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2 Assessment Exercise Limitation
2 Assessment Exercise Limitation
Prof
Dr
R.
Gosselink
!
Quality
of
life
Faculty
of
Kinesiology
and
Rehabilita;on
Sciences
KU
Leuven
!
Physical
Ac1vity
120
100
?
80
60
40
20
0
Control GOLD I GOLD II GOLD III GOLD IV
Pinto-Plato et al. Chest 132:1204, 2007 Gosselink et al. Am J Respir Crit Care Med 153:976-980, 1996
1
Incremental
exercise
test
Maximal
tests
:
Indica1ons
! Exercise
(in-)tolerance
?
! Limi1ng
factors
?
! Prognosis
! Dyspnea
:
cardiac-pulmonary
?
! Impairment
/
disability
?
! Exercise
prescrip1on
/
safety
?
! Preopera've
assessment
! Evalua'on
for
lung
transplanta'on
www.thoracic.org 2003
/h
ng
4. g
ng
in
bi
ti
ti
nd
8k
6k
PERIPHERAL
MUSCLES
ub
in
it
ta
5.
Pa
S
cr
S
S
k
k
al
al
W
2
IMPAIRED
EXERCISE
PERFORMANCE/DYSPNEA
Which
factors
do
contribute
to
exercise
limita1on?
Peripheral
Anxiety
Cardio-
Ven;latory
Oxygen
transport
Mo;va;on
muscle
circulatory
in
the
lungs
Selfesteem
strength
O2 O2 O2
l
Respiratory
muscle
weakness
l
Hyperina;on
. . O2
Hypoxemia/Hypercapnia
VE Q
during
exercise?
CO2
IMT
Body
posi;oning
Endurance
Interval-
Rollator
Muscle
training
Counseling
CO2 CO2 CO2
training
training
NIV
NEMS
Relaxa;on
Ac;ve
expira;on
ev.
suppl
O2
PLB
Nutri;on
Educa;on
Ventilation Cardiac output Muscle
O2 O2 O2
. . O2
Cardiovascular
response
VE Q
CO2
3
Cardio-circulatory
ceiling
Cardio-circulatory
ceiling
O2 O2
Heart rate Heart
rate
Predicted by age Predicted
by
age
220 - age 220
-
age
. . 210-(age x 0.65) .
.
210-(age
x
0.65)
Q Q 200
Q
Q
180
160
Stroke
volume
HR (bpm)
140
(on
itself
dicult
to
measure)
120
100
Signs
of
heart
disease
Ischemia
CO2 80 CO2
Arrhytmias
60
Blood
pressure
drop
1.0 2.0 3.0 4.0 5.0
VO2 (L/min)
90
Ven;latory
Response
70
50
30 Maximal
exercise
10
4
Ven;latory
limita;on
the
classical
approach
Ven;latory
Response
Ven;latory
Healthy
person
45
yrs
FEV1
4.71
L
(124%pred)
reserve
180
MVV
Normal
subjects
:
160
140 ~
30%
Exercise
maximal
ven;la;on
is
30
%
lower
VE (L/min)
120 VEmax
100 than
voluntary
max.
ven;la;on.
80
60
40 Respiratory
pa;ents
:
20
0 Decrease
or
even
disappearance
of
0 1 2 3 4 ven;latory
reserve.
VO2 (L/min)
Ven;latory
limita;on
the
classical
approach
Ven;latory
limita;on
the
classical
approach
Healthy
person
45
yrs
FEV1
4.71
L
(124%pred)
Healthy
person
45
yrs
FEV1
4.71
L
(124%pred)
Imagine
a
smoking
induced
reduc;on
of
the
FEV1
to
1
L
(26%pred)
180 180
160 160
140 140
VE (L/min)
VE (L/min)
120 120
100 100
80 80
60 60
40 40
20 20
0 0
0 1 2 3 4 0 1 2 3 4
VO2 (L/min) VO2 (L/min)
5
Ven;latory
limita;on
the
classical
approach
Ven;latory
limita;on
the
classical
approach
Healthy
person
45
yrs
FEV1
4.71
L
(124%pred)
Imagine
a
smoking
induced
reduc;on
of
the
FEV1
to
1
L
(26%pred)
O2
180 Airflow obstruction
160
VE
/
MVV
>
0.75
is
'abnormal'
140 PaCO2
will
increase
MVV: 37.5 x FEV1
VE (L/min)
6
Ven;latory
limita;on
O2 O2 O2
O2
PaCO2
.
VE
.
Q
Exercise-induced
hypoxemia/desatura;on
Blood
gases
response
at
the
begining
of
exercise
:
usually
shunt
to
exercise
progressively
during
exercise
:
usually
emphysema,
brosis
Alveolar
hypoven;la;on
:
less
frequent
than
EIH/EID
7
Oxygena1on
during
exercise
Exercise
induced
desatura;on
0
-1
35 -2
0
-3
-1
30 -4
DL,CO (ml/min/mmHg)
-2
-5
-3
CPX nl, -6
25 -4
-7
-5 6MWD drop CPX
-8
-6
-9 6MWD
20 -7
-10
-8 CPX
6MWD
15 -9
-10
0
-1
10 -2
-3
5 CPX nl, -4
0 6MWD drop
-6
-20 -10 0 10 20 -7
-8 CPX
O2 O2 O2
. O2
.
VE Q Peripheral
muscle
func;on
CO2
8
Muscular
limita1on
Factors
related
to
exercise
limita1on
in
COPD
.
VO2max
6MWD
100%
TL,CO
0.73*
NS
80%
160
140
VE (L/min)
120 Decondi;oning
Early
lac;c
acidosis
100
100 High
Vd/Vt
80
60
40
20
0
0 1 2 3 4
0
VO2 (L/min)
Normals
COPD
9
Isometric
or
isokine;c
muscle
tes;ng
l
Isokine;c
contrac;on
l
Isometric
contrac;on
l
Expensive
equipment
l Norma;ve data
Cybex Norm, Enraf Nonius,
Delft, The Netherlands
Hand-held
Dynamometry
l
Isometric
contrac;on
l
MAKE
vs.
BREAK
test
l
Electronic
hand
held
device
l
Norma;ve
data
10
Microfet, Biometrics, Almere, The
Netherlands
+ anchoring system, developed by the
technical service of the University
Visser et al. Neuromusc. Disorders 2003; 13:744-750 Hospital Gasthuisberg.
150
l
REPRODUCIBLE
100
(%pred)
Handgrip
75
l
NORMAL
VALUES
50
l
VALIDITY
AS
INDICATOR
OF
GENERAL
MUSCLE
FORCE
?
25
0
0 25 50 75 100 125 150
Knee
extension
force
Quadricepskracht
(%pred)
11
Quadriceps
Endurance
Muscular
limita1on
800
O2
! High
score
Fa1gue
600
O2 ! Muscle
weakness
seconds
400
*
! Peripheral
vascular
200 *
CO2 problems
0
COPD
controls
COPD
controls
! Myopathy
CO2
Male
Female
! Enzyme
deciencies
Van
t
Hul
et
al
Muscle
and
Nerve
2004;
29:267.
DECREASED
Conclusions
VENTILATORY
CAPACITY
MUSCLE
DECONDITIONING:
Exercise
intolerance
is
common
in
respiratory
INCREASED
pa;ents,
also
with
mild
disease.
VENTILATORY
The
impaired
respiratory
response
play
a
major
REQUIREMENT
part.
The
peripheral
muscle
response
play
an
important
role
in
this
exercise
intolerance
and
can
be
improved
by
exercise
training.
A
cardiovascular
part
is
generally
not
present
in
this
REDUCED
EXRCISE
exercise
intolerance.
CAPACITY
12
Constant
work
rate
test
:
Indica;ons
Constant
work
rate
test
:
Indica;ons
140
120
100 85%
Wmax
80
VO2max
60
Endurance
40 50%
20
0
13
Field
exercise
tests:
what
are
the
op1ons
Shulle
walking
test
BEEP
Increasing speed
! Externally
paced
test
Shutle
walking
tests
Incremental
shutle
walking
Endurance
shutle
walking
9m
14
6MWT:
a
test
for
physical
ac1vity?
Predict
Wmax
from
6
minute
walking
test?
180
Walking time (min)
150
120
90
60
30
0
0 25 50 75 100 125
6mwt %pred
15
Summary
M
ax
CW tes
St
im
ep
T
t
6M
al
SH
te
T
W
st
es
W
Exercise
Tolerance
Exercise
limita;on
Safety
Risk
Prescrip;on
Acute
eect
interv.
O2
Bronchodil.
Rollator
Eect
of
exercise
training
()
16