Upper extremity training in COPDTania Janaudis-Ferreira, BScPT, MSc, PhD Post Doctoral Research FellowPost Doctoral Research Fellow West Park Healthcare Centre, Toronto and Department of Physical Therapy, West Park Healthcare Centre, Toronto and Department of Physical Therapy, University of Toronto.University of Toronto.Conflict of interestl lI have no conflict of interest to declareObjectives of this session l lTo understand the impact of upper extremity To understand the impact of upper extremity dysfunction on dyspnea in COPDdysfunction on dyspnea in COPDl lTo understand the role of upper extremity To understand the role of upper extremity training as part of COPD rehabilitation and to get training as part of COPD rehabilitation and to get acquainted with different types of arm trainingacquainted with different types of arm trainingl lTo understand how to measure arm exercise To understand how to measure arm exercise capacity in patients with COPDcapacity in patients with COPDBackgroundl lAirflow limitationl lLung hyperinflationl lSystemic inflammationl lPeripheral muscle dysfunctionl lImpairments are encountered during hurried walking, stair climbing and simple activities of daily living (ADL)Dyspneaand exercise intoleranceImpairments during arm activities:Dyspnea and arm fatigueArm fatigue:Muscle strengthDyspnea Overhead arm activity FRC hyperinflationWorsens respiratory muscle mechanics burden on diaphragm worsening its force-generating capacity sensation of dyspneaDuring unsupported arm activity unable to use accessory musclesWhat we knowSystematic reviewsl lCostiCosti et al. and et al. and JanaudisJanaudis-Ferreira et al. (2009):-Ferreira et al. (2009):- -Upper extremity training increases arm exercise capacity Upper extremity training increases arm exercise capacity - -Effect on other clinical outcomes are unclear Effect on other clinical outcomes are unclear - - Methodological shortcomingsMethodological shortcomings ACCP/AACVPR guidelinesl lRecommend the inclusion of upper-extremity training in Recommend the inclusion of upper-extremity training in PRPRl l The best type of arm training is unknown due to lack of The best type of arm training is unknown due to lack of randomized controlled trialsrandomized controlled trialsJanaudis-Ferreira et al. 2009Characteristics of the arm training programs l lSupported and unsupported exercises:- -Cycle Cycle ergometerergometer ( (RiesRies et al. and Lake et al.) et al. and Lake et al.)- -Dowel lifts Dowel lifts (Epstein et al. and Holland et al.)(Epstein et al. and Holland et al.)- -Hand weights Hand weights ( (RiesRies et al. and et al. and BauldoffBauldoff et al.) et al.)- -Ball against wall Ball against wall (Lake et al.)(Lake et al.)- -Passing bean bags Passing bean bags (Lake et al.)(Lake et al.)- -Pulling ropes Pulling ropes (Lake et al.)(Lake et al.)- -Moving rings Moving rings (Lake et al.)(Lake et al.)Latest ResearchRecent RCTsl lAddressed the methodological shortcomings of the Addressed the methodological shortcomings of the previous studiesprevious studiesl lIncluded a comprehensive upper extremity resistance Included a comprehensive upper extremity resistance training with standardized training protocol/progressiontraining with standardized training protocol/progressionl lIncluded measures of HRQL and symptoms during ADL Included measures of HRQL and symptoms during ADL and arm testsand arm testsl lCostiCosti et al et al.: demonstrated improvements in arm function .: demonstrated improvements in arm function and ADLand ADLObjectivel lEvaluate 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 characteristicsl lTraining duration: Training duration: - -3 days/week (during 6 weeks)3 days/week (during 6 weeks)- -total of 18 sessionstotal of 18 sessionsl lMuscle groups: pectoralis, latissimus, deltoids, Muscle groups: pectoralis, latissimus, deltoids, rhomboids, biceps, triceps rhomboids, biceps, triceps l lInitial load: 10-12 RMInitial load: 10-12 RMl lControl group: sham (upper limb flexibility and stretching Control group: sham (upper limb flexibility and stretching exercises)exercises)CHEST PRESSPectoralis major, deltoids medial, tricepsPEC-DEC BUTTERFLYPectoralis major, middle deltoidsSEATED ROWRhomboids, Latissumus, biceps, trapezius, deltoidsLAT PULL DOWNLatissimus dorsi, deltoids , rhomboids, biceps, erector spinaeARM CURL BicepsTRICEPS PRESS DOWNTricepsFront arm raisesAnterior deltoidsShoulder PressMiddle deltoidsTraining ProtocollLarger muscles before smaller muscleslInitial loads 10 -12 repetition lStart with 1x12 for 4 sessions then 2x12 for the rest lLoads were increased if they could manage more than 12 repetitions for both sets on two consecutive sessions lRest 1-3 minutes between setslPatients rate dyspnea and arm fatigue (BORG), before and afterOutcome measuresl lDyspnea during ADL (CRDQ)Dyspnea during ADL (CRDQ)l lHealth-related quality of life (CRDQ)Health-related quality of life (CRDQ)l lArm exercise capacity (UULEX)Arm exercise capacity (UULEX)l lArm function (6PBRT)Arm function (6PBRT)l lArm fatigue and dyspnea during arm exercise Arm fatigue and dyspnea during arm exercise tests (Borg scale)tests (Borg scale)l lPeripheral muscle force (hand-held Peripheral muscle force (hand-held dynamometer)dynamometer)EquipmentsZhan et al. 2006Takahashi et al. 2003UULEX6PBRTMicrofet 2Significant findingsl lImprovements in arm function, arm exercise capacity and arm muscle strengthl lNo between-group differences in HRQL or dyspnea during ADLPossible mechanisms responsible for an increase in arm exercise capacityl lImproved aerobic capacity l lDesensitization or tolerance to symptomsl lIncrease force-generating capacity l lImproved muscular coordinationdecrease in dyspneaSummary of the resultsl lResistance arm training program improved arm Resistance arm training program improved arm function, arm exercise capacity and muscle function, arm exercise capacity and muscle strengthstrengthl lPatients achieved superior performance during Patients achieved superior performance during tests of arm exercise capacity without any tests of arm exercise capacity without any significant increase in significant increase in dyspneadyspnea or arm fatigue or arm fatigueEvidences for arm endurance training?l lNo study specifically examined the effects of No study specifically examined the effects of arm endurance training in COPDarm endurance training in COPDAssessmentHow should we measure arm exercise capacity in COPD? A systematic review.Tania Janaudis-FerreiraTania Janaudis-Ferreira1,21,2, Marla K. Beauchamp, Marla K. Beauchamp1 1, Roger , Roger GoldsteinGoldstein1,2,31,2,3, Dina Brooks, Dina Brooks1,21,21 1Respiratory Medicine, West Park Healthcare Centre, Toronto, CanadaRespiratory Medicine, West Park Healthcare Centre, Toronto, Canada 2 2Dept of Physical Therapy and Dept of Physical Therapy and 3 3Medicine, University of Toronto, Canada.Medicine, University of Toronto, Canada.Resultsl l41 articles were included in the review41 articles were included in the reviewl lFive categories of arm exercise tests were identified: Five categories of arm exercise tests were identified: (1) arm ergometry (1) arm ergometry (Peak ex. capacity, endurancePeak ex. capacity, endurance) )(2) ring shifts (2) ring shifts (Function, enduranceFunction, endurance) )(3) dowel or arm lifts (3) dowel or arm lifts (Peak ex. capacity, endurance, Peak ex. capacity, endurance, functionfunction) )(4) diagonal movement using PNF (4) diagonal movement using PNF (Peak ex. capacity)(Peak ex. capacity)(5) ADL-based test (5) ADL-based test (FunctionFunction) )l lOnly 4 studies assessed measurement properties of arm Only 4 studies assessed measurement properties of arm exercise tests (6PBRT, UULEX, Grocery Shelving Task exercise tests (6PBRT, UULEX, Grocery Shelving Task (GST) and an overhead task)(GST) and an overhead task)ResultsType of testType of testConstruct Construct ValidityValidityTest-retest Test-retest reliabilityreliabilityResponsivenessResponsivenessInterpretabilityInterpretabilityArm Arm ergometryergometryNoNoNoNoSomeSomeNoNoRing ShiftsRing ShiftsYes:Yes: 6PBRT 6PBRT and OHTand OHTYesYesSomeSomeNoNoDowel liftsDowel liftsYes:Yes:UULEXUULEXYesYesSomeSomeNoNoPNFPNFNoNoNoNoNoNoNoNoADL testADL testYes:Yes:GSTGSTYesYesYesYesNoNol Evidence for the measurement properties of the arm exercise testsConclusionsl lThe choice of the test should depend on the target construct being The choice of the test should depend on the target construct being measured and on the psychometric properties of the tests. measured and on the psychometric properties of the tests. l lArm ergometry may be best for measuring peak arm exercise Arm ergometry may be best for measuring peak arm exercise capacity and endurance during supported exercises but there is no capacity and endurance during supported exercises but there is no data on psychometric propertiesdata on psychometric propertiesl lUULEX, 6PBRT and GST may better reflect ADL and should be the UULEX, 6PBRT and GST may better reflect ADL and should be the tests of choice to measure peak unsupported arm exercise capacity tests of choice to measure peak unsupported arm exercise capacity (UULEX) and arm function (6PBRT and GST) (UULEX) and arm function (6PBRT and GST) l lThe responsiveness and interpretability of these tests have not been The responsiveness and interpretability of these tests have not been reported. reported. Thank you !Acknowledgements:- West Park Healthcare Centre Foundation- -Canada Research Chair Program - -Ontario Thoracic Society- Swedish Heart and Lung Foundation