Low Handgrip Strength in COPD Associated With Flare-ups

Low Handgrip Strength Is A Marker of Frailty 

Background: Frailty occurs with aging. Two components of frailty are muscle weakness and unintentional weight loss of more than 10 pounds. Handgrip strength is a measure muscle weakness and is a strong predictor of all cause mortality in the general population.

Device to measure handgrip strength

Device to measure handgrip strength

However, the importance of strength of the hand muscles in those with COPD is unknown.

D.r Martinez is the first author of study of handgrip strength

Dr. Carlos Martinez is Assistant Professor of Medicine at the University of Michigan School of Medicine

Study: Dr. Carlos Martinez and colleagues evaluated handgrip strength in 272 patients with COPD who were participants in a study called COPDGene funded by the National Institutes of Health. Subjects recorded the number of COPD flare-ups (exacerbations) in the past year and during 2 years of follow-up. The study was published in the November 2017 issue of the Annals of the American Thoracic Society (volume 14; pages 1638-1645).

Results: Subjects: Average age was 65 years; 45% were women; and 8% were African-American. During the previous year, 31% had a flare-up.

Handgrip Strength: 65% of the subjects had low handgrip strength compared with 15% in those living in a community without COPD. It was associated with lung function (amount of air exhaled in one second – called FEV1), shortness of breath, and distance walked in six minutes (called 6 minute walk test). The authors calculated that for every 1-kilogram decrease in handgrip strength, there was a 5% higher risk of having a flare-up.

Conclusions: Low muscle strength measured by handgrip testing was associated with a higher risk of a flare-up.

My Comments: Low handgrip strength is a marker of reduced physical performance in the elderly and has been shown to be a risk factor for all-cause death as well as cardiovascular mortality.

Resistance training can increase muscle strength

Woman with COPD doing arm curls with hand weights.

These findings of the study support the need for early identification of  muscle weakness in those with COPD. In addition, the results suggest that such individuals should be participate in physical therapy and/or in pulmonary rehabilitation. Resistance training 2 -3 times a week using light weights or stretch bands can increase general muscle strength including the muscles used for hand gripping.

Highlights from European Respiratory Society Congress

September 26 – 30, 2015, in Amsterdam

One of the highlights of the International Congress was a session on improving outcomes in those with COPD. A major emphasis was on the current goals of treatment:

  1. Reduce shortness of breath – which can generally be measured in a few weeks of starting a new inhaled bronchodilator medication
  2. Reducing the risk of an exacerbation (worsening of symptoms usually due to a chest infection) – this requires at least six months to assess.
David Singh, M.D., from University of Manchester in UK

David Singh, M.D., from University of Manchester in UK

Dr. David Singh of Manchester, United Kingdom, spoke about optimizing bronchodilation (opening the airways). He quoted one study that showed that most patients with COPD were still short of breath with activities after being started on a single long-acting  bronchodilator (Primary Care Respiratory Journal, year 2011, volume 20, page 46). He then discussed the role of using two different bronchodilators in a single inhaler to get the greatest benefit. In the US, there are two approved dual bronchodilators in a single inhaler – Anoro Ellipta and Stiolto Respimat. The evidence suggests that two bronchodilator medications that work in different ways can provide better stability in keeping the breathing tubes open longer. This means that it should be easier to breathe for those with COPD and should have a better quality of life.


Dr. Marc Miravitlies of the University Hospital in Barcelona, Spain, discussed both daytime and nighttime shortness of breath (medical word is dyspnea) in those with COPD. Studies show that many

Marc Miravitlles, M.D., of University Hospital in Barcelona, Spain

Marc Miravitlles, M.D., of University Hospital in Barcelona, Spain

individuals who have COPD wake up due to breathing difficulty. Also, poor sleep is considered a risk factor for having an exacerbation (worsening of shortness of breath and/or coughing up yellow-green mucus). Bronchodilators that work throughout the night should help if the sleep problem is due to COPD, but will not help if there is another cause like sleep apnea.

Dr. Neil Barnes, Medical Head of GlaxoSmithKline pharmaceutical company, spoke about the benefits and side effects of using inhaled corticosteroids (prednisone like medication). He emphasized that inhaled corticosteroids combined with long-acting beta-agonist bronchodilator (in US: brand names are Advair, Symbicort, and Breo) are widely prescribed, but should primarily be used in those who have had two or more exacerbations (worsening of symptoms) in the past year OR one exacerbation in the past year that required treatment in the hospital. A major concern about the use of

Neil Barnes, M.D., Medical Head of GalxoSmithKline pharmaceutical company

Neil Barnes, M.D., Medical Head of GlaxoSmithKline pharmaceutical company

inhaled corticosteroids is the risk of developing pneumonia.



My Comment: Each year at medical conferences there is growing research interest in helping those with COPD. Novel therapies are being evaluated in addition to improving inhaled bronchodilators. All of us need to promote greater public awareness of COPD and encourage the National Institute of Health, various professional organizations, and pharmaceutical companies to increase research funding.

For COPD Flare-ups: Stop Smoking, Pulmonary Rehab, and Medications

Preventing COPD Flare-ups or Exacerbations 

In the April 2015 issue of the journal CHEST (volume 147; pages 883-893), Criner and co-authors summarize available treatments that can help to reduce the chances of a COPD flare-up, also called an exacebation.

Dr. Criner wrote about preventing COPD flare-ups

Gerald Criner, M.D., Chair and Professor, Thoracic Medicine and Surgery at Temple University

The authors divided the types of treatment into three categories. These recommendations are based on studies for preventing a flare-up (exacerbation), but these treatments may also improve shortness of breath and quality of life.

Non-pharmacologic and vaccinations 

  1. flu vaccine
  2. stop smoking (counseling and treatments)
  3. pulmonary rehabilitation if the flare-up was within the past 4 weeks
  4. case management with direct access to a health care specialist at least monthly
  5. education about flare-ups with a written action plan and case management

 Inhaled medications (both beta-agonist and muscarinic antagonists are types of bronchodilators)

  1. long-acting beta-agonist
  2. long-acting muscarinic antagonist
  3. short-acting beta-agonist plus a short-acting muscarinic antagonist
  4. inhaled corticosteroid and long-acting beta-agonist combination
  5. long-acting beta-agonist and long-acting muscarinic antagonist

Oral medications

  1. long-term macrolide antibiotic (dose and duration of treatment are unknown)
  2. roflumilast (for those with chronic bronchitis form of COPD and a history of at least one flare-up in the previous year)
  3. theophylline
  4. N-acetylcysteine

If you have recently experienced one or more COPD flare-ups, you may wish to ask your doctor about these treatments to help reduce the chances of having another flare-up. For the inhaled medications, the different generic types are listed with the understanding that there are many specific brand names.