1. 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.

2. Conflict of interest I have no conflict of interest to declare I have no conflict of interest to declare

3. Objectives of this session To understand the impact of upper extremity dysfunction on dyspnea in COPD 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 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 To understand how to measure arm exercise capacity in patients with COPD

4. Background Airflow limitation Airflow limitation Lung hyperinflation Lung hyperinflation Systemic inflammation Systemic inflammation Peripheral muscle dysfunction Peripheral muscle dysfunction Impairments are encountered during hurried walking, stair climbing and simple activities of daily living (ADL) Impairments are encountered during hurried walking, stair climbing and simple activities of daily living (ADL) Dyspnea and exercise intolerance

5. Impairments during arm activities: Dyspnea and arm fatigue Arm fatigue: Muscle strength Dyspnea Overhead arm activity  FRC  hyperinflation Worsens respiratory muscle mechanics  burden on diaphragm worsening its force- generating capacity  sensation of dyspnea During unsupported arm activity – unable to use accessory muscles

6. What we know

7. Systematic reviews Costi et al. and Janaudis-Ferreira et al. (2009): 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

8. ACCP/AACVPR guidelines Recommend the inclusion of upper-extremity training in PR Recommend the inclusion of upper-extremity training in PR The best type of arm training is unknown due to lack of randomized controlled trials The best type of arm training is unknown due to lack of randomized controlled trials Janaudis-Ferreira et al. 2009

9. Characteristics of the arm training programs Supported and unsupported exercises: 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.)

10. Latest Research

11. Recent RCTs Addressed the methodological shortcomings of the previous studies Addressed the methodological shortcomings of the previous studies Included a comprehensive upper extremity resistance training with standardized training protocol/progression Included a comprehensive upper extremity resistance training with standardized training protocol/progression Included measures of HRQL and symptoms during ADL and arm tests Included measures of HRQL and symptoms during ADL and arm tests Costi et al.: demonstrated improvements in arm function and ADL Costi et al.: demonstrated improvements in arm function and ADL

13. 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. 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.

14. Training characteristics Training duration: Training duration: -3 days/week (during 6 weeks) -total of 18 sessions Muscle groups: pectoralis, latissimus, deltoids, rhomboids, biceps, triceps Muscle groups: pectoralis, latissimus, deltoids, rhomboids, biceps, triceps Initial load: 10-12 RM Initial load: 10-12 RM Control group: sham (upper limb flexibility and stretching exercises) Control group: sham (upper limb flexibility and stretching exercises)

15. CHEST PRESS Pectoralis major, deltoids medial, triceps

16. PEC-DEC BUTTERFLY Pectoralis major, middle deltoids

17. SEATED ROW Rhomboids, Latissumus, biceps, trapezius, deltoids

18. LAT PULL DOWN Latissimus dorsi, deltoids, rhomboids, biceps, erector spinae

19. ARM CURL Biceps TRICEPS PRESS DOWN Triceps

20. Front arm raises Anterior deltoids Shoulder Press Middle deltoids

21. 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

22. Outcome measures Dyspnea during ADL (CRDQ) Dyspnea during ADL (CRDQ) Health-related quality of life (CRDQ) Health-related quality of life (CRDQ) Arm exercise capacity (UULEX) Arm exercise capacity (UULEX) Arm function (6PBRT) Arm function (6PBRT) Arm fatigue and dyspnea during arm exercise tests (Borg scale) Arm fatigue and dyspnea during arm exercise tests (Borg scale) Peripheral muscle force (hand-held dynamometer) Peripheral muscle force (hand-held dynamometer)

23. Equipments Zhan et al. 2006 Takahashi et al. 2003 UULEX6PBRT Microfet 2

24. Significant findings Improvements in arm function, arm exercise capacity and arm muscle strength Improvements in arm function, arm exercise capacity and arm muscle strength No between-group differences in HRQL or dyspnea during ADL No between-group differences in HRQL or dyspnea during ADL

25. Possible mechanisms responsible for an increase in arm exercise capacity Improved aerobic capacity Improved aerobic capacity Desensitization or tolerance to symptoms Desensitization or tolerance to symptoms Increase force-generating capacity Increase force-generating capacity Improved muscular coordination Improved muscular coordination decrease in dyspnea

26. Summary of the results Resistance arm training program improved arm function, arm exercise capacity and muscle strength 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 Patients achieved superior performance during tests of arm exercise capacity without any significant increase in dyspnea or arm fatigue

27. Evidences for arm endurance training? No study specifically examined the effects of arm endurance training in COPD No study specifically examined the effects of arm endurance training in COPD

28. Assessment

29. How should we measure arm exercise capacity in COPD? A systematic review. Tania Janaudis-Ferreira 1,2, Marla K. Beauchamp 1, Roger Goldstein 1,2,3, Dina Brooks 1,2 1 Respiratory Medicine, West Park Healthcare Centre, Toronto, Canada 2 Dept of Physical Therapy and 3 Medicine, University of Toronto, Canada.

30. Results 41 articles were included in the review 41 articles were included in the review Five categories of arm exercise tests were identified: 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) Only 4 studies assessed measurement properties of arm exercise tests (6PBRT, UULEX, Grocery Shelving Task (GST) and an overhead task)

31. Results Type of test Construct Validity Test-retest reliability ResponsivenessInterpretability Arm ergometry NoNoSomeNo Ring Shifts Yes: 6PBRT and OHT YesSomeNo Dowel lifts Yes:UULEXYesSomeNo PNFNoNoNoNo ADL test Yes:GSTYesYesNo Evidence for the measurement properties of the arm exercise tests

32. Conclusions The choice of the test should depend on the target construct being measured and on the psychometric properties of the tests. 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 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) 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. The responsiveness and interpretability of these tests have not been reported.

33. Thank you ! Acknowledgements: - West Park Healthcare Centre Foundation - Canada Research Chair Program - Ontario Thoracic Society - Swedish Heart and Lung Foundation