March 9, 2009

Effect of Arm Exercise on Dyspnea in Patients with Chronic

Obstructive Pulmonary Disease:
A Systematic Review

Systematic Review Protocol

Table of Contents

Review Title 1
Centre Conducting the Review 1
Primary Reviewer 1
Secondary Reviewer 1
Reviewer Contacts 1
Background 1
Review Question/Objectives 2
Inclusion Criteria 2
Types of Studies 2
Types of Participants 3
Types of Interventions 3
Types of Outcomes 3
Search Strategy for Identification of Studies 3
Methods of the Review 4
Assessment of Methodological Quality 4
Data Extraction 5
Data Synthesis 5
Potential Conflict(s) of Interest 5
Acknowledgements 5
References 6
Appendix I – Conceptual Schema of Dyspnea in Patients with COPD 7
Appendix II – Critical Appraisal Checklist for Experimental Studies 8
Appendix III – Data Extraction Form for Experimental/Observational Studies 9
Systematic Review Title
Effectiveness of Arm Exercise on Dyspnea in Patients with Chronic Obstructive Pulmonary
Disease: A Systematic Review

Centre Conducting Review

Indiana Center for Evidence Based Nursing Practice

Purdue University Calumet, Indiana
United States of America

Primary Reviewer Secondary Reviewer

Lisa Hopp PhD, RN Jane Walker, PhD, RN
Telephone: +1 219.989.2823 Telephone: +1 219.989.2822
Facsimile: +1 219.989.2848 Facsimile: +
1 219.989.2848
Email: ljhopp@calumet.purdue.edu Email: walkerj@calumet.purdue.edu

Background
Chronic obstructive pulmonary disease (COPD) is a highly prevalent and progressive disease
associated with chronic symptoms and disability. In a recent update on the management of
COPD, Celli1 reported a global prevalence of COPD ranging from 7-19% with approximately
280 million cases worldwide. Since smoking causes nearly all COPD, its epidemiology parallels
the incidence and prevalence of tobacco use2. No cure exists for COPD and its symptoms
severely impact quality of life. Consequently, therapies are aimed at improving or delaying
progression of symptoms.
Dyspnea is one of the most debilitating aspects of COPD that leads to disability and poor quality
of life. It is the most common symptom that limits exercise capacity in these patients and the
most frequent reason that patients seek care and rehabilitation2.
The American and European Respiratory Societies2 defined dyspnea as “a subjective experience
of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity”.
Other terms associated with the sensation include breathlessness, shortness of breath and
increased breathing effort. Like pain, dyspnea is a combination of sensation and perception and
involves a complex combination of physiologic and psychological factors.
In recent years, COPD has been recognized as more than a pulmonary disease; in fact, it is a
multi-organ disease3. Investigators have focused on skeletal muscle dysfunction that contributes
to exercise intolerance and worsening dyspnea3. Evidence suggests that patients with COPD
may experience both peripheral muscle weakness and poor endurance, though the distribution
between upper and lower extremity dysfunction varies3. The etiologies of the poor muscle
function may include bioenergetics such as altered energy metabolism, oxygen transport and use,
inflammation and poor nutrition as well as deconditioning. Nonetheless, the exercise intolerance
and associated dyspnea may be remediable with rehabilitative therapies.3 While pharmacological

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therapies are aimed at optimizing airflow limitation and its associated symptoms, rehabilitative
efforts focus on improving the systemic, skeletal muscle consequences of COPD.
Patients with COPD frequently experience dyspnea during normal daily activities when they use
their upper extremities. These patients reported higher dyspnea scores and lower upper
extremity maximal power output compared with normal subjects during incremental arm
cranking4. During arm exercise, the etiology of the dyspnea may relate to dynamic
hyperinflation5 thoracoabdominal dyssynchrony, changes in ventilatory and postural muscle
recruitment and/or general peripheral muscle deconditioning (related to less use) with decreased
upper extremity strength and endurance in the face of increased ventilatory and metabolic
demands6. Furthermore, patients use their rib cage and shoulder muscles to simultaneously
stabilize their chest and as accessory muscles during tasks that require them to use their upper
extremities7. Thus the simple acts of daily living, such as combing their hair, reaching for and
carrying objects prove to be difficult and limited by dyspnea. Investigators suggest that arm
training may improve work effort and dynamic hyperinflation and subsequently dyspnea.
Furthermore, arm exercise may lead to greater upper extremity exercise capacity, reduced
ventilation and oxygen consumption during arm activity8.
Upper extremity training is a common element of pulmonary rehabilitation programs and is part
of clinical practice guidelines8. Training strategies vary but include endurance-type methods like
dowel lifting, arm cranking or ring placement as well as strength-type training lifting light
weights. Although there have been literature summaries of the effects of various pulmonary
rehabilitation interventions on dyspnea and other relevant outcomes to COPD9, no systematic
review about the effect of arm exercise exists in the Cochrane Library or other bibliographic
databases. Given the impact of dyspnea on activities of daily living and the quality of life in this
highly prevalent disease, a comprehensive systematic review will contribute to the understanding
of the effect of this treatment and identify the areas for further research.
Review Question/Objectives

The overall objective of this review is to determine the effect of arm exercise on dyspnea in
patients with chronic obstructive pulmonary disease (COPD).
The specific review question is as follows:
What is the effect of arm exercise on exercise-related and usual dyspnea in patients with stable
chronic obstructive pulmonary disease? The population of interest is patients with stable,
moderate-to-severe COPD who are breathing without mechanical assistance.
Inclusion Criteria
Types of Studies
We will consider any randomized controlled trial or well-designed controlled trial conducted
with stable moderate-to-severe COPD patients who are not acutely ill or breathing with
mechanical assistance. In the absence of RCTs, other research designs, single-group, before and
after studies, descriptive or observational studies will be considered for inclusion in a narrative
analysis in order to identify the best available evidence related to the effect of arm exercise on
dyspnea.

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Types of Participants
The review will include studies of adults with a diagnosis of stable moderate to very severe
chronic obstructive pulmonary disease. According to the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) and the American Thoracic/European Respiratory Society
Guidelines (ATS/ERS)1, the description of the severity of disease is as follows: stage II or
moderate disease is an FEV1 of 50-80% predicted; stage III or severe is an FEV1 of 30-50%
predicted and stage IV or very severe is an FEV1 <30% predicted. COPD includes patients with
chronic bronchitis and emphysema but not asthma.
Types of Interventions
The analytic and narrative component of the review will consider studies that tested any type of
arm exercise versus other types of exercise like lower extremity exercise alone or incombination
with arm exercise, sham exercise or no exercise. Arm exercise may include unsupported or
supported activities like dowel lifting, arm cranking or ring placement. Subgroup analysis of
supported and unsupported exercise is planned.
Types of Outcomes
Dyspnea is the primary outcome of interest. It may be labeled as dyspnea, breathlessness or
breathing effort. Therefore, the review will consider studies that include self-reported measures
of the following perceived sensations:
• exercise-related dyspnea, breathlessness or breathing effort
• usual or chronic dyspnea, breathlessness or breathing effort
Many studies will evaluate physiological outcomes that may mediate the sensation of dyspnea
such as upper extremity strength, endurance, breathing pattern, pulmonary volumes or
respiratory muscle function. This review will not include these complex outcomes or mediating
variables (see conceptualization in Appendix I) as the measurement strategies are heterogeneous
both in construct and methodology. In addition, measurement quality varies (Larson, 2006).
Finally, dyspnea, breathlessness or breathing effort is the patient-centered outcome that most
impacts the quality of life regardless of the mediating mechanism is most consistently measured.
Search Strategy for Identification of Studies
The comprehensive search strategy aims to find both published and unpublished studies from
1980-2009, published only in the English language. A three-step search strategy will be utilized
in each component of the review. An initial limited search of MEDLINE and CINAHL will be
undertaken followed by analysis of the text words contained in the title and abstract and the
index terms used to describe the article. A second search using all identified keywords and index
terms will then be undertaken across all included databases. Thirdly, the reference list of
identified reports and articles will be hand-searched for additional studies.

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The databases to be searched include:

CINAHL
The Cochrane Library
EBSCOHost Health Source: Nursing/Academic Edition

EMBASE
ISI Web of Science
MEDLINE

TRIP (Turning Research Into Practice)

BioMed Central

The search for unpublished studies will include:

Index to Theses
New York Academy of Medicine Grey Literature Report
AHRQ (Agency for Healthcare Research and Quality)
MEDNAR

World Health Organization Library (WHOLIT)

Initial keywords to be used will include:

Arm, upper extremity, upper limb, exercise, dyspnea, breathlessness, breathing effort, shortness
of breath, chronic obstructive lung disease, COPD, chronic airflow limitation, CAL, chronic
obstructive lung disease, COLD.

Example of MEDLINE Search:

1. Explode pulmonary disease, chronic obstructive
2. chronic obstructive pulmonary disease.mp. search as Keyword
3. Combine 1 OR 2
4. Explode arm
5. Explode upper extremity
6. upper extremity.mp. search as Keyword
7. upper limb.mp. search as Keyword
8. Combine 4 OR 5 OR 6 OR 7
9. Explode exercise OR exercise therapy
10. Explode dyspnea
11. Combine 8 AND 9 AND 10

Methods of the Review

Assessment of Methodological Quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological
validity prior to inclusion in the review using the Joanna Briggs Institute Critical Appraisal
Checklist for Experimental Studies (Appendix II), a standardized critical appraisal instrument.

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Any disagreements that arise between the reviewers will be resolved through discussion or in
consultation with a third reviewer.

Data Extraction
Data will be extracted from papers included in the review using standardized data extraction
tools. The Joanna Briggs Institute Data Extraction Form for Experimental/Observational Studies
(Appendix III) will be used.

Data extracted from intervention studies will include specific details about the sample
characteristics (age, pulmonary function), study design, specific intervention, and outcomes of
significance to the review question. Studies will be presented in a table and outcomes
synthesized using either meta-view and/or narrative.

Data Synthesis
Quantitative papers will, where possible, be pooled in statistical meta-analysis using the
Cochrane Collaboration’s RevMan Version 5. All results will be subject to double data entry.
Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their
95% confidence intervals will be calculated for analysis using a random effects model.
Heterogeneity will be assessed using the standard Chi-square test. Planned subgroup analysis
will include supported and unsupported arm exercise. Where statistical pooling is not possible
the findings will be presented in narrative form.

Potential Conflict(s) of Interest

No potential conflict of interest is anticipated.

Acknowledgements
Purdue University Calumet School of Nursing for support of the project.

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References

1. Celli, B. Update on the management of COPD. Chest. 2008; 133, 1451-1562.

2. American Thoracic Society (ATS). Dyspnea: Mechanisms, assessment, and management: A
consensus statement. Am J Respir Crit Care Med. 1999; 159, 321-340.
3. American Thoracic Society/European Respiratory Society (ATS/ERS). Skeletal muscle
dysfunction in chronic obstructive pulmonary disease: A statement of the American Thoracic
Society and the European Respiratory Society. Am J Respir Crit Care Med. 1999; 159, S1-
40.
4. Castagna, O., Boussuge, A.,Vallie, J.M., Prefaut, C. and Brisswalter, J. Is impairment similar
between arm and leg cranking exercise in COPD patients. Respiratory Medicine. 2007; 101,
547-553.
5. Gigliotti, F., Coli, C. Bianchi, R., Grazzini, M., Stendardi, L., Castellani, C. and Scano, G.
Arm exercise and hyperinflation in patients with COPD. Chest. 2005; 128, 1225-1232.
6. Couser, J.I., Martinez, F.J., and Celli, B.R. Respiratory response and ventilatory muscle
recruitment during arm elevation in normal subjects. Chest. 1992; 101, 336-340.
7. Larson, J.L. Development of an unsupported arm exercise test in patients with chronic
obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation. 2006; 26, 188-
190.
8. Ries, AL., Bauldoff, G.S., Carlin, B.W., Casaburi, R., Emery, C.F., Mahler, D.A., Make, B.,
Rochester, C.L., ZuWallack, R., and Herrerias, C. Pulmonary rehabilitation. Chest. 2007;
131, 4S-42S.
9. Hill, N.S. Pulmonary rehabilitation. Pro Am Thorac Soc. 2006; 3, 66-74.

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Appendix I

Conceptual Schema of Dyspnea in Patients with COPD

Arm exercises may improve dynamic hyperinflation, upper extremity endurance, load-capacity
imbalance and the mechanical disadvantage associated with dynamic hyperinflation.

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Appendix II
Critical Appraisal Checklist for Experimental Studies

Reviewer _________________________________________________ Date ______________

Author _________________________________________________ Year ________________

Record Number ____________________

Yes No Unclear N/A

1. Was the assignment to treatment groups random? □ □ □ □

2. Were participants blinded to treatment allocation? □ □ □ □

3. Was allocation to treatment groups concealed from □ □ □ □

the allocator?

4. Were the outcomes of people who withdrew □ □ □ □

described and included in the analysis?

5. Were those assessing outcomes blind to the □ □ □ □

treatment allocation?

6. Were the control and treatment groups comparable at entry? □ □ □ □

7. Were groups treated identically other than for the □ □ □ □

named interventions?

8. Were outcomes measured in the same way for all groups? □ □ □ □

9. Were outcomes measured in a reliable way? □ □ □ □

10. Was there adequate follow-up (>80%) □ □ □ □

11. Was appropriate statistical analysis used? □ □ □ □

Overall Appraisal: □ Include □ Exclude □ Seek further info.

Reviewer’s Comments (Including reasons for exclusion):

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Appendix III

Data Extraction Form for Experimental/Observational Studies

Reviewer _________________________________________________ Date ______________

Author _________________________________________________ Year ________________

Record Number ___________________

Study Method: □ RCT □ Quasi-RCT □ Longitudinal

□ Retrospective □ Observational □ Other

Participants:
Setting: _______________________________________________________________________

Population: ____________________________________________________________________

Sample size: ___________________________________________________________________

Intervention:
Intervention 1: _________________________________________________________________

Intervention 2: _________________________________________________________________

Intervention 3: _________________________________________________________________

Clinical Outcome Measures:

Outcome Description Scale/Measure

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Study Results:
Dichotomous Data

Outcome Intervention ( ) Intervention ( )

Number/Total Number Number/Total Number

Continuous Data

Outcome Intervention ( ) Intervention ( )

Mean and SD (Number) Mean and SD (Number)

Author’s Conclusions:
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Reviewer’s Comments:
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