This essay will address the physiotherapy problems of
Exercise Intolerance and breathlessness from Case Study 1. I will be evaluating
pulmonary rehabilitation and positioning when treating this patient, as well as
evaluating the outcome measure – FEV1.
This case study shows that Patient A has all the clinical
signs of suffering from exercise intolerance. Exercise intolerance is one of
the most common symptoms of COPD as well as one of first symptoms patients
notice. Patients are often trapped in a vicious circle regarding exercise, as
the dyspnea and exercise intolerance often lead to a sedentary lifestyle, which
results in deconditioning and worsened dyspnea (Criner, 2006). This then can lead to a reduced ability to
take part in activities of daily living and a reduced health related quality of
life. Exercise intolerance was thought to occur in COPD solely due to dyspnea,
however muscle fatigue is now thought to be a significant contributor to
exercise intolerance (Gosselink, 1996). As the level of patient A’s physical
activity decreased (from walking up inclines, to being unable to transfer out
of bed), his muscles underwent a process called deconditioning. The process of
deconditioning involves the structural and biochemical changes in muscles where
constant inactivity causes the muscles to partially replace muscular fibres with
fat. As there are now less muscular fibres to contract, muscles begin to get
weaker. Studies found vast differences in skeletal muscles in COPD patients
compared to healthy subjects. (Saey, 2003) conducted a study into contractile
fatigue after exercise in patients with COPD, where half of the 18 COPD
patients were found to have contractile fatigue after exercise. This group’s exercise
tolerance didn’t improve after using a bronchodilator which suggests it was
fatigue of the muscles not dyspnea or airway limitation, that affects exercise
intolerance. Patient A has a loss of bucket handle movement which suggest he
has weak respiratory muscles.
Patient A also has all the clinical signs of breathlessness.
Patient A complained of wheezing, and a tight chest during the subjective
examination, and the objective examination found that the patient not only had
a dangerously low value of 28% SpO2 (Supplementary O2 is recommended
at 90%), but he also has moderate hypoxemia, hyperinflation which leads to
shortness of breath as the less elastic alveoli or blockage in the airway due
to sputum interfere with expulsion of air. The constant smoking for 50 years
would play a large factor in damaging the elasticity of the alveoli. Patient A
is also using his accessory muscles to assist deep inspiration, which suggests
a lack of enough O2 during normal inhalation. The patient is
breathing apically, and the result is a shallow respiratory pattern, with failure
to ventilate the major part of the lungs.
The main goals of pulmonary rehabilitation are to reduce the
symptoms of COPD, improve the level of daily activity and, allow the patient to
become more independent (Troosters, 2005 and Derom, 2007). This would be particularly helpful for Patient
A. It has been shown to increase exercise tolerance, and help patients
reporting fear and anxiety. After a systematic review was carried out by (Bekkering,
2000 and Troosters, 2009) an update to the clinical practice guidelines were
It was recommended that pulmonary rehabilitation should include:
Exercise training of the muscles of ambulation –
Strength training of the upper and lower limbs
Education for lung disease
Available for COPD patients.
Exercise and Strength training helps to keep the muscles
stronger. It does this by damaging the muscles and your body naturally repairs
the muscle using satellite cells which fuse with the muscle fibres. These cells
transition of protein strands within the fibres. The strands increase the
strength of the muscle.
(Güell, 2006) designed a randomized, controlled trial with a
blinding outcome assessment on the impact of pulmonary rehabilitation on
psychosocial morbidity in patients with severe COPD. They were evaluated using the
Milon Health Behaviour Inventory, the Revised Symptom checklist, the 6-minute
walk and the chronic respiratory questionnaire. They found that PR may decrease psychosocial morbidity in
COPD patients. However, this study was limited to only 40 patients with
and age range of 65 +/-8 years with severe chronic flow limitation, so the data
is shouldn’t be generalised to the population as COPD affects a wide range of people.
However, despite this the, use of Psychosocial advice in pulmonary rehabilitation
is still been found to be helpful (Ginot, 2003 and Lewis, 1995), as well as
being recommended by the National Heart, Blood and Lung Institute.
One treatment to help manage breathlessness is called positioning.
Patient A seems to have trouble breathing at rest and positioning may help him
become comfortable. This is recommended in the (Journal of the British Thoracic Society, 2009) regarding positioning:
Passively fix the shoulder girdle. This helps to
optimise muscle efficiency and relief of breathlessness.
Assess the effectiveness of forward lean sitting
on relief of breathlessness in all patients with COPD, in both the chronic and
Modify the forward lean position for use in
standing and lying, for patients for whom forward lean sitting is effective.
Teach individualised energy conservation
techniques to help reduce dyspnoea during activities of daily living.
Assess the effectiveness of a gutter rollator
frame in the acute setting, for patients with COPD severely disabled by breathlessness.
(Landers, 2006) studied whether sitting posture can have an
effect on pulmonary rehabilitation. The study measured 14 COPD patients in
minute ventilation, forced vital capacity, and forced expiratory volume in 1
second, in a slumped and a upright position for 5 minutes. Landers found no
differences between the sitting positions. However, this could be due to the very
small sample size, or the individual differences in the severity of patients
COPD. Conversely, (O’Neill, 1983) found that there was a significant improvement
in a leaning forward position. Finding a comfortable position, in which he can
sleep in would help him psychosocially as well.
A commonly used outcome measure in Pulmonary Rehabilitation
is the lung function test, which tests the patients Forced Expiratory Volume in
1 second, otherwise known as FEV1. In basic terms, FEV1 is
a measure of lung function and it calculates the amount of air that a patient
can expel from their lungs in 1 second.
It is commonly used as an outcome measure as COPD is a progressive disease,
consequentially meaning that it gets worse over time, and the FEV1 value
can help deduce what GOLD (Global Initiative for Chronic Obstructive Lung
Disease) stage the patient is currently at.
There are many strengths of using FEV1 as an
outcome measure such as Scientific Evidence. As we know, FEV1 is a
measure of lung function, and there are many studies which investigate whether
there is a correlation between lung function performance and COPD. A systematic
review was conducted by (Young, 2007) into spirometric screening for early
signs of airflow limitation. They found that
reduced forced expiratory volume in one second FEV1 is more than a measure of airflow
limitation, but a marker of premature death. It helps to assess the baseline risk of COPD, lung cancer,
coronary artery disease and stroke.
Another strength of using lung function (FEV1) as
an outcome measure, is that the result of the tests are highly reproducible,
when performed correctly. A study was conducted (Malmberg, 2001) into the Acceptability, Reproducibility, and
Sensitivity of Forced Expiratory Volumes in Asthmatic Children during bronchial
challenge testing. They compared the FEV1 and the Peak Expiratory
Flow (PEF) of 105 children with newly diagnosed asthma. The responses were
compared, and the reproducibility at baseline and from duplicate measurements
at each challenge step was determined. Malmberg found that compared to PEF, FEV1
showed better baseline reproducibility, higher sensitivity and that during
challenge testing in subjects with an acceptable flow-volume, paired recordings
of FEV1 agreed within 0.1 L in 85% and within 0.2 L in 93% of measurements. This test
shows that the FEV1 can be considered valid and reliable in regard
to being an outcome measure for lung function in COPD patients.
However, there are some limitations regarding using lung
function as an outcome measure in COPD treatment. (Glaab, 2010) states that FEV1
has a few limitations as an outcome measure as changes in lung volumes can occur without accompanying changes in FEV1 as
well as that patients with a similar FEV1 may represent different
FEV1 has been used as a outcome measure, there is evidence that
suggests that FEV1 is a relatively poor correlate of all symptoms
such as breathlessness and the impact of COPD on daily life. For example,
anxiety and depression are common and important comorbidities in patients with
COPD. The presence of anxiety and/or depression in COPD patients is associated
with increased mortality, exacerbation rates, length of hospital stay, and
decreased quality of life and functional status (M Pumar, 2014). In addition (PW
Jones, 2006) suggests that the clinical
presentation of COPD is highly variable. The outcomes of COPD experienced by
the patient include: symptoms, weight loss, exercise intolerance,
exacerbations, health-related quality of life, health resource use and
As FEV1 is a strict measure of lung physiology
alone, IT may not adequately describe both the social impact of COPD and the
effectiveness of therapeutic interventions in individual patients, because COPD
can affect the social aspect of a patient, it’s difficult to say FEV1
is an accurate measure of COPD as a whole. Most researchers regard changes in
patient centred outcomes, such as symptoms, exacerbations, exercise capacity
and Health Related Quality of Life, as more important than changes in lung
function. Therefore, a new multidimensional measurement for COPD has been created
by a panel of COPD experts which is more comprehensive (BR Celli, 2005).
In conclusion, to my evaluation of Patient A’s problems,
possible treatments and the outcome measure I would you to track progression, I
believe pulmonary rehabilitation would be the best treatment to use alongside positioning.
This would help the patient both short-term and long-term.