Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore,

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the Candidate & Address / SUMAN SINGH
NO-8 3RD CROSS GANGAMMA LAYOUT GUDDADAHALLI HEBBAL R T NAGAR
BLR -560032
2 / Name of the Institution / KTG COLLEGE OF PHYSIOTHERAPY
3 / Course of study and subject / MASTER OF PHYSIOTHERAPY
(Physiotherapy in Cardio-Respiratory disorders and Intensive care)
4 / Date of admission to course / 16TH APRIL2012
5 / TITLE OF THE TOPIC
“THE EFFECTIVENESS OF HIGH-REPETITIVE SINGLE LIMB EXERCISES (HRSLE) ON EXERCISE CAPACITY AND QUALITY OF LIFE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)”
6 / Brief resume of the intended work:
6.1 Need for the study:
Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality in the world1. COPD was originally a disease more commonly seen in men, but now the disease affects men and women almost equally, as observed in international data2. Furthermore, women seem to be more sensitive to the negative effects of tobacco smoke, and develop very severe COPD to a larger extent compared to men3. Female COPD patients also demonstrate lower quality of life (QoL), more severe dyspnea and more sensitive airways than men with the same degree of airway obstruction4. Exercise intolerance is the key disabling factor in COPD, with decreased exercise capacity, increased leg fatigue and dyspnea among the most frequently reported symptoms5. Peripheral muscle weakness has been shown to contribute to exercise intolerance in COPD patients6. Nevertheless, Serres and colleagues7 argued that muscle weakness alone does not explain the decreased peripheral muscle performance seen in patients with COPD. Decreased capacity of local muscle endurance in both the upper and the lower limbs has been shown in COPD patients compared to healthy controls8.
Different training modalities have been evaluated to uncover the most effective way of training patients with COPD. The primary methods of exercise training within pulmonary rehabilitation have traditionally been different types of exercises incorporating a large amount of muscle mass. However, increased dyspnea during these whole body/large muscle mass exercises cause many COPD patients to stop exercising before their cardiovascular system or skeletal muscles are maximally stressed9. Training using a reduced muscle mass is a way of dealing with this issue. This has been found to achieve a higher metabolic rate due to less stress being placed on the respiratory system as ventilation is decreased compared to whole body exercises10. For example, three recent studies have shown positive effects of single limb training (SLT) (that is, one-legged cycling/knee extensor training) in patients with COPD11,12,13. Two of these studies11,12 focusing on one-legged cycling concluded that it was superior to two-legged cycling regarding aerobic capacity for COPD patients. Bjørgen and colleagues11 also demonstrated that the total amount of work was larger in the group working with one leg at a time compared to the group working with both legs simultaneously. This could be somewhat explained by an increased capacity of local muscle endurance due to increased oxygen uptake and increased maximal mitochondrial respiration in working muscles, as demonstrated in the one-legged knee extensor training study by Brønstad and colleagues13.
High-repetitive SLT (that is, exercising only one arm or one leg at a time) using elastic resistance bands on the upper and lower extremity muscles within an exercise regimen have previously been used with success in patients with chronic heart failure14. Elastic bands as resistance have also been used in patients with COPD15, however the concept of incorporating upper as well as lower extremity muscles within an SLT regimen has not been tested in patients with COPD. A goal-based multiple repetitions maximum (RM) test to obtain the accurate load using elastic bands has previously been used, though this is time consuming and could be anticipated to take between three and six attempts16,17 for each separate exercise.
There are no published studies investigating the effect of local high-repetitive single limb exercises in patients with COPD. In addition, because of the enhanced number of women affected by COPD2, a better understanding of the effects of training is of importance. Previous studies on SLT have only incorporated the leg muscles (quadriceps in particular)11,12,13. To be able to optimize training for all COPD patients while focusing on local muscle endurance, a study incorporating upper as well as lower extremity muscles is essential.
Hypothesis:
Experimental Hypothesis: High Repetitive Single Limb Exercises (HRSL) will have significant effect in improving the Exercise capacity and Quality of life in patients with Chronic Obstructive Pulmonary disease (COPD).
Null Hypothesis: High Repetitive Single Limb Exercises (HRSL) will not have significant effect in improving the Exercise capacity and Quality of life in patients with Chronic Obstructive Pulmonary disease (COPD).

6.2 Review of Literature:

Miranda EF et al., 2011 conducted a study on upper limb versus lower limb peripheral muscle dysfunction in patients with COPD.They documented that the degree of functional impairment appears to differ between the upper and lower limbs. Significant dyspnea and fatigue have been reported by these patients when performing tasks with unsupported upper limbs and two mechanisms have been proposed to explain this fact: neuromechanical dysfunction of respiratory muscles; and changes in lung volume during such activities. The neuromechanical dysfunction seen in COPD patients during this type of exercise is related to changes in the breathing pattern, as well as to the simultaneity of afferent and efferent muscle stimuli, resulting in respiratory muscle asynchrony. In addition, the increased ventilation during upper limb exercise in patients with COPD leads to dynamic hyperinflation at different workloads. During lower limb exercises, the strength and endurance of the quadriceps muscle is lower in COPD patients than in healthy subjects. This could by explained by abnormal muscle metabolism (decreased aerobic capacity), dependence on glycolytic metabolism, and rapid accumulation of lactate during exercise. In comparison with lower limb exercises, upper limb exercises result in higher metabolic and ventilatory demands, as well as in a more intense sensation of dyspnea and greater fatigue. Because there are differences between the upper and lower limb muscles in terms of the morphological and functional adaptations in COPD patients, specific protocols for strength training and endurance should be developed and tested for the corresponding muscle groups8.
Janaudis-Ferreira T et al.,2011 conducted a Randomized Controlled Trial. Resistance arm training in patients with COPD.The study aimed to evaluate the effect of upper extremity resistance training for patients with COPD on dyspnea during activity of daily living (ADL), arm function, arm exercise capacity, muscle strength, and health-related quality of life (HRQL).
Patients were randomly assigned to an intervention or control group. The intervention group underwent arm resistance training. The control group performed a sham. Both groups exercised three times a week for 6 weeks. Dyspnea during ADL and HRQL were measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Arm function and exercise capacity were measured using the 6-min pegboard and ring test (6PBRT) and the unsupported upper limb exercise test (UULEX), respectively. Muscle strength for the biceps, triceps, and anterior and middle deltoids was obtained using an isometric dynamometer.Thirty-six patients with COPD (66 ± 9 years) participated in the study. Compared with the control group, the magnitude of change in the intervention group was greater for the 6PBRT (P = .03), UULEX (P = .01), elbow flexion force (P = .01), elbow extension force (P = .02), shoulder flexion force (P = .029), and shoulder abduction force (P = .01). There was no between-group difference in dyspnea during ADL, HRQL, or symptoms during the 6PBRT or UULEX (all P values > .08).Resistance-based arm training improved arm function, arm exercise capacity, and muscle strength in patients with COPD. No improvement in dyspnea during ADL, HRQL, or symptoms was demonstrated18.
Costi S et al., 2009 conducted a randomized trial that consisted of 3 weeks of inpatient PR, comparing the short-term effects of unsupported UEET plus PR (intervention group) to those of PR alone (control group). A change in the 6-min ring test (6MRT) was the primary outcome; the ADL field test (four shuttle stations), the dyspnea score as assessed by the Medical Research Council scale, the London Chest Activity of Daily Living scale (LCADL), and the distance walked in 6 min served as secondary outcomes of the study. At the 6-month follow-up, we repeated the 6MRT and the LCADL.Fifty patients with COPD were randomly assigned to the two groups and completed the study. At the end of the study period, patients in the intervention group improved in the 6MRT and ADL field test compared with those patients in the control group (p = 0.018 and p = 0.010, respectively) with reduced perception of fatigue (p <or= 0.006). At the 6-month follow-up, 6MRT (p = 0.001) and LCADL (p = 0.039) scores were still significantly better in the intervention group compared with the control group.The trial corroborates the effectiveness of unsupported UEET in specifically improving functional exercise capacity of patients with COPD. Moreover, it also provides evidence that this training modality may ameliorate and maintain the patients' autonomy over and above standardPR19.
Bjorgen S et al., 2009 conducted a study on aerobic high intensity one and two legs interval cycling in chronic obstructive pulmonary disease.The purpose of this study was to investigate whether individual leg cycling could produce higher whole body peak oxygen uptake (VO(2peak)) than two legs cycling during aerobic high intensity interval training in chronic obstructive pulmonary disease (COPD) patients. Nineteen patients trained in 24 supervised cycling sessions either by one leg training (OLT) (n = 12) or by two legs training (TLT) (n = 7) at 4 x 4 min intervals at 85-95% of peak heart rate. Whole body VO(2peak) and peak work rate increased significantly by 12 and 23% in the OLT, and by 6 and 12% in the TLT from pre- to post-training, respectively, and were significantly greater in the OLT than the TLT (P < 0.05). The present study demonstrates that one leg aerobic high intensity interval cycling is superior to two legs in increasing whole body VO(2peak), indicating a muscle rather than a cardiovascular limitation to VO(2peak) in these COPD patients11.
Santiworakul A et al.,2009 investigated the effect of lower extremity exercise on maximum lower extremity muscle strength and physical capacity in COPD patients.Twenty moderate to very severe COPD patients were allocated into trained and control groups. The trained group received eight weeks of lower extremity functional exercise including forward step up, lateral step up, heel raise, and lunge at home. Maximum muscle strength and Six Minute Walk Distance (6MWD) assessments were performed at pre-training, week 4, and week 8 in hospital settings.There was no significant difference between trained and control groups in maximum muscle strength and 6MWD at the beginning of the program. However, there was a significant improvement in 6MWD after eight weeks of training, whereas there were no significant differences in the control group.They concluded that functional exercise may improve physical capacity in moderate to very severe COPD patients. It is beneficial and easy to perform at home20.
Houchen L et al., 2009 conducted a systemic review to examine whether the benefits from strength training are sustained after an initial training period in patients with chronic obstructive pulmonary disease (COPD).Criteria for inclusion in this review were that study participants had COPD and undertook an intervention that included strength training. A period of follow-up (>/=12 weeks) after strength training and a measure of muscle strength taken at this time were required. All experimental study designs were accepted, and the publication language had to be English. Reviews were excluded. The PEDro scale was used to assess the methodological quality of studies.Only three eligible studies were identified (PEDro scores ranged from 5 to 7). Two studies found that the benefits from strength training were still evidental at 12 weeks and 12 months after an initial 12-week and 6-month training period, respectively. The other study found no difference between the control and training groups 12 weeks after a 12-week training intervention. Only one study discussed continuation of strength training during the follow-up period. The results of these studies could not be pooled for meta-analysis, as the study interventions and assessments were heterogeneous. They concluded that despite an extensive search of the literature, only three articles were identified. Therefore, the long-term effects of strength training remain unknown. Further trials examining the sustainability of strength training with homogeneous populations, training programmes and assessments are warranted. This would enable the pooling of results for meta-analysis, and provide clearer recommendations to pulmonary rehabilitation practitioners5.
Stallberg B et al.,2009 validated the clinical COPD Questionnaire (CCQ) in primary care. The newly developed, short Clinical COPD Questionnaire, CCQ, was validated against the St George's Respiratory Questionnaire (SGRQ).111 patients diagnosed by general practitioners as having COPD completed the questionnaires twice, 2-3 months apart, without systematic changes in treatment. Within this sample of patients with "clinical COPD" a subgroup of patients with spirometry verified COPD was identified. All analyses was performed on both groups.The mean FEV1 (% predicted) was 58.1% for all patients with clinical COPD and 52.4% in the group with verified COPD (n = 83). Overall correlations between SGRQ and CCQ were strong for all patients with clinical COPD (0.84) and the verified COPD subgroup (0.82). The concordance intra-class correlation between SGRQ and CCQ was 0.91 (p < 0.05). Correlations between CCQ and SGRQ were moderate to good, regardless of COPD severity.
The CCQ is a valid and reliable instrument for assessments of health status on the group level in patients treated for COPD in primary care but its reliability may not be sufficient for the monitoring of individual patients21.
Dolmage TE et al., 2008 studied the effects of one-legged exercise training of patients with COPD.The purpose of this study was to determine whether one-legged exercise training would improve aerobic capacity compared with two-legged training in stable patients with COPD.Eighteen patients with COPD (mean FEV(1), 38 +/- 17% of predicted [+/- SD]) were randomized to two groups after completing an incremental exercise test. Both trained on a stationary cycle for 30 min, 3 d/wk, for 7 weeks. Two-legged trainers (n = 9) cycled continuously for 30 min, whereas one-legged trainers (n = 9) switched legs after 15 min. Intensity was set at the highest tolerated and increased with training.Both groups increased their training intensity (p < 0.001) and total work (p < 0.001). After training, the change in peak Vo2 of the one-legged group (0.189 L/min; confidence interval [CI], 0.089 to 0.290 L/min; p < 0.001) was greater than that of the two-legged group (0.006 L/min; CI, - 0.095 to 0.106 L/min; p = 0.91). This was accompanied by greater peak ventilation (4.4 L/min; CI, 1.8 to 7.1 L/min; p < 0.01) and lower submaximal heart rate (p < 0.05) and ventilation (p < 0.05) in the one-legged trained group.