6.1 Need for the study:
Chronic obstructive pulmonary disease (COPD) is a lung disease is characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.1 The incidence of COPD in India according to WHO report in 2000 showed 11% out of the global population.2
Chronic obstructive pulmonary disease (COPD) often develops changes in chest wall configuration. These changes have been related to airway obstruction, hyperinflation, and mechanical disadvantage of the respiratory muscles.3 It is suggested the individual typically first experiences some activity limitation because of dyspnoea, when FEV1 falls below 50%. When FEV1 reaches a level of 30-40% of predicted, there would be significant reduced upper-limb activity which may lead to muscle tightening and stiffness around the muscle quadrant, thereby further increasing chest wall resistance which can be disabling.4
The respiratory muscle are fundamental in the maintenance of respiratory mechanics and under physiopathological conditions muscle force is altered which is reflected as a reduction in the respiratory pressures.When a muscle loses its normal flexibility, the length-tension relationship is altered. This prevents the muscles from reaching sufficient peak tension, which evolves to muscle weakness and retraction. This muscle shortening can result from various factors, such as incorrect postural alignment, immobilization of the muscle, muscle weakness and ageing.5
Chest mobilization exercises are any exercises that combine active movements of the trunk or extremities with deep breathing. They are designed to maintain or improve mobility of the chest wall, trunk and shoulder girdle when it affects ventilation or postural alignment which has combine stretching of these muscle with deep breathing improves ventilation on that side of the chest. Chest mobilization exercises are also used to reinforce or emphasise the depth of inspiration or controlled expiration. This could be seen when a patient with hypomobility of the trunk muscle of one side of the body will not expand that part of chest fully during inspiration. A patient can improve expiration by leaning forward at hip or flexing the spine as he breathes out. This pushes the viscera superiorly into the diaphragm and further reinforces expiration.6
Upper limb activites commonly require unsupported arm exercise, which poses a unique challenge for patient with COPD whose upper limb muscles also may be required to act as accessory muscle of respiration. During unsupported arm exercise, the participation of these muscle in ventilation decreases, and there is a shift of respiratory work to the diaphragm.7
Supported arm exercise muscle of the upper torso and shoulder girdle serve both respiratory and postural function. Muscle such as upper and lower trapezium, latissimus dorsi, serratus anterior, sub clavius and pactoralis minor and major posses a thoracic and an extrathoracic anchoring points. Exercise depending on the anchoring point they may help position the arm or shoulder or if given an extra thoracic fulcrum, they may exert a pulling force on the rib cage. During supported arm exercise the diaphragm loses its force- generating capacity and muscle of the rib cage become more important in the generation of inspiratory pressure.8
However effect of unsupported and supported arm exercises on increase of chest expansion and vital capacity remain unclear.
Therefore, the purpose of the study is to compare the effectiveness of chest mobility exercises in supported and unsupported position in COPD are done in order to improve chest expansion during breathing.
Hypothesis:
Null Hypothesis:
There will be no significant difference between two exercise protocol of chest mobility on chest expansion.
Research Hypothesis:
There will be significant difference between two exercise protocol of chest mobility on chest expansion.
6.2 Review of Literature:
Costa D, Forti EMP, Barbalho-Moulim MC, Rasera-Junior (2009) compare the effects of conventional respiratory physical therapy (CRP) and CRP associated with transcutaneous electrical diaphragmatic stimulation (TEDS) on the pulmonary volumes and the thoracoabdominal mobility of patients undergoing bariatric surgery. Study concluded that the obese women who underwent bariatric surgery and received postoperative respiratory physical therapy did not have a reduction in pulmonary volumes.9
Carla Malaguti, Rafaella R Rondelli , Leandra M de Souza ,Marcia Domingues, and Simone Dal Corso (2009)conducted a studyto analyze the reliability and accuracy of chest wall mobility. Study suggested that despite high reliability of intra-observer and inter-observer measurement of chest wall mobility, both within and between visits, high variability was observed at chest wall levels tested. Although, there was an association between inspiratory capacity and measurements made at the abdominal level, chest wall mobility did not infer pulmonary function.3
Michael T. Put, Michelle Watson, Helen Seale, Jennifer D. Paratz (2008) conducted a study specific hold and relax stretching technique was capable of reversing the effect of tight chest wall muscles by increasing chest expansion, vital capacity, and shoulder range of motion and decreasing perceived dyspnea and respiratory rate in persons with chronic obstructive pulmonary disease (COPD).Results suggested that a stretching technique based on proprioceptive neuromuscular techniques is able to increase ROM in the chest and shoulder girdle and increase vital capacity in patients with COPD in the short term.10
Katarina Burianova, Renata Varekova, Ivan Vareka (2008) conducted a study to evaluate the pulmonary rehabilitation programme is useful for bronchial asthma patients and this program me should start as soon as asthma is diagnosed because it can help to improve or maintain chest mobility and respiratory muscle strength. Study suggested that a combination of special breathing and postural exercises and mobilization and soft tissue techniques has a positive effect on the chest mobility and respiratory muscle strength of bronchial asthma patients.11
Marlene Aparecida Moreno, Aparecida Maria Catai, Rosana Macher Teodori, Bruno Luis Amoroso Borges, Marcelo de Castro Cesar, Ester da Silva (2007) study conducted the effect that respiratory muscle stretching using the global postural re-education (GPR) method has on respiratory muscle strength, thoracic expansion and abdominal mobility in sedentary young males. Result shows respiratory muscle stretching using the GPR method was efficient in promoting an increase in maximal respiratory pressures, thoracic expansion and abdominal mobility, suggesting that it could be used as a physiotherapy resource to develop respiratory muscle strength, thoracic expansion and abdominal mobility.5
Chanavirut R, Khaidjapho K, Jaree P, and Pongnaratorn P (2006) conducted a study to the difference between yoga and other exercise is the predominant focus on sensations in the body. The present data indicate that six-week yoga training improves respiratory capacity especially chest wall expansion and lung volumes. Study suggested that a yoga training also improves muscle strength and flexibility and increased respiratory sensation maximum expiratory pressure and flow rate.12
Murat Ersoz, Barın Selçuk, Ramazan Gunduz, Aydan Kurtaran, Mufit Akyuz (2006) the purpose of this study was to evaluate chest mobility by means of chest expansion measurements in patients with spastic cerebral palsy. The results of this study showed that chest mobility as evaluated by chest expansion was decreased in spastic cerabral palsy patients when compared with normal controls of similar age and gender.13
Elaine Paulin; Antonio Fernando Brunetto; Celso Ricardo Fernandes Carvalho (2003) conduct a study to assess the effects of a physical exercise program designed to increase thoracic expansion on the functional and psychosocial capacity of patients suffering from moderate to severe chronic obstructive pulmonary disease. Study showed that exercises designed to improve thoracic expansion also improve chest expansion, quality of life and submaximal exercise capacity, as well as reducing dyspnea and depression, in patients with moderate to severe COPD.14
Philip L Witt, Joyce Mackinnon (1986) conducted a Trager Psychophysical Integration would have an effect on patients with documented chronic lung diseases. The criterion measures were forced vital capacity (FVC), forced expiratory volume at one second and at three seconds (FEV1, FEV3) chest expansion, respiratory rate and subjective breathing difficulty.Study suggested that a two-week regimen of Trager Psychophysical Integration administered by a physical therapist trained in the technique, our subjects exhibited significant changes at the p < .05 level in FVC, respiratory rate and chest expansion.15
6.3Objective of the study
- To compare supported and unsupported arm exercise for chest mobility in COPD patient.
7 / Materials and Methods:
7.1 Source of data
- ESI Hospital, Rajajinagar, Bangalore
- KCG Hospital ,Malleshwram, Bangalore
- Population: subject with COPD
- Sample design: convenience sampling
- Sample size: 30
- Type of study: comparative study.
Materials required:
- Measuring tape
- Chair
- Plinth
- Pulmonary function test apparatus.(Pneumocrak)
- Stable COPD patients
- Age:- 45-75 years
- Never involved any kind of upper limb exercises from 1month
- Predicted FEV1 should be mild to moderate
- Patient unable or unwilling to complete the study.
- Subject practicing any form of regular breathing exercises.
- Subject undergone any chest surgery.
- Subject having any other chest complication.
- Acute exacerbation during study
- Pain in shoulder
- Peri arthritis of shoulder
- Disability prevention mobility of thorax
- Back pain
- Unstable cardiac disease
- Cor pulmonale
- Acute illness
- Respiratory muscle fatigue
Subject who fulfill the inclusion criteria and exclusion criteria will be enrolled in the study. A written informed consent will be taken from each of subject prior to participation.
After randomising the patient to one of two groups chest expansion and vital capacity will be measured according to guidelines of American Thoracic Society.16
Subject will be randomly divided into two groups. Group A (n=15) and B group (n=15).
In Group A- patient is sitting in a chair with hands clasped behind the head have him or her horizontally abduct the arms during deep inspiration.Then, instruct the patient to bring the elbow together and bend forward during expiration.17
In Group B- patient is sitting in a chair have him or her reach with both arm over head during inspiration Then have the pt. bend forward at the hips and reach for the floor during expiration.17
Both group will instructed to perform these chest mobility exercises 6 sets for two session.
Thoracic flow cytometry: for measuring the chest expansion will used by the Kakizaki et al. method will be employed.18
Axillary, xiphoid and basal expansions will be determined using a tape measure. Each measurement will be obtained after maximal expiration followed by maximum inspiration and another maximal expiration. Measurements will be taken twice and the mean of the two values will be recorded.
Vital capacity: will be measured by the pulmonary function test according to the standard outline by American Thoracic Society.16
Chest expansion and vital capacity will repeated after 3 month.
Outcome measures:
- Vital Capacity
- Thoracic flow cytometry
- Statistical analysis will be performed by using SPSS software for windows(version 17) . alpha value will be set as .05.
- Unpaired t-test will be used to test for difference among the demographic variable and base line variable.
- Chi Square test will be used to analyse the gender difference between group.
- Paired t-test will be used to compare vital capacity and chest expansion before and after procedure within group.
- Unpaired t-test will be used to compare vital capacity and chest expansion between group.
As my study includes human subject, ethical clearance for the study has been obtained from the Institutional Ethical Committee, Padmashree Institute of Physiotherapy, Bangalore, as per the ethical guidelines for biomedical research on human subject, 2000 ICMR, New Delhi.
8 / List of References:
- World Health Organization [online]. WHO 2010 Available from: URL: respiration/copd/defination/en/index/html
- Kenji Shibuya, Colin D Mathers, Alan D Lopez. Chronic Obstructive Pulmonary Disease: consistent estimates of incidence, prevalence, and mortality by WHO region [online] 2001 Nov 30 Available from: URL: statistics/bod_copd.pdf
- Carla Malaguti, Rafaella R Rondelli, Leandra M de Souza, Marcia Domingue, Simone Dal Corso. Reliability of chest wall mobility and its correlation with pulmonary function in patient with Chronic Obstructive Pulmonary Disease Respiratory Care. 2009 Dec.; 54 (12):1703-1711.
- Fletcher C, Peto R. The natural history of chronic airflow obstruction. British Medical Journal 1977; 1:1645- 1648.
- Marlene Aparecida Moreno, Aparecida Maria Catai, Rosana Macher Teodori, Bruno Luis Amoroso Borges, Marcelo de Castro Cesar, Ester da Silva. Effect of a muscle stretching program using the global postural re-education method on respiratory muscle strength and thoracoabdominal mobilityof sedentary young males. J Bras Pneumol .2007; 33 (6): 679-686.
- Carolyn Kisner, Lynn Allen Colby. Therapeutic exercises –foundation and techniques. 4th ed. Jaypee Brother Medical Publishers (P) Ltd. 2002. p.756.
- Anne E.Holland, Catherine J. Hill, Elizabeth Nehez, George Ntoumenopoulos. Does unsupported upper limb exercise training improve symptoms and quality of life for patients with Chronic Obstructive Pulmonary Disease? Journal of Cardiopulmonary Rehabilitation. 2004;24:422-427.
- John E. Hodgkin, Bartolome R. Celli, Gerilynn L. Connors Pulmonary Rehabilitation – guidelines to success. 3rd ed. Lippincott Williams & Wilkins.; 2000. p. 156.
- Costa D, Forti EMP, Barbalho-Moulim MC, Rasera-Junior, Study on pulmonary volumes and thoracoabdominal mobility in morbidly obese women undergoing bariatric surgery, treated with two different physical therapy methods, Rev Bras Fisioter. 2009 July/Aug.;13(4):294-300.
- Michael T. Put, Michelle Watson, Helen Seale, Jennifer D. Paratz. Muscle stretching technique increases vital capacity and rangeof motion in patient with Chronic Obstructive Pulmonary Disease . Arch Phys Med Rehabil .2008 June; 89: p. 1103-1107.
- Katarina Burianova, Renata Varekova, Ivan Vareka .The effect of 8 week pulmonary rehabilitation programme on chest mobility and maximal inspiratory and expiratory mouth pressure in patient bronchial asthma . Acta. Univ. Palacki. Olomuc., Gymn. 2008; 38(3): 55-60.
- Chanavirut R, Khaidjapho K, Jaree P, and Pongnaratorn .Yoga exercise increases chest wall expansion and lung volumes in young health Thais. The Journal Of Physiological Sciences.2006 April;19(1):1-7.
- Murat Ersoz, Barın Selçuk, Ramazan Gunduz, Aydan Kurtaran, Mufit Akyuz . Decreased chest mobility in children with spastic cerebral palsy.The Turkish Journal of Pediatrics 2006 Oct./Nov.; 48: 344-350.
- Elaine Paulin; Antonio Fernando Brunetto; Celso Ricardo Fernandes Carvalh. Effects of a physical exercise program designed to increase thoracic expansion in Chronic Obstructive Pulmonary Disease patient. J. Pneumologia 2003 Sept./Oct. Sao Paulo ;29(5).
- Philip L. Witt, Joyce Mackinnon .A method to improve chest mobility of patient with Chronic Lung Disease. Physical Therapy 1986 Feb; 66(2): 214-217.
- American Thoracic Society. Recommended standardized procedures for pulmonary function test: Am. Rev. Respir. Dis. 1978; 118 (suppl):55-83.
- Carolyn Kisner, Lynn Allen Colby. Therapeutic exercises –foundation and techniques. 4th ed. Jaypee Brother Medical Publishers (P) Ltd. 2002. p. 757.
- Kakizaki F, Shibuya M, Yamazaki T, Yamada M, Suzuki H, Homma I. Preliminary report on the effects of respiratory muscle stretch gymnastics on chest wall mobility in patients with chronic obstructive pulmonary disease. Respir Care 1999;44:409-14.