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Foundations of physiotherapy practice

| December 3, 2012

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The aim of the essay was to explore COPD in both theory and practice in correlation with the three main body systems. The body systems investigated in detail where the respiratory, musculoskeletal, cardiovascular and the neurological systems. Each system was researched for the effects it has on exercise intolerance, quality of life and the limitations that develop for a patient as a result of COPD. The role of pulmonary rehabilitation is inspected throughout the essay and its significance in the management of patients with COPD is expressed immensely within the context of the essay. There is an evidence based background to the exercise program used for the leaflet; it underpins the importance of using both endurance and strength training in order to improve some of the symptoms of COPD. The use of breathing exercises and techniques is also incorporated as it is a substantial part of the rehabilitation program. The role of the physiotherapist is fully established in the essay. The physiotherapist is recognised for his/her role in each aspect in the management of the condition.

Chronic obstructive pulmonary disease (COPD) is a disease defined by airflow limitation that cannot be fully reversed. COPD is a combination of emphysema, and chronic bronchitis. Chronic bronchitis is defined by excessive mucus secretions and a productive cough for a sustained period of time (more than two years). Emphysema is defined by destruction of the alveoli and smallest airways and secondary effects on lung elasticity, and other airways (Gupta and Brooks, 2006, p.180).The airflow obstruction is generally progressive in nature correlated with an abnormal inflammatory response of the lungs to gases. Despite the fact COPD affects the lungs; it also contributes to a substantial systemic reaction (Celli et al., 2004).although evidence shows that no change in lung function (FEV1) occurs, no matter how radical the treatment for the patient may be. Even tough loss of lung function is not regained; affective pulmonary rehabilitation helps slow the rate of decline (Bellamy and Brooker, 2004, p.12). COPD is important common respiratory disorders in primary care. Diagnosis of COPD is often delayed until patients present with severe symptoms. There are a high percentage of individuals that are undiagnosed in the population. Aside from patients being advised to stop smoking, it is important that pulmonary rehabilitation is part of the management of this condition and physiotherapist understand how to prescribe appropriate exercise training for patients with COPD (Gupta and Brooks, 2006, p.180).Patients with COPD are in the largest percentage of individuals referred for pulmonary rehabilitation. There is an increase in the evidence-based support for pulmonary rehabilitation in the management of patients with COPD (Nici et al., 2006). It addresses the numerous needs of the patient. It has many components which are highly effective in caring for the patient. Pulmonary rehabilitation incorporates the following: smoking cessation, education, exercise training, psychology interventions, physiotherapy, and nutrition. Exercise training is a vital component of pulmonary rehabilitation and is aimed at improving some of the restricting problems associated with the disease, such as dyspnoea and exercise tolerance despite the irreversible deformities in lung function (Tiep, 1997, p.1652). Management is essential in helping the patient have a better quality of life, as patients with COPD sink into an inactive and dependent state causing them to be at high risk of depression and anxiety. (Maurer et al., 2008). Depression and anxiety are addressed in the psychosocial component of the rehabilitation program (Nici, et al., 2006, p.1399).

During the progression of COPD, all body systems in some way become affected (Tiep, 1997, p.1631).patients with COPD tend to stop or reduce their level of physical activity as exertion leads to the patient having unpleasant sensations. A vicious cycle can occur, with reductions in physical activities causing severe deconditioning, and more limitations in each system affected by the condition (Thomas, 2006, p. 62).The changes in each of these systems are coexisting factors that contribute to the exercise intolerance in patients with the disease. The respiratory system is affected greatly by COPD; it contributes to exercise intolerance in a number a ways. Ventilatory limitations occur for many reasons. An increase in both airway resistance and expiratory flow limitations causes a severe increase in the work of breathing. The elastic walls of the alveoli provide a certain amount of driving force behind the active process of exhalation (Rochester, 2003, p.61). Airflow obstruction leads to impaired lung emptying and a higher end expiratory lung volume due to the loss in elasticity of the alveolar walls. This worsens during exercise leading to dynamic hyperinflation. Hyperinflation restricts the tidal volume response to excretion, flattens the diaphragm and the accessory muscles are then used to aid respiration, and  the muscle length-tension relationship of the respiratory muscles is altered forcing the muscles into a shortened position which puts them at a mechanical disadvantage. The degree of hyperinflation a patient is subject to is an important indicator of their exercise tolerance and dyspnea during exercise (Bellamy and Booker, 2004, p 23). Ventilatory  limitations to exercise causes interruption in gas exchange that emerges from the increase dead space to tidal volume ratio, ventilation-perfusion mismatch, and the reduction in diffusing capacity caused by the loss of alveolar/capillary connections. The increased dead space to tidal volume ratio in turn causes an increased ventilatory demand, for the same degree of bodily exertion (Rochester, 2003, p. 61). Other factors also further increase ventilatory demand these include, lactic acidosis and hypoxemia which directly or indirectly limit exercise tolerance (Nici et al., 2006, p. 1391).

The musculoskeletal system is affected also, there is evidence showing that muscle dysfunction contributes to exercise intolerance in COPD.  The reduction in physical activities leads to damage in skeletal muscle function which in turn causes more symptoms at a less intensive level of work. Inactivity produces many structural and biomechanical changes in the skeletal muscle. Muscle strength is decreased in patients with COPD; peripheral muscle strength is to a much greater extent affected than upper limb muscles strength. The reduction in peripheral muscle strength may be directly linked with the fact there is a decrease in activity of the lower limbs in patients with COPD (Thomas, 2006, p. 63). There is also a reduction in endurance in both lower and upper limb muscles. Loss of lower limb muscle strength is equivalent to the reduction in muscle mass. With prolonged inactivity type 11a fibres (slow twitch fibres) convert to type 11b (fast twitch fibres), Reduction in fibre type and decrease in cross-sectional of type 1 and 11a fibres is linked to muscle atrophy. Reduction in oxidative capacity and muscle atrophy is standard in patients with COPD. Deconditioning is an important factor in skeletal muscle dysfunction (Mador and Bozkanat, 2001).

Chronic obstructive pulmonary disease has an extensive impact on the cardiovascular system. The increased right ventricular afterload which is caused by the increased pulmonary vascular resistance resulting from the structural abnormalities in pulmonary circulation, and the hypoxic pulmonary vasoconstriction all contribute to the effects of COPD on the cardiovascular system. All of these processes lead to structural changes in the heart which include right ventricular dilatation and hypertrophy, to help conserve right ventricular output (Vonk-Noordegraaf, et al., 2005, p. 1901). The impaired ventricular filling is caused by hyperinflation and or other mechanical impairments. Cardiac output is relatively maintained in patients with COPD compared to normal individuals both at rest and during physical activities. Studies have proven that exercise training has no measurable impact on the changes in the cardiovascular system as the result of COPD. Like the irreversible effects COPD has on lung function, exercise training can slow it down but it can never be reversed back to normal no matter how extensive the treatment (Sietsema, 2001, p. 656-657).

The neurological system is affected as a result of COPD. Neuropsychiatric disorders are common in patients with COPD, particularly depression and anxiety. The prevalence of depression is higher than anxiety it is over 20% higher than anxiety. They often go untreated in patients with COPD; the lack of adequate treatment leads to patients having a poor quality of life and is associated with premature death in COPD patients. The overall impact of depression and anxiety on COPD patients, their families, and society is important. Studies show that depression has been found to cause fatigue, dyspnoea, and disability (Maurer, et al., 2008, p. 43). Depression increases with hypoxemia, carbon dioxide levels, and dyspnea. Hypoxia in patients with COPD may be a major factor in the development of depression and anxiety due to lack of sufficient oxygen to the brain. However reduced physical capacity and negative self image may also be a causing factor in the development of the disease (Armstrong, 2010, p. 132). Pulmonary rehabilitation is the main intervention used to try and improve the systematic effects of COPD; its main concern is to control the symptoms and disease by including essential components such as the multidisciplinary team for support and guidance and the exercise training program for improvements in the patient’s physical limitations (Burton, et al., 1997, p. 879).

The exercise training program of pulmonary rehabilitation must address the individual patient’s limitation to physical activity; these limitations may include ventilation limitations, gas exchange irregularities, and skeletal or respiratory muscle dysfunction. Exercise training aims to improve motivation for exercise, neuropsychiatric well being, decrease symptoms and improve quality of life. Moreover, the substantial improvement in oxidative capacity and efficiency of skeletal muscles has caused a decrease in alveolar ventilation for same degree of exertion. This can reduce dynamic hyperventilation, thus decreasing exertional dyspnoea (Aliverti and Macklem, 2001, p. 229). Pulmonary rehabilitation normally focuses on lower limb training, as loss of peripheral muscle strength in patients is high as loss of quadriceps muscle is reduced by up to 20-30% with patients in the moderate to severe phase of COPD. This is why exercise training is used to improve muscle strength. The distribution of muscle strength in patients with COPD is not equal between the lower and upper limb, there is evidence to prove the better preservation of the upper limb muscle strength (Thomas, 2006, p. 63). However upper limb exercises should be incorporated into the training program. Upper limb training results in an improvement in a patient’s ability to perform daily activities involving the upper body. Upper limb exercises also reduce dyspnoea and ventilatory requirements for arm elevation.  Evidence based guidelines recommend the use of upper limb exercise as part of the exercise program as it is safe and requires little equipment (Rochester, 2003, p. 70) There are two types of exercise training used in the rehabilitation program aerobic endurance and strength training.

Aerobic endurance exercise training is the main component of pulmonary rehabilitation. Evidence from a number of randomized controlled trails supports the use of lower extremity exercise training, it has been found to significantly improve exercise tolerance, timed walking distance, sub maximal endurance time, and health related quality of life. Exercise training includes ground walking training, treadmill walking, cycle ergometery, and inspiratory muscle training (Gupta and Brooks, (2006), p. 182). Cycle ergometery training supervised by the physiotherapist to make sure the patient is performing the exercise at the right intensity, has been proven to improve exercise capacity in patients with COPD. Studies have shown that the combination of both inspiratory muscle training and cycle ergometery training has greater benefits for patients than just cycle ergometery alone. The addition of inspiratory muscle training enhances both inspiratory muscle endurance and strength, improves exercise capacity significantly more than just cycle ergometery training on its own (Wanke, et al., 1994, p. 2205-2211). Walking is an exercise prescribed to patients for endurance training, as it is a regular exercise that patients find easy and a large percentage of patients continue walking at home or after the rehabilitation programme. Patients are encouraged to walk to the point of breathlessness; this technique improves exercise tolerance in patients as they push themselves to get physically fit. The Physiotherapist gives support to patients, by reassuring them that breathlessness during walking doesn’t cause any damage to the lungs or heart it is beneficial in improving their quality of life (Bellamy and Booker, 2006, p. 115). Strength training is used in pulmonary rehabilitation for both the upper and lower body. In many studies patients rated their dyspnoea and fatigue the lowest after strength training. The strengthening exercises may include knee flexion and extension which works the quadriceps and hamstring muscles, also chest press which involves both pectoralis major and latissimus dorsi. Weights are used during each exercise and are altered increase or decrease the intensity. Strength training increases strength in all muscles that undergo the training this is due to muscle hypertrophy and improvements in neural recruitment patterns. Strength training has been proven by many studies to improve exercise performance and quality of life (Mador, et al., 2004, p. 2039-2041).

Studies have supported evidence that endurance training has little effect on muscle weakness and muscle atrophy, two problems in patients with COPD and contributes to their exercise intolerance and poor quality of life. As a result most pulmonary rehabilitation programs combine strength and endurance training together as it is more beneficial to the patients. Studies have proven that the addition of strength training to endurance training produced a greater improvement in muscle mass and strength than endurance training alone (Ortega, et al., 2002, p. 670). Another study investigated the combination of both strength and endurance combined and found it was effective in reducing depression and anxiety. Moreover, there is evidence to confirm the beneficial effects of the three methods of exercise training (strength, endurance, and or combined) on the quality of life and level of dyspnoea in patients with COPD (Mador, et al., 2004, p. 2043).

There is a debate as to whether high or low intensity training  in endurance and strength exercises should be used and to what beneficial effects either intensity will sustain in improving the symptoms of COPD. Low intensity training does result in improvements in symptoms, activities of daily living and health related quality of life, there is evidence to support the use of high intensity training producing greater physiologic training effects (Maltais, et al., 1997, p. 555-561). Training intensity that exceeds 60% of the peak exercise capacity is enough to cause some physiologic effects, even though higher percentages have been tolerated and are more beneficial. The effects of cycle ergometery training at high intensity work load were compared to low intensity work load in 19 patients with moderate to severe COPD. The group following the cycle ergometery at the high intensity work rate had a greater reduction in lactate production and ventilation requirements, although the low intensity group had a similar result but not as much significant gains in aerobic fitness (Rochester, 2003, p. 67-68). Therefore using high or low intensity training has beneficial effects, high intensity exercise training is more advantageous producing physiologic changes in patients that are capable to reach that level, low intensity exercise training is more tailored to the health benefits of the general population and for patients who are in a more fragile state (Calverley, et al., 2003, p. 468-470). Aside from endurance and strength training the pulmonary rehabilitation program has breathing exercises and techniques that are incorporated into the program. The role of the physiotherapist in the management of COPD is established especially in breathing exercises and techniques.

Physiotherapists play a crucial role in the exercise, assessment and education aspects of the pulmonary rehabilitation program they are a valuable part of the multidisciplinary team. They are there to provide specialist advice and support for the patient, especially during an exacerbation, when patients have trouble clearing their chest secretions, and to help control any anxiety or panic attacks they may lead to hyperventilation. When physiotherapist helps patients clear chest secretions it often involves teaching the patient about the active cycle of breathing technique (ACBT) using forced expiration to enhance chest clearance. Physiotherapists also use techniques to reduce the work of breathing, which involves the use of breathing retraining or relaxed breathing control. Diaphragmatic breathing and pursed lip breathing are two examples of breathing retraining; these are of benefit to manage panic attacks and breathlessness. Physiotherapists also teach a patient varies positioning techniques to help with dyspnoea. They have a major role in pulmonary rehabilitation programmes, along with respiratory management they provide advice and support for patients with mobility problems (Barnett, (2006), p. 174).

Physiotherapists are involved in educating and supporting patients in breathing retraining. The main goals of using diaphragmatic breathing and pursed lip breathing are to relieve breathlessness and encourage relaxation (Mikelsons, 2008, p. 3). Pursed lip breathing is a technique used where exhalation is accomplished through resistance created by narrowing (pursing) of the lips; it is often naturally taken up by COPD patients. Studies have shown that pursed lip breathing can have a positive effect on dyspnoea when performed by patients during exercise. Patients who experience reduction in dyspnoea due to pursed lip breathing also had reductions in end expiratory lung volume and increase supply in inspiratory muscle pressure-generating capacity. During breathing at rest and exercise pursed lip breathing contributed to a slower deeper breathing pattern in patients, and is a useful technique to apply when an onset of breathlessness comes upon a patient (Spahija, et al., 2005, p. 640-648). Diaphragmatic breathing is used as another technique to help with dyspnoea and dynamic hyperinflation. In diaphragmatic breathing physiotherapists teach patients to synchronize inspiration with abdominal expansion as they breathe slowly and deeply. On the exhalation the diaphragm is pushed up by the abdominal muscles which create a better length tension relationship and a better curved posture. This technique increases the capable force of the diaphragm as an inspiratory muscle. Diaphragmatic breathing has a significant increase in tidal volume and a major reduction in respiratory frequency which caused an increase in minute ventilation. In hypercapnic patients with COPD, diaphragmatic breathing helps with hyperinflation in these patients. However studies have shown that severely hyperinflated   patients are incapable of performing this breathing technique (Gigliotti, et al., 2003, p. 198). Secretion clearance is an important technique used for acute exacerbation management. Acute exacerbations are common in patients with COPD; they are associated with a poor quality of life and are a burden to both family and caregivers. Symptoms include dyspnea, purulent sputum, and an increase in sputum volume. Patient’s awareness of the symptoms of exacerbations and early intervention reduces the risk of hospitalization and leads to a better quality. Physiotherapists are important in providing such interventions to help patients with sputum clearance. Physiotherapeutic techniques used to help with sputum clearance include active cycle of breathing techniques (ACBT), percussions, vibrations, and shaking. ACBT consists of breathing control, lower thoracic expansion exercises and forced expiratory technique. ACBT aids bronchial clearance by improving mucociliary clearance while also decreasing adverse effects such as hypoxia and increased airflow obstruction. Compared to percussion, vibrations, and shaking ACBT has been proven to be the most effective technique in chest clearance with over 80% of physiotherapists the UK using it always or often when treating patients with COPD. Studies have shown that ACBT helps improve oxygenation, assists in sputum clearance, reduces anxiety, and enhances health related quality of life (Yohannes and Connolly, 2007, p 110-113).

Many patients with COPD adopt a forward leaning position to help with the feeling of breathlessness, this is a useful technique which physiotherapist teach patients to self manage dyspnoea, during the stable phase of COPD and when they get an acute exacerbation. There is evidence to reinforce the use of the forward leaning position to improve breathlessness and decrease work of breathing. This position promotes diaphragmatic function by allowing the shortened diaphragm to be lengthened by the movement of the abdominal content away from the diaphragm thus enhancing the length tension relationship. This position can be altered to suit individual, it can be used in everyday life such as standing leaning against a wall, window sill or shopping trolley. These functional positions enable patients to get out and improve both their breathlessness and quality of life (Mikelsons, 2008, p. 3). Studies support the use of breathing retraining, chest physiotherapy and exercise training as it contributes to improvements in dyspnoea, functional exercise capacity, and quality of life in COPD patients (Guell, et al., 2000, p. 978).

In conclusion, the importance of COPD as a disease is relatively high as it has been stated to be in the top four leading cause of death and disability in the world (Gupta and Brooks, 2006, p. 187). The considerable effects COPD has on the respiratory system are discussed showing the limiting effects it has on both ventilation and gas exchange all contribute to the exercise intolerance in patients. The musculoskeletal system is greatly hindered by the effects COPD has on the structural and biomechanical aspects causing limitations in the ability to exercise. COPD leads to cardiovascular problems which progressively get worse if patients aren’t introduced to the exercise training program to help slow down the deterioration. Anxiety and depression goes undiagnosed in a lot of patients with COPD but has been shown to contribute to both exercise intolerance and poor quality of life in patients. The intervention of the pulmonary rehabilitation program has been proven to help increase exercise capacity, decrease dyspnoea and improve health related quality of life. The support and advice from the physiotherapist in the exercise training program, breathing exercises and techniques is a key element to the success of the pulmonary rehabilitation program. In light of all the advantages of the rehabilitation program there is still the unsubstantial effect it has on lung function in patients with COPD.


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