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Case Study One

 

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 FEV1 / FVC = 0.63/1.2 with an FEV1 (% pred) of 22%. His weight is 90 kg, height 178 cm, BMI = 28.4. Resting HR = 85 beats/min; resting SpO2% = 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 and/or 2 L/min oxygen supplementation particularly if his breathlessness levels are elevated beyond 4 (somewhat severe) on the Borg scale or he needs to stop for rests.

Option 1:

Track walking using a wheeled walker (10 minutes) combined with 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 80%

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

Option 2:

Treadmill walking (10 minutes) combined with stationary cycling (10 minutes)

Walking Program

Convert six minute walk distance into walking speed x 80% intensity.

i.e. [(324m x 10)/1000] x 80% = 2.6 km/hr x 10 minutes duration. 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 interval training or supplemental oxygen 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 or supplemental oxygen if Bill needs to stop for rests.

Option 3:

Interval training (20 minutes walking eg treadmill)

Convert six minute walk distance into walking speed x 80% intensity.

i.e. [(324m x 10)/1000] x 80% = 2.6 km/hr. The treadmill may need to start at a lower speed to account for Bill being unfamiliar with treadmill walking.  Use 3-5 minute intervals of walking followed by 3 minutes rest for a total walking time of 20 minutes.  The duration of the intervals may need to be reduced if Bill needs to stop before the rest interval. Progress number of intervals for a total walking duration of 30 minutes then progress intensity. Consider supplemental oxygen if SpO2 remains low.

Option 4:

If Bill is unable to perform the walking or cycling programs to the prescribed intensity or is unable to complete the desired duration due to his back pain, consider an alternative exercise training mode such as water-based exercise. The water-based exercise program should be the same duration and intensity as the land-based program (i.e. initially 20 mins of lower limb endurance exercise building up to 30 mins at an intensity of 3-4 (moderate to somewhat severe) on the modified BORG dyspnoea scale). Examples include moving back and forth across the longest length of a pool with exercises such as walking/jogging forwards/backwards/sideways, bunny hops/frog jumps forwards/backwards/sideways, cross-country ski forwards/backwards/sideways, star jumps sideways, swinging like a pendulum sideways.3

Arm Exercises

Start with low weight, high repetition arm activities (total duration 10 minutes). See examples in the “Upper Limb Endurance Exercises” table. Arm exercises can be performed in the water using dumbbell floats.

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. Strength training in the water can be performed using floats or weights or the persons own body weight (eg. step ups or push ups).

Circuit

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