Impaired arm activity in COPD: a questionable goal for rehabilitation

Abstract

The most common extrapulmonary problems in chronic obstructive pulmonary disease (COPD) patients are cardiovascular comorbidities, muscle weakness and dysfunction [1][2][3]. Indeed, the reduced peripheral muscle mass and strength increase patient's symptoms during effort (fatigue and or dyspnoea) and progressively lead to disability. Furthermore, both lower and upper limb dysfunction has been shown to independently predict the long-term prognosis of COPD patients [2].The use of arms is involved in many daily domestic tasks and activities. To date, it has been shown that daily arm activities needing elevation above the shoulders may interfere with regular breathing and are associated with dynamic hyperinflation in COPD patients [4]. The research by MEIJER et al. [5], published in this issue of the European Respiratory Journal, investigated whether, and in which proportion of muscle effort, arm activities during daily life are different in COPD patients compared with matched healthy individuals. Notably, this study is the first to characterise arm activities associated with daily living in the COPD population.Daily arm and leg domestic activities were measured by accelerometers in moderate-to-severe COPD patients and controls. After correcting for the daily walking time, the time spent on arm activities was similar in COPD patients and healthy controls, whereas the intensity of these activities was lower in COPD patients. In addition, the authors assessed the relative effort of the trapezius, deltoid and biceps muscles using electromyography during 12 standard domestic activities involving upper limbs in both populations. COPD patients performed seven arm activities at a lower intensity compared to control subjects, while the degree of arm elevation was similar. Moreover, in COPD patients compared with controls, muscle effort was found to be performed at a higher proportion of the maximum for the trapezius during six activities (writing on a board, shaking hands, folding towels, putting towels on the shelf, walking at preferred speed and sweeping the floor) and for the biceps during only one activity (folding towels). Overall, the total effort over the total effort spent by the trapezius muscle during these specific arm activities in COPD patients was roughly twice that required in subjects without COPD.The findings by MEIJER et al. [5] challenge the anecdotal observation that arm activities may be problematic and poorly tolerated in patients suffering from COPD [6]. As a matter of fact, this study clearly indicates that domestic arm activities in COPD patients are performed differently from the point of view of intensity (less) but not time (same duration). Although mechanical efficiency and exercise capacity of the upper limb muscles are usually preserved in COPD patients, it is likely that repeated domestic arm activities may enhance their symptoms and ventilator constrains [7].

Arm strength training improves activities of daily living and occupational performance in patients with COPD

“…Although early guidelines suggest that unsupported arm training should be included as a component of pulmonary rehabilitation (PR) for patients with COPD , most recent PR guidelines for standard programmes do not specifically suggest the inclusion of arm training . Two major identified problems are inappropriateness of methods to assess impairment in defining the contribution of arm training in COPD and the probable mechanisms by which training improves arm function . Arm strength training leads to moderate improvements in peripheral muscle strength in COPD patients, but there is a lack of high‐quality studies supporting the claim that arm strength training improves functional arm tasks .…”

“…The effects of arm training on patients’ functional performance in daily life have not been extensively studied . Further well‐designed studies that have sufficiently strong and clinically meaningful outcome measurements are necessary . Therefore, this study aimed to investigate the effect of arm strength training, implemented without general exercise training, on arm exercise capacity, ADL and occupational performance in patients with COPD.…”

Reference values for the Unsupported Upper Limb Exercise test in healthy adults in Brazil

“…Peripheral muscle dysfunction is one of the most common extrathoracic manifestations of COPD and has been associated with poor prognosis. (1) Studies have shown that a reduction in muscle mass and strength is a predictor of mortality (2,3) and a marker of exacerbation risk in COPD patients. (4) The cause of peripheral muscle dysfunction is multifactorial, the main factors involved being physical inactivity, malnutrition, exacerbations, and corticosteroid use.…”