# Case Study Two

Janice is a 61 year old female with moderate to severe COPD. She is retired and lives with her husband. She is independent with all her ADLs although she sits while in the shower. Her main difficulties are walking while carrying loads as well as walking up hills and stairs. She has osteoporosis. She stopped smoking six months ago following a 40 pack year history of smoking. Her respiratory medications include Pulmicort and Ventolin. Janice wants to improve her fitness so she can take the dog for a 30 minute walk daily and be able to look after her grandchildren every week.

On assessment, her spirometry is FEV_{1 }/ FVC = 0.89/1.55 with an FEV_{1 }(% pred) of 43%. Her weight is 54 kg, height 149 cm, BMI = 24.3. Resting HR = 78 beats/min; resting SpO_{2}% = 96%. She is able to walk 456 m without rests in the best of two six minute walk tests. Her oxygen saturation was 94% at the end of the walk and she felt very severely breathless (dyspnoea score 7).

#### What exercise would you prescribe?

**Goal: **Begin with 15 minutes walking, 15 minutes cycling, arm endurance exercises and upper and lower limb strength training exercises. You may introduce these exercises over the first 3 visits. Progress the intensity and duration as able.

**Walking Program**

Use results of the 6MWT. For example, if Janice walks 456 m in six minutes an appropriate distance to walk in 15 minutes is:

= (456/6 x 15) x 80%

= 912 m (convert this into laps on a track length of 30 m = 30 laps). Then progress the walking time to 20 minutes as soon as able.

If a treadmill is available for walking exercise – convert six minute walk distance into walking speed x 80% to 100% intensity. Treadmill speed may need to be set 0.5-1.0 km/hr slower than calculated due to the unfamiliar nature of treadmill walking compared to walking on a flat track.

i.e. [(456/6 x 60)/1000] x 80% to 100% = 3.6 km/hr to 4.6 km/hr x 15 minutes duration. Progress duration (eg 20 minutes) then intensity of treadmill (e.g. increase speed, once maximum achieved, add incline eg flat to 5%).

**Cycling Program**

Use the Borg scale to set intensity level such that Janice feels moderately to somewhat severely breathless (3 to 4 on Borg Dyspnea Scale) during the cycle exercise.

Cycle at a speed to maintain this intensity for 15 minutes. Progress the duration of cycle time as able (e.g. 20 minutes). Interval training may also be considered for Janice.

**Arm Exercises**

The arm exercises that could be included are low weight (500g), high repetition arm activities. See examples in the “Upper Limb Endurance Exercises” tables.

**Strength training**

Start with 1 set of 3 lower limb and 3 upper limb strength training exercise. See examples in the strengthening exercises tables.

**Circuit**

The flexibility and balance exercises and stretches can be included in a group circuit class.