Cardiopulmonary Physical Therapy

Haneul Lee, DSc, PT

A comprehensive pulmonary rehabilitation program should incorporate the following components :

Patient assessment and goal-setting

Exercise and functional training

Self-management education

Nutritional intervention

Psychosocial management

The determination of safe and appropriate exercise should be preceded by a thorough musculoskeletal assessment by the physical therapist.

Assessment should begin with a manual muscle test of the upper and lower extremities and the trunk.

ROM and flexibility examination must focus on specific areas such as the rib cage, shoulders, cervical/thoracic/lumbar spine muscles.

Rib cage, shoulders and spine lose ROM as a result of progressive lung disease, poor posture, and accessory breathing muscle use.

The lower extremity musculature typically loses flexibility because of disuse.

Poor posture develops lung disease progresses, activity level decrease, and metabolic changes effect bone density.

Posture changes continue to occur with the loss of chest mobility, the adoption of propping postures, and the use of accessory breathing muscles of the shoulders, cervical and thoracic spine.

Poor postural habits further inhibit breathing mechanics, and particular attention should be given to chest wall mobility within the treatment plan.

Activity can be described in terms of intensity, workloads, duration, and frequency or number of repetitions.

Symptoms and musculoskeletal discomfort should be noted. The physical therapist may advance functional training by

the following: Increasing repetitions using lower weights and proper technique for

strength training

Encouraging a higher level of work within a given time : bike, ambulation

Encouraging fewer rest periods during task performance

Decreasing the dependence on adaptive equipment : wheelchairs, motorized carts, ambulatory assistive devices

General conditioning: A prescription for exercise can be written to improve

cardiopulmonary fitness based on the results of an exercise tolerancetest.

Mode

▪ Any type of aerobic activity which allows a graded workload can be used.

▪ Circuit program of multiple activities

(e.g. bike, walking, arm ergometer)

▪ Patient preference should enter into the decision-making process for mode of exercise

Walking (treadmill, track, supported walking via walker or wheelchair) Cycling Stationary bicycling Arm ergometer Arm lifting exercise with or without weights Step exercise Water exercises Swimming Modified aerobic dance

Warm-up and cool-down must be included in each exercise session. Warm-up exercise allows for gradual increase in heart rate, blood pressure, ventilation, and blood

flow to the exercising muscles. Cool-down reduced the risk of arrhythmias.

Intensity

▪ Patients with mild or moderate lung disease will likely reach their cardiovascular endpoint with an exercise test.

▪ Karvonen’s formula

([maximum heart rate-resting heart rate] *[40-85%]) + resting heart rate

▪ Patients with severe pulmonary disorders will likely reach a pulmonary endpoint before a cardiovascular endpoint.

▪ Intensity : at or near maximum heart rate

▪ RPE scale is also used to monitor exercise intensity.

Duration

▪ Using a high intensity for exercise, the patient may need an intermittent exercise program with rest periods for tolerance.

▪ Progression is directed first toward a duration of 20-30 minutes of continuous exercise before an increase in intensity is considered.

Frequency

▪ 20-30 minutes of exercise 3-5 times per week.

▪ If duration is < 20-30 minutes, exercise must be performed more frequently (5-7 per week)

May vary from 3 to 5 times per week 60 to 120 minutes per session Extend 0ver a period of 4 to 72 weeks At least 3 days per week – supervised exercise One or more unsupervised sessions per week in the home

with specific guidelines and instruction may be an effective alternative.

If the patient is very debilitated The duration of the initial exercise sessions can be shorter with more

frequent rest breaks

But, achieve fewer or no rest breaks and at least 30 minutes of endurance exercise within the first week

Inspiratory muscle trainers (IMTs) By increasing strength and endurance of muscles of ventilation,

the patient will have▪ Increased efficiency of ventilator muscles

▪ Decrease work of breathing

▪ Decreased possibility of respiratory muscle fatigue

IMT is appropriate for patients with ▪ Decreased compliance

▪ Decreased intrathoric volume

▪ Resistance to airflow alteration in length tension relationship of ventilator muscles

▪ Decreased strength of the respiratory muscles

IMT procedure1. Explain procedure to patient with emphasis on maintenance of

respiratory rate and tidal volume during training sessions.2. Determine maximum inspiratory pressure (MIP).3. Choose an4. opening which requires 30-50% of MIP (intensity), and allows 10-

15 minute training per session.5. Ask patient to inhale through device while maintaining their usual

respiratory rate and tidal volume for at least 10-15 minutes.6. Progression initially focused on increasing duration

to 30 minutes, then increasing intensity by using smaller apertures.

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Postoperative physical therapy sessions decrease the number and severity of pulmonary complications

prevent postoperative pulmonary complications▪ Remove any residual secretions

▪ Improve aeration

▪ Gradually increase activity

▪ Return to baseline pulmonary functioning

Physical findings of postoperative pulmonary complications

▪ Increased temperature

▪ Increase in white blood cell count

▪ Change in breath sounds from the preoperative evaluation

▪ Abnormal chest x-ray

▪ Decreased expansion of the thorax

▪ Shortness of breath

▪ Change in cough and sputum production

Physical therapy considerations

▪ Determine need for pain management

▪ Choose appropriate intervention based on the individual patient’s needs.

▪ Secretion removal techniques

▪ Breathing exercise to improve aeration, incentive spirometry

▪ Early mobilization

1. National Physical Therapy Examination, O’sullivan&Siegelman, TherapyEd2. Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass,

Elsevier3. Cardiovascular and pulmonary Physical Therapy Evidence to Practice, 5th

edition, Donna Frownfelter, Elizabeth Dean, Elsevier4. Cardiopulmonary Physical Therapy Management and Case Studies, 2nd edition,

W.Darlence Reid, Frank Chung, Kylie Hill, SLACK Inc.5. PTEXAM the complete study guide, Scott M Giles, Scorebuilders