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Skeletal muscle dysfunction is one of the major extrapulmonary complications of chronic obstructive pulmonary disease (COPD). Some studies have reported a relationship between physical activity (PA) level and skeletal muscle quality assessed by echo-intensity (EI) in healthy individuals but not in patients with COPD.The aim of this study is to investigate the relationships between PA level and both skeletal muscle EI and skeletal muscle mass in patients with COPD.We employed a cross-sectional design. Forty male outpatients with stable COPD were enrolled. Using B-mode ultrasonography, we measured the rectus femoris muscle cross-sectional area (RF-CSA) and EI (RF-EI). The RF-CSA and RF-EI were measured on frozen images using an electronic caliper and 8-bit gray-scale analysis, respectively. The objective PA level was determined by monitoring daily step counts and moderate-to-vigorous physical activity time (MVPA) with an activity monitor. A general regression model was used to assess the relationships between PA level and both RF-CSA and RF-EI. Age and body mass index (BMI) were adopted as confounding variables.Twenty-five outpatients with stable COPD (age, 70 ± 7 years old; forced expiratory volume in 1 s, 55.0 ± 24.9% of predicted values) were finally enrolled in the present study. Even after adjusting for age and BMI, the daily step counts and MVPA were significantly associated with RF-EI, and knee extensor force was associated with RF-CSA.The present study showed that PA level was associated with RF-EI in patients with COPD. In addition, RF-CSA was associated with knee extensor force. When assessing skeletal muscle using ultrasonography in patients with COPD, we should also assess EI.

Purpose Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease characterized by airflow limitation and is associated with decreased balance and increased fall risk. Since falls are related to increased mortality, interventions targeting balance and fall risk could reduce morbidity and mortality. The objective of this review was to systematically assess the effects of exercise-based interventions on fall risk and balance in patients with COPD. Methods PubMed, Web of Science, EMBASE, and CINAHL were screened for randomized controlled trails and within-group studies evaluating effects of exercise-based interventions on fall risk or balance in patients with COPD. Data were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results Fifteen studies were identified, 6 randomized controlled trails and 9 within-group studies. All interventions reported positive effects on balance outcomes. No studies reported fall risk. Taking current recommendations of balance outcome measures in patients with COPD into account, pulmonary rehabilitation combined with balance training had the highest effect size. Nine papers had concerns regarding bias, mostly due to the lack of blinding outcome assessors. Conclusions Exercise-based interventions have a positive effect on balance in patients with COPD. Pulmonary rehabilitation with balance training seems to have the most beneficial effect on balance. The effects on fall risk, as well as the long-term intervention effects remain unclear. A standardized balance assessment and research on long-term effects and fall risk are recommended.

Background Ultrasound imaging has been widely used for imaging of the diaphragm thickness (Tdi) and thickening. Few studies assessed the Tdi using ultrasonography in patients with chronic obstructive pulmonary disease (COPD). We measured the Tdi and thickening in patients with COPD compared with healthy younger and healthy older adults to reveal the influence of ageing and/or COPD. Methods Thirty-eight male patients with COPD (age 72 ± 8 years), 15 healthy younger (age 22 ± 1 years) and 15 healthy older (age 72 ± 5 years) male volunteers were recruited. We measured Tdi at total lung capacity (TdiTLC ), functional residual capacity (TdiFRC ) and residual volume (TdiRV ) using B-mode ultrasonography. We calculated the change ratio of TdiTLC and TdiRV (ΔTdi%). We used a one-way analysis of variance and multiple comparison test for the comparison analysis. Results The TdiTLC and the ΔTdi% were significantly lower in patients with COPD compared to the healthy adults. There was no significant difference in these values with age. There was no between group difference in the TdiFRC or TdiRV . Conclusions Our results indicate significant differences in TdiTLC and ΔTdi% between patients with COPD and healthy adults. Therefore, diaphragm ultrasonography can assess diaphragm dysfunction associated with COPD. We suggest that it is better to use TdiTLC and ΔTdi% (not only Tdi at rest) to assess diaphragm function.

Objectives We aimed to identify the inspiratory muscle strength thresholds below which exercise capacity is compromised in men with chronic obstructive pulmonary disease (COPD). Methods We measured the maximum static inspiratory mouth pressure (PImax) and the percentage of predicted values (%PImax) in 113 patients with COPD. Six-minute walk distance (6-MWD) was measured as an indicator of functional exercise capacity, and a 6-MWD of 0.90) and maximal sensitivity. Statistical significance was set at P Results The data of 96 patients (74 ± 6 years old; forced expiratory volume in 1-s [FEV1], 56.5 ± 26.2% predicted) were analyzed; three women and 14 participants with missing data were excluded. Multivariate logistic regression models identified significant associations of PImax (odds ratio at 99% confidence interval [CI]: 0.95 [0.92–0.98]) and %PImax (odds ratio at 99% CI: 0.97 [0.95–0.99]) with 6-MWD, after adjustments for height and FEV1. C-statistics showed that the area under the curves (99% CI) of PImax and %PImax were comparable (0.87 [0.77–0.96] and 0.83 [0.72–0.94]). The thresholds of PImax and %PImax were 45.1 cmH2O and 66%; PImax and %PImax also had moderate positive likelihood ratios of 4.44 and 5.00. Conclusions Thresholds of inspiratory muscle strength in men with COPD could help clinicians evaluate whether their patient's inspiratory muscle strength is inadequate to achieve a 6-MWD of ≥350 m, and identify patients who should be targeted for inspiratory muscle training.

Masahiro Iwakura,1,2 Kazuki Okura,2 Kazuyuki Shibata,1,2 Atsuyoshi Kawagoshi,2 Keiyu Sugawara,2 Hitomi Takahashi,2 Takanobu Shioya1 1Department of Rehabilitation, Akita City Hospital, 2Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan Background: Little is known regarding the relationship between balance impairments and physical activity in COPD. There has been no study investigating the relationship between balance and objectively measured physical activity. Here we investigated the association between balance and physical activity measured by an activity monitor in elderly COPD patients. Materials and methods: Twenty-two outpatients with COPD (mean age, 72±7 years; forced expiratory volume in 1 second, 53%±21% predicted) and 13 age-matched healthy control subjects (mean age, 72±6 years) participated in the study. We assessed all 35 subjects’ balance (one-leg standing test [OLST] times, Short Physical Performance Battery total scores, standing balance test scores, 4 m gait speed, and five-times sit-to-stand test [5STST]) and physical activity (daily steps and time spent in moderate-to-vigorous physical activity per day [MV-PA]). Possible confounders were assessed in the COPD group. The between-group differences in balance test scores and physical activity were analyzed. A correlation analysis and multivariate regression analysis were conducted in the COPD group. Results: The COPD patients exhibited significant reductions in OLST times (P=0.033), Short Physical Performance Battery scores (P=0.013), 4 m gait speed (P

Yoshino Terui,1 Masahiro Iwakura,1,2 Eriko Suto,3 Atsuyoshi Kawagoshi,2 Keiyu Sugawara,2 Hitomi Takahashi,2 Kouichi Hasegawa,3 Sachiko Uemura,1 Masahiro Satake,1 Takanobu Shioya1,4 1Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan; 2Department of Rehabilitation Medicine, Akita City Hospital, Akita, Japan; 3Department of Rehabilitation, Akita Prefectural Center for Rehabilitation and Psychiatric Medicine, Daisen, Japan; 4Geriatric Health Services Facility Nikonikoen, Akita, Japan Background: Individuals with COPD may experience ambulatory difficulty due to both effort intolerance arising from respiratory dysfunction and impaired balance control during walking. However, the trunk movement during walking has not been evaluated or adjusted for patients with COPD. The Lissajous index (LI) visually and numerically evaluates the left–right symmetry of the trunk movement during walking and is useful in clinical practice. In COPD patients, the LI is used as an indicator of the left–right symmetry of the trunk during walking. Here, we used the LI to evaluate the symmetry of COPD patients based on bilateral differences in mediolateral and vertical accelerations, and we investigated the correlation between the patients’ symmetry evaluation results and their physical function.Patients and methods: Sixteen stable COPD patients (all males; age 71.3±9.2 years) and 26 healthy control subjects (15 males; age 68.2±6.9 years) participated in this study. They performed the 10-minute walk test at a comfortable gait speed wearing a triaxial accelerometer, and we measured their trunk acceleration for the evaluation of symmetry. Motor functions were also evaluated in the patients with COPD.Results: The average mediolateral bilateral difference and LI values of the COPD patients were significantly larger than those of the healthy subjects. The COPD patients’ LI values were significantly correlated with their static balance.Conclusion: The LI measured using a triaxial accelerometer during walking is useful in balance assessments of patients with COPD. Keywords: chronic obstructive pulmonary disease, gait, accelerometer, Lissajou index, balance

Abnormalities of spatiotemporal gait parameters are frequently observed in chronic obstructive pulmonary disease (COPD). However, associations of gait parameters with clinical outcomes and their implementation into clinical practice have not been established.To investigate gait abnormalities and their association with clinical outcomes of COPD.This study included 34 male outpatients with COPD and 16 community-dwelling healthy men aged ≥65 years. The subjects underwent a ten-metre walk test wearing an accelerometer. Data on gait speed, step length, cadence, walk ratio, acceleration magnitude, and standard deviation of step time (step time SD) were collected. Forced expiratory volume in 1-second, modified Medical Research Council dyspnoea score, six-minute walk distance (6MWD), quadriceps muscle strength (QMVC), and physical activity (daily steps and time spent in moderate to vigorous physical activity per day) were measured in the COPD group as clinical outcomes of COPD. We tested group differences in gait parameters, associations between gait parameters and COPD clinical outcomes, and predictive capability of gait parameters for reductions in 6MWD, QMVC, and daily steps in COPD.All gait parameters except walk ratio deteriorated in COPD. Step time SD and gait speed were significant independent predictors of 6MWD in COPD (B=-0.440, p = 0.001, B = 0.339, p = 0.007, respectively). Step length was a significant independent predictor of QMVC (B=-0.609, p 0.001) and daily steps (B=-0.453, p = 0.006). Step length was a significant predictor of muscle weakness and physical inactivity, and step time SD was significant in predicting poor 6MWD in COPD.Significant associations between gait abnormalities measured by an accelerometer and deficits in extra-pulmonary features of COPD were observed. An accelerometer-based gait analysis could be an alternative approach to assessing gait abnormalities and screening of functional decline in COPD.

Summary Purpose We evaluated the effects of low-intensity and home-based pulmonary rehabilitation (PR) on physical activity (PA) and the feedback provided by a pedometer in stable elderly patients with chronic obstructive pulmonary disease (COPD). Methods We assessed PA using a newly developed triaxial accelerometer (A-MES™, Kumamoto, Japan), which measures the time spent walking, standing, sitting and lying down. Twenty-seven elderly patients with COPD (age 74 ± 8 yrs; %FEV 1 56.6 ± 18.7%) participated. They were randomly selected to undergo PR (pulmonary rehabilitation only) or PR + P (PR plus the feedback from using a pedometer). Their PA and pulmonary function, exercise capacity (6-min walking distance; 6MWD), quadriceps femoris muscle force (QF) were evaluated before the PR began (baseline) and at 1 year later. We compared the patients' changes in PA and other factors between the baseline values and those obtained 1 year later and analyzed the relationships between the changes in PA and other factors in the both groups. Results The increase in the time spent walking in the PR + P group (51.3 ± 63.7 min/day) was significantly greater than that of PR group (12.3 ± 25.5 min/day) after the PR. The improvement rate of daily walking time after PR was significantly correlated with that of the 6MWD and QF in all subjects. Conclusions These data suggest that low-intensity and home-based PR with the feedback from using pedometer was effective in improving PA, and the improvements of physiological factors were correlated with increased walking time in stable elderly patients with COPD.

Diaphragm function might be useful to predict nocturnal oxygen desaturation in COPD. Ultrasonography has been widely used for the assessment of the diaphragm. We aimed to investigate the relationship between the contractile capability of the diaphragm assessed by ultrasonography and the nocturnal percutaneous arterial oxygen saturation (NSpOTwenty-eight male patients with COPD (age, 73 ± 7 years; forced expiratory volume in 1 s (FEVAll participants had mild or no daytime hypoxaemia (PaOThis study suggested a close relationship between the NSpO

SummaryBackgroundOne of the major pathophysiologies in advanced chronic obstructive pulmonary disease (COPD) has been attributed to systemic inflammation. Meta-analysis of the 2005 Cochrane Database concluded the effect of nutritional supplementation alone on stable COPD was insufficient to promote body weight gain or exercise capacity. The aim of this study was to investigate the effectiveness of nutritional supplementation therapy using a nutritional supplement containing whey peptide with low-intensity exercise therapy in stable elderly patients with COPD.MethodIn stable elderly COPD patients with %IBW and %FEV1 of less than 110 and 80%, respectively, anti-inflammatory nutritional supplementation therapy was added to low-intensity exercise therapy. Thirty-six COPD patients were divided into those with and those without the ingestion of an anti-inflammatory nutritional supplement containing whey peptide, which exhibited an anti-inflammatory effect. These two groups were designated as the nutritional support and the control groups, respectively. The body composition, skeletal muscle strength, exercise tolerance, health-related QOL (HRQOL), and inflammatory cytokines were evaluated before and three months after nutritional support combined with exercise therapy in both the nutritional support group and the control group.ResultsIn the nutritional support group, the body weight, %IBW, FM, energy intake, %AC, Alb, PImax, PEmax, 6MWD, WBI, emotional function, and CRQ total were significantly increased, and the levels of hsCRP, IL-6, IL-8, and TNF-α were reduced significantly, while no significant change was noted in any item of physiological evaluation or any biomarker in the control group.ConclusionConcomitant use of a anti-inflammatory nutritional supplement containing whey peptide, which exhibits an anti-inflammatory effect, with exercise therapy in stable elderly COPD patients with %IBW

Masahiro Satake,1 Takanobu Shioya,1 Sachiko Uemura,1 Hitomi Takahashi,2 Keiyu Sugawara,2 Chikage Kasai,2 Noritaka Kiyokawa,2 Toru Watanabe,2 Sayaka Sato,2 Atsuyoshi Kawagoshi2 1Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan; 2Department of Rehabilitation, Akita City Hospital, Akita, Japan Abstract: The purpose of this study was to investigate the relationship between dynamic hyperinflation and dyspnea and to clarify the characteristics of dyspnea during the 6-minute walk test (6MWT) in chronic obstructive pulmonary disease patients. Twenty-three subjects with stable moderate chronic obstructive pulmonary disease (age 73.8±5.8 years, all male) took part in this study. During the 6MWT, ventilatory and gas exchange parameters were measured using a portable respiratory gas analysis system. Dyspnea and oxygen saturation were recorded at the end of every 2 minute period during the test. There was a significant decrease in inspiratory capacity during the 6MWT. This suggested that dynamic hyperinflation had occurred. Dyspnea showed a significant linear increase, and there was a significant negative correlation with inspiratory capacity. It was suggested that one of the reasons that dyspnea developed during the 6MWT was the dynamic hyperinflation. Even though the tidal volume increased little after 2 minutes, dyspnea increased linearly to the end of the 6MWT. These results suggest that the mechanisms generating dyspnea during the 6MWT were the sense of respiratory effort at an early stage and then the mismatch between central motor command output and respiratory system movement. Keywords: field walking test, chronic respiratory diseases, respiratory gas analysis, inspiratory capacity, IC, inspiratory reserve volume, IRV, Borg CR-10 scale, COPD

Atsuyoshi Kawagoshi,1,2 Noritaka Kiyokawa,2 Keiyu Sugawara,2 Hitomi Takahashi,2 Shunichi Sakata,3 Saori Miura,4 Sachie Sawamura,5 Masahiro Satake,1 Takanobu Shioya1 1Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, 2Department of Rehabilitation, Akita City Hospital, Akita, 3Kumamoto Technology and Industry Foundations, Kumamoto, 4Department of Rehabilitation, Saitama Medical University, Saitama, 5Department of Rehabilitation, Research Institute for Brain and Blood Vessels-Akita, Akita Prefecture Hospital Organization, Akita, Japan Background: The purpose of this study was to quantify the walking time and frequency of postural changes in daily life in patients with chronic obstructive pulmonary disease (COPD) using a new triaxial accelerometer system. Methods: Twenty-six elderly patients with stable COPD (age 76.8 ± 6.2 years; percent forced expiratory volume in one second [%FEV1] 52.9% ± 26.3%) and 20 age-matched elderly subjects (age 73.0 ± 4.2 years; %FEV1 124.0% ± 22.3%) participated in the study. The subjects’ time spent walking (slow, fast), standing, sitting, and lying down and the frequency of their postural changes (getting up, standing up) were assessed for 7 consecutive days using an Activity Monitoring And Evaluation System (A-MES™). We analyzed the relationships among walking times, frequency of postural changes, and physiologic factors in both COPD patients and controls. Results: The COPD patients’ total walking time, including slow (