Non-pharmacological approach to comorbidities in
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Transcript Non-pharmacological approach to comorbidities in
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Non-pharmacological approach
to comorbidities in COPD
[email protected]
Outline
• Inactivity driving morbidity in COPD
• Preventing morbidity by remaining active
• Treating morbidity by becoming active
Functional status in COPD
60
GOLD IV Mean 289
GOLD III Mean 365
GOLD II Mean 405
800
50
40
30
20
10
R 0.34 p < 0.01 (ECLIPSE)
R 0.30 p < 0.01 (Leuven)
1000
6MWD (m)
Percentage of patients (3x100%)
Predicting Functional status
600
400
200
0
0
20
40
60
80
100
120
FEV1 (%pred)
Agusti Respir Res 2010
UZ Leuven Rehab d-base 2010
Functional status in COPD
Predicting Functional status
partial R2
p
QF (Nm.kg-1)
0.21
0.001
FEV1 (%pred)
0.11
0.001
PImax (cmH2O)
0.01
0.01
800
6MWD (m)
N=496
R 0.53 p < 0.01 (Leuven)
1000
Factors associated to 6MWD
600
400
200
0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Quadr/Weight (Nm.kg-1)
UZ Leuven Rehab d-base 2010
Functional status in COPD
150
QF (% pred)
QF (% pred)
150
100
50
0
N=279
N=159
100
50
0
0
25
50
FEV1 (%pred)
75
COPD
Cont
Long term inactivity, driving morbidity
Physical inactivity drives morbidity
Steps.day-1 ( n )
12000
10000
-36% -43% moderate PA
8000
6000
4000
2000
0
Ctrl
Troosters Respir Med 2010
Watz AJRCCM 2008
I
II
III
IV
Long term inactivity, driving morbidity
KU-Leuven Rainbow study (Undiagnosed COPD )
Moderate PA (min)
150
Early COPD
Healthy NON smoking
Age
(Years)
64±6
Healthy
EX smoker
Gender (% Male)
90
Healthy
Smoker 27.1±4.1
BMI
(kg/m²)
Pack Years
49±23
COPD smoker
LAAC intake (%)
9
COPDI/IIEX
GOLD
(N)smoker 33/16
FEV1 (L)
2.61±0.58
FEV1 (%pred)
86±17
FEV1/FVC (%)
62±7
125
100
75
50
40
50
60
70
Age (yrs)
80
Smoking
controls
60±8
62
26.6±4.0
34±21
0
Healthy
controls
62±6
47
25.5±3.5
0
*
°
†
°
*
3.09±0.70
105±14
76±4
3.18±0.72
116±17
78±5
*
°
*
P
Long term inactivity, driving morbidity
KU-Leuven Rainbow study (Undiagnosed COPD )
Amount and Intensity of physical activity
are
important
to maintain health
Healthy
NON smoking
Moderate PA (min)
150
Healthy EX smoker
125
Healthy Smoker
Physical activity should be considered as a
COPD smoker
‘vital sign’
CDC Physical activity plan March 2010
100
COPD EX smoker
75
50
40
Haskell Circulation 2007
50
60
70
Age (yrs)
80
Inactivity a source of comorbidity?
4
3
QF (Nm/kg)
QF (Nm/kg)
5
2
1
4
3
2
1
0
0
0
50
100
Walking time (min)
150
0
10
20
30
40
50
60
Moderate PA (min)
70
80
90
Inactivity a source of comorbidity?
QF (Nm/kg)
4
3
2
1
0
0
50
100
150
Walking time (min)
Wagner Respirology 2006
Inactivity and Morbidity
Deconditioning
Cardiovascular morbidity
Insulin resistance
Cancer (Colon/Breast/Lung)
Arterial Hypertension
Bone and joint disease
(Osteoporosis Arthritis)
Depression
Inactivity and Morbidity
Comorbidity (%)
36
13
23
5
-
9
15
6
-
Mapel Arch Intern Med 2000 22
65
45
12
-
17
32
18
-
Soriano Chest 2005 28
22
-
-
-
10
26
4
-
-
18
18
2
9
-
-
-
-
Walsh ATS 2006 70
50
52
16
16
38
62
4
32
Van Manen J Clin Epidemiol 2001
Sidney Chest 2005
Chatila PATS 2008
Comorbidity in COPD: physical (in)-activity
COPD
Symptoms
(Dyspnea)
Airflow obstruction
Dynamic hyperinflation
Age, gender,
socialsuport,
socioeconomicstate,
educationallevel
Barriers
(symptoms)
Anxiety
Exercise
capacity
Physical
(in-)activity
(behavior)
Self-efficacy
Health beliefs
COMORBIDITY
Hematological
abnormalities
Inflammation
Exacerbations
Cardiovascular
morbidity
Pulmonary
hyertension
Osteoporosis
Inflammation
Mortality
Muscle
dysfunction
Steroids
Oxidativestress
Exacerbations
Endocrine
dysfunction
Steroids
Exacerbations
Sleep-disordered
Breathing
Mental
state
Hypoxia
Preventing morbidity by PA?
• No long term prospective data in COPD
• Epidemiological suggestions
• Data in other diseases (e.g. diabetes)
Mortality (Probability Survival)
Preventing morbidity by PA?
1.0
0.75
Tio
Control
SFC
Placebo
14.9%
16.5%
12.6%
15.2%
0.50
High
Average
Low
0.25
Very low: Mainly sitting work, no PA in leisure time
Low: < 2h/week low intensity physical activity
0.0
0
5
10
15
Very Low
20
Time (Years)
Garcia-Aymerich Thorax 2006
Preventing morbidity by PA?
Metformin 850mg Bid
Incidence Diabetes
-1
Placebo
7.5
5.0
2.5
40
(cumm %)
10.0
(MET-hr.wk )
Physical activity
Intensive lifestyle int.
30
20
10
0
0.0
0
1
2
Time (Yrs)
3
4
0
1
2
3
4
Time (Yrs)
All groups received standard package of guidelines regarding healthy life style
(written and annual session of 30')
Intensive life style = 16 face to face sessions followed by monthly session
Knowler NEJM 2002
Preventing morbidity by PA?
How could this be achieved in COPD?
Raise awareness in milder patients
Assess Physical activity
Provide feedback on PA levels
Discuss this with your patients
8000
7500
7000
6500
FEV1
TLC
Age
FB - R
(n=18)
UC - R
(n=17)
67 ± 17
112 ± 20
63 ± 8
62 ± 14
114 ± 14
61 ± 9
6000
5500
5000
4500
4000
Feedback
UC
Hospes Patient Educ Counsel 2008
Treating co-morbidity by exercise training?
Exercise tolerance: Weighted mean difference and IQR
110
100
90
80
70
60
50
40
30
20
10
0
20
10
0
Wmax
VO2max
Walking
(% baseline)
(% baseline)
30
Whole body end
Adapted fromTroosters AJRCCM 2005
Treating co-morbidity by exercise training?
Rehabilitation has a clear effect on
Quadr
80
QF (Nm)
60
HRQoL and symptoms
Exercise tolerance
40
20
0
Skeletal muscle weakness
Depressed mood status
-20
-40
-60
Exacerbations
St
ee
C
le
or
20
on
03
ad
o
20
M
03
er
Se ken
20
w
el
05
l2
00
Se
5
w
(
el
l 2 S)
de
00
Bl
5
o
k
de
20 (I)
Bl
ok 06
20 (C)
06
(C
St
P)
ee
le
Pi
tta
20
08
20
0
Pi
tta 8 (3
M
20
08 )
(6
W
M
al
)
ke
r2
00
D
al
8
la
s
20
09
Physical activity (% change)
Rehabilitation has the potential to improve PA
70
60
50
40
30
20
10
Weighted mean
+17%
0
Troosters Eur Respir Rev 2010
Rehabilitation impact on comorbidity?
Exercise training and Arterial Stiffness, marker of CV risk
PRE
POST
Pulse Wave Velosity
(m.s-1)
12
N=10
4 weeks of PR 5d/week
Endurance training
11
*
10
9
8
7
6
Controls
TR
Vivodtzef Chest 2010
Rehabilitation impact on comorbidity?
Exercise training and Arterial Stiffness, marker of CV risk
PRE
POST
Pulse Wave Velosity
(m.s-1)
12
11
*
10
9
8
7
6
Controls
TR
Vivodtzef Chest 2010
Rehabilitation impact on comorbidity?
Heart Transplantation
N=8/8
0
CO
TR
0
N=6/10
-5
-5
**
-15
-20
-20
+2
m
th
+8
m
on
th
on
+2
m
Mitchel Transplantation 2003
+8
m
-15
on
th
s
-10
s
-10
on
th
s
**
s
L2-L3 Bone mineral density
(% change vs pre TX)
Lung Transplantation
Calcitonin
Cal. + TR
Braith Transplantation 2006
Do co-morbidities complicate rehabilitation?
Crisafulli ERJ 2010
Do co-morbidities complicate rehabilitation?
Proportion of patients with clinical benefit
Exercise training yields significant effects, also in patients with comorbidity
Crisafulli ERJ 2010
Summary
• Comorbidity in COPD is at least partially driven by physical
inactivity
• BESIDES SMOKING CESSATION, early interventions aiming at
keeping patients active could potentially prevent
comorbidity
• Exercise training as a stimulus may treat some comorbidity
(muscle weakness, vascular, type II diabetes, osteoporosis,
depression)
• Patients with comorbidities are good candidates for exercise
training