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DOI: 10.14529/hsm170207
EFFECT OF AN INSPIRATORY MUSCLE STRENGTH TRAINING ON DYSPNOEA ARISING FROM UNSUPPORTED ARM ELEVATION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Mazin Hadi Kzar, [email protected], Ammar H. Hadi, [email protected] Hillah, 51001, Iraq
Aim. Present study aimed to identify the effect of an inspiratory muscle strength training program versus sham inspiratory muscle strength training program on the dyspnoea arising from unsupported arm elevation in COPD patients. Materials and Methods. Forty four COPD patients (U-40 to U-50) and with severe COPD (FEV1 = 50-70 % of predicted) were recruited and assigned to an experimental (EXP) or control group (CON). The training program consisted of 5 sessions/wk, (6 x 3 minute bouts of loaded breathing with 2 minutes rest periods between bouts) during 10 wk. Results. The outcome measured included airway obstruction (FEV1, FVC, FEV1/FVC, and PEFR), inspiratory muscle strength (maximal inspiratory pressure (PI, max)), and exercise capacity (six minute walk distance test (6MWDT)). Our inspiratory muscle strength training program improves of all parameters of the EXP, but no significant improve is at the level of FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) after sham inspiratory muscle strength training program for CON. FEV1 before training for EXP was (54,81 ± 3,53) and after training improved into (70,87 ± 1,54) while for CON was (77,81 ± 6,00) before training and (77,93 ± 5,8) after training. Conclusion. Our study found that SIMT by using threshold loading device resulted in improve pulmonary function indices and then alleviate symptoms and improve UAE performance, in addition to develop dyspnoea. Therefore, S-SIMT didn't lead to develop breathing symptoms, pulmonary function, and accessory muscles strength then effected on arm elevation.
Keywords: inspiratory muscle strength training, dyspnoea, unsupported arm elevation, chronic obstructive pulmonary disease.
1. Introduction
Approximately 47,800 Iraqis (males and females) have some form of COPD [43]. COPD is characterised by narrowed airways and significant inspiratory muscle atrophy [23]. Patients breathe at high lung volumes to maintain patency of their narrowed airways and are forced to generate greater pressures to overcome elastic recoil of the hyper inflated respiratory system [5]. In such breathing patterns, the diaphragm operates at a disadvantageous part of its length-tension curve [8, 29] and the pressure generating capacity of the flattened diaphragm is severely compromised [15]. From a theoretical perspective it is clear that any further hindrance to inspiration is likely to result in dyspnoea in COPD patients. In support of this, it has been shown that during exercise, diaphragm work is increased in COPD [21] and COPD patients use a larger proportion of their maximal inspiratory pressure (PI, max) than
healthy subjects at a given sub-maximal workload [1, 48].
This pattern of breathing is closely related to the dyspnoea sensation during exercise and may induce inspiratory muscle fatigue [4, 11]. This largely explains the reduced exercise capacity observed in COPD patients [31, 51]. Given the considerable work performed by the diaphragm at rest and particularly during exercise, the accessory inspiratory muscles are believed to play an important role in breathing in COPD patients. Previous studies have reported that unsupported arm elevation (UAE) can produce severe dyspnoea in COPD patients [50, 53]. Considering UAE is integral to many normal daily functions, for example hanging out the washing, shaving, brushing teeth and combing hair, dyspnoea arising from these activities can significantly impair quality of life in COPD patients.
Inspiratory muscle strength training (SIMT)
methods are used to improve inspiratory muscle atrophy and reduce dyspnoea in COPD patients [18]. SIMT protocols typically involve a high load with little repetitions (5-6 days a week, 15-30 minute at day, 4-12 weeks and training loads are 50-80 % of PI, max) [66, 17]. To examine the efficacy of SIMT, it is recommended that controls participate in sham-inspiratory strength training (S-SIMT) as it is suggested to provide the least biased estimates of treatment effects (Puhan and Schu'nemann, 2009). S-SIMT protocols are the same as SIMT except the load is maintained at 10 % of PI, max [26, 58].
A recent systematic review [25] has shown few changes in quality of life, six minute walk, functional exercise capacity and MIP in the group who received IMT compared with the sham group which did not have a significant effect. Some other studies showed a 6 minute walk was improved after limb muscle strength training in COPD patients [47] 6 Minute Walk also is considered a good predictor for dyspnoea after training by another studies [42, 63]. In contrast, no study into the effects of SIMT with UAE on FVC, FEV1, FEV1/ FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) has been conducted in COPD patients. In addition, no study has compared effects between SIMT and sham-SIMT with UAE on previous parameters in COPD patients. Just studies which were used IMT to improve SIMT, endurance IMT, dyspnoea and some other symptoms such (VO2 max, VE max and functional capacity). However, these results have not been enough to improve quality of life for patients with COPD and improve the impaired accessory inspiratory muscles which are responsible increasing dyspnoea in COPD patients [13]. It is also worth noting the time consuming nature of endurance training sessions which contrasts with the brief bouts of maximal contractions that can confer optimal gains in muscle strength [54, 67].
The most appropriate SIMT protocol to reduce dyspnoea during UAE, and improve exercise capacity remains unclear. Indeed, the most recent ACCP/AACVPR Pulmonary Rehabilitation Guidelines conclude that "the scientific evidence does not support the routine use of IMT as an essential component of pulmonary rehabilitation" and calls for a large-scale, multicentre randomised controlled trial (RCT) be performed with appropriate statistical power to more completely examine the role of IMT in treating patients with COPD [28, 30, 33]. However, the main aim of our study is to know the effects of SIMT vs S-SIMT on the dyspnoea arising from UAE in COPD patients.
2. Materials and Methods
2.1. Participants
The number of participants required for this study was calculated to be 44, based on the prevalence of moderate to severe COPD in Babylon, Iraq (n = 2400) [63], an effect size of 10 % ± SD 5 % and the power of the sample size calculation (0,80, C.I. = 20 % and P < 0,05). The effect size was estimated from previous studies that have reported a mean effect size of 0,73 for changes in PI, max, 0,20 for changes in six minute walk, 0,46 for changes in visual analog scale (VAS) [25, 37, 46]. Table 1 showed physical and pulmonary function characteristics in COPD subjects.
Participants recruited on the basis of age, sex, COPD severity, existing co-morbidities and treatment/management practices. The prevalence of COPD differs marginally between males and females in Iraq; however it does increase with age. The severity of COPD is typically classified/diagnosed by the percentage reduction in predicted FEV1, with dyspnoea most prominent in severe COPD patients (FEV1 = 50-70 %) [34]. Therefore, we intend to recruit 44 patients between the ages 40-50 years old with severe COPD (FEV1 = 50-70 % of predicted). Previous studies investigating the benefits of inspiratory
Table 1
Physical and pulmonary function characteristics in COPD subjects
Characteristics Mean SD Median Skewness coefficient
Age, Yr 43,13 4,02 45,00 0,54
Height, Cm 164,00 7,41 166,00 0,47
Weight, Kg 75,03 5,23 77,00 0,51
Duration of Disease, Mh 18,02 3,16 19,00 0,32
FEV1 % Pred 52,11 4,53 54,00 0,41
Duration of Smoking, Yr 14,14 2,52 15,00 0,53
BMI, Kg 27,8 3,14 25,00 0,44
Table 2
The equal between both groups in physical and pulmonary function characteristics
Characteristics Experiment Control T-test Significant
Mean SD Mean SD Calculated Sig
FVC % pred 77,86 9,04 77,92 9,05 0,43 0,37 No S
FEV1 % pred 52,82 3,43 52,94 3,82 1,02 0,43 No S
FEV1/FVC % pred 67,37 4,05 67,5 4,22 0,596 0,59 No S
PEFR % pred 38,25 7,63 38,31 6,92 0,318 0,61 No S
6MWDT Meter 305,9 26,81 306,4 26,41 1,32 0,18 No S
SpO2 before 6MWDT % pred 94,50 1,76 94,62 1,91 0,59 0,39 No S
SpO2 after 6MWDT % pred 93,62 2,27 93,81 2,20 1,24 0,47 No S
PI, max cm H20 47,00 3,08 47,06 4,07 0,52 0,45 No S
VAS Degree 6,71 1,61 6,46 1,68 1,03 0,60 No S
muscle training have used similar cohorts [6, 32, 35, 36, 64].
Table 1 shows that participants were homogeneous in our study characteristics because all skewness coefficient values are between (-1 to +1).
Researcher divided participants into two groups (experiment and control groups), each group involved (22) patients and to achieve the equal between groups we used independent samples T-test and the results are shown in table 2.
Table 2 shows that T-test values greater than (0,05) which mean no significant differences between both groups in physical and pulmonary ffunction characteristics. However, both groups are equal.
2.2. Exclusion criteria
Patients dependent on supplemental oxygen therapy are excluded, as it has been shown that long-term oxygen therapy of hypoxemic COPD patients with chronic respiratory failure can improve exercise capacity, survival, sleep, dyspnoea, PI, max and quality of life [2, 49, 61, 62]. Additionally, patients diagnosed as asthmatic, suffering acute or chronic heart failure (hypoxe-mia, hypercapnia, right heart failure and left ventricular systolic dysfunction, etc), or suffering hayfever, chronic sinusitis and pneumoconiosis were not eligible for inclusion in this study. Only those who meet strict inclusion criteria invited to participate in the study. Twenty two, healthy, age and sex matched controls recruited to participate in baseline testing measures.
Patients with severe COPD recruited for the study from a Moijan hospital. The patients were all new to an SIMT program and patients unable to complete a program of SIMT did not recruit. Our institutional ethics board approved all protocols and all the patients gave their informed consent prior to participating in the study.
2.3. Outcome Measures
2.3.1. Airway Obstruction
FEV1, FVC, FEV1/FVC, and PEFR used to assess the severity of airway obstruction. A spi-rometer [10] used to measure FEV1, FVC, FEV1/FVC, and PEFR. The spirometer is a simple test and an essential tool in the diagnoses of airway obstruction. Variability of spirometric measurements is greater than in most other clinical laboratory tests because the result is highly dependent on the consistency of the efforts made by patients and technicians [14, 65]. In addition, American thoracic society recommends the use of FEV1, FVC, FEV1/FVC, and PEFR to diagnose the severity of airway obstruction to detect COPD in patients [3].
Testing Procedures:
- Pre-test instructions: Participants asked not to smoke or drink tea or coffee on the morning of the measurements.
- Testing instructions: FEV1, FVC, FEV1/FVC, and PEFR assessed under 1 condition: seated with unsupported arm elevation (UAE). Patients instructed to breathe in fully, seal their lips around the mouthpiece, force the air out of the chest as hard and fast as they can until their lungs are completely "empty" and breathe in again and relax. Exhalation must continue until no more air can be exhaled, must be at least 6 seconds, and can take up to 15 seconds or more [10]. Three trials conducted using a computerized spirometer and the best trial recorded.
2.3.2. Severity of Dyspnoea
A visual analogue scale (VAS) [16, 68, 5] used to quantify the severity and progression of dyspnoea. The VAS is a 100 mm scale with severity descriptors, such as "no change in breath-lessness" and "great breathlessness" which correspond to markings along the scale [16]. The VAS is simple to administer and has been found to be
a valid measure of the intensity of breathlessness [5], reliable over short periods of time, sensitive to change, and correlates with minute ventilation and oxygen consumption during exercise in subjects with COPD [40, 41]. For example, a difference of one point on the VAS has clinical significance [60]. Furthermore, the VAS is a widely used tool for quantifying dyspnoea during exercise testing in patients with chronic obstructive pulmonary disease (COPD) [45].
Testing Procedure:
- Pre-test instructions: Participants asked not to smoke or drink tea or coffee on the morning of the measurements.
- Testing instructions: Dyspnoea assessed under 1 condition: seated with unsupported arm elevation (UAE). Subjects asked to breathe at a rate and depth that would be most comfortable to them and such that they can maintain the breathing pattern for at least 10-15 min. the participant sit on the chair with their arms flexed to 90° without any additional support (UAE) for a period of 3 minutes. Every minute, the subject will be asked to rate breathlessness on the VAS by pointing to the value corresponding to their most relevant descriptor of breathlessness [46].
2.3.3. Inspiratory Muscle Strength
Maximal inspiratory pressure (PI, max) assessed as a measure of inspiratory muscle strength. It is validity and reliability to measure PI, max [13]. A (Model MP-45, Validyne Corp, North-ridge, California, USA) pressure transducer used to measure airway pressures which connects into PowerLab (ML848/ 426-0341, AD Instruments, Australia). A tube type mouthpiece connected to a pressure transducer by 60 cm of pressure tubing. And an air leak provided at mouthpiece with a small hole (diameter = 1,6 mm) to minimize the contribution of ducal muscles during the maneuver. Using a pressure transducer to measure relaxed airway pressure (mouth pressure) is the most valid and reliable way [6].
Testing Procedure:
- Pre-test instructions: Participants asked not to smoke or drink tea or coffee on the morning of the measurements.
- Testing instructions: Maximal inspiratory pressure assessed under 1 condition: Subjects seated with their arms flexed to 90° without any additional support (UAE) asked to perform 2 sets of five PI, max maneuvers with 1 minute rest between maneuvers and 5 minutes rest between sets. The inspiratory pressure measured at the mouth from residual volume to total lung capacity.
The PI, max defined as the trial with the largest negative and positive pressure respectively, sustained for 1 second against an occluded airway [13]. The procedure then repeated.
2.3.4. Exercise Capacity
The six minute walk distance test (6MWDT) used to assess exercise capacity. The 6MWDT is a reliable and safe tool to assess the functional status of patients suffering from pulmonary diseases [20] and has previously been used to as an outcome measure to determine the effectiveness of treatment for patients with COPD [20]. It is also commonly used to evaluate breathlessness during walking [12]. The 6MWDT performed in accordance with the standard protocol provided by Guyatt and his colleagues (1985). The distance the patient was able to walk in 6 min determined in a measured corridor as described for the 6-min walk test by [27].
Testing Procedure:
- Pre-test instructions: Participants asked not to smoke or drink tea or coffee on the morning of the measurements.
- Testing instructions: Participants commenced a 6MWD test. Participants instructed to walk at their fastest pace and cover the longest possible distance in 6 minutes. The test performed just once. At the beginning of the test and immediately after the sixth minute, SpO2 was assessed by use Pulse Oximeter device.
Inspiratory Muscle Strength
Training Procedures
Participants with COPD randomized into two SIMT groups. Participants attended a 1 hour familiarization session where the specific training protocol instructed and the necessary training equipment and exercise adherence diary distributed. Two groups completed a 30 minute training protocol using the same inspiratory muscle strength training device (occluded airway device that allows variable loading), five days per week for 10 consecutive weeks. Training completed by myself in the lap of Morjan hospital. The specific training protocol slightly differ for each group as follows.
Group 1 - SIMT with UAE: The participant remains seated with arms rose to 90 degrees flexion (UAE) and completes 6 x 3 minute bouts of loaded breathing with 2 minute rest periods between bouts. The patients breathed against a load equivalent to 50-70 % of their baseline PI, max. The starting load was 50 % in week 1, 2, 3 and 4. Then, the load increased up to 55 % in week 5, 6, 7 and 8. In last 2 weeks, the load increased up to 60 %.
Group 2 - S-SIMT with UAE: The participant remains seated with arms rose to 90 degrees flexion (UAE) and completes 6 x 3 minute bouts of low-unloaded breathing with 2 minute rest periods between bouts. Patients breathed against a load equivalent to 10 % of their baseline PI, max throughout the 10 week period.
2.4. Data Analysis
We choose FVC, FEV1, FEV1/ FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) at baseline tests post training. We compared between improvements in FVC, FEV1, FEV1/ FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) that can be achieved and sustained during 10 weeks program of SIMT with UAE vs sham-SIMT. On theoretical grounds, it seems plausible that inspiratory muscle strength training should improve PI, max and alleviate the dyspnoea during UAE in COPD patients, regardless of whether such dyspnoea is due to impaired mechanical action of the accessory inspiratory muscles, stiffening of the ribcage or weight bearing load on the ribcage.
3. Results and Discussion
3.1. Results
Through the functional and physical measurements of participants (Table 2), no statistical differences were noted between the 2 groups for the above variables: FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) (P > 0,05). The T-test allowed us to conclude that the two groups SIMT and S-SIMT have similar dyspnoea.
The differences in the FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) values of the experiment and control groups of our population before versus after training program are summarized in Table 3 and 4. In experiment group, the FVC increase is significant; it is of the order of 77,86 ± 9,04 and 85,18 ± 3,31 (% Pred), respectively (P < 0,05), while it is only 77,81 ± ± 6,00 and 77,93 ± 5,8 (% Pred) in control group (P > 0,05).
Similarly, the FEV1, FEV1/FVC, PEFR, SpO2 before 6MWDT and SpO2 after 6MWDT, PI, max, and dyspnoea VAS increase is more
Table 3
FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) before versus after training program of experiment group
Parameters Before After T-test Significant
Mean SD Mean SD Calculated Sig
FVC % pred 79,87 9,04 84,18 3,31 3,31 0,005 S
FEV1 % pred 54,81 3,53 70,87 1,54 16,07 0,000 S
FEV1/FVC % pred 69,37 5,05 86,37 2,62 14,9 0,000 S
PEFR % pred 38,25 7,63 87,75 3,27 20,6 0,000 S
6MWDT Meter 326,9 28,91 490,3 44,28 10,48 0.000 S
SpO2 before 6MWDT % pred 94,5 1,75 96,87 0,71 5,32 0.000 S
SpO2 after 6MWDT % pred 93,62 2,47 95,68 1,35 3,84 0,02 S
PI, max cm H2O 47,00 4,08 48,25 4,38 2,26 0,04 S
VAS Degree 6,51 1,60 4,57 1,02 3,91 0,001 S
Table 4
FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) before versus after training program of control group
Parameters Before After T-test Significant
Mean SD Mean SD Calculated Sig
FVC % pred 77,81 6,00 77,93 5,8 1,00 0,33 No S
FEV1 % pred 55,63 3,3 59,00 7,30 1,50 0,15 No S
FEV1/FVC % pred 69,19 5,90 73,5 6,14 12,02 0,16 No S
PEFR % pred 44,18 8,47 41,37 4,68 1,24 0,23 No S
6MWDT Meter 304,6 25,65 318,0 21,97 0,605 0,55 No S
SpO2 before 6MWDT % pred 95,18 2,48 94,87 2,24 0,96 0,35 No S
SpO2 after 6MWDT % pred 93,18 2,90 93,25 2,56 0,293 0,771 No S
PI, max cm H2O 44,75 4,53 44,18 4,27 1,37 0,18 No S
VAS Degree 7,75 1,34 7,50 1,09 1,29 0,21 No S
pronounced in the experimental group compared to that of control group. In the experimental group it is, respectively, before training 54,81 ± ± 3,53, 69,37 ± 5,05, 38,25 ± 7,63; 326,9 ± 28,91, 94,5 ± 1,75; 93,62 ± 2,47 (% Pred); 47,00 ± 4,08 (cm H2O), and 6,51 ± 1.60 (Degree) (P < 0.05), and after training 70,87 ± 1,54, 86,37 ± 2,62, 87,75 ± 3,27, 490,3 ± 44,28, 96,87 ± 0,71, 95,68 ± ± 1,35 (% Pred); 48,25 ± 4,38 (cm H2O), and 4,57 ± 1,02 (Degree) (P < 0.05). In control group increase is before training only 77,81 ± 6,00, 55,63 ± 3,3, 69,19 ± 5,90, 44,18 ± 8,47, 304,6 ± ± 25,65, 95,18 ± 2,48, 93,18 ± 2,90 (% Pred); 44,75 ± 4,53 (cm H2O), and 7,75 ± 1,34 (Degree) (P < 0,05), while after training is only 77,93 ± ± 5,8, 59,00 ± 7,30, 73,5 ± 6,14, 41,37 ± 4,68, 318,0 ± 21,97, 94,87 ± 2,24, 93,25 ± 2,56 (% Pred), 44,18 ± 4,27 (cm H2O), 7,50 ± 1,09 (Degree) (P < 0,05). No significant increase is noticeable in control group compared to experiment group.
Before training, all our parameters were significantly similar in the two groups. FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS), Table 3 shows significant differences between before and after training (P < 0,005).
Our SIMT program improves of all parameters in the experimental group, but no significant improve is at the level of FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI, max, and dyspnoea (VAS) after S-SIMT.
3.2. Discussion
This study measured the effects of inspirato-ry muscle strength training (SIMT) vs sham in-spiratory muscle strength training (S-SIMT) on the dyspnoea arising from unsupported arm elevation in COPD subjects. The findings of this study revealed that in the experimental group, the FVC, FEV1, FEV1/FVC, PEFR, 6MWDT, SpO2 before and after 6MWDT, PI,max, and dyspnoea (VAS) significantly increased. In the control group, there was no significant difference between before and after training in all study parameters which mentioned above.
Very little researches into the effects of in-spiratory muscle strength training have been conducted in COPD patients. When comparing the relative merits of strength versus inspiratory muscle endurance training. Our founding agreement with founding of [9] showed that inspirato-ry muscle strength training uses to improve muscle strength and maximal sustainable ventilation capacity or maximal voluntary ventilation. Mador
et al. [39] found when added strength training to an endurance exercise program can produce significant improvements in muscle strength in patients with COPD but does not in quality of Life and maximal exercise capacity because the improvement in muscle strength was not large enough.
Recently studies have used threshold loading, maximal sustained voluntary ventilation and in-spiratory resistive breathing techniques to improve the respiratory muscle endurance and strength training and then quality of life in patients with COPD [52]. The result studies were different, [52] using targeted inspiratory resistive and threshold training to improve respiratory muscles in COPD patients. In addition, [24] showed that training using threshold loading improves significantly inspiratory muscle endurance but not muscle strength. In contrast, Weiner and colleagues (1992) found that training for 6 months by using threshold loading improves inspiratory muscle endurance and strength. Our results confirm that SIMT by using threshold loading device during UAE lead to improve breathing muscles strength and pulmonary function as well as dyspnea.
To my personal knowledge, the different results for these studies to improve dyspnoea and quality of life by using inspiratory muscle endurance and strength training are due to small attention to training intensity, study design, outcome measures and statistical power that will help to provide better guidance regarding the role of in-spiratory muscle training in pulmonary rehabilitation programs. However, it shows that no study used inspiratory muscle strength training by threshold pressure device during UAE to improve accessory inspiratory muscles, severity of dyspnoea and then quality of life in COPD patients. Our study compared between two kinds of training with UAE such as moderate intensity and low intensity, we found that moderate intensity results in improve accessory inspiratory muscles, severity of dyspnoea and then quality of life in COPD patients, but we couldn't find that with low intensity training.
Clinical studies have shown that inspiratory muscle training with moderate to high intensity is of benefit to COPD patients [19, 35, 44]. Such patients report a reduction in the dyspnoea and fatigue, increased exercise tolerance, and improved health status and quality of life, and display a reduction in the rate of hospital admissions [7, 36]. An improvement in exercise strength fol-
lowing a pulmonary rehabilitation program is usually accompanied by improved muscle condition, improved mechanical efficiency, and beneficial adaptations to the breathing pattern [22].
Several studies have investigated the role of inspiratory muscle training with support arm elevation in COPD patients that have aimed to improve inspiratory muscle endurance rather than inspiratory muscle strength with UAE. Such studies have typically reported only insignificant improvements in dyspnoea scores, exercise tolerance and quality of life. Smith et al. [59] found little evidence of clinically important benefits of IMT beyond an improvement in results of inspi-ratory muscle endurance tests. Although randomized controlled trials that evaluated the effect of inspiratory muscle training were considered, no distinction was made between trials of IMT vs conventional care and trials in which IMT was added to exercise therapy. In addition, Mador et al. [38] found that inspiratory muscle endurance training does not improve in quality of life or exercise performance. In contrast, Scherer et al. [57] found that inspiratory muscle endurance training improves dyspnoea, health-related quality of life, exercise performance and respiratory muscle in COPD patients.
4. Conclusion
In summary, our study found that SIMT by using threshold loading device resulted in improve pulmonary function indices and then alleviate symptoms and improve UAE performance, in addition to develop dyspnoea. Therefore, S-SIMT didn't lead to develop breathing symptoms, pulmonary function, and accessory muscles strength then effected on arm elevation.
Acknowledgement
We gratefully acknowledge the assistance of Ahmad Abdul Haleem, Alla Al-Haidar, and Hus-sam Mohamad.
References
1. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary Rehabilitation Joint ACCP/AACVPR Evidence-Based Guidelines. Chest, 1997, vol. 112, pp. 1363-1396.
2. American Thoracic Society. Standards for the Diagnosis and Care of Patients with Chronic Obstructive Pulmonary Disease (COPD) and Asthma. Am J RespirCrit Care Med, 1995, vol. 152, pp. 77-121.
3. American Thoracic Society. Screening for Adult Respiratory Disease. Am Rev Respir Dis, 1983, vol. 128, pp. 768-774.
4. Baarends E.M., Slebos D-J., Mostert R., Janssen P.P., Wouters E.F.M. Metabolic and Ventilatory Response Pattern to Arm Elevation in Patients with COPD and Healthy Age-Matched Subjects. Eur Respir J, 1995, vol. 8, pp. 1345-1351. DOI: 10.1183/09031936.95.08081345
5. Shahin B., Germain M., Kazem A., An-nat G. Benefits of Short Inspiratory Muscle Trai-ningon Exercise Capacity, Dyspnea, and Inspiratory Fraction in COPD Patients. International Journal of COPD, 2008, vol. 3(3), pp. 423-427. DOI: 10.2147/C0PD.S1822
6. Beckerman M., Magadle R., Weiner M., Weiner P. The Effects of 1 Year of Specific In-spiratory Muscle Training in Patients With COPD. Chest, 2005, vol. 128, pp. 3177-3182. DOI: 10.1378/chest.128.5.3177
7. Bellamy D., Bouchard J., Henrichsen S., Johansson G. International Primary Care Respiratory Group (IPCRG) Guidelines. Management of Chronic Obstructive Pulmonary Disease (COPD). Prim Care Res Jou, 2006, vol. 15, pp. 48-57. DOI: 10.1016/j.pcrj.2005.11.003
8. Black L.F., Hyatt R.E. Maximal Respiratory Pressures. Normalvalues and the Relationship to Age and Sex. Am Rev Respir Dis, 1969, vol. 99, pp. 696-702.
9. Boutellier U., Piwko P. The Respiratory System as an Exercise Limiting Factor in Normal Sedentary Subjects. Eur J Appl Physiol, 1992, vol. 64, pp. 145-152. DOI: 10.1007/BF00717952
10. Burt V.L., Whelton P., Roccella E.J. Prevalence of Hypertensionin the US Adult Population. Results from the Third National Heal-thand Nutrition Examination Survey, 1988-1991. Hypertension, 1995, vol. 25, pp. 305-313. DOI: 10.1161/01.HYP.25.3.305
11. Carrieri-Kohlman, Gormley M., Douglas K., Paul M., Stulbarg S. Exercise Training Decreases Dyspnoea and the Distress and Anxiety Associated With It Monitoring Alone May Be as Effective as Coaching. Chest, 1996, vol. 110, pp. 1526-1535. DOI: 10.1378/chest.110.6.1526
12. Carter R., Holiday D.B., Nwasuruba C., Stocks J., Grothucs C., Holiday B. Tiep. 6-Minute Walk Work for Assessment of Functional Capacity in Patients with COPD. Chest, 2003, vol. 123, pp. 1408-1415. DOI: 10.1378/chest.123.5.1408
13. Covey K., Larson L., Wirtz E. High Intensity Inspiratory Muscle Training in Patients With Chronic Obstructive Pulmonary Disease and Severely Reduced Function. J of Cardioy Reha, 2001, vol. 21, pp. 231-240. DOI: 10.1097/00008483-200107000-00008
14. Crapo R.O. Pulmonary-Function Testing. N Engl JMed, 1994, vol. 331, pp. 25-30. DOI: 10.1056/NEJM199407073310107
15. Decramer M. The Respiratory Muscles in Chronic Obstructive Pulmonary Disease Response of the Respiratory Muscles to Rehabilitation in COPD. J Appl Physiol, 2009, vol. 107, pp. 971-976. DOI: 10.1152/japplphysiol.91459.2008
16. Donner C.F., Muir J.F. Selection Criteria and Programmes for Pulmonaryrehabilitation in COPD Patients. Eur Respir J, 1997, vol. 10, pp.744-757.
17. Dourado V.Z., Tanni S.E., Antunes L.C.O., Paiva S.A.R., Campana A.O., Renno A.C.M., Godoy I. Effect of Three Exercise Programs on Patients with Chronic Obstructive Pulmonary Disease. Braz J of Med and Bio Res, 2009, vol. 42, pp. 263-271. DOI: 10.1590/S0100-879X2009000300007
18. Dulciane N.P., Assmann L.B., Bor din D.F., Ricardo G., Jost R.T., B-Filho M., Franc R.A., Cardoso D.M. Inspiratory Muscle Training with Threshold or Incentive Spirometry. Which is the Most Effective? Rev Port Pneumol, 2015, vol. 21(2), pp. 76-81.
19. Engstrom C.P., Persson L.O., Larsson S., Sullivan M. Long-Term Effects of a Pulmonary Rehabilitation Programme in Outpatients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Study. Scand J Rehab Med, 1999, vol. 31, pp. 207-213. DOI: 10.1080/003655099444371
20. Enright L. The Six-Minute Walk Test. Respir Care, 2003, vol. 48(8), pp. 783-785.
21. Chun E.M., Han S.J., Modi H.N. Analysis of Diaphragmatic Movement before and after Pulmonary Rehabilitation Using Fluoroscopy Imaging in Patients with COPD. Int J Chron Obstruct Pulmon Dis, 2015, vol. 10, pp. 193-199. DOI: 10.2147/COPD.S74438
22. Gigliotti F., Coli C., Bianchi R. Exercise Training Improves Exertional Dyspnoea in Patients with COPD. Evidence of Role of Mechanical Factors. Chest, 2003, vol. 123, pp. 1794-1802. DOI: 10.1378/chest.123.6.1794
23. Global Initiative for Chronic Obstructive Lung Disease. Bucket Guide to COPD Diagnosis, Management, and Prevention. 2015.
24. Goldstein R., De R.J., Long S., Dol-mage T., Avendano M.A. Applicability of a Threshold Loading Device for Inspiratory Muscle Testing and Training in Patients with COPD. Chest, 1989, vol. 96, pp. 564-571. DOI: 10.1378/chest.96.3.564
25. Gosselink R., Toosters T., Decramer M. Distribution of Muscle Weaknessin Patients with Stable Chronic Obstructive Pulmonary Disease. J Cardiopulm Rehabil, 2000, vol. 20, pp. 353-360. DOI: 10.1097/00008483-200011000-00004
26. Guyatt G.H., Berman L.B., Townsend M. A Measure of Quality of Life for Clinical Trials in Chronic Lung Disease. Thorax, 1987, vol. 42, pp. 773-778. DOI: 10.1136/thx.42.10.773
27. Guyatt H., Sullivan J., Thompson J., Fallen J., Pugsley O., Taylor D., Berman B. The -6 Minute Walk. A New Measure of Exercise Capacity in Patients with Chronic Heart Failure. CAN MED ASSOC J, 1985, vol. 132, pp. 919-923.
28. Hamnegard C.H., Wragg S., Kyroussis D., Aquilina R., Moxham J., Green M. Portable Measurementof Maximum Mouth Pressures. Eur Respir J, 1994, vol. 7, pp. 398-401. DOI: 10.1183/09031936.94.07020398
29. Hildegard M.D., Teodoro M.D. Inspira-tory Muscle Training in Patients with COPD, Effect on Dyspnoea, Exercise Performance, and Quality of Life. Chest, 2001, vol. 120, pp. 748-756. DOI: 10.1378/chest.120.3.748
30. Hill K., Jenkins S.C., Philippe D.L., Cecins N., Shepherd K.L., Green D.J., Hillman D.R., Eastwood P.R. High-Intensity Inspiratory Muscle Training in COPD. Eur Respir J, 2006, vol. 27, pp. 1119-1128. DOI: 10.1183/09031936.06.00105205
31. Hill K., Eastwood R., Cecins M., Jenkins C. Inspiratory Muscle Training for Patients With Chronic Obstructive Pulmonary Disease. A Practical Guide for Clinicians. Archives of Physical Medicine and Rehabilitation, 2011, vol. 91(9), pp. 1466-1470.
32. [Inspiratory Muscle Training]. Available at: http : //medical-dictionary .thefreedictionary. com/inspiratory+muscle+training.
33. Hul A., Gosselink R., Hollander P., Postmus P., Kwakkele G. Training with Inspiratory Pressure Support in Patients with Severe COPD. Eur Respir J, 2006, vol. 27, pp. 65-72. DOI: 10.1183/09031936.06.00036505
34. Jakeways N., McKeever T., Lewis S.A., Weiss S.T., Britton J. Relationship Between FEV1 Reduction and Respiratory Symptoms in the General Population. Eur Respir J, 2003, vol. 21, pp. 658-663. DOI: 10.1183/09031936.03.00069603
35. Lacasse Y., Wong E., Guyatt G.H., King D., Cook D.J., Goldstein R.S. Meta-Analysis of Respiratory Rehabilitation in Chronic Obstructive Pulmonary Disease. Lancet, 1996,
vol. 348, pp. 1115-1119. DOI: 10.1016/S0140-6736(96)04201-8
36. Lacasse Y., Brosseau L., Milne S., Martin S., Wong E., Guyatt G.H., Goldstein R.S. Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease. Cochrane Database Syst Rev, 2002, vol. 3, CD003793. DOI: 10.1016/s0031-9406(05)60714-6
37. Lotters F., van Tol B., Kwakkel G., Gosselink R. Effects of Controlled Inspiratory Muscle Training in Patients with COPD. A Meta-Analysis. Eur Respir J, 2002, vol. 20, pp. 570-576. DOI: 10.1183/09031936.02.00237402
38. Mador M. Effect of Respiratory Muscle Endurance Training in Patients With COPD Undergoing Pulmonary Rehabilitation. Chest, 2005, vol. 128, pp. 1216-1224. DOI: 10.1378/chest.128.3.1216
39. Mador M.J., Bozkanat E., Aggarwal A., Shaffer M., Kufel T.J. Endurance and Strength Training in Patients With COPD. Chest, 2004, vol. 125, pp. 2036-2045. DOI: 10.1378/chest.125.6.2036
40. Mador M.J., Rodis A., Magalang U.J. Reproducibility of Borg Scale Measurements of Dyspnoea During Exercise in Patients with COPD. Chest, 1995, vol. 107, pp. 1590-1597. DOI: 10.1378/chest.107.6.1590
41. Mahler D.A. The Measurement of Dyspnoea During Exercise in Patients with Lung Disease. Chest, 1992, vol. 101, pp. 242-247. DOI: 10.1378/chest.101.5.242S
42. Marin J.M., Carrizo S.J., Gascon M. Inspiratory Capacity, Dynamic Hyperinflation, Breathlessness, and Exercise Performance Du-ringthe 6-Minute-Walk Test in Chronic Obstructive Pulmonary Disease. Am J RespirCrit Care Med, 2001, vol. 163, pp. 1395-1399. DOI: 10.1164/ajrccm.163.6.2003172
43. Karzan M.A., Ismael H.M., Shekha ny K.A., Al-Attraqhchi A.A.F., Abdullah S., Aldabbagh R., Denning D.W. Burden of Serious Fungal Infection in Iraq, 2011. Available at: www.ncbi.nlm.nih.gov/pubmed/.
44. Morgan M.D.L., Calverley P.M.A., Clark C.J. British Thoracic Society. Pulmonary Rehabilitation. Thorax, 2001, vol. 56, pp. 827-834. DOI: 10.1136/thorax.56.11.827
45. Noseda A., Carpiaux J.P., Markstein C., Meyvaert A., de Maertelaer V. Disabling Dyspnoea in Patients with Advanced Disease. Lack of Effect of Nebulized Morphine. Eur Respir J, 1997, vol. 10, pp. 1079-1083. DOI: 10.1183/09031936.97.10051079
46. Noseda A., Carpiaux J.P., Schmerber J.,
Valente F., Yernault J.C. Dyspnoea and Flow-Volume Curve During Exercise in COPD Patients. Eur Respir J, 1994, vol. 7, pp. 279-285. DOI: 10.1183/09031936.94.07020279
47. Ortega F., Toral J., Cejudo P. Comparison of Effects of Strength and Endurance Training in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med, 2002, vol. 166, pp. 669-674. DOI: 10.1164/rccm.2107081
48. Pardy R.L., Leith D.E. Ventilatory Muscle Training. Respir Care, 1984, vol. 29, pp. 278-284.
49. Pauwels R.A., Lofdahl C.G., Laitinen L.A. Long-Term Treatment with Inhaled Budeso-nide in Persons with Mild Chronic Obstructive Pulmonary Disease Who Continue Smoke. N Engl J Med, 1999, vol. 340, pp. 1948-1953. DOI: 10.1056/NEJM199906243402503
50. Puhan M.A., Schu'nemann H.J. How to Increase the Value of Randomized Trials in COPD Research. Eur Respir J, 2009, vol. 34, pp. 552-558. DOI: 10.1183/09031936.00095408
51. Ramirez-Sarmiento A., Orozco-Levi M., Guell R. Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease Structural Adaptation and Physiologic Outcomes. Am J RespirCrit Care Med, 2002, vol. 166, pp. 1491-1497. DOI: 10.1164/rccm.200202-075OC
52. Reid W. Respiratory Muscle Training for Patients with Chronic Obstructive Pulmonary Disease. Phys Ther, 1995, vol. 75, pp. 996-1005. DOI: 10.1093/ptj/75.11.996
53. Ries A.L., Kaplan R.M., Blumberg E. Use of Factor Analysis to Consolidate Multiple Outcome Measures in Chronic Obstructive Pulmonary Disease. J Clin Epidermiol, 1991, vol. 6, pp. 497-503. DOI: 10.1016/0895-4356(91)90212-R
54. Rutten-van Molken, Roos M.B., Van Noord J.A. An Empirical Comparison of the St George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRQ) in a Clinical Trial Setting. Thorax, 1999, vol. 54, pp. 995-1003. DOI: 10.1136/thx.54.11.995
55. Sala, Roca, Marrades M., Suso J.M., Moreno, Barbera, Nadal, Jover, Rodriguez-Roisin. Effects of Endurance Training on Skeletal Muscle Bioenergetics in Chronic Obstructive Pulmonary Disease. AM J RespirCrit Care Med, 1999, vol. 159, pp. 1726-1734. DOI: 10.1164/ajrccm.159.6.9804136
56. Riera S.H., Rubio T.M., Ruiz F.O., Ramos P.C., Otero D.D.C., Hernandez T.E., Gomez J.C. Inspiratory Muscle Training in Patients With COPD* Effect on Dyspnoea, Exer-
cise Performance, and Quality of Life. Chest, 2001, vol. 120, pp. 748-756. DOI: 10.1378/chest.120.3.748
57. Scherer A., Spengler M. Respiratory Muscle Endurance Training in Chronic Obstructive Pulmonary Disease Impact on Exercise Capacity, Dyspnea, and Quality of Life. Am JRespir Crit Care Med, 2000, vol. 162, pp. 1709-1714. DOI: 10.1164/ajrccm.162.5.9912026
58. Sinderby Spahja. Diaphragm Activation using Exercise in Chronic Obstructive Pulmonary Disease. Am J RespirCrit Care Med, 2001, vol. 163, pp. 1637-1641. DOI: 10.1164/ajrccm.163.7.2007033
59. Smith K., Cook D., Guyatt G.H., Mad-havan J., Oxman A.D. Respiratory Muscle Training in Chronic Airflow Limitation. A Meta-Analysis. Am Rev Respir Dis, 1992, vol. 145, pp. 533-539. DOI: 10.1164/ajrccm/145.3.533
60. Solway S., Brooks D., Lau L., Golds tein R.S. The Shorttermeffect of a Rollator on Functional Exercise Capacity Amongindividuals with Severe COPD. Chest, 2002, vol. 122, pp. 56-65. DOI: 10.1378/chest.122.1.56
61. Spruit M.A., Gosselink R., Troosters T., De Paepe K., Decramer M. Resistance Ver sus Endurance Training in Patients with COPD and Peripheral Muscle Weakness. Eur Respir J, 2002, vol. 19, pp. 1072-1078. DOI: 10.1183/09031936.02.00287102
62. The Chief Health Officer. The Health of the People of New South Wales - Data Book RESPIRATORY DISEASE. 2008, pp. 1-128.
63. Van Stel F., Bogaard M., Rijssenbeek-Nouwens H.M., Colland T. Multivariable Assessment of the 6-Min Walking Test in Patients with Chronic Obstructive Pulmonary Disease. Am J RespirCrit Care Med, 2001, vol. 163, pp. 15671571. DOI: 10.1164/ajrccm.163.7.2001071
64. Weiner P., Weiner M. Inspiratory Muscle Training May Increase Peak Inspiratory Flow in Chronic Obstructive Pulmonary Disease. Respiration, 2006, vol. 73, pp. 151-156. DOI: 10.1159/000088095
65. Weiner P., Azgad Y., Ganam R. Inspira-tory Muscle Training Combined with General Exercise Reconditioning in Patients with COPD. Chest, 1992, vol. 102, pp. 1351-1356. DOI: 10.1378/chest.102.5.1351
66. Weiner P., Magadle R., Beckerman M., Weiner M., Berar-Yanay N. Maintenance of In-spiratory Muscle Training in COPD Patients. One Year Follow-Up. Eur Respir J, 2004, vol. 23, pp. 61-65. DOI: 10.1183/09031936.03.00059503
67. Wijkstra P.J., Ten Vergert E.M., Alte na R.V., Otten V., Postma D.S., Kraan J., Koe ter G.H. Quality of Life in Patients with Chro nic Obstructive Pulmonary Disease Improves after Rehabilitation at Home. Eur Respir J, 1994, vol. 7, pp. 269-273. DOI: 10.1183/09031936.94.07020269
68. Wilson R., Jones P.W. Differentiation Between the Intensityof Breathlessness and the Distress it Evokes in Normalsubjects During Exercise. Clin Sci, 1991, vol. 80, pp. 65-70. DOI: 10.1042/cs0800065
Received 4 April 2017
УДК 612.2 + 796 й01: 10.14529/Ивт170207
ВЛИЯНИЕ СИЛОВОЙ ТРЕНИРОВКИ ДЫХАТЕЛЬНЫХ МЫШЦ НА ОДЫШКУ, ВОЗНИКАЮЩУЮ ПРИ ПОДЪЕМЕ РУК БЕЗ ПОДДЕРЖКИ У ПАЦИЕНТОВ С ХРОНИЧЕСКОЙ ОБСТРУКТИВНОЙ БОЛЕЗНЬЮ ЛЕГКИХ
Мазин Хади Кзар, Амман Х. Хади
Хилла, 51001, Ирак
Цель. Целью настоящего исследования было выявить влияние программы силовой тренировки дыхательных мышц (СТДМ) на одышку, возникающую при подъеме рук без поддержки у пациентов с хронической обструктивной болезнью легких (ХОБЛ), по сравнению с эффектом имитационной программы силовой тренировки дыхательных мышц
(И-СТДМ). Материалы и методы исследования. Участники исследования - 44 пациента с ХОБЛ в возрасте от 40 до 50 лет, в том числе пациенты с тяжелой стадией ХОБЛ (ОФВ1 -50-70 % от должного) - были распределены на две группы: экспериментальную (ЭГ) и контрольную (КГ). Тренировочная программа включала 5 занятий в неделю (6 трехминутных кругов дыхательных упражнений с нагрузкой с двухминутными интервалами отдыха) на протяжении 10 недель. Результаты исследования. В ходе исследования измерялись показатели обструкции дыхательных путей (ОФВ1, ФЖЕЛ, индекс Тиффно и ПОС), сила дыхательных мышц (максимальное давление вдоха (PI, max)) и способность к физической нагрузке (проба с шестиминутной ходьбой (6мхп)). Установлено, что предложенная программа силовой тренировки дыхательных мышц в ЭГ способствовала значительному улучшению всех исследуемых параметров у испытуемых. При этом в КГ, где применялась имитационная программа силовой тренировки дыхательных мышц, не было зафиксировано статистически значимых улучшений таких показателей, как ФЖЕЛ, ОФВ1, индекс Тиффно, ПОС, насыщение кислородом до и после 6мхп, PI,max и одышка (оценивалась по визуально-аналоговой шкале). Показатель ОФВ1 в ЭГ перед началом тренировки составлял 54,81 ± 3,53, а после тренировки возрос до 70,87 ± 1,54. При этом соответствующий показатель в КГ составил 77,81 ± 6,00 до тренировки и 77,93 ± 5,8 после тренировки. Заключение. Установлено, что СТДМ с применением пороговой нагрузки улучшает показатели функции легких, купируя симптомы и облегчая подъем рук без поддержки, в том числе купируя одышку. Вместе с тем, применение И-СТДМ не имело положительного эффекта на респираторную симптоматику, функцию легких и силу вспомогательных мышц, не влияя, таким образом, на показатели подъема рук без поддержки.
Ключевые слова: силовая тренировка дыхательных мышц, одышка, поднятие рук без поддержки, хроническая обструктивная болезнь легких.
Мазин Хади Кзар, факультет физической культуры и спортивной науки, Хилла, 51001, Ирак, [email protected].
Амман Х. Хади, факультет физической культуры и спортивной науки, Хилла, 51001, Ирак, [email protected].
Поступила в редакцию 4 апреля 2017 г.
ОБРАЗЕЦ ЦИТИРОВАНИЯ
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Mazin Hadi Kzar, Ammar H. Hadi. Effect of an Inspiratory Muscle Strength Training on Dyspnoea Arising From Unsupported Arm Elevation in Patients with Chronic Obstructive Pulmonary Disease // Человек. Спорт. Медицина. - 2017. - Т. 17, № 2. - С. 70-80. DOI: 10.14529/hsm170207
Mazin Hadi Kzar, Ammar H. Hadi. Effect of an Inspiratory Muscle Strength Training on Dyspnoea Arising From Unsupported Arm Elevation in Patients with Chronic Obstructive Pulmonary Disease. Human. Sport. Medicine, 2017, vol. 17, no. 2, pp. 70-80. DOI: 10.14529/hsm170207
