PULMONARY REHABILITATION

DR.DIVYA A. PAREKH
MPT (CARDIO PULMONARY)
 CONTENT:
• DEFINITION
• PULMONARYREHABILITATION INTERDISCIPLINARY
TEAM
• PATIENT SELECTION
• PATIENT ASSESSMENT
• GOAL DEVELOPMENT
• SELF MANAGEMENT EDUCATION
• EXERCISE ASSESSMENT AND TRAINING
• PSYCHOSOCIAL INTERVENTION
• PATIENT –CENTERED OUTCOMES
 DEFINITION
American thoracic society (ATS) and the European
Respiratory Society statement on pulmonary
rehabilitation, pulmonary rehabilitation is an evidence
based, multidisciplinary and comprehensive
intervention for patients with chronic respiratory
disease who are symptomatic and often have decreased
daily life activities. Integrated in to the individualized
treatment of the patient, pulmonary rehabilitation is
designed to reduce symptoms,optimize functional
status, increase participation and reduce health care
costs through stabilizing or reversing systemic
manifestation of the disease.
Pulmonary rehabilitation includes:
• Patient selection
• Patient assessment
• Goal setting
• Self management education
• Exercise training
• Psycho social support
• Outcome measurement
 THE INTERDISCIPLINARY PULMONARY
REHABILITATION TEAM

CORE TEAM MEMBERS

• Medical director
• Program coordinator
• Physical therapist
• Nurse
• Respiratory therapist
OTHER RESOURCE PROFESSIONALS
• Clinical psychologist
• Dietician or nutritionist
• Social worker
• Occupational therapist
• Pharmacist
• Speech therapist
• Administrative assistant
 MEDICAL DIRECTOR
• This person is integrally involved in creating the
rehabilitative plan of care, provides supervision of
rehabilitation process, and therefore has high level of
involvement with patients and staff.
• Clinical responsibilities include providing expertise
on the appropriateness of the refferal,participating in
the initial assessment and treatment plan development
and reassessing the patients progress and goals during
the rehabilitation intervention.
 PHYSICAL THERAPIST
• Physical therapist may assess the patient,develope
treatment plan, supervise and deliver the exercise
programme.
 CLINICAL PSYCHOLOGIST
• conducting relaxation or stress management sessions.
• assessing the psychological status or cognitive
functioning.
 SOCIAL WORKER
• To detect any psychological or social problems and to
undertake counseling
• Counseling include grief and stages of loss; the
development of coping strategies to handle emotional
responses such as anxiety and depression; the impact
of the illness on the family; etc.
• Responsible for attending to the practical needs of
patients including discussion of the patient’s financial
status, and where necessary, facilitating the patient’s
access to social security benefits.
 OCCUPATIONAL THERAPIST
• Assisting the patient to function effectively and
independently in employment, family, social and
recreational activities. Where this is not possible or
appropriate, the occupational therapist should assist
the patient to live as productive life as possible.
• Vocational assessments to determine the feasibility
and capacity of the patient to resume work at a
reasonable level of physical or other occupational
demand
• Leisure and social activities are assessed.
 PATIENT SELECTION
• CONDITIONS APPROPRIATE FOR
PULMONARY REHABILITATION
• OBSTRUCTIVE DISEASES
• COPD
• Persistent asthma
• Bronchiectasis
• Cystic fibrosis
• Bronchiolitis obliterans
• RESTRICTIVE DISEASES
• Interstitial diseases
• -Interstitial fibrosis
• -Occupational and environmental lung disease.
• -Sarcoidosis
• Chest wall diseases
• -Kyphoscoliosis
• -Ankylosing spondylities
• NEURO MUSCULAR DISEASES
-Parkinson's diseases
-Post polio syndrome
-Amyotrophic lateral sclerosis
-Diaphragmatic dysfunction
-Multiple sclerosis
-Post tuberculosis syndrome
• OTHER CONDITIONS
• Lung cancer
• Primary pulmonary hypertension
• Before and after thoracic and abdominal surgery.
• Before and after lung transplantation
• Before and after lung volume reduction surgery
• Ventilator dependency
• Paediatric patient with respiratory diseases
• Obesity related respiratory diseases.
• CONDITIONS THAT COMMONLY LEAD TO
REFERRALS FOR PULMONARY
REHABILITATION
• Dyspnea
• Fatigue
• Chronic respiratory symptoms
• Impaired health related quality of life
• Decreased functional status
• Decreased occupational performance
• Difficulty performing activities of daily living
• Difficulty with medical regimen
• Psycho social problems underlying respiratory illness
• Nutrition depletion
• Increased use of medical resources.e.g
hospitalization, emergency room visit physician visits
• Gas exchange abnormalities including hypoxemia
• The degree of motivation is important in the selection
process, although this is difficult to assess.
• Discussing the patients financial ability to meet the
anticipated expenses of pulmonary rehabilitation is
necessary.
• Patients must also have a means of transportation to
and from the program.
 PATIENT ASSESSMENT
• The assessment process identifies the unique
problems of the patient.
• Reassessment during pulmonary rehabilitation
program is necessary to review progress and adjust
the program in order to best meet the patients goals.
 COMPONENTS OF THE INITIAL
PATIENT ASSESSMENT
• Patient interview
• Medical history
• Physical exam
• Diagnostic tests
• Symptom assessment
• Musculoskeletal and exercise assessment
• Activities of daily living assessment
• Nutrition assessment
• Education assessment
• Psychosocial assessment
• Pain assessment
• Goal development
 INTERVIEW
• The initial assessment should begin with patient
interview.
• Not only are important data obtained but the
foundation of trust credibility are established at this
time.
• Allows the patient to interact on personal level with
the rehabilitation staff.
 MEDICAL HISTORY
• The medical history provides information on the
severity of respiratory disease ,such as symptom
burden,exacerbations,medication
requirenments,supplemental oxygen use, physical
limitations.
• The medical history also important in highlighting
comorbid condition that may have direct bearing on
patients health ,safty and response of pulmonary
rehabilitation.
• Respiratory history
• Comorbidities
• Other medical and surgical history
• Family history
• Use of medical resources
• All current medication
• Oxygen use
• Allergies and drug intolerances
• Smoking history
• Occupational and environmental exposures
• Alcohol and other substance abuse history
• Social supports
 PHYSICAL ASSESSMENT
• Vital signs
• Height
• Weight
• Arterial oxygen saturation
• Breathing pattern
• Use of accessory muscles of respiration
• Chest examination
• Cardiac examination
• Presence of finger clubbing
• Upper and lower extremity evaluation
 DIAGNOSTIC TESTS
• Spirometery
• Oxygen saturation
• Chest radiograph
• Electrocardiogram
• Field test of exercise capacity
• CBC
• Screening for anxiety and depression
-beck depression inventory
-Anxiety and depression scale
 SYMPTOM ASSESSMENT
• Dyspnea
• Fatigue
• Cough and sputum production
• Wheeze
• Haemoptysis
• Chest pain
• Reflux
• Heart burn
• Oedema
• dysphagia
• Extremity pain or weakness
• Feelings of anxiety,panic,fear,isolation
• Depressive symptoms
 MUSCULOSKELETAL AND
EXERCISE ASSESSMENT
• Physical limitations
-Strength
-Range of motion
-Posture
-Functional abilities and activities
• Orthopaedic limitations
• Transferring abilities
• Exercise tolerance
• Gait and balance
 PAIN ASSESSMENT
• Location
• Duration
• Intensity
• character
ACTIVITIES OF DAILY LIVING
ASSESSMENT
• Basic ADLs such as: dressing,bathing,walking,eating
• House hold chores
• Leisure activities
• Job related activities
 NUTRITION ASSESSMENT
• Patient with respiratory disease often have significant
alteration in nutrition status and body composition.
• Under weight -decreased muscle mass
• Obesity -increased work of breathing
-have other comorbid illness

• BMI=weight (kg)/height2(m2)
• Dietary history
• Eating patterns and meal size
• Diet recall
• Fluid intake
• Alcohol consumption
• Need and use of nutritional supplements
 EDUCATION ASSESSMENT
• Knowledge of the disease and its treatment
• Self efficacy
• Barriers to learning: visual or hearing problems
cognitive impairment, language barrier, illiteracy
• Cultural diversity
PSYCHO SOCIAL ASSESSMENT
• The psychosocial area should address several areas:
• Motivational level
• Emotional distress
• Family and home situation
• Substance abuse
• Cognitive impairment
• Other psycho pathology and neuro psychological
impairment
 GOAL DEVELOPEMENT
• Goal development is a direct reflection of the
rehabilitation potential and must include short term
and long term goal.
• Goal should be formulated with the patient.
• At the completion of the comprehensive assessment
the patients rehabilitation potential should be
ascertained.
• Poor, fair and excellent potential can be made based
on the assessment information.
SELF MANAGEMENT EDUCATION

FAMILY

SELF
MANAGEMENT
PHYSICAL
THERAPIST

CARE
PATIENT
GIVER
• Self management education promotes learning by doing,
which increase knowledge ,enhances self confidence and
increases self efficacy.
• Self management education changes a patients behaviour
by teaching individualized problem solving skills.
• Self management education enhance communication
between patient and their health care providers:
 Improve adherence to their treatment plans.
 Reduce health care utilization.
 Reduce the probability of hospitalizations&readmissions.
• An education program must be individualized to each
patients need and concerns, diagnosis, disease
severity and comorbidities.
• Encourage active rather than passive learner
participation.
 EDUCATIONAL TOPICS
• Normal anatomy, physiology and pathophysiology.
• Description and interpretation of medical test.
• Breathing strategies and secretion clearance.
• Medications.
-oxygen
-bronchodilators
-steroids
-proper inhaler technique
-Antibiotics
• Respiratory devices
• Benefits of exercise and maintaining physical
activities
• Activities of daily living
• Eating right for weight gain/weight loss
• Irritant avoidance
• Early recognition and treatment of exacerbation
• Leisure activities and travel
• Coping with chronic lung disease
• Use a demonstration models and other teaching aids
because layperson frequently have difficulty to
understand the pulmonary anatomy.
• Description and interpretation of medical test should
be kept simple.
• Medical education should include:
-Prescribed doses
-Frequency
-Side effects and drug interactions
• The use of proper inhalation devices is recommended.
• Discuss the use of proper respiratory devices and
indication, contraindications and proper cleaning
• An exercise log or diary may be useful for patients to
self record there home exercise and physical activity.
• Independence is primary goal for patients with
chronic respiratory diseases.
• By applying:
-Breathing strategies to ADL.
-Using energy conservation techniques.
-Work simplification techniques.
• Avoidance of all environmental and occupational irritants
especially first and second hand cigarette smoke.
• Assist Smoking cessation with counselling, use of
combined behavioural and pharmacological management.
• Recognize exacerbations and promptly initiate treatment
may reduce severity and complication.
• Receiving influenza and pneumonia immunization.
• Frequent hand washing.
• Covering the mouth when coughing.
• Use of supplemental oxygen when travelling.
• Relaxation and stress management strategies should be
teach.
 EXERCISE ASSESSMENT
AND TRAINING
o Exercise assessment of the patient with chronic
pulmonary disease may be used to do the following:
• Quantify exercise capacity before beginning a
program.
• Establish a baseline outcome documentation.
• Help establish patient specific goals.
• Assist in formulating an exercise prescription for
exercise training.
• Detect exercise induce hypoxemia.
• Evaluate non pulmonary limitations to exercise.
• Help detect underlying cardiac abnormalities.
• Screen for exercise induce bronchospasm.
• Exercise testing in pulmonary rehabilitation is
generally of two types:
 WALK DISTANCE TESTS
• 6 MINUTE WALK TEST
• 12 MINUTE SHUTTLE WALK TEST
 INCREMENTAL MAXIMAL EXERCISE TEST
 SUB MAXIMAL EXERCISE TEST
 PRINCIPLES OF EXERCISE
TRAINING
• FREQUENCY OF EXERCISE
• INTENSITY OF EXERCISE
• TYPE[MODES]OF EXERCISE
• TIME OF EXERCISE
 FREQUENCY
• It is the number of session per week to be performed.
• 3 to 5 times per week.
• 1 or more un supervised session per week at home if
program constraints will not allow for supervised
exercise.
 INTENSITY
The rate at which the exercise is being performed.
Intensity of exercise can be prescribed and monitored
by several methods. Such as:-

• PERCIEVED EXERTION SCALE

• DYSPNEA SCALE
• MET
• A TARGET HEART RATE IS NOT ALWAYS USED IN
THE PULMONARY POPULATION BUT KEEPING IN
MIND
 MET
 Amount of oxygen consumption at rest or sitting.
 1MET= 3.5mL/kg/min
 Exercise can be prescribed and regulated by choice of
activity according to MET value for the patient.
 TYPE
1. Continuous
2. Interval
3. Circuit and
4. Circuit interval
 Continuous training :-
 Includes an activity performed at a constant
submaximal intensity.
 E.g:-walking, cycling, jogging, swimming,
step up and step down etc.
 Interval training:-
 Bouts of relatively intense work separated by period
of rest or less intense activity.
 In group rehabilitation various circuit training
approach has been used.
 It can be performed using little or no equipment.
 Walking,cycling,stationary bicycling, arm ergometry,
seated aerobics.
• WARM UP PERIOD
• AEROBIC CONDITIONING
• COOL DOWN PERIOD
 WARM UP PERIOD
 Preparatory phase of exercise
 15min devoted to warm up comment is recommended
(Association of Chartered Physiotherapists in Cardiac
Rehabilitation 2006)
 The warm-up consists of pulse-raising exercise,
mobilization of major joints and stretching and
specific warm up movements.
 AEROBIC CONDITIONING

 Aerobic conditioning should last for 20-30 minutes.

 It mostly include a continuous or interval approach
for exercise training.
 It depends upon the functional capacity and activity
level of the individual.
 The principal goal is to improve the duration and
efficiency of exercise and then to progress the
intensity
 This can be executed via continuous and interval
training.
 COOL DOWN PERIOD
 The aim is to return the cardiorespiratory system to
nearest pre-existing level.
 Period of 10 minutes is recommended.
 It consists of pulse lowering exercise, stretching of
large muscle group and joint mobilization at a slow
pace with steadily reduced intensity.
 TIME [DURATION]
• 20 to 90 minute.
• Initially started with shorter duration with frequent
rest.
 UPPER AND LOWER
EXTREMITY TRAINING
• It is most beneficial to direct exercise training to
those muscles involved in functional living.
• Lower extremity training involves large muscle group
this improve ambulatory stamina, balance and
performance in ADLs.
• Types of lower extremity training include the
following:
• Walking
• Stationary cycling
• Bicycling
• Stair climbing
• Upper extremity training also beneficial.
• Caution must be taken in chronic lung disease patient
who have been on long term steroid therapy lose bone
density. This patient osteoporotic and may increase
risk of compression fracture in vertebral segments.
• Post operative surgical pulmonary patients are
generally restricted from arm ergometry for 6 weeks
to allow incisional healing.
 STRENGTH TRAINING
• Strength training improve muscle strenght,increase
exercise endurance.
• Example of strength training include following:
• Hand and ankle weights
• Free weights
• Machine weights
• Elastic resistance
• Using body weight such as stair climbing or squats.
• Combination of aerobic training and strength
leads to gain strength and endurance.
• Safety and prevention of muscle tears are of crucial
importance especially person on chronic steroid
therapy who may risk of muscle or tendon rupture
when exposed to high intensity load.
• Precaution are warranted for post surgical patient and
osteoporosis and patient with primary arterial
hypertension.
• Gradually repetition increased.
 FLEXIBILITY,POSTURE AND
BODY MECHANICS
• To develop and maintain proper posture and good
body symmetry should also important.
• Lack of flexibility leads to poor posture.
• Balance training in older age group and fall risk
prevent.
• Modified yoga may be useful.
 RESPIRATORY MUSCLE
TRAINING
• Inspiratory muscle training
• 4 to 5 days per week
• Intensity 30 to 40% PI max
• 15 minute session over 2 months.
 EMERGENCY PROCEDURE
• All staff should be familiar with emergency
procedure.
• Emergency equipment should available.
• Oxygen source and delivery apparatus.
• Resuscitation mask.
• Fist aid supplies.
• Bronchodilator medication.
 DOCUMENTATION
• Documentation of treatment sessions include:
• Time and date
• Mode,duration,intensity of exercise
• Education
• Patients response to treatment
• Progress
 HOME EXERCISE PROGRAM
• Home exercise program should encourage exercise as
well life style modification to promote health and
functional status.
PSYCHO SOCIAL INTERVENTION
• Building a support systems
-Staff support
-Family members,friends,other program
participants.
• Patient counselling
-Self monitoring
-Gradual reduction in smoking,quitting,relapse
prevention and follow up.
PATIENT CENTERED OUTCOMES
• There are a two broad areas of outcome analysis:

-PATIENT CENTERED CLINICAL OUTCOMES

-PROGRAM PERFORMANCE MEASURES
PATIENT CENTERED CLINICAL OUTCOMES:
• EXERCISE CAPACITY
• 6 minute walk test
• shuttle walk test
• cardio pulmonary exercise stress test
• SYMPTOMS
• Dyspnea-VAS,BORG SCALE
• Fatigue-MULTI DIMENTIONAL FATIGUE
INVENTORY.
• HEALTH RELATED QUALITY OF LIFE[HRQL]
• GENERIC-
• SF 36
• DISEASE SPECIFIC-
• st. georges respiratory questionnaire[SGRQ]
• Chronic respiratory disease questionnaire [CRQ]
• FUNCTIONAL PERFORMANCE AND HOME
BASED ACTIVITY:
-Pedometer to monitor walking.
-Body weight.
-Body mass index.
-Health care utilization.
THANK YOU