Progression to chronic obstructive pulmonary disease (COPD): Could it be prevented by manual therapy and exercise during the ‘at risk’ stage (stage 0)?
Introduction
Two large studies have recently documented a high prevalence of COPD [1], [2]. The situation is set to deteriorate as the condition is projected to become the fifth most frequent cause of death worldwide by 2020 [3].
Cigarette smoking is recognised as the main predisposing factor for increasing the risk of developing COPD [4], [5]. However, only a minority of heavy smokers develop chronic airflow limitation [6], [7], [8]. Other possible predisposing factors include a history of childhood respiratory tract infections [9], [10], occupational exposure [11], [12], low birth weight [13], air pollution [14], [15] and diets low in anti-oxidants [16].
There is increasing recognition that COPD may be an inflammatory disease with systemic consequences [17], [18]. COPD itself may cause systemic inflammation [19], [20] or inflammation in the respiratory system may trigger airflow obstruction in susceptible individuals [21]. In the latter case, the inflammation precedes the onset of symptoms of chronic lung disease [18]. It is possible that adverse airway remodelling occurring as a result of childhood respiratory infections could render the person more susceptible to respiratory conditions such as COPD later in life [6], [22], [23]. In summary it would appear that apart from smoking, the trigger for the transition from non-diseased to COPD state remains unclear.
Investigating the period when diagnosis can first be confirmed and declining lung function begins to accelerate beyond what is attributable to age alone could provide further insight into the origins of the condition and hence possible intervention.
Persons ‘at risk’ of developing COPD (stage 0) are often characterised by normal spirometry in the presence of chronic symptoms such as cough and sputum production [4].
The current approach to intervention for people in this group is risk factor avoidance. The recommended interventions are health education, smoking cessation and influenza vaccination [4], [5]. Exercise training has been shown to benefit all levels of COPD [24], [25] by improving cardiovascular fitness, muscle function, muscle strength and endurance [5]. However, the role of exercise in preventing COPD remains to be tested in the ‘at risk’ group [4], [5], [26].
We propose that if interventions shown to improve chronic respiratory symptoms in COPD sufferers could be applied during the period when alterations in lung architecture associated with COPD begin i.e. the ‘at risk’ or stage 0, then moderation or even reversal of those changes becomes a possibility. If these interventions were low risk, low cost, effective and amenable to implementation in all parts of the world [27], considerable impact on the future burden of the disease would result. Hypothesis It is hypothesised that the application to ‘at risk’ individuals (stage 0), of therapeutic interventions known to improve chronic respiratory symptoms and cardiovascular function in mild/moderate COPD (stages 1 and 2) could delay progression of the disease (i.e. manifestation of mild/moderate COPD).
Section snippets
Evaluation and discussion
The hypothesis has two parts: identification of the therapeutic interventions (part 1) and delaying disease progression (part 2).
A possible step-wise approach to evaluate this hypothesis is outlined below, with steps (i)–(v) related to part 1 and step (vi) related to part 2 of the hypothesis.
Significance
If the hypothesis were confirmed, the potential to delay or even prevent the onset of COPD would be feasible. The benefit to individuals would be significant and the impact on the burden of disease considerable. There would be a paradigm shift, from COPD being considered a ‘progressive’ (once airflow limitation begins) and ‘not fully reversible’ (once a diagnosis is made), to being a ‘reversible’ condition. This would have immense impact on future projections for the disease, along with
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