Exercise for people with chronic pulmonary disease with Dr. Sunita Mathur

In the third episode of the Masters in Exercise podcast, host A interviews Dr. Sunita Mather, an associate professor at the University of Toronto, about exercise prescription for individuals with chronic obstructive pulmonary disease (COPD). They discuss the risk factors and symptoms of COPD, emphasizing the importance of monitoring shortness of breath and training peripheral muscles. Dr. Mather explains how systemic inflammation and deconditioning affect muscle function, advocating for resistance training alongside aerobic exercises to combat muscle atrophy. They also consider the potential benefits and challenges of high-intensity interval training for COPD patients, highlighting the need for tailored exercise assessments and overcoming barriers to participation.

• Dr. Sunita Mather is an associate professor focusing on improving skeletal muscle function and structure in individuals with muscle atrophy and weakness.
• Her interest in physical therapy stemmed from a personal involvement in sports, an interest in science, and an introduction to physiotherapy as a career option.
• Transitioned from clinical work to research, driven by an interest in exercise science and the opportunity to explore research during her academic career.

"I had an interest in sports and exercise, just personally, because being involved with competitive sports, like I think many physio students are these days as well."

• Demonstrates the initial personal connection to sports and exercise that led to a career in physical therapy.

"I started the program. It was very new to me, the whole area, but I really liked the exercise science piece of it, especially at that time."

• Highlights the appeal of exercise science within physical therapy, which contributed to her career choice.

"And a few of the professors talked to me to see, like, would you like to pursue more research? And I thought that would be a really interesting option."

• Illustrates how mentorship and exposure to research opportunities influenced her decision to pursue an academic career.

• Dr. Mather misses the clinical interaction with patients but values working with patient partners in research.
• She acknowledges the benefits of a balanced career combining clinical work and research, which fosters clinically relevant research questions.

"I do miss having that interaction. Even like now with data collection, I'm not even involved too much with the hands-on seeing the people coming in."

• Reflects on the lack of direct patient interaction in research and the value of that experience.

"I wish we had this option because you can come up with some very interesting clinically based questions when you have that option."

• Emphasizes the potential for generating relevant research questions when combining clinical practice with research.

• Dr. Mather's interest in muscle physiology began during her master's with the emergence of pulmonary rehabilitation.
• She explored muscle changes in COPD, recognizing muscle atrophy as a common issue across various clinical conditions.
• Her research expanded to include muscle imaging and biomechanics to understand muscle function in respiratory conditions.

"There were some new articles at the time on muscle changes in people with COPD. And I thought, that's really interesting."

• Indicates the initial intrigue in muscle physiology related to COPD and its broader implications.

"I was learning a lot of biomechanics and how to measure muscle and how to measure mobility."

• Highlights the integration of biomechanics in her research pursuits, focusing on muscle assessment.

• COPD is an obstructive lung condition characterized by irreversible airflow obstruction, airway inflammation, mucus overproduction, and destruction of alveolar walls.
• COPD involves chronic bronchitis, emphysema, and bronchiolitis, leading to systemic inflammation.

"COPD, it's considered an obstructive lung condition and has something called irreversible airflow obstruction."

• Defines COPD and distinguishes it from other respiratory conditions like asthma.

"There's a high degree of inflammation in the airways, in the lungs of people with COPD, and that can lead to systemic inflammation."

• Explains the inflammatory processes involved in COPD and their systemic effects.

• Smoking is the primary risk factor, with other contributors including environmental pollutants and genetic factors like Alpha1 Antitrypsin Disorder.
• The incidence of COPD in females is increasing, influenced by smoking trends and improved diagnosis.

"Smoking definitely. Like most people with COPD, especially in Canada, will have smoking-related COPD."

• Affirms smoking as the predominant risk factor for COPD.

"There was also like lack of understanding of the diagnosis of COPD in women previously, and then that started to improve."

• Discusses the historical underdiagnosis of COPD in women and the ongoing gender disparity in incidence rates.

• COPD, primarily a lung disease, also significantly affects peripheral muscles.
• Systemic inflammation is a key factor, where inflammatory cells from the lungs enter the bloodstream and accumulate in muscles.
• This inflammation can disrupt muscle fibers, impair mitochondrial function, and lead to muscle atrophy.
• Deconditioning due to reduced physical activity exacerbates muscle weakness but can be reversed with rehabilitation.
• Malnutrition and altered blood gases in COPD patients further impact muscle health.

"COPD causes a lot of inflammation in the airways and in the lungs, but those inflammatory cells also go into the bloodstream and they do get collected into the muscle."

• This quote highlights how inflammation originating in the lungs spreads to affect peripheral muscles, a key mechanism in COPD-related muscle degradation.

"Deconditioning is a primary factor in the muscle deconditioning, and that's something that can be reversed."

• Deconditioning from reduced activity is a significant but reversible factor in muscle weakness associated with COPD.

• The diaphragm experiences unique changes due to COPD, including reduced strength and endurance, largely due to mechanical changes in the chest wall.
• Accessory muscles may become overused and fatigue quicker, differing from the deconditioning seen in limb muscles.
• These adaptations are challenging to study but critical for understanding COPD's broader impact on muscle function.

"The diaphragm of someone with COPD is quite unique and it doesn't function as well as a healthy individual."

• The diaphragm undergoes specific changes in COPD, affecting its function and contributing to respiratory challenges.

• Non-invasive imaging techniques like MRI, CT scans, and ultrasound are used to study muscle atrophy and structure.
• Imaging provides insights into muscle architecture, fat infiltration, and overall muscle health without tissue destruction.
• Functional performance tests assess muscle strength, endurance, and power, complementing imaging studies.
• Muscle biopsies offer detailed cellular and molecular insights, particularly into muscle regeneration.

"We use a lot of non-invasive imaging techniques to look at muscle atrophy and muscle structure."

• Non-invasive imaging is a preferred method for assessing muscle changes, offering a comprehensive view without invasive procedures.

• COPD patients often hope for improvements in lung function, but exercise primarily enhances peripheral muscle function.
• Improved muscle function allows patients to perform more activities before experiencing shortness of breath.
• Exercise does not change lung function or oxygen saturation but improves quality of life by enhancing muscle capacity.

"The lung function itself doesn't change. But because the peripheral muscles improve, they're actually able to do more activity before they feel that shortness of breath."

• Exercise improves muscle function, allowing COPD patients to manage symptoms better, even if lung function remains unchanged.

• Resistance training is crucial for addressing muscle strength impairments and atrophy in COPD patients.
• Combining aerobic and resistance training provides greater strength benefits than aerobic training alone.
• Improved muscle strength from resistance training also enhances balance and overall physical function.

"Resistance training confers a different benefit than aerobic training."

• Resistance training specifically targets muscle strength, offering distinct advantages over aerobic exercise alone.

• Dyspnea (shortness of breath) is a primary limiting factor in exercise for COPD patients.
• It is often the main complaint during physical activity, particularly walking, and can deter patients from starting exercise routines.

"Half of them will say dyspnea, half of them will say leg fatigue."

• Dyspnea is a significant barrier to exercise, highlighting the need for tailored exercise programs for COPD patients.

• HIIT is a popular training method with potential benefits for COPD patients, though evidence is still emerging.
• It may help manage dyspnea by allowing for varied intensity levels.
• HIIT is already established in cardiac rehab and brain plasticity modulation, suggesting potential for broader applications.

"What is the evidence regarding how we can use this type of training in people with COPD?"

• The exploration of HIIT for COPD is ongoing, with interest in its ability to manage symptoms like dyspnea through structured intensity variations.

• Interval training for COPD patients often doesn't adhere to true high-intensity interval training (HIIT) principles.
• Clinical practices and literature have traditionally avoided pushing COPD patients to high-intensity levels due to fears of safety and tolerability.
• Studies in other lung diseases show potential benefits and patient preference for interval training over continuous exercise.

"In people with COPD, interval training was not done based on the real principles of interval training."

• This quote highlights the discrepancy between traditional interval training and its application in COPD, indicating a need for more rigorous adherence to HIIT principles.

"Most people actually preferred the interval. They quite liked doing it, they were able to tolerate it, they didn't desaturate."

• This suggests that, contrary to fears, patients may prefer and tolerate interval training well, even in conditions with higher desaturation risks than COPD.

• Clinicians often fear pushing COPD patients to high-intensity levels, despite evidence supporting its feasibility.
• Patients with COPD may have psychological barriers due to the chronic nature of their disease and fear of exacerbating symptoms.
• Lack of access to proper exercise testing tools in clinical settings hinders accurate prescription of interval training.

"The main barrier, I will say is really the clinicians. Even more than the patients, they don't have enough information to say, okay, I'm going to go high intensity."

• This quote underscores the role of clinician apprehension as a significant barrier to implementing high-intensity training in COPD patients.

"The fear of shortness of breath and, and the fear of oxygen desaturation is there in people with COPD more so than in other lung diseases."

• This highlights the psychological and physiological concerns that COPD patients have, which can impede their participation in more intensive exercise regimens.

• A graded exercise test is recommended by the American College of Sports Medicine for COPD patients, but not always feasible due to resource limitations.
• Incremental shuttle walk tests are suggested as an alternative to better assess exercise capacity.
• Some clinical programs successfully integrate lab-based tests to tailor high-intensity training, fostering collaboration between researchers and clinicians.

"I wouldn't think clinically it should be mandatory on a routine basis because it's just going to put another barrier in place to pulmonary rehab."

• This quote reflects the practical challenges of implementing mandatory graded exercise tests in routine clinical practice.

"It creates a nice partnership with the clinicians because they send the patients to our lab to do the training or to do the testing and then we provide the report."

• This illustrates the positive impact of collaboration between labs and clinicians in enhancing patient care and exercise prescription.

• Fear of dyspnea and lack of knowledge about exercise benefits are significant barriers for COPD patients.
• Self-efficacy and logistical issues, such as transportation and caregiver dependency, also hinder participation.
• Tele-rehabilitation is emerging as a viable solution to overcome some of these barriers.

"A lot of it is this fear of dyspnea. If they do too much activity, they're going to get short of breath and that's going to actually impair their health rather than improve it."

• This quote captures the common fear among COPD patients that exercise could worsen their condition, highlighting the need for better education.

"Nowadays with tele rehab being taken up more, some of those barriers are being overcome."

• This highlights the potential of tele-rehabilitation to mitigate logistical barriers and increase access to pulmonary rehabilitation programs.

• Social interaction is a crucial facilitator for exercise participation, akin to its role in stroke rehabilitation.
• Meeting others with COPD in a group setting provides social support and motivation not visible in individual settings.

"The benefits in terms of the social interaction, meeting other people with COPD is a big thing because it's not a condition you can visibly see."

• This quote emphasizes the importance of social support in motivating COPD patients to engage in rehabilitation programs.

• Pulmonary rehabilitation offers significant benefits for individuals with COPD, including reducing social isolation and providing social interaction.
• The relationship between patients and healthcare providers is crucial in facilitating participation in pulmonary rehab, especially with remote classes.
• People with COPD often experience social isolation similar to stroke patients, making the social component of pulmonary rehab vital.

"Pulmonary rehab definitely has that social interaction really helps a lot."

• Emphasizes the importance of social interaction in pulmonary rehab for individuals with COPD.

• Individual assessment is critical before prescribing exercise to COPD patients, as there's a wide range of physical performance not directly tied to lung function.
• Methods like the six-minute walk test or incremental shuttle walk test are essential for assessing aerobic capacity.
• Resistance training should be tailored to individual strength levels to avoid under-prescription.
• Progressive training is necessary as COPD patients often show quick adaptations due to initial deconditioning.
• A comprehensive exercise program should include balance training, flexibility, inspiratory muscle training, and upper limb training.
• Exercises involving shoulder-level and above movements are particularly beneficial due to their impact on everyday activities.

"Assessment, I'd say on aerobic and resistance would be very, very important."

• Highlights the necessity of individualized assessment in exercise prescription for COPD patients.

"You need to think beyond just your regular training principles."

• Encourages incorporating diverse training elements beyond traditional methods to maximize benefits for COPD patients.

• A career in research doesn't necessarily require a PhD; there are various ways to engage in research, including clinical trials and research assistant roles.
• Maintaining passion and interest in research is vital due to the inherent challenges and barriers.
• Research should reflect personal authenticity and diversity, contributing unique perspectives to the field.
• Encourages aspiring researchers to remain true to themselves and bring their personality into their work.

"You don't have to do it as your entire career. If you don't want to, that's fine."

• Emphasizes flexibility in pursuing research as a career, highlighting that it can be a part-time endeavor.

"You need to hold on to what is your true self and what is your authentic self and bring that to your research."

• Stresses the importance of personal authenticity and diversity in research.

• Success is defined by making a difference weekly, whether through teaching, research, or community involvement.
• The slow progress of research requires a long-term perspective to recognize success.
• Collaboration and working with students are key components of professional fulfillment.
• Personal success mirrors professional success, focusing on contributing positively to the community through volunteer work.

"Did I do something this week that helped, you know, progress someone or something?"

• Describes success as making a positive impact within a given timeframe.

"Am I doing something for my community? Am I, you know, making things better for my community?"

• Reflects the personal application of professional values, emphasizing community contribution.

• Sunita Mather is active on Twitter, where she shares her research articles and updates.
• Her professional information and initiatives can be found on the University of Toronto faculty pages and the Can Restore website.

"On Twitter, I usually do post my new articles and things. So it's Sunita Mather one."

• Indicates where to find Sunita Mather's professional updates and contributions online.