Literature Review: 6PBRT and UULEX as an Unsupported Upper Limb test in People with Respiratory and Musculoskeletal disability
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Published:
Jun 17, 2025
Keywords:
upper extremity function, pulmonary rehabilitation, exercise rehabilitation, exercise test, chronic obstructive pulmonary disease, activities of daily living.
Main Article Content
Abstract
Upper limb (UL) function is essential for daily activities, yet it is often overlooked in rehabilitation programs for individuals with respiratory and musculoskeletal disabilities. The six-minute pegboard and ring test (6PBRT) and the unsupported upper limb exercise test (UULEX) are two validated tools for assessing UL functional capacity. These tests simulate daily UL movements, measuring endurance, strength, and coordination, particularly in patients with chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, asthma, bronchiectasis, interstitial lung disease, and pulmonary hypertension. Research suggests that UL exercises improve dyspnea, endurance, and activities of daily living (ADLs), supporting their integration into rehabilitation programs. This review explores the methodology, clinical applications, and benefits of 6PBRT and UULEX, highlighting their role in comprehensive patient assessment and functional rehabilitation.
Keyword: upper extremity function, pulmonary rehabilitation, exercise rehabilitation, exercise test, chronic obstructive pulmonary disease, activities of daily living.
Keyword: upper extremity function, pulmonary rehabilitation, exercise rehabilitation, exercise test, chronic obstructive pulmonary disease, activities of daily living.
Article Details
How to Cite
Sunarjo, P., Nusdwinurintyas, N., & Clements. (2025). Literature Review: 6PBRT and UULEX as an Unsupported Upper Limb test in People with Respiratory and Musculoskeletal disability. Indonesian Journal of Physical Medicine and Rehabilitation, 14(1), 128 - 134. https://doi.org/10.36803/indojpmr.v14i1.473
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Literature Review
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References
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2. LEIDY NK. Functional Status and the Forward Progress of Merry-Go-Rounds. Nursing Research. 1994 Jul;43(4):196???202.
3. Takeda K, Kawasaki Y, Yoshida K, Nishida Y, Harada T, Yamaguchi K, et al. The 6-minute pegboard and ring test is correlated with upper extremity activity of daily living in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease. 2013 Jul;8:347.
4. Kruapanich C, Tantisuwat A, Thaveeratitham P, Lertmaharit S, Ubolnuar N, Mathiyakom W. Effects of Different Modes of Upper Limb Training in Individuals With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Annals of Rehabilitation Medicine. 2019 Oct 31;43(5):592–614.
5. Bui KL, Nyberg A, Maltais F, Saey D. Functional Tests in Chronic Obstructive Pulmonary Disease, Part 1: Clinical Relevance and Links to the International Classification of Functioning, Disability, and Health. Annals of the American Thoracic Society. 2017 May;14(5):778–84.
6. Bui KL, Nyberg A, Maltais F, Saey D. Functional Tests in Chronic Obstructive Pulmonary Disease, Part 2: Measurement Properties. Annals of the American Thoracic Society. 2017 May;14(5):785–94.
7. Felisberto R, Barros C, Nucci K, Albuquerque AL, Paulin E, Brito C, et al. Is the 6-minute pegboard and ring test valid to evaluate upper limb function in hospitalized patients with acute exacerbation of COPD? International Journal of Chronic Obstructive Pulmonary Disease. 2018 May;Volume 13:1663–73.
8. Lima VP, Velloso M, Pessoa BP, Almeida FD, Ribeiro-Samora GA, Janaudis-Ferreira T. Reference values for the Unsupported Upper Limb Exercise test in healthy adults in Brazil. Jornal Brasileiro de Pneumologia. 2020;46(1).
9. Cetin SY, Basakci Calik B, Ayan A, Cavlak U. Validity and reliability of the unsupported upper‐limb exercise test in individuals with rheumatoid arthritis. International Journal of Rheumatic Diseases. 2019 Oct 9;22(11):2025–30.
10. Calik-Kutukcu E, Tekerlek H, Bozdemir-Ozel C, Karaduz BN, Cakmak A, Inal-Ince D, et al. Validity and reliability of 6-minute pegboard and ring test in patients with asthma. Journal of Asthma. 2021 May 31;59(7):1387–95.
11. Cakmak A, Kocaaga E, Sonbahar-Ulu H, Inal-Ince D, Vardar-Yagli N, Calik-Kutukcu E, et al. Upper Extremity Exercise Capacity and Activities of Daily Living in Individuals With Bronchiectasis Versus Healthy Controls. Physical Therapy [Internet]. 2023 Apr 4;103(4):pzad012. Available from: https://pubmed.ncbi.nlm.nih.gov/37086209/
12. Mendes P, Wickerson L, Helm D, Janaudis-Ferreira T, Brooks D, Singer LG, et al. Skeletal muscle atrophy in advanced interstitial lung disease. Respirology. 2015 Jun 17;20(6):953–9.
13. Özcan Kahraman B. Effect of disease severity on upper extremity muscle strength, exercise capacity, and activities of daily living in individuals with pulmonary arterial hypertension. Turk Kardiyoloji Dernegi Arsivi-Archives of the Turkish Society of Cardiology. 2017;45(5):434–40.
14. Arena R, Cahalin LP, Borghi-Silva A, Phillips SA. Improving functional capacity in heart failure: The need for a multifaceted approach. Current Opinion in Cardiology [Internet]. 2014;29(5):467–74. Available from: https://www.mendeley.com/catalogue/722dd65a-f560-37ec-9fb2-03c18af50172/?utm_source=desktop&utm_medium=1.19.8&utm_campaign=open_catalog&userDocumentId=%7Bea528a42-35c4-4690-95e3-da234e030842%7D8
15. Patterson TL, Mausbach BT. Measurement of Functional Capacity: A New Approach to Understanding Functional Differences and Real-world Behavioral Adaptation in Those with Mental Illness. Annual review of clinical psychology [Internet]. 2010 Apr 27;6:139–54. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160788/
16. Ohara DG, Melo C de S, Reis IMM dos, Jamami M. Functional capacity assessment of upper limbs in healthy young adult subjects. Fisioterapia em Movimento. 2017 Mar;30(1):159–67.
17. Edemekong PF, Bomgaars DL, Levy SB. Activities of Daily Living (ADLs) [Internet]. NCBI. StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470404/
18. KATZ S. Assessing Self-maintenance: Activities of Daily Living, Mobility, and Instrumental Activities of Daily Living. Journal of the American Geriatrics Society [Internet]. 1983 Dec;31(12):721–7. Available from: https://pubmed.ncbi.nlm.nih.gov/6418786/
19. Lima VP, Velloso M, Almeida FD, Carmona B, Ribeiro-Samora GA, Janaudis-Ferreira T. Test–retest reliability of the unsupported upper-limb exercise test (UULEX) and 6-min peg board ring test (6PBRT) in healthy adult individuals. Physiotherapy Theory and Practice. 2018 Jan 19;34(10):806–12.
20. Lima VP, Brooks D, Konidis S, Araújo T, Ribeiro-Samora GA, Goldstein R, et al. Normative Values for the Unsupported Upper Limb Exercise Test and 6-Minute Pegboard and Ring Test in Healthy Canadian Adults. Physiotherapy Canada. 2020 Mar 30;72(4):e20190021.
21. Zhan S, Cerny FJ, Gibbons WJ, Mador MJ, Wu YW. Development of an Unsupported Arm Exercise Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation. 2006 May;26(3):180–7.
22. Takahashi T, Jenkins SC, Strauss GR, Watson CP, Lake FR. A New Unsupported Upper Limb Exercise Test for Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation. 2003 Nov;23(6):430–7.
23. Franklin BA. Exercise Testing, Training and Arm Ergometry. Sports Medicine. 1985;2(2):100–19.
24. Janaudis-Ferreira T, Beauchamp MK, Goldstein RS, Brooks D. How Should We Measure Arm Exercise Capacity in Patients With COPD? Chest. 2012 Jan;141(1):111–20.
25. Kulkarni MS, Alaparthi GK, Krishnan S, Ramakrishna A, Acharya V. Reference value for the six-minute peg board and ring test. A cross sectional study. Multidisciplinary Respiratory Medicine. 2020 Jun 3;15(1).
26. McKeough ZJ, Velloso M, Lima VP, Alison JA. Upper limb exercise training for COPD. Cochrane Database of Systematic Reviews. 2016 Nov 15;11(11).
27. Elmorsy AS, Mansour AE, Okasha AE. Effect of upper limb, lower limb and combined training on exercise performance, quality of life and survival in COPD. Egyptian Journal of Chest Diseases and Tuberculosis. 2012 Jul;61(3):89–93.
28. Matsunaga H, Hitoshi Ayabe, Tomotoshi Imanaga, Moriwaki A, Eto J, Kikuchi C, et al. Effects Of Upper Limb And Thoracic Muscle Exercise In Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine. 2011 May 1;183:A1476–6.
29. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Hand-held Dynamometry Correlation With the Gold Standard Isokinetic Dynamometry: A Systematic Review. PM&R [Internet]. 2011 May;3(5):472–9. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1934148210013250
2. LEIDY NK. Functional Status and the Forward Progress of Merry-Go-Rounds. Nursing Research. 1994 Jul;43(4):196???202.
3. Takeda K, Kawasaki Y, Yoshida K, Nishida Y, Harada T, Yamaguchi K, et al. The 6-minute pegboard and ring test is correlated with upper extremity activity of daily living in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease. 2013 Jul;8:347.
4. Kruapanich C, Tantisuwat A, Thaveeratitham P, Lertmaharit S, Ubolnuar N, Mathiyakom W. Effects of Different Modes of Upper Limb Training in Individuals With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Annals of Rehabilitation Medicine. 2019 Oct 31;43(5):592–614.
5. Bui KL, Nyberg A, Maltais F, Saey D. Functional Tests in Chronic Obstructive Pulmonary Disease, Part 1: Clinical Relevance and Links to the International Classification of Functioning, Disability, and Health. Annals of the American Thoracic Society. 2017 May;14(5):778–84.
6. Bui KL, Nyberg A, Maltais F, Saey D. Functional Tests in Chronic Obstructive Pulmonary Disease, Part 2: Measurement Properties. Annals of the American Thoracic Society. 2017 May;14(5):785–94.
7. Felisberto R, Barros C, Nucci K, Albuquerque AL, Paulin E, Brito C, et al. Is the 6-minute pegboard and ring test valid to evaluate upper limb function in hospitalized patients with acute exacerbation of COPD? International Journal of Chronic Obstructive Pulmonary Disease. 2018 May;Volume 13:1663–73.
8. Lima VP, Velloso M, Pessoa BP, Almeida FD, Ribeiro-Samora GA, Janaudis-Ferreira T. Reference values for the Unsupported Upper Limb Exercise test in healthy adults in Brazil. Jornal Brasileiro de Pneumologia. 2020;46(1).
9. Cetin SY, Basakci Calik B, Ayan A, Cavlak U. Validity and reliability of the unsupported upper‐limb exercise test in individuals with rheumatoid arthritis. International Journal of Rheumatic Diseases. 2019 Oct 9;22(11):2025–30.
10. Calik-Kutukcu E, Tekerlek H, Bozdemir-Ozel C, Karaduz BN, Cakmak A, Inal-Ince D, et al. Validity and reliability of 6-minute pegboard and ring test in patients with asthma. Journal of Asthma. 2021 May 31;59(7):1387–95.
11. Cakmak A, Kocaaga E, Sonbahar-Ulu H, Inal-Ince D, Vardar-Yagli N, Calik-Kutukcu E, et al. Upper Extremity Exercise Capacity and Activities of Daily Living in Individuals With Bronchiectasis Versus Healthy Controls. Physical Therapy [Internet]. 2023 Apr 4;103(4):pzad012. Available from: https://pubmed.ncbi.nlm.nih.gov/37086209/
12. Mendes P, Wickerson L, Helm D, Janaudis-Ferreira T, Brooks D, Singer LG, et al. Skeletal muscle atrophy in advanced interstitial lung disease. Respirology. 2015 Jun 17;20(6):953–9.
13. Özcan Kahraman B. Effect of disease severity on upper extremity muscle strength, exercise capacity, and activities of daily living in individuals with pulmonary arterial hypertension. Turk Kardiyoloji Dernegi Arsivi-Archives of the Turkish Society of Cardiology. 2017;45(5):434–40.
14. Arena R, Cahalin LP, Borghi-Silva A, Phillips SA. Improving functional capacity in heart failure: The need for a multifaceted approach. Current Opinion in Cardiology [Internet]. 2014;29(5):467–74. Available from: https://www.mendeley.com/catalogue/722dd65a-f560-37ec-9fb2-03c18af50172/?utm_source=desktop&utm_medium=1.19.8&utm_campaign=open_catalog&userDocumentId=%7Bea528a42-35c4-4690-95e3-da234e030842%7D8
15. Patterson TL, Mausbach BT. Measurement of Functional Capacity: A New Approach to Understanding Functional Differences and Real-world Behavioral Adaptation in Those with Mental Illness. Annual review of clinical psychology [Internet]. 2010 Apr 27;6:139–54. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160788/
16. Ohara DG, Melo C de S, Reis IMM dos, Jamami M. Functional capacity assessment of upper limbs in healthy young adult subjects. Fisioterapia em Movimento. 2017 Mar;30(1):159–67.
17. Edemekong PF, Bomgaars DL, Levy SB. Activities of Daily Living (ADLs) [Internet]. NCBI. StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470404/
18. KATZ S. Assessing Self-maintenance: Activities of Daily Living, Mobility, and Instrumental Activities of Daily Living. Journal of the American Geriatrics Society [Internet]. 1983 Dec;31(12):721–7. Available from: https://pubmed.ncbi.nlm.nih.gov/6418786/
19. Lima VP, Velloso M, Almeida FD, Carmona B, Ribeiro-Samora GA, Janaudis-Ferreira T. Test–retest reliability of the unsupported upper-limb exercise test (UULEX) and 6-min peg board ring test (6PBRT) in healthy adult individuals. Physiotherapy Theory and Practice. 2018 Jan 19;34(10):806–12.
20. Lima VP, Brooks D, Konidis S, Araújo T, Ribeiro-Samora GA, Goldstein R, et al. Normative Values for the Unsupported Upper Limb Exercise Test and 6-Minute Pegboard and Ring Test in Healthy Canadian Adults. Physiotherapy Canada. 2020 Mar 30;72(4):e20190021.
21. Zhan S, Cerny FJ, Gibbons WJ, Mador MJ, Wu YW. Development of an Unsupported Arm Exercise Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation. 2006 May;26(3):180–7.
22. Takahashi T, Jenkins SC, Strauss GR, Watson CP, Lake FR. A New Unsupported Upper Limb Exercise Test for Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation. 2003 Nov;23(6):430–7.
23. Franklin BA. Exercise Testing, Training and Arm Ergometry. Sports Medicine. 1985;2(2):100–19.
24. Janaudis-Ferreira T, Beauchamp MK, Goldstein RS, Brooks D. How Should We Measure Arm Exercise Capacity in Patients With COPD? Chest. 2012 Jan;141(1):111–20.
25. Kulkarni MS, Alaparthi GK, Krishnan S, Ramakrishna A, Acharya V. Reference value for the six-minute peg board and ring test. A cross sectional study. Multidisciplinary Respiratory Medicine. 2020 Jun 3;15(1).
26. McKeough ZJ, Velloso M, Lima VP, Alison JA. Upper limb exercise training for COPD. Cochrane Database of Systematic Reviews. 2016 Nov 15;11(11).
27. Elmorsy AS, Mansour AE, Okasha AE. Effect of upper limb, lower limb and combined training on exercise performance, quality of life and survival in COPD. Egyptian Journal of Chest Diseases and Tuberculosis. 2012 Jul;61(3):89–93.
28. Matsunaga H, Hitoshi Ayabe, Tomotoshi Imanaga, Moriwaki A, Eto J, Kikuchi C, et al. Effects Of Upper Limb And Thoracic Muscle Exercise In Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine. 2011 May 1;183:A1476–6.
29. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Hand-held Dynamometry Correlation With the Gold Standard Isokinetic Dynamometry: A Systematic Review. PM&R [Internet]. 2011 May;3(5):472–9. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1934148210013250