Resistance Training: Effects on COPD 1

Resistance Training: Effects on Chronic Obstructive Pulmonary Disorder

Sierra M. Moore, SPT

Central Michigan University

Doctor of Physical Therapy

 Resistance Training: Effects on COPD 2

Chronic Obstructive Pulmonary Disorder, otherwise known as COPD, is a progressive

disorder meaning it will become increasingly worse with time.1 The term is used to describe
those living with chronic bronchitis and emphysema.1,2 The disease is known for causing
increasing breathlessness.2 The leading cause of COPD is due to cigarette smoking. However,
the disease is caused from prolonged exposure to any lung irritants, such as air pollution, second-
hand smoke, dust, fumes, chemicals, etc.1 The symptoms most common with this disease is chest
tightness, coughing, an accumulation of mucus in the airways, wheezing, and shortness of breath
with normally, unchallenging tasks.1 It is important to know the symptoms and underlying
causes of disorders before treating patients, especially with COPD. It is the third leading cause of
death in the U.S.1 and 24 million people are currently affected2. Many people may have COPD
and not even know it. In the state of Michigan alone, 7.4% of the population is affected.2 This
may not seem as significant, but Michigan has a very high percentage of people living with
COPD (the highest being Kentucky with 9.3%).2 Even performing simple ADLs can worsen the
symptoms of dyspnea and fatigue; adding exercise can intensify these increased symptoms.
Unfortunately, there is no known cure or reversal of COPD damage.1 However, there is still hope
for an increased quality of life with treatments and lifestyle changes [that] can help you feel
better, stay more active, and slow the progress of the disease.1 It is also known that with
inactivity, all of the body systems are affected and a persons functional abilities will rapidly
decline.3 Patients with COPD avoid physical activity due to their previous level of activity and
because of their symptoms dyspnea.1-3 It is the responsibility of the physical therapist to
encourage and motivate these patients and to break the inactivity cycle. In order to break the
cycle, it will be important to implement a treatment that will not exacerbate symptoms. Recent
research on using resistance training and neuromuscular stimulation (NMES) with COPD has
had optimistic outcomes and adherence.
A study4 evaluating the effects of arm resistance training on COPD, recruited inpatients
and outpatients with COPD from a pulmonary rehabilitation program. In order to be included in
the study they had to have a diagnosis of COPD with a forced expiratory volume of <80% and
dyspnea or arm fatigue during at least one ADL with the use of the upper extremities4. Patients
that were excluded were those with an acute exacerbation of COPD that required a change in
their medications within the previous two months, if they were currently taking any oral
corticosteroids, or if they had a past surgical history involving their lungs4. It should also be
noted that they were not able to participate with a history of heart disease and/or if they had any
musculoskeletal or neurologic conditions that would affect their performance in the study4. The
patients participated in comprehensive inpatient and outpatient programs at the same time of the
study trials. These programs consisted of endurance training, strength training (LEs), and
breathing exercises. The inpatient program lasted for a total of six weeks, while the outpatient
lasted for a duration of 12 weeks.4
In this study, each patient was randomly assigned to either a control group (n=19) or an
intervention group (n=17). The intervention included a resistance arm training program (ATP)
three times a week for a total of 18 trials.4 The researchers decided to evaluate the biceps brachii,
triceps brachii, latissimus dorsi, deltoids, rhomboid major and minor, and pectoralis major and
minor muscles.4 The patients started lifting loads equal to their 10 to 12 repetition maximum
(RM). The repetition maximum is also known as the greatest amount of weight that you can lift
in one repetition. These loads were increased once the patient was able to tolerate more than 12
 Resistance Training: Effects on COPD 3

repetitions for two sessions in a row4. At the beginning and after each session, the patients rated
their arm fatigue and dyspnea using a visual analog scale (1-10). The control groups training
was in flexibility and stretching of the UEs for three times a week for a total of 18 sessions4.
During the ATP trials, a variety of measuring strategies were implemented. Dyspnea and the
patients health-related quality of life (HRQL) was measured using the Chronic Respiratory
Disease Questionnaire (CRDQ).4 Arm function was measured using the 6-min pegboard and ring
test as well as the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).4 Arm
exercise capacity (unsupported) was measured using an incremental unsupported upper limb
exercise test (UULEX).4 Peripheral muscle forced was measured by an isometric hand-held
dynamometer. The intervention rendered results with a greater increase in arm function, elbow
flexion/extension force, shoulder flexion force, and shoulder abduction force without a change in
dyspnea or fatigue.4 There was no difference between groups with their HRQL or DASH.
The resistance ATP increased the patients arm strength, function, and capacity to
exercise without an increase in dyspnea or arm fatigue. Although this may not seem very
significant, it is in the realm of COPD rehabilitation. It is common for a patient to have an
increase in symptoms of dyspnea and fatigue with endurance training of their LEs.4 Resistance
training of the UEs has benefits for implementation for a future patient with COPD. It shows
positive effects for the patients functioning, it is safe for the patient to perform, and there is not
an exacerbation of symptoms that is most commonly seen in endurance training. There were
some limitations of this study that should be taken in account. The majority of the participants
were inpatients, which increases exercise adherence since travel time/costs are taken out.4 It
would be interesting to see what the effects could be with flexibility training, stretching, and a
resistance ATP. Nevertheless, the positive effects of a resistance ATP will be taken into account
for future reference for patients diagnosed with COPD.
The second study5 evaluated the cardiopulmonary response during different modalities of
exercise rehabilitation for patients with COPD. The resistance training portion of the study
employed the use of a leg press with the LEs. This study provides a different perspective of
resistance training with the focus of the LEs. The participants for the study were patients of an
outpatient clinic. To qualify for the study, the patients had to have a diagnosis of COPD with
reduced exercise capacity and dyspnea5. They were not able to participate if they had a disability
and or locomotor problems that would hinder their ability to perform, recent infections or
exacerbations, and if they required supplemental oxygen5. The sessions were three times per
week and lasted 1.5 hours. The researchers set the load of the leg press to be 70% of the patients
1RM. It should be noted that the patients received counseling, nutritional consulting, and
occupational therapy5. This could have potentially increased the patients response in the
treatment outcomes.
All variables were recorded before and during the training session. The patients also rated
their dyspnea and fatigue using the modified Borg score. The results of the resistance training
showed a lower peak for VO2, VE, and C5. These results could be due to the shortness in
duration (~2 min; 3 sets of 8 repetitions) compared to the other modalities5. There was an
increase in the training load for the leg press throughout the program, but there was not a
significant change in the force of the quadriceps muscles5. The patients also displayed lower
cardiopulmonary distress and less dyspnea compared to whole body exercise, which is an
encouraging outcome for future guidelines. The benefits of using resistance training with the
population of patients with COPD are still noteworthy despite some of the studies limitations.
Both studies thus far have ruled out patients that have other comorbidities and/or circumstances
 Resistance Training: Effects on COPD 4

that may exacerbate their symptoms or limit their abilities to exercise. These results may reflect
the best circumstances of a patient with COPD when ruling out certain factors, making it
unrealistic. Resistance training of the LEs is still a safer way to exercise without
cardiopulmonary stress that is normally increased during training in this population. Thereby
decreasing the stress, the patient is capable of performing greater workloads, for longer periods
of time.
The next study6 compared the effects of endurance training and resistance training after
an inpatient rehab for COPD. This study consisted of forty-one patients between the ranges of
45-75 years old. The patients were able to participate if they were not physically active prior to
their admission to inpatient rehab, and if they did not have any musculoskeletal or cardiovascular
comorbidities6. They were left out if they were current smokers or if they required supplemental
oxygen as well. As requested by the researchers, the patients participated in twenty-four sessions
during the 12-week study in their own individual primary care practices6. The patients primary
care physiotherapists were contacted and given the necessary information to guide their
patient(s). They were randomly assigned to either and endurance training or a resistance training
plan. For resistance training, maximal voluntary contraction was measured for knee extension
and elbow flexion with a dynamometer6. Bilaterally, 15 repetition maximum tests were used to
measure the elbow flexors, latissimus dorsi, triceps brachii, and the abdominal muscles6. Several
questionnaires were also used to measure their functional status, health-related quality of life,
and their dyspnea.
The resistance training regimen involved a five minute warm up on the ergometer or the
treadmill at intensities equivalent to their Borg score 2-3 for dyspnea6. They were also required
to lift 12 repetitions at 50% of their predetermined load.6 After their warm up, the patients would
complete two sets of 12 repetitions to at the 15RM that had been determined in their inpatient
rehabilitation.6 Their workloads were increased approximately every three weeks for following
muscle groups: the elbow flexors and abdominal muscles (0.5-1.0 kg); latissimus dorsi and
triceps surae (5 kg); and knee extensors (10 kg).6 If the patient was unable to increase their load,
they were asked to perform three sets of 12 repetitions. If patients experienced any exacerbations
of symptoms preventing them to exercise, they were encouraged to return to their training
program as soon as possible. As an alternative, they were told to go for walks outside.6
The resistance training produced an increase in UE and abdominal muscle strength. The
patients experienced less dyspnea during their training, which is similar to the similar studies.
The patients also reported via questionnaire that they had an increase in their health-related
quality of life (HRQL). The researchers did not determine a decrease in the patients endurance
after their inpatient programs. The patients were contacted after one year, and 68% of the
patients stated they were exercising on a regular basis.6 Their HRQL scores were still maintained
compared to the endurance training group (scores returned to prior pre-IPR levels).6 There might
be a difference in adherence to resistance training compared to an endurance training with future
patients. Since there is not an increase in dyspnea during resistance training, the patient may be
more likely to continue to exercise. If a patient is continuing to use resistance training after
treatment, they are more likely to maintain their health gains.
A study7 investigating the metabolic response during resistance training and
neuromuscular electrical stimulation (NMES) discovered interesting results. The thirteen patients
that participated were beginning their inpatient rehabilitation when they were approached about
the study7. Prior to the study, each patients 70% 1RM was determined along with their Borg
score for dyspnea and fatigue. The patients each performed one session of resistance training that
 Resistance Training: Effects on COPD 5

involved a bilateral leg extension with three sets of their 70% 1RM7. They were allowed to rest
for a couple of minutes between each set. Another day they had one 21-minute NMES session
with electrodes on their quadriceps femoris muscles (bilaterally)7. The NMES machine was set
on a symmetrical biphasic square pulse at 75 Hz, a duty cycle of 6s on and 29s off, a pulse
time of 410 s, intensity adjusted to individual toleration7 The sessions ended after their Borg
scores were taken for a second time.
As would be expected, the resistance training had higher metabolic rates and increased
dyspnea and fatigue compared to NMES. In the NMES session there was a significantly lower
VO2 and VE peak7. It should be said, that even though the study had positive results, they may
not be generalized to the rest of the population. The majority of their patients had abnormal body
compositions with low BMIs and low fat-free mass7. These patients also had a poor peak
exercise capacity,7 but this could also be due to the fact that they were at the beginning of their
inpatient programs. The researchers determined that both would be suitable for those with mild-
severe COPD that had severe dyspnea, fatigue, or were bed-ridden.7 A therapist could even
alternate between the two modalities or determine which would be suitable based on the
individual patient.
The final study8 also examined the effects of NMES. In this study, the researchers were
interested in determining whether or not NMES could prevent muscle deterioration in those with
severe exacerbated COPD (SECOPD).8 There was a total of eleven patients with SECOPD that
had been recruited upon admission to the hospital.8 The study took place for 14 days and their
dominant leg was randomly assigned either non-NMES or NMES on their quadriceps muscles.8
The NMES was set to an asymmetrical bi-phase pulse wave, 400 ms pulse duration, 50 Hz
frequency, 8/20 s on/off cycle, in 30 min sessions was used.8 The use of NMES was found to
not only preserve the muscle function, but it also increased the strength of the quadriceps
muscles.8 This could be useful for clinical applications for those that are experiencing SECOPD
while they are in the hospital and/or after they have been discharged.8 The NMES machines are
easy to use and portable.7,8 This form of treatment may be even more attractive to a patient that
has severe dyspnea and fatigue. They do not have to leave the comforts of their home, they could
administer the treatment themselves, and it will not increase their symptoms.
Based on these findings, it would be in the best interest of the therapist and patient if the
treatment would be individualized to the person. Patients with mild to moderate forms of COPD
would most likely benefit from UE or LE resistance training. It has been shown to increase
muscle strength and HRQL scores.4,5 While resistance training produces less symptoms of
fatigue and dyspnea, it does not improve the patients symptoms in everyday life. It could
possibly prolong the time for conditions to worsen, while it has been known to keep the person
active for longer.3 In the case of a patient that is unable to exercise without severe increases in
dyspnea and fatigue it would be best to use the NMES treatment. This showed7 even less
dyspnea and fatigue than resistance training. If the patient is in the hospital, their initial muscle
strength decreases by 20% within the first week. The patients remaining strength will decrease
by 20% every week they continue to stay bed bound.9 The effects of hospitalization and
inactivity could be detrimental to a patients health. It is common for people to come out worse
than when they come in. A physical therapist can disrupt the effects of inactivity by using
NMES, breathing exercises, tilt tables, and bed exercises for those that are bed ridden with
COPD. The safest exercise for someone with SECOPD would be to use NMES. This has been
shown to create the least amount of symptoms, and it has been shown to sustain muscle function
while being immobile in the hospital.7,8 The NMES treatment actually increased the strength of
 Resistance Training: Effects on COPD 6

the muscle it was stimulating.7,8 Every patient will be different. They will each come into
treatment with different comorbidities, body size, severity of symptoms, motivation, etc. This is
why it is important to individualize their treatment. There is not a standard recommended
treatment for those with COPD, but these findings could provide implications for future practice.
 Resistance Training: Effects on COPD 7

Reference List

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2. COPD Statistics Across America. COPD Foundation.
http://www.copdfoundation.org/what-is-copd/copd-facts/statistics.aspx. Accessed
October 8, 2016.
3. Physical activity and exercise. My Lungs My Life.
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cycle/. Accessed October 8, 2016.
4. Janaudis-Ferreira T, Hill K, Goldstein RS, et al. Resistance Arm Training in Patients
With COPD. Chest. 2011;139(1):151-158. doi:10.1378/chest.10-1292.
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during resistance training and neuromuscular electrical stimulation (NMES) in patients
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doi:10.1016/j.rmed.2008.01.013.
8. Giavedoni S, Deans A, Mccaughey P, Drost E, Macnee W, Rabinovich RA.
Neuromuscular electrical stimulation prevents muscle function deterioration in
exacerbated COPD: A pilot study. Respiratory Medicine. 2012;106(10):1429-1434.
doi:10.1016/j.rmed.2012.05.005.
9. Pierson F. Principals and Techniques of Patient Care. 5th ed. Philadelphia , PA: F.A.
Davis; 2013.