Upper extremity training in COPDTania Janaudis-Ferreira, BScPT, MSc, PhDPost Doctoral Research Fellow West Park Healthcare Centre, Toronto and Department of Physical Therapy, University of Toronto.
Conflict of interest • I have no conflict of interest to declare
Objectives of this session • To understand the impact of upper extremity dysfunction on dyspnea in COPD • To understand the role of upper extremity training as part of COPD rehabilitation and to get acquainted with different types of arm training • To understand how to measure arm exercise capacity in patients with COPD
Background • Airflow limitation • Lung hyperinflation • Systemic inflammation • Peripheral muscle dysfunction • Impairments are encountered during hurried walking, stair climbing and simple activities of daily living (ADL) Dyspnea and exercise intolerance
Impairments during arm activities:Dyspnea and arm fatigue Overhead arm activity Dyspnea Arm fatigue: Muscle strength FRC During unsupported arm activity – unable to use accessory muscles hyperinflation Worsens respiratory muscle mechanics burden on diaphragm worsening its force-generating capacity sensation of dyspnea
Systematic reviews • Costi et al. and Janaudis-Ferreira et al. (2009): • Upper extremity training increases arm exercise capacity • Effect on other clinical outcomes are unclear - Methodological shortcomings
ACCP/AACVPR guidelines • Recommend the inclusion of upper-extremity training in PR • The best type of arm training is unknown due to lack of randomized controlled trials Janaudis-Ferreira et al. 2009
Characteristics of the arm training programs • Supported and unsupported exercises: • Cycle ergometer (Ries et al. and Lake et al.) • Dowel lifts (Epstein et al. and Holland et al.) • Hand weights (Ries et al. and Bauldoff et al.) • Ball against wall (Lake et al.) • Passing bean bags (Lake et al.) • Pulling ropes (Lake et al.) • Moving rings (Lake et al.)
Recent RCTs • Addressed the methodological shortcomings of the previous studies • Included a comprehensive upper extremity resistance training with standardized training protocol/progression • Included measures of HRQL and symptoms during ADL and arm tests • Costi et al.: demonstrated improvements in arm function and ADL
Objective • Evaluate the effect of a 6-week program of unsupported upper extremity resistance training for patients with COPD on dyspnea during ADL, arm function, arm exercise capacity, muscle strength and HRQL.
Training characteristics • Training duration: - 3 days/week (during 6 weeks) - total of 18 sessions • Muscle groups: pectoralis, latissimus, deltoids, rhomboids, biceps, triceps • Initial load: 10-12 RM • Control group: sham (upper limb flexibility and stretching exercises)
CHEST PRESS Pectoralis major, deltoids medial, triceps
PEC-DEC BUTTERFLY Pectoralis major, middle deltoids
SEATED ROW Rhomboids, Latissumus, biceps, trapezius, deltoids
LAT PULL DOWN Latissimus dorsi, deltoids , rhomboids, biceps, erector spinae
ARM CURL Biceps TRICEPS PRESS DOWN Triceps
Front arm raises Anterior deltoids Shoulder Press Middle deltoids
Training Protocol • Larger muscles before smaller muscles • Initial loads 10 -12 repetition • Start with 1x12 for 4 sessions then 2x12 for the rest • Loads were increased if they could manage more than 12 repetitions for both sets on two consecutive sessions • Rest 1-3 minutes between sets • Patients rate dyspnea and arm fatigue (BORG), before and after
Outcome measures • Dyspnea during ADL (CRDQ) • Health-related quality of life (CRDQ) • Arm exercise capacity (UULEX) • Arm function (6PBRT) • Arm fatigue and dyspnea during arm exercise tests (Borg scale) • Peripheral muscle force (hand-held dynamometer)
Equipments UULEX 6PBRT Microfet 2 Zhan et al. 2006 Takahashi et al. 2003
Significant findings • Improvements in arm function, arm exercise capacity and arm muscle strength • No between-group differences in HRQL or dyspnea during ADL
Possible mechanisms responsible for an increase in arm exercise capacity • Improved aerobic capacity • Desensitization or tolerance to symptoms • Increase force-generating capacity • Improved muscular coordination decrease in dyspnea
Summary of the results • Resistance arm training program improved arm function, arm exercise capacity and muscle strength • Patients achieved superior performance during tests of arm exercise capacity without any significant increase in dyspnea or arm fatigue
Evidences for arm endurance training? • No study specifically examined the effects of arm endurance training in COPD
How should we measure arm exercise capacity in COPD? A systematic review. Tania Janaudis-Ferreira1,2, Marla K. Beauchamp1, Roger Goldstein1,2,3, Dina Brooks1,2 1Respiratory Medicine, West Park Healthcare Centre, Toronto, Canada 2Dept of Physical Therapy and 3Medicine, University of Toronto, Canada.
Results • 41 articles were included in the review • Five categories of arm exercise tests were identified: (1) arm ergometry (Peak ex. capacity, endurance) (2) ring shifts (Function, endurance) (3) dowel or arm lifts (Peak ex. capacity, endurance, function) (4) diagonal movement using PNF (Peak ex. capacity) (5) ADL-based test (Function) • Only 4 studies assessed measurement properties of arm exercise tests (6PBRT, UULEX, Grocery Shelving Task (GST) and an overhead task)
Results • Evidence for the measurement properties of the arm exercise tests
Conclusions • The choice of the test should depend on the target construct being measured and on the psychometric properties of the tests. • Arm ergometry may be best for measuring peak arm exercise capacity and endurance during supported exercises but there is no data on psychometric properties • UULEX, 6PBRT and GST may better reflect ADL and should be the tests of choice to measure peak unsupported arm exercise capacity (UULEX) and arm function (6PBRT and GST) • The responsiveness and interpretability of these tests have not been reported.
Thank you ! Acknowledgements: - West Park Healthcare Centre Foundation • Canada Research Chair Program • Ontario Thoracic Society - Swedish Heart and Lung Foundation