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ORIGINAL ARTICLE
Year : 2015  |  Volume : 4  |  Issue : 4  |  Page : 243-246

Association of BODE index to daily living activities and upper limb strength in chronic obstructive pulmonary disease


1 JSS College of Physiotherapy, JSS Medical College, Mysore, Karnataka, India
2 Department of Pulmonology, JSS Medical College, Mysore, Karnataka, India

Date of Web Publication20-Oct-2015

Correspondence Address:
Renukadevi Mahadevan
JSS College of Physiotherapy, Ramanuja Road, Mysore - 570 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.167653

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  Abstract 

Context: Chronic obstructive pulmonary disease (COPD) is a progressive disease that reduces the functional capacity and the ability to perform activities of daily living (ADL). Aims: To determine the correlation between the BODE index (B - body mass index; O - airflow obstruction; D - dyspnea; and E - exercise capacity) with ADL and grip strength in COPD patients. Settings and Design: The study was conducted at JSS Hospital, Mysore. It was a correlational study. Subjects and Methods: Sixty-six COPD subjects were recruited by convenience sampling. Forced expiratory volume, body mass index, Six-Minute Walk Test, and Medical Research Council scale were assessed. The BODE index was calculated. The total score of London Chest Activities of Daily Living (LCADL) and grip strength were compared between the patients of the four quartiles of the BODE index. The association between LCADL and grip Strength with BODE index was analyzed. Statistical Analysis: Eta coefficient, Spearman's rank correlation coefficient and the analysis of variance were used. Results: The Eta coefficients showed the strength or the measure of associations of BODE index with age, grip strength, and LCADL. Spearman's correlation coefficient shows that there is an inverse association with grip strength and LCADL, and it was statistically significant as theP<0.05. Conclusions: ADL limitation and hand grip strength test have a strong association with the BODE index in patients with moderate to severe COPD.

Keywords: Activities of daily living, BODE index, chronic obstructive pulmonary disease, dyspnea, grip strength


How to cite this article:
Mahadevan R, Shankar P, Chaya S K. Association of BODE index to daily living activities and upper limb strength in chronic obstructive pulmonary disease. Int J Health Allied Sci 2015;4:243-6

How to cite this URL:
Mahadevan R, Shankar P, Chaya S K. Association of BODE index to daily living activities and upper limb strength in chronic obstructive pulmonary disease. Int J Health Allied Sci [serial online] 2015 [cited 2020 Jan 20];4:243-6. Available from: http://www.ijhas.in/text.asp?2015/4/4/243/167653


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, and it has been considered as a serious public health problem.[1] COPD is characterized by a chronic airflow limitation, pathological changes in the lung, comorbidities, and significant extrapulmonary effects.[2] COPD is characterized by the ventilator and metabolic limitation. As the disease progresses there is development and worsening of dyspnoea, significant weight loss, reduction in peripheral muscle strength, decrease in the quality of life, and reduction in the ability to perform activities of daily living (ADL).[3]

Forced expiratory volume in the first, second (FEV1) is the parameter used to evaluate the stage of the COPD, however, it does not evaluate the systemic repercussions of it, and may not accurately reflect the exercise capacity, the degree of dyspnea or the limitation to perform ADLs.[4]

The ability to exert physical effort independently influences the survival of these patients, and the mortality risk for patients with COPD can be assessed by the BODE index (B - body mass index; O - airflow obstruction; D - dyspnea; and E - exercise capacity), which is considered the best predictor of survival in these patients.[5]

ADL are defined as tasks that the individuals perform on a daily basis. Both the upper limb (UL) and the lower limb (LL) are involved in the most common ADL. The muscles that participate in the positioning of the UL, such as the trapezius, pectoralis minor, scalene, sternocleidomastoid, and intercostals, also perform ventilatory and postural functions. Therefore, the performance of ADL tests as a part of the routine evaluation of patients with respiratory functions should be considered.[6]

The variable that evaluates the exercise capacity in the BODE index is the distance walked during the Six-Minute Walk Test (6MWT). Although the 6MWT reflects the ability to perform the ADL, this test involves only the activity of walking. As the disease progresses other factors such as lung hyperinflation, may influence the ability to perform the ADL, especially those activities involving the ULs.[7],[8]

The ADL limitations can be evaluated globally by using scales that present domestic, physical, and leisure daily activities domains. Due to the impairments associated with COPD, however, exercise capacity must also be verified by other tests, such as the performance of ADL that require elevation of the UL and hand grip strength test (HGT) which constitutes a relevant indicator in the analysis of the general state of strength in an individual which is essential for the performance of ADL.[9],[10]

The hypothesis of this study was that the BODE index would correlate with the hand grip strength and ADL limitation. Therefore, the aims of this study were to investigate whether there is an association between ADL limitation and handgrip strength with the BODE mortality index.


  Subjects and Methods Top


The study was conducted at JSS hospital Mysore. Sixty-six male subjects with COPD in stages of 1, 2, 3, and 4 of the Global Initiative for Chronic Obstructive Lung Disease were evaluated from a convenience sample. The inclusion criteria was stable COPD means clinically stable subjects and had no history of infection and no exacerbation of respiratory symptoms or changes in medication for at least 2 months before the study. Participants who were unable to perform any of the assessments of the study and participants who presented associated diseases such as cardiomyopathy, musculoskeletal conditions, tuberculosis, asthma, and patients with uncontrolled arterial hypertension or hypoxemia SpO2 below 85% at rest were excluded. All participants were informed about the procedures and signed an informed consent form. The study was approved by the Human Ethics Research Committee of JSS College of Physiotherapy.

The association of BODE index to London Chest Activity of Daily Living scale (LCADL) and grip strength was analyzed. The BODE index was calculated individually incorporating the variables: FEV1%pred (percentage of predicted FEV1 in thefirst second. post bronchodilator), distance walked in the 6MWT (in meters), degree of dyspnea, and the body mass index (BMI). The degree of dyspnea was evaluated by the Medical Research Council scale which contains a score ranging from 0 to 4, where 4 indicates the highest degree of dyspnea. The BMI was calculated using the formula: Weight/height 2 (kg/m 2). The BODE index ranges from a minimum score of 0 to a maximum score of 10 points. The classification of patients was divided into quartiles, where: The quartile 1 include patients with scores ranging from 0 to 2; quartile 2 include patients with scores ranging from 3 to 4; quartile 3 include patients with scores ranging from 5 to 6, and quartile 4 include patients with scores ranging from 7 to 10. The higher the score, the greater the risk of mortality in patients with COPD (Celli et al. N Engl J Med. 2004).

LCADL scale composed of four domains relating to self-care domestic physical activities and leisure; allowing the evaluation of the degree of dyspnea on ADL and its response to a therapeutic intervention. The LCADL scale is composed of ordinary ADL such as dressing a shirt wearing shoes with socks making the bed and others comprising a total of 15 quantitative questions. For the questions 1–15 the patients report a score on a Likert scale ranging from 0 to 5 with a total maximum score of 75 points being the higher the score achieved, the greater the limitation to perform ADL due to dyspnea.[11]

Measurement of the isometric muscular force of the UL was obtained from the amount of hand grip strength measured by a manual dynamometer in force per kilogram (kgf), which is recommended by the American Society of Hand Therapists. Five (MVC) were performed by the dominant arm with a rest interval of 30 s. The mean of the repetitions was used for statistical analysis based on the values.

Statistical analysis

Eta coefficient was used to see the measure of association between a categorical variable BODE index and all the other interval variables such as age, grip strength, and LCADL. The Spearman's rank correlation coefficient was used after binning the interval variable to see the association with BODE index. The analysis of variance was done to see whether, Grip strength and LCADL vary among the BODE index.


  Results Top


The Eta correlation coefficient of the BODE index and age was 69%, with grip strength 76.2%, and with LCADL it was 70.1%.

Spearman's rank correlation coefficient

The spearman's rank correlation coefficient showed except age other variables such as grip strength and LCADL were statistically significant [Table 1].
Table 1: Association of BODE index using Eta coefficients and Spearman's rank correlation coefficient

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As shown in [Table 2] and [Table 3], ANOVA was used to analyze whether age, grip strength, and LCADL are equally distributed among the BODE index groups. Except age, it shows that the other variables, grip strength, and LCADL were statistically significant P <0.05.
Table 2: ANOVA: London chest activity of daily living scale

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Table 3: ANOVA: Grip strength

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Therefore, the result states that the Eta coefficients showed the strength or the measure of associations with the BODE index and the age, grip strength, and LCADL. Spearman's correlation coefficient shows that there is an inverse association with grip strength and LCADL, and it was statistically significant as the P <0.05.


  Discussion Top


There was a statistically significant difference between the quartiles as determined by one-way ANOVA (F (3,62) =7.804, P ≤ 0.001). A Dunne's T3 post hoc test revealed that the LCADL was statistically significantly lower in the higher quartiles. We can see that the significance level is ≤0.001 (P ≤ 0.001), which is below 0.05. Therefore, there is a statistically significant difference in the mean of LCADL scale between the different quartiles of BODE index.

The peripheral muscle dysfunction induced by COPD has an important impact on functional capacity. It is observed that as the disease progress the functional capacity is compromised making patients more disabled or dependent in performing ADL. Furthermore, it is common for these patients to report greater difficulty in performing ADL with the ULs than in activities that involve the LLs such as walking.[12]

Activities with the arms raised without support can lead to thoracoabdominal asynchrony and dyspnea even at lower intensities than activities performed with LLs. It is likely to occur more often in patients whose the Dynamic hyperinflation factor is present during exercise, limiting, therefore, the ADLs. In fact, a recent study showed that patients with greater dynamic hyperinflation perform fewer ADLs.[13],[14]

In this study, patients with higher ADL limitation correlated with higher BODE mortality index scores. Comparing the LCADL scores among the patients from the four quartiles of the BODE, all the patients from the quartile 1, 2, 3, and 4 showed a significantly higher score. Compared to the patients from the other quartiles groups quartile 3 and 4 showed a very highly significant score (P <0.05).

Grip strength had statistically significant difference between the quartiles as determined by one-way ANOVA (F (3,62) =21.449, P ≤ 0.001). A Dunne's T3 post hoc test revealed that grip strength decreased accordingly to quartiles, but highly sig decreased in higher quartiles.

With regard to peripheral muscle impairment, it was stated such impairment, with a consequent reduction of exercise capacity in patients with COPD may be due to low BMI, it can be due not only to a reduction in muscle mass but also to nutritional depletion, which results in low energy reserves that limit the execution of activities.[15]

In this study, however, the patients presented reduced UL grip strength, but the majority also had a normal BMI. These results support the idea that BMI may not adequately identify the loss of muscle mass in patients with COPD, other factors that may be associated with a weak UL musculature include prolonged use of corticosteroids cause protein degradation.[7],[16]

COPD patients who had high mortality score 5–6 (Q1), and 7–10 (Q2) have more decreased physical activity due to the disease condition and decreased functional capacity and increased dyspnoea level. Therefore, the grip strength and ADL is much restricted in these populations than Q1 and Q2. The present study had limitations. The sample size was small. Larger muscle groups like would have been used for assessing strength to correlate.

These data do support the hypothesis that there is a correlation between the BODE index and the variables assessed in LCADL, and HGT, suggesting their use in a predictive index of physical exercise capacity, perhaps used as a complement to the BODE index.


  Acknowledgment Top


The authors would like to thank the Department of Pulmonology for helping in screening the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Menezes AM, Perez-Padilla R, Jardim JR, Muiño A, Lopez MV, Valdivia G, et al. Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): A prevalence study. Lancet 2005;366:1875-81.  Back to cited text no. 1
    
2.
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease; 2008. Available from: http://www.goldcopd.org/uploads/users/files/GOLD_Report2014_Feb07.pdf. [Last accessed on 2014 Jun 19].  Back to cited text no. 2
    
3.
Donaldson GC, Seemungal TA, Patel IS, Bhowmik A, Wilkinson TM, Hurst JR, et al. Airway and systemic inflammation and decline in lung function in patients with COPD. Chest 2005;128:1995-2004.  Back to cited text no. 3
    
4.
Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005;171:972-7.  Back to cited text no. 4
    
5.
Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005-12.  Back to cited text no. 5
    
6.
Garrod R, Bestall JC, Paul EA, Wedzicha JA, Jones PW. Development and validation of a standardized measure of activity of daily living in patients with severe COPD: The London Chest Activity of Daily Living scale (LCADL). Respir Med 2000;94:589-96.  Back to cited text no. 6
    
7.
Gosselink R, Troosters T, Decramer M. Distribution of muscle weakness in patients with stable chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2000;20:353-60.  Back to cited text no. 7
    
8.
Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006;173:1390-413.  Back to cited text no. 8
    
9.
Sirguroh A, Ahmed S. Hand grip strength in patients with chronic obstructive pulmonary disease. Int J Curr Res Rev 2012;4:168-73.  Back to cited text no. 9
    
10.
Skumlien S, Hagelund T, Bjørtuft O, Ryg MS. A field test of functional status as performance of activities of daily living in COPD patients. Respir Med 2006;100:316-23.  Back to cited text no. 10
    
11.
Garrod R, Paul EA, Wedzicha JA. An evaluation of the reliability and sensitivity of the London Chest Activity of Daily Living scale (LCADL). Respir Med 2002;96:725-30.  Back to cited text no. 11
    
12.
Pitta F, Troosters T, Probst VS, Lucas S, Decramer M, Gosselink R. Potential consequences for stable chronic obstructive pulmonary disease patients who do not get the recommended minimum daily amount of physical activity. J Bras Pneumol 2006;32:301-8.  Back to cited text no. 12
    
13.
Celli BR, Rassulo J, Make BJ. Dyssynchronous breathing during arm but not leg exercise in patients with chronic airflow obstruction. N Engl J Med 1986;314:1485-90.  Back to cited text no. 13
    
14.
Garcia-Rio F, Lores V, Mediano O, Rojo B, Hernanz A, López-Collazo E, et al. Daily physical activity in patients with chronic obstructive pulmonary disease is mainly associated with dynamic hyperinflation. Am J Respir Crit Care Med 2009;180:506-12.  Back to cited text no. 14
    
15.
Mador MJ. Muscle mass, not body weight, predicts outcome in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2002;166:787-9.  Back to cited text no. 15
    
16.
Gosselink R, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med 1996;153:976-80.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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