Effectiveness of arm exercise on dyspnea in patients with chronic obstructive pulmonary disease: a systematic review

The aim of this systematic review was to examine the effect of arm exercise on exercise-related and usual dyspnea in patients with stable, moderate-to-severe chronic obstructive pulmonary disease. Dyspnea is a disabling symptom that is particularly troublesome when patients perform activities of daily living that involves using their arms.

We included any study where the effect of arm exercise could be isolated from other pulmonary rehabilitation strategies like whole body exercise, lower extremity training, and sham or control interventions. The participants were stable, moderate-to-severe patients with COPD, who were breathing without mechanical ventilation. The methods needed to include a measurement of exercise-related and/or chronic dyspnea.

We conducted an exhaustive, comprehensive search of the published and grey literature using a three-phase approach with no language or year of publication limits. We searched CINAHL and MEDLINE to identify all key words. Subsequently, we used a structured Boolean search of all relevant bibliographic and grey literature databases. Finally, we hand-searched the reference lists of included and other highly relevant, recent articles. Two independent investigators reviewed the search results to make the decision to retrieve studies for critical appraisal.

Two independent reviewers appraised all reports using standardized critical appraisal tools of the Joanna Briggs Institute, specific for the particular research design.

The search netted 269 unique reports; we appraised 18 studies and included 5 randomized controlled trials. Eleven studies were excluded because they were of poor methodological quality or because the effect of arm exercise could not be isolated. Two studies were not available from any library source. Arm exercise regimens varied but most included some type of low resistance, high repetition arm lift combinations. No findings could be pooled for meta-analysis. Only one study found significant improvements in exercise-related dyspnea but all studies were underpowered and many had significant dropout rates. These weaknesses may have masked some of the positive effects of arm exercise.

Arm exercise is safe but its effectiveness remains in question. Upper extremity training is theoretically sound but evidence from these low powered randomized controlled trials only suggests that it may be effective. If data can be pooled from future studies, this common rehabilitative practice may gain further empirical support.If clinicians integrate arm exercise into a program of pulmonary rehabilitation, one randomized controlled trial supported simple low resistance, high repetition training like ball and sand bag tossing and lifting weighted bars of wood with arms raised to the height of the shoulder or above. Patients should be supervised and intensity and duration of the arm exercises increased incrementally to symptom tolerance. Clinicians should monitor dyspnea during exercise and activities of daily living to assess clinical benefits. More research is necessary that uses reliable measurement of dyspnea and arm endurance. Investigators need to anticipate dropouts in this population, plan for intention-to-treat analyses and report data in a manner that will allow meta-analyses to pool smaller powered work in future studies.