Exercise in the management of breathlessness in the management of breathlessness ... •Treatment goal: ... MRC dyspnoea scale; Transition Dyspnoea

WHO Collaborating Centre for Palliative Care and Older People

Exercise in the management of

breathlessness

Matthew Maddocks PhDLecturer in Health Services Research

NIHR Clinical Trials Fellow

Background

• Breathlessness is common in advanced disease

– 90% chronic lung disease

– >50% cancer or heart failure

– renal / liver failure, neurological conditions, HIV/AIDS.

• It causes considerable distress and disability.

• It results in unplanned hospital attendances.

• Many perceive it as a challenge to treat (confidence,

structured approach, knowledge of treatments etc).

Maddocks et al. J Palliat Med 2015.

Breathlessness is (a bit) like pain…

Parshall et al. AJRCCM 2012;185:435-52.

Domain Description

Sensory-perceptive what does your breathing feel

like and how bad is it?

Affective distress how distressing or unpleasant

is your breathing?

Symptom impact or burden how does your breathing affect

your function?

The deconditioning spiral

• Treatment goal: break or slow down the spiral

• Requires education / reassurance around

normal exertional response and recovery

Donaldson et al. Int J COPD 2012;7:523-535.Maddocks & Wilcock. Lung Cancer 2012;76:128-9.

Detrimental effect of bed rest on muscle

Kortbein JAMA 2007

Changes are about 10-fold compared to the typical response in a young adult

Jolley & Moxham Eur Resp Rev 2009;818:66-79.

Pulmonary rehabilitation

Jolley & Moxham Eur Resp Rev 2009;818:66-79.

Current evidence for PR

• Overwhelming evidence supports exercise in the

context of pulmonary rehabilitation (PR)

• CRQ dyspnoea scale

– ↑ 0.79 (CI 0.56−1.03), n=1283

• SGRQ total score

– ↓ 6.89 (CI 9.26−4.52), n=1146

• Exercise performance

– shuttle walk ↑ 39.8 m (CI 22.4−57.2), n=694

– 6 min walk ↑ 44.0 m (CI 32.6−55.2), n=1879

McCarthy et al. Cochrane Database Syst Rev. 2015;2:CD003793.

CRQ dyspnoea domain (n=1286)

CRQ Mastery (n=1212)

PR and breathlessness

• Rehabilitation compared to usual care (n=41)

Wadell et al. COPD 2013;10:425-35

Domain Assessments

Sensory-perceptive Exertional breathlessness intensity ratings and

quality descriptors

Affective distress Intensity of breathing-related anxiety during

exercise; COPD / walking self-efficacy

Symptom impact or

burden

MRC dyspnoea scale; Transition Dyspnoea

Index; CRQ dyspnoea scale; SRGQ activity

scale; walking / cycling exercise performance

Wadell et al. COPD 2013;10:425-35

PR and breathlessness

Upper limb exercise

Jolley & Moxham Eur Resp Rev 2009;818:66-79.

Upper limb exercise

• Exercise training in COPD often focuses on lower

limb training (walking, cycling)

Kathiresan et al. J Thorac Dis 2010;2:223-36.

• 24 studies (n= )

• Improvements in:

– Endurance capacity

(SMD=1.25; 0.16 to 2.66)

– Peak exercise capacity

(SMD=1.27; 0.59 to 1.94)

– Arm muscle strength

(SMD=0.46; 0.10 to 0.81)

Arm exercise - breathlessness (intensity)

During daily

activity

During

exercise

WMD −0.58

(95% CI −1.13 to −0.02)

WMD −0.34

(95% CI −0.78 to 0.09)

Arm exercise – arm fatigue (intensity)

During daily

activity

During

exercise

WMD −0.55

(95% CI −1.08 to −0.01)

WMD 0.24

(95% CI −0.33 to 0.81)

Neuromuscular electrical

stimulation

Jolley & Moxham Eur Resp Rev 2009;818:66-79.

NMES in advanced disease: exercise

VO2 max during CPET improved in 2 of 3 studies.

Maddocks et al. Cochrane Database of Systematic Reviews 2013;1:CD009419

NMES and breathlessness

• Reduced functional impact of breathlessness

– CRQ dyspnoea

– Maugeri Resp Failure dyspnea in daily tasks

• Reduced breathlessness at exercise isotime

– demonstrated in 2 of 3 studies

– corresponding increases in exercise endurance

– single case of increased inspiratory capacity

Maddocks et al. Cochrane Database of Systematic Reviews 2013;1:CD009419

Take home messages

• A strong rationale and

evidence base supports a role

for exercise in breathlessness

management

• Exercise is an exemplar for

treating ‘total’ breathlessness

- not just symptom intensity

Thank you

matthew.maddocks@kcl.ac.uk @CSI_KCL