V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Problem solving

• Dysnea
• Impaired mucus clearance
• Impaired exercise performance
• Infections
• PA
Screening Referral

• Pulmonary function tests

• Pulmonary function tests
• and exercise test

• Recurrent respiratory infections
Case
• exacerbations with hypersecretion
history
• Adherence to treatment
• Exertional dyspnea
• Poor physical activity in daily
life (MRC ≥ 2), < 30 min/day
• Comorbid conditions
(cardiovascular disease)

• Exercise performance and

• Mucus quality and quantity
physical activity
Physical • Impaired cough:
• Respiratory and peripheral
assessment - airway collapse,
muscle function
- muscleweakness
• Quality of life

• Causes of exercise limitation / inactivity

• Causes of impaired cough
• Motivation / self-management
Analysis

• Optimal medical treatment no

• Referral physician
• Sufficient referral data

• Health education
• Self-management

Treatment
• Forced expiration • Excercise training
• Cough • Muscle training
• Adjuncts (PEP, PD) • Breathing exercises

• Exercise performance, physi-

• Number of respiratory infections
Outcome cal activity, Muscle strength,
with mucus retention - Symptoms
Quality of life

PA = physical activity; PEP = positive expiratory pressure; PD = postural drainage.

Royal Dutch Society for Physical Therapy

 V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Dyspnea, impaired physical activity and physical fitness

Spirometry / MRC-score / Physical activity (< 30 min./day)

FEV1 ≥ 50% pred. FEV1 ≥ 50% pred. FEV1 < 50% pred.
MRC-score <2 MRC-score ≥2 MRC-score ≥2

• Multidisciplinary
No physical therapy • Cycly ergometry*
Assessment
Advice:
• Increase physical activity
• Adapted sports activity
Wmax ≥ 70% pred. Wmax < 70% pred.
• Regular sports activity
VO2max ≥ 80% pred. VO2max < 80% pred.

Advice: • Multidisciplinary
• Increase physical activity Rehabilitation
• PT intake physical activity programme

• Physical activity programme

• Adapted sports activities

* The ‘Primary care physicians guideline’ and ‘Transmural guideline for COPD’ only recommend exercise testing in patients
with increased cardiovascular risk. The ‘ACSM guideline’ recommends exercise testing in any elderly subject, while the ‘Physical
therapy in COPD guideline’ recommends exercise testing in any COPD patient.
MRC = Medical Research Council dyspnea score
FEV = positive expiratory pressure

no physical therapy / advice to increase physical activity

treatment in primary care (physical activity program)
treatment in secondary/tertiary care (rehabilitation)

Royal Dutch Society for Physical Therapy

 V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Impaired exercise performance/dyspnea

• Peripheral • Anxiety
• Cardio- • Oxygen transport
• Ventilatory muscle • Motivation
circulatory in the lungs
strength • Self-esteem

• Respiratory
muscle weakness
• Hyperinflation

• Hypoxemia/Hypercapnia
during exercise?

• IMT
• Body positioning
• Rollator • Muscle training • Counseling
• Endurance • Interval training • NIV • EMS • Relaxation
training • ev. suppl. O2 • Active expiration • Nutrition • Education
• PLB

IMT = inspiratory muscle training; NIV = non-invasive ventilation; EMS = electrical muscle stimulation;
PLB = pursed lips breathing; ev. = eventually.

Royal Dutch Society for Physical Therapy

 V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Impaired Mucus Clearance

Yes • Hypersecretion? No

Yes
• Cough/Huff effective?
• Physically active?
• Treatment compliance?

No Yes

No

• See Flow Chart • No indication for physical

‘Impaired Exercise Performance’ therapy
(see figure 3)

• Inadequate technique?
• Airway collapse?
• Non-compliance?

Yes Yes

• Teach coughing/huffing/breathing exercise dependent on severity and

causes of obstruction
• Education - improve compliance

• Re-assessment • Evaluation: treatment effective?

• Confirm indication with
referring physician Yes
No

• ‘Stop’ treatment

• Other treatments:
• Postural drainage, PEP
• Flutter
• Report to referring physician
• Percussion/Vibration

PEP = positive expiratory pressure.

Royal Dutch Society for Physical Therapy