2. Introduction
Definitions
Team members
Symptoms
Pathophysiology
Aims or goals of Pulmonary Rehabilitation
Selection of patient
Assessment
Pulmonary rehabilitation components
Physical therapy care
Recent advances
References
3. Rehabilitation programs for patients with pulmonary
disease have existed for more than 25 years.
The American Thoracic Society position paper and most
of the research have shown the benefits of rehabilitation
for patients with COPD.
The need for early detection and treatment of respiratory
dysfunction is widely accepted.
4. Rehabilitation research is beginning to emphasize
functional outcomes such as improvement in lung
function, heart function, to improve maximal aerobic
capacity and decrease mortality rate.
It is concerned with the issues of disability.
5. Pulmonary Rehabilitation as defined by National
Institute of Health(1994) is “A multi-disciplinary
continuum of services directed to persons with
pulmonary disease and their families, usually by an
interdisciplinary team of specialists, with the goal of
achieving and maintaining the individual’s maximum
level of independence and functioning in the
community”
Physiotherapists play an integral part in management by
giving the techniques aimed to reduce the work of
breathing and improving disability.
6. It is an holistic approach to treatment of patients and their
families with respiratory disease and requires number of
health professionals such as:
The Advisory Board
The Medical Director
The Program Director
The Respiratory Care Specialist
The Exercise Specialist
The nutritionist or Dietitian
The Behavior Specialist
7. The main symptom is dyspnoea which is associated
with anxiety and fear.
Limitations during daily life and reductions in exercise
tolerance
Leg fatigue at lower work intensities compared to
normals.
8. Peripheral muscle dysfunction
Atrophy of muscles
Altered metabolism
Reduction in
type I &II
fibres
Corticosteroid
damage
Cachexia and
cytokine
production
Nutritional
defects
9. Reduce dyspnoea
Increase muscle endurance(peripheral and
respiratory)
Improve muscle strength(peripheral and respiratory)
Ensure long term commitment to exercise
To remove fear and anxiety
Increase knowledge of lung condition and promote
self-management
Improve nutritional status and health status
12. Exposure to risks for COPD
-cigarette smoking
-occupational exposure
-air pollution
-infections of lungs
-impaired immune defenses
Chest wall
- chest wall surgeries
- Intra-thoracic surgeries
All patients with respiratory symptoms of wheezing,
coughing or dyspnoea require preventive care.
13. Patients with severe limitation in their chest mobility
Inability to learn
Pyschiatric instability
Disruptive behaviour
Unstable angina
14. Assessment of patient should be done and than
followed by problem list, goals should be made for
proper pulmonary rehabilitation.
It includes:
1. history
(history of presenting illness, previous medical history,
drug history, family history, social history)
2.subjective assessment
15. -breathlessness (dyspnoea), cough,sputum and haemoptysis,
wheeze, chest pain, incontinence and other symptoms like
fever headache and peripheral oedema
-activity of daily living of patient by:
London Chest Activity Of Daily Living Scale (Garrod et al
2000)
-activity of health related quality of life by:
Chronic Respiratory Questionnaire(Guyatt et al 1987) and St
George’s Respiratory Questionnaire(Jones et al 1991)
-for dyspnoea by:
Baseline and Transition Dyspnoea Index(BDI)(Mahier et al
1984) and Medical Research Council Breathlessness
Score(Fletcher et al 1960), Borg Scale Of Perceived
Dyspnoea(Borg 1982)
16.
17.
18. 3.Objective assessment
- general observation like patient’s position, any drips,
drains, oxygen supply etc
-observation of chest shape, breathing pattern, chest
movement
-palpation of trachea position, chest expansion
-percussion
-auscultation(breath sounds, any abnormal sounds, heart
sounds)
-exercise capacity of patient
-examination of heart rate, blood pressure, respiratory
rate,spirometry
4.Test results
-ABG analysis, chest radiographs
19. General care
Pulmonary care
Exercise and functional training
Education
Pyschosocial management
Physical therapy management
20. General care
-As soon as patient comes, evaluation should be done for
medical and physical diagnosis
-Prescription of medicine and oxygen support
-Preventive care(smoking cessation, adequate hydration,
proper nutrition etc)
Pulmonary care
-respiratory treatment techniques for clearing accumulated
pulmonary secretions include:
-bronchial drainage
-breathing techniques
21. -cough facilitation
-postures to improve breathing
-relaxation techniques
-respiratory assistance devices to rest the breathing muscles
at night or during exercise
Exercise and functional testing
-instructions for energy conservation, activity pacing and
use of adaptive equipment to optimize the patient ability
for daily activities
Education
-to provide knowledge and instruction to their family
members and patient regarding disease, its effect,
treatment etc
22. Psychosocial management
-its important as chronic disease places stress on family
members as well as for patient
-so to provide them with coping strategies, stress
reduction, management techniques, behavioral
strategies, and financial assistance as possible
Physical therapy management
-physical therapy not only conduct exercise sessions,
they can also provide education regarding
educational sessions, smoking cessation programs,
weight control and stress management and relaxation
techniques.
23. It depends whether exercises are to be prescribed for
strength and endurance and than see the muscle
response.
It is based on three components :
1)frequency of training
2)duration of training
3)Intensity of training
4)Mode of exercise
24. How often? Daily /*2 week/*3 week
How long? 4 weeks/8 weeks/12 weeks
Length of sessions 40-60 minutes
Time of day afternoons/mornings
Exercise? Resisted/unloaded
training/aerobic/walking
Intensity? Limited by dyspnoea
(borg scale)/by VO2 peak
Regimen? Endurance/maximal
Assessment? Physiological/ functional
25. Physiological response to training
Improved mechanical efficiency
Improvement in mechanical efficiency can improve stride length and
gait coordination.
Cardiovascular
Reduction in heart rate, minute ventilation ,lowering of onset of
lactic acidosis, lowering maximum oxygen uptake.
Muscle changes
With endurance training , submaximal sustained effort result in
transformation from type IIb to type IIa fibres, increasing their
oxidative capacity.
With strength training, increase in size of muscle cells and number of
myofibrils. So to improve oxygen uptake and ability to maintain
aerobic muscle metabolism for prolonged period.
26. To measure exercise tolerance, laboratory test and field
test can be used.
It is needed to set intensity ,assess the benefit of
rehabilitation program, motivate the patient with exercise
Laboratory test measuring maximal oxygen consumption,
heart rate, workload, arterial oxygenation, blood lactate
levels
Field test like 12 min walking test and shuttle walking test
are used.
27. Pulmonary care
Indications:
1) removal of excessive secretions that lead to:
-obstruction of airways
-ventillatory defects
-produce symptoms of cough
-increase respiratory infections
-deterioration of lung function
2)when secretions are copious ,patients are chronic
28. -following treatment can be given based on patients
evaluation
Modified bronchial drainage position. foams or cushions
can be used to assume trendelenburg position.
For percussion and vibration if adequate assistance is not
there, palm cups, mechanical percussors, high frequency
chest compression system
Series of deep breathing exercise, forced
expirations(huffing), coughing, ACBT, autogenic drainage
use of mask providing positive expiratory pressure.
Sustained exercise
Diaphragmatic breathing, pursed lip breathing can be
given to improve lung function.
29.
30. To see whether patients can do it effectively and
independently
Short term goals
Long term goals
Functional training
Indications
For this
-environment modification
-task modification
-relief of dyspnoea
31.
32. Physical conditioning
Goals
According to patient condition,i.e
-patients with mild lung disease
-patients with moderate lung disease
-patient with severe lung disease
Strengthening
Goals
Lower extremity strengthening
Upper extremity strengthening
33.
34. Flexibility
Due to COPD, there is significant changes in posture and
reduced mobility
Indications
Exercises
Purpose
Respiratory muscle exercise
Exercise for improving respiratory muscle function are
important component of pulmonary rehabilitation.
The increased work of breathing and chest wall changes
with COPD make respiratory muscle fatigue
35. Two approaches for improving respiratory muscle fatigue:
Exercises
36. Progressive Resistance Exercise in Physical Therapy: A
Summary of Systematic Reviews
Nicholas F Taylor, Karen J Dodd and Diane L Damiano
PHYS THER. 2005; 85:1208-1223
Result showed that PRE was shown to improve the
ability to generate force, with moderate to large effect
sizes that may carry over into an improved ability to
perform daily activities
37. Impact of inspiratory muscle training in patients with
COPD: what is the evidence?
(R. Gosselink, J. De Vos, S.P. van den Heuvel, J. Segers,M.
Decramer,G. Kwakkel)
A meta-analysis including 32 randomised controlled trials
on the effects of inspiratory muscle training (IMT) in
chronic obstructive pulmonary disease (COPD) patients was
performed.
IMT improves inspiratory muscle strength and endurance,
functional exercise capacity,dyspnoea and quality of life.
Inspiratory muscle endurance training was shown to be less
effective than respiratory muscle strength training. In
patients with inspiratory muscle weakness the addition of
IMT to a general exercise training program improved PI,max
and tended to improve exercise performance.
38. H.Steven Sadowsky,Ellen A. Hillegass. Essentials of
cardiopulmonary physical therapy.
Jennifer A Pryor,S Ammani Prasad.Physiotherapy for
respiratory and cardiac problems(3rd edition)
Robert.L.Williams,James K. Stroller,Robert
M.kacmarek. Fundamentals of respiratory care(9th
edition)
Scot Irwin,Jan Stephen Tecklin.Cardiopulmonary
physical therapy(2nd edition)
-
39. Susan B O’Sullivan,Thomas J Schmitz.Physical
Rehabilitation(5th edition)
R. Gosselink,J. De Vos, S.P. van den Heuvel,J. Segers,M.
Decramer and G. Kwakkel. Impact of inspiratory
muscle training in patients with COPD: what is the
evidence? Eur Respir J 2011; 37: 416–425
Nicholas F Taylor, Karen J Dodd and Diane L Damiano.
Progressive Resistance Exercise in Physical Therapy: A
Summary of Systematic Reviews. PHYS THER. 2005;
85:1208-1223
