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Assesment of muscle function in chronic lung disease Deniz İNAL İNCE, PhD, PT Associated Professor Hacettepe University Faculty of Health Sciences Department of Physical Therapy & Rehabilitation PATOLOGY / INFLAMMATION / HIPOXEMIA DRUGS INACTIVITY / DECONDITIONING QCO2 VCO2 Muscle Heart Circulation QO2 Lungs VO2 Oxygen transport Wasserman K et al. Principles of Exercise Testing & Interpretation, 2005 Skeletal muscles Fiber Definition Metabolism Function I Slow, resistant to fatigue Oxidative Standing, quiet breathing IIa Fast, resistant to fatigue Oxidative/ glycolotic Walking, Hipervent IIb/x Fast Not resistant to fatigue Glycolotic Jumping Cough Chronic Lung Disease Hypoxia Acidosis Malnutrition Anabolism Inactivity Drugs SYSTEMIC INFLAMMATION Deconditioning Muscle mass Atrophy Fiber type Muscle metabolism Exercise capacity Health status QOL Mortality Hypoxia (oxidative stress) Muscle oksidative stress Mitokondria ATP level Myofilament Stimulus transmission Ca sensitivity Oksidative capacity Contractile fatigue Muscle disfunction Inactivity Physical activity Lower leg activity Fatigue Dyspnea Motor neuron activity Muscle mass Fiber type Inactivity Energy metabolism Antioxidant effect Disease severity Systemic inflammation Muscle oxidative stress Anabolic factors Myoflament contractility FFM Oxidatif capacity Skeletal muscle dysfunction Malnutrition Caloric intake Weight loss Muscle enzyme activity Metabolic fuel storage protein & caloric intake Protein katabolism Muscle mass 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 function Kas grubu Muscle group KUVVET STRENGTH Kontraksiyon tipi Contraction type DAYANIKLILIK ENDURANCE Hareketin Movementhızı velocity Alet Equipment ROM sınırı Hareket YORGUNLUK FATIGUE Practice session Specific protocol Evaluation of skeletal muscle strength Volitional Manual muscle testing 1 RM Dinamometer Nonvolitional Electrical stimulation Magnetic stimulation Manual muscle testing 5-pointMRC Percentages of normal values Ambulated patients ICU: 12 muscles Dinamometer Back lift dinamometer Isometric Hand grip Isometric dinamometer Isotonic evaluation 1 repetition maximum (1 RM) Free weights Dumbbells Exercise machines Dynamic contractions against hydraulic resistance Evaluation of skeletal muscle strength Volitional Manual muscle testing 1 RM Dinamometer Nonvolitional Electrical stimulation Magnetic 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* *p=0.01, ICU patients were weaker Mean ICU stay 18.5 days ☐ Stength ■ Endurance COPD Endurance Capacity of muscle to maintain a given level of force or work for a period of time Assessment 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 Leg fatigue 43% Dyspnea & Leg fatigue 31% Dyspnea 26% 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 Functional Strength before & after a given task Metabolic Lactic acid Blood ammonia Subjective Volitional Nonvolitional Motivational factors Borg scale VAS Fatigue scales Magnetic stimulation Quadriceps fatigue % of baseline force 100 90 80 70 60 Controls p<0.006 50 p<0.0017 40 COPD p<0.0002 30 p<0.0002 20 0 10 20 30 Number of trains 40 50 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 Melda Sağlam, Ebru Çalık, Naciye Vardar-Yağlı, Sema Savcı, Deniz İnal-İnce, Hülya Arıkan, Meral Boşnak-Güçlü, Lütfi Çöplü 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 r= 0.67, p<0.05 10.0 SAFE indeks 7.5 5.0 2.5 0.0 0 25 50 75 100 125 Yorgunluk Etki Ölçeği Toraks 2009 Thank you
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