SKELETAL MUSCLE TRAINING, PERIPHERAL AND

RESPIRATORY MUSCLESProf. Dr. Sema SAVCI

Hacettepe University Faculty of Health Sciences,

Department of Physical Therapy and Rehabilitation.

Chronic Respiratory Diseases

DyspneaDecreased exercise toleranceDecreased quality of life

Chronic Respiratory Diseases

Ventilatory limitationImpaired gas changingCardiac problemsSymptoms seen with effortPeripheral muscle weakness

muscle circulaion Ventilation

CO2

O2O2

CO2

Oxygen transporOxygen transportt

Pathology/ Inflammation/ HypoxemiaPathology/ Inflammation/ HypoxemiaMedicinesMedicines

Inactivity/ Inactivity/ DDeconditioningeconditioning

Wasserman, Principles of Exercise Testing and Interpretation 1994

Peripheral muscle adaptations

Muscle atrophyMuscle weaknessFatigue Morphological changes – Decreased numbers of

type I fibers – Increased numbers of

Type IIx fibers – Atrophy in type I and IIa

fibers – Decreased

capillarisation

Changes in metabolic capacity:

– Intramuscular pH – Concentration of ATP

– Muscle lactate level – Activity of

mitochondrial enzyme

Properties of muscles fiber types

Fibril type

Defination Metabolism

Myoglobulin /Mitochondria

Function

I Slow Fatigue resistant

Oxidative Rich red Standing, Normal breathing

IIa FastFatigue resistant

Oxidative/Glycolytic

Red-white Walking, hyperventilation

IIx FastNot fatigue resistant

Glycolytic Less white Jumping Coughing

Prevalence of muscle atrophy

Vestbo ve ark. AJRCCM 2006;173:79-83..

00

2020

3030

4040

5050

6060

1010

FF: : FFMFFM 14.62 kg/m 14.62 kg/m22

MM: : FFMFFM 17.05 kg/m 17.05 kg/m22

ratio

ratio

(%)

(%)

GOLD GOLD stagestage00 11 22 3 & 43 & 4

Normal Normal BMIBMI

26%womanwoman

manman

Muscle Weakness in Muscle Weakness in COPDCOPD

PePecctoralistoralismajormajor

StrengthStrength (kg) (kg)

00

2020

4040

6060

8080

100100

COPDCOPDControlsControls

LatissimusLatissimusdorsidorsi

QuadricepsQuadriceps

**

**

**

Bernard ve ark. AJRCCM 1998; 158: 629-634.

Peripheral muscle strength and endurance

30 % muscle strength decreased in patients with COPDPeripheral muscle strength is a determinant of exercise capacity (6-MWT and VO2 max) Reduction of peripheral muscle endurance results with reduction of exercise capacityEarly muscle fatigue appears.

Symptoms

26%

43%31%

Dyspnea

Leg Fatique Dyspnea and leg fatique

Killian ve ark. ARRD 1992; 146: 935-940.

Pulmonary Rehabilitation Programs

Exercise training OxygenBreathing training Patient education NutritionPhysicosocial and stress approaches

Exercise training and peripheral muscles

Exercise training

Aerobic/endurance training

Strength/resistive training

Aerobic Exercise Training

Peak VO2 ↑Reduces exercise oxygen consumption Reduces blood lactate levels at given workloadImproves oxidative capacity of peripheral musclesImproves symptoms

Increases neuromuscular coordinationImproves quality of life Decreases using health facilitiesImproves self-esteemImproves motivation

Aerobic Exercise Training

– Aerobic Exercise Training– Lower extremity aerobic exercise

trainingTreadmill, cycling, walking, climbing stairs, swimming.

– Upper extremity exercise trainingarm ergometry

Aerobic Exercise Training

Time: 30 min/dayIntensity: – 60-90% of max HR– 50-80% of VO2max– Dyspnea (Borg Scale 4-6)Frequency: 3-5 day/weekDuration: 4-6, 6-8, 12-24 weeks

Exercise Training –NIMV

Respiratory muscle loadDecreased work of breathingImprovement of ABG Dyspnea Exercise endurance capacity

Troosters et al AJRCCM 2005; 72:19-38

Peripheral muscle training

Intensity: %80-100 of 1 max.Repetitions : 1-3 set 1-8 timesResting : 2-3 minFrequency: 4-6 day/weekImprovement: 2-10%Benefits: muscle mass, strength, bone mineral density improvements.

Kramer WJ ve ark. Med Sci Sport Exerc 2002

Peripheral muscle strength-endurance

trainingIntensity: 70-85% of 1 maxRepetitions: 3 set 8-12 timesResting : 1-2 minFrequency: 2-4 day/weekImprovement: 60-70 %Benefits : improvement in muscle mass, and strength, bone mineral density and muscle endurance

Kramer WJ ve ark. Med Sci Sport Exerc 2002

Peripheral muscle endurance training

Intensity: 30-60% of 1 maxRepetitions: 1-3 set 20-30 timesResting : 1 min Frequency: 2-4 day/weekImprovement: no strength improvementBenefits : improvement in muscle oxidative capacity and capillarization, muscle endurance and exercise capacity.

Kramer WJ ve ark. Med Sci Sport Exerc 2002

Peripheral muscle training

COPD, 8 weeks85% of 1 max. – %16- %40 strength

improvements– Submaximal

exercise capacity ↑ and

– ↑quality of life

Simpson K, Thorax 1992

To investigate the effects of heavy resistance training in the elderly males with COPD (n=18, age range 65-80 years)Cross sectional area of quadriceps asssessed by MRIİsometric isokinetic knee extension, isometric trunk strength, leg extension power, stair climbing time, normal and max gait speed on a 30 m track.RE performed twice a week for 12 weeks.Significant improvements in muscle size, knee extension strength, leg extension power, functional performance in elderly male COPD patients.

Peripheral muscle training

Aerobic training+ muscle strength trainingImproves bone mineral density

Evans WJ. Med Sci Sport Exer 1999

Applicable at homeImproves endurance capacity and quality of life Clark CJ ve ark Eur Respir J 1996

Exercise and peripheral muscle training

Strength training should be started before aerobic training– Less dyspnea– Applicable at high

intensity

Neuromuscular electrical stimulation

Exercise performancePeripheral muscle strenghtQuality of life

It was hypothesised that this novel strategy would be particularly effective in improving functional impairment and the consequent disability which characterises patients with end stage COPD.Advanced COPD patient (n=15) were randomly assigned to either a home based 6 week quadriceps femoris NMES training programme. Group 1, n=9, age: 66.6 (7.7) years FEV1=38.0 (9.6)% or a 6 week control period before receiving NMES. Group 2, n=6, age: 65.0 (5.4) FEV1=39.5 (13.3)%. Knee extensor strength and endurance, whole body exercise capacity, and health related quality of life (Chronic Respiratory Disease Questionnaire, CRDQ) were assessed.

For severely disabled COPD patients short term electricalstimulation of selected lower limb muscles involved in ambulation can improve muscle strength andendurance, whole body exercise tolerance, and breathlessness during activities of daily living.

ES

To evaluate whether ES was a beneficial tecnique in the rehabilitation programs for severely deconditioned COPD patients after acute exacerbation.17 COPD patient participated in this study (FEV1, 30+3% pred, BMI 18+2.5 kg/m2) Group 1(n=8) usual rehab (UR), Group 2(n=9) UR +ES program for 4 weeks QMS, exercise capacity, HRQoL were measured before and after rehabilitation.

Chest 2006; 129:1540-1548.

Exercise training

Illness severityPatient’s first physical activity level Motivation of the patients Self monitarization

fibre type

External intercostalLower extremity muscles

External intercostalLower extremity muscles

1.biyopsy

2. biyopsy

. 40 % MIP

. 30’ / day, 5 d/week, 5 weeks

Ramírez et al. AJRCCM 2002

Respiratory muscle training

Respiratory muscle training

Inspiratory muscle training (MIP % 40)Placebo

50

70

90

MIP

(%

pred

icte

d) **

10

15

20

time

(min

)

**

before after

30

50

70

Tip

I L

ifler

(%

) **

2000

2500

3000

t

ypeI

I fib

res (

µm2 )

**

1500

Önce Sonra

Ramírez et al. AJRCCM 2002

IMT

The long term effects of inspiratory muscle training on inspiratory muscles, exercise capacity, perceived dyspnea, quality of life , and intensity of admission to hospital in patients with COPD

Results

Impairment in peripheral muscle effects exercise capacity and quality of life Exercise training (aerobic and resistance training) improves exercise tolerance and quality of lifeAerobic and resistance training together improves peripheral muscles functional impairments physiologically.High intensity training improves aerobic capacity and muscle strength much more

Thanks