Exercise training in COPD: the devil is in the details! · devil is in the details! Outline •...

Peter Klijn PhD Clinical exercise physiologist Human movement scientist Physical education teacher

Asthma Centre Heideheuvel

Part of Merem Treatment Centres

Exercise training in COPD: the

devil is in the details!

Outline

• Movie

• Study and results

• Background exercise training

• Nonlinear exercise training

We assume we can predict the outcome.

avec souris

VVMi < 16 kg/m2 mannen

VVMi < 15 kg/m2 vrouwen

VVMi ≥ 16 kg/m2 mannen

VVMi ≥ 15 kg/m2 vrouwen

Randomisatie

NLPE EPR

Randomisatie

COPD

FEV1% < 50%

FEV1/VC <70%

N=110

Stratificatie

N=33

60±7.1jaar

FEV1%pred 30.6±9.2

FFMi (kg/m2) 13.7±1.0

N=21

61.3±6jaar

FEV1%pred 31.2±9

FFMi (kg/m2) 17.4±1.6

N=22

61.9±5.3jaar

FEV1%pred 34.6±9

FFMi (kg/m2) 18.1±1.6

N=34

61.3±5.8jaar

FEV1%pred 32.7±9.7

FFMi (kg/m2) 13.9±1.0

NLPE EPR

http://www.merem.nl/heideheuvel/


Aim

• To compare the effects of NLPE training and traditional endurance and progressive resistance training on cycle endurance in patients with severe COPD and depleted or nondepleted FFM.

Exercise training

• 3 times/wk for 10 weeks • Alternate days

• 45-90 min/session

• Supervised exercise training

Workout logs

• ET segment • Intensity / duration

• RT segment • Intensity / number of reps

• Constant Work rate Test (CWT)

– 75% peak work rate (CPET)

• Quality of life • Chronic Respiratory

Questionnaire

• Isotonic 1-RM strength – Leg press

– Leg extension, pull down, chest press

• Bio-impedance analysis – Fat Free Mass

Measurements

Endurance and Progressive

Resistance training

• Treadmill walking – 60% 6MWTspeed, 10 min

– Progression: week 12, 15 min, 75% 6MWTspeed

• Cycle ergometer – 30% Wpeak first week

– Progression: week 12, 20-24min, 70-80% Wpeak

• leg press, leg extension, chest press,

pull down, – first week: 2 series, [8-10] repetitions, 50%1-RM

– Progression: 3 series, 60- >70% 1-RM

• BorgAH < 5: intensity increase

• BorgAH 5-6: intensity unchanged

• BorgAH ≥ 7 intensity decrease

Bernard et al. Am. J. Respir. Crit. Care Med. 159(3) 1999

Spruit et at., Eur .Respir. J. 19(6) 2002.

Ortega et al. Am. J. Respir. Crit . Care Med. 166(5) 2002

Mador et al. Chest 125(6) 2004.

Maltais et al. Am. J. Respir. Crit. Care Med. 155(3) 1997

0

200

400

600

800

1000

1200

Baseline 6 w eeks 12 w eeks

Measurement

Cycle

en

du

ran

ce (

seco

nd

s)

EPR-depleted

NLPE-depleted

0

200

400

600

800

1000

1200

Baseline 12 weeks

Measurement

Cy

cle

en

du

ran

ce

(s

ec

on

ds

)

EPR-nondepleted

NLPE-nondepleted

CWT Depleted patients

EPR (n=34)

NLPE (n=33)

First training period 15% (n=5)

42% (n=14)

Second training period

25% (n=7)

52% (n=16)

399

395

+414

+114

+569

+262

431

426

+528

+198

CWT Non-depleted

patients

EPR (n=21)

NLPE (n=22)

End of training

24% (n=5)

64% (n=14)

CWT EPR (n=55) NLPE (n=55) Difference (95%CI)

Time, s +238 s +539 s 300.6(197 - 404)

Peak SpO2 90.7 89.2 -1,5 (-5.2 – 2.2)

dyspnea 6,4 5,5 -0,9 (-1,6 - -0,1)

leg fatigue 6.5 4.7 -1.8 (-2.6 - -1.0)

CRQ-score

dyspnea +0.94 +1.90 0.96 (0.57 – 1.35)

fatigue +0.90 +1.64 0.74 (0.39 – 1.10)

emotions +0.83 +1.32 0.48 (0.19 – 0.78)

mastery +0.87 +1.39 0.52 (0.21 – 0.84)

Total group

Background

Exercise training

• The aim of exercise prescription in PR is to address the multiple contributors to exercise limitation. (Hill and Holland., Int J COPD 2014)

• Dyspnea

• Fatigue

• Anxiety

• Gas exchange abnormalities

• Altered respiratory mechanics

• Cardiovascular limitations

• Respiratory and peripheral muscle dysfunction

• Fat-free mass depletion



Background

Exercise training

• The aim of exercise prescription in PR is to address the multiple contributors to exercise limitation. (Hill and Holland., Int J COPD 2014)

• Do the right thing.

• Do the right thing right.

• Evidence based efficacy (Grade A).



A program of exercise training of the muscles of ambulation is recommended as a mandatory

component of pulmonary rehabilitation for patients with COPD.

Grade of recommendation, 1A.

Lower extremity exercise training at higher exercise intensity produces greater physiologic benefits

than lower intensity training in patients with COPD.

Grade of recommendation, 1B.

Both low-intensity and high-intensity exercise training produce clinical benefits for patients with

COPD. Grade of recommendation, 1A.

The addition of a strength-training component to a program of pulmonary rehabilitation increases

muscle strength and muscle mass.

Strength of evidence, 1A

Ries et al. Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007;131(5, Suppl):4S–42S.

Recommendations

Garber et al. American College of Sports Medicine. American College of Sports Medicine position stand: quantity and quality of exercise for

developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for

prescribing exercise. Med Sci Sports Exerc 2011;43:1334–1359.

Recommendations

Background

Exercise training

• Cornerstone of pulmonary rehabilitation. (Spruit et al., AJRCCM 188 (8), 2013)

• Both low-intensity and high-intensity exercise training produce clinical benefits for patients with COPD (Ries et al., Chest 131, 2007)

• Optimal resistance training prescription for patients with COPD is not determined. (O’Shea et al., Chest 2009)

• Non-responders – 1/3 to 1/4 do not improve their exercise capacity following pulmonary rehab

– Noise, Nuisance or Normal phenomenon?

• Individual needs



Highly variable training-induced strength and endurance adaptations in healthy individuals undergoing the same training plans.

high-responders

low-responders

nonresponders

http://www.merem.nl/heideheuvel/ Klijn et al; Am J Resp Crit Care Med 2013, 188(2)

Background

Exercise training


Skinner et al., the HERITAGE Family Study. J Appl Physiol 90 (5) 2001

633 inactive persons

17-65 yr

Cyclo ergometer

20 weeks, 3x/week

30 min 50 min

HR 55% VO2max HR 75% VO2max



Skinner et al., the HERITAGE Family Study. J Appl Physiol 90 (5) 2001 http://www.merem.nl/heideheuvel/


Hubal et al., Variability in muscle size and strength Med Sci Sports Exerc 37 2005 http://www.merem.nl/heideheuvel/


Davidsen et al., High responders to resistance training. J Appl Physiol 110 2011



Resistance

training


Overload

Progression Specificity

Variation

Fleck and Kraemer; Designing resistance training programs. 2004;

ACSM position stand. Progression models in RT for healthy adults. Med Sci Sports Exerc 2009

Resistance training


• Serres et al., Chest 113(4), 1998

• Mador et al., Am J Respir Crit Care Med 168(1) 2003

• Van‘t Hul et al., Muscle Nerve 29(2) 2004

• Janaudis-Ferreira et al., Respir Med 100(8) 2006

Beachle and Earle. Essentials of strength training and conditioning. 2008 http://www.merem.nl/heideheuvel/

Type IIx Type IIa

Type I


Traditional endurance and

progressive resistance training

Bernard et al 1999 – Endurance

• 80% Wpeak (HI)

– Strength • 60-80% 1-RM; 2-3 x (8-10) reps

• >10 reps / set increase in load

Ortega et al 2002 – Endurance

• 70% Wpeak

– Strength • 70-85% 1-RM; 4 x (6-8) reps;

1-RM every 2-wks

– Combined

• 70% Wpeak / 70-85% 1-RM;

2 x (6-8) reps

Spruit et al 2002 – Endurance

• 30-75% Wpeak; 10->25 min

• 60% 6MWDspeed; 10->20 min

– Strength • 70% 1-RM; 3 x 8 reps

• 2min walk 60% 6MWDspeed

Mador et al 2004 – Endurance

• Cycling: 50% Wpeak;

20 min 10% increase workload

• Walking: 1.1-2.0 mph

– Combined • Cycling: 50% Wpeak; 20 min

• Walking: 1.1-2.0 mph

• Strength: 60% 1-RM; 1-> 3 sets x 10

reps

– 3 sets without difficulty 5lb

increase



Nonlinear (Undulating) Model of Periodization

• Variation in intensity & volume by rotating different protocols (daily, weekly, biweekly) – Attempts to train various components of neuromuscular system

– Only one characteristic is trained in each workout



• An assessment of factors that determine the specific training program appropriate for an individual.

– Physiological requirements

– Biomechanical requirements

– Individual needs and deficiencies

Program design Needs analysis



• Physiological requirements • Aerobic energy system

• Anaerobic energy system

• Leg endurance

• Leg strength

• Biomechanical requirements • Knee and hip muscles

• Many submaximal contractions

• Individual deficiencies • FFM depletion

• Dyspnea

• Oxygen desaturation

• Fatigue


Needs analysis cycle endurance 75% Wmax


Volume Intensity Rest

• 1-2 series ≥20 Reps 30-39% 1-RM 1 min

• 2-3 series 12-15 Reps 40-49% 1-RM 1 min

• 3-4 series 8-10 Reps 50-65% 1-RM 2 min

• 4-5 series 5-6 Reps 70-80% 1-RM 2-3 min

• 4-5 series 1-3 Reps 85-90% 1-RM 3-4 min

Klijn et al; Am J Resp Crit Care Med 2013, 188(2) http://www.merem.nl/heideheuvel/

Nonlinear (undulating) RT


Table 1. General outline of NLPE program design and adaptations.

Pro

gram

de

sign

Physiological and psychological adaptation phase (Base training). First two to three training sessions

-aerobic cycle exercise, 2-3 series, 3-5 min, 50-60% Wmax and resistance exercise, 2 series [12-15 reps] 40-49% 1-RM

Progression: introduction of anaerobic higher intensity cycle exercise (3-5 series, 2-3 min, 65-70% Wmax) and high

repetition-volume leg press (≥20 repetitions). Daily, weekly or biweekly rotation of cycle work phase intensity and

repetition zones.

Phase of recovery or taper to reduce accumulated training fatigue. Reduction of cycle and resistance training volume and

number of sessions during the last week prior to exercise testing, while maintaining training intensity.

Pro

gre

ssiv

e

ove

rlo

ad

Criteria for adaptation and progression through the training program

Cycle exercise: - prolonging the aerobic work phase: 2-3 series of 6 to 8 min as tolerable*

- prolonging the anaerobic work phase: 2-3 series, 5 min

- increasing the anaerobic work intensity: 70-80% Wmax

Resistance training: - increasing the repetition-volume of the primary RT exercise (leg press)

- increasing the intensity (repetition-load) within the 1-RM range

Ind

ivid

ual

pat

ien

t ch

arac

teri

stic

s

Patients with low FFMi perform only resistance exercises during the first training period in order to improve muscle function or

muscle efficiency relative to muscle mass.

In case of severe oxygen desaturation on exertion ([SPO2] <86%) despite oxygen therapy, transient pre-exercise dyspnea or

fatigue, exercise-induced fear of dyspnea†, and low baseline or 6-week CWT (<8 min) only resistance training protocols are

used temporarily. Cycle protocols are used as tolerated* to apply training specificity: 3-5 series, 2-3 min, 65-70% Wmax.

Patients with higher baseline or 6-week CWT duration (≥ 8-10 min) are able to endure longer duration and higher intensity

exercise.

- prolonging the anaerobic work phase: 2 series, 7 min

- prolonging the aerobic work phase: 2 series, 10 min, 50-60% Wmax

- increasing anaerobic work intensity: 6-10 series, 1-2 min, 85-95% Wmax

- increasing aerobic work intensity: 4x4 min, 80-95%Wmax and 3 min active recovery, 50%Wmax.



Volume Exercise Intensity Rest Training 1

• 2-3 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min

Training 2


Training 3


Training 4


Training 5


Klijn et al; Am J Resp Crit Care Med 2013, 188(2)


Nonlinear RT




Training 7


Training 8


Training 9


Training 10




Nonlinear RT



Pro

gram

de

sign





repetition zones.



Pro

gre

ssiv

e

ove

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Ind

ivid

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pat

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s







exercise.









Training 7


Training 8

• 1-2 series 20-30 Reps LP 30-39% 1-RM 1 min 2-3 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min

Training 9


Training 10




Nonlinear RT



Pro

gram

de

sign





repetition zones.



Pro

gre

ssiv

e

ove

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ad







Ind

ivid

ual

pat

ien

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teri

stic

s







exercise.









Training 12


Training 13


Training 14


Training 15




Nonlinear RT




Training 17


Training 18


Training 19


Training 20




Nonlinear RT




Training 22


Training 23


Training 24


Training 25




Nonlinear RT


Klijn et al; Ned Tijdschr Geneesk 2013, 135(57).

Nonlinear periodized resistance training


No. of sessions


Traditional progressive training

Klijn et al; Ned Tijdschr Geneesk 2013, 135(57).


No. of sessions



Training characteristics



Pro

gram

de

sign





repetition zones.



Pro

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Ind

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pat

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exercise.








• 1-3 x (3-10) min 50-60% Wpeak 1-3 min



Nonlinear periodized cycle exercise


Hickson et al., Eur J Appl Physiol 1980



Lundberg et al., J Appl Physiol 116 2014


Lundberg et al., J Appl Physiol 114 2013

Background

Concurent exercise training



Pro

gram

de

sign





repetition zones.



Pro

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Ind

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exercise.








• 1-3 x (3-10) min 50-60% Wpeak 1-3 min

• 2-8 x (2-5)min 65-80% Wpeak 2-4 min

Compensation cycling following an anaerobic exercise session

• 1 x (5-10) min 50% Wpeak





1-3 x (3-10) min 50-60% Wpeak 1-3 min

• (2-3) x 3 min 1 min

• (2-4) x 4 min 1-2 min

• (2-3) x 5 min 1-2 min

• (1-3) x 6 min 1-2 min

• (1-2) x 7 min 1-3 min

• (1-2) x 8 min 1-3 min

• 1 x 9-10 min

2-8 x (2-5)min 65-80% Wpeak 2-3 min

• (4-8) x 2 min 1½-2 min

• (3-5) x 3 min 2 min

• (2-3) x 4 min 3 min

• (2-3) x 5 min 3-4 min




Nonlinear Periodized Exercise

Energy system cycle training Resistance training

Repetition range

Aerobic

≥ 20 Muscular endurance

Strength

12-15

Anaerobic

8-10

4-6

1-3





• 2 series 12-15 Reps LP PD LE CP 40-49% 1-RM 1 min

Training 2

• 2-3 series 4 min cycling 50% 2 min

• 2 series 12-15 Reps LP PD LE 40-49% 1-RM 1 min

Training 3


• 2 series 12-15 Reps LP CP LE 40-49% 1-RM 1 min

Training 4



• 1 series 5-10 min cycling 50% Wmax



Nonlinear periodized exercise training





Training 6




Training 7


• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps PD LE 40-49% 1-RM 1 min

Training 8










• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps CP LE 40-49% 1-RM 1 min

Training 10




Training 11



Training 12








Lower volume, shorter work phase duration, lower intensity and/or longer rest

• Dyspnea

• Anxiety

• Fatigue

Shorter work phase duration and/or longer rest

• Oxygen desaturation

Progression

• Intensity

• Volume

• Shorter rest







• 2 series 20-30 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps CP LE 40-49% 1-RM 1 min

Training 10




Training 11



Training 12

• 2-3 series 5 min cycling 70% 3½ min








Pro

gram

de

sign





repetition zones.



Pro

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Ind

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exercise.








• 1-2 x (8-10) min 50-60% Wpeak 1-3 min

• (15-30) x 30 sec >95% Wpeak 30 sec

• HI 4x4 min 80-90% Wpeak 3 min active rest 50%Wpeak

• 2 x 7 min 65-80% Wpeak 3-5 min

• 6-10 x (90-120)sec 85-95% Wpeak 2-3 min

Compensation cycling following an anaerobic exercise session

• 1 x (5-10) min 50% Wpeak






• 2 series 8 min cycling 60% Wmax 3 min

• 2 series 40-50 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps CP 40-49% 1-RM 1 min

Training 14

• 10 series 90 sec cycling 85% 2 min

• 4 series 4-6 Reps LP PD LE 70-80% 1-RM 2-3 min

• 1 serie 5-10 min cycling 50% Wmax

Training 15

• 2 series 50-60 Reps LP 30-39% 1-RM 1 min 2 series 12-15 Reps PD LE CP 40-49% 1-RM 1 min

Training 16

• 2 series 7 min cycling 70% Wmax 4 min


• 1 serie 5-10 min cycling 50% Wmax





†





‡ ‡






Pro

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repetition zones.



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exercise.







Take home message

The prescription of an “optimal” exercise training program that works for every individual is not possible as substantial variation exists in the ability of individuals to respond to a training stimulus!


Training smart!


Exercise training in COPD: the devil is in the details! · devil is in the details! Outline •...

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Transcript of Exercise training in COPD: the devil is in the details! · devil is in the details! Outline •...