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Assessing the effect of high-repetitive single limb exercises (HRSLE) on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD): study protocol for randomized controlled trial
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
2012 (English)In: TRIALS, ISSN 1745-6215, Vol. 13, 114- p.Article in journal (Refereed) Published
Abstract [en]

Background: Single-limb knee extension exercises have been found to be effective at improving lower extremity exercise capacity in patients with chronic obstructive pulmonary disease (COPD). Since the positive local physiological effects of exercise training only occur in the engaged muscle(s), should upper extremity muscles also be included to determine the effect of single limb exercises in COPD patients. Methods/design: Trial design: a prospective, assessor-blind, block randomized controlled, parallel-group multicenter trial. Participants: stage II-IV COPD patients, > 40 years of age, ex-smokers, with stable medical treatment will be included starting May 2011. Recruitment at three locations in Sweden. Interventions: 1) high-repetitive single limb exercise (HRSLE) training with elastic bands, 60 minutes, three times/week for 8 weeks combined with four sessions of 60 minutes patient education, or 2) the same patient education alone. Outcomes: Primary: determine the effects of HRSLE on local muscle endurance capacity (measured as meters walked during 6-minute walk test and rings moved on 6-minute ring and pegboard test) and quality of life (measured as change on the Swedish version of the Chronic Respiratory Disease Questionnaire). Secondary: effects on maximal strength, muscular endurance, dyspnea, self-efficacy, anxiety and depression. The relationship between changes in health-related variables and changes in exercise capacity, sex-related differences in training effects, feasibility of the program, strategies to determine adequate starting resistance and provide accurate resistance for each involved movement and the relationship between muscle fatigue and dyspnea in the different exercise tests will also be analyzed. Randomization: performed by a person independent of the recruitment process and using a computer random number generator. Stratification by center and gender with a 1: 1 allocation to the intervention or control using random block sizes. Blinding: all outcome assessors will be blinded to group assignment. Discussion: The results of this project will contribute to increase the body of knowledge regarding COPD and HRSLE.

Place, publisher, year, edition, pages
2012. Vol. 13, 114- p.
Keyword [en]
COPD; dyspnea; elastic resistance; exercise capacity; multicenter; quality of life; randomized controlled trial; single limb training
National Category
Medical and Health Sciences
URN: urn:nbn:se:umu:diva-60658DOI: 10.1186/1745-6215-13-114ISI: 000308893200001OAI: diva2:562826
Available from: 2012-10-26 Created: 2012-10-22 Last updated: 2014-04-29Bibliographically approved
In thesis
1. Single limb exercises in patients with chronic obstructive pulmonary disease: feasibility, methodology, effects and evidence
Open this publication in new window or tab >>Single limb exercises in patients with chronic obstructive pulmonary disease: feasibility, methodology, effects and evidence
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. COPD is a slowly progressive, inflammatory disease in the airways and lungs, caused mainly by smoking. The inflammation leads to a narrowing of the small airways (airway obstruction) and a destruction of tissue in the lungs. This gives a decreased expiratory airflow which leads to dyspnea, the primary symptom of the disease. The chronic airflow limitation also is associated with the development of limb muscle dysfunction. Decreases in both limb muscle strength and endurance have been shown which, in turn, is associated with exercise intolerance, one of the key disabling factors of the disease. Pulmonary rehabilitation including exercise training is the cornerstone of treatment and is strongly recommended. However, it is still unclear how to optimize exercise training for this group of patients. Also how to address the increase in dyspnea which limits the exercise stimulus, and how to assess muscular strength, need further study. Partitioning the exercising muscle mass, known as single limb exercises, is a novel exercise strategy aimed at reducing the negative consequences of chronic airflow limitation in patients with COPD.

The aim of this thesis was to study the current evidence of single limb approaches in patients with COPD, to examine the feasibility and effects of a high-repetitive single limb exercise (HRSLE) regimen in patients with COPD and to examine whether elastic resistance could be used to evaluate muscular strength.

This thesis is based on five papers. In order to study the evidence on single limb exercises, a systematic review of randomized controlled trials was performed. The review showed that single limb exercises, performed as one-legged cycling appeared to be more effective than two-legged cycling with regard to exercise capacity but not dyspnea, and might be included in exercise programs for patients with COPD (Paper I). Thirty healthy older women and men participated in a validation study comparing elastic resistance maximal strength with isokinetic dynamometry measurements. Excellent levels of agreement and no differences between the two pieces of equipment were found which indicates that elastic resistance could be used to evaluate muscular strength (Paper II). A study protocol was created for a randomized controlled trial designed to identify the effects of HRSLE in combination with COPD-specific patient training (experimental group) in comparison to patient information alone (control group) (Paper III). HRSLE was performed as resistance training, using a single limb at a time, elastic bands as resistance and a high number of repetitions (25 repetitions in 2 sets) with the aim of increasing limb muscle endurance. After eight weeks of exercise, the differences between the groups were in favor of the experimental group on lower- and upper-extremity functional capacity, upper-extremity endurance capacity and muscular function. No differences were seen between the groups on endurance-cycle capacity or health-related quality of life (Paper IV). In patients with COPD, the HRSLE regimen was considered feasible with a high attendance rate, excellent compliance and high relative exercise intensity. No severe adverse events occurred. The physiotherapists conducting the HRSLE in the clinical setting also found it to be feasible (Paper V).

This thesis shows that single limb exercises performed as one-legged cycling may be useful and effective for patients with COPD. Eight weeks of HRSLE was feasible and effective with regard to exercise capacity but without effect with regard to health-related quality of life. Elastic resistance could be used as exercise equipment to improve limb muscle function in patients with COPD and to evaluate muscular strength in healthy older adults.

Abstract [sv]

Kroniskt obstruktiv lungsjukdom (KOL) är idag ett stort globalt problem.  KOL är en långsamt fortskridande inflammatorisk sjukdom i luftvägar och lungor, i huvudsak orsakad av cigarrettrökning. Inflammationen leder till en förträngning i de små luftvägarna och förstör vävnaden i lungorna. Detta medför en luftvägsobstruktion där flödet av luft vid utandning är minskat, vilket bidrar till varierande grad av andnöd hos patienten. Luftvägsobstruktionen är relaterad till försämrad muskelfunktion hos patientgruppen. Både nedsatt muskulär styrka och uthållighet har påvisats vilket är relaterat till ett av huvudproblemen vid KOL; nedsatt förmåga till fysisk aktivitet och träning.  Lungrehabilitering inklusive fysisk träning är centralt i behandlingen och starkt rekommenderat. Det är dock inte fastställt hur patientgruppen skall träna för att optimera effekterna av träningen eller hur träningen bäst kan utvärderas. Det är också oklart hur man skall hantera den successivt ökande andfåddheten vid träning. Träning med en arm eller ett ben i taget, så kallad lokal muskelträning är en strategi som syftar till att minska andnöd under träning hos patienter med KOL

Syftet med denna avhandling var att undersöka vilken evidens det finns för lokal muskelträning hos patienter med KOL, utvärdera genomförbarhet och effekter av lokal högrepetitiv muskelträning utfört med elastiska träningsband hos patienter med KOL samt att undersöka ifall elastiska träningsband kan användas för att utvärdera muskelstyrka.

Avhandlingen består av fem delstudier. För att undersöka evidens för lokal muskelträning genomfördes en systematisk litteraturgranskning av randomiserade kontrollerade studier. Granskningen visade att lokal muskelträning, i form av cykling med ett ben i taget kan vara effektivt, avseende fysisk förmåga, men utan effekt avseende andfåddhet för patienter med KOL (delstudie 1). Trettio friska kvinnor och män, deltog i en valideringsstudie där jämförelser gjordes mellan maximal kraftutveckling utfört med elastiska träningsband och en isokinetisk dynamometer. Ett högt samband mellan de två metoderna och ingen skillnad i maximal kraft, indikerade att elastiska band kan användas för att utvärdera muskelstyrka (delstudie 2). Ett studieprotokoll skapades för en randomiserad kontrollerad studie, som syftade till att undersöka effekterna av lokal högrepetitiv muskelträning i kombination med KOL-specifik patientutbildning (interventionsgrupp) jämfört med enbart KOL-specifik patientutbildning (kontrollgrupp) (delstudie 3). Lokal högrepetitiv muskelträning utfördes i grupp med elastiska träningsband som redskap. Övningarna genomfördes med en arm eller ett ben i taget med 25 repetitioner i 2 set med syfte att påverka muskulaturens uthållighet. Efter åtta veckors träning hade interventionsgruppen bättre muskelfunktion i både övre och nedre extremitet samt en bättre funktionell förmåga jämfört med kontrollgruppen. Inga skillnader i effekt sågs mellan grupperna avseende uthållighet vid test på ergometercykel eller avseende hälsorelaterade utfallsmått, såsom livskvalitet och tilltro till sin egen förmåga (delstudie 4). För patienter med KOL, visade sig lokal högrepetitiv muskelträning vara en genomförbar metod avseende följsamhet och närvaro i träningen. De fysioterapeuter som ledde träningen i klinisk verksamhet ansåg att den var möjlig att genomföra med hög relativ intensitet och utan allvarliga biverkningar (delstudie 5).

Sammanfattningsvis visar denna avhandling att lokal muskelträning kan vara en användbar och effektiv metod för patienter med KOL. Åtta veckor med lokal högrepetitiv muskelträning är genomförbart och effektivt avseende fysisk förmåga hos dessa patienter. Elastiska träningsband kan användas som träningsredskap för att förbättra muskelfunktion hos patienter med KOL samt för att utvärdera muskelstyrka hos friska vuxna.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2014. 72 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1645
Chronic obstructive pulmonary disease, elastic resistance, exercise capacity, health-related quality of life, randomized controlled design, single limb exercises, systematic review, study protocol
National Category
urn:nbn:se:umu:diva-88024 (URN)978-91-7601-049-5 (ISBN)
Public defence
2014-05-23, Aulan, Vårdetarhuset, Umeå universitet, Umeå, 13:00 (Swedish)
Available from: 2014-04-30 Created: 2014-04-22 Last updated: 2014-06-13Bibliographically approved

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