Rehabilitation after lung transplantation

Thierry.troosters@kuleuven.be  

Outline  

• What  are  the  challenges  

•  Is  post  LTX  rehab  needed  • How  to  do  rehabilita:on  post  LTX  

•  Exercise  training  

•  Other  disciplines  

• Points  of  a?en:on  

The  transplanta:on:    impact  on  func:onal  status  

0  10  20  30  40  

50  

60  

70  

80  

QF  %pred  

0  

10  

20  

30  

40  

50  

60  

70  

FEV1  %pred  

0  50  

100  150  200  

250  

300  

350  

400  

6MWD  m  

Mauri  Am  J  Transplant  2008    

Mauri  Am  J  Transplant  2008    

0 10 20 30 40-100

-75

-50

-25

0

25

ICU-stay (days)

Δ Q

F Po

st-P

re L

TX(N

m)

The  transplanta:on:    impact  on  func:onal  status  

0   50   100   150   200   250   300   350  

0  

4  6  8  

10  

12  14  

Work  Rate  (WaLs)  

Serum  [La+]  (mmol.L-­‐1)  

VO2peak      ml.min-­‐1.kg-­‐1  

LT    ml.min-­‐1.kg-­‐1  VE    l.min-­‐1    MVV    l.min-­‐1  

18.7  8.3  64  92  

1.5  0.7  7.1  10    

±  ±  ±  ±  

36.9  16.7  119  136  

2.4  1.2  13  5  

±  ±  ±  ±  

LTX  (n=7)   Ctr  (n=7)  

Muscle  func:on  aCer  LTX  

Wang  AJRCCM  1999  

0   50   100   150   200   250   300   350  

0  

4  6  8  

10  

12  14  

Work  Rate  (WaLs)  

0%

20%

40%

60%

80%

100%

LTX Healthy

Type II

Type I

Serum  [La+]  (mmol.L-­‐1)  

Wang  AJRCCM  1999  

Muscle  dysfunc]on  much  like  that  seen  in  chronic  disease  Oxida]ve  capacity  specifically  impaired  

Muscle  func:on  aCer  LTX  

Post  LTX  (n=12)   Controls  (n=12)    Time  post  TX   months   35   ± 28   -­‐  FEV1   %pred   74   ± 24   108   ± 12  BMI   Kg.m-­‐2   22   ± 2.7   24   ± 3.4  VO2peak   %pred   63   ± 20   101   ± 16  Endurance   min   20   ± 10   36   ± 19  

Guerrero  Am  J  Physiol  Regul  Integr  Comp  Physiol  2005  

Func:onal  consequences  

Mechanisms  of  muscle  dysfunc:on  

Inac:vity  Exacerba:ons  Systemic  inflamma:on  Hypoxia  Oxyda:ve  stress  Malnutri:on  

Immobility  &  ICU  Ini:a:on  Immune  suppression  Reduced  anabolism  

Physical  ac:vity  ?  Rejec:on  Chronic    disease  

Pre-­‐LTX

1yPost-­‐LTX

Healthy

0100020003000400050006000700080009000

Daily  Steps

Pre-­‐LTX

1yPost-­‐LTX

Healthy

0255075

100125150175200225

Minutes  >  2  M

ETs

35%   28%  

63%  52%  

Langer  et  al.  JHLTX,  2009  

Mechanisms  of  muscle  dysfunc:on  

0  10  20  30  40  50  60  70  80  90  100  

<1yr    1-­‐5yrs  

Prevalen

ce    %

 

Hertz  J  Heart  and  lung  Transplanta]on  2002.  

Other  long  term  complica:ons  

Petrucci  Eur  J  Heart  Failure  2007.  

0  10  20  30  40  50  60  70  80  90  

100  

Employed   Drives  car   Drives  motorcycle  

Bicycle   Infec:on  previous  month  

Heart  n=79  Lung  n=72  

%  

Other  long  term  complica:ons  

Outline  

• What  are  the  challenges  

•  Pa:ents  start  with  muscle  weakness  

•  Pa:ents  remain  decondi:oned  

•  Long  term  ‘systemic  consequences’  

•  Social  problems  

Outline  

• What  are  the  challenges  

•  Is  post  LTX  rehab  needed  • How  to  do  rehabilita:on  post  LTX  

•  Exercise  training  

•  Other  disciplines  

• Points  of  a?en:on  

A  Randomized  controlled  trial  

Both  groups:  

●     Regular  measurements  of  daily  physical  ac:vity  

●     Feedback  on  daily  ac:vi:es  +  goal  segng    

Pre-LTX 160 days

Control

Exercise Training

Post-LTX 28 days

3mPost Random

12mPost Random

Resistance  exercises  Cycling  

Treadmill  walking  

Stair  climbing  /  Step  

Arm  Ergometry  

A  Randomized  controlled  trial  

Lung transplantations performed from November

2006 until October 2009 (n=145)

Analysed (n=18)

Lost to follow-up due to severe medical complications (n=3)

Allocated to intervention group (n=21) Received allocated intervention (n=21)

Lost to follow-up due to severe medical complications (n=2) or unwillingness to continue participation in the study (n=1)

Allocated to control group (n=19) Received allocated intervention (n=19)

Analysed (n=16)

Allocation

Analysis

Follow-Up

Enrollment

Randomized (n=40)

Excluded (n=105) ●  Not meeting inclusion criteria (n=72)

●  < 40 yrs (n=53) ●  > 6 wks hospital stay (n=19)

●  Declined to participate (n=33)

Interven:on   Control  Age  (yrs)   59   ± 4   59   ± 6  

Height  (cm)   165   ± 7   166   ± 7  

Weight  (kg)   61   ± 15   58   ± 13  

Gender  (m/f)   9   /   9   7   /   9  

Time  to  LTX  (days)   174   ± 118   152   ± 154  

Hospital  stay  (days)   27   ± 7   28   ± 7  

COPD  (%)   15   (83%)   14   (88%)  

SSLTX  (%)   15   (83%)   14   (88%)  

Acute  Rejec:on  (%)        6   (33%)   5   (31%)  

Baseline  Characteris:cs  

Pre Post

3mPost

1yPost

20

40

60

80

100

TrainingControl

Walking  (m

in/day)

Pre Post

3mPost

1yPost

0

25

50

75

100

125

>3METs  PA

 (min/day)

P  =  0.06  

*

*

*

 =  Interven:on  period  

*

*

*

Physical  ac:vity  

Pre Post

3mPost

1yPost

40

50

60

70

80

90

100 **

QF  %pred

Pre Post

3mPost

1yPost

40

50

60

70

80

90

100

TrainingControl

**

6MWD  %pred

*  =  p<0.05  

Physical  fitness  

Interven:on   Control   p  BMI  (kg/m2)  

Pre-­‐LTX  

1yPostLTX  

 

22.6  

24.4  

 

±  

±

 

4.6  

4.7  

 

21.5  

24.1  

 

±  

±

 

4.9  

4.0  

 

 

0.89  

BP  systolic  (mmHg)  

Pre-­‐LTX  

1yPost-­‐LTX  

 

129  

126  

 

±  

±

 

13  

8  

 

126  

142  

 

±  

±

 

12  

16  

 

 

0.00  

Diabetes  (%)  

Pre-­‐LTX  

1yPostLTX  

 

-­‐  

1  

 

 

(6%)  

 

-­‐  

4  

 

 

(25%)  

 

 

0.11  

Co-­‐morbidity  

Outline  

• What  are  the  challenges  

•  Is  post  LTX  rehab  needed  •  Pulmonary  rehabilita:on  is  essen:al  to  restore  exercise  tolerance  and  Physical  Ac:vity  

•  It  may  prevent  long  term  systemic  consequences  

•  Should  be  part  of  the  management  of  pa:ents  post  LTX  

Outline  

• What  are  the  challenges  

•  Is  post  LTX  rehab  needed  • How  to  do  rehabilita:on  post  LTX  

•  Exercise  training  

•  Other  disciplines  

• Points  of  a?en:on  

How  to  conduct  exercise  training  post  LTX  

• General  training  principles  apply  •  Intensity  •  Dura:on  •  Frequency  •  Specificty  

•  Focus  on  restoring  muscle  func:on  •  Include  resistance  training  

• A?en:on  for  balance  and  propriocep:on  as  these  pa:ents  may  start  moving  again...  

How  to  conduct  Rehab  post  LTX  

• A?en:on  for    •  Social  aspects  and  psychological  aspects  •  Compliance  and  relapse  of  old  behavior  •  Reïntegra:on,  work  

No  smokers   Ac]ve  smoking   Posi]ve  Co]nin  

Vos  Eur  Respir  J  2010  

Outline  

• What  are  the  challenges  

•  Is  post  LTX  rehab  needed  • How  to  do  rehabilita:on  post  LTX  

•  Exercise  training  

•  Other  disciplines  

• Points  of  a?en:on  

Factors  further  complica:ng  post  TX  exercise  performance  

• Gender  

Pre LT

X

Post LT

X

Post Reha

0

100

200

300

400

500

600

6MW

D (m

)

Pre LT

X

Post LT

X

Post Reha

30

40

50

60

70

80

90

QF

(% p

red)

Mauri  Am  J  Transplant  2008  

Male  Female  

• Osteoporosis  

Maalouf, J Clin Endocrinol Metab 2005

Factors  further  complica:ng  post  TX  exercise  performance  

0,8  

0,85  

0,9  

0,95  

1  

1,05  

1,1  

1,15  

Pre  LTX   Post  2months   Post  8months  

Control  (n=10)  

Alendronate  (n  =  10)  

Alendronate  +  training  (n  =  10)  

Δ  in  lumbar  v

ertebral  BMD  (L-­‐2  and

 L-­‐3)    %pre  

Braith J Heart Lung Transplantation 2006

Factors  further  complica:ng  post  TX  exercise  performance  

Factors  further  complica:ng  post  TX  exercise  performance  

•  Tendinopathy  

Chhajed, Eur Respir J 2002

No  

Tendini]s  

Rupture  

2.2±2.7  years  post  LTX   Risk  factors  Underlying  Emphysema  (p=0.07)  Use  of  fluoroquinolones  20/22  cases  

Factors  further  complica:ng  post  TX  exercise  performance  

Summary  

•  LTX  has  a  massive  further  impact  on  muscle  func:on  

•  Post  LTX  rehab  is  needed  to  restore  muscle  func:on  and  physical  ac:vity  

•  Specific  points  of  a?en:on  in  the  rehabilita:on  process  include    

•  Gender  •  Osteoporosis  

•  Tendinopathies  •  ‘Regained  mobility’  (fall  risk)