Effects of pulmonary rehabilitation and further adapted physical activities in patients with fibrosis interstitial idiopathic pneumonia

Contexte : Les tests de marche de 6 minutes (TM6) et de stepper de 6 minutes (TS6) permettent d’évaluer et de suivre en routine la tolérance à l’effort des patients porteurs pneumopathies interstitielles idiopathiques fibrosantes (PII-f). En général, les programmes de réhabilitation respiratoire (RR), améliorent la tolérance à l’effort et la performance à ces tests, la qualité de vie et les symptômes chez les patients atteints de PII-f, qu’ils soient réalisés en centre ou au domicile des patients. Peu d’études rapportent un maintien des bénéfices de la RR plusieurs mois après la fin de celle-ci chez les patients PII-f.Objectif : L’objectif général de la thèse était d’évaluer comparativement les adaptations cardioventilatoires au TM6 et TS6 chez les patients PII-f à différentes étapes de leur prise en charge en RR (pré et post-RR). Nous avions également pour objectif majeur d’évaluer la faisabilité et l’efficacité d’un programme de maintenance réalisé dans des structures proposant des activités physiques adaptées (APA) proches du domicile des patients PII-f sur le maintien des bénéfices à six mois post-RR.Matériel et méthodes : L’ensemble des patients atteints de PII-f ont réalisé un programme de RR au domicile de 8 semaines. Durant la période de suivi post-RR, les patients avaient le choix de bénéficier d’un suivi en APA dans une structure extérieure au domicile (groupe APA) ou de continuer la pratique d’une activité physique régulière en autonomie (groupe contrôle). Pré et post-RR, nous avons mesuré la tolérance à l’effort (TM6 et TS6) avec mesure des paramètres cardioventilatoires, les fonctions pulmonaires, la qualité de vie, la dyspnée, l’anxiété/dépression et la motivation des patients. Ces évaluations ont été réalisées aussi après 6 et 9 mois de suivi post-RR.Résultats : Parmi les 21 patients PII-f recrutés, 19 PII-f ont réalisé le programme de RR et sont revenus pour l’évaluation après 6 mois de suivi. Le TM6 et le TS6 induisent des adaptations cardioventilatoires différentes chez les patients atteints de PID, notamment une réponse ventilatoire supérieure au TS6 susceptible de jouer un rôle important sur la moindre désaturation en O2 observée comparé au TM6. A la suite d’un programme de RR, nous avons observé une amélioration des capacités physiques chez les patients PII-f. De manière individuelle, cependant, 58% des patients ne s’amélioraient pas post-RR, et 32% ne continuaient pas de pratiquer régulièrement les exercices physiques recommandés post-RR. La mise en place d’un programme de maintenance dans différentes structures locales proposant des APA proches du domicile chez des patients PII-f est réalisable et permet d’optimiser le maintien des bénéfices post-RR, qu’ils soient répondeurs ou non-répondeurs à la RR.Conclusion : Nos travaux ont souligné l’importance du choix du test d’effort, de la typologie de la PII-f et de la sévérité de l’hypoxémie sur les adaptations cardioventilatoires à l’effort, les adaptations physiologiques et l’évolution de la tolérance à l’effort post-RR. De plus, nous avons constaté que la réalisation de programmes de maintenance en APA, en s’appuyant sur des structures locales est réalisable et favorise un maintien des bénéfices à long terme chez les patients PII-f. Ainsi, l’évaluation des freins à l’activité physique chez un tiers des patients PII-f qui reste non-observant et arrête la pratique d’exercices physiques post-RR, est ainsi d’actualité. De plus, étudier plus précisément les différents profils de patients PII-f (répondeurs/non-répondeurs) pourrait être intéressant afin de comprendre les mécanismes potentiellement responsables de l’absence d’amélioration des capacités physiques post-RR chez les patients non-répondeurs, qu’elle soit liée à la pathologie, la médication ou une éventuelle pathologie musculaire associée.Context: The 6-minute walk test (6MWT) and 6-minute stepper test (6MST) are routinely performed to measure and monitor exercise tolerance in patients with fibrosis interstitial idiopathic pneumonia (f-IIP). In those patients, exercise capacity, quality of life and symptoms are usually improved after a pulmonary rehabilitation (PR) program which can either be performed in a rehabilitation centre or at home.Aim: First, we aimed, to compare the cardio-pulmonary adaptations during a 6MWT and a 6MST in patients with f-IIP, before and after PR. We aimed to assess patients’ adhesion to physical activity maintenance programs which are offered and located near the f-IIP patient's homes. And their efficiency in maintaining benefits observed post-PR.Methods: All the f-IIP patients included followed a 8-week PR program at home. During the post-PR follow-up period, patients voluntarily chose to perform physical activity in a structure proposed by the investigator (APA group), or by themselves at home (control group). Before and after the PR program, we quantified the patient's exercise capacity (6MWT and 6MST) and measured cardiopulmonary parameters during both tests, pulmonary function at rest, quality of life, dyspnoea at rest and after each exercise, anxiety/depression and patients’ motivation. The same evaluations were repeated at 6 and 9 months post-PR.Results: Among the 21 recruited f-IIP patients, 19 finished the PR program and had an evaluation at 6 months post-PR. The 6MST was characterized by a higher minute ventilation compared with the 6MWT, and this may have contributed to the lower O2 desaturation also observed during the 6MST. Following the PR program, there was a mean improvement of exercise tolerance in f-IIP patients. However, among the patients, 58% showed no improvement in the 6MWT distance post-PR nor in the cardiorespiratory parameters during the test, and 32% did not continue to practise a regular physical activity post-PR. Finally, the individual support from the investigators for the patients to follow a maintenance program in local structures, near the f-IIP patient's home, probably contributed to their voluntary inscription in these programs, which allowed the patients to maintain the post-PR benefits, whether they patients initially responded to the PR program or not.Conclusion: Our works emphasized the importance of selecting an appropriate test, according to the fixed objective; of the f-IIP clinicopathological entities, and of the hypoxemia severity on exercise cardiorespiratory and physiological adaptations and changes of exercise tolerance post-PR. Moreover, we observed that patients from the APA group regularly attended the chosen physical maintenance program in local structures, which contributed to the maintenance the post-PR benefits in f-IIP. The evaluation of physical activity engagement barriers, that lead to the non-participation of a third of f-IIP patients to physical activities post-PR, remains to be conducted. Further studies should also focus on the explanation for the absence of improvement of exercise tolerance and cardiorespiratory parameters in about half of f-IIP patients post-RR, either due to their pathology, medication, or possible muscle disorders

Impact d’une réhabilitation respiratoire et d’un suivi en activités physiques adaptées chez des patients atteints de pneumopathies interstitielles diffuses fibrosantes

Context: The 6-minute walk test (6MWT) and 6-minute stepper test (6MST) are routinely performed to measure and monitor exercise tolerance in patients with fibrosis interstitial idiopathic pneumonia (f-IIP). In those patients, exercise capacity, quality of life and symptoms are usually improved after a pulmonary rehabilitation (PR) program which can either be performed in a rehabilitation centre or at home.Aim: First, we aimed, to compare the cardio-pulmonary adaptations during a 6MWT and a 6MST in patients with f-IIP, before and after PR. We aimed to assess patients’ adhesion to physical activity maintenance programs which are offered and located near the f-IIP patient's homes. And their efficiency in maintaining benefits observed post-PR.Methods: All the f-IIP patients included followed a 8-week PR program at home. During the post-PR follow-up period, patients voluntarily chose to perform physical activity in a structure proposed by the investigator (APA group), or by themselves at home (control group). Before and after the PR program, we quantified the patient's exercise capacity (6MWT and 6MST) and measured cardiopulmonary parameters during both tests, pulmonary function at rest, quality of life, dyspnoea at rest and after each exercise, anxiety/depression and patients’ motivation. The same evaluations were repeated at 6 and 9 months post-PR.Results: Among the 21 recruited f-IIP patients, 19 finished the PR program and had an evaluation at 6 months post-PR. The 6MST was characterized by a higher minute ventilation compared with the 6MWT, and this may have contributed to the lower O2 desaturation also observed during the 6MST. Following the PR program, there was a mean improvement of exercise tolerance in f-IIP patients. However, among the patients, 58% showed no improvement in the 6MWT distance post-PR nor in the cardiorespiratory parameters during the test, and 32% did not continue to practise a regular physical activity post-PR. Finally, the individual support from the investigators for the patients to follow a maintenance program in local structures, near the f-IIP patient's home, probably contributed to their voluntary inscription in these programs, which allowed the patients to maintain the post-PR benefits, whether they patients initially responded to the PR program or not.Conclusion: Our works emphasized the importance of selecting an appropriate test, according to the fixed objective; of the f-IIP clinicopathological entities, and of the hypoxemia severity on exercise cardiorespiratory and physiological adaptations and changes of exercise tolerance post-PR. Moreover, we observed that patients from the APA group regularly attended the chosen physical maintenance program in local structures, which contributed to the maintenance the post-PR benefits in f-IIP. The evaluation of physical activity engagement barriers, that lead to the non-participation of a third of f-IIP patients to physical activities post-PR, remains to be conducted. Further studies should also focus on the explanation for the absence of improvement of exercise tolerance and cardiorespiratory parameters in about half of f-IIP patients post-RR, either due to their pathology, medication, or possible muscle disorders.Contexte : Les tests de marche de 6 minutes (TM6) et de stepper de 6 minutes (TS6) permettent d’évaluer et de suivre en routine la tolérance à l’effort des patients porteurs pneumopathies interstitielles idiopathiques fibrosantes (PII-f). En général, les programmes de réhabilitation respiratoire (RR), améliorent la tolérance à l’effort et la performance à ces tests, la qualité de vie et les symptômes chez les patients atteints de PII-f, qu’ils soient réalisés en centre ou au domicile des patients. Peu d’études rapportent un maintien des bénéfices de la RR plusieurs mois après la fin de celle-ci chez les patients PII-f.Objectif : L’objectif général de la thèse était d’évaluer comparativement les adaptations cardioventilatoires au TM6 et TS6 chez les patients PII-f à différentes étapes de leur prise en charge en RR (pré et post-RR). Nous avions également pour objectif majeur d’évaluer la faisabilité et l’efficacité d’un programme de maintenance réalisé dans des structures proposant des activités physiques adaptées (APA) proches du domicile des patients PII-f sur le maintien des bénéfices à six mois post-RR.Matériel et méthodes : L’ensemble des patients atteints de PII-f ont réalisé un programme de RR au domicile de 8 semaines. Durant la période de suivi post-RR, les patients avaient le choix de bénéficier d’un suivi en APA dans une structure extérieure au domicile (groupe APA) ou de continuer la pratique d’une activité physique régulière en autonomie (groupe contrôle). Pré et post-RR, nous avons mesuré la tolérance à l’effort (TM6 et TS6) avec mesure des paramètres cardioventilatoires, les fonctions pulmonaires, la qualité de vie, la dyspnée, l’anxiété/dépression et la motivation des patients. Ces évaluations ont été réalisées aussi après 6 et 9 mois de suivi post-RR.Résultats : Parmi les 21 patients PII-f recrutés, 19 PII-f ont réalisé le programme de RR et sont revenus pour l’évaluation après 6 mois de suivi. Le TM6 et le TS6 induisent des adaptations cardioventilatoires différentes chez les patients atteints de PID, notamment une réponse ventilatoire supérieure au TS6 susceptible de jouer un rôle important sur la moindre désaturation en O2 observée comparé au TM6. A la suite d’un programme de RR, nous avons observé une amélioration des capacités physiques chez les patients PII-f. De manière individuelle, cependant, 58% des patients ne s’amélioraient pas post-RR, et 32% ne continuaient pas de pratiquer régulièrement les exercices physiques recommandés post-RR. La mise en place d’un programme de maintenance dans différentes structures locales proposant des APA proches du domicile chez des patients PII-f est réalisable et permet d’optimiser le maintien des bénéfices post-RR, qu’ils soient répondeurs ou non-répondeurs à la RR.Conclusion : Nos travaux ont souligné l’importance du choix du test d’effort, de la typologie de la PII-f et de la sévérité de l’hypoxémie sur les adaptations cardioventilatoires à l’effort, les adaptations physiologiques et l’évolution de la tolérance à l’effort post-RR. De plus, nous avons constaté que la réalisation de programmes de maintenance en APA, en s’appuyant sur des structures locales est réalisable et favorise un maintien des bénéfices à long terme chez les patients PII-f. Ainsi, l’évaluation des freins à l’activité physique chez un tiers des patients PII-f qui reste non-observant et arrête la pratique d’exercices physiques post-RR, est ainsi d’actualité. De plus, étudier plus précisément les différents profils de patients PII-f (répondeurs/non-répondeurs) pourrait être intéressant afin de comprendre les mécanismes potentiellement responsables de l’absence d’amélioration des capacités physiques post-RR chez les patients non-répondeurs, qu’elle soit liée à la pathologie, la médication ou une éventuelle pathologie musculaire associée

Activités physiques et réadaptation respiratoire

National audienceIntroduction: Physical activity in daily life (PA) in patients with chronic respiratory disease is reduced. Inactivity is associated with an increased risk of hospitalisation and mortality. Even though pulmonary rehabilitation (PR) is associated with improved quality of life (fewer symptoms, greater exercise capacity…), its benefits with regard to PA remain unclear. State of the art: For each patient, it is important during a respiratory rehabilitation (RR) programme to evaluate PA and its determinants. Only programs aimed at improved self-management and including educational therapy (ETP) have shown a short-term increase of PA following PR. Several studies have reported better long-term adherence when professionals help the patient to construct a personalised PA project, with regular follow-up and an array of activities (local facilities, urban walking…) chosen by the patient and adapted to the environment. Perspectives: The ongoing SARS-CoV2 pandemic has highlighted the importance of human interaction, even at a distance using information and communication technologies, as a means of sustaining patient motivation. Future controlled and randomized studies should focus on the long-term impact on PA of innovative strategies in patients with chronic respiratory diseases. Moreover, it would be interesting to quantify the socioeconomic impact as well as the sustainable health benefits of the different strategies outlined in this review. Conclusion: It is not possible to offer a single solution likely to maintain RR benefits over an extended lapse of time. However, follow-up with an ETP and/or regular and customized support during the post-training period facilitates the long-term adoption of active behavior

APS et pathologies respiratoires

National audienc

Cardiorespiratory Response to Different Exercise Tests in Interstitial Lung Disease.

International audienceIntroduction: The 6-min stepper test (6MST) has been used as an alternative to the 6-min walk test (6MWT) to assess exercise tolerance in patients with interstitial lung disease (ILD). Recent data suggest that the tests may involve different energy pathways and cardiorespiratory responses. We thus aimed to compare the cardiorespiratory responses of ILD patients during the 6MWT and the 6MST.Methods: Thirty-one patients with ILD were randomized to perform both tests in the order 6MST → 6MWT (n = 16) or 6MWT → 6MST (n = 15). Gas exchange, HR, and pulse O2 saturation (SpO2) were measured continuously, and dyspnoea, leg discomfort, and blood lactate concentration were assessed before and immediately after each test.Results: Oxygen uptake (V˙O2) was lower (P = 0.002) and respiratory equivalent ratio for O2 (V˙E/V˙O2) and RER were higher (both P < 0.001) during the 6MST compared with the 6MWT. The 6MST was also associated with higher blood lactate concentrations (6MST, 4.16 ± 1.95 mmol·L; 6MWT, 2.84 ± 1.17 mmol·L; P = 0.01), higher leg discomfort scores (6MST 5 ± 3 points, 6MWT 3 ± 2 points; P < 0.001), and smaller decreases in SpO2 (6MST -5% ± 5%, 6MWT -9% ± 6%; P < 0.001).Conclusions: ILD patients exhibited greater ventilatory responses and lower arterial O2 desaturation during the 6MST compared with the 6MWT. The higher lactate concentrations and perceived muscle fatigue observed during the 6MST may indicate the presence of intertest differences in active muscle metabolism that could contribute to the distinct cardiorespiratory responses

Cardiorespiratory adaptation during 6-Minute Walk Test in fibrotic idiopathic interstitial pneumonia patients who did or did not respond to pulmonary rehabilitation

International audienceBackground: Pulmonary rehabilitation (PR) improves performance in the 6-min walk test (6MWT) in a subset of patients with fibrotic idiopathic interstitial pneumonia (f-IIP); however, a large proportion of patients does not respond to PR.Aim: To investigate the effects of a PR program on cardiorespiratory responses during a 6MWT and to identify the characteristics of patients who do not show improved performance after PR.Design: An observational study.Setting: Patients were recruited from the Competence Centre for Rare Pulmonary Diseases at Lille University Hospital, France and completed an 8-week home-based PR program.Population: A total of 19 patients with f-IIP; 12 with idiopathic pulmonary fibrosis (IPF) and 7 with fibrotic non-specific interstitial pneumonia.Methods: Patients underwent spirometry and completed a 6MWT before and after an 8-week PR program. Gas exchange, heart rate, and pulse O2 saturation were measured continuously during the 6MWT. Quality of life, dyspnea, and anxiety/depression were assessed using the Short-Form 36 (SF-36), the baseline/transition dyspnea index (BDI/TDI), and the Hospital Anxiety and Depression Scale (HADS) questionnaires.Results: Patients who did and did not improve the distance walked in the 6MWT by at least 30 m after PR were classified as responders (N.=9) and non-responders (N.=10), respectively. O2 uptake, ventilation rate, and distance covered during the 6MWT were significantly improved only in the responder group (P<0.05). Changes in SF-36, BDI/TDI, and HADS scores did not differ significantly between responders and non-responders. The non-responder group contained significantly more patients with IPF (P<0.05) and experienced greater arterial oxygen desaturation during the 6MWT compared with the responder group.Conclusions: Failure to improve performance in the 6MWT after PR was associated with a diagnosis of IPF, non-improvement in gas exchange, and greater arterial oxygen desaturation.Clinical rehabilitation impact: Most f-IIP patients who did not respond to PR were diagnosed with IPF and displayed greater hypoxemia during exercise. Clinical practitioners should seek to determine why patients fail to improve exercise performance after PR and propose an alternative exercise regimen to these patients

Exploiting Local Facilities for Post-Pulmonary Rehabilitation Maintenance Programs in Fibrotic Idiopathic Interstitial Pneumonia Patients: A Pilot Study

International audienc

Six-minute stepper test: a valid clinical exercise tolerance test for COPD patients

International audienc