COPD revalidatie: minder hard trainen met meer resultaat.

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1 COPD revalidatie: minder hard trainen met meer resultaat. De noodzaak van herstel van patiënten met ernstige COPD tijdens longrevalidatie Dr Peter Klijn, Klinisch inspanningsfysioloog en Drs Ir Eline bij de Vaate, Longarts

2 LONGREVALIDATIE Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. AJRCCM

3 DOELEN Minimaliseren symptomen Optimaliseren inspanningsvermogen Promoten autonomie Verbeteren participatie in dagelijks leven Verbeteren gezondheidsgerelateerde QoL Lange termijn gedragsverandering t.a.v. gezondheid Spruit et al. AJRCCM 2013 Gloekl et al. Eur Resp Rev 2013

4 + Homeostase Verstoring -

5 Anabolisme + Homeostase Verstoring -

6 tijd Gezonde balans tussen inspanning en herstel. tijd

7 EXERCISE TRAINING Cornerstone of pulmonary rehabilitation. (Spruit et al., AJRCCM 188 (8), 2013) High-intensity paradigm (Troosters et al 2010) Optimal resistance training prescription for patients with COPD is not determined. (O Shea et al., Chest 2009; Spruit et al AJRCCM 2013) Non-responders 1/4 to 1/3 do not improve their exercise capacity following pulmonary rehab

8 BEHOEFTE ANALYSE TOPSPORTERS

9 BEHOEFTE ANALYSE 5 km fietsen met mijn vrouw Zelfstandig mijn boodschappen doen Traplopen Wandelen met vrienden

10 Spruit et al; ERJ 19(6), 2002.

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12 Nonlinear exercise training in advanced COPD is superior to traditional exercise training: a randomized trial. Onderzoek naar de effecten van niet-lineair geperiodiseerde inspanningstraining (NLPE) t.o.v. traditioneel progressieve training van het algemeen uithoudingsvermogen en de perifere spierkracht (EPR) op de submaximale fietsduur (75% Wmax) en ziekte-specifieke kwaliteit van leven bij patiënten met ernstige COPD met en zonder depletie van de vetvrije massa. Klijn et al; Am J Resp Crit Care Med 2013, 188(2); Klijn et al; Ned Tijdschr Geneesk 2013, 135(57).

13 BEHOEFTE ANALYSE Fysiologische vereisten Aeroob energie systeem Anaeroob energie systeem Beenspieruithoudingsvermogen Beenspierkracht Biomechanische vereisten Spieren over knie en heup Veel sub maximale contracties Individuele beperkingen Klijn et al; Am J Resp Crit Care Med 2013, 188(2)

14 INDIVIDUAL DEFICIENCIES Dyspnea Fatigue Anxiety Gas exchange abnormalities Altered respiratory mechanics Cardiovascular limitations Respiratory and peripheral muscle dysfunction Fat-free mass depletion Aging Klijn et al; Am J Resp Crit Care Med 2013, 188(2) Hill and Holland, Int J COPD 2014

15 Zuurstofgebrek? Luchtwegvernauwing Verlies van elasticiteit (Dynamische) hyperinflatie

16 OBSTRUCTIE EN ROL MEDICATIE Open: EELV Zwart: EILV Cirkels: placebo Vierkant: salbutamol QB: quiet breathing Aliverti A. et al, Thorax 2005;60:

17 Brashier, JAPI 2012

18 Pathofysiologie Banzett et al, ERJ 2015 Cognities Gedrag

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20 TECHNICAL DEFINITION strategy or principle for organizing long term training. to divide the longer period into smaller periods with different goals, structures, and content of the training program.

21 NONLINEAR (UNDULATING) MODEL OF PERIODIZATION Variation in intensity / duration and volume by rotating different protocols train various components of neuromuscular system only one characteristic is trained in each workout achieve adequate recovery and prevent overtraining Daily / weekly

22 RECOVERY Immediate recovery uitvoering Short-term recovery 1 e sets en series 2 e oefeningen Training recovery Bishop et al., J Strength Cond Res 22(3) 2008

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24 NONLINEAR EXERCISE TRAINING Energy system cycle training Resistance training Repetition range Aerobic (1-4) x (3-10) min 50-60% W peak 1-3 min (15-30) x 30 sec >95% W peak 30 sec 20 reps 1 min Muscular endurance reps 1 min Anaerobic 8-10 reps 2 min 4-8x (2-7)min 65-80% W peak 2-5 min 6-10x (90-120)sec 85-95% W peak 1-3 min 4-6 reps 2-3 min 1-3 reps 3-4 min Strength Klijn et al; Am J Resp Crit Care Med 2013, 188(2)

25 Cycle endurance (seconds) Cycle endurance (seconds) 1200 depleted groups nondepleted groups EPR-depleted NLPE-depleted Baseline 6 w eeks 12 w eeks Measurem ent Baseline Measurement EPR-nondepleted NLPE-nondepleted 12 weeks CWT EPR (n=55) NLPE (n=55) Difference (95%CI) Time, s +238 s +539 s 300.6( ) End Sp O ,5 ( ) dyspnea 6,4 5,5-0,9 (-1,6 - -0,1) leg fatique ( ) Klijn et al; Am J Resp Crit Care Med 2013, 188(2)

26 KWALITEIT van LEVEN CRQ-score EPR (n-55) NLPE (n=55) Difference (95%CI) dyspnea ( ) fatigue ( ) emotions ( ) mastery ( ) Klijn et al; Am J Resp Crit Care Med 2013, 188(2)

27 SYMPTOMEN Cycle exercise Leg press Dyspnea Fatigue Exertion Dyspnea Fatigue Exertion EPR 4.0 ± ± ± ± ± ± 0.9 NLPE 2.9 ± ± ± ± 0.9 * 2.7 ± ± 0.7 *

28 Training smart! BEDANKT VOOR UW AANDACHT Soestdijkerstraatweg VX Hilversum