Arm Exercise and Hyperinflation in Patients with COPD: Effect of Arm Training BACKGROUND: Unlike studies on leg exercise, reports on the regulation of dynamic hyperinflation during arm exercise are scanty. We ascertained the following in patients with COPD: (1) whether and to what extent upper-limb exercise results in dynamic hyperinflation, and (2) the mechanism whereby an arm- training program (ATP) reduces arm effort and dyspnea. PATIENTS: Twelve patients with moderate-to-severe COPD were tested during incremental, symptom-limited arm exercise after a non-intervention control period (pre-ATP) and after ATP. METHODS: Exercise testing (1-min increments of 5 W) was performed using an arm ergometer. Oxygen uptake (V(O2)), carbon dioxide output, minute ventilation (Ve), tidal volume, and respiratory rate (RR) were measured continuously during the tests. Inspiratory capacity (IC), exercise dyspnea, and arm effort using a Borg scale were assessed at each step of exercise. RESULTS: Arm exercise resulted in a significant decrease in IC and significant positive relationships of IC with an increase in V(O2) and exercise dyspnea and arm effort. The results of ATP were as follows: (1) a significant increase in exercise capacity (p < 0.001); (2) no change in the relationships of exercise dyspnea and arm effort with Ve and IC, and of IC with V(O2); (3) at a standardized work rate, Ve, exercise dyspnea, and arm effort significantly decreased, while the decrease in IC was significantly less (p < 0.01) than before the ATP; the decrease in Ve was accomplished primarily by a decrease in RR; and (4) at standardized Ve, exercise dyspnea and arm effort decreased significantly. CONCLUSIONS: Arm exercise results in the association of dynamic hyperinflation, exercise dyspnea, and arm effort in COPD patients. An ATP increases arm endurance, modulates dynamic hyperinflation, and reduces symptoms. ABSTRACT Gigliotti, Francesco; Coli, Claudia; Bianchi, Roberto; Grazzini, Michela; et al. BACKGROUND 12 consecutive patients were selected as subjects -all suffered from moderate-to-severe COPD. -long history of smoking -moderate-to-severe chronic dyspnea -a clinically stable condition and no other significant disease contributing to dyspnea -motivation to participate in the program. Subjects performed routine spirometry to ascertain initial lung volumes. Ventilatory patterns were evaluated using a mass-flow sensor. From these, tital volume, respiratory rate, and minute ventilation were derived. Patients also performed an incremental, symptom-linked arm exercise on a stationary ergometer. Expired gas was analyzed for minute ventilation, V0 2, and VCO 2. For each run changes in minute vent., tital volume, and resp. rate were continuously. Pts were monitored using a 12 lead EKG and pulse oximetry. BP was recorded every two min. of ex and during recovery. End expiratory volume was calculated by having subjects perform inspiratory capacity maneuvers at end of each workload. Dsypnea was evaluated each min. during exercise. ATP: -80 % peak work rate on Ergometer until symptom limit -Unsupported arm exercise (shoulder abd/ext.) -Threading rings in series of pegs with arm above 90° -Study was 6 weeks -Subjects were own controls -Sessions conducted at same time of day MATERIALS AND METHODS Changes at Standardized WR -With arm exercise, IC decreased by 0.93 ±0.4 L (from 2.68 ±0.79 to 1.75 ±0.63 L -After the ATP, IC decreased by 0.59 ±0.27 L (from 2.6 ±0.83 to 2.01 ±0.81 L) and was significantly less than before ATP -ATP lowered HR and decreased VE by lengthening RR but did not modify VO2, and VCO2 shows individual changes in both exercise and arm effort with the ATP -In most patients, exercise dyspnea and arm exercise decreased at standardized WR. Changes at Standardized VE -The decrease in IC during arm exercise before ATP tended to significantly differ from the decrease after ATP -ATP reduced exercise dyspnea and arm effort, lowered HR, but did not modify WR, VO2, VCO2, VT, and RR. RESULTS CONCLUSIONS/CLINICAL SIGNIFICANCE Training that includes both upper and lower extremity exercise may improve endurance in COPD pts. Therapists should remember, however, that additional physiological and/or sensory factors can also be important to the perception of. The data indicate that arm exercise may result in the association of dynamic hyperinflation, dyspnea, and arm effort in patients with COPD. The ATP increases arm endurance, modulates dynamic hyperinflation, and reduces symptoms. ARTICLE TWO -Ennis S, Alison J, McKeough Z. The effects of arm endurance and strength training on arm exercise capacity in people with chronic obstructive pulmonary disease. Physical Therapy Reviews. 2009;14(4): This article, a systematic review, looked at 24 articles related to this topic and supports the general ideas of the original article. Like the original article this article suggests that arm endurance exercise can improve arm exercise capacity, and that arm strength training can improve arm strength. ARTICLE THREE -Janaudis-Ferreira T, Hill K, Goldstein R, Wadell K, Brooks D. Arm exercise training in patients with chronic obstructive pulmonary disease. Journal of cardiopulmonary rehabilitation and prevention. 2009;29: The third article, also a systematic review, only looked at 5 articles and supported the fact that an arm training program improves exercise capacity, but states that its effect on dyspnea and arm fatigue are unclear. So this article supports one part of the original article, but not the rest. None of the original article is refuted by anything in this review, however. Unlike studies on leg exercise, reports on the regulation of dynamic hyperinflation during arm exercise are scanty. The authors ascertained the following in patients with COPD: (1) whether and to what extent upper-limb exercise results in dynamic hyperinflation, and (2) the mechanism whereby an arm- training program (ATP) reduces arm effort and dyspnea. PURPOSE The purpose of this study was to determine if Arm exercise caused dynamic hperinflation of the lungs. The authors also looked at whether or not an arm training program could reduce arm effort and dyspnea when compared to pre-training measurements for the same individuals. DISCUSSIONS As predicted, arm exercise resulted in dynamic hyperinflation, and that correlates with increased dyspnea, arm effort and V0 2 consumption. ATP resulted in 1) increased exercise capacity at peak, 2) decreased vent and hyperinflation—probably due to decreased RR, 3) decreased dyspnea and arm effort. This study’s novel finding was that supported-arm exercise also caused hyperinflation in COPD patients. It is suggested that this occurs because of insufficient time to exhale all inspired air before next inspiration begins. Dynamic hyperinflation stresses the respiratory system in a number of ways, and also has a strong predictive value for the variability of VO 2. Mechanical factors may also affect this variability. Summary -In conclusion, studies have shown that LE activity increases dynamic hyperinflation as well as fatigue, but very little research had been done prior to this article on UE exercise’s correlation with it. -This article and the two noted systematic reviews tried to determine UE exercise’s effect on fatigue and what effect an arm training program has. -All three articles found that an arm training program can increase exercise capacity and two of the three found it also reduced fatigue and dyspnea. -So arm training should be incorporated into COPD patients’ routines in order to maximize health benefits of exercise training. Joshua Rose, DPT Student Bellarmine University Incremental Exercise Performance -At peak arm exercise, VE, VCO2, VO2, HR, exercise dyspnea, arm effort, and WR all increased -The ATP did not modify VE, VCO2, VO2, HR, exercise dyspnea, and arm effort -ATP increased the relationships of changes in exercise dyspnea and arm effort with changes in VE, VO2, VCO2, -Relationships of changes in VE with changes in VO2 and VCO2 were not altered with the ATP. RESULTS CONTINUED