Pulmonary Rehabilitation* Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

Andrew L. Ries, MD, MPH, FCCP (Chair); Gerene S. Bauldoff, RN, PhD, FCCP; Brian W. Carlin, MD, FCCP; Richard Casaburi, PhD, MD, FCCP; Charles F. Emery, PhD; Donald A. Mahler, MD, FCCP; Barry Make, MD, FCCP; Carolyn L. Rochester, MD; Richard ZuWallack, MD, FCCP; Carla Herrerias, MPH

Disclosures

CHEST. 2007;131(5):4S-42S. 

In This Article

Upper Extremity Training

Upper extremity exercise training specifically impacts the arms and has been shown to increase arm work capacity while decreasing VO 2 for a comparable work level. Postulated mechanisms for improvement in upper extremity function from such training in patients with chronic lung diseases include desensitization to dyspnea, better muscular coordination, and metabolic adaptations to exercise.

The previous 1997 guidelines panel recommended that "strength and endurance training of the upper extremities improves arm function in patients with COPD" and that "arm exercises are safe, and should be included in rehabilitation programs for patients with COPD" (strength of evidence, B). This was based on five randomized trials and one observational study.

The methodology of the earlier studies varied considerably. Arm training alone appeared to be less effective than leg training[124]; however, when combined with leg training, a significant improvement in functional status was noted compared to either modality alone.[124,125] Arm training by weight lifting significantly improved work capacity, reduced ventilatory requirements,[126] and reduced both metabolic and ventilatory requirements (ie, O2 uptake, CO2 production, and VE) following training.[127] Greater benefit in unsupported arm work (with reduced metabolic cost) was seen with unsupported arm exercise when compared to supported arm exercise via ergometry.[211]

Since the previous guideline, one observational study[128] and three RCTs[129,130,131] were identified that address upper extremity training ( Table 7 ). They further support the conclusion that arm training positively impacts arm activity tolerance and that arm exercise improves ventilatory requirements by reducing ventilation and the associated VO 2.

The study by Holland and colleagues[129] compared arm training combined with lower limb training vs lower limb training alone. The combined-training group reported a significant improvement in arm endurance (p = 0.02) compared to the group undergoing lower limb training alone. In addition, the combined-training group demonstrated a trend toward reduced Borg score for perceived dyspnea (p = 0.07). No difference in perceived fatigue ratings was noted.

Unsupported arm exercise has been shown to increase upper extremity activity tolerance and endurance when compared to control subjects.[130,131] Epstein and colleagues[131] evaluated respiratory muscle strength, endurance, and exercise capacity in 26 persons with severe COPD. The arm-exercise group demonstrated increased muscle recruitment from the diaphragm, reduced oxygen cost during arm elevation, increased endurance time (p < 0.05), and reduced ventilation. No differences were seen between groups for VE and mean inspiratory flow. Bauldoff and colleagues[130] studied unsupported arm training in 20 patients with moderate-to-severe COPD over an 8-week period. They noted significant improvement over time in ratings of perceived fatigue (p = 0.03) and a trend toward improvement in arm endurance (p = 0.07) in the arm-training group compared with control subjects. No difference was seen for ratings of perceived dyspnea.

In a prospective, case-control observational study, Franssen and colleagues[128] compared 33 stable patients with COPD to 20 healthy age-matched and gender-matched control subjects. Resting energy expenditure was significantly increased in the COPD group, and both lower and upper extremity tests demonstrated significantly lower peak workload, peak VO 2 and carbon dioxide output, respiratory exchange ratio, and end-exercise ventilation in the COPD patients. There were no significant differences in mechanical efficiency between the groups. As the mechanical efficiency and exercise capacity did not appear to be affected uniformly in patients with COPD, the relative preservation of upper limb activities may influence exercise-training prescriptions in the pulmonary rehabilitation of patients with COPD.

In summary, the new evidence provides additional support for the use of upper extremity exercise training in pulmonary rehabilitation for patients with COPD by demonstrating improvement in upper limb exercise capacity and reduced ventilation and VO 2 cost during arm activity following unsupported arm training. Given the lack of randomized studies comparing unsupported vs supported arm exercise, the best type of arm training is unknown.

15. Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. Grade of recommendation, 1A

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