The shortness of breath that comes with COPD typically limits a persons ability to be active, let alone to be involved in an exercise program. You have most probably noted a gradual reduction in the activities you enjoy that involve physical effort. And even if your COPD is only moderately severe you probably have noticed a reduction in the so-called "Activities of Daily Living." Understandably, you probably attribute this decline due to your dyspnea, and this is correct. However, this decline in your exertion ability is much more complex.
Exertion requires muscular effort, and muscular effort requires a steady supply of Oxygen, which is an essential metabolic source of energy. And muscular effort also produces waste products of metabolism, among them Carbon Dioxide ("CO2") which must be disposed of by the lungs. Yes, the lungs are critically important in taking in Oxygen and getting rid of waste Carbon Dioxide, and your breathing impairment will certainly limit your Oxygen delivery and CO2 excretion.
However, Oxygen and CO2 are carried to and from the muscles by your blood, and if your heart muscle has become deconditioned by inactivity or disease and can't pump blood efficiently, this may also be a significant factor limiting your exertion capability.
And then there are the peripheral muscles themselves, i.e. the external muscles, mainly the legs and arms, and whether or not they are efficiently metabolizing Oxygen and producing required energy. Unfortunately, perfectly normal muscles, if they become deconditioned by inactivity, become inefficient at the cellular level in the production of required oxygen metabolic energy. Severely deconditioned muscles are very inefficient in processing this vital oxygen metabolic energy, and muscle deconditioning is frequently a serious limitation to activity of the person with COPD. Ironically, these deconditioned muscles require more Oxygen and give up more CO2 for a given work load, thus producing an even greater burden on the lung and heart components of this complex overall system.
Typically the person with COPD progressively limits their activity because of exertion related dyspnea. As a result of this decreased activity the heart then becomes relatively deconditioned, and it therefore becomes a less efficient pump that has to work harder to achieve the same task level. Fortunately cardiac function limitation is usually not a major problem, but improving cardiac performance with an exercise program will provide some help to your overall exercise capability.
Peripheral muscle (i.e. mainly the muscles of the arms and legs) deconditioning frequently is a major culprit leading to severe weakness in COPD. Note, this is a "vicious circle" type problem, where inactivity leads to deconditioning and deconditioning leads to muscular weakness and inefficiency, which in turn now requires more effort by the heart and lungs for the same level of muscular effort.
Learning breathing control can improve your lung efficiency, and this will help you to feel better. But to achieve full rehabilitation benefits it is essential that you also rehabilitate your cardiac and peripheral muscle function. Unfortunately there is no medication that can do this for you. There is only one way to do this, and that is by a progressive exercise program. Recently there has been some interesting research using muscle stimulation to build-up leg muscle strength in severely weakened COPD patients in order to get them ambulated. At this time this interesting technique should be considered experimental.
Many pulmonary rehabilitation programs have a heavy emphasis on exercise, with formal classes of exercise training using exercise equipment such as bicycle ergometers, or treadmills, or structured walking and stair climbing protocols supervised by experts. And without question these programs have documented considerable patient rehabilitation benefit. Indeed, this is an excellent way to efficiently begin your rehabilitation program.
But unfortunately there are some problems with formal exercise-centric programs. First, they may not be available to you, or if available, they may be inconvenient to attend. Second, exercise ideally should be done every day (or at a minimum three times a week) for efficient rehabilitation, and many programs meet only one or two times during the working week, and rarely on weekends. Third, most formal programs are limited to only two or three months by insurance payments, and long term follow-up is not paid for by many insurance plans. And finally, formal exercise is frequently boring and unpleasant. Of necessity, the COPD exercise training required will produce increased dyspnea, and this is certainly not a pleasant experience. And these problems are compounded particularly if you are not doing exercise you enjoy, or if you are exercising at home and no longer in a supportive rehabitation environment to encourage you. For these and other reasons, most patients stop exercising within a year or so.This is very unfortunate, as what you have initially gained by exercise will now frequently be gradually lost.
Regardless, even if your initially gained exercise ability decreases with time, if an exercise program gets you ambulated and well started in the overall rehabilitation program, that initial exercise program will have been of great value.
However, there are effective alternatives to formal exercise programs, and for long term follow-up exercise.
This is based on the simple premise that if you have breathing control skills and can control your exertion dyspnea, you will then not be afraid of becoming short of breath. And if are not afraid of developing uncontrolled dyspnea you will become more active, because you want to become more active, and therefore do the many desirable things that you previously could not do.
And as you regain your ability to do more and more activities of daily living, you will develop more and more strength doing these activities, and you will then want to be even more active. The end result is the same as a formal exercise-centric program, namely, increased peripheral muscle and cardiac functionality.
Many home bound people with COPD find that with reconditioning and improving breathing control skills they can then more easily perform activities of daily living, and participate in family activities, or climb stairs once again. And with further progress they can progress to activities outside of the home, doing things they enjoy such as visiting friends or going shopping. All of this involves progressive exercise, which is a natural part of simply becoming more active. And this form of exercise is usually neither boring or unpleasant.
However, some structured home exercise is desirable, and to achieve this I would recommend the Yoga training videos developed by Dr. Vijai Sharma. Dr. Sharma is a Clinical Psychologist and credentialed Yoga teacher with a special interest in COPD. He has developed two training videos "Stretching Breathing Exercises adapted for people with severe COPD" and "Stretching Breathing for COPD for all levels of fitness." These videos are carefully designed to first provide safe training for a frail person with severe COPD, and secondly to provide more strenuous exercise for less disabled individuals.
The Yoga movements provide excellent stretching and posture maneuvers to mobilize the spine and chest wall, and improved general coordination and balance training permeates the exercises. And Yoga is intimately related to breathing exercises, and there are good breathing instructions directed to COPD needs. Teaching coordination of breathing with general body movements is well done, and this provides a bridge to more efficient movement for performance of activities of daily living. Dr. Sharma has a web site with many topics of interest for COPD patients, and you may purchase the videos at that site at http://www.mindpub.com/
If you are considering a home exercise device I would recommend one of the simpler and inexpensive Stationary Bicycles. Generally these devices are stable, and there is minimal danger of falling. And if you become short of breath you are already seated, and you simply stop peddling, and brace your arms on the handles for rescue breathing control. Adjust the tension so you can peddle with only minimal effort, and be able to maintain that peddling effort continuously for about two minutes. As you get stronger, try to gradually extend your peddling time to five minutes. When you can achieve that level of activity, then try applying a slight further increase in peddling tension. Then, try to gradually work up to ten minutes of continuous peddling, and do this preferably twice a day. To avoid boredom, do your exercise in front of your television, or listening to news or music.
As with all exercise programs, the trick to enabling progressive exercise success is learning how to recognize your dyspnea level that you know you can control with slow / deep breathing, or Pursed Lip Breathing. When you reach that point you should stop, regain your breathing comfort, and then continue with your exercise activity. Continuing beyond this breathing control point to levels of severe dyspnea makes it difficult to control and re-gain your breathing comfort. Be patient, and gradually push your breathing control point to further effort. As your peripheral muscle strength improves you will find that you are capable of more exertion, and this increased exertion capability done within dyspnea levels that you know you can control. If you know you have the skills to exert yourself, and be able to recognize your particular dyspnea control level, and then to be able to manager your dyspnea, you will now have the confidence to become progressively more active in whatever activity your are doing.
I would not recommend treadmills or stepping devices for home use because of the danger of falling. In particular the minature trampoline devices are dangerous and should be avoided. As to arm weight training, avoid heavy weights. A pair of dumb-bells for upper extremity exercises is convenient, but they should not weigh more than five pounds, and one to two pounds is adequate for most individuals. You are basically not training for strength, but mainly for reconditioning and endurance.
Some persons with severe COPD are so severely debilitated and weakened they are confined to bed, or so weakened they have great difficulty occasionally getting into a chair. Ideally such individuals should have initial professional help from a Visiting Nurse service, who in turn may be able to arrange for a temporary visiting Physical Therapist.
Even if bedridden, such individuals can and should begin their rehabilitation with chest mobilization and corrective breathing training, as well as developing Pursed Lip Breathing skills. This should provide some dyspnea relief, and having some breathing control skills will be helpful later when you are exerting and needing more ventilation.
Exercises that anyone can do, are called "Isometric Exercises." This is simply tensing muscle groups against one another. This type of exercise can be done by anyone, even those with severe arthritis problems, as there is little or no movement of joints involved. Isometric Exercises can be the bridge to regular exercise for the severely weakened patient.
Upper extremity exercises for those confined to bed, may be done by clasping your hands in front of you, next to the chest. Then press your hands firmly together, and hold them together firmly, to the count of five. Then pull your hands apart firmly while holding your hands together, and maintain this tension to the count of five. Repeat this cycle two or three times until you can do this exercise fairly easily. This will strengthen your shoulder muscles.
Do this exercise (and all of the other exercises) at least every two hours, and preferably every hour. Then build up your strength by a combination of stronger pressures, longer times of applying pressure, and more cycle repetitions. Decide what is best for you, but initially stay with pressure times of about five seconds until you are stronger.
Another shoulder muscle exercise is to place your hands by your side, palms down, next to your hips. Then press your hands firmly into the bed to the count of five, relax to the count of five, and then repeat the cycle two or three times. Extend this exercise in a manner as noted above as you get stronger.
The major muscles of concern here are the Quadriceps Muscles, which are on the front of your thighs and run between your knees and hips. These muscles are critically important as they stabilize the knee, and are essential to enable safe walking and getting up out of a chair. Quadriceps deterioration happens particularly rapidly in people confined to bed, and restoring their strength is a crucial component in preparing to get out of bed to a chair, and to walk safely.
The Quadriceps may be exercised by having your legs flat in bed, and then tensing the upper leg muscles firmly for five seconds, then relaxing for five seconds, and then repeating the cycle for two or three times. As above, build up this exercise as your strength improves.
Another lower extremity exercise, this time to strengthen the muscles about your hips and lower abdomen, is to have your legs flat in bed, and then press your heels firmly into the mattress for five seconds, relax for five seconds, then raise your heels an inch or two off the mattress for five seconds, then relax for five seconds, and then repeat the cycle two or three times. As above, build up this exercise as your strength improves.
If you have been confined to bed for some time, or feel weak, you should never attempt to initially get out of bed without assistance, and preferably with professional supervision by a Nurse or Physical Therapist. The initial chair should be a firm plain wood chair with a high back (which you can use for arm support) and preferably with side arms. A Walker device (either a Jump Walker or Rolling Walker) for additional arm support should also be used so you can assist in the transfer from bed to chair. Preferably two should initially assist, one to directly assist you, and the other to position and steady the chair. And you should definitely wear a stout Safety Belt (see the section on Breathing Belts) until you are well mobilized.
When ready, do not attempt to directly stand on the floor. Many weak patients develop a problem called Postural Hypotension, where your blood pressure abruptly falls on standing up, which can lead to dizziness, fainting and falling. First, dangle your legs for a couple of minutes, and if no dizziness is felt, then place your feet on the floor for a minute or two. If there is any hint of dizziness or excessive weakness, you can easily be slid back into bed from this position. At this point, try standing-up slowly for a minute or two, Progress to the chair only when you feel able to do so. Initially don't spend more than five or ten minutes in the chair.
As your strength improves and you and your assistants gain confidence in your capabilities, you may spend more time in the wooden chair, and then progress to an easy chair. Remember, getting out of a deeper easy chair is more difficult, so be sure your standing up strength and skills are adequate.
When safely mobilized to a chair, and particularly if you are spending extended periods of time in the chair, it is important that you continue with your isometric exercises, to further prepare you for walking and performing activities of daily living.
Continue with hand clasping exercise as before. For shoulder strengthening you may now grasp the seat or side arms of the chair and push down and pull up.
Another useful activity are the so-called Broomstick Exercises. Use the full length of an old broomstick, and use it to both mobilize and strengthen the upper extremities, and to develop neck and spine mobilization.
With the broomstick in your lap, and holding it palms up, bring the broomstick up to your chin, and then extend it in front of you, and then back to your lap.
Or, holding the broomstick palms down, bring the broomstick from your lap up to your chin, and from there extend the broomstick over your head, and then back again.
Or, palms down, place the broomstick over your knees, and then with arms extended swing it up and over your head, and back down again.
Or, with the broomstick over your head, rotate the broomstick and your head slowly as far as you can to the right, and then to the left.
Or, with the broomstick held at chin level, bring the broomstick straight down towards the left hip, and then to the right hip.
Or, with the broomstick held at chin level, touch the right end of the broomstick to the left knee, and at the same time look up over your left shoulder. Repeat this exercise touching the left end of the broomstick to the right knee, while looking up over your right shoulder. These neck and spine mobilization exercises may be difficult at first if your neck and spine are stiff. Be gentle, and gradually mobilize your neck and spine.
As your strength improves, light weight dumb-bells might be used. Again, one or two pound weights are adequate for most, and never more than five pounds.
The Quadriceps exercises should be done from the chair one leg at a time. Straighten your right leg out, then lift it from the floor until it is straight out, and then tense the thigh muscles and hold the tension for five seconds. Relax, and lower your leg to the floor and rest for five seconds. Repeat the cycle two or three times. Then do the same for the left leg.
These Quadriceps exercises may initially be too strenuous for some. In that case, start out with both feet flat on the floor, and tense both thighs for five seconds, relax for five seconds, and repeat the cycles two or three times.
For hip strengthening, sit up straight, knees together, and then lift the right knee up, then swing it outward, put the foot down, then bring it back up, and return to the starting position with the knees touching. Repeat two or three times, and then do the same for the left leg. This is one cycle of this exercise. Repeat the cycle two or three times.
For hip, lower abdominal and lower spine exercise, place your heels directly in front of the chair, and then push your heels into the floor. As you do this, tense your lower abdominal and back muscles. Hold this tension for five seconds, relax for five seconds, and repeat the cycle two or three times.
If you have done these exercises faithfully for about two weeks, you should now be prepared to begin walking training. And if you have been further developing your dyspnea recognition skills and breathing control skills, you will be even better prepared for walking exertion, and controlling any dyspnea of increased activity.
Being able to walk about is the fundamental goal that liberates you from confinement to bed or chair, or from doing many activities of daily living. If you have reasonable walking capability you can get out of your home to shop, or to visit friends and relatives, and generally do many of the things you would like to do.
And walking itself is an excellent form of general exercise. But you will need to start slowly, and build up you walking capability gradually. Remember, in the race between the rabbit and the turtle, the turtle won.
Initially, and until your strength develops, you should walk with an assistant and with the aid of a Safety Belt. And if unsteady, you should use a Walker assistive device, either a Jump Walker or a Rolling Walker with wheels for greater mobility. Later, when you no longer need an assistant, continue to use the Walker, and otherwise keep it handy should you suddenly feel weak or unsteady. If you feel the need for long term walker assistance you might consider investing in an excellent device called the Rollator, which is essentially a sophisticated Rolling Walker. Use of the Rollator might indeed make you capable of longer excursions outside the home.
Walk a bit further each week, and don't abandon the upper and lower extremity Isometric Exercises, which are best done while seated. And as you walk further, remember that you must be able to get back. Don't get yourself in a position where you need to stop and rest, or use a chair for resting, but cannot rest because you have gone too far. Pace yourself deliberately, and control your level of increased activity within your dyspnea control requirements. Never allow yourself to get so short of breath that you cannot control your breathing and recover from a dyspnea attack.
An excellent walking breathing control technique is called Paced Walking. Walk in a comfortable manner, and count your footsteps while breathing in and out. Breathe in - one - two (or one - two - three). Breathe out - one - two - three (or one - two - three - four). Note that breathing out must always be longer than breathing in, in order to prevent the problem of lung overinflation due to Dynamic Hyperinflation. Some require an even longer breathing out phase, up to five or six counts.
As you exercise there is a natural desire to breathe faster, which must be resisted, as breathing faster will cause Dynamic Hyperinflation and make your breathing acutely worse. Your best compromise is to breathe only slightly faster, about two or three breaths per minute over your resting breathing rate, while at the same time continuing to have longer expiration breaths. Never breathe faster than 15 breaths per minute. When this is no longer possible, stop and rest, and concentrate on breathing control and/or Pursed Lip Breathing.
Note that with shorter steps you may have more breath counts, and with longer steps you will have fewer breath counts. For example, with shorter steps your breath counting may now be Breathe in - one - two - three- four. Breathe out - one - two - three - four - five - six - seven. By adjusting your speed of walking and size of the steps you take you can make quite refined breathing timing signals suitable for your particular needs.
Stair climbing skills are usually required, even if you live in a one story home. You may need to climb a few stairs to get into your home, or climb at least a few stairs in many situations outside of the home situation.
For even the very short of breath person, you can still climb a few stairs quite easily, if done one step at a time, and if you have been doing your Isometric Quadriceps exercises. If possible, support yourself with one hand on a railing, and preferably have as assistant ready to help if needed.
Place one foot on the next step, take in a deep breath, and then exhale while stepping up with the other foot. Then stop, and take a few gentle, deep breaths, remembering to breathe out all the way. When you are sure your breathing is controlled, take another step, and again be sure you stop and rest before proceeding. If your "step up" leg gets tired, switch to your other leg to make the step up. Don't make the mistake of feeling embarrassed by your slow climbing progress, and trying to rush your stair climbing beyond your breathing capability.
A good stair climbing technique for those who are stronger and have good breathing control skills is called Paced Stair Climbing. Here you climb three stair steps at a time. To get the timing right it is necessary for you to climb very slowly and deliberately. On the first step up, breathe in (Note this is opposite for the exertion portion of the "one step at a time" technique). On the next two steps up, breathe out, and then stop and rest.
Don't proceed to the next three steps unless you have good breathing comfort and breathing control. As you again strength you may find that you can take six stairs at a time, or nine stairs at a time. If you are climbing stairs in multiples of three steps, try to get a slow rhythm to your breathing and stair climbing. Again, be sure to stop and rest if your dyspnea is increasing and you are in danger of losing your breathing control.
It is surprising how many COPD patients can learn to climb stairs very effectively. And if you develop this skill, make a point of climbing stairs for exercise, rather than using an elevator. This one is a real confidence builder.
Enclosed shopping malls are excellent for enjoyable walking exercise, as the problem of weather that is too hot, too cold, or raining is no longer a consideration. Plan to do this at least once a week, and preferably with friends, and make it into a social event. And you might consider forming a "Mall Walking Club" from members of your Pulmonary Rehabilitation class, or fellow members of a "Better Breathers" organization.
The harder you exercise, the greater will be the rehabilitation of your deconditioned peripheral muscles, and the greater will be the rehabilitation of your deconditioned heart muscle. The overall result is the improved ability of your heart to pump nourishing blood to your peripheral muscles, to supply Oxygen and remove Carbon Dioxide and waste products of metabolism. And likewise, your exercising peripheral muscles will now be working more efficiently, so they need relatively less Oxygen for a given level of work. This double benefit of exercise means that for a given level of exercise, you don't have to breathe as much, and therefor you can exercise more, within the constraints impose by your limited lung capacity. This is the essential basis for formal exercise training in pulmonary rehabilitation.
Most new COPD rehabilitation patients entering into exercise training will stop exercise because of dyspnea, but many will stop because of leg fatigue while walking or using an exercise bicycle. However, after some peripheral muscle reconditioning, almost all patients stop exercising because of the common denominator of dyspnea limitation. It is therefore essential that you understand how to breathe in an optimal manner if you are to exercise maximally and gain maximal exercise benefits.
With exercise there is a natural reflex to breathe faster, to meet the metabolic demands of your exercising muscles. Unfortunately, rapid breathing will precipitate the problem of Dynamic Hyperinflation, in what has been described as a "vicious circle" phenomenon producing lung overinflation. (You might want to review the module on Dynamic Hyperinflation if you are uncertain as to the mechanics of this very important topic.) Air Trapping and Dynamic Hyperinflation causes the lungs to so overinflate that an impossible mechanical situation develops, with extreme limitation to move air in and out of the lungs, and resulting severe dyspnea that forces the cessation of exercise. The respiratory breathing rate of untrained patients at peak exercise is about 30 to 31 breaths per minute. And keep in mind the breathing rate of untrained COPD patients at rest is frequently in the 18 to 20 breaths per minute range.
Establishing an exercise breathing pattern involves a number of complex conflicting constraints, and these breathing patterns will seem very counter-intuitive as to how you body is telling you to breathe. The most important thing to remember, is to never let your exertion breathing rate go faster than 15 breaths per minute, and always breathe out longer than you breathe in.
If you are using the Breathing Trainer, set the Respiratory Rate to 15 breaths per minute, the Tidal Volume to about 1000 to 1200 cc, and the Expiration Time to a minimum of 60% (and you may wish to set it to even 65 or 70%). The size of your breath will really always be dictated by how big a breathe you can achieve, within these timing constraints.
At all times be particularly aware of any sensations of lung overinflation. Soon into exercise you will almost always feel some overinflation and therefore the need to apply pressure on expiration to force the air out of your lungs, to correct any Air trapping and overinflation.
It is very important that you know when to stop exercising. Stop exercising when you cannot hold your breathing rate to 15 breaths per minute, or you cannot maintain your expiratory time to your set value of 60% (or 65 or 70%).
It is also very important that when you stop exercising that you not allow your breathing rate to increase greater than 15 breaths per minute. Maintain your breathing pattern with the longer expiratory phase, and you will recover more quickly. Otherwise you will cascade into an uncontrolled hyperventilation breathing pattern, which can be very distressing.
Learning when to stop exertion and rest is one of the very important breathing skills. Once you have developed this skill, you will no longer fear exerting yourself, as you will then know when to stop exerting yourself, and control your breathing, and promptly regain your breathing comfort.
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