Chest
Volume 128, Issue 3, September 2005, Pages 1225-1232
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Clinical Investigations
Arm Exercise and Hyperinflation in Patients With COPD: Effect of Arm Training

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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 nonintervention 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 ( V˙e), 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 V˙e and IC, and of IC with V˙o2; (3) at a standardized work rate, V˙e, 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 V˙e was accomplished primarily by a decrease in RR; and (4) at standardized V˙e, 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.

Section snippets

Subjects

We studied 12 consecutive patients with stable, moderate-to-severe COPD who were entering an outpatient pulmonary rehabilitation program. Patients satisfied the following criteria: (1) a long history of smoking and moderate-to-severe, chronic dyspnea (Medical Research Council grade 2 to 4); (2) clinically stable condition, with no exacerbation or hospital admission in the preceding 4 weeks; and (3) no other significant disease(s) potentially contributing to dyspnea. The patients were all

Functional Evaluation

Routine spirometry with the subjects in a seated position was performed as previously described.13, 14 FRC was measured by helium dilution technique. The normal values for lung volumes are those proposed by the European Respiratory Society.15 Before performing exercise, the ventilatory patterns were evaluated with subjects sitting comfortably in an armchair with a mass-flow sensor ( V˙max; Sensor Medics; Yorba Linda, CA). From the spirogram, we derived the tidal volume (Vt), respiratory

Arm Ergometry

All patients performed an incremental (5 W/min), symptom-limited arm exercise. A modified stationary ergometer (Monarch Instrument; Varberg, Sweden) was used to deliver precise workload adjustments. The ergometer was secured to a table at shoulder level with the subjects seated in a straight-back chair. Each patient was made familiar with the apparatus days before the test. Expired gas was analyzed for V˙e, oxygen uptake ( V˙o2), carbon dioxide output ( V˙co2) using

ATP

Each patient attended a 6-week outpatient pulmonary rehabilitation program. The program included education, breathing retraining, leisure walking, and unsupported arm exercise and arm training with an arm ergometer. For the training on the arm ergometer, the workload corresponding to 80% of the peak work rate (WR) observed in the pretraining incremental exercise test was set as the training intensity. Patients were instructed to maintain this work level until they reached a symptom limit.

Protocol

This is a single-center, two-period, controlled study in which subjects complete a 6-week nonintervention period before entering a 6-week pulmonary rehabilitation program involving regular exercise training. In an initial screening, subjects were tested for pulmonary function and gas exchange. They became familiar with exercise testing procedures and the various scales for rating symptom intensity, and completed an incremental, symptom-limited exercise test. Three experimental visits were held

Data Analysis

To compare responses to an identical level of exercise before and after the rehabilitation program, we selected the highest WR tolerated by a given patient during pre-ATP test, (the standardized WR). To compare responses to an identical level of ventilation, we selected the highest V˙e tolerated by a given patient during the pre-ATP test (the standardized V˙e). Nonparametric ratings of exertional breathlessness were compared before and after intervention using the Wilcoxon test. All

Results

Anthropometric and baseline function data of the 12 patients with moderate-to-severe airflow obstruction and hyperinflation, mild-to-moderate hypoxia, and mild carbon dioxide retention are shown in Table 1. The data did not change during the study.

Incremental Exercise Performance

At peak arm exercise, V˙e, V˙co2, V˙o2, HR, exercise dyspnea, arm effort, and WR all increased. The ATP did not modify V˙e, V˙co2, V˙o2, HR, exercise dyspnea, and arm effort but increased WR (p < 0.001) [Table 2]. The relationships of changes in exercise dyspnea and arm effort with changes in V˙e, V˙o2, V˙co2, and the relationships of changes in V˙e with changes in V˙o2 and V˙co2 were not altered with the ATP (Table 3).

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, p < 0.000004) [mean ± SD]. After the ATP, IC decreased by 0.59 ± 0.27 L (from 2.6 ± 0.83 to 2.01 ± 0.81 L, p < 0.0001) and was significantly less (p < 0.01) than before ATP (Table 4). ATP lowered HR (p < 0.03) and decreased V˙e (p < 0.01) by lengthening RR (p < 0.03) but did not modify V˙o2 and V˙co2 (Table 5). Figure 1 (left panel) shows individual changes in both exercise dyspnea (average, from

Changes at Standardized V˙e

The decrease in IC during arm exercise before ATP (0.68 ± 0.42 L; from 2.69 ± 0.62 to 2.01 ± 0.57 L; p < 0.03) tended to significantly differ (p < 0.057) from the decrease after ATP (0.43 ± 0.32 L; from 2.79 ± 0.66 to 2.35 ± 0.75 L; p < 0.007). ATP reduced exercise dyspnea (from 4 ± 1.7 to 2.75 ±1.2 au; p < 0.02) and arm effort (from 5.6 ± 3 to 4.6 ± 3.1 au; p < 0.01; Fig 1, right panel), lowered HR (p < 0.03), but did not modify WR, V˙o2, V˙co2, Vt, and RR (Table 6).

Relationships

Figure 2 shows the slopes of the relationships of changes in IC with changes in exercise dyspnea (left panel; all patients but patient 11) and arm effort (right panel; all patients but patients 6 and 11) before the ATP (r2 = 0.25 and r2 = 0.64, respectively) and after ATP (r2 = 0.37 and r2 = 0.60, respectively); no difference was found between before and after ATP. In each patient, a decrease in IC was significantly correlated with increase in V˙o2V˙o2/ΔIC, 0.01 ± 0.03 L/min/L;

Discussion

Arm exercise resulted in dynamic hyperinflation, which directly correlated with increases in dyspnea, arm effort, and V˙o2. The ATP resulted in the following: (1) a significant increase in exercise capacity at peak exercise; (2) a decrease in both ventilation and dynamic hyperinflation, primarily due to a decrease in RR at standardized WR; and (3) a decrease in dyspnea and arm effort at standardized WR and ventilation.

The novel finding of this study is the dynamic hyperinflation, ie, the

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    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    This work was supported by a grant from the Fondazione Don C. Gnocchi ONLUS (IRCCS), Florence, Italy.

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