Assesment of muscle function in chronic lung

disease

Deniz İNAL İNCE, PhD, PT Associated Professor

Hacettepe UniversityFaculty of Health Sciences

Department of Physical Therapy & Rehabilitation

MuscleHeart

Circulation Lungs

QCO2

Oxygen transportOxygen transport

PATOLOPATOLOGYGY / / I INFLAMNFLAMMATIONMATION / H / HIPOXEMIAIPOXEMIADRUGSDRUGS

INACTIVITYINACTIVITY / / DECONDITIONINGDECONDITIONING

Wasserman K et al. Principles of Exercise Testing & Interpretation, 2005

VO2

VCO2

QO2

Skeletal muscles FiberFiber DefinitionDefinition MMetabolismetabolism FunctionFunction

I Slow, resistant to

fatigue

Oxidative Standing, quiet

breathing

IIa Fast, resistant to

fatigue

Oxidative/glycolotic

Walking, Hipervent

IIb/x FastNot

resistant to fatigue

Glycolotic JumpingCough

DeconditioningMuscle mass AtrophyFiber typeMuscle metabolism

Malnutrition Malnutrition

Inactivity Inactivity

DrugsDrugs

AcidosisAcidosis

SYSTEMIC INFLAMMATION

Chronic Lung DiseaseChronic Lung Disease

Anabolism Anabolism

Exercise capacity Health status QOL Mortality

Hypoxia

Hypoxia (oxidative stress) Hypoxia (oxidative stress)

Muscle oksidative stress

Mitokondria Myofilament

ATP level

Oksidative capacity

Muscle disfunction

Stimulus transmission Ca sensitivity

Contractile fatigue

Inactivity

Fatigue

Inactivity

Dyspnea

Physical activity

Lower leg activity

Motor neuron activity

Antioxidant effect

Fiber type

Energy metabolism

Muscle mass

Muscle oxidative stress

Anabolic factors

Myoflament contractility

FFM Oxidatif capacity

Skeletal muscle dysfunction

Systemic inflammationDisease severity

Malnutrition

Muscle enzyme activity Metabolic fuel storage protein & caloric intake Protein katabolism Muscle mass

Caloric intake Weight loss

Corticosteroids Conractile proteins Glycolitic activity Growth factors Protein catabolism Tip 2 fiber atrophy

Changes in muscle structure & metabolism

Tip 1 muscle fiber Oksidative enzymes CSA Aerobic capasity Earlier anaerobic metabolism Muscle mass Muscle strength Muscle endurance Muscle fatigue

Lactate Blood ammonia Pi Earlier muscle acidosis

Muscle functionMuscle function

ENDURANCEENDURANCE

Practice sessionSpecific protocol

STRENGTHSTRENGTH

FATIGUEFATIGUE

Muscle group

Contraction type

Movement velocity

Equipment

ROM

Evaluation of skeletal muscle strength

Volitional Nonvolitional

Manual muscle testing1 RMDinamometer

Electrical stimulationMagnetic stimulation

Muscle mass

FFM

Manual muscle testing 5-pointMRC

Percentages of normal values

Ambulated patients

ICU: 12 muscles

Dinamometer

Back liftdinamometer

Isometric dinamometer

Isometric

Hand grip

Isotonic evaluation Isotonic evaluation 1 repetition maximum (1 RM)1 repetition maximum (1 RM)

Free weights Dumbbells Exercise machines

Dynamic contractions against hydraulic resistance

Evaluation of skeletal muscle strength

Volitional Nonvolitional

Manual muscle testing1 RMDinamometer

Electrical stimulationMagnetic stimulation

Magnetic stimulation

Action potential

Depolarization

At rest

Maximal voluntary ventilation

Quadriceps muscle strength

Young

Normal

Erderly

Normal

ICU patient

Age (years)

30 77 46

TwAP (N) 6.9 7.1 4.6*

Mean ICU stay 18.5 days

*p=0.01, ICU patients were weaker

☐ Stength

■ Endurance

COPDCOPD

Endurance

Capacity of muscle to maintain a given level of force or work for a period of time

AssessmentAssessment strength below target Number of repetitions % of force

Equipments: Same as strength evaluation

Endurance Fatigue

Reversible reduction in the force generated by the muscle itself for a given neural input

Symptoms at peak exercise

26%

31%43%

Dyspnea

Leg fatigue Dyspnea & Leg fatigue

Killian et al. Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. Am Rev Respir Dis 1992;146:935-940.

Mechanisms of fatigue Motor neuron Neuromuscular junction Conractile mechanism (Ca) Early anaerobic metabolism Lactic acid accumulation Blood ammonia ATP-PC depletion Muscle glycogen depletion

Evaluation of fatigue

Metabolic

Volitional Nonvolitional

Strength before & after a given task

Lactic acid Blood ammonia

Subjective

Borg scaleVASFatigue scales

Motivational factors

Functional

Magnetic stimulation

0 10 20 30 40 5020

30

40

50

60

70

80

90

100

COPD

Controls

p<0.0017

p<0.006

p<0.0002

p<0.0002

Number of trains%

of

bas

elin

e fo

rce

Quadriceps fatigue

Metabolic fatigue Lactic acid level

Metabolic fatigue Blood ammonia level

Subjective fatigue

0 100

Relationship between Disease severity & Periferal Muscle Endurance & Fatigue in Patients with Chronic Obstructive

Pulmonary Disease

22 COPD (62.5 years) FEV1: 50±29% GOLD Stage IV n=7 (31.8% )

Stage III n=6 (27.3% ) Stage II n=4 (18.2% ) Stage I n=5 (22.7% )

6MWT: 507±128 m SAFE: 3.7±2.5 Fatigue Impact: 32.9±31.3 Fatigue Severity: 40.6±17.0

0 25 50 75 100 1250.0

2.5

5.0

7.5

10.0

Yorgunluk Etki Ölçeği

SA

FE

in

dek

s

Melda Sağlam, Ebru Çalık, Naciye Vardar-Yağlı, Sema Savcı, Deniz İnal-İnce, Hülya Arıkan, Meral Boşnak-Güçlü, Lütfi Çöplü

r= 0.67, p<0.05

Toraks 2009

Thank you