The Collaborative Role of Physical Therapy in Providing Comprehensive Care for the Pulmonary Patient

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1 The Collaborative Role of Physical Therapy in Providing Comprehensive Care for the Pulmonary Patient Marci Gerken, PT, MPT The Ohio State University Wexner Medical Center OSU Outpatient Rehab February 26, 2013

2 COPD COPD is a systemic disease that has both pulmonary and non-pulmonary features (1) Non-pulmonary features that physical therapists can address during treatment include: Skeletal muscle dysfunction Osteoporosis

3 Skeletal Muscle Dysfunction in COPD Disuse and inactivity contribute to skeletal muscle dysfunction (1) Other systemic factors include systemic inflammation, malnutrition, corticosteroid use, hypoxemia, aging, and smoking (1)

4 Decreased Muscle Strength Research has shown that quadriceps femoris muscle strength is 20-30% lower in patients with moderate to severe COPD when compared to control subjects (1,2,3,4) Decreased muscle strength in patients with moderate COPD can contribute to poor exercise performance, increased shortness of breath, and worsening quality of life (1,2,5)

5 Decreased Muscle Strength Physical inactivity during hospitalization for acute exacerbations of COPD results in a decrease in quadriceps strength (6,7) Exercise during or shortly after acute exacerbations results in significant improvements in quadriceps strength (6,8,9)

6 Decreased Muscle Endurance Research has shown that limb muscle endurance is decreased by about 30% in patients with moderate COPD (1,10,11) Allaire and colleagues concluded that this decrease in muscle endurance is related to the mitochondria s reduced oxidative capacity leading to the development of oxidative stress in the muscle (1,12)

7 Muscle Fiber Atrophy Research has shown that limb muscles in patients with COPD develop significant reductions in mass and cross-sectional areas (1,13,14) Research by Mador and colleagues suggests that limb muscles of patients with COPD fatigue more than healthy subjects (1,15)

8 Muscle Fiber Type Shift In patients with severe COPD, there is a reduction in the proportion of type I (slow-twitch) muscle fibers and a shift towards type II (fast-twitch) muscle fibers (1) Type II muscle fibers are more prone to fatigue so a shift towards type II muscle fibers may factor into increased leg muscle fatigue and decreased endurance (1)

9 Non-Pharmacological Treatment for Muscle Dysfunction in COPD Exercise training reverses some of the underlying skeletal muscle abnormalities found with COPD (6) Exercise training significantly improves quadriceps strength, endurance, and fatigability (6,16,17,18)

10 Non-Pharmacological Treatment for Muscle Dysfunction in COPD Exercise training, in the form of pulmonary rehabilitation (PR), has emerged as the most effective non-pharmacological intervention in improving exercise capacity, dyspnea, and health status in COPD patients, as evidenced by numerous randomized controlled trials and meta-analyses. Given that PR does not directly improve lung mechanics or gas exchange, it is likely that the main area of improvement with exercise lies in the skeletal muscle. (6)

11 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Role #1: Evaluating and treating patients with orthopedic conditions that are limiting the pulmonary patient s participation in pulmonary rehab Using modalities (ultrasound, electrical stimulation, iontophoresis, hot/cold packs, aquatic therapy) to reduce pain Using manual therapy techniques to decrease muscle guarding and increase joint mobility

12 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Providing patients with stretches to address decreased flexibility of various muscle groups Providing patients with strengthening exercises to address isolated areas of muscle weakness Educating patients on proper posture and body mechanics to reduce the risk of aggravating orthopedic conditions

13 Case Study #1 70 y.o. male with c/o LBP and right LE pain PMH consisting of idiopathic pulmonary fibrosis, abdominal aortic aneurysm, DM, HTN, and inguinal hernia repair Pain limiting patient s ability to fully participate in pulmonary rehab exercise program Limited with walking on treadmill and elliptical Patient s goals: 1) be able to fully participate in pulmonary rehab, 2) be able to complete 6 minute walk test when returning to Cleveland Clinic for 6 month re-check, 3) increase standing and walking tolerance for everyday activities

14 Case Study #1 Patient s symptoms consistent with lumbar spinal stenosis Manual lumbar traction to reduce right LE pain and electrical stimulation/moist heat to reduce LBP Flexion based stretching exercises and core stabilization/hip strengthening exercises Patient education on proper posture/body mechanics

15 Case Study #2 58 y.o. female with knee OA Knee pain limiting patient s ability to fully participate in pulmonary rehab exercise program Physical therapy intervention consisting of aquatic therapy to decrease pain and improve patient s tolerance with pulmonary rehab exercise sessions Gain patient independence with aquatic therapy exercises for patient to continue with at heated community pool after discharge from physical therapy

16 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Role #2: Recommending appropriate modifications to the pulmonary patient s exercises in pulmonary rehab to avoid aggravating orthopedic conditions

17 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Role #3: Making recommendations for assistive devices and medical equipment when appropriate Examples: Rollator walker Wheelchair

18 Case Study #3 82 y.o. male with COPD with prescription for a scooter Evaluated by OSU s Assistive Technology Department s Wheelchair Seating Clinic Patient evaluated for power wheelchair with: Joystick control to put patient in a more upright position Tilt control and better seat cushion options Portable oxygen unit holder Allowed for increased maneuverability in tighter spaces to promote increased independence with everyday activities

19 Osteoporosis Patients with COPD have an increased risk for osteoporosis and fractures (19)

20 Osteoporosis Decreased bone mineral density and increased risk of fracture is associated with current or past tobacco smoking, inactivity, and weight loss in patients with COPD (19,20) Patients with COPD often are deficient in calcium and vitamin D nutritional status (19)

21 Osteoporosis Treatment with oral glucocorticosteroids is also a risk factor (19) Less negative effects of glucocorticosteroids are found with sporadic vs. continuous use and with continuous lower doses vs. frequent higher doses (19, 20) Oral glucocorticosteroids can cause rapid bone loss within the first few months of treatment and then a 2-5% bone loss per year with chronic use (19, 21) High doses of inhaled corticosteroids seem to increase bone loss, but it is difficult to determine the extent of the effect of the inhaled corticosteroids due to other risk factors, previous and/or current oral glucocorticosteroid use, and severity of the COPD (19, 20)

$Osteoporosis The more severe the COPD, the increase the risk for osteoporosis and fracture (19, 20, 22, 23) Hip and vertebral fractures can impair overall mobility Vertebral$

22 Osteoporosis The more severe the COPD, the increase the risk for osteoporosis and fracture (19, 20, 22, 23) Hip and vertebral fractures can impair overall mobility Vertebral fractures reduce lung function and decrease the forced vital capacity, resulting in increased operative risk in COPD patients with osteoporotic hip fractures (19, 20, 22, 24)

23 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Role #4: Providing osteoporosis screenings for LVRS patients Completing a 20 question questionnaire of risk factors for osteoporosis Recommending the need for a DXA scan as appropriate

24 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient It is suggested that men with 3 minor criteria of: BMI < 21 kg/m², current smoker, alcohol use >3 drinks/day, age >65 years, history of hip fracture in parent, history of rib fracture, inactivity, FEVı <50% predicted OR 1 major criteria of: systemic corticosteroids (3 months/year), major fragility fracture (spine-hip) have a DXA scan due to increased risk for osteoporosis (25)

25 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Role #5: Reducing fall risk in patients with COPD

26 Fall Risk in Patients with COPD Research suggests that older adults with COPD demonstrate balance deficits that may be associated with an increased risk in falls (26, 27) Balance training and fall prevention is not a requirement of Pulmonary Rehabilitation (26, 28)

27 Fall Risk in Patients with COPD A study by Beauchamp et al. assessed patients balance before and after a 6 week inpatient pulmonary rehab program The program consisted of: supervised endurance exercise training 4-5 days/week, LE/UE strength training 3 days/week, breathing exercises daily, and self-management education (26)

28 Fall Risk in Patients with COPD Results of study: Minor improvements in results of standard clinical tests of balance (26) No significant improvement in balance confidence (26) The incorporation of specific balance training exercises and fall prevention strategies during pulmonary rehabilitation needs to be reviewed (26)

29 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Assessing patients for history of falls Assessing patients for balance deficits and fall risk TUG: > 20 seconds indicates increased fall risk 40 Gait: < 10 seconds indicates safe community ambulation speed Berg Balance Test: < 45/56 indicates increased fall risk Tinetti Assessment Tool: <19 indicates high fall risk, indicates greater fall risk Dynamic Gait Index: < 17/24 indicates increased fall risk

30 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Addressing any balance deficits with balance training Addressing any abnormal gait patterns to reduce the risk of falling Educating patients on fall prevention strategies

31 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Role #6: Educating the pulmonary patients on osteoporosis Provide general overview of osteoporosis Statistics of osteoporosis and osteoporosisrelated fractures Risk factors for osteoporosis DXA scans to evaluate for osteoporosis Modifiable risk factors that patients can address to promote improved bone health

32 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Educating patients on home exercise program to: Improve flexibility to promote improved posture Improve strength of core muscles which stabilize the spine and provide the foundation for upper and lower extremity movements

33 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Educating patients in proper body mechanics, lifting techniques, joint protection of the spine, and exercise modifications

34 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Educating patients on modifiable risk factors they can control Nutrition Avoiding deconditioning by performing regular exercise Posture training Balance and coordination training Fall prevention strategies Maintaining a healthy lifestyle

35 The Role of PT in Providing Comprehensive Care for the Pulmonary Patient Encouraging patients to be advocates for their health and to address any concerns with their primary care physicians

36 References 1) Kim H, Mofarrahi M, Hussain S. Skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease. International Journal of COPD. 2008;3(4): ) Gosselink R, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med. 1996; 153: ) Bernard S, LeBlanc P, Whittom F, et al. Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;158: ) Franssen FM, Broekhuizen R, Janssen PP, et al. Limb muscle dysfunction in COPD: effects of muscle wasting and exercise training. Med Sci Sports Exerc. 2005;37:2 9. 5) Mostert R, Goris A, Weling-Scheepers C, et al. Tissue depletion and health related quality of life in patients with chronic obstructive pulmonary disease. Respir Med. 2000;94: ) Donaldson A, Maddocks M, Martolini D, et al. Muscle function in COPD: a complex interplay. Int J Chron Obstruct Pulmon Dis. 2012;7:

37 References 7) Spruit M, Gosselink R, Troosters T, et al. Muscle force during an acute exacerbation in hospitalised patients with COPD and its relationship with CXCL8 and IGF-I. Thorax. 2003;58(9): ) Seymour JM, Moore L, Jolley CJ, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010;65(5): ) Troosters T, Probst VS, Crul T, et al. Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2010;181(10): ) Serres I, Gautier V, Varray A, et al. Impaired skeletal muscle endurance related to physical inactivity and altered lung function in COPD patients. Chest. 1998;113: ) Van t HA, Harlaar J, Gosselink R, et al. Quadriceps muscle endurance in patients with chronic obstructive pulmonary disease. Muscle Nerve. 2004;29: ) Allaire J, Maltais F, Doyon JF, et al. Peripheral muscle endurance and the oxidative profile of the quadriceps in patients with COPD. Thorax. 2004;59:

38 References 13) Engelen MP, Schols AM, Does JD, et al. Skeletal muscle weakness is associated with wasting of extremity fat-free mass but not with airflow obstruction in patients with chronic obstructive pulmonary disease. Am J Clin Nutr. 2000;71: ) Hopkinson NS, Tennant RC, Dayer MJ, et al. A prospective study of decline in fat free mass and skeletal muscle strength in chronic obstructive pulmonary disease. Respir Res. 2007;8: ) Mador MJ, Bozkanat E, Kufel TJ. Quadriceps fatigue after cycle exercise in patients with COPD compared with healthy control subjects. Chest. 2003;123: ) Seymour JM, Moore L, Jolley CJ, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010;65(5): ) Mador MJ, Kufel TJ, Pineda LA, et al. Effect of pulmonary rehabilitation on quadriceps fatiguability during exercise. Am J Respir Crit Care Med. 2001;163(4): ) O Donnell DE, McGuire M, Samis L, et al. General exercise training improves ventilatory and peripheral muscle strength and endurance in chronic airflow limitation. Am J Respir Crit Care Med. 1998;157(5 Pt 1):

39 References 19) Mazokopakis EE, Starakis IK. Recommendations for diagnosis and management of osteoporosis in COPD men. ISRN Rheumatol Published online 10 August doi: /2011/ ) Langhammer A, Forsmo S, Syversen U. Long-term therapy in COPD: any evidence of adverse effect on bone? International Journal of Chronic Obstructive Pulmonary Disease. 2009;4: ) Manolagas SC, Weinstein RS. New developments in the pathogenesis and treatment of steroid-induced osteoporosis. Journal of Bone and Mineral Research. 1999;14(7): ) Graat-Verboom L, Wouters EFM, Smeen FWJM, et al. Current status of research on osteoporosis in COPD: a systematic review. European Respiratory Journal. 2009;34(1): ) Jorgensen NR, Schwarz P. Osteoporosis in chronic obstructive pulmonary disease patients. Current Opinion in Pulmonary Medicine. 2008;14(2):

$References 24) De Luise C, Brimacombe M, Pederson L, et al. Chronic obstructive pulmonary disease and mortality following hip fracture: a population-based cohort study.$

40 References 24) De Luise C, Brimacombe M, Pederson L, et al. Chronic obstructive pulmonary disease and mortality following hip fracture: a population-based cohort study. European Journal of Epidemiology. 2008;23(2): ) Lehouck A, Boonen S, Decramer M, et al. COPD, bone metabolism, and osteoporosis. Chest. 2011;139(3): ) Beauchamp MK, O Hoski S, Goldstein RS, et al. Effect of pulmonary rehabilitation on balance in persons with chronic obstructive pulmonary disease. Archives of Physical Medicine and Rehabilitation. 2010;91(9): ) Beauchamp MK, Hill K, Goldstein RS, et al. Impairments in balance discriminate fallers from non-fallers in COPD. Respir Med. 2009;103: ) Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5):4S-42S.

Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization. Prof. Dr. Müzeyyen Erk Cerrahpaşa Medical Faculty Chest Disease Dept.

Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization Prof. Dr. Müzeyyen Erk Cerrahpaşa Medical Faculty Chest Disease Dept. Plan Chronic Respiratory Disease Definition Factors Contributing