Upper extremity training in COPD
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Upper extremity training in COPD Tania Janaudis-Ferreira, BScPT, MSc, PhD Post 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 .

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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
Conflict of interest

  • I have no conflict of interest to declare


Objectives of this session
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
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
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
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
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
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
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
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 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
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
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
Equipments

UULEX

6PBRT

Microfet 2

Zhan et al. 2006

Takahashi et al. 2003


Significant findings
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
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
Summary of the results exercise capacity

  • 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
Evidences for arm exercise capacityendurance training?

  • No study specifically examined the effects of arm endurance training in COPD


Assessment
Assessment exercise capacity


How should we measure arm exercise capacity in copd a systematic review
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
Results systematic review.

  • 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)


Results1
Results systematic review.

  • Evidence for the measurement properties of the arm exercise tests


Conclusions
Conclusions systematic review.

  • 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
Thank you ! systematic review.

Acknowledgements:

- West Park Healthcare Centre Foundation

  • Canada Research Chair Program

  • Ontario Thoracic Society

    - Swedish Heart and Lung Foundation


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