Skeletal muscle dysfunction is one of the extrapulmonary symptoms of COPD leading to increased exercise intolerance and dyspnoea on exertion occurring mainly due to the muscle fibre atrophy and hyperinflation (Liao et.al., 2015; Kim et.al., 2008). Considering the severity of extrapulmonary symptoms there is a substantial need for the nonpharmacological interventions. The impact of resistance training (RT) has been analysed by many researchers and seems to be one of the most effective tools used in the management of COPD. Following the assessment of the severity of the disease and overall health status, it should be introduced as a crucial part of pulmonary rehabilitation. (Zanini et.al., 2015).

RT affects peripheral muscle strength, dyspnoea and exacerbation states amongst COPD patients. These aspects are consecutively reviewed on this page.

Peripheral muscle strength

The specific pulmonary rehabilitation (SPR) and usual pulmonary rehabilitation (UPR) have been compared by Zanini et.al. (2015) in order to access peripheral muscle strength in 60 individuals suffering from COPD. The responsiveness of three muscle strength tests was measured: sit-to-stand-test (STST) for 30 seconds, STST for 1 minute and 1 repetition maximum (1-RM) being the maximal weight that can be properly lifted for one repetition. These were subsequently used to assess the effect on the lower limbs muscles strength. SPR included 15 sessions with 7 resistance exercises each. Significant improvement has been noted in all free tests in the STR group leading to the conclusion that STR has bigger potential to induce peripheral muscle strength among COPD patients than UPR. It has also indicated overall increase in the strength of the muscles assessed. RT induced effects may therefore allow improvement in exercise tolerance among COPD patients (Seymour et.al., 2010).

 

Supporting evidence was provided by Vonabnk et.al. (2012) who conducted the 12-week study comparing three training groups: strength training (ST), endurance training (ET) and combined training (CT). Assessment of 1-RM was followed by 2 training sessions per week, each including 8 exercises: bench press, chest cross, shoulder press, pull downs, bicep curls, tricep extensions, sit-ups and leg press. Evaluation of the peripheral muscle strength has indicated significant improvement alongside with increase in maximum exercise capacity, surprisingly, at the similar level that was achieved in ET and CT groups. Muscle strength was measured in a very similar manner by Daabis et.al. (2017) before and after 8-week period of ST, ET and CT with 3 RT sessions per week. There was no significant improvement in exercise capacity contradicting the Vonbank’s conclusion, whereas the noticeable change in the muscle strength supported it.

The advantageous effects detected within these studies may occur not only due to peripheral muscle strength improvement, but also as a result of neural adaptations. Additionally, 1-RM which has been used as the strength indicator in all of these studies can result in patients’ muscles fatigue, making it impossible to assess their strength beforehand (Zanini et.al., 2015).

Dyspnoea and exacerbation 

Dyspnoea, known as shortness of breath, is another issue which patients suffering from moderate to severe COPD struggle with. Individuals with intolerable dyspnoea that may be unable to perform intense endurance training seem to tolerate RT better, as it leads to less fatigue and is relatively easy to perform. On top of that, RT was found to reduce overall occurrence of this symptom among all the patients (Daabis et.al., 2017). 

As stated by Rabe (2006), increased intensity of dyspnoea may be the indicator of the exacerbation. IGF-1, which is critical for the skeletal muscle maintenance and development, was found to be substantially decreased during exacerbations in the COPD patients’ serum (Kythreotis et.al). Similar results were obtained by Gupta et.al. alongside with decrease in dehydroepiandrosterone sulphate (DHEAS) and testosterone levels during both acute exacerbation and stable state. Interestingly, growth hormone, testosterone and IGF-1 were found to be elevated following the performance of resistance exercises leading to the assumption that RT may promote upregulation of these hormones (Kraemer et.al., 2005; Ye et.al., 2012). Therefore, RT should be taken into consideration as a nonpharmacological tool that allow counteracting the mechanisms associated with acute exacerbations by inducing secretion of the hormones strongly related to muscle hypertrophy. It is however unclear and needs further investigation if the RT is the only factor inducing increase in these anabolic hormones.

 

Training plan

According to Skumlien et.al. (2008) more studies are needed in order to assess if performing RT is leading to the improvement in ease of performing daily activities among COPD patients. Nevertheless, the choice of exercises to be performed by the patients should come from the desired goal of facilitating daily activities such as walking, climbing the stairs, reaching some objects, carrying shopping bags, etc. as recommended by Daabis et.al. (2017).  Multi-joint exercises such as deadlifts, static lunges and abdominal crunches were found to affect these activities by efficiently improving muscle strength, whereas single-joint exercises (shoulder raises, bicep curls) were useful to correct muscle imbalances (Zeng, et.al., 2018). 

Implementation of RT:

• Assessment of the severity of COPD, overall health and physical condition by GP and physiotherapist.
• Measurement of 1-RM as mentioned in the section: Peripheral muscle strength.
• Establishment of the workload: 50-80% of 1-RM (Skumlien et.al., 2008)
• Learning the proper technique and movement patterns.
• Implementation of resistance exercises (as shown in Table 1).

Table 1: Sets and repetition range for the multi-joint and single-joint resistance exercises across 1 week for the novice trainees suffering from COPD, as recommended by American College of Sports Medicine (2009).

Exercise	Sets	Repetition range
Deadlift	2	8-10
Static lunges	2	8-10
Shoulder raises	2	12-15
Bicep curls	2	12-15
Abdominal crunches	2	12-20

To be performed 3x/week. Each session: 5 minutes warm up on the treadmill prior to 5 resistance exercises, 2 minutes rest between each set and 3 minutes rest between each exercise (Skumlien et.al., 2008).

Resistance training  may lead to progressive decrease in exercise intolerance by targeting peripheral muscles strength and their functionality. This training modality has also proven to decrease an incidence and severity of other extrapulmonary symptoms of COPD. Nonetheless, in order for RT to be effective and feasible, it is crucial to introduce resistance exercises requiring small time investment and possibly minimising muscle fatigue. Combining RT with other physical activities and pharmacological treatment may result in improved quality of lives and decreased mortality of individuals suffering from COPD. 

Written by: Katarzyna Koscielecka (17801199)

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