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Evidence for single-limb exercises on exercise capacity, quality of life, and dyspnea in patients with chronic obstructive pulmonary disease or chronic heart failure
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.
2013 (English)In: Physical Therapy Reviews, ISSN 1083-3196, E-ISSN 1743-288X, Vol. 18, no 3, 157-172 p.Article in journal (Refereed) Published
Abstract [en]

Background: Although single-limb exercise (SLE) has been used for patients with chronic obstructive pulmonary disease (COPD) and for patients with chronic heart failure (CHF), the evidence for SLE has not been evaluated systematically and remains unclear.

Objectives: Determine the evidence for the effect of SLE compared to any comparator on outcome measurements for exercise capacity, quality of life (QoL) or dyspnea in patients with COPD or CHF.

Methods: PubMed, PEDro, and CENTRAL databases were searched from inception until 31 May 2011. Searches started 1 April 2011. English language randomized controlled trials (RCTs) were included. Extraction of data was performed by two review authors. Data and evidence for SLE were summarized in accordance with grading of recommendations assessment, development and evaluation (GRADE) guidelines. Authors of included studies were contacted for missing data.

Results: Six RCTs (two COPD and four CHF) were included. Low to very low-quality evidence indicates that SLE significantly improved exercise capacity, but not dyspnea, in patients with COPD, and significantly improved exercise capacity outcomes compared to a control in patients with CHF. However, when SLE was compared to non-SLE regimes in patients with CHF, positive effects were found irrespective of training regime regarding exercise capacity and QoL.

Conclusions: SLE appears to be effective in both conditions especially regarding exercise capacity, and might be included in exercise programs in patients with COPD or CHF. However, the evidence is low to very low according to GRADE and more clinical studies of high quality are required.

Place, publisher, year, edition, pages
2013. Vol. 18, no 3, 157-172 p.
Keyword [en]
Chronic heart failure; Chronic obstructive pulmonary disease; Evidence; GRADE; Single limb exercises
National Category
URN: urn:nbn:se:umu:diva-80246DOI: 10.1179/1743288X13Y.0000000072OAI: diva2:647815
Available from: 2013-09-12 Created: 2013-09-12 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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