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Basic techniques of pulmonary physical therapy (I)
100/04/24
Evaluation of breathing function
• Chart review– History
– Chest X‐ray
– Blood test
• Observation/palpation– Chest mobility
– Shape of chest wall
– Accessory muscle firing
– Respiratory rate
– Posture
• Physical examination– Breathe sound
– Dyspnea index
– Cough ability
– Functional capacity
Evaluation of breathing pattern
• Breathing pattern (I)– 2C2D– 3C1D
• Breathing pattern (II)– Upper chest paradox– Abdominal paradox– Excessive accessory muscle use
• Breathing pattern (III)– Paradoxical– Rapid and shallow– Prolong expiration, and etc.
Breathing retraining
• Active expiration• Pursed lips breathing• Specific body positions• Diaphragmatic breathing• Accessory muscle stretch • Breathing control• Relaxation breathing• Incentive spirometry (IS)
Active expiration
• Contraction of the abdominal muscles during expiration
• Lengthens the diaphragm – Improve the length‐tension relationship or geometry of the respiratory muscle (diaphragm)
– Assist the next inspiration• ↑transdiaphragmatic pressure• The efficacy of the contraction in moving the rib cage improves
• ↑strength and endurance of inspiratorymuscle
Length‐tension relationship
In same neural input, ↑length, ↑output of muscle
Pursed lips breathing
• Effects – Improves ventilation
– Releases trapped air in the lungs
– Keeps the airways open longer and decreases the work of breathing
– Prolongs exhalation to slow the breathing rate
– Improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs
– Relieves shortness of breath
– Causes general relaxation
• Active and prolonged expiration through half‐opened lips
Pursed lips breathing
Body position
• Upright position– Oxygen transport is optimized to the greatest degree (ventilation vs perfusion)
–Maximize lung volume and capacities (Fig)
– Anteroposterior dimension of chest wall is the greatest, and compression of the heart and lung is minimized
–Maximal expiratory pressure is greatest (cough, huffing, etc.)
To optimize thoraco‐abdominal movements
• Segmental breathing
Segmental breathing
Diaphragm breathing
• Move the abdominal wall predominantly during inspiration and to reduce upper rib cage motion– Improve chest wall motion– Improve distribution of ventilation–↓ the energy cost of breathing–↓ the contribution of rib cage muscle–↓ dyspnoea–↑ exercise performance
Diaphragm breathing
Accessory muscle stretch
• Accessory muscle– sternocleidomastoid (elevated sternum)
– scalene muscles (anterior, middle and posterior scalene)
– serratus anterior, pectoralis major & minor, upper trapezius, latissimus dorsi, erector spinae (thoracic), iliocostalislumborum, quadratus lumborum, serratus posterior superior and inferior, levatores costarum, transversus thoracis, subclavius
Accessory muscle stretch
Accessory muscle stretch
• Sidelying, with the upper arm elevated to stretch the intercostal muscles or in sitting, using active shoulder abduction combined with lateral flexion
• Active or passive bilateral arm flexion and spine extension may be combined with deep inspiration
Manual therapy techniques
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Breathing control
• Respiratory ratio– Inhalation: exhalation= 1:2
Relaxation breathing
• When hyperinflation caused by an ↑ activity of the inspiratory muscles during expiration
• Hyperinflation is due to altered lung mechanics (COPD)– Loss of elastic recoil pressure
– air trapping• Forward leaning→ COPD– Relief hyperinflation and paradoxical abdominal movement
– ↓EMG activity of the scalene and sternomastoidmuscles
– ↑transdiaphragmatic pressure, ↑thoraco‐abdominal movements
Relaxation breathing
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• Mechanical devices introduced in surgical patients
• Attempt to reduce postoperative complications by increasing inspiratorycapacity
• Activated by the patient’s inspiratoryeffort– Slow, deep inspiration– Mouthpiece– Visual feedback– Preset volume and hold at full inspiration for 2‐3 secs
Incentive spirometry
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Incentive spirometry
Manual therapy techniques
• Subjective assessment– Musculoskeletal dysfunction
• Postural and skeletal changes over time– Overuse of upper chest breathing patterns– Lack of lower rib expansion – Chronic hyperinflation typically leads to the
development of a barrel‐shaped chest • Physical assessment: posture
– The relaxed posture of the pelvis, lumbar, thoracic and cervical spines
– The position of the scapulae and the location of the humeral head within the glenoid
– The posture of the neck and head and alignment with the trunk and pelvis
– The point of maximal curve of each of these segments– Whether the spinal posture is fixed or able to be
corrected29
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Manual therapy techniques
• Physiotherapy management– Postural correction and motor control training• Educating awareness• Use visual, auditory and sensory feedback• Motor learning with training the holding ability of the postural stabilizers‐ frequent gentle repetitions of the corrected movement or position
• Initial focus: correct any posterior pelvic rotation in sitting and on reducing the lumbar and thoracic kyphosis
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Manual therapy techniques
–Mobilization techniques• Focus: – improving the range and quality of thoracic extension and rotation
– Increasing the mobility of the ribs
–Muscle‐lengthening techniques– Taping–Muscle retraining
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• Intercostal stretch– Stretch on expiration phase maintained
• Observation– Increased movement of area being stretched
• Suggested mechanism– Intercostal stretch receptors
Neurophysiological facilitation of respiration
• Anterior stretch‐lifting posterior basal area– Patient supine– Hands under lower ribs– Ribs lifted upward
• Observation– Expansion of posterior basal area– ↑epigastric movements
• Suggested mechanism– Dorsal root‐mediated intersegmental reflex– Stretch receptors in intercostals, back muscles
Neurophysiological facilitation of respiration