SKELETAL MUSCLE TRAINING, PERIPHERAL AND RESPIRATORY MUSCLES

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SKELETAL MUSCLE TRAINING, PERIPHERAL AND
RESPIRATORY MUSCLES

• Prof. Dr. Sema SAVCI
• Hacettepe University Faculty of Health Sciences,
• Department of Physical Therapy and Rehabilitation.

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Chronic Respiratory Diseases

• Dyspnea
• Decreased exercise tolerance
• Decreased quality of life

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Chronic Respiratory Diseases

• Ventilatory limitation
• Impaired gas changing
• Cardiac problems
• Symptoms seen with effort
• Peripheral muscle weakness

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Pathology/ Inflammation/ Hypoxemia Medicines Inact
ivity/ Deconditioning
CO2
CO2
muscle
Ventilation
circulaion
O2
O2
Oxygen transport
Wasserman, Principles of Exercise Testing and
Interpretation 1994
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Peripheral muscle adaptations

• Muscle atrophy
• Muscle weakness
• Fatigue
• 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 ?

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Properties of muscles fiber types
Fibril type Defination Metabolism Myoglobulin /Mitochondria Function
I Slow Fatigue resistant Oxidative Rich red Standing, Normal breathing
IIa Fast Fatigue resistant Oxidative/ Glycolytic Red-white Walking, hyperventilation
IIx Fast Not fatigue resistant Glycolytic Less white Jumping Coughing
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Prevalence of muscle atrophy
Normal BMI
60
F FFM ? 14.62 kg/m2 M FFM ? 17.05 kg/m2
50
40
30
ratio ()
woman
20
man
10
0
0
1
2
3 4
GOLD stage
Vestbo ve ark. AJRCCM 200617379-83.
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Muscle Weakness in COPD
COPD
Strength (kg)
Controls


100

80
60
40
20
0
Pectoralis
Latissimus
Quadriceps
major
dorsi
Bernard ve ark. AJRCCM 1998 158 629-634.
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Peripheral muscle strength and endurance

• 30 ? muscle strength decreased in patients with
  COPD
• Peripheral muscle strength is a determinant of
  exercise capacity (6-MWT and VO2 max)
• Reduction of peripheral muscle endurance results
  with reduction of exercise capacity
• Early muscle fatigue appears.
• 
  

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Symptoms
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Leg Fatique
Dyspnea and leg fatique
Dyspnea
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Killian ve ark. ARRD 1992 146 935-940.
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Pulmonary Rehabilitation Programs

• Exercise training
• Oxygen
• Breathing training
• Patient education
• Nutrition
• Physicosocial and stress approaches

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Exercise training and peripheral muscles
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Aerobic Exercise Training

• Peak VO2 ?
• Reduces exercise oxygen consumption
• Reduces blood lactate levels at given workload
• Improves oxidative capacity of peripheral muscles
• Improves symptoms

• Increases neuromuscular coordination
• Improves quality of life
• Decreases using health facilities
• Improves self-esteem
• Improves motivation

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Aerobic Exercise Training

• Aerobic Exercise Training
• Lower extremity aerobic exercise training
• Treadmill, cycling, walking, climbing stairs,
  swimming.
• Upper extremity exercise training
• arm ergometry

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Aerobic Exercise Training

• Time 30 min/day
• Intensity
• 60-90 of max HR
• 50-80 of VO2max
• Dyspnea (Borg Scale 4-6)
• Frequency 3-5 day/week
• Duration 4-6, 6-8, 12-24 weeks

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Exercise Training NIMV

• Respiratory muscle load
• Decreased work of breathing
• Improvement of ABG
• Dyspnea
• Exercise endurance capacity
  Troosters et al AJRCCM 2005 7219-38

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Peripheral muscle training

• Intensity 80-100 of 1 max.
• Repetitions 1-3 set 1-8 times
• Resting 2-3 min
• Frequency 4-6 day/week
• Improvement 2-10
• Benefits muscle mass, strength, bone mineral
  density improvements.

Kramer WJ ve ark. Med Sci Sport Exerc 2002
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Peripheral muscle strength-endurance training

• Intensity 70-85 of 1 max
• Repetitions 3 set 8-12 times
• Resting 1-2 min
• Frequency 2-4 day/week
• Improvement 60-70
• Benefits improvement in muscle mass, and
  strength, bone mineral density and muscle
  endurance

Kramer WJ ve ark. Med Sci Sport Exerc 2002
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Peripheral muscle endurance training

• Intensity 30-60 of 1 max
• Repetitions 1-3 set 20-30 times
• Resting 1 min
• Frequency 2-4 day/week
• Improvement no strength improvement
• Benefits improvement in muscle oxidative
  capacity and capillarization, muscle endurance
  and exercise capacity.

Kramer WJ ve ark. Med Sci Sport Exerc 2002
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Peripheral muscle training

• COPD, 8 weeks
• 85 of 1 max.
• 16- 40 strength improvements
• Submaximal exercise capacity ? and
• ?quality of life
• Simpson K, Thorax 1992

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• To investigate the effects of heavy resistance
  training in the elderly males with COPD (n18,
  age range 65-80 years)
• Cross sectional area of quadriceps asssessed by
  MRI
• Isometric 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.

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Peripheral muscle training

• Aerobic training muscle strength training
• Improves bone mineral density
• Evans WJ. Med Sci
  Sport Exer 1999
• Applicable at home
• Improves endurance capacity and quality of life
• Clark CJ ve ark Eur Respir J 1996

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Exercise and peripheral muscle training

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

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Neuromuscular electrical stimulation

• Exercise performance
• Peripheral muscle strenght
• Quality of life

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• 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 (n15) were randomly
  assigned to either a home based 6 week quadriceps
  femoris NMES training programme.
• Group 1, n9, age 66.6 (7.7) years FEV138.0
  (9.6) or a 6 week control period before
  receiving NMES.
• Group 2, n6, age 65.0 (5.4) FEV139.5 (13.3).
• Knee extensor strength and endurance, whole body
  exercise capacity, and health related quality of
  life (Chronic Respiratory Disease Questionnaire,
  CRDQ) were assessed.

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

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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,
  303 pred, BMI 182.5 kg/m2)
• Group 1(n8) usual rehab (UR), Group 2(n9) UR
  ES program for 4 weeks
• QMS, exercise capacity, HRQoL were measured
  before and after rehabilitation.
• 
  Chest 2006 1291540-1548.

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Exercise training

• Illness severity
• Patients first physical activity level
• Motivation of the patients
• Self monitarization

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Respiratory muscle training
1.biyopsy
2. biyopsy
. 40 MIP . 30 / day, 5 d/week, 5 weeks
External intercostal Lower extremity muscles
External intercostal Lower extremity muscles

fibre type
Ramírez et al. AJRCCM 2002
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Respiratory muscle training
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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

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Results

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

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Thanks