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A STUDY TO EVALUATE THE EFFECTIVENESS OF DIAPHRAGMATIC BREATHING AND PURSEDLIP BREATHING EXERCISE FOR IMPROVING FLOW RATE AND

FUNCTIONAL EXERCISE TOLERANCE IN PATIENTS WITH STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE

DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER’S DEGREE IN PHYSIOTHERAPY WITH SPECIALISATION IN CARDIOPULMONARY AND INTENSIVECARE PHYSIOTHERAPY

SUBMITTED BY MUHAMMED RAZI. C. K REG. NO: ASAH MPT 011

UNDER THE GUIDANCE OF Mr. PREM KUMAR, MPT

EXTERNAL EXAMINER

INTERNAL EXAMINER

DEPARTMENT OF PHYSIOTHERAPY A W H SPECIAL COLLEGE (AFFILIATED TO UNIVERSITY OF CALICUT) KALLAI, CALICUT -673003, KERALA. 2007-2009

DECLERATION BY THE STUDENT

I hereby declare that this dissertation entitled “A STUDY TO EVALUATE THE
EFFECTIVENESS PURSEDLIP OF DIAPHRAGMATIC BREATHING EXERCISE AND

BREATHING EXERCISE FOR IMPROVING FLOW RATE AND

FUNCTIONAL EXERCISE TOLERANCE IN PATIENTS WITH STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE ” is a bonafide and genuine research work

carried out by me under the guidance of Mr. Prem Kumar.

Place: Date:

Mr. MUHAMMED RAZI. C. K

CERTIFICATE

This is to certify that Mr. MUHAMMED RAZI. C. K is a bonafide student of Master of Physiotherapy Course with specialization CARDIO PULMONARY AND INTENSIVECARE PHYSIOTHERAPY at AWH Special College, Calicut. This dissertation entitled “ A STUDY TO EVALUATE THE EFFECTIVENESS OF
DIAPHRAGMATIC BREATHING EXERCISE AND PURSEDLIP BREATHING

EXERCISE FOR IMPROVING FLOW RATE AND FUNCTIONAL EXERCISE TOLERANCE IN PATIENTS WITH STABLE CHRONIC OBSTRUCTIVE

PULMONARY DISEASE” is submitted in partial fulfilment of the requirements for the

degree of Master of Physiotherapy from University of Calicut. This bonafide work has been carried our under my guidance and supervision.

Place: Date

MR.PREM KUMAR MPT (CARDIORESPIRATORY PHYSIOTHERAPY) Senior Lecturer Department of Physiotherapy AWH Special College Calicut.

CERTIFICATE

This is to certify that Mr. MUHAMMED RAZI is a bonafide student of Master of Physiotherapy Course with specialization in CARDIO PULMONARY AND INTENSIVECARE PHYSIOTHERAPY at AWH Special College, Calicut. This dissertation entitled “A STUDY TO EVALUATE THE EFFECTIVENESS OF
DIAPHRAGMATIC BREATHING EXERCISE AND PURSEDLIP BREATHING

EXERCISE FOR IMPROVING FLOW RATE AND FUNCTIONAL EXERCISE TOLERANCE IN PATIENTS WITH STABLE CHRONIC OBSTRUCTIVE

PULMONARY DISEASE” is submitted in partial fulfilment of the requirements for the

degree of Master of Physiotherapy from University of Calicut.

Place: Date:

Mr. RASHIJ. M MPT (Neurology and Psychosomatic disorder) Assistant Professor Head of the Department Dept of Physiotherapy AWH Special College Calicut.

CERTIFICATE

This is to certify that Mr. MUHAMMED RAZI is a bonafide student of Master of Physiotherapy course with specialization in CARDIO PULMONARY INTENSIVECARE PHYSIOTHERAPY at AWH Special College, Calicut. This dissertation is submitted in partial fulfilment of the requirements for the degree of Master of Physiotherapy from university of Calicut.

Place: Date:

Dr. P. K. ABDUL KADER Principal AWH Special College, Calicut

ADVISORS OF THE STUDY

DR. ANIL JOSEPH. MD, DTCD Pulmonologist. Chest Hospital, Kozhikode.

Mr. ROSHITH. C MPT (Rehabilitation) Assistant Professor Department of Physiotherapy AWH Special College

Mr. RASHIJ. M MPT (Neurology and Psychosomatic disorder) Assistant Professor Head of the Department Dept of Physiotherapy AWH Special College

ACKNOWLEDGEMENT

First and foremost I would like to thank my parents whose valuable support gave me Courage and Confidence throughout the study. I would like to express my deep sense of gratitude to Mr. Prem Kumar, Associate Professor, Department of Physiotherapy, AWH Special College, Calicut, for being my guide and bringing out the best in me and marking this study perfect with his valuable guidance. I am extremely thankful for his constant encouragement and inspiration during the course of this study. I wish to express my thanks to our co-ordinator Mr. Bhuvanesh Babu, Assistant Professor, Department of Physiotherapy, AWH Special College for his valuable help and guidance throughout the study that enlighten my courage in completing this dissertation successfully. I am outmost thankful to Mr. Rashij. C, MPT, Head of the department, Department of Physiotherapy, for the scholarly guidance and support in the fulfilment of my task. I am thankful to our respected Principal Mr. Abdul Kader and respected Vice Principal Mr. Prabakaran Nambiar and the Management of AWH Special College for all the facilities extended to me for the study. I express my thanks to Mr. Roshith. C, M.P.T, Mr. Deepak. T. V, M.P.T and MR. Suhas.K.P for helping me in this study. I extend my sincere thanks to Dr. V. Raju,

senior professor, Dept. of Statistics, University of Calicut for helping me in statistical analysis. I express my thanks to all staff members Dept. of Physiotherapy in AWH Special College for helping with their valuable suggestions. I am thankful to my friends Mr. Abhishek , Mr. Benson Baby, Mr. David Thomas, Mr. Linto Varghese, Mr. Akheel Ahammed.M. M, Mr. Ratheesh Kumar, Mr.Sajeevan T, Mr. Akheel M, Dr. Deepthi, Mr. Ibrahim and my colleagues who were always there to help me with my research study. My Sincere thanks to all the contributors whose name I have not mentioned but though they all deserve my gratitude. Last but not the least I would like to thank all the subjects of my study without whom this task would not have been possible. MUHAMMED RAZI. C. K.

Dedicated to my loving parents

LIST OF ABBREVIATION

COPD: Chronic Obstructive Pulmonary Disease VT: Tidal Volume FEV1: Forced Expiratory Volume in 1 Second FVC: Forced Vital Capacity 6MWT: Six Minute Walk Test DB: Diaphragmatic Breathing PLB: Pursed Lip Breathing WOB: Work of Breathing ATS: American Thoracic Society GOLD: Global Initiative for Chronic Obstructive Lung Disease RR: Respiratory Rate MRC: Medical Research Council HR: Heart Rate ADL: Activity of Daily Living

ABSTRACT
Objective: To evaluate the effectiveness of diaphragmatic breathing and pursed lip breathing exercise in stable COPD patients Methods: 30 Subjects were selected on the basis of inclusion and exclusion criteria. All the Subjects were divided equally into two groups, Group A and Group B based on convenience Sampling Technique. Before starting the training, pre-test scores are measured by using pulmonary function test and six minute walk test. Group A received diaphragmatic breathing and Group B received pursed lip breathing. At the end of sixth week, post-test scores of both groups were taken. Results: Pursed lip breathing group showed better improvements in pulmonary function test and six minute walk test, when compared to the diaphragmatic breathing group. Conclusion: Improvement of the flow rate and exercise performance in moderate COPD patients is associated with pursed lip breathing. Key words: Diaphragmatic breathing exercise, pursed lip breathing, stable COPD.

CONTENTS
CHAPTER 1. INTRODUCTION 1.1. Introduction 1.2. Need for the study 2. 3. REVIEW OF LITERATURE METHODOLOGY 3.1. Aim of the study 3.2. Objectives of the study 3.3. Research Design 3.4. Hypotheses 3.5. Population 3.6. Study settings 3.7. Samples and Sampling Method 3.8. Selection Criteria 3.9. Variables of the study 3.10. Research Tool 3.11. Duration of the study 3.12. Data collection procedure 8 16 Page no 1

4.

DATA ANALYSIS

21

5.

RESULTS

23

CHAPTER 6. DISCUSSION 6.1. Discussion 6.2. Limitations and Suggestions

Page no 25

7.

CONCLUSION

35

8.

REFERENCES

37

APPENDICES 1. Assessment form 2. Data collection form 3. Results tables 4. Graphs 5. Protocols 6. Informed consent form 7. Master chart

CHAPTER 1 INTRODUCTION

1.1 INTRODUCTION
Chronic obstructive pulmonary disease (COPD) has been defined by the Global initiative for chronic obstructive pulmonary disease (GOLD) as a disease characterized by air flow 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.(www . GOLD COPD .com) 1 The chronic airflow limitation characteristic of COPD is caused by a mixture of small airway disease and paranchymal destruction, the relative contribution of which varies from person to person. Chronic inflammation causes remodelling and narrowing of the small airways. Destruction of the lung parenchyma, also by inflammatory process, leads to the loss of alveolar attachments to the small airways and decreases lung elastic recoil, inturn these changes diminish the ability of the airways to remain open during expiration. Air flow limitation is measured by spirometry, as this is most widely available, reproducible test of lung function.2 COPD is a global health concern, and is a major cause of chronic morbidity and mortality worldwide. Many people suffer from this disease for years and die prematurely from it or its complications. The global burden of COPD is projected to be the fifth leading cause of death and GOLD estimates and suggests that the COPD will rise from the sixth to third most common cause of the death world wide by 2020. The burden of COPD in Asia is currently greater than that in developed Western countries.3 Worldwide cigarette smoking is the most commonly encountered risk factor for COPD, although in many countries, air pollution resulting from the bumming of wood and other biomass fuels also been identified as a COPD risk factor .The second most significant documented risk factor for COPD IS alpha-1 antitrypsin deficiency .Certain

occupational exposures like dusts and chemicals (vapours, irritants, fumes) and indoor and outdoor air pollutions are also associated with increased risk of COPD. The characteristic symptoms of COPD are cough, sputum production and dyspnoea on exertion. Chronic cough and sputum production often precede the development of airflow limitation by many years; although not all individuals with cough and sputum production go on to develop COPD. The natural course of COPD is characterized by occasional sudden worsening of symptoms called acute exacerbations, most of which are caused by infections or air pollution. This pattern offers a unique opportunity to identify those at risk for COPD and intervene when the disease is not yet a health problem. A major objective of GOLD is to increase awareness among health care providers and the general public of the significance of these symptoms and decrease morbidity and mortality from the disease .GOLD aims to improve prevention and management of COPD through a concerted world wide effort of people involved in all facets of health care and health care policy, and to encourage an expanded level of research interest in this highly prevalent disease.5 All population based studies in developed countries showed a markedly greater prevalence and mortality of COPD among men compared to woman .gender related differences in exposure to risk factors mostly cigarette smoking probably explain this pattern. 6 The goals of the global initiative for COPD are to increase awareness of COPD and decrease morbidity and mortality from the disease. GOLD aims to improve prevention and management of COPD through a concerted world wide effort of people involved in all facets of health care and health care policy, and to encourage an expanded level of research interest in this highly prevalent disease.7

Dyspnoea limiting physical activity is a common complaint in COPD patients with moderate to severe airflow obstruction and usually arises during the sixth or seventh decade of life. The onset of dyspnoea is often insidious and may be attributed incorrectly to the effects of ageing. Avoidance of activity as a strategy to limit the experience of dyspnoea leads to a sedentary lifestyle. Accompanying this lifestyle is locomotor muscle de condition pounds the effects of pulmonary dysfunction on dyspnoea. The reduction of maximum expiratory flow rate and slow forced emptying of lung are common problems seen in COPD that leads to dyspnoea and reduction in exercise tolerance. The COPD patients are reluctant to do exercises because of dyspnoea. In severe cases of COPD accessory muscles may required for respiration. 8 The four stage classification COPD severity provides an educational tool and a general indication of the approach to management. Stage 1: Mild COPD –Mild airflow limitation (FEV1/FVC <70%; FEV1>_80%

predicted.), and sometimes, but not always chronic cough and sputum production. Stage 2: Moderate COPD –Worsening airflow limitation (FEV1/FVC <70%, 50 %<

_FEV1<80% predicted.), with shortness of breath typically developing on exertion. Stage 3: Severe COPD –Further Worsening airflow limitation (FEV1/FVC <70%, 30 %< _FEV1<50% predicted.), with greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients quality of life. Stage 4: Very Severe COPD : Severe airflow limitation (FEV1/FVC <70%,

FEV1<30% predicted.), or FEV1<50% Predicted plus chronic respiratory failure .patients may have very severe COPD even if the FEV1 is >30%predicted when ever this complications are present.9

This conceptual frame work also emphasizes that COPD is usually progressive if exposure to the noxious agent is continued. The staging is based on airflow limitation as measured by spirometry which is essential for diagnosis and provides a useful description of severity of pathological changes in COPD. The overall approach to managing stable COPD should be characterized by a step wise increase in treatment, depending on the severity of the disease. The classification of severity of stable COPD incorporates an individualized assessment of disease severity and therapeutic response in to the management strategy.11 While disease prevention is the ultimate goal, once COPD has been diagnosed, effective management should be aimed at the following goals: -prevent disease progression -relieve symptoms -improve exercise tolerance -improve health status -prevent and treat complications -prevent and treat exacerbations -reduce mortality. The benefits of pulmonary rehabilitation program include improved exercise capacity, an enhanced sense of wellbeing and a reduced need for hospitalization. Pulmonary rehabilitation has been demonstrated to improve the health related quality of life, dyspnoea, and exercise tolerancecapacity.12

The goal of pulmonary rehabilitation program are to reduce symptoms, improve activity and daily function, and restore the highest level of independent function in patient with respiratory disease. Diaphragmatic breathing is an exercise to better use and to strengthen the diaphragm, the major and most efficient muscle of breathing. Regular practice of diaphragmatic breathing can help restore function of diaphragm and return to a more efficient breathing pattern. Practicing a deeper diaphragmatic style of breathing can help ease of work of breathing and expect more stale air.14 Pursed lip breathing is performed as expiratory blowing against pursed lips, is a pulmonary rehabilitation strategy instinctively or voluntarily employed in patients with COPD to relieve or control dyspnoea. Six minute walk test is simple, easy reproducible and requires no apparatus. It is a self paced exercise that patients could perform this test alone. It can be carried out at same time of the day at any time. Management of stable COPD involves the avoidance of risk factors to prevent disease progression and pharmacotherapy as needed to control symptoms. In addition to patient education, health advise and pharmacotherapy, these patients require specific counselling about smoking cessation, instruction in physical exercise, nutritional advise and continued nursing support. Not all approaches are needed for every patient and assessing the potential benefit of each approach at each stage of the illness is a crucial aspect of effective disease management. An effective COPD management plan includes four components .assess and monitors the disease, reduce risk factors, manage stable COPD and manage exacerbations.

The treatment programme includes preventive and general care management. It includes pharmacological and non pharmacological treatment. treatment Pharmacological

includes medications like B-2 agonists, ancholinergics, methylxanthines, and

bronchodilators. Other pharmacological treatment includes vaccines, antibiotics, mucolytic agents, antioxidant agents, immuno regulators, antitussives, vasodilators, and narcotics. therapy. non pharmacological treatment includes rehabilitation, education, oxygen

1.2 NEED FOR THE STUDY.
Reduction of maximum expiratory rate, slow forced emptying of lung and breathlessness are common problems seen in COPD. In severe cases of COPD, the use of accessory muscles was increased. Diaphragmatic breathing exercise and PLB are effective to relieve the symptoms. In other studies functional performance of the COPD patients are not evaluated. Hence the need of this study is to improve exercise tolerance along with the flow rates and rate of perceived exertion.

CHAPTER 2 REVIEW OF LITERATURE

REVIEW OF LITERATURE
American thoracic society has defined COPD as`` a disease state characterized by the presence of airflow limitation due to Chronic Bronchitis or Emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyper reactivity, and may be partially reversible. 15 Hyper inflation of lungs affects not only the bony components of the chest wall, but also the muscles of the thorax .the resting position of the diaphragm changes to a more flattened configuration .The angle of pull of diaphragm fibers becomes more horizontal with a decreased zone of apposition and decreased strength and range of contraction. In severe cases of hyperinflation the fibers of diaphragm will be aligned horizontally. Contraction of this much flattened diaphragm will pull the lower ribcage inward actually working against lung inflation.16 Dyspnoea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social and environmental factors and may induce secondary physiological and behavioural responses. (American thoracic society 1999)17 A scale such as the MRC breathlessness scale suggests five different grades of dyspnoea based on the circumstances in which it arises. Grade 1 - no dyspnoea except with strenuous exercise. Grade 2 - dyspnoea when walking up an incline or hurrying on the level. Grade 3 -walks slower than most on the level, or stops after 15 minutes of walking on the level.

Grade 4 -stops after a few minutes of walking on the level. Grade 5 - dyspnoea with minimal activity such as getting dressed, too dyspnoea to leave the house.18 COPD patients frequently develop nocturnal oxygen destruction because of alveolar hypoventilation, worsening of ventilation-perfusion mismatch, and sometimes obstructive sleep apneas. In contrast, little is known about their oxygen status during the various activities of daily life.19 The diagnosis of COPD confirmed by spirometry, a test that measures breathing, it measures the forced expiratory volume in one second (FEV1) which is the greatest volume of air that can be breathed out in the first second of a large breath. Spirometry also measures the Forced vital capacity (FVC) which is the greatest volume of air that can be breathed out in a whole large breath. Normally at least 70% of the FVC comes out in the 1st second, ie, FEV1/FVC ratio is >70%.In COPD this ratio is less than normal, i.e., FEV1/FVC ratio is <70% even after a bronchodilator medication has been given. Spirometry helps to determine the severity of COPD. The FEV1 is expressed as a percent of a predicted normal value based on a person’s age , gender ,height and weight. Pulmonary function test provides greater information regarding illness and serving that may not be otherwise obtainable. For the purpose of clinical research spirometry has significant advantages including reliability, validity, reproductively, quality control, maintenance of records and values that are more physiologically specific.20 Diaphragmatic breathing facilitates outward motion of the abdominal wall while reducing upper ribcage motion during inspiration. Accordingly, individual skill in performing diaphragmatic breathing is assessed by observation or measurement of abdominal excursion during the respiratory cycle. It increase the tidal volume and no

change in minute ventilation, which indicate a substantial slowing of respiratory frequency.21 Diaphragmatic breathing changes the breathing pattern and it is most helpful in reducing respiratory rate, minute ventilation and it also increases tidal volume in severe chronic obstructive pulmonary disease patients. The study of Levine et al. provides the first evidence that appropriate adaptive response occur in the inspiratory intercostals muscles of patients with chronic

obstructive pulmonary disease. Levenson et al. states that abdominal muscle contraction should be encouraged to lengthen the diaphragm and increase its force generating capacity. In severe COPD patients with hypercapneoa and reduced inspiratory muscle strength recovering from an episode of acute respiratory failure, deep diaphragmatic breathing is able to improve blood gases whereas inspiratory muscle effort increases and dyspnoea worsens. Diaphragmatic breathing (DB) has been claimed, but not demonstrated, to correct abnormal chest motion, decrease the work of breathing (WOB) and dyspnoea. Ambrosino et al. reported improvement in maximal exercise tolerance in mild COPD patients undergoing deep DB. Campbell and friend postulated that the increased abdominal motion during DB may shift ventilation towards the base of the lungs. Brach et al. found that DB did not alter regional ventilation for the group as a whole. Two people , however, increased ventilation to the base of one lung by more than 20%. Unfortunately; the authors were not able to explain this finding. The study by Sackner et al. demonstrated that half of the subjects had minimal abdominal displacement during DB. Another study by Sackner et al. Showed that DB was associated with distorted chest wall motion. Diaphragmatic breathing caused increased paradoxical and asynchronous

movements of the rib cage. The amount of asynchrony was not correlated with disease severity. Gosselink et al. report increased VO2 and work of breathing in people with severe COPD who performed DB with no spontaneous changes in respiratory frequency. The work of breathing was calculated according to the method of Collett et al. which relates changes in mechanical work to changes in VO2 during loaded breathing. Gosselink et al. found that during resting breathing, DB increased VO2 (by an average of 17 ml/min) but had no effect on Vt, breathing frequency, duty cycle ( inspiratory time divided by total respiratory cycle time). When compared with natural breathing, DB during load breathing was associated with a lower mechanical efficiency, increased paradoxical rib cage motions and no change in VO2 or dyspnoea. Diaphragmatic breathing improves the ventilation, decreases work of breathing, decreases dyspnoea and normalize breathing pattern in patients with chronic obstructive pulmonary disease. Breathing techniques are included in the rehabilitation program of patients with chronic pulmonary disease (COPD). In patients with COPD, breathing techniques aim to relieve symptoms and ameliorate adverse physiological effects by increasing strength and endurance of the respiratory muscles, optimizing the pattern of thoraco-abdominal motion; and reducing dynamic hyperinflation of the rib cage and improving the gas exchange. Evidence exists to support the effectiveness of purse-lip breathing, forward leaning position, active expiration and inspiratory muscle training but not for diaphragmatic breathing. Diaphragmatic breathing exercises attempts to enhance diaphragmatic exertion throughout the respiratory cycle for the purpose of reducing accessory muscle use and providing a more normalized breathing pattern. DB exercises allegedly enhance

diaphragmatic descent during inspiration and diaphragmatic ascent during expiration. Diaphragmatic breathing exercises are designed to improve the efficiency of ventilation, decreases work of breathing, increase the excursion of diaphragm, improve gas exchange and oxygenation. Diaphragmatic breathing exercises are also used to mobilize secretions during postural drainage. Diaphragmatic and PLB reveals that the use of PLB appears tobe an effective way to decrease dyspnoea and improve gas exchange in stable COPD. Sackner et al –reported the effects of DB on VT and respiratory frequency in patients with COPD respiratory inductance plethysmography was used to measure chest wall movements, and these changes were calibrated using spirometric measurements to indicate actual volume change. Gosselink et al found that during resting breathing, DB increased Vo2, but had no effect on VT, breathing frequency, duty cycle or VE. Pursed lip breathing is often used in patients with severe airway disease. By opposing the lips during expiration the airway pressure inside the chest is maintained, preventing the floppy airways from collapsing. Thus overall air flow is increased.22 Falling described PLB as easiest breathing technique and often employed instinctively. Patients inhale through the nose over several seconds with the mouth closed and then exhale slowly over 4-6 seconds. Through pursed lips held in a whistling or kissing position. This is done with or without the contraction of abdominal muscles.23 PLB is thought to keep airways open by creating a backpressure in the airways. It is thought to help a patient with COPD with repeated attacks of shortness of breath .studies suggest that PLB decreases the respiratory rate ,increases the tidal volume and improves the exercise tolerance.24

PLB leads to reduced diaphragmatic and increased ribcage and accessory muscle recruitment. It provides a perception of control over breathing. PLB is performed as expiratory blowing against pursed lips ,is a pulmonary rehabilitation strategy instinctively or voluntarily employed in patient with COPD to relieve or control dyspnoea.24 Thoman and colleagues reported on comparison of spontaneous breathing.PLB and slow breathing was done in an attempt to clarify whether the effect of PLB were due to slowing of respiratory rate. The investigators reported that PLB slow breathing frequency and that both slow, deep breathing and PLB result in a similar increase in tidal volume. 25 The 6MWT has first been introduced as a functional exercise test by Lipkin in 1986. Its results are highly correlated with those of the 12 minutes’ walk test from which it was derived and with those of cycle ergo meter or treadmill based exercise tests . The 6MWT is also a valuable instrument to assess progression of functional exercise capacity in different clinical intervention studies. The reliability of the test in healthy elderly persons is high and it is considered as a valid and reliable test to assess the exercise

capacity of elderly patients with chronic obstructive pulmonary disease. Several authors studied the determining factors of the 6MWT-distance in healthy adults and propose either reference equations or normative data for the 6MWT-outcome. Troosters et al. found that age, gender, height and weight explained 66% of the 6MWT-distance variability in 51 healthy adults aged 50–85 years. 6MWT is used for the objective evaluation of the functional exercise capacity. The strongest indication for the 6 MWT is for measuring the response to therapeutic interventions for pulmonary disease. The self paced 6 MWT asses the sub maximal level

of functional capacity. The 6 MWT is easy to administer, better tolerated and more reflective of ADL than the other walk test.26 6MWT is a simple test to evaluate the functional capacity by measuring the distance walked during a defined period of time. In an attempt to accommodate patients with respiratory disease for whom walking 12 minute was too exhausting. It elevates global and integrated response of organ involved during exertion like cardiovascular system, pulmonary system etc.27 The six-minute walk test is an objective method, to measure the ability to perform daily living activities. It is more often performed, to evaluate the functional status, monitor therapy, or assess the prognosis in patients with cardiac and pulmonary diseases. In comparison to traditional pulmonary exercise test, 6MWT needs less technical support or equipment, making it a simple and inexpensive method to measure functional capacity. The validity and the reliability of 6MWT was studied in different conditions, including obstructive lung diseases, interstitial lung diseases, pulmonary hypertension, heart failure and peripheral arterial diseases.

The improvement in health related quality of life after pulmonary rehabilitation clearly exceeds the minimal clinically important difference. When disease specific instruments were used, the lower limit of the 95% confidence interval exceeded the minimal clinically important difference.28

CHAPTER 3 METHODOLOGY

3.1 AIM OF THE STUDY To evaluate the effectiveness of diaphragmatic breathing exercise and pursed lip breathing exercise in stable COPD patients. 3.2 OBJECTIVES OF THE STUDY To evaluate the effectiveness of diaphragmatic breathing exercise in stable COPD patients. To evaluate the effectiveness of Pursed lip breathing exercise in stable COPD patients. 3.3 RESEARCH DESIGN Pre-test and post-test experimental design. 3.4 HYPOTHESES Null hypothesis There is no significant difference between diaphragmatic breathing exercise and pursed lip breathing exercise in stable COPD patients. Alternate hypothesis There is significant difference between diaphragmatic breathing exercise and pursed lip breathing exercise in stable COPD patients. 3.5 POPULATION Patients who are diagnosed as stable COPD, referred by pulmonologist were taken as population of the study.

3.6 STUDY SETTINGS 1. Department of physiotherapy, Chest Hospital, Kozhikode. 3.7 SAMPLES AND SAMPLING METHOD 30 Patients who are diagnosed as stable COPD, referred by Pulmonologist were selected as samples for the study from the population using convenience sampling method. 3.8 SELECTION CRITERIA Inclusion criteria 1. Patients diagnosed as Stable COPD. 2. Haemodynamically stable COPD patients 3. Both male and female patients 4. Patients with 50 to 70 yr old 5. Moderate COPD patients. 6. FEV1 with 50-80% Exclusion Criteria 1. Patients with cardiac, metabolic, or endocrine disorders 2. Acute exacerbation of COPD 3. Thoracic or abdominal surgery within last 2 months 4. Patients with unstable vital sign

5. Patient with pleural disorder 6. Mentally retarded patients and un co operative patients 7. Patients with unstable cardiac disease 8. Subjects who are not able to do spirometry 9. Patients like infectious diseases like tuberculosis and pneumonia 10. Any orthopaedic deformities of the chest 3.9 VARIABLES OF THE STUDY Independent variables Diaphragmatic breathing exercise Pursed lip breathing exercise Dependent variables FEV1,FVC Six minute walk test 3.10 RESEARCH TOOLS 1. Sphygmomanometer. 2. Spirometer. 3. Respiratory assessment form. 4. Borgs scale for rate of perceived exertion. 5. Stethoscope.

6. Inch tape. 7. Stop watch. 3.11 DURATION OF THE STUDY Total duration of study was six weeks. 3.12 DATA COLLECTION PROCEDURE 30 Subjects were selected on the basics of inclusion and exclusion criteria. All the subjects were divided equally into two groups, Group A and Group B. Each group consisted of 15 subjects, the study procedures were explained to the subjects and informed consent was obtained prior to study. Before starting the training, pre-test scores were measured by using Pulmonary function test and six minute walk test. Group A- Subjects in Group A (n=15) received Diaphragmatic breathing exercises as per the appendix Group B- Subjects in Group B (n=15) received Pursed lip breathing exercise as per the appendix At the end of sixth week post test scores of both groups were taken by using pulmonary function test and six minute walk test.

CHAPER 4 DATA ANALYSIS

DATA ANALYSIS
Data was analysed using a paired T test to find out within group difference of dependent variable and a univariate analysis of variance to find out between group differences. There was one within group factor which was time and a between subject factor which was group. All data was analysed using SPSS version 12.O with significance level kept at 0.05.

CHAPTER 5 RESULTS

RESULTS
Six minute walk test. A t-test was done to analyse the within group difference of six minute walk test. There was a significant improvement for six minute walk test in group A from pre to post. T value (14, 0.05) = -10.088, P<0.000. Group B also showed a significant improvement from pre to post for six minute walk test. T value (14, 0.05) = -6.859, P<0.000. Univariate analysis of variance was done to analyse the between group

difference of six minute walk test and showed a significant difference between groups, F value (1, 27, 0.05) = 45.645, P<0.000. FEV 1 A t-test was done to analyse the within group difference of FEV1.There was no significant difference for FEV1 in group A from pre to post. T value(14,0.05) = -0.866, P<0.401.But Group B showed a significant difference from pre to post for FEV 1,T value(14,0.05)= 6.144,P<0.000. Univariate analysis of variance was done to analyse the between group difference of FEV1 and showed a significant difference between groups, F value (1, 27, 0.05) = 29.25, P<0.000. FVC A t-test was done to analyse the within group difference of FVC. There was no significant difference for FVC in group A from pre to post. T value(14,0.05) = -1.684, P<0.114.But Group B showed a significant difference from pre to post for FVC,T value(14,0.05) = -4.971, P<0.000. Univariate analysis of variance was done to analyse the between group difference of FVC and showed a significant difference between groups, F value (1, 27, 0.05) = 24.681, P<0.000.

CHAPTER 6 DISCUSSION

6.1 DISCUSSION
The study is an experimental comparative study to find out the effectiveness of DB & PLB exercise in patients with stable COPD. The patients are divided in two group A and group B comprising of 15 patients each. Both groups were trained twice daily for 15 minutes for 6 days per week for 6 weeks. The Outcome measurement of the study was 6MWT, spirometry of measurement of FEV1 and FVC. Group A received DBE and group B received PLB exercises. Group which received DBE showed significant improvement in 6 MWT than the PLB exercises group and PLB group showed significant improvement in FEV1 and FVC compared with DBE group. But there was no significant improvement in FEV1 and FVC in DBE group from pre to post. In both groups there was significant improvement in 6MWT from pre to post. Pursed lip breathing results in a positive expiatory pressure and is thought to have similarities with continuous positive airway pressure and positive end expiratory pressure. By creating an obstruction at the lip, this active expiration may be intensified and the resulting greater increase in positive expiratory pressure may increase bronchial pressure and thus “tansmural” pressure, leading to a diminution of airway collapse: In various studies there was a linear relationship between the effectiveness of PEP breathing in decreasing the nonelectric resistance across the lung and airway and the collapsibility of airways Bianchi R et al assessed the volumes of chest wall compartments using an optoelectronic plethysmograph and concluded that by decreasing respiratory frequency and lengthening expiratory time, pursed lip breathing decreases end expiratory volume of chest wall, which is mostly at the abdominal level et al. decrease in end expiratory

volume of abdomen and modulates the breathlessness. Changes in end expiratory volume of chest wall are related to baseline airway obstruction (FEV1) but not due to hyperinflation. So, improvement in dyspnoea observed after breathing exercises can be attributed to the decrease in respiratory rate, increase in tidal volume, decreased physiological dead space to tidal volume ratio, improved blood gases and decrease the work of breathing by decreasing or preventing airway collapse and promoting more homogenous ventilation as observed in various clinical trials of breathing exercises. Esteve et al found that breathing pattern training, enhanced with visual feedback increased the FEV1, and FVC in patients with COPD following pulmonary rehabilitation having breathing exercises as a component and this area needs further evaluation by more clinical trials. Thoman R, proposed that those segments of lungs with greatest fall or greater increase in flow resistance will receive disproportionately less of the tidal volume. Therefore, the abnormal and uneven distribution of gases in emphysema will be accentuated with increased respiratory rate. So the slowing of respiration alone would be expected to enhance the ventilation of those subdivisions of the lung which normally are under ventilated. They found that tidal volume increases while respiratory rate decreases and CO2 elimination improves without significant change in forced residual capacity and volume of slow space by pulsed lip breathing. They found that indeed there was an increase in ventilatory rates of those most slowly ventilated lung components, when respiratory rate slowed down with pursed lip breathing. Mueller et al also observed that pursed lip breathing was accompanied by both increased tidal volume and decreased respiratory rate, more so in subjects who claimed benefit from pursed lip breathing in comparison to the subjects who did not feel improvement with pursed lip breathing. An improvement in PO2 was observed in both groups during rest, but not during exercise

and he concluded that benefits of pursed lip breathing were due to decreased airway collapse, decreased respiratory rate, and increased tidal volume but found no relationship between symptomatic benefit from pursed lip breathing and improvement in ABG. Mueller as well as other investigators found that although pursed lip breathing was more effective in the sense that less air exchange was required to absorb a given amount of oxygen, there was no increase in oxygen uptake This suggests that PLB does not significantly alter the work of breathing. It is known that hyperactivity of the

inspiratory muscles is a cause for the sensation of dyspnoea. Their assumption that decrease in dyspnoea sensation which is often thought to be related to pursed lip breathing might be caused by reduced activity of respiratory muscle is still a matter of debate. Through encouraging the use of diaphragm, the principal and efficient muscle of inspiration, the oxygen cost of breathing can be decreased. Decreasing the use of accessory muscles also decreases the work of breathing. The bio feed can be used to discourage accessory muscle firing during the ventilatory cycles. Because use of the diaphragm as in diaphragmatic breathing was found to increase rather than decrease the level of dyspnea at present routine use of diaphragmatic breathing in pulmonary rehabilitation is not recommended. Killian and co workers showed that exercise capacity in COPD patient is mainly limited by subjective symptoms such as muscle fatigue and dyspnoea without the patient reaching their physiological limitations. Now as this is well known that a “vicious cycle” of exertional dyspnoea, exercise and activity limitation, psychosocial illness are the major causes of poor health related quality of life in COPD patients, there are increasing evidence that physical reconditioning which is most essential component of pulmonary rehabilitation can improve the exercise capacity and health related quality of lives.

Casciari RJ et al found in their study that breathing retraining increases exercise performance in subjects with severe chronic obstructive pulmonary disease. Schans et al observed that positive expiratory pressure breathing which is in range of mouth pressure reached during expiration with pursed lip in patients with COPD increases the efficiency of ventilation at rest and during exercise, since same work load is achieved with less ventilation. So the improvement in exercise tolerance seems to be due to the decrease in the sensation of dyspnoea. That’s why these patients do not feel panic at the time of respiratory distress. Their self-confidence could be improved, which progressively increases activities of daily living that mimics exercise of physical reconditioning that can ultimately restore the patient to the highest level of functional capacity and improved health related quality of life. However, the effect on quality of life has not been evaluated by other workers. Evidence suggests that diaphragmatic breathing does not change regional ventilation in people with COPD. This technique increase total ventilation but if so ,this suggest this may due to the slower ,deeper breathing patterns that may occur during DB rather than an exaggeration of abdominal motion. Some authors noted an increase in the work of breathing; this may be due to increased paradoxical rib motion during DB. The relaxed expiration effects of less air tapping, results in reduction of hyperinflation, which turns into reduced respiratory rate, dyspnoea and improved tidal volume and oxygen saturation in resting condition. A study by Gosse link proved deep breathing exercise which includes diaphragmatic breathing immediate decrease respiratory rate, dyspnea and anxiety. Jones et al confirmed that DB results lower oxygen cost and respiratory rate. The pursed-lip breathing shifts a major portion of the inspiratory work of breathing from the diaphragm to the ribcage muscles, resting the diaphragm and reducing dyspnoea.

Techniques such as PLB help to reduce respirations while improving the expiratory phase. Slow controlled expiration postpones small airway collapse, thereby reducing air trapping that occurs with forced expiration. Some patients may benefit from Diaphragmatic breathing technique. The patient is taught to employ only the diaphragm during inspiration and to maximize abdominal protrusion. During expiration, the patient may contract the abdominal wall muscles to displace the diaphragm more cephalic. Not all patients with COPD benefit from this technique; therefore, close clinical monitoring to ascertain efficacy is required. The study of Levine et al. provides the first evidence that appropriate adaptive response occur in the inspiratory intercostals muscles of patients with chronic

obstructive pulmonary disease. Levenson et al. states that abdominal muscle contraction should be encouraged to lengthen the diaphragm and increase its force generating capacity. Ambrosino et al. reported improvement in maximal exercise tolerance in mild COPD patients undergoing deep DB. Campbell and friend postulated that the increased abdominal motion during DB may shift ventilation towards the base of the lungs. Brach et al. found that DB did not alter regional ventilation for the group as a whole. Unfortunately; the authors were not able to explain this finding. The study by Sackner et al. demonstrated that half of the subjects had minimal abdominal displacement during DB. Another study by Sackner et al. Showed that DB was associated with distorted chest wall motion. Diaphragmatic breathing caused increased paradoxical and asynchronous movements of the rib cage. The amount of asynchrony was not correlated with disease severity. Gosselink et al. report increased VO2 and work of breathing in people with severe COPD who performed DB with no spontaneous changes in respiratory frequency.

The work of breathing was calculated according to the method of Collette et al. which relates changes in mechanical work to changes in VO2 during loaded breathing. Dechman G reported that Diaphragmatic breathing improves the ventilation, decreases work of breathing, decreases dyspnoea and normalize breathing pattern in patients with chronic obstructive pulmonary disease. Breathing techniques are included in the rehabilitation program of patients with chronic pulmonary disease (COPD). In patients with COPD, breathing techniques aim to relieve symptoms and ameliorate adverse physiological effects by increasing strength and endurance of the respiratory muscles, optimizing the pattern of thoraco abdominal motion; and reducing dynamic hyperinflation of the rib cage and improving the gas exchange. Evidence exists to support the effectiveness of purse-lip breathing, forward leaning position, active expiration and inspiratory muscle training but not for diaphragmatic breathing. Diaphragmatic breathing exercises attempts to enhance diaphragmatic exertion throughout the respiratory cycle for the purpose of reducing accessory muscle use and providing a more normalized breathing pattern. DB exercises allegedly enhance diaphragmatic descent during inspiration and diaphragmatic ascent during expiration. Diaphragmatic breathing exercises are designed to improve the efficiency of ventilation, decreases work of breathing, increase the excursion of diaphragm, exchange and oxygenation. The PLB group patients showed markedly reduced RR stable COPD after performing the breathing exercises. The reduced rate was associated with commensurate the reduction of COPD .Motley reported that the effect of PLB on ventilatory parameters and arterial blood gases in people with COPD. They uniformly reported that the improve gas

technique decreases respiratory rate, minute ventilation and increases tidal volume pursed-lip breathing also has been documented to increases partial pressure of oxygen in arterial blood, and the percentage of haemoglobin sites that are bound to oxygen in arterial blood, changes in oxygen consumption are less consistent. Pursed-lip breathing has been reported to decrease dyspnoea, and therefore, may improve exercise tolerance, and reduce limitations in activities of daily living. Breslin reported that, during PLB, decreased diaphragm activity during inspiration was accompanied by increased use of rib cage muscles. Both abdominal and rib cage accessory muscle activity increased during expiration. Respiratory rate decreased as did the duty cycle. In addition, Breslin’s estimate of the resting diaphragm tension-time index indicates that, as a group, the subjects were above the diaphragm fatigue threshold described by Bellemare and Grassino. A breathing pattern above this threshold purportedly leads to imminent respiratory failure. These data are surprising because all of the subjects lived in the community and were medically stable. There is a clinical improvement of the six minute walk test after breathing exercises from pre to post test. The ability to walk for a distance is an easy way to measure exercise capacity in patients with pulmonary diseases. A variety of walk tests, including self-paced walk tests, controlled-pacing incremental walk tests and time- paced tests, are considered to be objective measurements of functional capacity. Six minute walk test is found to be an effective way of assessing exercise tolerance. Its validity, reliability and reproducibility, were studied in several populations. The 6MWD had no significant correlation with the level of borg-scale or oxygen saturation at baseline, or at the end of the test. There were no significant differences in FEV1, FVC between female and male patients. Spirometric values correlate modestly with 6MWD. FVC had a stronger positive correlation with distance walk than FEV1.

The 6MWD had no significant correlation with volumetric lung measurements. There was a significant correlation between 6MWD in patients with respiratory diseases. O’Donnell and colleagues proposed that people with COPD have “a very fine control of expiratory flow whereby intrathocic pressure is continuously adjusted to a level that is just enough to attain maximal flow”. Furthermore, they proposed that this active control develops with the disease process, suggesting that imposing retraining techniques is not uniformly helpful in this population.

6.2 LIMITATIONS AND SUGGESTIONS
Limitations: 1. The study was performed for a short duration. 2. The study was done on a Small sample size, which decreases the power to detect treatment effects. 3. The study did not include long term follow up. 4. As the measurements were taken manually, there may be a chance of error Suggestions 1. To establish the efficacy of the treatment, a large sample sized study is required. 2. For more valid result, a long term study must be carried out. 3. Follow up programmes can be included to assess the long term effects of treatment. 4. Further study can be done to check the effects of these techniques on other conditions. 5. Effects of these techniques on other stages of COPD can be studied. 6. Further study should include more measurement tools.

CHAPTER 7 CONCLUSION

CONCLUSION
Results indicates that PLB are effective for alleviating the symptoms like

dyspnoea and airflow limitations and both exercises are effective in improving the exercise tolerance in the management of COPD. This was shown by improvement in FEV1, FVC and six minute walk test. PLB help to reduce respiratory rate while improving the expiratory phase. Slow controlled expiration postpones small airway collapse, thereby reducing air trapping that occurs with forced expiration. Diaphragmatic breathing improves the ventilation, decreases work of breathing, decreases dyspnoea and normalize breathing pattern in patients with chronic obstructive pulmonary disease. The effectiveness of DB and PLB is increasingly being called in to question. In addition, the negative effects of these procedures have been reported. Interventions that focus on optimizing respiratory mechanics may result in a better therapeutic outcome rather than a focus on breathing patterns that primarily may be the result of impaired respiratory mechanics.

CHAPTER 8 REFERENCES

REFERENCES
1. www. GOLD COPD.com 2. Susan b O’Sullivan Thomas schmite physical rehabilitation Assessement and Treatment 4th edition India:jayapee brothers 2001 pp:448 3. Global initiative for chronic obstructive pulmonary disease. 4. Risk factor: Global initiative for chronic obstructive pulmonary disease. 5. Anthony S. Fauci., Harrison’s principles of internal medicine, 14th edition, vol.2, USA: Mc Graw-Hill companies Inc.., 1998, pp, 1041-1046. 6. Harsh Mohan. Harsh Mohan’s text book of pathology, 5th edition, India: jaypee Brothers, 2005, pp.485-491. 7. Stable COPD Global initiative for chronic obstructive pulmonary disease. 8. Jennifer A Pryor, physiotherapy for respiratory and cardiac problems-adults and pediatrics, 3rd edition, London, London: Churchill Livingstone 2002, pp.205-206. 9. John R. Bach., pulmonary rehabilitation –obstructive & paralytic conditions, 1st edition, New Jersy: Hanleus and Beltus inc., 1995, pp.27-33. 10. Carolyn Kisner, Lynn Allen Colby., “Therapeutics exercises foundations and techniques”; 5th edition 2007, pp.886. 11. Belman et. Al., “Reliability of Borg scale for dyspnoea”. Chest Journal, 4, 2002, pp.37.

12. ACCP/AACVPR

pulmonary

rehabilitation

guidelines

panel.

Pulmonary

rehabilitation ; joint ACCP/AACVPR Evidence based guidelines.J.Cardiopulm Rehabil.1997;17:371-405 13. Downs AM: Clinical Applications of Airway clearance Techniques. In Frontfelter, D, Dean, E (eds) Cardiovascular and pulmonary physical therapy: Evidence and practice, ed 4. Mosby, st. Louis, 2006 pp.341-362. 14. Dechman G., Wilson C.R., “Evidence underlying breathing retraining in people with stable COPD”, physical therapy, 84, 2004, pp.1189-1197. 15. American Thoracic Society , lung function testing selection of refence values and interpretativestrategies.AM REV Respir.dis,1991:144:1202-18. 16. Susan b O’Sullivan Thomas schmite physical rehabilitation Assessement and Treatment 4th edition India:jayapee brothers 2001 pp:448 17. Gosselink, R.”breathing technique in patients with chronic obstructive pulmonary disease(COPD)” chronic Respir dis.2004; 1(3):163-72(issn:1479-9723) 18. Shortness of breath Wikipedia free encyclopaedia. 19. Comparison of the oxygen cost of breathing exercises and spontaneous breathing in patients with stable chronic obstructive pulmonary disease. 20. Meilan Han, mark J Rosen, ”spirometry understand for diagnosing COPD” chest 2007 21. Diaphragmatic breathing reduces efficiency of breathing in patients with chronic obstructive pulmonary disease. Vol.151 ,No 4

22. Green RH, singh SJ, Williams J, Morgan MD. A randomized controlled trial of four weeks versus seven weeks of pulmanory rehabilitation in chronic obstructive pulmonary disease. Thorx 2001;56:143-5 23. Dechman G., Wilson C.R., “Evidence underlying breathing retraining in people with stable COPD”, physical therapy, 84, 2004, pp.1189-1197. 24. Ries, AL pulmonary rehabilitation and lung volume reduction surgery Fessler, H E Reilly, J sugar Baker , D J eds. Lung volume reduction surgery for emphysema 2004.123-148 marcel Dukker, New York, 25. Comparison of the oxygen cost of breathing exercises and spontaneous breathing in patients with stable chronic obstructive pulmonary disease. 26. Thom TJ .International comparison in COPD mortality,AM REV Respir Dis 1989,140 S27-34 27. Hatem FS Almery.Annuals of Thorax medicine,Six minute walk test in

respiratory disease;A university Hospital experience.2006;vol.1 pp:16-19 28. Carter et .al Chest. Six minute walk work assessment of functional capacity in patients with COPD. Chest Journal.2003;123:pp 1408-1415 29. Tony Reybrouck, Clinical usefulness and limitation of 6 min walk test in patients with cardiovascular and pulmonary disease. Chest 2003;vol 23,no.2,pp 325-327 30. Ellen A. Hillegas, H. Stephen sadowsky., Essentials of cardio pulmonary physiotherapy. 1st edition, Tokio: W. B. Saunsders Company, 1998, pp. 275-277. 31. Levensen . CR: Breathing exercises in Zaidal, CC (ed) pulmonary Management in physical Therapy. Churchill Livingstone , New York,1992

32. Gosselink R.K.”controlled breathing and dyspnoea in patients with COPD”, journal of rehabilitation, research and development,40,2003,pp.25-34 33. Meilan K Han ,” spirometry utilization for COPD “; april 2007 34. Sandiego , karla R Kendrick, sunita C Baxi, Robert m smith., “usefulness of modified 0-10 Borg scale in assisting the degree of dysnoea in patients with COPD and asthma” may 2001 35. Vitacca, M.clini ,E. Blanchi , L . Ambrosino , N>” Acute effects of deep diaphragmatic breathing in COPD patients with chronic respiratory insufficiency “. European Respiratory journal,11,1998,pp.408-415 36. G.Viegi, a.Scognamigtio,S.Baladacci,fPistelli,L.Carrozzi Epidemiology Group CNRinstitute of pulmonary Clinical

environmental

pathology,Pisa,Italy.Respiration 2001;64,4-19 37. Mary B King, JamesO judge , Robert Whipple, Lesile Walfson.’Reliability and responsiveness of two physical performance”physiotherapy journal 20000:80:pp8-16 38. T.Troosters ,j.Vilaro,R.Robionvich,A.cases, J Barberus , physiological responses to six min walk test in patients with COPD. Eur Respir journal 2002 39. R Gosslink, T Troosters and M Decramer. Exercise training in COPD patients. The basic question.Eur. Respir journal jan 2001 40. Vogiatiz J, Nanas S, Roussos C. Interval training as an alternative modality to continue exercise in patients with COPD. Eur . Respir J.2008:20:12-19

41. Salman G F , Mosier M C, Beasley B W,Calkins D R,rehabilitation for patients with COPD; meta-analysis of randomized Med.2003.mar,18(3):213-21 42. Lacasse, Brosseau L, milne S, Martin s, Wong E , Guyatt G H,et al, pulmonary rehabilitation for COPD. Cochrane Database syst.Rev. 2002; (3):CD003793 43. Stulbarg, MS, Carrieri- Kohlman, V, semir- Deviren, S,etal, Exercises training improves outcomes of a dyspnea self management program J. Cardio pulmon . Reholb.2002, 22, 109-121 44. C R Kothari ‘research methodology methods and techniques.2nd edition 2004 45. S.P Guptha, Statistical methods 12 ed, Sulthanchand and sons publishers 2000, 28th edition. 46. Ries AL, Kaplan RM,Myers R, prewitt LM. Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial. Am J Rspir Crit Care Med 2003;167:880-8 47. Belman MJ, Botnick WC, Nathan SD, chon KH. Ventilatory load characteristics during ventilatory muscle training. Am J Respir Crit Care Med 1994;149:926-9 48. Lotters F, van Tol B , Kwakkel G , Gosselink R. Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis. Eur Respir J 2002;20:570-6 49. Bernard S, Whittom F, Leblanc P, Jobin J, Belleau R, Berube C ,et al. Aerobic and strength training in patients with chronic obstructive pulmonary disease, Am J Respir Crit Care Med 1999;159:896-901 controlled trial.J.Gen.Intern

50. Schols AM, Slangen j,Volovics L, Wouters EF. Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am j Respir Crif Care Med 1996;157:1791-7 51. MurrayCJL,LopezAD,Evidence based health policy 1996;274:740-3 52. SametJM,Definitions and methodology in COPDresearch,In:Hensley M Saunders N ,eds clinical epidemiology of Newyork:narcel Dekker;1989 p1-22. 53. Vermeire PA,PrideNB ,A splitting look at chronic non specific lung disease.Eur Respir.J 1991;4;490-6. 54. Lange .P, Parner J, Vestbo J, SchnohrP,Jensen GA 15 year follow up study of ventilatory function in adults with asthma. N .Engl J Med 1998;339:1194-200. 55. Humer felts ,Gulsuik ,Skjaerven R ,Nilssen S ,Kvale G,Sulneim O,ET AL. Decline in FEV1 and airflow limitation related to occupational exposures in men of urban country. 56. Muller JB, Wright JL, Wiggs BR, Pare PD ,Hogg JC .Reassessment of inflammation of airways in chronic bronchitis. 57. Casio.M, Ghezzo H ,Hogg JC ,Corbin R ,Loveland M ,Dosman J et al ,the relation between structural changes in small airways and pulmonary function test .N.Engl J Med ,1978,298;1277-81 58. Georgo poolos D, Anthonisen NR, symptoms and signs of COPD. In:cherniack NS,ed. chronic obstructive pulmonary disease. Toronto; WB Saunders:1991 p.357-63. chronic obstructive pulmonary disease.

59. Burrows B, Niden AH, Barclay WR, Kasik JE, chronic obstructive pulmonary disease H, and Relationship of clinical and physiological findings to the severity of airways obstruction. AMREV Resp.dis 1965;91:665-78. 60. Celli BR .Pulmonary rehabilitation in patients with COPD.AMJ Respircrit care med 1995:152,861-4 61. Vestbo J Sorensent, Lange P,Brix J Torry P, Viskum K, Longterm effects of inhaled dudesonide in mild and moderate COPD.A randomized control trial.Lancet 1999:353:1819-23. 62. Chronic obstructive pulmonary disease. From wikipedia, free encyclopaedia 63. The effects of pulmonary rehabilitation in elderly patients. 64. Six minute walk test in respiratory disease: a university hospital experience. 65. New strategies to improve exercise tolerance in chronic obstructive pulmonary disease 66. Dyspnoea in COPD: Can inspiratory muscle training help? 67. Inspiratory muscle training in chronic airflow limitation: effect on exercise performance. 68. Effects of a short term pulmonary rehabilitation program on patients with chronic respiratory failure due to pulmonary emphysema. 69. Dyspnea in health and obstructive pulmonary disease: the role of respiratory muscle function and training.

70. Inspiratory muscle training in patients with COPD: effect of dyspnoea, exercise performance, and quality of life. 71. Bartlome R Celli, Pulmonary rehabilitation for COPD, Post graduate medicine online, 1998. 72. Scot Irwin, cardio pulmonary physical therapy,4th edition, U.S: Mosby ,2000 73. Alexandra Hough, physiotherapy in respiratory care- a problem solving approach, 1st edition. London: chapman and Hall, 1991, pp.79-80.

APPENDICES

APPENDIX – 1
ASSESSMENT FORM Subjective Assessment Name Age Sex Occupation Weight Height Chief complaints HISTORY Present medical history Past medical history Personal History Associated Problems H/O Allergens Family History Occupational History : : : : : : : : : : : : : : Date of admission : Date of assessment :

Socioeconomic status Psychological History

: :

EVALUATION OF CARDINAL SYMPTOMS Chest Wall Pain Musculoskeletal Neuralgic Angina Pleuritic Cough Nocturnal cough Productive cough Prolonged cough Early morning productive cough Short cough Cough syncope Sputum Consistency Smell Colour Haemoptysis Dyspnoea Grade

Orthopnea Trepopnea Paroxismal nocturnal dyspnea Platypnea MODIFIED BORG SCALE: Wheeze Clubbing Cyanosis grade: score:

OBJECTIVE ASSESSMENT Vital signs Heart rate Blood pressure : :

Respiratory rate : Temperature :

ON OBSERVATION Built :

Posture : Face evaluation

Colour Distress Puffiness Neck evaluation Use of accessory muscles: Distension of veins Chest wall Expansion: Movement: Deformities: Pattern of breathing Rate Depth Rhythm : : : :

Spinal deformities Scoliosis Kyphosis Kyphoscoliosis : : :

Ankylosing spondylosis : External Appliances ON PALPATION Trachial shift : :

Tenderness over chest wall : Accessory muscle spasm Trachial fremitus Movement of Diaphragm ON PERCUSSION Resonant Hyper resonant Hypo resonant Dull : : : : : : :

ON AUSCULTATION Wheeze :

Crepitation :

Breath sounds Tracheal Bronchial Diaphragmatic : : :

Vocal Resonance: Pleural rub Pericardial rub : :

Heart sounds Mitral Tricuspid Aortic Pulmonary: : : :

ON EXAMINATION Chest Expansion Axillary (…….cm) ECG : Nipple (……cm) Xiphoid process(…….cm)

Echocardiogram: Chest X ray ABG PFT Bronchoscopy : : : :

Clinical Diagnosis:

APPENDIX – 2

DATA COLLECTION FORM NAME AGE SEX Group

Serial number

Outcome Measures

Pre Test Score

Post Test Score

1

6 Minute walk test

2

FEV1

3

FVC

APPENDIX 3

RESULT TABLES T-Test 6 Minute Walk Test (Group A) Paired samples statistics
Mean N Std. Deviation Std. Error Mean PairgrpA_6MWT_pre & 1. grpA_6MWT _post 280.6667 301.6667 15 15 44.59607 43.36995 11.51466 11.19807

Paired samples correlations
N Pair grpA_6MWT_pre & 1. grpA_6MWT _post 15 Correlation .984 Sig. .000

Paired sample test
Paired difference mean Std. deviation Std. Error mean 95% confidence interval of the difference Lower Pair grpA_6MWT_pre 1. grpA_6MWT_post -21.00 8.06226 2.08167 -25.4647 Upper -16.53527 -10.088 14 .000 t df Sig. (2-tailed)

T-Test of FEV1

Paired samples statistics
Mean N Std. Deviation Std. Error Mean PairgrpA_FEV1_pre & 1. grpA_ FEV1_post 1.4533 1.4587 15 15 .15235 .14347 .03934 .03704

Paired samples correlations
N Pair grpA_ FEV1_pre & 1. grpA_ FEV1_post 15 Correlation .989 Sig. .000

Paired sample test
Paired difference mean Std. deviation Std. Error mean 95% confidence interval of the difference Lower Pair grpA_ FEV1_pre 1. grpA_ FEV1_post .00053 .02386 .00616 -.0185 Upper .00078 -.866 14 .401 t df Sig. (2-tailed)

T-Test of FVC

Paired samples statistics
Mean N Std. Deviation Std. Error Mean PairgrpA_FVC_pre & 1. grpA_ FVC _post 2.1707 2.1900 15 15 .17702 .15996 .04571 .04130

Paired samples correlations
N Pair grpA_ FVC _pre & 1. grpA_ FVC _post 15 Correlation .970 Sig. .000

Paired sample test
Paired difference mean Std. Deviation Std. Error mean 95% confidence interval of the difference Lower Pair grpA_ FVC _pre 1. grpA_ FVC _post .01933 .04448 .01148 -.04396 Upper .00530 -1.684 14 .114 T df Sig. (2-tailed)

T-Test 6 Minute Walk Test (Group B)

Paired samples statistics
Mean N Std. Deviation Std. Error Mean PairgrpB_6MWT_pre & 1. grpB_6MWT _post 287.00 292.6667 15 15 39.9016 39.6352 10.3025 10.2337

Paired samples correlations
N Pair grpB_6MWT_pre & 1. grpB_6MWT _post 15 Correlation .997 Sig. .000

Paired sample test
Paired difference mean Std. Deviation Std. Error mean 95% confidence interval of the difference Lower Pair grpB_6MWT_pre 1. grpB_6MWT_post -5.666 3.1997 .82616 -7.4386 Upper -3.8947 -6.859 14 .000 t df Sig. (2-tailed)

T-Test of FEV1

Paired samples statistics
Mean N Std. Deviation Std. Error Mean Pairgrp B_FEV1_pre & 1. grp B_ FEV1_post 1.500 1.5720 15 15 .2426 .2334 .0626 .0602

Paired samples correlations
N Pair grpB_ FEV1_pre & 1. grpB_ FEV1_post 15 Correlation .983 Sig. .000

Paired sample test
Paired difference mean Std. deviation Std. Error mean 95% confidence interval of the difference Lower Pair grpB_ FEV1_pre 1. grpB_ FEV1_post -.072 .0453 .01172 -.0971 Upper -.0468 -6.144 14 .000 T df Sig. (2-tailed)

T-Test of FVC

Paired samples statistics
Mean N Std. Deviation Std. Error Mean PairgrpB_FVC_pre & 1. grpB_ FVC _post 2.283 2.383 15 15 .3127 .2713 .08074 .07007

Paired samples correlations
N Pair grpB_ FVC _pre & 1. grpB_ FVC _post 15 Correlation .974 Sig. .000

Paired sample test
Paired difference mean Std. Deviation Std. Error mean 95% confidence interval of the difference Lower Pair grpB_ FVC _pre 1. grpB_ FVC _post -.100 .0779 .0201 -.1431 Upper -.0568 -4.971 14 .000 T df Sig. (2-tailed)

Univariate Analysis of Variance- 6 MINUTE WALK TEST (6MWT)

Descriptive statistics Dependant Variable 6MWT post
Group Group A Group B Total Mean 301.6667 292.6667 297.1667 Std. Deviation 43.3699 39.6352 41.0777 N 15 15 30

Tests of Between-Subjects Effects Dependant Variable 6MWT post
Source Type III Sum of Squares Corrected Model Intercept Group 6MWT-pre Error Total Corrected total 47921.623a 279.964 1711.757 47314.123 1012.544 2698175 48934.167 2 1 1 1 27 30 29 Df Mean Squares 23960.811 279.964 1711.757 47314.123 37.502 638.927 7.465 45.645 1261.655 .000 .011 .000 .000 F Sig.

Pair-wise Comparison Dependant Variable 6MWT post
Group Group Mean Difference Std. Error Sig. 95% Confidence Interval for Difference Lower Bound GroupA GroupB 15.153 2.243 .000 10.551 Upper Bound 19.755

Univariate Tests

Dependant Variable 6MWT post
Sum of Squares Contract Error 1711.757 1012.544 Df 1 27 Mean Square 1711.757 37.502 F 45.645 Sig. .000

Univariate Analysis of Variance- FEV1 Descriptive statistics Dependant Variable FEVI post
Group Group A Group B Total Mean 1.4587 1.5720 1.5153 Std. Deviation .14347 .23346 .19892 N 15 15 30

Tests of Between-Subjects Effects Dependant Variable FEV1 post
Source Type III Sum of Squares Corrected Model Intercept Group FEV1-pre Error Total Corrected total
1.115a

Df

Mean Squares

F

Sig.

2 1 1 1 27 30 29

.557 .008 .036 1.018 .001

457.735 6.658 29.25 836.352

.000 .016 .000 .000

.008 .036 1.018 .033 70.035 1.148

Pair-wise Comparison

Dependant Variable FEV1 post
Group Group Mean Difference Std. Error Sig. 95% Confidence Interval for Difference Lower Bound GroupA GroupB -.069 .013 .000 -.096 Upper Bound -.043

Univariate Tests Dependant Variable FEV1 post
Sum of Squares Contract Error .036 .033 Df 1 27 Mean Square .036 .001 F 29.25 Sig. .000

Univariate Analysis of Variance- FVC Descriptive statistics Dependant Variable FVC post
Group Group A Group B Total Mean 2.190 2.3833 2.2867 Std. Deviation .1599 .2713 .2399 N 15 15 30

Tests of Between-Subjects Effects Dependant Variable FVC post

Source

Type III Sum of Squares

Df

Mean Squares

F

Sig.

Corrected Model Intercept Group FVC-pre Error Total Corrected total

1.596a

2 1 1 1 27 30 29

.798 .054 .067 1.315 .003

292.43 19.754 24.681 482.117

.000 .000 .000 .000

.054 .067 1.315 .074 158.535 1.669

Pair-wise Comparison Dependant Variable FVC post
Group Group Mean Difference Std. Error Sig. 95% Confidence Interval for Difference Lower Bound GroupA GroupB -.097 .020 .000 -.137 Upper Bound -.057

Univariate Tests Dependant Variable FVC post
Sum of Squares Contract Error .067 .074 Df 1 27 Mean Square .067 .003 F 24.681 Sig. .000

APPENDIX 4

GRAPH FOR 6 MINUTE WALK TEST

GRAPH FOR FEV1

GRAPH FOR FVC

APPENDIX 5
EXERCISE PROTOCOLS

APPENDIX 5 EXERCISE PROTOCOLS
Diaphragmatic Breathing Exercise: The patient is asked to get relaxed and comfortable position in which gravity assists the diaphragm such as a semi –fowler’s position. Hands placed on the rectus abdominus just below the anterior costal margin with elbows supported and keeping the shoulder relaxed. Ask the patient to breathe in slowly and deeply through the nose and keep the shoulder and upper chest relaxed allowing the abdomen to rise. Tell the patient to slowly let all the air out using controlled expiration. Ask the patient to keep his hand over the rectus abdominis and feel the movement. The patients hands should rise during inspiration and fall during expiration Patient should feel the contraction of the abdominal muscle. Practice diaphragmatic breathing in a variety of positions

Pursed-Lip Breathing Exercise Make the patient in a comfortable position and relax as much as possible It is performed by inhaling through the nose and exhaling through pursed lips. Abdominal muscles may or may not be used for exhalation. Instruct the patient to breathe in slowly and deeply. The expiration must be relaxed, have the patient loosely purse the lips and exhale.

APPENDIX – 6
INFORMED CONSENT FORM Institute’s name & address: Department of physiotherapy A.W.H Special collage Kallai Calicut Name of the researcher: Title of the study: MUHAMMED RAZI C. K “ A Study To Evaluate The Effectiveness Of Diaphragmatic Breathing And Pursed lip Breathing Exercise For Improving Flow Rate And Functional Exercise Tolerance In Chronic Disease” Phone number: 09895419487 Patients With Stable Pulmonary

Obstructive

I ---------------------------------------------- agree to participate in the research conducted by Mr. Muhammed Razi. C. K for the partial fulfilment of his Masters in Physiotherapy program of the Department of Physiotherapy of A.W.H Special Collage, Kallai, under Calicut University. The project is under supervision of Mr. Premkumar. The purpose is to find out the effectiveness of diaphragmatic breathing and pursed lip

breathing exercise for improving flow rate and functional exercise tolerance in patients with stable chronic obstructive pulmonary disease. My participation will consist essentially of attending once daily 6 days in a week for 6 weeks and each session approximately 30 minutes. I will be either treated with diaphragmatic breathing exercises and pursed lip breathing exercises. I understand that diaphragmatic breathing and pursed lip breathing exercise has no any side effects or danger. I am free to withdrawn from the project at any time before or during the interventions, refuse to participate and refuse to answer questions. I have received assurance from the researcher that the information’s, I share will remain strictly confidential. Anonymity will be assured not using name and any type of publications or Non participation will not affect on service that I or my family members may receive from the physiotherapy department of this institution. These are 2 copies of the consent form one of which I may keep. If I have any questions about the conduct of the research project I may contact the researcher.

Researcher name: MUHAMMED RAZI. C.K Official address: Department of Physiotherapy A.W.H special collage Kallai. Date:

Respondent’s signature

Researchers signature

Appendix 7
MASTER CHART Pre 6MWT
310 300 325 290 250 260 300 270 340 285 360 250 260 200 210 220 280 350 330 310 320 280 320 310 260 300 305 220 240 260

Sl no
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

group
A A A A A A A A A A A A A A A B B B B B B B B B B B B B B B

Age
57 61 63 69 66 67 62 58 64 67 59 65 63 65 58 68 59 68 53 65 66 62 58 66 62 58 59 66 58 64

Post 6MWT
325 340 340 320 280 275 320 300 350 300 375 270 280 220 230 225 285 350 330 320 325 290 330 315 265 310 310 225 245 265

Pre FEV1
1.27 1.53 1.42 1.33 1.2 1,67 1.66 1.42 1.32 1.52 1.4 1.67 1.63 1.37 1.39 0.92 1.43 1.52 1.67 1.81 1.87 1.32 1.62 1.23 1.63 1.57 1.43 1.32 1.46 1.7

Pre FVC
2.22 2.3 2.1 2 1.98 2.44 2.42 2.1 1.95 2.23 2.1 2.43 2.31 1.98 2 1.73 2.1 2.2 2.44 2.85 2.85 2 2.4 2.2 2.39 2.29 2.1 1.98 2.13 2.59

Post FEV1
1.29 1.57 1.44 1.34 1.23 1.69 1.63 1.43 1.35 1.49 1.42 1.67 1.6 1.35 1.38 1.03 1.62 1.58 1.7 1.9 1.9 1.4 1.75 1.3 1.72 1.6 1.47 1.38 1.5 1.73

Post FVC
2.23 2.33 2.15 2.1 2 2.45 2.4 2.1 2 2.16 2.13 2.42 2.32 1.96 2.1 1.96 2.3 2.28 2.52 2.95 2.9 2.2 2.43 2.22 2.44 2.3 2.32 2.1 2.23 2.6