Precision Medicine in Exercise Training by Professor Mick Steiner

Posted by mm269 at May 19, 2017 01:30 PM |

Exercise training in the form of pulmonary rehabilitation (PR) is a highly effective intervention for people who suffer with activity limitation due to chronic respiratory disease. PR at a group/population level, the efficacy and effectiveness of PR in delivering meaningful improvements in exercise capacity and quality of life has been demonstrated in numerous well conducted clinical trials and has been summarized in the recent updated cochrane systematic review (http://www.cochrane.org/CD003793/AIRWAYS_pulmonary-rehabilitation-for-chronic-obstructive-pulmonary-disease). Indeed, the conclusion of this review was that additional trials testing the effectiveness of PR are not needed and that efforts should focus on the refinement of the treatment offer in relation to identifiable subgroups of patients.Pulmonary Rehab

Although the intensity (“dose”) of exercise training is individually prescribed, PR is currently provided in a “one size fits all” format regardless of disease pathophysiology or individual health need. Moreover, PR does not reliably address key treatable traits linked to adverse health outcomes in COPD, particularly reduced physical activity, cardio-metabolic health risk and frailty. Importantly, we now know that the character and severity of underlying lung or skeletal muscle pathophysiology is a key determinant of the training response suggesting that a stratified therapeutic approach to exercise therapies has potential value. For example, patients with severe lung disease in whom a pathological limit to ventilation limits exercise performance, high relative exercise workloads are needed to deliver physiological benefit. This incurs substantial exercise related discomfort due to breathlessness, imposing an additional barrier to accessing successful therapy. Likewise whilst PR improves physical capacity, this does not reliably translate into increases in daily physical activity, a potentially crucial step in improving longer term cardiometabolic risk.

There is, therefore, a pressing need to deliver personalised exercise and anabolic therapies targeting systemic treatable traits/phenotypes not currently adequately addressed by PR. This would aim to enhance clinical benefits of exercise and anabolic therapies (and thereby health outcomes) at an individual level and widen access to therapy at a population level.

Broad effectiveness of PR in those that attend and complete PR was demonstrated in the recent large scale national audit of PR outcomes in England and Wales. (https://www.rcplondon.ac.uk/projects/national-copd-audit-programme-pulmonary-rehabilitation-workstream). However, the audit also shows that a substantial number of patient do not attend or complete PR thereby limiting the population benefit of treatment.

The challenge for the pulmonary rehabilitation scientific community is to deploy the principles of precision medicine to develop clinical metrics that identify sub-populations with distinct exercise/health needs and then to develop and test stratified exercise/physical activity interventions that address these needs in relevant target patient groups.

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