Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disorder (COPD): Part III
(3/8/11)- The U.S. Food and Drug Administration has approved roflumilast, a pill taken daily to decrease the frequency of flare-ups or worsening of symptoms from severe Chronic Obstructive Pulmonary Disorder (COPD).
Roflumilast is an inhibitor of an enzyme called phosphodiesterase type 4 (PDE), but it is not intended to treat another form of COPD which involves primary emphysema.
The pill is marketed by the St. Louis based Forest Pharmaceuticals, a subsidiary of Forest Laboratories.
There were two Phase 3 clinical studies of the pill involving over 1,500 patients aged 40 and older. Those treated had a history of COPD associated with chronic bronchitis and had experienced a worsening of the disease during the 12 months prior to beginning the treatment.
The pill is not recommended for people younger than 18 years of age. The most common adverse affects are diarrhea, nausea, headache, insomnia, back pain, decreased appetite and dizziness.
12 million people have been diagnosed with chronic obstructive pulmonary disease (COPD). Deaths attributed to COPD now total 5 percent of all mortality in the United States with heart disease actually the most common cause of death in persons with COPD. It is the fourth leading cause of deaths in the United States.
(5/3/04)- As we have written in previous articles, COPD, a
leading cause of mortality and morbidity, is characterized by a
restricted airflow which reduces breathing capacity and causes
shortness of breath. Ultimately, these factors interfere with
daily activities and have a drastic limiting factor on quality of
life.
Exercise training in pulmonary rehabilitation programs target
functional capacity. This training is an important add-on to any
medical treatment and can prove essential to increased quality of
life. Many of these exercise programs involve intense supervision
by health care professionals and tend to be costly. In the
economic atmosphere that exists today involving a cost conscious
approach to health care, these programs may lose out to
"quick-fix" programs.
With this in mind, we searched the professional literature to see
if these were any reports of pulmonary rehabilitation exercise
programs that involve minimal supervision (low cost) and meet
optimal criteria for program success. The American Journal of
Physical Medicine Rehabilitation (2004; 83:337-343) reported on a
study by M. Ferrari et al. which, if it can be replicated in a
more rigid randomized, placebo controlled fashion, holds promise
for a low resource intensive home-based program involving
patients monitoring their own exercise session, improving their
exercise tolerance and enhancing their quality of life.
The program included lower and upper limb training on a three
times per week basis for 12 weeks. The first two sessions were
conducted at a clinic and monitored by a physiotherapist and the
remainder was performed at home.
Because many of our readers have difficulty obtaining the primary
source of information on this program, we are quoting the
"program" directly as outlined in the article.
Lower Back Training
"For lower back training, patients used a simple ergocycle
with a mechanical brake. The training session consists of three
stages. In the first, the patient pedaled for five minutes
without applying the brake. Then the patient was instructed to
set the brake to maintain heart rate as close as possible to 70%
of the maximum heart rate reached during the preliminary exercise
test. This second phase lasted 20 minutes and was followed by 10
minutes of pedaling without applying the brake. The pedaling
frequency was about 60 rotations per minute at all times. Heart
rate was self-monitored using a pulse meter. If patients were
able to cycle for 20 minutes during the second phase of the
training, the time on the cycle was extended by 5 minutes to a
total exercise time of 40 minutes."
Upper Limb Training
"Upper limb training was performed by repeatedly raising and
lowering a dowel from waist to the shoulder, using an
interval-training regimen with alternate periods of exercise and
rest as tolerated by the patient [e. g 2 minutes of exercise and
one minute of rest). When patients were able to perform the upper
limb exercise for 10 minutes, a 1kg weight was added to each arm.
Stretching exercises for the hamstrings, quadriceps, calves,
shoulders, neck and lower back were performed after each
session."
The above exercise training program also included a psychosocial
counseling and group and individual instruction on the
appropriate use of medication and cooperative self management of
the lung disease. Research "mavens" will point out that
the study involved a small N and that educational counseling
component confounds the results, along with the fact that there
was no control group. The authors of the research acknowledge
this: "Although our results suggest the effectiveness of the
program, further controlled, randomized studies are needed to
confirm the findings of this nonrandomized investigation."
The investigators conclusion of their study states "Our data
shows a 12 week, low cost pulmonary rehabilitation program,
performed at home with minimal supervision, can improve quality
of life and exercise tolerance in patients with COPD." There
is no claim that it cures COPD.
Despite all the criticisms of this study we cited above, one is
hard pressed to deny the role of exercise in aiding in the
pulmonary rehabilitation process. However, success of these
pulmonary exercise programs depends on the persistence of the
enrolled individuals to do the exercises over an extended period
of time. Minimal supervision may not be the answer in all cases.
It is the old case of "different strokes for different
folks." Investigators will have to develop programs that
match the personalities of individuals to programs. In many cases
it will need to include educational components, a not so
insignificant factor, for pulmonary programs to work. Lastly, it
would seem important to develop preventative programs to lower
this devastating syndrome to many elderly individuals.
For other articles in this series see:
Respiratory Infection-A Hidden
Killer of the Elderly-Part I
Respiratory Disease-COPD-Part II
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated March 8, 2011
http://www.therubins.com
e-mail: rubin@brainlink.com or hrubin12@nyc.rr.com