ambulation ○ Decreased strength ○ Gardening Decreased activity tolerance ○ Shopping ○ ○ Altered respiratory volumes ● Environmental Factors Activity Limitations ● Multiple-story home ○ ○ Decreased transfers ○ Supportive daughter lives nearby Decreased standing balance ○ Personal Factors ● ○ Decreased gait ○ Discouraged by inability to move Decreased ability to negotiate stairs ○ 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 ● Outcomes: ● Unable to tolerate any endurance training due ○ Transfers improved from contact guard to to drop in O2 saturation with any sustained supervision activity ○ Ambulation goals were removed ● Focused on resistance/strength training Stair negotiation goals removed ○ ● Performed exercises for 3 sets of 15 while O2 ○ Bilateral lower extremity strength saturation was closely monitored 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 old 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: Secondary: ● Walking Distance ● Health Related Quality of Life ● Lean Body Mass ● Activities of Daily Living ● Muscle Strength ● Dyspnea ● Exercise Capacity ● Adverse Events ● Total Mortality

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 ● Resistance training was an appropriate training and endurance training choice for patient ● Resistance training may be used as alternative ● Adherence may be more important than ● Limitations type of intervention ○ Low quality evidence ● Patient should see similar outcomes as ○ No double blinding participation in endurance training ○ High drop-out rates ○ Array of outcome measures used

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 Strength Training ● 1-hour session 3x per week ● 1-hour session 3x per week ● 12 weeks ● 12 weeks ● Brief warm-up ● Brief warm-up ● 30-35 minutes walking at rating of ● Exercises for all major muscle groups perceived dyspnea of 3-5 ● 3 x 8 at 80% 1 rep max ● 10-15 minutes upper extremity endurance ● Increased weight by 10% when 3 x 8 training with light resistance bands achieved ● Brief cooldown

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

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) Endurance Strength

Conclusion Application ● Both programs can increase physical function, ● Endurance may be slightly better, although endurance training may be more resistance training still appropriate beneficial ● Patient capabilities and preference ● Endurance training may lead to more need to be taken into account when improvement in health-related quality of life choosing intervention ● Limitations: ○ Only 11 male patients ○ No randomization ○ Time between interventions ○ Volunteer bias