PACE Health Management

Synergistic Dominance & Low Back Pain

Sam Buchanan – Exercise Physiologist

For this blog article, we explore the role that over-active hamstrings play in cases of low back pain. It’s a known fact that 60-80% of us will at some stage get struck down with low back pain, in varying degrees of course. So what is the relation of hamstrings in low back pain then? To the common person they only sit behind your thigh, work to bend your knee and are first to pull up sore after bouts of running; think again.

When a client is presented to you with low back pain, a full posture and movement assessment should be performed. Special attention needs to be focussed on the pelvic position (degree of anterior tilt) and the curvature of the lumbar spine. According to Wagner, et.al 2010, people with underactive gluteus maximus and overactive hamstrings tend to suffer from low back pain, in what is known as ‘Synergistic Dominance’.

When a person is presented to you with lumbar lordosis, there is an obvious tightness of psoas leading to an ‘altered reciprocal inhibition’ of Gluteus Maximus. An altered reciprocal inhibition means that the nerves are not driving messages well enough to the antagonist, causing the agonist to take over. In this case of low back pain, the overactive psoas muscle is causing less neural patterns to reach gluteus maximus, causing dysfunction and imbalances.

The gluteus maximus plays a vital role in lumbar spine stability, helping in propulsion of the walking/ running pattern and stabilising the sacro-illiac joints. In this case of low back pain, gluteus maximus is not firing correctly, giving pathway to its synergist muscle to take over. This is referred to as ‘synergistic dominance’. Therefore the hamstrings take       over as the role of the gluteus maximus, which are less capable in providing stability to the lumbar spine and vulnerable SI joint.

In a well-trained athlete or individual, the hamstrings serve as a good synergist to the gluteus maximus, however are not designed to act a sole hip extensor and/or lumbar stabiliser. Therefore, given the extra workload the hamstrings then become vulnerable to early fatigue, strains, SI joint pain and lumbar spine pain.

So how would you overcome this Synergistic Dominance of hamstrings and return the neural messages to gluteus maximus? It involves rebalancing the hip flexor complex with regular activation of gluteus maximus. In a synergistic dominant client, the hamstrings are trained by the brain to activate before the glutes.

Here are a few tips and exercises to re-train your glutes:

1. Begin by squeezing your glutes only, lying in the prone position

2. Progress this to prone lying hip extension.

3. Practice contracting your transverse Abdominis at the same time, while extending your hip. Larsen et.al, 2010 describes that by contracting your TA while extending your hip, your gluteus maximus will fire with greater contraction than the hamstring complex.

4. Progress this to a floor bridge. Ensure glutes are squeezed entire exercise, and the heels are closer to your glutes, to ensure hamstrings are eliminated.

5. Ensure regular stretching of the hip flexor complex.

Larsen, K. Prone hip extension with lower abbdominal hollowing improves relative timing of gluteus maximus activation in relation to biceps femoris. Manual Therapy, 2010. 15: 61-65

Wagner, T. Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings. J Orthopedic & Sports Physical Therapy, 2010. 40(2): 112 - 119

Rehabilitation follow a Hip Arthroscopy

The most common condition associated with Hip Arthroscopic surgery are tears in the Labrum of the hip. The Acetabular Labrum (hip labrum) is a ring of cartilage that surrounds the joint socket known as the Acetabulum. The primary function of the Labrum is to deepen the hip joint to assist in structural stability, in addition partially sealing the joint to avoid distracting forces that lead to dislocations. Given its weight bearing capabilities, the labrum can be exposed to trauma from twisting and pivoting motions, causing partial of full tears commonly to the anterior portion of the labrum.

Following failure to relieve pain and symptoms and return to function through conservative treatment (exercise rehabilitation), surgical intervention can then be considered. The most common form of surgical intervention is through arthroscopy (casually referred to as a ‘tidy-up’) and repair, where the torn portion is stitched back together. The aim of the surgery is to remove the damaged tissue while preserving as much of the labrum as possible, whereby the removal of the unstable flap of cartilage is thought to relieve associated groin pain.

Following surgery, the most common functional impairments may include:

Inflammation of the hip complex

Pain

Decreased joint mobility

Decreased muscle extensibility and strength

Altered proprioception

Decreased muscular endurance

Given these are common functional impairments, the key components of your exercise program should be:

Gentle Stretching and Mobility

You will need to stretch and improve range of motion of the hip. Stretch the key muscles such as psoas, piriformis, quadriceps and hamstring groups. In addition to this, very gentle passive range of motion exercises are highly indicated.

Strengthening exercises

The key areas to strengthen in your rehabilitation should include the hip abductors, adductors and extensors. Begin these isometrically and progress as weight bearing status improves.

Gait re-training

Once weight bearing status has improved and the patient has re-gained some muscle strength, then gait re-training his highly effective.

Balance and Proprioception

This is crucial as you regain neuromuscular control of movements.

With the increase in number of surgical intervention treating labral tears, it is important for the clinician to stay up to date with the most current protocols of rehabilitation. With a labral tear, it is vitally important to note the size and location of tear. As the labrum is most commonly torn anteriorly, it is important to avoid putting stress over this area.

 Below are some functional precautions to take in rehabilitation to avoid damaging the hip:

Avoid sitting with knees lower than hips

Legs crossed

Hip flexor muscles contracted

Pressure on the femur i.e. direct weight bearing

Avoid excessive hip hyperextension; especially in lunges and prone hip extension

Avoid excessive loading through quads and hamstrings and hip flexion exercises

Cycling should be done on an upright bike to avoid excessive hip extension.

Phases of Rehabilitation

Phase 1: Initial Exercises Weeks 1-4

The primary goals following hip arthroscopy are to repair or minimize pain and inflammation, protect the surgically repaired tissue and initiate early exercise. Generally, patients are 50% weight bearing for 7-10 days following surgery and moving into weight bearing as tolerated. It is important to maintain a symmetrical gait pattern in this phase of rehabilitation; otherwise muscular imbalances may develop quickly.

Strength Exercises Phase 1:

Isometric contractions of hip adductors, abductors, extensors and Transverse Abdominis

Seated Hip Flexion (shorter lever to avoid irritation of psoas)

Progress to straight leg raise hip flexion

Low- level closed chain exercises; Very light leg press (allows weight bearing through lower limbs).

Criteria to progress into Phase II are to gain ROM greater or equal to %75 of uninvolved side. Additionally, the ability to complete an AROM side lying abduction pain free is included. (The movement should be pure Gluteus Medius)

Phase 2: Intermediate Exercises Weeks 5-7

The primary focus on phase two is continuing to progress ROM and flexibility while increasing strength of the hip complex. Below are some great examples of flexibility exercises:

Seated piriformis stretch

Seated adductor stretch

Kneeling psoas stretch

Passive internal/ external rotation of the hip

It is also important to progress your core strengthening exercises in this phase.  The strength goal is to achieve endurance in order to progress into the next phase. Strength exercises in this phase may include:

Static Wall Squat (with theraband to control valgus force

<Crab Walks with theraband

Double leg Bridge (progressing to single leg as tolerated)

Increasing resistance on the bike

¼ Squats

Criteria to progress into Phase III are to perform a normal gait pattern without positive Trendelenburg sign. ROM should symmetrical to your uninvolved side.

Phase III: Advanced Exercises Weeks 8-12

The primary focus of this phase is for the patient to achieve full symmetrical ROM to the uninvolved side, as well progressing into functional exercises. Stretching and flexibility exercises should become more aggressive, in particular passive ROM exercises.

The strength exercises should now include multi-planar movements, as well as multi-muscle involvement. As the progression from this phase is to return to sport, eccentric control must be emphasised in this phase in order to control shock absorption. Exercises challenging proprioception and having the hip muscles in functional positions are highly indicated. Strength exercises in this phase may include:

Walking lunge

Walking lunge with medicine ball rotation

Plyometrics in a hydrotherapy pool

Swiss ball hamstring curls

Transverse Abdominis leg slides

Theraband hip extension, abduction, adduction

Side bridge

Single Leg bridge

Criteria to progress to phase IV are symmetrical ROM and flexibility of psoas and piriformis of uninvolved side. Trendelenburg should be absolutely no issue by this phase. If so, regress and have a look at your work of gluteus medius.

Phase IV: Return to Sport 12+ Weeks

The primary focus of this phase is to return the patient to competition, previous activity or activities of daily living. Flexibility and ROM exercises must be maintained in the phase. The individual may feel like they can return to running in this phase, however constant re-assessment of range of motion, strength, muscular endurance and eccentric control must be viewed prior.

To return the individual to running, firstly start with straight line movements and then progress to lateral. It is important to provide the athlete with exercises specific to their sport. In order for the person to return to sport, they must perform some sort of agility test; for example the Illinois Agility test. Other common functional exercises to assess ability may include Single Leg squats for 3 minutes (muscular endurance), lateral bounding for 90 seconds and forward, backward and sideward running for 2 minutes. The final assessment box to tick is the ability of the individual to have sound neuromuscular control during all multi-planar movements.

Benefits of exercise in the treatment and management of PCOS

Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder affecting 5-10% of reproductive aged women. It is characterized by the presence of polycystic ovaries, menstrual dysfunction, infertility and hyper-androgenism. It has also been documented that there are metabolic and cardiovascular (CVD) complications as well as psychological problems including depression, poor body image and self esteem as well as reduced health-related quality of life.

The cause is unknown however there have been links to genetics, insulin resistance and lifestyle.

It has been found that 80% of women with PCOS are insulin resistant; this increase in insulin can increase the production of male hormones (androgens) in the ovary. This in turn acts on ovarian tissue, disturbing ovarian hormone regulation and the menstrual cycle resulting in infertility. Increases in androgens can also cause excessive hair growth, acne, darkened skin patches or scalp hair loss.

Insulin resistance is in part caused by lifestyle factors including being overweight and poor diet. Women with PCOS can have a genetic disposition to insulin resistance however it is estimated that 40-60% of females with PCOS are overweight or obese due to a reduced energy expenditure contributing to the development of insulin resistance. Women with PCOS are up to four times more likely to develop pre-diabetes and type 2 diabetes in their 30’s and 40’s compared to women without PCOS. There is also the risk of having gestational diabetes. Being above a women’s healthy weight range can worsen the insulin resistance and also the symptoms of PCOS.

PCOS is also a major unrecognised risk factor for cardiovascular disease as there is an increase in subclinical atherosclerosis, dyslipidemia, inflammatory proteins which can alter blood vessels and increases in blood pressure. These risk factors increase the chance of heart disease or stroke 2-fold compared to women without PCOS. While being overweight can worsen these risks, it has been found that these risks in PCOS are independent of the effect of obesity.

It is well documented that a weight loss of 5-14% via energy restriction improves CVD risk factors, hormonal profile and reproductive function in overweight and obese women with PCOS. A lifestyle modification program which includes a tailored exercise program as well as a reduced calorie diet have been found to substantially reduce body weight in women with PCOS compared to dieting or exercise alone.

Research is limited in regards to the frequency, intensity and type of exercise that is most beneficial for women with PCOS; however most research is centred on aerobic training programs which consist of 200-300 minutes at moderate intensity in conjunction with regular dietary advice for three months. These studies have shown improvements in restoring normal menstrual function, reducing body weight, improving fasting insulin and having a positive effect on self esteem as PCOS symptoms can reduce with body weight reductions.

The multifaceted complications associated of PCOS can have a large impact on the health of many women. This therefore demonstrates the importance of an effective lifestyle modification program that can provide ongoing advice and constant motivation for women with PCOS to engage in healthy behaviours. An accredited exercise physiologist can provide such services to ensure women are performing exercises in a safe manner and help overcome any injuries or barriers women may face in beginning a new exercise program.

Jenna Neivandt

Exercise Physiologist

References

Farid, N. (2009). Exercise in the treatment of PCOS. Diagnosis and Management of Polycystic Ovary Syndrome. Pg 203-204.

Moran, L. J., Harrison, C. L., Hutchinson, S. K., Stepto, N. K., Strauss, B. J. & Teede, H. J. (2011).  Exercise decreases anti-mullerian hormone in anovultatory overweight women with Polycystic Ovary Syndrome – A pilot study. Hormonal Metabolic Research, 43 (13), pg 977-979.

Polycystic Ovary Syndrome (2012). Retrieved from http://www.managingpcos.org.au/health-professionals/hp-about-pcos.

Thomson, R. L., Buckley, J. D. & Brinkworth, G. D. (2010). Exercise for the treatment and management of overweight women with polycystic ovary syndrome: a review of the literature. International Association for the Study of Obesity (12). Pg 202-210.

Thomson, R. L., Buckley, J. D. & Brinkworth, G. D. (2009).  The effects of exercise and lifestyle management in overweight women with polycystic ovary syndrome. School of Health Sciences, University of South Australia.

My thoughts on monitoring overtraining…

Mark Simpson 

Senior Exercise Physiologist 

Monitoring training load for an athlete may possibly be the most important aspect of any strength and conditioning program. Debate will always remain concerning, set and rep and prescription, the type of tactical and conditioning training, the type of speed training methods etc, however all these facets of training may not be as important as when to prescribe training. 

It appears as though there is no diagnostic tool to identify early signs of over training, which would suggest that a number of varying measures should possibly be used as a holistic approach to the problem. This approach may include, power output assessment, general health, state of mood, training time monotony and strain.

Hormonal assessment such as Testosterone: Cortisol ratios for overtraining is well documented (Lehman et al, 1993, Fry & Kraemer, 1997 and Fry et al, 1991) at this point however most of this type of testing is intrusive, expensive and not practical in most cases.

More recently Meeusen et al, 2004 published a test protocol examining hormonal response to a short maximal effort separated by 4 hours. Their findings may give an indication of over reaching or over training. This format, in team sports at least is hardly practical. It would require the athlete to perform the short test, perform no physical activity until the next test 4 hours later. In my experience using an athletes time this way on top of then performing their required training would not be well received.

I feel that a simple assessment that can be reproduced week after week is the key. A lot of clubs monitor load, strain and monotony on a weekly basis to review and preview load and training for the past week and the next few weeks. In the appropriate structure this method combined with a very brief survey to establish mood, sleeping patterns and indicate an upper respiratory problems ie sore throat all combine to provide a possible assessment of overtraining.

A holistic approach should be applied when attempting to monitor overtraining. As noted in the lecture, there are numerous physiological, psychological, metabolic and performance signs and symptoms of overtraining, so it is unrealistic to that one measure could successfully track all these signs. When determining which measures to use, it is important to think of what is practical for the sport/athletes that are being monitored. For example, while lab and other various stress tests may provide accurate results, they are not practical in most sport settings. Likewise RPE’s may not be successful in team sports as athletes may not take them seriously and do not want to seem ‘weak’ to their team mates by saying the session felt hard when someone else said it was easy. 

I believe short, invasive tests that are easy to administer should be used to evaluate the physiological state of the athlete. Again not all measures are applicable for every sport but i think some of the better measures involve checking morning heart rates, session RPE’s and food diaries to assess appetite. It is also a good idea to undertake 1RM tests and short sprint tests periodically throughout the year. This will help evaluate the effectiveness of training, but also a decrease in performance may be a sign of overtraining. It may be a good idea every week or so to ask and record how your athlete has been feeling and sleeping. 

I think it is also very important that the strength and conditioning coach explains the concept of over-reaching and overtraining to the athletes so they understand the importance of why such things need to be monitored. If they are aware of what to look for then they can speak up if they feel they are suffering any of these symptoms. This may be easier said than done, however knowledge is better than ignorance and it may be worth a try.

Total Hip Replacement Surgery By Sam Buchanan- Exercise Physiologist

Achieving greater patient outcomes

This blog article seeks to provide information and reasoning for an individual when a Total Hip Replacement looks a likely outcome from chronic hip pain. It will provide a basic understanding of a Total Hip Replacement, from indications to surgery to pre/post-surgical care.

In addition, the new concept of ‘Anterior Hip Replacement Surgery’ will be explored, as a new and improved method in providing faster and improved patient outcomes.

What is a Total Hip Replacement?

A total replacement has become a common operation due to advances in surgery and quality of artificial joints. The hip joint is a ball and socket joint that connects the femur to the pelvic bone (or acetabulum), which is held together by muscles, ligaments and tendons. The inside of the joint has a smooth protective covering of cartilage that plays a vital role in movement between the head of femur and acetabulum. When the joint is diseased, the cartilage tends to wear away, decreasing its cushion like role and increasing bone on bone contact within the joint. You could hardly imagine the pain, stiffness, limping and muscle weakness this causes to the individual!

Common major causes of joint damage can include:

·       Osteoarthritis: Where joint wear and tear causes restricted movement, stiffness and pain. This is directly associated with age.

·       Rheumatoid Arthritis: A generalised disease which affects many joints; it is significant by increasing inflammation and severe degeneration of joints that worsens over time.

·       Trauma-related arthritis: Results from injury or damage caused by a sports injury or car accident for example. This causes long-term pain and immobility.

One of the major considerations for a total hip replacement, is when other treatments have not relieved pain or disability. The aim of the replacement is to provide the patient with pain relief, increase in quality of life/activities of daily living and restore normal hip function. The hip replacement or ‘arthroplasty’ is the full replacement of the ball and socket of the hip joint, with an artificial joint (or prosthesis). There are two components to this:

·       Femoral Component: This forms the head and stem of the femur. The stem is made of titanium and is inserted via a drilled hole in the femoral shaft.

·       Acetabular Component: This replaces the socket of the joint, by ‘reaming’ or drilling out worn and damaged cartilage, which then a new plastic cup relines the acetabulum.

Recovery after the Hip Replacement Surgery

For the 3 months post the operation, dislocation of the prosthesis is at a significant risk. This can have severe implications on your recovery time and quality. To keep this risk at a low, here are some simple guidelines to follow:

·       DO NOT flex your trunk more than 90 degrees when sitting or standing

·       DO NOT sit on low furniture

·       DO NOT cross your legs when in bed or sitting

·       DO NOT twist your affected side or pivot when getting up from bed or chairs

·       USE an elevated toilet seat and normal chair

·       USE slip on shoes to avoid tying shoelaces

One of the most important aspects of your recovery is for the Physiotherapist of Exercise Physiologist to get you standing out of bed a day or two after surgery. For a successful replacement, you cannot afford the joint to become immobile.

Below are other important aspects associated to your post-surgery period:

·       Some pain is expected, but severe pain must be avoided. Panadol Osteo will be prescribed regularly, for pain relief purposes and so you can perform your exercise rehabilitation properly.

·       Some surgeons require you to wear ‘compressive’ stocking to help reduce leg swelling, but also promote venous return. To aid this, the patient must also move their foot ‘up and down’ for circulation. Deep Vein Thrombosis (or blood clots) is a result of immobility, therefore blood circulation is highly important.

·       A pillow must be placed between your legs to keep proper alignment in your hip, and to reduce the chance of dislocation.

Exercise Rehabilitation

It is vitally important to regain strength and mobility in your replaced him, which will also decrease the chance of dislocations.

Below are some basic exercises to get you going. 

Bed Hip Exercises:

Hip and Knee Flexion

Gently bend your left/right knee by sliding your heel toward buttock. Repeat with other leg

Hip Abduction

Slide left/right leg out to the side, no more than 30 degrees. Ensure that the knees and toes point towards the roof

Quads over Fulcrum

Place a rolled up towel under your left/right knee. Straighten your leg to lift your heel off the bed. Hold for 5 seconds, lower slowly.                                                                                   

Knee Extensions

Sitting over the edge of bed or chair, straighten your left/right knee and hold for the count of 5 and lower slowly. Complete both legs.

Standing Hip Exercises 

These exercises are to be completed when you have been discharged from hospital. This is usually 5 days following your surgery.

Abduction

Stand tall, hold bench or table. Raise leg sideways in line with the body. Remember to keep the toes facing forward.

Hip Extension

Stand tall, raise leg behind. Remember to keep leg and back straight.

Marching on the spot

Stand tall, raise operated slowly towards chest 

Heel Raises

Rise up onto toes, keeping straight legs

Mini Squats

Face a bench or chair and bend both knees, keeping heels on the ground. Straighten knees again.

Once it has been 6 weeks since discharge from hospital, you will have a review assessment with your surgeon. Here, the surgeon will advise you on progress, and outline what daily tasks you can return to. For most, it will be return to work for half days for the first week, then full duties following that. A final follow up with your surgeon will occur 12 months from discharge to monitor full progress.

The future of Total Hip Replacement surgery

The current method of surgery for a replacement is rather invasive on the muscles and surrounding structures of the hip, hence the lengthy recovery process and pain associated. Therefore, with a quicker and easier recovery process in mind, a new ‘Anterior’ method is being discovered. This Anterior Total Hip Replacement method can replace the standard posterio-lateral method, meaning a quicker recovery following surgery.

During the Anterior method, the patient is placed on his/her back, opposed to the tradition side method. This position gives the surgeon greater accuracy in assessing pelvic position as well as putting in the new components of the hip. In addition, only a 10-12cm incision is made, where it is usually double the length in traditional methods.           

Patients who have the Anterior method are usually off ambulatory aids, such as crutches, within 2-3 weeks, as opposed to 3-6 weeks with the traditional method. In saying this, it is not common as you need specialised surgical equipment to complete the surgery, such as the Hana table which places the patient in a specific stable supine position. Equipment like this is very expensive and is mostly performed overseas in American hospitals.

 All of this is very encouraging however, in providing the patient with quicker and complication-free recovery from such an intrusive procedure. The hip replacement surgery will remain as one of the best invented procedures in improving quality of life for the individual.

The Role of Physical Activity in the Management of Respiratory Conditions: Asthma and Chronic Obstructive Pulmonary Disease (COPD)

Zoe Lechte - Exercise Physiologist

PACE Health Management

 Each year in Australia, lung disease causes nearly 350,000 hospitalisations, and is the cause of approximately 14% of all deaths (4).

 It is estimated that Chronic Obstructive Pulmonary Disease (COPD) affects over 2 million Australians, almost 18.6% of the population aged over 40. It is estimated that by the year 2050, if nothing is done to alter current trends, 4.5 million Australians will suffer from COPD (1).  Almost 10% of the Australian adult population currently has asthma. Asthma and COPD together cost Australia over $1 billion annually (5).

As well as financial cost, respiratory conditions have a huge affect on those suffering from these conditions. If an individual suffers from breathlessness upon moderate exertion, they may decrease their participation in physical activities. This may lead to physical deconditioning, leading to increased breathlessness in low intensity exercise. This downward spiral can continue until individuals experience dyspnea (shortness of breath) during simple activities of daily living, decreasing independence and quality of life.

Smoking is single largest cause of COPD. In addition to smoking, other risk factors include passive smoking, exposure to air pollutants, occupational dust and chemicals, genes, gender, a history of childhood respiratory infection, socioeconomic status, and under-diagnosis (1).  

There is considerable evidence supporting physical activity in the management and treatment of respiratory conditions. This article aims to explore the role that physical activity can have in the treatment and management of COPD and asthma, and how specific exercise prescription can be used as a treatment to improve quality of life and maintain independence in those living with respiratory conditions. Although some signs and symptoms can be similar, physiologically asthma and COPD have key differences, and therefore have different considerations when prescribing exercise as a treatment modality.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Pathophysiology:

COPD is a collective term for conditions characterised by progressive airflow limitation that is not fully reversible. COPD includes chronic bronchitis and emphysema.

Chronic bronchitis is defined by the presence of cough and sputum production for at least three months in each of two consecutive years. It refers to the inflammation and scarring of the airways, and excessive mucus production, and results in a characteristic cough (1,3). 

Emphysema is characterised by alveolar dilation and destruction. Elastic tissue in the lungs is damaged, causing to difficulty during expiration, which can cause hyperinflation. As healthy alveoli (air sacs in lungs) are destroyed, the surface area of the lung exposed to oxygen is reduced, resulting in reduced ability to deliver oxygen to the bloodstream. Lung tissue does not repair itself, therefore the damage is progressive and permanent (1).

There are four stages of COPD which are used to diagnose and determine severity, known as the GOLD guidelines (Global Initiative for Chronic Obstructive Lung Disease).

·    Stage I: Mild COPD – Characterised by mild airflow limitation (FEV1/FVC<0.70; FEV1≥80% predicted). Symptoms of chronic cough and sputum production may be present, but not always. Individual is usually unaware that lung function is abnormal (2).

·    Stage II: Moderate COPD – Characterised by worsening airflow limitation (FEV1/FVC < 0.70; 50% ≤FEV1 <80% predicted), with breathlessness typically developing on exertion and cough and sputum production sometimes also present. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms (2).

·    Stage III: Severe COPD – Characterised by further worsening of airflow limitation (FEV1/FVC < 0.70; 30% ≤FEV1<50% predicted), greater breathlessness, reduced exercise capacity, fatigue, and repeater exacerbations that almost always have an impact on quality of life (2).

·    Stage IV: Very Severe COPD – Characterised by severe airflow limitation (FEV1/FVC < 0.70; FEV1< 30% predicted or FEV1 < 50% predicted plus the presence of chronic respiratory failure). Respiratory failure may also lead to effects on the heart such as cor pulmonale. At this stage, quality of life is very appreciable impaired and exacerbations may be life threatening (1).

Treatment of COPD

As COPD is not curable, once diagnosed, management aims are to improve quality of life, increase capacity for exercise and ultimately, slow progression of disease, prevent and treat exacerbations and complications and reduce mortality.

To manage COPD, cessation of smoking is needed to help improve symptoms and slow rate of progression, medications such as reliever inhalers can be used to dilate airways and improve respiration, and oxygen therapy can be prescribed for those who are unable to maintain adequate oxygen levels in the bloodstream. Pulmonary rehabilitation is now perceived to be equal to pharmacological and oxygen therapy in the treatment of COPD (7).  

Pulmonary rehabilitation includes assessment, exercise training, education, nutritional intervention and psychosocial support, and programs aim to increase exercise tolerance and improve physical function, reduce breathlessness, improve quality of life, improve mood and motivation, improve knowledge of condition, and increase participation in activities of daily living.

The Role of Exercise

Exercise has many benefits for those with COPD including increasing energy levels, muscular strength and endurance, cardiovascular endurance, bone density, the ability to complete activities of daily living, self-esteem and confidence, and decreasing breathlessness, likelihood of developing comorbidities and depression (7,9).

Increasing physical activity also assists in reversing the downward spiral of breathlessness. This spiral displays that respiratory impairment leads to dyspnea during moderate exertion, then abstention from exercise, to physical deconditioning. It then displays dyspnea during mild exertion, leading to further abstention from activity, further deconditioning, to finally experiencing dyspnea during activities of daily living (6).

Exercise Prescription for COPD:

Mild COPD: 20-60minutes of cardiovascular exercise such as walking at least 3-5 days per week, in addition to functional resistance, postural exercises and flexibility (2).

Moderate to severe COPD: Highly dependant on exercise capacity of individual. Cardiovascular exercise such as walking, at an intensity of 3-4 out of 10 on a dsypnea scale – indicating moderate shortness of breath. , training may be intermittent, and frequent rest breaks included as necessary (2).

Special Considerations: When exercising with COPD, the participant should be aware of techniques to alleviate breathlessness, such as pursed lip breathing, relaxed breathing and recovery positions. Exercise sessions should include warm up, aerobic and cool down components.

Individuals with COPD often have co-morbidies which must also be taken into account when prescribing exercise, including diabetes, cardiovascular disease, osteoporosis, arthritis or depression. Difficulty breathing, fatigue, shakiness, chest pain and other signs and symptoms should be closely monitored.

As these individuals are often on medication which may alter their heart rate, exercise intensity should not be monitored using heart rate alone. If possible, monitor oxygen saturation, and use a dyspnea or breathlessness scale to monitor intensity. 

ASTHMA

Pathophysiology:

Asthma is a chronic inflammatory disorder of the airways, characterised by airway hyperresponsiveness (AHR), airway obstruction (which is mainly reversible with treatment), and episodes of dyspnea, chest tightness, coughing, and wheezing (8).

Inflammation of the airways is a consistent feature of asthma. Inflammatory cells are activated which promotes the release of chemical mediators, which contribute to inflammation.  Over a period of time, chronic inflammation can lead to airway remodelling - structural changes in the smooth muscle and epithelium of the airways. Structural thickening of airway walls and subsequent airway narrowing can be largely irreversible (3,8).

Inflammation is caused by triggers, which can include allergens (animal hair, dust mites, moulds etc.), air pollutants such as cigarette smoke, cold air, exercise, infections and some drugs. In 90% of asthmatics, exercise is a cause of bronchoconstriction. When exercising, the rate and depth of breathing increases (hyperpnoea), and the lungs are not able to humidify the increased volume of air. This results in evaporative water loss, cooling and drying of the airways, which releases inflammatory mediators that over time cause damage to the airways and constrict airway smooth muscle. This is known as exercise-induced bronchoconstriction (3,8). 

Why then, is exercise recommended in the treatment of asthma?

Treatment of Asthma:

Whilst asthma can be very incapacitating and dangerous if it is poorly managed, most individuals can live full and active lives by developing and following an Asthma Action Plan. These plans include instructions from an individual’s doctor, assisting them to recognise signs and symptoms and to effectively apply treatment for worsening symptoms (3,8).

Pharmacological agents are the primary treatments for asthmatics. Three main categories of asthma medication are used to control or prevent asthmatic symptoms.

·    Controllers aim to reduce inflammatory mechanisms associated with asthma, and are usually taken daily.

·    Relievers are used to relieve bronchoconstriction, and are only used when necessary. Increased use of these displays loss of control of asthma, and indicates that a review of an individual’s treatment plan is needed.

·    Preventers are rapidly acting inhaled beta 2 antagonists, which can be used to prevent exercise-induced bronchoconstriction, if taken prior to exercise (3,8).

The Role of Exercise

In addition to pharmacological interventions, exercise has a secondary role in asthma management. In addition to assisting an asthmatic maintain a healthy lifestyle, regular aerobic exercise results in an increased VO2max. Due to this, an increased level of exercise intensity can be completed at a reduced percentage of an individual’s VO2max, decreasing the likelihood of exercise-induced bronchoconstriction (8).

Exercise Prescription for Asthmatics:

An asthmatic participating should consult their GP prior to beginning an exercise program, to ensure their Asthma Action Plan is appropriate, and to ensure they are aware of the correct use of preventers. Reliever medication should always be available, and should exercise-induced bronchoconstriction occur, the asthmatic should cease activity or continue with caution.

Initially, the recommended guidelines are 40-60% of Oxygen Uptake Reserve, between 20-60mins duration on 3-5 days per week. As cardiovascular fitness increases, the individual can progress to high intensity exercise, for example interval training or team sports (8). 

Warm up: Asthmatics should always begin with a rhythmic, low intensity warm up, which continues until they perspire mildly. Light flexibility routine can also be performed.  

Aerobic Component: Aerobic training should stress the system without straining it. Begin at a low intensity and gradually increase as fitness level improves. Aerobic training can include walking, jogging, running, cycling, swimming and game activities.

Warm down: Should be included following every training session or game, consisting of low intensity, rhythmic exercise until heart rate (HR) returns to within 20bpm of pre-exercise rate.

Special Considerations: When training outdoors, air pollutants may trigger airway hyperresponsiveness from vehicle emissions and other pollutants. Swimming has been found to produce less exercise-induced bronchoconstriction than running or cycling, however chlorine gas and other compounds found around indoor swimming pools can be highly irritable to the lungs, particularly in young children.

Due to hyperpnoea during exercise, training in cold temperatures can promote airway remodelling due to breathing in large volumes of cold, dry air.

Scuba diving is one sport in which it is not advised for asthmatics to participate, due to significant dangers for participants (8).

Summary:

Whilst there are many benefits of exercise for individuals with a respiratory condition, this population can be at an increased risk of decreasing physical activity due to their symptoms of breathlessness.

It is essential that this population is educated about their condition, and how physical activity can assist them to continue to do the things they love, complete activities of daily living, and maintain or increase their independence.

If you or somebody you know experiences symptoms of respiratory disease such as breathlessness, wheezing, a chronic cough or increased mucus production, talk to your medical professional as soon as possible. The earlier COPD is detected, the earlier it can be managed, and you can aim to prevent your symptoms worsening.

An Accredited Exercise Physiologist can tailor a specific exercise program to assist in the management of respiratory conditions and co-morbidities and can also provide education to this population.

At PACE Exercise Physiology Frankston and Malvern, Lungs in Action group exercise program is run for those who have completed pulmonary rehabilitation. This group aims to extend the benefits of pulmonary rehabilitation by enabling those with stable chronic disease to complete physical and social activities in a safe environment.

For more information on exercise physiology and respiratory conditions or Lungs in Action, please contact us on (03) 9770 6770, or info@pacehm.com.au

References:

1.     Access Economics (2008). Economic Impact of COPD and Cost Effective Solutions, Report for the Australian Lung Foundation, October, Canberra.

2.     American College of Sports Medicine (2010). ACSM’s guidelines for exercise testing and prescription (8^th Ed). USA: Lippincott Williams and Wilkins

3.     American College of Sports Medicine (2010). ACSM’s Resource Manual for guidelines for exercise testing and prescription (6^th Ed). USA: Lippincott Williams and Wilkins

4.     Australian Bureau of Statistics. Underlying causes of deaths in Australia. 2009 

5.     Australian Centre for Asthma Monitoring (2011). Asthma in Australia. AIHW Asthma Series no.4, Cat. no.ACM22, Canberra: AIHW.

6.     Haas, F., Salazar-Schicchi, J., Axen, K. (1993). Desensitization to dyspnoea in chronic obstructive pulmonary disease. Principles and Practice of Pulmonary Rehabilitation, PA, WB Saunders Company; 241-25 

7.     Majewski, M., Rozek, K. & Alawale, O. (2010). Ambulatory pulmonary rehabilitation programme in patients suffering from chronic obstructive -pulmonary disease (COPD): a preliminary study. Fizoterapia, 18(4), 11-20.

8.     Morton, A.R & Fitch, K.D. (2011). Australian Association for Exercise and Sports Science position statement on exercise and asthma. Journal of Science and Medicine in Sport, 14, 312-316.

9.     Wadell, K., Henriksson-Larsen, K., Lundgren, R., & Sundelin, G. (2005). Group training in patients with COPD – Long-term effects after decreased training frequency. Disability and Rehabilitation, 27(10), 571-581.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The purpose of this review is to examine and discuss the causes and effects of Chronic Obstructive Pulmonary Disease (COPD) on patients, therefore prescription and execution of an exercise intervention can be given in a safe and effective manner. 

COPD is a progressive, degenerative lung disease that blocks or obstructs the passage of air through the lungs. As prevalence continues to increase it becomes one of the most serious chronic diseases worldwide, being the forth most common cause of death. It affects 15-20% of smokers and although it is preventable and treatable, it is not fully reversible once diagnosed.

Risk Factors
Smoking is the main risk factor for the progression of COPD and has been shown to have a dose-response relationship with the development of this condition. A cigarette contains over 4000 chemicals and chronic exposure to these can lead to an increase in inflammatory cells in the lungs, limiting airflow. This then causes rapid loss of lung function resulting in different short and long-term complications. Other risk factors include occupational dust, chemicals and air pollution which can cause coughing and mucous production leading to bronchitis and the development of COPD overtime. A history of lung infections, allergies, low socio economic status, older age and genetics may also contribute. Poor exercise and dietary habits such as a diet low in fish, fruit and vegetables has been shown to contribute to an increased risk. The more risk factors a patient is exposed to the higher the chance of COPD developing.

Aetiology and Pathophysiology
COPD is a combination of chronic bronchitis and emphysema. Characteristics of chronic bronchitis include reduced airflow due to inflammation in the bronchial tubes and increased mucus production. Emphysema is characterized by a decrease in airflow through the destruction of the lung tissue and contributes to a loss of lung elasticity, small airway closure and destruction of the lung parenchyma. Contributors to the progression of COPD include an overproduction of protease, imbalance of antioxidants, deficient repair and replacement and individual autoimmune response. Narrowing and distortion of the small airways is due to inflammation as a consequence of smoking and exposure to second hand smoke or chemicals. Overtime the high level of chemical exposure leads to infiltration of inflammatory cells, excess production of mucus blocking airways along with destruction and pathological remodelling of the extracellular matrix of the alveolar walls (fibrosis). Finally if no intervention is put in place gradual and permanent destruction of the alveolar walls and lung tissue occurs. As there is damage to the air sacs where oxygen is absorbed into the blood stream it decreases the amount of oxygen going to the working muscles causing the heart to have to pump harder which can lead to co existing cardiac issues from the extra stress placed on the body. If other risk factors are involved it could increase these effects and quicken the process. Symptoms like difficulty breathing in and out, fatigue and breathlessness can appear along the progression of the disease which can limit activity due to discomfort causing muscle wasting and further limitations in activity.  

Co Morbidities
Co existing diseases can make it difficult to achieve good results in an intervention and need to be considered. Patients with COPD commonly present with a wide variety of co morbidities such as obesity, diabetes, cardiac disease and musculoskeletal problems such as osteoporosis. Obesity is associated with causing several abnormalities in respiratory function as it alters the mechanics decreasing lung volume. It can also cause narrowing and closure of the dependant pathways, along with reduced respiratory muscle strength. Due to obese persons increased weight load, musculoskeletal issues and heart problems can arise as the body is put under higher amounts of stress and requires to work harder to supply oxygen to the muscles. Cardiac diseases are common especially pulmonary hypertension (PH) which usually occurs in conjunction with COPD. It is caused by the remodelling of the pulmonary arteries which can be initiated by the products contained in a cigarette. The thickening of the arterial walls and increases in resistance are due to the reduction of the vessel wall diameter. PH has similar symptoms and complications such as exertional dyspnoea, chest pain, fatigue, palpitations, dizziness, decreased exercise tolerance, functional limitation and decreased quality of life (QOL). As smoking is the main cause of COPD which can be linked with alcoholism, depression and anxiety, these psychological problems need to be considered if present.

Short-Term and Long-Term Complications
Short term complications associated with COPD include difficulty breathing, breathlessness, coughing, mucous production, fatigue, wheezing and frequent exasperations. These can lead to consequences such as absence from work, decreased income, impaired ability to perform activities of daily living (ADL’s), lack of physical activity and isolation from social events. Symptoms tend to worsen with increased movement, so the patients tend to limit this by not participating in exercise or moderate activity. Overtime this can lead to exercise intolerance, increased limitation in ADL’s, ventilator and circulatory constraints, pulmonary gas exchange impairment and peripheral muscle abnormalities. This then can result in reduced oxygen delivery to the skeletal muscles during exercise, which worsens all the short term complications such as breathlessness if they try to increase movement. Changes such as a lower percentage of slow twitch fibres, reduced diameter of type two fibres and lower oxidative enzyme activities may also be seen over time. Evidence exists for locomotor muscle impairment and dysfunction in COPD patients which is due to deficits in strength, endurance and muscle atrophy. The above issues can lead to psychological problems like depression, anxiety and decreased QOL, which develops into a continuous cycle for the patient unless an intervention is put into place.

Best Practice Guidelines
It is suggested that clients with COPD should make behavioural and lifestyle changes depending on the cause and risk factors that contributed to their disease. The biggest and most beneficial change they can make is to stop smoking, as although COPD can’t be reversed this has been shown to slow the progression of the disease. Along with cessation of smoking, patients with COPD should try to eliminate or minimise any exposure to chemical pollutants, air pollution or occupation dust that may have contributing factor.  Along with these changes a patient may require further education making it an important part the rehabilitation program.

A healthy balanced diet including smaller portions more frequently and adequate fluid intake is recommended to help minimise symptoms and manage COPD. Weight loss can occur as patients can feel breathless after large meals due to diaphragmatic splinting, leading to reduced food intake. The body will also have to work harder to breathe burning more calories resulting in a further decline in weight, suggesting adequate energy intake be maintained. It has also been put forward that patients should protect themself from cold air and respiratory infections to help maintain good health.

Pharmacological treatments used as directed can help maintain reoccurring symptoms.  Bronchodilators such as short-acting beta agonists have been shown to increase forced expiratory volume (FEV), reduce breathlessness, increase exercise capacity and improve health status. Inhaled steroids can be used to try and treat exasperations although research has shown it to only to be beneficial in some patients with COPD. Similarly, oxygen therapy can be required and beneficial for a selection of patients but is determined by their general practioner through a serious of tests. Surgical interventions have also been trialled but have found to be ineffective with the risks out-weighing the benefits.

Exercise Testing and Prescription

Exercise assessment along with a thorough medical and exercise history is crucial before starting any exercise program, especially for those with chronic conditions such as COPD. The assessment is used to establish baseline levels for the patient, help them set appropriate goals, assist in the formulation of the exercise intervention and can be used to screen any abnormalities or limitations. Some common assessments used include the Chronic Respiratory Questionnaire (CRQ), London Chest Activities of Daily Living Scale, Stair climb power test, Incremental and endurance shuttle walk tests and 6 minute walk test (6MWT). Many studies have shown that exercise in conjunction with pharmacotherapy and oxygen therapy can have positive effects on people with COPD. It can result in an improvement in exercise tolerance, increased ability to perform ADLs, improved QOL and a range of positive physiological changes. Research has shown that if adequate screening and medical therapy is completed that the risk of exercise for these patients with COPD are quite low. It is recommended that heart rate, saturation of oxygen (Sao2) and dyspnoea levels are measured pre and post exercise to help monitor the signs and symptoms of the patient.

Although exercise sessions for patients with COPD need to be individualised and depend on certain factors, there is a wide range of research that has developed guidelines for this population.  Rochester, (2003) recommend that when prescribing exercise for patients with COPD a combination of endurance and strength training involving the whole body should be used. This program should last for at least 20-30min, be completed 3 to 5 times a week, at an intensity of 60-70% of Vo2max. Similarly, the American Association of Cardiovascular and Pulmonary Rehabilitation (2011) suggests at least three sessions a week for 20-90min at either a low or high intensity. Wadell, Henriksson-Larsen, Lundgren and Sundelin, (2005) conducted a study on training frequency and intensity to discover that one session a week, compared to three was insufficient in maintaining fitness gains and that a higher intensity was more beneficial to patients with COPD. Research has also shown that aerobic lower limb training of 6-12weeks can increase exercise endurance, improve walking distance by 80m and increase treadmill endurance by 10min. It was found that compared to education and medical management alone patients who also received exercise training achieved greater walking endurance and showed a decrease in dyspnoea and fatigue over an eight week program (reported by Ries & collegues as sited in Rochester, 2003).

The American Association of Cardiovascular and Pulmonary Rehabilitation (2011) suggests that aerobic training via walking (outdoors or on treadmill), cycling, swimming and arm ergometry are all ways to successfully increase the endurance capacity and improve QOL in patients with COPD. It is also recommend that resistance training of lower repetitions and higher weight loads are included in the program for strength gains to help increase the patient’s ability to perform ADL’s, although no exact repetition and set ranges were mentioned. To decrease the risk of falls in older patients and improve their posture, flexibility and balance are important components to be included into the exercise program1. Majewski, Rozek and Alawale, (2010) looked at another method of training by combining strength and cardio fitness into a circuit styled session. They found that two sessions per week for six weeks was insufficient and not intense enough for improvements to be made. But it was suggested that an eight week program of three sessions a week for 50min involving the main muscle groups may be more beneficial in producing physical and psychological improvements. Similarly, Leung, Alison, McKeough and Peters, (2010) found that ground walking of 30-45min, three times a week for eight weeks lead to improvements in patients with COPD as it improved peak walking capacity and QOL. Hydrotherapy is another suggested alternative that has been found to show improvements and may be a better option for people with additional musculoskeletal conditions. Along with patients exercise program it is important to include a warm-up and cool-down. A warm-up allows a gradual increase in heart rate, ventilation, blood flow and blood pressure to the working muscles; while a cool down reduces the risk of a bronchospasms, arrhythmias and orthostatic hypotension. In conclusion after reviewing the literature it is evident that at least three sessions a week for a duration of 30min minimum, over an eight week period is required to show the greatest improvements and benefits in patients with COPD.

Common Clinical Goals
The main purpose of a pulmonary exercise program is to prevent de-conditioning and help the patient manage their disease. Two ways this is achieved is by trying to improve breathing and respiratory function through breathing exercises and by increasing the endurance level of the patient by improving the amount of oxygen being respired and entering the bloodstream. Endurance can be increased by prescribing low resistance aerobic training and by conducting patient education. Education is also used to try and decrease modifiable risk factors causing beneficial lifestyle modifications such as increased fruit and veg intake along with cessation from smoking. Some additional aims of the program are to restore independence via completion of ADLs and to improve general exercise tolerance through behaviour modifications and exercise. As postural deformities can be a problem the clinician also aims to prevent or these issues through postural awareness training and exercise. As a result it should lead to control of their symptoms, improved QOL, reduced disease progression and complications, along with reduce mortality.

Outcome Measures
When working with patients with COPD it is required to examine:
1:Exercise Capacity which can be done using the 6MWDT, shuttle walk test, cardiopulmonary exercise stress test or questionnaires (LCAQ) .
2: Symptoms such as dyspnoea/fatigue which can be done using the BORG and VAS scale. 3: Health Related QOL which can be achieved using various questionnairesincluding the human activity profile and the perceived quality of improvement scale. Functional performance, home based activity, patient adherence, knowledge, psychological outcomes are other areas suggested for assessment depending on the individuals circumstances. During a session measurements like a patients need for oxygen supplementation, the BORG scale, dyspnoea indices, symptom scores and exacerbation rate should be monitored pre, post and during exercise.

Contraindicated Exercise
Contraindications to exercise testing for patients with respiratory conditions such as COPD are limited and only really becomes an issue when they have co existing cardiovascular abnormalities. Cardiac disease, asthma, respiratory acidosis, interstitial lung disease, anaemia and central sleep apnoea need to be ruled out and if found the patient needs to be referred back to their doctor.PH was seen as a contraindication to exercise but is now allowed as long as there is close supervision by an experienced personal and the exercise is sub maximal. Some absolute contraindications for exercise testing in this population include unstable angina or myocardial infarction during the previous month. Some relative contradictions include a resting heart rate of more than 120bpm or blood pressure more than 180/100. Tests should be terminated if the patient reports chest pain, intolerable dyspnoea, lower limb cramps, vertigo, productive cough, intense sweating or became pale. SpO2 should be maintained between 90 and 94% and if it falls below 90% exercise needs to be discontinued.

Safety Factors and Adverse Event Action Plans
An independent evaluation should be performed on all patients before beginning an exercise program with all sessions being documented. The majority of adverse events in COPD patients were found to result from muscle soreness and pain or heart disease.
As patients with COPD will often have shortness of breath and tend to fatigue faster at lower levels of exertion, special care needs to be taken to make sure that frequent rest breaks are included and activity levels are continually modified. Emergency equipment that should be available includes an oxygen source and delivery apparatus (if required), resuscitation mask, first aid supplies and bronchodilator medications. The professional should also have a current level 2 first aid qualification. The site of exercise should have a rapid, appropriate, practiced response plan in case of an emergency. Termination of exercise must occur if chest pain/discomfort, burning sensation, heaviness or pressure in neck/jaw/arms, dizziness, unusual shortness of breath, palpations or if extreme fatigue develops.

Conclusion
COPD is an irreversible, degenerative lung disease caused by smoking or exposure to chemical irritants. It can lead to short and long term complications such as breathlessness, decreased QOL and limited ability to perform ADL’s. Research indicates that for benefits an initial assessment followed by an exercise program for this population should be conducted for at least 30min, three times a week. Included should be a combination of strength, aerobic, flexibility and balance exercises, along with a warm-up and cool-down. Being one of the leading causes of death further research needs to be conducted in the area of COPD and exercise prescription, so maximum benefits can be achieved by these patients.