What is physical therapy of respiratory disease?

Introduction:

 Physical Therapy plays a major role in recovery of patients with respiratory problems such as emphysema, pulmonary fibrosis or lung cancer, asthma, chronic obstructive pulmonary disease ( COPD ), pulmonary hypertension, respiratory tract infections.

In this article you would come to know about the physical therapy techniques in musculoskeletal dysfunction in respiratory disease. 

The person with respiratory disease has a typical posture with tightness of the pectoral chest muscle and weakness of the serratus anterior and the middle and lower fibres of the trapezius. This poor posture results in increased thoracic kyphosis and protracted position of the scapula, also position of the shoulder joint is anteriorly with the humerus in glenoid fossa.

Subjective Assessment: 

Initial assessment of patient with respiratory disease by a Physical therapist include questioning regarding headache, neck, shoulder or thoracic pain and any upper limb pain or paresthesia. The intensity of pain can be measured by an absolute visual analogue scale ( AVAS ) . 

Physical assessment: 

A Physical therapist does the assessment in a systematic manner from evaluation of patient posture to assessment of joint mobility, muscle recruitment pattern, muscle length and strength and endurance.

The assessment is ideally performed in sitting, supine and prone position, examination of dyspnoeic ( not breathing or able to breathe except with difficulty) patients may need to be conducted in semi-supine, sitting or high side lying.

Therapist observes the resting posture of patient with cervical, thoracic and lumbar spine, the scapula and also arms. Thoracic kyphosis with stiffness in the upper thoracic spine and cervical lordosis should be noted.

Also Physical therapist does the assessment manually by palpating mobility of the upper and middle ribs in anteriorly and posteriorly during a deep inspiration, while the lower ribs are assessed by palpating laterally. Joint movements are also checked specially scapulo-humeral rhythm and strength and endurance of specific muscles need to be examined by physical therapist. Neural tissue provocation tests and test for reflexes, power and sensation should be performed.

Physical Therapy Management of Respiratory Disease: 

The patients main problems need to be prioritized before treatment can be started, Many techniques are used by physical therapist in order to overcome different respiratory problems such as joint restriction may be treated with passive mobilization techniques, active assisted exercises or active exercises. Posture may be improved by educating awareness of positioning using visual, auditory and sensory feedback.

Postural correction may change the patients breathing pattern and intensity of dyspnoea (shortness of breathe) therefore these factors need to be monitored carefully during treatment by physical therapist. 

Mobilization Techniques by physical therapist:

Physical therapy management of joint restriction and pain may include passive mobilizations of cervical and thoracic apo-physeal joints, also the therapist focus usually be on improving the range of thoracic extension and on increasing the mobility of the ribs. Physical therapist perform thoracic extension of  patient in a precise manner by instructing the patient to flex his arm combined with deep inspiration and expiration to improve rib mobility and spine extension. 

As seen in many patients following thoracotomy, patients may tend to immobilize the arm on the side of the incision and need to be encourage to move within pain limits as early as possible to reduce the risk of frozen shoulder and scapular movement. 

The long term ventilated patient may also develop musculo-skeletal problems so routine passive mobilization of the shoulder through its full range of flexion, external rotation, and abduction should be mandatory by the physical therapist. 

Muscle Lengthening techniques by physical therapist: 

Physical therapist should have a close sharp observation of the chest, shoulder and back muscles, which becomes tight in respiratory  patients. Some of the tight muscles which need attention are deltoid, Pectoralis, sternocleidomastoid, upper and middle fibres of trapezius levator scapular, Pectoralis minor, Teres major, Latissimus Dorsi  and subscapularis.

Techniques performed by physical therapist for the tight muscles are hold and relax technique and myofascial release. Where possible patient should be taught to perform their own stretches and mobilizations as part of long term maintenance. 

Use of Gym Ball by physical therapist: 

A gym ball may be useful for encouraging a more upright sitting posture in younger patients. Prone position over the ball may be used to stimulate the anti gravity muscles. Side lying over the ball will assist with rib mobility and stretching of the Inter coastal muscles if mobility and shortness of breath allow.  

Muscle retraining and recruitment are a part of treatment of patients with respiratory problem by the Physical Therapist.

What is Breathing Control in Respiratory Problems: 

Breathing control is normal tidal breathing using the lower chest with relaxation of the upper chest and shoulders. This use to be known as 'diaphragmatic breathing' where minimal effort is expended and breathing exercises where either inspiration is emphasized, as in thoracic expansion exercises and inspiratory muscle training or expiration as emphasized, as in the huff of the forced expiration technique. This breathing technique is used by physical therapist in respiratory condition. 

How Breathing Control Technique is performed by Physical Therapist:

To be taught breathing control the person should be in a comfortable well supported position and is encouraged to relax his upper chest, shoulders and arms while using the lower chest. Physical therapist uses his one hand to position lightly on the upper abdomen. As the patient breathes in, the hand should be felt to rise up and out; as the patient breathes out, the hand sings down and in.

Inspiration through the nose allows the air to be warmed, humidified and filtered before it reaches the upper Airways.

Any breathless person with asthma, emphysema, pulmonary fibrosis or lung cancer, will benefit from using breathing control in position which encourage relaxation of the upper chest and shoulders and allow movement of the lower chest and abdomen. One of the most useful positions is high side lying. Other useful positions are

* Relaxed sitting

* Forward lean standing

* Relaxed standing

* Forward lean standing

Surgical patients should continue their breathing exercises in between the treatment sessions with the physical therapist.

Active cycle of breathing technique ( ACBT) in physical therapy: 

This technique is used by physical therapist to mobilize and clear access bronchial secretions and to improve lung function. ACBT is a cycle of breathing control, thoracic expansion exercises and forced expiration technique ( FET ). 

Thoracic expansion exercises are deep breathing exercises emphasizing inspiration and increasing lung volume capacity.

The forced expiration technique is a combination of force expiration (huffs) and breathing control also known as in simple terms huffing.

Techniques performed by physical therapist for chest airway clearance: 

1. Chest clapping - This is performed by the Therapist using a curved hand with a rhythmical flexion and extension action of the wrist. This technique is often done with two hands but, depending on the area of the chest, let may be more appropriate to use one hand. For the infant, chest clipping is performed using two or three fingers of one hand. In patients with neuromuscular weakness or paralysis and the intellectually impaired, chest clipping is a useful technique to stimulate coughing probably by the mobilization of secretions.

2. Chest shaking, vibrations and compression- In this technique the therapist hands are placed on the chest wall and during expiration, vibratory action in the direction of the normal movement of the ribs is transmitted through the chest using body weight. This helps to mobilize secretions and this technique is combined with thoracic expansion exercises.

Other techniques which are useful in respiratory patients are

➤ Incentive Spirometry

➤ Glossopharyngeal breathing

➤ Intermittent positive pressure breathing

➤ Airway suction

• Related article: chest-physiotherapy by Dr Shailendra Chourey

Conclusion: 

Physical therapy should be the line of treatment in many respiratory problems, I hope you like the information regarding respiratory diseases. Please let me know in the comment section about your experience