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

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


Dyspnea
and
exercise intolerance
Impairments are encountered during
hurried walking, stair climbing and simple
activities of daily living (ADL)
Impairments during arm activities:
Dyspnea and arm fatigue
Dyspnea
Overhead
arm activity
Arm fatigue:
 FRC
During
unsupported arm
activity – unable
to use accessory
muscles
Muscle strength
 hyperinflation
Worsens respiratory muscle
mechanics
 burden on diaphragm
worsening its forcegenerating capacity
 sensation
of dyspnea
What we know
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
Type of exercise
Supported and unsupported exercises
Program duration
6-8 weeks
Training frequency
3x/w; daily; twice/day
Number of sets
3-10
Number of repetitions
4-10
Training progression
After a pre-determined period or base on
symptoms
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.)
-
Latest Research
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
Takahashi et al. 2003
Zhan et al. 2006
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
decrease in
dyspnea
Improved aerobic capacity
 Desensitization or tolerance to symptoms
 Increase force-generating capacity
 Improved muscular coordination

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
Assessment
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
2Dept
Medicine, West Park Healthcare Centre, Toronto, Canada
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
Type of test
Construct
Validity
Test-retest
reliability
Responsiveness
Interpretability
Arm
ergometry
No
No
Some
No
Ring Shifts
Yes:
6PBRT
and OHT
Yes
Some
No
Dowel lifts
Yes:
UULEX
Yes
Some
No
PNF
No
No
No
No
ADL test
Yes:
GST
Yes
Yes
No
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