retraining obstructive pulmonary disease subjects: from theory to practice alain varray diplôme...
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RETRAINING OBSTRUCTIVE RETRAINING OBSTRUCTIVE
PULMONARY DISEASE SUBJECTS:PULMONARY DISEASE SUBJECTS:
From theoryFrom theory to practice to practice
Alain VARRAY
Diplôme Européen Universitaire
en Activités Physiques Adaptées
COPDCOPDChronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease
Permanent and irreversible bronchial obstruction chronic hypoxemia
In 2020: probably 3rd cause of mortality in the world
From a clinical point of view:Main symptom: dyspneaVery poor respiratory function (permanent)obvious and high exercise intolerance
Physical Activity and COPD: Physical Activity and COPD: not evident at all !not evident at all !
2 main hurdles :PA increased breathlessness
to be avoided in dyspneic individuals
PA does not change respiratory function so,
PA considered difficult and useless
or even non relevant
Major changesMajor changes
In ten years, many works have improved our understanding of the COPD/exercise interface :
Exercise tolerance is not only linked to COPD severity
COPD muscle shows important abnormalities Quantitative aspect (low muscle mass) Qualitative aspect (muscle structure) Functional consequences Metabolic aspect: the muscle impairments
are not linked with insufficient O2 delivery
2001 AJRCCM editorial : COPD as a muscle disease
WHAT IS THE CONSEQUENCE ?WHAT IS THE CONSEQUENCE ?
Reminder of reasons in favor of PA avoidance Poor exercise tolerance due to pulmonary function
impossible to improve it (chronic disease)exercise induces dyspnea worsening
New evidences in favor of APA :Alteration of muscle function early dyspnea
PA can be used to improve muscle function
for the same disease severity improve exercise tolerance is possible, so better quality of life
COPD MUSCLE STRUCTURECOPD MUSCLE STRUCTURE
Less fat free mass Loss of maximal force Predictive of peak V'O2
________________ Baarends et al. Eur Respir J, 1997, 10 : 2807-13.
Localized muscle endurance Localized muscle endurance
Interest of localized exercise:
Muscle evaluation without cardiorespiratory limitation
Exercise with adequate O2 supply
Despite this: Endurance time (Tlim)
______ Serres, Gauthier, Varray, Préfaut. Chest, 1998, 113: 900-05.
0
50
100
150
200
250
300
350
400
COPD CONTROL
Tlim
(s)
.
*
Muscle structure abnormalities: typologyMuscle structure abnormalities: typology
Whittom, Jobin, Simard, Leblanc, Simard, Bernard, Belleau, Maltais. Med Sci Sports Exerc, 1998; 30: 1467-74.
CONTROL
COPD
Muscle structure abnormalitiesMuscle structure abnormalities
Decreased activity of oxidative enzymes in COPD Maltais et al, Am J Respir Crit Care Med, 1996.
Citrate synthase, HADH Normal activity of glycolytic enzymes:
LDH, HK, PFK
Explains excessive anaerobic contribution during exercise (localized or general)…
Excessive anaerobic contribution – Excessive anaerobic contribution – localized exerciselocalized exercise
Mean Power Output (W.cm2)
0.0 0.1 0.2 0.3 0.4
Pi/P
Cr
0
1
2
3
4
CONTROL
_______________________ Wuyam, Payen, Levy, et al. Eur Respir J, 1992, 5: 157-62.
Excessive anaerobic contribution – Excessive anaerobic contribution – localized exerciselocalized exercise
Mean Power Output (W.cm2)
0.0 0.1 0.2 0.3 0.4
Pi/P
Cr
0
1
2
3
4
CONTROLCOPD
_______________________ Wuyam, Payen, Levy, et al. Eur Respir J, 1992, 5: 157-62.
**
**
**
Excessive anaerobic contribution – Excessive anaerobic contribution – general exercisegeneral exercise
Maltais, Jobin, Sullivan, Bernard, Whittom, Killian, Desmeules, Belanger, LeBlanc. J Appl Physiol
1998, 84: 1573-80.
Excessive anaerobic contribution – Excessive anaerobic contribution – general exercisegeneral exercise
Maltais, Jobin, Sullivan, Bernard, Whittom, Killian, Desmeules, Belanger, LeBlanc. J Appl Physiol
1998, 84: 1573-80
**
**
*
Muscle oxidative stress evidenceMuscle oxidative stress evidence
• COPD tested in local muscle exercise conditions (quadriceps)
• Assessment of oxidative stress (TBARs)
*
Couillard, Koechlin, Cristol, Varray, Prefaut. Eur Respir J, 2002, 20: 1123-9.
• Consequences on:
Muscle membrane integrity
Impairment of oxidative pathways
Muscle impairment occurs before any Muscle impairment occurs before any problem in Oproblem in O22 supply supply
Warm-up (min)
0 1 2 3
M-W
ave
am
plit
ud
e (
% p
re-e
xe
rcis
e v
alu
es)
75
80
85
90
95
100
105
110
115
EXERCISE (% total duration)
25 50 75 100
Recovery (min)
0 5 10 15
Gosselin, Poulain, Ramonatxo, Ceugniet, Préfaut, Varray. Muscle & Nerve, 2003, 27: 170-9.
Muscle impairment occurs before any Muscle impairment occurs before any problem in Oproblem in O22 supply supply
Warm-up (min)
0 1 2 3
M-W
ave
am
plit
ud
e (
% p
re-e
xe
rcis
e v
alu
es)
75
80
85
90
95
100
105
110
115 ELDERLY NON COPD
EXERCISE (% total duration)
25 50 75 100
Recovery (min)
0 5 10 15
Gosselin, Poulain, Ramonatxo, Ceugniet, Préfaut, Varray. Muscle & Nerve, 2003, 27: 170-9.
Muscle impairment occurs before any Muscle impairment occurs before any problem in Oproblem in O22 supply supply
Warm-up (min)
0 1 2 3
M-W
ave
am
plit
ud
e (
% p
re-e
xe
rcis
e v
alu
es)
75
80
85
90
95
100
105
110
115 COPDELDERLY NON COPD
EXERCISE (% total duration)
25 50 75 100
Recovery (min)
0 5 10 15
*
*****
***
**** **
** **
Gosselin, Poulain, Ramonatxo, Ceugniet, Préfaut, Varray. Muscle & Nerve, 2003, 27: 170-9.
Consequences for exercise adaptationsConsequences for exercise adaptations
Decreased aerobic pathway for a given exercise intensity
Abnormal, excessive anaerobic contribution
Lactic acid Lactic acid [H [H++]]
HH++ + HCO + HCO33- - (buffering)(buffering)
COCO22 production production [H[H++] ]
Excessive stimulation of respiratory centers + respiratory limitation
Dyspnea worseningEven with stable disease severity
X
INTENSE EXERCISE INTENSE EXERCISE
SEVERESEVEREDECREASEDDECREASED
RESPIRATORY IMPAIRMENTRESPIRATORY IMPAIRMENT
DYSPNEA
ACTIVITYACTIVITY
DECONDITIONINGDECONDITIONING
STOPPEDSTOPPED MODERATEMODERATE
MODERATE EXERCISEMODERATE EXERCISE
DAILY ACTIVITIESDAILY ACTIVITIES
Dyspnea spiral…
….even if stable disease severity
INTENSE EXERCISEINTENSE EXERCISE
MEDERATE EXERCISE MEDERATE EXERCISE
DAILY ACTIVITIESDAILY ACTIVITIES
SEVERE MODERATESEVERE MODERATEDECREASED STOPPEDDECREASED STOPPED
RESPIRATORY IMPAIRMENTRESPIRATORY IMPAIRMENT
DYSPNEADYSPNEA
ACTIVITYACTIVITY DECONDITIONINGDECONDITIONING
INITIAL OR PRIMEINITIAL OR PRIMEPATHOLOGYPATHOLOGY
SECONDARYSECONDARYPATHOLOGY:PATHOLOGY:
DeconditioningDeconditioning++
Muscle Muscle dysfunctiondysfunction
SYNTHESISSYNTHESIS
PRIME PATHOLOGY: DYSPNEA due to respiratory impairment
SECONDARY PATHOLOGY: dyspnea due to respiratory center hyper activation Deconditioning consequence Muscle dysfunction
DYSPNEA MANAGEMENT : Fight against prime pathology (medical treatment) Subject RECONDITIONING = fight against secondary
pathology
AIMS OF EXERCISE TRAININGAIMS OF EXERCISE TRAINING
Fight against Deconditioning and muscle dysfunction :
cardio respiratoryperipheral
To solve problems due to prime and secondary pathology
TO DECREASE TO DECREASE DYSPNEADYSPNEA
A.P.A. JUSTIFICATIONA.P.A. JUSTIFICATION
PRIME PATHOLOGY:Medical and paramedical managementTreatment stabilisation and optimization
SECONDARY PATHOLOGY :EPSA teacher directly concernedWork on relationship between
Metabolic effects physical practice and Health increase
Decreased dyspnea so increased quality of life
BASIC KNOWLEDGE NEEDED TO BASIC KNOWLEDGE NEEDED TO OPTIMIZE A.P.A.OPTIMIZE A.P.A.
Good adaptation of exercise testingMethodological basis of individualizationExercise tests too often done incorrectly
dyspnea measurement (diagnosis and evaluation)
Optimal training intensity Field test development Retraining follow-up
ADAPTED EXERCISE TESTINGADAPTED EXERCISE TESTING
Basic principle : Individualize on standardized basis
Main principles:Continuous testProgressively increasedStep duration = 1 minTotal test duration = about 10 min after
warm-up so imperative individualization of load increment
WHY INDIVIDUALIZATION ?WHY INDIVIDUALIZATION ?
Initially, exercise inadaptation are proportional to pathology severity
Most of the time : exercise testing too short impossible ventilatory threshold assessment No maximal exercise test (RER<1.10) Bad interpretation of subject ability to
perform exercise and training programing
HOW INDIVIDUALIZE ?HOW INDIVIDUALIZE ?
STEPS:Calculation of theoretical max. O2 uptakeCorrection according FEV1 (% theoretical)Calculation of expected maximal power
output by converting in watts (remove 250 ml/min and divide by 10.3)
Warm-up = 20 % of expected Pmax during 3 min
Step = 8% of expected Pmax (every minute)
CALCULATION OF THEORETICAL VCALCULATION OF THEORETICAL VOO22maxmax
Predicted maximal O2 uptake(ml.min-1)
MEN
a) if weight<0.79 x height - 60.7
b) if weight>0.79 x height - 60.7
WOMEN
c) if weight<0.65 x height - 42.8
d) if weight>0.65 x height - 42.8
weight x (50.72 - 0.372 x age)
(0.79 x height - 60.7) x (50.72 - 0.372 x age)
(42.8 + weight) x (22.78 - 0.17 x age)
height x (14.81 - 0.11 x age)
Wasserman et al., Principles of exercise testing and interpretation. Wasserman et al., Principles of exercise testing and interpretation. Lea & Febiger, Philadelphia, 1986: pp.72.Lea & Febiger, Philadelphia, 1986: pp.72.
height in cm ; weight in kgheight in cm ; weight in kgage in yearsage in years
EXAMPLEEXAMPLE
Man: 38 years, 80 kg, 1.76 m and FEV1 = 65% of theoretical value
V'O2max théor. (formula b)=2865 ml.min-1
Corrected V'O2max =2865 x 0,65= 1862 ml.min-1
Expected Pmax =(1862-250)/10,3 = 156 watts SO:
Warm-up = 156 x 0,2 = 31 watts Increment = 156 x 0,08 = 12,5 watts per
minute
EXAMPLE FOR EXPECTED Pmax =EXAMPLE FOR EXPECTED Pmax =156 WATTS156 WATTS
Warm-up: 3 minWarm-up: 3 min 10 steps of 1 min10 steps of 1 min 2 min2 min 3 min3 min
31 watts31 watts 12.5 12.5 wattswatts
UnloadeUnloaded d cyclingcycling
restrest
20 % exp. Pmax20 % exp. Pmax 80 % exp. Pmax / 1080 % exp. Pmax / 10 RecoveryRecovery
MEASUREMENT OF VENTILATORY MEASUREMENT OF VENTILATORY THRESHOLDTHRESHOLD
DURING INCREMENTAL EXERCISE/Recording V’O2 and V’CO2 (breath-by-breath)Averaging every 10 secondsComputation of V’O2 / V’CO2 relationship
Ventilatory threshold = breakdown of linearity
Interest of individualization at Interest of individualization at ventilatory thresholdventilatory threshold
directly function of aerobic physical fitness Individualization / real capacities Before excessive hyperventilation Very well tolerated (no or few dyspnea) Efficient to induce training effects Easy learning of individualized practice Usable in current life If impossible to measure dyspnea
threshold
DYSPNEA by Visual Analog Scale (VAS)DYSPNEA by Visual Analog Scale (VAS)
NO DYSPNEA ASPHYXIA
10 or 20 cm
At each work load (every min) dyspnea evaluationDelete mark after measurement from zero point
=3,7=1,8 =5,6=1,1 =2,4
RATIONALERATIONALE
Disadvantage of individualized training :Regular cardio respiratory evaluation =>
cost Solution :
Adapted field test
One of the most popular :6 or 12 min walking test
6 MINUTE WALKING TEST6 MINUTE WALKING TEST
From Cooper test (12 min) shortened until 6 min
Linearity of walking pace (12 = 2 x 6) highly simple Excellent reproducibility
If correct learningWithout verbal encouragementalone
Very well correlated with V'O2sl
ADAPTED TO ASSESS TRAINING EFFECTS ADAPTED TO ASSESS TRAINING EFFECTS ??
NOT YET STUDIED :Relationship with physical fitness =
Not sufficient (correlation cause to effect relationship)
QUESTION :6 min walking test is it able to identify
physiological modifications due to retraining ?
Protocol : study of relationshipsAerobic physical fitness and 6 min WT
Before and after retraining
RELATIONSHIP 6MWT AND VENTILATORY RELATIONSHIP 6MWT AND VENTILATORY THRESHOLDTHRESHOLD
WT Distance (m)
0 500 600 700 800 900
VT
h (
l/min
)
0.00.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
BEFORE TRAINING
p<0.001r = 0.79
WT Distance (m)
0 500 600 700 800 900
VT
h (
l/m
in)
0.00.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
AFTER TRAINING
p<0.01r = 0.67
RELATIONSHIP 6MWT AND VRELATIONSHIP 6MWT AND VOO22slsl
WT Distance (m)
0 500 600 700 800 900
VO
2 S
L (
ml/m
in.k
g)
015
20
25
30
35
40
45 r = 0.89
p<0.001
BEFORE TRAINING
WT Distance (m)
0 500 600 700 800 900
VO
2 S
L (
ml/m
in.k
g)
015
20
25
30
35
40
45p<0.001r = 0.78
AFTER TRAINING
oo
PHYSICAL FITNESS PREDICTIONPHYSICAL FITNESS PREDICTION
For VO2 sl (r=0.95):
For ventilatory threshold (r=0.91):
In addition:After training measured and calculated
values non different (diff. Mean = 0.06 l.min-1)
2.63 - FEV10.124 + weight0.019 + Distance0.004sl2OV
1.577 - FEV10.095 - weight0.014 + Distance0.003V Th
6 MIN WALKING TEST6 MIN WALKING TEST
Sensitive to physical fitness variation: ventilatory threshold +++++
Max O2 uptake +/-
Possible aerobic physical fitness prediction Stables relationships throughout training Valid equations even after training
INTEREST ++++
Enright and Sherrill, Am Rev Resp Crit Care Med, 1998, 158: 1384-87.
ADDITIONAL INTEREST
Possible to use predictive equations:
Quantification of impairment vs normal population
Lim it o f norm alityca lcula ted va lue - 153 m eters
M en(7.57 x height) - (5.02 x age) - (1 .76 x w e ight) - 309 m
height in cm ; w e ight in kg ; age in years
L im it o f norm alityca lcula ted va lue - 139 m eters
W om en(2.11 x height) - (2.29 x w e ight) - (5 .78 x age) + 667 m
height in cm ; w e ight in kg ; age in years
Predictive equationsage ranged from 40 to 80 years
Enright and Sherrill, Am Rev Resp Crit Care Med, 1998, 158: 1384-87.
STATE OF THE ARTSTATE OF THE ART
Works of literature :No consensus
Most of the time :Training intensities based on % reserve
heart rate [ HRrest + (HRmax - HRrest) % ] Interest :
Simplicity of realization
PROBLEMPROBLEM : NEED TO CERTIFY : NEED TO CERTIFY EFFECTIVENESS OF RESULTSEFFECTIVENESS OF RESULTS
Relevance ???No consideration of cardio respiratory
fitnessstandardization is in opposition to
individualization
QUESTION :Which method lead to best results ?
-- INTEREST ---- INTEREST --
Stays in specialized centers :More and more shortened
SO :High need to be as efficient as possibleThat is
Obtain best results every time In a minimum amount of time
PROTOCOLPROTOCOL
2 groups studied :Trained at the same absolute HR, but :
1 gpe at ventilatory threshold (individualization)
1 gpe at 50% of reserve HR (standardtion )training at the same frequency and duration
Blind final evaluation
RESULT 1 RESULT 1 RESERVE HR NO RELEVENT INTENSITYRESERVE HR NO RELEVENT INTENSITY
Moyennes individuelles des fréquences cardiaques (bat.min-1)
80 90 100 110 120 130 140
Diff
éren
ces
indi
vidu
elle
s en
tre
50%
de
fréq
uenc
eca
rdia
que
de r
éser
ve e
t Fc
au s
euil
vent
ilato
ire
(bat
.min
-1)
-25
-20
-15
-10
-5
0
5
10
15
20
25
30
+2 DS
Moyenne
-2 DS
% de VO2SL pré-entraînement
50 60 70 80 90 100
Del
ta la
ctat
e (m
mo
l.l-1
)
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
***
NS
NSNS
NS
NS
NSNS
NS
NS
*
**
% de VO2SL pré-entraînement
50 60 70 80 90 100
Del
ta V
E (
l.min
-1)
-14
-12
-10
-8
-6
-4
-2
0
2
4
NS NS NSNS
NS
NS
NS
NS
NS
**
***
**
o
o
o
Entraînement standardiséEntraînement individualisé
p i
nte
r-g
rou
pe
< 0
.001
p i
nte
r-g
rou
pe
< 0
.001
Reserve HR :Random resultsUnder- or over-estimation of efficient
intensities
CONCLUSIONCONCLUSION
Another reserve HR % choice cannot be a solution to
improve this technique
GENERAL RESULTSGENERAL RESULTS
Exercise adaptations : Better exercise tolerance : dyspnea decrease Restoration on self confidence
Enhancement of quality of life : General well-being, emotional state (Ojanen et al,
1993) durable effect (Dekhuijzen et al., 1990)
Improvement of psychological state : Never linked with resting pulmonary function Always related to possible physical activity amount
linked to functional state
Main resultsMain results
Validated in international literature:Original studies and meta-analysisEvidence-based medicine: rating the
strength of evidence
Respiratory rehabilitation based on A.P.AFromFrom:Joint ACCP/AACVPR Evidence-Based Guidelines. Chest, 1997, 112:1363:96.Fabbri and Hurd; GOLD Scientific Committee. Eur Respir J, 2003, 22: 1-2. Unique technique assessed with grade A for:
breathlessness health-related quality of life depression and anxiety associated with
COPD hospitalization number and durationAmazingly better exercise tolerance
exercise capacity dyspnea for a given exercise intensity
Grade B for: Improved survival
AEROBIC PHYSICAL FITNESSAEROBIC PHYSICAL FITNESS
___________________________ Vallet et al., Rev. Mal. Resp., 1993
Entraînés Non entraînés
VO
2SL
(l.m
in-1
)
0
1
2
Entraînés Non entraînés
Seu
il ve
ntila
toire
(l.m
in-1
)
0
1
2
T0 T6
**
*
ns
ns
o
Ven
tilat
ory
Thr
esho
ld (
l.min
-1)
Trained UntrainedTrained Untrained
Effects on ventilatory requirementEffects on ventilatory requirement
______ Varray, Mercier, Préfaut. Int. J. Rehab. Res., 1995, 18: 297-312.
Very high ventilatory savings
VENTILATORY REQUIREMENTVENTILATORY REQUIREMENT
Ventilation decrease for a given exercise intensity:
Increased ventilatory comfort for any exercise intensity
Decreased respiratory cost (dyspnea )
SO: more O2 for exercising muscles : Exercise capacity increased Better exercise efficiency
0
0.5
1
1.5
2
2.5
3
3.5V
O2
(l/m
in)
Before training After training
respiratory muscles
exercising muscles
o
respiratory muscles
exercising muscles
BREATHING PATTERNBREATHING PATTERN
% de VEmax pré-entraînement
20 40 60 80 100
VT (
l)
0.2
0.4
0.6
0.8
1.0
1.2
1.4Avant entraînement
Après entraînement
o
_________________ Varray et al., Int. J. Rehab. Res., 1995
Before training
After training
% of pre-training ventilation
BREATHING PATTERN MODIFICATION BREATHING PATTERN MODIFICATION
• VT always higher for a given ventilation : Better alveolar ventilation Airways turbulences decrease for a given
obstruction level Explanation of the effects on dynamic
hyperinflation Dyspnea decrease during exercise (lower fb) Reduced ventilatory cost
% de VO2SL pré-entraînement
50 60 70 80 90 100
Del
ta la
ctat
e (m
mol
.l-1
)
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
***
NS
NSNS
NS
NS
NSNS
NS
NS
*
**
% de VO2SL pré-entraînement
50 60 70 80 90 100
Del
ta V
E (l
.min
-1)
-14
-12
-10
-8
-6
-4
-2
0
2
4
NS NS NSNS
NS
NS
NS
NS
NS
**
***
**
o
o
o
Entraînement standardiséEntraînement individualisé
p in
ter-
grou
pe <
0.0
01
p in
ter-
grou
pe <
0.0
01
Individualization versus standardizationIndividualization versus standardization
Standard training Individualised training
% pre-training pic V’O2 % pre-training pic V’O2
% de VEmax pré-entraînement
50 60 70 80 90 100
VT
(l)
1.2
1.4
1.6
1.8
2.0
2.2
2.4
% de VEmax pré-entraînement
50 60 70 80 90 100
VT (
l)
1.2
1.4
1.6
1.8
2.0
2.2
2.4
NS
NS
NS
NS
NS
NS
o
***
**
**
**
**
*
o
Avant entraînement
Après entraînement
Avant entraînement
Après entraînement
GROUPE STANDARDISATIONGROUPE INDIVIDUALISATION
Individualization versus standardization Individualization versus standardization (breathing pattern)(breathing pattern)
_____________________ Vallet et al., Eur. Resp. J., 1997
% pre-training V’E max % pre-training V’E max
Before training
After training
Before training
After training
INDIVIDUALIZED GROUP STANDARDIZED GROUP
Effects on muscle dysfunction – Effects on muscle dysfunction – localized exerciselocalized exercise
Tlim (secondes)
0 100 200 300 400 500 600 700 800 900
Wlim
0
500
1000
1500
2000
2500
3000
3500
4000
*
*
*
Avant entraînementPuissance critique avant entraînement
Après entraînementPuissance critique après entraînement
Before trainingCritical power before training
After trainingCritical power after training
Localized exercise
No cardiorespiratory limitation
Assessment of muscle function per se
__________ Serres, Varray, Vallet, Micallef, Préfaut. J Cardiopulm Rehab, 1997, 17: 232-8.
Delay in fatiguethreshold
Effects on muscle dysfunction – Effects on muscle dysfunction – localized exerciselocalized exercise
Tlim (secondes)
0 100 200 300 400 500 600 700 800 900
Wlim
0
500
1000
1500
2000
2500
3000
3500
4000
*
*
*
Avant entraînementPuissance critique avant entraînement
Après entraînementPuissance critique après entraînement
Before trainingCritical power before training
After trainingCritical power after training
__________ Serres, Varray, Vallet, Micallef, Préfaut. J Cardiopulm Rehab, 1997, 17: 232-8.
Local endurance
+250%
Effects on muscle dysfunction – Effects on muscle dysfunction – general exercisegeneral exercise
Gosselin, Lambert, Poulain, Martin, Prefaut, Varray. Muscle & Nerve, 2003, 28: 744-53.
Muscle efficiencyMuscle efficiency
_________________________ Gosselin et al., Muscle & Nerve, 2003.
Before trainingAfter training
COST/EFFECTIVENESS RELATIONSHIPSCOST/EFFECTIVENESS RELATIONSHIPS
5 years PRE-R.R. 4.24* / 1069** 2.34* / 586** 3.2* / 801**
5 years POST-R.R. 6.28* / 1570** 3.78* / 946** 1.67* / 417**
EVOLUTION COST/ 5 years (1193$/day) + 600 000 $ + 430 000 $ - 458 000 $
GROUP 1 GROUPE 2 GROUPE 3 Treatment : Treatment: Respiratory medical Médical + Education Rehabilitation n = 50 n = 50 n = 50
* : hospitalization days /patient/year ** : total hospitalization days during 5 years
+ work of Trautner (Eur. Resp. J., 1993) - asthma and health management :
For 1 DM (cost), 5 DM saved for public health economy
Sneider, J. Sneider, J. Cardio-pulm. Cardio-pulm. Rehab., 1988Rehab., 1988