INTERDISCIPLINARY THERAPIES
Pulmonary Rehabilitation
Pulmonary rehabilitation is a program that involves a team of healthcare providers who work to improve the well-being of people with chronic respiratory disorders. While professional roles may overlap, each individual brings their own expertise to the rehabilitation effort. This team often includes physicians, nurses, respiratory therapists, physical therapists, occupational therapists, dietitians or nutritionists, psychologists, and social workers. Pulmonary rehabilitation is an outpatient program based in a hospital or clinic, and some therapies can also be provided in a patient’s home.
Pulmonary rehabilitation has many benefits, including improved:
- Quality of life
- Management of anxiety and depression
- Muscle strength
- Management of routine activities, work, outings, and social activities
(NHLBI, 2021)
The pulmonary rehabilitation team performs lung function, exercise, and possibly blood tests to help develop an individualized care plan. The patient’s medical history and prescribed treatment plan are reviewed, along with an assessment of mental health and diet. The team works together to create a plan that fits the individual patient’s needs in the areas described below (Celli, 2020).
Exercise training is designed to improve endurance and muscle strength. It may include:
- Endurance training
- Lower-extremity exercise
- Upper-extremity exercise
- Interval exercise training
- Resistance/strength training
- Alternative exercise training
- Breathing retraining
- Ventilatory muscle training
- Tai chi
- Flexibility training
- Transcutaneous electrical nerve stimulation
Nutritional counseling can be included in the pulmonary rehab program, since being either overweight or underweight can affect breathing. An eating plan can be developed to help the patient work toward a healthy weight.
Education about asthma and how to manage symptoms may include:
- How to avoid situations that make symptoms worse
- How to avoid infections
- When and how to take prescribed medications
- Proper use of inhalers
Promotion of healthy behaviors and health preservation may include:
- Smoking cessation
- Regular exercise
- Nutritional counseling and weight management
- Vaccines
A pulmonary rehab program may include teaching the individual energy-saving techniques for performing daily tasks, such as ways to avoid reaching, lifting, or bending.
Stress relieving techniques may be included since stress can affect energy breathing.
Breathing techniques can be used to increase oxygen levels, decrease how often breaths are taken, and keep airways open longer.
Psychological counseling and/or group support may be part of the pulmonary rehab program, as individuals with chronic lung disease are more prone to depression, anxiety, and other emotional problems. These comorbidities are associated with poor asthma control, greater functional disability, lower quality of life, and more frequent hospitalizations and physician’s visits (Rodriguez, 2019b).
Respiratory Therapy
Respiratory therapists (RTs) are key members of the asthma pulmonary rehabilitation team providing treatment to patients from infants to adults. They may work in acute care settings, patients’ homes, outpatient clinics, emergency departments, and in the community providing patients with asthma trigger management and asthma education and assisting in the development and implementation of the patient’s asthma action plan. RTs are involved in diagnosis, acute treatment, follow-up, and monitoring.
Respiratory therapists help identify the patient’s asthma triggers and how to manage them, demonstrate new medical devices and new medications, and perform testing such as spirometry and the 6-minute walk test (State of Indiana, 2021).
Physical Therapy
Physical therapists are concerned with developing, maintaining, optimizing, and restoring an individual’s physical and functional mobility capabilities. Physical therapy has been shown to improve asthma symptom control, exercise capacity, and sense of well-being. The majority of patients who receive physical therapy treatment are seeking relief from dyspnea and hyperventilation.
Physical therapy works to:
- Maintain or improve exercise tolerance
- Improve functional abilities
- Maintain and improve physical activity, coaching patients toward improving health behavior
- Reduce breathlessness and the work of breathing
- Improve the efficiency of ventilation
- Mobilize and aid the expectoration of secretions
- Improve knowledge and understanding of the disease process
- Reduce thoracic pain
BREATHING RETRAINING TECHNIQUES
Breathing retraining improves symptoms, psychological well-being, and quality of life in adults with asthma. They may also be effective in reducing rescue bronchodilator medication usage. Patients with mild to moderate asthma may benefit the most from breathing retraining techniques. The goal is to normalize breathing patterns by stabilizing respiratory rate and increasing expiratory airflow. The instructions provided by the physical therapist include:
- Decrease breaths taken (reduce respiratory rate).
- Take smaller breaths to reduce tidal volume.
- Use diaphragmatic deep breathing with abdominal muscles and lower thoracic chest movement.
- Breathe through the nose.
- Relax and control breathing.
- Decrease expiratory flow through pursed-lip breathing.
All of these techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing pattern, and anxiety (Mackey et al., 2021).
CHEST WALL MOBILIZATION
Structured chest wall mobilization is a physical therapy technique designed for the maintenance or improvement of mobility of the chest wall, trunk, and shoulder girdles. Chest mobilization exercises can also be used to increase chest wall mobility, flexibility, and thoracic compliance. Chest wall mobilization includes:
- Lateral flexion of the chest wall
- Chest wall extension
- Lateral gliding of thoracic spine
- Pectoralis major muscle stretching
(Swapna et al., 2020)
BUTEYKO TECHNIQUE
This technique is specific for reducing hyperinflation. It is based on the theory that bronchospasm is caused by hyperventilation that leads to a low PaCO2, resulting in asthmatic symptoms. The goal of this technique is to reduce ventilation and subsequently lung volume. The instructions for this technique include:
- Breathe normally through the nose for 2 to 3 minutes.
- Breathe out normally then close the nose with one’s fingers and hold.
- Remember the number of seconds to be recorded.
- On the first need to breathe, release the nose and return to nasal breathing (control pause).
- Wait 3 minutes.
- Repeat and hold the breath for as long as possible (maximum pause).
Persons with mild asthma can hold the breath for up to 20 seconds, those with moderate asthma for 15 seconds, and those with severe asthma for up to 10 seconds. This is practiced twice a day, with the goal of increasing the control pause to 60 seconds and the maximum pause to 2 minutes. The aim is reduction in minute volume by reducing respiratory rate and increasing carbon dioxide levels (Mackey et al., 2021).
PHYSICAL TRAINING
Physical training increases fitness and cardiorespiratory performance, reduces symptoms, and improves quality of life. The development of asthma symptoms while exercising can reduce patients’ willingness to exert themselves physically. Because of this fear, further deterioration in physical health and quality of life may occur, which can result in anxiety and depression. It has been suggested that behavior change intervention focusing on increasing participation in physical activity may have an impact on asthma and quality of life (Mackey et al., 2021).
RESPIRATORY MUSCLE TRAINING
Hyperinflation increases lung volume, which leads to an alteration in inspiratory muscle mechanics. The muscles become shortened, resulting in a poor length-tension relationship for contraction. There is a decreased capacity for tension generation when breathing that results in the use of accessory muscles for inspiration.
This training involves breathing exercises done using an external device that makes breathing more difficult. The device used sets up a load to breathe against. During inspiration, air is only released when enough effort is used to force open the values of the device. The respiratory muscles must then work harder, resulting in increased strength, which leads to easier diaphragmatic breathing and reduced hyperinflation (Mackey et al., 2021).
AIRWAY CLEARANCE TECHNIQUES
Physical therapy may assist in the removal of secretions in the airways using:
- Percussions/vibrations: The clapping of the chest with a cupped hand to vibrate the airways. This moves mucus from smaller airways into larger ones where it can be coughed up. This can also be done using a device designed to vibrate the chest.
- Effective coughing: There are two extremely effective techniques for coughing:
- Deep coughing:
- Start by inhaling deeply and hold the breath for 2 to 3 seconds.
- Using stomach muscles, forcefully expel the air while avoid a hacking cough or just clearing the throat.
- Huff coughing:
- Take a breath that is slightly deeper than normal.
- Using stomach muscles, exhale rapidly three times with the mouth open, making a “ha-ha-ha” sound.
- Follow this by controlled diaphragmatic breathing and a deep cough if mucus is felt to be moving.
- Deep coughing:
- Postural drainage: This technique uses gravity to help drain mucus by placing the body in specific positions to drain the five lobes of the lungs.
(Physiopedia, 2021b; Mackey et al., 2021)
(See also “Asthma Inpatient Respiratory Therapy” earlier in this course.)
EDUCATION
Besides specific exercises and positional instruction, physical therapists provide extensive patient education, including (but not limited to):
- Asthma disease process
- Use of bronchodilator and other medications
- Prevention of chest infection
- Correct standing and sitting posture to allow for appropriate chest expansion and lung function
(Mackey et al., 2021)
Occupational Therapy
Occupational therapists work with patients with pulmonary diseases such as asthma to increase their potential for independence. They play a major role in pulmonary rehabilitation, combining exercise training, education, and counseling to teach patients how to live a fuller life with a chronic lung condition.
Occupational therapy may include education about the anatomy and physiology of the lungs, various medications and their purpose, and medication management. Occupational therapists may teach relaxation techniques, energy conservation, and stress management techniques and preventative actions the patient can use to manage asthma.
STRESS MANAGEMENT
Occupational therapy strategies that assist with stress management include panic control, progressive relaxation techniques, and breath support exercises to help the patient with asthma better adapt to daily life and to decrease the effects of stress. OTs offer strategies to decrease shortness of breath and improve quality of life and continued participation in meaningful occupations by introducing adaptive, compensatory, and restorative techniques and interventions.
Occupational therapy assists patients to learn to:
- Identify their symptoms of stress (physical, emotional, and behavioral)
- Recognize and understand causes of stress
- Identify personal strengths and skills
- Learn ways to change self-defeating beliefs or thoughts to improve quality of life
- Learn new coping skills and ways to relax
- Make lifestyle changes to balance work, recreation, and rest
- Assist with smoking cessation or elimination of other undesirable health behaviors
- Learn different relaxation and meditation techniques
Learning to relax is an essential tool in the arsenal for management of asthma. Occupational therapists teach techniques such as:
- Deep breathing
- Progressive muscle relaxation
- Autogenic therapy, in which the patient is taught to connect mind and body so that the body responds to the mind’s commands
- Guided imagery
- Mindfulness-based meditation
- Cognitive behavioral therapy
- Solution-focused therapy
- Therapeutic use of activity
- Motivational interviewing
ENERGY CONSERVATION
Occupational therapists are knowledgeable about activity analysis, grading activities, ergonomics, and body mechanics. Energy conservation and work simplification techniques reduce unnecessary oxygen expenditure while the patient is involved in activity. Five important principles are incorporated into daily activities and routines in order to conserve energy, including:
- Plan and organize daily routines and activities:
- Alternate between heavy and light tasks and simplify tasks as much as possible.
- Prepare ahead for tasks by gathering and organizing necessary tools and or supplies.
- Have adequate rest periods after completing activities and before starting another one.
- Use appropriate equipment to simplify activities:
- Use modern household utensils or electric appliances.
- Use assistive devices such as long-handled reachers to reduce the need for stooping or bending over to pick things up from the floor.
- Use kitchen trolleys to assist with pushing and carrying objects.
- Work with appropriate pacing:
- Allow adequate time for completion of an activity, remain relaxed, and complete the task at a gentle pace.
- Rest when feeling tired to prevent exhaustion.
- Avoid inappropriate posture that may affect breathing:
- Sit down to perform daily activities whenever possible.
- Avoid activities that require long periods of standing, squatting, or stooping.
- Avoid moving arms above shoulder level.
- Use correct body mechanics:
- Keep posture upright while performing an activity to conserve energy.
- Keep arms close to the body while carrying objects.
- Carry a load equally between both arms at the same time.
- Keep elbows on the table or other firm surface while performing an activity such as shaving or grooming.
- Maintain proper posture: When sitting down to rest, Keep the body straight and lean forward slightly. Relax shoulders and keep hands on tights. Feet should both be on the floor.
(Alam, 2016)
RECOMMENDATIONS FOR ACTIVITIES OF DAILY LIVING
Cooking
- Use a ventilation fan in the kitchen for cooking to avoid cooking vapors and smoke inhalation.
- Sit to perform cooking preparation activities such as peeling or chopping vegetables.
Eating
- Ensure good posture and avoid stooping or semi-inclined positions.
- Support elbows on the table.
- Place all dishes within reach.
- Eat lighter and more frequent meals to minimize shortness of breath.
Grooming
- Sit in front of the sink for cleaning the face, brushing the teeth, shaving, and combing or styling the hair.
- Support elbows on the sink rim.
- Use a small-sized towel.
- Use an electric toothbrush and razor to minimize upper limb exertion.
Dressing and Undressing
- Do not wear tight clothing or clothing with zippers or buttons in the back.
- Wear shoes without shoelaces to avoid having to bend to tie them.
- Sit when possible.
Toileting
- Do not strain during bowel movements; use coordinated breathing.
- Eat a diet with adequate fruits and vegetables to prevent constipation.
- Use a raised toilet seat to ensure proper height and ease of rising.
Bathing
- Choose a time of day when energy and stamina are the greatest.
- Use bronchodilators if prescribed.
- Prepare and keep all necessary supplies close at hand.
- Use a shower chair to sit if needed.
- Use bath grab rails while bathing in a tub.
Laundry
- Minimize repeated squatting when loading and unloading washer and dryer.
House Cleaning
- Plan one task a day to do such as laundry on Monday, dusting on Tuesday, etc.
- Use a mask when dusting.
Shopping
- Use a planned route and map for shopping.
- Use online ordering and delivery for heavy groceries.
- Use a wheeled cart for shopping.
(Alam, 2016)
FAMILY SUPPORT
Family support is also provided by occupational therapists, especially for parents of children, helping to discover efficient ways to adjust habits and routines to conserve energy and to take part in physical activity. Parents are provided with instruction in coping, positioning, breathing techniques, counseling, and medication management for their children.
Alternative or Complementary Treatments
A number of people with asthma look for alternative or complementary treatments to control or enhance control of asthma symptoms. Such treatments might include herbs, dietary supplements, acupuncture, chiropractic, massage therapy, biofeedback, homeopathy, nutrition, and botanicals. Because there have been limited research studies done on such treatments for asthma, the effectiveness and safety of many are unknown, they are not approved by the FDA or by the medical profession, and they are not prescribed by physicians.
Some treatments include:
- Breathing exercises: Papworth method and yogic breathing (pranayama) can help prevent hyperventilation. These practices may offer modest benefits, if any, and do not seem to improve the allergic reaction that triggers asthma symptoms. However, breathing exercises may help with relaxation.
- Acupuncture: Some research suggests that acupuncture may reduce the need for inhaled steroids in children, but more definitive studies are needed.
- Chiropractic manipulation: Some studies have found that spinal manipulation may help reduce the number of asthma attacks and need for medication, particularly in children. However, there is not enough evidence to support its use as an effective asthma treatment.
- Diet, vitamins, and supplements: Studies show that certain vitamins and nutrients found in foods may help relieve asthma symptoms in some people. Three promising ones include antioxidants, omega-3 fatty acids, and vitamin D.
- Massage: Studies suggest that massage may help children with asthma breathe more easily, including a recent study of children ages 4–8 whose lung function improved greatly after receiving gentle, 20-minute bedtime back rubs by a parent.
- Relaxation techniques: Medication, biofeedback, hypnosis, and progressive muscle relaxation have been shown to help lower blood pressure and slow breathing. It is uncertain if they help improve asthma, but they can help reduce stress.
- Herbal supplements marketed for asthma treatment have not been thoroughly tested, and the FDA does not regulate them in the same way as medicines. Issues of concern include lack of quality and dose control, minor to severe side effects, and drug interactions. Use of supplements should be discussed with one’s healthcare provider.
(Mayo Clinic, 2020e)