Respiratory response to arm elevation in patients with chronic airflow obstruction

Utility of the Shortness of Breath in Daily Activities Questionnaire (SOBDA-Q) to Detect Sedentary Behavior in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Sedentary behavior has been shown to be an independent predictor of mortality in patients with chronic obstructive pulmonary disease (COPD). However, physicians have difficulty ascertaining patients' activity levels because they tend to avoid shortness of breath. The reformed shortness of breath (SOB) in the daily activities questionnaire (SOBDA-Q) specifies the degree of SOB by measuring low-intensity activity behavior in everyday living. Therefore, we aimed to explore the utility of the SOBDA-Q in detecting sedentary COPD. We compared the modified Medical Research Council dyspnea scale (mMRC), COPD assessment test (CAT), and SOBDA-Q with physical activity levels (PAL) in 17 healthy patients, 32 non-sedentary COPD patients (PAL ≥ 1.5 METs·h), and 15 sedentary COPD patients (PAL < 1.5 METs·h) in this cross-sectional study. CAT and all domains of the SOBDA-Q in all patients are significantly correlated with PAL, even after adjusting for age. The dietary domain has the highest specificity, and the outdoor activity domain has the highest sensitivity for detecting sedentary COPD. Combining these domains helped determine patients with sedentary COPD (AUC = 0.829, sensitivity = 1.00, specificity = 0.55). The SOBDA-Q is associated with PAL and could be a useful tool for determining patients with sedentary COPD. Moreover, eating and outing inactivity claims reflect sedentary behavior in patients with COPD.

The effect of unsupported arm elevations on regional chest wall volumes and thoracoabdominal asynchrony in patients with chronic obstructive pulmonary disease

Objective: To compare the effect of unsupported arm elevation (UAE) in different planes on chest wall volumes, thoracoabdominal asynchrony (TAA), ventilatory demands, dyspnea, and arm fatigue in patients with chronic obstructive pulmonary disease (COPD) and healthy subjects. Methods: Twenty-one patients with COPD and healthy-matched subjects performed UAE in shoulder flexion, scaption, abduction, and resting. Pulmonary total and regional chest wall volumes (V_RCp), abdominal rib cage volume, abdominal volume, TAA, and ventilatory demands during arm positions were measured using optoelectronic plethysmography. Results: In both groups, V_RCp and TAA were significantly affected during UAEs compared with the resting position. The healthy subjects had significantly decreased V_RCp (L) (p < 0.05) during scaption (0.14 ± 0.07) and abduction (0.15 ± 0.06) than during flexion (0.18 ± 0.07) and no significantly different TAA between UAEs. The COPD group had no significantly different V_RCp between UAEs, had significantly increased TAA (p < 0.05) during scaption (31.1°±9.5°) and abduction (32.3°±9.9°) than during flexion (29.7°±9.1°); and had significantly worse V_RCp (p = 0.007), TAA (p = 0.0001), ventilatory demands (p < 0.05), dyspnea ((p = 0.03), and arm fatigue (p = 0.002). Conclusions: In patients with COPD, UAE in different planes similarly restricted the upper chest wall volume. Shoulder scaption and abduction significantly impaired TAA, ventilation, dyspnea, and arm fatigue compared with flexion. These results may help to select the appropriate UAE during physical activities.

Upper Limb Extremity Muscle-Dysfunction in Chronic Obstructive Pulmonary Disease: A Narrative Review

Background:

Peripheral muscle dysfunction is one of the major comorbidities seen in chronic obstructive pulmonary disease. Focusing more on upper extremity, unsupported elevation of arms results in a change in the recruitment pattern of the respiratory muscles. Over the years, many tests were developed to assess the upper limb capacity and include them in various rehabilitation protocol.

Objective:

To review the evidence on mechanism, tests, and rehabilitation protocol for the upper limb extremity muscle-dysfunction occurring in chronic obstructive pulmonary disease.

Methods:

PubMed and Google scholar databases were searched. Based on the inclusion criteria’s:- Chronic Obstructive Pulmonary Diseases patients, any Randomized Controlled or clinical trials, systematic reviews, explaining upper limb extremity muscle dysfunction, various tests to assess upper limb functional capacity and different ways of upper limb extremity training, a total of 15 articles were retrieved.

Results:

The mechanism of upper extremity muscle dysfunction is now well understood. Various tests were designed in order to assess arm strength, arm endurance and functional capacity. All the studies which included upper limb extremity training as a part of the rehabilitation program, showed beneficial results in terms of reduction of dyspnoea and arm fatigue, as well as improving the activity performing capacity.

Conclusion:

This review concluded that the alteration in the upper limb extremity muscles is an inevitable consequence of chronic obstructive pulmonary diseases, which can be confirmed by various upper extremity tests, with patients responding positively to the upper limb training incorporated during pulmonary rehabilitation protocols.

Reference value for the six-minute peg board and ring test. A cross sectional study

Introduction

In our daily life, arm activities, whether supported or unsupported play a major role. Both simple and complex activities require the muscles, namely trapezius, pectoralis minor, scalene, and intercostals, to participate in arm positioning. These muscles also enact as the accessory respiratory muscles. Therefore, arm elevation increases the load on these muscles and they fail to perform dual activities, resulting in arm fatigue and a feeling of dyspnoea in healthy individuals as well as in chronic obstructive pulmonary disease patients. Various upper limb exercise tests were designed to measure this impairment, one of them being the six-minute peg board and ring test. The aim of the study is to derive a reference value for the six-minute peg board and ring test among healthy Indian population (Mangalore) from the age of 20-70 years of either gender. Also, to find a correlation among the number of rings and body mass index, arm length, arm and forearm circumference, the strength of shoulder and elbow flexors-extensors, grip strength of both sides and level of physical activity.

Methods

Participants performed two tests, thirty minutes apart. They were asked to load as many rings as possible in 6 minutes. Arm length, arm and forearm circumference were measured with a measuring tape. Shoulder and elbow flexors-extensors were assessed using a handheld push-pull dynamometer. Grip strength was measured with the Jamar hand-held dynamometer. Level of physical activity was assessed using International Physical Activity Questionnairelong form.

Results

The samples consisted of 450 healthy individuals between the age of 20-70 years. Reference values for each age group for both genders were reported. We found that age was correlated with the six-minute peg board and ring test score (p<0.05). We also found a correlation between the strength variables and the test results (p=0.001). However, no correlation was found between the arm length, arm and forearm circumference and the level of physical activity with the number of rings.

Conclusion

In this study, we derived a reference value for the six-minute peg board and ring test. There was a correlation among age, strength variables and the number of rings.

Pulmonary Rehabilitation Effects on Heart Rate Recovery in Restrictive Lung Disease Patients

Objective:

The study aimed to evaluate heart rate recovery in subjects with restrictive lung disease (RLD) and healthy age matched subjects before and after a rehabilitation program (RP).

Methods:

This is a cross-sectional study on subjects of both genders, with over 40 years old with and without any diagnosis of restrictive lung disease and who were able to perform physical tasks were included in the study. They were evaluated for sociodemographic profile, lifestyle (ILP), Framingham score, physical capacity (6MWT and treadmill incremental testing) and heart rate recovery before and after RP.

Results:

65 subjects were assigned into either G1 (patients with RLD, n=26) or G2 (healthy subjects, n= 39). Initially, patients with RLD increased their heart rate (HR) from 79 to 120bpm, and after the recovery post-exercise, the first minute they reduced HR by nine beats. In the fifth minute after the exercise, HR returned to baseline values. After the RP, mean HR was 71bpm and 79bpm in G1 and G2, respectively. Increased mean 6MWT peak HR in both the groups was seen (110bpm and 120bpm, G1 and G2, respectively). In the first minute of resting, mean HR decreased to 86bpm (- 24bpm) and 72 (-48bpm) in G1 and G2, respectively. In the fifth minute after exercise, HR recovery in both the groups was complete.

Conclusion:

The RP was effective in improving the first-minute heart rate recovery in patients with restrictive lung disease and, there was an inverse correlation of heart rate recovery with disease severity.

Wrist Actigraphy Validation of Exercise Movement in COPD

A wrist actigraph is a device used in sleep research studies to measure whole body movements. The purpose of this study was to evaluate the feasibility, sensitivity, and validity of wrist actigraphy during pulmonary rehabilitation (PR) upper-extremity exercise in chronic obstructive pulmonary disease (COPD) patients. In this study, 20 patients wore Octagonal Basic Motionlogger® actigraphs during two 90-minute PR sessions while the investigator recorded details of the subject's upper-extremity movements. Concurrent validity with supervised exercise records was supported for upper-extremity endurance (UEE) intensity at baseline ( r = .885, p < .001) and 1 week ( r = .935, p < .001). Criterion validity was supported for UEE ( r = .56, p = .01) and combined lower- and upper-extremity resistance ( r = .72, p < .01) compared with rank-ordered type of exercise. Wrist actigraphy is shown to be a feasible, sensitive, and valid instrument to measure upper-extremity movement during PR in COPD patients.

Posture and mobility of the upper body quadrant and pulmonary function in COPD: an exploratory study

BACKGROUND

There is limited evidence regarding interactions between pulmonary (dys)function, posture, and mobility of the upper body quadrant in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

This exploratory study aimed to investigate whether postural alignment and mobility of the upper quadrant are related to changes in pulmonary function and compare such variables between patients with COPD and healthy individuals.

METHOD

Fifteen patients with COPD (67.93±9.71yrs) and 15 healthy controls (66.80±7.47yrs) participated. Pulmonary function (FEV1, FVC) was assessed with spirometry. Alignment and mobility of the head, thoracic spine, and shoulder were assessed using digital photographs. Pectoralis minor muscle (PmM) length and thoracic excursion were assessed with a measuring tape. Groups were compared and linear regression analyses were used to assess potential relationships between postural and mobility variables and pulmonary function.

RESULTS

Patients with COPD were more likely to have a forward head position at maximal protraction (28.81±7.30º vs. 35.91±8.56º, p=0.02) and overall mobility of the head (21.81±10.42º vs. 13.40±7.84º, p=0.02) and a smaller range of shoulder flexion (136.71±11.91º vs. 149.08±11.58º, p=0.01) than controls. Patients' non-dominant PmM length and maximal head protraction were predictors of FEV1 (r2adjusted=0.34). These variables, together with the upper thoracic spine at maximal flexion and thoracic kyphosis at maximal extension, were predictors of FVC (r2adjusted=0.68).

CONCLUSION

Our findings suggest that impaired pulmonary function is associated with muscle length and mobility adaptations. Further studies are needed to understand the underlying mechanisms and clinical value of these relationships.

The relationship between anthropometric indicators and walking distance in patients with chronic obstructive pulmonary disease

Background

Exercise intolerance is a major issue affecting many people with COPD. Six-minute walking distance (6MWD) is a widely used indicator of exercise capacity in patients with COPD. The process is strenuous and time-consuming, especially for patients who have muscle wasting. Anthropometric indicators that reflect body lean mass, such as body mass index (BMI), mid-arm circumference (MAC), and calf circumference (CC), may have value in predicting exercise intolerance.

Purpose

This study attempted to determine the abilities of simple anthropometric indicators including BMI, MAC, and CC in reflecting the exercise intolerance of COPD patients.

Methods

We recruited 136 nonhospitalized ambulatory COPD patients without acute conditions from a general hospital in Taiwan. Each subject’s BMI, MAC, and CC were measured, and they were examined with pulmonary function tests and a 6-minute walk test.

Results

Among the three anthropometric indicators examined, CC showed the strongest correlation with the 6MWD, followed by MAC and BMI. CC was also strongly associated with functional capacity, followed by MAC, according to the receiver operating characteristic curves. CC and MAC, but not BMI, were significantly associated with exercise intolerance according to logistic regression models that controlled for potential confounders.

Conclusion

Among the three variables examined, CC and walking distance may have the strongest association in COPD patients. CC may have value in serving as an adjunct to 6MWD in evaluating exercise intolerance of patients with COPD.

Dynamic hyperinflation during activities of daily living in COPD patients

The objective of this study was to investigate whether some activities of daily living (ADLs) usually related to dyspnea sensation in patients with chronic obstructive pulmonary disease (COPD) are associated with dynamic lung hyperinflation (DH) and whether the use of simple energy conservation techniques (ECTs) might reduce this possible hyperinflation. Eighteen patients (mean age: 65.8 ± 9.8 years) with moderate-to-severe COPD performed six ADLs (walking on a treadmill, storing pots, walking 56 meters carrying a 5-kilogram weight, climbing stairs, simulating taking a shower, and putting on shoes) and had their inspiratory capacity (IC) measured before and after each task. The patients were moderately obstructed with forced expiratory volume in 1 second (FEV1): 1.4 ± 0.4 L (50% ± 12.4); FEV1/forced vital capacity: 0.4 ± 8.1; residual volume/total lung capacity: 52.7 ± 10.2, and a reduction in IC was seen after all six activities ( p < 0.05): (1) going upstairs, 170 mL; (2) walking 56 meters carrying 5 kilogram weight, 150 mL; (3) walking on a treadmill without and with ECT, respectively, 230 mL and 235 mL; (4) storing pots without and with ECT, respectively, 170 mL and 128 mL; (5) taking a shower without and with ECT, respectively, 172 mL and 118 mL; and (6) putting on shoes without and with ECT, respectively, 210 mL and 78 mL). Patients with moderate to severe COPD develop DH after performing common ADLs involving the upper and lower limbs. Simple ECTs may avoid DH in some of these ADLs.

The 6-minute pegboard and ring test is correlated with upper extremity activity of daily living in chronic obstructive pulmonary disease

Background

Upper-extremity exercise is for pulmonary rehabilitation. The 6-minute pegboard and ring test (6PBRT) was developed to evaluate arm exercise capacity in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to characterize the 6PBRT and evaluate its relationship with upper-extremity activities of daily living (ADLs) in COPD patients.

Methods

Twenty outpatients with mild to very severe COPD underwent the 6PBRT and spirometry, and their maximal inspiratory and expiratory pressures and grip strength were measured. For the 6PBRT, subjects were asked to move as many rings as possible in 6 minutes, and the score was the number of moved rings during the 6-minute period. Upper-extremity ADLs were evaluated with the upper extremity activities subdomain of the modified Pulmonary Functional Status and Dyspnea Questionnaire. Upper-extremity ADLs were also measured objectively by using a wrist accelerometer every day for 1 week.

Results

There was a positive correlation between 6PBRT score and inspiratory capacity (r = 0.71, P , 0.001), inspiratory capacity/total lung capacity predicted (r = 0.68, P , 0.01), and forced vial capacity (r = 0.57, P , 0.01). There was also a positive correlation between 6PBRT score and accelerometer count (r = 0.54, P , 0.05) and a negative correlation between 6PBRT score and arm activity score (ρ = −0.49, P , 0.05).

Conclusion

The 6PBRT may be a predictive test to maintain and improve upper-extremity ADL during pulmonary rehabilitation in patients with COPD.

Effect of upper extremity exercise in people with COPD

BACKGROUND

Exercise for people with COPD has focused on leg training, such as walking and cycling. The role and effectiveness of arm training has not been investigated in detail. This review was undertaken to examine the literature for the effectiveness of upper extremity exercise on arm exercise capacity and arm strength in people with COPD.

METHODS

Trials relating to arm endurance and strength training in COPD were located by searching electronic databases and screening the reference lists of pertinent articles. Where possible, effect sizes and 95% CI were determined and meta-analysis used.

RESULTS

The search strategy yielded 24 articles. Unsupported arm training improved arm endurance capacity (standard mean difference [SMD] =1.25; 95% CI=0.16 to 2.66) and was the optimal mode of arm endurance training. Combined unsupported and supported arm training was also found to have a large positive effect on peak arm exercise capacity (SMD=1.27; 95% CI=0.59 to 1.94). In addition arm strength training produced moderate improvements in arm strength (SMD=0.46; 95% CI=0.10 to 0.81).

CONCLUSION

This review suggests that in the short term, arm endurance training improves arm exercise capacity and arm strength training improves arm strength. Further research is required, in people with COPD, to investigate the long-term effects of arm training.

Current best practice in pulmonary rehabilitation for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a chronic condition that negatively affects several patient-centered outcomes. Among these, exercise capacity, dyspnea, and quality of life are the most relevant. In this article, factors contributing to exercise limitation, increase in exercise-induced dyspnea, quality of life deterioration, and other pathophysiological aspects in patients with COPD are analyzed in detail. Pulmonary rehabilitation (PR) is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. PR has been clearly shown to induce favorable and long-lasting effects on all patient-centered outcomes. In addition, PR appears to have positive (even if not conclusively demonstrated) effects on other important outcomes in patients with COPD: number and severity of exacerbations, healthcare resource utilization, and survival. The organization of PR treatment, its components, outcome assessment, and future directions are discussed in light of the most robust scientific evidence.

Peripheral muscle dysfunction in COPD: lower limbs versus upper limbs

In patients with COPD, the degree of functional impairment appears to differ between the upper and lower limbs. Significant dyspnea and fatigue have been reported by these patients when performing tasks with unsupported upper limbs and two mechanisms have been proposed to explain this fact: neuromechanical dysfunction of respiratory muscles; and changes in lung volume during such activities. The neuromechanical dysfunction seen in COPD patients during this type of exercise is related to changes in the breathing pattern, as well as to the simultaneity of afferent and efferent muscle stimuli, resulting in respiratory muscle asynchrony. In addition, the increased ventilation during upper limb exercise in patients with COPD leads to dynamic hyperinflation at different workloads. During lower limb exercises, the strength and endurance of the quadriceps muscle is lower in COPD patients than in healthy subjects. This could by explained by abnormal muscle metabolism (decreased aerobic capacity), dependence on glycolytic metabolism, and rapid accumulation of lactate during exercise. In comparison with lower limb exercises, upper limb exercises result in higher metabolic and ventilatory demands, as well as in a more intense sensation of dyspnea and greater fatigue. Because there are differences between the upper and lower limb muscles in terms of the morphological and functional adaptations in COPD patients, specific protocols for strength training and endurance should be developed and tested for the corresponding muscle groups.

Chest wall kinematics and breathlessness during unsupported arm exercise in COPD patients

We hypothesised that chest wall displacement inappropriate to increased ventilation contributes to dyspnoea more than dynamic hyperinflation or dyssynchronous breathing during unsupported arm exercise (UAE) in COPD patients. We used optoelectronic plethysmography to evaluate operational volumes of chest wall compartments, the upper rib cage, lower rib cage and abdomen, at 80% of peak incremental exercise in 13 patients. The phase shift between the volumes of upper and lower rib cage (RC) was taken as an index of RC distortion. With UAE, no chest wall dynamic hyperinflation was found; sometimes the lower RC paradoxed inward while in other patients it was the upper RC. Phase shift did not correlate with dyspnoea (by Borg scale) at any time, and chest wall displacement was in proportion to increased ventilation. In conclusions neither chest wall dynamic hyperinflation nor dyssynchronous breathing per se were major contributors to dyspnoea. Unlike our prediction, chest wall expansion and ventilation were adequately coupled with each other.

How should we measure arm exercise capacity in patients with COPD? A systematic review

BACKGROUND

There are no recommendations on how to measure arm exercise capacity in individuals with COPD. The objectives of this study were (1) to synthesize the literature on measures of arm exercise capacity in individuals with COPD, (2) to describe the psychometric properties and the target construct of each measure, and (3) to make recommendations for clinical practice and research.

METHODS

Studies conducted in patients with COPD that included a measure of arm exercise capacity were identified after searches of five electronic databases (PubMed, CINAHL, EMBASE, PEDro, and Cochrane Library) and reference lists of pertinent articles. One reviewer performed data extraction, and two assessed the quality of the studies that described measurement properties, using the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist.

RESULTS

Of 654 reports, 41 met the study criteria. Five types of arm exercise tests were identified: arm ergometry, ring shifts, dowel lifts, proprioceptive neuromuscular facilitation, and activities of daily living. Four studies assessed the measurement properties of the unsupported upper-limb exercise test (UULEX), the 6-min pegboard and ring test (6PBRT), a test involving weight shifts, and the grocery-shelving task (GST). Validity studies were of fair to good quality, whereas reliability studies were of poor quality.

CONCLUSIONS

Arm ergometry may be the best method for measuring peak supported arm exercise capacity and endurance. The UULEX, 6PBRT, and GST may better reflect activities of daily living and should be the tests of choice to measure peak unsupported arm exercise capacity (UULEX) and arm function (6PBRT and GST).

Effect of upper limb, lower limb and combined training on health-related quality of life in COPD

OBJECTIVES

To study the effect of unsupported upper limb and lower limb exercise training and their combined influence on the exercise performance and health-related quality of life in COPD patients.

MATERIALS AND METHODS

Thirty patients were randomly assigned to one of the three groups, through block randomization. Of the three groups, group A received upper limb training, group B received lower limb training, and group C received both upper and lower limb training. Patients in group A, B, and C underwent exercise training five times a week for four weeks. The outcome measures used in the study were unsupported upper limb endurance test (UULEX), Six-Minute Walk Test (6-MWT), and a Chronic Respiratory Questionnaire. Statistical analysis was performed with analysis of variance, Wilcoxon scale, and a Kruskal Wallis one way ANOVA test, and a P value of .05 was used in the study.

CONCLUSION

The combined upper limb and lower limb training group showed a significant improvement in the exercise performance and health-related quality of life.

Parasternal muscle activity decreases in severe COPD with salmeterol-fluticasone propionate

BACKGROUND

The effect of the long acting beta(2)-agonist/corticosteroid combination salmeterol-fluticasone propionate (SFC) on respiratory muscles and ventilation in severe COPD is unknown. As COPD hyperinflation worsens, diaphragm efficiency decreases, and a compensatory increase in chest wall inspiratory muscle activity occurs. If a bronchodilator successfully alleviates hyperinflation and improves diaphragm efficiency in severe COPD, then the extraordinary activation of the chest wall may be relieved. We examined directly the effect on the parasternal intercostal respiratory chest wall muscle and ventilation of four puffs of salmeterol 25 microg and fluticasone propionate 125 microg via the metered dose combination inhaler in 12 patients with severe Global Initiative on Obstructive Lung Disease stage III-IV COPD, mean FEV(1) = 0.91 L (32% predicted).

METHODS

We measured parasternal intercostal electromyogram (EMG) recorded from implanted fine-wire electrodes, ventilation, and breathing pattern, during resting and CO(2)-stimulated breathing. Full pulmonary function tests were recorded at the beginning and end of the study.

RESULTS

In this patient group, severe airflow obstruction and hyperinflation were poorly reversible after SFC: FEV(1) increased 4.2%, functional residual capacity decreased 1.4%, and inspiratory capacity increased 5.9%. However, with SFC there was a significant increase in minute ventilation, tidal volume, and mean inspiratory flow. There was a very large decrease in directly recorded parasternal EMG, with parasternal EMG disappearing completely in some patients after SFC.

CONCLUSIONS

In severe COPD, with minimal change in hyperinflation or pulmonary mechanics, salmeterol-fluticasone induced a significant decrease in activity of the chest wall parasternal inspiratory muscle. This may be of practical benefit to reverse the extensive use of the chest wall muscles and alleviate dyspnea in severe COPD.

Limited Functional Performance in Chronic Obstructive Pulmonary Disease: Nature, Causes and Measurement

Patients with chronic obstructive pulmonary disease (COPD) frequently describe limitations in functional performance. These limitations predict mortality, adversely affect health-care burden and impair health-related quality of life. The optimal method for quantifying the functional performance in COPD subjects has not been established. This paper discusses the (i) nature of limited functional performance reported by individuals with COPD, (ii) mechanisms that contribute to these limitations, (iii) assessment techniques available to provide markers of functional performance and (iv) areas for further research in measuring functional performance of COPD subjects.

Noninvasive proportional assist ventilation and pressure support ventilation during arm elevation in patients with chronic respiratory failure. A preliminary, physiologic study

BACKGROUND

It has been shown that upper limbs activity increases the respiratory workload in patients with chronic respiratory failure (CRF). The object of the present study was to investigate whether, in these patients: (i) noninvasive positive pressure ventilation (NPPV) could sustain the inspiratory muscles to meet the greater ventilatory demand during upper limbs activity with the arm elevation test (AE); (ii) proportional assist ventilation (PAV) might be superior to pressure support ventilation (PSV) during AE, because of its potential more adaptable response to sudden changes in the ventilatory pattern.

METHODS

The study was performed in the pulmonary function laboratory of the Pulmonary Division in Verona General Hospital, Verona, Italy. We studied 8 male patients with CRF due to chronic obstructive pulmonary disease (COPD). Each patient received 2 treatment in random order with a crossover design: spontaneous breathing (SB), SB with AE, either PSV or PAV without and with AE, SB without and with AE, either PSV or PAV without and with AE. We measured: lung function tests, lung mechanics, ventilatory pattern and diaphragmatic effort (pressure time product, PTP(di)).

RESULTS

(i) AE increases minute ventilation (+14%) and PTP(di) (+64%); (ii) ventilatory support, both with PSV and PAV unloads the diaphragm both at rest (PTP(di) -77% and -54%, respectively) and during arm elevation (PTP(di) -54% and -44%, respectively).

CONCLUSIONS

PAV and PSV unloads the diaphragm in patients with CRF due to COPD both during SB and AE; PAV can be more efficient than PSV in assisting the diaphragm during AE in producing a greater level of minute ventilation for a similar rise in PTP(di) compared to PSV. Noninvasive ventilatory support should be considered in rehabilitation programs for training of upper limbs activity.

Feasibility of Distractive Auditory Stimuli on Upper Extremity Training in Persons With Chronic Obstructive Pulmonary Disease

OBJECTIVE

To determine the feasibility of distractive auditory stimuli (DAS) used during an upper extremity training (UET) program on perceived dyspnea, functional performance, and health-related quality of life. In addition, to determine the appropriate music tempo used during the UET.

DESIGN

Experimental, randomized, 3-group design with testing at baseline and 4 weeks.

SETTING

Outpatient.

PATIENTS

Thirty patients (13 male and 17 female) with moderate to severe chronic obstructive pulmonary disease (FEV1 41.27% +/- 18% predicted).

INTERVENTION

Moderate DAS group (n = 10) and slow DAS group (n = 10) subjects were instructed to perform UET for up to 15 minutes 3 to 5 times a week using DAS (walkman, audiocassettes). The control group (n = 10) received the same instructions, but no DAS.

MEASURES AND RESULTS

Primary outcome measures were perceived dyspnea, functional performance using the 6-minute peg and ring board (6MRPB) count and health-related quality of life. In addition, all subjects recorded the time of UET performance using self-report (daily logs). A significant increase was seen in 6MRPB count (P = .002) between groups. Moderate DAS subjects increased 6MPRB count 46 +/- 21 rings and slow DAS subjects increased 46 +/- 20 rings from baseline to 4 weeks whereas control subjects increased only 5 +/- 4 rings. No significant differences were noted for the remaining variables.

CONCLUSION

Subjects who used DAS (music) while performing UET improved functional performance whereas controls failed to continue improvement. The DAS is a feasible adjunct to UET that may have the potential to augment the effectiveness of pulmonary rehabilitation training.

Does Unsupported Upper Limb Exercise Training Improve Symptoms and Quality of Life for Patients With Chronic Obstructive Pulmonary Disease?

PURPOSE

Many patients with chronic obstructive pulmonary disease (COPD) report dyspnea and fatigue when performing upper limb activities. Unsupported upper limb training has been shown to improve upper limb endurance, but its effects on symptoms and quality of life have not been examined. The aim of this study was to compare the effects of upper limb and lower limb training with lower limb training alone on exercise capacity, symptoms, and quality of life with COPD.

METHODS

For this study, 38 patients with moderate to severe COPD were randomly allocated to unsupported upper limb endurance training or to a control group that completed a sham training task. All the patients underwent lower limb endurance training. The 6-minute walk test, the Incremental Unsupported Upper Limb Exercise Test, and the Chronic Respiratory Disease Questionnaire (CRQ) were completed before training and then 6 weeks afterward. Both patients and assessors were blinded to group allocation.

RESULTS

All the patients reported symptoms associated with upper limb activities on the initial CRQ. Both groups showed significant improvements in all domains of the CRQ and in the 6-minute walk test after training. Only the upper limb training group showed improvement in upper limb endurance time (57 +/- 75 vs 2 +/- 58 seconds; P = .02). There were no significant differences between the groups for 6-minute walk test or any domain of the CRQ.

CONCLUSIONS

Unsupported upper limb training for patients COPD improves upper limb exercise capacity, but has no additional effect on symptoms or quality of life, as compared with leg training alone. This type of upper limb training may not adequately address the complex interaction between respiratory mechanics and upper limb function.

Recondicionamento muscular na DPOC: principais intervenções e novas tendências

Há algum tempo o condicionamento físico vem sendo parte obrigatória no tratamento de portadores de DPOC. Estes pacientes apresentam comumente intolerância ao exercício de intensidade variável e relacionada à disfunção muscular esquelética. Neste sentido, o exercício físico apresenta-se como ramo mais importante no processo de reabilitação pulmonar. O exercício aeróbio e o treino de força com pesos são fundamentais no incremento de capacidade física e qualidade de vida, principalmente naqueles indivíduos que apresentam as formas moderada ou grave da DPOC. Além disso, espera-se atualmente maior desenvolvimento nas pesquisas em relação à aplicação de estimulação elétrica neuromuscular (EENM) e ao uso criterioso de substâncias ergogênicas tais como esteróides anabolizantes e creatina oral. Tendo em vista as repercussões negativas da disfunção muscular e a importância da reabilitação pulmonar no tratamento da DPOC, esta revisão tem como objetivo reunir informações de estudos relevantes acerca das principais estratégias para o recondicionamento muscular esquelético nestes pacientes nos últimos 15 anos.

Arm positioning alters lung volumes in subjects with COPD and healthy subjects

Subjects with chronic obstructive pulmonary disease (COPD) have difficulty performing arm exercise, particularly if the arms are unsupported and elevated. The purpose of this study was to evaluate the effect of arm position on static lung volumes in COPD and healthy subjects. Lung volumes were measured by plethysmography in nine COPD subjects (mean age +/- SD = 67.3 +/- 10.3 years; % pred FEV1 +/- SD = 39.7 +/- 10.9%) and nine healthy subjects (mean age +/- SD = 55.8 +/- 8.8 years; % pred FEV1 +/- SD = 102.9 +/- 12.2%) with the arms below 90 degrees shoulder flexion, at 90 degrees shoulder flexion and above 90 degrees shoulder flexion. In all subjects a significant increase in functional residual capacity (FRC) and reduction in inspiratory capacity (IC) was shown with arms above 90 degrees shoulder flexion when compared with both arms below 90 degrees shoulder flexion (mean increase in FRC (95% CI) was 0.17 L (0.06 to 0.27) for COPD and 0.29 L (0.11 to 0.47) for healthy subjects; mean reduction in IC (95% CI) was 0.24 L (0.1 to 0.38) for COPD and 0.45 L (0.22 to 0.68) for healthy subjects) and arms at 90 degrees shoulder flexion (mean increase in FRC (95% CI) was 0.15 L (0.01 to 0.29) for COPD and 0.22 L (0.11 to 0.34) for healthy subjects; mean reduction in IC (95% CI) was 0.14 L (0.01 to 0.26) for COPD and was 0.29 L (0.17 to 0.42) for healthy subjects). These changes may alter lung mechanics and, in COPD subjects, may affect their ability to perform arm exercise above shoulder height

Sex differences in thoracic dimensions and configuration

The volume of adult female lungs is typically 10-12% smaller than that of males who have the same height and age. In this study, we investigated how this volume difference is distributed between the rib cage and the diaphragm abdomen compartments. Internal rib cage dimensions, diaphragm position relative to spine, and diaphragm length were compared in 21 normal male and 19 normal female subjects at three different lung volumes using anterior-posterior and lateral chest radiographs. At all lung volumes examined, females had smaller radial rib cage dimensions in relationship to height than males, a greater inclination of ribs, a comparable diaphragm dome position relative to the spine, and a shorter diaphragm length. Female subjects exhibited a greater inspiratory rib cage muscle contribution during resting breathing than males, presumably reflecting an improved mechanical advantage conferred to these muscles by the greater inclination of ribs. Because of a greater inclination of ribs, female rib cages could accommodate a greater volume expansion. The results suggest a disproportionate growth of the rib cage in females relative to the lung, which would be well suited to accommodate large abdominal volume displacements as in pregnancy.

Breathing retraining and exercise conditioning in patients with chronic obstructive pulmonary disease (COPD): a physiological approach

In this review we shall consider the commonest techniques to reduce dyspnea that are being applied to patients with chronic obstructive pulmonary disease (COPD) subjected to a pulmonary rehabilitation program (PRP). Pursed lip breathing (PLB) and diaphragmatic breathing (DB) are breathing retraining strategies employed by COPD patients in order to relieve and control dyspnea. However, the effectiveness of PLB in reducing dyspnoea is controversial. Moreover, DB may be associated with asynchronous and paradoxical breathing movements, reflecting a decrease in the efficiency ofthe diaphragm. Exercise training (EXT) is a mandatory component of PRP.EXT has been shown to improve exercise performances and peripheral muscle strength. Recent studies have focused on the effect of EXT on breathlessness. However, concerns persist as to whether the decreased sensation of dyspnea for a given exercise stimulus is principally due to psychological benefits of rehabilitation or to improved physiological ability to perform exercise. The effect of EXT on breathlessness may be reinforced by inhaling oxygen. However, two studies have recently shown that breathing supplemental oxygen during training has either a marginal effect or no advantage over training. In a comprehensive PRP, strength training (ST) and arm endurance training (AET) could have a role in decreasing peripheral muscle weakness and metabolic and ventilatory requirements for AET. The role of unloading the respiratory muscles during EXT has to be

Exercise training in chronic obstructive pulmonary disease

Exercise limitation is a common and disturbing manifestation of COPD. The exercise intolerance is often caused by multiple interrelated anatomic and physiologic disturbances. Importantly, exercise tolerance can be improved despite the presence of fixed structural abnormalities in the lung. Exercise training, undertaken alone or in the context of comprehensive PR, improves exercise endurance and, to a lesser degree, the maximal tolerated workload of patients with COPD. Pulmonary rehabilitation also improves dyspnea and QOL. Exercise training and PR should be considered for all patients lacking contraindications who experience exercise intolerance despite optimal medical therapy. Lower-extremity training should be included routinely in the exercise prescription. The choice of type and intensity of training should be based primarily on the patient's individual baseline functional status, symptoms, needs, and long-term goals. When tolerated, high-intensity (continuous or interval) training may lead to greater improvements in aerobic fitness than low-intensity training but is not absolutely necessary to achieve gains in exercise endurance. Upper-extremity training should be undertaken when possible. Ventilatory muscle training should be considered for patients who continue to experience exercise limitation and breathlessness despite medical therapy and general exercise reconditioning. Exercise tolerance may improve following exercise training because of gains in aerobic fitness or peripheral muscle strength; enhanced mechanical skill and efficiency of exercise; improvements in respiratory muscle function, breathing pattern, or lung hyperinflation; as well as reduction in anxiety, fear, and dyspnea associated with exercise. Gains made in exercise tolerance can last up to 2 years following a limited duration (6-12 week) rehabilitation program.

Respiratory response during arm elevation in isolated diaphragm weakness

Upper extremity exercise is associated with a significant metabolic and ventilatory cost that is particularly evident in patients with severe chronic airflow obstruction. In these patients abnormal ventilatory muscle recruitment has been hypothesized to relate to impaired diaphragm function resulting from hyperinflation. Similar data have never been reported in patients with isolated diaphragm weakness but without airflow obstruction or hyperinflation, a group that would ideally define the role of diaphragm function during arm elevation (AE). We prospectively studied 15 patients with isolated diaphragm weakness of varying severity (Pdi(sniff), 31.74 +/- 3.75 cm H(2)O) as contrasted with eight normal subjects (Pdi(sniff), 111. 77 +/- 13.35 cm H(2)O) of similar age. Patients with diaphragm weakness demonstrated significant lung volume restriction with normal DL(CO)/VA. There was no difference in resting oxygen consumption (V O(2)), carbon dioxide production (V CO(2)), minute ventilation (V E), and tidal volume (VT) between the two groups; however, a borderline difference in resting breathing frequency (f(b)) (p = 0.056) was evident. Both groups demonstrated a rise in V O(2), V CO(2), and V E during 2 min of AE anteriorly. Normal subjects demonstrated a statistically significant rise in VT but a statistically insignificant rise in f(b) during AE. In contrast, patients with diaphragm weakness demonstrated a statistically significant rise in f(b) during AE but a statistically insignificant rise in VT. In patients the observed rise in VT directly correlated with baseline Pdi(sniff) (r = 0.59, p = 0.02) and Pdi(max) (r = 0.81, p = 0.002). Both groups demonstrated a rise in Pdi during AE. The rise in Pdi during AE directly correlated to Pdi(sniff) in the patients (r = 0.69, p = 0.004). Observed end-expiratory Ppl rose during arm elevation in both the patient group and in the normal control group, but no evidence of a differential response to AE was found. In those patients with greater diaphragm weakness (Pdi(sniff) < 30 cm H(2)O), abnormal respiratory muscle function (lesser rise in Pdi) and a lesser increase in VT during AE were more evident. These data highlight the importance of diaphragm function in determining the metabolic and respiratory muscle response to arm elevation.

End-expiratory lung volume during arm and leg exercise in normal subjects and patients with cystic fibrosis

There are no reports concerning the regulation of end-expiratory lung volume (EELV) and flow-volume relationships during upper limb exercise in health and disease. We studied EELV during such exercise in 22 adults with cystic fibrosis (CF) and nine age-matched healthy control subjects. Subjects with CF were grouped according to the severity of their lung disease, as follows: mild = FEV1 > 80% predicted; moderate = FEV1 40 to 80% predicted, and severe = FEV1 < 40% predicted. EELV was calculated from measurements of inspiratory capacity (IC) made at each workload during an incremental arm and leg ergometer test to peak work capacity. In the control group, the decrease in EELV was significantly smaller for arm than for leg exercise at peak work (-0.13 L versus -0.53 L, p < 0.001) and for arm than for leg exercise at an equivalent submaximal ventilation (-0.13 L versus -0.46 L, p < 0.01). In the groups with moderate and severe CF, arm exercise resulted in an increase in EELV from resting levels (dynamic hyperinflation) that was not significantly different from the increase observed for leg exercise. For CF subjects there was a significant inverse relationship between FEV1 and changes in EELV from rest to peak arm exercise (r = -0.46, p < 0.05). In normal subjects, there was a difference in the EELV response for arm versus leg exercise. In CF subjects with airflow limitation, dynamic hyperinflation occurred with both forms of exercise.

Arm training reduces the VO2 and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) may develop dyspnea with minimal arm activity, thoracoabdominal dyssynchrony with unsupported arm exercise (UAEX) and increased oxygen uptake (VO2), and minute ventilation (VE) with simple unsupported arm elevation (UAE) and UAEX. We investigated whether unsupported arm training, as the only form of exercise, could decrease the VO2 and VE cost (percentage increase from resting baseline) associated with unsupported arm elevation and exercise, respectively.

METHODS

Twenty-six patients with severe COPD were randomized to 21-24 sessions of unsupported arm (ARMT) or low-intensity resistive breathing (RBT) training as the only form of exercise. Patients were studied before and after training using a metabolic cart and esophageal and gastric pressures to evaluate metabolic and respiratory muscle function.

RESULTS

After ARMT, the VO2 (58% vs 38% increase, P < 0.05) and VE (41% v. 21% increase, P < 0.05) cost for UAEX at exercise isotime decreased and endurance time increased. Similarly the VO2 (25% vs 18% increase, P < 0.05) cost decreased and VE no longer increased in response to 2 minutes of UAE after ARMT. The RBT group showed no such change. No improvement in ventilatory load or respiratory muscle function could be identified to explain the physiologic changes observed. After ARMT, mean inspiratory flow (VT/TL), a measure of central respiratory drive, was reduced during UAEX and the expected increase during UAE did not occur.

CONCLUSION

We conclude that arm training reduces the VO2 and VE cost of UAE and UAEX, possibly through improved synchronization and coordination of accessory muscle action during unsupported arm activity.

Home-based, upper-arm exercise training for patients with chronic obstructive pulmonary disease

Prior studies demonstrate the ability of upper extremity training to increase arm strength and endurance when incorporated into a pulmonary rehabilitation program. However, patients with severe chronic obstructive pulmonary disease (COPD) may have transportation or mobility problems that make it difficult to travel to a rehabilitation site to obtain this training. This pilot study was designed to determine whether a home-based, upper-arm exercise program could increase arm strength and endurance, and decrease perceptions of breathlessness and fatigue during five activities of daily living. Twenty patients with severe COPD (FEV1 0.80 +/- 0.42) were randomized to an experimental (n = 10) or control group (n = 10). The experimental-group training included three upper arm exercises five times a week for 8 weeks, with training level incremented during weekly home visits. Control-group subjects were contacted weekly to equalize attention from health care providers. During the upper-extremity endurance test for number of rings moved, no significant differences between groups were seen for interaction or treatment. However, there was a significant interaction between treatment and time for perceived fatigue (p = 0.0012), with the experimental group perceiving less fatigue during upper arm work than did the control group. No change was seen in perceived breathlessness. Findings of this study suggest that a home-based, upper-arm exercise program can reduce perceptions of fatigue for patients with severe COPD during activities involving upper arm work. Testing in a larger sample is indicated to determine whether this training can also improve ability to perform unsupported arm work.

[Abdominal respiratory muscle activity in patients with stable chronic obstructive pulmonary disease]

With the purpose of defining the pattern of abdominal respiratory muscle activity in patients with chronic obstructive pulmonary disease (COPD), we studied the electromyogram of the rectus abdominis (RA), the external oblique (EO) and transversus (TM) muscles in 14 patients with different degrees of airways obstruction (FEV1: 41 +/- 12%; FEV1/FVC: 45 +/- 10%; RV: 198 +/- 38%; PaO2: 75.8 +/- 12 y PaCO2: 41.4 +/- 5.7 mmHg). The EMG was obtained by insertion of bipolar electrodes guided by an ultrasound image of the abdominal wall to locate the position of the muscles. The measurements were recorded in supine decubitus position in 5 situations: a) breathing at tidal volume; b) slow expiration until RV; c) with inspiratory load; d) with expiratory load, and e) during relaxed breathing with the arms raised. Recordings were also made in the same situations with 10 patients sitting. Eight patients presented phasic expiratory activity during relaxed breathing (TM activity alone or accompanied by EO). We found no significant differences in degree of hyperinflation or in arterial gases between patients with phasic expiratory activity and those without. There were significant differences between these 2 groups, however, as to degree of airways obstruction, for absolute values of FEV1 (p < 0.02) and in raw values (p < 0.04). Slow breathing until RV recruited muscular activity in 13 patients; the muscles did not operate in unison, however, with TM acting first. Recruitment was also observed when inspiratory and expiratory loads were placed, although in this case the 3 muscles acted simultaneously. Phasic activity was observed in only 2 patients for recordings made with arms raised, at which time there was greater tonic muscle activity. The phasic activity pattern recorded when patients were sitting was very similar to that obtained in supine position. In summary, some patients with stable COPD have phasic expiratory activity of the abdominal muscles when resting. These muscles do not appear to act as a unit and this phasic expiratory activity is related to severity of upper airways obstruction.

Effect of a walking aid on disability, oxygenation, and breathlessness in patients with chronic airflow limitation

PURPOSE

This study assessed the effect of a wheeled walking aid on disability, oxygenation, and breathlessness in patients with severe disability secondary to chronic irreversible airflow limitation.

METHODS

Eleven subjects with chronic irreversible airflow limitation, mean forced expired volume in 1 second (FEV1) 0.71 L +/- .33 L, were studied. Subjects performed four 6-minute walk tests, two on each of two study days, twice unaided and twice with the assistance of a wheeled walking aid. A randomized cross-over design was used. All subjects were oriented to 6-minute walk tests, use of bronchodilators was controlled, and standard encouragement was given during each walk test. Outcome measures were the distance walked in 6 minutes, change in oxyhemoglobin saturation during the walk, and breathlessness using a modified Borg Scale.

RESULTS

The use of a wheeled walker resulted in a significant increase in 6-minute walking distance, a significant reduction in hypoxemia with walking and a significant reduction in breathlessness during the walk test.

CONCLUSIONS

The use of a wheeled walker resulted in significant decreases in disability, hypoxemia, and breathlessness during a 6-minute walk test. By reducing disability and breathlessness, a wheeled walker may improve quality of life in individuals with severe impairment in lung function.

Relationship of thermodilution cardiac output to metabolic measurements and mixed venous oxygen saturation

To determine the individual contributions of variables in the Fick equation to cardiac output, we simultaneously measured oxygen uptake (VO2), carbon dioxide production (VCO2), venous oxygen saturation (SvO2) and thermodilution cardiac output (Qth) in 28 medical and surgical ICU patients. Patients were intubated and ventilated with the intermittent mandatory ventilation mode. VO2 and VCO2 (averaged over 3 min) were obtained from a metabolic cart. SvO2 was measured with fiberoptic reflectance oximetry (and COoximetry). Thirty-nine studies (average duration, 4.3 h) with 151 Qth measurements were performed. The relationships between Qth and VO2, Qth and VCO2, Qth and SvO2, and 1/Qth and SvO2, as well as between the sequential changes in these variables were analyzed by least squares linear regression. The ability of changes in the variables VO2, VCO2, and SvO2 to predict changes in Qth were analyzed by receiver operating characteristic (ROC) curves. Qth was weakly related to VO2 (r = 0.45), VCO2 (r = 0.45), or SvO2 (r = 0.36). Changes in Qth were weakly related to changes in VCO2 (r = 0.40), and even less to changes in VO2 (r = 0.18) and SvO2 (r = 0.13). The areas under the ROC curves for increases in Qth > 10 percent were as follows: 0.66 for VCO2, 0.50 for VO2, and 0.55 for SvO2. The areas for decreases in Qth < 10 percent were as follows: 0.78 for VCO2, 0.65 for VO2, and 0.49 for SvO2. None of the above oximetry relationships were substantially altered by use of COoximetry venous oxygen saturations. We conclude that Qth cannot be predicted well solely from VO2, VCO2, or SvO2 nor can changes in Qth be predicted well solely from changes in VO2, VCO2, or SvO2. Of the metabolic variables, changes in VCO2 best predicted changes in Qth.

The ventilatory response to arm elevation of patients with chronic obstructive pulmonary disease

Although arm activity is poorly tolerated by patients with COPD, the ventilatory response to arm elevation alone is not well understood. We therefore studied the ventilatory response to arm elevation using a customized arm support sling to eliminate the effect of an increase in metabolic activity that might be attributable to independent arm elevation and used leg exercise to increase metabolic activity. During arm elevation at rest, there was a significant decrease in vital capacity (180 ml) and a small decrease in functional residual capacity (120 ml) as measured by body plethysmography. Minute ventilation was unchanged. When supported arm elevation (SAE) was compared with the control arm position (CAP), minute ventilation was unchanged although the pattern of breathing became more rapid and shallow (mean +/- SD, SAE vs CAP: fb = 17.9 +/- 5.3 vs 16.2 +/- 4.8 breaths.min-1; VT = 533 +/- 126 vs 579 +/- 142 ml; p < 0.05). During steady-state leg exercise, the increase in VO2, VCO2 and VE did not differ between SAE and CAP; however, both fb and VT changed toward a more rapid, shallow pattern of breathing (SAE vs CAP: fb = 24.3 +/- 3.0 vs 22.8 +/- 3.5 breaths.min-1; VT = 990 +/- 293 vs 1,081 +/- 309 ml; p < 0.05). During unsupported arm elevation VO2, VCO2, and VE, and fb were significantly greater than during the CAP. Approaches that train arm muscles and strategies that either support arm muscles or allow for frequent rests during upper arm activity may improve the endurance and the quality of life for COPD patients.

Supported arm exercise vs unsupported arm exercise in the rehabilitation of patients with severe chronic airflow obstruction

OBJECTIVE

Compare unsupported (UAEx) vs supported (SAEx) arm exercise in training of patients with severe chronic airflow obstruction (CAO).

DESIGN

Randomized trial of UAEx vs SAEx training added to a 10-week outpatient program of lower extremity (LE) exercise training, respiratory muscle training, breathing retraining, psychological support, and teaching.

SETTING

The Lahey Clinic Medical Center, a tertiary referral center.

PATIENTS

Forty patients with CAO entered the rehabilitation program with 32 completing training and testing.

INTERVENTIONS

All underwent progressive bicycle ergometer and treadmill training and respiratory muscle training using a threshold inspiratory pressure trainer. Patients were randomized to progressive SAEx training (arm cycle ergometer, n = 17) or UAEx training (raising weighted dowel, n = 18).

MAIN OUTCOME MEASURES AND RESULTS

There was no significant difference in disease severity or exercise capacity between the two groups. Twelve-min walk test, bicycle ergometer power output, and respiratory muscle function improved with no significant difference in improvement between the two groups. Both groups showed similar improvements in arm ergometer testing while those trained with UAEx showed greater improvement in dowel testing (UAEx > SAEx, p = 0.002). In 17 patients VO2isotime (time at which patient performed pre-training and post-training tests) was measured during dowel testing. Only those trained with UAEx showed decreases in VO2isotime (UAEx trained, p = 0.02; SAEx, p = 0.18). VO2 during the last minute of a 2-min period of simple arm elevation was also measured in 17 patients. Only those trained with UAEx showed decreases in VO2 (UAEx, p = 0.02; SAEx, p = 0.20).

CONCLUSION

We confirm that a pulmonary rehabilitation program incorporating exercise training improves LE and respiratory muscle function. Arm exercise training improved arm activity with greater increases in unsupported arm activity seen in those trained with unsupported arm training. Metabolic cost of UAEx decreased only in those trained with UAEx. As UAEx is typical of activities of daily living in patients with CAO, the changes seen with UAEx training may be of greater clinical significance. Arm training should be incorporated in exercise training and a simple program of UAEx appears the optimal format.

Pulmonary rehabilitation that includes arm exercise reduces metabolic and ventilatory requirements for simple arm elevation

Simple arm elevation results in increased metabolic and ventilatory requirements in patients with chronic airflow obstruction (CAO). These demands contribute to the dyspnea that is frequently reported when these patients perform activities of daily living involving the arms. We hypothesized that a comprehensive pulmonary rehabilitation (PR) program that includes upper extremity training would lower the ventilatory requirement for arm elevation. Metabolic and ventilatory responses to 2 min of simple arm elevation were studied in 14 patients with CAO before and after PR. Respiratory muscle strength was determined in 11 patients by measurement of maximal transdiaphragmatic pressure (Pdimax). Oxygen uptake (VO2), carbon dioxide production (VCO2), heart rate (HR), minute ventilation (VE), tidal volume (VT), and respiratory rate were measured at rest with the arms down and during 2 min of arm elevation. Before PR, arm elevation led to significant increases in VO2, VCO2, HR, and VE. After PR, pulmonary function, Pdimax, and resting metabolic and ventilatory parameters with the arms down were unchanged; however, during arm elevation, VO2, VCO2, and VE were significantly less than they were before PR. We conclude that a comprehensive PR program that includes upper extremity exercises leads to a reduction in the ventilatory requirement for simple arm elevation. This type of program may allow patients with CAO to perform sustained upper extremity activities with less dyspnea.