### Case Studies

Bill is a 57 year old man with severe COPD. He is a retired truck driver who lives with his wife and son. He has difficulty walking on the flat, showering and carrying heavy loads. These activities produce breathlessness and low back pain as he has had a previous fracture to the pelvis. As a result, his wife assists him with most ADLs. He stopped smoking three months ago following an 80 pack year history of smoking. The respiratory medications he uses are Seretide, Ventolin and Spiriva. He is keen to lose some weight and be able to return to gardening.

On assessment, his spirometry is FEV_{1 }/ FVC = 0.63/1.2 with an FEV_{1 }(% pred) of 22%. His weight is 90 kg, height 178 cm, BMI = 28.4. Resting HR = 85 beats/min; resting SpO_{2}% = 93%. He is able to walk 324 m with two rests in the best of two six-minute walk tests but desaturated to 86% on room air and felt very severely breathless (dyspnoea score = 7) at the end of the walk.

**What exercise would you prescribe?**

**Goal: **20 minutes lower limb endurance exercise, arm endurance exercises and upper & lower limb strength training exercises. You may introduce these exercises over the first 3 supervised sessions depending on back pain. Progress the duration to achieve 30 minutes of lower limb endurance exercise as soon as able, then progress the intensity.

**Lower Limb Endurance Exercise Program**

Given the severity of Bill’s impairment, options for training may include use of a wheeled walker (rollator), interval training particularly if his breathlessness levels are elevated beyond 4 (somewhat severe) on the Borg scale or he needs to stop for rests.

Track walking using a wheeled walker (10 minutes) plus stationary cycling (10 minutes).

**Walking Program**

Use results of 6MWT so if Bill walks 324 m in six minutes, an appropriate distance to walk in 10 minutes is:

= (324m/6min x 10min) x 0.8

= 432 m in 10 minutes (convert this into laps on a track. Foe example if the track length is 30 m = 14 laps). Then progress the walking time (eg 15 minutes). Consider interval training (eg. 1 min walk, 1 min rest) or if Bill needs to stop for rests.

**Cycling Program**

Use the Borg scale to set intensity level such that Bill feels moderately to somewhat severely breathless (3 to 4 on Borg dyspnoea scale) during the cycle exercise. Cycle at a speed to maintain this intensity for 10 minutes. Progress the cycle time (eg 15 minutes) as soon as able. Consider interval training if Bill needs to stop for rests.

**If you wanted to use treadmill walking rather than track walking**

Convert six minute walk distance into walking speed for the treadmill using the following equation:

i.e. [(324m x 10)/1000] x 0.8 = 2.6 km/hr. The treadmill may need to start at a lower speed to account for Bill being unfamiliar with treadmill walking. Progress the walking time (eg 15 minutes) as soon as able. Consider intermittent training if Bill needs to stop for rests.

For intermittent training: Use 3-5 minutes of walking followed by 3 minutes rest for a total walking time of 10-15 minutes. The duration of the exercise interval may need to be reduced if Bill needs to stop before the rest interval. Progress number of exercise intervals for a total walking duration of 30 minutes, then progress intensity.

**Arm Exercises**

Start with low weight, high repetition arm activities (total duration 10 minutes). See examples in the “Upper Limb Endurance Exercises” table.

**Strength training**

Start with 1 set of 10 repetitions of each of 3 lower limb and 3 upper limb strength training exercises. See examples in the strengthening exercises tables. Build up to 3 sets of each exercise.

**Circuit**

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

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 due to her breathlessness. 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 Breo Ellipta, Incruse Ellipta 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 FEV1 / FVC = 0.89/1.55 with an FEV1 (% pred) of 43%. Her weight is 54 kg, height 149 cm, BMI = 24.3. Resting HR = 78 beats/min; resting SpO2% = 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 severely breathless (dyspnoea score 5).

**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**

Track walking:

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

= (456m/6mins x 15mins) x 80%

= 912 m in 15 minutes (convert this into laps on a track. If the track length is 30 m = 30 laps). Then progress the walking time to 20 minutes as soon as able.

Treadmill walking:

If you wish to use a treadmill for walking exercise – convert six minute walk distance into walking speed on the treadmill.

i.e. [(456m x 10)/1000] x 80% = 3.6 km/hr for . Treadmill speed may need to be set slower than calculated due to the unfamiliar nature of treadmill walking compared to walking on a flat track.

Start with 15 minutes and progress duration (eg 30 minutes) then intensity of treadmill (e.g. increase speed. Once Janice’s maximum walking speed is achieved, progress intensity by adding an incline (eg 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 dyspnoea 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).

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 10 repetitions of each of 3 lower limb and 3 upper limb strength training exercise. Progress to 3 sets of 10 repetitions for each exercise. See examples in the strengthening exercises tables.

**Circuit**

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