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Foundations for physiotherapy practice

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Introduction

This essay will explore the disease COPD and explain the systemic effects that the disease has on the body as a whole. Exercise is investigated in the essay and shows how it may change the quality of life of a patient and decrease certain symptoms of COPD; it will also explain the negative effects that inactivity may cause a patient with COPD. There is varies interventions used to make living with COPD more tolerable for patients. It talks about how exercise benefits the body by decreasing dyspnoea, how increasing the body’s muscle strength will relieve fatigue and decrease the respiratory demand. The affects of exercising on anxiety and depression are examined also. The physiotherapists role will be included detailing all the different techniques that they use for treatment including breathing control, airway clearance, inspiratory muscle training which helps with inspiratory endurance and strength and improving mobility. Finally the important of upper body and strength exercises will be questioned as to how it helps with improving mobility and promoting rehabilitation.

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Chronic obstructive pulmonary disease (COPD) is an umbrella term used to describe somebody who suffers from both Chronic bronchitis (Bronchitis is inflammation of the bronchi (the airways of the lungs) and emphysema (Emphysema is damage to the smaller airways and air sacs (alveoli) of the lungs). COPD is the term most preferred but you may also hear it called COLD (chronic obstructive lung disease) or COAD (chronic obstructive airway disease). Pulmonary means ‘affecting the lungs’. COPD causes a chronic (ongoing) cough with phlegm, is rare before the age of 35 and there is permanent damage to the airways. The narrowed airways are fixed, and so symptoms are chronic (persistent). Treatment to open up the airways is limited as a result. (patient.co.uk, 2010) As before COPD or chronic obstructive pulmonary disease is two disorders in one emphysema and chronic bronchitis. Bronchitis affects the airways with inflammation narrowing the airway sometimes with phlegm. Chronic bronchitis is a more specific condition and it is defined by the amount of phlegm that a person has coughed up over a particular time frame. To be described as chronic bronchitis a person has to be coughing up phlegm every morning for at least 3 consecutive months within a period of at least two years. Chronic bronchitis is mostly caused by cigarette smoking it can also occur form environmental factors. Emphysema is the other disorder you must be diagnosed with to be diagnosed with COPD. Emphysema affects your alveoli which are the little sacs of air at the end of bronchiole in your lungs where gaseous exchange occurs. These are normally made from a very elastic tissue so that they can expand when air fills the lungs. In emphysema, large numbers of the alveoli have been destroyed and there is much less area where gaseous exchange can take place so although people can breathe in it cannot get into the bloodstream. (Miles and Roberts, 2005, PP.1-3)

Another systemic effect of COPD is the effect on the musculoskeletal system because of the breathlessness which reduces your exercise capacity which has a knock on effect. When you don’t exercise it has adverse effects on your body muscle wastage and weakening means you may become breathless easier as you will have less muscle and/or strength to perform the same tasks and will require more effort and put more metabolic demand on your body compared to if you had stronger muscles. Muscle weakness whatever the cause has severe consequences, including exercise limitation, reduced quality of life, more of a demand for healthcare assistance and its resources and more severely reduced survival. Physical de-conditioning may lead to a marked decrease in a patient’s ability to cope with activities of daily living, finding even the simplest of tasks to be leaving them breathless, consequently leading to a decrease in quality of life and also decreased survival. It is apparent that systemic manifestations are typical in COPD. Granted, many patients demonstrate a gradual and significant weight loss that exacerbates the course and prognosis of disease. This weight loss is also accompanied by peripheral muscle dysfunction and weakness. (Decramer, M. Et al. 2005, PP. s3-s10)

With COPD it is not just the physical effects that play a role in the disease there are neuropsychiatric disorders like depression and anxiety which are more common in people with COPD. Depression in people with COPD rises with an increase in hypoxemia, carbon dioxide levels or dyspnoea. Hypoxemia may be a substantial cause in the development of depression and anxiety in COPD due to brain injury; however oxygen therapy results in little or no improvement in the severity of the depression. Another cause of morbidity of depression and anxiety is negative self-perception and restrictions in behavioural functioning due to reduced physical capacity. (Armstrong 2010 PP. 132) Although the COPD patient population is proven to be more depressed than the general medical population, it is not more anxious, the levels of anxiety observed in the general medical or surgical population on the wards were very similar to those observed in the COPD population. Despite the similarities compared to the other wards the anxiety levels are still high compared to the population without any disease or disorder. (Light, R, W.et al. 1985, PP.35-38) COPD patients with psychiatric conditions spend twice as much time in hospital compared to those without depression and anxiety. It is also found that the quality of life of COPD patients can be impaired in all dimensions compared to those without depression and anxiety, high impact was seen both on walking around, mobility, sleep and rest. (MIKKELSEN, R, L. 2004, PP.65-70) Anxious patients tend to have quite significantly shorter pre-rehabilitation exercise capacity compared with non-anxious patients as do patients with increased depression compared with those who are not depressed. Patients following a pulmonary rehabilitation program for COPD show a statistically significant fall in both anxiety and depression as they progress in their program, with no patients showing any increases in either depression or anxiety. Patients with higher starting anxiety level show a significantly larger increase their exercise capacity than those who start off with lower anxiety levels. Exercise rehabilitation is shown to produce clear improvements in anxiety and depression and to some extent reduces the number of patients with high anxiety and depression compared to no intervention. So exercise benefits COPD suffers with anxiety and depression at least as much as do those with lower levels. (Nicholas, Rudkin, and White, 1999, PP. 362-365)

COPD has effects on the cardiovascular system by increasing the risk of cardiovascular disease by up to three-fold. Several different studies have shown that the function of endothelial in COPD is abnormal in both the pulmonary and systemic circulations. The means that underlie these abnormalities are also unclear. It is obvious that tobacco smoking is a shared risk factor for both COPD and cardiovascular disease. Although, it is possible that there are other factors which may quite substantially increase the cardiovascular risk of patients with COPD. With this in mind, many authors agree that the persistent, low-grade, systemic inflammation that occurs in COPD may contribute further to the pathobiology of these cardiovascular abnormalities in COPD. If true, this may have substantial therapeutic implications in the management of these patients because anti-inflammatory therapy would be beneficial not only for the chronic inflammatory process which their lungs are undergoing but also for the prevention of cardiovascular disease. (Agust??, 2005, 367-370.) It is shown that the leading causes of mortality in those with COPD are cardiovascular in nature. Cardiovascular causes are listed as the main cause of death in nearly 50% of the cases, Nevertheless, this data, suggest that a large proportion of patients with COPD die from cardiovascular complications. (Sin and Man, 2005, p8-11)

The impact on cardiovascular function in COPD is mainly due to the increased right ventricular afterload caused by an increase in pulmonary vascular resistance resulting from the structural changes that take place in the pulmonary circulation with the disease

One of the most beneficial treatments for COPD and its symptoms is exercise; exercise is proven to have a beneficial effect on your body compared to not exercising. By exercising you significantly increase your muscle strength and endurance. This means muscle dystrophy and atrophy are stopped and even reversed. You see a significant increase in endurance when you walk also as a result of exercising regularly and it also promotes increased efficiency of peripheral muscle oxygen extraction after muscle training, with less contribution from anaerobic (lactic acid) metabolism during exercise. (Clark, Cochrane, and Mackay, 1996, PP. 2590-2596)

Aerobic capacity (VO2max) or maximum oxygen uptake is decreased with patients presenting with COPD, due to this the body starts to utilise the anaerobic energy system, this means that for walking the same distance as a normal person you will be utilising the phosphate and the lactic acid system which use less oxygen therefore your muscles fatigue easier. Lactate or metabolic threshold (VO2u) is known as exercise intensity with a sustained increase in blood lactate that cannot be prevented. Lactate threshold may be elevated by as much as 100% of its resting value by successful aerobic training in a normal subject. A de-conditioned individual there for has the potential for a significantly greater improvement in VO2max and VO2u with exercise training. When effective, this modality of physical reconditioning leads to improved functional exercise capacity and reduced breathlessness. Early implementation is desirable to obtain more meaningful responses. (COOPER, 2001, PP. S671-s679)

Upper extremity exercise is also important for people who suffer from COPD as they are restricted in the amount of upper body exertion they can achieve even as much as to elevate their arm may cause dyspnoea and increased respiratory demands.

It is shown that during unsupported arm exercise the respiratory muscles of the rib cage work actively help to maintain the posture of the upper torso and extended arms; due to this they decrease their roll in respiration in COPD patients. Therefore dyspnoea is worse with arm exercise than it is with leg exercise at the same total body oxygen consumption, suggesting that the load borne by the other inspiratory muscles must increase for the same level of increasing ventilation. (Grazzini, 2005, PP. 1403-1412) The increased demands even during a simple arm elevation may play a role in the development of the patient’s dyspnoea. The limitation that occurs is a major problem that patients report when performing daily living activities involving the arms. It is important to apply an intervention of exercise training to try help. An upper extremity training regime for patients with COPD results in a reduction of ventilation requirements which will allow patients with COPD to perform sustained upper extremity activity with considerably less dyspnoea. A comprehensive pulmonary rehab programme that includes arm exercises, results in reduced metabolic and ventilator requirements for a simple arm lift. The addition of such training has been shown to improve upper extremity exercise endurances. Subjects who are in the early stages or whom are less severe may tolerate these increased loads without difficulty, whereas in severely obstructed patients with minimal reserve, increased ventilatory exertion and the associated recruitment of the diaphragm may contribute to increased dyspnoea. Although has some beneficial effects in this and most other studies to date, ventilatory capacity does not improve in terms of pulmonary function tests nor does fev or fev1. Additionally there is no cross over benefit to arm exercises or lower body exercises so it is important to incorporate both into a pulmonary rehabilitation for a patient with COPD to seek maximum benefit from the program. (Couser, Martinez and Celli, 1993, PP. 37-41)

With COPD muscle wastage is quite common and 25% of all patients suffer from it. Muscle weakness and wastage also has adverse effects on fatigue. Leg fatigue for example limits patients with COPD in exercise. Normally the perception for muscle fatigue is higher in people with weak leg muscles than to those who are said to have strong legs. Patients with stronger muscles are said to have better exercise capacity this is true for people without COPD. Quadriceps strength has been found to have a significant effect on exercise capacity. So it is said that “leg fatigue is inversely proportional to leg muscle strength”. (Bourbeau, Nault, and Borycki, 2002, PP.190-191) Strength training is also appealing because it improves muscle strength and mass much better compared to aerobic training. In addition strength training causes less dyspnoea in the exercise period compared to aerobic training. Because of this it may be easier to tolerate for patients with severe cases of COPD. There are different types of strength training can be used depending on the desired objective or the condition the patient is in. The different types are strength training where you are lifting between (90-100%) of one rep max (RM) this is using low repetitions with high weight which ameliorates strength, whereas when you use a lower weight and higher repetitions you work at a lower intensity for more reps which works on endurance. Moderate intensity work at (10-12) reps performed at 60-80% of one RM is ideal for patients with COPD as it fulfils the objective of building muscle strength and endurance while avoiding the likelihood of muscle injury which is common in high weight low repetition work. It is important to have your medication and a partner. This is important because, effectively, you may become disabled due to your breathlessness. (Bourbeau, Nault, and Borycki, 2002, PP.190-191)

Physiotherapists address many of the symptoms of COPD like reducing the work of breathing, promoting clearance of the airways, improving mobility and promoting rehabilitation. Promoting successful management of these complex patients is in two parts: the accurate assessment of the patient to identify clear goals of treatment and team work, which underpins a thorough knowledge of the individual patient. (Mikelsons, 2008, PP. 2-7) There are three main techniques which may improve the efficiency of your breathing, pursed lip breathing, diaphragmatic breathing and paced breathing. These three techniques encourage complete emptying of your lungs and slower, deeper breaths, which will improve the efficiency of your breathing and encourages control of your breathing.

Diaphragmatic breathing involves encouraging patients to move the abdominal wall predominantly during inspiration with reduction of rib cage movement and inhale slowly and deeply, in order to improve chest wall movement and the distribution of ventilation, decrease the work of breathing and improve exercise capacity. By utilizing the main muscle of inspiration, the diaphragm, it encourages relaxation of smaller, less efficient respiratory muscles. Using the diaphragm allows more air to move into the lungs with each breath which makes each breath more efficient. Diaphragmatic breathing also decreases the work of breathing by reducing the use smaller, less efficient muscles of the neck and shoulders. (NYU Medical Centre 1997). Diaphragmatic breathing (DB) has been claimed, but not demonstrated, to correct abnormal chest wall motion, in turn decrease the work of breathing (WOB) and dyspnoea and improve ventilation distribution. (Vitacca et al., 1998)

Pursed lip breathing is commonly used in COPD patients as it is thought to alleviate dyspnoea. (Spahija, de Marchie, and Grassino, 2005, PP. 640-650) PLB is done by breathing in through the nose and out through the mouth against a resistance created by pursing the lips, this helps to prevent airway collapse. PLB helps you exhale more completely because it slows your respiratory rate and helps to keep your airways open longer. It has been shown that by performing PLB during exertion can lead to a reduction in respiratory rate and increased recovery rate compared with spontaneous breathing PLB can be used just prior to and during activities that have made you short of breath in the past.. PLB during exertion may therefore be a useful addition to the breathless patient’s regime and may be taught as a strategy to reduce respiratory rate of patients with COPD. It is good to use PLB when walking on inclines, up stairs and during any exercise or exertion. Despite the exercises being effective in reducing respiratory rate and decreasing work of breathing it is of note that it has been shown that fatigue of the diaphragm may develop earlier when using slow, deep breathing, but no differences in dyspnoea or exercise tolerance were found.12 R. Garrod, K. Dallimore and J. Cook et al., An evaluation of the acute impact of pursed lips breathing on walking distance in nonspontaneous pursed lips breathing chronic obstructive pulmonary disease patients, Chronic Respir Dis 2 (2) (2005), pp. 67–72. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (12) Paced breathing involves coordinating your breathing pattern with the activity you are doing. For example, when walking on level surfaces breathe in for a count of 2 steps and out for a count of 4 steps. This will help regulate your breathing reducing anxiety and promote good relaxed and controlled breathing allowing you to continue with your activity. Physiotherapists prescribe Breathing exercises like Diaphragmatic breathing, breathing control and pursed lip breathing are to relieve breathlessness and promote relaxation. (NYU Medical Centre, 1997)

Physiotherapists also teach a techniques called airway clearance techniques the most popular being called active cycle breathing technique (ACBT) which is used for acute exarberations of COPD during exercise. This technique is done by using an alternating depth of breathing to move phlegm from the small airways at the bottom of your lungs to the larger airways near the top where they can be cleared more easily with huffing/coughing in turn making it easier to breath by removing obstructions. ACBT is used by 88% of physiotherapists to treat acute exarberations of COPD. (Connolly and Yohannes 2007 pp. 110-113) Airway clearance techniques have a variety of different techniques such as the ACBT which has been explained, forced expiration technique (FET), and postural drainage (PD). PD is when the physiotherapist puts the patient in positions which make it easier to remove sputum because the cilia are damaged and cannot aid in its clearance of sputum. FET is used instead of coughing to remove sputum, it is found to be more effective than coughing. The main indicator for determining which of the techniques to use of any airway clearance technique is how much sputum they can clear while coughing independently. This will be a key indicator for a patient in the self-management of their disease and patients will be taught modifications of their airway clearance regime during an acute exacerbation by their physiotherapist. (Mikelsons, 2008 pgs 2-7)

Physiotherapists may prescribe inspiratory muscle training (IMT) which has been used for co-ordination of respiratory muscles allows maximization of the use of abdominal muscles as inspiratory accessory muscles and has been proven to show benefits in exercise tolerance, Inspiratory muscle endurance and strength, breathlessness and improve quality of life. (Mikelsons, 2008 pgs 2-7) state that by including IMT in an exercise programme it has been shown to increase maximal inspiratory pressure, perception of breathlessness and health-related quality of life.50 R. Magadle, A.K. McConnell, M. Beckerman and P. Weiner, Inspiratory muscle training in pulmonary rehabilitation programme in COPD patients, Respir Med 101 (2007), pp. 1500–1505. Article | PDF (465 K) | View Record in Scopus | Cited By in Scopus (8) High-intensity IMT has also been shown to produce beneficial reductions in dyspnoea and fatigue in COPD patients. Usually a physiotherapist would prescribe training that would take place over 6 to 9 weeks using from 30 to 60% of maximal inspiratory pressure depending on the patient and how much they can manage, this differs from person to person. Another study by (Lotters et al., 2002 pp. 570-577) also had positive results and stated that IMT alone significantly improves inspiratory muscle strength and endurance, whereas the sensation of dyspnoea significantly decreases in patients with COPD. Although there are no significant additional effects of IMT on exercise performance IMT plus general exercise reconditioning has strong significant training effects on inspiratory muscle strength and endurance, especially in patients with inspiratory muscle weakness. In addition, a clinically significant decrease in dyspnoea sensation at rest and during exercise is also a result of IMT.

Conclusion

In conclusion there is an array of benefits of exercise training demonstrated in the essay which include, increase in exercise capacity, decrease in breathlessness, substantial changes in health related quality of life, decrease in anxiety, and improvements in depression. It has been shown that the inclusion of strength training is also necessary in the exercise prescription to help reduce fatigue; it has shown benefits in relief of respiratory demand in turn reducing dyspnoea. When evaluating anxiety and depression, there have been studies that show a higher rate of depression and anxiety in COPD patients than the general public. In comparison with the general medical population the rate of anxiety was not proven to be higher but much the same, although the level of depression in patients with COPD tended to be higher due to the disease having a reduced physical capacity and knowing that it will gradually get worse. Although by including a pulmonary rehabilitation program for COPD, patients show a statistically significant fall in both anxiety and depression as they progress in their program, with no patients showing any increases in either depression or anxiety. The inclusion of IMT used by physiotherapists combined with an exercise program has been shown to significantly increase in inspiratory muscle strength and inspiratory muscle endurance leading to the reduction of dyspnoea. Combining all of these techniques help in the management of COPD however it has to be said that although exercise improves certain symptoms of COPD, there still a null outcome when it comes to improvements in lung function (FEV1 or FEV).

Referencing

Agust?? A. G. N. (2005) Systemic Effects of Chronic Obstructive Pulmonary Disease. American thoracic society, 2 (4), 367-370.

Armstrong, C. L. Ed. (2010) Handbook of medical neuropsychology: applications of cognitive neuroscience. New York: Springer.

Bourbeau, J. Nault, D. and Borycki, E. (2002) Comprehensive management of chronic obstructive pulmonary disease. Canada: BC Decker Inc.

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Decramer, M. et al. (2005) Systemic effects of COPD. Respiratory medicine, 99 (2), S3-s10.

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