1. 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

2. Muscle Heart Circulation Lungs Q CO 2 Oxygen transport PATOLOGY / INFLAMMATION / HIPOXEMIA DRUGS INACTIVITY / DECONDITIONING Wasserman K et al. Principles of Exercise Testing & Interpretation, 2005 VO2VO2 V CO 2 QO2QO2

3. Skeletal musclesFiberDefinition Metabolism Function ISlow, resistant to fatigue OxidativeStanding, quiet breathing IIaFast, resistant to fatigue Oxidative/ glycolotic Walking, Hipervent IIb/xFast Not resistant to fatigue GlycoloticJumping Cough

4. Deconditioning Muscle mass  Atrophy Fiber type Muscle metabolism Malnutrition Inactivity Drugs Acidosis SYSTEMIC INFLAMMATION Chronic Lung Disease  Anabolism Exercise capacity  Health status  QOL  Mortality  Hypoxia

5. Hypoxia (oxidative stress) Muscle oksidative stress MitokondriaMyofilament  ATP level  Oksidative capacity Muscle disfunction  Stimulus transmission  Ca sensitivity Contractile fatigue

6. Inactivity Fatigue Inactivity Dyspnea  Physical activity  Lower leg activity  Motor neuron activity Antioxidant effect  Fiber type Energy metabolism Muscle mass 

7. Muscle oxidative stress  Anabolic factors Myoflament contractility   FFM  Oxidatif capacity Skeletal muscle dysfunction Systemic inflammation Disease severity

8. Malnutrition  Muscle enzyme activity   Metabolic fuel storage    protein & caloric intake  Protein katabolism   Muscle mass   Caloric intake Weight loss

9. Corticosteroids  Conractile proteins   Glycolitic activity   Growth factors   Protein catabolism   Tip 2 fiber atrophy

10. 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

11. Muscle function Kas grubuKontraksiyon tipiHareketin hızıAletHareket sınırı YORGUNLUK DAYANIKLILIK KUVVET ENDURANCE Practice session Specific protocol STRENGTH FATIGUE Muscle group Contraction type Movement velocity Equipment ROM

12. Evaluation of skeletal muscle strength Volitional Nonvolitional Manual muscle testing 1 RM Dinamometer Electrical stimulation Magnetic stimulation Muscle mass FFM

13. Manual muscle testing  5-pointMRC  Percentages of normal values   Ambulated patients   ICU: 12 muscles

15. Dinamometer Back lift dinamometer Isometric dinamometer Isometric Hand grip

17. Isotonic evaluation 1 repetition maximum (1 RM) Free weights Dumbbells Exercise machines

18. Dynamic contractions against hydraulic resistance

19. Evaluation of skeletal muscle strength Volitional Nonvolitional Manual muscle testing 1 RM Dinamometer Electrical stimulation Magnetic stimulation

20.  Action potential  Depolarization  At rest  Maximal voluntary ventilation

21. Quadriceps muscle strength 

22. Young Normal Erderly Normal ICU patient Age (years) 307746 TwAP (N)6.97.14.6* Mean ICU stay 18.5 days *p=0.01, ICU patients were weaker

23. ☐ Stength ■ Endurance COPD

24. 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

25. Endurance Fatigue Reversible reduction in the force generated by the muscle itself for a given neural input

26. Symptoms at peak exercise 26% 31% 43% Dyspnea Leg fatigue Dyspnea & Leg fatigue 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.

27. Mechanisms of fatigue  Motor neuron  Neuromuscular junction  Conractile mechanism (Ca)  Early anaerobic metabolism  Lactic acid accumulation  Blood ammonia   ATP-PC depletion  Muscle glycogen depletion

28. Evaluation of fatigue Metabolic VolitionalNonvolitional Strength before & after a given task Lactic acid Blood ammonia Subjective Borg scale VAS Fatigue scales Motivational factors  Functional

29. Magnetic stimulation Quadriceps fatigue

32. Metabolic fatigue  Lactic acid level

33. Metabolic fatigue  Blood ammonia level

34. Subjective fatigue 0100

36. Relationship between Disease severity & Periferal Muscle Endurance & Fatigue in Patients with Chronic Obstructive Pulmonary Disease  22 COPD (62.5 years)  FEV 1 : 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 Melda Sağlam, Ebru Çalık, Naciye Vardar-Yağlı, Sema Savcı, Deniz İnal-İnce, Hülya Arıkan, Meral Boşnak-Güçlü, Lütfi Çöplü r= 0.67, p<0.05 Toraks 2009

37.  Thank you