The Clinical Respiratory Journal
ORIGINAL ARTICLE
Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial Andre Nyberg1, Britta Lindström1, Anette Rickenlund2,3 and Karin Wadell1,4 1 Department 2 Department 3 Department 4 Department
of of of of
Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
Abstract Background and Aims: High-repetitive resistance training (RT) is recommended to increase peripheral muscular endurance in healthy adults; however, the effects of RT with this design on exercise capacity and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD) is unknown. The study aimed to investigate if low-load/high-repetition elastic band RT could improve functional capacity, muscular function, endurance cycle capacity or HRQOL in patients with COPD. Methods: A prospective, randomized, controlled, multicentre trial was constructed with concealed allocation, blinded outcome assessment and intention-to-treat analysis. A total of 44 patients with moderate-to-very-severe COPD (forced expiratory volume during the first second, 44.6% predicted) were included. Patients were randomized to either the experimental group receiving 8 weeks of RT (three sessions/week) in combination with patient education (four occasions) or the control group receiving the patient education alone. Results: At post-tests, the between-group differences were in favor of the experimental group on the 6-min walk test [mean difference (95% confidence interval)]: 34 m (14–54) and the 6-min pegboard and ring test [20 rings (3–37)]. No difference between groups was found on the chronic respiratory disease questionnaire [0.1 (−0.2 to 0.4)]. On secondary outcomes, results were in favor of the experimental group regarding upper extremity endurance capacity, muscular function and depression, but no difference was seen between groups on endurance cycle capacity and HRQOL. Conclusion: RT can increase functional capacity and muscular function but not cycle endurance capacity and HRQOL in patients with moderate-to-severe COPD. Please cite this paper as: Nyberg A, Lindström B, Rickenlund A and Wadell K. Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial. Clin Respir J 2014; ••: ••–••. DOI:10.1111/crj.12141.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
Key words exercise – lower extremity – pulmonary disease, chronic obstructive – quality of life – resistance training – single limb – upper extremity Correspondence Andre Nyberg, MSc, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, 90187 Umeå, Sweden. Tel: +46 90 786 9089 Fax: +46 90 786 9267 email: [email protected] Received: 09 December 2013 Revision requested: 14 February 2014 Accepted: 04 April 2014 DOI:10.1111/crj.12141 Authorship and contributorship Mr Nyberg made substantial contributions to conception and design of the study, designing of the training program, performing tests and assessing outcome measures, performing and interpreting data analyses, writing the manuscript, and approving the final version of the manuscript. Dr Lindström made substantial contributions to conception and design of the study, providing critical revisions that are important for the intellectual content of the manuscript, helping write the manuscript, and approving the final version of the manuscript. Dr Rickenlund made substantial contributions to acquisition of data, analysis and interpretation of data, providing critical revisions that are important for the intellectual content of the manuscript, and approving the final version of the manuscript.
1
High repetitive resistance training in COPD
Dr Wadell, as primary investigator, made substantial contributions to conception and design of the study, interpreting data analyses, providing critical revisions that are important for the intellectual content of themanuscript, and by helping write the manuscript and approving the final version of the manuscript. Ethics The study was approved by the Regional Ethical Board, Umeå University, Umeå,
Nyberg et al.
Sweden (Dnr: 2010-344-31 M) performed in accordance to the Declaration of Helsinki. Written informed consent was obtained from all participants. Conflicts of interest Andre Nyberg has stated explicitly that there are no conflicts of interest in connection with this article. Britta Lindström has stated explicitly that there are no conflicts of interest in connection with this article. Anette Rickenlund stated explicitly that there are no
Introduction The presence of an impaired skeletal muscle function in patients with chronic obstructive pulmonary disease (COPD) is well known (1, 2). Both a decrease in peripheral muscular strength and endurance contributes to the muscular dysfunction that is strongly associated with exercise intolerance, one of the key features in the disease (3, 4). At a functional level, peripheral muscular weakness is considered a significant determinant of the reduced exercise capacity in COPD (2) and is present in all stages of the disease (5). As a consequence, the design of most previous studies on resistance training (RT) primarily focus on increasing muscular strength, i.e. high load and low number of repetitions (2, 6). However, the effects of RT with this design on lower extremity functional capacity, e.g. walking in COPD are small and there is currently no evidence to support the use of RT compared with a passive control for increasing walking in this group of patients (6). Because quadriceps muscular endurance has been shown to be associated to physical activity level and to be reduced to a larger extent in comparison with quadriceps strength (1, 4), the potential effect of a RT regimen on peripheral muscular endurance is of interest. Even though peripheral muscular endurance have been shown to be improved by low-load/highrepetition RT in healthy adults (7), little is known on the effects of RT with this design and its potential effect on walking capacity in patients with COPD. Moreover, in addition to walking, it is not clear whether changes in upper extremity functional capacity or healthrelated quality of life (HRQOL) could be achieved using this approach in patients with COPD. The limited availability to weight machines, the predominant choice of exercise equipment in RT, after completing a pulmonary rehabilitation program has highlighted the need to investigate alternate exercise equipment, such as elastic bands (6). However, to our knowledge, no study have used elastic resistance with
2
conflicts of interest in connection with this article. Karin Wadell has received financial support from the Swedish Research Council (Dnr:522-2009-2694), the Strategic Research Program in Care Sciences (223-654-10), the Medical Faculty of Umeå University (223-3357-09), the Swedish Heart and Lung Foundation (20110214), the Swedish Heart and Lung Association (E160/11), and the County Council of Västerbotten, Sweden. Clinical Trial Registration: Clinicaltrials.gov (NCT01354067)
focus on peripheral muscular endurance in patients with COPD. The aim of the study was to investigate if 8 weeks of low-load/high-repetition elastic band RT in addition to COPD-specific patient education (PE) improve walking capacity, upper extremity functional capacity, peripheral muscular endurance, endurance cycle capacity or HRQOL in patients with COPD compared with PE alone.
Materials and methods Study design A prospective, block, randomized, controlled, parallelgroup, multicentre trial was conducted with concealed allocation, blinded outcome assessment and intentionto-treat analysis. After baseline measurements and inclusion tests patients were randomly allocated into either the experimental (RT in combination to PE) or control group (PE alone). The design of the study prevented blinding of physiotherapists conducting RT and PE. To keep outcome assessment blinded, a second trained assessor was available during outcome assessment to step in if a patient revealed his/her group allocation at any process during the intervention. Further description of the study design and randomization procedure, including measurements taken to keep the allocation sequence concealed is available (8).
Patients Patients with COPD fulfilling the following inclusion criteria were considered eligible: ex-smoker, stable moderate-to-very-severe COPD (no exacerbations or change in medication within 4 weeks preceding start of intervention) (9, 10) and living
ORIGINAL ARTICLE
Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial Andre Nyberg1, Britta Lindström1, Anette Rickenlund2,3 and Karin Wadell1,4 1 Department 2 Department 3 Department 4 Department
of of of of
Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
Abstract Background and Aims: High-repetitive resistance training (RT) is recommended to increase peripheral muscular endurance in healthy adults; however, the effects of RT with this design on exercise capacity and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD) is unknown. The study aimed to investigate if low-load/high-repetition elastic band RT could improve functional capacity, muscular function, endurance cycle capacity or HRQOL in patients with COPD. Methods: A prospective, randomized, controlled, multicentre trial was constructed with concealed allocation, blinded outcome assessment and intention-to-treat analysis. A total of 44 patients with moderate-to-very-severe COPD (forced expiratory volume during the first second, 44.6% predicted) were included. Patients were randomized to either the experimental group receiving 8 weeks of RT (three sessions/week) in combination with patient education (four occasions) or the control group receiving the patient education alone. Results: At post-tests, the between-group differences were in favor of the experimental group on the 6-min walk test [mean difference (95% confidence interval)]: 34 m (14–54) and the 6-min pegboard and ring test [20 rings (3–37)]. No difference between groups was found on the chronic respiratory disease questionnaire [0.1 (−0.2 to 0.4)]. On secondary outcomes, results were in favor of the experimental group regarding upper extremity endurance capacity, muscular function and depression, but no difference was seen between groups on endurance cycle capacity and HRQOL. Conclusion: RT can increase functional capacity and muscular function but not cycle endurance capacity and HRQOL in patients with moderate-to-severe COPD. Please cite this paper as: Nyberg A, Lindström B, Rickenlund A and Wadell K. Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial. Clin Respir J 2014; ••: ••–••. DOI:10.1111/crj.12141.
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
Key words exercise – lower extremity – pulmonary disease, chronic obstructive – quality of life – resistance training – single limb – upper extremity Correspondence Andre Nyberg, MSc, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, 90187 Umeå, Sweden. Tel: +46 90 786 9089 Fax: +46 90 786 9267 email: [email protected] Received: 09 December 2013 Revision requested: 14 February 2014 Accepted: 04 April 2014 DOI:10.1111/crj.12141 Authorship and contributorship Mr Nyberg made substantial contributions to conception and design of the study, designing of the training program, performing tests and assessing outcome measures, performing and interpreting data analyses, writing the manuscript, and approving the final version of the manuscript. Dr Lindström made substantial contributions to conception and design of the study, providing critical revisions that are important for the intellectual content of the manuscript, helping write the manuscript, and approving the final version of the manuscript. Dr Rickenlund made substantial contributions to acquisition of data, analysis and interpretation of data, providing critical revisions that are important for the intellectual content of the manuscript, and approving the final version of the manuscript.
1
High repetitive resistance training in COPD
Dr Wadell, as primary investigator, made substantial contributions to conception and design of the study, interpreting data analyses, providing critical revisions that are important for the intellectual content of themanuscript, and by helping write the manuscript and approving the final version of the manuscript. Ethics The study was approved by the Regional Ethical Board, Umeå University, Umeå,
Nyberg et al.
Sweden (Dnr: 2010-344-31 M) performed in accordance to the Declaration of Helsinki. Written informed consent was obtained from all participants. Conflicts of interest Andre Nyberg has stated explicitly that there are no conflicts of interest in connection with this article. Britta Lindström has stated explicitly that there are no conflicts of interest in connection with this article. Anette Rickenlund stated explicitly that there are no
Introduction The presence of an impaired skeletal muscle function in patients with chronic obstructive pulmonary disease (COPD) is well known (1, 2). Both a decrease in peripheral muscular strength and endurance contributes to the muscular dysfunction that is strongly associated with exercise intolerance, one of the key features in the disease (3, 4). At a functional level, peripheral muscular weakness is considered a significant determinant of the reduced exercise capacity in COPD (2) and is present in all stages of the disease (5). As a consequence, the design of most previous studies on resistance training (RT) primarily focus on increasing muscular strength, i.e. high load and low number of repetitions (2, 6). However, the effects of RT with this design on lower extremity functional capacity, e.g. walking in COPD are small and there is currently no evidence to support the use of RT compared with a passive control for increasing walking in this group of patients (6). Because quadriceps muscular endurance has been shown to be associated to physical activity level and to be reduced to a larger extent in comparison with quadriceps strength (1, 4), the potential effect of a RT regimen on peripheral muscular endurance is of interest. Even though peripheral muscular endurance have been shown to be improved by low-load/highrepetition RT in healthy adults (7), little is known on the effects of RT with this design and its potential effect on walking capacity in patients with COPD. Moreover, in addition to walking, it is not clear whether changes in upper extremity functional capacity or healthrelated quality of life (HRQOL) could be achieved using this approach in patients with COPD. The limited availability to weight machines, the predominant choice of exercise equipment in RT, after completing a pulmonary rehabilitation program has highlighted the need to investigate alternate exercise equipment, such as elastic bands (6). However, to our knowledge, no study have used elastic resistance with
2
conflicts of interest in connection with this article. Karin Wadell has received financial support from the Swedish Research Council (Dnr:522-2009-2694), the Strategic Research Program in Care Sciences (223-654-10), the Medical Faculty of Umeå University (223-3357-09), the Swedish Heart and Lung Foundation (20110214), the Swedish Heart and Lung Association (E160/11), and the County Council of Västerbotten, Sweden. Clinical Trial Registration: Clinicaltrials.gov (NCT01354067)
focus on peripheral muscular endurance in patients with COPD. The aim of the study was to investigate if 8 weeks of low-load/high-repetition elastic band RT in addition to COPD-specific patient education (PE) improve walking capacity, upper extremity functional capacity, peripheral muscular endurance, endurance cycle capacity or HRQOL in patients with COPD compared with PE alone.
Materials and methods Study design A prospective, block, randomized, controlled, parallelgroup, multicentre trial was conducted with concealed allocation, blinded outcome assessment and intentionto-treat analysis. After baseline measurements and inclusion tests patients were randomly allocated into either the experimental (RT in combination to PE) or control group (PE alone). The design of the study prevented blinding of physiotherapists conducting RT and PE. To keep outcome assessment blinded, a second trained assessor was available during outcome assessment to step in if a patient revealed his/her group allocation at any process during the intervention. Further description of the study design and randomization procedure, including measurements taken to keep the allocation sequence concealed is available (8).
Patients Patients with COPD fulfilling the following inclusion criteria were considered eligible: ex-smoker, stable moderate-to-very-severe COPD (no exacerbations or change in medication within 4 weeks preceding start of intervention) (9, 10) and living
