COPD Rehab at Home
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COPD Rehab at Home
Exercise Program Improves Endurance and Quality of Life
Increasing evidence indicates that pulmonary rehabilitation improves dyspnea, exercise capacity and quality of life in patients with chronic obstructive pulmonary disease.
However, in large countries like Canada, individuals often live at great distances from specialized centers, making it difficult to travel to attend rehabilitation programs and contributing to a low participation level.
In light of this problem, we became interested in designing a home-based exercise pro-gram with minimal supervision to improve maximal exercise capacity, endurance capacity, walking distance, muscle strength and quality of life.
Nineteen emphysema patients being evaluated for possible lung volume reduction surgery completed the program in our study.1 We selected this group because rehabilitation is part of the pre-operative preparation of these patients. As our patients were referred from as far as 800 km from our center, we had to offer them a home program.
We evaluated patients for one or two consecutive days before and after the exercise program. We performed anthropometric measurements and pulmonary function studies. Patients underwent progressive stepwise exercise testing on a cycle ergometer to maximal capacity. They also performed an endurance test at 80 percent of the peak work rate achieved during the initial maximal exercise test (the duration of the test is recorded) and a six-minute walking test.
We measured maximal voluntary strength during dynamic contractions against a hydraulic resistance machine. Patients performed maximal effort at high velocity, and we used the higher value from two sets of measurements obtained for each muscle group: lower limbs during bilateral knee extension, shoulder girdle during a seated press and a bilateral movement combining elbow flexion and shoulder adduction.
Lastly, we assessed quality of life with the Chronic Respiratory Questionnaire, which addresses dyspnea, fatigue, emotion and mastery.
Exercise Training Program
The exercise training program included stretching, strength training and aerobic training. Training sessions began with 10 minutes of stretching each muscle group to be used during exercise.
Patients strength-trained using gravity elastic bands with three levels of resistance (usually differentiated by color) and free weights (1, 1.5 and 2 kg). They performed 10 movements for each exercise, but this number progressively increased until patients could complete 30 repetitions.
Six arm exercises included flexion and extension of elbows; flexion, extension and adduction of shoulders; and push-ups on the knees. Flexion and abduction of the hip with straight leg, contraction of the gluteus maximus, and flexion and extension of the knees comprised the five leg exercises. Patients also worked abdominal muscles by performing sit-ups and sit-ups with left and right rotations.
The patients used a portable, calibrated, magnetically braked ergocycle machine for aerobic training. They adjusted work rate (watt) using the position of the workload shift lever and pedaling speed (rpm). A digital screen displayed the rpm and the number of watts. With the system we used, the work rate varied from 0 watts to 999 watts with an accuracy of ±5 watts.
The initial training intensity was fixed at 50 percent of the initial maximal work rate achieved during the maximal exercise test for up to 45 minutes. In order to avoid injury and to improve tolerance for sub-maximal exercise such as walking, we emphasized the need for longer duration and lower intensity of training. Duration was set at 15 minutes and progressively increased by five minutes to 10 minutes as tolerated (dyspnea Borg score=4) until patients achieved a 45-minute target. Intensity was increased in 5-watt steps and up when participants could maintain the training intensity for 45 minutes.
Patients trained five times per week for 10 to 12 weeks. We supervised participants by making weekly phone calls to verify comprehension, progression of the training program and any related problems. Weekly, each patient also filled out and mailed a diary to us, reporting the intensity, duration and frequency of training.
An average of 0.5 ±0.6 exacerbations of disease per patient required treatment with systemic oral steroids and/or oral antibiotics. The main duration of training was 11 ±2 weeks. According to patients’ diaries, the training frequency was 4.9 ±0.5 and 5.1 ±0.5 sessions per week for the strength and aerobic components. Mean training intensity increased progressively while the training duration quickly stabilized at 200 minutes per week at week four. The patients completed 97 ±5 percent of the recommended sessions.
Peak work rate, peak VO2 and arterial lactate level increased respectively by 18 percent (p=0.02), 11 percent (p=0.05) and 21 percent (p=0.04) after training. Endurance time and six-minute walking distance also increased significantly. After the program, we observed 7 percent increase of strength for the pectoralis major muscle and a 6 percent (p<0.05) increase for the latissimus dorsi muscle. Lastly, each dimension of the questionnaire for quality of life showed a significant increase after training.
This program is simple to implement even in remote areas. By limiting our intervention to an initial two-hour period of teaching, one phone call a week and one postal invoice to transmit a patient journal, cost is minimal.
This program is based only on exercise without other important interventions that are included in the usual multidisciplinary programs, such as relaxation techniques, breathing exercises, coaching, nutrition counseling and patient education. Our study included very motivated individuals taking part in a lung volume reduction program in which exercise was a prerequisite to the surgery; the same results could not have been obtained with a general population of COPD patients.
Therefore, similar studies need to be conducted in larger groups of heterogeneous COPD patients who are not being proposed to receive LVRS. Research should also compare home-based exercise training to multidisciplinary programs usually available in specialized centers. Efficacy in other respiratory diseases must also be evaluated.
Dr. LeBlanc is a respirologist and teaching director and Debigaré is a PhD student at the Research Center, both at Laval Hospital in Quebec, Canada.
For a list of references, please call Jennifer Gillespie at (610) 278-1400, ext. 153, or see www.Respiratory-care-sleep-medicine.advanceweb.com.