Exercise in the management of breathlessness

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1 WHO Collaborating Centre for Palliative Care and Older People Exercise in the management of breathlessness Matthew Maddocks PhD Lecturer in Health Services Research NIHR Clinical Trials Fellow

2 Maddocks et al. J Palliat Med Background Breathlessness is common in advanced disease 90% chronic lung disease >50% cancer or heart failure renal / liver failure, neurological conditions, HIV/AIDS. It causes considerable distress and disability. It results in unplanned hospital attendances. Many perceive it as a challenge to treat (confidence, structured approach, knowledge of treatments etc).

3 Parshall et al. AJRCCM 2012;185: Breathlessness is (a bit) like pain Domain Sensory-perceptive Description what does your breathing feel like and how bad is it? Affective distress how distressing or unpleasant is your breathing? Symptom impact or burden how does your breathing affect your function?

4 The deconditioning spiral Treatment goal: break or slow down the spiral Requires education / reassurance around normal exertional response and recovery Maddocks & Wilcock. Lung Cancer 2012;76: Donaldson et al. Int J COPD 2012;7:

5 Detrimental effect of bed rest on muscle Changes are about 10-fold compared to the typical response in a young adult Kortbein JAMA 2007

6 Jolley & Moxham Eur Resp Rev 2009;818:66-79.

7 Pulmonary rehabilitation

8 Jolley & Moxham Eur Resp Rev 2009;818:66-79.

Current evidence for PR Overwhelming evidence supports exercise in the context of pulmonary rehabilitation (PR) CRQ dyspnoea scale 0.79 (CI 0.56 1.03), n=1283 SGRQ total score 6.

9 Current evidence for PR Overwhelming evidence supports exercise in the context of pulmonary rehabilitation (PR) CRQ dyspnoea scale 0.79 (CI ), n=1283 SGRQ total score 6.89 (CI ), n=1146 Exercise performance shuttle walk 39.8 m (CI ), n=694 6 min walk 44.0 m (CI ), n=1879 McCarthy et al. Cochrane Database Syst Rev. 2015;2:CD

10 CRQ dyspnoea domain (n=1286)

11 CRQ Mastery (n=1212)

12 PR and breathlessness Rehabilitation compared to usual care (n=41) Domain Sensory-perceptive Affective distress Symptom impact or burden Assessments Exertional breathlessness intensity ratings and quality descriptors Intensity of breathing-related anxiety during exercise; COPD / walking self-efficacy MRC dyspnoea scale; Transition Dyspnoea Index; CRQ dyspnoea scale; SRGQ activity scale; walking / cycling exercise performance Wadell et al. COPD 2013;10:425-35

13 PR and breathlessness Wadell et al. COPD 2013;10:425-35

14 Upper limb exercise

15 Jolley & Moxham Eur Resp Rev 2009;818:66-79.

16 Upper limb exercise Exercise training in COPD often focuses on lower limb training (walking, cycling) 24 studies (n= ) Improvements in: Endurance capacity (SMD=1.25; 0.16 to 2.66) Peak exercise capacity (SMD=1.27; 0.59 to 1.94) Arm muscle strength (SMD=0.46; 0.10 to 0.81) Kathiresan et al. J Thorac Dis 2010;2:

17 Arm exercise - breathlessness (intensity) During exercise WMD 0.34 (95% CI 0.78 to 0.09) During daily activity WMD 0.58 (95% CI 1.13 to 0.02)

18 Arm exercise arm fatigue (intensity) During exercise WMD 0.24 (95% CI 0.33 to 0.81) During daily activity WMD 0.55 (95% CI 1.08 to 0.01)

19 Neuromuscular electrical stimulation

20 Jolley & Moxham Eur Resp Rev 2009;818:66-79.

21 NMES in advanced disease: exercise VO 2 max during CPET improved in 2 of 3 studies. Maddocks et al. Cochrane Database of Systematic Reviews 2013;1:CD009419

22 NMES and breathlessness Reduced functional impact of breathlessness CRQ dyspnoea Maugeri Resp Failure dyspnea in daily tasks Reduced breathlessness at exercise isotime demonstrated in 2 of 3 studies corresponding increases in exercise endurance single case of increased inspiratory capacity Maddocks et al. Cochrane Database of Systematic Reviews 2013;1:CD009419

23 Take home messages A strong rationale and evidence base supports a role for exercise in breathlessness management Exercise is an exemplar for treating total breathlessness - not just symptom intensity

24 Thank

Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease

WHO Collaborating Centre for Palliative Care and Older People Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease Matthew Maddocks MCSP PhD NIHR Post-Doctoral Research