Assesment of muscle function in chronic lung
disease
Deniz İNAL İNCE, PhD, PT Associated Professor
Hacettepe UniversityFaculty of Health Sciences
Department of Physical Therapy & Rehabilitation
MuscleHeart
Circulation Lungs
QCO2
Oxygen transportOxygen transport
PATOLOPATOLOGYGY / / I INFLAMNFLAMMATIONMATION / H / HIPOXEMIAIPOXEMIADRUGSDRUGS
INACTIVITYINACTIVITY / / DECONDITIONINGDECONDITIONING
Wasserman K et al. Principles of Exercise Testing & Interpretation, 2005
VO2
VCO2
QO2
Skeletal muscles FiberFiber DefinitionDefinition MMetabolismetabolism FunctionFunction
I Slow, resistant to
fatigue
Oxidative Standing, quiet
breathing
IIa Fast, resistant to
fatigue
Oxidative/glycolotic
Walking, Hipervent
IIb/x FastNot
resistant to fatigue
Glycolotic JumpingCough
DeconditioningMuscle mass AtrophyFiber typeMuscle metabolism
Malnutrition Malnutrition
Inactivity Inactivity
DrugsDrugs
AcidosisAcidosis
SYSTEMIC INFLAMMATION
Chronic Lung DiseaseChronic Lung Disease
Anabolism Anabolism
Exercise capacity Health status QOL Mortality
Hypoxia
Hypoxia (oxidative stress) Hypoxia (oxidative stress)
Muscle oksidative stress
Mitokondria Myofilament
ATP level
Oksidative capacity
Muscle disfunction
Stimulus transmission Ca sensitivity
Contractile fatigue
Inactivity
Fatigue
Inactivity
Dyspnea
Physical activity
Lower leg activity
Motor neuron activity
Antioxidant effect
Fiber type
Energy metabolism
Muscle mass
Muscle oxidative stress
Anabolic factors
Myoflament contractility
FFM Oxidatif capacity
Skeletal muscle dysfunction
Systemic inflammationDisease severity
Malnutrition
Muscle enzyme activity Metabolic fuel storage protein & caloric intake Protein katabolism Muscle mass
Caloric intake Weight loss
Corticosteroids Conractile proteins Glycolitic activity Growth factors Protein catabolism Tip 2 fiber atrophy
Changes in muscle structure & metabolism
Tip 1 muscle fiber Oksidative enzymes CSA Aerobic capasity Earlier anaerobic metabolism Muscle mass Muscle strength Muscle endurance Muscle fatigue
Lactate Blood ammonia Pi Earlier muscle acidosis
Muscle functionMuscle function
ENDURANCEENDURANCE
Practice sessionSpecific protocol
STRENGTHSTRENGTH
FATIGUEFATIGUE
Muscle group
Contraction type
Movement velocity
Equipment
ROM
Evaluation of skeletal muscle strength
Volitional Nonvolitional
Manual muscle testing1 RMDinamometer
Electrical stimulationMagnetic stimulation
Muscle mass
FFM
Manual muscle testing 5-pointMRC
Percentages of normal values
Ambulated patients
ICU: 12 muscles
Dinamometer
Back liftdinamometer
Isometric dinamometer
Isometric
Hand grip
Isotonic evaluation Isotonic evaluation 1 repetition maximum (1 RM)1 repetition maximum (1 RM)
Free weights Dumbbells Exercise machines
Dynamic contractions against hydraulic resistance
Evaluation of skeletal muscle strength
Volitional Nonvolitional
Manual muscle testing1 RMDinamometer
Electrical stimulationMagnetic stimulation
Magnetic stimulation
Action potential
Depolarization
At rest
Maximal voluntary ventilation
Quadriceps muscle strength
Young
Normal
Erderly
Normal
ICU patient
Age (years)
30 77 46
TwAP (N) 6.9 7.1 4.6*
Mean ICU stay 18.5 days
*p=0.01, ICU patients were weaker
☐ Stength
■ Endurance
COPDCOPD
Endurance
Capacity of muscle to maintain a given level of force or work for a period of time
AssessmentAssessment strength below target Number of repetitions % of force
Equipments: Same as strength evaluation
Endurance Fatigue
Reversible reduction in the force generated by the muscle itself for a given neural input
Symptoms at peak exercise
26%
31%43%
Dyspnea
Leg fatigue Dyspnea & Leg fatigue
Killian et al. Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. Am Rev Respir Dis 1992;146:935-940.
Mechanisms of fatigue Motor neuron Neuromuscular junction Conractile mechanism (Ca) Early anaerobic metabolism Lactic acid accumulation Blood ammonia ATP-PC depletion Muscle glycogen depletion
Evaluation of fatigue
Metabolic
Volitional Nonvolitional
Strength before & after a given task
Lactic acid Blood ammonia
Subjective
Borg scaleVASFatigue scales
Motivational factors
Functional
Magnetic stimulation
0 10 20 30 40 5020
30
40
50
60
70
80
90
100
COPD
Controls
p<0.0017
p<0.006
p<0.0002
p<0.0002
Number of trains%
of
bas
elin
e fo
rce
Quadriceps fatigue
Metabolic fatigue Lactic acid level
Metabolic fatigue Blood ammonia level
Subjective fatigue
0 100
Relationship between Disease severity & Periferal Muscle Endurance & Fatigue in Patients with Chronic Obstructive
Pulmonary Disease
22 COPD (62.5 years) FEV1: 50±29% GOLD Stage IV n=7 (31.8% )
Stage III n=6 (27.3% ) Stage II n=4 (18.2% ) Stage I n=5 (22.7% )
6MWT: 507±128 m SAFE: 3.7±2.5 Fatigue Impact: 32.9±31.3 Fatigue Severity: 40.6±17.0
0 25 50 75 100 1250.0
2.5
5.0
7.5
10.0
Yorgunluk Etki Ölçeği
SA
FE
in
dek
s
Melda Sağlam, Ebru Çalık, Naciye Vardar-Yağlı, Sema Savcı, Deniz İnal-İnce, Hülya Arıkan, Meral Boşnak-Güçlü, Lütfi Çöplü
r= 0.67, p<0.05
Toraks 2009
Thank you