Respiratory Muscle Training (eBook)

Front Cover 1
Respiratory Muscle Training: Theory and Practice 4
Copyright 5
Contents 6
Acknowledgements 8
Dedication 10
Foreword 12
Preface 14
REFERENCES 16
Part I: Theoretical basis of respiratory muscle training 18
Introduction to Part I 18
Chapter 1: Anatomy and physiology of the respiratory system 20
THORACIC STRUCTURE AND FUNCTION 20
Introduction 20
The airways 20
The alveoli 21
The blood vessels 22
The lymphatics 23
The nerves 23
Innervation of airways 23
Innervation of blood vessels 23
Afferents 23
The muscles 23
Respiratory pump muscles 23
Inspiratory muscles 23
Expiratory muscles 25
Other respiratory muscles 25
Functional properties of respiratory pump muscles 25
Upper airway muscles 26
Gross structure of the respiratory system 26
GAS EXCHANGE 27
Diffusion 27
Perfusion 30
OXYGEN AND CARBON DIOXIDE TRANSPORT 32
Oxygen transport 32
Carbon dioxide transport 34
ACID-BASE BALANCE 35
CONTROL OF BREATHING 37
The rhythm generator 37
Afferent inputs to the respiratory controller 37
Hering-Breuer reflex 37
Irritant and other rapidly adapting receptors 38
C-fibres (J-receptors) 38
Peripheral proprioceptors and metaboreceptors 38
Chemical control of breathing 39
Central chemoreceptors 39
Peripheral chemoreceptors 39
Control of exercise hyperpnoea 40
Respiratory muscle control 41
MECHANICS OF BREATHING 41
Overview 41
Pressures within the thorax 42
Lung and thoracic cage compliance 43
Airway resistance 44
Exhalation mechanics 44
Effects of lung properties upon breathing 46
Work of breathing 47
Lung volumes and capacities 47
Mechanical properties of respiratory pump muscles 48
DYSPNOEA AND BREATHING EFFORT 50
REFERENCES 52
Chapter 2: Exercise physiology and training principles 54
CARDIORESPIRATORY RESPONSES TO EXERCISE 54
Respiratory 54
Introduction 54
The respiratory pump during exercise 54
Cardiovascular 58
Introduction 58
The cardiovascular system during exercise 58
MECHANISMS OF FATIGUE 59
Definition of fatigue 59
Indicators of fatigue 60
Potential sites and causes of fatigue 60
Afferent feedback, fatigue and perception of effort 62
Task failure and task dependency 62
Summary 63
CARDIORESPIRATORY LIMITATION OF EXERCISE TOLERANCE 63
CARDIORESPIRATORY FITNESS 65
Maximal oxygen uptake 65
Lactate threshold 66
Exercise economy 66
PRINCIPLES OF CARDIORESPIRATORY TRAINING 67
Cardiovascular training adaptations 67
Myocardial adaptations 67
Circulatory adaptations 67
Muscle adaptations 68
Respiratory training adaptations 68
METHODS OF CARDIORESPIRATORY TRAINING 68
Exercise modality 68
Aerobic capacity (VO2max) 69
Lactate threshold 70
REFERENCES 70
Chapter 3: The respiratory muscles 74
CHANGES IN RESPIRATORY MUSCLE FUNCTION AND BREATHING MECHANICS 74
Respiratory disease 75
Chronic obstructive pulmonary disease 75
Asthma 78
Bronchiectasis 79
Cystic fibrosis 79
Restrictive chest wall disorders 79
Chronic heart failure and pulmonary hypertension 80
Neurological and neuromuscular disease 81
Spinal cord injury 81
Other NMDs 83
Obesity 83
Ageing 84
Miscellaneous conditions 85
Diabetes 85
Renal failure 86
Cancer 86
Anorexia nervosa 86
Myopathic pharmacological agents 86
Surgery 87
Mechanical ventilation 87
Pregnancy 88
Obstructive sleep apnoea 88
RESPIRATORY MUSCLE INVOLVEMENT IN EXERCISE LIMITATION 89
Healthy people 89
Respiratory disease 92
Chronic obstructive pulmonary disease 92
Asthma 94
Bronchiectasis 94
Cystic fibrosis 94
Restrictive chest wall disorders 94
Sarcoidosis and interstitial lung disease 95
Chronic heart failure and pulmonary hypertension 95
Neurological and neuromuscular disease 97
Spinal cord injury 97
Other NMDs 97
Obesity 98
Ageing 98
Miscellaneous conditions 99
Diabetes 99
Cancer 99
Anorexia nervosa 99
Pregnancy 100
Vocal cord dysfunction and inspiratory stridor 100
NON-RESPIRATORY FUNCTIONS OF THE RESPIRATORY MUSCLES 100
THE RATIONALE FOR RESPIRATORY MUSCLE TRAINING 102
REFERENCES 103
Chapter 4: Functional benefits of respiratory muscle training 114
RESPIRATORY MUSCLE RESPONSES TO RMT 114
Structural adaptations to RMT 115
Patients 115
Healthy people 115
Functional adaptations to RMT 116
Inspiratory muscle adaptations to resistance training 116
Expiratory muscle adaptations to resistance training 117
Adaptations to simultaneous inspiratory and expiratory muscle resistance training 118
Functional adaptations to respiratory endurance training 118
Summary 119
RESPONSES TO RMT IN HEALTHY PEOPLE 119
Influence of RMT upon time trials and tests of endurance 119
Influence of RMT upon tests of anaerobic endurance and sprinting 124
Influence of RMT under hypoxic conditions 125
DISEASE-SPECIFIC FUNCTIONAL RESPONSES TO RMT 125
Respiratory disease 125
Chronic obstructive pulmonary disease 125
Asthma 127
Bronchiectasis 128
Cystic fibrosis 129
Restrictive chest wall disorders 129
Chronic heart failure 130
Neurological and neuromuscular disease 132
Spinal cord injury 132
Other NMDs 133
Obesity 135
Ageing 136
Miscellaneous conditions 136
Diabetes 136
Renal failure 137
Myopathic pharmacological agents 137
Surgery 137
Mechanical ventilation 138
Obstructive sleep apnoea 139
Vocal cord dysfunction and inspiratory stridor 140
General conclusions 140
REFERENCES 140
Part II: Practical application of respiratory muscle training 150
Introduction to Part II 150
Chapter 5: Methods of respiratory muscle training 152
GENERAL TRAINING PRINCIPLES 152
Overload 152
Healthy people 152
Patients 153
Specificity 154
Training for strength 154
Training for endurance 154
The effect of lung volume (muscle length) 154
Reversibility 155
Detraining 155
Maintenance 155
DIFFERENT FORMS OF RMT AND THEIR OUTCOMES 155
Resistance training 155
Inspiratory flow resistive loading 156
Dynamic inspiratory flow resistive loading 156
Inspiratory pressure threshold loading 156
Expiratory pressure threshold loading 157
Concurrent IPTL and EPTL 157
Endurance training 157
Voluntary isocapnic hyperpnoea training 157
Summary 158
PROPRIETARY TRAINING EQUIPMENT 158
Resistance training 158
Passive flow resistance devices 158
Dynamically adjusted flow resistance devices 158
Pressure threshold devices 160
Endurance training 160
MERITS AND LIMITATIONS OF DIFFERENT TRAINING METHODS AND EQUIPMENT 160
REFERENCES 161
Chapter 6: Implementing respiratory muscle training 166
GENERAL PRINCIPLES OF FOUNDATION IMT 166
Context of RMT in the treatment pathway 166
Indications and contraindications for IMT 167
Indications 167
Contraindications 168
Patient selection 169
Precautions 169
PRACTICAL ISSUES 169
Posture during training 169
Optimizing breathing technique 170
Diaphragm breathing 170
Breathing pattern during IMT 173
Tidal volume 173
Inspiratory flow rate 174
Combining inspiratory and expiratory training 175
Secretions 175
MONITORING PROGRESS 175
Assessment of respiratory muscle function 175
Maximal respiratory pressures 175
Equations 177
Sniff inspiratory pressure 177
Peak inspiratory flow rate 177
Inspiratory muscle endurance 177
Evaluating clinical benefits 178
GETTING STARTED 180
Protocol selection 180
Setting the training load 181
Repetition failure 182
The influence of daily activities and exacerbations 182
Use of training diaries 182
PROGRESSING TRAINING 182
MAINTENANCE TRAINING 184
INCORPORATING RMT INTO A STRUCTURED REHABILITATION PROGRAMME 184
Pre-habilitation 184
Rehabilitation component 184
INSPIRATORY MUSCLE `WARM-UP´ AND STRETCHING 185
`Warm-up´ 185
Stretching 186
INSPIRATORY MUSCLE `COOL-DOWN´ 186
REFERENCES 187
Chapter 7: Functional training of the respiratory muscles 192
THE RATIONALE FOR FUNCTIONAL TRAINING 192
ASSESSING PATIENT NEEDS 193
Assessment of dyspnoea 194
Reflexive assessment of dyspnoea 194
Assessment of dyspnoea during exercise 194
Assessment of dyspnoea during loaded breathing 197
Assessment of load/capacity imbalance 197
FUNCTIONAL TRAINING EXERCISES 198
Underlying principles 198
Stretching and mobilizing 201
Breath control 203
Swiss ball bounce 203
Procedure: 203
Marching on the spot 203
Procedure: 203
Ball bounce on the spot 203
Procedure: 203
Trunk strength and lumbopelvic stability exercises 204
Plank 205
Benefits 205
Procedure 205
Variations 205
Side bridge 206
Benefits 206
Procedure 206
Variations 206
Bridge 207
Benefits 207
Procedure 207
Variations 207
Plank with lower body instability 208
Benefits 208
Procedure 208
Variations 208
Plank with upper body instability 209
Benefits 209
Procedure 209
Variations 209
Gluteal bridge 210
Benefits 210
Procedure 210
Variations 210
Gluteal bridge with upper body instability 211
Benefits 211
Procedure 211
Variations 211
Gluteal bridge with lower body instability 212
Benefits 212
Procedure 212
Variations 212
Leg raise 213
Benefits 213
Procedure 213
Variations 213
Braced curl-up 214
Benefits 214
Procedure 214
Variations 214
Seated hip extension 215
Benefits 215
Procedure 215
Variations 215
Reverse curl 216
Benefits 216
Procedure 216
Variations 216
Hip extension 217
Benefits 217
Procedure 217
Variations 217
Superman 218
Benefits 218
Procedure 218
Variations 218
Ski squats with leg lift 219
Benefits 219
Procedure 219
Variations 219
Bent leg deadlift 220
Benefits 220
Procedure 220
Dynamic trunk activation exercises 221
Arm resistance 221
Benefits 221
Procedure 221
Stance variations 221
Arm movement variations 222
Rise with overhead weight 223
Benefits 223
Procedure 223
Variations 223
Squat with overhead resistance 224
Benefits 224
Procedure 224
Variations 224
Bag pick-up 225
Benefits 225
Procedure 225
Variations 225
Side crunch 226
Benefits 226
Procedure 226
Trunk lateral rotation 227
Benefits 227
Procedure 227
Trunk anti-rotation press 228
Benefits 228
Procedure 228
Variations 228
Close arm dip 229
Benefits 229
Procedure 229
Variations 229
Postural control exercises 230
Standing leg lift 230
Benefits 230
Procedure 230
Variations 230
Dumbbell running 231
Benefits 231
Procedure 231
Variations 231
Resisted front raise 232
Benefits 232
Procedure 232
Variations 232
Step-up/down 233
Benefits 233
Procedure 233
Variations 233
Sit-stand 234
Benefits 234
Procedure 234
Lunge 235
Benefits 235
Procedure 235
Pushing and pulling exercises 236
Upright chest press 236
Benefits 236
Procedure 236
Variations 236
Shoulder press 237
Benefits 237
Procedure 237
Variations 237
Resisted pull 238
Benefits 238
Procedure 238
Variations 238
Suggested workout protocols 239
Protocol one: ambulatory patient with moderate chronic obstructive pulmonary disease (COPD) and breathlessness during acti... 239
Protocol two: ambulatory patient with heart failure and low back pain 239
Protocol three: active patient with neuromuscular disease and a history of falls 239
Protocol four: healthy older person with idiopathic dyspnoea 239
REFERENCES 239
Glossary 242
Index 244