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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
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