DISSERTATION SYNOPSIS

DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By MARVANIA GUNJAN JAMNADASUNDER THE GUIDANCE OF S. NATARAJANVIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2011-2013RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1.Name of the Candidate

and AddressMARVANIA GUNJAN JAMNADASVIKAS COLLEGE OF PHYSIOTHERAPY

AIRPORT ROAD

MARYHILL, KONCHADY

MANGALORE 575008

2.Name of the InstitutionVIKAS COLLEGE OF PHYSIOTHERAPYMangalore.

3.Course of study and subjectMaster of Physiotherapy in Cardiorespiratory Disorders and Intensive care

4.Date of admission to Course

24-06-2011

5.Title of the TopicEFFECT OF THORACIC MOBILITY AND STRENGTH ON DYSPNEA, CHEST EXPANSION AND EXERCISE CAPACITY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISORDERS.

6BRIEF RESUME OF THE INTENDED WORK

6.1) Need for the study

COPD, which stands for chronic obstructive pulmonary disease, by definition is stated as a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.1

It is second most common lung disorder following pulmonary tuberculosis and constitutes 25-30% of cases in non-tubercular chest clinics in India2. It has been even predicted to become the third leading cause of death and fifth commonest cause of disability by 2020 in the world.3 Even prevalence rates vary a lot being 5% in males and 2.7% in females of over 30 years of age.4 The disease affects function of other organs of body besides lung even leading to dysfunction of respiratory muscles.3 Patients with COPD often develop changes in chest wall configuration. These changes have been related to airway obstruction, hyperinflation, and mechanical disadvantage of respiratory muscles. In addition, disuse resulting from reduced upper limb activity may lead to muscle tightening and stiffness around the muscle quadrant, thereby further increasing chest wall resistance and the work of breathing.5

In COPD marked postural changes are observed which includes elevated, protracted or abducted scapulae with medially rotated humerus, and kyphotic spinal deformities.6,7 The hyperinflated lungs places the pectoralis major in a shortened position, which leads to increase in resistance of chest wall to expand this causes a decrease in exercise capacity and pulmonary function.8Gooselink R. et al studied Peripheral muscle weakness contributes to exercise limitation in COPD pts.18 Also Victor D. et al studied relation of thoracic muscle strength to exercise capacity in copd pts and concluded that skeletal muscle strengthening should be emphasized.20 Pulmonary rehabilitation plays a fundamental role in management of patients with COPD. It is multi dimensional and various components include chest physiotherapy (bronchial drainage, breathing exercise, coughing technique), aerobic exercise, strengthening exercise, functional training & psychosocial training.26 Efficacy of pulmonary rehabilitation have been demonstrated in many studies.27 However very few studies has been done to find the effects of thoracic muscle strengthening and stretching on dyspnea, chest expansion and exercise capacity in COPD pts. Thus, the major aim of this study is to find the effects of thoracic muscle strengthening and stretching on dyspnea, chest expansion and exercise capacity in copd pts.Hypothesis :

Null hypothesis:There is no significant difference between the effects of thoracic muscle strengthening and stretching on dyspnea, chest expansion and exercise capacity in copd pts.Alternate hypothesis:There is significant difference between the effects of thoracic muscle strengthening and stretching on dyspnea, chest expansion and exercise capacity in copd pts.

6.2 Review of literature:Carla M et al (2009) in their research regarding reliability of chest wall mobility and its correlation with pulmonary function in patients with COPD concluded that there was an association between inspiratory capacity and measurement at abdominal level, chest wall mobility did not correlate with pulmonary function.5Donrawee L et al (2009) studied acute benefits of chest wall stretching exercise on expired tidal volume, dyspnea and chest expansion in a patient with COPD. The results showed a significant clinical improvement ofexpired tidal volume, reduction in dyspnea level and increase in chest expansion.23Michael T. Putt et al (2008) in their research regarding the effect of pectoralis muscle stretching technique in COPD to improve vital capacity concluded that hold and relax stretching technique increases vital capacity significantly. Also it provided evidence that hold and relax technique can improve the restrictive component of COPD and possibly overcome some of the postural changes of COPD.8Victor Z. et al (2006) investigated the influence of thoracic and upper limb muscle function on 6 min walk distance in copd patients. This study showed the importance of skeletal musculature of the thorax and upper limbs in submaximal exercise tolerance and could open new perspectives for training programs designed to improve functional activity in copd pts.20Kriel, Achmat (2005) did considerable research on chest wall expansion and lung function found that if chest wall movements are restricted in anyway, decrements in pulmonary function and exercise capacity are seen. Furthermore, there is significant increase in oxygen cost associated with external chest wall restriction.9Roger E. et al (2011) studied the role of spinal manipulation, soft tissue therapy, and exercise in copd and concluded that applying these interventions to the chest wall in copd could reduce chest wall rigidty, thereby improving breathing mechanics, thus reducing the work of respiratory musclesand delays the onset of dyspnea and improving exercise capacity in copd.22 Elaine Pauline, Antonio Brunetto, Celso Carvalho (2003) studied 30 moderate to severe COPD patients and found that exercises aimed at increasing thoracic expansion in COPD patients improve thoracic expansion, quality of life and submaximal exercise capacity, as well as reducing dyspnea and depression.11Hightower et al. (1999) tested the effects of rib cage mobilization and respiratory muscle stretching on vital capacity and chest wall expansion in fourteen elderly adults aged 58 to 83. Although the results indicated that the experimental group showed an improvement in xiphoid and axillary chest wall expansion measurements following manual stretching and rib mobilization compared to a control group.12Caro et al. (1959) the effects of restricting chest cage expansion on pulmonary function in man was tested. The results of this study showed that restricting chest wall expansion in normal man reduced the total lung capacity and its subdivisions. Following the release of chest restriction, the mechanical changes in the lungs were reversed. Thus, any abnormality that affects the muscles of respiration or rib biomechanics will have an effect on the optimal functioning of the lungs and respiratory system as a whole.13Gonzalez et al. (1999) makes mention of the fact that chest wall restriction, whether it be caused by disease or mechanical constraints, can cause decrements in pulmonary function and exercise capacity. Thus, any abnormality e.g. hypertonicity affecting the muscles of respiration, especially the intercostal muscles, or rib biomechanics will have an effect on the optimal functioning of the lungs and the respiratory system as a whole. Gonzalez et al. (1999) also stated that there is a significant increase in oxygen cost associated with external chest wall restriction, which is directly related to the level of chest wall restriction.156.3 Objectives of the study:1. To determine the effects of thoracic muscle strengthening and stretching on dyspnea, chest expansion and exercise capacity in copd pts.

2. To design a new rehabilitation program to emphasis the importance of thoracic muscle strengthening and stretching along with chest physiotherapy & breathing exercises.

7.Materials and methods:7.1 Source of data: opd of vikas college of physiotherapy & govt. wenlock hospital.7.2 Method of collection of data Population :-stable COPD patients. Sample design :- random sampling

Sample size :- 30

Type of Study :- experimental comparative study

Duration of study :-3 months

Materials required: Measuring tape

Chair

Plinth

Stopwatch, sphygmomanometer, markers(to mark 6 minute walk distance)

St. George respiratory questionnaire

American thoracic scale to measure dyspnea grade.Inclusion criteria :

Patients diagnosed as having COPD by physician

Patients who have not had any episodes of acute exacerbation of COPD in the past two months(stable COPD patients)

Both male and female

Not involved in any upper limb exercises from past one month

Predicted FEV1 should be mild to moderate

Exclusion criteria:

Acute exacerbation during or before study

Pain in shoulder

Periarthritis of shoulder

Disability preventing mobility of thorax

Back pain

Unstable cardiac disease

Cor pulmonale

Acute illness

Respiratory muscle fatigue

Any other spinal deformity, soft tissue lesion around chest wall.

Outcome measures: Chest girth measurement.

6 minute walk performance.

St. George respiratory questionnaire American thoracic scale to measure dyspnea grade.7.3 Methodology:

A total of 30 subjects fulfilling inclusion criteria will be selected for the study. All the subjects will be informed of the objectives of the study. Informed consent will be taken from the subjects prior to participation. The Subjects will then be randomly assigned to one of the two groups: group A (n=15) and group B (n=15). Patients will be blinded to the group allocation. Each subject will undergo formal evaluation including chest girth measurement, 6 minute walk test, subject will grade their dyspnea levels on American thoracic scale and fill st.georges respiratory questionnaire. 8 Weeks of training program will be done where subjects will be called 3 times in a week for exercise session. Total of 24 sessions wil be conducted for both the groups.

GROUP A:

Subjects of this group will receive thoracic mobility and stretching exercise like thoracic rotations and lateral stretching in sitting position, stretching of pectoralis major, scalenes and trapezius muscle groups.30,31 and thoracic strengthening exercise like back extensors, latissimus dorsi, rhomboids, serratus anterior along with breathing exercise and other chest physiotherapy techniques.30,31 GROUP B:

Subjects of this group will receive chest physiotherapy techniques and breathing exercises.

After 8 weeks of exercise session, chest girth measurements (at 3 levels), American thoracic scale to assess dyspnea, 6 min walk test, St George respiratory questionnaire will be assessed.Statistics:

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 groups.

Paired t test will be used to compare chest girth, spirometric value, 6 min walk performance, questionnaire score pre and post treatment in intra group comparison.

Unpaired t-test will be used to compare in between groups.

7.4 Ethical Clearance:-

As this study involve human subjects, the ethical clearance has been obtained from the ethical committee of our institute, to carry out necessary investigation and interventions on pts necessary for the study.

8REFERENCES:1. Pauwels R. Global strategy for the diagnosis, management and prevention of COPD.NHLBI/WHO GOLD workshop summary. Am J Rrspi Crit Care Med 2001; 163:12562. Guleria JS. Chronic Obstructive Pulmonary Disease In: API Textbook of Medicine, 5th ed. National book Depot, Bombay. 1992

3. Lopez AD, Murray CC. The global burden of disease, 1990-2002. Nat Med 1998; 4:1241-12434. Jindal SK, Gupta D, Aggarwal AN. Guidelines for management of chronic obstructive pulmonary disease in india: A Guide for physicians (2003). Indian J. Chest Dis. Allied Sci 2004:46:137-153.5. Carla M et al, Reliability of chest wall mobility& its correlation with pulmonary function in pts with copd. Respiratory care. 2009; 54(12).6. Warren A. Mobilization of the chest wall. Phys Ther 1968; 48:582-585.

7. Witt P, Mackinnon J. Trager psychophysical integration- a method to improve chest mobility of patients with chronic lung disease. Phys Ther 1986; 66:214-217.

8. Michael TP, Michelle W, Helen S, Paratz JD. Muscle stretching techniques increases vital capacity and range of motion in patients with Chronic Obstructive Pulmonary Disease. Arch Phys Med Rehab 2008; 89:1103-1107.

9. Kriel. Achmat. An investigation into the immediate effect of rib mobilization and sham laser application on chest wall expansion and lung function in healthy asymptomatic males: a pilot study. Dept. of chiropractic, Durban institute of technology, 2005. Available from: URL: http://hdl.handle.net/10321/18910. Sibuya M. Yamada M, Kanamaru A, Tanaka K, Suzuki H, Noguchi E, Altose MD, Humma I. Effect of chest wall vibration on dyspnea in patients with chronic respiratory disease. Am J Respir Crit Care Med 1994; 149(5):123.5-124011. MacIntyre NR. Muscle dysfunction associated with chronic obstructive pulmonary disease. Respir Care 2006; 51:840-8.12. Elaine P, Antonio FB, Celso RFD. Effects of a physical exercise program designed to increase thoracic expansion in chronic obstructive pulmonary disease patients. J.Pneumologiavol.29no.5So PauloSept./Oct.200313. Hightower, M., Nguyen, T., Long, K., Pollock, M., Ngan, G. and Wetzel,G. 1999. The Effects of Respiratory Muscle Stretching and Rib Cage Mobilization on Vital Capacity and Chest wall Expansion in the Older Adult. Abstracts presented at the 1999 Pennsylvania Physical Therapy Association14. Caro, C.G., Butler, J. and Dubois, A.B. 1959. Some Effects of Restriction of Chest Cage Expansion on Pulmonary Function in Man: An Experimental Study. The Journal for Clinical Investigation 39 (4):573-583.15. 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; 44:409-14.16. Gonzalez J. et al 1999, a chest wall restrictor to study effects on pulmonary function and exercise. Respiration. Internal journal of thoracic medicine, 66 (2).17. Jubran A et al. effect of hyperinflation on rib cage abdominal motion. Am rev respire dis 1992;146(6).18. American and European respiratory society. Skeletal muscle dysfunction in copd. Am j respire crit care med 1999;159.19. Gosselink R.peripheral muscle weakness contributes to exercise limitation in copd. Am j respire crit care med 1996;15320. Wegner r, factor analysis of exercise capacity, dyspnea ratings, and lung function in copd. Eur respire j 1994;721. Victor d et al, relationship of upper limd and thoracic muscle strength to 6 min walk distance in copd patients. Chest 2006;12922. Sarah b et al, aerobic and strength training in patients with copd. Am j respire crit care med1999;15923. Roger e et al. the role of spinal manipulation, soft tissue therapy, and exercise in copd. Journal of alt and com medicine 2011;17(9)24. Donrawee l et al. acute effects of chest wall stretching exercise on expired tidal volume, dyspnea, and chest expansion in a copd pt. journal of bodywork and movement therapy. 2009;13(4)25. Donald r, immediate effects of osteopathic manipulative treatment in elderly patients with copd. J am osteopath assoc .2008;108(5)26. M.Orozco. structure and function of the respiratory muscles in patients with copd. Eur respire j 2003;22(46)27. Seron P et al. effect of inspiratory muscle training on muscle strength and quality of life in copd. Arch bronconeumol.2005;41(11)28. Susana M et al. clinical outcomes of expiratory muscle training iin severe copd patients. Elsevier respiratory medicine 2006.29. Carolyn b et al. validation of st george respiratory questionnaire in bronchiectasis. Am j respire. Crit. Care med 1997;156(2)30. Kendall F, muscle testing and function, 4th edition, pg no: 138,139,279,282,283.31. Kisner C. et al, Therapeutic exercise foundation and techniques.32. ATS Statement: guidelines for six minute walk test. Am j respire crit care med, 2002;(166)

9.Signature of the candidate :

10.Remarks of the Guide

11.

Name and Designation of

11.1 Guide : 11.2 Signature :

11.3 Co-Guide : 11.4 Signature : 11.5 Head of the Department : 11.6 Signature :