Effects of unsupported arm training on arm exercise-related perception in COPD patients
Highlights
► The impact of upper extremity training on UAE dyspnea and arm fatigue remains unclear. ► Arm training might affect unsupported arm exercise-related perception by decreasing motor output to respiratory muscles. ► UAET improved outcome measurements without affecting chest wall operational volumes or configuration. ► A reduction in ventilation correlated with a simultaneoreduction in chemical output. ► A decrease in ventilatory demand relative to decreased central motor output accounted for a decrease in arm and respiratory effort in UAET.
Introduction
Many patients with chronic obstructive pulmonary disease (COPD) complain of dyspnea during arm exercise. The increased demand during simple arm elevation may play a role in the development of dyspnea and in the limitation that is frequently reported by these patients when performing daily-life activities involving the arms (Celli et al., 1986, Tangri and Wolf, 1973). To limit dyspnea and arm fatigue, COPD patients often reduce the use of their arms during activities.
Upper extremity training is increasingly recognized as an important component of pulmonary rehabilitation (Ries et al., 2007). While arm ergometry may be best for measuring peak arm exercise capacity and endurance during supported arm exercise, the unsupported arm exercise (UAE) test may better reflect daily-life activity (Janaudis-Ferreira et al., 2012).
Although some studies have demonstrated improvement in UAE after upper extremity training (Holland et al., 2004, Janaudis-Ferreira et al., 2011, McKeough et al., 2005), suggesting that the test can be sensitive to changes in arm exercise capacity, the impact of upper extremity training on UAE dyspnea and arm fatigue remains unclear (Costi et al., 2009, Martinez et al., 1993, Neiderman et al., 1991, Ries et al., 1988) or undemonstrated (Costi et al., 2009, Couser et al., 1993, Janaudis-Ferreira et al., 2011, Lake et al., 1990).
Surprisingly, despite the discrepancy between respiratory patients’ self-reported dyspnea and the true extent of the pathophysiology, few studies (Costi et al., 2009, Couser et al., 1993, Janaudis-Ferreira et al., 2011, Martinez et al., 1993) have investigated the effect of upper extremity training on ratings of perceived dyspnea by applying psychophysical methods, that is, the quantitative study of the relationship between stimuli and the evoked conscious sensory response. Critical appraisal of symptoms can only come with application of psychophysical techniques applied within the framework of respiratory and sensory physiology (Killian et al., 1992). We based this study on sensory-perceptual measures which include real-time rating of intensity. We avoided using impact measures which, although very important, “do not directly assess what breathing feels like” (ATS, 2012). On this basis we have recently demonstrated that neither chest wall dynamic hyperinflation nor dyssynchronous breathing per se are the major contributors to dyspnea during either cycling leg exercise (Innocenti Bruni et al., 2012) or UAE (Romagnoli et al., 2011) in COPD patients. Using the same approach we tried to document the impact of unsupported arm exercise training (UAET) on UAE-related perceptions. The finding that patients stop UAE mainly because of arm effort prompted us to speculate that afferent information elicited by arm/torso muscles and conveyed to the motor-sensory cortex is perceived as a sensation of excessive arm effort (Romagnoli et al., 2011).
We therefore hypothesized that a decrease in ventilatory demand reflective of decreased central motor output might explain the salutary effects of UAET in patients with COPD.
Section snippets
Subjects
Eleven male COPD patients with moderate-to-severe airway obstruction participated in the study. COPD was diagnosed on the basis of history, physical examination, chest radiograph, and results of pulmonary function studies. All patients were clinically stable and on appropriate medication.
Study design
The study was conducted over 3 days: baseline lung function (day 1), incremental UAE test (day 2), constant load UAE test (day 3). Compartmental chest wall volumes were evaluated on day 3 at rest and at
Patients
Patients were in stage 3 (6 patients) and 4 (5 patients) of the GOLD classification (Global Initiative for Chronic Obstructive Lung Disease, 2005) (GOLD 2011). In most of them a mild to moderate level of hyperinflation was found. Eight patients were mildly hypoxemic (range 63–68 mmHg). Group expiratory flow limitation was 91.7 ± 10% VT. Rehabilitation did not change lung function significantly (Table 1).
Arm exercise
Peak incremental exercise responses are shown in table E/1 of the supplement.
Ten patients
Discussion
The main findings of this study are as follows: (1) A lower level of ventilation relative to decreased central motor output accounted for a decrease in arm effort and respiratory effort, and increase in endurance exercise following UAET; (2) UAET improved dyspnea without affecting chest wall operational volumes or configuration.
Because of the load which COPD places on an already stressed system of some patients with severe airflow limitation, arm exercise contributes to disabling dyspnea during
References (37)
- et al.
Exercise training decreases dyspnea and the distress and anxiety associated with it. Monitoring alone may be as effective as coaching
Chest
(1996) - et al.
Effects of unsupported upper extremity exercise training in patients with COPD: a randomized clinical trial
Chest
(2009) - et al.
Pulmonary rehabilitation that includes arm exercise reduces metabolic and ventilatory requirements for simple arm elevation
Chest
(1993) - et al.
Resistance arm training in patients with COPD: a randomized controlled trial
Chest
(2011) - et al.
How should we measure arm exercise capacity in patients with COPD? A systematic review
Chest
(2012) - et al.
Emerging concepts in evaluation of ventilatory limitation during exercise: the excessive tidal flow-volume loop
Chest
(1999) - et al.
Upper-limb and lower-limb exercise training in patients with chronic airflow obstruction
Chest
(1990) - et al.
Supported arm exercise vs. unsupported arm exercise in the rehabilitation of patients with severe chronic airflow obstruction
Chest
(1993) - et al.
Upper extremity exercise training in chronic obstructive pulmonary disease
Chest
(1988) - et al.
Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines
Chest
(2007)
Chest wall kinematics and breathlessness during unsupported arm exercise in COPD patients
Respiratory Physiology & Neurobiology
The breathing pattern in chronic obstructive lung disease during the performance of some common daily activities
Chest
Human respiratory muscle action and control during exercise
Journal of Applied Physiology
Update on the mechanisms, assessment, and management of dyspnea
American Journal of Respiratory and Critical Care Medicine
Exercise training falls to increase skeletal muscle enzymes in patients with chronic obstructive pulmonary disease
The American Review of Respiratory Disease
Psychophysical basis of perceived exertion
Medicine and Science in Sports and Exercise
Dyssynchronous breathing during arm but not leg exercise in patients with chronic airflow obstruction
The New England Journal of Medicine
Arm training reduces the and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease
Journal of Cardiopulmonary Rehabilitation
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